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UBE2V2 Ubiquitin-conjugating enzyme E2 variant 2 is a protein that in humans is encoded by the UBE2V2 gene. Ubiquitin-conjugating enzyme E2 variant proteins constitute a distinct subfamily within the E2 protein family. # Structure UBE2V2 has sequence similarity to other ubiquitin-conjugating enzymes but lack the conserved cysteine residue that is critical for the catalytic activity of E2s. The protein encoded by this gene also shares homology with ubiquitin-conjugating enzyme E2 variant 1 and yeast MMS2 gene product. # Function UBE2V2 has also been implicated as an intracellular sensor of reactive electrophilic species, which are present in high levels during periods of pathogenic and/or environmental stress. The C69 residue of UBE2V2 is capable of binding with various RES. It has been shown that binding of RES to UBE2V2 promotes UBE2V2-mediated activation of Ube2N, another E2 protein that complexes with UBE2V2. Activated Ube2N has been shown to play a major role in promoting DNA-damage responses. Thus, UBE2V2 may promote genome integrity by directly sensing RES and effecting DNA damage responses. It may also be involved in the differentiation of monocytes and enterocytes. # Interactions UBE2V2 has been shown to interact with HLTF. Although UBE2V2 itself lacks ubiquitin-conjugating activity, it can interact with different Ubiquitin-conjugating enzymes to facilitate their catalytic activities. For instance, UBE2V2 can complex with UBE2N to form a heterodimer capable of synthesizing Lys-63 linked polyubiquitin chains. UBE2V2 may facilitate UBE2N activity by coordinating UBE2N's positioning to promote ubiquitin chain formation specifically at Lys-63, as the ubiquitin molecule has multiple potential Lysine binding sites. Similarly, it has been shown that UBE2V2 interact with the ubiquitin-conjugating enzyme, Ubc13, to induce Ubc13 to adopt an active conformation that can create Lys-63 polyubituitin chains on various substrates. Addition of Lys-63 polyubiquitin chains to intracellular targets is distinct from the canonical Lys-48 polyubiquitin chains in that Lys-63 chains do not mediate proteasomal degradation of its substrate. Although their function remains poorly characterized, Lys-63 chains have been shown to regulate signaling pathways by either activating or inhibiting its target protein function. For example, TRIM5alpha restriction of retroviral reverse-transcription is dependent on UBE2V2/UBE2N-mediated poly-ubiquitination. UBE2V2 has been shown to regulate TRIM21 antiviral activity in an analogous manner.

This report provides recommendations for use of a newly developed recombinant outer-surface protein A (rOspA) Lyme disease vaccine (LYMErix,™ SmithKline Beecham Pharmaceuticals) for persons aged 15-70 years in the United States. The purpose of these recommendations is to provide health-care providers, public health authorities, and the public with guidance regarding the risk for acquiring Lyme disease and the role of vaccination as an adjunct to preventing Lyme disease. The Advisory Committee on Immunization Practices recommends that decisions regarding vaccine use be made on the basis of assessment of individual risk, taking into account both geographic risk and a person's activities and behaviors relating to tick exposure. *sensu lato: including all subordinate taxa of a taxon that would otherwise be considered separately. † sensu stricto: excluding similar taxa that otherwise would be considered together.# INTRODUCTION Lyme disease is a tickborne zoonosis caused by infection with the spirochete Borrelia burgdorferi. The number of annually reported cases of Lyme disease in the United States has increased approximately 25-fold since national surveillance began in 1982; during 1993-1997, a mean of 12,451 cases annually were reported by states to CDC (1,2, CDC, unpublished data, 1998). In the United States, the disease is primarily localized to states in the northeastern, mid-Atlantic, and upper north-central regions, and to several areas in northwestern California (1 ). Lyme disease is a multisystem, multistage, inflammatory illness. In its early stages, Lyme disease can be treated successfully with oral antibiotics; however, untreated or inadequately treated infection can progress to late-stage complications requiring more intensive therapy. The first line of defense against Lyme disease and other tickborne illnesses is avoidance of tick-infested habitats, use of personal protective measures (e.g., repellents and protective clothing), and checking for and removing attached ticks. Early diagnosis and treatment are effective in preventing late-stage complications. Recently, two Lyme disease vaccines have been developed that use recombinant B. burgdorferi lipidated outer-surface protein A (rOspA) as immunogen -LYMErix,™ SmithKline Beecham Pharmaceuticals, and ImuLyme,™ Pasteur Mérieux Connaught. As of publication of this report, only LYMErix has been licensed by the U.S. Food and Drug Administration for use in the United States; therefore, these recommendations apply only to the use of that vaccine. Additional statements will be provided as other Lyme disease vaccines are licensed. Results of a large-scale, randomized, controlled (Phase III) trial of safety and efficacy of LYMErix in persons aged 15-70 years residing in disease-endemic areas of the northeastern and north-central United States indicate that the vaccine is safe and efficacious when administered on a three-dose schedule of 0, 1, and 12 months (3,4 ). Information regarding vaccine safety and efficacy beyond the transmission season immediately after the third dose is not available. Thus, the duration of protective immunity and need for booster doses beyond the third dose are unknown. # CLINICAL FEATURES OF LYME DISEASE Clinical Description Most often, Lyme disease is evidenced by a characteristic rash (erythema migrans) accompanied by nonspecific symptoms (e.g., fever, malaise, fatigue, headache, myalgia, and arthralgia) (5)(6)(7). The incubation period from infection to onset of erythema migrans is typically 7-14 days but can be as short as 3 days or as long as 30 days. Some infected persons have no recognized illness (i.e., asymptomatic infection determined by serologic testing), or they manifest only nonspecific symptoms (e.g., fever, headache, fatigue, and myalgia). Lyme disease spirochetes disseminate from the site of inoculation by cutaneous, lymphatic, and bloodborne routes. The signs of early disseminated infection usually occur from days to weeks after the appearance of a solitary erythema migrans lesion. In addition to multiple or secondary erythema migrans lesions, early disseminated infection can be manifested as disease of the nervous system, the musculoskeletal system, or the heart (5)(6)(7). Early neurologic manifestations include lymphocytic meningitis; cranial neuropathy, especially facial nerve palsy; and radiculoneuritis. Musculoskeletal manifestations can include migratory joint and muscle pains with or without objective signs of joint swelling. Cardiac manifestations are rare but can include myocarditis and transient atrioventricular block of varying degree. B. burgdorferi infection in the untreated or inadequately treated patient can progress to late-disseminated disease from weeks to months after infection (5)(6)(7). The most common objective manifestation of late-disseminated Lyme disease is intermittent swelling and pain of one or some joints, usually large, weight-bearing joints (e.g., the knee). Some patients experience chronic axonal polyneuropathy, or encephalopathy, the latter usually manifested by cognitive disorders, sleep disturbance, fatigue, and personality changes. Infrequently, Lyme disease morbidity can be severe, chronic, and disabling (8,9 ). An ill-defined post-Lyme disease syndrome occurs in some persons after treatment for Lyme disease (10)(11)(12). Lyme disease is rarely, if ever, fatal. # Diagnosis The diagnosis of Lyme disease is based primarily on clinical findings, and treating patients with early disease solely on the basis of objective signs and a known exposure is often appropriate (13 ). Serologic testing can, however, provide valuable supportive diagnostic information in patients with endemic exposure and objective clinical findings that indicate later-stage disseminated Lyme disease (13 ). When serologic testing is indicated, CDC recommends testing initially with a sensitive first test, either an enzyme-linked immunosorbent assay (ELISA) or an indirect fluorescent antibody test, followed by testing with the more specific Western immunoblot (WB) test to corroborate equivocal or positive results obtained with the first test (14 ). Although antibiotic treatment in early localized disease can blunt or abrogate the antibody response, patients with early disseminated or late-stage disease usually have strong serologic reactivity and demonstrate expanded WB immunoglobulin G (IgG) banding patterns to diagnostic B. burgdorferi antigens (15,16 ). Antibodies often persist for months or years after successfully treated or untreated infection. Thus, seroreactivity alone cannot be used as a marker of active disease. Neither positive serologic test results nor a history of previous Lyme disease ensures that a person has protective immunity. Repeated infection with B. burgdorferi has been reported (17 ). B. burgdorferi can be cultured from 80% or more of biopsy specimens taken from early erythema migrans lesions (18 ). However, the diagnostic usefulness of this procedure is limited because of the need for a special bacteriologic medium (i.e., modified Barbour-Stoenner-Kelly medium) and protracted observation of cultures. Polymerase chain reaction (PCR) has been used to amplify genomic DNA of B. burgdorferi in skin, blood, cerebrospinal fluid, and synovial fluid (19,20 ), but PCR has not been standardized for routine diagnosis of Lyme disease. # Treatment Lyme disease can usually be treated successfully with standard antibiotic regimens (5,6 ). Early and uncomplicated infection, including infection with isolated cranial nerve palsy, usually responds satisfactorily to treatment with orally administered antibiotics (21 ). Parenteral antibiotics are generally recommended for treating meningitis, carditis, later-stage neurologic Lyme disease, and complicated Lyme disease arthritis. Late, complicated Lyme disease might respond slowly or incompletely, and more than one antibiotic treatment course can be required to eliminate active infection (8,9 ). Refractory Lyme disease arthritis is associated with expression of certain Class II major histocompatibility complex (MHC II) molecules (22 ), and can require anti-inflammatory agents and surgical synovectomy for relief of symptoms (8 ). In a limited number of patients, persistent or recurrent symptoms after appropriate antibiotic therapy often can be attributed to causes other than persistent infection (22,23 ). # EPIDEMIOLOGY OF LYME DISEASE Antigenic Variation of B. burgdorferi Sensu Lato* In the United States, a number of genospecies of B. burgdorferi sensu lato have been isolated from animals and ticks, but only OspA expressing B. burgdorferi sensu stricto † has been isolated from humans (24 ). Existing evidence also demonstrates that rOspA vaccines will be protective against most if not all human infections in the United States (25 ). B. burgdorferi sensu stricto also occurs in Europe, but the dominant European and Asian genospecies are B. garinii and B. afzelii, both of which are antigenically distinct from B. burgdorferi sensu stricto (26 ) and vary in their expression of OspA. Vaccines using combinations of immunogenic proteins might be necessary to provide protection against multiple genospecies (27 ). # Routes of Transmission Humans acquire B. burgdorferi infection from infected ticks at the time the tick takes a blood meal (28 ); Lyme disease is not spread by person-to-person contact or by direct contact with infected animals. Transplacental transmission of B. burgdorferi has been reported (29,30 ), but the effects of such transmission on the fetus remain unclear. The results of two epidemiologic studies document that congenital Lyme disease must be rare, if it occurs at all (31,32 ). Transmission in breast milk has not been described. B. burgdorferi can be cultured from the blood in some patients with early acute infection, and it is able to survive for several weeks in stored blood. However, at least one study has found that the risk for transfusion-acquired infection is minimal (33 ). # Tick Vectors of Lyme Disease B. burgdorferi is transmitted to humans by ticks of the Ixodes ricinus complex (34 ). I. scapularis, the black-legged or deer tick, is the vector in the eastern United States; I. pacificus, the western black-legged tick, transmits B. burgdorferi in the western United States (35,36 ). I. scapularis is also a vector for human granulocytic ehrlichiosis and babesiosis (34,37 ). In their nymphal stage, these ticks feed predominantly in the late spring and early summer. The majority of Lyme disease cases result from bites by infected nymphs. In highly enzootic areas of the United States, approximately 15%-30% of questing I. scapularis nymphs and up to 14% of I. pacificus nymphs are infected with B. burgdorferi (38)(39)(40)(41). However, in the southern United States, the prevalence of infection in I. scapularis ticks is generally 0%-3% (36 ). The risk for acquiring Lyme disease in the United States varies with the distribution, density, and prevalence of infection in vector ticks (Appendix). During the past several decades, the distribution of I. scapularis has spread slowly in the northeastern and upper north-central regions of the United States (42 ). Although deer are not competent reservoirs of B. burgdorferi, they are the principal maintenance hosts for adult black-legged ticks, and the presence of deer appears to be a prerequisite for the establishment of I. scapularis in any area (43 ). The explosive repopulation in the eastern United States by white-tailed deer during recent decades has been linked to the spread of I. scapularis ticks and of Lyme disease in this region. The future limits of this spread are not known (42 ). # Distribution of Human Cases of Lyme Disease Lyme disease is endemic in several regions in the United States, Canada, and temperate Eurasia (1,44 ). The disease accounts for more than 95% of all reported cases of vectorborne illness in the United States. Using a national surveillance case definition (45 ), state health officials reported >62,000 cases to CDC during 1993-1997, and the national mean annual rate during this 5-year period was 5.5 cases/100,000 population (1,2, CDC, unpublished data, 1998). Persons of all ages are equally susceptible to infection, although the highest reported rates of Lyme disease occur in children aged <15 years and in adults aged 30-59 years (1 ). Both underreporting and overdiagnosis are common (46)(47)(48). Approximately 90% of cases are reported by approximately 140 counties located along the northeastern and mid-Atlantic seaboard and in the upper north-central region of the United States (Appendix). A rash similar to erythema migrans of Lyme disease, but not caused by B. burgdorferi infection, has been described in patients who have been bitten by ticks in the southern United States (49,50 ). This rash is suspected of being associated with the bite of Amblyomma americanum ticks (51 ). # Populations at Risk for Lyme Disease Most B. burgdorferi infections result from periresidential exposure to infected ticks (38,(52)(53)(54)(55) during property maintenance, recreation, and leisure activities. Thus, persons who live or work in residential areas surrrounded by woods or overgrown brush infested by vector ticks are at risk for acquiring Lyme disease. In addition, persons who participate in recreational activities away from home (e.g., hiking, camping, fishing, and hunting) in tick habitat and persons who engage in outdoor occupations (e.g., landscaping, brush clearing, forestry, and wildlife and parks management) in endemic areas might also be at elevated risk for acquiring Lyme disease (56)(57)(58). # PREVENTION AND CONTROL OF LYME DISEASE # Avoidance of Tick Habitat Whenever possible, persons should avoid entering areas that are likely to be infested with ticks, particularly in spring and summer when nymphal ticks feed. Ticks favor a moist, shaded environment, especially that provided by leaf litter and lowlying vegetation in wooded, brushy, or overgrown grassy habitat. Both deer and rodent hosts must be abundant to maintain the enzootic cycle of B. burgdorferi. Sources of information regarding the distribution of ticks in an area include state and local health departments, park personnel, and agricultural extension services. # Personal Protection Persons who are exposed to tick-infested areas should wear light-colored clothing so that ticks can be spotted more easily and removed before becoming attached. Wearing long-sleeved shirts and tucking pants into socks or boot tops can help keep ticks from reaching the skin. Ticks are usually located close to the ground, so wearing high rubber boots can provide additional protection. Applying insect repellents containing DEET (n,n-diethyl-m-toluamide) to clothes and exposed skin and applying permethrin, which kills ticks on contact, to clothes, should also help reduce the risk of tick attachment. DEET can be used safely on children and adults but should be applied according to the U.S. Environmental Protection Agency guidelines to reduce the possibility of toxicity (59 ). Because transmission of B. burgdorferi from an infected tick is unlikely to occur before 36 hours of tick attachment (28,60 ), daily checks for ticks and their prompt removal will help prevent infection. # Strategies for Reducing Tick Abundance The number of ticks in endemic residential areas can be reduced by removing leaf litter, brush, and woodpiles around houses and at the edges of yards and by clearing trees and brush to admit more sunlight, thus reducing deer, rodent, and tick habitat (61 ). Tick populations have also been effectively suppressed by applying pesticides to residential properties (62,63 ). Community-based interventions to reduce deer populations or to kill ticks on deer and rodents have not been extensively implemented, but might be effective in reducing communitywide risk for Lyme disease (64 ). The effectiveness of deer feeding stations equipped with pesticide applicators to kill ticks on deer and other baited devices to kill ticks on rodents is currently under evaluation. # Prophylaxis After Tick Bite The relative cost-effectiveness of postexposure treatment of tick bites to avoid Lyme disease in endemic areas is dependent on the probability of B. burgdorferi infection after a tick bite (65 ). In most circumstances, treating persons for tick bite alone is not recommended (6,66 ). Persons who are bitten by a deer tick should remove the tick and seek medical attention if any signs and symptoms of early Lyme disease, ehrlichiosis, or babesiosis develop during the ensuing days or weeks. # Early Diagnosis and Treatment Lyme disease is readily treatable in its early stages (5,6 ). The early diagnosis and proper antibiotic treatment of Lyme disease are important strategies for avoiding the morbidity and costs of complicated and late-stage illness. # LYME DISEASE VACCINE Description LYMErix is made from lipidated rOspA of B. burgdorferi sensu stricto. The rOspA protein is expressed in Escherichia coli and purified. Each 0.5-mL dose of LYMErix contains 30 µg of purified rOspA lipidated protein adsorbed onto aluminum hydroxide adjuvant. # Mechanism of Action Several studies in animals have provided evidence that B. burgdorferi in a vector tick undergoes substantial antigenic change between the time of tick attachment on a mammalian host and subsequent transmission of the bacterium to the host. The spirochetes residing in the tick gut at the initiation of tick feeding express primarily OspA. As tick feeding begins, the expression of outer-surface protein C (OspC) is increased and the expression of OspA is decreased, so that spirochetes that reach the mammalian host after passing through the tick salivary glands express primarily OspC (67 ). Thus, the rOspA vaccine might exert its principal protective effect by eliciting antibodies that kill Lyme disease spirochetes within the tick gut (68,69 ). # Route of Administration, Vaccination Schedule, and Dosage LYMErix is administered by intramuscular injection, 0.5 mL (30 µg), into the deltoid muscle. Three doses are required for optimal protection. The first dose is followed by a second dose 1 month later and a third dose administered 12 months after the first dose. Vaccine administration should be timed so that the second dose of the vaccine (year 1) and the third dose (year 2) are administered several weeks before the beginning of the B. burgdorferi transmission season, which usually begins in April. The safety and immunogenicity of alternate dosing schedules are currently being evaluated. # VACCINE PERFORMANCE # Safety # Randomized, Controlled Clinical (Phase III) Trial of LYMErix A total of 10,936 subjects aged 15-70 years living in Lyme disease-endemic areas were recruited at 31 sites and randomized to receive three doses of vaccine or placebo (3 ); 5,469 subjects received at least one 30-µg dose of rOspA vaccine, and 5,467 subjects received at least one injection of placebo. The subjects were then followed for 20 months. Information regarding adverse events that were believed to be related or possibly related to injection were available from 4,999 subjects in each group. Soreness at the injection site was the most frequently reported adverse event, which was reported without solicitation by 24.1% of vaccine recipients and 7.6% of placebo recipients (p < 0.001). Redness and swelling at the injection site were reported by <2% of either group but were reported more frequently among vaccine recipients than among those who received placebo (p < 0.001). Myalgia, influenza-like illness, fever, and chills were more common among vaccine recipients than placebo recipients (p < 0.001), but none of these was reported by more than 3.2% of subjects (3 ). Reports of arthritis were not significantly different between vaccine and placebo recipients, but vaccine recipients were significantly (p < 0.05) more likely to report arthralgia or myalgia within 30 days after each dose (70 ). No statistically significant differences existed between vaccine and placebo groups in the incidence of adverse events more than 30 days after receiving a dose, and no episodes of immediate hypersensitivity among vaccine recipients were noted (3 ). # Safety in Patients with Previously Diagnosed Lyme Disease The safety of three different dosage strengths of rOspA vaccine with adjuvant in 30 adults with previous Lyme disease was evaluated in an uncontrolled safety and immunogenicity trial (71 ). Doses were administered at 0, 1, and 2 months. Follow-up of subjects was conducted 1 month after the third dose. No serious adverse events were recorded during the study period. In the randomized controlled Phase III trial of LYMErix, the incidence of adverse events among vaccinees who were seropositive at baseline was similar to the incidence among those who were seronegative (70 ). The incidence of musculoskeletal symptoms within the first 30 days after vaccination was higher among vaccinees with a self-reported previous history of Lyme disease compared with vaccinees with no such history. This difference was not statistically significant at the p = 0.05 level in the placebo group. No statistically significant difference existed in the incidence of late musculoskeletal adverse events between vaccine and placebo recipients with a selfreported previous history of Lyme disease (70 ). # Risk for Possible Immunopathogenicity of rOspA Vaccine After infection with B. burgdorferi, persons who express certain MHC II molecules are more likely than others to develop chronic, poorly responsive Lyme arthritis associated with high levels of antibody to OspA in serum and synovial fluid (22 ). In chronic Lyme arthritis patients, the levels of antibody to OspA, and especially to the C-terminal epitope of OspA, have been found to correlate directly with the severity and duration of the arthritis (72 ). Researchers have proposed that an autoimmune reaction might develop within the joints of some Lyme arthritis patients as a result of molecular mimicry between the dominant T-cell epitope of OspA and human leukocyte function associated antigen 1 (hLFA-1) (73 ). The Phase III trial did not detect differences in the incidence of neurologic or rheumatologic disorders between vaccine recipients and their placebo controls during the 20 months after the initial dose (3 ). However, because the association between immune reactivity to OspA and treatment-resistant Lyme arthritis is poorly understood, the vaccine should not be administered to persons with a history of treatment-resistant Lyme arthritis. # Efficacy Randomized, Controlled Trial (Phase III) of LYMErix Using an intention-to-treat analysis, the vaccine efficacy in protecting against "definite" Lyme disease after two doses was 49% (95% confidence interval = 15%-69%) and after three doses was 76% (95% CI = 58%-86%) (3 ). (In this study, "definite" Lyme disease was defined as the presence of erythema migrans or objective neurologic, musculoskeletal, or cardiovascular manifestations of Lyme disease, plus laboratory confirmation of infection by cultural isolation, PCR positivity, or WB seroconversion.) Efficacy in protecting against asymptomatic infection (no recognized symptoms, but with WB seroconversions recorded in year 1 or year 2) was 83% (95% CI = 32%-97%) in year 1 and 100% (95% CI = 26%-100%) in year 2. # Immunogenicity A subset of adult subjects enrolled in the Phase III clinical trial of LYMErix was studied for the development of OspA antibodies at months 2, 12, 13, and 20 (3 ). At month 2, one month after the second injection, the geometric mean antibody titer (GMT) of IgG anti-OspA antibodies was 1,227 ELISA units/mL. Ten months later, the GMT had declined to 116 ELISA units/mL. At month 13, one month after the third injection, a marked anamnestic response resulted in a GMT of 6,006 ELISA units/mL. At month 20, the mean response had decreased to 1,991 ELISA units/mL (70 ). An analysis of antibody titers and the risk for developing Lyme disease for a subset of subjects enrolled in the Phase III clinical trial concluded that a titer >1,200 ELISA units/mL correlated with protection (SmithKline Beecham poster at Infectious Disease Society of America Conference, Denver, Colorado, November 1998). # Effect of Vaccination on the Serologic Diagnosis of Lyme Disease Care providers and laboratorians should be advised that vaccine-induced anti-rOspA antibodies routinely cause false-positive ELISA results for Lyme disease (74 ). Experienced laboratory workers, through careful interpretation of the results of WB, can usually discriminate between B. burgdorferi infection and previous rOspA immunization, because anti-OspA antibodies do not develop after natural infection. # COST-EFFECTIVENESS OF LYME DISEASE VACCINATION The cost of Lyme disease has been evaluated from both a societal and a thirdparty-payer perspective (75 ). The cost-effectiveness of vaccinating against Lyme disease has also been analyzed from a societal perspective (76 ). At an assumed cost of vaccination of $100/person/year, a vaccine effectiveness of 0.85, a probability of 0.85 of correctly identifying and treating early Lyme disease, and an assumed incidence of Lyme disease of 1,000/100,000 persons/year, the net cost of vaccination to society was $5,692/case averted and $35,375/complicated neurologic or arthritic case avoided (Figure 1). Using these same baseline assumptions, the societal cost of vaccination exceeds the cost of not vaccinating, unless the incidence of Lyme disease is >1,973/100,000 persons/year. Of the variables examined, the incidence of Lyme disease had the greatest impact on cost-effectiveness of vaccination. The likelihood of early diagnosis and treatment also has a substantial impact on vaccine costeffectiveness because of the reduced incidence of sequelae when Lyme disease is diagnosed and patients are treated early in the disease. Most disease-endemic states and counties report Lyme disease incidence that are substantially below 1,000/100,000 persons/year. For example, in 1997, the highest reported state incidence was 70/100,000 persons in Connecticut, and the highest reported county incidence was 600/100,000 population in Nantucket County, Massachusetts. However, some studies document that approximately 10%-15% of physician-diagnosed cases of Lyme disease are reported to state authorities in highly endemic areas (46,47 ). Epidemiologic studies of populations at high risk in the northeastern United States have estimated annual incidence of >1,000/100,000 persons/ year in several communities (77)(78)(79)(80). # ASSESSING THE RISK FOR LYME DISEASE The decision to administer Lyme disease vaccine should be made on the basis of an assessment of individual risk, which depends on a person's likelihood of being bitten by tick vectors infected with B. burgdorferi. This likelihood is primarily determined by the following: - density of vector ticks in the environment, which varies by place and season; - the prevalence of B. burgdorferi infection in vector ticks; and - the extent of person-tick contact, which is related to the type, frequency, and duration of a person's activities in a tick-infested environment. Assessing risk should include considering the geographic distribution of Lyme disease. The areas of highest Lyme disease risk in the United States are concentrated within some northeastern and north-central states. The risk for Lyme disease differs not only between regions and states and counties within states (Appendix), but even within counties and townships. Detailed information regarding the distribution of Lyme disease risk within specific areas is best obtained from state and local public health authorities. The second step in determining Lyme disease risk is to assess a person's activities. Activities that place persons at high risk are those that involve frequent or prolonged exposure to the habitat of infected ticks at times of the year when the nymphal stages of these ticks are actively seeking hosts, which in most endemic areas is April-July. Typical habitat of Ixodes ticks are wooded, brushy, or overgrown grassy areas that are favorable for deer and the ticks' rodent hosts. Several recreational, property # FIGURE 1. Cost-effectiveness of Lyme disease vaccination OBJECTIVE This MMWR provides recommendations regarding prevention and control of Lyme disease. These recommendations were developed by CDC staff members and the ACIP members. This report is intended to guide clinical practice and policy development related to administration of the Lyme disease vaccine. Upon completion of this educational activity, the reader should be able to describe the epidemiology of Lyme disease in the United States; list effective methods of Lyme disease prevention; describe the characteristics and use of the currently licensed Lyme disease vaccine; and recognize the most common adverse reactions following administration of Lyme disease vaccine. # EXPIRATION -June 4, 2000 The response form must be completed and returned electronically, by fax, or by mail, postmarked no later than 1 year from the publication date of this report, for eligibility to receive continuing education credit. # INSTRUCTIONS 1. Read this MMWR (Vol. 48, RR-7 ), which contains the correct answers to the questions beginning on the next page. 2. Complete all registration information on the response form, including your name, mailing address, phone number, and e-mail address, if available. # Indicate whether you are registering for Continuing Medical Education (CME) credit, Continuing Education Unit (CEU) credit, or Continuing Nursing Education (CNE) credit. 4. Select your answers to the questions, and mark the corresponding letters on the response form. To receive continuing education credit, you must answer all of the questions. Questions with more than one correct answer will instruct you to "indicate all that are true." 5. Sign and date the response form. # MMWR Response Form for Continuing Education Credit June 4, 1999 / Vol. 48 / No. RR-7 # Recommendations for the Use of Lyme Disease Vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP) Fill in the appropriate block(s) to indicate your answer(s). To receive continuing education credit, you must answer all of the questions. . A B C D E 2. A B C D E 3. A B C D E 4. A B C D E 5. A B C D E 6. A B C D E 7. A B C D E 8. A B C D E 9. A B C D E 10. A B C D E F 11. A B C D E F 12. A B C D E 13. A B C D E 14. A B C 15. A B C D E 16. A B C D E 17. A B C D E 18. A B C D E Detach or photocopy. 1.2 hours of CNE credit maintenance, occupational, or leisure pursuits that are carried out in tick habitat can be risky activities. When in highly endemic areas, persons can reduce their risk for Lyme disease and other tickborne illnesses by avoiding tick-infested habitats. If exposure to a tick-infested habitat cannot be avoided, persons should use repellents, wear protective clothing, and regularly check themselves for ticks. Persons who are unlikely to seek medical care for early manifestations of Lyme disease can be at increased risk for Lyme disease complications. Morbidity from Lyme disease can be substantially reduced by detecting and treating the infection in its early stages, because early and correct treatment usually results in a prompt and uncomplicated cure. # RECOMMENDATIONS FOR USE OF LYME DISEASE VACCINE Lyme disease vaccine does not protect all recipients against infection with B. burgdorferi and offers no protection against other tickborne diseases. Vaccinated persons should continue to practice personal protective measures against ticks and should seek early diagnosis and treatment of suspected tickborne infections. Because Lyme disease is not transmitted person-to-person, use of the vaccine will not reduce risk among unvaccinated persons. Decisions regarding the use of vaccine should be based on individual assessment of the risk for exposure to infected ticks and on careful consideration of the relative risks and benefits of vaccination compared with other protective measures, including early diagnosis and treatment of Lyme disease. The risk for Lyme disease is focally distributed in the United States (Appendix). Detailed information regarding the distribution of Lyme disease risk within specific areas is best obtained from state and local public health authorities. The following recommendations are made regarding use of Lyme disease vaccine: -Lyme disease vaccination may be considered for persons aged 15-70 years who are exposed to tick-infested habitat but whose exposure is neither frequent nor prolonged. The benefit of vaccination beyond that provided by basic personal protection and early diagnosis and treatment of infection is uncertain. -Lyme disease vaccination is not recommended for persons who have minimal or no exposure to tick-infested habitat. - Travelers can obtain some protection from two doses of vaccine but will not achieve optimal protection until the full series of three doses has been administered. All travelers to high-or moderate-risk areas during Lyme disease transmission season should practice personal protection measures as described earlier and seek prompt diagnosis and treatment if signs or symptoms of Lyme disease develop. Lyme disease is endemic in some temperate areas of Europe and Asia; however, considerable heterogeneity of expression exists in the Eurasian strains of B. burgdorferi sensu lato that infect humans, and whether the rOspA vaccine licensed for use in the United States would protect against infection with Eurasian strains is uncertain. - Pregnant Women -Because the safety of rOspA vaccines administered during pregnancy has not been established, vaccination of women who are known to be pregnant is not recommended. No evidence exists that pregnancy increases the risk for Lyme disease or its severity. Acute Lyme disease during pregnancy responds well to antibiotic therapy, and adverse fetal outcomes have not been reported in pregnant women receiving standard courses of treatment. A vaccine pregnancy registry has been established by SmithKline Beecham Pharmaceuticals. In the event that a pregnant women is vaccinated, health-care providers are encouraged to register this vaccination by calling, toll-free, (800) 366-8900, ext. 5231. - Persons with Immunodeficiency -Persons with immunodeficiency were excluded from the Phase III safety and efficacy trial, and no data are available regarding Lyme disease vaccine use in this group. # Persons with Musculoskeletal Disease -Persons with diseases associated with joint swelling (including rheumatoid arthritis) or diffuse musculoskeletal pain were excluded from the Phase III safety and efficacy trial, and only limited data are available regarding Lyme disease vaccine use in such patients. - Persons with a Previous History of Lyme Disease -Vaccination should be considered for persons with a history of previous uncomplicated Lyme disease who are at continued high risk. -Persons who have treatment-resistant Lyme arthritis should not be vaccinated because of the association between this condition and immune reactivity to OspA. -Persons with chronic joint or neurologic illness related to Lyme disease, as well as second-or third-degree atrioventricular block, were excluded from the Phase III safety and efficacy trial, and thus, the safety and efficacy of Lyme disease vaccine in such persons are unknown. - Vaccine Schedule, Including Spacing and Timing of Administration -Three doses of the vaccine should be administered by intramuscular injection. The initial dose should be followed by a second dose 1 month later and a third dose 12 months after the first dose. Vaccine administration should be timed so that the second dose of the vaccine (year 1) and the third dose (year 2) are administered several weeks before the beginning of the B. burgdorferi transmission season, which usually begins in April. - Boosters -Whether protective immunity will last longer than 1 year beyond the month-12 dose is unknown. Data regarding antibody levels during a 20-month period after the first injection of LYMErix indicate that boosters beyond the month-12 booster might be necessary (see Immunogenicity). Additional data are needed before recommendations regarding vaccination with more than three doses of rOspA vaccine can be made. # Simultaneous Administration with Other Vaccines -The safety and efficacy of the simultaneous administration of rOspA vaccine with other vaccines have not been established. If LYMErix must be administered concurrently with other vaccines, each vaccine should be administered in a separate syringe at a separate injection site. # FUTURE CONSIDERATIONS # Recommendations for Surveillance, Research, Education, and Program Evaluation Activities - Determine safety, immunogenicity, and efficacy of Lyme disease vaccine in children. - Determine optimal vaccine dosage schedules and timing of administration. - Determine the need for and spacing of booster doses. - Determine safety and efficacy of the vaccine in persons aged >70 years. - Develop additional serodiagnostic tests that discriminate between infection and vaccine-induced antibody production. - Develop a program of Lyme disease vaccine education for care providers and prospective vaccine clients. - Develop an information sheet to be distributed to prospective vaccine recipients or to persons at the time of vaccine administration. - Conduct surveillance for rare or late-developing adverse effects of vaccination. - Establish postlicensure epidemiologic studies of safety, efficacy, prevention effectiveness, cost-effectiveness, and patterns of use. - Develop a program to monitor vaccine use at the local, state, and national levels and to measure its public health and economic impact. - Develop population-based studies to assess the impact of vaccine use on incidence of Lyme disease in communities. - Continue to develop maps of geographic distribution of Lyme disease with improved accuracy and predictive power. exposure were compiled on a county-unit scale for the United States. Then geographic information systems (GIS) technology was used to combine these data and categorize each of the 3,140 counties into four risk classes. # ENTOMOLOGIC RISK Vector Distribution Vector data were obtained from a national distribution map of Ixodes scapularis and I. pacificus, which was previously published by CDC (2 ). These data delineate three classes of tick distribution based on all published and unpublished county collection records available to CDC before 1998. The three classes are as follows: - established populations (≥6 ticks reported or more than one life stage); - reported occurrence (<6 ticks reported and only one life stage); and - absence of ticks or missing data. Although these data are currently the best source of vector distribution available, many gaps exist because of uneven sampling efforts among the counties. Therefore, a neighborhood analysis GIS procedure was used to modify the original tick distribution to smooth absent data and minimize the impact of reporting gaps. In this process, the original tick coverage map was rasterized to 1 km, and each cell was given a numeric value corresponding to the county tick class (0 = absent; 1 = reported; and 2 = established). A neighborhood analysis was performed using ERDAS IMAGINE- image-processing software. This function employed a moving filter (25 by 25 km), which summed the values of the area surrounding each 1-km pixel and created a new focally smoothed image. An outline of counties was overlaid to define boundaries on the smoothed map, and new values were summed from the total pixel values for each county. The three original vector classes were maintained with the new classification. The revised map employed a threshold reclassification based on mean summary statistics generated from the neighborhood analysis. This procedure resulted in a weighted value for each county that was determined by the classes of surrounding counties, thus smoothing the map to minimize rough edges and isolated holes in the data. The modified vector distribution increased the number of counties containing I. scapularis and I. pacificus from 1,058 counties (34% of total counties) in the original data set to 1,404 (45% of total) in the modified version. This modification resulted in greater continuity among adjacent counties, as well as a less-conservative description of vector distribution. # Infection Prevalence in Vectors The prevalence of infection with B. burgdorferi is low throughout the distribution of I. pacificus (3 ) with the exception of one California county (4 ). Within the entire southern distribution of I. scapularis, prevalence of infection with B. burgdorferi is low compared with the Northeast and upper Midwest (3 ). One possible reason for these *ERDAS IMAGINE map production computer software, a product of ERDAS, Inc., 2801 Buford Highway, Atlanta, GA 30329-2137, (404) 248-9000, . The national map illustrates a clear focal pattern of Lyme disease risk with the greatest risk occurring in the Northeast and upper Midwest regions. Overall, 115 (4%) counties were classified as high risk, followed by 146 (5%) moderate risk, 1,143 (36%) low risk, and 1,736 (55%) as minimal or no-risk counties. Lyme disease risk is measurable as a function of two epidemiologic parametersentomologic risk and human exposure. Entomologic risk for Lyme disease is defined as the density per unit area of host-seeking nymphal ticks infected with Borrelia burgdorferi (1 ). Field studies needed for determination of entomologic risk require trained entomologists, and such studies are limited to a narrow seasonal window within the life-cycle of vector ticks. Limited resources preclude the direct measurement of entomologic risk over large geographic areas; therefore, indirect measures were used to estimate risk to develop this national Lyme disease risk map. First, data on vector distribution, abundance, B. burgdorferi infection prevalence, and human # High risk # Moderate risk # Low risk # Minimal or no risk # Areas of predicted Lyme disease transmission Note: This map demonstrates an approximate distribution of predicted Lyme disease risk in the United States. The true relative risk in any given county compared with other counties might differ from that shown here and might change from year to year. Risk categories are defined in the accompanying text. Information on risk distribution within states and counties is best obtained from state and local public health authorities. differences is the geographic variations in abundance of hosts that are competent reservoirs of infection for immature ticks. The white-footed mouse (Peromyscus leucopus) is the principal host for ticks in the Northeast and upper Midwest and is a competent reservoir for the spirochete. But in the Southeast and West Coast regions, reptiles appear to serve as major hosts for immature ticks, and reptiles are either inefficient or incompetent reservoir hosts for spirochetes. This pattern of tick-host association might result from the greater population density of lizards relative to rodents ( 5), resulting in reduced transmission rates in regions where lizards dominate. An index was created to map the effect of host-species composition on infection prevalence in I. scapularis ticks. # National Lyme disease risk map with four categories of risk A literature survey was conducted to identify a complete list of hosts for I. scapularis (6 ). A total of 38 nondomestic host species was identified, including 32 mammal species and 6 reptile species. Birds were excluded because of their migratory nature and their uncertain role as natural reservoir hosts. Species range maps were obtained from the literature (7,8 ), then digitized by county into ArcView GIS- software for presence or absence of reservoir hosts. The county data were then summed to determine the total host species composition available for I. scapularis. A ratio of total reptiles divided by the total hosts multiplied by 100 was calculated for each county and mapped. The reptile ratio index delineates those areas having a high reptile-to-total-hosts ratio (>10) and forms a linear boundary, below which reptiles are more likely to serve as hosts for ticks. The geographic boundary runs roughly on the 38º north latitude from Virginia to Missouri. This reptile ratio illustrates that although total hosts in the northern states can be equal to those of the southern states, reptiles dilute the force of transmission, thus lowering the prevalence of infection in ticks and creating less of a risk to humans in the South. # HUMAN EXPOSURE TO RISK CDC case reports were used as a measure of human exposure to entomologic risk. County-specific data were compiled for the years 1994-1997. Counties comprising the ninetieth percentile of all human cases reported during this 4-year period were selected to represent counties with high human exposure. These 137 counties reported a minimum total of 23 cases. Heuristic, or procedure-based decision rule, was employed to construct the national Lyme disease risk map. Expert decision rule was applied to construct the risk classification as follows: # Risk Classes - High Risk. Counties where I. scapularis or I. pacificus populations are established and where prevalence of infection is predicted to be high, and which are in the top tenth percentile of counties reporting human cases during the 4-year period, 1994-1997.

Borazine Borazine is an inorganic compound composed of the elements boron, nitrogen and hydrogen. In this cyclic compound three hydroborane (BH) units and three amino units (NH) alternate. The compound was synthesised in 1926 by the chemists Alfred Stock and Pohland by a reaction of diborane with ammonia. The structure is isoelectronic and isostructural with benzene and for this reason borazine is called inorganic benzene by a proposal of Nils Wiberg and the compound also goes by the name of borazol from the German name for benzene which is benzol. # Synthesis Borazine is synthesized from diborane and ammonia in a 1:2 ratio at 250 - 300 °C with a conversion of 50%. An alternative more efficient route begins with lithium borohydride and ammonium chloride with improved chemical yield: In a two-step process to borazine, boron trichloride is first converted to trichloroborazine: The B-Cl bonds are subsequently converted to B-H bonds: # Properties Borazine is a colourless liquid with an aromatic smell. In water it decomposes to boric acid, ammonia, and hydrogen. Borazine, with a standard enthalpy change of formation ΔHf of -531 kJ/mol, is thermally very stable. ## Structure Borazine is isostructural with benzene and bond lengths are identical just as in benzene. The distance between boron and nitrogen in the ring is 0.1436 nm, the carbon carbon bond in benzene has a length of 0.1397 nm. The boron nitrogen bond is between that of the boron nitrogen single bond with 0.151 nm and the boron nitrogen double bond which is 0.131 nm. This suggests partial delocalisation of nitrogen lone pair electrons. ## Mesomers The electronegativity of boron (2.04 on the Pauling scale) compared to that of nitrogen (3.04) and also the electron deficiency on the boron atom and the lone pair on nitrogen favor alternative mesomer structures for borazine. Boron is the Lewis acid and nitrogen is the Lewis base. # Reactions Borazine is more reactive than benzene. It reacts with hydrogen chloride in an addition reaction. If borazine were truly aromatic like benzene this reaction would not occur without a Lewis acid catalyst. The addition reaction with bromine takes place without catalyst. Borazines interact with nucleophilic attack at boron and electrophilic attack at nitrogen. Heating borazine at 70 °C expulses hydrogen with formation of a borazinyl polymer or polyborazylene in which the monomer units are coupled in a para fashion by new boron - nitrogen bonds. # Applications Borazine and borazine derivatives are potential precursors to boron nitride ceramics. Boron nitride can be prepared by heating polyborazylene to 1000 °C. Borazines are also starting materials for other potential ceramics such as boron carbonitrides:

Endogeny The word endogenous means "arising from within", the opposite of exogenous. # Biology Endogenous substances are those that originate from within an organism, tissue, or cell . Endogenous retrovirus are caused by ancient infections of germ cells in humans, mammals and other vertebrates. Their proviruses remain in the genome and are passed on to the next generation. Endogenous processes include circadian rhythms. In some biological systems, endogeneity refers to the recipient of DNA (usually in prokaryotes). However, due to homeostasis, discerning between internal and external influences is often difficult. # Psychology An emotion or behaviour is endogenous if it is spontaneously generated from an individual's internal state. # Economics and finance A variable is called endogenous if it is explained within the model in which it appears. For example, in a supply and demand model of an agricultural market, changes in the weather or in consumer tastes would be exogenous variables that might shift the supply and demand curves; the price and quantity of trade would be the endogenous variables explained by the model. nl:Endogeen (aardwetenschappen) fi:Endogeeninen

Korean Guideline for Iron Chelation Therapy in Transfusion-Induced Iron Overload # Introduction Regular red blood cell (RBC) transfusions are the major supportive care for many Korean patients with aplastic anemia (AA), myelodysplastic syndromes (MDS), or other rare anemias. Physicians most commonly use the hemoglobin (Hgb) level to determine whether or not to transfuse [bib_ref] Red blood cell transfusion practice in elective orthopedic surgery: a multicenter cohort..., Vuille-Lessard [/bib_ref]. However, most guidelines recommend that transfusions should be given for symptoms of anemia and that the decision to transfuse should not be based on the Hgb level alone [bib_ref] Clinical practice guideline: red blood cell transfusion in adult trauma and critical..., Napolitano [/bib_ref]. An optimal RBC transfusion regimen involves administering sufficient RBCs to maximize clinical benefits while avoiding unnecessary transfusions that increase costs and expose patients to potential risks, including infection and iron overload. Hence, the Korean Society of Blood Transfusion (KSBT) recommends transfusion to be considered at Hgb concentrations of 7 g/dL or less in chronically anemic patients. KSBT does not rec-ommend routine RBC transfusion when Hgb > 7 g/dL. Furthermore, KSBT only recommends RBC transfusion in those patients with symptoms such as dyspnea, palpitation on exertion, or edema. Chronic transfusion therapy inevitably leads to secondary iron overload, which can cause significant damage to many organs such as the liver, heart, and endocrine system. Recently, deferasirox (DFX), an oral iron chelator, has been introduced and has been shown to improve the treatment of iron overload [bib_ref] Tailoring iron chelation by iron intake and serum ferritin: the prospective EPIC..., Cappellini [/bib_ref]. To summarize the evidence and provide practical guidelines for iron chelation in Korea, the Korean Society of Hematology Aplastic Anemia Working Party (KSHAAWP) describes here general considerations regarding iron overload in transfusion dependent patients and proposes guidelines for the treatment of iron overload based on published clinical evidence and the experience of the expert panel. ## Pathophysiology of iron overload Iron metabolism and the mechanism of organ damage Iron is involved in many critical steps of cellular metabolism such as cellular respiration, heme synthesis, production of oxygen radicals, antioxidation, and DNA synthesis and repair, as well as in cellular proliferation and inflammation. Normal body iron stores are 3-4 g; an excess of iron of 20 g or more can lead to organ damage [bib_ref] Practical management of iron overload, Porter [/bib_ref]. Most additional iron can be stored within the reticuloendothelial system (RES). However, if the iron level exceeds the capacity of the RES to retain it, the excess iron will be released into the plasma. Normally, transferrin binds this released iron but, if the plasma iron concentration continues to rise, transferrin saturation may result. This scenario may occur with sequential transfusions: when the RES cannot retain all of the iron, it then diffuses into the plasma in amounts that exceed the capacity of transferrin to bind it. As a result, non-transferrin-bound iron, which seems to be the major mediator of extrahepatic tissue damage in transfusional iron overload, appears in the plasma [bib_ref] Impact of transfusion dependency and secondary iron overload on the survival of..., Malcovati [/bib_ref]. The harmful effects of excess iron may result from deposition into tissues and organs, but also from oxidative stress. Non-transferrin-bound plasma iron is deposited specifically in tissues with high level of transferrin receptors (eg, liver, heart, anterior pituitary, and pancreas). As the human body has no mechanism for excreting excess iron, and each unit of transfused RBCs contains 200-250 mg of iron, iron overload can readily occur in patients given multiple transfusions, typically after 10 to 20 transfusions (6). In the absence of treatment to reduce iron overload, progressive cardiomyopathy, cirrhosis, endocrinopathy and diabetes can have a serious impact on morbidity and mortality. Iron chelation therapy in patients given multiple transfusions aims to prevent or reverse some of these consequences and has been associated with a reduced morbidity and mortality [bib_ref] Improvement in iron status and liver function in patients with transfusional iron..., Hoffbrand [/bib_ref]. ## Measuring and monitoring body iron Serum ferritin is the most common indirect parameter used to assess body iron stores in the clinical setting. Measurement of serum ferritin is easy and inexpensive but individual values may be affected by infection, inflammation, liver disease, vitamin C deficiency, and hemolysis [bib_ref] Serum ferritin, liver iron stores, and liver histology in children with thalassaemia, Virgiliis [/bib_ref]. Although ferritin is not the most accurate marker of iron overload, ferritin levels do correlate with transfusion burden [bib_ref] Prognostic factors and life expectancy in myelodysplastic syndromes classified according to WHO..., Malcovati [/bib_ref] and liver iron concentration (LIC) [bib_ref] Serum ferritin, liver iron stores, and liver histology in children with thalassaemia, Virgiliis [/bib_ref] , and trends in ferritin levels are useful for following iron load. Liver biopsy is considered the gold standard for direct measurement of total body iron, but the use of this invasive technique is excluded in many patients because of thrombocytopenia and neutropenia, which may predispose to bleeding and infectious complications [bib_ref] Monitoring chelation therapy to achieve optimal outcome in the treatment of thalassaemia, Porter [/bib_ref]. Non-invasive measurement techniques are being developed, including T2* MRI and magnetic susceptometry using a superconducting quantum interference device (SQUID). These techniques have been shown in some studies to provide results that correlate well with liver biopsy-determined iron concentrations [bib_ref] Iron-chelating therapy and the treatment of thalassemia, Olivieri [/bib_ref] [bib_ref] Magnetic-susceptibility measurement of human iron stores, Brittenham [/bib_ref] [bib_ref] Assessment of iron distribution between liver, spleen, pancreas, bone marrow, and myocardium..., Papakonstantinou [/bib_ref] , but they are not widely available worldwide. The data reported in a recent study indicate that serial measurements of serum ferritin are useful for monitoring chelation therapy with DFX so that doses may be adjusted according to the ongoing iron load due to transfusion [bib_ref] Tailoring iron chelation by iron intake and serum ferritin: the prospective EPIC..., Cappellini [/bib_ref]. The DFX prescribing information recommends monitoring serum ferritin monthly to assess the patient's response to therapy and adjusting the DFX dose, if necessary, every 3 to 6 months (16). ## Clinically available iron chelators Currently, three chelating agents are available: deferoxamine, deferiprone, and DFX. ## Deferoxamine (desferal tm ) Deferoxamine (DFO) has been in widespread clinical use since the late 1970s and has provided unequivocal evidence that effective chelation therapy can arrest the progression of, and prevent early death from, iron overload [bib_ref] Intensive iron-chelation therapy with desferrioxamine in iron-loading anaemias, Pippard [/bib_ref]. DFO is a trihydroxamic acid sideraphore secreted by Streptomyces pilosus, a fungus. DFO is a hexadentate chelator with a very high and selective affinity for iron. One molecule of DFO binds one atom of iron. DFO is administered as long parenteral infusions because the plasma half-life is short (min) and it is not active orally. It is usually given as an overnight subcutaneous infusion 5 to 7 nights per week. It is mainly distributed extracellularly and the protein binding in plasma is low (< 10%). After complexing with iron it is excreted rapidly as ferrioxamine, mainly through the kidney and one-third into bile through the feces. Thus, its efficacy is also dependent upon adequate urine output and may be facilitated by dialysis in the case of kidney dysfunction. This requirement is extremely demanding and can result in poor adherence, thereby compromising efficacy and outcomes [bib_ref] Iron chelation therapy, Hershko [/bib_ref]. ## Deferiprone (ferriprox tm ) Deferiprone (L1; CP20; 1,2-dimethyl-3-hydroxypyrid-4-one) is an orally active hydroxypyridineone first used in humans in 1987. Deferiprone is a bidentate chelator. Three molecules of deferiprone are needed to bind one atom of iron. An advantage of this compound is that the iron chelate of deferiprone carries no net charge and, therefore, can penetrate membranes easily, allowing removal of potentially toxic iron from tissues [bib_ref] The design of orally active iron chelators, Hider [/bib_ref]. Other major advantages include oral administration and rapid absorption through the gastrointestinal tract. Deferiprone is mainly metabolized as glucuronide conjugates and is excreted via the renal route. It has a half-life of 2-3 hr. The typical dosage of deferiprone is 75 mg/kg/day in 3 divided doses, up to 100 mg/ http://dx.doi.org/10.3346/jkms.2013. kg daily [bib_ref] Randomized controlled trial of deferiprone or deferoxamine in beta-thalassemia major patients with..., Pennell [/bib_ref] [bib_ref] Safety and effectiveness of 100 mg/kg/day deferiprone in patients with thalassemia major:..., Taher [/bib_ref]. Deferiprone is rapidly absorbed mainly from the stomach and reaches the circulation quickly. However, there may possibly be food-drug interactions or other gastric factors that delay the appearance of the drug in the blood following oral administration. Wide variations in the metabolism and clearance of deferiprone among patients have been observed, mainly depending on the iron overload and availability of chelatable iron [bib_ref] Oral iron chelators, Cappellini [/bib_ref]. This agent is approved in some Asian and European countries for second-line treatment of iron overload, but not in the USA and Canada due to its narrow therapeutic index and safety concerns including a risk of agranulocytosis [bib_ref] Efficacy and safety of deferiprone (Ferriprox), an oral iron-chelating agent, in pediatric..., Won [/bib_ref] [bib_ref] The safety and effectiveness of deferiprone in a large-scale, 3-year study in..., Ceci [/bib_ref]. ## Deferasirox (exjade tm ) DFX (ICL670) is a new oral tridentate iron (Fe 3+ ) chelator developed specifically for the treatment of chronic iron overload. It is an N-substituted bis-hydroxyphenyl-triazole selected from more than 700 compounds screened as part of a national drug development program [bib_ref] Development of tridentate iron chelators: from desferrithiocin to ICL-670, Nick [/bib_ref]. Two molecules of DFX are needed to bind one atom of iron. With a plasma half-life of 8 to 16 hr, oncedaily dosing permits circulating drug to continuously scavenge non-transferrin-bound "labile plasma iron, " which is the chemical species responsible for generating toxic oxygen intermediaries that can cause tissue damage in iron-overloaded subjects [bib_ref] Role of iron in inducing oxidative stress in thalassemia: can it be..., Rachmilewitz [/bib_ref]. Hepatocytes readily take up DFX, which chelates hepatocellular iron. The DFX-iron complex is then excreted in the bile [bib_ref] Pharmacokinetics, metabolism, and disposition of deferasirox in beta-thalassemic patients with transfusion-dependent iron..., Waldmeier [/bib_ref]. Within cells, DFX chelates cytosolic iron, leading to ferritin degradation by the proteasome [bib_ref] Specific iron chelators determine the route of ferritin degradation, De Domenico [/bib_ref]. ## Clinical benefits Iron chelation therapy has been shown to be beneficial in patients with transfusion-dependent anemia, especially β-thalassemia major. One small, randomized trial and many other observational studies have demonstrated that maintenance of low serum ferritin levels using iron chelators was associated with a reduction in end-organ toxicity as well as prolongation of survival in patients with transfusion-dependent anemia [bib_ref] Update on iron chelators in thalassemia, Neufeld [/bib_ref] [bib_ref] Iron-chelating therapy for transfusional iron overload, Brittenham [/bib_ref]. In Korea, thalassemia is very rare and major indication for iron chelation therapy includes AA and MDS [bib_ref] Iron chelation therapy in the myelodysplastic syndromes and aplastic anemia: a review..., Lee [/bib_ref]. Guidelines for the management of AA or MDS suggest that iron chelation therapy should be considered for the patients with iron overload, although the guidelines often differ in specific details [bib_ref] Guidelines for the diagnosis and management of aplastic anaemia, Marsh [/bib_ref] [bib_ref] Iron chelation therapy in MDS: what have we learnt recently?, Schmid [/bib_ref]. Few studies have assessed the efficacy of iron chelation therapy in patients with AA. The prospective 1-yr Evaluation of Patients' Iron Chelation with DFX (EPIC) study enrolled the largest number (n = 116) of AA patients and showed the effectiveness of DFX in reducing body iron (4). However, no trial has established the long-term effectiveness of iron chelation therapy in preventing organ toxicity or improving survival in patients with AA. Clinical effects of iron chelation therapy in iron overloaded patients with MDS have been studied in several aspects: survival prolongation, improvement of organ function, improved outcomes after allogeneic hematopoietic stem cell transplantation (HSCT), and cytopenia improvement in lower risk MDS. However, these potential benefits of iron chelation therapy in MDS patients remain controversial [bib_ref] Controversies surrounding iron chelation therapy for MDS, Leitch [/bib_ref]. For example, iron chelation therapy may not be beneficial in patients with MDS whose expected survival is less than one year. In individual patients receiving long-term transfusion, the benefits of iron chelation therapy may vary according to the morbidity associated with the therapy, the estimated prognosis of MDS, and the latency period between the onset of transfusion and the development of clinical manifestations of iron overload [bib_ref] Iron-chelating therapy for transfusional iron overload, Brittenham [/bib_ref]. Recent retrospective data suggest that efficient iron chelation therapy may prolong survival in patients with MDS [bib_ref] Does iron chelation therapy improve survival in regularly transfused lower risk MDS..., Rose [/bib_ref] [bib_ref] Improving clinical outcome in patients with myelodysplastic syndrome and iron overload using..., Leitch [/bib_ref]. The Groupe Francophone des Myelodysplasies reported a retrospective study in which 97 patients with low or intermediate-1 IPSS risk presenting for RBC transfusion over a one-month period were analyzed, and 53 patients (55%) received iron chelation therapy for at least 6 months. Median survival was 124 months in the group of patients receiving standard or adequate chelation (n = 41, deferoxamine by infusion at least 3 days per week, or deferiprone, deferasirox, or a combination of agents) compared to 85 months in those receiving low or weak chelation (n = 12; deferoxamine by intermittent bolus) and 53 months in non-chelated patients (n = 44) (P < 0.01) [bib_ref] Does iron chelation therapy improve survival in regularly transfused lower risk MDS..., Rose [/bib_ref]. In a retrospective study from Vancouver, the four year survival was 80% for chelated patients with low or intermediate-1 IPSS risk MDS and it was 44% for non-chelated patients (P < 0.03) [bib_ref] Improving clinical outcome in patients with myelodysplastic syndrome and iron overload using..., Leitch [/bib_ref]. So far, there have been no randomized trials examining whether morbidity or mortality would be improved with iron chelation therapy in patients with MDS. One randomized trial is currently recruiting patients to prospectively assess the efficacy and safety of iron chelation therapy with DFX compared to placebo in MDS patients with transfusional iron overload. Although iron chelation therapy is well established to reverse hepatic or cardiac dysfunction and reduce the risk of diabetes mellitus in beta-thalassemia major, there have been only limited data for the effects of iron chelation therapy on organ function in MDS. Retrospective nationwide survey of Japanese patients with transfusion-dependent MDS and AA showed that effective chelation with deferoxamine resulted in improved serum ferritin, liver enzymes, and fasting blood sugar [bib_ref] Iron-chelating therapy and the treatment of thalassemia, Olivieri [/bib_ref] [bib_ref] Long-term outcome of continuous 24-hour deferoxamine infusion via indwelling intravenous catheters in..., Davis [/bib_ref] [bib_ref] Retrospective nationwide survey of Japanese patients with transfusion-dependent MDS and aplastic anemia..., Takatoku [/bib_ref]. The EPIC study enrolled 341 patients with MDS and overall median serum ferritin decreased significantly at 1 yr (P = 0.002). Alanine aminotransferase levels also decreased significantly and the change correlated significantly with reduction in serum ferritin (P < 0.001) [bib_ref] Deferasirox in ironoverloaded patients with transfusion-dependent myelodysplastic syndromes: results from the large..., Gattermann [/bib_ref]. In higher risk MDS, unlikely the case with lower risk MDS who would live long enough to experience adverse effects of http://dx.doi.org/10.3346/jkms.2013.28.11.1563 iron overload-induced tissue damage, the major benefit of iron chelation therapy is not likely to come from reduction in end organ damage due to tissue iron overload, but from potential beneficial effects on other outcomes such as reduction of infections, prevention or delay of leukemic evolution, and improved outcomes after allogeneic HSCT [bib_ref] Objectives of iron chelation therapy in myelodysplastic syndromes: more than meets the..., Pullarkat [/bib_ref]. It has been evidenced that iron overload increases infection risk and iron chelators, especially DFX with in vitro fungicidal effects and long half-life, may lower infection risk in higher risk MDS with neutropenia [bib_ref] Objectives of iron chelation therapy in myelodysplastic syndromes: more than meets the..., Pullarkat [/bib_ref] [bib_ref] Natural resistance, iron and infection: a challenge for clinical medicine, Bullen [/bib_ref]. Excessive labile plasma iron (LPI) in iron overload can lead to increased generation of reactive oxygen species (ROS), which can induce genomic instability in hematopoietic stem cells [bib_ref] Regulation of reactive oxygen species and genomic stability in hematopoietic stem cells, Naka [/bib_ref]. Thus, use of iron chelating agents in higher risk MDS may prevent or delay progression to AML [bib_ref] Objectives of iron chelation therapy in myelodysplastic syndromes: more than meets the..., Pullarkat [/bib_ref]. In a subgroup analysis of 18 patients with low or intermediate-1 risk MDS who were treated with subcutaneous deferoxamine, median leukemia-free survival was not reached at 226 months compared with a matched control group who had a median leukemia-free survival of 40 months [bib_ref] Controversies surrounding iron chelation therapy for MDS, Leitch [/bib_ref]. In the allogeneic HSCT setting, iron overload is known to increase the risk of transplant-related mortality (TRM) and other complications including fungal infections, hepatic dysfunction, and hepatic veno-occlusive disease after HSCT [bib_ref] Iron overload adversely affects outcome of allogeneic hematopoietic cell transplantation, Pullarkat [/bib_ref] [bib_ref] Iron overload might increase transplant-related mortality in haematopoietic stem cell transplantation, Altès [/bib_ref] [bib_ref] Iron overload in bone marrow transplant recipients, Strasser [/bib_ref] [bib_ref] Iron overload manifesting as apparent exacerbation of hepatic graftversus-host disease after allogeneic..., Kamble [/bib_ref]. Until now, the adverse prognostic impacts of iron overload on the transplantation outcomes have been evaluated in the patients with various hematologic disorders including thalassemia, MDS, and acute leukemia [bib_ref] Iron overload adversely affects outcome of allogeneic hematopoietic cell transplantation, Pullarkat [/bib_ref] [bib_ref] Antin JH. Prognostic impact of elevated pretransplantation serum ferritin in patients undergoing..., Armand [/bib_ref] [bib_ref] Red blood cell transfusion dependence and outcome after allogeneic peripheral blood stem..., Platzbecker [/bib_ref] [bib_ref] Effect of iron overload and iron-chelating therapy on allogeneic hematopoietic SCT in..., Lee [/bib_ref]. Therefore, for candidates to allogeneic HSCT, iron chelation therapy seems to be important to reduce TRM and achieve better transplantation outcome. According to a recent report, iron chelation therapy should be considered in patients with iron overload because it can prevent organ damage by reducing the iron overload and also may improve hematopoiesis [bib_ref] Improvement in hematopoiesis after iron chelation therapy with deferasirox in patients with..., Lee [/bib_ref]. In this study, 4 cases of AA raised the possibility of a potential additive benefit on hematopoiesis following iron chelation therapy with DFX. Possible effect on hematopoiesis is DFX can suppress LPI and ROS and may inhibit apoptosis. Other possible effects of DFX on hematopoiesis include altering intracellular levels of the nuclear transcription factor NF-kB or increasing erythropoietin levels [bib_ref] Controversies surrounding iron chelation therapy for MDS, Leitch [/bib_ref] [bib_ref] Objectives of iron chelation therapy in myelodysplastic syndromes: more than meets the..., Pullarkat [/bib_ref]. ## Current status of iron overload and practice in korea According to a multicenter, cross-sectional survey of 1,128 adult Korean patients with AA or MDS, a substantial proportion (n = 331, 29%) suffered from iron overload (serum ferritin > 1,000 ng/mL), and all of the patients analyzed who were treated with DFO iron chelation therapy experienced organ damage. Interestingly, in these patients, iron chelation treatment was not actively administered until complications related to iron overload had appeared. Among the 331 patients who were diagnosed with iron overload, 97 also had organ dysfunction and they were heavily transfused, with a high iron burden (high serum ferritin level) and a long duration of disease. This study also showed that there was a correlation between serum ferritin and the number of transfusions, duration of transfusion therapy, and duration of transfusion dependence [bib_ref] Iron chelation therapy in the myelodysplastic syndromes and aplastic anemia: a review..., Lee [/bib_ref]. In a retrospective analysis of 101 Korean children receiving HSCT, patients were divided into three groups according to their ferritin levels at the time of transplantation as follows: patients with serum ferritin > 1,000 ng/mL at the time of HSCT, serum ferritin < 1,000 ng/mL before HSCT without iron chelation therapy, and serum ferritin that decreased to < 1,000 ng/ mL after iron chelation therapy before HSCT. In this study, patients with serum ferritin < 1,000 ng/mL before HSCT had higher survival rates and lower treatment-related mortality compared to patients with serum ferritin > 1,000 ng/mL. The authors concluded that iron chelation therapy before HSCT can improve the outcome (50). ## Korean guideline for iron chelation therapy Iron chelation therapy is critical and there is much evidence of its clinical benefits in patients with transfusion-induced iron overload. To optimize iron chelation therapy, the KSHAAWP has constructed a Korean guideline for the treatment of transfusion-induced iron overload. Components of the Korean iron chelation guideline are given below. ## Determining patients who need iron chelation therapy Transfusion-dependent patients (MDS, AA, pure red cell aplasia, myelofibrosis, etc.) need iron chelation therapy. Transfusion-dependent patients are defined as those receiving > 8 RBC units with a serum ferritin level > 1,000 ng/mL in at least two successive tests. Patients should have a life expectancy of more than 1 yr. ## Initiating iron chelation Oral DFX and deferoxamine are available in Korea. However, due to short half life and poor compliance, deferoxamine is not recommended as a standard treatment for iron overload. Oral DFX is a recommended treatment in Korean patients with iron overload. The recommended initial daily dose of DFX is 20 mg/ kg body weight, taken on an empty stomach at least 30 min before food. Tablets are available in dosages of 125, 250, or 500 mg and should be dispersed in water or orange or apple juice. ## Monitoring and maintenance therapy After initiating iron chelation therapy, serum ferritin levels and organ functions including cardiac, hepatic and renal functions http://dx.doi.org/10.3346/jkms.2013. should be checked monthly during the first 3 months and then at least once every 3 months. It is recommended that serum ferritin levels be maintained below 1,000 ng/mL and that, when ferritin levels are < 500 ng/mL at two successive tests, iron chelation should be discontinued. If ferritin levels continue to increase after initiating therapy, increase the DFX dose up to 30 mg/kg/day. After discontinuing iron chelation, if serum ferritin levels increase above 1,000 ng/mL, restart DFX at the same dose. This guideline is summarized in . ## Adverse events ## Gastrointestinal disturbances Safety data for DFX have been reported in many studies for patients with various anemias [bib_ref] Relative response of patients with myelodysplastic syndromes and other transfusion-dependent anaemias to..., Porter [/bib_ref] [bib_ref] Patient-reported outcomes of deferasirox (Exjade, ICL670) versus deferoxamine in sickle cell disease..., Vichinsky [/bib_ref] [bib_ref] A phase 3 study of deferasirox (ICL670), a once-daily oral iron chelator,..., Cappellini [/bib_ref] [bib_ref] Phase II clinical evaluation of deferasirox, a once-daily oral chelating agent, in..., Galanello [/bib_ref]. In the EPIC study, DFX was well tolerated with a clinically manageable side effect profile [bib_ref] Tailoring iron chelation by iron intake and serum ferritin: the prospective EPIC..., Cappellini [/bib_ref]. According to previous studies, the most common drug-related adverse events (AE) were gastrointestinal (GI) disturbances such as abdominal pain (6%), nausea (22%), vomiting (8%), and diarrhea (15%). These events were seen to be generally mildto-moderate in severity and dose dependent, tended to occur early in the course of treatment and usually lasted less than 1 week, and in general, resolved spontaneously without the need for dose adjustment or discontinuation of treatment [bib_ref] Tailoring iron chelation by iron intake and serum ferritin: the prospective EPIC..., Cappellini [/bib_ref]. ## Expert panel recommendations for gi disturbances Management of diarrhea requires an exact diagnosis to exclude other etiologies. The expert panel recommends hydration and the use of loperamide for a maximum of 2 days, with evening pre-prandial DFX dosing. The panel does not recommend administration before bedtime because of the risk of esophageal irritation and bleeding. The panel does not recommend DFX dose reduction in cases of mild diarrhea. In cases of persisting moderate-to-severe diarrhea, dose reduction to 10 mg/kg/day should be considered for moderate diarrhea but cease DFX administration for severe diarrhea. When moderate diarrhea has resolved, the DFX dose should be increased in 5 mg/kg/day steps to the target dose. In severe cases, the panel recommends re-initiating the DFX dose at 10 mg/kg/day and adjusting the dose in increments of 5 mg/kg each week to the target dose. These recommendations are summarized in . In cases of abdominal pain the panel recommends evening pre-prandial dosing and consumption of soft food for several hours after taking DFX. The panel does not recommend the use of narcotic analgesic drugs or non-steroidal anti-inflammatory drugs because of side effects. If patients have persistent mildto-moderate pain, dose reductions should be considered before discontinuation. Reduce the dose in steps of 5 mg/kg/day . Korean guideline for iron overload Determining which patients need iron chelation therapy (all criteria must be satisfied) · Transfusion-dependent patients: MDS, AA, primary red cell aplasia, myelofibrosis, etc. · RBC transfusion ≥ 8 units · Ferritin > 1,000 ng/mL · Life expectancy ≥ 1 yr Initiating Iron Chelation · Starting dose: deferasirox (DFX) 20 mg/kg/day · If not effective, DFX dose can be increased to 30 mg/kg/day · Take on an empty stomach at least 30 min before food · Tablets are available in dosages of 125, 250, or 500 mg · Disperse in water or orange or apple juice Monitoring and maintenance therapy · Check ferritin levels and organ functions including renal, hepatic function every month for the first 3 months · After 3 months, check ferritin levels and organ functions at 3 month intervals · Maintain the ferritin level at < 1,000 ng/mL · If the ferritin level is < 500 ng/mL, stop iron chelation · After discontinuing of iron chelation, if the ferritin level is > 1,000 ng/mL, restart DFX . Management of adverse events -Diarrhea (reported incidence: 15%). · Hydration · Loperamide · Pre-prandial evening DFX dosing · Reduce DFX dose to 10 mg/kg/day in moderate diarrhea · Discontinue DFX dose in severe diarrhea ## Diarrhea resolves · Continue hydration · Re-escalate DFX dose to target dose in increments of 5 mg/kg each week in moderate diarrhea · Re-initiate DFX dose at 10 mg/kg/day and dose adjust in increments of 5 mg/kg each week to target dose in severe diarrhea Diarrhea persists or is worse after treatment · Investigate other reasons for diarrhea · Discontinue DFX therapy if diarrhea is unmanageable on re-initiation http://dx.doi.org/10.3346/jkms.2013. and increment the dose in steps of 5 mg/kg/day after the pain has resolved. If persistent severe abdominal pain occurs, temporarily discontinue DFX treatment and re-initiate and escalate in 5 mg/kg/day steps after the abdominal pain has resolved. These recommendations are summarized in [fig_ref] Figure 2: Management of adverse events -Abdominal pain [/fig_ref]. For the management of nausea and vomiting the expert panel recommends hydration, and preprandial administration of DFX in the evening should be considered. In cases of severe vomiting reduce the DFX dose in steps of 5 mg/kg/day. When the symptoms have resolved, re-initiate DFX and increase the dose in increments up to the target dose. These recommendations are summarized in [fig_ref] Figure 3: Management of adverse events -Nausea/vomiting [/fig_ref]. ## Renal adverse events Some mild increases in serum creatinine levels have been observed and these appear to be dose dependent. In patients with β-thalassemia, 3% overall had serum creatinine values that increased more than 33% above baseline but were still within the normal range [bib_ref] Effectiveness and safety of ICL670 in iron-loaded patients with thalassaemia: a randomised,..., Nisbet-Brown [/bib_ref]. In patients with AA, 25% experienced an increase in serum creatinine to more than 33% above baseline and higher than the upper limit of normal (ULN) on two consecutive visits, but there were no progressive increases. The only factor identified as having a significant impact on serum creatinine was concomitant use of the immunosuppressive agent cyclosporine, a drug with a well-recognized potential to Pre-prandial evening DFX dosing · Take soft food for several hours after DFX · Do not recommend DFX before bedtime · Do not use narcotic pain medications or non-steroidal anti-inflammatory drugs · Consider dose reduction in step of 5 mg/kg/day before discontinuation in mild-to-moderate cases · Temporarily discontinue DFX in severe cases Abdominal pain resolves · Continue DFX · Re-escalate DFX dose to target dose in increments of 5 mg/kg each week in moderate abdominal pain · Re-initiate DFX dose at 10 mg/kg/day and dose adjust in increments of 5 mg/kg each week to target dose in severe abdominal pain Abdominal pain persists or is worse after treatment · Investigate other reasons for abdominal pain · Reduce DFX dose in steps of 5 mg/kg/day before discontinuation in persistent mild-to-moderate abdominal pain · Discontinue DFX therapy if abdominal pain is unmanageable on re-initiation impair renal function. Careful monitoring of renal function is necessary in patients with AA who are receiving concomitant cyclosporine and DFX (4). ## Expert panel recommendations for renal adverse events The management of serum creatinine increases should be individualized. It is recommended that serum creatinine levels be assessed in duplicate before initiating therapy and monitored monthly thereafter. Patients who have additional renal risk factors, such as preexisting renal or co-morbid conditions, are elderly, or are receiving medicine that depresses renal function should be monitored weekly during the first month after initiation or modification of the DFX dose and monitored monthly thereafter. In patients who exhibit serum creatinine elevations to more than 33% above baseline but still within the normal range at two consecutive visits, the daily dose should be reduced by 10 mg/kg. If there is a progressive increase in serum creatinine beyond ULN, DFX should be discontinued [bib_ref] Clinical application of deferasirox: practical patient management, Vichinsky [/bib_ref]. Once the creatinine level has returned to within the normal range, and if the clinical benefit is expected to exceed the potential risks, DFX should be re-initiated at 10 mg/kg/day and increased in 5 mg/ kg/day steps to the target dose. These recommendations are summarized in [fig_ref] Figure 4: Management of renal adverse events [/fig_ref]. ## Hepatic and skin adverse events In the 1-yr trials, up to 2% of patients developed elevations in serum transaminases. These elevations were not related to dose [bib_ref] Tailoring iron chelation by iron intake and serum ferritin: the prospective EPIC..., Cappellini [/bib_ref]. In previous studies, up to 11% of patients developed dosedependent skin eruptions and most symptoms were mild to moderate [bib_ref] Tailoring iron chelation by iron intake and serum ferritin: the prospective EPIC..., Cappellini [/bib_ref]. ## Expert panel recommendations for hepatic and skin adverse events As a precaution, liver function should be monitored monthly. Furthermore, following any severe or persistent elevations in serum transaminase levels, dose modification should be considered and a hepatologist should be consulted. Therapy may be restarted in patients once serum transaminase levels have returned to within normal limits and levels should be monitored monthly. In cases of mild-to-moderate skin adverse events, the expert · If Cr > 33% above baseline but still within normal range at two consecutive visits, DFX should be reduced by 10 mg/kg · Discontinue DFX dose if progressive Cr elevation Creatinine level returns to normal range · Re-escalate DFX dose to target dose in increments of 5 mg/kg each week in case of reduced dosing · Re-initiate DFX dose at 10 mg/kg/day and dose adjust in increments of 5 mg/kg each week to target dose in case of discontinuation Creatinine level progressively increases · Investigate other reasons for renal impairment · Discontinue DFX therapy · Do not reduce dose in mild-to-moderate cases · Temporarily discontinue DFX in severe cases · Short-term use of steroid Skin eruptions resolve · Continue DFX in mild-to-moderate cases · Re-initiate DFX dose at 10 mg/kg/day and dose adjust in increments of 5 mg/kg each week to target dose in case of discontinuation Skin eruptions persist or are worse after treatment · Investigate other reasons for skin eruptions · Discontinue DFX therapy http://dx.doi.org/10.3346/jkms.2013.28.11.1563 panel does not recommend dose reduction because most skin eruptions resolved spontaneously without treatment. But if the skin eruptions persist or are worse after 1 week the panel advises a temporary discontinuation of DFX treatment until the skin eruptions have disappeared. Short-term use of a steroid should be considered. DFX should then be reinitiated and the dose should be escalated in 5 mg/kg/day steps. These recommendations are summarized in [fig_ref] Figure 5: Management of skin adverse events [/fig_ref]. ## Other general considerations Although the increases in adverse events described above have been reported as dose dependent, recent data showed that the safety profile of DFX in patients who received more than 30 mg/ kg/day was consistent with that of patients who received less than 30 mg/kg/day. Interestingly, this study also demonstrated that no adverse events were observed following escalation to over 30 mg/kg/day that were not present at lower doses. There was a higher incidence of drug-related AEs and higher treatment discontinuation rates in patients with MDS than in patients with other chronic anemias [bib_ref] Tailoring iron chelation by iron intake and serum ferritin: the prospective EPIC..., Cappellini [/bib_ref]. This may be related to the risk of disease progression, preexisting co-morbidities, use of concomitant medication, and the advanced ages of patients with MDS. Most AEs resolved spontaneously and no patients with renal or hepatic failure or drug-related cytopenia have been reported in any of the studies to date. The only contraindication to DFX is prior hypersensitivity to the drug. DFX has not been investigated in pregnant or breast feeding women, or in pediatric patients younger than 2 yr. Iron chelation should be ceased as soon as pregnancy is confirmed. Caution should be considered in patients older than 65 yr due to a greater frequency of preexisting suppressed hepatic, renal, or cardiac function. # Conclusion Iron overload is a major concern in patients with chronic anemia for whom regular transfusions are necessary. Evidence from many clinical trials has demonstrated clear reduction of the iron burden and improvement in organ function after administration of DFX to patients with transfusion-induced iron overload. This guideline could help many Korean physicians to anticipate potential effects, alert patients to the likelihood of key events, and readily provide effective management according to the recommendations outlined. [fig] Figure 2: Management of adverse events -Abdominal pain (reported incidence: 6%). [/fig] [fig] Figure 3: Management of adverse events -Nausea/vomiting (reported incidence: 22%, 8%). [/fig] [fig] Figure 4: Management of renal adverse events (reported incidence: 25%). [/fig] [fig] Figure 5: Management of skin adverse events (reported incidence: 11%). [/fig]

Daclatasvir # Disclaimer WikiDoc MAKES NO GUARANTEE OF VALIDITY. WikiDoc is not a professional health care provider, nor is it a suitable replacement for a licensed healthcare provider. WikiDoc is intended to be an educational tool, not a tool for any form of healthcare delivery. The educational content on WikiDoc drug pages is based upon the FDA package insert, National Library of Medicine content and practice guidelines / consensus statements. WikiDoc does not promote the administration of any medication or device that is not consistent with its labeling. Please read our full disclaimer here. # Overview Daclatasvir is a hepatitis C virus (HCV) NS5A inhibitor that is FDA approved for the treatment of patients with chronic HCV genotype 1 or 3 infection with sofosbuvir and with or without ribavirin. Common adverse reactions include headache, anemia, nausea, and fatigue (≥10%). # Adult Indications and Dosage ## FDA-Labeled Indications and Dosage (Adult) Daclatasvir is indicated for use with sofosbuvir, with or without ribavirin, for the treatment of patients with chronic hepatitis C virus (HCV) genotype 1 or genotype 3 infection. - Limitations of Use: Sustained virologic response (SVR12) rates are reduced in HCV genotype 3-infected patients with cirrhosis receiving Daclatasvir in combination with sofosbuvir for 12 weeks. - Testing Prior to Initiation of Therapy NS5A Resistance Testing in HCV Genotype 1a-Infected Patients with Cirrhosis: Consider screening for the presence of NS5A polymorphisms at amino acid positions M28, Q30, L31, and Y93 in patients with cirrhosis who are infected with HCV genotype 1a prior to the initiation of treatment with Daclatasvir and sofosbuvir with or without ribavirin. - Recommended Dosage - The recommended dosage of Daclatasvir is 60 mg, taken orally, once daily, with or without food. - Table 1 provides the recommended Daclatasvir-containing treatment regimens and duration based on HCV genotype and patient population. The optimal duration of Daclatasvir and sofosbuvir with or without ribavirin has not been established for HCV genotype 3 patients with cirrhosis or for HCV genotype 1 patients with Child-Pugh C cirrhosis. - For patients with HCV/HIV-1 coinfection, follow the dosage recommendations in Table 1. - For specific dosage recommendations for sofosbuvir, refer to the prescribing information. - For HCV genotype 1 or 3 patients with Child-Pugh B or C cirrhosis or post-transplantation patients, the starting dose of ribavirin is 600 mg once daily, increasing up to 1000 mg daily as tolerated. The starting dose and on-treatment dose of ribavirin can be decreased based on hemoglobin and creatinine clearance. - For HCV genotype 3 patients with compensated cirrhosis (Child-Pugh A), the recommended dosing of ribavirin is based on weight (1000 mg for patients weighing less than 75 kg and 1200 mg for those weighing at least 75 kg administered orally in two divided doses with food). - Table 1:Recommended Treatment Regimen and Duration for Daclatasvir in Patients with Genotype 1 or 3 HCV DAKLINZA: Daclatasvir's Brand name - Dosage Modification Due to Drug Interactions Refer to the drug interactions and contraindications sections for other drugs before coadministration with Daclatasvir. - Table 2:Recommended Daclatasvir Dosage Modification with CYP3A Inhibitors and Inducers DAKLINZA: Daclatasvir's Brand name Dosage reduction of Daclatasvir for adverse reactions is not recommended. - Discontinuation of Therapy If sofosbuvir is permanently discontinued in a patient receiving Daclatasvir with sofosbuvir, then Daclatasvir should also be discontinued. ## Off-Label Use and Dosage (Adult) ### Guideline-Supported Use There is limited information regarding Off-Label Guideline-Supported Use of Daclatasvir in adult patients. ### Non–Guideline-Supported Use There is limited information regarding Off-Label Non–Guideline-Supported Use of Daclatasvir in adult patients. # Pediatric Indications and Dosage ## FDA-Labeled Indications and Dosage (Pediatric) Safety and effectiveness of Daclatasvir in pediatric patients younger than 18 years of age have not been established. ## Off-Label Use and Dosage (Pediatric) ### Guideline-Supported Use There is limited information regarding Off-Label Guideline-Supported Use of Daclatasvir in pediatric patients. ### Non–Guideline-Supported Use There is limited information regarding Off-Label Non–Guideline-Supported Use of Daclatasvir in pediatric patients. # Contraindications - When Daclatasvir is used in combination with other agents, the contraindications applicable to those agents are applicable to the combination regimen. Refer to the respective prescribing information for a list of contraindications. - Daclatasvir is contraindicated in combination with drugs that strongly induce CYP3A and, thus, may lead to lower exposure and loss of efficacy of Daclatasvir. Contraindicated drugs include, but are not limited to those listed in Table 3. - Table 3:Drugs that are Contraindicated with Daclatasvir Daclatasvir: Daclatasvir's Brand name # Warnings The concomitant use of Daclatasvir and other drugs may result in known or potentially significant drug interactions, some of which may lead to: - loss of therapeutic effect of Daclatasvir and possible development of resistance, - dosage adjustments of concomitant medications or Daclatasvir, - possible clinically significant adverse reactions from greater exposures of concomitant drugs or Daclatasvir. See Table 3 for drugs contraindicated with Daclatasvir due to loss of efficacy and possible development of resistance. See Table 7 for steps to prevent or manage other possible and known significant drug interactions. Consider the potential for drug interactions before and during Daclatasvir therapy, review concomitant medications during Daclatasvir therapy, and monitor for the adverse reactions associated with the concomitant drugs. Postmarketing cases of symptomatic bradycardia and cases requiring pacemaker intervention have been reported when amiodarone is coadministered with sofosbuvir in combination with another HCV direct-acting antiviral, including Daclatasvir. A fatal cardiac arrest was reported in a patient receiving a sofosbuvir-containing regimen (ledipasvir/sofosbuvir). Bradycardia has generally occurred within hours to days, but cases have been observed up to 2 weeks after initiating HCV treatment. Patients also taking beta blockers or those with underlying cardiac comorbidities and/or advanced liver disease may be at increased risk for symptomatic bradycardia with coadministration of amiodarone. Bradycardia generally resolved after discontinuation of HCV treatment. The mechanism for this bradycardia effect is unknown. Coadministration of amiodarone with Daclatasvir in combination with sofosbuvir is not recommended. For patients taking amiodarone who have no alternative treatment options and who will be coadministered Daclatasvir and sofosbuvir: - Counsel patients about the risk of serious symptomatic bradycardia. - Cardiac monitoring in an inpatient setting for the first 48 hours of coadministration is recommended, after which outpatient or self-monitoring of the heart rate should occur on a daily basis through at least the first 2 weeks of treatment. Patients who are taking sofosbuvir in combination with Daclatasvir who need to start amiodarone therapy due to no other alternative treatment options should undergo similar cardiac monitoring as outlined above. Due to amiodarone’s long elimination half-life, patients discontinuing amiodarone just prior to starting sofosbuvir in combination with Daclatasvir should also undergo similar cardiac monitoring as outlined above. Patients who develop signs or symptoms of bradycardia should seek medical evaluation immediately. Symptoms may include near-fainting or fainting, dizziness or lightheadedness, malaise, weakness, excessive tiredness, shortness of breath, chest pain, confusion, or memory problems. If Daclatasvir and sofosbuvir are administered with ribavirin, the warnings and precautions for ribavirin, in particular the pregnancy avoidance warning, apply to this combination regimen. Refer to the ribavirin prescribing information for a full list of the warnings and precautions for ribavirin. # Adverse Reactions ## Clinical Trials Experience If Daclatasvir and sofosbuvir are administered with ribavirin, refer to the prescribing information for ribavirin regarding ribavirin-associated adverse reactions. The following serious adverse reaction is described below and elsewhere in the labeling: - Serious Symptomatic Bradycardia When Coadministered with Sofosbuvir and Amiodarone. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Approximately 2400 subjects with chronic HCV infection have been treated with the recommended dose of Daclatasvir in combination with other anti-HCV drugs in clinical trials. Six hundred seventy-nine subjects have received a Daclatasvir and sofosbuvir-based regimen. Safety experience from three clinical trials of Daclatasvir and sofosbuvir with or without ribavirin is presented. - Daclatasvir and Sofosbuvir In the ALLY-3 trial, 152 treatment-naive and treatment-experienced subjects with HCV genotype 3 infection were treated with Daclatasvir 60 mg once daily in combination with sofosbuvir for 12 weeks. The most common adverse reactions (frequency of 10% or greater) were headache and fatigue. All adverse reactions were mild to moderate in severity. No subjects discontinued therapy for adverse events. In the ALLY-2 trial, 153 treatment-naive and treatment-experienced subjects with HCV/HIV-1 coinfection were treated with Daclatasvir 60 mg once daily (dose-adjusted for concomitant antiretroviral use) in combination with sofosbuvir for 12 weeks. The most common adverse reaction (frequency of 10% or greater) was fatigue. The majority of adverse reactions were mild to moderate in severity. No subjects discontinued therapy for adverse events. Adverse reactions considered at least possibly related to treatment and occurring at a frequency of 5% or greater in ALLY-3 or ALLY-2 are presented in Table 4. - Table 4:Adverse Reactions (All Severity) Reported at ≥5% Frequency, Daclatasvir + Sofosbuvir, Studies ALLY-3 and ALLY-2 - Daclatasvir, Sofosbuvir, and Ribavirin In the ALLY-1 trial, 113 subjects with chronic HCV infection, including 60 subjects with Child-Pugh A, B, or C cirrhosis and 53 subjects with recurrence of HCV after liver transplantation, were treated with Daclatasvir 60 mg once daily in combination with sofosbuvir and ribavirin for 12 weeks. The most common adverse reactions (frequency of 10% or greater) among the 113 subjects were headache, anemia, fatigue, and nausea. The majority of adverse reactions were mild to moderate in severity. Of the 15 (13%) subjects who discontinued study drug for adverse events, 13 (12%) subjects discontinued ribavirin only and 2 (2%) subjects discontinued all study drugs. During treatment, 4 subjects in the cirrhotic cohort underwent liver transplantation. Adverse reactions considered at least possibly related to treatment and occurring at a frequency of 5% or greater in either treatment cohort in ALLY-1 are presented in Table 5. - Table 5:Adverse Reactions (All Severity) Reported at ≥5% Frequency in Either Treatment Cohort, Daclatasvir + Sofosbuvir + Ribavirin, Study ALLY-1 Daclatasvir: Daclatasvir's Brand name - Laboratory Abnormalities Selected Grade 3 and 4 treatment-emergent laboratory abnormalities observed in clinical trials of Daclatasvir in combination with sofosbuvir with or without ribavirin are presented in Table 6. - Table 6:Selected Grade 3 and 4 Laboratory Abnormalities in Clinical Trials of Daclatasvir + Sofosbuvir ± Ribavirin, Studies ALLY-3, ALLY-2, and ALLY-1 Daclatasvir: Daclatasvir's Brand name ## Postmarketing Experience The following adverse reactions have been identified during postapproval use of Daclatasvir. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Cardiac Disorders: Serious symptomatic bradycardia has been reported in patients taking amiodarone who initiate treatment with sofosbuvir in combination with another HCV direct-acting antiviral, including Daclatasvir. # Drug Interactions Daclatasvir is a substrate of CYP3A. Therefore, moderate or strong inducers of CYP3A may decrease the plasma levels and therapeutic effect of daclatasvir. Strong inhibitors of CYP3A (eg, clarithromycin, itraconazole, ketoconazole, ritonavir) may increase the plasma levels of daclatasvir. Daclatasvir is an inhibitor of P-glycoprotein transporter (P-gp), organic anion transporting polypeptide (OATP) 1B1 and 1B3, and breast cancer resistance protein (BCRP). Administration of Daclatasvir may increase systemic exposure to medicinal products that are substrates of P-gp, OATP 1B1 or 1B3, or BCRP, which could increase or prolong their therapeutic effect or adverse reactions (see TABLE 7). Refer to the prescribing information for other agents in the regimen for drug interaction information. The most conservative recommendation should be followed. Table 7 provides clinical recommendations for established or potentially significant drug interactions between Daclatasvir and other drugs. Clinically relevant increase in concentration is indicated as “↑” and clinically relevant decrease as “↓” for drug interaction data. - Table 7:Established and Other Potentially Significant Drug Interactions Daclatasvir: Daclatasvir's Brand name Based on the results of drug interaction trials, no clinically relevant changes in exposure were observed for cyclosporine, darunavir (with ritonavir), dolutegravir, escitalopram, ethinyl estradiol/norgestimate, lopinavir (with ritonavir), methadone, midazolam, tacrolimus, or tenofovir with concomitant use of daclatasvir. No clinically relevant changes in daclatasvir exposure were observed with cyclosporine, darunavir (with ritonavir), dolutegravir, escitalopram, famotidine, lopinavir (with ritonavir), omeprazole, sofosbuvir, tacrolimus, or tenofovir. No dosage adjustment for daclatasvir is necessary with darunavir/cobicistat or moderate CYP3A inhibitors, including atazanavir (unboosted), fosamprenavir, ciprofloxacin, diltiazem, erythromycin, fluconazole, or verapamil. # Use in Specific Populations ### Pregnancy Pregnancy Category (FDA): - Risk Summary No adequate human data are available to determine whether or not Daclatasvir poses a risk to pregnancy outcomes. In animal reproduction studies in rats and rabbits, no evidence of fetal harm was observed with oral administration of daclatasvir during organogenesis at doses that produced exposures up to 6 and 22 times, respectively, the recommended human dose (RHD) of 60 mg of Daclatasvir. However, embryofetal toxicity was observed in rats and rabbits at maternally toxic doses that produced exposures of 33 and 98 times the human exposure, respectively, at the RHD of 60 mg of Daclatasvir. In rat pre- and postnatal developmental studies, no developmental toxicity was observed at maternal systemic exposure (AUC) to daclatasvir approximately 3.6 times higher than the RHD of Daclatasvir. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. If Daclatasvir and sofosbuvir are administered with ribavirin, the combination regimen is contraindicated in pregnant women and in men whose female partners are pregnant. Refer to the ribavirin prescribing information for more information on use in pregnancy. - Data - Animal Data Daclatasvir was administered orally to pregnant rats at doses of 0, 50, 200, or 1000 mg/kg/day on gestation days 6 to 15. Maternal toxicity (mortality, adverse clinical signs, body-weight losses, and reduced food consumption) was noted at doses of 200 and 1000 mg/kg/day. In the offspring, malformations of the fetal brain, skull, eyes, ears, nose, lip, palate, or limbs were observed at doses of 200 and 1000 mg/kg. The dose of 1000 mg/kg was associated with profound embryolethality and lower fetal body weight. No malformations were noted at 50 mg/kg/day. Systemic exposure (AUC) at 50 mg/kg/day in pregnant females was 6 times higher than exposures at the RHD. In rabbits, daclatasvir was initially administered at doses of 0, 40, 200, or 750 mg/kg/day during the gestation days 7 to 19. Daclatasvir dosing was modified due to vehicle toxicity during the study to doses of 20, 99, and 370 mg/kg/day, respectively. Maternal toxicity was noted at doses of 200/99 and 750/370 mg/kg/day with adverse clinical signs and severe reductions in body weight and food consumption. Mortality and euthanasia occurred in multiple dams at 750/370 mg/kg/day. At 200/99 mg/kg/day, fetal effects included increased embryofetal lethality, reduced fetal body weights, and increased incidences of fetal malformations of the ribs as well as head and skull. No malformations were noted in rabbits at 40/20 mg/kg/day. Systemic exposures (AUC) at 40/20 mg/kg/day were 22 times higher than exposures at the RHD. In a pre- and postnatal developmental study, daclatasvir was administered orally at 0, 25, 50, or 100 mg/kg/day from gestation day 6 to lactation day 20. At 100 mg/kg/day, maternal toxicity included mortality and dystocia; developmental toxicity included slight reductions in offspring viability in the perinatal and neonatal periods and reductions in birth weight that persisted into adulthood. There was neither maternal nor developmental toxicity at doses up to 50 mg/kg/day. Systemic exposures (AUC) at this dose were 3.6 times higher than the RHD. Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Daclatasvir in women who are pregnant. ### Labor and Delivery There is no FDA guidance on use of Daclatasvir during labor and delivery. ### Nursing Mothers - Risk Summary It is not known whether Daclatasvir is present in human milk, affects human milk production, or has effects on the breastfed infant. Daclatasvir was present in the milk of lactating rats. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Daclatasvir and any potential adverse effects on the breastfed child from Daclatasvir or from the underlying maternal condition. If Daclatasvir is administered with ribavirin, the nursing mothers information for ribavirin also applies to this combination regimen. Refer to ribavirin prescribing information for additional information. - Data Milk concentrations of daclatasvir were evaluated on lactation day 10 as part of the rat pre- and postnatal development study. Daclatasvir was present in rat milk with concentrations 1.7 to 2 times maternal plasma levels. ### Pediatric Use Safety and effectiveness of Daclatasvir in pediatric patients younger than 18 years of age have not been established. ### Geriatic Use Of 1184 subjects treated with the recommended dose of Daclatasvir in ten clinical trials, 7% of subjects were 65 years of age or older. Safety was similar across older and younger subjects and there were no safety findings unique to subjects 65 years and older. SVR12 rates were comparable among older and younger subjects. No dosage adjustment of Daclatasvir is required for elderly patients. ### Gender There is no FDA guidance on the use of Daclatasvir with respect to specific gender populations. ### Race There is no FDA guidance on the use of Daclatasvir with respect to specific racial populations. ### Renal Impairment No dosage adjustment of Daclatasvir is required for patients with any degree of renal impairment. Refer also to the sofosbuvir and ribavirin prescribing information for information regarding use in patients with renal impairment. ### Hepatic Impairment Based on a hepatic impairment study in non–HCV-infected subjects, no dosage adjustment of Daclatasvir is required for patients with mild (Child-Pugh A), moderate (Child-Pugh B), or severe (Child-Pugh C) hepatic impairment. ### Females of Reproductive Potential and Males If Daclatasvir and sofosbuvir are administered with ribavirin, the information for ribavirin with regard to pregnancy testing, contraception, and infertility also applies to this combination regimen. Refer to ribavirin prescribing information for additional information. ### Immunocompromised Patients There is no FDA guidance one the use of Daclatasvir in patients who are immunocompromised. # Administration and Monitoring ### Administration There is limited information regarding Daclatasvir Administration in the drug label. ### Monitoring There is limited information regarding Daclatasvir Monitoring in the drug label. # IV Compatibility There is limited information regarding the compatibility of Daclatasvir and IV administrations. # Overdosage There is no known antidote for overdose of Daclatasvir. Treatment of overdose with Daclatasvir should consist of general supportive measures, including monitoring of vital signs and observation of the patient’s clinical status. Because daclatasvir is highly protein bound (>99%), dialysis is unlikely to significantly reduce plasma concentrations of the drug. # Pharmacology ## Mechanism of Action Daclatasvir is a direct-acting antiviral agent (DAA) against the hepatitis C virus. ## Structure Daclatasvir is an inhibitor of HCV nonstructural protein 5A (NS5A). The chemical name for drug substance daclatasvir dihydrochloride is carbamic acid, N,N′--4,4′-diylbis]]bis-, C,C′-dimethyl ester, hydrochloride (1:2). Its molecular formula is C40H50N8O62HCl, and its molecular weight is 738.88 (free base). Daclatasvir dihydrochloride has the following structural formula: Daclatasvir dihydrochloride drug substance is white to yellow. Daclatasvir is freely soluble in water (>700 mg/mL). This drug contain 60 mg daclatasvir (equivalent to 66 mg daclatasvir dihydrochloride) and the inactive ingredients anhydrous lactose (116 mg), microcrystalline cellulose, croscarmellose sodium, silicon dioxide, magnesium stearate, and Opadry green. Daclatasvir 30 mg tablets (equivalent to 33 mg daclatasvir dihydrochloride) contain the inactive ingredients anhydrous lactose (58 mg), microcrystalline cellulose, croscarmellose sodium, silicon dioxide, magnesium stearate, and Opadry green. Daclatasvir 90 mg tablets (equivalent to 99 mg daclatasvir dihydrochloride) contain the inactive ingredients anhydrous lactose (173 mg), microcrystalline cellulose, croscarmellose sodium, silicon dioxide, magnesium stearate, and Opadry green. Opadry green contains hypromellose, titanium dioxide, polyethylene glycol 400, FD&C blue #2/indigo carmine aluminum lake, and yellow iron oxide. ## Pharmacodynamics Cardiac Electrophysiology At a dose 3 times the maximum recommended dose, daclatasvir did not prolong the QT interval to any clinically relevant extent. ## Pharmacokinetics The pharmacokinetic properties of daclatasvir were evaluated in healthy adult subjects and in subjects with chronic HCV. Administration of daclatasvir tablets in HCV-infected subjects resulted in approximately dose-proportional increases in Cmax, AUC, and Cmin up to 60 mg once daily. Steady state is anticipated after approximately 4 days of once-daily daclatasvir administration. Exposure of daclatasvir was similar between healthy and HCV-infected subjects. Population pharmacokinetic estimates for daclatasvir 60 mg once daily in chronic HCV-infected subjects are shown in Table 8. - Table 8:Population Pharmacokinetic Estimates for Daclatasvir in Chronic HCV-Infected Subjects Receiving Daclatasvir 60 mg Once Daily and Sofosbuvir 400 mg Once Daily In HCV-infected subjects following multiple oral doses of daclatasvir tablet ranging from 1 mg to 100 mg once daily, peak plasma concentrations occurred within 2 hours post dose. In vitro studies with human Caco-2 cells indicated that daclatasvir is a substrate of P-gp. The absolute bioavailability of the tablet formulation is 67%. - Effect of Food on Oral Absorption In healthy subjects, administration of a daclatasvir 60 mg tablet after a high-fat, high-caloric meal (approximately 951 total kcal, 492 kcal from fat, 312 kcal from carbohydrates, 144 kcal from protein) decreased daclatasvir Cmax and AUC(0-inf) by 28% and 23%, respectively, compared with fasted conditions. A food effect was not observed with administration of a daclatasvir 60 mg tablet after a low-fat, low-caloric meal (approximately 277 total kcal, 41 kcal from fat, 190 kcal from carbohydrates, 44 kcal from protein) compared with fasted conditions. With multiple dosing, protein binding of daclatasvir in HCV-infected subjects was approximately 99% and independent of dose at the dose range studied (1-100 mg). In subjects who received daclatasvir 60 mg tablet orally followed by 100 μg -daclatasvir intravenous dose, estimated volume of distribution at steady state was 47 L. Daclatasvir is a substrate of CYP3A, with CYP3A4 being the primary CYP isoform responsible for metabolism. Following single-dose oral administration of 25 mg 14C-daclatasvir in healthy subjects, the majority of radioactivity in plasma was predominately attributed to parent drug (97% or greater). Following single-dose oral administration of 25 mg 14C-daclatasvir in healthy subjects, 88% of total radioactivity was recovered in feces (53% of the dose as unchanged daclatasvir) and 6.6% of the dose was excreted in the urine (primarily as unchanged daclatasvir). Following multiple-dose administration of daclatasvir in HCV-infected subjects, with doses ranging from 1 mg to 100 mg once daily, the terminal elimination half-life of daclatasvir ranged from approximately 12 to 15 hours. In subjects who received daclatasvir 60 mg tablet orally followed by 100 μg -daclatasvir intravenous dose, the total clearance was 4.2 L/h. - Renal Impairment The pharmacokinetics of daclatasvir following a single 60 mg oral dose was studied in non–HCV-infected subjects with renal impairment. Using a regression analysis, the predicted AUC(0-inf) of daclatasvir was estimated to be 26%, 60%, and 80% higher in subjects with creatinine clearance (CLcr) values of 60, 30, and 15 mL/min, respectively, relative to subjects with normal renal function (CLcr of 90 mL/min, defined using the Cockcroft-Gault CLcr formula), and daclatasvir unbound AUC(0-inf) was predicted to be 18%, 39%, and 51% higher for subjects with CLcr values of 60, 30, and 15 mL/min, respectively, relative to subjects with normal renal function. Using observed data, subjects with end-stage renal disease requiring hemodialysis had a 27% increase in daclatasvir AUC(0-inf) and a 20% increase in unbound AUC(0-inf) compared to subjects with normal renal function as defined using the Cockcroft-Gault CLcr formula. Daclatasvir is highly protein bound to plasma proteins and is unlikely to be removed by dialysis. - Hepatic Impairment The pharmacokinetics of daclatasvir following a single 30 mg oral dose was studied in non–HCV-infected subjects with mild (Child-Pugh A), moderate (Child-Pugh B), and severe (Child-Pugh C) hepatic impairment compared to a corresponding matched control group. The Cmax and AUC(0-inf) of total daclatasvir (free and protein-bound drug) were lower by 46% and 43%, respectively, in Child-Pugh A subjects; by 45% and 38%, respectively, in Child-Pugh B subjects; and by 55% and 36%, respectively, in Child-Pugh C subjects. The Cmax and AUC(0‑inf) of unbound daclatasvir were lower by 43% and 40%, respectively, in Child-Pugh A subjects; by 14% and 2%, respectively, in Child-Pugh B subjects; and by 33% and 5%, respectively, in Child-Pugh C subjects. - Pediatric Patients The pharmacokinetics of daclatasvir in pediatric patients has not been evaluated. - Geriatric Patients Population pharmacokinetic analysis in HCV-infected subjects showed that within the age range (18-79 years) analyzed, age did not have a clinically relevant effect on the pharmacokinetics of daclatasvir. - Gender Population pharmacokinetic analyses in HCV-infected subjects estimated that female subjects have a 30% higher daclatasvir AUC compared to male subjects. This difference in daclatasvir AUC is not considered clinically relevant. - Race Population pharmacokinetic analyses in HCV-infected subjects indicated that race had no clinically relevant effect on daclatasvir exposure. - Cytochrome P450 (CYP) Enzymes Daclatasvir is a substrate of CYP3A. In vitro, daclatasvir did not inhibit (IC50 greater than 40 microM) CYP enzymes 1A2, 2B6, 2C8, 2C9, 2C19, or 2D6. Daclatasvir did not have a clinically relevant effect on the exposure of midazolam, a sensitive CYP3A substrate. - Transporters Daclatasvir is a substrate of P-gp. However, cyclosporine, which inhibits multiple transporters including P-gp, did not have a clinically relevant effect on the pharmacokinetics of daclatasvir. Daclatasvir, in vitro, did not inhibit OCT2 and did not have a clinically relevant effect on the pharmacokinetics of tenofovir, an OAT substrate. Daclatasvir demonstrated inhibitory effects on digoxin (a P-gp substrate) and rosuvastatin (an OATP 1B1, OATP 1B3, and BCRP substrate) in drug-drug interaction trials. Drug interaction studies were conducted with daclatasvir and other drugs likely to be coadministered or drugs used as probes to evaluate potential drug-drug interactions. The effects of daclatasvir on the Cmax, AUC, and Cmin of the coadministered drug are summarized in Table 9, and the effects of the coadministered drug on the Cmax, AUC, and Cmin of daclatasvir are summarized in Table 10. For information regarding clinical recommendations. Drug interaction studies were conducted in healthy adults unless otherwise noted. - Table 9:Effect of Daclatasvir on the Pharmacokinetics of Concomitant Drugs DAKLINZA: Daclatasvir's Brand name - Table 10:Effect of Coadministered Drugs on Daclatasvir Pharmacokinetics DAKLINZA: Daclatasvir's Brand name No clinically relevant interaction is anticipated for daclatasvir or the following concomitant medications: peginterferon alfa, ribavirin, or antacids. No clinically relevant interaction is anticipated for daclatasvir with concomitant use of rilpivirine. - Mechanism of Action Daclatasvir is an inhibitor of NS5A, a nonstructural protein encoded by HCV. Daclatasvir binds to the N-terminus of NS5A and inhibits both viral RNA replication and virion assembly. Characterization of daclatasvir-resistant viruses, biochemical studies, and computer modeling data indicate that daclatasvir interacts with the N-terminus within Domain 1 of the protein, which may cause structural distortions that interfere with NS5A functions. - Antiviral Activity Daclatasvir had median EC50 values of 0.008 nM (range, 0.002-0.03 nM; n=35), 0.002 nM (range, 0.0007-0.006 nM; n=30), and 0.2 nM (range, 0.006-3.2 nM; n=17) against hybrid replicons containing genotypes 1a, 1b, and 3a subject-derived NS5A sequences, respectively, without detectable daclatasvir resistance-associated polymorphisms at NS5A amino acid positions 28, 30, 31, or 93. Daclatasvir activity was reduced against genotypes 1a, 1b, and 3a subject-derived replicons with resistance-associated polymorphisms at positions 28, 30, 31, or 93, with median EC50 values of 76 nM (range, 4.6-2409 nM; n=5), 0.05 nM (range, 0.002-10 nM; n=12), and 13.5 nM (range, 1.3-50 nM; n=4), respectively. Similarly, the EC50 values of daclatasvir against 3 genotype 3b and 1 genotype 3i subject-derived NS5A sequences with polymorphisms (relative to a genotype 3a reference) at positions 30+31 (genotype 3b) or 30+62 (genotype 3i) were ≥3620 nM. Daclatasvir was not antagonistic with interferon alfa, HCV NS3/4A protease inhibitors, HCV NS5B nucleoside analog inhibitors, and HCV NS5B non-nucleoside inhibitors in cell culture combination antiviral activity studies using the cell-based HCV replicon system. - Resistance - In Cell Culture HCV genotype 1a, 1b, and 3a replicon variants with reduced susceptibility to daclatasvir were selected in cell culture, and the genotype and phenotype of daclatasvir-resistant NS5A amino acid variants were characterized. Phenotypic analysis of genotype 1a replicons expressing single NS5A M28T, Q30E, Q30H, Q30R, L31V, Y93C, Y93H, and Y93N substitutions exhibited 500-, 18500-, 1083-, 900-, 2500-, 1367-, 8500-, and 34833-fold reduced susceptibility to daclatasvir, respectively. For genotype 1b, L31V and Y93H single substitutions and L31M/Y93H and L31V/Y93H combinations exhibited 33-, 30-, 16000-, and 33667-fold reduced susceptibility to daclatasvir, respectively. A P32-deletion (P32X) in genotype 1b reduced daclatasvir susceptibility by >1,000,000-fold. For genotype 3a, single A30K, L31F, L31I, and Y93H substitutions exhibited 117-, 320-, 240-, and 3733-fold reduced susceptibility to daclatasvir, respectively. - In Clinical Studies Among subjects with HCV genotype 1 or genotype 3 infection and treated in the ALLY-1, -2, and -3 trials with Daclatasvir and sofosbuvir with or without ribavirin for 12 weeks, 31 subjects (11 with genotype 1a, 1 with genotype 1b, and 19 with genotype 3) qualified for resistance analysis due to virologic failure. Post-baseline NS5A and NS5B population-based nucleotide sequence analysis results were available for 31 and 28 subjects, respectively. Virus from all 31 subjects at the time of virologic failure harbored one or more of the following NS5A resistance-associated substitutions (including pre-existing amino acid polymorphisms or treatment-emergent substitutions): M28T, Q30H/K/R, L31M/V, H54R, H58D/P, or Y93C/N for genotype 1a subjects, P32-deletion (P32X) for the genotype 1b subject, and A30K/S, L31I, S62A/L/P/R/T, or Y93H for genotype 3 subjects. Among HCV genotype 1a virologic failure subjects, the most common NS5A amino acid substitutions occurred at position Q30 (Q30H/K/R; 73% , all treatment-emergent). Among HCV genotype 3 virologic failure subjects, the most common NS5A amino acid polymorphism or treatment-emergent substitution was Y93H (89% , treatment-emergent in 11 of 17 subjects). For NS5B, 6 of 28 subjects at the time of virologic failure had virus with NS5B substitutions possibly associated with sofosbuvir resistance or exposure: A112T, L159F, E237G, or Q355H (genotype 1a subjects), or S282T+Q355H (genotype 3 subject). - Persistence of Resistance-Associated Substitutions Limited data for Daclatasvir and sofosbuvir regimens on the persistence of daclatasvir resistance-associated substitutions are available. In a separate long-term follow-up study of predominately HCV genotype 1-infected subjects treated with daclatasvir-containing regimens in phase 2/3 clinical trials, viral populations with treatment-emergent NS5A resistance-associated substitutions persisted at detectable levels for more than 1 year in most subjects. - Effect of Baseline HCV Amino Acid Polymorphisms on Treatment Response Genotype 1a NS5A polymorphisms: In HCV genotype 1a-infected subjects with cirrhosis, the presence of an NS5A amino acid polymorphism at position M28, Q30, L31, or Y93 (defined as any change from reference identified by population-based nucleotide sequencing) was associated with reduced efficacy of Daclatasvir and sofosbuvir with or without ribavirin for 12 weeks in the ALLY-1 and ALLY-2 trials (see Table 11). Due to the limited sample size, insufficient data are available to determine the impact of specific NS5A polymorphisms at these positions on SVR12 rates in subjects with cirrhosis. Six of 54 subjects (11%) with cirrhosis had one of the following specific NS5A polymorphisms at baseline: M28V/T (n=2), Q30R (n=1), L31M (n=2), or Y93N (n=1); 2 subjects with M28V or Q30R achieved SVR12 while 4 subjects with M28T, L31M, or Y93N did not achieve SVR. Eleven of 112 subjects (10%) without cirrhosis had one or more of the following specific NS5A polymorphisms at baseline: M28T/V (n=3), Q30H/L/R (n=5), L31M (n=1), and Y93C/H/S (n=4); all noncirrhotic subjects with these baseline NS5A polymorphisms achieved SVR12. Based on an analysis of 1026 HCV genotype 1a NS5A amino acid sequences from pooled clinical trials, the prevalence of polymorphisms at these positions was 11% overall, and 11% in the U.S. Genotype 1b NS5A polymorphisms: In a pooled analysis of 43 subjects infected with HCV genotype 1b with available baseline nucleotide sequence data in ALLY-1 and -2, virus from 21% (n=9) of subjects receiving Daclatasvir and sofosbuvir with or without ribavirin had one of the following baseline NS5A amino acid polymorphisms: R30K/M/Q (n=4), L31M (n=2), or Y93H (n=3). All 9 subjects with NS5A polymorphisms achieved SVR12, including 5 who were noncirrhotic and 4 who were in the post-transplant period. Genotype 3 NS5A polymorphisms: In the ALLY-3 trial in which HCV genotype 3-infected subjects received Daclatasvir and sofosbuvir for 12 weeks, the presence of an NS5A Y93H polymorphism was associated with a reduced SVR12 rate (see Table 11). In a pooled analysis of 175 subjects infected with HCV genotype 3 with available baseline nucleotide sequence data in the ALLY-1, -2, and -3 trials, virus from 7% (13/175) of subjects had the NS5A Y93H polymorphism, and all 13 of these subjects were in the ALLY-3 trial. Phylogenetic analysis of NS5A sequences indicated that all genotype 3 subjects with available data in the ALLY-1, -2, and -3 trials (n=175) were infected with HCV subtype 3a. - Table 11:Impact of NS5A Amino Acid Polymorphisms on SVR12 Rates in Subjects with HCV Genotype 1a or Genotype 3 Infection in Phase 3 Trials of Daclatasvir + Sofosbuvir ± Ribavirin DAKLINZA: Daclatasvir's Brand name - Cross-Resistance Based on resistance patterns observed in cell culture replicon studies and HCV-infected subjects, cross-resistance between daclatasvir and other NS5A inhibitors is expected. Cross-resistance between daclatasvir and other classes of direct-acting antivirals is not expected. The impact of prior daclatasvir treatment experience on the efficacy of other NS5A inhibitors has not been studied. Conversely, the efficacy of Daclatasvir in combination with sofosbuvir has not been studied in subjects who have previously failed treatment with regimens that include an NS5A inhibitor. ## Nonclinical Toxicology - Carcinogenesis and Mutagenesis A 2-year carcinogenicity study in Sprague Dawley rats and a 6-month study in transgenic (Tg rasH2) mice were conducted with daclatasvir. In the 2-year study in rats, no drug-related increase in tumor incidence was observed at doses up to 50 mg/kg/day (both sexes). Daclatasvir exposures at these doses were approximately 6-fold (males and females) the human systemic exposure at the therapeutic daily dose of Daclatasvir. In transgenic mice no drug-related increase in tumor incidence was observed at doses of 300 mg/kg/day (both sexes). Daclatasvir was not genotoxic in a battery of in vitro or in vivo assays, including bacterial mutagenicity (Ames) assays, mammalian mutation assays in Chinese hamster ovary cells, or in an in vivo oral micronucleus study in rats. If Daclatasvir and sofosbuvir are administered in a regimen containing ribavirin, the information for ribavirin on carcinogenesis and mutagenesis also applies to this combination regimen (see prescribing information for ribavirin). - Impairment of Fertility Daclatasvir had no effects on fertility in female rats at any dose tested. Daclatasvir exposures at these doses in females were approximately 24-fold the human systemic exposure at the therapeutic daily dose of Daclatasvir. In male rats, effects on reproductive endpoints at 200 mg/kg/day included reduced prostate/seminal vesicle weights, minimally increased dysmorphic sperm, as well as increased mean pre-implantation loss in litters sired by treated males. Daclatasvir exposures at the 200 mg/kg/day dose in males were approximately 26-fold the human systemic exposure at the therapeutic daily dose of Daclatasvir. Exposures at 50 mg/kg/day in males produced no notable effects and was 4.7-fold the exposure in humans at the recommended daily dose of Daclatasvir. If Daclatasvir and sofosbuvir are administered with ribavirin, the information for ribavirin on impairment of fertility also applies to this combination regimen. # Clinical Studies The efficacy of Daclatasvir in combination with sofosbuvir and with or without ribavirin was evaluated in three phase 3 clinical trials, as summarized in Table 12. HCV RNA levels were measured during these clinical trials using the COBAS® TaqMan® HCV test (version 2.0), for use with the High Pure System. The assay had a lower limit of quantification (LLOQ) of 25 IU per mL. Sustained virologic response was the primary endpoint and was defined as HCV RNA below the LLOQ at post-treatment week 12 (SVR12). - Table 12:Genotype 1 and 3 Patient Populations from Daclatasvir Trials DAKLINZA: Daclatasvir's Brand name ALLY-3 was an open-label trial that included 152 subjects with chronic HCV genotype 3 infection and compensated liver disease who were treatment naive (n=101) or treatment experienced (n=51). Most treatment-experienced subjects had failed prior treatment with peginterferon/ribavirin, but 7 subjects had been treated previously with a sofosbuvir regimen and 2 subjects with a regimen containing an investigational agent. Previous exposure to NS5A inhibitors was prohibited. Subjects received Daclatasvir 60 mg plus sofosbuvir 400 mg once daily for 12 weeks and were monitored for 24 weeks post treatment. The 152 treated subjects in ALLY-3 had a median age of 55 years (range, 24-73); 59% of the subjects were male; 90% were white, 5% were Asian, and 4% were black. Most subjects (76%) had baseline HCV RNA levels greater than or equal to 800,000 IU per mL; 21% of the subjects had compensated cirrhosis, and 40% had the IL28B rs12979860 CC genotype. SVR12 and outcomes in subjects without SVR12 in ALLY-3 are shown by patient population in Table 13. SVR12 rates were comparable regardless of HCV treatment history, age, gender, IL28B allele status, or baseline HCV RNA level. For SVR outcomes related to baseline NS5A amino acid polymorphisms. - Table 13:ALLY-3: SVR12 in Treatment-Naive and Treatment-Experienced Subjects with or without Cirrhosis with Genotype 3 HCV Treated with Daclatasvir in Combination with Sofosbuvir for 12 Weeks ALLY-2 was an open-label trial that included 153 subjects with chronic hepatitis C and HIV coinfection who received Daclatasvir and sofosbuvir for 12 weeks. Subjects with HCV genotype 1, 2, 3, 4, 5, or 6 infection were eligible to enroll. Subjects were HCV treatment-naive (n=101) or HCV treatment-experienced (n=52). Prior exposure to NS5A inhibitors was prohibited. The dose of Daclatasvir was 60 mg once daily (dose-adjusted for concomitant antiretroviral use) and the dose of sofosbuvir was 400 mg once daily. The 153 treated subjects had a median age of 53 years (range, 24-71); 88% of subjects were male; 63% were white, 33% were black, and 1% were Asian. Sixty-eight percent of subjects had HCV genotype 1a, 15% had HCV genotype 1b, 8% had genotype 2, 7% had genotype 3, and 2% had genotype 4. Most subjects (80%) had baseline HCV RNA levels greater than or equal to 800,000 IU per mL; 16% of the subjects had compensated cirrhosis, and 73% had IL28B rs12979860 non-CC genotype. Concomitant HIV therapy included PI-based regimens (darunavir + ritonavir, atazanavir + ritonavir, or lopinavir/ritonavir) for 46% of subjects, NNRTI-based regimens (efavirenz, nevirapine, or rilpivirine) for 26%, integrase-based regimens (raltegravir or dolutegravir) for 26%, and nucleoside-only regimens (abacavir + emtricitabine + zidovudine) for 1%. Two patients were not receiving treatment for HIV. SVR and outcomes in subjects with HCV genotype 1 without SVR12 in ALLY-2 are shown by patient population in Table 14. Available data on subjects with HCV genotype 2, 4, 5, or 6 infection are insufficient to provide recommendations for these genotypes; therefore, these results are not presented in Table 14. SVR12 rates were comparable regardless of antiretroviral therapy, HCV treatment history, age, race, gender, IL28B allele status, HCV genotype 1 subtype, or baseline HCV RNA level. For SVR outcomes related to baseline NS5A amino acid polymorphisms. No subjects switched their antiretroviral therapy regimen due to loss of plasma HIV-1 RNA suppression. There was no change in absolute CD4+ T-cell counts at the end of 12 weeks of treatment. - Table 14:ALLY-2: SVR12 in Subjects with Genotype 1 and 3 HCV/HIV Coinfection Treated with Daclatasvir in Combination with Sofosbuvir for 12 Weeks ALLY-1 was an open-label trial of Daclatasvir, sofosbuvir, and ribavirin that included 113 subjects with chronic HCV infection and Child-Pugh A, B, or C cirrhosis (n=60) or HCV recurrence after liver transplantation (n=53). Subjects with HCV genotype 1, 2, 3, 4, 5, or 6 infection were eligible to enroll. Subjects could be HCV treatment-naive or treatment-experienced, although prior exposure to NS5A inhibitors was prohibited. Subjects received Daclatasvir 60 mg once daily, sofosbuvir 400 mg once daily, and ribavirin for 12 weeks and were monitored for 24 weeks post treatment. Subjects received an initial ribavirin dose of 600 mg or less daily with food; the initial and on-treatment dosing of ribavirin was modified based on hemoglobin and creatinine clearance measurements. If tolerated, the ribavirin dose was titrated up to 1000 mg per day. A high proportion of reductions in ribavirin dosing occurred in the trial. By week 6, approximately half of the subjects received 400 mg per day or less of ribavirin. In total, 16 subjects (15%) completed less than 12 weeks and 11 subjects (10%) completed less than 6 weeks of ribavirin therapy, respectively. For the cohort of patients with cirrhosis (Child-Pugh A, B, or C), the median time to discontinuation of ribavirin was 43 days (range, 8-82, n=9). For the post-transplant cohort, the median time to discontinuation of ribavirin was 20 days (range, 3-57, n=7). The 113 treated subjects in ALLY-1 had a median age of 59 years (range, 19-82); 67% of the subjects were male; 96% were white, 4% were black, and 1% Asian. Most subjects (59%) were treatment-experienced, and most (71%) had baseline HCV RNA levels greater than or equal to 800,000 IU per mL. Fifty-eight percent of subjects had HCV genotype 1a, 19% had HCV genotype 1b, 4% had genotype 2, 15% had genotype 3, 4% had genotype 4, and 1% had genotype 6, 77% had IL28B rs12979860 non-CC genotype. Among the 60 subjects in the cirrhosis cohort, 20% were Child-Pugh A, 53% were Child-Pugh B, and 27% were Child-Pugh C, and 35% had a Baseline Model for End-Stage Liver Disease (MELD) score of 15 or greater. Most (55%) of the 53 subjects in the post-transplant cohort had F3 or F4 fibrosis (based on FibroSURE® results). SVR12 and outcomes in subjects without SVR12 in ALLY-1 are shown for subjects with HCV genotype 1 by patient population in Table 15. Available data on subjects with HCV genotype 2, 4, 5, or 6 infection are insufficient to provide recommendations; therefore, these results are not presented in Table 15. SVR12 rates were comparable regardless of age, gender, IL28B allele status, or baseline HCV RNA level. For SVR12 outcomes related to baseline NS5A amino acid polymorphisms. No HCV genotype 1 or genotype 3 subjects with Child-Pugh C cirrhosis had baseline resistance-associated NS5A amino acid polymorphisms. SVR12 rates were comparable between genotype 3 (5/6 with Child-Pugh B or C cirrhosis and 10/11 post-liver transplant) and genotype 1 subjects with or without decompensated cirrhosis. - Table 15:ALLY-1: SVR12 in Genotype 1 Subjects with Child-Pugh A, B, or C Cirrhosis or with HCV Genotype 1 Recurrence after Liver Transplantation Treated with Daclatasvir in Combination with Sofosbuvir and Ribavirin for 12 Weeks # How Supplied Daclatasvir is packaged in bottles as described in the table. ## Storage Store Daclatasvir tablets at 25°C (77°F), with excursions permitted between 15°C and 30°C (59°F and 86°F). # Images ## Drug Images ## Package and Label Display Panel # Patient Counseling Information Advise the patient to read the FDA-approved patient labeling (Patient Information). - Drug Interactions Inform patients of the potential for drug interactions with Daclatasvir, and that some drugs should not be taken with Daclatasvir. - Symptomatic Bradycardia When Used in Combination with Sofosbuvir and Amiodarone Advise patients to seek medical evaluation immediately for symptoms of bradycardia, such as near-fainting or fainting, dizziness or lightheadedness, malaise, weakness, excessive tiredness, shortness of breath, chest pain, confusion or memory problems. - Daclatasvir Combination Therapy with Sofosbuvir Inform patients that Daclatasvir should not be used alone. Daclatasvir should be used in combination with sofosbuvir with or without ribavirin for the treatment of HCV genotype 1 or HCV genotype 3 infection. - Missed Doses Advise patients to take Daclatasvir every day at the regularly scheduled time with or without food. Inform patients that it is important not to miss or skip doses and to take Daclatasvir for the duration that is recommended by the physician. For instructions for missed doses of other agents in the regimen, refer to the respective prescribing information. - Pregnancy Advise patients to avoid pregnancy during combination treatment with Daclatasvir and sofosbuvir with ribavirin for 6 months after completion of treatment. Inform patients to notify their healthcare provider immediately in the event of a pregnancy. # Precautions with Alcohol Alcohol-Daclatasvir interaction has not been established. Talk to your doctor regarding the effects of taking alcohol with this medication. # Brand Names DAKLINZA™ # Look-Alike Drug Names There is limited information regarding Daclatasvir Look-Alike Drug Names in the drug label. # Drug Shortage Status # Price

Radiology Image Insertion # Overview It is important to have accurate insight when you are interpreting an imaging series such as CT scans, MRIs, or angiography. From a student's point of view, it may be needlessly complicated to look for a lesion in many frames. For this reason, creating an animated image with highlighted lesions is preferable to uploading many images, since it makes the image more accessible for all users. Here we describe how to make an animated GIF file with highlighted lesions. # How to insert an imaging series for CT scan or MRI If you want to present a series of images (e.g., CT scans, MRIs) instead of uploading many discrete images, you can highlight the pathologic part of the image by encircling it in yellow and then combine the images to create a GIF file by following the steps listed below: - The raw image - 1st highlighted image - 2nd highlighted image - 3rd highlighted image - 4th highlighted image - 5th highlighted image - 6th highlighted image - 7th highlighted image - 8th highlighted image - 9th highlighted image - 10th highlighted image - 11th highlighted image Here are 2 examples for imaging series:

Neurofibromin 1 Neurofibromin 1 (NF1) is a gene in humans that is located on chromosome 17. NF1 codes for neurofibromin, a GTPase-activating protein that negatively regulates RAS/MAPK pathway activity by accelerating the hydrolysis of Ras-bound GTP. There are currently five known neurofibromin isoforms that are expressed in different tissues and perform different functions. NF1 has a high mutation rate and mutations in NF1 can alter cellular growth control, and neural development, resulting in neurofibromatosis type 1 (NF1, also known as von Recklinghausen syndrome). Symptoms of NF1 include cutaneous neurofibromas, café au lait pigment spots, plexiform neurofibromas, skeletal defects and optic nerve gliomas. # Gene NF1 encodes the protein neurofibromin, a GTPase-activating protein, which primarily regulates the protein Ras. NF1 is located on the long arm of chromosome 17, position q11.2 and was identified in 1990 through positional cloning. NF1 spans over 350-kb of genomic DNA and contains 62 exons. 58 of these exons are constitutive and 4 exhibit alternative splicing ( 9a, 10a-2, 23a, and 28a). The genomic sequence starts 4,951-bp upstream of the transcription start site and 5,334-bp upstream of the translation initiation codon, with the length of the 5’ UTR being 484-bp long. There are three genes that are present within intron 27b of NF1. These genes are EVI2B, EVI2A and OMG, which are encoded on the opposite strand and are transcribed in the opposite direction of NF1. EVI2A and EVI2B are human homologs of the Evi-2A and Evi-2B genes in mice that encode proteins related to leukemia in mice. OMG is a membrane glycoprotein that is expressed in the human central nervous system during myelination of nerve cells. ## Promoter Early studies of the NF1 promoter found that there is great homology between the human and mouse NF1 promoters. The major transcription start site has been confirmed, as well as two minor transcription start sites in both the human and mouse gene. The major transcription start is 484-bp upstream of the translation initiation site. The open reading frame is 8,520-bp long and begins at the translation initiation site. NF1 exon 1 is 544-bp long, contains the 5’ UTR and encodes the first 20 amino acids of neurofibromin. The NF1 promoter lies within a CpG island that is 472-bp long, consisting of 43 CpG dinucleotides, and extends into the start of exon 1. This CpG Island begins 731-bp upstream of the promoter and no core promoter element, such as a TATA or CCATT box, has been found within it. Although no core promoter element has been found, consensus binding sequences have been identified in the 5’ UTR for several transcription factors such as Sp1 and AP2. A methylation map of five regions of the promoter in both mouse and human was published in 1999. This map showed that three of the regions (at approximately – 1000, – 3000, and – 4000) were frequently methylated, but the cytosines near the transcription start site were unmethylated.  Methylation has been shown to functionally impact Sp1 sites as well as a CREB binding site. It has been shown that the CREB site must be intact for normal promoter activity to occur and methylation at the Sp1 sites may affect promoter activity. Proximal NF1 promoter/5’ UTR methylation has been analyzed in tissues from NF1 patients, with the idea that reduced transcription as a result of methylation could be a “second hit” mechanism equivalent to a somatic mutation. There are some sites that have been detected to be methylated at a higher frequency in tumor tissues than normal tissues. These sites are mostly within the proximal promoter; however, some are in the 5’ UTR as well and there is a lot of interindividual variability in the cytosine methylation in these regions. ## 3' UTR A study in 1993 compared the mouse NF1 cDNA to the human transcript and found that both the untranslated regions and coding regions were highly conserved. It was verified that there are two NF1 polyadenylated transcripts that differ in size because of the length of the 3’ UTR, which is consistent with what has been found in the mouse gene. A study conducted in 2000 examined whether the involvement of the 3’ UTR in post-transcriptional gene regulation had an effect on the variation of NF1 transcript quantity both spatially and temporally. Five regions of the 3’ UTR that appear to bind proteins were found, one of which is HuR, a tumor antigen. HuR binds to AU-rich elements which are scattered throughout the 3' UTR and are thought to be negative regulators of transcript stability. This supports the idea that post-transcriptional mechanisms may influence the levels of NF1 transcript. ## Mutations NF1 has one of the highest mutation rates amongst known human genes, however mutation detection is difficult because of its large size, the presence of pseudogenes, and the variety of possible mutations. The NF1 locus has a high incidence of de novo mutations, meaning that the mutations are not inherited maternally or paternally. Although the mutation rate is high, there are no mutation “hot spot” regions. Mutations tend to be distributed within the gene, although exons 3, 5, and 27 are common sites for mutations. The Human Gene Mutation Database contains 1,347 NF1 mutations, but none are in the “regulatory” category. There have not been any mutations conclusively identified within the promoter or untranslated regions. This may be because such mutations are rare, or they do not result in a recognizable phenotype. There have been mutations identified that affect splicing, in fact 286 of the known mutations are identified as splicing mutations. About 78% of splicing mutations directly affect splice sites, which can cause aberrant splicing to occur. Aberrant splicing may also occur due to mutations within a splicing regulatory element. Intronic mutations that fall outside of splice sites also fall under splicing mutations, and approximately 5% of splicing mutations are of this nature. Point mutations that effect splicing are commonly seen and these are often substitutions in the regulatory sequence. Exonic mutations can lead to deletion of an entire exon, or a fragment of an exon if the mutation creates a new splice site. Intronic mutations can result in the insertion of a cryptic exon, or result in exon skipping if the mutation is in the conserved 3’ or 5’ end. # Protein NF1 encodes neurofibromin (Nf1), which is a 320-kDa protein that contains 2,818 amino acids. Neurofibromin is a GTPase-activating protein (GAP) that negatively regulates Ras pathway activity by accelerating hydrolysis of Ras-bound guanosine triphosphate (GTP). Neurofibromin localizes in the cytoplasm; however, some studies have found neurofibromin or fragments of it in the nucleus. Neurofibromin does contain a nuclear localization signal that is encoded by exon 43, but whether or not neurofibromin plays a role in the nucleus is currently unknown. Neurofibromin is ubiquitously expressed, but expression levels vary depending on the tissue type and developmental stage of the organism. Expression is at its highest level in adult neurons, Schwann cells, astrocytes, leukocytes, and oligodendrocytes. The catalytic RasGAP activity of neurofibromin is located in a central portion of the protein, that is called the GAP-related domain (GRD). The GRD is closely homologous to RasGAP and represents about 10% (229 amino acids) of the neurofibromin sequence. The GRD is made up of a central portion called the minimal central catalytic domain (GAPc) as well as an extra domain (GAPex) that is formed through the coiling of about 50 residues from the N- and C- terminus. The Ras-binding region is found in the surface of GAPc and consists of a shallow pocket that is lined by conserved amino acid residues. In addition to the GRD, neurofibromin also contains a Sec14 homology-like region as well as a pleckstrin homology-like (PH) domain. Sec14 domains are defined by a lipid binding pocket that resembles a cage and is covered by a helical lid portion that is believed to regulate ligand access. The PH-like region displays a protrusion that connects two beta-strands from the PH core that extend to interact with the helical lid found in the Sec14 domain. The function of the interaction between these two regions is presently unclear, but the structure implies a regulatory interaction that influences the helical-lid conformation in order to control ligand access to the lipid binding pocket. ## Function Through its NF1-GRD domain, neurofibromin increases the rate of GTP hydrolysis of Ras, and acts as a tumor suppressor by reducing Ras activity. When the Ras-Nf1 complex assembles, active Ras binds in a groove that is present in the neurofibromin catalytic domain. This binding occurs through Ras switch regions I and II, and an arginine finger present in neurofibromin. The interaction between Ras and neurofibromin causes GAP-stimulated hydrolysis of GTP to GDP. This process depends on the stabilization of residues in the Ras switch I and switch II regions, which drives Ras into the confirmation required for enzymatic function. This interaction between Ras and neurofibromin also requires the transition state of GDP hydrolysis to be stabilized, which is performed through the insertion of the positively charged arginine finger into the Ras active site. This neutralizes the negative charges that are present on GTP during phosphoryl transfer. By hydrolyzing GTP to GDP, neurofibromin inactivates Ras and therefore negatively regulates the Ras pathway, which controls the expression of genes involved in apoptosis, the cell cycle, cell differentiation or migration. Neurofibromin is also known to interact with CASK through syndecan, a protein which is involved in the KIF17/ABPA1/CASK/LIN7A complex, which is involved in trafficking GRIN2B to the synapse. This suggests that neurofibromin has a role in the transportation of the NMDA receptor subunits to the synapse and its membrane. Neurofibromin is also believed to be involved in the synaptic ATP-PKA-cAMP pathway, through modulation of adenylyl cyclase. It is also known to bind the caveolin 1, a protein which regulates p21ras, PKC and growth response factors. ## Isoforms There are currently five known isoforms of neurofibromin (II, 3, 4, 9a, and 10a-2) and these isoforms are generated through the inclusion of alternative splicing exons (9a, 10a-2, 23a, and 48a) that do not alter the reading frame. These five isoforms are expressed in distinct tissues and are each detected by specific antibodies. Neurofibromin type II, also named GRD2 (domain II-related GAP), results from the insertion of exon 23a, which causes the addition of 21 amino acids in the 5’ region of the protein. Neurofibromin type II is expressed in Schwann cells and has reduced GAP activity. Neurofibromin type 3 (also called isoform 3’ ALT) contains exon 48a which results in the insertion of 18 amino acids into the 3’ terminal. Neurofibromin type 4 contains exons 23a and 48a, which results in the insertion of 21 amino acids in the 5’ region, and 18 amino acids in the 3’ terminal. Neurofibromin 9a (also referred to as 9br), includes exon 9a which results in the insertion of 10 amino acids in the 5’ region. This isoform shows little neuronal expression and may play a role in memory and learning mechanisms. An isoform with insertion of exon 10a-2 has been studied introduces a transmembrane domain. The inclusion of exon 10a-2 causes the insertion of 15 amino acids in the 5’ region. This isoform is expressed in most human tissues, therefore it likely performs a housekeeping function in intracellular membranes. It has been suggested that the quantitative differences in expression between the different isoforms may be related to the phenotypic variability of neurofibromatosis type 1 patients. # RNA editing In the NF1 mRNA, there is a site within the first half of the GRD where mRNA editing occurs. Deamination occurs at this site, resulting in the conversion of cytidine into uridine at nucleotide 3916. This deamination changes an arginine codon (CGA) to an in-frame translation stop codon (UGA). If the edited transcript is translated, it produces a protein that cannot function as a tumor suppressor because the N-terminal of the GRD is truncated. The editing site in NF1 mRNA was shown to have high homology to the ApoB editing site, where double stranded mRNA undergoes editing by the ApoB holoenzyme. NF1 mRNA editing was believed to involve the ApoB holoenzyme due to the high homology between the two editing sites, however studies have shown that this is not the case. The editing site in NF1 is longer than the sequence required for ApoB mediated mRNA editing, and the region contains two guanidines which are not present in the ApoB editing site. # Clinical significance Mutations in NF1 are primarily associated with neurofibromatosis type 1 (NF1, also known as von Recklinghausen syndrome). NF1 is the most common single gene disorder in humans, occurring in about 1 in 2500-3000 births worldwide. NF1 is an autosomal dominant disorder, but approximately half of NF1 cases arise from de novo mutations. NF1 has high phenotypic variability, with members of the same family with the same mutation displaying different symptoms and symptom intensities. Café-au-lait spots are the most common sign of NF1, but other symptoms include lisch nodules, cutaneous neurofibromas, plexiform neurofibromas, skeletal defects, and optic nerve gliomas. In addition to neurofibromatosis type I, mutations in NF1 can also lead to juvenile myelomonocytic leukemia, Watson syndrome, and breast cancer. # Model organisms Model organisms have been used in the study of NF1 function. A conditional knockout mouse line, called Nf1tm1a(KOMP)Wtsi was generated as part of the International Knockout Mouse Consortium program, a high-throughput mutagenesis project to generate and distribute animal models of disease to interested scientists. Male and female animals underwent a standardized phenotypic screen to determine the effects of deletion. Twenty six tests were carried out on mutant mice and four significant abnormalities were observed. Over half the homozygous mutant embryos identified during gestation were dead, and in a separate study none survived until weaning. The remaining tests were carried out on heterozygous mutant adult mice: females displayed abnormal hair cycling while males had an decreased B cell number and an increased monocyte cell number.

Guidelines for the management of common congenital heart diseases in India: A consensus statement on indications and timing of intervention⋆ # Introduction Congenital heart diseases (CHDs) are the most common birth defects, responsible for nearly one-third of all congenital birth defects.The birth prevalence of CHD is reported to be 8e12 per 1000 live births. [bib_ref] The global burden of congenital heart disease, Hoffman [/bib_ref] If access to screening, early diagnosis, and treatment is available, more than 90% of patients born with CHD survive to adult life with good long-term outcomes. [bib_ref] The adult with congenital heart disease: born to be bad, Warnes [/bib_ref] Most middleand low-income countries lack such an advanced level of care for children with CHD. Considering birth prevalence as 9 per 1000, the estimated number of children born with CHD every year in India approximates 2,40,000, posing a tremendous challenge for the families, society, and health-care system. ## Justification for developing indian guidelines Evidence-based recommendations for management of CHD have been published by task force members from a number of national and international associations, but these are primarily meant for children born in high-income countries. Applicability of these guidelines to the Indian population with CHD is likely to be limited. Majority of patients with CHD are not diagnosed in the antenatal period and often present late in the course of the disease. These patients are often underweight and malnourished and have co-morbidities such as recurrent infections and anemia. Many of the late presenters have an advanced level of pulmonary hypertension, ventricular dysfunction, hypoxia, polycythemia, and so on. Modifications in the treatment protocol may be required for optimizing the outcomes in such patients. All these factors justify the need for separate guidelines for management of CHD in India, including the timing of intervention. A statement on "consensus on timing of intervention for common congenital heart disease" that originated from a Meeting of Working Group on Management of Congenital Heart Disease in India was published in the year 2008.This statement was revised and updated in a subsequent National Consensus Meeting, which was held in New Delhi after a gap of 10 years, in August 2018. Considering the growing population of postoperative patients, including those needing regular follow-up, we added protocols for follow-up of these patients. ## Preamble 1. Every pediatrician/cardiologist/other health-care provider must strive to get a complete diagnosis on a patient suspected of having heart disease, with the help of a higher center, if needed. 2. The proposed guidelines are meant to assist health-care providers (pediatrician, cardiologist, pediatric cardiologist) for managing cases with CHDs in their practice. Although these may be applicable to the majority, each case needs individualized care, and exceptions may have to be made. Guidelines are intended to define practices, meeting the needs of patients in most, but not all circumstances, and should not replace clinical judgment. 3. These guidelines are in reference to current health-care scenario prevalent in India. Subsequent modifications may be necessary in future as the pediatric cardiology practice evolves. 4. The recommendations are classified into three categories according to their strength of agreement: Class I (is recommended/is indicated): General agreement that the given treatment or procedure is beneficial, useful, and effective. Class II: Conflicting evidence and/or a divergence of opinion or both about the usefulness/efficacy of the given treatment or procedure. IIa Should be considered: Weight of evidence/opinion is in favor of usefulness/efficacy. IIb May be considered: Usefulness/efficacy is less well established. Class III (is not recommended): Evidence or general agreement that the given treatment or procedure is not useful/ effective and in some cases may be harmful. ## Aims and objectives The aim of the study was to outline the optimal timing of intervention in common CHDs and to formulate guidelines and protocols for follow-up of patients who have undergone surgery/ catheter interventions for CHD. ## Guidelines for individual congenital heart defects ## Atrial septal defect background Atrial septal defect (ASD) is the second most common congenital heart defect with a prevalence of 56 per 100,000 live births.The defect is usually diagnosed incidentally; symptoms may develop as age advances. Atrial arrhythmias tend to occur in those older than 40 years. Spontaneous closure of the defect is rare if the defect is > 8 mm at birth, and after 2e3 years of age. [bib_ref] Predictive factors for spontaneous closure of atrial septal defects diagnosed in the..., Radzik [/bib_ref] Fourteen percent of patients with large ASD develop the serious complication of pulmonary vascular disease, usually between 20 and 40 years of age. [bib_ref] Natural history and prognosis of atrial septal defect, Craig [/bib_ref] Ostium secundum ASD (75%) is the commonest type. Other types include ostium primum (15e20%), sinus venosus (5e10%), and coronary sinus (<1%) defect. ## Diagnostic workup The workup includes clinical assessment, X-ray of the chest, electrocardiogram (ECG), and echocardiography. Transesophageal echo may be required if transthoracic windows are suboptimal. Diagnostic catheterization is performed in those with pulmonary hypertension and suspected pulmonary vascular disease. ## Indication for closure An ASD with a left-to-right shunt associated with evidence of right ventricular volume overload (class I). Indications for ASD closure remain the same irrespective of the method of closure. ## Contraindications for closure Irreversible pulmonary vascular occlusive disease (class III) is a contraindication for closure. Patients with borderline operability due to pulmonary vascular disease should be referred to a higher center for further evaluation. Ideal age of closure I. In an asymptomatic child, surgery is indicated at 2e4 years of age (class I). For sinus venosus defect, surgery may be delayed to the age of 4e5 years (class IIa). II. In case of symptomatic ASD in infancy (congestive heart failure and pulmonary arterial hypertension), early closure is recommended (class I) after ruling out associated lesions (e.g., total anomalous pulmonary venous drainage, left ventricular inflow obstruction, aortopulmonary window , and so on). III. If presenting beyond the ideal age, elective closure is indicated irrespective of age as long as there is left-to-right shunt with right heart volume overload and pulmonary vascular resistance (PVR) is within the operable range (class I). # Method of closure Surgical closure is the established method of closure (class I). Device closure is a more recent method, used for secundum ASDs only (class I). Device closure is not advised for secundum ASDs if rims are deficient (<5 mm), and in those weighing <15 kg (owing to higher likelihood of complications). ## Recommendations for follow-up I. With regard to follow-up after surgery, clinical evaluation and echocardiography are to be performed in the first year only. No further follow-up is required if there is no residual defect, pulmonary hypertension, or arrhythmia. The patient/ guardian should be explained about reporting to the hospital in case of any cardiac symptoms, or symptoms suggestive of arrhythmias. II. Follow-up after device closure is as follows: a. Antiplatelet agents: aspirin (3e5 mg/kg/day) should be given a day before or immediately after the procedure and then continued. i. Device 30 mm: aspirin (3e5 mg/kg/day) should be continued for a total duration of 6 months. ii. Device >30 mm: aspirin (3e5 mg/kg/day) and clopidogrel (1.5e2 mg/kg/day) should be given for 3 months, followed by aspirin alone for 3 more months. b. Echocardiography should be performed at discharge, 1 month, 6 months, 1 year, and then every 3e5 yearly. III. Infective endocarditis (IE) prophylaxis is recommended for 6 months after device or surgical closure. However, all patients are advised to maintain good oro-dental hygiene after this period also. ## Isolated ventricular septal defect Background Ventricular septal defect (VSD) is the most common congenital heart defect (excluding the bicuspid aortic valve [BAV]); its prevalence varies from 3 to 5 per 1000 live births. 9,10 Clinical manifestations depend on the size of the defect and the pulmonary and systemic vascular resistances. Some of the small-and moderatesized VSDs can close spontaneously. In the historic series of Dr. Paul Wood, 11 52% of patients with large VSD developed irreversible pulmonary vascular disease with the onset in infancy in four-fifths of them. The perimembranous region (80%) is the commonest site of VSD; the outlet or subpulmonary (5e7%), inlet (5e8%), and muscular (5e20%) regions are the other sites. VSDs are best classified according to the size of the defect: I. Small (restrictive) VSD: The diameter of the defect is less than one-third the size of the aortic orifice. Right ventricular and pulmonary artery (PA) pressures are normal, the left-to-right shunt is < 1.5:1, and the size of left-sided cardiac chambers is normal. II. Moderate VSD (restrictive): The diameter of defect is more than one-third but less than the size of the aortic orifice, right ventricular and PA systolic pressure varies from normal to two-thirds of systemic pressure, the left-to-right shunt is > 1.5:1, and left-sided cardiac chambers are dilated. III. Large VSD (nonrestrictive): The diameter of the defect is equal to or more than the size of the aortic orifice, and right ventricular and PA systolic pressures vary from systemic to near-systemic pressures. The degree of the left-to-right shunt depends on PVR. The left-sided cardiac chambers are dilated when PVR is normal or mildly elevated. ## Diagnostic workup The workup includes clinical assessment, X-ray of the chest, ECG, and echocardiography. Cardiac catheterization may be required in patients with pulmonary hypertension and suspected pulmonary vascular disease or for interventional purpose. ## Indications and timing of closure (all class i recommendations) I. For patients with small VSD (no symptoms, normal PA pressure, normal left heart chambers, and no cusp prolapse), recommendations are as follows: a. Annual follow-up is needed until 10 years of age and then every 2e3 yearly. b. Closure is indicated if the patient has had an episode of endocarditis, develops cusp prolapse with aortic regurgitation (AR), or develops progressive significant right ventricular outflow tract obstruction. II. For patients with moderate VSD, recommendations are as follows: a. When asymptomatic (normal PA pressure with left heart dilation), closure of VSD is indicated by 2e5 years of age. b. When symptomatic, but controlled with medications, VSD closure is indicated by 1e2 years of age. III. For patients with large VSD, recommendations are as follows a. In case of poor growth/congestive heart failure not controlled with medications, closure is indicated as soon as possible. b. In case of controlled heart failure, closure is indicated by 6 months of age. IV. VSD with aortic cusp prolapse In case of any VSD with cusp prolapse and directly related AR that is more than trivial, surgery is indicated whenever AR is detected. All patients with VSD must be advised to maintain good orodental hygiene. ## Contraindications for closure Severe pulmonary arterial hypertension with irreversible pulmonary vascular occlusive disease (class III) is a contraindication for closure. Patients with borderline operability due to pulmonary vascular disease should be referred to a higher center for further evaluation. The decision to operate or not should be made on an individual basis, taking into account the total picture of the case including results of the investigations. ## Modes of vsd closure surgery I. Patch closure is the standard therapy in most patients. II Pulmonary artery banding may be considered as a palliative option for patients with multiple VSDs (Swiss cheese VSDs) and inaccessible VSDs (class I) and for patients with contraindications for cardiopulmonary bypass, for example, sepsis (class IIa). ## Device closure I. Eligibility criteria are as follows: weight >8 kg (5 kg for muscular VSD) and left-to-right shunt >1.5:1. II. Indications are as follows: muscular VSD and postoperative residual VSD (class I) and perimembranous VSD with at least 4-mm distance from the aortic valve (class IIb). III. Contraindications for device closure are as follows: Preexisting left bundle branch block or conduction abnormalities, AR of any degree, associated lesions requiring surgery, and inlet or subpulmonic VSD. IV. Device should not be deployed if the patient develops any AR, conduction defect, or mitral or tricuspid regurgitation at the time of procedure. ## Recommendations for follow-up I. Clinical evaluation, ECG, and echocardiography are to be performed in the first year only. No further follow-up is required if there is no residual defect or pulmonary hypertension. The patient/guardian should be explained about reporting to the hospital in case of any cardiac symptoms or symptoms suggestive of arrhythmias. However, for those who underwent device closure, a long-term follow-up is recommended to look for late-onset complications such as conduction abnormalities, AR, and so on. II. IE prophylaxis is recommended for 6 months after device or surgical closure. However, all patients are advised to maintain good oro-dental hygiene after this period also. ## Atrioventricular septal defect Background Atrioventricular septal defects (AVSDs) account for 4e5% of all congenital heart defects. Clinical manifestations and outcome of patients with AVSD depends on the size of VSD, the degree of ventricular hypoplasia (if any), atrioventricular valve regurgitation, the presence or absence of left ventricular outflow tract obstruction, and the presence or absence of associated syndromes. Down syndrome is present in 50% of patients with AVSD, and these patients tend to develop an early and more severe form of pulmonary vascular disease. [bib_ref] Pulmonary vascular disease in infants with complete atrioventricular septal defect, Frescura [/bib_ref] The complete form of AVSD, if left untreated, has a survival of only 54% at 6 months and 35% at 12 months. [bib_ref] Survival and probability of cure without and with operation in complete atrioventricular..., Berger [/bib_ref] The partial form of AVSD has a better survival of 50% at 20 years of age. 14 Types of AVSD I. Complete AVSD: It is characterized by large septal defect with an atrial component (ostium primum defect) and a ventricular component (inlet septal defect), common atrioventricular valve ring, and common atrioventricular valve. It is generally associated with a large left-to-right shunt, pulmonary arterial hypertension, and congestive heart failure. II. Partial AVSD: It is characterized by primum ASD with separate annuli of the right and left atrioventricular valve. III. Intermediate AVSD: This condition is characterized by two separate atrioventricular valves with primum ASD and a small restrictive inlet VSD. IV. Unbalanced AVSD: One of the ventricular chambers is hypoplastic. It is usually associated with complex congenital defects such as heterotaxy syndrome (isomerism). ## Diagnostic workup The workup includes clinical assessment, X-ray of the chest, ECG, and echocardiography. Cardiac catheterization is indicated for assessment of operability in patients with pulmonary hypertension and suspected pulmonary vascular disease. Ideal age of surgery I. Complete AVSD a. In case of uncontrolled heart failure, complete surgical repair is indicated as soon as possible (class I). b. In case of controlled heart failure, complete surgical repair is indicated by 3 months of age (class I). c. Pulmonary artery banding may be considered in select patients younger than 3 months of age (class IIb). II. Partial or intermediate AVSD (stable and with normal PA pressures): Surgical repair is indicated at 2e3 years of age (class I). III. Associated moderate or severe atrioventricular valve regurgitation may necessitate early surgery in partial or intermediate forms. IV. Those presenting beyond the age of 6 months with significant pulmonary hypertension and suspected elevated PVR should be referred to a higher center for further evaluation to assess operability. All patients with AVSD must be advised to maintain good orodental hygiene. ## Contraindication for surgical repair AVSD associated with severe pulmonary arterial hypertension and irreversible pulmonary vascular disease (class III) is a contraindication for surgical repair. ## Important determinants of long-term prognosis These include left atrioventricular valve stenosis/regurgitation (5e10%), subaortic stenosis (5%), atrial arrhythmias, late-onset complete heart block (CHB), and issues related to Down syndrome (if present). ## Recommendations for follow-up I. Lifelong follow-up is required. II. In patients with no significant residual abnormality, annual follow-up is required until 10 years of age, followed by 2e3 yearly follow-up. The patient should undergo physical examination, ECG, and echocardiography at each visit; Holter monitoring may be required in select cases. III. IE prophylaxis is recommended for 6 months after surgical closure. However, all patients are advised to maintain good oro-dental hygiene after this period also. ## Patent ductus arteriosus Background Patent ductus arteriosus (PDA) constitutes 5e10% of all congenital heart defects.Clinical manifestations depend on the diameter and length of PDA and the relative systemic and pulmonary vascular resistances. Small PDA in full-term neonates may close up to 3 months of age, whereas a large PDA is unlikely to close spontaneously. In the historic work by Dr. Paul Wood, 11 79% of patients with large PDA had onset of Eisenmenger syndrome in infancy. PDA is best classified according to the defect size: large-sized (significant left heart volume overload and severe pulmonary arterial hypertension with or without congestive heart failure), moderate-sized (some degree of left heart volume overload and mild to moderate pulmonary arterial hypertension), and smallsized (minimal or no left heart overload and no pulmonary hypertension). Very small PDA diagnosed only on echo-Doppler is hemodynamically insignificant, and it is labeled as a silent PDA. ## Diagnostic workup The workup includes clinical assessment, X-ray of the chest, ECG, and echocardiography. Cardiac catheterization is rarely required for operability assessment in older children and adults with pulmonary hypertension and suspected pulmonary vascular disease. It is usually performed as a part of the device closure procedure. Computed tomographic angiography (CTA) is sometimes performed in adults if the suitability of PDA anatomy for device closure is not apparent on echocardiography. Ideal age of closure I. In case of large/moderate PDA with congestive heart failure and pulmonary arterial hypertension, early closure is indicated (by 3 months of age) (class I). II. In case of moderate PDA (no congestive heart failure), closure is indicated between the age of 6 months and 1 year (class I). If failure to thrive is present, closure can be accomplished earlier (class IIa). III. In case of small PDA, closure is indicated at the age of 12e18 months (class I). IV. Those presenting beyond the age of 6 months with large PDA, significant pulmonary hypertension, and suspected elevated PVR, should be referred for operability assessment to a higher center. All patients with PDA must be advised to maintain good orodental hygiene. ## Contraindication for closure PDA associated with severe pulmonary arterial hypertension with irreversible pulmonary vascular occlusive disease; and silent PDA (class III). # Method of closure I. In those weighing >6 kg, the method of closure can be individualised: device closure (preferred as less invasive), coil occlusion, or surgical ligation (class I). II. In those weighing <6 kg, the method of closure can be as follows: surgical ligation (class I) and device/coils (off-label use; class IIb). ## Recommendations for follow-up I. Follow-up after device closure or surgery: Clinical evaluation, ECG, and echocardiography are to be performed in the first year only. No further follow-up is required if there is no residual defect and no pulmonary hypertension. The patient/guardian should be explained about reporting to a hospital in case of any cardiac symptoms. II. IE prophylaxis is recommended for 6 months after device or surgical closure. However, all patients are advised to maintain good oro-dental hygiene after this period also. ## Aortopulmonary window Background APW is a rare anomaly, comprising 0.1% of all congenital heart defects.It is associated with other anomalies in half of the cases, most commonly type A interrupted aortic arch. [bib_ref] Anatomy and pathogenesis of aorticopulmonary septal defect, Kutsche [/bib_ref] Clinical manifestations depend on the diameter of APW, the relative systemic and pulmonary vascular resistances, and associated lesions. Large APW is associated with very early development of advanced pulmonary vascular disease. APW can be proximal, distal, or a combination of both. [bib_ref] Congenital heart surgery nomenclature and database project: aortopulmonary window, Jacobs [/bib_ref] ## Diagnostic workup The workup includes clinical assessment, X-ray of the chest, ECG, and echocardiography. Cardiac catheterization is performed for diagnostic purposes in those with severe pulmonary hypertension and suspected pulmonary vascular disease. CTA is performed for older children and adults, where anatomical details are not clear on echocardiography. Ideal age of closure I. In case of uncontrolled heart failure, surgical repair should be done as soon as possible (class I). II. In case of controlled heart failure, defect should be electively repaired surgically by 3 months of age (class I). III. Those presenting beyond the age of 6 months with severe pulmonary hypertension and suspected elevated PVR, should be referred to a higher center for further evaluation to assess operability. All patients with APW must be advised to maintain good orodental hygiene. ## Contraindication for closure Severe pulmonary arterial hypertension with irreversible pulmonary vascular disease (class III) is a contraindication for closure. # Method of closure Surgical patch repair is the treatment of choice (class I). Transcatheter device closure can be performed in case of small defects with adequate rims all around (class IIa). ## Recommendations for follow-up I. Follow-up after surgery: Clinical evaluation, ECG, and echocardiography are to be performed annually until 5 years. No further follow-up is required if there is no residual defect or pulmonary hypertension. The patient/guardian should be explained about reporting to the hospital in case of any cardiac symptoms. II. Lifelong follow-up is required in those with APW who have residual pulmonary hypertension and in those who had elevated PVR before surgery. III. IE prophylaxis is recommended for 6 months after surgical or device closure. However, all patients are advised to maintain good oro-dental hygiene after this period also. ## Coarctation of the aorta background Coarctation of the aorta (CoA) constitutes 6e8% of all congenital heart defects.It is more common in males. BAV is the commonest associated congenital anomaly, seen in 80% of cases. [bib_ref] Aortic valvular stenosis with coarctation of the aorta, with special reference to..., Smith [/bib_ref] Clinical presentation depends on the age at presentation. The diagnosis may be incidental in older patients while they are being investigated for hypertension. Untreated patients who have survived infancy have a 25% survival at 46 years and 10% survival at 56 years. [bib_ref] Natural history of coarctation of the aorta, Campbell [/bib_ref] The risk of residual hypertension and early atherosclerotic cardiovascular disease is increased with late repair. [bib_ref] Prognosis of surgically corrected coarctation of the aorta. A 20-year postoperative appraisal, Maron [/bib_ref] The prevalence of residual hypertension is only 6% in patients who undergo repair between 1 and 5 years of age in comparison with 30e50% in patients who undergo repair at an older age. 20 ## Diagnostic workup The workup includes clinical assessment, X-ray chest, ECG, and echocardiography. CTA/cardiac magnetic resonance imaging (cMRI) may be required in select cases, especially in adults when anatomy is unclear on echocardiography and for follow-up after surgical or catheter intervention. Cardiac catheterization is primarily performed for catheter intervention. ## Indications for intervention The following are the indications for intervention: [formula] I. [/formula] ## Ideal age for intervention I. In patients with left ventricular dysfunction/congestive heart failure or severe upper limb hypertension (for age), immediate intervention (class I) is indicated. II. In patients with normal left ventricular function, no congestive heart failure, and mild upper limb hypertension, intervention is indicated beyond 3e6 months of age (class I). III. In patients with no hypertension, no heart failure, and normal ventricular function, intervention is indicated at 1e2 years of age (class I), or later whenever the patient presents. ## Mode of intervention I. For neonatal presentation, surgery is the preferred mode of intervention. Aortic arch hypoplasia, if associated, should also be repaired. II. For critically ill neonates who are considered high risk for surgery (shock-like syndrome and severe left ventricular dysfunction), balloon angioplasty may be performed to tide over the crisis (class IIa). III. For infants with native coarctation, surgery (class I) or balloon angioplasty (class IIa) may be performed. IV. For infants with recoarctation, balloon angioplasty (class I) is the preferred mode of intervention. V. For children weighing <25 kg with native coarctation, balloon angioplasty (class I) or surgery (class IIa), may be performed. VI. For children weighing <25 kg with recoarctation, balloon angioplasty ± stenting (class I) is the preferred mode of intervention. VII. For children weighing >25 kg and adults, with native coarctation, catheter-based stenting (class IIa) is the preferred mode of intervention. VIII. For children weighing >25 kg and adults, with recoarctation, catheter-based stenting (class I) is the preferred mode of intervention. ## Indications of using a covered stent (provided the anatomy is suitable) The following are the indications: I. Native coarctation where risk of rupture of the aorta is high (BAV with ascending aorta dilation, nearly atretic isthmus [<3-mm diameter], Turner syndrome, age >60 years, Marfan syndrome). II. Recoarctation with aneurysm or pseudoaneurysm at the site of CoA. ## Important determinants of long-term prognosis Residual or recurring coarctation, status of the aortic valve (if bicuspid), aneurysms of the ascending aorta or aneurysm at the intervention site, premature coronary artery disease, and berry aneurysms of the circle of Willis are important determinants of long-term prognosis. ## Follow-up recommendations I. Lifelong follow-up is required. II. Annual follow-up is required initially, later every 2e3 years if there are no residual lesions. III. Clinical assessment should include measuring upper and lower limb blood pressure. Echocardiography should be done at each follow-up to exclude any residual issues and to assess for other abnormalities, such as BAV. IV. Beyond 5 years of age, echocardiography alone may not be sufficient for evaluation. cMRI or CTA is recommended every 3e5 years or earlier. cMRI is preferable in postsurgical and posteballoon angioplasty patients whereas CTA is preferred after endovascular stenting. IE prophylaxis is needed for 6 months after surgery and intervention. However, all patients are advised to maintain good orodental hygiene after this period also. # Aortic stenosis background Aortic stenosis (AS) is most often due to stenosis of the aortic valve (80e85%) but can also be due to obstruction below the valve (subvalvar, 15%, mostly due to discrete membrane) or above the valve (supravalvar, least common). AS is more common in males. BAV has been identified in 1% of the general population; however, the incidence of valvar AS is 0.2e0.4/1000 live births.BAV occurs in 9% of asymptomatic first-degree relatives of patients with BAV. [bib_ref] A prospective study to assess the frequency of familial clustering of congenital..., Huntington [/bib_ref] Severity of AS usually progresses in 89% of children younger than 2 years, and 61% of children older than 2 years. [bib_ref] Natural history of congenital aortic valvar stenosis: an echo and Doppler cardiographic..., Kiraly [/bib_ref] Ascending aorta dilation (aortopathy), as defined by a Z score >2, has been seen in 74% of children with BAV, and the dilatation tends to worsen over time. [bib_ref] Dilatation of the ascending aorta in paediatric patients with bicuspid aortic valve:..., Warren [/bib_ref] ## Diagnostic workup The workup includes clinical assessment, X-ray of the chest, ECG, and echocardiography. It is reasonable to screen first-degree relatives of patients with BAV or unicuspid aortic valve with echocardiography for valve disease and aortopathy. CTA/cMRI may be required in older patients with BAV to assess severity of aortopathy and in select cases of supravalvar AS. Cardiac catheterization is performed primarily for therapeutic balloon valvuloplasty for valvar AS. Exercise testing may be performed for asymptomatic patients with borderline gradients and a normal ECG. ## Indications and timing of treatment Valvar AS I. Immediate intervention is required in the following situations: a. Newborns with severe AS who are duct dependent (balloon dilation or surgical valvotomy) (class I). b. Patients with left ventricular dysfunction due to severe AS, regardless of the valve gradient (class I). II. Elective balloon dilation is required in the following situations: a. Asymptomatic or symptomatic patients with AS having a peak gradient of >64 mmHg or a mean gradient of >40 mmHg on echo Doppler (class I). b. Patients with symptoms due to AS (angina, exercise intolerance) or ECG showing ST segment changes at rest or during exercise: balloon dilation should be considered for peak to peak gradient (invasively measured) of 40 mmHg (class I). c. An asymptomatic child or adolescent with a peak to peak gradient (invasively measured) of 40 mmHg but without STeT wave changes, if the patient wants to participate in strenuous competitive sports (class IIb). III. Balloon dilation should not be performed for AS in the presence of preexisting AR of more than mild severity (class III). Subvalvar AS due to discrete membrane. Surgical intervention is indicated in the following situations: I. Patients with a peak instantaneous gradient of 50 mmHg (class I). II. Patients with a peak instantaneous gradient of <50 mmHg associated with AR of more than mild severity (class I). III. Patients with a peak instantaneous gradient between 30 and 50 mmHg (class IIb). IV. Symptomatic patients with a peak instantaneous gradient <50 mmHg in the following situations: a. Presence of left ventricular dysfunction attributable to obstruction (class I). b. When pregnancy is being planned (class IIa). c. When the patient plans to engage in strenuous/competitive sports (class IIa). Supravalvar AS. Surgical intervention is indicated in the following situations: I. Symptomatic patients with a peak instantaneous gradient 64 mmHg and/or mean gradient 50 mmHg on echo-Doppler (class I). II. Patients with a mean Doppler gradient <50 mmHg, if they have symptoms (exertional dyspnea, angina, syncope), or left ventricular systolic dysfunction, or severe left ventricular hypertrophy attributable to obstruction, or evidence of myocardial ischemia due to coronary ostial involvement (class I). III. Asymptomatic patients with a mean Doppler gradient 50 mmHg may be considered for surgery when the surgical risk is low (class IIb). All patients with AS must be advised to maintain good orodental hygiene. ## Important determinants of long-term prognosis Residual or recurring stenosis, progressive aortic dilation, and complications related to prosthetic valve function, such as stuck valve leaflet, paravalvular leak, patient-prosthetic mismatch, and pannus formation. Recommendations for follow-up I. All patients with AS require life-long follow-up, irrespective of the type of intervention. II. Clinical assessment, ECG, and echocardiography are required, the interval depending on the severity of stenosis. III. For those who have undergone a valve replacement, periodic monitoring of anticoagulation (international normalized ratio [INR] levels) is essential. Follow-up after valve interventions should be conducted annually. IV. Echocardiography is the mainstay for follow-up for assessment of aortic valve, ventricular function, and aforementioned postoperative issues. V. Patients who have significant AS and are planned for an intervention should refrain from any sporting activity. Those with asymptomatic moderate stenosis can exercise with low or moderate intensity. Patients with a mild degree of stenosis can participate in all sports. VI. IE prophylaxis is recommended in patients with a prosthetic valve. However, all patients with AS are advised to maintain good oro-dental hygiene. # Pulmonic stenosis background Pulmonary stenosis (PS) constitutes 8e10% of all patients with CHD. [bib_ref] The incidence of congenital heart disease, Hoffman [/bib_ref] The obstruction is at the valve level in 80e90% of patients. The pulmonary valve is dysplastic in 10e20% of patients. [bib_ref] Congenital pulmonary stenosis resulting from dysplasia of valve, Koretzky [/bib_ref] Older patients with valvar PS are often asymptomatic, and the diagnosis is made on incidental detection of a murmur. Occasionally, however, they present in heart failure due to right ventricular dysfunction secondary to severe PS. PS may remain stable, progress, or rarely improve. The natural history of patients with valvar PS is excellent with the 1-year, 2-year, and 15-year actuarial survival rate of 97%, 96%, and 94%, respectively. 25 ## Diagnostic workup The workup includes clinical assessment, X-ray of the chest, ECG, and echocardiography. Cardiac catheterization is performed for balloon valvuloplasty. Indications and timing of treatment for valvar pulmonic stenosis I. Immediate intervention is required in the following situations: a. Newborns with severe PS who are duct dependent (class I). b. Infants, children, or adults with right ventricular dysfunction due to severe PS, regardless of the valve gradient (class I). II. Elective balloon dilation is required in the following situations: a. Asymptomatic or symptomatic patients with valvar PS having a peak instantaneous gradient of >64 mmHg on echo-Doppler (class I). b. Neonates and infants with any degree of PS who have hypoxia due to mild hypoplasia of the right ventricle (RV), even if right ventricular function is normal (class IIa). c. Patients with valvar PS due to dysplastic valve, who meet the aforementioned criteria (class IIa). ## Mode of intervention I. Balloon dilatation (class I) is the preferred mode of intervention. II. Surgical intervention is reserved for subvalvar or supravalvar PS (indications same as in valvar PS), Noonan syndrome (dysplastic valve) with hypoplastic annulus, and failed balloon dilatation (class I). Recommendations for follow-up I. All patients with PS require life-long follow-up. II. Clinical assessment, ECG, and echocardiography is required at each visit, the interval depending on the severity of stenosis. III. Infants with mild PS in whom intervention is not indicated, should be followed up 3-monthly until one year of age. Thereafter, they should be followed up every 1e2 years until 10 years of age and later every 3e5 years. Those with more than mild stenosis (native or after balloon dilation) may be followed up every year beyond the infancy period. IV. IE prophylaxis is recommended in patients with a prosthetic valve. However, all patients with PS are advised to maintain good oro-dental hygiene. ## Tetralogy of fallot Background Tetralogy of Fallot (TOF) is the commonest cyanotic CHD with a prevalence of 0.4 per 1000 live births, constituting about 5% of all congenital heart defects. [bib_ref] The incidence of congenital heart disease, Hoffman [/bib_ref] The clinical signs and symptoms generally vary in accordance with the degree of right ventricular outflow tract obstruction. Intermittent hypercyanotic spells are one of the defining features of TOF. Peak incidence of these episodes occurs between the second and sixth month of life, and these become infrequent after 2 years of age.Patients with untreated TOF have an estimated 1-year, 3-year, and 10-year survival of 66%, 49%, and 24%, respectively. 27 ## Diagnostic workup The workup includes clinical assessment, pulse oximetry, ECG, X-ray of the chest, and echocardiography. CTA or cardiac catheterization and angiography should be performed for older children and adults to confirm echocardiographic findings and to delineate coronary artery anatomy and aortopulmonary collaterals. Indications and timing of surgery I. All patients need surgical repair. II. In stable patients with minimal cyanosis, total repair is indicated at 6e12 months of age or earlier according to the institutional policy (class I). Those presenting later in life should undergo surgical repair whenever diagnosed. III. For symptomatic children aged <6 months with significant cyanosis or history of spells despite therapy, palliation (by systemic-to-pulmonary artery shunt or stenting of the ductus arteriosus/right ventricular outflow tract or pulmonary valve balloon valvuloplasty) or total repair is indicated depending on the anatomy and center's experience (class I). IV. Lower threshold for earlier surgery if no requirement of the transannular patch is anticipated. V. For patients having TOF with absent pulmonary valve who are stable, medical management is indicated until 1 year of age followed by total correction with repair of PA branch dilation/aneurysm (class I). VI. For patients with an anomalous left anterior descending artery from the right coronary artery crossing the right ventricular outflow tract, who are likely to need right ventricle to pulmonary artery conduit (class I), the intervention varies as per weight of the patient: a. For those weighing <10 kg and with significant cyanosis, aorto-pulmonary shunt is indicated. b. For those weighing >10 kg, total repair using a conduit, or double-barrel approach after two years of age is indicated. ## Important determinants of long-term prognosis These include pulmonary regurgitation (almost invariably present after repair), residual lesions (VSD, right ventricular outflow tract obstruction, PA branch stenosis), right ventricular outflow tract aneurysms, aortic root dilatation, ventricular dysfunction, conduction abnormalities, and arrhythmias. Recommendations for follow-up I. All patients operated for TOF require life-long follow-up in view of the aforementioned postoperative issues. II. Asymptomatic patients with no residual lesion but with free pulmonary regurgitation, not requiring intervention, should be followed up every 1e2 years. III. Clinical assessment, ECG, and echocardiography are to be done at each visit. Holter monitoring is indicated in patients suspected of having arrhythmia. IV. Cardiac catheterization should be performed if any residual lesion is suspected. It may also be required for a percutaneous intervention such as stenting of the PA branch for stenosis. V. cMRI is an important investigation for follow-up of these patients. In asymptomatic patients, the baseline study should be performed 10 years after surgery with periodic follow-up, with frequency of repeat imaging determined by anatomic and physiological findings. Right ventricular volumes and function assessment by cMRI are useful to determine the timing of pulmonary valve replacement. VI. Infective endocarditis prophylaxis is indicated for uncorrected patients, patients with percutaneous or surgical pulmonary valve replacement, and after surgical repair, for 6 months. However, all patients with TOF are advised to maintain good oro-dental hygiene even after 6 months of surgical repair. ## Indications for pulmonary valve replacement 28 The following are the indications: I. Symptomatic patients with symptoms attributed to severe right ventricular volume overload with moderate or severe pulmonary regurgitation (class I ## Vsd with pulmonary atresia Background VSD with pulmonary atresia (VSD-PA) is the most severe form of TOF, accounting for 20% of all forms of TOF. [bib_ref] Congenital heart disease among 815,569 children born between 1980 and 1990 and..., Samanek [/bib_ref] This CHD usually presents in the neonatal period with cyanosis owing to the right-to-left shunt at the ventricular level. The degree of cyanosis depends on the magnitude of pulmonary blood flow, which in turn depends on the size of PDA and/or the number and size of aortopulmonary collaterals. Untreated patients with VSD-PA have a very dismal outcome with the 1-year and 10-year survival being 50% and 8%, respectively. 27 ## Diagnostic workup The workup includes clinical assessment, pulse oximetry, ECG, X-ray of the chest, and echocardiography. Additional imaging, in the form of cardiac catheterization, CTA/cMRI, or a combination of these, is essential for planning definitive repair. ## Indications and timing of intervention Management depends on the type of VSD-PA, the institutional experience, and the clinical presentation. Generally, this lesion requires a multistage management. Type A (short-segment VSD-PA with PDA) I. In case of presentation with significant cyanosis at less than one year of age: Aortopulmonary shunt (class I) or PDA stenting (class IIa) is indicated depending on the institutional preference and feasibility. II. After the 1st intervention or for those presenting at one year of age, total correction is indicated at about 1 year of age because a RV-to-PA conduit is not required (class I). Type B (long-segment pulmonary atresia with PDA) I. In case of those presenting with significant cyanosis at less than one year of age: Aortopulmonary shunt (class I) or PDA stenting (class IIa) is indicated depending on the institutional preference and feasibility. II. After the 1st intervention or in those presenting at one year of age (class I), the intervention varies as follows: a. In case of optimal pulmonary blood flow with good-sized PAs, total repair is indicated with RV-to-PA conduit at the age of 3e4 years. b. In case of suboptimal pulmonary blood flow with small-sized PAs, an additional shunt followed by total repair with RV-to-PA conduit is indicated at the age of 3e4 years. c. In case of increased pulmonary blood flow with large-sized PAs, total repair with the RV-to-PA conduit is indicated by the age of 1 year. Type C (long-segment pulmonary atresia with confluent branch pulmonary arteries supplied by multiple aorto-pulmonary collateral arteries (MAPCAs)) (class I) I. In case of neonatal presentation, options are aortopulmonary shunt +/-unifocalisation of MAPCAs, or RV to PA conduit keeping VSD open. II. After the 1st intervention or in late presenters, the intervention varies as follows: a. In case of optimal pulmonary blood flow with good-sized PAs, total repair with RV to PA conduit and VSD closure is indicated at 3e4 years of age. b. In case of borderline PAs with large MAPCAs: i. Unifocalisation þ RV-to-PA conduit at the age of 6e12 months. ii. Total repair with RV-to-PA conduit and VSD closure at the age of 3e4 years. c. In case of increased pulmonary blood flow and large PAs, single-stage repair (unifocalisation of MAPCAs þ RV-to-PA conduit þ VSD closure) is indicated at about 1 year of age preferably with a weight of >10 kg. Type D (long-segment pulmonary atresia with nonconfluent branch pulmonary arteries supplied by MAPCAs) (class IIa) I. In case of neonatal presentation, aortopulmonary shunt þ unifocalisation of MAPCAs is indicated. II. After the 1st intervention or at late presentation: a. Unifocalisation þ RV-to-PA conduit at the age of 6e12 months. b. Total repair with RV-to-PA conduit and VSD closure at the age of 3e4 years. ## Important determinants of long-term prognosis These include conduit obstruction, degeneration, PA branch stenosis, residual VSD, aortic root dilatation, and functional abnormalities such as right ventricular volume and pressure overload, ventricular dysfunction, conduction abnormalities, and arrhythmias. Patients who have undergone palliative procedures continue to have cyanosis and may develop complications due to right-toleft shunting. ## Recommendations for follow-up I. All patients with VSD-PA require life-long follow-up. II. Annual follow-up is required for those with no residual lesion. III. Palliated patients need to be seen more frequently if their oxygen saturation is low and to decide for the next intervention. IV. cMRI is an important investigation for follow-up of these patients to determine the timing of conduit revision and pulmonary valve replacement. V. Infective endocarditis prophylaxis is indicated in noncorrected or palliated patients with cyanosis; in patients with conduits; in patients who have undergone pulmonary valve replacement; and after surgical repair for 6 months. All patients are advised to maintain good oro-dental hygiene even after 6 months of surgical repair. Indications for conduit replacement [bib_ref] ESC Guidelines for the management of grown-up congenital heart disease (new version..., Baumgartner [/bib_ref] The following are the indications: I. Symptomatic patients with right ventricular pressure greater than 80 mmHg on echo Doppler and/or moderate to severe pulmonary regurgitation (class I). II. Asymptomatic patients with right ventricular pressure greater than 80 mmHg on echo Doppler with at least one of the following symptoms (class IIa): a. Depressed right ventricular function b. Progressive right ventricular dilation c. Progressive tricuspid regurgitation d. Sustained atrial or ventricular arrhythmias ## Transposition of the great arteries background Transposition of the great arteries (TGA) is the most common cyanotic CHD at birth, accounting for approximately 5% of all CHDs.In 70% of cases, there is no associated defect (simple TGA) apart from ASD, PDA, or insignificant VSD. Association of TGA with other defects such as large VSD, left ventricular outflow tract obstruction or coarctation, etc., is referred to as complex TGA. [bib_ref] Clinical guidelines for the management of patients with transposition of the great..., Sarris [/bib_ref] It is a serious disease, and most patients with TGA present very early in life, within few days or weeks after birth. The average life expectancy for an untreated newborn is 0.65 years with mortality rate at one year being close to 90%. [bib_ref] Natural history of transposition of the great arteries: anatomy and birth and..., Liebman [/bib_ref] With the advent of improved surgical techniques and postoperative care, long-term survival is more than 90% with very low reintervention rates. [bib_ref] Cardiovascular outcomes after the arterial switch operation for D-transposition of the great..., Khairy [/bib_ref] ## Diagnostic workup The workup includes clinical assessment, pulse oximetry, ECG, X-ray of the chest, and echocardiography. Echocardiography is the key tool to establish the diagnosis and to assess site and adequacy of intermixing, associated malformations, coronary artery anatomy, and adequacy of the left ventricle to support systemic circulation after an arterial switch operation (ASO). Cardiac catheterization is generally performed for balloon atrial septostomy. CTA/cMRI is rarely required to clarify anatomy of the aortic arch or to evaluate a surgically relevant coronary anomaly suspected on echocardiography. ## Indications and timing of surgery Surgery is indicated for all patients with TGA except in those with irreversible pulmonary vascular disease. Presurgical stabilization in neonates is achieved by intravenous infusion of prostaglandin E1 to keep the ductus arteriosus open, and/or balloon atrial septostomy to create an adequate ASD (class I). Timing and type of surgery I. For patients with TGA with intact ventricular septum presenting soon after birth, arterial switch operation (ASO) is the best option (class I). ASO should be done between 7 days to 3 weeks of age; earlier if the baby is unstable or has associated persistent pulmonary hypertension of the newborn. Exact timing is based on institutional preference but is best done before 4 weeks. II. For patients with TGA with intact ventricular septum presenting beyond 3e4 weeks of life with regressed left ventricle, the type of surgery varies as follows: a. If the patient is presenting between the age of 1 and 2 months, ASO is indicated; extracorporeal membrane oxygenator (ECMO) support may be required in some cases (class IIa). b. If the patient is presenting between the age of 2 and 6 months, the options for surgical repair are: ASO with ECMO support or rapid two-stage ASO ac or an atrial switch operation (if rapid two-stage or ECMO is not feasible) (class IIa). c. If the patient is presenting between the age of 6 months and 2 years, atrial switch operation (Senning or Mustard operation) (class IIa) is indicated. Rapid two-stage ASO ac ac The first stage of rapid two-stage ASO involves retraining of the regressed left ventricle by performing PA banding along with the addition of a modified aortopulmonary shunt as the first stage. may be considered in select cases after detailed evaluation (class IIb). d. If the patient is presenting later in life with a regressed left ventricle, the patient must be assessed for operability; atrial switch operation is recommended in operable patients. III. For patients with TGA with a large VSD and/or a large PDA, ASO with VSD and/or PDA closure by 6 weeks of age (class I) is recommended. These patients tend to develop early pulmonary vascular disease and may become inoperable by the age of 6 months to one year. IV. For patients with TGA with VSD and CoA, ASO with VSD closure and arch repair is recommended as soon as possible (class I). It is preferable to repair all lesions in a single stage. V. For patients with TGA with VSD and significant left ventricular outflow tract obstruction, the type and timing of surgery varies as follows (class I): a. In those with subvalvar pulmonary obstruction with normal or near-normal pulmonary valve and pulmonary annulus, ASO with resection of subvalvar stenosis is recommended. b. If the obstruction involves the pulmonary valve or is subpulmonary but not amenable to resection, the approach is as follows: i. For neonates and infants presenting with significant cyanosis, surgical options depend on the patient's age and surgeon's preference: a) Systemic-to-pulmonary artery shunt (at any age) followed by Rastelli-type repair (at 2e3 years of age, or when the child weighs >10 kg), or root translocation later. b) R eparation a l'Etage Ventriculaire procedure (usually done at the age of 4e6 months) c) Pulmonary root translocation (usually done at the age of 6e12 months). d) Nikaidoh procedure (usually done beyond 6e9 months of age) ii. For older, stable patients, presenting beyond 2e3 years of age, one of the following surgeries may be opted for: Rastelli-type repair, Nikaidoh procedure, or root translocation surgery. c. If the VSD is remote and not amenable to one of the biventricular repairs, multistage palliative cavopulmonary connection (class IIa) is recommended. ## Important determinants of long-term prognosis Long-term prognosis after surgery depends on the type of surgery performed. Attention should be paid to specific issues such as residual defects, coronary insufficiency with resultant myocardial ischemia/ventricular dysfunction, supravalvar obstruction of outflow tracts, neoaortic valve regurgitation, neoaortic root dilatation, arrhythmias, residual pulmonary hypertension, and recurring or late pulmonary hypertension. Specific issues after atrial switch operation include atrial arrhythmias, baffle leaks and obstructions, and development of right ventricular dysfunction. Recommendations for follow-up I. All patients need lifelong follow-up. Follow-up intervals depend on age, type of surgery, and residual findings. II. In operated patients with no residual defects, follow-up visits should be at 1, 3, and 6 months after surgery, yearly after that until the onset of adult life, and every 2e3 yearly thereafter. III. Follow-up visits should include clinical assessment, ECG, and echocardiography. IV. Holter monitoring is done when suspecting arrhythmias or myocardial ischemia. Frequent Holter monitoring may be required after atrial switch operation. V. CTA or cMRI for coronary evaluation should be done at least once at 5e10 years of age. Earlier and more frequent evaluation of coronary arteries may be carried out in cases who had intramural coronary artery or difficult coronary transfer at the time of surgery. Infective endocarditis prophylaxis is recommended in patients with cyanosis, in cases with use of conduits or other prosthetic material during surgery, and for 6 months after definitive surgery. However, all patients are advised to maintain good oro-dental hygiene even after 6 months of definitive surgery. ## Double outlet right ventricle background Double outlet right ventricle (DORV) constitutes less than 1% of all congenital heart defects.VSD is the only outlet for the left ventricle, and it could be subaortic (60e65%), subpulmonary (20e25%), doubly committed (3e5%) or remote (noncommitted, 5%). [bib_ref] Double-outlet right ventricle. Anatomic and angiocardiographic correlations, Sridarormont [/bib_ref] The clinical presentation is variable and depends on the location of VSD, the presence or absence of obstruction to pulmonary blood flow, and associated cardiac anomalies. [bib_ref] The incidence of congenital heart disease, Hoffman [/bib_ref] Clinical presentation of DORV can be divided into three types: TOF-like presentation, VSD-like presentation, and TGA-like presentation. Patients with subaortic or subpulmonary VSD can have total biventricular repair. Those with noncommitted or remote VSD have complex anatomy and may not be suitable for biventricular repair. ## Diagnostic workup The workup includes clinical presentation, ECG, X-ray of the chest, and echocardiography. Cardiac catheterization is performed in late presenters with pulmonary hypertension suspected of having high PVR. It may also be done in other patients, especially adults, to define the anatomy better. The presence of associated arch hypoplasia or coarctation may necessitate CTA or cMRI. Threedimensional reconstruction of CT images helps to assess routability of VSD to aorta. ## Indications and timing of surgery Surgery is indicated for all patients with DORV except in those with irreversible pulmonary vascular disease. Timing and the type of surgery depends on the DORV variant (class I): I. For those with DORV with subaortic VSD and severe PS (TOFtype DORV), the type of surgery varies as follows: a. For those presenting with significant cyanosis at the age of <3e4 months: aortopulmonary shunt is indicated. b. For those presenting with significant cyanosis at the age of >3e4 months, total repair with closure of VSD and infundibular resection is indicated. c. For stable patients with no or minimal cyanosis, total repair with closure of VSD and infundibular resection is indicated by the age of 6e12 months. or later if presenting beyond this age. II. For those with DORV and large subaortic VSD and pulmonary hypertension (VSD-type DORV), VSD closure is indicated by 6 months of age. In patients presenting beyond 6 months of age, VSD can be closed, if operable on assessment. III. For those with DORV and subpulmonary VSD and pulmonary hypertension (TGA-type DORV), ASO with VSD closure is indicated by 6 weeks of age. If presenting beyond 3 months, patient should be evaluated for operability. IV. For those with DORV with subpulmonary VSD and severe PS, the type of surgery varies as follows: a. If pulmonary obstruction is localized, for example, subvalvar fibrous membrane or ridge, ASO with resection of subvalvar stenosis is indicated. b. If pulmonary obstruction is tubular or valvar, one should try to perform biventricular repair as far as possible, and this may necessitate a conduit from the RV to PA. Univentricular palliation is done if biventricular repair is not possible. A systemic-to-PA shunt may be required in those presenting early with significant cyanosis. Please refer to the section on "TGA with VSD and left ventricular outflow tract obstruction" for more details. V. For those with DORV and remote VSD or associated with other complex anatomy, biventricular or univentricular repair is indicated depending on the anatomy. ## Recommendations for follow-up I. All patients need lifelong follow-up; frequency to be individualized depending on the type of surgery, presence or absence of residual lesions, and functional status. II. If there is no residual defect after surgery, annual follow-up is needed until adult life and then every 2 years. III. Follow-up visits should include clinical assessment, ECG, and echocardiography. IV. Holter monitoring should be done every 2e3 years after the age of 5 years. Infective endocarditis prophylaxis is recommended for patients with cyanosis and for cases with conduits or other prosthetic material in the heart. Prophylaxis is also required for 6 months after definitive surgery. However, all patients with DORV are advised to maintain good oro-dental hygiene even after 6 months of definitive surgery. ## Congenitally corrected tga background Congenitally corrected TGA (ccTGA) is a congenital heart defect characterized by atrio-ventricular and ventriculo-arterial discordance. This double discordance results in physiologically corrected circulation as the great arteries receive appropriate blood. ccTGA is a rare condition occurring in 0.3 per 10,000 live births and constitutes 0.5% of all congenital heart defects.Although the physiology is corrected, anatomy is not corrected, and the morphologic RV supports systemic arterial circulation. In more than 90% of cases, ccTGA is accompanied by other cardiac lesions: VSDs in 80%, PS (obstruction of the outflow from morphologic left ventricle) in 30e50%, abnormalities of the conduction system in 15e50%, ASD in 12%, and tricuspid valve abnormalities (as detected at autopsy) in 90%. [bib_ref] Congenitally corrected transposition of the great arteries: current treatment options, Dyer [/bib_ref] Mismatch between visceral situs and cardiac position is common, with dextrocardia/mesocardia in one-fourth of patients. The risk of developing CHB is 2% per year, and about 30% patients develop CHB by adulthood. [bib_ref] Complete atrioventricular block in patients with atrioventricular discordance, Huhta [/bib_ref] The function of the RV deteriorates after the second decade even in those without any associated anomaly. [bib_ref] Long-term function of the morphological right ventricle in adult patients with congenitally..., Dimas [/bib_ref] ## Diagnostic workup The workup includes clinical assessment, ECG, X-ray of the chest, and echocardiography. Cardiac catheterization may have to be performed for demonstrating coronary anatomy or for measurement of PA pressure and PVR. ## Indications and timing of surgery The indications and timing of surgery in ccTGA patients depends on the presence of associated anomalies. [bib_ref] What do we really know about the management of patients with congenitally..., Tweddell [/bib_ref] [bib_ref] ACC/AHA 2008 guidelines for the management of adults with congenital heart disease:..., Warnes [/bib_ref] General recommendations I. Tricuspid valve (systemic atrioventricular valve) surgery for severe regurgitation should be considered before systemic ventricular failure (ejection fraction <45%) sets in (class IIa). II. Anatomic repair (double switch operationdatrial switch plus arterial switch or Rastelli) may be considered when the left ventricle is functioning at systemic pressure and when such surgery is feasible (class IIa). Indications and timing for specific groups of ccTGA I. In case of no associated anomalies, patient should be regularly followed to look for development of tricuspid regurgitation, CHB, or right ventricular dysfunction (class I). Neonatal double switch operation may be considered (class IIb). II. If associated with large VSD, the type of surgery varies as per age: a. At the age of <3 months, PA banding is indicated, followed later by double switch operation (atrial plus arterial switch) (class I). b. At the age of >6 months, double switch operation (atrial plus arterial switch) is indicated, provided that the patient has not developed irreversible pulmonary vascular disease (class I). c. At the age of 3e6 months, PA banding followed by double switch operation or direct double switch operation can be done, depending on institutional policy (class IIa). III. If associated with large VSD and severe left ventricular outflow tract obstruction (PS), the type of surgery varies as follows: a. If VSD is routable, double switch operation (atrial switch plus Rastelli) (class I) is indicated; univentricular repair pathway may be followed if the surgeon is not comfortable doing double switch operation and saturation is low (class IIa). b. If VSD is not routable, the type of intervention varies as follows: i. If saturation is good, patient may be regularly followed after informed discussion with the family (class IIa). ii. If saturation is low, univentricular repair pathway (class I) is indicated. IV. If associated with CHB, permanent, dual chamber pacemaker implantation (class I) is indicated. V. If associated with severe tricuspid regurgitation in an adult, cardiac catheterization should be done to measure the pressure in the left ventricle. a. In case of good right ventricular function and prepared left ventricle, double switch operation and tricuspid valve repair (class IIa) is indicated. b. In case of good right ventricular function and low left ventricular pressure, tricuspid valve repair/replacement (class IIb) is indicated. VI. If associated with severe right ventricular dysfunction in an adult, possible management options are: PA banding/cardiac resynchronization therapy/cardiac transplant (class IIa). ## Recommendations for follow-up I. All patients with ccTGA require lifelong follow-up, usually every year. II. Clinical assessment, ECG, and echocardiography should be done at each visit. III. Additional imaging may be required for better delineation of anatomy and function in adult patients, best done with cMRI. IV. Holter monitoring, exercise testing, and electrophysiological study may be indicated in select patients. Infective endocarditis prophylaxis is recommended for all patients with cyanosis and in cases with conduits or other prosthetic material in the heart. However, all patients with ccTGA are advised to maintain good oro-dental hygiene. ## Univentricular hearts (single ventricles) Background Univentricular hearts are defined as presence of one ventricle instead of two, or the second ventricle is rudimentary without an inlet portion. It also includes those congenital heart defects where two-ventricle (or biventricular) repair is not possible. Classical examples include double inlet left ventricle, tricuspid atresia, hypoplastic left heart syndrome, unbalanced AVSD, and nonroutable or multiple VSDs. These defects are grouped together as "functional univentricular" heart because the management is on the lines of single ventricle. [bib_ref] Congenital heart surgery nomenclature and database project: single ventricle, Jacobs [/bib_ref] Univentricular hearts constitute 2.8% of all congenital heart defects. [bib_ref] The incidence of congenital heart disease, Hoffman [/bib_ref] [bib_ref] Univentricular heart, Khairy [/bib_ref] The clinical presentation depends on the ratio of pulmonary to systemic blood flow. ## Diagnostic workup The workup includes clinical assessment, pulse oximetry, ECG, X-ray of the chest, and echocardiography. Cardiac catheterization is required for assessing PVR in patients with unrestricted pulmonary blood flow, those presenting late, and for interventions such as occlusion of aortopulmonary collaterals and in certain operated patients with treatable complications. cMRI may be required for older children and adults who have undergone Fontan operation for assessing ventricular volumes and function. Timing and type of intervention Preamble. Surgery for univentricular heart is a palliative procedure. The life expectancy is less than normal (exact age cannot be predicted) and is interposed by interventions over these years. [bib_ref] ACC/AHA 2008 guidelines for the management of adults with congenital heart disease:..., Warnes [/bib_ref] The treating physician must inform and discuss the details with the family before surgery. The timing and type of intervention depends on the age at presentation and presence or absence of obstruction to pulmonary blood flow. I. For those presenting in the neonatal period or within 2-3 months of life, the type of intervention is as follows (class I): a. In those with increased pulmonary blood flow, PA banding is indicated at 4e6 weeks of age, preferably before the age of 3 months. b. In those with decreased pulmonary blood flow (PS group): systemic-to-pulmonary artery shunt or stenting of the ductus arteriosus (depends on institutional policy and clinical scenario) is done if systemic arterial saturation is consistently below 70e75% or if there is pulmonary atresia with ductdependent pulmonary circulation. II. For those presenting later in life or who have undergone first surgery earlier, the type of intervention varies as follows: a. In those with pulmonary hypertension and no PS, most patients presenting beyond the age of 3e4 months would be unsuitable for PA banding or any definitive repair in the future owing to irreversible increase in PVR. A minority may continue to have low resistance and should be offered PA banding after complete evaluation (including cardiac catheterization for operability). b. In those with normal pulmonary pressure and resistance due to PS/previous PA banding/previous aortopulmonary shunt, the type of intervention varies as follows: i. Bidirectional Glenn procedure is indicated between 6e12 months of age (class I). ii. Total cavopulmonary connection or completion of Fontan procedure (preferably extracardiac) is indicated between 4 and 7 years of age when the child weighs 15e20 kg. If Fontan is required earlier (owing to increasing cyanosis or due to pulmonary arteriovenous malformations), a lateral tunnel Fontan can be performed at an age of 3e4 years. Fenestration of the Fontan circuit is indicated in high-risk cases. iii. In adults who have a balanced pulmonary blood flow and are asymptomatic with minimal desaturation, the role of palliative surgeries is not clear; however, such patients should remain under follow-up. ## Important determinants of long-term prognosis The patients palliated for univentricular hearts experience a number of morbidities in the long term. These include development of ventricular dysfunction, growth failure, worsening cyanosis, arrhythmias, atrioventricular valve regurgitation, thrombosis and thromboembolic events, protein losing enteropathy, plastic bronchitis, hepatic dysfunction, and chronic Fontan failure. Recommendations for follow-up I. All patients with univentricular heart (operated or unoperated) require lifelong follow-up. Frequency should be individualized, but it should be at least once a year in stable cases. II. Follow-up includes clinical assessment, oxygen saturation, ECG, X-ray of the chest, and echocardiography. In addition, hematological, kidney, and liver function tests should be done for all post Fontan patients. cMRI may be performed at least once in adult life and then repeated, if indicated. Periodic imaging of the liver by ultrasound, and additional imaging by CT/MRI/biopsy is indicated, starting 10 years after total cavopulmonary connection. 42 III. After surgery, aspirin (3e5 mg/kg/day) is recommended for all patients. Oral anticoagulants (warfarin) and sildenafil are recommended in a select group or as per institution policy. 43 IV. The threshold for performing cardiac catheterization during follow-up should be low as a number of complications can be successfully treated if diagnosed in time. Infective endocarditis prophylaxis is recommended in patients with cyanosis and in cases with conduits or other prosthetic material in the heart. However, all patients with univentricular heart are advised to maintain good oro-dental hygiene. ## Persistent truncus arteriosus background Persistent truncus arteriosus accounts for less than 1% of all congenital heart defects. Aortic arch interruption or CoA is found in 15e20% of patients with truncus arteriosus. Patients usually present in the first few weeks of life due to congestive heart failure and failure to thrive. Untreated patients have a very high mortality, mainly due to congestive heart failure, with a survival rate of 35% at 6 months and 10% at 1 year.Classification of truncus arteriosus [bib_ref] The anatomy of common aorticopulmonary trunk (truncus arteriosus communis) and its embryologic..., Van Praagh [/bib_ref] The classification is as follows: I. Type A1: The aorta and main PA originate from a single large common trunk. II. Type A2: Both pulmonary arteries arise separately and directly from the truncus. III. Type A3: One PA arises from the truncus, and the other is supplied by the PDA or collaterals from the aorta. IV. Type A4: There is an associated obstructive lesion of the aortic arch. ## Diagnostic workup The workup includes clinical assessment, pulse oximetry, X-ray of the chest, ECG, and echocardiography. CTA and cMRI are useful when the anatomy is unclear on echocardiography, especially for evaluation of the aortic arch. Cardiac catheterization is indicated in patients presenting late for operability assessment. ## Ideal age for surgery Surgery is indicated for all, unless the patient is inoperable due to irreversible pulmonary vascular disease. I. In case of uncontrolled heart failure, surgical repair is indicated as soon as possible (class I). II. In case of controlled heart failure, surgical repair is indicated by 3e6 weeks of age (class I). Type of surgery Total repair is indicated using the RV-to-PA conduit. The prospects of repeat surgeries in future for conduit obstruction should be discussed with the family. Truncal valve repair is performed if the valve is regurgitant. ## Contraindication for surgery Severe pulmonary arterial hypertension with irreversible pulmonary vascular occlusive disease (class III) is a contraindication for surgery. Signs of inoperability include age more than 1 year, resting systemic arterial saturation <85%, and absence of cardiomegaly. ## Important determinants of long-term prognosis These include residual or progressive pulmonary hypertension, the need for conduit replacement, progressive truncal/neoaortic valve regurgitation, aortic root dilatation/aneurysm, and recurrent arch obstruction in Type A4. Recommendations for follow-up after surgery I. Lifelong follow-up is required in view of aforementioned postoperative issues. II. Follow-up after surgery includes clinical assessment, X-ray of the chest, ECG, and echocardiography at 1, 6, and 12 months and yearly thereafter in stable cases. Infective endocarditis prophylaxis is recommended after surgical repair due to the presence of conduit. All patients are advised to maintain good oro-dental hygiene. ## Total anomalous pulmonary venous connection background Total anomalous pulmonary venous connection (TAPVC) accounts for 1% of all patients born with congenital heart defects. [bib_ref] The incidence of congenital heart disease, Hoffman [/bib_ref] TAPVC is classified into four types depending on the site of drainage: supracardiac (45e50%), cardiac (15e20%), infracardiac (26e28%), and mixed (where the drainage is at two or more sites, 5e8%). [bib_ref] Total anomalous pulmonary venous connection: morphology and outcome from an international population-based..., Seale [/bib_ref] Each type can be obstructive or nonobstructive. Obstruction to the drainage of pulmonary veins is most common in the infracardiac variety and least common in the cardiac type. If not treated, TAPVC has a very high mortality, with 85% dying in the first year of life. Exceptionally, some may present later during adult life with features suggestive of a large ASD and mild desaturation. ## Diagnostic workup The workup includes clinical assessment, ECG, X-ray of the chest, and echocardiography. Cardiac catheterization may be required for older children and adults for assessing PA pressures and defining the anatomy. Indications and timing of surgery (all are class I recommendations) I. All patients need surgical repair. II. Patients with obstructive TAPVC should undergo emergency surgery. III. Surgery should be performed as early as possible for those with nonobstructive TAPVC, even if they are asymptomatic. IV. Those presenting late should be evaluated for the onset of pulmonary vascular disease and operated if the data suggests operable status. ## Important determinants of long-term prognosis These include pulmonary vein stenosis, pulmonary hypertension, stenosis of surgically created anastomosis, and late-onset arrhythmias. Recommendations for follow-up I. After surgery, patients should be followed up at one month,months, and then annually for 5 years if there is no residual defect and pulmonary hypertension. II. ECG and echocardiography should be carried out at each visit. III. CTA/cMRI should be carried out in operated patients suspected to have developed pulmonary venous obstruction. IV. Because arrhythmias can occur long after TAPVC surgery, parents/patients should be informed to report if any symptom suggestive of arrhythmia develops later. Infective endocarditis prophylaxis is indicated for noncorrected patients and for patients after surgical repair for 6 months. However, all patients with TAPVC are advised to maintain good orodental hygiene after this period also. ## Ebstein's anomaly of the tricuspid valve background Ebstein's anomaly is rare, constituting less than 1% of all congenital heart defects.Patients usually present either in the neonatal period or during adolescence or adult life. Older patients present with murmur, arrhythmias, or cyanosis. The estimated survival is 76% and 53% at 10-year and 15-year follow-up, respectively, when diagnosed in adulthood. [bib_ref] The adult patient with Ebstein anomaly, outcome in 72 unoperated patients, Attie [/bib_ref] Prognosis is poor in those diagnosed during fetal or neonatal life. ## Diagnostic workup The workup includes clinical assessment, ECG, X-ray of the chest, and echocardiography. Cardiac catheterization is rarely performed and may be done for evaluating coronary arteries in older patients (age >40 years) planned for surgical repair of Ebstein's anomaly. cMRI provides quantitative measurement of the functional right ventricular size, volume, and function, which are important when planning surgical repair. ## Indications and timing for treatment Tricuspid valve repair is best done at about 2 years of age for stable cases. I. Surgery is indicated (class I) for those with any of the following: deteriorating exercise capacity, cyanosis (oxygen saturation <90%), paradoxical embolism, progressive cardiomegaly on chest X-ray (CT ratio >0.65), or progressive dilation or dysfunction of the RV on echocardiography. II. If the patient is symptomatic with arrhythmias, catheter ablation is indicated. Surgery is indicated, if arrhythmia is not amenable to catheter ablation (class IIa). ## Types of surgery The type of surgery depends on the underlying anatomy and size of the functional ventricle and is as follows: I. Tricuspid valve repair; replacement only if repair cannot be achieved II. Tricuspid valve repair with bidirectional cavopulmonary anastomosis (one and a half ventricle repair) III. Single-ventricle repair (aortopulmonary shunt/Glenn followed by Fontan surgery) ## Important determinants of long-term prognosis These include recurrence of tricuspid valve regurgitation with need for reoperation, right ventricular dilatation and dysfunction, supraventricular and ventricular tachyarrhythmias, and need for pacemaker implantation. ## Recommendations for follow-up I. Lifelong follow-up is required for all patients with Ebstein's anomaly. II. ECG, X-ray of the chest, and echocardiography should be performed at each visit. Holter monitoring, exercise testing, and cMRI may be required for select patients. III. Asymptomatic patients who are not candidates for surgery can be followed up every 2e3 years. IV. Those who have undergone tricuspid valve replacement with a prosthetic valve should be closely monitored by INR testing for optimal anticoagulation. Infective endocarditis prophylaxis is indicated for patients who have undergone tricuspid valve replacement, have previous history of endocarditis, or have cyanosis. However, all patients with Ebstein's anomaly are advised to maintain good oro-dental hygiene. ## Mitral regurgitation and aortic regurgitation background Mitral regurgitation (MR) and aortic regurgitation (AR) occur most commonly secondary to acute or chronic rheumatic heart disease, and both may coexist in some patients. Congenital MR is uncommon; however, congenital AR due to a BAV is not rare. A proportion of patients with VSD, subaortic stenosis, and TOF develop AR in the course of the disease. These valve lesions can also develop secondary to infective endocarditis. Mild to moderate valve regurgitation has a long asymptomatic period; however, the deterioration is fast once symptoms develop. Dyspnea is a late feature in the course of both, chronic MR and chronic AR. ## Diagnostic workup The workup includes clinical assessment, ECG, X-ray of the chest, and echocardiography. Measurement of left ventricular dimensions by serial echo-Doppler helps in deciding the timing of valve surgery. Exercise testing is performed for select cases where symptoms are out of proportion to severity of the valve lesion. Cardiac catheterization is rarely required. CTA or cMRI may be needed in select cases of AR to define the ascending aorta and aortic arch. Role of drug therapy I. Drugs are not required for asymptomatic cases with mild or moderate MR. II. Angiotensin-converting enzyme inhibitors are indicated in patients with severe MR and severe AR. These drugs are usually required over a short term prior to surgery but may be used for a long term in patients with symptoms, or patients with left ventricular dysfunction who are not candidates for valve surgery. It may be used in asymptomatic patients with normal left ventricular systolic function to extend the compensated phase, prior to the need for valve surgery. III. Diuretics to be used in those with dyspnea due to heart failure. IV. Sodium nitroprusside infusion is recommended for treatment of acute MR; invasive blood pressure (BP) monitoring is required in these cases. V. Anticoagulants (oral) to be prescribed if atrial fibrillation is present. VI. Secondary prophylaxis, preferably with long-acting benzathine penicillin injection, is required for patients who have underlying rheumatic heart disease as the etiology of MR or AR. ## Indications and timing of surgery Mitral regurgitation [bib_ref] Acute rheumatic fever and rheumatic heart disease, Carapetis [/bib_ref] All patients with valvular regurgitation must be advised to maintain good oro-dental hygiene. Type of valve surgery 50 I. Valve repairs are preferable to valve replacements (class I). II. Valve replacement in those in whom the valve cannot be repaired (class IIa). a. The Ross procedure is indicated for young patients with nonrheumatic AR (if expertise is available). b. The bioprosthetic valve is indicated in the following cases: i. Female patients planning pregnancy in future ii. Compliance with oral anticoagulation is dubious c. Prosthetic metallic valve replacements are indicated for the rest of the patients. ii. Prosthetic metallic valve: lifelong d. Oral anticoagulants are also indicated for patients who are in atrial fibrillation. II. Aspirin (dose: 3e5 mg/kg/day) should be given in addition to anticoagulation (class I) for 6 months after valve repair and bioprosthetic valve implantation, and lifelong in case of prosthetic metallic valves. New oral anticoagulant drug (dabigatran) and anti-Xa agents (apixaban and rivaroxaban) should not be used in place of warfarin/ other anticoumarin drugs in patients with prosthetic valves (class III). ## Recommendations for follow-up I. Patients with valve lesions require lifelong follow-up. II. For asymptomatic patients with MR or AR, clinical assessment, ECG, and echocardiography are recommended as per the following frequency: a. For patients with mild MR or AR, clinical assessment is recommended every year and echocardiography every 2 years. b. For patients with moderate MR or AR, clinical assessment is recommended every 6 months and echocardiography every year. c. For patients with severe MR or AR, clinical assessment and echocardiography is recommended every 6 months. More frequent follow-up may be carried out in patients showing progressive left ventricular dilation. III. For operated patients with no residual abnormality: clinical assessment, ECG, and echocardiography are recommended as follows: a. For patients with bioprosthetic valve or after valve repair, follow-up is recommended every 1e2 years. b. For patients with prosthetic metallic valves, follow-up is recommended every year. In addition, these patients require frequent monitoring of INR and fluoroscopy (for valve motion). IV. Postsurgical patients with residual valve abnormality are followed up as for native valve regurgitation. ## Infective endocarditis prophylaxis All patients must be advised to maintain good oro-dental hygiene after valve surgery. Prophylaxis is reasonable before dental procedures that involve manipulation of gingival tissue, the periapical region of teeth, or perforation of the oral mucosa, in patients with prosthetic heart valves, patients with use of prosthetic material for cardiac valve repair, such as annuloplasty rings and chords and patients with previous infective endocarditis (class IIa). 51 ## Financial support Nil. ## Conflicts of interest The authors have none to declare. ## Disclaimer These recommendations are for use by the physicians only and are not to be used for medicolegal purposes.

Tosylchloramide # Overview Tosylchloramide or N-chloro tosylamide, sodium salt, sold as chloramine-T, is a N-chlorinated and N-deprotonated sulfonamide used as a biocide and a mild disinfectant. It is a white powder that gives unstable solutions with water. Trade names of chloramine-T products include Chloraseptin, Chlorazol, Clorina, Disifin, Halamid, Hydroclonazone, Trichlorol, Minachlor, and generic Chloramin T or Tosylchloramide Sodium, among others. # Uses ## Iodination and radioiodination Hypochlorite released from chloramine-T acts as an effective oxidizing agent for iodide to form iodine monochloride (ICl). ICl rapidly undergoes electrophilic substitution predominantly with activated aromatic rings, such as those of the amino acid tyrosine. Thus, chloramine-T is widely used for the incorporation of iodine to peptides and proteins. Chloramine-T together with iodogen or lactoperoxidase is commonly used for labeling peptides and proteins with radioiodine isotopes (123I, 125I or 131I). ## Biocide Chloramine-T is available in tablet or powder form and has to be dissolved before use. It is sprayed on a surface and allowed to stand for at least 15 minutes before being wiped off or allowed to dry. It used in areas such as hospitals, laboratories, nursing homes, funeral homes, medical, dental and veterinary facilities, where control of pathogens is required, for disinfecting surfaces and soaking medical and dental equipment. The substance is also used for parasite control and for drinking water disinfection. Chloramine-T is as an algicide, bactericide, virucide, fungicide (including spores), germicide. It is also effective against mycobacteria such as tuberculosis, foot-and-mouth disease and avian influenza. The molecular structure of toluenesulfonylamide is similar to para-aminobenzoic acid, an intermediate in bacterial metabolism, which is disrupted by this sulfonamide (in the same way as by a sulfa drug). Therefore, chloramine-T is capable of inhibiting with bacterial growth with two mechanisms, with the phenylsulfonamide moiety and the hypochlorite, which destroys the DNA structure via oxidation and thereby prevents microbes from reproducing and reforming. ## Protective agent Chloramine-T reacts readily with mustard gas to yield a harmless crystalline sulfimide; chloramine-T derivatives are being studied as protective agents against poison gas. # Certifications - EN 13713 Bactericidal - EN 14675 Virucidal - EN 14476 Virucidal Norovirus - EN 1650 Fungicidal - EN 13704 Sporicidal Clostridium difficile

Ventral tegmentum # Overview The ventral tegmentum or the ventral tegmental area (VTA) (tegmentum, Latin for covering) is part of the midbrain, lying close to the substantia nigra and the red nucleus. # Pathways The VTA consists of dopamine, GABA, and glutamate neurons, and is part of two major dopamine pathways: - the mesolimbic pathway, which connects the VTA to the nucleus accumbens - the mesocortical pathway, which connects the VTA to cortical areas in the frontal lobes. # Functions The ventral tegmentum is considered to be part of the pleasure system, or reward circuit, one of the major sources of incentive and behavioural motivation. Activities that produce pleasure tend to activate the ventral tegmentum, and psychostimulant drugs (such as cocaine) directly target this area. Hence, it is widely implicated in neurobiological theories of addiction. It is also shown to process various types of emotion and security motivation, where it may also play a role in avoidance and fear-conditioning. # Presence of Gap Junctions The VTA has been shown have have a large network of GABA neurons that are interconnected via Gap junctions.

Doppler echocardiography # Overview Doppler echocardiography is a procedure which uses ultrasound technology to examine the heart by creating an image of it and measuring the speed and direction of blood flow. This procedure is frequently used to examine children's hearts for heart disease because there is no age or size requirement. - Continuous generation of ultrasound waves coupled with continuous reception Two crystal transducer with dual function: one crystal devoted to generation, one for receiving - Measures all velocities along transducer beam - Density of signal can be compared to forward flow - Shape of flow curve gives information about pressure gradient across the valve - Advantage: ability to measure high blood flow velocities accurately - Disadvantage: lack of selectivity or depth discrimination # Resources - Echocardiography (Ultrasound of the heart) - Doppler Examination - Introduction

Inferior cerebellar peduncle # Overview The upper part of the posterior district of the medulla oblongata is occupied by the inferior peduncle, a thick rope-like strand situated between the lower part of the fourth ventricle and the roots of the glossopharyngeal and vagus nerves. The inferior peduncles connect the medulla spinalis and medulla oblongata with the cerebellum, and are sometimes named the restiform bodies. # Function The inferior cerebellar peduncle carries many types of input and output fibers that are mainly concerned with integrating proprioceptive sensory input with motor vestibular functions such as balance and posture maintenance. Proprioceptive information from the body is carried to the cerebellum via the posterior spinocerebellar tract. This tract passes through the inferior cerebellar peduncle and synapses within the paleocerebellum. Vestibular information projects onto the archicerebellum. This peduncle also carries information directly from the Purkinje cells to the vestibular nuclei in the dorsal brainstem located at the junction between the pons and medulla.

Mental wellbeing at work This guideline covers how to create the right conditions for mental wellbeing at work. It aims to promote a supportive and inclusive work environment, including training and support for managers and helping people who have or are at risk of poor mental health. # Recommendations Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. The recommendations in this guideline apply to micro, small, medium-sized and large organisations equally, although some recommendations may need to be tailored to specific organisations and circumstances. # Strategic approaches to improving mental wellbeing in the workplace Adopt a tiered approach to mental wellbeing in the workplace by using organisational-level approaches as the foundation for good mental wellbeing (the first tier), followed by individual approaches (the second tier) and targeted approaches (the third tier). Adopt a preventive and proactive strategic approach to mental wellbeing at work in your organisation. Take into account: workplace culture workload job quality and role autonomy concerns that employers and employees may have about mental health, including stigma.See also the section on organisation-wide approaches. Proactively promote mental wellbeing by ensuring that it is embedded in the overall business strategy of all organisational policies and practices. Take into account the recommendations in the section on supportive work environment. Ensure that a stress risk assessment is carried out for each role as required by the Health and Safety at Work etc Act 1974, for example using the Health and Safety Executive's risk assessment template: If any risks are identified, take proactive steps to reduce the risks and their negative impacts. If a high-risk role is indicated, see the section on organisational-level approaches for high-risk occupations. Discuss with employees as necessary and feed back the results of the assessment to them. Ensure that systems are in place to provide support for employees for whom external factors are influencing their mental wellbeing. See the section on training and support for managers. Monitor and evaluate the support you provide at least on an annual basis using a relevant evaluation tool. Public Health England's evaluation in health and wellbeing provides a list of resources and summarises what they are used for. When measuring mental wellbeing, use a validated measure of mental wellbeing, for example the government's voluntary reporting on disability, mental health and wellbeing: a framework to support employers (for large employers), What Works Wellbeing's workplace wellbeing questionnaire or Warwick Medical School's Warwick-Edinburgh Mental Wellbeing Scales (WEMWBS). For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on strategic approaches to improving mental wellbeing in the workplace . Full details of the evidence and the committee's discussion are in: evidence review A: organisational universal-level approaches evidence review B: manager interventions evidence review C: targeted organisational-level approaches evidence review D: universal individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work evidence review G: expert testimony. Loading. Please wait. # Supportive work environment Foster a positive, compassionate and inclusive workplace environment and culture to support psychological safety and mental wellbeing by: ensuring active leadership and management support and engagement increasing mental health literacy encouraging and facilitating peer support (for example, using mental health champions and peer mentoring or 'buddying') supporting people who manage and support employees encouraging employees to recognise and take action to prevent discrimination in the workplace, for example by establishing and supporting staff networks being aware that mental wellbeing in the workplace also depends on factors beyond the workplace itself (such as physical health, domestic relationships, home environment and financial circumstances) and also on societal discrimination (such as racism, homophobia and sexism) promoting good communication and engagement with employees including mental health awareness in manager training (see the section on training and support for managers). Develop policies, processes and ways of working with staff that are equitable and inclusive, and that encourage a fair and supportive workplace environment and culture, in order to maximise employee wellbeing. Take into account: legal obligations (such as the Equality Act 2010 and Health and Safety at Work etc Act 1974) statutory requirements (such as the ACAS codes of practice) employer-led strategies or interventions (such as anti-bullying, work-life balance, confidentiality and flexible working). Offer employees a private space and protected time to engage with interventions, taking into account the need for confidentiality. Ensure that all employees have the opportunity and the means to access interventions (such as private access to the internet and IT equipment for remotely delivered interventions).See also the sections on organisational commitment, senior leadership and leadership style of line managers in the NICE guideline on workplace health: management practices, and the section on workplace culture and policies in NICE's guideline on workplace health: long-term sickness absence and capability to work. For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on supportive work environment . Full details of the evidence and the committee's discussion are in: evidence review A: organisational universal-level approaches evidence review B: manager interventions evidence review C: targeted organisational-level approaches evidence review D: universal individual-level approaches evidence review E: targeted individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. # External sources of support Use external expertise in the local authority (see the section on local and regional strategies and plans), Department for Work and Pensions and other agencies (for example, from the voluntary, charity and social enterprise sector or chambers of commerce) to access support for employees, including action plans and toolkits (for example, from What Works Wellbeing, Business in the Community, Mind and the Health and Safety Executive). Make employees aware that if they have mental health problems, they can use the Department for Work and Pensions' access to work mental health support service. NHS and social care staff can use the staff mental health and wellbeing hubs (and other national health and wellbeing support offers). Use local and national resources, and advice from a variety of evidence-informed sources, such as the local Improving Access to Psychological Therapies services offer, the employee's GP, professional bodies, unions and trade organisations (for example, Federation of Small Businesses, ACAS and the Chartered Institute of Personnel and Development ).See also the section on early intervention in NICE's guideline on workplace health: long-term sickness absence and capability to work. For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on external sources of support . Full details of the evidence and the committee's discussion are in: evidence review A: organisational universal-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work evidence review G: expert testimony. Loading. Please wait. # Organisation-wide approaches Involve employees and workplace representatives in identifying and minimising sources of stress at work. (See also the section on job design in NICE's guideline on workplace health: management practices.) Consider using workplace accreditations or charters, such as guidance to improve the organisation-wide workplace environment and culture (for example, the Workplace Wellbeing Charter, Mindful Employer and Mind's Workplace Wellbeing Index). Tailor interventions to meet the needs of the organisation and its employees (for example, according to the industry sector or the size of the organisation). Refer to existing guidance and best practice on job quality, work design and organisation to identify and reduce work stressors, such as Health and Safety Executive's Management Standards for work-related stress, Mindful Employer or COVID‑19-specific advice (for example, from the CIPD). Consider using staff surveys or other engagement approaches, for example working with employee representative organisations (such as trade unions or staff networks), to determine whether tailored solutions are needed to improve mental wellbeing in the workplace (for example, What Works Wellbeing's employee wellbeing snapshot survey). Consider giving all employees free access to an employee assistance programme and occupational health services, and raise awareness of them if they are offered (for small and medium-sized enterprises). (See also the section on making this guideline relevant for small and medium-sized enterprises ). Have a plan for responding to unexpected traumatic events affecting employees, such as the death of a colleague, a pandemic or a terrorist attack. This should include supporting people socially and with their mental wellbeing. For example, see the UK Health Security Agency's course on COVID-19: psychological first aid or NHS England and NHS Improvement's guidance on responding to the needs of people affected by incidents and emergencies.See also the section on monitoring and evaluation in NICE's guideline on workplace health: management practices. For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on organisation-wide approaches . Full details of the evidence and the committee's discussion are in: evidence review A: organisational universal-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work evidence review G: expert testimony. Loading. Please wait. # Training and support for managers Offer systematic support for managers. Include training, and regular refresher training, in: line management communication skills (the ability to listen, communicate clearly, understand and empathise). Equip managers with the knowledge, tools, skills and resources to: improve awareness of mental wellbeing at work promote mental wellbeing and prevent poor mental wellbeing improve employees' understanding of and engagement in organisational decisions improve communication between managers and employees.This should include managing people remotely. When offering mental health training for managers, consider including: how to have a conversation on mental wellbeing with an employee, including at times of crisis information about mental wellbeing how to identify early warning signs of poor mental wellbeing resources on mental wellbeing, including knowing where to go for further help or support in complex situations awareness of the stigma associated with poor mental wellbeing -ngoing management and monitoring of mental wellbeing in the workplace topics suggested by managers. Ensure that all managers have time to attend relevant training sessions. Empower managers to make necessary adjustments to workload or work intensity for their employees, for example flexible or hybrid working. Encourage managers to address their own mental health needs as well as those of their employees, for example by peer-to-peer support for managers on mental wellbeing. Consider a group approach to deliver mental health training. Training could be delivered either face to face or using online formats. Evaluate how mental health training for managers affects employee outcomes (for example, by surveying employees and managers or focus groups) and feed the results back into future training and strategy.See also the section on training in NICE's guideline on workplace health: management practices. For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on training and support for managers . Full details of the evidence and the committee's discussion are in: evidence review B: manager interventions evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work evidence review G: expert testimony. Loading. Please wait. # Individual-level approaches Do not use individual-level approaches to replace organisational strategies for reducing work stressors, or for the main purpose of increasing productivity. Encourage managers to create opportunities for fostering good relationships with (and between) employees, for example by socialising with them at work (in person or virtually). Create opportunities to talk with them about their general health and wellbeing. Encourage managers to discuss mental wellbeing with employees, and employees to discuss any mental wellbeing concerns they may have with their manager or another relevant person (for example, another manager, a mental wellbeing champion or a union representative): Use these conversations to identify and understand any sources of stress. Agree whether any additional support is needed and what this might be (see the section on external sources of support). Agree steps to minimise work-related stressors (see the section on approaches for employees who have or are at risk of poor mental health). Offer all employees (or help them to access) mindfulness, yoga or meditation on an ongoing basis. This can be delivered in a group or online, or using a combination of both.See also the section on supporting employers in NICE's guideline on physical activity in the workplace. For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on individual-level approaches . Full details of the evidence and the committee's discussion are in: evidence review C: targeted organisational-level approaches evidence review D: universal individual-level approaches evidence review E: targeted individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. # Approaches for employees who have or are at risk of poor mental health Ensure that confidentiality is discussed when talking with someone about their mental health (see recommendation 1.2.2), and be clear about when confidentiality will and will not be respected (that is, when the employee is considered at risk to themselves or others because of their mental health). Offer organisational support to employees identified as having or being at risk of poor mental health. This may include flexible working hours; changes to the job, workplace or culture to minimise any risks to mental wellbeing; or maintaining supportive line management relationships. (See recommendation 1.5.5 and recommendation 1.6.3.) Remind them that they can visit their GP for further assessment and support. Consider working with them to create a wellness action plan (see Mind's guides to wellness action plans). Assess whether this has highlighted if changes need to be made at an organisational level. Discuss with the employee if they would like to: have further support and, if so, whether they prefer a particular type of support have ongoing regular, confidential discussions about their mental health support needs. For employees who want further support, offer (or provide access to): cognitive behavioural therapy sessions or mindfulness training or stress management training.If employees choose not to have an intervention now, tell them that the offer will still be available in the future if they reconsider. Reassure colleagues that it is their choice whether to continue with an intervention or restart it at any time.See also the sections on sustainable return to work and reducing recurrence of absence in NICE's guideline on workplace health: long-term sickness absence and capability to work. For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on approaches for employees who have or are at risk of poor mental health . Full details of the evidence and the committee's discussion are in: evidence review C: targeted organisational-level approaches evidence review D: universal individual-level approaches evidence review E: targeted individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. # Organisational-level approaches for high-risk occupations The following recommendations are aimed at organisations, workplaces or workforces where employees are likely to experience traumatic events in the normal course of their work (such as the emergency services). See also recommendation 1.1.4. Regularly review organisational-level policies and protocols on how to support employees in high-risk occupations after an occupational traumatic event. Use data such as reasons for absence and staff turnover to ensure that support is targeted in the right way. Ensure that practice is consistent with established best practice (for example, Mind's Blue Light Programme). Offer task-focused skills training (for example, through imagery, simulation and skills training) before deployment for employees in high-risk occupations (such as emergency services) to ensure that they have the skills needed to deal with predictable and stressful occupational events.See also NICE's guideline on post-traumatic stress disorder. For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on organisational-level approaches for high-risk occupations . Full details of the evidence and the committee's discussion are in: evidence review D: universal individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. # Engaging with employees and their representatives Work with employees and their representative organisations (for example, trade unions and staff networks; see recommendation 1.2.1) to consult about how, when and where mental wellbeing interventions are offered and delivered, for example through staff surveys. Take account of the following potential barriers and facilitators when consulting with employees about interventions: workplace culture (including the concern that raising issues can impact negatively on staff roles or job security) workload concerns that employers and employees may have about mental health, including stigma, and how this may affect their ability to discuss any difficulties or engage with certain forms of support timing of the intervention and the option of delivering it in and outside the workplace and work hours specific needs and preferences of employees specific reasonable needs of the employing organisation. Ensure that factors associated with an employee such as contract type, income level, protected characteristics and job role are not barriers to accessing interventions. Do this by: monitoring intervention uptake and identifying groups where uptake is relatively low having a mechanism to identify, understand and overcome barriers to participating in the intervention. For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on engaging with employees and their representatives . Full details of the evidence and the committee's discussion are in evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. # Local and regional strategies and plans These recommendations are for local and regional authorities. Take a leadership role in championing mental wellbeing and preventing poor mental wellbeing at work as part of the local authority role in public health and wellbeing. Engage with local and regional employers, employee representatives, chambers of commerce, local enterprise partnerships and voluntary, charity and social enterprises to develop and promote health and wellbeing strategies to include mental wellbeing at work. Integrate mental wellbeing at work into local and regional public health activities and strategies. Raise awareness among the general public and employers of the importance of mental wellbeing at work, for example through social media. Identify and address local barriers and facilitators to employer engagement with local mental wellbeing at work initiatives. This could include, for example, working with employers to ensure they know about resources or services that can help them improve the mental wellbeing of their employees and minimise the resource impact that this will have, especially for micro, small and medium-sized enterprises. Offer support to help local employers improve the mental wellbeing and prevent poor mental wellbeing of their employees. This support could include advice on enablers of mental health and on developing action plans towards accreditation (see recommendation 1.4.2) or setting up a Local Workplace Health Accreditation Scheme. Curate or work with local business support organisations to list local and national sources of support for employers and employees, such as Mind, Mental Health at Work, the Department for Work and Pensions' access to work mental health support service and, for NHS and social care staff, staff mental health and wellbeing hubs (and other national health and wellbeing support offers). Explore and evaluate the value of incentives or pilot incentive programmes to promote uptake of support and encourage employers to participate in accreditation schemes (see recommendation 1.4.2). Use contracting and ethical procurement arrangements to strongly encourage supply chain organisations to promote mental wellbeing among their employees (for example, public sector organisations must use the Public Services Act 2012). For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on local and regional strategies and plans . Full details of the evidence and the committee's discussion are in: evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work evidence review G: expert testimony. Loading. Please wait. # Making this guideline relevant for small and medium-sized enterprises (including micro-enterprises) Business owners and owner-managers should address their own mental health needs as well as those of their employees. Take a preventive approach to mental wellbeing at work, for example using mental health and communication skills training to foster positive mental wellbeing, as well as tackling poor mental wellbeing. Refer to the Mental Health at Work website for curated resources and toolkits on how to improve the mental wellbeing of your employees. Seek advice and support from local authorities; local enterprise partnerships; voluntary, charity and social enterprises; trade unions and other bodies; and, for NHS and social care staff, staff mental health and wellbeing hubs (and other national health and wellbeing support offers), on how to prevent poor mental wellbeing in your employees, and how to support employees through mental ill health. Think about signing up to the Mental Health at Work Commitment to help achieve better mental health outcomes for employees. Think about accessing employee assistance programmes and occupational health services. See the Department for Work and Pensions' access to work mental health support service as an example of a low-cost service (see recommendation 1.11.2). For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on additional approaches for small and medium-sized enterprises . Full details of the evidence and the committee's discussion are in: evidence review D: universal individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work evidence review G: expert testimony. Loading. Please wait. # Terms used in this guideline This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary and the Think Local Act Personal's Care and Support Jargon Buster. ## Employee Everyone aged 16 or over in full- or part-time employment, including people on permanent, training, temporary or zero-hours contracts, those who are self-employed and volunteers. ## Mental health literacy A person's knowledge and beliefs about mental health problems and how to look after their own mental health. It includes knowing how mental health problems are managed and treated, how to seek information about them and how to recognise them. ## Organisation For the purposes of this guideline, organisation refers to any size of workplace, including micro, small and medium-sized enterprises. ## Psychological safety A person's desire and need to feel comfortable and safe in the workplace to express themselves and communicate openly. ## Role autonomy A person's ability to influence what happens in their work environment, in particular to influence matters that are relevant to their personal goals and the way in which they carry out their work. ## Staff networks Groups of employees who come together in a safe environment for discussion and support, and from which they can be a voice for change in the workplace. This includes raising awareness of issues in the wider organisation. They are commonly groups of people who identify as an under-represented group or who have a protected characteristic in the Equality Act 2010. ## Stress The Health and Safety Executive (HSE) guide on working together to reduce stress at work defines stress as the adverse reaction people have to excessive pressures or other types of demand placed on them.# Recommendations for research The guideline committee has made the following recommendations for research. # Key recommendations for research ## Individual-level interventions What is the long-term effectiveness and cost effectiveness of universal individual-level interventions on mental wellbeing in different types of organisations? For a short explanation of why the committee made the recommendation for research, see the rationale section on individual-level approaches . Full details of the evidence and the committee's discussion are in: evidence review D: universal individual-level approaches evidence review E: targeted individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. ## Organisational-level approaches for all organisations What is the long-term impact and cost effectiveness of employee assistance programme provision on mental wellbeing? For a short explanation of why the committee made the recommendation for research, see the rationale section on organisation-wide approaches . Full details of the evidence and the committee's discussion are in evidence review A: organisational universal-level approaches. Loading. Please wait. ## Training for managers What is the long-term effectiveness (more than 6 months) of manager training on employee mental wellbeing? For a short explanation of why the committee made the recommendation for research, see the rationale section on training and support for managers . Full details of the evidence and the committee's discussion are in: evidence review B: manager interventions evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. ## Approaches for micro, small and medium-sized enterprises What are the specific needs of different kinds of micro, small and medium-sized enterprises (SMEs) in promoting mental wellbeing in the workplace, including organisational, targeted and individual level approaches? For a short explanation of why the committee made the recommendation for research, see the rationale section on additional approaches for small and medium-sized enterprises . Full details of the evidence and the committee's discussion are in: evidence review D: universal individual-level approaches evidence review E: targeted individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. ## Core outcomes for study reporting Which mental wellbeing and productivity outcomes should be used in a core outcome set for research into workplace mental wellbeing? For a short explanation of why the committee made the recommendation for research, see the rationale section on strategic approaches to improving mental wellbeing in the workplace . Full details of the evidence and the committee's discussion are in: evidence review A: organisational universal-level approaches evidence review B: manager interventions evidence review C: targeted organisational-level approaches evidence review E: targeted individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. # Other recommendations for research ## Supportive work environment What are the views of organisations about the benefits of investing in mental wellbeing? For a short explanation of why the committee made the recommendation for research, see the rationale section on supportive work environment . Full details of the evidence and the committee's discussion are in: evidence review A: organisational universal-level approaches evidence review B: manager interventions evidence review C: targeted organisational-level approaches evidence review D: universal individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. ## Identifying employees at risk of poor mental wellbeing What tools (for example, wellbeing surveys) can be used to identify employees at risk of poor mental wellbeing rather than mental ill health? For a short explanation of why the committee made the recommendation for research, see the rationale section on approaches for employees who have or are at risk of poor mental health . Full details of the evidence and the committee's discussion are in: evidence review A: organisational universal-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. ## Needs of different employee groups What specific needs of employees from different groups (such as income levels, ethnic groups, male or female groups, and age groups) need addressing to facilitate access to individual-level interventions? How effective are individual-level interventions across different groups (such as income levels, ethnic groups, male or female groups, and age groups)? For a short explanation of why the committee made the recommendations for research, see the rationale section on individual-level approaches . Full details of the evidence and the committee's discussion are in: evidence review C: targeted organisational-level approaches evidence review D: universal individual-level approaches evidence review E: targeted individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. ## Approaches for micro, small and medium-sized enterprises What is the long-term effectiveness of universal individual-level interventions in different kinds of SMEs? For a short explanation of why the committee made the recommendation for research, see the rationale section on making this guideline relevant for small and medium-sized enterprises (including micro-enterprises) . Full details of the evidence and the committee's discussion are in: evidence review D: universal individual-level approaches evidence review E: targeted individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait. ## Addressing study reporting What are the key characteristics of an organisation and its employees that need to be included in reporting research into workplace mental wellbeing? For a short explanation of why the committee made the recommendation for research, see the rationale section on strategic approaches to improving mental wellbeing in the workplace . Full details of the evidence and the committee's discussion are in: evidence review A: organisational universal-level approaches evidence review B: manager interventions evidence review C: targeted organisational-level approaches evidence review E: targeted individual-level approaches evidence review F: barriers and facilitators to the implementation and delivery of interventions to improve and protect mental wellbeing at work. Loading. Please wait.# Rationale and impact These sections briefly explain why the committee made the recommendations and how they might affect practice. # Strategic approaches to improving mental wellbeing in the workplace Recommendations 1.1.1 to 1.1.7 ## Why the committee made the recommendations The committee noted that the range and nature of workplaces and organisations (especially in terms of the number of employees) made it challenging to make generic recommendations for all organisations. They agreed that some organisations might need to tailor the recommendations to make them relevant. The committee agreed on the need for organisations to embed strategic approaches to mental wellbeing into their organisational policies and practices, based on their understanding that this approach was fundamental to mental wellbeing at work and based on the evidence and expert testimony. The committee recognised that the ability of organisations to promote and support mental wellbeing is negatively affected by health inequalities and by work stressors such as bullying, poor communication, job insecurity (including zero-hours contracts), workload, monotony, isolation and poor prospects. In contrast, it is enhanced by good job quality (including a fair wage), role autonomy, organisational fairness, respect, recognition, peer support and clear communication. The committee were clear that some of these factors were outside of the remit of this guideline. A wide range of evidence from the UK showed that organisation-wide interventions may help to improve mental wellbeing and stress outcomes for employees, and may also benefit employers. The committee agreed that, in their experience, 1 of the key foundations of mental wellbeing in the workplace was an organisational commitment to it, together with a recognition that mental wellbeing is a spectrum and poor mental wellbeing is not a weakness. Organisations that took a strategic and whole-hearted approach to improving mental wellbeing from the top down tended to have the most success. The committee agreed that this was best demonstrated by organisations with a preventive and proactive approach to mental wellbeing – that is, they proactively took steps to promote mental wellbeing rather than simply tackling poor mental wellbeing. They agreed that because these organisational-level responses were so important, the first recommendations in the guideline should establish that organisation-wide strategic approaches were the foundation of good mental wellbeing at work, and that individual and targeted approaches could enhance these but were not a substitute for them. In the committee's experience, it is unlikely that individual or targeted interventions would be successful without an organisation-wide approach, but it noted the temptation for organisations to start with individual approaches because it seems easier. The committee also agreed with expert testimony on the impacts of the pandemic on mental wellbeing in the workplace that highlighted the need to view mental wellbeing as equally important to physical wellbeing in the workplace and to take it into account when drafting polices or introducing new practices. Expert testimony about the long-term impacts of the COVID‑19 pandemic on mental wellbeing in the workplace highlighted that employers of all sizes are legally required to carry out a stress risk assessment for each role (and record it if they have more than 5 employees) under the Health and Safety at Work etc Act 1974. The committee saw this as a good opportunity for organisations to identify risks to employees' mental wellbeing, and subsequently take steps to reduce stressors. The committee also highlighted that employees may have poor mental wellbeing as a result of external factors that are beyond the control of the employer, such as caring responsibilities, health concerns and discrimination (such as homophobia or racism). But they agreed that it is important for organisations to ensure that they provide additional support to groups affected by these issues. The committee also agreed, based on their experience, that it is important for any interventions to be evaluated and monitored as part of an ongoing strategy of employee engagement, and that validated measures of wellbeing need to be part of this process. The committee noted that further research is needed to understand how data and outcomes could best be used to improve mental wellbeing in the workplace. In particular, research could investigate which outcomes would be useful in a core outcome set for research into workplace mental wellbeing, and to understand how more detailed reporting of the nature of organisation and employee characteristics can be included in research into workplace mental wellbeing (see the recommendations for research on core outcomes for study reporting and addressing study reporting). ## How the recommendations might affect practice The use of tiered approaches to support mental wellbeing at work reflects best practice and therefore would not have a large resource impact in organisations that have already adopted best practice. This may have more of an impact for other organisations. Smaller organisations may not always have the resources to offer all aspects of the tiered approach. They can best use resources by concentrating on ensuring that they have an organisation-wide approach in place. Improving employee wellbeing might lead to less absenteeism and presenteeism and may improve staff retention and productivity. Return to recommendations # Supportive work environment Recommendations 1.2.1 to 1.2.4 ## Why the committee made the recommendations The committee agreed that overall, a supportive, inclusive work environment and climate is crucial for good mental wellbeing in the workforce. Social interactions, including those between managers and employees, play an important role in this. Having the right policies can help to create a supportive workplace environment and culture. It can help to ensure that leadership is supportive and engaged, that there are effective peer support networks and there is good organisational-wide mental health literacy. A supportive work environment can be achieved by adhering to existing legal obligations (such as health and safety) and statutory requirements (such as the ACAS codes of practice), and engaging with employees to draft and refine policies such as anti-bullying. Organisations can also promote mental wellbeing interventions by reducing any potential barriers to using them and supporting employees to access them. This would embed the importance of mental wellbeing into the organisational culture (see the section on engaging with employees and their representatives). Despite the lack of strong evidence for leadership interventions, the committee were confident that management buy‑in is important for promoting the wellbeing of employees. They cited the government review Thriving at work, which provides an evidence-based whole-settings approach to improving mental wellbeing, including the importance of leadership, culture and effective people management. The committee noted that there was little evidence on the views of organisations about mental wellbeing. (See the recommendation for research on supportive work environment.) ## How the recommendations might affect practice The recommendations reflect current good practice around communication across the organisation, active leadership involvement and engagement with employees. The committee noted that many organisations would already have structures in place like those they recommended, and that to align them with the recommendations would not have a large resource impact. The committee agreed that for organisations that were resource poor and that had not previously invested in a supportive work environment, the use of freely available external resources could help minimise costs. Return to recommendations # External sources of support Recommendations 1.3.1 to 1.3.3 ## Why the committee made the recommendations The committee agreed that supporting mental wellbeing in the workplace might be particularly challenging for organisations with limited resources, especially micro, small and medium-sized ones. They agreed that it was important to help employers find external, low-cost or free resources to support them in promoting mental wellbeing. Based on expert testimony from a mental health and productivity pilot and their experience, the committee agreed that it was the responsibility of employers and local and regional authorities to be aware of sources of support available in their area. These sources could be national, local or within the organisation, for example an occupational health service or an employee assistance programme (if the organisation has these). By being able to direct employees to these, employers will be helping and supporting employees by providing them with tools and resources. The Department for Work and Pensions' access to work mental health support service has guidance to help employers understand mental ill health and how to support employees with mental health concerns. It can also support employees by offering eligible employees an assessment to find out their needs and help them develop a support plan. ## How the recommendations might affect practice The recommendations encourage employers to use expertise and resources that are external to their organisation when appropriate. These sources of support are freely available and will provide employers with information and resources to support their employees. They will also help organisations who are committed to improving the mental wellbeing of their employees to manage the resource impact. Return to recommendations # Organisation-wide approaches Recommendations 1.4.1 to 1.4.7 ## Why the committee made the recommendations Evidence from the UK showed that organisation-wide interventions may help to improve mental wellbeing and stress outcomes for employees and may also benefit employers. Although the evidence had some limitations in terms of its quality, the committee concluded that the work environment can be improved in 2 ways: employers can work with their employees to identify work stressors and put in place solutions to deal with these stressors, or employers can use evidence-based methods that are specifically tailored to their organisation. The committee clarified their use of the word 'stress' to be the adverse reaction people have to excessive pressures or other types of demand placed on them. Based on the evidence and their experience, the committee strongly advised that organisational-level approaches are the best starting point when considering strategies to improve mental wellbeing at work. These approaches demonstrate a commitment to mental wellbeing at work, which is essential for encouraging employees to take up interventions. The committee emphasised that individual-level approaches are not a suitable alternative to organisational-level approaches because these are less likely to be effective on their own. They noted that because of the variation in the size and structure of workplaces, many interventions might need to be tailored to match the specific workplace in which they were going to be delivered. This could be done through staff surveys, for example. The committee heard expert testimonies about insights from the Thriving at Work Leadership Council, the mental health and productivity pilot, participatory organisational interventions, and prevention and management of work-related stress and mental ill health. They agreed with the experts that striving to attain workplace charters or accreditation was a useful way for organisations to work with external bodies to improve mental wellbeing and make their organisation a more attractive place to work. These would also allow employers to access external support and advice about improving and maintaining mental wellbeing at work. The committee also agreed that existing guidance, such as the Health and Safety Executive's Management Standards for work-related stress, would be useful. The committee agreed that employee assistance programmes and occupational health services are good options for supporting employees' mental wellbeing, although they noted that there was a lack of evidence about how effective they are. They agreed with expert testimony about major challenges to small and medium-sized enterprises in improving the mental wellbeing of staff, what they can do to improve staff mental wellbeing and that low-cost schemes such as Mindful Employer may be useful for smaller organisations with limited resources. The committee also discussed that some employees in occupations that are not generally considered high-risk may be exposed to traumatic events at work – for example, because of a pandemic or terror attack – and that employers need to have plans in place to support employees in case such events do occur. The lack of published evidence about the effectiveness of employee assistance programmes led the committee to make a recommendation for research on organisational-level approaches for all organisations because evidence on this could help NICE to make more specific recommendations on this topic in future. ## How the recommendations might affect practice The recommendations reflect good practice in communication across the organisation, in active leadership involvement and in engaging with employees. There should not be an extensive resource impact because the recommendations involve adhering to existing best practice. Return to recommendations # Training and support for managers Recommendations 1.5.1 to 1.5.8 ## Why the committee made the recommendations The committee agreed it was important that all line managers received training and support. They considered that this was good practice in all industries and all sizes of organisation, and that managers benefit in terms of their mental wellbeing from feeling skilled to perform their line management duties. There was a range of evidence showing that manager training interventions were effective (especially in terms of outcomes for the manager who had been trained) or had no effect, although the committee noted that much of this evidence was uncertain. There was no evidence of unintended consequences associated with these interventions. There was some higher quality evidence that manager training can help to increase managers' knowledge of how to reduce stigma, and also help to increase their confidence in identifying and supporting employees who may be at risk of poor mental health. This agreed with the experience of the committee, who found that training managers in mental health awareness can increase their knowledge and willingness to discuss mental health. Reducing stigma and equipping managers with skills to have conversations with employees about mental health is likely to facilitate conversations between managers and employees about any concerns about their mental wellbeing. This makes it more likely that managers can support employees with mental health issues. Providing managers with skills to discuss mental wellbeing improves the relationship between manager and employee so that they can identify and reduce work stressors. The evidence also showed that increasing managers' knowledge leads to more employees using the support services on offer. Although the evidence was not strong in this area, the committee agreed some points that would be a useful core for the content of mental health training for managers. They also agreed it was important for people to be able to suggest topics they thought were important. The committee agreed with the qualitative evidence that manager training interventions delivered in groups had added benefit because they allow managers to learn from each other and to reinforce best practice. Therefore, the committee agreed, based on their experience and the evidence, that it can be helpful to offer group training as part of mental health awareness training. But they acknowledged that this might not be possible, for example in smaller organisations. Expert testimony about major challenges to small and medium-sized enterprises in improving the mental wellbeing of staff and what they can do to improve staff mental wellbeing, managing mental health in the workplace during and after COVID‑19, and committee experience, highlighted that managers have additional pressures related to their role, and that delivering any training in a group format would provide peer support. The committee also discussed that because of the increased pressures faced by managers, it is important that they are supported by human resources, occupational safety, and health and wellbeing professionals. The committee discussed expert testimony about managing mental health in the workplace during the COVID‑19 pandemic and about the likely long-term impacts of COVID‑19 on mental wellbeing in the workplace. It helped them to make recommendations about the content of management training to support mental wellbeing. They agreed that managers should be empowered to make reasonable adjustments to the workload or intensity to reduce stressors for employees. This would give employees relief from work stress sooner because requests would not need to be escalated before support could be given. This expert testimony also highlighted the value of peer-to-peer support for managers, which the committee agreed matched their own expert experience. The committee further discussed that although there was some data on the effectiveness of the interventions reviewed in terms of employee outcomes, overall, there was insufficient data and they had to extrapolate from their expertise and experience along with the small amount of evidence they had. They suggested that this may be because interventions had a short follow up of 3 months. This might be sufficiently long to show a difference in manager outcomes, but it may not be long enough to show a change in employee outcomes, including mental wellbeing. Therefore, the committee agreed that further research is needed on employee outcomes with longer follow ups (see the recommendation for research on training for managers). ## How the recommendations might affect practice The committee agreed that most organisations with a management structure would have some form of manager training programme, and that these recommendations reflect good practice in training managers. If the recommendations are built into those existing training structures, the committee agreed the resource impact of these recommendations would be small. For other organisations, the committee agreed that buying in external training could be expensive, but that training costs could be minimised by using free training resources. Return to recommendations # Individual-level approaches Recommendations 1.6.1 to 1.6.4 ## Why the committee made the recommendations The committee agreed that within the 3‑tiered approach covered in the section on strategic approaches to improving mental wellbeing in the workplace, it was important for organisations to prioritise an organisational approach to improving mental wellbeing in the workplace. The committee emphasised that individual-level approaches are not a suitable alternative to organisational-level approaches because these are less likely to be effective on their own. So, individual approaches need to be additional to organisational approaches and not a substitute for them. The committee recognised the importance of good relationships between managers and employees, and of employees being able to approach managers to discuss any concerns. Making opportunities – for example, for small talk – to develop good relationships could help with this. This would help employees to discuss issues they may have outside work and it may help to identify support that could be put into place. The committee also highlighted that in some cases, a manager could have a negative impact on an employee's mental wellbeing. Therefore, mechanisms are needed for employees to discuss any concerns with an appropriate person. The committee saw evidence on a range of individual-level interventions that aimed to improve mental wellbeing in an unselected population. They were clear that these were not a substitute for organisational-level approaches. The evidence they were presented with had some limitations, but the committee agreed that mindfulness, meditation and yoga were most effective overall in reducing job stress and mental health symptoms and having a positive effect on employee mental wellbeing. The evidence showed that these interventions were effective when delivered either in a group or online. The committee decided that employees should be able to choose how the interventions are delivered (see the section on engaging with employees and their representatives). The committee noted a lack of evidence about the long-term effectiveness of universal individual-level interventions in all organisations (see the recommendation for research on individual-level interventions) and a lack of evidence about the specific needs of different groups, for example different age groups or employees from different cultural backgrounds that prevented them from making specific recommendations about this. (See the recommendations for research on the needs of different employee groups.) ## How the recommendations might affect practice The committee recognised that many small businesses would not have the resources to provide mindfulness, yoga or meditation interventions, but noted that there are free or low-cost options for all of these, which would only need signposting by employers. Return to recommendations # Approaches for employees who have or are at risk of poor mental health Recommendations 1.7.1 to 1.7.5 ## Why the committee made the recommendations The committee raised concerns that managers may face difficulties around confidentiality if they think that an employee is at risk of harming themselves or others. To reduce the burden placed on individuals, the committee decided that organisations should have clear policies on confidentiality. The committee discussed that a preventive approach is important for reducing poor mental wellbeing. But they acknowledged that some employees will already have poor mental health and others will be at increased risk of poor mental health. Therefore, these employees should be offered support. The committee suggested that, although there was no specific evidence for them, wellness action plans were likely to be a useful way to open a dialogue between managers and employees about mental health concerns and what support could be put in place to help employees. They could also help to highlight needs for organisational change. The evidence agreed with the committee's collective experience and showed that cognitive behavioural therapy, mindfulness and stress management were effective in improving mental wellbeing outcomes in employees with poor mental health. However, there was more limited evidence for cognitive behavioural therapy than for the other 2 options. They noted that if treatment is commissioned by the employer, they are required to check that the provider has the necessary qualifications and is accredited and regulated by relevant professional organisations to offer the interventions. The committee noted that there was a potential resource impact for offering these and that for smaller organisations, free or low-cost options existed (for example, online resources such as the local Improving Access to Psychological Therapies scheme). The committee thought it was important that employees were made aware of the option to not have an intervention and to take up an offer of it at a later date, or to stop an intervention at any time and restart it later. This avoids employees feeling pressured to start or continue an intervention. They also agreed it was important that employers recognise that an employee may prefer a particular type of intervention, possibly because of their previous experiences with interventions. The committee noted the lack of evidence about which strategies can be used to identify employees at risk of poor mental wellbeing. (See the recommendation for research on identifying employees at risk of poor mental wellbeing.) ## How the recommendations might affect practice The recommendations reflect good practice around managing and supporting employees. The committee noted a potential resource impact to implement interventions, both in terms of work hours and financial resources. But this could be limited by using free resources. They noted that there may be a resource impact to offering flexible working hours, job changes or other organisational support to people at risk of poor mental health but assessed that this would often be very low. Return to recommendations # Organisational-level approaches for high-risk occupations Recommendations 1.8.1 to 1.8.3 ## Why the committee made the recommendations If the psychosocial risk assessment (see the section on strategic approaches to improving mental wellbeing in the workplace) for a role indicates that it is high risk, it is important that organisations have additional processes in place to support employees. The committee agreed that it was important to make sure these processes conformed to best practice in the field, and from their experience, they were able to identify Mind's Blue Light Programme as an example of best practice. There was good evidence showing that when police and healthcare professionals were given the skills to deal with stressful occupational events through task-focused skills training (including imagery and simulation), mental health symptoms were reduced, and mental wellbeing and quality of life improved. Based on this evidence, the committee decided that organisations should provide task-focused skills training for employees in high-risk occupations. They also recommended, in line with the evidence, that employees in high-risk occupations are offered support after a traumatic event. The committee noted that there were exceptional circumstances, for example, the COVID‑19 pandemic, which could cause stressful occupational events more widely (for example, some people might find homeworking or social distancing in the workplace stressful). ## How the recommendations might affect practice All high-risk occupations should already have policies and procedures in place on how to deal with predictable and stressful occupational events. These recommendations will not affect the resources needed for this. Return to recommendations # Engaging with employees and their representatives Recommendations 1.9.1 to 1.9.3 ## Why the committee made the recommendations The committee suggested that consulting employees about the type and format of organisational approaches and individual interventions offered would help employers understand what good mental wellbeing would look like in their organisation. It would also help them to tailor their approach to the needs of their employees and the organisation. They believed that this would give employers the opportunity to raise awareness about why the interventions are being implemented, which could improve employee support for them. The committee discussed that by providing interventions during the working day, employers would give employees a beneficial break from work and send a clear message about the importance of mental wellbeing. However, organisations should be flexible because employees may also prefer to access interventions outside work hours. The committee also noted that people will have different preferences about how they learn. For example, some employees would benefit from a group setting, whereas others would prefer one-to-one or online interventions. This highlights the importance of engaging with employees to ensure that their needs are considered, and that if online interventions are offered, digital exclusion does not prevent any employee from accessing the intervention. The committee also discussed, based on their experience, that the effectiveness of certain interventions may be different for different groups. Factors may include socioeconomic factors such as low income and whether people have disabilities, work in urban or rural locations or have good digital access. The committee agreed that staff surveys and consultation could be used to regularly monitor intervention accessibility. ## How the recommendations might affect practice The committee discussed the resource implications of these recommendations but overall did not think they would be significant in most cases. They noted that some organisations may not be able to provide interventions during work hours for financial reasons. In these cases, it may be better to provide interventions outside work hours rather than not making them available at all. They also noted that some organisations may not have the space to provide certain interventions on site, and this may affect the type or format of intervention offered. Return to recommendations # Local and regional strategies and plans Recommendations 1.10.1 to 1.10.9 ## Why the committee made the recommendations The committee discussed that local and regional authorities should be role models in ensuring that their own workplaces actively promote mental wellbeing, given their role in public health. The committee highlighted that many local and regional authorities already have strategies in place to improve physical wellbeing in their population, and that these could be expanded to include mental wellbeing as part of a more holistic approach to wellbeing. This includes working with employers to ensure they know about resources or services that can help them improve the mental wellbeing of their employees and minimise the resource impact that this will have, especially for small and medium-sized enterprises and micro-enterprises. This could be done together with local enterprise partnerships and chambers of commerce. This can also be tailored to the needs of each organisation. The committee heard expert testimony about a mental health and productivity pilot that included the possibility of local authorities using financial incentives to encourage employers to think about job quality and wellbeing in their workplaces. The committee discussed this and also discussed that in times of financial hardship, there may be non-financial incentives that are more achievable for local authorities. Because there was limited evidence about this, the committee agreed that it would not be appropriate to recommend incentive schemes, but that any authorities interested in them could introduce them as a pilot or as an evaluation. Local and regional authorities will have ethical procurement frameworks in place, and a duty under the Social Value Act to consider wider social, economic and environmental factors during procurement. Therefore, the committee suggested that local and regional authorities could consider how organisations in their supply chains value job quality and mental wellbeing in the workplace. ## How the recommendations might affect practice Local and regional authorities already have schemes in place to help employers improve mental wellbeing in their workplaces, including the Department for Work and Pensions' access to work mental health support service. Many sources of support have already been curated by organisations such as Mind and Business in the Community, and local and regional authorities would only need to signpost employers to these. The committee were aware that some local authorities may be having funding difficulties and did not want to place too much of a burden on them. Expert testimony about a mental health and productivity pilot discussed the possibility of local authorities using financial incentives to encourage employers to think about job quality and wellbeing in their workplaces. However, the committee noted that local and regional authorities may be able to provide other forms of incentives that do not need extra funds, for example dedicated advice and guidance. Return to recommendations # Making this guideline relevant for small and medium-sized enterprises (including micro-enterprises) Recommendations 1.11.1 to 1.11.5 ## Why the committee made the recommendations The committee heard from expert testimony from the Thriving at Work Leadership Council that many business owners are at risk of poor mental health and exhaustion as a result of the pandemic. They noted that leaders need to ensure that they also consider their own mental wellbeing. The committee noted that a lot of the evidence was from larger organisations, and that small and medium-sized enterprises (SMEs) are likely to have fewer resources to help them address mental wellbeing in the workplace, such as occupational health and human resource professionals. The committee discussed that taking a preventive approach to ensuring good mental wellbeing could avoid problems later on (for employees and for the organisation). They agreed that employers could find a lot of guidance and resources on how to do this through the Mental Health at Work website, and Health and Safety Executive resources. Public bodies such as local authorities and local enterprise partnerships should also be able to signpost employees of SMEs to information on how to prevent poor mental wellbeing at work and promote positive mental wellbeing, as well as signposting them to resources and services to support employees with poor mental health, such as the Department for Work and Pensions' access to work mental health support service. The committee suggested that SMEs may also want to sign up to the Mental Health at Work Commitment, which is a framework to help organisations improve the mental wellbeing of their employees. The committee agreed that further research into SMEs was needed – particularly on the specific needs of SMEs for implementing individual-level interventions and the long-term effectiveness of universal individual-level interventions in both larger organisations and SMEs. So they made a recommendation for research on specific needs of different kinds of micro, small and medium-sized enterprises (SMEs) in promoting mental wellbeing in the workplace, including organisational, targeted and individual-level approaches and a recommendation for research on long-term effectiveness of universal individual-level interventions in different kinds of SMEs. These would enable NICE to make more specific recommendations for SMEs in future. ## How the recommendations might affect practice The committee were aware that, compared with larger organisations, SMEs may face additional constraints in terms of time and resources. The recommendations reflect ways that smaller organisations can look after the mental wellbeing of their workforce, without needing too much time or specialist knowledge about mental wellbeing. The committee also discussed that employee assistance programmes and occupational health services may be a useful way of helping employees, and that smaller organisations may benefit from free or low-cost services such as the Department for Work and Pensions' access to work mental health support service or Mindful Employer. Return to recommendations# Context This guideline is for all people aged 16 or over in full-time or part-time employment, including those on permanent, training, temporary or zero-hours contracts, and those who are self-employed and volunteers. This guideline has been updated because NICE identified new evidence that could affect the recommendations. Despite evidence that better mental wellbeing and job satisfaction are associated with increased workplace performance and productivity, the government review Thriving at work estimates that 15% of UK workers have an existing mental health condition. Poor mental wellbeing costs employers in the UK an estimated £42 billion to £45 billion annually through presenteeism, sickness absence and staff turnover (Deloitte Mental health and employers: refreshing the case for investment). The total annual cost of poor mental wellbeing to the government, including NHS costs, benefit provision and tax revenue losses, is between £24 billion and £27 billion. Lost output costs the economy between £74 billion and £99 billion (Thriving at work). Changes to workplaces and working patterns as a result of the COVID‑19 pandemic have had a large impact on working practices and organisational cultures; however, it is unclear what the longer-term effects of this will be. Workplace policies and activities to promote and protect employee mental wellbeing vary widely. Mental wellbeing has been described as 'feeling good and functioning well', reinforcing that mental wellbeing is on a spectrum and positive mental wellbeing is not just the absence of symptoms of poor mental health. Consequently, the aim of interventions should not just be to prevent poor mental health, but instead should promote positive mental wellbeing. The Department for Work and Pensions reports that most employers have basic health and wellbeing policies, including at least 1 covering flexible working, sick pay or injury training (Department for Work and Pensions Health and wellbeing at work: a survey of employees). Larger and public sector organisations are more likely to offer at least 1 of the following: health screening, occupational health services, independent counselling or stress management.

Diabetes Management in Correctional Institutions [bib_ref] Challenges of improving quality in the correctional setting, Puisis [/bib_ref] ## Intake medical assessment ## Reception screening Reception screening should emphasize patient safety. In particular, rapid identification of all insulin-treated persons with diabetes is essential in order to identify those at highest risk for hypo-and hyperglycemia and diabetic ketoacidosis (DKA). All insulin-treated patients should have a capillary blood glucose (CBG) determination within 1-2 h of arrival. Signs and symptoms of hypo-or hyperglycemia can often be confused with intoxication or withdrawal from drugs or alcohol. Individuals with diabetes exhibiting signs and symptoms consistent with hypoglycemia, particularly altered mental status, agitation, combativeness, and diaphoresis, should have finger-stick blood glucose levels measured immediately. ## Intake screening Patients with a diagnosis of diabetes should have a complete medical history and physical examination by a licensed health care provider with prescriptive authority in a timely manner. If one is not available on site, one should be consulted by those performing reception screening. The purposes of this history and physical examination are to determine the type of diabetes, current therapy, alcohol use, and behavioral health issues, as well as to screen for the presence of diabetes-related complications. The evaluation should review the previous treatment and the past history of both glycemic control and diabetes complications. It is essential that medication and medical nutrition therapy (MNT) be continued without interruption upon entry into the correctional system, as a hiatus in either medication or appropriate nutrition may lead to either severe hypo-or hyperglycemia that can rapidly progress to irreversible complications, even death. ## Intake physical examination and laboratory All potential elements of the initial medical evaluation are included in of the ADA's "Standards of Medical Care in Diabetes," referred to hereafter as the "Standards of Care" (4). The essential components of the initial history and physical examination are detailed in People with diabetes should ideally receive medical care from a physiciancoordinated team. Such teams include, but are not limited to, physicians, nurses, dietitians, and mental health professionals with expertise and a special interest in diabetes. It is essential in this collaborative and integrated team approach that individuals with diabetes assume as active a role in their care as possible. Diabetes selfmanagement education is an integral component of care. Patient selfmanagement should be emphasized, and the plan should encourage the involvement of the patient in problem solving as much as possible. It is helpful to house insulin-treated patients in a common unit, if this is possible, safe, and consistent with providing access to other programs at the correc-tional institution. Common housing not only can facilitate mealtimes and medication administration, but also potentially provides an opportunity for diabetes selfmanagement education to be reinforced by fellow patients. ## Nutrition and food SERVICES -Nutrition counseling and menu planning are an integral part of the multidisciplinary approach to diabetes management in correctional facilities. A combination of education, interdisciplinary communication, and monitoring food intake aids patients in understanding their medical nutritional needs and can facilitate diabetes control during and after incarceration. Nutrition counseling for patients with diabetes is considered an essential component of diabetes self-management. People with diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of MNT for persons with diabetes. Educating the patient, individually or in a group setting, about how carbohydrates and food choices directly affect di- abetes control is the first step in facilitating self-management. This education enables the patient to identify better food selections from those available in the dining hall and commissary. Such an approach is more realistic in a facility where the patient has the opportunity to make food choices. The easiest and most cost-effective means to facilitate good outcomes in patients with diabetes is instituting a hearthealthy diet as the master menu. There should be consistent carbohydrate content at each meal, as well as a means to identify the carbohydrate content of each food selection. Providing carbohydrate content of food selections and/or providing education in assessing carbohydrate content enables patients to meet the requirements of their individual MNT goals. Commissaries should also help in dietary management by offering healthy choices and listing the carbohydrate content of foods. The use of insulin or oral medications may necessitate snacks in order to avoid hypoglycemia. These snacks are a part of such patients' medical treatment plans and should be prescribed by medical staff. Timing of meals and snacks must be coordinated with medication administration as needed to minimize the risk of hypoglycemia, as discussed more fully in the MEDICATION section of this document. For further information, see the ADA Position Statement "Nutrition Principles and Recommendations in Diabetes". URGENT AND EMERGENCY ISSUES -All patients must have access to prompt treatment of hypo-and hyperglycemia. Correctional staff should be trained in the recognition and treatment of hypoand hyperglycemia, and appropriate staff should be trained to administer glucagon. After such emergency care, patients should be referred for appropriate medical care to minimize risk of future decompensation. Institutions should implement a policy requiring staff to notify a physician of all CBG results outside of a specified range, as determined by the treating physician (e.g., Ͻ50 or Ͼ350 mg/dl). ## Hyperglycemia Severe hyperglycemia in a person with diabetes may be the result of intercurrent illness, missed or inadequate medication, or corticosteroid therapy. Correctional institutions should have systems in place to identify and refer to medical staff all patients with consistently elevated blood glucose as well as intercurrent illness. The stress of illness in those with type 1 diabetes frequently aggravates glycemic control and necessitates more frequent monitoring of blood glucose (e.g., every 4 -6 h). Marked hyperglycemia requires temporary adjustment of the treatment program and, if accompanied by ketosis, interaction with the diabetes care team. Adequate fluid and caloric intake must be ensured. Nausea or vomiting accompanied with hyperglycemia may indicate DKA, a life-threatening condition that requires immediate medical care to prevent complications and death. Correctional institutions should identify patients with type 1 diabetes who are at risk for DKA, particularly those with a prior history of frequent episodes of DKA. For further information see "Hyperglycemic Crisis in Diabetes". ## Hypoglycemia Hypoglycemia is defined as a blood glucose level Ͻ70 mg/dl. Severe hypoglycemia is a medical emergency defined as hypoglycemia requiring assistance of a third party and is often associated with mental status changes that may include confusion, incoherence, combativeness, somnolence, lethargy, seizures, or coma. Signs and symptoms of severe hypoglycemia can be confused with intoxication or withdrawal. Individuals with diabetes exhibiting signs and symptoms consistent with hypoglycemia, particularly altered mental status, agitation, and diaphoresis, should have their CBG levels checked immediately. Security staff who supervise patients at risk for hypoglycemia (i.e., those on insulin or oral hypoglycemic agents) should be educated in the emergency response protocol for recognition and treatment of hypoglycemia. Every attempt should be made to document CBG before treatment. Patients must have immediate access to glucose tablets or other glucose-containing foods. Hypoglycemia can generally be treated by the patient with oral carbohydrates. If the patient cannot be relied on to keep hypoglycemia treatment on his/her person, staff members should have ready access to glucose tablets or equivalent. In general, 15-20 g oral glucose will be adequate to treat hypoglycemic events. CBG and treatment should be repeated at 15-min intervals until blood glucose levels return to normal (Ͼ70 mg/dl). Staff should have glucagon for intramuscular injection or glucose for intravenous infusion available to treat severe hypoglycemia without requiring transport of the hypoglycemic patient to an outside facility. Any episode of severe hypoglycemia or recurrent episodes of mild to moderate hypoglycemia require reevaluation of the diabetes management plan by the medical staff. In certain cases of unexplained or recurrent severe hypoglycemia, it may be appropriate to admit the patient to the medical unit for observation and stabilization of diabetes management. Correctional institutions should have systems in place to identify the patients at greater risk for hypoglycemia (i.e., those on insulin or sulfonylurea therapy) and to ensure the early detection and treatment of hypoglycemia. If possible, patients at greater risk of severe hypoglycemia (e.g., those with a prior episode of severe hypoglycemia) may be housed in units closer to the medical unit in order to minimize delay in treatment. MEDICATION -Formularies should provide access to usual and customary oral medications and insulins necessary to treat diabetes and related conditions. While not every brand name of insulin and oral medication needs to be available, individual patient care requires access to short-, medium-, and long-acting insulins and the various classes of oral medications (e.g., insulin secretagogues, biguanides, ␣-glucosidase inhibitors, and thiazolidinediones) necessary for current diabetes management. Patients at all levels of custody should have access to medication at dosing frequencies that are consistent with their treatment plan and medical direction. If feasible and consistent with security concerns, patients on multiple doses of shortacting oral medications should be placed in a "keep on person" program. In other situations, patients should be permitted to self-inject insulin when consistent with security needs. Medical department nurses should determine whether patients have the necessary skill and responsible behavior to be allowed selfadministration and the degree of supervision necessary. When needed, this skill should be a part of patient education. Reasonable syringe control systems should be established. ## Recommendations In the past, the recommendation that regular insulin be injected 30 -45 min before meals presented a significant problem when "lock downs" or other disruptions to the normal schedule of meals and medications occurred. The use of multiple-dose insulin regimens using rapid-acting analogs can decrease the disruption caused by such changes in schedule. Correctional institutions should have systems in place to ensure that rapidacting insulin analogs and oral agents are given immediately before meals if this is part of the patient's medical plan. It should be noted however that even modest delays in meal consumption with these agents can be associated with hypoglycemia. If consistent access to food within 10 min cannot be ensured, rapid-acting insulin analogs and oral agents are approved for administration during or immediately after meals. Should circumstances arise that delay patient access to regular meals following medication administration, policies and procedures must be implemented to ensure the patient receives appropriate nutrition to prevent hypoglycemia. Both continuous subcutaneous insulin infusion and multiple daily insulin injection therapy (consisting of three or more injections a day) can be effective means of implementing intensive diabetes management with the goal of achieving near-normal levels of blood glucose. While the use of these modalities may be difficult in correctional institutions, every effort should be made to continue multiple daily insulin injection or continuous subcutaneous insulin infusion in people who were using this therapy before incarceration or to institute these therapies as indicated in order to achieve blood glucose targets. It is essential that transport of patients from jails or prisons to off-site appointments, such as medical visits or court appearances, does not cause significant disruption in medication or meal timing. Correctional institutions and police lockups should implement policies and procedures to diminish the risk of hypo-and hyperglycemia by, for example, providing carry-along meals and medication for patients traveling to off-site appointments or changing the insulin regimen for that day. The availability of prefilled insulin "pens" provides an alternative for off-site insulin delivery. ## Recommendations - Formularies should provide access to usual and customary oral medications and insulins to treat diabetes and related conditions. (E) - Patients should have access to medication at dosing frequencies that are consistent with their treatment plan and medical direction. (E) - Correctional institutions and police lock-ups should implement policies and procedures to diminish the risk of hypo-and hyperglycemia during offsite travel (e.g., court appearances). (E) ple with diabetes to evaluate diabetes management regimens. The frequency of monitoring will vary by patients' glycemic control and diabetes regimens. Patients with type 1 diabetes are at risk for hypoglycemia and should have their CBG monitored three or more times daily. Patients with type 2 diabetes on insulin need to monitor at least once daily and more frequently based on their medical plan. ## Routine screening for and management of diabetes complications Patients treated with oral agents should have CBG monitored with sufficient frequency to facilitate the goals of glycemic control, assuming that there is a program for medical review of these data on an ongoing basis to drive changes in medications. Patients whose diabetes is poorly controlled or whose therapy is changing should have more frequent monitoring. Unexplained hyperglycemia in a patient with type 1 diabetes may suggest impending DKA, and monitoring of ketones should therefore be performed. Glycated hemoglobin (A1C) is a measure of long-term (2-to 3-month) glycemic control. Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control) and quarterly in patients whose therapy has changed or who are not meeting glycemic goals. Discrepancies between CBG monitoring results and A1C may indicate a hemoglobinopathy, hemolysis, or need for evaluation of CBG monitoring technique and equipment or initiation of more frequent CBG monitoring to identify when glycemic excursions are occurring and which facet of the diabetes regimen is changing. In the correctional setting, policies and procedures need to be developed and implemented regarding CBG monitoring that address the following. SELF-MANAGEMENT EDUCATION -Self-management education is the cornerstone of treatment for all people with diabetes. The health staff must advocate for patients to participate in self-management as much as possible. Individuals with diabetes who learn self-management skills and make lifestyle changes can more effectively manage their diabetes and avoid or delay complications associated with diabetes. In the d e v e l o p m e n t o f a d i a b e t e s s e l fmanagement education program in the correctional environment, the unique circumstances of the patient should be considered while still providing, to the greatest extent possible, the elements of the "National Standards for Diabetes Self-Management Education". A staged approach may be used depending on the needs assessment and the length of incarceration. [fig_ref] Table 2 -: Major components of diabetes self-management education [/fig_ref] sets out the major components of diabetes self-management education. Survival skills should be addressed as soon as possible; other aspects of education may be provided as part of an ongoing education program. Ideally, self-management education is coordinated by a certified diabetes educator who works with the facility to develop polices, procedures, and protocols to ensure that nationally recognized education guidelines are implemented. The educator is also able to identify patients who need diabetes self-management education, including an assessment of the patients' medical, social, and diabetes histories; diabetes knowledge, skills, and behaviors; and readiness to change. STAFF EDUCATION -Policies and procedures should be implemented to ensure that the health care staff has adequate knowledge and skills to direct the management and education of persons with diabetes. The health care staff needs to be involved in the development of the correctional officers' training program. The staff education program should be at a lay level. Training should be offered at least biannually, and the curriculum should cover the following. - what diabetes is - signs and symptoms of diabetes - risk factors - signs and symptoms of, and emergency response to, hypo-and hyperglycemia - glucose monitoring - medications - exercise - nutrition issues including timing of meals and access to snacks [formula] Recommendations - Include diabetes in correctional staff education programs. (E) [/formula] ALCOHOL AND DRUGS -Patients with diabetes who are withdrawing from drugs and alcohol need special consideration. This issue particularly affects initial police custody and jails. At an intake facility, proper initial identification and assessment of these patients are critical. The presence of diabetes may complicate detoxification. Patients in need of complicated detoxification should be referred to a facility equipped to deal with high-risk detoxification. Patients with diabetes should be educated in the risks involved with smoking. All inmates should be advised not to smoke. Assistance in smoking cessation should be provided as practical. TRANSFER AND DISCHARGE -Patients in jails may be housed for a short period of time before being transferred or released, and it is not unusual for patients in prison to be transferred within the system several times during their incarceration. One of the many challenges that health care providers face working in the correctional system is how to best collect and communicate important health care information in a timely manner when a patient is in initial police custody, is jailed short term, or is transferred from facility to facility. The importance of this communication becomes critical when the patient has a chronic illness such as diabetes. Transferring a patient with diabetes from one correctional facility to another requires a coordinated effort. To facilitate a thorough review of medical information and completion of a transfer summary, it is critical for custody personnel to provide medical staff with sufficient notice before movement of the patient. Before the transfer, the health care staff should review the patient's medical record and complete a medical transfer summary that includes the patient's current health care issues. At a minimum, the summary should include the following. - the patient's current medication schedule and dosages - the date and time of the last medication administration - any recent monitoring results (e.g., CBG and A1C) - other factors that indicate a need for immediate treatment or management at the receiving facility (e.g., recent episodes of hypoglycemia, history of severe hypoglycemia or frequent DKA, concurrent illnesses, presence of diabetes complications) - information on scheduled treatment/ appointments if the receiving facility is responsible for transporting the patient to that appointment - name and telephone/fax number of a contact person at the transferring facility who can provide additional information, if needed The medical transfer summary, which acts as a quick medical reference for the receiving facility, should be transferred along with the patient. To supplement the flow of information and to increase the probability that medications are correctly identified at the receiving institution, sending institutions are encouraged to provide each patient with a medication card to be carried by the patient that contains information concerning diagnoses, medication names, dosages, and frequency. Diabetes supplies, including diabetes medication, should accompany the patient. The sending facility must be mindful of the transfer time in order to provide the patient with medication and food if needed. The transfer summary or medical record should be reviewed by a health care provider upon arrival at the receiving institution. Planning for patients' discharge from prisons should include instruction in the long-term complications of diabetes, the necessary lifestyle changes and examinations required to prevent these complications, and, if possible, where patients may obtain regular follow-up medical care. A quarterly meeting to educate patients with upcoming discharges about community resources can be valuable. Inviting community agencies to speak at these meetings and/or provide written materials can help strengthen the community link for patients discharging from correctional facilities. Discharge planning for the patients with diabetes should begin 1 month before discharge. During this time, application for appropriate entitlements should be initiated. Any gaps in the patient's knowledge of diabetes care need to be identified and addressed. It is helpful if the patient is given a directory or list of community resources and if an appointment for follow-up care with a community provider is made. A supply of medication adequate to last until the first postrelease medical appointment should be provided to the patient upon release. The patient should be provided with a written summary of his/her current heath care issues, including medications and doses, recent A1C values, etc. ## Recommendations ## Sharing of medical information and RECORDS -Practical considerations may prohibit obtaining medical records from providers who treated the patient before arrest. Intake facilities should implement policies that 1) define the circumstances under which prior medical records are obtained (e.g., for patients who have an extensive history of treatment for complications); 2) identify person(s) responsible for contacting the prior provider; and 3) establish procedures for tracking requests. Facilities that use outside medical providers should implement policies and procedures for ensuring that key information (e.g., test results, diagnoses, physicians' orders, appointment dates) is received from the provider and incorporated into the patient's medical chart after each outside appointment. The procedure should include, at a minimum, a means to highlight when key information has not been received and designation of a person responsible for contacting the outside provider for this information. All medical charts should contain CBG test results in a specified, readily accessible section and should be reviewed on a regular basis. ## Children and adolescents with DIABETES -Children and adolescents with diabetes present special problems in disease management, even outside the setting of a correctional institution. Children and adolescents with diabetes should have initial and follow-up care with physicians who are experienced in their care. Confinement increases the difficulty in managing diabetes in children and adolescents, as it does in adults with diabetes. Correctional authorities also have different legal obligations for children and adolescents. ## Nutrition and activity Growing children and adolescents have greater caloric/nutritional needs than adults. The provision of an adequate amount of calories and nutrients for adolescents is critical to maintaining good nutritional status. Physical activity should be provided at the same time each day. If increased physical activity occurs, addi- Medical management and follow-up Children and adolescents who are incarcerated for extended periods should have follow-up visits at least every 3 months with individuals who are experienced in the care of children and adolescents with diabetes. Thyroid function tests and fasting lipid and microalbumin measurements should be performed according to recognized standards for children and adolescents [bib_ref] Consensus Guidelines 2000: ISPAD Consensus Guidelines for the Management of Type 1..., Pediatric [/bib_ref] in order to monitor for autoimmune thyroid disease and complications and comorbidities of diabetes. Children and adolescents with diabetes exhibiting unusual behavior should have their CBG checked at that time. Because children and adolescents are reported to have higher rates of nocturnal hypoglycemia [bib_ref] Nocturnal hypoglycemia detected with the continuous glucose monitoring system in pediatric patients..., Kaufman [/bib_ref] , consideration should be given regarding the use of episodic overnight blood glucose monitoring in these patients. In particular, this should be considered in children and adolescents who have recently had their overnight insulin dose changed. PREGNANCY -Pregnancy in a woman with diabetes is by definition a high-risk pregnancy. Every effort should be made to ensure that treatment of the pregnant woman with diabetes meets accepted standards. It should be noted that glycemic standards are more stringent, the details of dietary management are more complex and exacting, insulin is the only antidiabetic agent approved for use in pregnancy, and a number of medications used in the management of diabetic comorbidities are known to be teratogenic and must be discontinued in the setting of pregnancy. ## Summary and key POINTS -People with diabetes should receive care that meets national standards. Being incarcerated does not change these standards. Patients must have access to medication and nutrition needed to manage their disease. In patients who do not meet treatment targets, medical and behavioral plans should be adjusted by health care professionals in collaboration with the prison staff. It is critical for correctional institutions to identify particularly high-risk patients in need of more intensive evaluation and therapy, including pregnant women, patients with advanced complications, a history of repeated severe hypoglycemia, or recurrent DKA. A comprehensive, multidisciplinary approach to the care of people with diabetes can be an effective mechanism to improve overall health and delay or prevent the acute and chronic complications of this disease. [fig] Figure 1 -: Essential components of the initial history and physical examination. Alb/Cr ratio, albumin-to-creatinine ratio; ALT, alanine aminotransferase; AST, aspartate aminotransferase. [/fig] [table] Table 2 -: Major components of diabetes self-management education [/table]

NFKB2 Nuclear factor NF-kappa-B p100 subunit is a protein that in humans is encoded by the NFKB2 gene. # Function NF-κB has been detected in numerous cell types that express cytokines, chemokines, growth factors, cell adhesion molecules, and some acute phase proteins in health and in various disease states. NF-κB is activated by a wide variety of stimuli such as cytokines, oxidant-free radicals, inhaled particles, ultraviolet irradiation, and bacterial or viral products. Inappropriate activation of NF-kappa-B has been linked to inflammatory events associated with autoimmune arthritis, asthma, septic shock, lung fibrosis, glomerulonephritis, atherosclerosis, and AIDS. In contrast, complete and persistent inhibition of NF-kappa-B has been linked directly to apoptosis, inappropriate immune cell development, and delayed cell growth. For reviews, see Chen et al. (1999) and Baldwin (1996). # Clinical significance Mutation of the NFKB2 gene has been linked to Common variable immunodeficiency (CVID) as the cause of the disease. Other genes might also be responsible. The frequency of NFKB2 mutation in CVID population is yet to be established. The protein NFKB2 can become mutated and lead to hereditary endocrine and immuneodeficiences. The mutation occurs at the C-terminus of NFKB2 and it causes common variable immunodeficienciency which in turn causes endocrine deficiency and immunodeficiencies. A NFKB2 mutation can cause things like adrenocorticotropic hormone deficiency and DAVID syndrome which is a pituitary hormone deficiency and CVID. The mutations that occur within the C-terminus affect the serine 866 and 870. These serines are considered phosphorylation sites for NFKB2. These mutations at the serine’s in the C-terminus lead to CVID in combination with other endocrine deficiencies. These endocrine deficiencies along with the mutation of NFKB2, lead scientists to believe that mutation of NFKB2 is a rare hereditary disease called DAVID’s disease. # Interactions NFKB2 has been shown to interact with: - BCL3, - BTRC, - MAP3K8, - NFKB1, - NFKBIE, - RELA, - RELB, - REL, and - TSC22D3.

Estrogen # Overview Estrogens (alternative spellings: oestrogens or œstrogens) are a group of steroid compounds, named for their importance in the estrous cycle, and functioning as the primary female sex hormone. Estrogens are used as part of some oral contraceptives, in estrogen replacement therapy of postmenopausal women, and in hormone replacement therapy for transwomen. Like all steroid hormones, estrogens readily diffuse across the cell membrane; inside the cell, they interact with estrogen receptors. # Types of estrogen The three major naturally occurring estrogens in women are estradiol, estriol, and estrone. In the body these are all produced from androgens through actions of enzymes. - From menarche to menopause the primary estrogen is 17β-estradiol. In postmenopausal women more estrone is present than estradiol. - Estradiol is produced from testosterone and estrone from androstenedione. - Estrone is weaker than estradiol. Premarin, a commonly prescribed estrogenic drug, contains the steroidal estrogens equilin and equilenin, in addition to estrone sulfate. A range of synthetic and natural substances have been identified that also possess estrogenic activity. Synthetic substances of this kind are known as xenoestrogens, plant products with estrogenic activity are called phytoestrogens, and those produced by fungi are known as mycoestrogens. Unlike estrogens produced by mammals, these substances are not necessarily steroids. # Estrogen production Testosterone is synthesized during steroidogenesis, with cholesterol as the starting molecule. Estrogen is produced primarily by developing follicles in the ovaries, the corpus luteum, and the placenta. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) stimulate the production of estrogen in the ovaries. Some estrogens are also produced in smaller amounts by other tissues such as the liver, adrenal glands, and the breasts. These secondary sources of estrogen are especially important in postmenopausal women. Synthesis of estrogens starts in theca interna cells in the ovary, by the synthesis of androstenedione from cholesterol. Androstenedione is a substance of moderate androgenic activity. This compound crosses the basal membrane into the surrounding granulosa cells, where it is converted to estrone or estradiol, either immediately or through testosterone. The conversion of testosterone to estradiol, and of androstenedione to estrone, is catalyzed by the enzyme aromatase. Estradiol levels vary through the menstrual cycle, with levels highest just before ovulation. # Functions While estrogens are present in both men and women, they are usually present at significantly higher levels in women of reproductive age. They promote the development of female secondary sex characteristics, such as breasts, and are also involved in the thickening of the endometrium and other aspects of regulating the menstrual cycle. In males estrogen regulates certain functions of the reproductive system important to the maturation of sperm and may be necessary for a healthy libido.. Furthermore, there are several other structural changes induced by estrogen, in addition to other functions. - Structural promote formation of female secondary sex characteristics accelerate height growth accelerate metabolism (burn fat) reduce muscle mass stimulate endometrial growth increase uterine growth maintenance of vessel and skin reduce bone resorption, increase bone formation morphic change (endomorphic -> mesomorphic -> ectomorphic) - promote formation of female secondary sex characteristics - accelerate height growth - accelerate metabolism (burn fat) - reduce muscle mass - stimulate endometrial growth - increase uterine growth - maintenance of vessel and skin - reduce bone resorption, increase bone formation - morphic change (endomorphic -> mesomorphic -> ectomorphic) - protein synthesis increase hepatic production of binding proteins - increase hepatic production of binding proteins - coagulation increase circulating level of factors 2, 7, 9, 10, antithrombin III, plasminogen increase platelet adhesiveness - increase circulating level of factors 2, 7, 9, 10, antithrombin III, plasminogen - increase platelet adhesiveness - Lipid increase HDL, triglyceride, height growth decrease LDL, fat depositition - increase HDL, triglyceride, height growth - decrease LDL, fat depositition - Fluid balance salt (sodium) and water retention increase growth hormone increase cortisol, SHBG - salt (sodium) and water retention - increase growth hormone - increase cortisol, SHBG - gastrointestinal tract reduce bowel motility increase cholesterol in bile - reduce bowel motility - increase cholesterol in bile - Melanin increase pheomelanin, reduce eumelanin - increase pheomelanin, reduce eumelanin - Cancer support hormone-sensitive breast cancers (see section below) - support hormone-sensitive breast cancers (see section below) - Lung function promotes lung function by supporting alveoli (in rodents but probably in humans) . - promotes lung function by supporting alveoli (in rodents but probably in humans) . On the other hand, sexual desire rather depend on androgen levels than for estrogen levels. ## Role in cancer About 80% of breast cancers, once established, rely on supplies of the hormone estrogen to grow: they are known as hormone-sensitive or hormone-receptor-positive cancers. Suppression of production in the body of estrogen is a treatment for these cancers. # Medical applications Since estrogen circulating in the blood can negatively feed-back to reduce circulating levels of FSH and LH, most oral contraceptives contain a synthetic estrogen, along with a synthetic progestin. Even in men, the major hormone involved in LH feedback is estradiol, not testosterone. As more fully discussed in the article on Hormone replacement therapy , estrogen and other hormones are given to postmenopausal women in order to prevent osteoporosis as well as treat the symptoms of menopause such as hot flashes, vaginal dryness, urinary stress incontinence, chilly sensations, dizziness, fatigue, irritability, and sweating. Fractures of the spine, wrist, and hips decrease by 50-70% and spinal bone density increases by ~5% in those women treated with estrogen within 3 years of the onset of menopause and for 5-10 years thereafter. Before the specific dangers of conjugated equine estrogens were well understood, standard therapy was 0.625 mg/day of conjugated equine estrogens (such as Premarin). There are, however, risks associated with conjugated equine estrogen therapy. Among the older postmenopausal women studied as part of the Women's Health Initiative (WHI), an orally-administered conjugated equine estrogen supplement was found to be associated with an increased risk of dangerous blood clotting. The WHI studies used one type of estrogen supplement, a high oral dose of conjugated equine estrogens (Premarin alone and with medroxyprogesterone acetate as PremPro). In a study by the NIH, esterified estrogens were not proven to pose the same risks to health as conjugated equine estrogens. Hormone replacement therapy has favorable effects on serum cholesterol levels, and when initiated immediately upon menopause reduces the incidence of cardiovascular disease. Estrogen has a protector effect on atherosclerosis : it lowers LDL and triglycerides, it raises HDL levels and has endothelial vasodilatation properties plus an anti-inflammatory component. Research is underway to determine if risks of estrogen supplement use are the same for all methods of delivery. In particular, estrogen applied topically may have a different spectrum of side-effects than when administered orally, and transdermal oestrogens do not affect clotting as they are absorbed directly into the systemic circulation, avoiding first-pass metabolism in the liver. This route of administration is thus preferred in women with a history of thrombo-embolic disease. Estrogen is also used in the therapy of vaginal atrophy, hypoestrogenism (as a result of hypogonadism, castration, or primary ovarian failure), amenorrhea, dysmenorrhea, and oligomenorrhea. Estrogens can also be used to suppress lactation after child birth. Hormone-receptor-positive breast cancers are treated with drugs which suppress production in the body of estrogen. This technique, in the context of treatment of breast cancer, is known variously as hormonal therapy, hormone therapy, or anti-estrogen therapy (not to be confused with hormone replacement therapy). Certain foods such as soy may also suppress the effects of estrogen and are used as an alternative to hormone therapy. In humans and mice, estrogen promotes wound healing. At one time, estrogen was used to induce growth attenuation in tall girls. Recently, estrogen-induced growth attenuation was used as part of the controversial Ashley Treatment to keep a developmentally disabled girl from growing to adult size. Under certain circumstances, estrogen may also be used in males for treatment of prostate cancer. Most recently, estrogen has been used in experimental research as a way to treat patients suffering from bulimia nervosa, in addition to Cognitive Behavioral Therapy, which is the established standard for treatment in bulimia cases. The estrogen research hypothesizes that the disease may be linked to a hormonal imbalance in the brain. Estrogen has also been used in studies which indicate that it may be an effective drug for use in the treatment of traumatic liver injury. # Health risks and warning labels The labeling of estrogen-only products in the U.S. includes a boxed warning that unopposed estrogen (without progestagen) therapy increases the risk of endometrial cancer. Based on a review of data from the WHI, on January 8, 2003 the FDA changed the labeling of all estrogen and estrogen with progestin products for use by postmenopausal women to include a new boxed warning about cardiovascular and other risks. The estrogen-alone substudy of the WHI reported an increased risk of stroke and deep vein thrombosis (DVT) in postmenopausal women 50 years of age or older and an increased risk of dementia in postmenopausal women 65 years of age or older using 0.625 mg of Premarin conjugated equine estrogens (CEE). The estrogen-plus-progestin substudy of the WHI reported an increased risk of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli and DVT in postmenopausal women 50 years of age or older and an increased risk of dementia in postmenopausal women 65 years of age or older using PremPro, which is 0.625 mg of CEE with 2.5 mg of the progestin medroxyprogesterone acetate (MPA). # Estrogens in cosmetics Some hair shampoos on the market include estrogens and placental extracts; others contain phytoestrogens. There are case reports of young children developing breasts after exposure to these shampoos. These products are often marketed to African-American consumers. On September 9, 1993, the FDA determined that not all topically-applied hormone-containing drug products for OTC human use are generally recognized as safe and effective and are misbranded. An accompanying proposed rule deals with cosmetics, concluding that any use of natural estrogens in a cosmetic product makes the product an unapproved new drug and that any cosmetic using the term "hormone" in the text of its labeling or in its ingredient statement makes an implied drug claim, subjecting such a product to regulatory action. In addition to being considered misbranded drugs, products claiming to contain placental extract may also be deemed to be misbranded cosmetics if the extract has been prepared from placentas from which the hormones and other biologically active substances have been removed and the extracted substance consists principally of protein. The FDA recommends that this substance be identified by a name other than "placental extract" and describing its composition more accurately because consumers associate the name "placental extract" with a therapeutic use of some biological activity. # History The existence and effects of estrogen were established from 1923 to 1938 in which the formulation was led by a group of scientists instead of pharmaceutical companies. Thereafter, the market for hormonal drug research opened up. The “first orally effective estrogen”, Emmenin, derived from the late-pregnancy urine of Canadian women, was introduced in 1930 by Collip and Ayerst Laboratories . Estrogens are not water-soluble and cannot be given orally, but the urine was found to contain estriol glucuronide which is water soluble and becomes active in the body after hydrolization. Scientists continued to search for new sources of estrogen because of concerns associated with the practicality of introducing the drug into the market. At the same time, a German pharmaceutical drug company, formulated a similar product as Emmenin that was introduced to German women to treat menopausal symptoms. In 1938, British scientists obtained a patent on a newly formulated nonsteroidal estrogen, Diethylstilbestrol (DES), that was cheaper and more powerful than the previously manufactured estrogens. Soon after, concerns over the side effects of DES were raised in scientific journals while the drug manufacturers came together to lobby for governmental approval of DES. It was only until 1941 when estrogen therapy was finally approved by the Food and Drug Administration (FDA) for the treatment of menopausal symptoms.

Apremilast for treating active psoriatic arthritis Evidence-based recommendations on apremilast (Otezla) for treating active psoriatic arthritis. # Recommendations Apremilast, alone or in combination with disease-modifying antirheumatic drugs (DMARDs), is recommended as an option for treating active psoriatic arthritis in adults only if: they have peripheral arthritis with 3 or more tender joints and 3 or more swollen joints and their disease has not responded to adequate trials of at least 2 standard DMARDs, given either alone or in combination and the company provides apremilast with the discount agreed in the patient access scheme. Stop apremilast at 16 weeks if the psoriatic arthritis has not shown an adequate response using the Psoriatic Arthritis response Criteria (PsARC), defined as an improvement in at least 2 of the 4 PsARC criteria (including joint tenderness or swelling score) with no worsening in any criteria. If the disease has a Psoriasis Area and Severity Index (PASI) 75 response, a dermatologist should decide whether to continue treatment with apremilast after 16 weeks based on skin response. When using the PsARC healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect a person's responses to components of the PsARC and make any adjustments they consider appropriate. This guidance is not intended to affect the position of patients whose treatment with apremilast was started within the NHS before this guidance was published. Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop.# The technology Description of the technology Apremilast (Otezla, Celgene) is a small-molecule inhibitor of phosphodiesterase 4 (PDE4). Apremilast down-regulates the inflammatory response by modulating the expression of inflammatory and anti-inflammatory cytokines and mediators associated with psoriatic arthritis (including tumour necrosis factor -alpha and interleukin -23). Marketing authorisation Apremilast 'alone or in combination with disease-modifying antirheumatic drugs (DMARDs), is indicated for the treatment of active psoriatic arthritis in adult patients who have had an inadequate response or who have been intolerant to a prior DMARD therapy'. Adverse reactions The summary of product characteristics includes the following adverse reactions for apremilast: gastrointestinal (GI) disorders (most commonly diarrhoea and nausea); upper respiratory tract infections; headache; and tension headache. For full details of adverse reactions and contraindications, see the summary of product characteristics. Recommended dose and schedule Apremilast is an oral tablet. The recommended dosage is 30 mg twice daily after an initial titration schedule. A single 10-mg dose is given on the first day of treatment; this is titrated to 30 mg twice daily over 5 days (see the summary of product characteristics for the dose titration schedule). Price The price of apremilast is £550.00 for a 28-day pack (56×30-mg tablets) (excluding VAT; British National Formulary online, accessed September 2016). The company has agreed a patient access scheme with the Department of Health. This scheme provides a simple discount to the list price of apremilast, with the discount applied at the point of purchase or invoice. The level of the discount is commercial in confidence. The Department of Health considered that this patient access scheme does not constitute an excessive administrative burden on the NHS.# Evidence The appraisal committee (section 6) considered evidence submitted by Celgene and a review of this submission by the evidence review group. This appraisal was a rapid review of the published NICE technology appraisal guidance on apremilast for treating psoriatic arthritis (TA372). It focused on cost‑effectiveness analyses using a patient access scheme agreement, which provides apremilast at a reduced cost. The discount is commercial in confidence. See the committee papers for full details of the rapid review evidence, and the history for full details of the evidence used for NICE's original technology appraisal guidance on apremilast for treating psoriatic arthritis. See section 4.24 onwards for the rapid review consideration.# Committee discussion The appraisal committee reviewed the data available on the clinical and cost effectiveness of apremilast, having considered evidence on the nature of psoriatic arthritis and the value placed on the benefits of apremilast by people with the condition, those who represent them, and clinical experts. It also took into account the effective use of NHS resources. # Clinical need and practice The committee heard from patient experts about the nature of psoriatic arthritis and their experiences of treatment. It heard that psoriatic arthritis is a lifelong condition that seriously affects people's quality of life. It can develop at a young age and affects all aspects of a person's life including education, work, self-care, and social and family life. The committee heard from the patient expert that skin symptoms can have a major psychological impact, and that joint symptoms can have an even greater impact on the psychological and functional aspects of living with the condition. The committee concluded that psoriatic arthritis substantially decreases quality of life. The committee considered the current treatment pathway for people with psoriatic arthritis. It heard from clinical experts that after taking non-steroidal anti-inflammatory drugs and disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, most people with non-responsive disease will have a tumour necrosis factor (TNF)‑alpha inhibitor, starting with the lowest cost drug as recommended in NICE technology appraisal guidance on etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis and golimumab for the treatment of psoriatic arthritis. It heard from the clinical experts that use of more than 1 TNF‑alpha inhibitor is established practice in the NHS; if the disease fails to respond or loses response to the first TNF‑alpha inhibitor, or it causes adverse effects, a second TNF‑alpha inhibitor will often be used. The committee considered where apremilast would fit into this existing treatment pathway. It heard from the patient expert that when treatment with a TNF‑alpha inhibitor is contraindicated, or it is stopped because of loss of effectiveness or adverse effects (the clinical experts noted approximately 10% of patients per year stop TNF‑alpha inhibitor treatment), there may be no alternative treatments available. Therefore, patients and clinicians value having a range of treatment options available, and there is an unmet need for treatments that offer a different mechanism of action to the TNF‑alpha inhibitors or that are administered orally, as with apremilast (a PDE4 inhibitor). The committee was aware that apremilast had the same marketing authorisation as the currently recommended biological treatments, but that the company had stated that apremilast would be used before these treatments in clinical practice, based on its oral route of administration, safety profile compared with current biological and conventional DMARD treatments, no specific requirements in the marketing authorisation for regular monitoring, and a cheaper cost compared with current biological therapies. The committee was also aware of a written statement from the clinical expert that apremilast could be considered an alternative first- or second-line drug, because it was likely more effective than methotrexate. However, the written statement from the clinician had noted that placement in the pathway would also depend on treatment cost. The committee heard from the clinical experts that it would be useful to have an additional treatment option before TNF‑alpha inhibitors, because the psoriatic arthritis population is heterogeneous and some people cannot tolerate DMARD therapy, or their disease does not respond adequately to it. The committee concluded that it was possible that apremilast could be used as a treatment before TNF‑alpha inhibitors, but that any use or positioning of apremilast would need to be supported by clinical and cost‑effectiveness evidence, particularly because several effective treatment options are already recommended for psoriatic arthritis. The committee considered the most appropriate comparators for this appraisal. It was aware that in June 2015, NICE published guidance on ustekinumab for treating active psoriatic arthritis which, as an IL12/23 inhibitor, offered a different mechanism of action to the TNF‑alpha inhibitors. However, it accepted that current usage of this drug was likely to be low, both because it had only relatively recently received a positive recommendation, and also because the recommendation is more restrictive than the currently recommended TNF‑alpha inhibitors (ustekinumab is recommended as a treatment option only if treatment with TNF‑alpha inhibitors is contraindicated but would otherwise be considered, or if the person has had treatment with 1 or more TNF‑alpha inhibitors). The committee was also aware that certolizumab pegol (another TNF‑alpha inhibitor) is another possible treatment option for people with psoriatic arthritis; however, it heard from the clinical experts that it is rarely used in clinical practice. The committee concluded that the most appropriate comparators for this appraisal were the TNF‑alpha inhibitors adalimumab, etanercept, infliximab and golimumab (because they have a similar marketing authorisation to apremilast, and are the most commonly used treatments in clinical practice after the failure of a DMARD) and that ustekinumab could be considered as a comparator if it became relevant to consider making a recommendation specifically for a population for whom TNF‑alpha inhibitors are not appropriate. The committee heard from the clinical and patient experts that although methotrexate works well, some people fear the adverse effects associated with it (such as hair loss, nausea and lethargy) and the need for frequent blood tests. The experts stated that apremilast may be better tolerated, although it is associated with a higher incidence of diarrhoea initially compared with some DMARDs such as leflunomide. The clinical experts stated that there is no evidence on whether apremilast is better tolerated than TNF‑alpha inhibitors and that, in general, the TNF‑alpha inhibitors are well tolerated; apremilast is no better or worse than the TNF‑alpha inhibitors, and most patients do not experience unacceptable problems. The clinical experts also suggested that, as with any new treatment, apremilast would need extra monitoring because its long-term adverse events are unknown. The committee was aware of new evidence about the adverse effects of apremilast that the company had submitted in response to the appraisal consultation document, which provided further evidence about the adverse event profile for apremilast. The committee concluded that apremilast has an acceptable adverse event profile in people with active psoriatic arthritis. # Clinical effectiveness The committee considered the evidence presented by the company on the clinical effectiveness of apremilast. It noted that the main sources of evidence were the PSA-002, PSA-003 and PSA-004 trials that compared apremilast (20 mg and 30 mg) with placebo in patients with active psoriatic arthritis (3 or more swollen and tender joints for at least 6 months) that had not responded to treatment with up to 3 DMARDs or 1 TNF‑alpha inhibitor. The committee noted that the trials were well conducted and showed that apremilast is more effective than placebo after 16 weeks of treatment for a number of joint, skin and soft tissue outcomes; the primary outcome was ACR20, with a response experienced by 37% of people having apremilast compared with 19% having placebo (p≤0.0001). The clinical experts noted that apremilast was associated with a similar ACR20 response to methotrexate. The committee acknowledged that in response to the appraisal consultation document the company stated that it considered this opinion to be subjective, because little comparative evidence is available in this area. The committee also noted that apremilast was effective for associated problems such as dactylitis and enthesitis. The committee agreed that apremilast was a clinically effective treatment compared with placebo. The committee considered the more stringent ACR outcomes (ACR50 and ACR70) presented in the apremilast trials. It heard from the clinical experts that although ACR20 is an accepted outcome measure for treatments of psoriatic arthritis and was the primary outcome in the apremilast trials, people may still have painful and swollen joints and that people start to notice a benefit at ARC50 or ACR70. The committee agreed that there was a difference between apremilast and placebo but that the absolute differences were less than those seen for ACR20. The committee considered the evidence from the company's network meta-analysis that compared apremilast with TNF‑alpha inhibitors in the total population, and in the population who had not been treated with TNF‑alpha inhibitors. The committee heard from the evidence review group (ERG) that the methods used to identify both published and unpublished studies for the network meta-analysis were appropriate, and the studies were mostly well reported. The committee discussed the ERG's concerns that the placebo responses for some outcomes were high which made it difficult to compare the relative efficacies of apremilast with the different comparators. The committee noted that the results showed that apremilast had a clinical benefit compared with placebo. However, apremilast demonstrated less clinical benefit than any of the TNF‑alpha inhibitors, in either population. The committee concluded that apremilast is not as clinically effective as the TNF‑alpha inhibitors for treating psoriatic arthritis. The committee considered the HAQ‑DI outcome used by the company to calculate functional capacity and to assess disease progression. It heard from the ERG that there were uncertainties about the results from the apremilast trials because they were not blinded after 24 weeks and there were no stopping rules, which was likely to have influenced the HAQ‑DI results. The committee noted that the company had provided evidence to argue against this in its response to the appraisal consultation document; for example, the company stated that participants remained blinded to initial treatment and dose during the unblinded period. However, the committee remained concerned that, in comparison with more objective measures of disease progression such as radiographic assessments, there was a higher possibility of bias. The committee considered the lack of radiographic assessment in the apremilast trials. It heard from the clinical experts that it would be difficult to justify using apremilast early in the treatment pathway (before TNF‑alpha inhibitors) without evidence that it can prevent radiological progression, because there is evidence to show that TNF‑alpha inhibitors slow disease progression. The committee also heard from the patient experts that they want treatments that can stop the disease from progressing. It noted that the company had stated in its response to the appraisal consultation document that the relationship between radiographic progression and functional capacity was unclear, and that other measures such as disease activity were equally, if not more, important when considering the impact of disease on quality of life. The committee accepted that it may be necessary to interpret radiographic evidence with caution, and that disease activity outcomes play an important role in functional capacity. However, it noted that apremilast not only lacked radiographic evidence about disease progression, but had consistently shown the worst performance of any active comparator for all outcomes presented in the network meta-analyses. Because it is a new treatment, there is a lack of long-term clinical effectiveness data for apremilast. The committee concluded that the lack of radiographic evidence and the clinical-effectiveness evidence did not support the use of apremilast before TNF‑alpha inhibitors in clinical practice. # Cost effectiveness The committee considered the company's revised model which, as in the original base case, compared treatment sequences with and without apremilast, rather than comparing apremilast with a single comparator. This provided a revised base-case incremental cost‑effectiveness ratio (ICER) of approximately £19,500 per quality-adjusted life year (QALY) gained when adding apremilast to a treatment sequence of adalimumab, etanercept, and best supportive care. Apremilast remained cost effective (when assuming a maximum acceptable ICER of £30,000 per QALY gained) in exploratory analyses, including when varying apremilast HAQ-DI progression in relation to best supportive care (£22,700 to £29,100 per QALY gained). The committee accepted that the use of treatment sequences was a valid approach to modelling. The committee considered whether the structural and parameter assumptions in the company's treatment sequences in the revised base case reflected clinical practice. It noted that most analyses by the company compared treatment sequences that had a different number of active comparators before progression to best supportive care, with the base case comparing 3 active treatments for the apremilast group with 2 for the comparator group. The committee agreed that, in clinical practice, patients would likely receive more than the 2 active treatments patients were assumed to receive in the comparator group before they progressed to best supportive care. This was because there are a number of active comparators available for treating psoriatic arthritis, particularly since the positive recommendation for ustekinumab. The committee also considered that models comparing sequences, rather than more traditional direct comparisons, created additional uncertainty in the model. Treatment sequences of different lengths may exacerbate uncertainties in the model, which may also be less easily identifiable, because they are less likely to affect each arm equally than with direct comparisons or equal length sequences. The committee further understood from the assessment group analyses that, assuming all other things were equal, replacing apremilast in the intervention group of the company revised base case with any of the TNF‑alpha inhibitors would result in a QALY gain over the comparator sequence. The committee concluded that in order to prevent the model being confounded by any QALY gain occurring only because of one group in the model having an additional active treatment, in a selected and unrealistically short sequence, it was more informative to make inferences from modelling the same number of active comparators in each treatment sequence. The committee noted that the company had presented a limited exploratory analysis using treatment sequences of equal length in which apremilast was used instead of adalimumab in a sequence of adalimumab, etanercept, golimumab and best supportive care. However, the committee noted that this needed to be seen in the context of the ERG's multiple calculations using sequences with an equal number of active comparators, and also noted that the company considered this scenario to be of limited relevance. The committee also noted that the analyses should be consistent with the direct clinical and cost differences between the TNF‑alpha inhibitors and apremilast. The committee considered the company's assumptions about the improvement and progression of joint symptoms (measured using HAQ‑DI). It noted that these were key drivers of the economic model and that people whose disease continued to respond to treatment at the end of the trial period retained the same HAQ‑DI score (that is, apremilast was assumed to halt HAQ‑DI progression while people remained on treatment, therefore zero HAQ‑DI progression was applied). The committee noted that the company's rationale for assuming that apremilast halts disease progression was based on acceptance in previous NICE appraisals for psoriatic arthritis that TNF‑alpha inhibitors halt disease progression. The committee was aware that the assumption that TNF‑alpha inhibitors halt disease progression was supported radiographically and also by clinical practice evidence over a number of years. However, there was uncertainty about whether this assumption was equally relevant for apremilast, which has a different mechanism of action and limited evidence of use in clinical practice because it is a relatively new treatment. The committee also noted that people who progressed to best supportive care were assumed to experience subsequent natural progression of their disease, resulting in an increase (worsening) in HAQ‑DI score over time of 0.006 every 28 days, up to a maximum score of 3. The committee noted that this score appeared high but heard from the clinical experts that, although it is not possible to know if people would experience a linear progression of disease, the clinical experts considered that the increase in HAQ‑DI over time is likely to be within the same range as that used by the company. The committee heard from the ERG that experience with rheumatoid arthritis shows that HAQ‑DI does not have a linear trajectory; the rate of progression of the disease slows down over time. However, the committee also noted comments from the company in response to the appraisal consultation document that the linearity of HAQ‑DI progression was hypothetical and that the appraisal for ustekinumab for treating active psoriatic arthritis had assumed linear progression. The committee also noted that patients with the best HAQ‑DI responses would be likely to remain in the trials, making the HAQ‑DI appear to improve over time. The committee acknowledged that there is a lack of evidence to inform these model assumptions, and this added uncertainty to the model. However, the assumption that apremilast completely halts HAQ‑DI progression represented a best-case scenario that was not supported by clinical evidence (see sections 4.8, 4.9 and 4.10). The committee considered the use of HAQ‑DI and PASI scores mapped to EQ‑5D to produce utility values of health in the company's original base case. The committee noted that the utility values in the company's revised base case were derived from the apremilast trial. Although this reflected the preferences of the committee as expressed in the appraisal consultation document, the committee noted that this had little impact on results compared with the values used in the original base case. The committee was also surprised at the estimates of utility, which appeared very low and similar to technologies for end of life conditions. However, the committee agreed that the company had used a legitimate source for utility values by using the available trial data, and accepted the utility values for its decision-making. The committee discussed the costs included in the model, particularly the monitoring costs for apremilast treatment. It noted that in response to the appraisal consultation document the company had stated that monitoring costs for apremilast should not be included because there were no specific requirements for screening or regular monitoring, but that it had updated its revised base case to include an equal level of monitoring for all active treatments. The committee heard from the clinical experts that, as with any new drug, apremilast would initially need more monitoring compared with the current standard of care. It therefore concluded that the revised model had correctly accounted for monitoring costs for apremilast. The committee considered the assumption of different trial periods for apremilast (16 weeks) and TNF‑alpha inhibitors (12 weeks) for PsARC responses. The committee heard from the ERG that the use of different time points could favour apremilast and that, if the trial period for TNF‑alpha inhibitors were also increased to 16 weeks, the PsARC responses may increase. The clinical experts agreed that using different trial periods could influence the results. The committee acknowledged that the company had carried out a scenario analysis altering the length of the apremilast trial period to 24 weeks but leaving the TNF‑alpha inhibitor response at 12 weeks. The committee concluded that the longer trial period of apremilast could have given a relatively optimistic case for apremilast compared with other comparators. The committee considered the company's assumptions for placebo responses in the original and revised model. It noted that in the original model, the placebo response rate was discounted from best supportive care, but not from the absolute response rates of apremilast or the TNF‑alpha inhibitors used in the model. However, in the revised base case, the company had included a placebo response for best supportive care. The committee agreed that inclusion of placebo response rates in the model was necessary and accepted this revision to the model. The committee noted that the company's original base case results were based on uncertain assumptions. It appreciated that the company had attempted to address this uncertainty by making several changes in its revised model (including equal levels of monitoring for apremilast and TNF‑alpha inhibitors, a placebo response for best supportive care, and utility values derived from the apremilast trial), and also by presenting several exploratory analyses. However, most ICERs presented by the company were based on treatment sequences with an unequal number of treatments, which was not the committee's preference (see sections 4.11 and 4.19). The committee therefore went on to consider the exploratory analyses presented by the ERG. The committee noted that the ERG had based its analyses on the revised company base case and, therefore, as in the company revised base case, it accounted for several uncertainties in the original base case. Also, the ERG had used the committee's preferred treatment sequences, with an equal number of active comparators before progression to best supportive care, for its exploratory analyses. The committee concluded that the exploratory analyses presented by the ERG were the most appropriate for decision-making. The committee considered the results for apremilast as a treatment before TNF‑alpha inhibitor therapy, using its preferred exploratory analyses from the ERG (see sections 4.11 and 4.17). The committee noted that all the ERG's sequences in which apremilast was the first treatment in a sequence (after DMARDs) resulted in cost savings but also a QALY loss, resulting in ICERs that reflected 'savings per QALY lost'. For example, when comparing a sequence of apremilast, adalimumab, etanercept and best supportive care with adalimumab, etanercept, golimumab, and best supportive care, and when using the committees preferred assumption of some HAQ-DI progression for apremilast (at half the rate of that for best supportive care) there was a cost saving of £6,739 in the apremilast sequence, but a QALY loss of −0.368, resulting in an ICER of £18,300 saved per QALY lost. The committee considered this to be the most plausible scenario because it used its preferred assumptions, and also because the results were consistent with the clinical and cost data; that is, when compared with TNF‑alpha inhibitors, apremilast cost less but was also the least effective active treatment. The committee noted that, in situations in which an ICER is derived from a technology that is less effective and less costly than its comparator, the commonly assumed decision rule of accepting ICERs below a given threshold is reversed, and so the higher the ICER, the more cost effective a treatment becomes. The committee was aware that psoriatic arthritis is a chronic and progressive condition, that patients want treatments that stop disease progression (see section 4.10), and that apremilast was the least effective treatment in the company analyses. Taking all of the above into account, the committee agreed that the ICER for apremilast was not high enough to compensate for the clinical effectiveness that would be lost. It therefore concluded that apremilast was not a cost‑effective option compared with TNF‑alpha inhibitors for people with psoriatic arthritis that has responded inadequately to DMARDs. The committee considered whether there was any evidence to consider apremilast as a treatment after TNF‑alpha inhibitor therapy, or for people who could not take TNF‑alpha inhibitors. It noted that evidence in this area was limited. The available clinical effectiveness evidence for apremilast was mostly for a population who had not previously had TNF‑alpha inhibitors. The cost‑effectiveness evidence was limited because the company had rejected this possible positioning of apremilast, even though such comparisons (particularly with ustekinumab) were listed in the final scope issued by NICE. The company had presented 2 direct comparisons of apremilast with best supportive care, and when assuming apremilast HAQ‑DI progression at a rate half that of best supportive care, the ICER for apremilast was £21,700 per QALY gained. The committee noted, however, that the company had not explored the analyses further because it did not consider best supportive care to be an appropriate comparator. Following the publication of ustekinumab for treating active psoriatic arthritis, and given the range of other treatments available for psoriatic arthritis, there are a number of other possible treatments used after TNF‑alpha inhibitors that would be available before best supportive care, and these had not been explored as comparators. The committee also considered the ERG's scenarios for apremilast used after TNF‑alpha inhibitors, which included the committee's preferred model assumption of the same number of active treatments in each sequence. The committee was aware of the ERG's comments about the validity of its exploratory analyses and agreed that as these were the only scenarios presented for apremilast used after TNF‑alpha inhibitors, they should be taken into account in its decision-making. The committee noted that in all the ERG's exploratory analyses the apremilast treatment sequence resulted in cost savings but a QALY loss, resulting in ICERs that reflected 'savings per QALY lost'. For example, a treatment sequence in which apremilast replaced golimumab in a sequence of adalimumab, etanercept, golimumab and best supportive care, assuming HAQ-DI progression at a rate equal to half of best supportive care, resulted in a cost saving of £5,343 and a QALY loss of −0.362, with an ICER of £14,800 saved per QALY lost. The committee agreed that this was the most plausible scenario that had been presented because it used the committee's preferred assumptions about treatment sequences with an equal number of treatments and some HAQ-DI progression for apremilast, the results were consistent with the clinical and cost data (that is, when compared with TNF‑alpha inhibitors, apremilast cost less but was also the least effective active treatment), and also because of the limited evidence presented by the company. The committee agreed that the ICER for apremilast was not high enough to compensate for the clinical effectiveness that would be lost. It therefore concluded that apremilast could not be recommended as a treatment after TNF‑alpha inhibitors. It was unable to make recommendations for its use when people cannot take TNF‑alpha inhibitors, because of a lack of evidence for its use in these circumstances. The committee discussed whether apremilast is considered innovative. It heard from clinical and patient experts that apremilast may provide an additional treatment option for patients, because of its different mode of action and oral formulation. However, given its conclusion on clinical efficacy (see sections 4.6 to 4.8) the committee considered that apremilast was not a step-change in treatment. The committee concluded that there were no additional gains in health-related quality of life over those already included in the QALY calculations, and that there was no need to change its conclusions on that basis. The committee was aware of NICE's position statement on the Pharmaceutical Price Regulation Scheme (PPRS) 2014, and in particular the PPRS payment mechanism, and accepted the conclusion 'that the 2014 PPRS payment mechanism should not, as a matter of course, be regarded as a relevant consideration in its assessment of the cost effectiveness of branded medicines'. The committee heard nothing to suggest that there is any basis for taking a different view with regard to the relevance of the PPRS to this appraisal. It therefore concluded that the PPRS payment mechanism was not relevant for its consideration of the cost effectiveness of any of the technologies in this appraisal. # Rapid review ## Positioning of apremilast The committee noted that the company's rapid review submission had presented a base case for apremilast as a pre-TNF‑alpha inhibitor treatment only, despite the committee previously stating that the clinical evidence did not support the use of apremilast before the more effective TNF‑alpha inhibitors (section 4.10). The committee had also previously accepted that it was possible that in clinical practice, apremilast might be used before TNF‑alpha inhibitors (section 4.3); for example, some patients may prefer an oral treatment and may therefore be willing to accept some reduced effectiveness. However, the committee agreed that any recommendation it made would be on the basis of whether apremilast could be considered a cost‑effective treatment option alongside all other existing treatment options; it was not producing a treatment sequencing guideline. The committee discussed whether the company had presented enough analyses to fully consider the likely impact of apremilast, should it be recommended. It noted that the company had not explored the full treatment pathway in its rapid review submission, with most analyses limited to a maximum of 3 treatments in a sequence. However, the committee appreciated that the company had updated several assumptions in its base case to address committee concerns (for example, the base case now included an equal rather than uneven number of active treatments in each arm), and had also presented several new analyses which contributed to reducing the uncertainties outlined in the previous NICE technology appraisal. These included the addition of direct head-to-head comparisons with several comparators from the scope, scenarios where apremilast was positioned after TNF‑alpha inhibitors, and the addition of the scope comparator ustekinumab. The committee agreed that, in addition to the base case presented, it would have also preferred to see a company base case for apremilast as a post-TNF‑alpha inhibitor treatment. However, it concluded that the company and ERG exploratory analyses helped to reduce uncertainty in the cost‑effectiveness results. ## HAQ-DI The committee was aware that HAQ-DI was a principle uncertainty in the original company model for the previous NICE technology appraisal. It noted and appreciated that although there was a lack of evidence to support the exact value, the company had modelled some HAQ-DI progression for apremilast (at a rate of 50% of best supportive care) in its revised analyses. Both the company and the ERG had also attempted to explore this uncertainty by using different rates of HAQ-DI progression for apremilast, and the committee heard from the company that it now had access to 3-year clinical trial data for apremilast, showing that HAQ-DI had been maintained for patients using apremilast. The committee concluded that the company had taken the correct approach by including some HAQ-DI progression for apremilast in its base case and that, in the absence of more robust evidence, the value used of 50% of the rate of best supportive care was a pragmatic assumption. ## Modelled response to treatment The committee noted that the modelled response to treatment was binary, with modelled patients achieving either response or no response, using PsARC (psoriatic arthritis response criteria, which assesses several joint and skin outcomes). The committee considered whether this binary categorisation would accurately capture response to treatment, which may be more nuanced in clinical practice. It heard from the company that disease progression for psoriatic arthritis is driven by swollen joints. The committee also noted that the company had explored using ACR20 as a measure of response to treatment in its analyses, and this did not have a substantial effect on results. The committee concluded that the modelled response to treatment was imperfect, but appropriate for decision-making. ## Declining effectiveness assumption The committee noted that any TNF‑alpha inhibitor given in a modelled treatment sequence after previous TNF‑alpha inhibitor treatment was assumed to be less effective. The committee heard that the evidence for this was indirect. The committee concluded that although there was uncertainty about the declining effectiveness assumption for TNF‑alpha inhibitors, it was plausible that the effectiveness of a TNF‑alpha inhibitor could be affected by the use of a prior TNF‑alpha inhibitor. The company also highlighted that this assumption did not affect any head-to-head analyses. The committee accepted this assumption for decision-making. ## Most plausible ICERs The committee discussed whether it could identify a most plausible ICER. It noted that the base-case ICER with the apremilast patient access scheme was £39,052 saved per QALY lost. The committee also considered the sensitivity and scenario analyses presented by both the company and the ERG. All showed that, as in the company's base case, using apremilast resulted in cost savings but a QALY loss. All were over £20,000 saved per QALY lost, and most were also over £30,000 saved per QALY lost. The committee agreed that the analyses that produced ICERs of less than £30,000 saved per QALY lost were not the most realistic scenarios. It agreed that the inclusion of the apremilast patient access scheme had increased the cost savings such that they were at a more acceptable level given the QALYs that would be lost. ## Biosimilars The committee was aware that biosimilars for the comparators infliximab and etanercept are now available, and that the company had not included biosimilar infliximab despite it being a comparator in the scope. The committee considered what effect the inclusion of biosimilars could have had on the cost‑effectiveness results. It heard from the ERG that it had done some informal analyses in the context of the company base case (comparing a sequence of apremilast, adalimumab, etanercept and best supportive care with adalimumab, etanercept, golimumab, and best supportive care). Adding biosimilar etanercept to the base case did not substantially change cost‑effectiveness results. Importantly, the committee was also aware that in direct head-to-head comparisons, apremilast demonstrated the highest cost‑effectiveness results when compared with infliximab (the ICER was over £40,000 saved per QALY lost without the apremilast patient access scheme), so although the inclusion of biosimilar infliximab would worsen (that is, lower) the ICER for apremilast, the overall interpretation of the result was likely to be the same. The committee concluded that it would have preferred to have seen the inclusion of biosimilar infliximab, but that the cost‑effectiveness results were still appropriate for decision-making. ## Recommendation The committee agreed that, because apremilast is a less effective treatment than the currently available treatment options (see section 4.8), it was particularly important to consider the possible consequences of a positive recommendation for individual patients. It stated that the addition of apremilast to the existing treatment pathway would mean patients would have access to an additional treatment with a different mechanism of action. Furthermore, the committee agreed that some patients may be willing to accept a certain level of reduced effectiveness because apremilast, unlike the TNF‑alpha inhibitors and ustekinumab, is taken orally. The committee therefore agreed that apremilast could improve patient choice while also offering the opportunity of cost savings for the NHS (with cost savings at a more acceptable level given the QALY gain that would be lost). It concluded that apremilast could be recommended as a cost‑effective use of NHS resources. The committee emphasised that apremilast should be seen as just one option in the context of a range of existing treatment options. The committee was aware that NICE technology appraisal guidance on etanercept, infliximab and adalimumab and golimumab for the treatment of psoriatic arthritis recommend that the least costly treatment option should be used first. However, the committee agreed that apremilast should not be used based on cost alone, because all clinical-effectiveness results showed it to be the least effective treatment. The committee agreed that the intention of its recommendation was to improve individual patient and clinician choice while also offering the chance of cost savings for the NHS. Apremilast in routine NHS practice should not be a barrier for access to existing treatments; patients and their clinicians should still have the choice of the full range of treatments, including the more expensive and more effective TNF‑alpha inhibitors, if they are more clinically appropriate. The committee concluded that the decision to use apremilast should not be made based on cost alone, and that individual patient factors, including patient needs and preferences, should also be taken into consideration. ## Starting and stopping rules The committee noted several comments from consultation on the appraisal consultation document regarding the apremilast recommendation compared with previous NICE recommendations for TNF‑alpha inhibitors, specifically etanercept, infliximab and adalimumab and golimumab for the treatment of psoriatic arthritis. There was concern during consultation that inconsistent wording might imply that apremilast should be used at a different point in the pathway to the TNF‑alpha inhibitors, which was not the committee's intention (see section 4.31). The committee therefore went on to discuss aligning the apremilast recommendation to the starting (see section 4.33) and stopping rules (see section 4.34) in previous psoriatic arthritis appraisals. The committee was aware that NICE technology appraisal guidance on etanercept, infliximab and adalimumab and golimumab for the treatment of psoriatic arthritis included treatment eligibility criteria, outlining that patients should have peripheral arthritis with 3 or more tender joints and 3 or more swollen joints, and to have previously had at least 2 standard DMARDs (administered either individually or in combination). The committee considered whether to add these treatment eligibility criteria to its recommendations for apremilast. It agreed that aligning apremilast recommendation with the recommendations for TNF‑alpha inhibitors would help to avoid any confusion about apremilast's intended position in the treatment pathway. The committee concluded that the treatment eligibility criteria included in the previous appraisals should also be specified in the recommendation for apremilast. The committee noted comments from consultation on the appraisal consultation document that it is important to ensure access to more effective treatments is not delayed after an inadequate response to apremilast. It was aware that NICE technology appraisal guidance on etanercept, infliximab and adalimumab and golimumab for the treatment of psoriatic arthritis include a stopping rule stating that treatment should be stopped in patients whose disease has not demonstrated an adequate response to treatment at 12 weeks. The committee noted that, for apremilast, the clinical trial data primary outcomes and the company model had measured response to treatment at 16 weeks. The committee concluded that its recommendation should specify that if an adequate response to apremilast is not observed at 16 weeks, treatment with apremilast should be stopped and other treatments considered. # Summary of appraisal committee's key conclusions TA433 Appraisal title: Apremilast for treating active psoriatic arthritis Section Key conclusion Apremilast, alone or in combination with disease-modifying antirheumatic drugs (DMARDs), is recommended as an option for treating active psoriatic arthritis in adults only if: they have peripheral arthritis with 3 or more tender joints and 3 or more swollen joints and their disease has not responded to adequate trials of at least 2 standard DMARDs, given either alone or in combination and the company provides apremilast with the discount agreed in the patient access scheme. Treatment should be discontinued in people whose psoriatic arthritis has not shown an adequate response using the Psoriatic Arthritis response Criteria (PsARC) at 16 weeks. Apremilast is a clinically effective treatment compared with placebo. Evidence from the company's network meta-analysis that compared apremilast with TNF alpha inhibitors in the total population, and also in people who had not had TNF alpha inhibitors, showed that apremilast was not as clinically effective as the TNF alpha inhibitors for treating psoriatic arthritis. The base-case ICER with the apremilast patient access scheme was £39,052 saved per QALY lost. All exploratory analyses presented by both the company and the ERG also showed that using apremilast resulted in cost savings but a QALY loss. The committee agreed that some patients may be willing to accept a certain level of reduced effectiveness because apremilast, unlike the TNF‑alpha inhibitors and ustekinumab, is administered orally, and that patients would have access to an additional treatment with a different mechanism of action. The choice to use apremilast should not be made based on cost alone, because all clinical effectiveness results showed it to be the least effective treatment. Current practice Clinical need of patients, including the availability of alternative treatments Psoriatic arthritis is a lifelong condition that seriously affects people's quality of life. There is an unmet need for treatments that offer a different mechanism of action to the TNF‑alpha inhibitors or that are administered orally, as with apremilast (a PDE4 inhibitor). The technology Proposed benefits of the technology How innovative is the technology in its potential to make a significant and substantial impact on health-related benefits? Apremilast may provide an additional treatment option for patients, because of its different mode of action and oral formulation. However, the committee considered that apremilast was not a step-change in treatment. What is the position of the treatment in the pathway of care for the condition? The committee concluded that it was possible that apremilast could be used as a treatment before TNF‑alpha inhibitors, for example some people may prefer an oral treatment and may therefore be willing to accept some reduced effectiveness, but that any use or positioning of apremilast would need to be supported by clinical- and cost‑effectiveness evidence. Adverse reactions Apremilast has an acceptable adverse event profile in people with active psoriatic arthritis. Evidence for clinical effectiveness Availability, nature and quality of evidence The main sources of evidence were the PSA-002, PSA-003 and PSA-004 trials that compared apremilast (20 mg and 30 mg) with placebo. The methods used to identify both published and unpublished studies for the company's network meta-analysis were appropriate and the studies were mostly well reported. Relevance to general clinical practice in the NHS Treatment with a DMARD such as methotrexate, followed by TNF‑alpha inhibitors in people who can take them, is established practice in the NHS but that there is an unmet need for treatments that have a different mechanism of action to TNF‑alpha inhibitors. Uncertainties generated by the evidence Placebo responses for some outcomes were high, which made it difficult to compare the relative efficacies of apremilast with the different comparators. There were uncertainties about the PSA-002, PSA-003 and PSA-004 results because the trials were not blinded after 24 weeks and there were no stopping rules. The committee also considered the lack of radiographic assessment in the trials. Because it is a new treatment, there is a lack of long-term clinical-effectiveness data for apremilast. Are there any clinically relevant subgroups for which there is evidence of differential effectiveness? No specific committee consideration. Estimate of the size of the clinical effectiveness including strength of supporting evidence Apremilast is a clinically effective treatment compared with placebo. Evidence from the company's network meta-analysis that compared apremilast with TNF‑alpha inhibitors in the total population, and also in people who had not had TNF‑alpha inhibitors, showed that apremilast was not as clinically effective as the TNF‑alpha inhibitors for treating psoriatic arthritis. Evidence for cost effectiveness Availability and nature of evidence The company base case compared treatment sequences with and without apremilast. The committee accepted that the use of treatment sequences was a valid approach to modelling. Uncertainties around and plausibility of assumptions and inputs in the economic model The company had not explored the full treatment pathway in its rapid review submission, with most analyses limited to a maximum of 3 treatments in a sequence. However, the committee appreciated that the company had updated several assumptions in its base case to address committee concerns, and had also presented several new analyses which contributed to reducing the uncertainties outlined in the previous appraisal of apremilast in this indication. The committee agreed that, in addition to the base case presented, it would have also preferred to see a company base case for apremilast as a post-TNF‑alpha inhibitor treatment. However, it concluded that the company and ERG exploratory analyses helped to reduce uncertainty in the cost‑effectiveness results. Incorporation of health-related quality-of-life benefits and utility values Have any potential significant and substantial health-related benefits been identified that were not included in the economic model, and how have they been considered? The utility values in the company's revised base case were derived from the apremilast trial. The committee was surprised at the estimates of utility, which appeared very low and similar to technologies for end of life conditions. However, it agreed that the company had used a legitimate source for utility values by using the available trial data, and accepted the utility values for decision-making. The committee did not hear that there were any additional gains in health-related quality of life over those already included in the QALY calculations. Are there specific groups of people for whom the technology is particularly cost effective? No specific committee consideration. What are the key drivers of cost effectiveness? HAQ‑DI was a principle driver of the economic model. Although there was a lack of evidence to support the exact value, the company had modelled some HAQ-DI progression for apremilast (at a rate of 50% of best supportive care) in its revised analyses. Both the company and the ERG had also attempted to explore this uncertainty by using different rates of HAQ-DI progression for apremilast. Most likely cost‑effectiveness estimate (given as an ICER) The base-case ICER with the apremilast patient access scheme was £39,052 saved per QALY lost. The committee also considered the sensitivity and scenario analyses presented by both the company and the ERG. All showed that, as in the company's base case, using apremilast resulted in cost savings but a QALY loss. All company and ERG ICERs were over £20,000 saved per QALY lost. Most company and ERG ICERs were also over £30,000 saved per QALY lost. The committee agreed that the analyses that were under £30,000 saved per QALY lost were not the most realistic scenarios and agreed that the addition of the apremilast patient access scheme had increased the cost savings for apremilast so that they were at a more acceptable level given the QALYs that would be lost. Additional factors taken into account Patient access schemes (PPRS) The company has agreed a patient access scheme with the Department of Health. This scheme provides a simple discount to the list price of apremilast. The level of the discount is commercial in confidence. End-of-life considerations Not applicable. Equalities considerations and social value judgements Not applicable.

Technology and youth seem destined for each other. They are both young, fast paced, and ever changing. In the last 20 years there has been an explosion in new technology. This new technology has been eagerly embraced by young people and has led to expanding knowledge, social networks, and vocabulary that includes instant messaging ("IMing"), blogging, and text messaging.# Electronic Aggression is any type of harassment or bullying that occurs through e-mail, a chat room, instant messaging, a website (including blogs), or text messaging. New technology has many potential benefits for youth. With the help of new technology, young people can interact with others across the United States and throughout the world on a regular basis. Social networking sites like Facebook and MySpace also allow youth to develop new relationships with others, some of whom they have never even met in person. New technology also provides opportunities to make rewarding social connections for those youth who have difficulty developing friendships in traditional social settings or because of limited contact with same-aged peers. In addition, regular Internet access allows teens and pre-teens to quickly increase their knowledge on a wide variety of topics. # Examples of Electronic Aggression - Disclosing someone else's personal information in a public area (e.g., website) in order to cause embarrassment. - Posting rumors or lies about someone in a public area (e.g., discussion board). - Distributing embarrassing pictures of someone by posting them in a public area (e.g., website) or sending them via e-mail. - Assuming another person's electronic identity to post or send messages about others with the intent of causing the other person harm. - Sending mean, embarrassing, or threatening text messages, instant messages, or e-mails. However, the recent explosion in technology does not come without possible risks. Youth can use electronic media to embarrass, harass, or threaten their peers. Explore the Internet. Visit the websites your child frequents, and assess the pros and cons. Remember, most websites and on-line activities are beneficial. They help young people learn new information, interact with others, and connect with people who have similar interests. Talk to your child. Parents and caregivers often ask children where they are going and who they are going with when they leave the house. You should ask these same questions when your child goes on the Internet. Because children are reluctant to disclose victimization for fear of having their Internet and cellular phone privileges revoked; develop solutions to prevent or address victimization that do not punish the child. Talk with other parents and caregivers. Talk to other parents and caregivers about how they have discussed technology use with their children. Ask about the rules they have developed and how they stay informed about their child's technology use. Connect with the school. Parents and caregivers are encouraged to work with their child's school and school district to develop a class for parents and caregivers that educates them about school policies on electronic aggression, recent incidents in the community involving electronic aggression, and resources available to parents and caregivers who have concerns. Work with the school and other partners to develop a collaborative approach to preventing electronic aggression. # Educate yourself. Stay informed about the new devices and websites your child is using. Technology changes rapidly, and many developers offer information to keep people aware of advances. Continually talk with your child about "where they are going" and explore the technology yourself. Technology is not going away, and forbidding young people to access electronic media may not be a good long-term solution. Together, parents and children can come up with ways to maximize the benefits of technology and decrease its risks.

ANAPC5 Anaphase-promoting complex subunit 5 is an enzyme that in humans is encoded by the ANAPC5 gene. The anaphase-promoting complex (APC) consists of at least 8 protein subunits, including APC5, CDC27 (APC3; MIM 116946), CDC16 (APC6; MIM 603461), and CDC23 (APC8; MIM 603462). # Interactions ANAPC5 has been shown to interact with ANAPC1, ANAPC4, CDC27 and PABPC1.

Interleukin-4 receptor The interleukin 4 receptor is a type I cytokine receptor. IL4R is its human gene. # Function This gene encodes the alpha chain of the interleukin-4 receptor, a type I transmembrane protein that can bind interleukin 4 and interleukin 13 to regulate IgE antibody production in B cells. Among T cells, the encoded protein also can bind interleukin 4 to promote differentiation of Th2 cells. A soluble form of the encoded protein can be produced by an alternate splice variant or by proteolysis of the membrane-bound protein, and this soluble form can inhibit IL4-mediated cell proliferation and IL5 upregulation by T-cells. Allelic variations in this gene have been associated with atopy, a condition that can manifest itself as allergic rhinitis, sinusitis, asthma, or eczema. Two transcript variants encoding different isoforms, a membrane-bound and a soluble form, have been found for this gene. Interactions of IL-4 with TNFα promote structural changes to vascular endothelial cells, thus playing an important role in tissue inflammation. The binding of IL-4 or IL-13 to the IL-4 receptor on the surface of macrophages results in the alternative activation of those macrophages. Alternatively activated macrophages (AAMΦ) downregulate inflammatory mediators such as IFNγ during immune responses, particularly with regards to helminth infections. # Interactions Interleukin-4 receptor has been shown to interact with SHC1. # Structure The N-terminal (extracellular) portion of interleukin-4 receptor is related in overall topology to fibronectin type III modules and folds into a sandwich comprising seven antiparallel beta sheets arranged in a three-strand and a four-strand beta-pleated sheet. They are required for binding of interleukin-4 to the receptor alpha chain, which is a crucial event for the generation of a Th2-dominated early immune response.

This guideline summarizes suggested wait times for common indications where Computed Tomography (CT) is the recommended first imaging test. The purpose is to inform primary care practitioners of how referrals are prioritized by Radiologists and Radiology departments across the province. This guideline is an adaptation of the British Columbia Radiological Society (BCRS) CT Prioritization Guidelines (2013). 1 Management of the listed clinical problems is beyond the scope of this guideline. However, in some cases, notes and alternative tests are provided for additional clinical context. Primary care practitioners are encouraged to consult a Radiologist if they have any concerns or questions regarding which appropriate imaging test to choose for a problem. If in doubt consult with a Radiologist and review provincial guidance materials. 2 # Background The 2013 BCRS CT Prioritization Guidelines were developed to provide imaging departments with a consistent, provincial approach to prioritizing commonly ordered CT tests according to suggested maximum wait times. The BCRS guidelines were developed by consensus and are based on BC expert opinion with representation of Radiologists from across the province. Several considerations apply: - These are guidelines, and as such, are designed to apply in general terms. They are not intended to replace clinical judgement or practitioner-to-practitioner discussion. - Prioritization levels were selected to match other similar guidelines for Magnetic Resonance Imaging (MRI) and Ultrasound (US) and are typically assigned by Radiologists rather than referring practitioners. - These guidelines should not be applied rigidly to each case, as varying clinical factors may shift an indication from one priority level to another. - Access to CT and the ability to respond to CT requests will depend on resources and local availability. - Providing detailed patient information is essential to aid with the prioritization process. - The clinical topics included in this guideline represent broad examples, and do not encompass all possible scenarios or all requirements for CT examinations. # Priority Level Definitions The priority levels defined below (Table 1) are in alignment with the Canadian Association of Radiologists national designation Five Point Classification System. 3 # P1 An examination immediately necessary to diagnose and/or treat life-threatening disease. Such an examination will need to be done either stat or not later than the day of the request. Immediately to 24 hours # P2 An examination indicated within one week of a request to resolve a clinical management imperative. Maximum 7 calendar days # P3 An examination indicated to investigate symptoms of potential importance. Maximum 30 calendar days # P4 An examination indicated for long-range management or for prevention. Maximum 60 calendar days # P5 Timed follow-up exam or specified procedure date recommended by Radiologist and/or clinician. Source: Adapted from the Canadian Association of Radiologists National Maximum Wait Time Access Targets for Medical Imaging. # Prioritization of Potential Diagnoses CT is widely indicated for and includes but is not limited to the following 4 The following potential diagnoses, where CT is the recommended first test, are grouped according to body system and then further subdivided into priority levels. For each system, an overview table is presented followed by a more detailed table outlining additional notes and alternative tests where CT may be less appropriate due to ionizing radiation exposure. For CT also consider the patient risk of radiation exposure, refer to Appendix A: Radiation Exposure. Referring practitioners should include clear, pertinent clinical history on radiology requisitions to assist the triaging/ prioritizing of examinations and interpretation of images and may consider noting the priority directly on the requisition where possible. # Pediatric Consider alternatives to CT, if appropriate, to reduce radiation exposure for pediatric patients. See Appendix A: Radiation Exposure, for more information.

CS gas CS gas is the common name for 2-chlorobenzalmalononitrile (also called o-Chlorobenzylidene Malononitrile) (chemical formula: C10H5ClN2), a substance that is used as a riot control agent and is generally accepted as being non-lethal. CS was discovered by two Americans, Ben Corson and Roger Staughton, at Middlebury College in 1928, and the chemical gets its name from the first letters of the scientists' surnames. The compound is actually a solid at room temperature, though it is used as an aerosol. CS was developed and tested secretly at Porton Down in Wiltshire, England, in the 1950s and 1960s. CS was used first on animals, then subsequently on British Army servicemen volunteers. Notably, CS has a limited effect on animals due to "under-developed tear-ducts and protection by fur". # Production CS is synthesized by the reaction of 2-chlorobenzaldehyde and malononitrile via the Knoevenagel condensation: The reaction is catalysed with weak base like piperidine or pyridine. The production method has not changed since the substance was discovered by Carson and Staughton. Other bases, solvent free methods and microwave promotion have been suggested to improve the production of the substance. The physiological properties have been discovered already by the chemists first synthesising the compound in 1928: "Physiological Properties – Certain of these dinitriles have the effect of sneeze and tear gases. They are harmless when wet but to handle the dry powder is disastrous. (sic)" ## Use as an aerosol As 2-chlorobenzalmalononitrile is a solid at room temperature, not a gas, a variety of techniques have been used to make this solid usable as an aerosol: - Melted and sprayed in the molten form. - Dissolved in organic solvent. - CS2 dry powder (CS2 is a siliconized, micro-pulverized form of CS). - CS from thermal grenades by generation of hot gases. In the Waco Siege, CS was dissolved in the organic solvent dichloromethane (also known as methylene chloride). When the volatile dichlormethane evaporated, the CS crystallized with the dichloromethane molecules as an aerosol. Another method typically used for grenades is to combine CS with a pyrotechnic composition which burns to generate an aerosol of CS-laden smoke. As the smoke disperses, tiny CS crystals 'ride' the smoke molecules to their targets, where they affect the eyes, nose, throat and skin causing extreme irritation. # Effects Many types of tear gas and other Riot Control Agents have been produced with effects ranging from mild tearing of the eyes to immediate vomiting and prostration. CN and CS are the most widely used and known, but around 15 different types of tear gas have been developed worldwide e.g. Adamsite or Bromoacetone, CNB, and CNC. CS has become the most popular due to its strong effect and lack of toxicity in comparison with other similar chemical agents. The effect of CS on a person will depend on whether it is packaged as a solution or used as an aerosol; the size of solution droplets and the size of the CS particulates after evaporation are factors determining its effect on the human body. Certain individuals, however, have been found to be particularly sensitive to CS and/or the organic solvents that are utilized. Studies on the use of CS on the public have noted that it may be ineffective against persons who are either mentally ill or who are under the effects of drugs and alcohol. Persons who have had contact with CS sometimes develop allergic contact dermatitis, even with blisters and crust. Studies show that most of the effects are of a relative short term, but individuals notice some mild effects even after months. The chemical reacts with moisture on the skin and in the eyes causing a burning sensation and the immediate forceful and uncontrollable shutting of the eyes. Reported effects can include tears streaming from the eyes, running nose full of mucus, burning in the nose and throat areas, disorientation, dizziness and restricted breathing. In highly concentrated doses it can also induce severe coughing and vomiting. Almost all of the immediate effects wear off in a matter of minutes. # Use CS is used in spray form by many police forces as a temporary incapacitant and to subdue attackers or persons who are violently aggressive. Officers that are trained in the use and application of CS spray are routinely exposed to it as part of their training. Recently, blank pistol cartridges carrying CS in powder form have been released to public. These, when fired in relatively close ranges, fully expose the target to the effects of CS, and are employed as a potent defensive weapon in regions where blank firing pistols are legally permitted for such use. Although predominantly used by police it has also been used in criminal attacks in various countries. Use of CS in war is prohibited under the terms of the 1997 Chemical Weapons Convention (signed in 1993) because it could trigger retaliation with more toxic agents such as nerve gas. Domestic police use of CS, however, is legal in many countries. ## Cyprus CS was first tested in the field by the British army in Cyprus in 1958. At this time it was known by the code name T792. ## Vietnam It has been reported that thousands of tons of CS gas were used by the U.S. forces in Vietnam to bring Viet Cong into the open, other estimates report 15 million pounds (7500 tons) of CS being used. It was also used by the North Vietnamese forces in some battles like Hue in 1968 or during the Easter Offensive in 1972. ## Northern Ireland CS gas was used extensively in the Bogside area of Derry, Northern Ireland during the "Battle of the Bogside", a two-day riot in August, 1969. A total of 1,091 canisters containing 12.5g of CS each, and 14 canisters containing 50g of CS each, were released in the densely populated residential area. On 30 August the Himsworth Inquiry was set up to investigate the medical effects of its use in Derry. Its conclusions, viewed in the political context of the time, still pointed towards the necessity of further testing of CS gas before being used as a riot control agent. During the rioting in Belfast, the following year, known as the Falls Curfew, the Army fired up to 1,600 canisters into the densely populated Falls Road area. Not long after, the British Army and RUC ceased using CS in Northern Ireland. Up to this point, it had been used in crowd control scenarios in Derry and Belfast. ## Iraq Iraq successfully developed CS during the 1970s and during the 1980s produced tons of the substance firstly at Salman Pak and later at al-Muthanna. Saddam Hussein used CS against the Kurds in his own country and against Iran during the Iran-Iraq War. Blackwater Worldwide, acting as an agent of the United States, deployed CS in the Iraq War from a helicopter hovering over a checkpoint in the Green Zone in Bagdhad. ## Philippines CS tear gas was used in submersion of the mutiny in Makati that was led by Sen. Antonio Trillanes. The tear gas was fired in the building and all the people in the building including reporters were affected. ## England, Scotland & Wales CS tear gas was first used in mainland Britain to quell rioting in the Toxteth area of Liverpool in 1981. Personal incapacitant spray (PIS) was sanctioned for use by police in England and Wales in 1995. The CS preparation in this case is CS dissolved in the organic solvent MiBK, or methyl iso-butyl ketone, an industrial de-greasing agent. The aerosol propellant used in this preparation is nitrogen. Officers in Scotland carry CS spray on their belt. It has been noted that the solvent MiBK is itself harmful, and can cause inflammation, dermatitis, burns to the skin and liver damage. A six month trial by 16 police forces in England began on the 1 March 1996. Only two weeks later, on 16 March 1996, a Gambian asylum seeker, Ibrahima Sey was taken to Ilford Police Station in East London. Whilst incapacitating the man, police sprayed him with CS and held him on the ground for over 15 minutes. The man died, the case was taken to court and although a verdict of "unlawful killing" was given by the jury at the end of the inquiry into his death, no charges were brought against any member of the police force. The forces that do use the PIS in the UK require that police constables should themselves be sprayed with a 3% dissolved CS, during self-defense training, in order for them to be able to be authorized to carry it as personal protection equipment. They are also trained in helping the incapacitated person recover quickly once successfully restrained. Most forces currently issue CS spray to its officers, but there has been a recent move for a few forces to issue PAVA Spray (pelargonic acid vanillylamide aka nonivamide). The CS spray used by UK police has 5 times as much CS as the spray used by American police forces (5% dissolved CS and 1% CS respectively). In 1999 the UK mental health charity MIND called for a suspension in its use until it is fully tested and there is proof that CS is safe. More recently, in February 2006, there were calls to have CS spray banned in the UK after Dan Ford, from Wareham in Dorset, was permanently facially scarred after being sprayed in the face with a police CS canister. Mr Ford was subsequently advised by doctors to stay out of sunlight for at least 12 months. About the incident, his cousin, Donna Lewis, was quoted as saying, "To look at him, it was like looking at a melting man, with liquid oozing from his face." However, it is not yet confirmed that Mr Ford's injury is a reaction to having been exposed to police CS spray, or whether an unrelated chemical exposure has caused the injury. An investigation is ongoing. The British Armed Forces use CS gas annually to test their CBRN equipment. During initial training they introduce recruits to CS gas by ordering them into a small enclosed space known as a Respirator Test Facility (RTF) and igniting chemical tablets to induce CS production. When recruits have carried out their CBRN drills (which include immediate actions for decontamination, an eating drill, a drinking drill and a gas mask canister change) the NCO in charge of the RTF will order them to remove their respirators and inhale the CS. This is apparently to inform the trainees of what CS effects feel like, so they can have trust in their equipment and procedures, thus proving to themselves that it works in the contaminated environment in training, and are then able to take this confidence to the battlefield environment. In 2005, a student from Mayfield School in Essex, used CS Gas inside a school. Several students were taken to A&E, but all survived. The remaining students of the school were held in classrooms and halls, until it was confirmed by the local police and firefighters that the scene was safe. The event was reported only in a local newspaper, the Ilford Recorder. ## United States CS is used by many police forces within the United States. It was most infamously used as one of a number of techniques by FBI law enforcement officials in the 1993 Waco Siege. Members of the US armed forces are exposed to CS during initial training, and during training refresher courses or equipment maintenance exercises, using CS tablets that are melted on a hotplate. This is to demonstrate the importance of properly wearing a gas mask or a Protective mask, as the agent's presence quickly reveals an improper fit or seal of the mask's rubber gaskets against the face. These exercises also encourage confidence in the ability of the equipment to protect the wearer from such chemical attacks. Basic Combat Trainees in the United States Army are always exposed in a gas-chamber environment using the tablet form, and often the Drill Sergeants put them in formation near the end of their 9 week cycle and throw CS grenades at them. ## Elsewhere CS was used in large quantities to quell a protest in Lusaka, Zambia in July 1997 and the 1999 WTO protest in Seattle. Amnesty International reported that it had been manufactured by the UK company Pains-Wessex. Subsequently, Amnesty called for an export ban when the receiving regime is either not fully trained in the use of CS, or had shown usage "contrary to the manufacturer’s instructions". In September 2000, the Guardian Newspaper revealed how a UK company, HPP, used legal loopholes to export CS to a private security company in Rwanda, in breach of United Nations sanctions. The Guardian also reported that CS was used by the Hutu militia in Rwanda to flush Tutsis out of buildings before hacking them to death. CS has been used by the government in South Africa; by Israel against Palestinians and Israelis; by the South Korean government in Seoul, and during the Balkan conflicts by Serbia. CS tear gas was used at the G8 protests in Genoa, Italy and Quebec, Canada during the FTAA anti-globalization demonstrations during the Quebec City Summit of the Americas. The Canadian, Norwegian and Australian Armies train their soldiers with CS gas in a manner similar to that of the USA, as it is a basic part of NBC (nuclear, biological, chemical) or more recently within NATO, CBRN (Chemical, Biological, Radiological, Nuclear) training. Gas is released by burning tablets, usually in a tent or a small building reserved for this purpose (a "gas hut"), and soldiers are exposed to it on three occasions. During the first two exposures the soldier enters the tent or gas hut wearing a gas mask. During the first exposure he removes his gas mask and leaves the tent or hut. During the second exposure he must remove the mask, receive facial exposure, then replace and clear the mask. In the third exposure he enters the tent unprotected, must fit and clear the gas mask before leaving. Other drills such as drinking and under-mask decontamination are usually also practised yearly. Symptoms are a burning sensation on any moist skin, whether due to perspiration or other fluids such as tears or in the nasal membranes. # Toxicity Although described as a non-lethal weapon for crowd control, many studies have raised doubts about this classification. As well as creating severe pulmonary damage, CS can also significantly damage the heart and liver. On September 28, 2000, Prof. Dr. Uwe Heinrich released a study commissioned by John C. Danforth, of 'The Office of Special Counsel', to investigate the use of CS by the FBI at the Branch Davidians' Mount Carmel compound. He concluded that the lethality of CS used would have been determined mainly by two factors: whether gas masks were used and whether the occupants were trapped in a room. He suggests that if no gas masks were used and the occupants were trapped, then, "...there is a distinct possibility that this kind of CS exposure can significantly contribute to or even cause lethal effects." Many reports have associated CS exposure with miscarriages, this is consistent with its reported clastogenic effect (abnormal chromosome change) on mammalian cells. When CS is metabolized, cyanide can be detected in human tissue. According to the United States Army Center for Health Promotion and Preventive Medicine, CS emits "very toxic fumes" when heated to decomposition, and at specified concentrations CS gas is an immediate danger to life and health. They also state that those exposed to CS gas should seek medical attention immediately. # Decontamination CS contamination can be removed by washing with an alkaline solution of water and 5% sodium bisulfite. A quick way to decontaminate the eyes is to pour cow's milk into them. Vision will be restored although breathing difficulties and pain will persist.

H3F3B (gene) H3 histone, family 3B (H3.3B) is a protein in humans that is encoded by the H3F3B gene. # Function Histones are basic nuclear proteins that are responsible for the nucleosome structure of the chromosomal fiber in eukaryotes. Two molecules of each of the four core histones (H2A, H2B, H3, and H4) form an octamer, around which approximately 146 bp of DNA is wrapped in repeating units, called nucleosomes. The linker histone, H1, interacts with linker DNA between nucleosomes and functions in the compaction of chromatin into higher order structures. # Gene This gene contains introns and its mRNA is poyadenylated, unlike most histone genes. The protein encoded is a member of the histone H3 family. Unlike most histone genes, H3F3B is not located in a cluster, but rather is isolated in the telomeric region of chromosome 17. # Clinical significance Somatic mutations in the H3F3B gene are associated with chondroblastoma. A rare de novo germline mutation of the H3F3B gene (A30P) has been linked to a syndrome with a range of developmental and behavioral abnormalities including microcephaly, mild strabismus, seizure disorder, autistic continuum, hypothyroidism, global developmental delay, and low muscle tone.

SepsiTest assay for rapidly identifying bloodstream bacteria and fungi Evidence-based recommendations on the SepsiTest assay for rapidly identifying bloodstream bacteria and fungi. # Recommendation There is currently insufficient evidence to recommend the routine adoption in the NHS of the SepsiTest assay for rapidly identifying bloodstream bacteria and fungi. The test shows promise and further research to provide robust evidence is encouraged, particularly to demonstrate the value of using the test results in clinical decision‑making (see sections 5.18 to 5.22). # Clinical need and practice # The problem addressed In current practice, people who are clinically unwell and who have a suspected bloodstream infection have empirically prescribed broad‑spectrum antibiotics, that is, antibiotics that are prescribed based on clinical presentation, until the identity of the pathogen causing the infection is known. Broad‑spectrum antibiotics and, if appropriate, antifungals, are used because they are effective against a wide range of bacterial and fungal pathogens and are likely to achieve a therapeutic response. But, although clinically effective, broad‑spectrum antibiotic use is associated with people developing superinfection and with antimicrobial resistance. Rapidly identifying the bacterial and fungal pathogen may allow earlier targeted treatment and shorten the length of use of broad‑spectrum antibiotics and antifungals, which may help antimicrobial stewardship by conserving the effectiveness of existing antimicrobials. Three molecular tests, the LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay, were identified during scoping as relevant to the assessment (see section 3 for additional details). These tests are designed to rapidly detect and identify bacterial and fungal DNA that may be in the bloodstream in people who are suspected of having sepsis. These tests are intended to be used with clinical assessment and established microbiology techniques that provide information on which antimicrobials are likely to be effective against the identified pathogen. The tests are designed to be run on whole blood samples and without the prior incubation or the pre‑culture steps that are needed for tests used in current standard practice. The absence of these steps means that pathogens may be identified earlier. It is possible that blood culture would still be needed to give definitive antimicrobial‑susceptibility data, if this is not provided by the rapid diagnostic test. The rapid detection and identification of bacterial and fungal DNA may be particularly beneficial in people who are suspected of having a severe infection and who need quick medical intervention. The purpose of this assessment is to evaluate the clinical and cost effectiveness of using the LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay for rapidly identifying bloodstream bacteria and fungi in the NHS. # The condition ## Sepsis and bloodstream infection Sepsis is a life‑threatening condition characterised by the body's inflammatory response to an infection. According to the Surviving Sepsis Campaign's International guidelines for the management of severe sepsis and septic shock, sepsis is diagnosed if there is evidence of systemic inflammation, in addition to a documented or presumed infection in the body. Systemic illness often happens if bacteria invade normally sterile parts of the body. One example of this is when bacteria or fungi invade the bloodstream (bloodstream infection); a process that often causes an inflammatory immune response. Bacterial infections are the most common cause of sepsis and bloodstream infection, but they can also be caused by fungal infections, and less commonly by viral infections. The most common sites of infection associated with sepsis are the lungs, urinary tract, abdomen and pelvis. Other sources of infection leading to sepsis include skin infections (such as cellulitis), post‑surgical infections and infections of the nervous system (such as meningitis or encephalitis). People who have recently been admitted to hospital are at risk of getting hospital‑acquired infections that can lead to sepsis and bloodstream infection. The increased use of invasive procedures, such as catheterisation and life support measures, as well as immunosuppressive therapy and antibiotic therapy may have resulted in more healthcare‑associated bloodstream infections. Community‑acquired bloodstream infections may also occur in people who have not had recent contact with healthcare services. The pathogens infecting these people may differ from those associated with hospital‑acquired bloodstream infection. The bacteria most commonly associated with bloodstream infection in adults include gram‑negative species such as Escherichia coli, Klebsiella and Pseudomonas, and gram‑positive species such as Staphylococcus aureus, non-pyogenic streptococci, Enterococcus and Streptococcus pneumoniae. The types of pathogens causing bloodstream infection can differ in children compared with those causing infection in adults, and can include Neisseria meningitidis. Polymicrobial infection and anaerobic bacteraemia are also thought to occur less often in children. # The diagnostic and care pathways ## Diagnosing sepsis and bloodstream infection Diagnostic criteria for sepsis are listed in the Surviving Sepsis Campaign's International guidelines for the management of severe sepsis and septic shock. In summary, regular observations of all vital signs should be taken and recorded, kidney and liver function tests should be done, and inflammatory biomarkers and serum lactate should be measured. These guidelines state that a diagnosis of sepsis should be based on infection, documented or suspected, with hyperthermia or hypothermia, tachycardia and at least 1 indication of altered organ function. The guidelines also make the following specific recommendations relating to detecting localised and bloodstream infection: At least 2 samples for blood culture should be collected (aerobic and anaerobic) before antimicrobial therapy is started if such cultures do not cause significant delay (greater than 45 minutes) in the start of antimicrobial administration. At least 1 sample should be drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (less than 48 hours) inserted. The blood cultures can be drawn at the same time if they are taken from different sites. Cultures from other sites that may be the source of infection, such as urine, cerebrospinal fluid, wounds, respiratory secretions or other bodily fluids, should be collected before starting antimicrobial therapy, if doing so does not cause significant delay in the start of antimicrobial treatment. Imaging studies such as CT or X‑ray should be done to confirm a potential source of infection. Assays to diagnose systemic fungal infection should be used if available and invasive candidiasis is suspected. ## Blood cultures Public Health England's standards for the investigation of blood cultures are available. A blood culture set for diagnosing bloodstream infection is defined as 1 aerobic and 1 anaerobic bottle. For adults it is recommended that 20–30 ml of blood is cultured per set, and that 2 consecutive blood culture sets from 2 separate venepuncture sites should be collected during any 24‑hour period for each septic episode. The first set should be taken before starting antimicrobial treatment because the presence of antibiotics or antifungals may inhibit the growth of pathogens in blood culture. Blood culture sample collection differs for infants and neonates, for whom a single aerobic bottle or low‑volume blood culture bottle may be requested. The criterion for calculating total blood‑culture volume in neonates and children is based on weight rather than age and relates to total patient blood volume. It has been suggested that the volume of blood drawn should be no more than 1% of the patient's total blood volume. In infants and children, the level of bacteraemia is usually higher than in adults and so the sensitivity of detection is not thought to be substantially reduced by a lower blood‑to‑medium ratio. Blood culture bottles should be incubated within 4 hours of the blood sample being taken. Many laboratories now use automated culture systems that alert laboratory staff once growth has been detected. When a blood culture has been detected as positive it is recommended that: Gram staining and rapid antigen testing should be done within 2 hours. Direct or automated isolate identification should be done within 24 hours (extending to 48 hours if traditional microbiology techniques such as morphological identification are used). Rapid species identification may be done after blood culture using techniques such as MALDI‑TOF mass spectrometry. Identification should be followed by sensitivity testing to determine the antimicrobials that the identified pathogen is susceptible to. If direct or automated sensitivity testing is used, a report should be made within 24 hours, extended to 48 hours if traditional techniques, such as the disc diffusion method, are used. A preliminary positive report is made within 2 hours of identification and sensitivity testing, and a final positive report should be made within 5 days of the sample arriving in the laboratory. If a blood culture is negative, it is recommended that a preliminary negative report is provided within 48 hours of the sample arriving in the laboratory and a final negative report should be issued within 5 days unless extended culture is being done, such as if fungi or unusual, fastidious or slow growing organisms are suspected. ## Treating sepsis and bloodstream infection Sepsis treatment varies based on the initial infection, the organs affected and the extent of tissue damage. The management of severe sepsis and septic shock is described in the Surviving Sepsis Campaign's International guidelines for the management of severe sepsis and septic shock. The guidelines recommend that effective intravenous antimicrobials should be given within the first hour of recognising severe sepsis and septic shock. Initial empirical antimicrobial therapy should include 1 or more drugs that have activity against all likely pathogens (bacterial, fungal or viral) and that penetrate in adequate concentrations into the tissues thought to be the source of sepsis. Frequently used broad‑spectrum antibiotics for more serious infections include cephalosporins and aminoglycosides. The guidelines recommend that the choice of empirical antimicrobial therapy be based on: the patient's history, including drug intolerances recent antibiotic treatments (previous 3 months) underlying disease the clinical syndrome susceptibility patterns of pathogens in the community and hospital previous microbiology reports identifying pathogens that have previously colonised or infected the patient. Clinicians prescribing antimicrobial therapy should take into account the Department of Health's guidance on antimicrobial stewardship, which is based on the 'start smart then focus' strategy. The guidance recommends that when empirical antimicrobials are prescribed, the clinical diagnosis should be reviewed after 48 to 72 hours to allow an antimicrobial prescribing decision to be made. This decision should take into account available microbiology results to determine if therapy can be stopped or changed; that is, the de‑escalation, substitution or addition of antimicrobial agents to the treatment plan. Narrowing the spectrum of antimicrobial coverage and shortening the duration of therapy may reduce the risk of a person developing a superinfection, and reduce treatment‑related adverse events. Adverse events associated with using broad‑spectrum antimicrobials may include diarrhoea, nausea, vomiting, hearing loss, damage to the kidneys and an increased risk of superinfection with Clostridium difficile. Narrowing the spectrum of antimicrobial coverage may also be associated with an increase in treatment efficacy in some scenarios. Reducing the spectrum of antimicrobial coverage and duration of antibiotic therapy may also contribute to antimicrobial stewardship and protect the effectiveness of existing antibiotics. Surveillance data for England for the period 2010 to 2013 suggest that rates of methicillin‑resistant Staphylococcus aureus (MRSA) have fallen while the incidence of bloodstream infections caused by resistant gram-negative Enterobacteriaceae bacteria, such as Klebsiella and Escherichia coli, has increased (English surveillance programme for antimicrobial utilisation and resistance, 2014). Of particular concern in some regions of England is the increasing resistance to carbapenem antibiotics, which are often used as a last resort for treating severe infections when other antibiotics have not brought the infection under control.# The diagnostic tests # The interventions ## The LightCycler SeptiFast Test MGRADE The LightCycler SeptiFast Test MGRADE (Roche Diagnostics) is a CE‑marked, in vitro, diagnostic, real‑time polymerase chain reaction (PCR) test that simultaneously detects and identifies DNA from 25 bacterial and fungal pathogens. The test needs 1.5 ml of ethylenediaminetetraacetic acid (EDTA)‑treated whole blood. The LightCycler SeptiFast Test MGRADE involves 3 distinct processes: specimen preparation by mechanical lysis and purification of DNA, real‑time PCR amplification of target DNA in 3 parallel reactions (gram‑positive bacteria, gram‑negative bacteria and fungi), and detection using fluorescence‑labelled probes specific to the target DNA. The test takes a minimum of 6 hours, depending on laboratory workflow. The SeptiFast Identification Software set v2.0 analyses the samples and generates a report, which contains all the relevant laboratory data and details of the identified species. The software also includes a crossing point cut‑off rule, which is intended to reduce the positive rate for coagulase‑negative Staphylococci and Streptococcus species based on the assumption that they are contaminants and not causal agents when the crossing point value is less than 20. If Staphylococcus aureus is identified in a sample, an aliquot of the SeptiFast Test MGRADE eluate can be further tested for the MecA gene using the LightCycler SeptiFast MecA Test MGRADE. The test can determine the likely methicillin resistance of Staphylococcus aureus through PCR, using the LightCycler 2.0 instrument. The test has an analytical sensitivity of 100 colony‑forming units/ml for coagulase‑negative Staphylococci, Streptococcus agalactiae, Streptococcus pyogenes, Streptococcus pneumonia and Streptococcus mitis. The minimum analytical sensitivity for all other pathogens detected by the LightCycler SeptiFast test MGRADE is 30 colony‑forming units/ml. ## SepsiTest SepsiTest (Molzym Molecular Diagnostics) is a CE‑marked PCR in vitro test for detecting bacterial and fungal DNA in 1 ml of k‑EDTA- or citrate‑treated whole blood. The test is able to identify species from more than 200 genera of bacteria and 65 genera of fungi. The SepsiTest involves 3 distinct processes: extracting and purifying microbial DNA using centrifugation, universal PCR and sequencing. The PCR result, which is available after 4 hours, indicates whether bacteria or fungi are present in the sample. Amplicons from positive samples are then sequenced to confirm the PCR result and to determine which bacteria or fungi species are present. If readable sequences are available from sequence analysis, bacteria and fungi can be identified using the SepsiTest‑BLAST online tool. Sequencing results may be available in 3 to 4 hours depending on the analyser used. The analytical sensitivity of SepsiTest ranges from 10 to 80 colony‑forming units/ml, depending on the target species. ## IRIDICA BAC BSI assay The IRIDICA BAC BSI assay (Abbott Laboratories) is a CE‑marked, in vitro, diagnostic test for detecting and identifying DNA from bacteria and candida in 5 ml of whole blood treated with EDTA. The test can also detect the MecA (Staphylococcus‑specific methicillin resistance), vanA and vanB (Enterococcus‑specific vancomycin resistance), and KPC (gram‑negative associated carbapenem resistance) genes, which are associated with antibiotic resistance. The test is designed for use with the IRIDICA system, which combines broad‑range PCR with electrospray ionisation time‑of‑flight mass spectrometry to amplify and detect pathogens. The estimated time to result is at least 5 hours and 55 minutes. The IRIDICA analysis computer consists of a proprietary database and software, which identifies the organism present in the sample by comparing the sequence of the sample with a library of known sequences. The BAC BSI assay is able to identify more than 780 bacteria and candida. The mean limit of detection for the assay is 39 colony‑forming units/ml, with a range of 0.25 to 128 colony‑forming units/ml depending on the target species. # The comparators Two comparators are included, blood culture alone and blood culture with MALDI‑TOF mass spectrometry: Blood culture alone refers to the incubation of whole blood followed by the identification of pathogens by traditional microbiology techniques. Blood culture with MALDI‑TOF mass spectrometry refers to the incubation of whole blood followed by the identification of pathogens using MALDI‑TOF mass spectrometry.# Outcomes The Diagnostics Advisory Committee (section 6) considered evidence from a number of sources (section 7). Full details of all the evidence are in the committee papers. # How outcomes were assessed The assessment consisted of a systematic review of the evidence on test performance and clinical‑effectiveness data for the LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI and comparator tests. Studies were included if they evaluated 1 of the interventions, compared with either blood culture or blood culture with MALDI‑TOF mass spectrometry (MS), to analyse whole blood samples collected from people being treated for suspected sepsis. Studies that compared 1 of the interventions with another intervention were also included. In total, 66 studies met the inclusion criteria. Diagnostic‑accuracy data were reported in 62 of the 66 studies and were included in meta‑analyses, which were based on a bivariate normal model with Markov Chain Monte Carlo simulation. Inter‑study heterogeneity was explored using meta‑regression. Intermediate or clinical outcome measures were reported in 41 of the 66 studies and were included in a narrative analysis. Sixty four of the 66 studies were single‑index test, single‑gate studies, that is, studies in which only patients with the target condition (suspected sepsis) were recruited. Three of these 64 studies were randomised controlled trials (RCTs). The remaining 2 studies were single‑gate studies that reported results for both the LightCycler SeptiFast Test MGRADE and SepsiTest. Only 3 of the 66 studies included patients from the UK. Most of the studies were done in other European countries. Of the studies that included patients from the UK, 1 study (Dark et al. 2009) used the SeptiFast assay to test 50 patients and 1 other study (Vincent et al. 2015) used the IRIDICA assay to test 529 patients from 6 European countries. The third UK study (Warhurst et al. 2015) reported the use of SeptiFast in 795 patients with sepsis and was judged to be the highest quality and most applicable included study. All studies were assessed using the QUADAS‑2 tool. The results of 65 of the 66 studies were considered to be at risk of bias and may not be applicable to the decision problem. The issues of greatest uncertainty included patient selection and blinding to the index test or reference standard. The External Assessment Group also reported concerns about 21 of the 66 studies, which did not report whether the blood samples for the index test and reference standard were drawn at the same time, and 6 of the 66 studies, which used a mixture of reference standards. In addition, only 28 of the 66 studies reported using blood sampling and test methods that were in accordance with the company's instructions for use. Studies also reported different units of analysis for diagnostic‑accuracy data, such as per patient, per sample, per episode of sepsis, and species or pathogen level. # Diagnostic accuracy Of the 62 studies that reported diagnostic‑accuracy data, 55 reported data for the LightCycler SeptiFast Test MGRADE; 5 reported data for SepsiTest; and 4 reported data for the IRIDICA BAC BSI assay. Two of the 62 studies that reported data for both the Light Cycler SeptiFast Test MGRADE and SepsiTest were counted as individual studies for each test. ## LightCycler SeptiFast Test MGRADE There were 54 studies that compared the LightCycler SeptiFast Test MGRADE with blood culture and were combined in a meta‑analysis. The pooled estimate for sensitivity was 0.65 (95% credible interval  0.60 to 0.71; 95% prediction interval 0.29 to 0.90) and for specificity was 0.86 (95% CrI 0.84 to 0.89; 95% prediction interval 0.62 to 0.96). The proportion of discordant results varied across studies from 6% to 46% (median 17%). One study (Tafelski et al. 2015) compared the LightCycler SeptiFast Test MGRADE with blood culture plus MALDI‑TOF MS. It reported a sensitivity of 0.58 (95% confidence interval  0.30 to 0.86) and a specificity of 0.74 (95% CI 0.64 to 0.85). Reasons for heterogeneity in sensitivity and specificity estimates between studies were explored using meta‑regression for clinically relevant variables. The following variables were explored: age (neonates and children) exposure to antibiotics before blood sample collection suspected community- or healthcare‑acquired infection febrile neutropenia studies with inclusion or exclusion of contaminants.There was no evidence that sensitivity and specificity estimates were affected by these variables. ## SepsiTest Four studies compared SepsiTest with blood culture and were combined in a meta‑analysis. The pooled estimate for sensitivity was 0.48 (95% CrI 0.21 to 0.74; 95% prediction interval 0.07 to 0.90) and for specificity was 0.86 (95% CrI 0.78 to 0.92; 95% prediction interval 0.66 to 0.95). The proportion of discordant results varied between studies and ranged from 14% to 26% (median 22%). One study (Loonen et al. 2014) compared SepsiTest with blood culture plus MALDI‑TOF MS. The study reported a sensitivity of 0.11 (95% CI 0.00 to 0.23) and specificity of 0.96 (95% CI 0.92 to 1.00). No subgroup analyses were possible for the SepsiTest. ## IRIDICA BAC BSI Four studies compared the IRIDICA BAC BSI assay with blood culture and were combined in a meta‑analysis. Two of these studies reported data using an earlier version of the IRIDICA PCR/ESI‑MS analyser known as the PLEX‑ID system, which has different desalter and mass spectrometry modules. The pooled estimate for sensitivity was 0.81 (95% CrI 0.69 to 0.90; 95% prediction interval 0.55 to 0.94) and for specificity was 0.84 (95% CrI 0.71 to 0.92; 95% prediction interval 0.50 to 0.96). The proportion of discordant results varied between studies and ranged from 7% to 30% (median 18%). No studies compared the IRIDICA BAC BSI assay with blood culture plus MALDI‑TOF MS and no subgroup analyses were possible for this intervention. # Intermediate and clinical outcomes There were 41 studies included that reported data relating to the time to pathogen identification for the index test, time to treatment, test‑failure rate, mortality, duration of intensive care unit or hospital stay, duration of antibiotic therapy or reported changes in antimicrobial treatment plan. None of the included studies reported data on re‑admission rates, adverse events associated with broad‑spectrum antimicrobial use, morbidity, changes in disease severity over time, rates of superinfection, rates of resistant infection, or health‑related quality of life. ## Light Cycler SeptiFast Test MGRADE There were 37 studies that reported data on intermediate and clinical outcomes for the LightCycler SeptiFast Test MGRADE. In addition, 1 study (Schreiber et al. 2013) reported data for both the LightCycler SeptiFast Test MGRADE and SepsiTest. No studies compared the LightCycler SeptiFast Test MGRADE with the IRIDICA BAC BSI assay. There were 21 studies using the LightCycler SeptiFast Test MGRADE that reported turnaround times of a minimum of 4 hours to a median of 26.25 hours for pathogen identification. Some of these studies also reported the time for pathogen identification using blood cultures, which ranged from a turnaround time of a minimum of 24 hours to a median of 80 hours. Time-to-treatment change for the LightCycler SeptiFast Test MGRADE was reported in 3 RCTs: Tafelski et al. (2015) reported a mean time of 18.8 hours (standard deviation  5.6) from taking the blood sample to changing treatment using the LightCycler SeptiFast Test MGRADE and a mean time of 38.3 hours (SD 14.5) using blood culture and MALDI‑TOF MS. Rodrigues et al. (2013) reported a mean time of 9.7 hours from taking the blood sample to a change in treatment using the LightCycler SeptiFast Test MGRADE compared with a mean time of 50.1 hours using blood culture (p=0.004). Idelevich et al. (2015) reported a mean time to changing treatment of 21.4 hours (range 16.2 to 46.3 hours) in the LightCycler SeptiFast Test MGRADE group compared with 47.5 hours (range 7.3 to 59.2 hours) in the blood culture group (p=0.018). There were 7 studies that reported test‑failure rates for the LightCycler SeptiFast Test MGRADE, which ranged from 1.5% to 24.2%. It is not clear why there is a large variation in failure rates between studies. Duration of stay in an intensive care unit, or hospital, or both were reported in 13 studies that compared the LightCycler SeptiFast Test MGRADE with blood culture. In most of these studies, it was unclear if the duration of stay was recorded from before, during or after blood sampling. Also, most of the studies did not present comparative data. Of the 4 studies that did report between group differences, 1 study (Alvarez et al. 2012) reported a statistically significant difference (p<0.05) in intensive care unit and hospital duration of stay in favour of the LightCycler SeptiFast Test MGRADE. Three other studies (Idelevich et al. 2014; Mancini et al. 2014; Rodrigues et al. 2013) reported no significant difference in duration of stay. One RCT (Tafelski et al. 2015) reported a duration of empirical antimicrobial therapy (antibiotics which are prescribed based on clinical presentation) of 18.8 hours (SD ±5.6) for patients in the LightCycler SeptiFast Test MGRADE group compared with 38.3 hours (SD ±14.5) for patients in the blood culture with MALDI‑TOF MS group. There were 14 studies that reported details of change in antimicrobial treatment, 10 of which did not report comparative data. Three studies compared the LightCycler SeptiFast Test MGRADE with blood culture. One RCT (Rodrigues et al. 2013) reported that therapy was adjusted for 35% of patients in the LightCycler SeptiFast Test MGRADE group compared with 24% of patients in the blood culture group. In contrast, a further RCT (Idelevich et al. 2015) reported that 9.5% of patients in the LightCycler SeptiFast Test MGRADE had an adjustment to therapy compared with 10.5% in the blood culture group. One study based on propensity score matching (Mancini et al. 2014) reported no differences in management. One RCT (Tafelski et al. 2015) compared the LightCycler SeptiFast Test MGRADE with blood culture plus MALDI‑TOF MS. Testing with the LightCycler SeptiFast Test MGRADE resulted in a change of treatment for 9.8% of patients compared with 13.5% of patients in the blood culture plus MALDI‑TOF MS group. Mortality data were reported in 17 studies, 12 of which reported data on a cohort level only. The mortality rates reported ranged from 4% to 61%; but the length of follow‑up was highly variable across the studies. One study (Alvarez et al. 2012) reported no statistically significant differences between the LightCycler SeptiFast Test MGRADE and blood culture for both 28‑day and 6‑month mortality. One other study (Rodrigues et al. 2013) also reported no statistically significant difference in 28‑day mortality. One propensity score matching study (Mancini et al. 2014) reported no statistically significant difference in mortality (p=0.39) between a prospective cohort (LightCycler SeptiFast Test MGRADE) and retrospective cohort (blood culture). Although, when more strict matching criteria were applied, the LightCycler SeptiFast Test MGRADE was associated with a statistically significant reduction in mortality (3.13% compared with 14.71%; p=0.04). A reduction in mortality associated with using the LightCycler SeptiFast Test MGRADE was reported in 2 further studies (Idelevich et al. 2015; Tafelski et al. 2015), but the reductions were not statistically significant. ## SepsiTest One study (Loonen et al. 2014) reported a mortality rate of 3.2% for the study cohort but the duration of follow‑up was not reported. In addition, Schreiber et al. (2013) reported an intensive care unit mortality rate of 16% and a 28‑day mortality rate of 24% for the study cohort. No other intermediate or clinical‑outcome data were reported for the SepsiTest. ## IRIDICA BAC BSI One study, which was unpublished at the time of guidance development, reported data relevant to test‑failure rates for the IRIDICA BAC BSI assay. These data are considered to be academic in confidence and cannot be reported at this time. One study (Vincent et al. 2015) reported that an adjudication panel of 3 clinical experts retrospectively recommended a change in management based on the IRIDICA BAC BSI assay for 41% of all patients. This increased to 57% of patients when the IRIDICA BAC BSI assay was positive and blood culture was negative. One study (Vincent et al. 2015) reported a mortality rate of 29% for the study cohort, but did not report the duration of follow‑up. # Costs and cost effectiveness The External Assessment Group conducted a search to identify studies investigating the cost effectiveness of the LightCycler SeptiFast Test MGRADE, SepsiTest or the IRIDICA BAC BSI assay. The External Assessment Group also constructed a conceptual economic model to determine the cost effectiveness of the technologies. ## Systematic review of cost-effectiveness evidence Four studies were included and were assessed according to their relevance to the decision problem: 3 studies included the LightCycler SeptiFast Test MGRADE, 2 of which were within‑study cost‑minimisation analyses (that is, a cost‑minimisation analysis conducted within a clinical study), and 1 was a cost‑effectiveness analysis. The remaining study included a cost‑minimisation analysis of the IRIDICA PLEX‑ID hybrid assay. The target population, condition and setting varied across the 4 studies. The 2 studies that were within‑study cost‑minimisation analyses of using the LightCycler SeptiFast Test MGRADE when compared with blood culture reported cost savings of €178.75 per sample (Mancini et al. 2014) and €183.00 per patient (Alvarez et al. 2012). The third study, Lehmann et al. (2010), reported incremental cost‑effectiveness ratios (ICERs) of €11,477 per incremental survivor and €3,107 per quality‑adjusted life year (QALY) gained when using the LightCycler SeptiFast Test MGRADE compared with blood culture. When the use of an IRIDICA‑PLEX‑ID hybrid system was compared with blood culture, Bilkovski et al. (2014) reported cost savings of $1,123,372 per 422 tests. None of the studies considered the effect of a potential reduction in antibiotic resistance. The External Assessment Group concluded that the existing economic evaluations had limited relevance to either the UK or the decision problem because of differences in patient populations, costs of the interventions and standard care. In particular, Mancini et al. (2014) included haematology patients for whom relatively expensive empirical antifungals were prescribed that are unlikely to be representative of the UK treatment pathway. ## Economic analysis The External Assessment Group developed a conceptual economic model designed to explore the cost effectiveness of the LightCycler SeptiFast Test MGRADE, SepsiTest and the IRIDICA BAC BSI assay. The population included in the model was hospitalised patients with suspected bloodstream infection. The model comprised a decision tree with a lifetime time horizon and took the perspective of the NHS and personal social services. The key clinical outcomes included in the model were 30‑day mortality, duration of stay in intensive care unit, duration of hospital stay and antimicrobial treatment. Data on the diagnostic accuracy of the interventions, intermediate outcomes and clinical outcomes were taken from the clinical‑effectiveness systematic review when possible. Expert opinion was also sought to populate key clinical outcomes and supplement the data available from the systematic review. Routine sources of costs and prevalence data were also used when appropriate. A discount rate of 3.5% per annum was applied to both costs and effects. The potential effect of the tests on antimicrobial stewardship was not included in the model, because there was insufficient evidence to show how the tests would affect antimicrobial use and the subsequent development of resistant organisms. The incremental cost per test was calculated using the cost of the test, the net effect on duration of intensive care unit and hospital stay, and changes in the costs of antimicrobial treatment. The estimated cost per day for an intensive care unit bed was £1057 and for a general ward bed was £275. A course of empirical antimicrobial treatment was estimated to cost £350. It was assumed that the cost per test was dependent upon both test throughput and whether laboratory equipment needed to be bought to use the tests. The range of technology costs included in the model were as follows: LightCycler SeptiFast Test MGRADE £153.67 to £205.54 SepsiTest £108.30 to £149.53 IRIDICA BAC BSI £197.35 to £314.61 MALDI‑TOF MS £6.94 to £232.39. Incremental QALYs were calculated by assuming 11.32 discounted QALYs per 30‑day mortality avoided, based on the estimated number of discounted life years for an adult patient with sepsis and the estimated quality of life after an episode of sepsis. The model assumed a mean age of 58 years and that 60% of the cohort were male. Patients were assumed to have a utility value of 0.68 at 5 years after an episode of severe sepsis (Cuthbertson et al. 2013) unless the utility value predicted for the age and sex profile of a patient in the general population was lower. In these instances, the lower utility value was applied. ## Economic-analysis results Five deterministic analyses were done: Base case 1: interventions compared with blood culture, with clinical‑outcome data taken from the systematic review. Base case 2: interventions compared with blood culture, with clinical‑outcome estimates taken from expert opinion. Threshold analyses. Interventions compared with MALDI‑TOF MS. Data taken from studies comparing more than 1 intervention. The following assumptions were common to all analyses: The only parameter to affect QALY gain or loss was 30‑day mortality rate. Negative rapid tests did not affect any of the 4 key outcomes. Failed rapid tests did not affect any of the 4 key outcomes. If 2.4 tests per day were run, laboratories ran tests Monday to Friday only, with 3 times the number of tests run on Monday to account for samples building up over a weekend. If 17 or 68 tests per day are run, laboratories did 3 runs per day and worked 24 hours a day, 7 days a week. The purchase cost of machines needed for the interventions and comparators was equally divided over 7 years of use. It was assumed that no additional staff costs or laboratory estate costs were incurred when using the interventions. The time scale of testing was 1 year although discounted QALYs accrued in subsequent years were included. Incremental QALYs were accrued through the number of avoided 30‑day mortalities. If accuracy data from Warhurst et al. (2015) were used, the LightCycler SeptiFast Test MGRADE had a failure rate of 6.9%. A failure rate of 1.4% was assumed when pooled accuracy data was used. IRIDICA BAC BSI had a failure rate of 1.9%. SepsiTest had a failure rate of 0%. Patients were treated with either 18 g per day of piperacillin/tazobactam or 3 g per day of meropenem for 7 days. ‑day mortality rates were assumed to be either 13% or 29%. MALDI‑TOF MS was only used on positive samples (8.7% of all blood cultures). MALDI‑TOF MS had a sensitivity of 79.8% at species level compared with blood culture. LightCycler SeptiFast test MGRADE diagnostic-accuracy data were derived from Warhurst et al. (2015) unless otherwise specified. SepsiTest and IRIDICA BAC BSI diagnostic-accuracy data were derived from the External Assessment Group's meta‑analyses unless otherwise specified. In this analysis, clinical‑outcome data from the clinical‑effectiveness review were included. This resulted in the assumption that there were no clinical benefits associated with the interventions for 30‑day mortality, duration of stay in the intensive care unit or duration of stay in hospital. The costs of antimicrobials were also unchanged in this analysis. All interventions were compared with blood culture only. The results of the analysis showed that all the interventions were dominated by blood culture (that is, blood culture was less expensive and more effective than all of the interventions). Regardless of the test throughput assumed in different scenarios, the interventions remained dominated (more expensive with no additional clinical benefit) because of the lack of QALYs gained. In addition, a threshold analysis was done for base case 1 to assess the reduction in antimicrobial costs that would be needed for each intervention to be cost neutral. The results suggested that the reductions needed would be 44% to 59% for the LightCycler SeptiFast Test MGRADE, 31% to 43% for the SepsiTest and 56% to 90% for the IRIDICA BAC BSI, although the rate of positive tests associated with each intervention suggested that their costs could not be offset solely by a reduction in antimicrobial therapy use. In this analysis, the key clinical‑outcome parameters were populated using an average of estimated values provided by clinical experts. The External Assessment Group used these values in a range of scenarios that assumed a 30‑day mortality rate of either 13% or 29%, a throughput of 2.4, 17 or 68 tests per day and a maximum acceptable ICER of £20,000 or £30,000 per QALY gained. The comparator used in this analysis was blood culture. For each scenario, the net monetary benefit of each intervention was estimated. A positive net monetary benefit suggests that the benefits associated with the intervention outweigh the costs, and the intervention with the largest net monetary benefit is estimated to be the most cost effective. MALDI‑TOF MS was also included in the analysis to estimate the relative cost effectiveness between the 2 comparators included in the assessment. In all scenarios modelled, MALDI‑TOF MS produced a positive net benefit compared with blood culture. In 1 scenario (30‑day mortality rate 13%, 2.4 tests per day, maximum acceptable ICER of £20,000 per QALY gained), SepsiTest had the highest net monetary benefit when it was assumed that equipment to run the test had to be bought. In the same scenario, the IRIDICA BAC BSI assay had the highest net monetary benefit when only the test reagents and consumables were purchased. In all other modelled scenarios, the IRIDICA BAC BSI assay had the highest net monetary benefit. ICERs were also calculated using the data from expert opinion. When it was assumed that no additional equipment had to be bought or the 30‑day mortality rate was 29%, the ICERs became more favourable because of either a decrease in incremental costs or an increase in incremental QALY gain. The External Assessment Group also explored the effect of applying the pooled estimates of sensitivity and specificity from the meta‑analyses to the LightCycler SeptiFast Test MGRADE. This assumption produced more favourable ICERs for the LightCycler SeptiFast Test MGRADE through increasing the estimated sensitivity of the test (65% pooled estimate compared with 51% from Warhurst et al. 2015), while maintaining specificity at 86%. The External Assessment Group used a range of threshold analyses to explore the effect of key clinical outcomes. In all analyses, it was assumed that the comparator equipment had already been bought but that the equipment for the interventions needed to be bought. The threshold levels resulting from the analyses, which assumed 2.4 tests run per day and a maximum acceptable ICER of £20,000 per QALY gained, suggested reductions in 30‑day mortalities ranging from 0.09 to 0.14 per 100 tests would be needed for the interventions to be considered cost effective compared with blood culture. Antimicrobial costs would need to reduce by £149.53 to £314.61 per 100 tests. The results were similar when the interventions were compared with MALDI‑TOF MS. The threshold analyses that assumed either 17 or 68 tests run per day produced lower threshold values. The values of the reductions needed were also lower when a maximum acceptable ICER of £30,000 per QALY gained was assumed. The External Assessment Group also explored the cost effectiveness of both the LightCycler SeptiFast Test MGRADE and SepsiTest compared with MALDI‑TOF MS, based on data from 2 studies (Tafelski et al. 2015; Loonen et al. 2014) that used MALDI‑TOF MS in addition to blood culture. The effect estimates based on expert opinion were also included in the analysis. It was assumed that both interventions had a failure rate of 0% and that equipment to run the tests needed to be bought. The results of these analyses suggested that when compared with MALDI‑TOF MS (and blood culture), the LightCycler SeptiFast Test MGRADE dominated (less costly and more effective) MALDI‑TOF MS (and blood culture), and SepsiTest had ICERs ranging from £23,375 to £34,848 per QALY gained with a 30‑day mortality rate of 13% and from £10,479 to £15,621 per QALY gained with a 30‑day mortality rate of 29%. An analysis was run using data from 2 studies (Schreiber et al. 2013; Leitner et al. 2013), which evaluated both the LightCycler SeptiFast Test MGRADE and SepsiTest with blood culture. The analysis was done to compare the relative cost‑effectiveness estimates with those derived in base case 2 that were based on indirect comparisons of the relative effectiveness of the interventions from expert opinion. The analysis assumed a 0% test‑failure rate for both interventions and that equipment to run the tests needed to be bought. A range of scenarios were presented with 30‑day mortality rates of 13% or 29% and a throughput of 2.4, 17 or 68 tests per day. In all scenarios, the ICER for the LightCycler SeptiFast Test MGRADE was greater than £30,000 per QALY gained when compared with SepsiTest.# Considerations The Diagnostics Advisory Committee reviewed the evidence available on the clinical and cost effectiveness of using the LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay to rapidly identify bloodstream bacteria and fungi in people with a suspected bloodstream infection. # Clinical effectiveness The Committee considered the evidence for the diagnostic accuracy of each of the rapid molecular tests compared with blood culture. It noted that 54 studies reported data for the LightCycler SeptiFast Test MGRADE, 6 of which included children or neonates, 4 reported data for SepsiTest and 4 reported data for the IRIDICA BAC BSI assay. The Committee noted that most of the included studies were considered to have unclear risks of bias, particularly about details of the reference standard and the populations included in the studies. The Committee considered that the unclear risk of bias was attributable to poor reporting in the studies, and concluded that it was not possible to adequately assess the quality of the studies included in the diagnostic accuracy meta‑analyses. The Committee noted that 2 studies compared either the LightCycler SeptiFast Test MGRADE or SepsiTest with MALDI‑TOF mass spectrometry (MS). It considered that both of these studies had relatively small sample sizes and it is likely that the results are not applicable to the UK because of differences in clinical practice in Europe, where the studies were done. The Committee concluded that there was insufficient evidence to establish either the diagnostic accuracy or the clinical utility of the rapid molecular tests against this comparator. Also, because of insufficient clinical data, the Committee concluded that there was too much uncertainty in the analyses for it to be confident that the rapid molecular tests would be cost effective compared with MALDI‑TOF MS. The Committee questioned the assumption in the diagnostic accuracy meta‑analyses that blood culture is 100% accurate and noted that clinical specialists consider it to be an imperfect reference standard. It heard from the External Assessment Group that on this basis it was possible that the pooled estimates of sensitivity and specificity had been underestimated in the analysis, and so the rate of false positive and false negative results may also have been overestimated. The Committee discussed the reasons for false positive results with the rapid molecular tests. It noted that false positives may be real false positives in situations in which the rapid molecular test detects DNA from contaminant organisms in the blood sample which may result from the testing process. But it also heard from clinical specialists that it is possible that the rapid molecular tests may give more accurate results in some scenarios, such as the detection of fastidious organisms that may not grow in culture. The Committee also heard from clinical specialists that the rapid molecular tests may detect transient bacteraemia in some people, but that the clinical implications of this are not fully understood. It is possible that people may have extended courses of antibiotics and stay in hospital for longer if transient bacteraemia is detected. The Committee concluded that although the sensitivity and specificity may have been underestimated in the meta‑analyses, the absence of data on the clinical significance of discordant results means that the size of any underestimation cannot be determined. The Committee discussed the number of positive blood cultures in the included diagnostic accuracy studies and their prevalence in clinical practice. It heard from clinical specialists that blood culture is often negative in practice, with only around 10% of blood cultures being positive. The Committee considered that the low prevalence of positive blood cultures was likely to mean that there would be a relatively low number of false negative rapid molecular test results in routine practice. Also, the absolute rate of false‑positive rapid molecular test results is likely to be high because of the greater prevalence of negative blood cultures. The Committee concluded that although the absolute number of false‑negative rapid molecular test results was likely to be low in practice, the consequences of changing antimicrobial treatment in this group could be severe. The Committee discussed the studies included in the clinical‑outcomes systematic review. It noted that fewer studies reported clinical‑outcome data compared with diagnostic‑accuracy data, and that studies typically reported data for the LightCycler SeptiFast Test MGRADE only. The Committee noted that most of the studies were done in Europe or the USA and questioned the applicability of the clinical‑outcome studies to the UK. It heard from clinical specialists that although the treatment of sepsis is based on international guidelines, clinical outcomes such as duration of intensive care unit stay and duration of antimicrobial therapy cannot usually be applied to the UK from international studies because of differences in antibiotic prescribing practices. The Committee concluded that although the included studies provide some indication of the likely effect of the rapid molecular tests on clinical outcomes, additional UK‑based studies are needed to show the clinical utility of the tests in practice. The Committee considered the test turnaround times reported in the studies and heard from clinical specialists that the shorter times seen in research studies are unlikely to be seen in routine clinical practice, unless a molecular service is available 24 hours a day. It noted that 24‑hour services may become available if microbiology laboratories are joined into networks or centralised, but that this was unlikely to happen in the very near future. The Committee also noted that in some studies, the reported test‑failure rates for the LightCycler SeptiFast Test MGRADE were high (up to 24.2%) and considered that this could further affect its potential to rapidly deliver information for clinical decision‑making. The Committee questioned why the reported test‑failure rates were high in some studies but heard from the External Assessment Group that the reasons for the failed tests were not reported. The Committee concluded that faster reporting of results is highly dependent on laboratory infrastructure and that the turnaround times needed to gain benefits from the rapid molecular tests are unlikely to be achieved in routine practice. The Committee considered the data for mortality and duration of intensive care unit or hospital stay and noted that the studies were unlikely to have had sufficient power to detect statistically significant differences for these clinical endpoints. The Committee also noted that most of the studies did not report statistically significant differences between the rapid molecular tests and standard practice. Also, it heard from clinical specialists that both mortality and duration of stay among people with suspected bloodstream infection are likely to be influenced by multiple factors, and that any differences are unlikely to be solely because of the use of a rapid molecular test. The Committee concluded that mortality and duration of stay may not be appropriate primary clinical outcomes for studies, and suggested that future studies should consider using change in antimicrobial prescribing as a surrogate clinical outcome. The Committee discussed the plausibility of the rapid molecular tests having an effect on antimicrobial prescribing. It noted that the results of the clinical‑effectiveness analysis suggested that only small numbers of people, if any, would have changes made to their antimicrobial treatment plan. The Committee heard from clinical specialists that there may be some situations in which the rapid molecular tests could affect patient management. Also, it heard that these situations would be restricted to instances in which the rapid test was positive, because the current accuracy of the tests was not sufficient to convince clinicians to withdraw antibiotic therapy on the basis of a negative test result. The Committee concluded that although the rapid molecular tests might give results more quickly, it was unlikely that the information they give would have an effect on patients' treatment plans and antimicrobial prescribing at present. # Cost effectiveness The Committee discussed the results of the economic analyses and questioned whether the use of an imperfect reference standard to calculate the estimates of diagnostic accuracy for the rapid molecular tests could have introduced bias. The Committee heard from the External Assessment Group that negative results were assumed not to have an effect on outcomes and that false‑positive results were associated with benefits in the model. The Committee concluded that any underestimate of pooled diagnostic accuracy in the clinical‑effectiveness analysis is unlikely to have a substantial effect on the results of the economic model. The Committee questioned the assumptions made about the number of tests processed per day. It heard from clinical experts that the estimates based on 68 tests per day were unrealistic and that a large service laboratory would be unlikely to get more than 40 blood cultures per day. The Committee noted that the External Assessment Group had also produced estimates based on 2.4 and 17 tests per day. The Committee heard from the External Assessment Group that an assumption of 68 tests per day was included as an extreme scenario to show the effect on the results of the economic analyses. The Committee concluded that the most representative scenarios in the economic analyses were those that assumed either 2.4 or 17 tests per day. The Committee discussed the differences in the results produced in the 2 different base cases of the economic analyses. It noted that the main difference between the 2 base cases came from the difference in data source for clinical outcomes: base case 1 used data taken from the systematic review, and base case 2 used data based on expert opinion. The Committee noted that the systematic review suggested that the rapid molecular tests had no effect on clinical outcomes, but some of the clinical experts thought that the tests may be beneficial, although their estimates of the size of the benefit varied widely. The Committee concluded that the tests may offer clinical benefit, but there is too much uncertainty in the size of the benefit to determine the effect of introducing the tests into clinical practice. The Committee also noted that the incremental cost‑effectiveness ratios (ICERs) in base case 2 ranged from the rapid molecular tests being more costly and equally effective (dominated) than blood culture, to being less costly and more effective (dominant) than blood culture alone, when using estimates from individual clinicians. The Committee considered that the wide range of ICERs resulted from the high level of variation between the clinicians' estimates. The Committee concluded that the effect of introducing the rapid molecular tests on NHS resources was highly uncertain and that the results of the economic analyses were subject to substantial uncertainty. The Committee considered the likely effect of the costs and outcomes that had been excluded from the economic analyses and noted that these included laboratory overhead and additional staff costs, and clinical benefits that may be accrued through improved antimicrobial stewardship. The Committee noted that because the results of the clinical‑effectiveness analysis suggested that the effect of the rapid molecular tests on antimicrobial prescribing was highly uncertain, it would have been inappropriate to extrapolate the clinical outcomes to estimate an effect on antimicrobial stewardship. It also noted that the rapid molecular tests would most likely increase laboratory overhead costs, and possibly staff costs, and concluded that because of the clinical uncertainties their absence from the economic analyses was unlikely to have a substantial effect. The Committee considered the results of the threshold analyses and noted the reductions in antimicrobial costs that would be needed for the tests to be considered cost effective. The Committee noted that this ranged from £823.34 to £1482.28 per 100 positive tests, depending on whether the rapid molecular tests were compared with blood culture or blood culture plus MALDI‑TOF MS. The Committee concluded that because of the prevalence of positive tests in clinical practice, the costs of the rapid molecular tests were unlikely to be offset by reduced antimicrobial costs alone. The Committee noted that the economic analyses did not include neonates and children, and that the model was based on an adult population with a mean age of 58 years. The Committee considered that the estimated quality‑adjusted life year (QALY) gain by avoided 30‑day mortalities would be greater for children and neonates because of their greater number of life years remaining, but accepted that there were insufficient clinical‑utility data for this population for an economic analysis. # Additional considerations The Committee considered the potential benefits of the interventions in practice. It heard from clinical experts that because the tests can be used directly on whole blood samples, they may be able to give information on a pathogen's identity earlier in the care pathway than tests that need incubated blood samples or samples from culture plates, which could be beneficial for antimicrobial stewardship. Also, it heard that the information from the rapid molecular tests may be used to modify a person's antimicrobial therapy, particularly when empirical antimicrobial therapy (antibiotics which are prescribed based on clinical presentation) has been prescribed. The Committee concluded that one of the key claimed benefits of the rapid molecular tests is their potential to contribute towards antimicrobial stewardship. The Committee considered that because the rapid molecular tests need to be used in addition to blood culture for antimicrobial susceptibility testing, they may be less suitable for use in neonates and children. The Committee heard from clinical experts that this is a particular issue for tests that need a large volume of whole blood. The Committee also heard from clinical specialists that using a lower volume of blood from these patients for the molecular tests may have an adverse effect on the test's sensitivity and concluded that further exploration of these analytical issues should be encouraged. # Research considerations The Committee discussed the value of developing research recommendations for the rapid molecular tests. The Committee considered that for the tests to have clinical utility in both research settings and routine practice, clinicians would need to be certain that the tests are sufficiently accurate, and be confident that basing antimicrobial prescribing decisions on the results of the tests would not lead to adverse outcomes for people. The Committee noted that the reported accuracy data from the systematic review were unlikely to be sufficient for clinical decision‑making at present. The Committee concluded that further research in the UK is needed to determine the clinical scenarios in which the tests may offer most benefit in clinical decision‑making and to quantify their clinical utility. The Committee also considered that future studies should investigate using the rapid molecular tests in conjunction with other biomarkers, such as procalcitonin, and diagnostic tests that may be used to assess people with suspected sepsis. The Committee considered that, conceptually, the molecular tests show promise for the early identification of fungal pathogens in people who are thought to be at increased risk of developing invasive fungal infections. The Committee concluded that if the accuracy of the tests was sufficient to guide clinical decision‑making in this population, they could offer substantial value and address a clinically unmet need. The Committee encouraged future studies in this population and highlighted that the studies should aim to quantify the clinical utility of the rapid molecular tests, including their effect on antifungal prescribing. The Committee noted that studies planned by the National Institute for Health Research Health Technology Assessment Programme may investigate the use of rapid tests for identifying fungal pathogens. The Committee considered the utility of further research to quantify the levels of certainty about the results of rapid molecular tests, which clinicians need to have before they decide to change treatment and level of care for patients. The Committee noted that the results of an elicitation exercise could be used to guide the development of future diagnostic tests that are designed to be used to change treatment plans for patients who are acutely unwell, and wished to encourage this research. The Committee considered that because an increasing number of microbiology laboratories are adopting MALDI‑TOF MS for rapidly identifying bloodstream bacteria and fungi, future studies aiming to establish the clinical utility of rapid molecular tests should include this technology as a comparator when possible. The Committee noted that there was insufficient evidence to determine whether the tests were clinically effective in children and neonates. It wished to encourage the inclusion of these populations in future research studies, and noted that particular consideration should be given to establishing whether the blood volumes needed for the tests in this assessment are suitable for these populations.

Mammaglobin-A Mammaglobin-A also known as secretoglobin family 2A member 2 is a protein that in humans is encoded by the SCGB2A2 gene. # Function SCGB2A2 is a member of the superfamily of secretoglobins, a group of small dimeric secreted and sometimes glycosylated proteins. Expressed mainly in mucosa, secretoglobins seem to be involved in cell signalling, immune response, and chemotaxis, and may also serve as transporters for steroid hormones in humans.> # Clinical significance SCGB2A2 expression is highly specific of mammary tissue, and is increasingly used for identification and detection of disseminated breast cancer cells.

Candesartan (patient information) # IMPORTANT WARNING Do not take candesartan if you are pregnant or breast-feeding. If you become pregnant while taking candesartan, call your doctor immediately. # Why this medication is prescribed Candesartan is used to treat high blood pressure. It blocks the action of certain chemicals that tighten the blood vessels, so blood flows more smoothly. This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information. # How this medication should be used Candesartan comes as a tablet to take by mouth. It is usually taken once or twice a day with or without food. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take candesartan exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Candesartan controls high blood pressure but does not cure it. Continue to take candesartan even if you feel well. Do not stop taking candesartan without talking to your doctor. # Other uses for this medicine Candesartan is sometimes used to treat congestive heart failure. Talk to your doctor about the possible risks of using this drug for your condition. # Special precautions Before taking candesartan: - tell your doctor and pharmacist if you are allergic to candesartan, benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), hydrochlorothiazide (HydroDIURIL), irbesartan (Avapro), lisinopril (Prinivil, Zestril), losartan (Cozaar), moexipril (Univasc), quinapril (Accupril), ramipril (Altace), sulfas, telmisartan (Micardis), trandolapril (Mavik), valsartan (Diovan), or any other drugs. - tell your doctor and pharmacist what prescription and nonprescription medications you are taking, especially barbiturates; diuretics ('water pills'); lithium (Eskalith, Lithobid); medications for diabetes; nonsteroidal anti-inflammatory medications (ibuprofen , naproxen , and others); other medications for high blood pressure; potassium supplements; and vitamins. - tell your doctor if you have or have ever had heart, kidney, or liver disease or diabetes. - if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking candesartan. # Special dietary instructions Talk to your doctor before using salt substitutes containing potassium. If your doctor prescribes a low-salt or low-sodium diet, follow these directions carefully. # What you should do if you miss a dose Take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one. # Side Effects ## Minor Side Effects Candesartan may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away: - dizziness - lightheadedness - congestion - cough - diarrhea - headache - muscle aches - back pain - fever - sore throat - runny nose ## Severe Side Effects If you experience any of the following symptoms, call your doctor immediately: - swelling of the face, eyes, lips, tongue, arms, or legs - difficulty breathing or swallowing - fainting - rash If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online or by phone . # Storage conditions needed for this medication Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication. # In case of emergency/overdose In case of overdose, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911. # Other information Keep all appointments with your doctor and the laboratory. Your blood pressure should be checked regularly to determine your response to candesartan. Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription. # Brand names - Atacand®

Sandbox: DDx pancrease - Done: - Zollinger-Ellison syndrome, Adenocarcinoma of pancreas, Solid-pseudopapillary tumour of pancreas, Insulinoma, Gastrinoma, Glucagonoma, VIPoma, Somatostatinoma - Zollinger-Ellison syndrome, Adenocarcinoma of pancreas, Solid-pseudopapillary tumour of pancreas, Insulinoma, Gastrinoma, Glucagonoma, VIPoma, Somatostatinoma , , Intraductal papillary mucinous neoplasm, Mucinous cystic neoplasm, Pancreatic intraepithelial neoplasia, Pancreatoblastoma, Serous cystadenoma, carcinoma,Intraductal papillary mucinous neoplasm (IPMN), Serous cystadenoma, Mucinous cystic neoplasm, , ,, Pancreatic ductal adenocarcinoma Solid-pseudopapillary neoplasm - Rare - Colloid carcinoma - Hepatoid carcinoma - Signet ring cell - Pancreatic teratoma - Pancreatic lymphoma - Pancreatic Sarcoma - Undifferentiated carcinoma/Undifferentiated carcinoma with osteoclast-like giant cell - Neurofibroma - Elderly - Positive history of other cancer - Present with abdominal pain, malabsorption symptoms, gastric outlet obstruction symptoms, and gastrointestinal bleeding symptoms

Phenazepam Phenazepam is a benzodiazepine drug, which was developed in Soviet Union and now produced in Russia and some CIS countries. Phenazepam is used in the treatment of neurological disorders such as epilepsy, alcohol withdrawal and insomnia. It can be used as a premedication before surgery as it augments the effects of anesthetics and reduces anxiety. # Dosage An average phenazepam dosage is 0.5 mg 2-3 times daily. The maximum daily dosage must not exceed 10 mg. # Side effects Side effects include dizziness, loss of coordination, drowsiness. As with other sedatives, in case of abrupt discontinuation following prolonged use, severe withdrawal symptoms may occur. # Legal Status Phenazepam does not appear in the list of Controlled Substances in the Laws of either the USA or the UK, where in each country, benzodiazepines are generally Class C, Schedule IV substances. Like all benzodiazepines, it is legally classified as a C-IV substance in accordance with the analogue act in the U.S. (Flunitrazepam, aka "rohypnol", is dually scheduled.) According to the official investigation report, effects of phenazepam on pilot Pavel Gruzin may have contributed to errors that caused the crash of Crossair Flight 498.

IDH3G Isocitrate dehydrogenase subunit gamma, mitochondrial is an enzyme that in humans is encoded by the IDH3G gene. Isocitrate dehydrogenases (IDHs) catalyze the oxidative decarboxylation of isocitrate to 2-oxoglutarate. These enzymes belong to two distinct subclasses, one of which utilizes NAD(+) as the electron acceptor and the other NADP(+). Five isocitrate dehydrogenases have been reported: three NAD(+)-dependent isocitrate dehydrogenases, which localize to the mitochondrial matrix, and two NADP(+)-dependent isocitrate dehydrogenases, one of which is mitochondrial and the other predominantly cytosolic. NAD(+)-dependent isocitrate dehydrogenases catalyze the allosterically regulated rate-limiting step of the tricarboxylic acid cycle. Each isozyme is a heterotetramer that is composed of two alpha subunits, one beta subunit, and one gamma subunit. The protein encoded by this gene is the gamma subunit of one isozyme of NAD(+)-dependent isocitrate dehydrogenase. This gene is a candidate gene for periventricular heterotopia. Several alternatively spliced transcript variants of this gene have been described, but only some of their full length natures have been determined. # Structure IDH3 is one of three isocitrate dehydrogenase isozymes, the other two being IDH1 and IDH2, and encoded by one of five isocitrate dehydrogenase genes, which are IDH1, IDH2, IDH3A, IDH3B, and IDH3G. The genes IDH3A, IDH3B, and IDH3G encode subunits of IDH3, which is a heterotetramer composed of two 37-kDa α subunits (IDH3α), one 39-kDa β subunit (IDH3β), and one 39-kDa γ subunit (IDH3γ), each with distinct isoelectric points. Alignment of their amino acid sequences reveals ~40% identity between IDH3α and IDH3β, ~42% identity between IDH3α and IDH3γ, and an even closer identity of 53% between IDH3β and IDH3γ, for an overall 34% identity and 23% similarity across all three subunit types. Notably, Arg88 in IDH3α is essential for IDH3 catalytic activity, whereas the equivalent Arg99 in IDH3β and Arg97 in IDH3γ are largely involved in the enzyme's allosteric regulation by ADP and NAD. Thus, it is possible that these subunits arose from gene duplication of a common ancestral gene, and the original catalytic Arg residue were adapted to allosteric functions in the β- and γ-subunits. Likewise, Asp181 in IDH3α is essential for catalysis, while the equivalent Asp192 in IDH3β and Asp190 in IDH3γ enhance NAD- and Mn2+-binding. Since the oxidative decarboxylation catalyzed by IDH3 requires binding of NAD, Mn2+, and the substrate isocitrate, all three subunits participate in the catalytic reaction. Moreover, studies of the enzyme in pig heart reveal that the αβ and αγ dimers constitute two binding sites for each of its ligands, including isocitrate, Mn2+, and NAD, in one IDH3 tetramer. # Function As an isocitrate dehydrogenase, IDH3 catalyzes the reversible oxidative decarboxylation of isocitrate to yield α-ketoglutarate (α-KG) and CO2 as part of the TCA cycle in glucose metabolism. This step also allows for the concomitant reduction of NAD+ to NADH, which is then used to generate ATP through the electron transport chain. Notably, IDH3 relies on NAD+ as its electron acceptor, as opposed to NADP+ like IDH1 and IDH2. IDH3 activity is regulated by the energy needs of the cell: when the cell requires energy, IDH3 is activated by ADP; and when energy is no longer required, IDH3 is inhibited by ATP and NADH. This allosteric regulation allows IDH3 to function as a rate-limiting step in the TCA cycle. Within cells, IDH3 and its subunits have been observed to localize to the mitochondria. # Clinical Significance The IDH3G gene may be involved in drug resistance in gastric cancer. # Interactive pathway map Click on genes, proteins and metabolites below to link to respective articles. - ↑ The interactive pathway map can be edited at WikiPathways: "TCACycle_WP78"..mw-parser-output cite.citation{font-style:inherit}.mw-parser-output q{quotes:"\"""\"""'""'"}.mw-parser-output code.cs1-code{color:inherit;background:inherit;border:inherit;padding:inherit}.mw-parser-output .cs1-lock-free a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-lock-limited a,.mw-parser-output .cs1-lock-registration a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-lock-subscription a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-subscription,.mw-parser-output .cs1-registration{color:#555}.mw-parser-output .cs1-subscription span,.mw-parser-output .cs1-registration span{border-bottom:1px dotted;cursor:help}.mw-parser-output .cs1-hidden-error{display:none;font-size:100%}.mw-parser-output .cs1-visible-error{display:none;font-size:100%}.mw-parser-output .cs1-subscription,.mw-parser-output .cs1-registration,.mw-parser-output .cs1-format{font-size:95%}.mw-parser-output .cs1-kern-left,.mw-parser-output .cs1-kern-wl-left{padding-left:0.2em}.mw-parser-output .cs1-kern-right,.mw-parser-output .cs1-kern-wl-right{padding-right:0.2em}

Greater celandine The greater celandine (Chelidonium majus, aka. 'Tetterwort') is a yellow flowering plant in the poppy family, native to Europe and the Mediterranean basin. It is also widespread in North America, having been brought there by settlers as a herbal remedy for skin problems such as warts as early as 1672. Greater celandine is plant of size may reach 30 to 120 cm high, with an erect stem. The leaves are deeply divided, 30-cm long. The flowers comprise four yellow petals, each about 1 cm long, with two sepals. The flowers appear from May to July. The seeds are small and black, and possess an elaiosome, which attracts ants to disperse the seeds (myrmecochory). A double-flowered variety, a naturally occurring mutation, also exists. It is considered an aggressive invasive plant in natural areas (both woods and fields). Control is mainly via pulling or spraying the plant before seed dispersal. The greater celandine is the only species in the genus Chelidonium, and is not closely related to the lesser celandine, which is in a different family. # Pharmacology The whole plant is toxic in moderate doses as it contains a range of isoquinoline alkaloids but there are numerous therapeutic uses when used at the correct dosage. The main alkaloid present in the herb and root is coptisine. Other alkaloids present include berberine, chelidonine, sanguinarine and chelerythrine. Sanguinarine is particularly toxic with a lethal dose of only 18mg per kg body weight Despite this acute toxicity, sangunarine is present in such small quantities that the LD50 dose would require >50g of raw herb to be ingested. Caffeic acid derivatives are also present. The effect of the fresh herb is of a mild analgesic, cholagogic, antimicrobial, oncostatic and central nervous system sedative. In animal test, Celandine is shown to be cytostatic. An immune stimulating effect has also been noted. Some studies show that the alkaloid extraction can have the same effects. The alkaloids are known to cause immobilization in mice after been taken orally or injected. The alkaloids cause limpness and tone reduction of smooth muscle in rabbits. The alkaloids are also noted to stimulate the heart and lungs of frogs, cats and dogs, raising the blood pressure and widening the arteries. Early studies of Celandine showed that it causes contact dermatitis and eye irritation, particularly from contact with the red to yellow latex. This effect has not been observed in animal studies; no inflammation was observed in rabbit eye tests. The latex can leave a non-permanent stain. Stains on skin of the fingers are sometimes reported to cause eye irritation after rubbing the eyes or handling contact lenses. When any part of the plant causes eye irritation, wash it out with clear water and when needed seek medical help. The latex is also known to stain clothes. # Herbalism The aerial parts and roots of Greater Celandine are used in herbalism. The above ground parts are gathered during the flowering season and dried at high temperatures. The root is harvested in Autumn between August and October and dried. The fresh rhizome is also used. Celandine has a hot and bitter taste. The latex has a narcotic fragrance. Preparations are made from alcoholic and hot aqueous extractions (tea). The average daily dosage is 2 to 4 g, equivalent to 12 to 13 mg total alkaloids. For fluid extracts, the daily dosage is 1 to 2 ml of 1:1 25% alcoholic extraction, up to 3 times per day. For hot tea infusions, 1.5 desert spoonfuls left in boiling water for 10 minutes can be taken 3 times a day. It was formerly used by gypsies as a foot refresher; modern herbalists use its purgative properties. . Greater celandine acts as a mild sedative which has been used historically to treat asthma, bronchitis, and whooping cough. The herb's antispasmodic effect improves bile flow in the gallbladder and has been reputed to treat gallstones and gallbladder pain. As far back as Pliny the Elder and Dioscorides (1st century AD) this herb has been recognized as a useful detoxifying agent. The root has been chewed to relieve toothache.

Donepezil (patient information) # Why this medication is prescribed Donepezil is used to treat dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and may cause changes in mood and personality) associated with Alzheimer's disease (AD; a brain disease that slowly destroys the memory and the ability to think, learn, communicate and handle daily activities). Donepezil is in a class of medications called cholinesterase inhibitors. It improves mental function (such as memory, attention, social interaction, reasoning and language abilities, and ability to perform activities of daily living) by increasing the amount of a certain naturally occurring substance in the brain. Donepezil may improve the ability to think and remember or slow the loss of these abilities in people who have AD. However, donepezil will not cure AD or prevent the loss of mental abilities at some time in the future. # How this medication should be used Donepezil comes as a tablet and an orally disintegrating tablet (tablet that dissolves quickly in the mouth) to take by mouth. It is usually taken once a day, in the evening at bedtime, with or without food. Take donepezil at around the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. It may take awhile before you experience the full benefits of donepezil. Take donepezil exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Donepezil helps control the symptoms of Alzheimer's disease but does not cure it. Continue to take donepezil even if you feel well. Do not stop taking donepezil without talking to your doctor. Your doctor may start you on a low dose of donepezil and increase your dose after 4-6 weeks. To take the orally disintegrating tablet, place the tablet on your tongue. The tablet will quickly dissolve and can be followed with a drink of water. # Other uses for this medicine This medication may be prescribed for other uses; ask your doctor or pharmacist for more information. # Special precautions Before taking donepezil: - tell your doctor and pharmacist if you are allergic to donepezil or any other medications. - tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Be sure to mention any of the following: antihistamines; aspirin and other nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn); bethanechol (Duvoid, Urabeth, Urecholine); carbamazepine (Tegretol); dexamethasone (Decadron, Dexone); ipratropium (Atrovent); ketoconazole (Nizoral); medications for glaucoma, irritable bowel disease, motion sickness, myasthenia gravis, Parkinson's disease, ulcers, or urinary problems; phenobarbital (Luminal, Solfoton); phenytoin (Dilantin); quinidine (Quinidex);and rifampin (Rifadin, Rimactane). Your doctor may need to change the doses of your medications or monitor you carefully for side effects. - tell your doctor if you have or have ever had gastrointestinal (GI) bleeding;an ulcer,asthma, or obstructive pulmonary disease (chronic bronchitis or emphysema), or heartdisease. - tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking donepezil, call your doctor. - if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking donepezil. # Special dietary instructions Unless your doctor tells you otherwise, continue your normal diet. # What to do if you forget a dose If you forget to take a dose of donepezil, skip the missed dose and continue with your regular dosing schedule. Do not take a double dose to make up for a missed one. If you do not take donepezil, for 1 week or longer, you should call your doctor before starting to take this medication again. # Side effects ## Minor side effects Donepezil may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away: - nausea - vomiting - diarrhea - loss of appetite - weight loss - frequent urination - muscle cramps - joint pain, swelling, or stiffness - pain - excessive tiredness - drowsiness - headache - dizziness - nervousness - depression - confusion - changes in behavior - abnormal dreams - difficulty falling asleep or staying asleep - discoloration or bruising of the skin - red, scaling, itchy skin ## Severe side effects Some side effects can be serious. If you experience any of these symptoms, call your doctor immediately: - fainting - slow heartbeat - chest pain - black or tarry stools - red blood in stools - bloody vomit - vomiting material that looks like coffee grounds - inability to control urination - difficulty urinating or pain when urinating - lower back pain - fever - seizures Donepezil may cause other side effects. Call your doctor if you have any unusual problems while taking this medication. # Storage conditions needed for this medication Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication. # In case of emergency/overdose In case of overdose, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911. Symptoms of overdose may include: - nausea - vomiting - drooling - sweating - slow heartbeat - difficulty breathing - muscle weakness - fainting - seizures # Other information Keep all appointments with your doctor. Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription. # Brand names - Aricept® - Aricept® ODT

Cefazolin sodium description # Description Cefazolin for Injection, USP, Pharmacy Bulk Package bag SmartPak® should be used only in patients who require a 1 gram dose and not any fraction thereof. Cefazolin for Injection USP, Pharmacy Bulk Package bag SmartPak® should not be used in patients who require less than the 1 gram dose of cefazolin. Cefazolin for Injection, USP, is a sterile, lyophilized, semisynthetic cephalosporin for intravenous administration. It is the sodium salt of 3-{-methyl}-8-oxo-7- -5-thia-1-azabicyclo oct-2-ene-2-carboxylic acid. Each Pharmacy Bulk Package contains 48 mg (2.1 mEq) of sodium per 1 gram of cefazolin sodium. Cefazolin for Injection, USP, is supplied in 100 grams and 300 grams SmartPak® Pharmacy Bulk Packages bags equivalent. Each SmartPak® Pharmacy Bulk Package bag contains cefazolin sodium equivalent to 100 grams or 300 grams of cefazolin. BEFORE ADMINISTRATION, THIS PHARMACY BULK PACKAGE REQUIRES RECONSTITUTION USING STERILE WATER FOR INJECTION, USP TO A CONCENTRATION OF 100 mg per mL AND FURTHER DILUTION IN 50 mL OF A COMPATIBLE SOLUTION AND INFUSED INTRAVENOUSLY. THIS PRODUCT IS NOT INTENDED TO BE USED IN PEDIATRIC AND RENALLY IMPAIRED PATIENTS WHO REQUIRE LESS THAN A 1 GRAM DOSE. A Pharmacy Bulk Package is a container of a sterile preparation for intravenous use that contains many single doses. The contents are intended for use in a pharmacy admixture service and are restricted to the preparation of admixtures for intravenous infusion. The molecular formula is C14H13N8NaO4S3. The molecular weight is 476.49. The structural formula is as follows: The pH of the reconstituted solution is between 4 and 6.

Carnosinemia Carnosinemia, also called carnosinase deficiency or aminoacyl-histidine dipeptidase deficiency, is a rare autosomal recessive metabolic disorder caused by a deficiency of carnosinase, a dipeptidase (a type of enzyme that splits dipeptides into their two amino acid constituents). Carnosine is a dipeptide composed of beta-alanine and histidine, and is found in skeletal muscle and cells of the nervous system. This disorder results in an excess of carnosine in the urine, cerebrospinal fluid (CSF), blood and nervous tissue. Neurological disorders associated with a deficiency of carnosinase, and the resulting carnosinemia ("carnosine in the blood") are common. # Enzymology Carnosinase in humans has two forms: 1. Cellular, or tissue carnosinase. This form of the enzyme is found in every bodily tissue. It is a dimer, and hydrolyzes both carnosine and anserine, preferring dipeptides that have a histidine monomer in the c-terminus position. Tissue carnosinase is often considered a "non-specific dipeptidase", based in part on its ability to hydrolyze a range of dipeptide substrates, including those belonging to prolinase. 2. Serum carnosinase. This is the carnosinase found in the blood plasma. Deficiency of this form of carnosinase, along with carnosinuria ("carnosine in the urine"), is the usual metabolic indicator of systemic carnosinase deficiency. Serum carnosinase is a glycoprotein, and splits free carnosine and anserine in the blood. This form of the dipeptidase is not found in human blood until late infancy, slowly rising to adult levels by age 15. Unlike tissue carnosinase, serum carnosinase also hydrolyzes the GABA metabolite homocarnosine. Homocarnosinosis, a neurological disorder resulting in an excess of homocarnosine in the brain, though unaffected by tissue carnosinase, is caused by a deficiency of serum carnosinase in its ability to hydrolyze homocarnosine. A deficiency of tissue and serum carnosinase, with serum being an indicator, is the underlying metabolic cause of carnosinemia. # Symptoms A variety of neurological symptoms have been associated with carnosinemia. They include: hypotonia, developmental delay, mental retardation, degeneration of axons, sensory neuropathy, tremors, demyelinization, gray matter anomalies, myoclonic seizures, and loss of purkinje fibers. # Genetics The gene for carnosinase is located on chromosome 18, an autosome. The carnosine dipeptidase-1 gene (CNDP1) controls tissue and serum carnosinase. Mutations in CNDP1 are responsible for carnosinase deficiency, resulting in carnosinemia. Carnosinemia is an autosomal recessive disorder, which means the defective gene is located on an autosome, and two copies of the defective gene - one from each parent - are required to inherit the disorder. The parents of an individual with an autosomal recessive disorder both carry one copy of the defective gene, but usually do not experience any signs or symptoms of the disorder.

Penicillin G procaine indications and usage # Indications and Usage To reduce the development of drug-resistant bacteria and maintain the effectiveness of Bicillin C-R and other antibacterial drugs, Bicillin C-R should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy. This drug is indicated in the treatment of moderately severe infections due to penicillin-G-susceptible microorganisms that are susceptible to serum levels common to this particular dosage form. Therapy should be guided by bacteriological studies (including susceptibility testing) and by clinical response. Bicillin C-R is indicated in the treatment of the following in adults and pediatric patients: Moderately severe to severe infections of the upper-respiratory tract, scarlet fever, erysipelas, and skin and soft-tissue infections due to susceptible streptococci. NOTE: Streptococci in Groups A, C, G, H, L, and M are very sensitive to penicillin G. Other groups, including Group D (enterococci), are resistant. Penicillin G sodium or potassium is recommended for streptococcal infections with bacteremia. Moderately severe pneumonia and otitis media due to susceptible Streptococcus pneumoniae. NOTE: Severe pneumonia, empyema, bacteremia, pericarditis, meningitis, peritonitis, and arthritis of pneumococcal etiology are better treated with penicillin G sodium or potassium during the acute stage. When high, sustained serum levels are required, penicillin G sodium or potassium, either IM or IV, should be used. This drug should not be used in the treatment of venereal diseases, including syphilis, gonorrhea, yaws, bejel, and pinta.

Rifampin isoniazid pyrazinamide microbiology # Microbiology ## Mechanism of Action ### Rifampin Rifampin inhibits DNA-dependent RNA polymerase activity in susceptible Mycobacterium tuberculosis organisms. Specifically, it interacts with bacterial RNA polymerase, but does not inhibit the mammalian enzyme. ### Isoniazid Isoniazid inhibits the biosynthesis of mycolic acids which are major components of the cell wall of Mycobacterium tuberculosis. ### Pyrazinamide The exact mechanism of action by which pyrazinamide inhibits the growth of Mycobacterium tuberculosis organisms is unknown. ## Drug Resistance Organisms resistant to rifampin are likely to be resistant to other rifamycins. β-lactamase production should have no effect on rifampin activity. In the treatment of tuberculosis, the small number of resistant cells present within large populations of susceptible cells can rapidly become predominant. In addition, resistance to rifampin has been determined to occur as single-step mutations of the DNA-dependent RNA polymerase. Since resistance can emerge rapidly, appropriate susceptibility tests should be performed in the event of persistent positive cultures. ## Activity in vitro and in vivo Rifampin, isoniazid, and pyrazinamide at therapeutic levels have demonstrated bactericidal activity against both intracellular and extracellular Mycobacterium tuberculosis organisms (see Indications And Usage). Pyrazinamide alone is only active at a slightly acidic pH (pH 5.5) in vitro and in vivo. Isoniazid kills actively growing tubercle bacilli. ## Susceptibility Testing Prior to initiation of therapy, appropriate specimens should be collected for identification of the infecting organism and in vitro susceptibility tests. In vitro testing for Mycobacterium tuberculosis isolates: Two standardized in vitro susceptibility methods are available for testing isoniazid, rifampin, and pyrazinamide against Mycobacterium tuberculosis organisms. The agar proportion method (CDC or CLSI M24-A) utilizes Middlebrook 7H10 medium impregnated with isoniazid at 0.2 and 1.0 mcg/mL and rifampin at 1.0 mcg/mL for the final concentrations of drug. The final concentration for pyrazinamide is 25.0 mcg/mL at pH 5.5. After 3 weeks of incubation MIC99 values are calculated by comparing the quantity of organisms growing in the medium containing drug to the control cultures. Mycobacterial growth in the presence of drug ≥1% of the control indicates resistance. The radiometric broth method employs the BACTEC 460 machine to compare the growth index from untreated control cultures to cultures grown in the presence of 0.2 and 1.0 mcg/mL of isoniazid and 2.0 mcg/mL of rifampin. Strict adherence to the manufacturer's instructions for sample processing and data interpretation is required for this assay. The radiometric broth method has not been approved for the testing of pyrazinamide. Susceptibility test results obtained by the two different methods can only be compared if the appropriate rifampin or isoniazid concentrations are used for each test method as indicated above. Both test procedures require the use of Mycobacterium tuberculosis H37Rv, ATCC 27294, as a control organism. The clinical relevance of in vitro susceptibility test results for mycobacterial species other than Mycobacterium tuberculosis using either the radiometric broth method or the proportion method has not been determined.

VIPoma overview # Overview VIPoma is a rare tumor of the non-beta cells of the pancreas that results in the overproduction of the hormone vasoactive intestinal peptide (VIP). On histopathological analysis, composition of uniform, small to intermediate-sized cells in clusters, nests, and trabecular growth patterns with hyperchromatic nuclei and scant cytoplasm are seen. VIPoma must be differentiated from ganglioneuroblastoma, ganglioneuroma, factitious diarrhea, bile salt enteropathy, rectal vilous adenomas, and laxative abuse. The incidence VIPoma is approximately 0.01 per 100,000 individuals worldwide, and females are more commonly affected than males. If left untreated, patients with VIPoma may progress to develop watery diarrhea, abdominal pain, bloating, nausea, vomiting, skin rash, backache, flushing, and lethargy. Common complications of VIPoma include metastasis, cardiac arrest from low blood potassium level, and dehydration. The presence of metastasis is associated with a particularly poor prognosis, with a 5 year survival rate of 60%. The hallmark of VIPoma is watery diarrhea. A positive history of abdominal pain, weight loss, numbness, and weakness is suggestive of VIPoma. Common physical examination findings of VIPoma include tachycardia, rash, facial flushing, abdominal tenderness, and abdominal distention. Laboratory tests used in the diagnosis of VIPoma include serum vasoactive intestinal polypeptide (VIP) levels, basal gastric acid output, and basic metabolic pannel for potassium, bicarbonate, magnesium, and calcium levels. On CT scan VIPoma is characterized by hypervascularity with diffuse multiple metastatic nodulation. Abdominal MRI is helpful in the diagnosis of VIPoma which is characterized by a mass that is hypointense on T1-weighted and hyperintense on T2-weighted MRI. Initial treatment in patient with VIPoma is prompt replacement of fluid and electrolyte losses, steroids may be used to provide symptomatic relief. Surgery is the mainstay of treatment. # Historical Perspective VIPoma which is also known as Verner-Morrison syndrome was first described in 1958 by Verner and Morrison. # Pathophysiology A VIPoma is a rare tumor of the non-beta cells of the pancreas that results in the overproduction of the hormone vasoactive intestinal peptide (VIP). On microscopichistopathological analysis, findings of VIPoma are composition of uniform, small to intermediate-sized cells in clusters, nests, and trabecular growth patterns with hyperchromatic nuclei and scant cytoplasm. # Causes The cause of VIPoma has not been identified. # Differentiating VIPoma From Other Diseases VIPoma must be differentiated from ganglioneuroblastoma, ganglioneuroma, factitious diarrhea, bile salt enteropathy, rectal vilous adenomas, and laxative abuse. # Epidemiology and Demographics The annual incidence of VIPoma is approximately 0.01 per 100,000 (approx. 1 in 10 million) individuals worldwide. Female are more commonly affected by VIPoma than male. The incidence of VIPoma increases with age, the median age at diagnosis in adults is 50 years. VIPoma in children is usually diagnosed between age 2 to 4. # Risk Factors The most important risk factor in the development of VIPoma is a positive family history of multiple endocrine neoplasia type 1. # Screening According to the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for VIPoma. # Natural History, Complications and Prognosis If left untreated, patients with VIPoma may progress to develop watery diarrhea, abdominal pain, bloating, nausea, vomiting, skin rash, backache, flushing, and lethargy. Common complications of VIPoma include metastasis, cardiac arrest from low blood potassium level, and dehydration. The presence of metastasis is associated with a particularly poor prognosis among patients with VIPoma, with a 5 year survival rate of 60%. # Diagnosis ## Diagnostic Study of Choice The diagnostic study of choice for Vipoma is the measurement of serum vasoactive intestinal polypeptide (VIP) concentration. ## History and Symptoms The hallmark of Vipoma is watery diarrhea. A positive history of abdominal pain, weight loss, numbness, and weakness is suggestive of VIPoma . The most common symptoms of VIPoma include watery diarrhea like cholera, dehydration, lethargy, muscle weakness, weight loss, numbness, and flushing. ## Physical Examination Common physical examination findings of VIPoma include tachycardia, rash, facial flushing, abdominal tenderness, muscle weakness, and abdominal distention. ## Laboratory Findings Laboratory tests used in the diagnosis of VIPoma include serum vasoactive intestinal polypeptide (VIP) levels, basal gastric acid output, and CMP for potassium, bicarbonate, magnesium, and calcium levels. ## Electrocardiogram There are no ECG findings associated with VIPoma. ## X-ray There are no x-ray findings associated with VIPoma. ## CT On CT scan VIPoma is characterized by hypervascularity with diffuse multiple metastatic nodulation. CT scan are highly accurate for tumor localization of primary neuroendocrine pancreatic tumor. Since most of them are more than 3cm in size at the time of presentation. Sensitivity of contrast enhanced CT for VIPoma approaches 100%. ## MRI Abdominal MRI is helpful in the diagnosis of VIPoma. On abdominal MRI, VIPoma is characterized by a mass which is hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI. ## Echocardiography or Ultrasound Endoscopic ultrasound may be helpful in the diagnosis of VIPoma. Finding on ultrasound suggestive of VIPoma is hypoechoic tumor in the distal part of pancreas. ## Other Imaging Findings Other imaging studies for VIPoma include somatostatin receptor scintigraphy and PET scan using radiolabeled somatostatin analogs. ## Other Diagnostic Studies Other diagnostic studies for VIPoma include immunohistochemical staining test, which demonstrates staining for markers such as chromogranin A, cytokeratin 19, synaptophysin, Ki-67, neuron specific enolase, PGP 9.5. # Treatment ## Medical Therapy Initial treatment in patient with VIPoma is prompt replacement of fluid and correction of electrolyte imbalance and acid-base disturbance. Somatostatin analogues like short acting octreotide is useful for controlling diarrhea by blocking the release of VIP. Octreotide is later replaced by longer acting depot preparation of somatostatin analogues like sandostatin or lanreotide. ## Interventions The mainstay of treatment for VIPoma is surgery. Hepatic artery embolization or transcatheter chemoembolization with doxorubicin or cisplatin is usually reserved for patients with liver metastases. Moreover, in patients with liver metastases less than 3 cm radiofrequency ablation and cryoablation can be used. ## Surgery Surgery is the mainstay of treatment for VIPoma. Surgery should be considered after initial symptomatic management of VIPoma inoperable cases. Complete surgical resection of the tumor is the only curative treatment for VIPoma. If the tumor cannot be removed completely, surgical debulking may have palliative effect for control of hormonal symptoms. ## Primary Prevention There are no established measures for the primary prevention of VIPoma. ## Secondary Prevention Effective measures for the secondary prevention of VIPoma include history and physical examination, serum VIP levels and indicated markers, and multi-phasic CT scan or MRI.

Splenic marginal zone lymphoma overview # Overview Splenic marginal zone lymphoma (SMZL) is rare, indolent B-cell lymphoma that may arise from either pre germinal or germinal/post germinal center replacing the normal architecture of the white pulp of the spleen. Chromosomal aberrations and gene mutations involved in the pathogenesis of splenic marginal zone lymphoma include 7q32 deletion, gain of function 3q, 4q and NOTCH2, TP53, KLF2 and immunoglobulin heavy chain gene. On microscopic histopathological analysis, micronodular lymphocytic infiltration of the white pulp along with biphasic distribution of neoplastic B-cells in the follicles of spleen, mixed pattern of lymphocytic infiltration of the bone marrow and villous lymphocytes in peripheral blood, are the characteristic findings of splenic marginal zone lymphoma (SMZL). Hepatitis C viral antigen is also assumed to be involved in its causation. Splenic marginal zone lymphoma (SMZL) must be differentiated from other B-cell lymphomas such as chronic lymphocytic leukemia, follicular lymphoma, and mantle cell lymphoma and unclassifiable splenic lymphomas including hairy cell leukemia variant (HCL-v) and splenic diffuse red pulp small B-cell lymphoma (SDRPL). The incidence of splenic marginal zone lymphoma (SMZL) increases with age; the median age at diagnosis is 65-70 years. Splenic marginal zone lymphoma (SMZL) affects men and women equally. There are no established risk factors. According to the the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening. Low Hemoglobin levels, high lactate dehydrogenase levels, low blood serum albumin levels, and genetic mutations in NOTCH2 TP53 genes are associated with poor prognosis. According to the Lugano classification, there are four stages of splenic marginal zone lymphoma (SMZL) based on the number of nodes and extranodal involvement. The most common symptoms of splenic marginal zone lymphoma include fever, weight loss, skin rash, night sweats, chest pain, abdominal pain, bone pain, and painless swelling in the neck, axilla, groin, thorax, and abdomen. Common physical examination findings of splenic marginal zone lymphoma (SMZL) include fever, rash, ulcer, splenomegaly, chest tenderness, abdomen tenderness, bone tenderness, peripheral lymphadenopathy, and central lymphadenopathy. Laboratory tests for splenic marginal zone lymphoma (SMZL) include complete blood count (CBC), blood chemistry studies, cytogenetic analysis, flow cytometry, immunohistochemistry, genetic testing, FISH, PCR, and immunophenotyping. Lymph node or extranodal tissue( spleen, bone marrow) biopsy is diagnostic of splenic marginal zone lymphoma.splenomegaly and lymphadenopathy and other organs involvement may be seen on abdominal ultrasound, CT scan, MRI and PET scan in patients with splenic marginal zone lymphoma (SMZL). Other diagnostic studies include laparoscopy, laparotomy. The optimal therapy for splenic marginal zone lymphoma (SMZL) depends on the clinical presentation of the patient. Asymptomatic patients may be observed closely without any treatment. Splenomegaly related symptoms such as abdominal distension, tenderness, early satiety, bloating and cytopenia due to hypersplenism may be managed with splenectomy but if bone marrow is involved it will persist even after surgery. Splenectomy was considered to be the first line treatment option but studies reported recently that rituximab alone or in combination with chemotherapy is equally effective if not better in terms of complete remission, progression free and overall survival and in addition there is no surgical risk. Studies have also shown that patients who relapsed while on treatment with rituximab, responded well with retreatment. Patients with hepatitis C who developed splenic marginal zone lymphoma (SMZL) have shown tumor regression with antiviral therapy. # Historical Perspective The term splenic marginal zone lymphoma (SMZL) was used by C. Schmid in 1992 and is described as separate entity from marginal zone lymphoma in the World Health Organization classification of lymphoid neoplasms in 2001. # Pathophysiology The exact pathogenesis of splenic marginal zone lymphoma (SMZL) is not clearly understood but according to some studies chronic immunologic stimulation and certain gene mutations are assumed to be involved. The common chromosomal aberrations and genetic mutations in splenic marginal zone lymphoma (SMZL) includes 7q32 deletion, gain of function mutation in 3q and NOTCH2, TP53, KLF2 gene mutations. These genes control certain cell regulation pathways that are involved in normal functioning of the cell. Hepatitis C viral antigen has also been assumed to be involved in its pathogenesis. Spleen, bone marrow, lymph nodes, liver and blood may be infiltrated with the tumor and have certain distintive features. On microscopic histopathological analysis, B-cells, villous lymphocytes, and sinus invasion are characteristic findings of splenic marginal zone lymphoma (SMZL). # Causes Some studies suggest an association between Hepatitis C and splenic marginal zone lymphoma (SMZL) and assume that it may have some role in its causation. # Differential Diagnosis Splenic marginal zone lymphoma (SMZL) must be differentiated from other B-cell lymphomas such as chronic lymphocytic leukemia, follicular lymphoma, mantle cell lymphoma and unclassifiable B-cell lymphomas including Hairy cell leukemia variant (HCL-v) and splenic diffuse red pulp small B-cell lymphoma (SDRPL) on the basis of cytogenetics, immunophenotyping and morphological as the treatment for these conditions varies. # Epidemiology and demographics Splenic marginal zone lymphoma (SMZL) constitutes less than 1% of all non-Hodgkin's lymphomas. Its incidence increases with age. It is found to be more common in caucasians. Splenic marginal zone lymphoma (SMZL) affects men and women equally. # Risk Factors There are no established risk factors for splenic marginal zone lymphoma. # Screening According to the the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for splenic marginal zone lymphoma # Natural History, Complications and Prognosis Splenic marginal zone lymphoma (SMZL) is a rare, slow growing B-cell lymphoma that is mostly asymptomatic at the time of diagnosis. It is commonly diagnosed at an old age. Patients typically have splenomegaly, lymphocytosis or cytopenias. Bone marrow is frequently involved but lymphadenopathy and liver involvement is rare.There are automimmune conditions that may develop in this conditions such autoimmune hemolytic anemia, idiopathic thrombocytopenic purpura, angioedema and von-willebrand disease. It may transform into diffuse large B-cell lymphoma. The prognosis is generally good. Several factors including lymphadenopathy, non-hematopoietic site involvement, histologic transformation affects the prognosis. Low Hemoglobin levels, high lactate dehydrogenase levels, low blood serum albumin levels, and genetic mutations such as mutations in NOTCH2, TP53, KLF2 are associated with poor prognosis among patients with splenic marginal zone lymphoma. # Diagnosis ## Diagnostic Study of Choice Histological examination of the spleen is considered as a gold standard for the diagnosis of splenic marginal zone lymphoma (SMZL). But as splenectomy is not as frequently performed as it was other diagnostic options are sought which includes histological analysis and immunohistochemistry of the bone marrow biopsy and peripheral blood. Cytogenetic analysis is also helpful in making the diagnosis. ## Staging According to the Lugano classification, there are four stages of splenic marginal zone lymphoma (SMZL) based on the number of nodes and extranodal involvement. ## History and Symptoms The most common symptoms of splenic marginal zone lymphoma (SMZL) include fever, weight loss, skin rash, night sweats, chest pain, abdominal pain, bone pain, and painless swelling in the neck, axilla, groin, thorax, and abdomen. ## Physical Examination Common physical examination findings of splenic marginal zone lymphoma (SMZL) include fever, rash, ulcer, splenomegaly, chest tenderness, abdomen tenderness, bone tenderness, peripheral lymphadenopathy, and central lymphadenopathy. ## Laboratory tests Laboratory tests for splenic marginal zone lymphoma (SMZL) include complete blood count (CBC), blood chemistry studies, immunohistochemistry, genetic testing, flow cytometry, FISH, PCR, and immunophenotyping. ## Biopsy Lymph node or extranodal tissue biopsy is diagnostic of splenic marginal zone lymphoma (SMZL). ## CT CT scan may be helpful in the diagnosis and estimating the extent of tumor spread in splenic marginal zone lymphoma (SMZL). ## MRI MRI may be helpful in the diagnosis of splenic marginal zone lymphoma (SMZL). ## Ultrasound Abdomen ultrasound may be helpful in the diagnosis of splenic marginal zone lymphoma (SMZL). Findings on ultrasound abdomen suggestive of splenic marginal zone lymphoma (SMZL) include splenomegaly and lymphadenopathy. ## Other Imaging Studies PET scan may be helpful in the diagnosis of splenic marginal zone lymphoma (SMZL). ## Other Diagnostic Studies Other diagnostic studies for splenic marginal zone lymphoma (SMZL) include laparoscopy and laparotomy. # Treatment ## Medical Therapy There is no standardized treatment of splenic marginal zone lymphoma (SMZL) The optimal therapy depends on the clinical presentation. Asymptomatic patients may only be observed routinely without any treatment as it is an indolent tumor. Symptomatic patients may treated with either surgery, immunotherapy, chemotherapy, immunochemotherapy or antiviral drugs. Both surgery and immunotherapy are equally effective but recently immunotherapy is considered as a better treatment option as there is no risk of complications that are associated with surgery. ## Surgery Splenectomy was considered to be the 1st line treatment option for splenic marginal zone lymphoma (SMZL) but recent studies have shown that rituximab is equally effective if not better treatment option in terms of overall survival. Splenectomy is still performed but mainly in patients with splenomegaly without lymphadenopathy having low surgical risk or in those who are refractory to rituximab therapy.

ZFPM2 Zinc finger protein ZFPM2, i.e. zinc finger protein, FOG family member 2, but also termed Friend of GATA2, Friend of GATA-2, FOG2, or FOG-2, is a protein that in humans is encoded by the ZFPM2 and in mice by the Zfpm2 gene. The zinc finger-containing protein encoded by this gene is a widely expressed member of the FOG family of regulators of transcription factors. The family consists of the ZFPM1 and ZFPM2 genes in humans and Zfpm1 and Zfpm2 genes in mice. Its members may act as coactivators and/or corepressors to modulate the activity of GATA transcription factors. That is, the ZFPM2 protein appears able to interact directly with and thereby either enhance or repress the ability of GATA transcription factors to stimulate the expression of their target genes; the direction of ZFPM2's actions depends on the contexts of the promoter sections of the various GATA target genes. The ZFPM2 protein interacts primarily with the GATA4 but also with GATA2, GATA5, and GATA6 transcription factors. ZFPM2 protein's interaction with GATA4 is notable for controlling the embryonic development of various tissues, particularly the heart, diaphragm, and gonads. Correspondingly, ZFPM2 mutations are responsible for certain forms of congenital heart defects, congenital diaphragmatic hernias , and ambiguous genitalia in mice as well as humans. # Gene The ZFPM2 gene is found in a wide range of animal species from flies to humans. The human gene is located on the long or "q" arm of chromosome 8 at position 23.1 (i.e. 8q23.1) and consists of 9 exons. The equivalent mouse gene, Zfpm2, is located on chromosome 15 and consists of 8 exons. Knockout of ZFPM2 is embryonic lethal in mice, with mice dying at embryonic day 12.5-15.5 due to congenital cardiac defects (thin heart ventricular muscle, common atrioventricular canal, and the tetralogy of Fallot malformation. ZFPM2 expression in mice is also required for normal development of the gonads, lung and diaphragm. # Protein Both the human and mouse ZFPM2 proteins consists of 1151 amino acids and are expressed in various tissues. The human protein is expressed at relatively high levels in the adult ovary and uterine endometrium while the mouse protein is expressed at relatively high levels in the central nervous system cerebellum and, during the early stages of its development, the heart. Human ZFPM2 contains 8 zinc finger structural motifs and interacts directly with various members of the GATA transcription factor family to modify their ability to stimulate the expression of their target genes. For example, it has been shown to bind directly with the N-terminal zinc finger of the GATA4 transcription factor to inhibit its ability to stimulate the expression of a target gene in an in vitro model system. The extreme N terminal end of the ZFPM2 protein contains two domains, one of which interacts directly with the Mi-2/NuRD complex (i.e. nucleosome remodeling and histone deacetylase complex or NuRD complex) and other of which binds CTBP1 or CTBP2 proteins. The NuRD complex and the CtBPs are classified as corepressors. that act to promote the ability of ZFPM2 to inhibit the ability of GATA proteins to stimulate the expression of their target genes. # Pathophysiology ZFPM2 regulates the expression of certain GATA target genes by up-regulating or down-regulating the ability of the GATA transcription factors, primarily GATA3, GATA4, GATA5, and GATA6, to stimulate the expression of their target genes. Interactions with the NuRD complex or a CTBP can cause ZFPM2 to inhibit the ability of GATA3-6 proteins to stimulate the expression of their target genes. # Clinical relevancy ## Congenital heart disease Mutations in the ZFPM2 gene are responsible for rare and sporadic cases of congenital heart disease. These include cases of Tetralogy of Fallot, truncus arteriosus, failure to from the pulmonary artery valve combined with ventricular septal defect, double outlet right ventricle, transposition of the great arteries, and interrupted aortic arch. Sporadic cases of Tetralogy of Fallot were also found in cases where the levels of Hypermethylation at CpG sites in the ZFPM2 gene promotor were greatly elevated; these cases were associated with decreases cardiac tissue levels of mRNA for ZFPM2. These cases likely reflect the role of ZFPM2 in promoting GATA4's function in the embryonic development of the heart. ## Congenital diaphragmatic hernia ZFPM2 heterozygous gene mutations are responsible for sporadic cases of congenital diaphragmatic hernias. This development disorder may be the underlying cause for the development of congenital lung dysplasia and pulmonary vascular disorder that leads to pulmonary hypertension. These defects are considered due to haploinsufficiency in ZFPM2 protein and consequential failure of GATA4 to promote normal lung development. ## Sex development Heterozygous mutations in the ZFPM2 gene are responsible for sporadic, very rare cases of a familial form of disorders of sex development, ambiguous genitalia. The disorder likely reflects haploinsufficiency of the ZFPM2 protein and consequential reduced regulation of GATA4 in promoting normal development of the gonads.

Tatuaje Tatuaje is a brand of hand-made premium cigar owned by Tatuaje Cigars, Inc.. It was created by Pete Johnson (owner of Tatuaje Cigars) in close consultation with José "Pepin" Garcia and is manufactured at the El Rey de los Habanos factory in Miami, Florida, and at Tabacalera Cubana S. A. (TACUBA) in Estelí, Nicaragua. # Background and History Tatuaje means "tattoo" in Spanish, and the name reflects Pete Johnson's tattoos. The brand was developed by Pete and Don Pepin, who worked in a very close collaboration to achieve the blend that Pete was seeking. Tatuaje was the first brand that Don Pepin made on his own. The first Tatuajes were released in 2003. In the October, 2004, issue of Cigar Aficionado (CA), the Tatuaje Cabinet Especiales was given a rating of 90. The brand continues to get high ratings. # Awards/Recognition/Ratings - The Tatuaje Cabinet Especiales was designated one of the 25 Best Cigars of 2004 by Cigar Aficionado magazine. - The Tatuaje Cabinet Taino was designated by Cigar Aficionado as no.4 in the 25 Best Cigars for 2005. - The Tatuaje Cabinet Noella was designated as no. 9 in the 25 Best Cigars for 2006. and was given a 92 rating at that time. - Leaf and Ale named the Tatuaje brand as the 2006 Cigar of the Year. - Tatuaje has consistently been given high ratings in Cigar Aficionado magazine as well as Cigar Insider Online. - Tatuaje J21 Reserva was praised in Maxim Magazine's August 2007 print issue. # Description The cigars can all be considered full-bodied cigars, but vary in strength. All are Nicaraguan Puros (constructed solely of tobaccos grown in Nicaragua). The brand consists of four ranges of regular production cigars along with several limited release vitolas (specific sizes) manufactured specifically for certain retailers. # Regular Production ## Tatuaje Cabinet There are six (6) vitolas in this range. Seven are listed below, although the Petit is technically not a Cabinet vitola, but is unique to itself. The band is a simple brown band with white lettering. The Cabinet range uses a Corojo 99 viso wrapper, although those chosen for the Especiales are lighter in color. The filler blends vary, resulting in a range of strength from the refined mellowness of the Especiales to the near-Cuban strength of the Cazadores. A bit of trivia: the first initials of the first six vitolas as given here spell out the name of one of Pete's dogs, Hunter. ## Tatuaje Reserva There are three (3) vitolas in this range. Again, the filler blends vary. The wrapper used is a Nicaraguan viso, except for the J21, which uses a ligero leaf. The cigars sport a second band, black with Reserva and the frontmark in gold lettering. ## Tatuaje RC There are but two vitolas in this range, both figurados. They are medium-bodied cigars which start out strong, then mellow gradually over the length of the cigar. The band is tri-colored, with red, white and blue stripes, and each cigar is foil wrapped from the head to the mid-section, similar to the old Cuban style of foil-wrapped figurados. The numbers in the vitola name is the length in millimeters. ## Tatuaje Cojonu The three vitolas in this range are full-bodied cigars. Beginning in August of 2006, the wrapper was changed to a ligero from a viso wrapper. In addition to the regular Tatuaje band, there is a second, gold band with the year of that vitola's introduction in black. The Gran Cojonu, however, is bandless. In addition, it has a shag (untrimmed) foot. The year in the model name refers to the year of introduction. Thus, the Cojonu 2003 was introduced in 2003. Plans are to introduce a new model every three years. A new model/vitola of the Cojonu will be introduced every three years. ## Series P This range is a medium-filler cigar (60% medium filler, 40% long-filler). Medium bodied, it is a Nicaraguan puro, and uses the same filler blend as the Havana VI, and is made at TACUBA in Estelí, Nicaragua. The wrapper is Nicaraguan Habano and the binder is, of course, also Nicaraguan. ## Nuevitas Jibaro The Nuevitas Jibaro is actually not part of the Tatuaje line and was created by Pete Johnson. Although Pepin Garcia is usually associated with Mr. Johnson's cigars, he was not involved in the creation or production of this small line. They were made by Pedro Martin's old Tropical Tobacco (since purchased by AGANORSA and now known as Tabacalera Tropical)in Estelí, Nicaragua. The design of the cigar was modeled after a custom-rolled Cuban Cohiba. It was a very strong blend. Mr. Johnson discontinued production of the cigar rather than have the production moved to another factory. The cigars were unbanded with an unfinished foot and the line was limited to two vitolas, both figurados, the No. 1 (5 x 54) and the No. 2 (6 x 52). # Special Productions - Bombazos (4" x 46) were produced for Fumare Cigar in Reno, Nevada. It is a strong, spicy blend. - El Cohete (4" x 50) was produced for Tower Cigars. It was packed in cabinets of 25, each numbered, dated and signed by Pete Johnson. There were only 50 such cabinets available. It was made in Pepin Garcia's Miami factory. - La Maravilla (5 5/8" x 46) was produced for Leaf and Ale. The wrapper is an aged viso wrapper, with the wrapper covering the foot of the cigar, similar to the Gran Cojonu. The cigars are packed in foil, which is part of a unique fermentation process that is used on the cigars: they are rolled, then wrapped in foil to seal in the flavors, and aged in that form, similar to how some Cuban cigars are aged wrapped in burlap. # Other Tatuaje Cigars - In November of 2006 a special production of Tatuaje Noellas Reservas was released to Tatuaje retailers. - The Thermonuclear, a Triple Ligero, was a 'fun experiment' not generally offered for sale due to its strength, as the name implies. # See Also - Photos and more information can be found at Vitolas.net - Moretti, Michael. Tatooed Cigars. Cigar Aficionado online, 11 August 2003. - Perelman, Richard B. Perelman's Pocket Cyclopedia of Cigars, 2006 edn. Los Angeles: Perelman, Pioneer & Co., (2005). p. 524-525. # Notes - ↑ Comment by Pete Johnson on Cigar Family forum - ↑ Cigar Aficionado Daily Cigar News, by Michael Moretti, 11 August 2003. - ↑ CA Cigar of the Week - ↑ Cabinet Taino rated 92, CA, December, 2005. - ↑ Cigar Aficionado, February, 2007, p. 66 - ↑ February, June, August, October, December, 2006 issues; January, August 2007 issues as well as numerous Cigar Insider issues. - ↑ Tatuaje page at vitolas.net - ↑ Series P information page at company website. - ↑ Tobacco Europe article, 01 Sep 2002. - ↑ Nicaragua: Growing by Leaps & Bounds, by E. Edward Hoyt III, SmokeShop Magazine, December, 2003. - ↑ Much of the information in this account was provided by Pete Johnson, in litt, April, 2007

Transoral carbon dioxide laser surgery for primary treatment of oropharyngeal malignancy # Recommendations Current evidence on the efficacy and safety of transoral carbon dioxide laser surgery for the primary treatment of oropharyngeal malignancy is adequate to support the use of this procedure with normal arrangements for clinical governance, consent and audit. This procedure should only be carried out by clinicians who have been trained in the use of transoral carbon dioxide laser surgery in the oropharynx. Patient selection for this procedure should be done by a multidisciplinary team in accordance with the NICE cancer service guidance on improving outcomes in head and neck cancers (CSGNH 2004). Clinicians should enter details of all patients undergoing transoral carbon dioxide laser surgery for the primary treatment of oropharyngeal malignancy onto the Data for Head and Neck Oncology (DAHNO) database.# Indications and current treatments Malignancies in the oropharynx (which includes the tonsils, the base of the tongue and the soft palate) are usually squamous cell carcinomas originating in the epithelial cell lining. The incidence of these malignancies has increased significantly in younger patients, probably because of the increased prevalence of human papillomavirus infection. Presenting features include a persistent sore throat, a lesion in the mouth or throat, white or red patches that may be swollen or bleeding, and pain in the ear. Patients tend to present with advanced or sometimes metastatic disease. Oropharyngeal malignancies can be treated by surgery (using open or minimally invasive approaches for tumour resection and reconstruction), radiotherapy, chemotherapy, or a combination of these methods. Surgical resection may include neck dissection to remove lymph nodes. When the malignancy is considered to be unresectable, palliative chemotherapy and radiotherapy can be used.# The procedure Transoral carbon dioxide laser surgery is a minimally invasive endoscopic approach for treating tumours in the oropharynx. It is usually performed under general anaesthesia, with the patient supine and tilted head-down. The tumours are visualised using a modified mouth gag and/or an endoscope. The carbon dioxide laser device is coupled to an operating microscope and the laser beam is used to excise the tumour completely, together with an adequate margin of tissue around it. Large tumours are removed in 2 or more pieces as a multiblock resection. Fibre-optic carbon dioxide lasers, flexible delivery systems and robots have been developed, all of which increase the range of angles of approach that can be used to achieve tumour resection. Laser resection of tumours is sometimes combined with either simultaneous or staged neck dissection if there is cervical lymphadenopathy or a suspicion of occult metastases. Adjuvant radiotherapy and/or chemotherapy is also offered to some patients, based on a number of factors such as T-stage, nodal status, extracapsular spread of tumour, margin status and histology.# Efficacy This section describes efficacy outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview. A retrospective comparative case series of 223 patients with T1 oropharyngeal carcinoma treated by transoral carbon dioxide laser surgery (TLS) with or without neck dissection (±ND) (n=53) or by electrocautery (n=170) reported that there was no significant difference in 5-year disease‑specific survival (89% for TLS±ND and 87% for electrocautery; p>0.05). A prospective case series of 204 patients (of whom 203 were analysed) with stage III or IV oropharyngeal cancers treated by TLS±ND alone (53 patients) or by TLS±ND and combined adjuvant treatment (150 patients: 117 radiotherapy alone, 33 chemoradiotherapy) reported that rates of 5-year overall survival, disease-specific survival and disease-free survival were 78%, 84% and 74% respectively across all groups. TLS combined with postoperative adjuvant radiotherapy (in 117/204 patients) reduced the risk of death by over 50% (hazard ratio 0.33 to 0.48) compared against the risk of death in the group who received TLS±ND alone (53/204 patients). The retrospective comparative case series of 223 patients reported a 5-year local control rate of 95% for TLS±ND and 91% for electrocautery (p>0.05; not significant). The retrospective case series of 69 patients reported that 4% (3/69) of patients had disease recurrence at the primary site at a mean follow-up of 44 months. The 5-year local regional control rate in patients in whom adjuvant therapy was not indicated was 82%. The 5-year local regional control rate in patients who declined adjuvant therapy was 74%. The specialist advisers listed key efficacy outcomes as local control, survival, margin control and local recurrence.# Safety This section describes safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview. Bleeding within the first 7 days after the procedure was reported in 10% (5/48) of patients in a retrospective case series of 48 patients with squamous cell carcinoma of the base of the tongue treated by transoral carbon dioxide laser surgery with or without neck dissection (TLS±ND) and adjuvant radiotherapy. The bleeding was from a vessel at the base of the tongue in 1 patient, at the lateral oropharyngeal wall in 1 patient, at the aryepiglottic fold in 1 patient, and from the wound cavity (no further details given) in 2 patients. All complications were managed by micropharyngoscopy with electrocoagulation. Public consultation also reported a single death due to severe haemorrhage. Severe dysphagia and recurrent aspiration were reported in 6% (3/48) of patients in the retrospective case series of 48 patients, as a result of extended tumour resection, including 'resection in adjacent sites and structures'. All 3 patients needed gastrostomy tubes. Airway loss (needing surgical cricothyroidotomy) was reported in 1 patient in the prospective case series of 204 patients; this occurred during reoperative resection of a tumour-positive margin. Tracheostomies (permanent or temporary) were needed in 11% (6/53) of patients in the TLS±ND group and 5% (9/170) of patients in the electrocautery group in the retrospective comparative case series of 223 patients (no significance test reported). Bilateral hypoglossal nerve paresis (due to 'stretch-related complications' of the endoscopic approach to the pharynx) was reported in 1 patient in the prospective case series of 204 patients. Postoperative 'velopharyngeal incompetence' (not severe enough to prevent oral intake or good speech) was also reported in 11 patients. Further details were not reported. The specialist advisers listed theoretical adverse events as subcutaneous emphysema, numbness of the tongue, damage to the oral cavity or teeth during access retraction, and inadequate surgical margins.# Further information For related NICE guidance see the NICE website # Information for patients NICE has produced information on this procedure for patients and carers (Information for the public). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance NICE interventional procedures guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. This guidance was developed using the NICE interventional procedures guidance process. We have produced a summary of this guidance for patients and carers. Information about the evidence the guidance is based on is also available. NICE produces guidance, standards and information on commissioning and providing high-quality healthcare, social care, and public health services. We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland. Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England. Your responsibility This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Copyright © National Institute for Health and Care Excellence 2014. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. ISBN: 978-1-4731-0498-3

Nitrogen triiodide Nitrogen triiodide, also called nitrogen iodide, is the chemical compound with the formula NI3. It is a sensitive contact explosive: small quantities explode with a gunpowder-like snap when touched even lightly, releasing a purple cloud of iodine vapor. NI3 has a complex structural chemistry that has required relatively heroic efforts to elucidate because of the instability of the derivatives. # Decomposition The decomposition of NI3 proceeds via the following reaction: # Structure of NI3 and its derivatives Nitrogen triiodide is a dark red compound, first characterized by X-ray crystallography in 1990, when it was prepared by an ammonia-free route. Boron nitride reacts with iodine fluoride in trichlorofluoromethane at -30 °C to produce pure NI3 in low yield. NI3 is pyramidal (C3v molecular symmetry), as are the other nitrogen trihalides as well as ammonia. The material that is usually called "nitrogen triiodide" is prepared by the reaction of iodine with ammonia. When this reaction is conducted at low temperatures in anhydrous ammonia, the initial product is NI3·(NH3)5, but this material loses some ammonia upon warming to give the 1:1 adduct NI3·(NH3). This adduct was first reported by Bernard Courtois in 1812, and its formula was finally determined in 1905 by Silberrad. Its solid state structure consists of chains of -NI2-I-NI2-I-NI2-I-... Ammonia molecules are situated between the chains. In the dark and kept cold and damp with ammonia, NI3·(NH3) is stable. The dry material is, however a contact explosive decomposing according to the following equation: The instability of NI3 itself or NI3NH3 can be attributed to the great stability of N2. # Nitrogen triiodide in classroom demonstrations and popular culture - Small amounts of nitrogen triiodide are sometimes synthesized as a demonstration to high school chemistry students or as an act of "chemical magic". To highlight the sensitivity of the compound, it is usually detonated by touching it with a feather but even the slightest air current or other movement can cause detonation. Nitrogen triiodide is also notable for being the only known explosive that detonates when exposed to alpha particles and nuclear fission products. - NI3·NH3 explosions leave orange-to-purple iodine stains that can be removed by sodium thiosulfate solution. - Nitrogen triiodide is the contact explosive used in Brainiac: Science Abuse, named "Peter Logan's Exploding Paste" on the show, although the details of its production are not mentioned for safety purposes. - In Robert Heinlein's novel Farnham's Freehold, the eponymous Hugh Farnham uses nitrogen triiodide (made from ammonia and iodine) as a blasting powder.

Dermatology Dermatology (from Greek δερμα, "skin") is a branch of medicine dealing with the skin and its appendages (hair, sweat glands, etc). # Scope of the field Dermatologists are physicians (Medical Doctors) specializing in the diagnosis and treatment of diseases and tumors of the skin and its appendages. There are medical and surgical sides to the specialty. Dermatologic surgeons practice skin cancer surgery (including Mohs' micrographic surgery), laser surgery, photodynamic therapy (PDT) and cosmetic procedures using botulinum toxin ('Botox'), soft tissue fillers, sclerotherapy and liposuction. Dermatopathologists interpret tissue under the microscope (histopathology). Pediatric dermatologists specialize in the diagnoses and treatment of skin disease in children. Immunodermatologists specialize in the diagnosis and management of skin diseases driven by an altered immune system including blistering (bullous) diseases like pemphigus. In addition, there is a wide range of congenital syndromes managed by dermatologists. # Subspecialties The skin is the largest organ of the body and the most visible. Although many skin diseases are isolated, some are manifestations of internal disease. Hence, a dermatologist is schooled in aspects of surgery, rheumatology (many rheumatic diseases can feature skin symptoms and signs), immunology, neurology (the "neurocuteaneous syndromes", such as neurofibromatosis and tuberous sclerosis), infectious diseases and endocrinology. The study of genetics is also becoming increasingly important. ## Venereology and phlebology Venereology, the subspecialty that diagnoses and treats sexually transmitted diseases, and phlebology, the specialty that deals with problems of the superficial venous system, are both part of a dermatologist's expertise. ## Cosmetic dermatology Cosmetic dermatology has long been an important part of the field, and dermatologists have been the primary innovators in this area. In the 1900's dermatologists employed dermabrasion to improve acne scarring and fat microtransfer was used to fill in cutaneous defects. More recently, dermatologists have been the driving force behind the development and safe and effective employment of lasers, new dermal filling agents (collagen and hyaluronic acid), botulinum toxin ("Botox"), nonabrative laser rejuvenation procedures, intense pulsed light systems, photodynamic therapy, and chemical peeling. ## Dermatologic surgery Dermatologic surgery (dermasurgery) is performed by all dermatologists. Surgery is an integral part of dermatology residency training; thus all dermatologists are well trained in cutaneous surgery. In North America specialized training through a 1 year dermatologic surgery fellowship is available upon completion of the dermatology residency, and usually focuses on training in Mohs' micrographic surgery. Most dermatologic surgeons who have a special interest in this field apply for fellowship status in the American Society for Dermatologic Surgery, a professional organization dedicated to supporting and educating these physicians. Techniques available to a dermatologic surgeon include lasers, traditional scalpel surgery, electrosurgery, cryosurgery, photodynamic therapy, liposuction, blepharoplasty (cosmetic eyelid surgery), minimally-invasive facelift surgery (e.g., the S-lift), and a variety of topical and injectable agents such as dermal fillers including fat transfer and hyaluronic acid. Some specially trained dermatologic surgeons perform Mohs' surgery, which can be an effective method for the treatment of recurrent, indistinct, or difficult skin cancers. # Diagnosis Any mole that is irregular in color or shape should be examined by a dermatologist to determine if it is a malignant melanoma, the most serious and life-threatening form of skin cancer. Following a visual examination and a dermatoscopic exam (an invaluable new instrument that illuminates a mole without reflected light), a dermatologist may biopsy a suspicious mole. If it is malignant, it will be excised in the dermatologist's office. ## Medical history The first step of any contact with a physician is the medical history. In order to classify a cutaneous eruption, the dermatologist will ask detailed questions on the duration and temporal pattern of skin problems, itching or pain, relation to food intake, sunlight, over-the-counter creams and clothing. When an underlying disease is suspected, an additional detailed history of related symptoms will be elicited (such as arthritis in a suspected case of lupus erythematosus). ## Physical examination Dermatology has the obvious benefit of having easy access to tissue for diagnosis. Physical examination is generally done under bright light and preferably involves the whole body. At this stage, the doctor may apply Wood's light, which may aid in diagnosing types of mycosis or demonstrate the extent of pigmented lesions, or use a dermatoscope which enlarges a suspected lesion and visualizes it without reflected light. The dermatoscope is helpful in differentiating a benign naevus from melanoma or a seborrheic keratosis from a mole. A morphological classification of dermatological lesions is important in the diagnosis of dermatological disorders. Dermatologic diagnosis is often dependent upon pattern recognition of lesions and symptoms. ## Microbiology Culture or Gram staining of suspected infectious lesions may identify a pathogen and help direct therapy. ## Biopsy If the diagnosis is uncertain or a cutaneous malignancy is suspected, the dermatologic surgeon may perform a small punch biopsy (using a local anesthetic) for examination under the microscope by the dermatologist who is a trained dermatopathologist. # Therapy The skin is obviously accessible to topical local therapy. Antibiotic creams can help eliminate infections, while inflammatory skin diseases (such as eczema and psoriasis) often respond to steroid creams or topical anthralin. Dermatologists are innovators of new immune enhancing treatments, like topical imiquimod for superficial cancers and injection immunotherapy for warts as discussed below. ## Topical medications Topical medications treat many dermatological diseases, but dermatologists also use oral medications. Antibiotics and immune suppressants or immune enhancing agents (injection immunotherapy or topical imiquimod) for dermatological diseases or tumors. Isotretinoin ("Accutane") is used for severe cystic acne vulgaris and often produces a lifetime remission of this disfiguring disease. Isotretinoin prescribing in the U.S. is now controlled by a cumbersome FDA governmental website called iPLEDGE. Various new modalities of treatment are in the foray; with the advent of laser technology things are quite promising. ## Photomedicine Photomedicine involves the use of ultraviolet light, often in combination with oral or topical agents, to treat skin disease (e.g., psoriasis or mycosis fungoides). ## Surgical therapies Surgical intervention by a dermatologic surgeon may be necessary, for example, to treat varicose veins or skin cancer. Varicose veins can be treated with sclerotherapy (injecting an agent that obliterates the vein) or the long-pulsed Nd:YAG laser. Skin cancers can be managed with excision (including Mohs cancer surgery), cryosurgery, x-ray, or with the recent topical immune enhancing agent imiquimod. (See above section on "Dermatologic Surgery" for more details.) ## Psychodermatology and hypnodermatology Psychodermatology and hypnodermatology involve using hypnosis in combination with other pseudo-psychological therapies to treat skin disorders. # Training programs ## Residency training program in North America A minimum of 12 years of college and post graduate training is required to become a dermatologist in the United States and Canada. This includes graduation from a 4-year college where they will take Pre-Medicine, then a 4-year medical school followed by a year of post graduate training in medicine, surgery or pediatrics (called an internship) after which a physician may apply for admission to graduate dermatology residency training. Dermatology residencies are the most competitive in terms of admission. Following the successful completion of formal residency training in dermatology (3 years) the physician is qualified to take certifying board examinations (written) by the American Board of Dermatology or the American Osteopathic College of Dermatology. Once board certified, dermatologists become Diplomates of the American Board of Dermatology or the American Osteopathic College of Dermatology AOCD. They are then eligible to apply for fellowship status in the American Academy of Dermatology. Some dermatologists undertake advanced subspecialty training in programs known as fellowships after completion of their residency training. These fellowships are either one or two years in duration. Fellowships in dermatology include pediatric dermatology, surgical dermatology including Mohs micrographic surgery, dermatopathology (pathology of skin diseases) and dermatological immunology. ## Training programme in Australia An Australian specialist dermatologist will have completed 4-6 years of medical school (depending on institution), one internship year and at least one year of general medical or surgical service in the public hospital system, prior to becoming eligible for specialist training in dermatology. The selection process is rigorous and transparent; candidates must pass science and pharmacology exams and engage in monitored and assessed practical training in all aspects of medical and surgical dermatology. At the completion of the 5 year training programme, trainees sit a national written examination held over two days. Successful candidates may then proceed to the practical viva examination, similarly held over 2 days. Successful candidates may then apply for Fellowship status with the Australasian College of Dermatologists. ## Training program in India To be a dermatologist in India, a minimum of 2 years (for diploma ) or 3 years (for MD) of training is required after graduation from medical school and internship. The period involves rigorous training in all aspects of general dermatology, cosmetic dermatology, dermatopathology, dermatosurgery, venereal diseases (including HIV) and leprosy. At the end of the training period the resident has to go through written tests and clinical exams. The postgraduate qualification awarded is DVD (Diploma in Venereology and Dermatology) and MD (dermatology, venereology and leprosy). Many specialists also go for certification by the national board (for the award of 'diplomate of national board'). The Indian Association of Dermatologists, Venereologists and Leprologists(IADVL)is one of the largest dermatolological associations in the world. # Research From the basic science of cutaneous genetics and immunology, to the practical application of new knowledge and technology in the diagnosis and management of skin disease (like psoriasis) and surgical treatment of skin cancer, dermatologists have been among the leaders in the field. The annual meeting of the American Academy of Dermatology is one of the keys for rapid dissemination of new knowledge to the practicing dermatologist and dermatologic surgeon. # Dermatological diseases - List of dermatological diseases # History The work De morbis cutaneis ("On the diseases of the skin" - 1572) by Geronimo Mercuriali from Forlì (Italy) is known as the first scientific tractation about Dermatology. Early photographic documentation of skin diseases was produced by Balmanno Squire, Dr. Alfred Hardy, Dr. A. de Montméja, Dr. Howard Franklin Damon, Dr. George Henry Fox and Dr. Oscar G. Mason in the latter 1800s. # Notes - ↑ Wu JJ, Tyring SK. ""...has been the most competitive of all specialties for at least the last 5-6 years." This is confirmed by data from the electronic residency application service (ERAS)". Retrieved 2007-06-23.CS1 maint: Uses authors parameter (link) .mw-parser-output cite.citation{font-style:inherit}.mw-parser-output q{quotes:"\"""\"""'""'"}.mw-parser-output code.cs1-code{color:inherit;background:inherit;border:inherit;padding:inherit}.mw-parser-output .cs1-lock-free a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-lock-limited a,.mw-parser-output .cs1-lock-registration a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-lock-subscription a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-subscription,.mw-parser-output .cs1-registration{color:#555}.mw-parser-output .cs1-subscription span,.mw-parser-output .cs1-registration span{border-bottom:1px dotted;cursor:help}.mw-parser-output .cs1-hidden-error{display:none;font-size:100%}.mw-parser-output .cs1-visible-error{display:none;font-size:100%}.mw-parser-output .cs1-subscription,.mw-parser-output .cs1-registration,.mw-parser-output .cs1-format{font-size:95%}.mw-parser-output .cs1-kern-left,.mw-parser-output .cs1-kern-wl-left{padding-left:0.2em}.mw-parser-output .cs1-kern-right,.mw-parser-output .cs1-kern-wl-right{padding-right:0.2em} - ↑ Wu JJ, Ramirez CC, Alonso CA et al. ""Dermatology continues to be the most competitive residency to enter..." Arch Dermatol. 2006;142:845-850". Retrieved 2007-06-25.CS1 maint: Uses authors parameter (link) CS1 maint: Explicit use of et al. (link) # Further reading - Dermatology Times - a newsmagazine

Romosozumab # Disclaimer WikiDoc MAKES NO GUARANTEE OF VALIDITY. WikiDoc is not a professional health care provider, nor is it a suitable replacement for a licensed healthcare provider. WikiDoc is intended to be an educational tool, not a tool for any form of healthcare delivery. The educational content on WikiDoc drug pages is based upon the FDA package insert, National Library of Medicine content and practice guidelines / consensus statements. WikiDoc does not promote the administration of any medication or device that is not consistent with its labeling. Please read our full disclaimer here. # Black Box Warning # Overview Romosozumab is a sclerostin inhibitor that is FDA approved for the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. There is a Black Box Warning for this drug as shown here. Common adverse reactions include arthralgia and headache. # Adult Indications and Dosage ## FDA-Labeled Indications and Dosage (Adult) Indication - Romosozumab is indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. Dosage - Two separate syringes (and two separate subcutaneous injections) are needed to administer the total dose of 210 mg of romosozumab. Inject two 105 mg/1.17 mL prefilled syringes, one after the other. ## Off-Label Use and Dosage (Adult) ### Guideline-Supported Use There is limited information regarding romosozumab Off-Label Guideline-Supported Use and Dosage (Adult) in the drug label. ### Non–Guideline-Supported Use There is limited information regarding romosozumab Off-Label Non-Guideline-Supported Use and Dosage (Adult) in the drug label. # Pediatric Indications and Dosage ## FDA-Labeled Indications and Dosage (Pediatric) Safety and effectiveness of romosozumab have not been established in pediatric patients. ## Off-Label Use and Dosage (Pediatric) ### Guideline-Supported Use There is limited information regarding romosozumab Off-Label Guideline-Supported Use and Dosage (Pediatric) in the drug label. ### Non–Guideline-Supported Use There is limited information regarding romosozumab Off-Label Non-Guideline-Supported Use and Dosage (Pediatric) in the drug label. # Contraindications Romosozumab is contraindicated in patients with: - Hypocalcemia. Pre-existing hypocalcemia must be corrected prior to initiating therapy with romosozumab. - A history of systemic hypersensitivity to romosozumab or to any component of the product formulation. Reactions have included angioedema, erythema multiforme, and urticaria. # Warnings - In a randomized controlled trial in postmenopausal women, there was a higher rate of major adverse cardiac events (MACE), a composite endpoint of cardiovascular death, nonfatal myocardial infarction and nonfatal stroke, in patients treated with romosozumab compared to those treated with alendronate. - Romosozumab should not be initiated in patients who have had a myocardial infarction or stroke within the preceding year. Consider whether the benefits outweigh the risks in patients with other cardiovascular risk factors. Monitor for signs and symptoms of myocardial infarction and stroke and instruct patients to seek prompt medical attention if symptoms occur. If a patient experiences a myocardial infarction or stroke during therapy, romosozumab should be discontinued. - Hypersensitivity reactions, including angioedema, erythema multiforme, dermatitis, rash, and urticaria have occurred in romosozumab-treated patients. If an anaphylactic or other clinically significant allergic reaction occurs, initiate appropriate therapy and discontinue further use of romosozumab. - Hypocalcemia has occurred in patients receiving romosozumab. Correct hypocalcemia prior to initiating romosozumab. - Monitor patients for signs and symptoms of hypocalcemia. Patients should be adequately supplemented with calcium and vitamin D while on romosozumab. - Patients with severe renal impairment (estimated glomerular filtration rate 15 to 29 mL/min/1.73 m2) or receiving dialysis are at greater risk of developing hypocalcemia. Monitor serum calcium and adequately supplement patients who have severe renal impairment or are receiving dialysis with calcium and vitamin D. Instruct patients with severe renal impairment, including those receiving dialysis, about the symptoms of hypocalcemia and the importance of maintaining calcium levels with adequate calcium and vitamin D supplementation. - Osteonecrosis of the jaw (ONJ), which can occur spontaneously, is generally associated with tooth extraction and/or local infection with delayed healing, and has been reported in patients receiving romosozumab. A routine oral examination should be performed by the prescriber prior to initiation of romosozumab treatment. Concomitant administration of drugs associated with ONJ (chemotherapy, bisphosphonates, denosumab, angiogenesis inhibitors, and corticosteroids) may increase the risk of developing ONJ. Other risk factors for ONJ include cancer, radiotherapy, poor oral hygiene, pre-existing dental disease or infection, anemia, and coagulopathy. - For patients requiring invasive dental procedures, clinical judgment of the treating physician and/or oral surgeon should guide the management plan of each patient based on benefit-risk assessment. Patients who are suspected of having or who develop ONJ while on romosozumab should receive care by a dentist or an oral surgeon. In these patients, dental surgery to treat ONJ may exacerbate the condition. Discontinuation of romosozumab should be considered based on benefit-risk assessment. - Atypical low-energy or low trauma fractures of the femoral shaft have been reported in patients receiving romosozumab. These fractures can occur anywhere in the femoral shaft from just below the lesser trochanter to above the supracondylar flare and are transverse or short oblique in orientation without evidence of comminution. Causality has not been established as these fractures also occur in osteoporotic patients who have not been treated. - Atypical femoral fractures most commonly occur with minimal or no trauma to the affected area. They may be bilateral and many patients report prodromal pain in the affected area, usually presenting as dull, aching thigh pain, weeks to months before a complete fracture occurs. - During romosozumab treatment, patients should be advised to report new or unusual thigh, hip, or groin pain. Any patient who presents with thigh or groin pain should be suspected of having an atypical fracture and should be evaluated to rule out an incomplete femur fracture. Patient presenting with an atypical femur fracture should also be assessed for symptoms and signs of fracture in the contralateral limb. Interruption of romosozumab therapy should be considered based on benefit-risk assessment. # Adverse Reactions ## Clinical Trials Experience - Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. - The safety of romosozumab for the treatment of postmenopausal osteoporosis was evaluated in a multicenter, randomized, double-blind, placebo-controlled study (Study 1, NCT01575834) of 7180 postmenopausal women aged 55 to 90 years (mean age of 71 years). A total of 3581 and 3576 women received at least one dose of romosozumab and placebo, respectively, administered once every month during the 12-month double-blind study period. Women received at least 500 mg calcium and 600 international units of vitamin D supplementation daily and 77% received a loading dose of 50,000 to 60,000 international units of vitamin D within one week of randomization (if serum 25-hydroxyvitamin D concentrations were 40 ng/mL or less). - The safety of romosozumab for the treatment of postmenopausal osteoporosis in patients at high risk of fracture was evaluated in a multicenter, randomized, double-blind, alendronate-controlled study (Study 2, NCT01631214) of 4093 postmenopausal women aged 55 to 90 years (mean age of 74 years). A total of 2040 and 2014 women received at least one dose of romosozumab and alendronate, respectively, during the 12-month double-blind study period. Women received at least 500 mg calcium and 600 international units vitamin D supplementation daily and 74% received a loading dose of 50,000 to 60,000 international units of vitamin D within one week of randomization (if serum 25-hydroxyvitamin D concentrations were 40 ng/mL or less). - In Study 1, during the 12-month double-blind treatment period, the incidence of all-cause mortality was 0.7% (24/3576) in the placebo group and 0.8% (29/3581) in the romosozumab group. The incidence of nonfatal serious adverse events was 8.3% in the placebo group and 9.1% in the romosozumab group. The percentage of patients who withdrew from the study due to adverse events was 1.1% in the placebo group and 1.1% in the romosozumab group. The most common adverse reactions reported with romosozumab (greater than or equal to 5% and at a higher incidence than placebo) were arthralgia and headache. The most common adverse reaction leading to discontinuation of romosozumab was arthralgia (6 subjects in the placebo group and 5 subjects in the romosozumab group). - In Study 2, during the 12-month double-blind treatment period, the incidence of all-cause mortality was 1.1% (22/2014) in the alendronate group and 1.5% (30/2040) in the romosozumab group. The incidence of nonfatal serious adverse events was 13.3% in the alendronate group and 11.9% in the romosozumab group. The percentage of patients who withdrew from the study due to adverse events was 1.2% in the alendronate group and 1.2% in the romosozumab group. The most common adverse reactions reported with romosozumab (greater than or equal to 5%) were arthralgia and headache. - Table 1 outlines the most common adverse reactions occurring in greater than or equal to 2% of romosozumab treated women in at least one study. - The adverse reactions described below are from the 12-month treatment periods of Study 1 (placebo-controlled) and Study 2 (alendronate-controllmed). Major Adverse Cardiac Events (MACE) - During the 12-month double-blind treatment period of the placebo-controlled trial (Study 1), myocardial infarction occurred in 9 women (0.3%) in the romosozumab group and 8 (0.2%) women in the placebo group; stroke occurred in 8 women (0.2%) in the romosozumab group and 10 (0.3%) women in the placebo group. These events occurred in patients with and without a history of myocardial infarction or stroke. Cardiovascular death occurred in 17 women (0.5%) in the romosozumab group and 15 (0.4%) women in the placebo group. The number of women with positively adjudicated MACE was 30 (0.8%) in the romosozumab group and 29 (0.8%) in the placebo group, yielding a hazard ratio of 1.03 (95% confidence interval ) for romosozumab compared to placebo. - During the 12-month double-blind treatment period of the active-controlled trial (Study 2), myocardial infarction occurred in 16 women (0.8%) in the romosozumab group and 5 (0.2%) women in the alendronate group; stroke occurred in 13 women (0.6%) in the romosozumab group and 7 (0.3%) women in the alendronate group. These events occurred in patients with and without a history of myocardial infarction or stroke. Cardiovascular death occurred in 17 women (0.8%) in the romosozumab group and 12 (0.6%) women in the alendronate group. The number of women with positively adjudicated MACE was 41 (2.0%) in the romosozumab group and 22 (1.1%) in the alendronate group, yielding a hazard ratio of 1.87 (95% confidence interval ) for romosozumab compared to alendronate. Hypersensitivity Reactions - Across both trials, hypersensitivity reactions were reported in 364 (6.5%) women in the romosozumab group and 365 (6.5%) women in the control group. Reported reactions included angioedema (3 women in the romosozumab group vs. 3 women in the control group), erythema multiforme (1 woman in the romosozumab group vs. no woman in the control group), dermatitis (32 women in the romosozumab group vs. 42 women in the control group), rash (60 women in the romosozumab group vs. 53 women in the control group), and urticaria (23 women in the romosozumab group vs. 27 women in the control group). Although angioedema, dermatitis and urticaria were not reported at a higher incidence with romosozumab than control, there were cases of angioedema, dermatitis and urticaria that were determined to be related to romosozumab use. Hypocalcemia - Across both trials, adverse events of hypocalcemia occurred in 2 romosozumab-treated women and in 1 woman in the control group. Decreases in albumin-adjusted serum calcium to below the lower limit of the reference range (8.3 mg/dL) were reported in 14 (0.2%) women in the romosozumab group and 10 (0.2%) women in the control group. No patient receiving romosozumab developed serum calcium less than 7.5 mg/dL. The nadir in albumin-adjusted serum calcium occurred by month 1 after romosozumab dosing in patients with normal renal function. Injection Site Reactions - Across both trials, injection site reactions occurred in 278 (4.9%) women in the romosozumab group and 157 (2.8%) women in the control group. The most common injection site reactions were pain (94 women in the romosozumab group; 70 in the control group) and erythema (80 women in the romosozumab group and 14 women in the control group). Injection site reactions resulted in discontinuation of treatment in 7 (0.1%) romosozumab-treated patients and 3 (< 0.1%) patients in the control group. Osteonecrosis of the Jaw - Across both trials, osteonecrosis of the jaw occurred in one patient during treatment with romosozumab. Atypical Subtrochanteric and Diaphysial Fractures - Across both trials, atypical femoral fracture occurred in one patient during treatment with romosozumab. ## Immunogenicity - As with all therapeutic proteins, there is potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors, including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies in the studies described below with the incidence of antibodies in other studies or to other romosozumab products may be misleading. - The immunogenicity of romosozumab was evaluated using an immunoassay for the detection of anti-romosozumab-aqqg antibodies. An in vitro biological assay was performed to detect neutralizing antibodies for those subjects whose sera tested positive for anti-romosozumab-aqqg antibodies. - Among 5914 postmenopausal women treated with romosozumab 210 mg monthly, 18.1% of subjects developed antibodies to romosozumab-aqqg. Of the subjects who developed antibodies to romosozumab-aqqg, 4.7% had antibodies that were classified as neutralizing. Development of antibodies to romosozumab-aqqg was associated with lower serum romosozumab-aqqg concentrations. Antibodies to romosozumab-aqqg were generally not associated with changes in the efficacy or safety of romosozumab. ## Postmarketing Experience There is limited information regarding Romosozumab Postmarketing Experience in the drug label. # Drug Interactions There is limited information regarding Romosozumab Drug Interactions in the drug label. # Use in Specific Populations ### Pregnancy Pregnancy Category (FDA): Risk Summary - Romosozumab is not indicated for use in women of reproductive potential. In animal reproduction studies, weekly administration of romosozumab-aqqg to pregnant rats during the period of organogenesis at exposures greater than 32 times the clinical exposure produced skeletal abnormalities in the offspring. Administration of romosozumab-aqqg to rats prior to mating and through to the end of lactation produced minimal to slight decreases in femoral bone mineral density and/or cortical circumferences in the offspring at 1.5 to 56 times the expected exposure in humans. Animal Data - Reproductive and developmental effects of romosozumab-aqqg were assessed in the rat in a preliminary and definitive embryo-fetal development study, a combined fertility and embryo-development study, and a pre- and postnatal development study. - Skeletal malformations including syndactyly and polydactyly occurred in 1 out of 75 litters across all rat reproductive toxicity studies, in the litter of a dam given weekly subcutaneous romosozumab-aqqg doses of 300 mg/kg (equivalent to at least 32 times the clinical exposure observed in humans following a monthly subcutaneous dose of 210 mg, based on area under the concentration-time curve comparison). - In the offspring of female rats given weekly romosozumab-aqqg doses from 6 weeks before cohabitation through mating and lactation, femoral periosteal and endocortical circumferences were slightly decreased at 10, 60, and 300 mg/kg (equivalent to 1.5, 19, and 56 times the clinical exposure following a monthly subcutaneous dose of 210 mg, based on AUC comparison). Cortical thickness was increased at 300 mg/kg (equivalent to 56 times expected clinical exposure). Femoral metaphysical bone mineral density was slightly decreased at 60 and 300 mg/kg (equivalent to 19 and 56 times expected clinical exposure). Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Romosozumab in women who are pregnant. ### Labor and Delivery There is no FDA guidance on use of Romosozumab during labor and delivery. ### Nursing Mothers - Romosozumab is not indicated for use in women of reproductive potential. In animal studies where pregnant rats were given weekly doses of romosozumab-aqqg from 6 weeks before cohabitation through mating and lactation at 10, 60, or 300 mg/kg (equivalent to 1.5, 19 or 56 times the clinical exposure following a monthly subcutaneous dose of 210 mg, based on AUC comparison), romosozumab-aqqg was dose-dependently present in the serum of offspring on postnatal day 21 at 0.01 to 2.4 times maternal exposure due to gestational and/or lactational exposure. ### Pediatric Use - Safety and effectiveness of romosozumab have not been established in pediatric patients. ### Geriatic Use - Of the 6544 postmenopausal women with osteoporosis in the clinical studies of romosozumab, 5234 (80%) were age 65 years and over and 2390 (37%) were age 75 years and over. No overall differences in safety or efficacy were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in response between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. ### Gender - Romosozumab is indicated for postmenopausal women. ### Race There is no FDA guidance on the use of Romosozumab with respect to specific racial populations. ### Renal Impairment - No dose adjustment is required in patients with renal impairment. - Patients with severe renal impairment (estimated glomerular filtration rate 15 to 29 mL/min/1.73 m2 by MDRD equation) or receiving dialysis are at greater risk of developing hypocalcemia. Monitor calcium concentrations and adequately supplement calcium and vitamin D in patients who have severe renal impairment or are receiving dialysis. ### Hepatic Impairment There is no FDA guidance on the use of Romosozumab in patients with hepatic impairment. ### Females of Reproductive Potential and Males There is no FDA guidance on the use of Romosozumab in women of reproductive potentials and males. ### Immunocompromised Patients There is no FDA guidance one the use of Romosozumab in patients who are immunocompromised. # Administration and Monitoring ### Administration - Two separate syringes (and two separate subcutaneous injections) are needed to administer the total dose of 210 mg of romosozumab. Inject two 105 mg/1.17 mL prefilled syringes, one after the other. - Romosozumab should be administered by a healthcare provider. - The recommended dose of romosozumab is 210 mg administered subcutaneously in the abdomen, thigh or upper arm. Administer romosozumab once every month. - The treatment duration for romosozumab is 12 monthly doses. - Patients should be adequately supplemented with calcium and vitamin D during treatment with romosozumab. - If the romosozumab dose is missed, administer as soon as it can be rescheduled. Thereafter, romosozumab can be scheduled every month from the date of the last dose. Step 1. Prior to Administration: - Remove two syringes from the carton. - Visually inspect romosozumab for particles and discoloration prior to administration. Romosozumab is a clear to opalescent, colorless to light yellow solution. Do not use if the solution is cloudy or discolored or contains particles. - Do not use the syringe if: any part appears cracked or broken the gray needle cap is missing or not securely attached the expiration date printed on the label has passed - any part appears cracked or broken - the gray needle cap is missing or not securely attached - the expiration date printed on the label has passed - Always hold the prefilled syringe by the syringe barrel to remove the syringe from the tray. See Figure A. Do not grasp the plunger rod. Do not grasp the gray needle cap. Do not remove the gray needle cap until you are ready to inject. - Do not grasp the plunger rod. - Do not grasp the gray needle cap. - Do not remove the gray needle cap until you are ready to inject. - Allow romosozumab to sit at room temperature for at least 30 minutes before injecting. Do not warm in any other way. Step 2: Select the Injection Site and Prepare the Syringe - Prepare and clean two injection sites, one for each of the two injections. See Figure B. - The recommended subcutaneous injection sites include: The thigh Abdomen, except for a two-inch area right around the navel Outer area of upper arm - The thigh - Abdomen, except for a two-inch area right around the navel - Outer area of upper arm - Clean the injection sites with alcohol wipes. Let the skin dry. Choose a different site each time you give an injection. If you want to use the same injection site, make sure it is not the same spot on the injection site you used for a previous injection. Do not inject into areas where the skin is tender, bruised, red, or hard. Avoid injecting into areas with scars or stretch marks. - Choose a different site each time you give an injection. If you want to use the same injection site, make sure it is not the same spot on the injection site you used for a previous injection. - Do not inject into areas where the skin is tender, bruised, red, or hard. Avoid injecting into areas with scars or stretch marks. - Choose the first syringe. Pull the gray needle cap straight off and away from your body when you are ready to inject. See Figure C. - Do not put the gray needle cap back onto the syringe. Step 3: Inject romosozumab - Insert needle and inject all the liquid subcutaneously. Do not administer into muscle or blood vessel. See Figure D. - When done, gently lift the syringe off of the skin. Step 4: Syringe and Needle Cap Disposal - Immediately dispose of the syringe and needle cap in the nearest sharps container. Important: Repeat all steps with the second syringe to inject the full dose. ### Monitoring - Monitor for signs and symptoms of myocardial infarction and stroke and instruct patients to seek prompt medical attention if symptoms occur. - Monitor patients for signs and symptoms of hypocalcemia. Patients should be adequately supplemented with calcium and vitamin D while on romosozumab. - Monitor calcium concentrations and adequately supplement calcium and vitamin D in patients who have severe renal impairment or are receiving dialysis. # IV Compatibility There is limited information regarding the compatibility of Romosozumab and IV administrations. # Overdosage There is limited information regarding Romosozumab overdosage. If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately. # Pharmacology ## Mechanism of Action - Romosozumab inhibits the action of sclerostin, a regulatory factor in bone metabolism. Romosozumab increases bone formation and, to a lesser extent, decreases bone resorption. Animal studies showed that romosozumab-aqqg stimulates new bone formation on trabecular and cortical bone surfaces by stimulating osteoblastic activity resulting in increases in trabecular and cortical bone mass and improvements in bone structure and strength. ## Structure There is limited information regarding Romosozumab Structure in the drug label. ## Pharmacodynamics - In postmenopausal women with osteoporosis, romosozumab increased the bone formation marker procollagen type 1 N-telopeptide (P1NP) with a peak increase from baseline of approximately 145% compared to placebo 2 weeks after initiating treatment, followed by a return to concentrations seen with placebo at month 9 and a decline from baseline to approximately 15% below the concentration change seen with placebo at month 12. - Romosozumab decreased the bone resorption marker type 1 collagen C-telopeptide (CTX) with a maximal reduction from baseline of approximately 55% compared to placebo 2 weeks after initiating treatment. CTX remained below concentrations seen with placebo and was approximately 25% below the concentration change seen with placebo at month 12. - After discontinuation of romosozumab, P1NP levels returned to baseline within 12 months; CTX increased above baseline levels within 3 months and returned toward baseline levels by month 12. ## Pharmacokinetics - Administration of a single dose of 210 mg romosozumab in healthy volunteers resulted in a mean (standard deviation ) maximum romosozumab-aqqg serum concentration (Cmax) of 22.2 (5.8) mcg/mL and a mean (SD) AUC of 389 (127) mcg*day/mL. Steady-state concentrations were achieved by month 3 following the monthly administration of 210 mg to postmenopausal women. The mean trough serum romosozumab-aqqg concentrations at months 3, 6, 9, and 12 ranged from 8 to 13 mcg/mL. - Romosozumab-aqqg exhibited nonlinear pharmacokinetics with exposure increasing greater than dose proportionally (e.g., 550-fold increase in mean AUCinf for the 100-fold increase in subcutaneous doses ranging from 0.1 to 10 mg/kg [0.03 to 3.3 times the approved recommended dosage for a 70 kg woman). Absorption - The median time to maximum romosozumab-aqqg concentration (Tmax) is 5 days (range: 2 to 7 days). Distribution - The estimated volume of distribution at steady-state is approximately 3.92 L. Elimination - Romosozumab-aqqg exhibited nonlinear pharmacokinetics with the clearance of romosozumab-aqqg decreasing as the dose increased. The estimated mean systemic clearance (CL/F) of romosozumab-aqqg was 0.38 mL/hr/kg, following a single subcutaneous administration of 3 mg/kg (the approved recommended dosage for a 70 kg woman). The mean effective t1/2 was 12.8 days after 3 doses of 3 mg/kg (the approved recommended dosage for a 70 kg woman) every 4 weeks. Metabolism - The metabolic pathway of romosozumab-aqqg has not been characterized. As a humanized IgG2 monoclonal antibody, romosozumab-aqqg is expected to be degraded into small peptides and amino acids via catabolic pathways in a manner similar to endogenous IgG. Anti-Product Antibody Formation Affecting Pharmacokinetics - Development of anti-romosozumab-aqqg antibodies was associated with reduced serum romosozumab-aqqg concentrations. The presence of anti-romosozumab-aqqg antibodies led to decreased mean romosozumab-aqqg concentrations up to 22%. The presence of neutralizing antibodies led to decreased mean romosozumab-aqqg concentrations up to 63%. Specific Populations - No clinically significant differences in the pharmacokinetics of romosozumab-aqqg were observed based on age (20-89 years), sex, race, disease state (low bone mass or osteoporosis), prior exposure to alendronate, or renal impairment including end-stage renal disease (ESRD) requiring dialysis. The effect of ESRD not requiring dialysis on the pharmacokinetics of romosozumab-aqqg is unknown. Body Weight - The exposure of romosozumab-aqqg decreases with increasing body weight. ## Nonclinical Toxicology Carcinogenicity - In a rat carcinogenicity study, once-weekly romosozumab-aqqg doses of 3, 10 or 50 mg/kg were administered by subcutaneous injection to Sprague-Dawley rats from 8 weeks up to 98 weeks of age, resulting in systemic exposures that were up to 19 times the systemic exposure observed in humans following a monthly subcutaneous dose of 210 mg romosozumab (based on AUC comparison). Romosozumab-aqqg caused a dose-dependent increase in bone mass with trabecular and cortical bone thickening at all doses. There were no effects of romosozumab-aqqg on mortality and romosozumab-aqqg did not cause significant increases in tumor incidence in male or female rats. Mutagenicity - Mutagenesis has not been evaluated, as monoclonal antibodies are not expected to alter DNA or chromosomes. Impairment of Fertility - No effects on fertility were observed in male and female rats given subcutaneous romosozumab-aqqg doses up to 300 mg/kg (up to 56 times the systemic exposure observed in humans following a monthly subcutaneous dose of 210 mg romosozumab, based on AUC comparison). No effects were noted in reproductive organs in rats and cynomolgus monkeys dosed subcutaneously for 6 months with weekly doses up to 100 mg/kg (exposures up to 38 and 93 times, respectively, the systemic exposure observed in humans administered monthly subcutaneous doses of 210 mg based on AUC comparison). - No adverse effects were noted in rats and monkeys after 26 once-weekly subcutaneous romosozumab-aqqg doses up to 100 mg/kg, equivalent to systemic exposures of 38 and 93 times, respectively, the systemic exposure observed in humans following a monthly subcutaneous dose of 210 mg romosozumab (based on AUC comparison). - Bone safety studies of up to 12-month duration were conducted in ovariectomized rats and monkeys with once-weekly romosozumab-aqqg doses yielding exposures ranging from 1 to 22 times the systemic exposure in humans given monthly doses of 210 mg, based on AUC comparison. Romosozumab-aqqg increased bone mass and improved cancellous bone microarchitecture and cortical bone geometry by increasing bone formation on periosteal, endocortical, and trabecular surfaces, and decreasing bone resorption on trabecular and endocortical surfaces. The increases in bone mass were significantly correlated with increases in bone strength. In rats and monkeys, bone quality was maintained at all skeletal sites at doses ranging from 1 to 22 times human exposure, and slightly improved in vertebrae at 19 to 22 times human exposure. There was no evidence of mineralization defects, osteoid accumulation, or woven bone formation. # Clinical Studies Study 1 (NCT01575834) was a randomized, double-blind, placebo-controlled study of postmenopausal women aged 55 to 90 years (mean age of 71 years) with bone mineral density (BMD) T-score less than or equal to −2.5 at the total hip or femoral neck. Women were randomized to receive subcutaneous injections of either romosozumab (N = 3589) or placebo (N = 3591) for 12 months. At baseline, 18% of women had a vertebral fracture. After the 12-month treatment period, women in both arms transitioned to open-label anti-resorptive therapy (denosumab) for 12 months while remaining blinded to their initial treatment. Women received 500 to 1000 mg calcium and 600 to 800 international units vitamin D supplementation daily. The coprimary efficacy endpoints were new vertebral fracture at month 12 and month 24. Effect on Fractures - Romosozumab significantly reduced the incidence of new vertebral fractures through month 12 compared to placebo. In addition, the significant reduction in fracture risk persisted through the second year in women who received romosozumab during the first year and transitioned to denosumab compared to those who transitioned from placebo to denosumab (see Table 2). - Romosozumab significantly reduced the incidence of clinical fracture (a composite endpoint of symptomatic vertebral fracture and nonvertebral fracture) at 12 months. However, 88% of these clinical fractures were nonvertebral fractures and the incidence of nonvertebral fractures was not statistically significantly different when comparing romosozumab-treated women to placebo-treated women at month 12 or month 24. Effect on BMD - Romosozumab significantly increased BMD at the lumbar spine, total hip, and femoral neck compared with placebo at month 12. The treatment differences in BMD were 12.7% at the lumbar spine, 5.8% at the total hip, and 5.2% at the femoral neck. - Following the transition from romosozumab to denosumab at month 12, BMD continued to increase through month 24. In patients who transitioned from placebo to denosumab, BMD also increased with denosumab use. The differences in BMD achieved at month 12 between romosozumab and placebo patients were overall maintained at month 24, when comparing patients who transitioned from romosozumab to denosumab to those who transitioned from placebo to denosumab. There was no evidence of differences in effects on BMD at the lumbar spine or total hip across subgroups defined by baseline age, baseline BMD, or geographic region. - After romosozumab discontinuation, BMD returns to approximately baseline levels within 12 months in the absence of follow-on antiresorptive therapy. Bone Histology and Histomorphometry - A total of 154 transiliac crest bone biopsy specimens were obtained from 139 postmenopausal women with osteoporosis at month 2, month 12, and/or month 24. All of these biopsies were adequate for qualitative histology and 138 (90%) were adequate for full quantitative histomorphometry assessment. Qualitative histology assessments from women treated with romosozumab showed normal bone architecture and quality at all time points. There was no evidence of woven bone, mineralization defects, or marrow fibrosis. - Histomorphometry assessments on biopsies at months 2 and 12 compared the effect of romosozumab with placebo (15 specimens at month 2 and 39 specimens at month 12 in the romosozumab group, 14 specimens at month 2 and 31 specimens at month 12 in the placebo group). At month 2 in women treated with romosozumab, histomorphometric indices of bone formation at trabecular and endocortical surfaces were increased. These effects on bone formation were accompanied by a decrease in indices of bone resorption. At month 12, both bone formation and resorption indices were decreased with romosozumab, while bone volume, and trabecular and cortical thickness were increased. Study 2 (NCT01631214) was a randomized, double-blind, alendronate-controlled study of postmenopausal women aged 55 to 90 years (mean age of 74 years) with BMD T-score less than or equal to −2.5 at the total hip or femoral neck and either one moderate or severe vertebral fracture or two mild vertebral fractures, or BMD T-score less than or equal to -2.0 at the total hip or femoral neck and either two moderate or severe vertebral fractures or a history of a proximal femur fracture. Women were randomized (1:1) to receive either monthly subcutaneous injections of romosozumab (N = 2046) or oral alendronate 70 mg weekly (N = 2047) for 12 months, with 500 to 1000 mg calcium and 600 to 800 international units vitamin D supplementation daily. After the 12-month treatment period, women in both arms transitioned to open-label alendronate 70 mg weekly while remaining blinded to their initial treatment. - This was an event driven trial. The coprimary efficacy endpoints were the incidence of morphometric vertebral fracture at 24 months and time to the first clinical fracture through the primary analysis period, which ended when at least 330 subjects had a clinical fracture and all subjects had completed the 24-month visit. Clinical fracture was a composite endpoint of nonvertebral fracture and symptomatic vertebral fracture. Effect on Fractures - Romosozumab significantly reduced the incidence of new vertebral fracture at 24 months (see Table 3). - Romosozumab significantly reduced the risk of clinical fracture through the end of the primary analysis period (see Table 4). This was an event-driven trial and the duration of follow-up varied across subjects. The median duration of subject follow-up for the primary analysis period was 33 months. Subjects with nonvertebral fracture comprised 83% of the subjects with clinical fracture during the primary analysis period. - Romosozumab followed by alendronate also significantly reduced the risk of nonvertebral fracture through the primary analysis period (with a median follow-up of 33 months), with a hazard ratio of 0.81 (95% CI: 0.66, 0.99; p = 0.04) compared to alendronate alone. Effect on Bone Mineral Density (BMD) - Romosozumab significantly increased BMD at the lumbar spine, total hip, and femoral neck compared with alendronate at month 12. The treatment differences in BMD were 8.7% at the lumbar spine, 3.3% at the total hip, and 3.2% at the femoral neck. - Twelve months of treatment with romosozumab followed by 12 months of treatment with alendronate significantly increased BMD compared with alendronate alone. The BMD increase with romosozumab over alendronate observed at month 12 was maintained at month 24. The treatment differences in BMD at month 24 were 8.1% at the lumbar spine, 3.8% at the total hip, and 3.8% at the femoral neck. - There was no evidence of differences in effects on BMD at the lumbar spine or total hip across subgroups defined by baseline age, baseline BMD, or geographic region. # How Supplied - Romosozumab (romosozumab-aqqg) injection is a clear to opalescent, colorless to light yellow solution for subcutaneous injection supplied in a single-use prefilled syringe. - Each single-use prefilled syringe contains 105 mg of romosozumab in a deliverable volume of 1.17 mL. To deliver a full dose, inject two 105 mg/1.17 mL romosozumab prefilled syringes, one after the other for a total dose of 210 mg. ## Storage - Refrigerate romosozumab at 2°C to 8°C (36°F to 46°F) in the original carton to protect from light. Do not freeze. Do not shake. - If removed from the refrigerator, romosozumab can be kept at room temperature up to 25°C (77°F) in the original carton and must be used within 30 days. If not used within 30 days, discard romosozumab. - Do not expose romosozumab to temperatures above 25°C (77°F). # Images ## Drug Images ## Package and Label Display Panel # Patient Counseling Information - Advise the patient to read the FDA-approved patient labeling (MEDICATION GUIDE). Major Adverse Cardiac Events - Advise patients to seek immediate medical attention if they experience signs or symptoms of a myocardial infarction or stroke. Hypersensitivity Reactions - Advise patients to seek immediate medical attention if they experience signs or symptoms of a hypersensitivity reaction including angioedema, erythema multiforme, dermatitis, rash, and urticaria. Calcium and Vitamin D Supplements to Prevent Hypocalcemia - Advise patients to take calcium and vitamin D supplements daily to reduce the risk of hypocalcemia. Advise patients to seek immediate medical attention for symptoms of hypocalcemia. Osteonecrosis of the Jaw - Advise patients to practice good oral hygiene during treatment with romosozumab and tell their dentist that they are receiving romosozumab before having dental work. Atypical Femoral Fracture - Advise patients to report signs and symptoms that could be consistent with impending atypical femoral fracture including new or unusual thigh, hip, or groin pain. ## Medication Guide # Precautions with Alcohol Alcohol-Romosozumab interaction has not been established. Talk to your doctor regarding the effects of taking alcohol with this medication. # Brand Names Evenity # Look-Alike Drug Names There is limited information regarding Romosozumab Look-Alike Drug Names in the drug label. # Drug Shortage Status # Price

ISCU Iron-sulfur cluster assembly enzyme ISCU, mitochondrial is a protein that in humans is encoded by the ISCU gene. It encodes an iron-sulfur (Fe-S) cluster scaffold protein involved in and cluster synthesis and maturation. A deficiency of ISCU is associated with a mitochondrial myopathy with lifelong exercise intolerance where only minor exertion causes tachycardia, shortness of breath, muscle weakness and myalgia. # Structure ISCU is located on the q arm of chromosome 12 in position 23.3 and has 8 exons. ISCU, the protein encoded by this gene, is a member of the NifU family. It is an iron-sulfur transferase that contains binding sites for and clusters. ISCU contains a transit peptide, 4 beta strands, 4 alpha helixes, and 4 turns. Alternative splicing results in transcript variants encoding different protein isoforms that localize either to the cytosol or to the mitochondrion. A pseudogene of this gene is present on chromosome 1. # Function ISCU encodes a component of the iron-sulfur (Fe-S) cluster scaffold responsible for the synthesis and maturation of and clusters. Fe-S clusters are cofactors that play a role in the function of a diverse set of enzymes, including those that regulate metabolism, iron homeostasis, and oxidative stress response. In one process, the cluster transiently assembles on ISCU and is then transferred to GLRX5 in a cysteine desulfurase complex NFS1-LYRM4/ISD11 dependent process. ISCU has two isoforms, isoform 1, which is found in the mitochondrion and isoform 2, which is found in the nucleus and cytoplasm. # Clinical significance ISCU mutations have been found in patients with hereditary mitochondrial myopathy with exercise intolerance and lactic acidosis. This disease is a result of a deficiency of ISCU that corresponds to the deficiency of mitochondrial iron-sulfur proteins and impaired muscle oxidative metabolism. Characteristics of mitochondrial myopathy with deficiency of ISCU may include lifelong exercise intolerance in which exertion can cause tachycardia, dyspnoea, cardiac palpitations, shortness of breath, fatigue, pain of active muscles, rhabdomyolysis, myoglobinuria, elevated lactate and pyruvate, decreased oxygen utilization, large calves, and possibly weakness. ## Genetics This disorder has been associated with several different mutations and is inherited in an autosomal recessive manner. It was originally believed to affect only those of northern Swedish ancestry, however the disease has been found in those of Norwegian and Finnish decent as well. The carrier rate in northern Sweden has been estimated at 1:188. ISCU deficiency has been linked to pathogenic variants including intronic variants c.418+382G>C, g.7044G>C, and IVS5+382 G>C as well as a c.149G>A missense mutation in exon 3. The intronic mutations have been suggested to activate a cryptic splice site, resulting in the production of a splice variant that encodes a putatively non-functional protein. # Interactions ISCU has been shown to have 235 binary protein-protein interactions including 79 co-complex interactions. ISCU appears to interact with ISCS, NUP62, SDHB, HPRT1, CCDC172, GOLGA2, IKZF1, KRT40, AGTRAP, NECAB2, FAM9B, BANP, LNX1, MID2, GOLGA6L9, ccdc136, KRT34, SPERT, PICK1, YWHAB, SFN, mbl, E7, dnaX, hscB, MAPk-Ak2, hale, and cv-c.

Renal replacement therapy for acute renal failure in children: European Guidelines Acute renal failure (ARF) is uncommon in childhood and there is little consensus on the appropriate treatment modality when renal replacement therapy is required. Members of the European Pediatric Peritoneal Dialysis Working Group have produced the following guidelines in collaboration with nursing staff. Good practice requires early discussion of patients with ARF with pediatric nephrology staff and transfer for investigation and management in those with rapidly deteriorating renal function. Patients with ARF as part of multiorgan failure will be cared for in pediatric intensive care units where there should be access to pediatric nephrology support and advice. The choice of dialysis therapy will therefore depend upon the clinical circumstances, location of the patient, and expertise available. Peritoneal dialysis has generally been the preferred therapy for isolated failure of the kidney and is universally available. Intermittent hemodialysis is frequently used in renal units where nursing expertise is available and hemofiltration is increasingly employed in the intensive care situation. Practical guidelines for and the complications of each therapy are discussed. # Introduction Acute renal failure (ARF) is uncommon in childhood, but its incidence may be increasing and modalities of treatment changing with an increasing number of children being treated in the intensive care unit (ICU) with multiorgan failure. Traditionally children with ARF with renal involvement were only treated with peritoneal dialysis, but extracorporeal techniques are being increasingly used in ICUs. Members of the European Pediatric Dialysis Working Group reviewed all modalities of renal replacement therapy for ARF in children and developed the following guidelines in collaboration with nursing staff during three meetings and extensive e-mail discussion. There are no randomized trials of renal replacement treatment in children with ARF. The guidelines are based upon published reports and consensus opinion to emphasize good practice. ARF is recognized when renal excretory function declines rapidly. Rising values of plasma urea and creatinine are usually accompanied by oliguria (<1 ml/ kg per hour), but occasionally patients may be polyuric. The cause of ARF may be pre-renal, intrinsic, or postrenal (obstructive) problems, and causes differ between neonates and older children [bib_ref] Acute renal failure, Fitzpatrick [/bib_ref] [bib_ref] Choice of dialysis modality for management of pediatric acute renal failure, Flynn [/bib_ref]. The incidence of ARF in children is hard to define, as often renal insufficiency in the newborn and on ICUs is conservatively managed by ICU staff. Outside the neonatal period, ARF is an uncommon condition accounting for 8 referrals per million population per year to one regional pediatric nephrology unit in the United Kingdom [bib_ref] A review of acute renal failure in children: incidence, etiology and outcome, Moghal [/bib_ref]. ARF may occur as isolated failure of the kidneys alone, with other organ systems functioning normally, or in association with multiple organ failure. The mortality of the latter group is considerably higher, especially with the growth in pediatric intensive care. For example, the mortality in neonates and infants is 51% after cardiac surgery for congenital heart defects [bib_ref] A review of acute renal failure in children: incidence, etiology and outcome, Moghal [/bib_ref] , but only 3%-6% for children with intrinsic renal disease such as hemolytic uremic syndrome (HUS) in developed countries [bib_ref] The pathogenesis and treatment of hemolytic uraemic syndrome, Kaplan [/bib_ref] [bib_ref] Pediatric acute renal failure: outcome by modality and disease, Bunchman [/bib_ref]. The case mix in different units treating ARF, and hence mortality and morbidity rates, will therefore vary according to local clinical activity and resources [bib_ref] Prognosis of acute renal failure in children: a multivariate analysis, Arora [/bib_ref] [bib_ref] Causes, management approaches, and outcome of acute renal failure in children, Flynn [/bib_ref]. Many pediatric renal units will be close to pediatric ICUs (PICUs) in hospitals that may offer cardiac surgery, liver transplantation, and specialist treatment for metabolic disorders, oncology patients, etc. [bib_ref] Pediatric acute renal failure: outcome by modality and disease, Bunchman [/bib_ref]. Other renal units may be in hospitals that do not have a PICU on site and conversely there may be hospitals offering pediatric intensive care with no specialist pediatric nephrology service. ## Recommendations All children with ARF require discussion with a pediatric nephrologist. Early transfer for investigation and management is essential in those with rapidly deteriorating renal function or in those with hemodynamic or biochemical disturbances (good practice). All children with ARF as part of multi-organ failure require transfer to a designated regional pediatric ICU where there should be access to pediatric nephrology advice and support (good practice). ## Rationale Since there are few comprehensive regional pediatric nephrology centers the distances that families may have to travel can be considerable. Children with acute renal impairment may be managed in local hospitals, but it is essential that early referral is made, especially if children have evidence of rapidly deteriorating renal function and require an urgent histological diagnosis to determine if immunosuppressive therapy or other treatment is required. Indications for referral include oligoanuria, especially if associated with fluid overload, hypertension, hyperkalemia, hyponatremia, acidosis, or the need for blood transfusion. Dialysis is often accompanied by early nutritional support and pediatric nephrology units should be equipped to provide the necessary medical and nursing expertise, combined with dietetic and psychosocial support. The latter support is also important if the child is managed conservatively. Neonates and premature infants with ARF require transfer to a tertiary neonatal unit with pediatric nephrology team expertise. Patients with ARF and multi-organ failure require prompt transfer to a designated regional PICU. The choice of dialysis therapy for ARF depends upon the clinical circumstances, patient location, and expertise available. Peritoneal dialysis (PD) has generally been considered the preferred therapy if there is isolated failure of the kidneys, such as HUS. It is regarded as a simpler technique that is universally available. However, hemofiltration (HF) and hemodiafiltration (HDF) are increasing in popularity in PICUs where the facilities to perform hemodialysis (HD) may not be available. HD may be the preferred mode of treatment in more-stable patients with adequate vascular access treated on renal units where specialist nurses are available. Although extracorporeal techniques such as continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodiafiltration (CVVHDF) are used quite frequently in adult ICUs, there is still limited expertise in many PICUs. Such techniques are very dependent on technology and are more costly than PD [bib_ref] Cost analysis of dialysis modalities for pediatric acute renal failure, Reznik [/bib_ref]. They are also dependent upon the availability of appropriate nursing expertise [bib_ref] Nursing management concepts for CRRT in the child, Baldwin [/bib_ref]. Such expertise can be developed and maintained in units remote from the pediatric nephrology center by an outreach service using a renal critical care nurse educator [bib_ref] A renal critical care educator: the interface between paediatric intensive care and..., Harvey [/bib_ref]. ## Recommendation There is no evidence for the optimum level of renal function for starting renal replacement therapy nor for the optimum dialysis modality. Advantages and disadvantages are listed in [fig_ref] Table 1: Advantages and disadvantages of various modalities of renal replacement therapy for acute... [/fig_ref]. Consideration should be given to establishing national and international databases to collect these data along with patient outcomes [bib_ref] Pediatric acute renal failure: outcome by modality and disease, Bunchman [/bib_ref] [bib_ref] Dialysis therapy for children with acute renal failure: survey results, Warady [/bib_ref]. ## Choice of therapy Acute PD The main advantage of PD is that it is continuous therapy that requires neither anticoagulation nor vascular access, and the technique can be used in hemodynamically unstable patients [bib_ref] Peritoneal dialysis for management of pediatric acute renal failure, Flynn [/bib_ref]. Acute PD can be performed in units with no HD expertise and is effective in children of all ages, including neonates [bib_ref] Peritoneal dialysis for acute renal failure in children, Reznik [/bib_ref] [bib_ref] Managing acute renal failure in very low birthweight infants, Coulthard [/bib_ref] [bib_ref] Peritoneal dialysis in infants and children, Lattouf [/bib_ref] [bib_ref] Management of acute renal failure in newborns, Gouyon [/bib_ref]. PD has been used in treating acute pancreatitis, tumor lysis syndrome, intoxications, metabolic diseases, and other pathological conditions in children [bib_ref] Successful long-term peritoneal dialysis in a very low birth weight infant with..., Rainey [/bib_ref] [bib_ref] Is there a role for continuous renal replacement therapies in patients with..., Davenport [/bib_ref] [bib_ref] Acute hemodynamic effects of post cardiotomy peritoneal dialysis in neonates and infants, Dittrich [/bib_ref] [bib_ref] Emergency dialysis in neonatal metabolic crises, Daschner [/bib_ref]. The choice of PD as therapy has always to be individualized, balancing advantages against disadvantages. ## Limitations in the use of pd Inborn areas of metabolism in the newborn period lead to acute accumulation of neurotoxic metabolites that can be better removed using techniques such as CVVHDF [bib_ref] Continuous venovenous hemodiafiltration in neonatal onset hyperammonemia, Hiroma [/bib_ref] [bib_ref] Current strategies for the management of neonatal urea cycle disorders (proceedings of..., Summar [/bib_ref]. The latter technique requires good vascular access, which can still be a major problem in small children [bib_ref] Dialysis in neonates with inborn errors of metabolism, Schaefer [/bib_ref]. Newborns with respiratory diseases, even if on ventilatory treatment, can be treated with PD provided that the fill and exchange volumes are adapted to the clinical situation. However, caution is necessary in neonates with necrotizing enterocolitis and older children with suspected bowel perforation [bib_ref] Peritoneal dialysis in neonates after major abdominal surgery, Mattoo [/bib_ref]. ## Preparation for pd Dialysis is only possible if the access provides free flow in and out of the abdomen. The choice is between catheters inserted at the bedside under sedation or the placement of a chronic PD catheter by a pediatric surgeon in the operating theater, or exceptionally at the bedside in the ICU. The rigid Trocath catheter with a stylet has largely disappeared and surgically placed Tenckhoff catheters are reported to have fewer complications [bib_ref] Comparison of temporary and permanent catheters for acute peritoneal dialysis, Wong [/bib_ref] [bib_ref] Tenckhoff catheters prove superior to Cook catheters in pediatric acute peritoneal dialysis, Chadha [/bib_ref] [bib_ref] Acute peritoneal dialysis in preterm newborns and small infants: surgical management, Huber [/bib_ref]. However, small catheters for percutaneous placement using a Seldinger technique are invaluable in providing acute PD rapidly, especially in the neonatal PICU [bib_ref] Dialysis therapy for children with acute renal failure: survey results, Warady [/bib_ref] [bib_ref] New perspectives for PD in acute renal failure related to new catheter..., Vande Walle [/bib_ref]. Blockage by the omentum is always a risk with PD catheters. If the catheter is to be placed surgically then consideration should be given to partial omentectomy [bib_ref] Omentectomy with peritoneal catheter placement in acute renal failure, Pumford [/bib_ref]. In patients who are having a PD catheter inserted under general anesthetic a cephalosporin antibiotic (20 mg/kg) should be given as a single intravenous dose up to 1 h prior to implantation of the catheter [bib_ref] Guidelines by an ad hoc European committee for elective chronic peritoneal dialysis..., Watson [/bib_ref]. Any subsequent accidental contamination should result in the use of prophylactic antibiotics, e.g., cefuroxime 125 mg/l in the dialysate for 48 h. For catheters that are inserted percutaneously, prophylactic antibiotics, e.g., cefuroxime 125 mg/l, should be added to the dialysis fluid unless the patient is on systemic treatment. Heparin, 500 units/l, should be prescribed to prevent catheter blockage with fibrin. This is generally maintained for the first 48 h, and longer if the PD fluid remains slightly bloodstained [bib_ref] Effects of intraperitoneal heparin on peritoneal transport in a chronic animal model..., Pawlaczyk [/bib_ref] [bib_ref] Effect of intraperitoneal administration of heparin to patients on continuous ambulatory peritoneal..., Takahashi [/bib_ref]. ## Pd prescription This needs to be individualized according to patient size and condition. Automated PD machines are the preferred method for delivering the individualized dialysis prescription and accurately measuring ultrafiltration [bib_ref] New perspectives for PD in acute renal failure related to new catheter..., Vande Walle [/bib_ref]. Such machines are now available that can deliver dialysis volumes accurately down to 60 ml with 10-ml increments. Although such machines now have improved accuracy of ultrafiltration measurements, the dead space of the tubing can reduce dialysis efficiency. A manual PD set can be used, using burettes that can accurately measure inflow and outflow, with the PD fluid warmed appropriately [bib_ref] Continuous peritoneal dialysis in newborns, Zaramella [/bib_ref]. With manual sets, attempts should be made to maintain a closed drainage system, which can help reduce the frequency of peritoneal contamination [bib_ref] The epidemiology of peritonitis in acute peritoneal dialysis: a comparison between open-and..., Valeri [/bib_ref]. Such manual PD sets are commercially available for neonatal patients. ## Choice of dialysis solution The choice of dialysis solution will depend upon the weight, blood pressure, and hydration status of the child, bearing in mind the need to create nutritional space as part of the management strategy. The general principle is to commence with the lowest concentration of glucose solution possible (1.36%), with stepwise increments. Care is needed if 3.86% glucose solution is required as (1) rapid ultrafiltration can occur (especially in infants) and (2) hyperglycemia may develop (especially in septic and multi-organ failure patients) leading to hyperosmolarity and loss of effective ultrafiltration. Icodextrine solutions need a longer dwell time to obtain significant ultrafiltration and so are rarely indicated in ARF. Lactate-containing dialysis solutions are likely to be replaced by bicarbonate solutions, which are being evaluated in chronic PD. The routine use of bicarbonate solutions should be considered in neonates or in patients with reduced lactate metabolism or with lactic acidosis [bib_ref] Lactate-or bicarbonatebuffered solutions in continuous extracorporeal renal replacement therapies, Kierdorf [/bib_ref] [bib_ref] Advantages of HCO3 solution with low sodium concentration over standard lactate solutions..., Vande Walle [/bib_ref]. ## Practical points Patients should be connected and automated PD or manual cycles started immediately after catheter implantation. Heparin (500 units/l) should be added to the dialysis fluid to prevent fibrin deposition and to improve peritoneal solute permeability [bib_ref] Effects of intraperitoneal heparin on peritoneal transport in a chronic animal model..., Pawlaczyk [/bib_ref] [bib_ref] Effect of intraperitoneal administration of heparin to patients on continuous ambulatory peritoneal..., Takahashi [/bib_ref] , but it can be absorbed and care is needed in patients with coagulation disorders. Dialysis fill volumes of 10-20 ml/kg (300-600 ml/m 2 ) should be used initially, depending on the body size and cycle in and out, until the dialysate becomes clear. A PD program with 1-h dwells should be used during the first 24 h. Shorter cycles can be considered initially if hyperkalemia needs urgent treatment. The program should be adjusted with increasing dwell times and cycle fill volume (if no leakage problems) until the desired fill volume (800-1,200 ml/m 2 ) is achieved, with adequate ultrafiltration and biochemical control [bib_ref] Watson AR on behalf of the European Paediatric Peritoneal Dialysis Working Group..., Fischbach [/bib_ref]. High intraperitoneal pressure (IPP) can be a problem in the first 2-3 days after surgical catheter insertion. The measurement of IPP may limit the risk of leakage when the fill volumes are being increased and allow optimized pain management, but is not yet in routine use [bib_ref] Measurement of IPP: a useful tool for the improvement of dialysis prescription, Fischbach [/bib_ref]. Inflow/outflow pain on PD usually diminishes with time. Tidal dialysis is an alternative [bib_ref] Adequacy of dialysis with tidal and continuous cycling peritoneal dialysis in children, Holtta [/bib_ref] and bicarbonate dialysis should be considered [bib_ref] Bicarbonate and bicarbonate/ lactate peritoneal dialysis solutions for the treatment of infusion..., Mactier [/bib_ref]. The amount of ultrafiltration that is prescribed will partly depend upon the volume of oral, nasogastric, or total parenteral nutrition that is required, combined with fluid for drugs. Ultrafiltration may not be enough without the use of 2.27% or 3.86% glucose solutions. The clinical, biochemical, and nutritional status of the patient should be assessed regularly in conjunction with an experienced renal dietitian [bib_ref] Guidelines by an ad hoc European committee on the assessment of growth..., Coleman [/bib_ref]. Optimal nutrition is necessary to avoid a catabolic state and associated production of blood urea nitrogen and uremic products. ## Rationale Patients with ARF need constant assessment while on PD, and adequacy should be judged in terms of clinical status, ultrafiltration achieved, and biochemical parameters, particularly urea, creatinine, and bicarbonate levels [bib_ref] Watson AR on behalf of the European Paediatric Peritoneal Dialysis Working Group..., Fischbach [/bib_ref]. Although a link between the dialysis dose and the outcome of adult patients in ARF has been established [bib_ref] Treatment of acute renal failure, Star [/bib_ref] , there are no guidelines as to what constitutes adequate PD in a child with ARF. The aim is to deliver maximum clearance to compensate for the catabolic stress. ## Complications of acute pd Leakages can be a difficult problem and are mostly due to a leakage around the catheter. The incidence can be reduced by proper surgical technique when using a Tenkhoff catheter [bib_ref] Dialysate leaks in peritoneal dialysis, Lebland [/bib_ref] or resuturing around a percutaneous catheter. Fibrin glue injected into the catheter tunnel is a technique under evaluation [bib_ref] Fibrin glue successfully used in peritoneal dialysis catheter leakage in children, Van De Kar [/bib_ref]. Poor drainage due to mechanical blockage or catheter migration is all too common. Flushing the catheter and preventing fibrin accumulation by increasing the heparin dosage and/or urokinase is suggested initially [bib_ref] Local fibrinolytic therapy with urokinase for peritoneal dialysis catheter obstruction, Stadermann [/bib_ref]. A plain abdominal X-ray is rarely justified, as repeated poor drainage will require catheter relocation. If available, a laparoscopic technique may be used to correct poor drainage or replace the malfunctioning catheter [bib_ref] Malfunctioning peritoneal dialysis catheter repaired by laparoscopic surgery, Julian [/bib_ref]. Hernias can be a problem in neonates and infants, particularly males. They do not usually require interruption of PD and can be repaired electively by laparoscopic or direct measures when the child's clinical condition has improved or stabilized. Peritonitis remains a constant threat, especially if there has been a lot of manipulation of the catheter. The standard features of cloudy PD fluid require urgent attention. ## Continuous extracorporeal techniques Continuous arteriovenous hemofiltration (CAVH) has largely been replaced by pumped CVVH and CVVHDF, particularly in ICUs [bib_ref] Outcome in children receiving continuous venovenous hemofiltration, Goldstein [/bib_ref]. Such continuous renal replacement therapies (CRRT) have expanded the possible role of blood purification in the management of critically ill patients. However, there is a lack of randomized trials in patients with sepsis, and a recent analysis failed to show a benefit for hemofiltration [bib_ref] The use of extracorporeal techniques to remove humoral factors in sepsis, Mcmaster [/bib_ref]. Studies in adult ICU patients have shown a lower mortality in patients treated with CRRT compared with intermittent HD. However, a recent meta-analysis of studies before 1996 concluded that the evidence was insufficient to draw strong conclusions regarding the mode of renal replacement therapy for ARF in the critically ill [bib_ref] Continuous versus intermittent renal replacement therapy: a meta-analysis, Kellum [/bib_ref]. A recent randomized trial in adult ICU patients showed a significant survival advantage when the intensity of ultrafiltration was increased [bib_ref] Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute..., Ronco [/bib_ref]. ## Practical guidelines for prescription Since the concentration of solutes in the filtrate is the same as in the plasma, biochemistry is controlled by removing large volumes of filtrate and replacing it with electrolyte-containing fluid (HF replacement fluid). As most solutes are distributed within the extracellular and intracellular fluid compartments (total body water), the exchange volume of filtration necessary to control biochemistry relates to total body water. Clinical experience has shown that a turnover of approximately 50% of body weight in 24 h is usually adequate for CVVH. The extracorporeal circuit requires good central venous access, usually via a dual-lumen catheter, to allow the high blood flows necessary to prevent clotting in the hemofilter. For neonates a 5-FG dual-lumen catheter may be adequate, and access can be obtained via the umbilical vein [bib_ref] Treatment of hydrops fetalis with hemofiltration, Castillo [/bib_ref]. A single-lumen catheter using a "single needle" for CVVHD in very low birth weight infants has also been described [bib_ref] Haemodialysis and ultrafiltration in babies weighing under 1000 g, Coulthard [/bib_ref] , but this method may be compromised by high recirculation rates with most available systems. However, the smaller the access the greater the problems [bib_ref] Continuous renal replacement therapy and plasma exchange in newborns and infants, Ponikvar [/bib_ref]. It is possible to consider placing two small singlelumen catheters in different central veins. A low blood flow rate, high hematocrit, and high plasma protein concentration will limit the rate at which filtration can occur and solutes (particularly of higher molecular weight) are removed. For a given blood flow rate, pre-dilution results in higher clearance of solutes than does post-dilution [bib_ref] CRRT efficiency and efficacy in relation to solute size, Clark [/bib_ref] , but at the expense of greater use of replacement fluid (approximately 20%-50% more). Pre-dilution has the potential for extending filter life. As with HD, the blood volume in the extracorporeal circuit should be less than 10% of the patient's circulatory volume. Blood flows of 6-9 ml/kg per min or 8% of circulating blood volume prevents excessive hemoconcentration in the filter. Automated machines with appropriate accuracy for children are recommended for delivering the CRRT prescription safely [bib_ref] Continuous renal replacement therapy: opinion and evidence, Ronco [/bib_ref] , and have replaced pump-assisted hemofiltration using volumetric pumps [bib_ref] An introduction to continuous renal replacement therapy, Bellomo [/bib_ref]. To achieve a 50% exchange of total body water in 24 h, an appropriate filter should be selected with a surface area of no more than the surface area of the patient. Suggested maximum filtration rates are: Under post-dilution conditions, the filtration rate should never exceed one-third of the blood flow. Several filter materials are now available. Synthetic membranes have replaced cellulose acetate, as they are more biocompatible, causing less complement reaction and anticoagulation needs. The synthetic polysuphone membranes are also thought to aid convective clearance of solutes through solute drag [bib_ref] Use of pump-assisted hemofiltration in children with acute renal failure, Ellis [/bib_ref]. A variety of replacement fluids are available such as lactate, bicarbonate, and buffer-free solutions. Bicarbonate or buffer-free solutions should be used in young infants and those intolerant of lactate. If a commercially available bicarbonate solution were freely available, then this would be the solution of choice. Careful monitoring of electrolytes, glucose, and phosphate is essential, as the constituents vary between the solutions. ## Anticoagulation The goals of anticoagulation are to prevent clotting of the circuit and maintain adequate clearances with minimal risk to the patient. Heparin is the standard anticoagulant in Europe, but the choice of dosage will depend upon the patient's coagulation status, adequacy of blood flow, and blood viscosity. In most patients, heparin should be administered as an initial bolus (maximum 50 units/kg) at the time of connection to the extracorporeal circuit, followed by a continuous infusion of 0-30 units/kg per hour. The activated clotting time (ACT) or whole blood activated partial thromboplastin time (aPPT) are usually used to monitor treatment. The optimal ACT during hemofiltration is 120-180 s. The aPPT should be between 1.2 and 1.5 times the respective baseline value. Some patients can be treated without heparin in the circuit [bib_ref] Pediatric acute renal failure: outcome by modality and disease, Bunchman [/bib_ref]. In those patients who are severely thrombocytopenic or where there is suspected heparin-induced thrombocytopenia, alternative treatment with prostaglandin infusions or recombinant hirudin [bib_ref] Heparin induced thrombocytopaenia thrombosis (HIT/T) syndrome: diagnosis and treatment, Baglin [/bib_ref] , a direct thrombin inhibitor, can be considered [bib_ref] Heparin-induced thrombocytopenia type II on hemodialysis: switch to danaparoid, Neuhaus [/bib_ref]. Regional anticoagulation with citrate has been favored by some centers [bib_ref] Regional citrate anticoagulation for continuous arteriovenous hemodialysis: an update after 12 months, Mehta [/bib_ref] [bib_ref] Citrate clearance in children receiving continuous venovenous renal replacement therapy, Chadha [/bib_ref]. Sodium citrate chelates ionized calcium necessary for the coagulation cascade and systemic anticoagulation is avoided by infusing calcium through a separate central line. The disadvantages include the possibility of various acidbase and electrolyte disturbances, including hypernatremia, hypocalcemia, and metabolic alkalosis. ## Adjustment of the prescription Any formula for the prescription of HF is at best an approximation or starting point, as the needs will be determined by many unmeasured variables, such as the rate of solute production, nutritional intake, and the actual volumes of the extracellular fluid and intracellular fluid compartments. If only fluid removal is required, then relatively low rates of filtration are needed, often referred to as slow continuous ultrafiltration (SCUF). There will be negligible solute removal under these circumstances. Correction of "uremia" and electrolyte disturbance requires the turnover of large volumes per kilogram of fluid, typically of the order of 50% of body weight per day for post-dilution and 75% for pre-dilution (approximately 20-30 ml/kg per hour). In catabolic patients, the clearances achieved with standard CVVH may not be sufficient. Solute removal may be increased by attempting "high-volume exchange," but this may be limited by the practical problems of pediatric patients with limitations of vascular access and hemoconcentration in the filter. In these cases, small solute clearances can be maximized by establishing diffusive mass transport via a dialysis circuit. This can be performed with CVVHDF or without an additional major ultrafiltration component (CVVHD). CVVHDF latter technique requires an additional pump to achieve separate control of the dialysate in-and outflow and of the replacement fluid flow. CVVH substitution fluid bags can be used as dialysis fluid. Dialysis fluid flow should be 2-3 times the blood flow if maximal efficacy is desired. This setting requires frequent manual bag exchanges and continuous supervision of the system. For practical purposes, the HD component can be added for several hours per day to a CVVH regimen. CVVHD has recently been recommended as the method of choice for the treatment of inborn errors of metabolism, since it supplies maximal clearance of ammonium and other neurotoxic metabolites. When CVVHD is unavailable, large volume turnover of body water with CVVH will provide the next best therapy. Rates of up to 100 ml/kg per hour have been reported [bib_ref] Pediatric CRRT, Wilkins [/bib_ref]. If possible, the blood pump speed also needs to be increased. When high turnover and blood flow rates are in use, patients should be carefully monitored for hypothermia, hypokalemia, and circulatory failure. Hypothermia may need to be treated with an external warming blanket and hypokalemia will require replacement. Blood flow should not be increased if the patient develops cardiovascular instability. ## Cvvh and extracorporeal membrane oxygenation In the authors 0 experience, the best results are achieved when pre-diluted fully automated CVVH is used, attached to the venous (outflow from patient) side of the extracorporeal membrane oxygenation (ECMO) circuit. This appears to reduce problems of shunting blood around the oxygenator and overcomes the problems of the increased hematocrit that may be associated with ECMO. It also reduces the complications of excessive fluid and solute clearances, with a free flow when systemic hemofilters are used in line with the ECMO circuit. When using CVVH in the suggested configuration, the "pigtails" provide access with very little resistance, causing the arterial and venous pressure alarms to activate and shut down the circuit. Therefore, three-way taps are used to create more resistance to flow into and out of the CVVH circuit. When treating neonatal patients, the ECMO circuit increases the extracorporeal blood volume very significantly. Therefore, the blood pump speed should be calculated taking into account the patient's blood volume and the priming volume of the ECMO circuit. ## Complications of continuous extracorporeal techniques Complications of continuous extracorporeal techniques are described in reference. ## Hypotension Hemofiltration is most commonly used in sick septic children, many of whom will be on pressor therapy. Indeed, the need for pressor agents gives a poorer prognosis [bib_ref] Pediatric acute renal failure: outcome by modality and disease, Bunchman [/bib_ref]. Care should have been taken to minimize the amount of blood in the extracorporeal circuit and blood priming of the HF circuit may be necessary at the outset. Fluid removal is obviously adjusted according to the patient's clinical state during the treatment. ## Clotting of the filter and lines This is one of the commonest complications and again is related to the patient's changing clinical status and problems with anticoagulation. This complication occurred in 24% of 89 patients treated with CVVH in a 2year local audit (B. Harvey, unpublished observations). Other potential complications of bleeding, anticoagulation toxicity, and infections appear to be minimal. Air embolism is a rare but preventable complication of extracorporeal circuits, and is greatly reduced with the proper use of automated machinery. ## Intermittent hd The advantages and limitations of intermittent HD are described in reference [bib_ref] Dialysis in infants and children, Mendley [/bib_ref]. ## Advantages The main advantage of HD is the relatively rapid removal of uremic toxins and ultrafiltration of fluid. This makes the technique well suited for acute situations. Limitations HD is not a continuous therapy and it requires good vascular access as with HF. A purified water supply is also required, as well as anticoagulation, which should always be minimized. The technique might not be applicable for hemodynamically unstable patients. Often the major limiting factor is the availability of expert nursing staff, especially in the ICU [bib_ref] Support for renal replacement therapy in the paediatric intensive care unit, Harvey [/bib_ref]. Practical guidelines for prescription HD is only possible with good vascular access provided either by a double-lumen HD catheter or a single-lumen catheter of sufficient diameter to achieve flows for singleneedle dialysis. Catheter lengths vary from 5 cm for neonates to 20 cm for large adolescents. Bloodline choice depends on the priming (extracorporeal) volume, which traditionally has not exceeded 10% of the blood volume (approximately 80 ml/kg). Dialyzer choice depends on the priming volume and maximum flow rate, with a surface area that should not exceed the child's surface area and with a urea clearance between 3 and 5 ml/kg per min. There is no evidence for dialyzer choice in pediatric practice, but meta-analysis in adult patients with ARF suggested synthetic membranes conferred a significant survival advantage over cellulosebased membranes, but with no similar benefit for recovery of renal function [bib_ref] Influence of dialysis membranes on outcomes in acute renal failure: a meta-analysis, Subramanian [/bib_ref]. Bloodline priming is usually performed with isotonic saline. Small babies, anemic patients, and those in an unstable cardiocirculatory condition, require priming with albumin or blood. ## Hd catheter care After the session the catheter should be flushed with isotonic saline and filled with undiluted heparin (1,000 IU/ml), with volumes according to manufacturer's recommendations (usually marked on the catheter itself). ## Hd prescription The first session should not exceed 2-3 h, but the standard time is usually 4 h. Longer sessions are advisable to avoid too-rapid ultrafiltration and disequilibrium syndrome. All children should be dialyzed using volume-controlled machines and with bicarbonate dialysate. The blood pump rate is usually 6-8 ml/kg per min, but depends upon the catheter and patient size. The ultrafiltration target should not exceed 0.2 ml/kg per min for acute patients who should be carefully monitored for hypovolemia and hypotension. Sodium profiling is rarely used in pediatric HD practice. Anticoagulation is usually with heparin (50-100 IU/kg per session including initial bolus). Reinfusion is usually performed with isotonic saline. ## Complications occurring during acute hd For hypotension, the ultrafiltration should be switched off and isotonic saline infused into the venous line until the blood pressure normalizes; additional 20% albumin 5 ml/ kg might be helpful. Hypertension is treated according to standard hypertension protocols available elsewhere. Disequilibrium syndrome is now a rare event with adequate control of ultrafiltration and stepwise reduction of uremic toxins. Hypoglycemia should not occur with the use of glucose-containing dialysis fluid. In cases of anemia transfusions are avoided unless patient symptomatic. Erythropoietin may be given intravenously at the end of dialysis (50-200 IU/kg) to maintain hemoglobin levels. ## Medications The clearance of drugs on HD or during CRRT needs to be considered. Reference should be made to standard texts . [table] Table 1: Advantages and disadvantages of various modalities of renal replacement therapy for acute renal failure (CVVH continuous venovenous hemofiltration, CVVHDF continuous venovenous hemodiafiltration) [/table]

Psi-DOM Ψ-DOM, or 2,6-dimethoxy-4-methylamphetamine, is a hallucinogenic drug and a structural isomer of the better-known hallucinogen DOM. Ψ-DOM was first reported by Alexander Shulgin in his book PIHKAL. Ψ-DOM has similar effects to DOM, but is only around 1/3 - 1/2 the potency, with an active dose reported to be between 15-25 milligrams. The effects of Ψ-DOM last for around 6-8 hours. The activity of Ψ-DOM (and Ψ-2C-T-4) demonstrates that the two methoxy groups on the psychedelic phenethylamines are not strictly limited to the 2,5 positions on the phenyl ring. Indeed any of the 2Cx or DOx series of drugs could alternatively be made as the 2,6 isomer and would still be expected to show similar activity, although slightly less potent. In theory this would vastly expand the range of different hallucinogens that could be derived from this family of drugs. The 2,6 isomer of another similar drug 2C-D-FLY (see 2C-B-FLY) has also been made by David Nichols and found to be active, this might by extension be referred to as Ψ-2C-D-FLY.

Manganism Manganism or manganese poisoning is a toxic condition resulting from chronic exposure to manganese and first identified in 1837 by James Couper. Its symptoms resemble those of idiopathic Parkinson's disease, which it is often misdiagnosed as, although there are particular differences in both the symptoms (nature of tremors, for example), response to drugs such as Levadopa, and affected portion of the basal ganglia. Symptoms are also similar to Lou Gehrig's disease and multiple sclerosis. Manganism has become an active issue in workplace safety as it has been the subject of numerous product liability lawsuits against manufacturers of arc welding supplies. In these lawsuits, welders have accused the manufacturers of failing to provide adequate warning that their products could cause welding fumes to contain dangerously high manganese concentrations that could lead welders to develop manganism. # External references - Lucchini et al., "Metals and Neurodegeneration" - Research paper on heavy metals poisoning - Antonini., "Health Effects of Welding" - Critical review including manganese discussion from National Institute of Occupational Safety and Health (NIOSH) - Welding and Manganese Poisoning - Safety Corner column in IBEW Journal regarding manganese and welding. - AWS Study on Welding and Exposure to Manganese - Report of an independent study commissioned by the American Welding Society - Welding Fume Product Liability - Viewpoint of plaintiffs on welding rod litigation - Welding Rod Litigation Information Network - Viewpoint of defense on welding rod litigation nl:Manganisme

HOXB8 Homeobox protein Hox-B8 is a protein that in humans is encoded by the HOXB8 gene. # Function This gene is a member of the Antp homeobox family and encodes a nuclear protein with a homeobox DNA-binding domain. It is included in a cluster of Homeobox B genes located on chromosome 17. The encoded protein functions as a sequence-specific transcription factor that is involved in development. Increased expression of this gene is associated with colorectal cancer. Mice that have had the murine ortholog (see Homology (biology) § Orthology) of this gene knocked out exhibit an excessive pathologic grooming behavior. This behavior is similar to the behavior of humans suffering from the obsessive-compulsive spectrum disorder trichotillomania. Transplantation of normal (wild-type) bone marrow into a Hoxb8 mutant mouse results in a reduction of compulsive grooming.

Bucladesine # Overview Bucladesine is a cyclic nucleotide derivative which mimics the action of endogenous cAMP and is a phosphodiesterase inhibitor. Bucladesine is a cell permeable cAMP analog. The compound is used in a wide variety of research applications because it mimics cAMP and can induce normal physiological responses when added to cells in experimental conditions. cAMP is only able to elicit minimal responses in these situations. The neurite outgrowth instigated by bucladesine in cell cultures has been shown to be enhanced by nardosinone.

SNAP29 Synaptosomal-associated protein 29 is a protein that in humans is encoded by the SNAP29 gene. # Function This gene, a member of the SNAP25 gene family, encodes a protein involved in multiple membrane trafficking steps. Two other members of this gene family, SNAP23 and SNAP25, encode proteins that bind a syntaxin protein and mediate synaptic vesicle membrane docking and fusion to the plasma membrane. The protein encoded by this gene binds tightly to multiple syntaxins and is localized to intracellular membrane structures rather than to the plasma membrane. While the protein is mostly membrane-bound, a significant fraction of it is found free in the cytoplasm. Use of multiple polyadenylation sites has been noted for this gene. # Model organisms Model organisms have been used in the study of SNAP29 function. A conditional knockout mouse line, called Snap29tm1a(EUCOMM)Wtsi was generated as part of the International Knockout Mouse Consortium program—a high-throughput mutagenesis project to generate and distribute animal models of disease to interested scientists. Male and female animals underwent a standardized phenotypic screen to determine the effects of deletion. Twenty five tests were carried out on mutant mice and two significant abnormalities were observed. No homozygous mutant embryos were identified during gestation, and therefore none survived until weaning. The remaining tests were carried out on heterozygous mutant adult mice; no significant abnormalities were observed in these animals. # Interactions SNAP29 has been shown to interact with Syntaxin 3 and EHD1.

Zygomatic bone # Overview The zygomatic bone (malar bone) is a paired bone of the human skull. It articulates with the maxilla, the temporal bone, the sphenoid bone and the frontal bone. It forms part of the orbit and is commonly referred to as the cheekbone. It is situated at the upper and lateral part of the face: it forms the prominence of the cheek, part of the lateral wall and floor of the orbit, and parts of the temporal and infratemporal fossae . It presents a malar and a temporal surface; four processes, the frontosphenoidal, orbital, maxillary, and temporal; and four borders. # Surfaces The malar surface is convex and perforated near its center by a small aperture, the zygomaticofacial foramen, for the passage of the zygomaticofacial nerve and vessels; below this foramen is a slight elevation, which gives origin to the Zygomaticus. The temporal surface, directed backward and medialward, is concave, presenting medially a rough, triangular area, for articulation with the maxilla, and laterally a smooth, concave surface, the upper part of which forms the anterior boundary of the temporal fossa, the lower a part of the infratemporal fossa. Near the center of this surface is the zygomaticotemporal foramen for the transmission of the zygomaticotemporal nerve. # Process The zygomatic process is a protrusion from the rest of the skull, like the bumper of a car. Most of it belongs to the zygomatic bone, but there are other bones contributing to it too, namely the frontal bone, maxilla and temporal bone. # Borders The antero-superior or orbital border is smooth, concave, and forms a considerable part of the circumference of the orbit. The antero-inferior or maxillary border is rough, and bevelled at the expense of its inner table, to articulate with the maxilla; near the orbital margin it gives origin to the Quadratus labii superioris. The postero-superior or temporal border, curved like an italic letter f, is continuous above with the commencement of the temporal line, and below with the upper border of the zygomatic arch; the temporal fascia is attached to it. The postero-inferior or zygomatic border affords attachment by its rough edge to the Masseter. # Ossification The zygomatic bone is generally described as ossifying from three centers - one for the malar and two for the orbital portion; these appear about the eighth week and fuse about the fifth month of fetal life. Mall describes it as being ossified from one center which appears just beneath and to the lateral side of the orbit. After birth, the bone is sometimes divided by a horizontal suture into an upper larger, and a lower smaller division. In some quadrumana the zygomatic bone consists of two parts, an orbital and a malar. # Articulations The zygomatic articulates with four bones: the frontal, sphenoidal, temporal, and maxilla. # Additional illustrations - The seven bones which articulate to form the orbit. - Facial bones. - Left zygomatic bone. Malar surface. - Left zygomatic bone. Temporal surface. - Articulation of left palatine bone with maxilla. - Side view of the skull. - Left infratemporal fossa. - The skull from the front. - Horizontal section of nasal and orbital cavities. - Left orbicularis oculi, seen from behind. - Nerves of the orbit, and the ciliary ganglion. Side view. # Beauty High cheek bones are seen as a sign of beauty in many cultures and is a characteristic of many high fashion models.

Beleric Beleric, also known as the bastard myrobalan, Terminalia bellirica, is a large deciduous tree common on plains and lower hills in Southeast Asia, where it is also grown as an avenue tree. The leaves are about 15 cm long and crowded toward the ends of the branches. It is considered a good fodder for cattle. This species is used by some tribes in the Indian subcontinent for hallucination purposes; they smoke dried kernels. Too much of this can cause nausea and vomiting. Terminalia bellirica Roxb seeds have an oil content of 40%, the fatty-acid methyl ester of which meets all of the major biodiesel requirements in the USA (ASTM D 6751-02, ASTM PS 121-99), Germany (DIN V 51606) and European Union (EN 14214).

Ceric ammonium nitrate # Overview Ceric ammonium nitrate, or in lab jargon "CAN", is the chemical compound with the formula (NH4)2Ce(NO3)6. This orange-red, water-soluble salt is widely used as an oxidising agent in organic synthesis. This compound is used as a standard oxidant in quantitative analysis, # Properties and structure Two components comprise this salt, the anion 2- and a pair of NH4+ counter ions, which are not involved in the reactions of CAN. In the anion each nitrato group is chelated to the cerium atom in a bidentate manner as shown below: File:Metal nitrate bonding.gif Although the N-O bonds (on the metal side of the nitrato group) are unsymmetrical. The anion 2- has idealized Th molecular symmetry. The CeO12 core defines an icosahedron. # Preparation The anion 2- is generated by dissolving Ce2O3 in hot concentrated HNO3. # Key reactions (NH4)2Ce(NO3)6 is a stronger oxidizing agent (E° ~ 0.96 V vs. N.H.E.) than even Cl2. Few shelf-stable reagents are stronger oxidants. In the redox process Ce(IV) is converted to Ce(III), a one-electron change, signaled by the fading of the solution color from orange to a pale yellow (providing that the substrate and product are not strongly colored). CAN is useful as an oxidant for many functional groups, some of which are listed below. - Oxidation of C-H bonds: Alkenes produces dinitroxylation, although the outcome is solvent-dependent. Methylarenes undergo benzylic oxidation. - Alkenes produces dinitroxylation, although the outcome is solvent-dependent. - Methylarenes undergo benzylic oxidation. - Oxidation of alcohols, phenols, and ethers Benzylic alcohols are converted into carbonyl compounds. Quinones are produced from catechols and hydroquinones. - Benzylic alcohols are converted into carbonyl compounds. - Quinones are produced from catechols and hydroquinones. - Oxidation of nitroalkanes An alternative to the Nef reaction, e.g. for ketomacrolide synthesis where complicating side reactions usually encountered using other reagents are avoided using CAN. - An alternative to the Nef reaction, e.g. for ketomacrolide synthesis where complicating side reactions usually encountered using other reagents are avoided using CAN. Oxidative halogenation can be promoted by CAN as an in situ oxidant, for benzylic bromination, the iodination of ketones and uracil derivatives. In synthetic organic chemistry the use of protecting groups is basically ubiquitous. Two related protecting groups used to protect alcohols are the para-methoxybenzyl and 3,4-dimethoxybenzyl ethers. They are added to alcohols either as para-methoxybenzyl chloride in the presence of NaH, Ba(OH)2, Ag2O or a stannylene acetal with DMF or DMSO as solvent, or as para-methoxybenzyl trichloroacetimidate with ether and 0.3 mol% triflic acid. 3,4-Dimethoxybenzyl ethers are produced in the same ways. When no longer needed the para-methoxybenzyl ether can be cleaved either by aqueous mineral acids in methanol or camphor sulfonic acid (CSA) in methanol or they can be cleaved oxidatively with either 2,3-dichloro-5,6-dicyano-1,4-benzoquinone (DDQ) in dichloromethane/water or with ceric ammonium nitrate (CAN) in acetonitrile/water. The reaction mechanism is probably similar for DDQ and CAN. DDQ accepts two electrons from the para-methoxybenzyl ether, one at a time. The DDQ becomes 2,3-dichloro-5,6-dicyano-1,4-hydroquinone and the para-methoxybenzyl ether (minus two electrons) gains a water molecule on the benzylic carbon. The alcohol is remade and the para-methoxybenzyl ether becomes para-methoxybenzaldehyde. CAN probably works the same way. Since Ce(IV) gains one electron to become Ce(III), two Ce(IV) ions each accept one electron from the para-methoxybenzyl ether to become two Ce(III). Two electrons in total are taken from the para-methoxybenzyl ether. The para-methoxybenzyl ether (minus two electrons) gains a water molecule on the benzylic carbon. The alcohol is remade and the para-methoxybenzyl ether becomes para-methoxybenzaldehyde. The balanced equation is as follows: 2(NH4)2Ce(NO3)6 + H3CO-para-C6H4-CH2-O-R + H2O → 4NH4+ + 2Ce(III) + 12NO3- + 2H+ + H3CO-para-C6H4-CHO + H-O-R # Applications It has been shown that catalytic amounts of aqueous CAN in tap water can be used to efficiently synthesize various quinoxaline derivates in excellent yields. Quinoxaline derivates are known for their applications in areas such as the following: dyes, organic semiconductors, and DNA cleaving agents. These derivatives are also important components in antibiotics such as Echinomycin and Actinomycin which are known to inhibit the growth of Gram-positive bacteria and can be used against transportable tumors. There are many methods for the synthesis of quinoxaline derivatives, however, most of these suffer from unsatisfactory product yields, expensive metal precursors, harsh reaction conditions for the use of those precursors, as well as other problems. CAN provides both an inexpensive and nontoxic solution to these problems. CAN has many other synthetic applications, and it sometimes allows to carry out reactions that are not possible using other catalysts. For instance, the CAN-catalyzed three-component reaction between anilines and alkyl vinyl ethers provides an efficient entry into 2-methyl-1,2,3,4-tetrahydroquinolines and the corresponding quinolines obtained by their aromatization. CAN is also an important component of Chrome etchant, a material that is used in the production of Photomasks and Liquid Crystal Displays.

Kennel cough Kennel cough or tracheobronchitis is a highly contagious canine illness characterized by inflammation of the upper respiratory system. It can be caused by viral infections such as canine distemper, canine adenovirus, canine parainfluenza virus, or canine respiratory coronavirus, or bacterial infections such as Bordetella bronchiseptica. It is so named because the infection can spread quickly among dogs, such as in the close quarters of a kennel. # Infection Both viral and bacterial causes of kennel cough are spread through the air by infected dogs sneezing and coughing. It can also spread through contact with contaminated surfaces and through direct contact. It is highly contagious, even days or weeks after symptoms disappear. Exposure occurs in environments where there are other dogs in proximity, such as pet stores, kennels, dog shows, and groomers. Symptoms begin usually 3 to 5 days after exposure. The disease can progress to pneumonia. # Symptoms Symptoms can include a harsh, dry hacking/coughing, retching, sneezing, snorting or gagging;in response to light pressing of the trachea or after excitement or exercise. The presence of a fever varies from case to case. The disease can last from 10-20 days. Diagnosis is made by seeing these symptoms and having a history of exposure. # Treatment and prevention Antibiotics are given to treat any bacterial infection present. Cough suppressants are used if the cough is not productive (nothing is being coughed up). The prognosis is good. Prevention is by vaccinating for canine adenovirus, distemper, parainfluenza, and Bordetella. In kennels, the best prevention is to keep all the cages disinfected. Most kennels will not board dogs without proof of vaccination.

Mesenchymal stem cell # Overview Mesenchymal stem cells or MSCs are multipotent stem cells that can differentiate into a variety of cell types. Cell types that MSCs have been shown to differentiate into in vitro or in vivo include osteoblasts, chondrocytes, myocytes, adipocytes, and as described lately, into beta-pancreatic islets cells. They can also transdifferentiate into neuronal cells. While the terms Mesenchymal Stem Cell and Marrow Stromal Cell have been used interchangeably, neither term is sufficiently descriptive as discussed below: - Mesenchyme is embryonic connective tissue that is derived from the mesoderm which differentiates into hematopoietic and connective tissue, whereas MSCs do not differentiate into hematopoietic cells. - Stromal cells are connective tissue cells which form the supportive structure in which the functional cells of the tissue reside. While this is an accurate description for one function of MSCs, the term fails to convey the relatively recently discovered roles of MSCs in repair of tissue. - Because the cells called MSCs by many labs today can encompass multipotent cells derived from other non-marrow tissues, such as adult muscle side-population cells or the Wharton's jelly present in the umbilical cord as well as in the dental pulp of deciduous baby teeth, yet do not have the capacity to reconstitute an entire organ, the term Multipotent Stromal Cell has been proposed as a better replacement. # Historical background Scientists Ernest A. McCulloch and James E. Till first revealed the clonal nature of marrow cells in the 1960s. An ex vivo assay for examining the clonogenic potential of multipotent marrow cells was later reported in the 1970s by Friedenstein and colleagues. In this assay system, stromal cells were referred to as colony-forming unit-fibroblasts (CFU-f). Subsequent experimentation revealed the plasticity of marrow cells and how their fate could be determined by environmental cues. Culturing marrow stromal cells in the presence of osteogenic stimuli such as ascorbic acid, inorganic phosphate and dexamethasone could promote their differentiation of into osteoblasts. In contrast, the addition of transforming growth factor-beta (TGF-b) could induce chondrogenic markers. # Modern culturing of MSCs The majority of modern culture techniques still take a CFU-f approach, where raw unpurified bone marrow or ficoll-purified bone marrow monocytes are plated directly into cell culture plates or flasks. Mesenchymal stem cells, but not red blood cells nor haematopoetic progenitors are adherent to tissue culture plastic with 24-48 hours. However, at least one publication has identified a population of non-adherent MSCs that are not obtained by the direct plating technique. Other flow cytometry-based methods allow the sorting of bone marrow cells for specific surface markers, such as STRO-1. STRO-1+ cells are generally more homogenous, have higher rates of adherence, and higher rates of proliferation, but the exact differences between STRO-1+ cells and MSCs aren't clear. # Features of MSCs MSCs have a large capacity for self-renewal while maintaining their multipotency. Beyond that, there is little that can be definitively said. The standard test to confirm multipotency is differentiation of the cells into osteoblasts, adipocytes, and chondrocytes, however, the degree to which the culture will differentiate varies among individuals and it isn't clear if this variation is due to a different amount of "true" progenitor cells in the culture or if individuals' progenitors have variable differentiation capacities. The capacity of cells to proliferate and differentiate is known to decrease with the age of the donor, as well as the time in culture. Likewise, whether this is due to a decrease in the number of MSCs, or a change to the existing MSCs isn't known. Some have reported that MSCs have an immunosuppressive effect, whereas others have found that MSCs effectively stimulate an immune response to internalized medium components such as bovine serum albumin. This confusion is directly related to the fact that as yet there is no test one could theoretically perform on a single cell to determine if that cell is an MSC or not. There are surface antigens which can be used to isolate a population of cells which have similar self-renewal and differentiation capacities, yet MSCs, as a population, typically do not all express the proposed markers, and it isn't certain which ones must be expressed in order for that cell to be classified as an MSC. It may be that the therapeutic properties attributed to MSCs results from the interaction between the different cells which make up an MSC culture, suggesting that there is no one cell which has all the properties.

Congenital syphilis overview # Overview Congenital Syphilis is caused by Treponema pallidum, its transmitted to the fetus in utero from an infected mother via the placenta. The severity of the disease is dependent on the stage of maternal infection and the duration of exposure to the fetus. Transmission is typically in the second trimester and the highest rates of transmission are seen in women with primary syphilis. The rates of transmission decrease with the increasing duration of the maternal infection, as the concentration of spirochetes in the blood stream decreases. Syphilis infection to the fetus in utero can result in stillborn, miscarriage and a live birth with severe manifestations of hydrops. Prenatal screening for syphilis during the first trimester is recommended to all pregnant women and adequate treatment with penicillin prevents the transmission to the fetus. # Historical Perspective Congenital syphilis was first described in an English 17th century in a pediatric textbook. Transplacental transmission from an asymptomatic infected mother was first described in 1906. Sir Jonathan Hutchinson described the triad of notched incisors, interstitial keratitis, and eighth cranial nerve deafness as a criterion for diagnosis of congenital syphilis. # Classification Congenital syphilis can be classified into early (presenting 0-2 years) and late (greater 2 years) based upon on time of presentation. There is also a diagnostic classification of syphilis used for surveillance purpose. # Pathophysiology Pathophysiology of congenital syphilis is still unclear.The risk of transmission to the fetus is dependent on the stage of the maternal disease (dependent on the spirochete concentration in the blood stream) and the duration of exposure to the fetus in utero. The risk of vertical transmission of syphilis from an infected untreated mother decreases as maternal disease duration progresses: transmission risk of 70–100% for primary syphilis and 40% for early latent syphilis to 10% for late latent disease. The variation in the percentages with the duration of infection is due to the concentration of spirochetes in the blood stream, which decrease with the duration of maternal syphilis infection. # Causes Congenital syphilis is caused by the bacterium Treponema pallidum, which is passed from mother to child during fetal development or at birth. # Screening Routine screening for syphilis during the antenatal period is recommended. # Diagnosis ## History symptoms Infants present with symptoms such as failure to gain weight or failure to thrive, fever, irritability, small blisters on the palms and soles, and with watery discharge from the nose. ## Physical Examination Physical examination findings suggestive of congenital syphilis include low birth weight, signs of prematurity, skin edema, pleural effusion, vesicular skin rash, corneal clouding, jaundice and deafness. ## Laboratory Findings Prental diagnosis is by detection of IgM antibodies aganist T.pallidum in the blood collected by chordocentesis, antenatal ultrasound is commonly done and the findings suggestive of congenital syphilis include: hydrops fetalis characterised by scalp oedema, placental thickening, serous cavity effusion, and polyhydramnios. Other additional findings inlcude hepatosplenomegaly, placentomegaly, non-continuous gastrointestinal obstruction and dilatation of the small bowel. Postnatal diagnosis is by examination of the placenta or umbilical cord using a silver stain demonstrates spirochetes or a T. pallidum PCR test can be done. # Treatment ## Medical Therapy Medical therapy for neonate presenting with symptoms of congenital syphilis is aqueous penicillin G. However evaluation and management is dependent on the clinical senario of presentation. # Prevention ## Primary Prevention Primary preventive measures include routine screening in pregnant females, individuals with high risk behaviours, and those residing in highly prevalent areas, abstinence from intimate physical contact with an infected person, consistent use of latex condoms, limiting no of sexual partners, avoid sharing sex toys and practice of safe sex. ## Secondary Prevention Regular follow up of infants with congenital syphilis to examine for the re-appearance of signs and symptoms of syphilis after recommended treatment has shown to improve outcomes.

Choana # Overview Choana (plural: Choanae) is the posterior nasal aperture. The choanae are separated by the vomer. # Boundaries It is the opening between the nasal cavity and the nasopharynx. It is therefore not a structure but a space bounded as follows: - anteriorly and inferiorly by the horizontal plate of palatine bone, - superiorly and posteriorly by the sphenoid bone - laterally by the medial pterygoid plates. # Etymology The term is a latinization from the Greek "choanē" meaning funnel. # Choanae in different animals The only animals with choana are the tetrapoda, and they could as well be called Choanata (they are also the only ones with a vomeronasal organ, which has an embryonic origin from the olfactory structure). These internal nasal passages evolved while the vertebrates still lived in water. At this point they already needed to gulp air to get enough oxygen, and rather than open their jaws each time to do this, some groups acquired small openings to breathe through as a better design. ## Fish Fish don't have choana, instead they have a pair of external nostrils: two tubes whose frontal openings lie close to the upper jaw, and the posterior openings further behind near the eyes. A 400-million-year-old fossil lobe-finned fish called Kenichthys campbelli has something between a choana and the external nostrils seen on other fish, which makes it look like it has a cleft palate or cleft lip. The reason seems to be that the posterior opening of the external nostrils has migrated into the mouth for some reason. ## Tetrapods Similar migration is still seen in the tetrapod embryo, and can cause a baby to be born with a cleft palate. Why it should migrate is a mystery, since the nostrils would be useless as a breathing device before their final position inside the mouth. They could also already breath air through their spiracles. Tetrapods are also equipped with a lacrimal duct, or tear duct. How it evolved is not known, but it has an internal connection with the choana. It's possible that the choana started as a natural crack between maxilla and premaxilla because of an incomplete fusion in air breathing animals. If this gap got wider and deeper with time, the frontal part of it would have to fuse together to avoid weakening the upper jaw, creating a small opening on the upper lip. Some more migrating, and this gap would meet the anterior pair of the external nasal openings. The posterior pair of the openings was then free to form the lacrimal duct if a migration caused them to come in contact with the eyes. ## Choanae analogues in other animals and fossils This wouldn't been the first time the jaws evolved some sort of opening. For instance, snakes have evolved a cleft in the lower jaw, allowing them to stick out their tongue without having to open the jaw. For an animal living in water, the formation of a paired cleft on the upper jaw would be quite logical. Terrestrial vertebrates would in any case need a way to breath without needing to open their jaws each time. Some fossil species are said to have both conventional external nostrils and a choana, but only more fossils will give a real answer to how the choanas evolved. ## Lungfish and hagfishes In addition to tetrapods, the lungfish has internal nostrils too. These seem to have a different origin than those of the tetrapods, and lungfish have no tear duct either. Hagfishes have a single internal nostril that opens inside the mouth cavity, while Chimaerae have open canals that leads water from their external nostrils into their mouth and through their gills.

Tocilizumab for treating giant cell arteritis Evidence-based recommendations on tocilizumab (RoActemra) for treating giant cell arteritis in adults. # Recommendations Tocilizumab, when used with a tapering course of glucocorticoids (and when used alone after glucocorticoids), is recommended as an option for treating giant cell arteritis in adults, only if: they have relapsing or refractory disease they have not already had tocilizumab tocilizumab is stopped after 1 year of uninterrupted treatment at most and the company provides tocilizumab according to the commercial arrangement. This recommendation is not intended to affect treatment with tocilizumab that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop. Why the committee made these recommendations Giant cell arteritis is usually treated with a high dose of glucocorticoids, which is gradually reduced over time. High doses of glucocorticoids may cause a number of problems, including skin problems, weight gain, diabetes and osteoporosis. Clinical trial results show that after having tocilizumab plus a tapering course of glucocorticoids for 1 year, more people stay in remission and need lower doses of glucocorticoids compared with people having glucocorticoids alone. In the full population, the most plausible cost-effectiveness estimates were above the range normally considered to be a cost-effective use of NHS resource, even when tocilizumab is used for only 1 year. For the subgroup of people with relapsing or refractory disease, using the committee's preferred assumptions (including that tocilizumab is given for 1 year at most), the most likely cost-effectiveness estimate compared with glucocorticoids alone is £24,977 per quality-adjusted life year gained. This is within the range normally considered to be a cost-effective use of NHS resources, so tocilizumab is recommended.# Information about tocilizumab # Marketing authorisation indication Tocilizumab (RoActemra, Roche) has a marketing authorisation for 'the treatment of adults with giant cell arteritis'. # Dosage in the marketing authorisation Subcutaneous injection (162 mg) once every week in combination with a tapering course of glucocorticoids. Tocilizumab can be used alone following discontinuation of glucocorticoids, but monotherapy should not be used for the treatment of acute relapses. Treatment beyond 52 weeks should be guided by disease activity, physician discretion and patient choice. # Price £913.12 for 4 syringes containing 162 mg tocilizumab (excluding VAT). The company has a commercial arrangement. This makes tocilizumab available to the NHS with a discount. The size of the discount is commercial in confidence. It is the company's responsibility to let relevant NHS organisations know details of the discount.# Committee discussion The appraisal committee considered evidence submitted by Roche and a review of this submission by the evidence review group (ERG). See the committee papers for full details of the evidence. # A new treatment option ## People would welcome a new treatment that reduces the cumulative amount of glucocorticoids needed Giant cell arteritis causes inflammation in the walls of the arteries in the head and neck, and less commonly the aorta (known as large vessel giant cell arteritis). The patient experts explained that this causes symptoms such as headache, jaw pain, fatigue and muscle and joint pains. More serious complications include vision loss, stroke, aortic aneurysm and dissection, and myocardial infarction. It is with visual symptoms that people often first present to health services. Initial treatment in the NHS is with high-dose glucocorticoids, usually prednisolone. The dose is tapered gradually over 18 to 24 months to minimise the risk of the disease flaring up. The clinical experts explained that although glucocorticoids are effective at managing the disease, large cumulative doses can cause serious side effects such as diabetes and osteoporosis. The patient experts also noted unpleasant side effects with glucocorticoids such as skin changes and weight gain. They highlighted that because the disease is most common among people 50 years and older, these side effects are often in addition to existing health problems. The patient experts emphasised that glucocorticoid-sparing agents are very important for people with giant cell arteritis, especially for those with relapsing or refractory disease, who are subject to excessive cumulative dosage of glucocorticoids. The committee concluded that people with giant cell arteritis would welcome a new treatment option that reduces flares of the disease and the cumulative amount of glucocorticoids needed. # Subgroups ## People with relapsing or refractory giant cell arteritis have the highest unmet need Tocilizumab has a UK marketing authorisation for use in adults with giant cell arteritis. At the first committee meeting, the company presented clinical- and cost-effectiveness analyses which divided the overall population into 2 subgroups: people with newly diagnosed disease and people with relapsing disease. The clinical experts explained that newly diagnosed giant cell arteritis is treated differently to relapsing disease. People with a new diagnosis are usually offered high doses of glucocorticoids (40 mg to 60 mg of prednisolone daily). This is because the priority is to prevent vision loss, and at this stage people have not been exposed to a high cumulative dose of glucocorticoids, so there are fewer concerns about glucocorticoid-related adverse events. People with relapsing disease are usually offered lower doses of glucocorticoids in an attempt to manage flares and minimise additional glucocorticoids exposure; as such, the clinical and patient experts considered that tocilizumab would be most valuable to people with relapsing disease. The committee agreed that there were important differences between the 2 subgroups. It considered how many people with newly diagnosed disease would then go on to have relapses. The clinical experts explained that it is difficult to identify people whose disease may relapse, although there are some whose disease does not respond to initial high doses of glucocorticoids and that never achieve remission. The committee also acknowledged differences within the subgroup of people with relapsing disease: for example, some people's disease may relapse frequently, whereas for others relapses may be rare. Furthermore, the clinical experts explained there were differences in the severity of flares in this subgroup. In response to consultation, the company stated that tocilizumab would be most valuable to people with relapsing or refractory giant cell arteritis and therefore amended its cost-effectiveness model to focus on this subgroup only (section 3.14). It was also noted that, although clinician and patient groups also highlighted a high unmet need in patients with newly diagnosed giant cell arteritis with comorbidities, there was no data available for the company to do an analysis in this subgroup. The committee concluded that the relapsing or refractory subgroup was distinct and biologically plausible and had the highest unmet need. Therefore it considered both the full population and the relapsing or refractory subgroup in its decision making. # Clinical evidence ## The weekly tocilizumab and 52‑week glucocorticoid taper arms of GiACTA reflect the license and British Society for Rheumatology guidelines The main clinical evidence for tocilizumab came from GiACTA, a multicentre, double-blind, randomised controlled trial. The trial followed patients for 52 weeks, at which point they were enrolled in an open-label extension study which is still ongoing. Patients in the tocilizumab arm had tocilizumab plus glucocorticoids for 26 weeks, followed by tocilizumab alone for the remaining 26 weeks. The primary outcome of the trial investigated whether more people achieve sustained disease remission at 52 weeks with tocilizumab and glucocorticoids compared with glucocorticoids alone. Secondary outcomes included time to first flare after disease remission and cumulative glucocorticoid dose. The trial included 4 arms: tocilizumab every week with 26‑week prednisone taper (n=100) tocilizumab every 2 weeks with 26‑week prednisone taper (n=50) placebo with 26‑week prednisone taper (n=50) placebo with 52‑week prednisone taper (n=51).The company presented clinical-effectiveness data for all 4 arms, but in its economic model used only the weekly tocilizumab and the placebo with 52‑week prednisone taper arms. This is because weekly tocilizumab reflects the marketing authorisation, and the 52‑week glucocorticoid taper reflects the minimum tapering regimen recommended in British Society for Rheumatology guidelines on giant cell arteritis. The committee noted that splitting the trial into 4 arms meant that the numbers in each arm were small, especially when the population was further divided into newly diagnosed and relapsing subgroups. It also noted that prednisolone, not prednisone, is usually used in the NHS, but considered that the 2 drugs are very similar. The committee concluded that the 2 arms included in the company's economic model (that is, weekly tocilizumab and placebo with 52‑week prednisone taper) are most relevant to clinical practice in England. ## Patients in GiACTA reflect those with giant cell arteritis in England The committee noted a number of differences in the baseline characteristics between the treatment groups in GiACTA, but the ERG explained that these generally balanced out with no obvious skew. However, the committee was concerned that the mean age in the trial was lower than the mean age of people with the disease in the UK (69 years and 73 years respectively). In addition, 40% of patients in GiACTA had large vessel disease, compared with only around 5% of people with giant cell arteritis seen in clinical practice in England. Large vessel disease tends to be associated with a longer disease duration and more relapses than giant cell arteritis affecting the head and neck. However, the clinical experts explained that most people with giant cell arteritis affecting the head and neck also have large vessel disease. It is less likely to be diagnosed in the NHS because there is a lower utilisation of advanced imaging than in the trial. As such, the proportion in the trial is likely to reflect the true proportion with large vessel disease in England. The committee concluded that the patients in the trial reflect those with giant cell arteritis in England. ## The 52‑week glucocorticoid taper does not reflect clinical practice in England and might bias the results in favour of tocilizumab The committee was concerned that 52 weeks (12 months) is the shortest glucocorticoid taper recommended in the British Society for Rheumatology guidelines. The clinical experts explained that in clinical practice, glucocorticoids would usually be tapered over 18 to 24 months. The committee considered that this might mean that the number of flares in the comparator arm (that is, placebo with 52‑week glucocorticoid taper) may be higher, and the time to first flare shorter, than in clinical practice in England. In response to consultation, the company proposed a revision to the comparator arm of the cost-effectiveness model to incorporate the slowest tapering regimen (24 months) recommended by the British Society for Rheumatology guidelines. The committee was also aware that 49% of patients in the comparator arm did not have disease remission after the 6‑week screening phase of the trial, but that nonetheless they had to start the 52‑week tapering regimen. The committee was concerned that this might bias the primary end point of the trial (sustained remission at 52 weeks) in favour of tocilizumab, because it is less likely that people whose disease has not responded to high-dose glucocorticoids would achieve remission with lower doses. In response to consultation, the company submitted evidence from a new exploratory analysis that suggested there is no difference in primary end point analysed by remission status at baseline in the trial. However, without any statistical analyses from the company to support this conclusion, the committee remained concerned about potential bias in the primary end point in favour of tocilizumab. It concluded that the 52‑week glucocorticoid taper arm of the trial does not reflect clinical practice in England and might bias the results in favour of tocilizumab. ## Tocilizumab plus a tapering course of glucocorticoids is more effective than glucocorticoids alone The company presented results for the overall intention-to-treat population of GiACTA, as well as for both the newly diagnosed and relapsing subgroups. The results showed that tocilizumab plus a tapering course of glucocorticoids was more effective than glucocorticoids alone at increasing the proportion of patients sustaining remission at 52 weeks, and increasing the time to first flare for the overall population and both subgroups (see table 1). The committee recalled that in clinical practice, newly diagnosed disease and relapsing disease are managed differently, but the results were similarly effective across both subgroups. The committee concluded that tocilizumab is more effective than glucocorticoids alone at increasing sustained remission and time to first flare. Population Sustained remission at 52 weeks (%) Time to first flare hazard ratio (99% confidence interval) Median cumulative glucocorticoids dose (mg) Overall population: tocilizumab (n=100) (0.18 to 0.82) Overall population: placebo (n=51) (0.18 to 0.82) Newly diagnosed subgroup: tocilizumab (n=47) (0.29 to 1.59) Newly diagnosed subgroup: placebo (n=23) (0.29 to 1.59) Relapsing subgroup: tocilizumab (n=53) (0.14 to 0.81) Relapsing subgroup: placebo (n=28) (0.14 to 0.81) # Adverse events ## Because tocilizumab is taken with glucocorticoids, the extent to which glucocorticoid-related adverse events are reduced is unclear The committee considered the benefits of tocilizumab in terms of a reduction in cumulative glucocorticoid dose and risk of glucocorticoid-related adverse events. The committee noted that although the tapering regimen with tocilizumab is shorter than when glucocorticoids are used alone, disease flares are treated by increasing the glucocorticoid dose, and a tapering regimen restarted. As such, people taking tocilizumab could still be exposed to large cumulative doses of glucocorticoids. The committee acknowledged that the median cumulative glucocorticoid dose was lower in the tocilizumab arm of GiACTA (see table 1), but noted that this was over the relatively short 52‑week follow-up. It was concerned that despite the lower median cumulative glucocorticoid dose in the tocilizumab arm, the rate of glucocorticoid-related adverse events was similar between trial arms (50% compared with 49%). The committee acknowledged that this might be because many glucocorticoid-related adverse events only manifest in the longer term. In response to consultation, the company provided new evidence from post-hoc trial analyses that showed a higher rate of glucocorticoid-related adverse events being seen in the comparator arm. However, the committee was concerned that the data were analysed retrospectively and not based on standard or prespecified criteria. In addition, the company did not provide any statistical analyses to support the comparison of glucocorticoid-related adverse events between arms. The committee concluded that because glucocorticoids still need to be taken with tocilizumab, the extent to which glucocorticoid-related adverse events are reduced is unclear. # The company's economic model ## The structure of the model is adequate for decision making The company's economic model had a 30-year time horizon and included separate health states for remission based on whether patients are having glucocorticoids or not. Patients in the model could also have a flare, giant cell arteritis-related adverse events and glucocorticoid-related adverse events. Both taking glucocorticoids and disease flares were associated with a utility decrement. The committee concluded that the structure of the model was adequate for decision making. # Duration of tocilizumab treatment ## A 1-year stopping rule can be implemented in NHS practice In its original model, the company assumed that treatment with tocilizumab stops after 2 years. The committee was concerned that in clinical practice treatment may continue well beyond 2 years. This is because the risk of relapse continues, and there is no evidence that tocilizumab modifies the underlying disease when treatment stops (it may just supress it for the duration of treatment). In addition, tocilizumab treatment may be stopped and restarted in the event of a relapse. After consultation, however, the company argued that most patients would not need the full 2 years of tocilizumab treatment. It proposed that, based on clinical expert opinion, up to 1 year of treatment would be sufficient to sustain remission in the longer term and to reduce the cumulative glucocorticoid burden. The company therefore implemented a 1-year stopping rule in its revised economic model for people with relapsing or refractory disease. This stopping rule assumed that patients only had 1 course of treatment, even if they had another flare. It supported its position by providing supporting evidence from a literature review of published case reports of tocilizumab in giant cell arteritis, in which most patients had tocilizumab for less than 1 year (range 1 to 53 months). However, the committee was concerned that the evidence was based only on case reports, and that most included no follow-up details. Nevertheless, it noted that GiACTA showed that 1 years' treatment with tocilizumab is effective in sustaining remission and reducing cumulative glucocorticoid burden. It also noted that the 1-year treatment duration provided results that were most internally valid. Both the clinical and patient experts agreed that many patients are likely to need less than 1 year of tocilizumab to achieve sustainable remission, and that a 1-year stopping rule would be acceptable. As a relevant commissioner, NHS England specialised services also stated that a 1-year stopping rule could be implemented in NHS practice. The committee therefore concluded that it would include the 1-year stopping rule in its decision making. # Extrapolation of time to first flare ## The company's extrapolation after 52 weeks lacks validity In order to extrapolate time to first flare beyond the 52 weeks of the trial, the company fitted separate parametric models to the 2 arms (weekly tocilizumab with 26‑week prednisone taper and placebo with 52‑week prednisone taper) in its economic model. It used a Weibull distribution for the weekly tocilizumab arm (implying a decreasing risk of flare over time) and an exponential distribution for the comparator arm (implying a constant risk of flare over time). The committee was concerned that extrapolating in this way meant that the benefit of tocilizumab over glucocorticoids alone was assumed to continue for the 30-year time horizon of the model, despite tocilizumab treatment stopping at 2 years. Moreover, the extrapolation for the comparator arm was based on the glucocorticoid taper period, when the risk of flare is highest. The committee was concerned that this would exaggerate the risk of flare for patients in the comparator arm that had successfully completed the 52‑week glucocorticoid taper. The clinical experts explained that after 10 years, they would expect around 25% of people who had successfully completed a glucocorticoid taper to not have disease relapse; in contrast, at the same time point, the company's model predicted that almost all patients in the comparator arm would have disease relapse. Longitudinal cohort data also suggest that at 5 years, 30% to 50% of people having glucocorticoids alone will not have disease relapse; at the same time point, the company's model predicted this to be less than 2%. The committee concluded that the company's extrapolation of time to first flare lacked validity. ## The ERG's approach to extrapolation is more appropriate The ERG suggested an alternative approach to extrapolating time to first flare for the comparator arm, in which it switches to the same Weibull distribution as the weekly tocilizumab arm after 2 years. The committee considered that this addressed the issue of the relative benefit of tocilizumab continuing after treatment stops, because all patients that have successfully completed the taper in either arm have the same decreasing risk of disease relapse. Using this approach, the ERG predicted that at year 5 around 12% of patients in the comparator arm would not have relapsing disease (falling to 8% by year 10). The committee concluded although the ERG's approach may still overestimate the risk of flare in the comparator arm, it provided more clinically realistic estimates of the proportion of patients with disease relapse after having glucocorticoids alone. # Estimating rates of subsequent flares ## The ERG's approach results in more realistic estimates of subsequent flares The company used GiACTA data to estimate rates of subsequent flares that were used in the economic model. The ERG noted that the company's estimate for the tocilizumab newly diagnosed subgroup was higher than for the relapsing subgroup, which is clinically implausible. In addition, the company's model predicted a high number of flares for people having glucocorticoids alone, which lacks validity. For example, over the same period of 10 years, a longitudinal cohort study of people with giant cell arteritis taking glucocorticoids alone (Labarca et al. 2016) reported less than half the flares predicted by the company's model. The ERG derived probabilities based on this study that were logically consistent across the subgroups. The committee considered that when the ERG's probabilities for subsequent flare are combined with its approach to time to first flare extrapolation, the predicted mean number of flares over the model time horizon for the comparator arm is more plausible than the company's approach. In the company's revised model for people with relapsing or refractory disease, it proposed an additional 10% adjustment to the ERG's estimated rates of subsequent flares to provide a better estimate in the control arm of the relapsing subgroup. The ERG stated that this had already been accounted for in its own estimates, so no adjustments were needed. The committee concluded that the ERG's approach to estimating the probability of subsequent flares was more appropriate. # Utility values in the model ## The company's model adequately captures the negative effect of flares and glucocorticoids on quality of life The company used a common utility value for the remission health state in both treatment arms, and applied a utility decrement of -0.13 for 4 weeks to capture how a flare negatively affects quality of life. The company accounted for the negative effects of glucocorticoids by including increased probabilities of diabetes and fracture in the model, which are associated with costs and disutilities. In addition, all patients having glucocorticoids in the model were assigned a utility decrement of -0.07 for the duration of their treatment, reflecting the negative effects of common side effects such as weight gain and skin changes. The committee acknowledged that the disutility estimate does not include an exhaustive list of adverse events that can result from glucocorticoid treatment, but considered the source to be the most relevant reference. The ERG noted that within the disutility estimate is a separate 'base' disutility estimate (‑0.03) to capture common side effects for all patients having glucocorticoids. This was applied during each cycle patients were in the subsequent remission state. It assumed, after a relapse, people would continue to incur both the 'base' disutility and the specific side effects for the remainder of their lifetime. The ERG considered that unless patients continued to have lifelong treatment with glucocorticoids, it might not be appropriate to continue applying the 'base' disutility. Nevertheless, the committee concluded that the company's model adequately captures the negative effect of flares and glucocorticoids on quality of life. # The company's updated economic analysis ## The company's ICER for tocilizumab in relapsing or refractory disease is £18,801 per QALY gained with a 1-year stopping rule The company's original base-case deterministic incremental cost-effectiveness ratio (ICER) for the overall population was £28,272 per quality-adjusted life year (QALY) gained. This was based on a 2-year stopping rule and included a confidential patient access scheme discount for tocilizumab. In response to consultation, the company updated its economic model to focus only on the subgroup of people with relapsing or refractory giant cell arteritis. The updated economic model included the committee's preferred assumptions, specifically: a mean age of 73 years (section 3.4) switching the time to first flare extrapolation for glucocorticoids alone to the same Weibull function as tocilizumab after 2 years (section 3.10) basing the probabilities of subsequent flares on longitudinal cohort data (section 3.12).The updated model also included a number of company-preferred assumptions and corrections, specifically: incorporating a 1-year stopping rule for tocilizumab (section 3.9) incorporating the slowest glucocorticoid taper regimen (24 months) in the comparator arm to match NHS practice incorporating the costs for emergency department visits updating the costs of glucocorticoid-related adverse events to reflect 2017 health care utilisation, specifically: including additional costs for a yearly DEXA scan and prophylaxis medication inflating diabetes costs from 2005 to 2017 estimates revising fracture costs (based on Kanis et al. 2007) revising infection costs (based on Sarnes 2011) adjusting the ERG's flare rate to better reflect relapsing or refractory giant cell arteritis in the comparator arm of GiACTA correcting 2 programming errors: using the average weight of the relapsing and refractory population in GiACTA to calculate concomitant medication dosage (instead of the UK population), and correcting the yearly concomitant medication costs applied to the comparator arm.When incorporating these changes, the deterministic ICER for tocilizumab plus prednisolone compared with prednisolone alone, incorporating the confidential patient access scheme, was £18,801 per QALY gained in people with relapsed or refractory giant cell arteritis (a probabilistic ICER was not provided). # The ERG's updated alternative economic analysis ## The ERG's ICER for tocilizumab in relapsing and refractory disease is £24,977 per QALY gained when a 1-year stopping rule is applied The ERG's original base-case probabilistic ICER for the overall population was £65,801 per QALY gained. This was based on a 2-year stopping rule and included the committee's preferred assumptions. A confidential patient access scheme discount for tocilizumab was also applied. The ERG's revised economic model included a 1-year stopping rule, and focused only on people with relapsing or refractory disease. It made a number of other changes in its revised model, specifically: using both the average weight and body surface area estimates of the relapsing or refractory population in GiACTA to calculate the dosages of concomitant medication incorporating an alternative estimate for emergency department visits based on NHS reference costs including costs for a single DEXA scan, instead of yearly scans, and using average generic cost estimate for oral therapies (taken from NICE's technology appraisal guidance on bisphosphonates for treating osteoporosis) using fracture cost estimates that are consistent with those used in NICE's technology appraisal guidance on bisphosphonates for treating osteoporosis.The ERG did not consider the company's proposed change to the glucocorticoid tapering regimen to be appropriate, because only the cost of the comparator glucocorticoid taper regimen was adjusted and no adjustment was made to address the uncertainties about how this may affect the number of flares and time to first flare. The ERG also noted that the reference data used to update the infection costs in the company's updated economic model was taken from a US study (Sarnes 2011), so the generalisability of the findings to the NHS is unclear. In addition, the ERG considered the company's proposed additional adjustment to the ERG's estimated rates of subsequent flares (section 3.12) to be inappropriate. The ERG therefore did not make these changes in its revised analysis. When the ERG made its adjustments, the revised model produced ICERs for tocilizumab plus prednisolone compared with prednisolone alone of £24,977 (deterministic) and £24,032 (probabilistic) per QALY gained in people with relapsed or refractory giant cell arteritis (including the patient access scheme discount). # The most plausible ICER after consultation ## Tocilizumab is cost-effective only for relapsing or refractory giant cell arteritis and when a 1-year stopping rule is applied The committee preferred the ERG's estimates for both the overall population and people with relapsing or refractory giant cell arteritis, because they better reflected its preferred assumptions. It therefore concluded that the most plausible ICERs for tocilizumab plus prednisolone compared with prednisolone alone, incorporating the confidential patient access scheme, were £65,501 (2-year treatment duration) and £36,960 (1-year treatment duration) per QALY gained for the overall population and £55,924 (2-tear treatment duration) and £24,977 (1-year treatment duration) per QALY gained for people with relapsing or refractory giant cell arteritis. The ICERs for the overall population were higher than the range normally considered to be a cost-effective use of NHS resources (usually £20,000 to £30,000 per QALY), as were the ICERs when a 2-year treatment duration was applied, so the committee concluded that it would recommend tocilizumab as a cost-effective use of NHS resources only for treating relapsing or refractory giant cell arteritis and if a 1-year stopping rule is applied. # Other factors ## There are no additional benefits that are not captured in the QALY calculations The clinical experts highlighted that tocilizumab is the first new treatment for giant cell arteritis in several years. The committee was aware that before its marketing authorisation was granted, tocilizumab received a Promising Innovative Medicines designation for this indication. The patient experts explained that high doses of glucocorticoids are needed to treat flares and afterwards the tapering regimen must be restarted. This can have a large negative effect on quality of life, which may not be captured in the modelling. However, the committee noted that in the model, patients have a substantially lower utility during a flare, which is assumed to last for 4 weeks (section 3.8). In addition, after a disease flare, all patients have glucocorticoids and this is associated with a utility decrement (section 3.13). The committee concluded that there were no additional benefits that had not been captured in the QALY calculation. ## The recommendations do not have a different impact on people protected by equality legislation than on the wider population The committee discussed equality issues, and agreed that its recommendations apply equally regardless of age. In addition, issues related to differences in prevalence or incidence of a disease cannot be addressed in a technology appraisal. The committee concluded that its recommendations do not have a different impact on people protected by the equality legislation than on the wider population.

# Background Neuroendocrine tumours (NETs) are a family of tumours, occurring with an incidence of about 5.25 cases per 100,000 1 . The incidence of NETs is increasing over the last 3 decades. NETs can arise in several organs; the most common sites are the ileum and pancreas, followed by other sites within the GI tract, the lungs, thyroid, parathyroid, adrenal glands, and pituitary gland. However, NETS can occur anywhere in the body 2,3 . NETs are often classified as functioning or nonfunctioning tumours, the latter of which do not present with hormone hypersecretion, and are often found as a bulky tumours with metastatic disease. The five-year survival rate for patients with NETs depends largely upon the location of the primary tumour and the extent of disease. Patients with localized disease can expect five-year survival rates ranging from 65% for ileal tumours to 84% for lung tumours and 90% for rectal tumours 4 . As expected, patients with distant disease carry a worse prognosis with five-year survival rates ranging from 24% in the rectum and 27% in the lungs to 54% in the ileum 5 . Few curative options are available for patients with unresectable, progressive, or metastatic NETs. Peptide receptor radionuclide therapy (PRRT) has been studied in the clinical trial setting since about the year 2000. Several agents are potentially available, including 90Y-DOTAOC 6 , 111ln-DTPAOC 7 , 177Lu-DOTATATE 8 , which are radionuclides bound to the somatostatin analog octreotide. These agents work by binding to the tumour receptors and emitting radiation to the tumour. The Health Canada approved product (Lutathera, 177Lu-DOTATATE) is administered with a dose of 200mCi every 8 weeks for a total of four cycles. Dosing and timing may differ based on a centre's specific clinical research trial protocol. The most common side effects of treatment are nausea /vomiting, fatigue and decreased blood counts. Rare severe toxicities include myelodysplasia, acute leukemia, renal failure and hormonal crisis (if the tumour is secretory). The full listing of adverse events can be viewed further in the Lutathera product monographand/or the centre's trial protocol. The purpose of this guideline is to provide evidence-based recommendations on the use of PRRT for NETs and to define which patients are candidates for this treatment. This guideline will focus on the role of 177Lu-DOTATATE 9,10 # Search Strategy The National Guidelines Clearinghouse and individual cancer agencies' websites were searched for guidelines on the use of peptide receptor radionuclide therapy. Among the guidelines identified, Cancer Care Ontario's document, Radionuclide Therapy for Neuroendocrine Malignancies (August 15, 2011), was deemed appropriate by the working group for adaptation. The search strategy employed by Cancer Care Ontario was current to 2010 11 . In order to make the guideline adaptation current to 2018, the MEDLINE and EMBASE database was searched (2010 through 2021) using the same search strategy. The search initially resulted in1530 citations after duplicates were removed. Studies that did not report response rates or survival rates were excluded, as well as prospective studies that included 30 or fewer patients or retrospective studies that included 100 or fewer patients. A total of 60 publications were deemed relevant. Evidence is summarized in the table in Appendix A. # Target Population The recommendations in this guideline apply to patients diagnosed with unresectable, progressive, or metastatic neuroendocrine tumours. Recommendations 1. Peptide receptor radionuclide therapy (PRRT) is an appropriate treatment option for patients with unresectable or metastatic; progressive or symptomatic, NETs. Consideration for treatment is to be determined at a multidisciplinary neuroendocrine tumour board. # Required work up - Confirm diagnosis and staging of NET with histopathology and biochemical assays. The tumour differentiation must be present on the pathology report: Grade 1 (ki-6720%) tumours 12 . - Images should be reviewed to assess for receptor heterogeneity. If there is discordance between imaging modalities with presence of lesions that are suspected to be dedifferentiated based on absence of uptake on somatostatin receptor imaging or if they exhibit a rapid progression pattern on anatomic imaging, an FDG PET-CT should be performed to exclude aggressive or dedifferentiated disease that would not be amenable to PRRT and for prognostic purposes. - Baseline tumor markers should be obtained prior to initiating therapy, depending on origin and hormonal secretion status (secreting or not, ex: CgA and 5-HIAA, Insulinemia, etc). - Somatostatin receptor imaging (SRI) using PET or SPECT, such as Ga68 DOTA PET, octreotide scan or other available SRI imaging , to determine if tumour is somatostatin receptor positive. Sufficient tumour uptake is defined as higher than normal liver uptake. - For Higher grade tumors: ki67 >10%, it is recommended that Diagnostic imaging (CT and MRI), should be less than 3 months old. - If PRRT is received within a clinical trial, additional work up may be required based on the study protocol. - Conduct an appropriate laboratory assessment at baseline and before each cycle (directed at known side effects of treatment) o hematologic: CBCD (complete blood count and differential) o kidney function: electrolytes, creatinine and eGFR o liver function: bilirubin, albumin, INR, ALT o metabolic: fasting glucose - Perform cross sectional imaging (CT and/or MRI) at baseline (within 6 months of therapy initiation or less in case of suspected significant interval changes: significant elevation in tumor markers, clinical deterioration or other imaging showing significant progression) and at follow-up to assess tumour response. If PRRT is offered within a clinical trial, additional imaging may be required for tumour response assessment as per the trial protocol. # Development and Revision History This guideline was reviewed and endorsed by the Alberta Provincial Endocrine Tumour Team. Members include . Evidence was selected and reviewed by a working group comprised of members from the Alberta Provincial Endocrine Tumour Team, external participants identified by the Working Group Lead, and a methodologist from the Guideline Resource Unit. A detailed description of the methodology followed during the guideline development process can be found in the Guideline Resource Unit Handbook. This guideline was originally developed in 2021. # Maintenance A formal review of the guideline will be conducted in 2023. If critical new evidence is brought forward before that time, however, the guideline working group members will revise and update the document accordingly. # Abbreviations # Copyright © (2021) Alberta Health Services This copyright work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivative 4.0 International license. You are free to copy and distribute the work including in other media and formats for non-commercial purposes, as long as you attribute the work to Alberta Health Services, do not adapt the work, and abide by the other license terms. To view a copy of this license, see /. The license does not apply to AHS trademarks, logos or content for which Alberta Health Services is not the copyright owner.

Bleed Purple Foundation # Overview The Bleed Purple Foundation is a recognized charitable organization under section 501(c)(3) of the IRS code located in Denver, Colorado. Founded in 2005 by members of the Theta Zeta chapter of Delta Tau Delta International Fraternity in order to aid one of their brothers who was diagnosed with stage III-B Hodgkin's Lymphoma. As a sign of brotherhood and steadfast solidarity, the brothers came together and organized a head-shaving auction on the University of San Diego campus which raised more than US$4,000 for their brother. Thus, Bleed Purple was born. Bleed Purple's mission is to support college students suffering from cancer. As a college student, making ends meet can often be a challenge. Between classes, campus club meetings, unpaid internships and late-night study groups, finding time for a job that pays rent, let alone medical bills, is nearly impossible. Bleed Purple strives to bring together the Greek community in an effort to support college students diagnosed with cancer. The principal goal of Bleed Purple is to provide relief to college students with cancer who are facing financial hardships that often accompany the disease.

Anisocoria Anisocoria is a condition characterized by an unequal size of the pupils. # Causes To a certain extent, this is normal. Anisocoria to a mild degree (generally 0.3 to 0.5 mm) can be found in about 20% of people. This form is termed "simple anisocoria." When pathological, it may be seen in a variety of nervous system pathologies such as Wernicke-Korsakoff syndrome. In the absence of any deformities of the iris or eyeball proper, anisocoria is usually the result of a defect in efferent nervous pathways controlling the pupil traveling in the oculomotor nerve (parasympathetic fibers) or the sympathetic pathways. Physical lesions and drugs causing anisocoria will do so via disruption of these pathways. Some examples of drugs which may affect the pupils include pilocarpine, cocaine, tropicamide and scopolamine. Additionally, dilation of the pupil is termed mydriasis and constriction of the pupil is termed miosis. # Complete Differential Diagnosis of Anisocoria In alphabetical order - Adie's Syndrome - Alcohol intoxication - Aniridia - Argyll-Robertson Pupil - Arsenic poisoning - Botulism - Brain tumor - Cavernous sinus thrombosis - Cerebral aneurysm - Congenital - Degenerative neurologic disorders - Diabetes Mellitus - Diphtheria - Drugs - Encephalitis - Herpes Zoster - Horner's Syndrome - Injury to the iris - Internal carotid artery aneurysm - Intracranial hemorrhage - Iridocyclitis - Ischemia - Keratitis - Lead poisoning - Meningitis - Multiple Sclerosis - Narrow Angle Glaucoma - Neoplastic - Neurofibromatosis - Ocular prosthesis - Retinal disease - Syphilis - Syringomyelia - Tabes Dorsalis - Trauma - Tuberculosis # Interpretation Clinically, it is important to establish which of the two pupils is behaving abnormally. - If the smaller of the two pupils is the abnormal one, dimming the ambient light will not cause it to dilate, in which case a defect in sympathetic fibers is suspected, as seen in Horner's syndrome. - Alternatively, if the abnormal pupil is the larger one, it will fail to contract in response to light, raising suspicion for a parasympathetic nerve defect, possibly an oculomotor nerve palsy. A relative afferent pupillary defect or RAPD also known as a Marcus Gunn pupil does not cause anisocoria. When anisocoria occurs and the examiner is unsure whether the abnormal pupil is the constricted or dilated one, if a one-sided ptosis is present then the abnormally sized pupil can be presumed to be the one on the side of the ptosis.

Norethindrone acetate and Ethinyl estradiol # Disclaimer WikiDoc MAKES NO GUARANTEE OF VALIDITY. WikiDoc is not a professional health care provider, nor is it a suitable replacement for a licensed healthcare provider. WikiDoc is intended to be an educational tool, not a tool for any form of healthcare delivery. The educational content on WikiDoc drug pages is based upon the FDA package insert, National Library of Medicine content and practice guidelines / consensus statements. WikiDoc does not promote the administration of any medication or device that is not consistent with its labeling. Please read our full disclaimer here. # Overview Norethindrone acetate and Ethinyl estradiol is a contraceptive agent that is FDA approved for the treatment of acne-contraception, contraception, moderate to severe abnormal vasomotor function in menopause and for prophylaxis of postmenopausal osteoporosis, in women with an intact uterus. Common adverse reactions include abdominal cramps, abdominal pain, bloating symptom, nausea headache, break-through bleeding, pain of breast. # Adult Indications and Dosage ## FDA-Labeled Indications and Dosage (Adult) ### Contraception - Norethindrone acetate and ethinyl estradiol tablets, USP are indicated for the prevention of pregnancy in women who elect to use oral contraceptives as a method of contraception. - Oral contraceptives are highly effective. Table I lists the typical accidental pregnancy rates for users of combination oral contraceptives and other methods of contraception. The efficacy of these contraceptive methods, except sterilization, depends upon the reliability with which they are used. Correct and consistent use of methods can result in lower failure rates. - Dosing information - The tablet dispenser has been designed to make oral contraceptive dosing as easy and as convenient as possible. The tablets are arranged in three rows of seven tablets each, with the days of the week appearing on the tablet dispenser above the first row of tablets. - Note: Each tablet dispenser has been preprinted with the days of the week, starting with Sunday, to facilitate a Sunday-Start regimen. Six different day label strips have been provided with the Detailed Patient & Brief Summary Patient Package Insert in order to accommodate a Day-1 Start regimen. If the patient is using the Day-1 Start regimen, she should place the self-adhesive day label strip that corresponds to her starting day over the preprinted days. - Important: The patient should be instructed to use an additional method of protection until after the first week of administration in the initial cycle when utilizing the Sunday-Start regimen. - The possibility of ovulation and conception prior to initiation of use should be considered. - Dosage and Administration for 21-Day Dosage Regimen - To achieve maximum contraceptive effectiveness, norethindrone acetate and ethinyl estradiol tablets, USP should be taken exactly as directed and at intervals not exceeding 24 hours. - Norethindrone acetate and ethinyl estradiol tablets, USP provide the patient with a convenient tablet schedule of “3 weeks on –1 week off.” Two dosage regimens are described, one of which may be more convenient or suitable than the other for an individual patient. For the initial cycle of therapy, the patient begins her tablets according to the Day-1 Start or Sunday-Start regimen. With either regimen, the patient takes one tablet daily for 21 consecutive days followed by one week of no tablets. - A. Sunday-Start Regimen: - The patient begins taking tablets from the top row on the first Sunday after menstrual flow begins. When menstrual flow begins on Sunday, the first tablet is taken on the same day. The last tablet in the dispenser will then be taken on a Saturday, followed by no tablets for a week (7 days). For all subsequent cycles, the patient then begins a new 21-tablet regimen on the eighth day, Sunday, after taking her last tablet. Following this regimen, of 21 days on–7 days off, the patient will start all subsequent cycles on a Sunday. - B. Day-1 Start Regimen: - The first day of menstrual flow is Day 1. The patient places the self-adhesive day label strip that corresponds to her starting day over the preprinted days on the tablet dispenser. She starts taking one light green tablet daily, beginning with the first light green tablet in the top row. The patient completes her 21-tablet regimen when she has taken the last tablet in the tablet dispenser. She will then take no tablets for a week (7 days). For all subsequent cycles, the patient begins a new 21-tablet regimen on the eighth day after taking her last tablet, again starting with the first tablet in the top row after placing the appropriate day label strip over the preprinted days on the tablet dispenser. Following this regimen of 21 days on–7 days off, the patient will start all subsequent cycles on the same day of the week as the first course. Likewise, the interval of no tablets will always start on the same day of the week. - Tablets should be taken regularly with a meal or at bedtime. It should be stressed that efficacy of medication depends on strict adherence to the dosage schedule. ### Acne-Contraception - Dosing information - 1 tablet ORALLY daily for 21 consecutive days followed by 1 week of no tablets. ### Menopause - Moderate to severe abnormal vasomotor function - Dosing information - Femhrt(R), 1 tablet ORALLY daily; initiate therapy at the lowest effective dose and for the shortest duration consistent with treatment goals and risks. ### Postmenopausal osteoporosis, In women with an intact uterus; Prophylaxis - Dosing information - Femhrt(R), 1 tablet ORALLY daily; initiate therapy at the lowest effective dose and for the shortest duration consistent with treatment goals and risks. ## Noncontraceptive health benefits= - The following non-contraceptive health benefits related to the use of oral contraceptives are supported by epidemiological studies which largely utilized oral contraceptive formulations containing estrogen doses exceeding 0.035 mg of ethinyl estradiol or 0.05 mg of mestranol (79 to 84). - Effects on menses: - Increased menstrual cycle regularity - Decreased blood loss and decreased incidence of iron deficiency anemia - Decreased incidence of dysmenorrhea - Effects related to inhibition of ovulation: - Decreased incidence of functional ovarian cysts - Decreased incidence of ectopic pregnancies - Effects from long-term use: - Decreased incidence of fibroadenomas and fibrocystic disease of the breast - Decreased incidence of acute pelvic inflammatory disease - Decreased incidence of endometrial cancer - Decreased incidence of ovarian cancer ## Off-Label Use and Dosage (Adult) ### Guideline-Supported Use - There is limited information regarding Off-Label Guideline-Supported Use of Norethindrone acetate and Ethinyl estradiol tablet in adult patients. ### Non–Guideline-Supported Use - There is limited information regarding Off-Label Non–Guideline-Supported Use of Norethindrone acetate and Ethinyl estradiol tablet in adult patients. # Pediatric Indications and Dosage ## FDA-Labeled Indications and Dosage (Pediatric) ### Acne - Contraception - Dosing information - 15 years of age and older and after menarche has begun, 1 tablet ORALLY daily for 21 consecutive days followed by 1 week of no tablets ### Contraception - Dosing information - after menarche has begun, 1 tablet ORALLY daily for 21 consecutive days followed by 1 week of no tablets - Safety and efficacy of femhrt(R) not established. Use of Junel(R), Loestrin(R), Microgestin(R) or Tri-Legest(R) for contraception before menarche is not indicated. - Safety and efficacy of Tri-Legest(R) for acne in children less than 15 years of age not established ## Off-Label Use and Dosage (Pediatric) ### Guideline-Supported Use - There is limited information regarding Off-Label Guideline-Supported Use of Norethindrone acetate and Ethinyl estradiol tablet in pediatric patients. ### Non–Guideline-Supported Use - There is limited information regarding Off-Label Non–Guideline-Supported Use of Norethindrone acetate and Ethinyl estradiol tablet in pediatric patients. # Contraindications Oral contraceptives should not be used in women who currently have the following conditions: - Thrombophlebitis or thromboembolic disorders - A past history of deep vein thrombophlebitis or thromboembolic disorders - Cerebral vascular or coronary artery disease - Known or suspected carcinoma of the breast - Carcinoma of the endometrium or other known or suspected estrogen-dependent neoplasia - Undiagnosed abnormal genital bleeding - Cholestatic jaundice of pregnancy or jaundice with prior pill use - Hepatic adenomas or carcinomas - Known or suspected pregnancy # Warnings - The use of oral contraceptives is associated with increased risks of several serious conditions including myocardial infarction, thromboembolism, stroke, hepatic neoplasia, and gallbladder disease, although the risk of serious morbidity or mortality is very small in healthy women without underlying risk factors. The risk of morbidity and mortality increases significantly in the presence of other underlying risk factors such as hypertension, hyperlipidemias, obesity, and diabetes. - Practitioners prescribing oral contraceptives should be familiar with the following information relating to these risks. - The information contained in this package insert is principally based on studies carried out in patients who used oral contraceptives with higher formulations of estrogens and progestogens than those in common use today. The effect of long-term use of the oral contraceptives with lower formulations of both estrogens and progestogens remains to be determined. - Throughout this labeling, epidemiological studies reported are of two types: retrospective or case control studies and prospective or cohort studies. Case control studies provide a measure of the relative risk of a disease, namely, a ratio of the incidence of a disease among oral contraceptive users to that among nonusers. The relative risk does not provide information on the actual clinical occurrence of a disease. Cohort studies provide a measure of attributable risk, which is the difference in the incidence of disease between oral contraceptive users and nonusers. The attributable risk does provide information about the actual occurrence of a disease in the population (adapted from References 8 and 9 with the author's permission). For further information, the reader is referred to a text on epidemiological methods. Thromboembolic Disorders and Other Vascular Problems a. Myocardial Infarction - An increased risk of myocardial infarction has been attributed to oral contraceptive use. This risk is primarily in smokers or women with other underlying risk factors for coronary artery disease such as hypertension, hypercholesterolemia, morbid obesity, and diabetes. The relative risk of heart attack for current oral contraceptive users has been estimated to be two to six. The risk is very low under the age of 30. - Smoking in combination with oral contraceptive use has been shown to contribute substantially to the incidence of myocardial infarctions in women in their mid-thirties or older with smoking accounting for the majority of excess cases. Mortality rates associated with circulatory disease have been shown to increase substantially in smokers over the age of 35 and non-smokers over the age of 40 (Table II) among women who use oral contraceptives. - Oral contraceptives may compound the effects of well-known risk factors, such as hypertension, diabetes, hyperlipidemias, age and obesity (19). In particular, some progestogens are known to decrease HDL cholesterol and cause glucose intolerance, while estrogens may create a state of hyperinsulinism (20 to 24). Oral contraceptives have been shown to increase blood pressure among users. Similar effects on risk factors have been associated with an increased risk of heart disease. Oral contraceptives must be used with caution in women with cardiovascular disease risk factors. b. Thromboembolism - An increased risk of thromboembolic and thrombotic disease associated with the use of oral contraceptives is well established. Case control studies have found the relative risk of users compared to non-users to be 3 for the first episode of superficial venous thrombosis, 4 to 11 for deep vein thrombosis or pulmonary embolism, and 1.5 to 6 for women with predisposing conditions for venous thromboembolic disease. Cohort studies have shown the relative risk to be somewhat lower, about 3 for new cases and about 4.5 for new cases requiring hospitalization. The risk of thromboembolic disease due to oral contraceptives is not related to length of use and disappears after pill use is stopped. - A two- to four-fold increase in relative risk of postoperative thromboembolic complications has been reported with the use of oral contraceptives (15,32). The relative risk of venous thrombosis in women who have predisposing conditions is twice that of women without such medical conditions (15,32). If feasible, oral contraceptives should be discontinued at least four weeks prior to and for two weeks after elective surgery of a type associated with an increase in risk of thromboembolism and during and following prolonged immobilization. Since the immediate postpartum period is also associated with an increased risk of thromboembolism, oral contraceptives should be started no earlier than four to six weeks after delivery in women who elect not to breast feed. c. Cerebrovascular Diseases - Oral contraceptives have been shown to increase both the relative and attributable risks of cerebrovascular events (thrombotic and hemorrhagic strokes), although, in general, the risk is greatest among older (> 35 years), hypertensive women who also smoke. Hypertension was found to be a risk factor for both users and nonusers, for both types of strokes, while smoking interacted to increase the risk for hemorrhagic strokes (33 to 35). - In a large study, the relative risk of thrombotic strokes has been shown to range from 3 for normotensive users to 14 for users with severe hypertension. The relative risk of hemorrhagic stroke is reported to be 1.2 for non-smokers who used oral contraceptives, 2.6 for smokers who did not use oral contraceptives, 7.6 for smokers who used oral contraceptives, 1.8 for normotensive users, and 25.7 for users with severe hypertension. The attributable risk is also greater in older women. d. Dose-Related Risk of Vascular Disease from Oral Contraceptives - A positive association has been observed between the amount of estrogen and progestogen in oral contraceptives and the risk of vascular disease (37 to 39). A decline in serum high-density lipoproteins (HDL) has been reported with many progestational agents. A decline in serum high-density lipoproteins has been associated with an increased incidence of ischemic heart disease. Because estrogens increase HDL cholesterol, the net effect of an oral contraceptive depends on a balance achieved between doses of estrogen and progestin and the nature of the progestin used in the contraceptives. The amount and activity of both hormones should be considered in the choice of an oral contraceptive. - Minimizing exposure to estrogen and progestogen is in keeping with good principles of therapeutics. For any particular oral contraceptive, the dosage regimen prescribed should be one which contains the least amount of estrogen and progestogen that is compatible with the needs of the individual patient. New acceptors of oral contraceptive agents should be started on preparations containing the lowest dose of estrogen which produces satisfactory results for the patient. e. Persistence of Risk of Vascular Disease - There are two studies which have shown persistence of risk of vascular disease for ever-users of oral contraceptives. In a study in the United States, the risk of developing myocardial infarction after discontinuing oral contraceptives persists for at least 9 years for women 40 to 49 years who had used oral contraceptives for 5 or more years, but this increased risk was not demonstrated in other age groups. In another study in Great Britain, the risk of developing cerebrovascular disease persisted for at least 6 years after discontinuation of oral contraceptives, although excess risk was very small. However, both studies were performed with oral contraceptive formulations containing 50 mcg or higher of estrogens. 2. Estimates of Mortality from Contraceptive Use - One study gathered data from a variety of sources which have estimated the mortality rate associated with different methods of contraception at different ages (Table III). These estimates include the combined risk of death associated with contraceptive methods plus the risk attributable to pregnancy in the event of method failure. Each method of contraception has its specific benefits and risks. The study concluded that with the exception of oral contraceptive users 35 and older who smoke and 40 and older who do not smoke, mortality associated with all methods of birth control is low and below that associated with childbirth. The observation of a possible increase in risk of mortality with age for oral contraceptive users is based on data gathered in the 1970's but not reported until 1983. However, current clinical practice involves the use of lower estrogen dose formulations combined with careful restriction of oral contraceptive use to women who do not have the various risk factors listed in this labeling. - Because of these changes in practice and, also, because of some limited new data which suggest that the risk of cardiovascular disease with the use of oral contraceptives may now be less than previously observed (Porter JB, Hunter J, Jick H, et al. Oral contraceptives and nonfatal vascular disease. Obstet Gynecol 1985;66:1-4; and Porter JB, Hershel J, Walker AM. Mortality among oral contraceptive users. Obstet Gynecol 1987;70:29-32), the Fertility and Maternal Health Drugs Advisory Committee was asked to review the topic in 1989. The Committee concluded that although cardiovascular disease risks may be increased with oral contraceptive use after age 40 in healthy non-smoking women (even with the newer low-dose formulations), there are greater potential health risks associated with pregnancy in older women and with the alternative surgical and medical procedures which may be necessary if such women do not have access to effective and acceptable means of contraception. - Therefore, the Committee recommended that the benefits of oral contraceptive use by healthy non-smoking women over 40 may outweigh the possible risks. Of course, older women, as all women who take oral contraceptives, should take the lowest possible dose formulation that is effective. Carcinoma of the Reproductive Organs - Numerous epidemiological studies have been performed on the incidence of breast, endometrial, ovarian, and cervical cancer in women using oral contraceptives. Most of the studies on breast cancer and oral contraceptive use report that the use of oral contraceptives is not associated with an increase in the risk of developing breast cancer. Some studies have reported an increased risk of developing breast cancer in certain subgroups of oral contraceptive users, but the findings reported in these studies are not consistent. - Some studies suggest that oral contraceptive use has been associated with an increase in the risk of cervical intraepithelial neoplasia in some populations of women. However, there continues to be controversy about the extent to which such findings may be due to differences in sexual behavior and other factors. - In spite of many studies of the relationship between oral contraceptive use and breast and cervical cancers, a cause and effect relationship has not been established. Hepatic Neoplasia - Benign hepatic adenomas are associated with oral contraceptive use, although the incidence of benign tumors is rare in the United States. Indirect calculations have estimated the attributable risk to be in the range of 3.3 cases/100,000 for users, a risk that increases after four or more years of use. Rupture of rare, benign, hepatic adenomas may cause death through intra-abdominal hemorrhage. - Studies from Britain have shown an increased risk of developing hepatocellular carcinoma in long-term (> 8 years) oral contraceptive users. However, these cancers are extremely rare in the U.S., and the attributable risk (the excess incidence) of liver cancers in oral contraceptive users approaches less than one per million users. Ocular Lesions - There have been clinical case reports of retinal thrombosis associated with the use of oral contraceptives. Oral contraceptives should be discontinued if there is unexplained partial or complete loss of vision; onset of proptosis or diplopia; papilledema; or retinal vascular lesions. Appropriate diagnostic and therapeutic measures should be undertaken immediately. Oral Contraceptive Use Before and During Early Pregnancy - Extensive epidemiological studies have revealed no increased risk of birth defects in women who have used oral contraceptives prior to pregnancy. Studies also do not suggest a teratogenic effect, particularly insofar as cardiac anomalies and limb reduction defects are concerned when taken inadvertently during early pregnancy. - The administration of oral contraceptives to induce withdrawal bleeding should not be used as a test for pregnancy. Oral contraceptives should not be used during pregnancy to treat threatened or habitual abortion. - It is recommended that for any patient who has missed two consecutive periods, pregnancy should be ruled out before continuing oral contraceptive use. If the patient has not adhered to the prescribed schedule, the possibility of pregnancy should be considered at the time of the first missed period. Oral contraceptive use should be discontinued if pregnancy is confirmed. Gallbladder Disease - Earlier studies have reported an increased lifetime relative risk of gallbladder surgery in users of oral contraceptives and estrogens. More recent studies, however, have shown that the relative risk of developing gallbladder disease among oral contraceptive users may be minimal. The recent findings of minimal risk may be related to the use of oral contraceptive formulations containing lower hormonal doses of estrogens and progestogens. Carbohydrate and Lipid Metabolic Effects - Oral contraceptives have been shown to cause glucose intolerance in a significant percentage of users. Oral contraceptives containing greater than 75 mcg of estrogens cause hyperinsulinism, while lower doses of estrogen cause less glucose intolerance. Progestogens increase insulin secretion and create insulin resistance, this effect varying with different progestational agents. However, in the non-diabetic woman, oral contraceptives appear to have no effect on fasting blood glucose. Because of these demonstrated effects, prediabetic and diabetic women should be carefully observed while taking oral contraceptives. - A small proportion of women will have persistent hypertriglyceridemia while on the pill. As discussed earlier (see WARNINGS 1a. and 1d.), changes in serum triglycerides and lipoprotein levels have been reported in oral contraceptive users. Elevated Blood Pressure - An increase in blood pressure has been reported in women taking oral contraceptives and this increase is more likely in older oral contraceptive users and with continued use. Data from the Royal College of General Practitioners and subsequent randomized trials have shown that the incidence of hypertension increases with increasing concentrations of progestogens. - Women with a history of hypertension or hypertension-related diseases or renal disease should be encouraged to use another method of contraception. If women elect to use oral contraceptives, they should be monitored closely, and if significant elevation of blood pressure occurs, oral contraceptives should be discontinued. For most women, elevated blood pressure will return to normal after stopping oral contraceptives, and there is no difference in the occurrence of hypertension among ever and never users. Headache - The onset or exacerbation of migraine or development of headache with a new pattern which is recurrent, persistent, or severe requires discontinuation of oral contraceptives and evaluation of the cause. Bleeding Irregularities - Breakthrough bleeding and spotting are sometimes encountered in patients on oral contraceptives, especially during the first three months of use. Non-hormonal causes should be considered, and adequate diagnostic measures taken to rule out malignancy or pregnancy in the event of breakthrough bleeding, as in the case of any abnormal vaginal bleeding. If pathology has been excluded, time or a change to another formulation may solve the problem. In the event of amenorrhea, pregnancy should be ruled out. - Some women may encounter post-pill amenorrhea or oligomenorrhea, especially when such a condition was preexistent. ### Precautions - 1. Patients should be counseled that this product does not protect against HIV infection (AIDS) and other sexually transmitted diseases. Physical Examination and Follow-Up - It is good medical practice for all women to have annual history and physical examinations, including women using oral contraceptives. The physical examination, however, may be deferred until after initiation of oral contraceptives if requested by the woman and judged appropriate by the clinician. The physical examination should include special reference to blood pressure, breasts, abdomen and pelvic organs, including cervical cytology, and relevant laboratory tests. In case of undiagnosed, persistent or recurrent abnormal vaginal bleeding, appropriate measures should be conducted to rule out malignancy. Women with a strong family history of breast cancer or who have breast nodules should be monitored with particular care. Lipid Disorders - Women who are being treated for hyperlipidemia should be followed closely if they elect to use oral contraceptives. Some progestogens may elevate LDL levels and may render the control of hyperlipidemias more difficult. Liver Function - If jaundice develops in any woman receiving such drugs, the medication should be discontinued. Steroid hormones may be poorly metabolized in patients with impaired liver function. Fluid Retention - Oral contraceptives may cause some degree of fluid retention. They should be prescribed with caution, and only with careful monitoring, in patients with conditions which might be aggravated by fluid retention. Emotional Disorders - Women with a history of depression should be carefully observed and the drug discontinued if depression recurs to a serious degree. Contact Lenses - Contact lens wearers who develop visual changes or changes in lens tolerance should be assessed by an ophthalmologist. # Adverse Reactions ## Clinical Trials Experience - An increased risk of the following serious adverse reactions has been associated with the use of oral contraceptives (see WARNINGS section): - Thrombophlebitis - Arterial thromboembolism - Pulmonary embolism - Myocardial infarction - Cerebral hemorrhage - Cerebral thrombosis - Hypertension - Gallbladder disease - Hepatic adenomas or benign liver tumors - There is evidence of an association between the following conditions and the use of oral contraceptives, although additional confirmatory studies are needed: - Mesenteric thrombosis - Retinal thrombosis - The following adverse reactions have been reported in patients receiving oral contraceptives and are believed to be drug-related: - Nausea - Vomiting - Gastrointestinal symptoms (such as abdominal cramps and bloating) - Breakthrough bleeding - Spotting - Change in menstrual flow - Amenorrhea - Temporary infertility after discontinuation of treatment - Edema - Melasma which may persist - Breast changes: tenderness, enlargement, secretion - Change in weight (increase or decrease) - Change in cervical erosion and secretion - Diminution in lactation when given immediately postpartum - Cholestatic jaundice - Migraine - Rash (allergic) - Mental depression - Reduced tolerance to carbohydrates - Vaginal candidiasis - Change in corneal curvature (steepening) - Intolerance to contact lenses - The following adverse reactions have been reported in users of oral contraceptives and the association has been neither confirmed nor refuted: - Pre-menstrual syndrome - Cataracts - Changes in appetite - Cystitis-like syndrome - Headache - Nervousness - Dizziness - Hirsutism - Loss of scalp hair - Erythema multiforme - Erythema nodosum - Hemorrhagic eruption - Vaginitis - Porphyria - Impaired renal function - Hemolytic uremic syndrome - Budd-Chiari syndrome - Acne - Changes in libido - Colitis ## Postmarketing Experience There is limited information regarding Norethindrone acetate and Ethinyl estradiol Postmarketing Experience in the drug label. # Drug Interactions Effects of Other Drugs on Oral Contraceptives Rifampin - Metabolism of both norethindrone and ethinyl estradiol is increased by rifampin. A reduction in contraceptive effectiveness and increased incidence of breakthrough bleeding and menstrual irregularities have been associated with concomitant use of rifampin. Anticonvulsants - Anticonvulsants such as phenobarbital, phenytoin, and carbamazepine, have been shown to increase the metabolism of ethinyl estradiol and/or norethindrone, which could result in a reduction in contraceptive effectiveness. Troglitazone - Administration of troglitazone with an oral contraceptive containing ethinyl estradiol and norethindrone reduced the plasma concentrations of both by approximately 30%, which could result in a reduction in contraceptive effectiveness. Antibiotics - Pregnancy while taking oral contraceptives has been reported when the oral contraceptives were administered with antimicrobials such as ampicillin, tetracycline, and griseofulvin. However, clinical pharmacokinetic studies have not demonstrated any consistent effect of antibiotics (other than rifampin) on plasma concentrations of synthetic steroids. Atorvastatin - Coadministration of atorvastatin and an oral contraceptive increased AUC values for norethindrone and ethinyl estradiol by approximately 30% and 20%, respectively. Other - Ascorbic acid and acetaminophen may increase plasma ethinyl estradiol concentrations, possibly by inhibition of conjugation. A reduction in contraceptive effectiveness and increased incidence of breakthrough bleeding has been suggested with phenylbutazone. Effects of Oral Contraceptives on Other Drugs - Oral contraceptive combinations containing ethinyl estradiol may inhibit the metabolism of other compounds. Increased plasma concentrations of cyclosporine, prednisolone, and theophylline have been reported with concomitant administration of oral contraceptives. In addition, oral contraceptives may induce the conjugation of other compounds. Decreased plasma concentrations of acetaminophen and increased clearance of temazepam, salicylic acid, morphine, and clofibric acid have been noted when these drugs were administered with oral contraceptives. Interactions with Laboratory Tests Certain endocrine and liver function tests and blood components may be affected by oral contraceptives: - Increased prothrombin and factors VII, VIII, IX, and X; decreased antithrombin 3; increased norepinephrine-induced platelet aggregability. - Increased thyroid binding globulin (TBG) leading to increased circulating total thyroid hormone, as measured by protein-bound iodine (PBI), T4 by column or by radioimmunoassay. Free T3 resin uptake is decreased, reflecting the elevated TBG; free T4 concentration is unaltered. - Other binding proteins may be elevated in serum. - Sex-binding globulins are increased and result in elevated levels of total circulating sex steroids and corticoids; however, free or biologically active levels remain unchanged. - Triglycerides may be increased. - Glucose tolerance may be decreased. - 8Serum folate levels may be depressed by oral contraceptive therapy. This may be of clinical significance if a woman becomes pregnant shortly after discontinuing oral contraceptives. # Use in Specific Populations ### Pregnancy Pregnancy Category (FDA): Oral Contraceptive Use Before and During Early Pregnancy - Extensive epidemiological studies have revealed no increased risk of birth defects in women who have used oral contraceptives prior to pregnancy (61 to 63). Studies also do not suggest a teratogenic effect, particularly insofar as cardiac anomalies and limb reduction defects are concerned (61,62,64,65) when taken inadvertently during early pregnancy. - The administration of oral contraceptives to induce withdrawal bleeding should not be used as a test for pregnancy. Oral contraceptives should not be used during pregnancy to treat threatened or habitual abortion. - It is recommended that for any patient who has missed two consecutive periods, pregnancy should be ruled out before continuing oral contraceptive use. If the patient has not adhered to the prescribed schedule, the possibility of pregnancy should be considered at the time of the first missed period. Oral contraceptive use should be discontinued if pregnancy is confirmed. Pregnancy Category (AUS): There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Norethindrone acetate and Ethinyl estradiol in women who are pregnant. ### Labor and Delivery There is no FDA guidance on use of Norethindrone acetate and Ethinyl estradiol during labor and delivery. ### Nursing Mothers - Small amounts of oral contraceptive steroids have been identified in the milk of nursing mothers, and a few adverse effects on the child have been reported, including jaundice and breast enlargement. In addition, oral contraceptives given in the postpartum period may interfere with lactation by decreasing the quantity and quality of breast milk. If possible, the nursing mother should be advised not to use oral contraceptives but to use other forms of contraception until she has completely weaned her child. ### Pediatric Use - Safety and efficacy of norethindrone acetate and ethinyl estradiol tablets have been established in women of reproductive age. Safety and efficacy are expected to be the same for postpubertal adolescents under the age of 16 and for users 16 years and older. Use of this product before menarche is not indicated. ### Geriatic Use There is no FDA guidance on the use of Norethindrone acetate and Ethinyl estradiol in geriatric settings. ### Gender There is no FDA guidance on the use of Norethindrone acetate and Ethinyl estradiol with respect to specific gender populations. ### Race There is no FDA guidance on the use of Norethindrone acetate and Ethinyl estradiol with respect to specific racial populations. ### Renal Impairment There is no FDA guidance on the use of Norethindrone acetate and Ethinyl estradiol in patients with renal impairment. ### Hepatic Impairment There is no FDA guidance on the use of Norethindrone acetate and Ethinyl estradiol in patients with hepatic impairment. ### Females of Reproductive Potential and Males There is no FDA guidance on the use of Norethindrone acetate and Ethinyl estradiol in women of reproductive potentials and males. ### Immunocompromised Patients There is no FDA guidance one the use of Norethindrone acetate and Ethinyl estradiol in patients who are immunocompromised. # Administration and Monitoring ### Administration - The tablet dispenser has been designed to make oral contraceptive dosing as easy and as convenient as possible. The tablets are arranged in three rows of seven tablets each, with the days of the week appearing on the tablet dispenser above the first row of tablets. - Note: Each tablet dispenser has been preprinted with the days of the week, starting with Sunday, to facilitate a Sunday-Start regimen. Six different day label strips have been provided with the Detailed Patient & Brief Summary Patient Package Insert in order to accommodate a Day-1 Start regimen. If the patient is using the Day-1 Start regimen, she should place the self-adhesive day label strip that corresponds to her starting day over the preprinted days. - Important: The patient should be instructed to use an additional method of protection until after the first week of administration in the initial cycle when utilizing the Sunday-Start regimen. - The possibility of ovulation and conception prior to initiation of use should be considered. Dosage and Administration for 21-Day Dosage Regimen - To achieve maximum contraceptive effectiveness, norethindrone acetate and ethinyl estradiol tablets, USP should be taken exactly as directed and at intervals not exceeding 24 hours. - Norethindrone acetate and ethinyl estradiol tablets, USP provide the patient with a convenient tablet schedule of “3 weeks on –1 week off.” Two dosage regimens are described, one of which may be more convenient or suitable than the other for an individual patient. For the initial cycle of therapy, the patient begins her tablets according to the Day-1 Start or Sunday-Start regimen. With either regimen, the patient takes one tablet daily for 21 consecutive days followed by one week of no tablets. A. Sunday-Start Regimen: - The patient begins taking tablets from the top row on the first Sunday after menstrual flow begins. When menstrual flow begins on Sunday, the first tablet is taken on the same day. The last tablet in the dispenser will then be taken on a Saturday, followed by no tablets for a week (7 days). For all subsequent cycles, the patient then begins a new 21-tablet regimen on the eighth day, Sunday, after taking her last tablet. Following this regimen, of 21 days on–7 days off, the patient will start all subsequent cycles on a Sunday. B. Day-1 Start Regimen: - The first day of menstrual flow is Day 1. The patient places the self-adhesive day label strip that corresponds to her starting day over the preprinted days on the tablet dispenser. She starts taking one light green tablet daily, beginning with the first light green tablet in the top row. The patient completes her 21-tablet regimen when she has taken the last tablet in the tablet dispenser. She will then take no tablets for a week (7 days). For all subsequent cycles, the patient begins a new 21-tablet regimen on the eighth day after taking her last tablet, again starting with the first tablet in the top row after placing the appropriate day label strip over the preprinted days on the tablet dispenser. Following this regimen of 21 days on–7 days off, the patient will start all subsequent cycles on the same day of the week as the first course. Likewise, the interval of no tablets will always start on the same day of the week. - Tablets should be taken regularly with a meal or at bedtime. It should be stressed that efficacy of medication depends on strict adherence to the dosage schedule. Special Notes on Administration - Menstruation usually begins two or three days, but may begin as late as the fourth or fifth day, after discontinuing medication. If spotting occurs while on the usual regimen of one tablet daily, the patient should continue medication without interruption. - If the patient forgets to take one or more light green tablets, the following is suggested: - One tablet is missed - take tablet as soon as remembered - take next tablet at the regular time - Two consecutive tablets are missed (week 1 or week 2) - take two tablets as soon as remembered - take two tablets the next day - use another birth control method for seven days following the missed tablets - Two consecutive tablets are missed (week 3) - Sunday-Start Regimen: - take one tablet daily until Sunday - discard remaining tablets - start new pack of tablets immediately (Sunday) - use another birth control method for seven days following missed tablets - Day-1 Start Regimen: - discard remaining tablets - start new pack of tablets that same day - use another birth control method for seven days following missed tablets - Three (or more) consecutive tablets are missed - Sunday-Start Regimen: - take one tablet daily until Sunday - discard remaining tablets - start new pack of tablets immediately (Sunday) - use another birth control method for seven days following missed tablets - Day-1 Start Regimen: - discard remaining tablets - start new pack of tablets that same day - use another birth control method for seven days following missed tablets - The possibility of ovulation occurring increases with each successive day that scheduled light green tablets are missed. While there is little likelihood of ovulation occurring if only one light green tablet is missed, the possibility of spotting or bleeding is increased. This is particularly likely to occur if two or more consecutive light green tablets are missed. - In the rare case of bleeding which resembles menstruation, the patient should be advised to discontinue medication and then begin taking tablets from a new tablet dispenser on the next Sunday or the first day (Day-1), depending on her regimen. Persistent bleeding which is not controlled by this method indicates the need for reexamination of the patient, at which time nonfunctional causes should be considered. - Use of Oral Contraceptives in the Event of a Missed Menstrual Period - If the patient has not adhered to the prescribed dosage regimen, the possibility of pregnancy should be considered after the first missed period and oral contraceptives should be withheld until pregnancy has been ruled out. - If the patient has adhered to the prescribed regimen and misses two consecutive periods, pregnancy should be ruled out before continuing the contraceptive regimen. - After several months on treatment, bleeding may be reduced to a point of virtual absence. This reduced flow may occur as a result of medication, in which event it is not indicative of pregnancy. ### Monitoring - Women with a history of hypertension or hypertension-related diseases or renal disease (76) should be encouraged to use another method of contraception. If women elect to use oral contraceptives, they should be monitored closely, and if significant elevation of blood pressure occurs, oral contraceptives should be discontinued. For most women, elevated blood pressure will return to normal after stopping oral contraceptives (75), and there is no difference in the occurrence of hypertension among ever and never users (74,76,77). - Women with a strong family history of breast cancer or who have breast nodules should be monitored with particular care. - Oral contraceptives may cause some degree of fluid retention. They should be prescribed with caution, and only with careful monitoring, in patients with conditions which might be aggravated by fluid retention. # IV Compatibility There is limited information regarding the compatibility of Norethindrone acetate and Ethinyl estradiol and IV administrations. # Overdosage - Serious ill effects have not been reported following acute ingestion of large doses of oral contraceptives by young children. Overdosage may cause nausea, and withdrawal bleeding may occur in females. # Pharmacology There is limited information regarding Norethindrone acetate and Ethinyl estradiol Pharmacology in the drug label. ## Mechanism of Action - Combination oral contraceptives act by suppression of gonadotropins. Although the primary mechanism of this action is inhibition of ovulation, other alterations include changes in the cervical mucus (which increase the difficulty of sperm entry into the uterus) and the endometrium (which reduce the likelihood of implantation). ## Structure - Norethindrone acetate and ethinyl estradiol tablets, USP are progestogen-estrogen combinations. - Norethindrone acetate and ethinyl estradiol tablets, USP provide a continuous dosage regimen consisting of 21 oral contraceptive tablets. - Each light green tablet contains norethindrone acetate (17 alpha-ethinyl-19-nortestosterone acetate), 1.5 mg; ethinyl estradiol (17 alpha-ethinyl-1,3,5(10)-estratriene-3, 17 beta-diol), 0.03 mg. Also contains colloidal silicon dioxide, compressible sugar, croscarmellose sodium, D&C Yellow #10 aluminum lake, FD&C Blue #1 aluminum lake, FD&C Yellow #6 aluminum lake, hypromellose, lactose monohydrate, magnesium stearate, polyethylene glycol 400, polyethylene glycol 8000, pregelatinized starch, sodium lauryl sulfate and Vitamin E. - The structural formulas are as follows: ## Pharmacodynamics There is limited information regarding Norethindrone acetate and Ethinyl estradiol Pharmacodynamics in the drug label. ## Pharmacokinetics - The pharmacokinetics of norethindrone acetate and ethinyl estradiol tablets have not been characterized; however, the following pharmacokinetic information regarding norethindrone acetate and ethinyl estradiol is taken from the literature. Absorption - Norethindrone acetate appears to be completely and rapidly deacetylated to norethindrone after oral administration, since the disposition of norethindrone acetate is indistinguishable from that of orally administered norethindrone (1). Norethindrone acetate and ethinyl estradiol are subject to first-pass metabolism after oral dosing, resulting in an absolute bioavailability of approximately 64% for norethindrone and 43% for ethinyl estradiol (1 to 3). Distribution - Volume of distribution of norethindrone and ethinyl estradiol ranges from 2 to 4 L/kg (1 to 3). Plasma protein binding of both steroids is extensive (> 95%); norethindrone binds to both albumin and sex hormone binding globulin, whereas ethinyl estradiol binds only to albumin (4). Metabolism - Norethindrone undergoes extensive biotransformation, primarily via reduction, followed by sulfate and glucuronide conjugation. The majority of metabolites in the circulation are sulfates, with glucuronides accounting for most of the urinary metabolites (5). A small amount of norethindrone acetate is metabolically converted to ethinyl estradiol. Ethinyl estradiol is also extensively metabolized, both by oxidation and by conjugation with sulfate and glucuronide. Sulfates are the major circulating conjugates of ethinyl estradiol and glucuronides predominate in urine. The primary oxidative metabolite is 2-hydroxy ethinyl estradiol, formed by the CYP3A4 isoform of cytochrome P450. Part of the first-pass metabolism of ethinyl estradiol is believed to occur in gastrointestinal mucosa. Ethinyl estradiol may undergo enterohepatic circulation (6). Excretion - Norethindrone and ethinyl estradiol are excreted in both urine and feces, primarily as metabolites (5,6). Plasma clearance values for norethindrone and ethinyl estradiol are similar (approximately 0.4 L/hr/kg) (1 to 3). Special Population Race - The effect of race on the disposition of norethindrone acetate and ethinyl estradiol tablets have not been evaluated. Renal Insufficiency - The effect of renal disease on the disposition of norethindrone acetate and ethinyl estradiol tablets has not been evaluated. In premenopausal women with chronic renal failure undergoing peritoneal dialysis who received multiple doses of an oral contraceptive containing ethinyl estradiol and norethindrone, plasma ethinyl estradiol concentrations were higher and norethindrone concentrations were unchanged compared to concentrations in premenopausal women with normal renal function. Hepatic Insufficiency - The effect of hepatic disease on the disposition of norethindrone acetate and ethinyl estradiol tablets has not been evaluated. However, ethinyl estradiol and norethindrone may be poorly metabolized in patients with impaired liver function. Drug-Drug Interactions - Numerous drug-drug interactions have been reported for oral contraceptives. A summary of these is found under PRECAUTIONS, Drug Interactions. ## Nonclinical Toxicology There is limited information regarding Norethindrone acetate and Ethinyl estradiol Nonclinical Toxicology in the drug label. # Clinical Studies There is limited information regarding Norethindrone acetate and Ethinyl estradiol Clinical Studies in the drug label. # How Supplied - Gildess® 1.5/30 (21 Tablets) (norethindrone acetate 1.5 mg and ethinyl estradiol 0.03 mg tablets, USP) is packaged in cartons of six tablet dispensers. Each tablet dispenser contains 21 light green, round, film-coated tablets debossed “93” on one side and “914”on the other side. - Blister pack tablet dispenser NDC 0603-7606-02. - Boxes of 6 tablet dispensers NDC 0603-7606-15. ## Storage - Store at 20° to 25°C (68° to 77°F) . # Images ## Drug Images ## Package and Label Display Panel # Patient Counseling Information - Oral contraceptives, also known as "birth control pills" or "the pill," are taken to prevent pregnancy and, when taken correctly, have a failure rate of about 1% per year when used without missing any pills. The typical failure rate of large numbers of pill users is less than 3% per year when women who miss pills are included. For most women oral contraceptives are also free of serious or unpleasant side effects. However, forgetting to take pills considerably increases the chances of pregnancy. - For the majority of women, oral contraceptives can be taken safely. But there are some women who are at high risk of developing certain serious diseases that can be life-threatening or may cause temporary or permanent disability. The risks associated with taking oral contraceptives increase significantly if you: - Smoke - Have high blood pressure, diabetes, high cholesterol - Have or have had clotting disorders, heart attack, stroke, angina pectoris, cancer of the breast or sex organs, jaundice, or malignant or benign liver tumors. - You should not take the pill if you suspect you are pregnant or have unexplained vaginal bleeding. # Precautions with Alcohol - Alcohol-Norethindrone acetate and Ethinyl estradiol tablet interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication. # Brand Names Loestrin 1/20 Loestrin 1.5/30 Junel 1/20, Junel 1.5/30, Microgestin 1/20, Microgestin 1.5/30, Femhrt 1/5, Femhrt Lo. # Look-Alike Drug Names There is limited information regarding Norethindrone acetate and Ethinyl estradiol Look-Alike Drug Names in the drug label. # Drug Shortage Status # Price

Tricuspid atresia overview # Overview Tricuspid atresia is the fourth most common cyanotic congenital heart disease after tetralogy of Fallot, transposition of the great arteries (TGA), and hypoplastic left heart syndrome, whether the nonoxygenated blood can not flow from right atrium to right ventricle due to nondevelopment or total agenesia of the tricuspid valve. The right ventricle is small and the pulmonary artery in some cases is hypoplastic. Atrial septal defect (ASD) or patent foramen oval (PFO) is necessary for passing the blood from the right atrium to the left system and without them the infants will not survive. The majority of infants die without palliative surgery. Tricuspid atresia was first discovered by Friedrich Ludwig kreysig in 1817, a German physician who found the obstruction between the right atrium and right ventricle in the autopsy of cyanotic infants. The classic term of tricuspid atresia was used firstly by schuberg in 1861. Tricuspid atresia occurs during prenatal development. In tricuspid atresia, there is no continuity between the right atrium and right ventricle. Inferior vena cava and superior vena cava collect venous nonoxygenated blood into the right atrium. Through atrial septal defect (ASD), blood come into the left atrium, then left ventricle and aorta.This blood is a mixture of saturated and unsaturated O2. If there is a ventricular septal defect (VSD), this mixed blood in the left ventricle flows into the right ventricle, then via pulmonary artery reaches pulmonary bed and becomes oxygenated, then returns back into the left atrium via pulmonary veins. In diminished pulmonary blood flow whether the flow is dependent on patent ductus arteriosus (PDA), the mixed-blood in aorta flows from this passage into pulmonary artery and pulmonary bed. In the presence of normal positioning of great arteries, cyanosis is more prominent and is affected by the size of VSD. Transposition of the great arteries (TGA) and subaortic stenosis are other associated anomalies. Some Genes mutation in tricuspid valvopathy includes : missense mutation in RASA1 that regulates Ras/ERK cascade, a missense mutation in NFATC1 that downregulates the Ras/ERK pathway. Familial recurrence of tricuspid atresia is rare. Few cases of an autosomal recessive pattern of inheritance are reported.Patients with tricuspid atresia should be differentiated from other cardiac causes of cyanosis and lung olygemia include: Tetralogy of Fallot, Total anomalous pulmonary venous connection, Pulmonary atresia, Tricuspid stenosis. Worldwide, the prevalence of tricuspid atresia is 7.8 per 100,000 persons. Tricuspid atresia is a congenital heart disease observed among infants at the time of birth. Tricuspid atresia affects males and females equally. There is no racial predilection for tricuspid atresia. Common risk factors related to tricuspid atresia include: chromosomal abnormality, taking teratogenic medications by mother during pregnancy such asphenytoin,retinoic acid, smoking, alcohol consumption during pregnancy, Mother comorbidities such as diabetes mellitus, hypertension, obesity, phenylketonuria, thyroid disease, epilepsy, connective tissue disorders, Infections during pregnancy such as rubella,cytomegalovirus, Coxsackie, herpes virus 6, toxoplasmosis gondi, parvovirus B19, HIV,influenza. Early clinical features in infants include cyanosis of lips and tongue, difficulty in breathing, tiring easily during feeding. The severity of cyanosis in infants with pulmonary stenosis is dependent on the amount of pulmonary blood flow passing through patent ductus arteriosus. After physiologic closure of patent ductus arteriosus (PDA), the cyanosis will be aggravated. In patients with normal pulmonary blood flow, complications of heart failure may occur. Prognosis is generally poor without surgery and 90% of patients will die before 10 years old. Symptoms of tricuspid atresia in neonates may include: central cyanosis in mucous membranes and tongue, poor feeding and growth retardation, difficulty in breathing, rapidheartbeats, rapid breathing.Symptoms of longstanding cyanosis and hyperviscosity syndrome as a result of secondary erythrocytosis in older children include the following: headache, alter mentation, faintness, dizziness, visual disturbances, paresthesia, tinnitus, myalgia. Patients with pulmonary stenosis and closed PAD usually appear cyanotic after birth. Conversely, patients with VSD and high pulmonary blood flow without stenotic pulmonary arteries present with signs of overt heart failure without cyanosis.In cyanotic older patients laboratory findings may include:Polycythemia due to secondary erythrocytosis, elevated prothrombin time and partial thromboplastin time, decreased levels of factors 5,7,8,9: qualitative and quantitative, platelet disorder, increased fibrinolysis and paradoxical thrombotic tendency, proteinuria, hyperuricemia, renal failure, uric acid nephrolithiasis. An ECG may be helpful in the diagnosis of tricuspid atresia. Findings on an ECG suggestive of tricuspid atresia include: left axis deviation, left ventricle hypertrophy, right atrium enlargement, left atrium enlargement. Findings on an x-ray suggestive of tricuspid atresia include: situs solitus , left-sided aortic arch, levocardia , absent main pulmonary artery, pulmonary oligemia with decreasedvascular markings, right aortic arch in %25 of cases. Common advantages of cardiac CT scan include assessment of Fontan circuit with an injection of contrast into superior vena cava and filling of the pulmonary system, assessment of right ventricle and left ventricle morphology and function, assessment of vascular stenting patency. Cardiac MRI (CMR) is commonly used for long term management of Fontan patients.Three-dimensional echocardiography is a modality of choice for assessment of: cardiac output, anatomy of valves, anatomy of the septal structure, chamber sizing and volume, the severity of valvular regurgitation and stenosis. Catheterization may measure the gradient between the left ventricle and left atrium in subaortic stenosis. The mainstay of therapy for the cyanotic neonate with severe pulmonary stenosis and small-sized VSD is using prostaglandin E1 (PGE1) for keeping patency of ductus arteriosis. For patients with heart failure symptoms initiating diuretic for reduction of congestion and then starting ACEI is recommended. Surgery is the mainstay of therapy for tricuspid atresia. In the first 8 weeks of life if there are severe Cyanosis and pulmonary obstruction and normal positioning aorta and pulmonary artery, making a shunt between systemic subclavian artery to the pulmonary artery is necessary which is called Blalock -Taussig (BT shunt). If the pulmonary artery comes from the left ventricle and is overflowed, pulmonary artery banding is useful for lowering the pulmonary blood flow. In older children, bi-direction Glenn shunt which is the connection between superior vena cava to the pulmonary artery is planned for transferring the blood to the pulmonary system. Fontan procedure is a conduit between the inferior vena cava and the pulmonary artery whether transfers the systemic venous blood to pulmonary circulation at the age of 2-3 years old. Effective measures for the primary prevention of tricuspid atresia as prenatal screening include fetal sonography between 10-14 weeks of pregnancy for measurement of nuchal translucency thickness, fetal echocardiography between 18-22 weeks of pregnancy. Secondary prevention strategies following the Fontan procedure include serial checking EKG, Transthoracic echocardiography, Pulse oximetry, Holter monitoring, Cardiac MRI, Exercise test. # Historical Perspective Tricuspid atresia was first discovered by Friedrich Ludwig kreysig in 1817, a German physician who found the obstruction between the right atrium and right ventricle in the autopsy of cyanotic infants. The classic term of tricuspid atresia was used firstly by schuberg in 1861. # Pathophysiology Tricuspid atresia occurs during prenatal development. In tricuspid atresia, there is no continuity between the right atrium and right ventricle. Inferior vena cava and superior vena cava collect venous nonoxygenated blood into the right atrium. Through atrial septal defect (ASD), blood come into the left atrium, then left ventricle andaorta.This blood is a mixture of saturated and unsaturated O2. If there is a ventricular septal defect (VSD), this mixed blood in the left ventricle flows into the right ventricle, then via pulmonary artery reaches pulmonary bed and becomes oxygenated, then returns back into the left atrium via pulmonary veins. In diminished pulmonary blood flow whether the flow is dependent on patent ductus arteriosus (PDA), the mixed-blood in aorta flows from this passage into pulmonary artery and pulmonary bed. In the presence of normal positioning of great arteries, cyanosis is more prominent and is affected by the size of VSD. Transpositioning great arteries (TGA) and subaortic stenosis are other associated anomalies. # Causes Some Genes mutation in tricuspid valvopathy includes : missense mutation in RASA1 that regulates Ras/ERK cascade, a missense mutation in NFATC1 that downregulates the Ras/ERK pathway. Familial recurrence of tricuspid atresia is rare. Few cases of an autosomal recessive pattern of inheritance are reported. # Differentiating tricuspid atresia from Other Diseases Patients with tricuspid atresia should be differentiated from other cardiac causes of cyanosis and lung olygemia include: Tetralogy of Fallot, Total anomalous pulmonary venous connection, Pulmonary atresia, Tricuspid stenosis. # Epidemiology and Demographics Worldwide, the prevalence of tricuspid atresia is 7.8 per 100,000 persons. Tricuspid atresia is a congenital heart disease observed among infants at the time of birth. Tricuspid atresia affects males and females equally. There is no racial predilection for tricuspid atresia. # Risk Factors Common risk factors related to tricuspid atresia include: chromosomal abnormality, taking teratogenic medications by mother during pregnancy such asphenytoin,retinoic acid, smoking, alcohol consumption during pregnancy, Mother comorbidities such as diabetes mellitus, hypertension, obesity, phenylketonuria, thyroid disease, epilepsy, connective tissue disorders, Infections during pregnancy such as rubella,cytomegalovirus, Coxsackie, herpes virus 6, toxoplasmosis gondi, parvovirus B19, HIV,influenza. # Natural History, Complications, and Prognosis Early clinical features in infants include cyanosis of lips and tongue, difficulty in breathing, tiring easily during feeding. The severity of cyanosis in infants with pulmonary stenosis is dependent on the amount of pulmonary blood flow passing through patent ductus arteriosus. After physiologic closure of patent ductus arteriosus (PDA), the cyanosis will be aggravated. In patients with normal pulmonary blood flow, complications of heart failure may occur. Prognosis is generally poor without surgery and 90% of patients will die before 10 years old. # Diagnosis ## Diagnostic Study of Choice ## History and Symptoms Symptoms of tricuspid atresia in neonates may include: central cyanosis in mucous membranes and tongue, poor feeding and growth retardation, difficulty in breathing, rapidheartbeats, rapid breathing.Symptoms of longstanding cyanosis and hyperviscosity syndrome as a result of secondary erythrocytosis in older children include the following: headache, alter mentation, faintness, dizziness, visual disturbances, paresthesia, tinnitus, myalgia. ## Physical Examination Patients with pulmonary stenosis and closed PAD usually appear cyanotic after birth. Conversely, patients with VSD and high pulmonary blood flow without stenotic pulmonary arteries present with signs of overt heart failure without cyanosis. ## Laboratory Findings In cyanotic older patients laboratory findings may include:Polycythemia due to secondary erythrocytosis, elevated prothrombin time and partial thromboplastin time, decreased levels of factors 5,7,8,9: qualitative and quantitative, platelet disorder, increased fibrinolysis and paradoxical thrombotic tendency, proteinuria, hyperuricemia, renal failure, uric acid nephrolithiasis. ## Electrocardiogram An ECG may be helpful in the diagnosis of tricuspid atresia. Findings on an ECG suggestive of tricuspid atresia include: left axis deviation, left ventricle hypertrophy, right atrium enlargement, left atrium enlargement. ## X-ray Findings on an x-ray suggestive of tricuspid atresia include: situs solitus , left-sided aortic arch, levocardia , absent main pulmonary artery, pulmonary oligemia with decreasedvascular markings, right aortic arch in %25 of cases. ## Echocardiography Three-dimensional echocardiography is a modality of choice for assessment of: cardiac output, anatomy of valves, anatomy of the septal structure, chamber sizing and volume, the severity of valvular regurgitation and stenosis, Pericardial effusion. ## CT scan Common advantages of cardiac CT scan include assessment of Fontan circuit with an injection of contrast into superior vena cava and filling of the pulmonary system, assessment of right ventricle and left ventricle morphology and function, assessment of vascular stenting patency. ## MRI Cardiac MRI(CMR) is commonly used for long term management of Fontan patients. ## Cardiac catheterization Catheterization may measure the gradient between the left ventricle and left atrium in subaortic stenosis. # Treatment ## Medical Therapy The mainstay of therapy for the cyanotic neonate with severe pulmonary stenosis and small-sized VSD is using prostaglandin E1 (PGE1) for keeping patency of ductus arteriosis. For patients with heart failure symptoms initiating diuretic for reduction of congestion and then starting ACEI is recommended. ## Interventions ## Surgery Surgery is the mainstay of therapy for tricuspid atresia. In the first 8 weeks of life if there are severe Cyanosis and pulmonary obstruction and normal positioning aorta and pulmonary artery, making a shunt between systemic subclavian artery to the pulmonary artery is necessary which is called Blalock -Taussig (BT shunt). If the pulmonary artery comes from the left ventricle and is overflowed, pulmonary artery banding is useful for lowering the pulmonary blood flow. In older children, bi-direction Glenn shunt which is the connection between superior vena cava to the pulmonary artery is planned for transferring the blood to the pulmonary system. Fontan procedure is a conduit between the inferior vena cava and the pulmonary artery whether transfers the systemic venous blood to [[pulmonary circulation at the age of 2-3 years old. ## Primary Prevention Effective measures for the primary prevention of tricuspid atresia as prenatal screening include fetal sonography between 10-14 weeks of pregnancy for measurement of nuchal translucency thickness, fetal echocardiography between 18-22 weeks of pregnancy. ## Secondary Prevention Secondary prevention strategies following the Fontan procedure include serial checking EKG, Transthoracic echocardiography, Pulse oximetry, Holter monitoring, Cardiac MRI, Exercise test.

Interstitial nephritis overview # Overview Two main diseases involve the renal tubules are: Acute tubular necrosis due to Ischemic or toxic injury .(for more about ATN click here), and tubulointerstitial nephritis with Inflammatory involvement of tubules and interstitium and its consequent reactions. Since some cases of TIN are due  to bacterial infection, and the renal pelvis is deeply involved, therefore pyelonephritis is term describes this condition; and In general, the term interstitial nephritis is used for TIN that is owing to  nonbacterial causes of tubular injury such as  drugs, viral infections,autoimmune systemic diseases, in which these condition mechanism of damage is due to inflammatory responses not direct damage. # Historical Perspective In 1938, Councilman was the first to discover the association between systemic infections and the development of TIN; in autopsy kidneys of children dying of diphtheria and scarlet fever. He described the findings as: cellular and fluid exudation in the interstitial tissue of kidneys, before the era of antibiotics. The widespread use of renal biopsy and histological examination in TIN revealed a cellular infiltration, which is dominantly composed of T cells, together with somemacrophages and plasma cells, and led to the discovery of similar findings in association with drug-related renal failure and the same conditions. # Classification There is no established system for the classification of TIN, however according to clinical manifestations and the inflammatory process, TIN, in spite of the etiologic agent, can be divided into acute and chronic categories. # Pathophysiology It is thought that acute interstitial nephritis is mediated by hypersensitivity reaction to endogenous or exogenous antigens expressed by tubular cells. Numerous drugs such as antibiotics, NSAIDS, sulfa-containing drugs, etc, as well as systemic diseases, and Infections may lead injury to renal cells. the cascade activation owing to cellular injury toward inflammatory cell infiltration, and activation of cytokines causes an immunologic reaction in acute or chronic process. In acute interstitial nephritis, this cascade activation can cause renal tubular dysfunction, whereas in chronic interstitial nephritis an insidious interstitial fibrosis,scarring, , and tubular atrophy spreads gradually and causes progressive chronic renal insufficiency. # Causes Common causes of interstitial nephritis include drug side effects, particularly analgesics and antibiotics. Other common causes include associated nephrologic conditions, as well as microbial infections. # Differentiating TIN from Other Diseases # Epidemiology and Demographics Interstitial nephritis accounts for 10-15% of kidney disease worldwide. Analgesic-induced nephritis is 5-6 times more common in women. The elderly have more severe disease and increased risk of permanent damage. Children exposed to lead poisoning are more likely to develop nephritis as young adult. # Risk Factors There are no established risk factors for TIN; Whereas according to etiologic causative factors, consumption of culprit drugs in causing TIN,previous history of hypersensitivity reactions to specific drug, presence of autoimmune systemic disease or some neoplasia or genetic condition, occupational or environmental exposure to heavy metals, and infection etiologies in association with obstructive uropathy, play role in in the development of TIN. # Screening There is insufficient evidence to recommend routine screening for TIN. # Natural History, Complications, and Prognosis In the majority of patients with TIN, recovery of renal function has been observed, and improvement immediately occurs upon stopping the offensive agent, nevertheless, about 12% of patients may progress to develop ESRD and its complications; and thus require dialysis or transplantation. However there is no definite prognostic indicators for TIN, but renal failure lasts for >3 weeks, elderly patients and presence of tubular atrophy and interstitial fibrosis in the renal biopsy are associated with worse prognosis. # Diagnosis ## Diagnostic Study of Choice Renal biopsy is the gold standard and definitive test of establishing the diagnosis of TIN, however it is not needed in all patients and often considered to make a definitive diagnosis for patients who do not improve following withdrawal of offensive agent or in the presence of doubtful findings. ## History and Symptoms The majority of patients with interstitial nephritis are asymptomatic. However, nonspecific signs and symptoms may present depending upon underlying etiology and timing of presentation. Non specific symptoms include nausea, vomiting, malaise, and oliguria. Hematuria though not so common is also seen in some patients with tubulointerstitial nephritis. Other symptoms of interstitial nephritis include hypersensitivity reaction, such as rash, fever, and eosinophilia. ## Physical Examination There are no physical examination findings specific to interstitial nephritis, and no characteristic findings exist. The presence of fever, rash in acute tubulointerstitial nephritis, livido reticularis, on physical examination may be suggestive of TIN, and provide clues to the diagnosis. ## Laboratory Findings A variable combination of laboratory findings of TIN, such as rise in the plasma creatinine concentration, eosinophilia, eosinophiluria, changes of urine sediment, as well as evidences of tubulointerstitial damage based upon the culprit agent may present. In some studies a variable amount of proteinuria among older patients and NSAID-induced AIN has been reported, although nephrotic-range proteinuria among patients with TIN is rare. ## Electrocardiogram There are no ECG findings associated with TIN, however electrolyte imbalances due to complications of TIN may cause changes in ECG. ## X-ray There are no x-ray findings associated with TIN. ## Echocardiography and Ultrasound There are no echocardiography/ultrasound findings associated with TIN. ## CT scan There are no CT scan findings associated with TIN. ## MRI There are no MRI findings associated with TIN. ## Other Imaging Findings ## Other Diagnostic Studies # Treatment ## Medical Therapy The mainstay of treatment for tubulointerstitial nephritis is discontinuation of potentially offending agen. The majority of patients due to drug-induced interstitial nephritis, improve spontaneously, however, renal function may not return to previous condition. No additional measures is needed among patients with minimal rise in the serum creatinine or those who demonstrate betterment after discontinuation of offending agent; otherwise if renal failure persists after removing the culprit drug, obtaining a renal biopsy and attempt glucocorticoids therapy for patients with biopsy-confirmed AIN must be considered. ## Primary Prevention There are no established measures for the primary prevention of tubulointerstitial nephritis. ## Secondary Prevention The mainstay preventive action is to stay away from re-exposure to the offensive agents of the acute episode. Among patients with chronic inflammatory diseases such as Sjogren's syndrome, sarcoidosis, or SLE, proper control of the underlying condition alongside with consideration of offensive agent is important and should be kept in mind.

Warthin's tumor overview # Overview Warthin's tumor is a type of benign tumor of the salivary glands. It is also known as benign papillary cystadenoma lymphomatosum. Its etiology is unknown, but there is a strong association with the cigarette smoking. Smokers are at 8 times greater risk of developing Warthin's tumor than the general population. Warthin's tumor arises from salivary gland epithelium, which are secretory cells of the salivary gland. On gross pathology, cystic and multicentric appearance are characteristic findings of Warthin's tumor. On microscopic histopathological analysis, papillae, fibrous capsule, and cystic spaces are characteristic findings of Warthin's tumor. Warthin's tumor must be differentiated from salivary gland cysts, salivary gland lymphoma, and salivary gland cancer. The prevalence of Warthin's tumor is estimated to be 2000 to 2500 cases annually. Warthin's tumor commonly affects elderly patients greater than 60 years old. Males are more commonly affected with Warthin's tumor than females. The male to female ratio ranges from 2.6:1 to 10:1. The most potent risk factor in the development of Warthin's tumor is smoking. Other risk factors include irradiation, Epstein-Barr virus, and alcohol. If left untreated, few patients with Warthin's tumor may progress to develop facial paralysis. Common complications of Warthin's tumor include squamous cell carcinoma and facial paralysis. Prognosis is generally good. The most common symptoms of Warthin's tumor include swollen salivary gland, lump near the back of the lower jaw, jaw pain, the sensation of pressure, facial nerve paralysis, tinnitus, impaired hearing, earache, etc. X-ray, computed tomography (CT) scan and magnetic resonance imaging (MRI) may help diagnosis. Surgery is the mainstay of treatment for Warthin's tumor. As a benign tumor, the prognosis of Warthin's tumor is good. # Historical Perspective Warthin's tumor was first discovered by Hildebrand, a German surgeon, in 1895. # Pathophysiology Warthin's tumor arises from salivary gland epithelium, which are secretory cells of the salivary gland. On gross pathology, cystic and multicentric appearance are characteristic findings of Warthin's tumor. On microscopic histopathological analysis, papillae, fibrous capsule, and cystic spaces are characteristic findings of Warthin's tumor. # Causes There are no known direct causes for Warthin's tumor. # Differential Diagnosis Warthin's tumor must be differentiated from salivary gland cysts, salivary gland lymphoma, and salivary gland cancer. # Epidemiology and Demographics The prevalence of Warthin's tumor is estimated to be 2000 to 2500 cases annually. Warthin's tumor commonly affects elderly patients greater than 60 years old. The male is more commonly affected with Warthin's tumor than female. The male to female ratio ranges from 2.6:1 to 10:1. # Risk Factors The most potent risk factor in the development of Warthin's tumor is smoking. Other risk factors include irradiation, Epstein-Barr virus, and alcohol. # Natural history, Complications and Prognosis If left untreated, few patients with Warthin's tumor may progress to develop facial paralysis. Common complications of Warthin's tumor include squamous cell carcinoma and facial paralysis. Prognosis is generally good. # History and Symptoms The hallmark of Warthin's tumor is swelling of jaw, cheek, mouth, or neck. A positive history of swollen salivary gland and jaw pain is suggestive of Warthin's tumor. The most common symptoms of Warthin's tumor include tinnitus, an earache, and blood in saliva. # Physical Examination Patients with Warthin's tumor usually appear well. Physical examination of patients with Warthin's tumor is usually remarkable for mobile nontender mass which is firm, solitary, and normal in color and appearance. # Laboratory Findings There are no diagnostic lab findings associated with Warthin's tumor. # CT Neck CT scan may be helpful in the diagnosis of Warthin's tumor. Findings on CT scan suggestive of Warthin's tumor include cystic lesion posteriorly within the parotid with a focal tumor nodule and absence of calcifications. # MRI On MRI, Warthin's tumor is characterized by well-defined bilateral lesions which are heterogeneous and variable in signal intensity. # Echocardiography or Ultrasound Neck ultrasound may be helpful in the diagnosis of Warthin's tumor. Findings on neck ultrasound suggestive of Warthin's tumor include well defined, ovoid, hyperechoic mass with internal cystic areas and hypervascularity. # Other Imaging Findings Other diagnostic studies for Warthin's tumor include scintigraphy, which demonstrates uptake of with Tc99-pertechnetate, thallium, and FDG-PET. # Biopsy On biopsy, Warthin's tumor is characterized by cystic spaces surrounded by two uniform rows of cells with centrally placed pyknotic nuclei, papillae with a two rows of pink epithelial cells, and lymphoid stroma. # Surgery Surgery is the mainstay of treatment for Warthin's tumor. # Reference

Cardiomegaly overview # Overview Cardiomegaly is defined as an enlargement of the heart above its normal size. Cardiomegaly is generally first detected on chest X ray, and less often it is detected on routine physical examination. Cardiomegaly may be the first sign of an occult systemic or cardiovascular disease. # Pathophysiology Cardiomegaly involves two main processes in the heart muscle. Hypertrophy causes the heart to enlarge due to thickening to the cardiac muscle, and dilation causes enlargement due to stretching of the heart muscle. Dilation occurs as a result of volume overload in the heart. # Causes There are many causes for the condition of cardiomegaly, including medications, genetic conditions, endocrine conditions, infectious processes, toxins and iatrogenic causes. # Differentiating Cardiomegaly from other Diseases There is a large differential for cardiomegaly, as it is a finding that is seen in many conditions. The differential can be narrowed based on the chamber of the heart affected, and whether the cardiomegaly is caused by dilation or by hypertrophy. Other physical findings, imaging studies, and laboratory findings need to be taken into consideration when determining the underlying diagnosis caused the manifestation of an enlarged heart. # Diagnosis ## History and Symptoms The history and symptoms can suggest the underlying cause of cardiomegaly. The patient may have a history of rheumatic heart disease or congenital heart disease, or a history of alcohol abuse which may suggest dilated cardiomyopathy. Symptoms such as chest pain, or other cardiac or respiratory symptoms may help in illiciting the underlying cause. ## Physical Examination A comprehensive physical examination with a thorough cardiac exam will reveal cardiomegaly, and may indicated the nature of the underlying cause. The body habitus of the individual needs to be taken into account when evaluating findings on cardiac examination. ## Laboratory Findings Laboratory tests that should be obtained when a person is suspected or known to have cardiomegaly are: a complete blood count, thyroid stimulating hormone levels, and a blood urea nitrogen. These are common, high yield tests. Other tests can be ordered based on suspicions as to the underlying cause of the cardiomegaly, obtained through patient history and physical examination. ## Electrocardiogram An EKG is a standard method of evaluating a patient with cardiomegaly. It can help to determine the cause, severity, and the specific chamber which is affected. A q wave would indicate an area of muscle death accounting for the enlargement, and ST elevation may suggest a myocardial infarction, myocarditis or pericarditis. ## Chest X Ray Cardiomegaly is easily visualized on chest x ray. Cardiomegaly is traditionally defined as a cardiothoracic ratio that is more than 0.5 on a PA film. Other findings on chest x ray can help to determine the specific chamber that is contributing most to the enlargement of the heart. ## Echocardiogram Echocardiogram recommended for those patients presenting suspected valvular disease, aberrant chamber size, ventricular function, and wall motion abnormalities. ## Other Diagnostic Studies Exercise or pharmacological stress testing may be indicated in those patients suspected of having coronary artery disease. Patients suspected of having valvular disease or coronary artery disease may need a cardiac catheterization for full evaluation following echocardiography. # Treatment ## Medical Therapy There are both acute and chronic pharmacotherapies used to manage the cardiomegaly. Diuretics and ACE inhibitors are the standard therapy for chronic management of cardiomegaly. Acute therapies include digoxin, diuretics, antiarrhythmics, pre-load and after-load reducing medications. ## Surgery In patients who are awaiting a transplant for end-stage symptomatic heart failure, implantable ventricular assist devices may serve as a temporary aid for compensation. Transplantation may be considered in a few cases.

PMPCB Mitochondrial-processing peptidase subunit beta is an enzyme that in humans is encoded by the PMPCB gene. This gene is a member of the peptidase M16 family and encodes a protein with a zinc-binding motif. This protein is located in the mitochondrial matrix and catalyzes the cleavage of the leader peptides of precursor proteins newly imported into the mitochondria, though it only functions as part of a heterodimeric complex. # Structure The Mitochondrial-processing peptidase subunit beta precursor protein is 54.4 KDa in size and composed of 489 amino acids. The precursor protein contains a 45 amino acid N-terminal fragment as mitochondrion targeting sequence. After cleavage, the matured PMPCB protein is 49.5 KDa in size and has a theoretical pI of 5.76. # Function Mitochondrial-processing peptidase (MPP) is a metalloendopeptidase, containing two structurally related subunits, mitochondrial-processing peptidase subunit alpha and subunit beta, working in conjunction for its catalytic function. Containing the catalytic site, the beta subunit PMPCB protein cleaves presequences (transit peptides) from mitochondrial protein precursors and releases of N-terminal transit peptides from precursor proteins imported into the mitochondrion, typically with Arg in position P2. # Interactions As the beta subunit of Mitochondrial-processing peptidase, PMPCB forms a heterodimer with the subunit Mitochondrial-processing peptidase subunit alpha. In addition, PMPCB has been shown to interact with PMPCA and Frataxin. # Clinical significance The majority of mitochondrial proteins is nuclear-coded, which necessitates proper translocations of mitochondrial targeting proteins. Many mitochondrial proteins are synthesized in a precursor form that contains mitochondria targeting sequence. These precursors are usually cleaved by peptidases and proteases before they arrive their sub-organellar locations. It is likely that altered activity of the mitochondrial processing peptidases is essential to ensure the correct maturation of mitochondrial proteins and that altered activity of these proteases will have dramatic effects in the activity, stability and assembly of mitochondrial proteins. Evidences showed that MPP was involved in the proteolytic maturation of Frataxin, a protein responsible for iron homeostasis. Accordingly, MPP deficiency was shown to be involved in Friedreich ataxia, an autossomic recessive neurodegenerative disorder

RRH Peropsin, a visual pigment-like receptor, is a protein that in humans is encoded by the RRH gene. Peropsin is an opsin and so belongs to the guanine nucleotide-binding protein (G protein)-coupled receptors. Peropsin genes have seven-exons as neuropsin and RGR-opsin genes. # Phylogeny The peropsins are one of the four subgroups of the Go/RGR opsins, also known as RGR/Go or Group 4 opsins. Go/RGR opsins are one of the four major groups of type-II opsins, also known as metazoan or animal opsins. The Go/RGR opsins consist of four groups: The Go-opsins, the RGR-opsins, the peropsins, and the neuropsins. Animal opsins belong to four classes: C-opsins (ciliary), R-opsins (rhabdomeric), Cnidops (cnidarian), and Go/RGR-opsins. Three of these subclades occur only in Bilateria (all but Cnidops). However, the bilaterian clades constitute a parphyletic taxon without the Cnidops.

Molecular Biomarkers for the Evaluation of Colorectal Cancer Objectives: To develop evidence-based guideline recommendations through a systematic review of the literature to establish standard molecular biomarker testing of colorectal cancer (CRC) tissues to guide epidermal growth factor receptor (EGFR) therapies and conventional chemotherapy regimens.Methods:Thevened an expert panel to develop an evidence-based guideline to establish standard molecular biomarker testing and guide therapies for patients with CRC. A comprehensive literature search that included more than 4,000 articles was conducted.Results: Twenty-one guideline statements were established.Conclusions: Evidence supports mutational testing for EGFR signaling pathway genes, since they provide clinically actionable information as negative predictors of benefit to anti-EGFR monoclonal antibody therapies for targeted therapy of CRC. Mutations in several of the biomarkers have clear prognostic value. Laboratory approaches to operationalize CRC molecular testing are presented. Molecular testing to select targeted and conventional therapies for patients with colorectal cancer (CRC) has been the focus of a number of recent studies and is becoming standard practice for management of patients with CRC. Molecular markers that predict response to a specific therapy or treatment regimen are known as predictive biomarkers. [bib_ref] NCCN task force report: evaluating the clinical utility of tumor markers in..., Febbo [/bib_ref] Monoclonal antibody therapies that target the epidermal growth factor receptor (EGFR) bind the EGFR extracellular domain, blocking EGFR signaling pathways. Anti-EGFR monoclonal antibodies have been the main targeted therapies for CRC that require knowledge of the mutational status of genes in the pathway as predictive biomarkers of response to these therapies. [bib_ref] EGFR antibodies in colorectal cancer: where do they belong?, Grothey [/bib_ref] [bib_ref] Effects of KRAS, BRAF, NRAS, and PIK3CA mutations on the efficacy of..., De Roock [/bib_ref] [bib_ref] implications for targeted therapies in metastatic colorectal cancer, De Roock [/bib_ref] Initial clinical trial data demonstrated that patients with CRC carrying activating mutations of KRAS affecting exon 2 codons 12 and 13 did not benefit from anti-EGFR monoclonal antibody therapy. [bib_ref] EGFR antibodies in colorectal cancer: where do they belong?, Grothey [/bib_ref] [bib_ref] Effects of KRAS, BRAF, NRAS, and PIK3CA mutations on the efficacy of..., De Roock [/bib_ref] [bib_ref] implications for targeted therapies in metastatic colorectal cancer, De Roock [/bib_ref] Subsequent studies described other mutations in genes of the EGFR signaling pathways involving other exons of KRAS and in NRAS, BRAF, PIK3CA, and PTEN that may affect response of CRC to anti-EGFR antibody therapies. Guidelines addressing the molecular testing of EGFR pathway genes beyond KRAS have not been established and are needed in clinical practice. The DNA mismatch repair (MMR) status of CRC may have predictive value in some clinical settings. While testing of CRC for MMR has been recommended for all patients with CRC as a workup test to evaluate for possible Lynch syndrome, [bib_ref] American Gastroenterological Association Institute guideline on the diagnosis and management of Lynch..., Rubenstein [/bib_ref] guidelines for the use of MMR as a predictive biomarker of response to therapy have not been reported. Recent molecular biomarker data have shown the importance of microsatellite instability (MSI) testing, a marker of deficient mismatch repair (dMMR), for the selection of patients for immunotherapy (see section on emerging biomarkers below). Alterations of a number of critical genes in CRC development and progression such as dMMR and BRAF activating mutations have been shown to affect prognosis, as measured by several metrics of tumor progression or survival. [bib_ref] Does microsatellite instability predict the efficacy of adjuvant chemotherapy in colorectal cancer?..., Guetz [/bib_ref] [bib_ref] Microsatellite instability as a marker of prognosis and response to therapy: a..., Guastadisegni [/bib_ref] [bib_ref] Mutation profiling and microsatellite instability in stage II and III colon cancer:..., Gavin [/bib_ref] The utility of incorporating prognostic biomarkers in the management of patients with CRC has not been well defined in clinical practice. Defining the utility of information gathered from prognostic molecular biomarkers for clinical management of patients with CRC is warranted. The postgenome era and the emphasis on precision genomic-based medicine are providing enormous amounts of new data and many promising new molecular cancer biomarkers that may emerge as molecular diagnostic tools that can be used to enhance successful treatment of patients with CRC and other cancers. Laboratories and regulatory agencies are faced with challenges to rapidly and efficiently provide new test results for the management of patients with cancer. Laboratory testing of molecular biomarkers involves the selection of assays, type of specimens to be tested, timing of ordering of tests, and turnaround time for testing results. Recent years have shown that a plethora of technical approaches can effectively be used as long as test specificity and sensitivity meet the clinical needs. While earlier testing approaches were focused on one or a few testing targets, the current need for multiple molecular markers from potentially minute tumor samples is leading to greater use of gene panels such as targeted next-generation sequencing (NGS) cancer panels, which can assay from a few to hundreds of genes and amplicons with known mutational hotspots in cancer. There is a need for current evidence-based recommendations for the molecular testing of CRC tissues to guide EGFR-targeted therapies and conventional chemotherapy regimens. Therefore, the current recommendations were developed through collaboration of four societies: American Society for Clinical Pathology (ASCP), College of American Pathologists (CAP), Association for Molecular Pathology (AMP), and American Society of Clinical Oncology (ASCO). This guideline follows well-established methods used in their development as well as for regular updates, such that new advances in the molecular testing for clinical management of CRC can be integrated in future updates of the guideline in a timely manner. ## Panel composition The ASCP, the CAP Pathology and Laboratory Quality Center (the Center), the AMP, and the ASCO convened an expert panel consisting of practicing pathologists, oncologists, geneticists, and a biostatistician with expertise and experience in molecular biomarker testing and targeted therapies for CRC. The ASCP, CAP, AMP, and ASCO jointly approved the appointment of the project, cochairs, and expert panel members. In addition, a methodologist experienced in systematic review and guideline development consulted with the panel throughout the project. ## Conflict of interest policy Prior to acceptance on the expert or advisory panel, potential members completed a joint guideline conflict of interest (COI) disclosure process, whose policy and form (in effect July 2011) require disclosure of material financial interest in, or potential for benefit of significant value from, the guideline's development or its recommendations 12 months prior through the time of publication. The potential members completed the COI disclosure form, listing any relationship that could be interpreted as constituting an actual, potential, or apparent conflict. All project participants were required to disclose conflicts prior to beginning and continuously throughout the project's timeline. Disclosed conflicts of the expert panel members are listed in Appendix 1 and Appendix 2 . The ASCP, CAP, AMP, and ASCO provided funding for the administration of the project; no industry funds were used in the development of the guideline. All panel members volunteered their time and were not compensated for their involvement, except for the contracted methodologist. Please see the Supplemental Digital Content (SDC) at American Journal of Clinical Pathology online for full details on the COI policy. ## Objective The scope of the project was to develop an evidencebased guideline to help establish standard molecular biomarker testing, guide targeted therapies, and advance personalized care for patients with CRC. The panel addressed the following key questions: 1. What biomarkers are useful to select patients with CRC for targeted and conventional therapies? 2. How should tissue specimens be processed for biomarker testing for CRC management? 3. How should biomarker testing for CRC management be performed? 4. How should molecular testing of CRC be implemented and operationalized? 5. Are there emerging genes/biomarkers that should be routinely tested in CRC? # Materials and methods This evidence-based guideline was developed following standards as endorsed by the Institute of Medicine.A detailed description of the methods and systematic review (including the quality assessment and complete analysis of the evidence) can be found in the SDC. ## Literature search and selection A comprehensive search for literature was performed in MEDLINE using the OvidSP (August 1, 2013) and PubMed (September 17, 2013) interfaces. The initial MEDLINE search encompassed the publication dates of January 1, 2008, through August 1, 2013 (OvidSP), and January 1, 2008, through . A supplemental literature search was performed using Scopus to identify relevant articles published between January 1, 2008, and September 25, 2013, in journals not indexed in MEDLINE. The literature search of the electronic databases involved two separate searches in each database, the first using Medical Subject Headings (MeSH) terms and keywords for the concepts "colorectal cancer," "biomarkers," "treatment," and "treatment outcomes" and the second using terms for the concepts "colorectal cancer," "biomarkers," and "laboratory methods." Limits were set for human studies published in English, and a publication filter was applied to exclude lower levels of evidence such as letters, commentaries, editorials, and case reports. The Ovid search was rerun on February 12, 2015, to identify articles published since In addition to the searches of electronic databases, an Internet search of international health organizations, the National Guidelines Clearinghouse, and Guidelines International Network was conducted for existing relevant guidelines or protocols. Guidelines were included if they were published since 2008 in English. The proceedings of the meetings of the ASCO and ASCO-Gastrointestinal Cancers Symposium, European Society for Medical Oncology, and the American Association for Cancer Research from 2012 and 2013 were also searched for relevant abstracts. A focused examination of all systematic reviews retrieved by the initial literature search and retained after full-text review was performed to identify primary research studies not already included. In addition, recommendations from the expert panel were reviewed, and the reference lists of all articles deemed eligible for inclusion were scanned for relevant reports. The results of all searches were combined and deduplicated. Detailed information regarding the literature search strategy can be found in the SDC. homolog), MLH1 (MutL homolog 1) methylation, or gene expression profiles 5. Comparative studies 6. Human studies [bib_ref] Microsatellite instability as a marker of prognosis and response to therapy: a..., Guastadisegni [/bib_ref] ## . studies published in english Exclusion Criteria 1. All other tumor primaries and types (ie, noncolorectal or nonrectal cancers, tumor types other than adenocarcinoma or adenocarcinoma with neuroendocrine differentiation) 2. Patients with noninvasive tumors (ie, intraepithelial, dysplasia, in situ, polyps without carcinoma) 3. Studies of colorectal cancers without biomarker testing, novel biomarkers-for example, VEG-F (vascular endothelial growth factor), XRCC1 (X-ray repair complementing defective repair in Chinese hamster cells 1), IGF (insulin-like growth factor), ERCC (excision repair cross-complementing rodent repair deficiency, complementation group 1), micro-RNA, TYMS (thymidylate synthetase), GCC (guanylyl cyclase C), LINE (long interspersed nucleotide element) methylation, CIMP (CpG island methylator phenotype), HER2 (V-erb-b2 erythroblastic leukemia viral oncogene homolog 2), CIN (chromosomal instability) status LOH (loss of heterozygosity), and germline (genetics only) testing 4. Non-English-language articles 5. Animal studies 6. Studies published prior to 2002 7. Noncomparative studies, letters, commentaries, or editorials 8. Studies that did not address at least one of the defined inclusion criteria 9. Studies with fewer than 50 patients per comparison arm ## Outcomes of interest The primary outcomes of interest included survival outcomes and performance characteristics of laboratory testing assays. Survival outcomes included overall survival (OS), disease-free survival (DFS), progression-free survival (PFS), recurrence-free survival, time to recurrence, response to therapy (eg, complete and partial response). Laboratory data and test performance characteristics included percent mutation, concordance of testing methods, sensitivity of testing methods, specificity of testing methods, concordance of detected mutations between primary and metastatic mutations (number [%] of cases with mutations vs number of cases with no mutations in the gene of interest), and concordance of mutations (synchronous primary vs metastatic, metachronous primary vs metastatic, between synchronous metastases, between metachronous metastases). ## Quality assessment An assessment of the quality of the evidence was performed for all retained studies following application of the inclusion and exclusion criteria by the methodologist. Using this method, studies deemed to be of low quality would not be excluded from the systematic review but would be retained and their methodologic strengths and weaknesses discussed where relevant. Studies would be assessed by confirming the presence of items related to both internal and external validity, which are all associated with methodologic rigor and a decrease in the risk of bias. The quality assessment of the studies was performed by determining the risk of bias by assessing key indicators, based on study design, against known criteria. (Refer to the SDC for detailed discussion of the quality assessment.) For strength of the evidence, the panel considered the level of evidence, as well as its quantity and quality of included studies. The level of evidence was based on the study design as described in [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref].In general, level I and II evidence is considered most appropriate to answer clinical questions, but in the absence of such high-quality evidence, the panel considered data from lower quality studies. The quantity of evidence refers to the number of studies and number of cases included for each outcome in the recommendation. The quality of studies reflects how well the studies were designed to eliminate bias and threats to validity. The appropriateness of the study design and data collected, relevance and clarity of findings, and adequacy of conclusions were evaluated. Each study was assessed individually (refer to the SDC for individual assessments and results) and then summarized by study type. Components such as generalizability and applicability were also considered when determining the strength of evidence. A summary of the overall quality of the evidence was given considering the evidence in totality. Ultimately, the designation (ie, rating or grade) of the strength of evidence is a judgment by ## Assessing the strength of recommendations Development of recommendations requires that the panel review the identified evidence and make a series of key judgments (using procedures described in the SDC). Grades for strength of recommendations were developed by the CAP Pathology and Laboratory Quality Center and are described in [fig_ref] Table 3: Grades for Strength of Recommendation a [/fig_ref]. 11 ## Guideline revision This guideline will be reviewed every 4 years or earlier in the event of publication of substantive and high-quality evidence that could potentially alter the original guideline recommendations. If necessary, the entire panel will reconvene to discuss potential changes. When appropriate, the panel will recommend revision of the guideline to the ASCP, CAP, AMP, and ASCO for review and approval. ## Disclaimer Practice guidelines and consensus statements reflect the best available evidence and expert consensus supported in practice. They are intended to assist physicians and patients in clinical decision making and to identify questions and settings for further research. With the rapid flow of scientific information, new evidence may emerge between the time a practice guideline or consensus statement is developed and when it is published or read. Guidelines and statements are not continually updated and may not reflect the most recent It is the responsibility of the treating physician or other health care provider, relying on independent experience and knowledge, to determine the best course of treatment for the patient. Accordingly, adherence to any practice guideline or consensus statement is voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances and preferences. The ASCP, CAP, AMP, and ASCO make no warranty, express or implied, regarding guidelines and statements and specifically exclude any warranties of merchantability and fitness for a particular use or purpose. The ASCP, CAP, AMP, and ASCO assume no responsibility for any injury or damage to persons or property arising out of or related to any use of this statement or for any errors or omissions. # Results A total of 4,197 studies met the search term requirements. A total of 123 articles were included for data extraction. Excluded articles were available as discussion or background references. The panel convened 14 times (11 teleconference webinars and three face-to-face meetings) from July 27, 2013, through September 24, 2015, to develop the scope, draft recommendations, review and respond to solicited feedback, and assess the quality of evidence that supports the final recommendations. Additional work was completed via electronic mail. An open comment period was held from March 30, 2015, through April 22, 2015, during which draft recommendations were posted on the AMP website. Twenty-one guideline statements had an agreement ranging from 60% to 94% for each statement from the opencomment period participants (refer to Outcomes in the SDC for full details). The website received a total of 248 comments. Teams of three to four expert panel members were assigned three to five draft recommendations to review all comments received and provide an overall summary to the rest of the panel. Following panel discussion and the final quality of evidence assessment, the panel members determined whether to maintain the original draft recommendation as is, revise it with minor language change, or consider it as a major recommendation change. The expert panel modified eight draft statements based on the feedback during the open-comment period and the considered judgment process. Resolution of all changes was obtained by majority consensus of the panel using nominal group technique (rounds of email discussion and multiple edited recommendations) among the panel members. The final recommendations were approved by the expert panel with a formal vote. The panel considered the risks and benefits throughout the whole process in their considered judgment process. Formal cost analysis or cost-effectiveness was not performed. Each organization instituted a review process to approve the guideline. The ASCP assigned the review of the guideline to a Special Review Panel. For the CAP, an independent review panel (IRP) representing the Council on Scientific Affairs was assembled to review and approve the guideline. The IRP was masked to the expert panel and vetted through the COI process. The AMP approval process required the internal review of an independent panel led by the Publications and Communications Committee Chair and Executive Committee approval. The ASCO approval process required the review and approval of the Clinical Practice Guidelines Committee. # Guideline statements 1. Recommendation: Patients with CRC being considered for anti-EGFR therapy must receive RAS mutational testing. Mutational analysis should include KRAS and NRAS codons 12 and 13 of exon 2, 59 and 61 of exon 3, and 117 and 146 of exon 4 ("expanded" or "extended" RAS) [fig_ref] Table 4: Guideline Statements and Strength of Recommendations Guideline Statement Strength of Recommendation 1 [/fig_ref]. Aberrant activation of EGFR signaling pathways in CRC is primarily associated with activating mutations of genes in the mitogen-activated protein kinase and phosphatidylinositol-3-kinase (PI3K) pathways. Together, KRAS, NRAS, and BRAF mutations have been reported to occur in more than half of all CRC cases, and KRAS or NRAS and BRAF mutations are inversely associated, with a small proportion of individual CRCs showing cooccurrence of RAS and RAF mutations. [bib_ref] Effects of KRAS, BRAF, NRAS, and PIK3CA mutations on the efficacy of..., De Roock [/bib_ref] [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] Cetuximab and panitumumab are antibodies that bind to the extracellular domain of EGFR, blocking the binding of EGF and other EGFR endogenous ligands, thereby blocking EGFR signaling. Earlier studies reported the effects of anti-EGFR antibody treatment independent of KRAS status. [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Impact of the specific mutation in KRAS codon 12 mutated tumors on..., Modest [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] However, it was later reported that targeted EGFR therapies with cetuximab or panitumumab improve PFS and OS in patients with metastatic CRC with wild-type KRAS but not for patients with mutated KRAS. [bib_ref] EGFR antibodies in colorectal cancer: where do they belong?, Grothey [/bib_ref] [bib_ref] Effects of KRAS, BRAF, NRAS, and PIK3CA mutations on the efficacy of..., De Roock [/bib_ref] [bib_ref] K-ras mutations and benefit from cetuximab in advanced colorectal cancer, Karapetis [/bib_ref] In these earlier studies, only mutations of KRAS exon 2 were considered. Based on the available clinical trial data in 2009, the ASCO recommended that patients with metastatic CRC who are candidates for anti-EGFR antibody therapy should have their tumors tested for KRAS mutations in a Clinical Laboratory Improvements Amendments '88 (CLIA)accredited laboratory. 2 ## Strong recommendation 12. Laboratories must provide clinically appropriate turnaround times and optimal utilization of tissue specimens by using appropriate techniques (eg, multiplexed assays) for clinically relevant molecular and immunohistochemical biomarkers of colorectal cancer. Expert consensus opinion 13. Molecular and IHC biomarker testing in colorectal carcinoma should be initiated in a timely fashion based on the clinical scenario and in accordance with institutionally accepted practices. ## Expert consensus opinion Note: Test ordering can occur on a case-by-case basis or by policies established by the medical staff. 14. Laboratories should establish policies to ensure efficient allocation and utilization of tissue for molecular testing, particularly in small specimens. Expert consensus opinion 15. Members of the patient's medical team, including pathologists, may initiate colorectal carcinoma molecular biomarker test orders in accordance with institutionally accepted practices. Expert consensus opinion. Laboratories that require send-out of tests for treatment predictive biomarkers should process and send colorectal carcinoma specimens to reference molecular laboratories in a timely manner. ## Expert consensus opinion Note: It is suggested that a benchmark of 90% of specimens should be sent out within 3 working days. 17. Pathologists must evaluate candidate specimens for biomarker testing to ensure specimen adequacy, taking into account tissue quality, quantity, and malignant tumor cell fraction. Specimen adequacy findings should be documented in the patient report. Expert consensus opinion 18. Laboratories should use colorectal carcinoma molecular biomarker testing methods that are able to detect mutations in specimens with at least 5% mutant allele frequency, taking into account the analytical sensitivity of the assay (limit of detection or LOD) and tumor enrichment (eg, microdissection). ## Expert consensus opinion Note: It is recommended that the operational minimal neoplastic carcinoma cell content tested should be set at least two times the assay's LOD. [bib_ref] American Society of Clinical Oncology provisional clinical opinion: testing for KRAS gene..., Allegra [/bib_ref]. Colorectal carcinoma molecular biomarker results should be made available as promptly as feasible to inform therapeutic decision making, both prognostic and predictive. ## Expert consensus opinion Note: It is suggested that a benchmark of 90% of reports be available within 10 working days from date of receipt in the molecular diagnostics laboratory. 20. Colorectal carcinoma molecular biomarker testing reports should include a results and interpretation section readily understandable by oncologists and pathologists. Appropriate Human Genome Variation Society and Human Genome Organisation nomenclature must be used in conjunction with any historical genetic designations. ## Expert consensus opinion A large body of evidence was available to guide the recommendation in the current guideline for RAS testing in colorectal cancers [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref] ; all supplemental materials can be found at American Journal of Clinical Pathology online). From 2008 to 2015, there were 311 primary studies that included 74,546 patients and reported treatment outcomes for patients with RAS mutations compared with nonmutated/wild type. [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Impact of the specific mutation in KRAS codon 12 mutated tumors on..., Modest [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] The most common comparison of anti-EGFR antibody treatment outcomes was between KRAS mutation vs KRAS nonmutated/wild type. [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] American Society of Clinical Oncology provisional clinical opinion: testing for KRAS gene..., Allegra [/bib_ref] [bib_ref] Concordance of predictive markers for EGFR inhibitors in primary tumors and metastases..., Baas [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] Cetuximab in the first-line treatment of K-ras wild-type metastatic colorectal cancer: the..., Ku [/bib_ref] [bib_ref] Effect of KRAS mutational status in advanced colorectal cancer on the outcomes..., Lin [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Is K-ras gene mutation a prognostic factor for colorectal cancer: a systematic..., Ren [/bib_ref] [bib_ref] Meta-analysis of the predictive value of KRAS mutations in treatment response using..., Tsoukalas [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] EGFR gene copy number as a predictive biomarker for the treatment of..., Yang [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] [bib_ref] Clinical implementation of KRAS testing in metastatic colorectal carcinoma: the pathologist's perspective, Ross [/bib_ref] Some studies also compared the effects of adding an anti-EGFR inhibitor to KRAS nonmutated/wild-type patients vs chemotherapy alone. [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] Cetuximab in the first-line treatment of K-ras wild-type metastatic colorectal cancer: the..., Ku [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Is K-ras gene mutation a prognostic factor for colorectal cancer: a systematic..., Ren [/bib_ref] [bib_ref] Meta-analysis of the predictive value of KRAS mutations in treatment response using..., Tsoukalas [/bib_ref] A few studies reported anti-EGFR antibody treatment outcomes for the following comparisons: KRAS G13D vs codon 12 mutations, [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] KRAS codon 13 mutations vs other mutations, [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] and G13D vs other exon 2 mutations. [bib_ref] Association of KRAS p.G13D mutation with outcome in patients with chemotherapy-refractory metastatic..., De Roock [/bib_ref] The reported anti-EGFR therapy outcomes in these studies were pooled survival, [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Impact of the specific mutation in KRAS codon 12 mutated tumors on..., Modest [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] Association of KRAS p.G13D mutation with outcome in patients with chemotherapy-refractory metastatic..., De Roock [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] EGFR gene copy number as a prognostic marker in colorectal cancer patients..., Jiang [/bib_ref] [bib_ref] Effect of KRAS mutational status in advanced colorectal cancer on the outcomes..., Lin [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Is K-ras gene mutation a prognostic factor for colorectal cancer: a systematic..., Ren [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] pooled PFS, [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] Association of KRAS p.G13D mutation with outcome in patients with chemotherapy-refractory metastatic..., De Roock [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] EGFR gene copy number as a prognostic marker in colorectal cancer patients..., Jiang [/bib_ref] [bib_ref] Effect of KRAS mutational status in advanced colorectal cancer on the outcomes..., Lin [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] and pooled objective response rate (ORR). [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] Thirteen studies reported significant differences between comparators. [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Association of KRAS p.G13D mutation with outcome in patients with chemotherapy-refractory metastatic..., De Roock [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] EGFR gene copy number as a prognostic marker in colorectal cancer patients..., Jiang [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Is K-ras gene mutation a prognostic factor for colorectal cancer: a systematic..., Ren [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] The systematic review literature of data on anti-EGFR therapy outcomes is presented in Supplemental [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. Five of these studies detected a significant pooled survival advantage of anti-EGFR-treated patients for KRAS nonmutated/wild type compared with KRAS mutation. [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Is K-ras gene mutation a prognostic factor for colorectal cancer: a systematic..., Ren [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] Three studies detected an advantage for patients with nonmutated tumors given anti-EGFR treatment compared with KRAS mutation-positive patients given chemotherapy alone. [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] Twenty of the included studies pooled PFS, [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] Association of KRAS p.G13D mutation with outcome in patients with chemotherapy-refractory metastatic..., De Roock [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] EGFR gene copy number as a prognostic marker in colorectal cancer patients..., Jiang [/bib_ref] [bib_ref] Effect of KRAS mutational status in advanced colorectal cancer on the outcomes..., Lin [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] with 19 reporting significant differences between comparators. [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] Association of KRAS p.G13D mutation with outcome in patients with chemotherapy-refractory metastatic..., De Roock [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] EGFR gene copy number as a prognostic marker in colorectal cancer patients..., Jiang [/bib_ref] [bib_ref] Effect of KRAS mutational status in advanced colorectal cancer on the outcomes..., Lin [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] Fourteen papers detected a significant PFS advantage for adding an anti-EGFR inhibitor to chemotherapy for KRAS nonmutated/wild-type patients compared with chemotherapy alone. [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] Effect of KRAS mutational status in advanced colorectal cancer on the outcomes..., Lin [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] Sixteen of the included papers pooled ORR, [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] with 14 reporting significant differences between comparators. [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] Eight studies detected ORR advantages for adding an anti-EGFR inhibitor to chemotherapy for patients with nonmutated/wild-type tumors compared with chemotherapy alone, [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] and four detected an ORR advantage for KRAS nonmutated/wild-type patients over mutation patients. [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] Survival advantages (OS and PFS, ORR) for G13D mutations over codon 12 and G13D over other mutations were reported in two studies [bib_ref] Association of KRAS p.G13D mutation with outcome in patients with chemotherapy-refractory metastatic..., De Roock [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] and codon 13 over other KRAS mutations. [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] Recent studies showed conclusive evidence that in addition to mutations in KRAS exon 2, other RAS mutations in KRAS exons 3 and 4 and NRAS exons 2, 3, and 4 were also associated with nonresponse of metastatic CRC to anti-EGFR monoclonal antibody therapy. [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] [bib_ref] Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer, Douillard [/bib_ref] [bib_ref] leucovorin, and irinotecan plus cetuximab treatment and RAS mutations in colorectal cancer, Van Cutsem [/bib_ref] Douillard et al 44 published a reanalysis of the Panitumumab Randomized Control Trial in Combination with Chemotherapy for Metastatic Colorectal Cancer to Determine Efficacy (PRIME) trial, reporting that patients with any RAS mutations were associated with inferior PFS and OS with panitumumab-FOLFOX4 treatment, which was consistent with the findings previously reported for patients with KRAS mutations in exon 2. Subsequently, a meta-analysis of nine randomized clinical trials provided further evidence that not all KRAS exon 2 nonmutated/wild-type tumors benefit from anti-EGFR monoclonal antibody treatment in metastatic CRC. [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] Patients with colorectal cancers that are KRAS exon 2 nonmutated/ wild type but harbor RAS mutations in KRAS exons 3 and 4 or NRAS exons 2, 3, and 4 also have significantly inferior anti-EGFR treatment outcomes benefit compared with those without any RAS mutations. RAS mutations occur mostly at exon 2, followed by mutations in exons 3 and 4 [fig_ref] Table 7: Prevalence of New RAS Mutations Across Studies a Study New RAS Total,... [/fig_ref]. The results suggest that "extended" or "expanded" RAS mutation testing (KRAS exons 2, 3, and 4 and NRAS exons 2, 3, and 4) must be performed before the administration of an anti-EGFR monoclonal antibody therapy. [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] In summary, current evidence indicates that both cetuximab and panitumumab should only be prescribed for patients with metastatic CRCs that are nonmutated/wild type for all known RAS-activating mutations. [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] This recommendation is supported by 34 studies, [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Impact of the specific mutation in KRAS codon 12 mutated tumors on..., Modest [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] comprising 29 systematic studies, [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] American Society of Clinical Oncology provisional clinical opinion: testing for KRAS gene..., Allegra [/bib_ref] [bib_ref] Concordance of predictive markers for EGFR inhibitors in primary tumors and metastases..., Baas [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] EGFR gene copy number as a prognostic marker in colorectal cancer patients..., Jiang [/bib_ref] [bib_ref] Cetuximab in the first-line treatment of K-ras wild-type metastatic colorectal cancer: the..., Ku [/bib_ref] [bib_ref] Effect of KRAS mutational status in advanced colorectal cancer on the outcomes..., Lin [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Is K-ras gene mutation a prognostic factor for colorectal cancer: a systematic..., Ren [/bib_ref] [bib_ref] Meta-analysis of the predictive value of KRAS mutations in treatment response using..., Tsoukalas [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] EGFR gene copy number as a predictive biomarker for the treatment of..., Yang [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] [bib_ref] Clinical implementation of KRAS testing in metastatic colorectal carcinoma: the pathologist's perspective, Ross [/bib_ref] [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] two meta-analyses, 14,23 one randomized controlled trial, [bib_ref] Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer, Douillard [/bib_ref] one prospective cohort study, [bib_ref] Molecular patterns in deficient mismatch repair colorectal tumours: results from a French..., Mahamat [/bib_ref] and one retrospective cohort study. 43 Of the 29 systematic reviews, [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] American Society of Clinical Oncology provisional clinical opinion: testing for KRAS gene..., Allegra [/bib_ref] [bib_ref] Concordance of predictive markers for EGFR inhibitors in primary tumors and metastases..., Baas [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] EGFR gene copy number as a prognostic marker in colorectal cancer patients..., Jiang [/bib_ref] [bib_ref] Cetuximab in the first-line treatment of K-ras wild-type metastatic colorectal cancer: the..., Ku [/bib_ref] [bib_ref] Effect of KRAS mutational status in advanced colorectal cancer on the outcomes..., Lin [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Is K-ras gene mutation a prognostic factor for colorectal cancer: a systematic..., Ren [/bib_ref] [bib_ref] Meta-analysis of the predictive value of KRAS mutations in treatment response using..., Tsoukalas [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] EGFR gene copy number as a predictive biomarker for the treatment of..., Yang [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] [bib_ref] Clinical implementation of KRAS testing in metastatic colorectal carcinoma: the pathologist's perspective, Ross [/bib_ref] [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] only three reported using a multidisciplinary panel, [bib_ref] American Society of Clinical Oncology provisional clinical opinion: testing for KRAS gene..., Allegra [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] and only one reported taking patient preferences into account, 37 although 13 examined important patient subtypes. [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] EGFR gene copy number as a prognostic marker in colorectal cancer patients..., Jiang [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Is K-ras gene mutation a prognostic factor for colorectal cancer: a systematic..., Ren [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] EGFR gene copy number as a predictive biomarker for the treatment of..., Yang [/bib_ref] All but one had welldescribed and reported methods sections. [bib_ref] Clinical implementation of KRAS testing in metastatic colorectal carcinoma: the pathologist's perspective, Ross [/bib_ref] Seven did not report on conflict of interest. [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Meta-analysis of the predictive value of KRAS mutations in treatment response using..., Tsoukalas [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] [bib_ref] Clinical implementation of KRAS testing in metastatic colorectal carcinoma: the pathologist's perspective, Ross [/bib_ref] Only nine rated the quality of the included evidence, and these same nine were the only ones that reported on the strength of the included evidence. [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] KRAS testing for Anti-EGFR therapy in advanced colorectal cancer: an evidence-based and..., Health Quality Ontario [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] Is K-ras gene mutation a prognostic factor for colorectal cancer: a systematic..., Ren [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] None of the studies included a plan for updating. None of the systematic reviews reported industry funding, two reported no funding, [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] and 11 did not report on the source of funding, if any. [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Meta-analysis of the predictive value of KRAS mutations in treatment response using..., Tsoukalas [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] [bib_ref] Clinical implementation of KRAS testing in metastatic colorectal carcinoma: the pathologist's perspective, Ross [/bib_ref] [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] Two of these systematic reviews were deemed to have a low risk of bias, were deemed to have a low to moderate risk of bias, [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] [bib_ref] A systematic review and meta-analysis of KRAS status as the determinant of..., Adelstein [/bib_ref] [bib_ref] American Society of Clinical Oncology provisional clinical opinion: testing for KRAS gene..., Allegra [/bib_ref] [bib_ref] Association between KRAS codon 13 mutations and clinical response to anti-EGFR treatment..., Chen [/bib_ref] [bib_ref] Systematic review: anti-epidermal growth factor receptor treatment effect modification by KRAS mutations..., Dahabreh [/bib_ref] [bib_ref] The clinical effectiveness and cost-effectiveness of cetuximab (mono-or combination chemotherapy), bevacizumab (combination..., Hoyle [/bib_ref] [bib_ref] EGFR gene copy number as a prognostic marker in colorectal cancer patients..., Jiang [/bib_ref] [bib_ref] Effect of KRAS mutational status in advanced colorectal cancer on the outcomes..., Lin [/bib_ref] [bib_ref] Assessment of somatic k-RAS mutations as a mechanism associated with resistance to..., Linardou [/bib_ref] [bib_ref] KRAS p.G13D mutation and codon 12 mutations are not created equal in..., Mao [/bib_ref] [bib_ref] Does anti-EGFR therapy improve outcome in advanced colorectal cancer? A systematic review..., Vale [/bib_ref] [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] 12 were deemed to have a moderate risk of bias, [bib_ref] Clinical outcome of panitumumab for metastatic colorectal cancer with wild-type KRAS status:..., Ibrahim [/bib_ref] [bib_ref] Cetuximab and panitumumab in KRAS wild-type colorectal cancer: a meta-analysis, Petrelli [/bib_ref] [bib_ref] Concordance of predictive markers for EGFR inhibitors in primary tumors and metastases..., Baas [/bib_ref] [bib_ref] Bin Sadiq BM. Cetuximab-based therapy for metastatic colorectal cancer: a meta-analysis of..., Ibrahim [/bib_ref] [bib_ref] Cetuximab in the first-line treatment of K-ras wild-type metastatic colorectal cancer: the..., Ku [/bib_ref] [bib_ref] Clinical impact of anti-epidermal growth factor receptor monoclonal antibodies in first-line treatment..., Loupakis [/bib_ref] [bib_ref] PIK3CA exon 20 mutations as a potential biomarker for resistance to anti-EGFR..., Mao [/bib_ref] [bib_ref] Resectability and outcome with anti-EGFR agents in patients with KRAS wild-type colorectal..., Petrelli [/bib_ref] [bib_ref] Predictive and prognostic value of KRAS mutations in metastatic colorectal cancer patients..., Qiu [/bib_ref] [bib_ref] Meta-analysis of the predictive value of KRAS mutations in treatment response using..., Tsoukalas [/bib_ref] [bib_ref] EGFR gene copy number as a predictive biomarker for the treatment of..., Yang [/bib_ref] [bib_ref] Overall and KRAS-specific results of combined cetuximab treatment and chemotherapy for metastatic..., Zhang [/bib_ref] and one was deemed to have a high risk of bias. [bib_ref] Clinical implementation of KRAS testing in metastatic colorectal carcinoma: the pathologist's perspective, Ross [/bib_ref] Of the two meta-analyses obtained, 14,23 both had wellreported and reproducible methods sections, both described the planned pooling a priori, and both discussed the limitations of their analyses. Neither was based on a systematic review of the literature, and neither did a quality assessment of the included studies. One reported nonindustry funding, [bib_ref] Association of KRAS p.G13D mutation with outcome in patients with chemotherapy-refractory metastatic..., De Roock [/bib_ref] and the other reported industry funding. 14 One was deemed to have a low to moderate risk of bias, [bib_ref] Association of KRAS p.G13D mutation with outcome in patients with chemotherapy-refractory metastatic..., De Roock [/bib_ref] and the other was deemed to have a moderate risk of bias. [bib_ref] Impact of the specific mutation in KRAS codon 12 mutated tumors on..., Modest [/bib_ref] The single randomized controlled trial did not report on any details of the randomization, including blinding, the expected effect size and power calculation, and the length of follow-up. [bib_ref] Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer, Douillard [/bib_ref] It did report on differences in baseline patient characteristics. This trial did report at least partial industry funding and was deemed to have a low to moderate risk of bias. [bib_ref] Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer, Douillard [/bib_ref] The single prospective cohort study reported a balance between treatment and assessment groups, reported on baseline characteristics, and made adjustments in the analysis when differences were found. [bib_ref] Molecular patterns in deficient mismatch repair colorectal tumours: results from a French..., Mahamat [/bib_ref] It reported nonindustry funding and was deemed to have a low risk of bias. [bib_ref] Molecular patterns in deficient mismatch repair colorectal tumours: results from a French..., Mahamat [/bib_ref] The single retrospective cohort study reported that the treatment and assessment groups were in balance and also reported on baseline patient characteristics. [bib_ref] Simultaneous identification of 36 mutations in KRAS codons 61 and 146, BRAF,..., Bando [/bib_ref] It did not report that adjustments were made in the analysis to account for differences, where differences were found. This study reported nonindustry funding and was deemed to have a low risk of bias. [bib_ref] Simultaneous identification of 36 mutations in KRAS codons 61 and 146, BRAF,..., Bando [/bib_ref] All of the evidence that supported this recommendation was assessed, and none was found to have methodologic flaws that would raise concerns about their findings. BRAF activating mutations occur in about 8% of advanced disease patients with CRC [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] and in approximately 14% of patients with localized stage II and III CRC. [bib_ref] Mutation profiling and microsatellite instability in stage II and III colon cancer:..., Gavin [/bib_ref] [bib_ref] The catalogue of somatic mutations in cancer (COSMIC), Forbes [/bib_ref] As such, mutations in BRAF constitute a substantial subset of patients with CRC. The key questions related to BRAF mutations are whether patients whose cancers carry a BRAF mutation have a poorer outcome compared with BRAF mutation-negative tumors and whether the presence of a mutation predicts benefit from or lack thereof to anti-EGFR therapy. Four systematic reviews 20,50-52 and three systematic reviews that included meta-analyses [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] [bib_ref] Effect of BRAF V600E mutation on tumor response of anti-EGFR monoclonal antibodies..., Cui [/bib_ref] pertaining to the prognostic and predictive value of BRAF mutations in patients with CRC were identified through our systematic review process [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. These studies revealed that patients with advanced CRC who possess a BRAF mutation have significantly poorer outcomes as measured by PFS and OS and have a decreased response rate to anti-EGFR therapy relative to those with nonmutated BRAF. Poorer OS was also demonstrated for those patients with earlier stage II and III CRC having a BRAF mutation [bib_ref] Mutation profiling and microsatellite instability in stage II and III colon cancer:..., Gavin [/bib_ref] [bib_ref] Microsatellite instability and BRAF mutation testing in colorectal cancer prognostication, Lochhead [/bib_ref] ; however, the poorer outcome appears to be primarily the result of decreased OS after relapse in these patients rather than a harbinger of an increased rate of relapse. Finally, while outcomes in advanced disease patients with BRAF mutations were poorer relative to nonmutation patients, the data were consistent with a modest beneficial impact from the use of anti-EGFR agents relative to those patients whose tumors contained a RAS mutation. [bib_ref] Meta-analysis of BRAF mutation as a predictive biomarker of benefit from anti-EGFR..., Rowland [/bib_ref] In summary, patients with CRC that contains a BRAF mutation have a worse outcome relative to nonmutation patients. Selected patients for BRAF mutation testing include patients with metastatic disease, since these patients have particularly poor outcomes. It is important to know the BRAF c.1799 (p.V600) mutation status of a patient's CRC since standard therapy is not adequate for patients with metastatic disease and BRAF mutation. For these patients, some studies suggest the use of FOLFIRINOX (folinic acid [leucovorin calcium], 5-fluorouracil, irinotecan hydrochloride, and oxaliplatin) as first-line therapy, followed by enrollment in a clinical trial. [bib_ref] FOLFOXIRI plus bevacizumab versus FOLFIRI plus bevacizumab as firstline treatment of patients..., Cremolini [/bib_ref] Furthermore, early clinical trials data suggest that the combination of a BRAF plus EGFR inhibitor appears to be effective in this population. [bib_ref] Dual inhibition of MEK and PI3K pathway in KRAS and BRAF mutated..., Temraz [/bib_ref] Data in support of molecular testing for BRAF c.1799 (p.V600) mutations in CRC continue to emerge from clinical trials. A recent publication of the PETACC-8 (oxaliplatin, fluorouracil, and leucovorin with or without cetuximab in patients with resected stage III colon cancer randomised phase 3) trial reported that trials in the adjuvant setting should consider mismatch repair, BRAF, and KRAS status for stratification, since BRAF p.V600 and KRAS mutations were associated with shorter DFS and OS in patients with microsatellite-stable colon cancer but not in those with tumors with MSI. [bib_ref] BRAF mutation in colorectal cancer: an update, Barras [/bib_ref] This recommendation is supported by seven systematic reviews, 20,47,48,50-53 three of which included meta-analysis. [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] [bib_ref] Effect of BRAF V600E mutation on tumor response of anti-EGFR monoclonal antibodies..., Cui [/bib_ref] None of the systematic reviews reported the composition of their panel, so multidisciplinary panel representation could not be confirmed, and none reported patient representation on the panel. All but the systematic review reported by Baas et al 20 reported examining important patient subgroups. All of the systematic reviews reported well-described and reproducible methods. Three did not report how conflicts of interest were managed and reported on. [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] [bib_ref] BRAF V600E mutation and resistance to anti-EGFR monoclonal antibodies in patients with..., Mao [/bib_ref] [bib_ref] Effect of BRAF V600E mutation on tumor response of anti-EGFR monoclonal antibodies..., Cui [/bib_ref] Only two reported on a quality assessment of the included literature, [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] [bib_ref] Systematic review of pharmacogenetic testing for predicting clinical benefit to anti-EGFR therapy..., Lin [/bib_ref] and only one rated the strength of the evidence. [bib_ref] Systematic review of pharmacogenetic testing for predicting clinical benefit to anti-EGFR therapy..., Lin [/bib_ref] None reported a plan for updating. While none of the systematic reviews reported industry funding, one study did not report any funding support. [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] Overall, the risk of bias assessment for this body of evidence ranged from low [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] [bib_ref] Systematic review of pharmacogenetic testing for predicting clinical benefit to anti-EGFR therapy..., Lin [/bib_ref] to moderate, 20,51,53 and none were found to have methodologic flaws that would raise concerns about their findings. 2b. Recommendation: BRAF p.V600 mutational analysis should be performed in dMMR tumors with loss of MLH1 to evaluate for Lynch syndrome risk. Presence of a BRAF mutation strongly favors a sporadic pathogenesis. The absence of BRAF mutation does not exclude risk of Lynch syndrome. dMMR occurs via several mechanisms. In sporadic CRC, dMMR is most frequently caused by epigenetic silencing through CpG methylation primarily of MLH1, with few cases resulting from somatic mutation of one of the MMR genes. In Lynch syndrome CRC, the underlying mechanism is usually a germline mutation of one of the four (MLH1, MSH2, MSH6, and PMS2) mismatch repair genes and, in rare patients, a deletion involving EPCAM (epithelial cell adhesion molecule), a gene adjacent to MSH2, that leads to epigenetic inactivation of the MSH2 gene. dMMR occurs in 15% to 20% of all colorectal cancers, and of these, about three-fourths are due to MLH1 epigenetic silencing. 5,62 dMMR underlies widespread mutations in the genome and MSI. BRAF p.V600 mutations rarely occur in patients with germline-based dMMR but have been reported in up to three-fourths of those with epigenetic MMR gene silencing [fig_ref] Table 8: BRAF Clinical Practice Guidelines, Systematic Reviews, Meta-Analyses, Prospective Cohort Studies, and Retrospective... [/fig_ref]. Thus, testing for BRAF mutations serves as a means for distinguishing germline from epigenetic dMMR, particularly in those cases where the dMMR is the result of epigenetic silencing of MLH1. For tumors with a mutation in BRAF and dMMR, it may be concluded that the basis for their dMMR is less likely to be germline. [bib_ref] American Gastroenterological Association Institute guideline on the diagnosis and management of Lynch..., Rubenstein [/bib_ref] [bib_ref] Correlation of tumour BRAF mutations and MLH1 methylation with germline mismatch repair..., Parsons [/bib_ref] [bib_ref] Microsatellite instability and colorectal cancer, Geiersbach [/bib_ref] In contrast, tumors with dMMR in the absence of a BRAF mutation may have either germline or an epigenetic (MLH1 gene promoter hypermethylation) basis for the dMMR, and specific testing for MLH1 promoter hypermethylation may be used to further refine the risk of Lynch syndrome before initiating definitive genetic testing. Identification of those patients with germline-based dMMR has clear implications for the patient's family members. 3. Recommendation: Clinicians should order mismatch repair status testing in patients with colorectal cancers for the identification of patients at high risk for Lynch syndrome and/or prognostic stratification. The molecular pathology underlying most MSI tumors is somatically acquired CpG methylation of the promoter of the gene, MLH1. About three-fourths of colorectal cancers with MSI due to MLH1 promoter hypermethylation will have an acquired BRAF mutation as well. The reason for this is not understood. Less than one-third of individuals A systematic review of 31 studies 7 reporting survival on 12,782 patients whose tumors were characterized for MSI showed a favorable prognosis, as determined by both OS and DFS [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref] , but this is dependent on stage. In addition, the presence of MSI in CRC was reported to be predictive for nonresponse to 5-fluorouracil-based adjuvant chemotherapy of early stage disease, 6 although this has not been corroborated [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. [bib_ref] Implications of mismatch repair-deficient status on management of early stage colorectal cancer, Kawakami [/bib_ref] Emerging data indicate that MMR status may have predictive value in some settings, specifically in patients with advanced disease being considered for anti-programmed cell death protein-1 (PD-1)/ programmed cell death ligand protein-1 (PD-L1) immune checkpoint inhibitor therapy. [bib_ref] PD-1 blockade in tumors with mismatch-repair deficiency, Diaz [/bib_ref] [bib_ref] PD-1 blockade in tumors with mismatch-repair deficiency, Le [/bib_ref] This recommendation is supported by two systematic reviews that included 38 studies and 16,472 patients. [bib_ref] Does microsatellite instability predict the efficacy of adjuvant chemotherapy in colorectal cancer?..., Guetz [/bib_ref] [bib_ref] Microsatellite instability as a marker of prognosis and response to therapy: a..., Guastadisegni [/bib_ref] Both of these systematic reviews included a well-described and reproducible methods section, and both reported on potential conflicts of interest. Only one, the systematic review reported by Guastadisegni et al, [bib_ref] Microsatellite instability as a marker of prognosis and response to therapy: a..., Guastadisegni [/bib_ref] reported the source of funding, which was nonindustry. Due to deficits in the reporting, one of these systematic reviews was deemed to have a moderate risk of bias, 6 and the other was deemed to have a low to moderate risk of bias 7 ; however, neither of these were found to have any major methodologic flaws that would cause us to question their findings. ## No recommendation: There is insufficient evidence to recommend BRAF c.1799 (p.V600) mutational status as a predictive molecular biomarker for response to anti-EGFR inhibitors. As noted in recommendation 2a, mutations in position p.V600 in BRAF are associated with poor prognosis, especially in patients with metastatic disease. Response rates to chemotherapy regimens, including regimens with cetuximab and panitumumab, are lower in patients harboring BRAF p.V600 mutations [bib_ref] BRAF V600E mutation and resistance to anti-EGFR monoclonal antibodies in patients with..., Mao [/bib_ref] [bib_ref] Effect of BRAF V600E mutation on tumor response of anti-EGFR monoclonal antibodies..., Cui [/bib_ref] [bib_ref] Promising biomarkers for predicting the outcomes of patients with KRAS wildtype metastatic..., Yang [/bib_ref] [fig_ref] Table 8: BRAF Clinical Practice Guidelines, Systematic Reviews, Meta-Analyses, Prospective Cohort Studies, and Retrospective... [/fig_ref]. Similarly, the PFS and OS after treatment with EGFR monoclonal antibodies in combination with chemotherapy are lower in patients with BRAF p.V600 mutations. [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] Many of these analyses used nonrandomized cohorts, thereby making evaluation of the potential predictive value of the BRAF p.V600 mutation impossible to discern [fig_ref] Table 8: BRAF Clinical Practice Guidelines, Systematic Reviews, Meta-Analyses, Prospective Cohort Studies, and Retrospective... [/fig_ref]. In addition, the poor prognosis and low mutation prevalence make evaluation of the relative benefit of EGFR inhibitors difficult to evaluate in individual randomized clinical trials. Meta-analyses of randomized studies of EGFR monoclonal antibodies have been completed to address the question of the predictive role of BRAF p.V600 mutations. A meta-analysis of 463 patients with KRAS wild-type and BRAF p.V600 mutated tumors did not provide sufficient evidence to exclude a magnitude of benefits seen in KRAS/ BRAF wild-type tumors. Nor was there sufficient evidence to identify a statistically significant benefit to this treatment. [bib_ref] Meta-analysis of BRAF mutation as a predictive biomarker of benefit from anti-EGFR..., Rowland [/bib_ref] A second meta-analysis showed that EGFR monoclonal antibody treatment in patients whose tumors contain a BRAF p.V600 mutation was not associated with significant OS (P ¼ .43), although there was a trend for better PFS (P ¼ .07).This suggests insufficient evidence to recommend the use of BRAF p.V600 as a predictive marker for benefit of anti-EGFR monoclonal antibodies. More data are required to definitively determine the predictive value of BRAF mutations relative to anti-EGFR therapy. This recommendation was supported by five systematic reviews [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] [bib_ref] BRAF V600E mutation and resistance to anti-EGFR monoclonal antibodies in patients with..., Mao [/bib_ref] [bib_ref] Effect of BRAF V600E mutation on tumor response of anti-EGFR monoclonal antibodies..., Cui [/bib_ref] [bib_ref] Promising biomarkers for predicting the outcomes of patients with KRAS wildtype metastatic..., Yang [/bib_ref] [fig_ref] Table 8: BRAF Clinical Practice Guidelines, Systematic Reviews, Meta-Analyses, Prospective Cohort Studies, and Retrospective... [/fig_ref]. None of these systematic reviews reported forming a multidisciplinary panel, and none reported including patient representatives in developing their research questions or interpreting their outcomes. All of the systematic reviews examined important patient subtypes, and all used well-described and reproducible methods. Only the systematic review by Yuan et al [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] reported on any potential conflicts of interest, the article by Mao et al 51 stated conflicts were not examined, and the other three did not report anything regarding conflicts. [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] [bib_ref] Effect of BRAF V600E mutation on tumor response of anti-EGFR monoclonal antibodies..., Cui [/bib_ref] [bib_ref] Promising biomarkers for predicting the outcomes of patients with KRAS wildtype metastatic..., Yang [/bib_ref] Only two, the systematic reviews reported by Yang et al [bib_ref] Promising biomarkers for predicting the outcomes of patients with KRAS wildtype metastatic..., Yang [/bib_ref] and Yuan et al, [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] rated the quality of the included evidence, although none of the studies reported on the strength of the evidence. None of the studies discussed any plans for future updating. Four reported nonindustry funding for their systematic reviews, 48,51,53,71 and one did not report the source of funding, if any. [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] Two of the systematic reviews were deemed to have a low risk of bias, [bib_ref] The prognostic role of BRAF mutation in metastatic colorectal cancer receiving anti-EGFR..., Yuan [/bib_ref] [bib_ref] Promising biomarkers for predicting the outcomes of patients with KRAS wildtype metastatic..., Yang [/bib_ref] one was deemed to have a low to moderate risk of bias, [bib_ref] Predictive and prognostic roles of BRAF mutation in patients with metastatic colorectal..., Xu [/bib_ref] and two were deemed to have a moderate risk of bias. [bib_ref] BRAF V600E mutation and resistance to anti-EGFR monoclonal antibodies in patients with..., Mao [/bib_ref] [bib_ref] Effect of BRAF V600E mutation on tumor response of anti-EGFR monoclonal antibodies..., Cui [/bib_ref] Overall, none of the systematic reviews were found to have methodologic flaws that would raise concerns about their findings. ## No recommendation: There is insufficient evidence to recommend PIK3CA mutational analysis of colorectal carcinoma tissue for therapy selection outside of a clinical trial. Note: Retrospective studies have suggested improved survival with postoperative aspirin use in patients whose colorectal carcinoma harbors a PIK3CA mutation. Despite comprehensive RAS testing (recommendation 1), many patients still fail to respond to EGFR monoclonal antibody therapy. Additional biomarkers to guide patient selection for such therapy are desired. PIK3CA mutations are observed in 10% to 18% of patients with CRC, primarily in exons 9 and 20, and lead to a constitutive activation of p100a enzymatic activity, leading to an increased PI3K activity and high oncogenic transformation ability. However, mutations of KRAS or NRAS and PIK3CA mutations can be detected alternatively and, in some cases, concurrently in a single CRC. [bib_ref] Effects of KRAS, BRAF, NRAS, and PIK3CA mutations on the efficacy of..., De Roock [/bib_ref] [bib_ref] Mutation profiling and microsatellite instability in stage II and III colon cancer:..., Gavin [/bib_ref] PIK3CA mutations are positively correlated with KRAS exon 12 and 13 mutations. [bib_ref] Effects of KRAS, BRAF, NRAS, and PIK3CA mutations on the efficacy of..., De Roock [/bib_ref] Several meta-analyses and one individual patient data large pooled analysis have examined the prognostic role of PIK3CA in patients with stage IV CRC, both overall and in the KRAS nonmutated/wild-type population. These studies have generally indicated poorer response rate and PFS in patients with the PIK3CA mutation, a finding that appears to be driven primarily by patients with exon 20 mutation 3,33,50,71 [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. These meta-analyses have included many of the same studies, as well as observed and acknowledged between-study heterogeneity, and all have concluded further prospective data are necessary. Contradictory recent studies have also been recently reported. [bib_ref] PIK3CA, BRAF, and PTEN status and benefit from cetuximab in the treatment..., Karapetis [/bib_ref] None of the studies considered the independent role of PIK3CA in the context of comprehensive RAS testing. De Roock et al 3 estimated that comprehensive PIK3CA testing would increase response rate in the first-line setting by only 1%. The prognostic impact of PIK3CA in stage I to III disease has been inconsistent. [bib_ref] Prognostic role of PIK3CA mutation in colorectal cancer: cohort study and literature..., Liao [/bib_ref] [bib_ref] Predictive and prognostic analysis of PIK3CA mutation in stage III colon cancer..., Ogino [/bib_ref] [bib_ref] PIK3CA mutation is associated with poor prognosis among patients with curatively resected..., Ogino [/bib_ref] Multiple prospective observational studies have demonstrated an association between aspirin use and decreased CRC mortality. [bib_ref] Effect of aspirin on long-term risk of colorectal cancer: consistent evidence from..., Flossmann [/bib_ref] [bib_ref] A large cohort study of long-term daily use of adult-strength aspirin and..., Jacobs [/bib_ref] [bib_ref] Aspirin dose and duration of use and risk of colorectal cancer in..., Chan [/bib_ref] Data on aspirin as a treatment for CRC (postdiagnosis usage) are more limited and drawn only from observational studies. Domingo et al [bib_ref] Evaluation of PIK3CA mutation as a predictor of benefit from nonsteroidal anti-inflammatory..., Domingo [/bib_ref] and Liao et al 82 found a survival advantage for posttreatment aspirin users only in patients whose tumors exhibit PIK3CA mutations; however, a recent cohort study did not validate these observations. [bib_ref] Impact of regular aspirin use on overall and cancer-specific survival in patients..., Kothari [/bib_ref] Multiple prospective studies are under way to address the potential benefit of adding aspirin or other nonsteroidal anti-inflammatory drugs to adjuvant therapy. This recommendation is supported by two systematic reviews 33,40 obtained from our systematic review. None reported the composition of a multidisciplinary panel, reported patient representation or study quality, rated strength of the evidence reviewed, or disclosed a plan for updating. However, both systematic reviews did include relevant patient subgroups and included methods that were well described and reproducible. In both systematic reviews, information about the potential conflicts of the panelists was reported, and funding was provided by nonindustry sources. Both were found to have a moderate risk of bias, but neither of the studies providing the evidence base for recommendation 5 were found to have methodologic flaws that would raise concerns about their findings. At the present time, the retrospective data for the use of PIK3CA mutation to deny anti-EGFR antibody therapy in patients with stage IV CRC or as a selection factor for use of aspirin in stage I to III tumors are insufficient for clinical use outside of a clinical trial. Although there is evidence suggesting that PTEN is a critical factor in cancer development, the association between PTEN expression and predictive/prognostic value remains controversial, with several studies suggesting an [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. Tests used included IHC and FISH. Of the four studies that reported overall survival rates, 20,50,85,86 three studies reported on pooled outcomes. [bib_ref] Systematic review of pharmacogenetic testing for predicting clinical benefit to anti-EGFR therapy..., Lin [/bib_ref] [bib_ref] Phosphatase and tensin homolog expression related to cetuximab effects in colorectal cancer..., Shen [/bib_ref] [bib_ref] Loss of PTEN expression as a predictor of resistance to anti-EGFR monoclonal..., Wang [/bib_ref] One study reported a significant difference in favor of normal PTEN expression, [bib_ref] Loss of PTEN expression as a predictor of resistance to anti-EGFR monoclonal..., Wang [/bib_ref] and the others reported no significant differences. [bib_ref] Concordance of predictive markers for EGFR inhibitors in primary tumors and metastases..., Baas [/bib_ref] [bib_ref] Systematic review of pharmacogenetic testing for predicting clinical benefit to anti-EGFR therapy..., Lin [/bib_ref] [bib_ref] Phosphatase and tensin homolog expression related to cetuximab effects in colorectal cancer..., Shen [/bib_ref] For PFS, three studies pooled outcomes, 50,85,86 two detected a significant difference in favor of normal PTEN expression, [bib_ref] Phosphatase and tensin homolog expression related to cetuximab effects in colorectal cancer..., Shen [/bib_ref] [bib_ref] Loss of PTEN expression as a predictor of resistance to anti-EGFR monoclonal..., Wang [/bib_ref] and one showed no significant difference. [bib_ref] Systematic review of pharmacogenetic testing for predicting clinical benefit to anti-EGFR therapy..., Lin [/bib_ref] For ORR, two studies pooled outcomes, and both found loss of PTEN expression associated with a poorer response. [bib_ref] Phosphatase and tensin homolog expression related to cetuximab effects in colorectal cancer..., Shen [/bib_ref] [bib_ref] Loss of PTEN expression as a predictor of resistance to anti-EGFR monoclonal..., Wang [/bib_ref] Several studies have shown an association between PTEN loss and local recurrence, advanced TNM stage, lymph node metastasis, and a lower 5-year survival rate. [bib_ref] PTEN mutations are common in sporadic microsatellite stable colorectal cancer, Nassif [/bib_ref] [bib_ref] Loss of PTEN expression is associated with colorectal cancer liver metastasis and..., Sawai [/bib_ref] [bib_ref] Expression of PPARgamma and PTEN in human colorectal cancer: an immunohistochemical study..., Lin [/bib_ref] [bib_ref] PTEN expression and mutation in colorectal carcinomas, Li [/bib_ref] However, several other studies have found no correlation between PTEN status and patient survival, tumor grade, TNM stage, lymphatic invasion, and liver metastasis. [bib_ref] Clinicopathological significance of PTEN loss and the phosphoinositide 3-kinase/Akt pathway in sporadic..., Colakoglu [/bib_ref] [bib_ref] The prognostic role of KRAS, BRAF, PIK3CA and PTEN in colorectal cancer, Eklof [/bib_ref] [bib_ref] Prognostic impact and the relevance of PTEN copy number alterations in patients..., Price [/bib_ref] Regarding response to EGFR-targeted therapies, several studies have shown an association with PTEN loss and lack of response to cetuximab and panitumumab. [bib_ref] PTEN loss of expression predicts cetuximab efficacy in metastatic colorectal cancer patients, Frattini [/bib_ref] [bib_ref] PI3KCA/PTEN deregulation contributes to impaired responses to cetuximab in metastatic colorectal cancer..., Perrone [/bib_ref] [bib_ref] PIK3CA mutations in colorectal cancer are associated with clinical resistance to EGFR-targeted..., Sartore-Bianchi [/bib_ref] [bib_ref] PTEN status in advanced colorectal cancer treated with cetuximab, Negri [/bib_ref] However, other published studies failed to demonstrate a clear correlation between loss of PTEN expression and response to anti-EGFR therapy. [bib_ref] Analysis of PTEN, BRAF, and EGFR status in determining benefit from cetuximab..., Laurent-Puig [/bib_ref] [bib_ref] Predictive role of multiple gene alterations in response to cetuximab in metastatic..., Ulivi [/bib_ref] Given the significant discordance in results, the role of PTEN as a prognostic or predictive biomarker in CRC is still largely unknown, and research into the prognostic and predictive significance of PTEN is ongoing. This recommendation is supported by 20 studies, 4,20,50,84-100 four 20,50,85,86 of which met the inclusion criteria for inclusion in our systematic review. All four of these were systematic reviews and included 42 studies and 3,412 patients. None of these systematic reviews reported using a multidisciplinary panel or reported including the patient perspective or a plan for future updating. Three 50,85,86 reported on important patient subgroups. All four had welldescribed and reproducible methods sections. Three [bib_ref] Concordance of predictive markers for EGFR inhibitors in primary tumors and metastases..., Baas [/bib_ref] [bib_ref] Systematic review of pharmacogenetic testing for predicting clinical benefit to anti-EGFR therapy..., Lin [/bib_ref] [bib_ref] Loss of PTEN expression as a predictor of resistance to anti-EGFR monoclonal..., Wang [/bib_ref] reported that potential conflicts of interest were examined. Only two 50,86 rated the quality of the included evidence, and these same two were also the only two that rated the strength of the evidence. Only three 20,50,86 reported on the source of any funding, but all three reported nonindustry funding. One was deemed to have a low risk of bias, 50 one was deemed to have a low to moderate risk of bias, [bib_ref] Loss of PTEN expression as a predictor of resistance to anti-EGFR monoclonal..., Wang [/bib_ref] and two were deemed to have a moderate risk of bias. [bib_ref] Concordance of predictive markers for EGFR inhibitors in primary tumors and metastases..., Baas [/bib_ref] [bib_ref] Phosphatase and tensin homolog expression related to cetuximab effects in colorectal cancer..., Shen [/bib_ref] None of the studies were found to have any methodologic flaws that would bring doubt to their findings. ## Expert consensus opinion: Metastatic or recurrent colorectal carcinoma tissues are the preferred specimens for treatment predictive biomarker testing and should be used if such specimens are available and adequate. In their absence, primary tumor tissue is an acceptable alternative and should be used. In clinical practice, one or more specimens of CRC from an individual patient may become available for molecular testing during the course of the disease. These specimens may include initial diagnostic biopsy or surgical resection specimens of the primary tumor and resection, biopsy, or cytologic specimens from metastatic and recurrent tumor. Discordance between primary and metastatic lesions may be attributed to a number of mechanisms, including tumor heterogeneity already present in the primary tumor, tumor evolution, where novel mutations are acquired, and, in some cases, the presence of separate primaries. The systematic literature review for the CRC guideline was done to identify studies that compared the mutational status of primary vs metastatic CRC. An earlier systematic literature search that was conducted to include studies testing concordance of KRAS, BRAF, PIK3CA, and loss of PTEN expression in CRC 20 reported the results of 21 studies, with an overall concordance rate of 93% (range, 76%-100%) for KRAS, 93% for BRAF status, a range of 89% to 94% for PIK3CA, and 68% for loss of PTEN. [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref] shows the summary of two subsequent studies where KRAS, NRAS, BRAF, and PIK3CA mutation and PTEN expression were compared in paired primary vs metastatic tumor lesions. [bib_ref] Analysis of the concordance in the EGFR pathway status between primary tumors..., Cejas [/bib_ref] [bib_ref] Comparative genomic analysis of primary versus metastatic colorectal carcinomas, Vakiani [/bib_ref] Overall concordance rates between primary and metastatic lesions were high with more than 90% concordance [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. [bib_ref] Analysis of the concordance in the EGFR pathway status between primary tumors..., Cejas [/bib_ref] [bib_ref] Comparative genomic analysis of primary versus metastatic colorectal carcinomas, Vakiani [/bib_ref] In the study by Lee et al, analysis of [bib_ref] Comparative genomic analysis of primary versus metastatic colorectal carcinomas, Vakiani [/bib_ref] 98.8 PIK3CA (117) [bib_ref] Analysis of the concordance in the EGFR pathway status between primary tumors..., Cejas [/bib_ref] 94.0 PIK3CA (84) [bib_ref] Comparative genomic analysis of primary versus metastatic colorectal carcinomas, Vakiani [/bib_ref] 92.8 PTEN IHC (117) KRAS mutation in primary and recurrent tumors after radical resection showed 20.3% discordance. [bib_ref] KRAS discordance between primary and recurrent tumors after radical resection of colorectal..., Lee [/bib_ref] This recommendation was supported by two retrospective cohort studies 101,102 that were obtained in the systematic review. Both of these studies compared results within a single cohort. The study reported by Cejas et al 101 reported at least partial industry funding, and the study reported by Vakiani et al 102 did not report the source of funding, if any. The study by Cejas et al 101 was deemed to have a low to moderate risk of bias, and the study by Vakiani et al 102 was deemed to be low. Overall, neither of these studies had any methodologic flaws that would raise concerns about the reported findings. In summary, given that discordance of mutational status between primary and metastatic or recurrent CRC lesions may occur in a number of cases, metastatic or recurrent CRC tissues are the preferred specimens for treatment predictive biomarker testing. However, if these specimens are not available, primary tumor tissue is an acceptable alternative, given the overall high rates of concordance for the mutation status of EGFR pathway genes. ## Expert consensus opinion: Formalin-fixed, paraffin-embedded (FFPE) tissue is an acceptable specimen for molecular biomarker mutational testing in colorectal carcinoma. Use of other specimens (eg, cytology specimens) will require additional adequate validation, as would any changes in tissue-processing protocols. The systematic review identified a number of studies, summarized in [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref] , where CRC KRAS mutational testing was performed using FFPE specimens as well as fresh or frozen specimens. Recommendation 17 highlights the importance of review of stained sections of tumor selected for testing by a pathologist to verify the tumor cell content population of the sample and demarcate regions for potential macrodissection or microdissection to enrich for cancer cells. Biopsy and resection specimens are similarly acceptable, as long as sufficient tumor cells are present [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. Cytology specimens may be adequate for testing but will require proper validation. The use of FFPE cell blocks allows for the evaluation of tumor cell content and viability. [bib_ref] Evaluation of EGFR mutation status in cytology specimens: an institutional experience, Aisner [/bib_ref] Laboratories will need to establish the minimum tumor cell content for specimens based on the performance characteristics of their validated assay. [bib_ref] Molecular testing guideline for selection of lung cancer patients for EGFR and..., Lindeman [/bib_ref] [bib_ref] RAS testing of colorectal carcinoma-a guidance document from the Association of Clinical..., Wong [/bib_ref] Liquid biopsy tests use serum or plasma and may be used for monitoring tumor recurrence and emergence of treatment resistance. The noninvasive nature of this approach (monitoring through blood testing) offers great potential for clinical use. [bib_ref] Detection of circulating tumor DNA in early-and late-stage human malignancies, Bettegowda [/bib_ref] However, at the present time, the clinical application of liquid biopsy assays awaits robust validation and further studies to determine their clinical utility. 9. Strong Recommendation: Laboratories must use validated colorectal carcinoma molecular biomarker testing methods with sufficient performance characteristics for the intended clinical use. Colorectal carcinoma molecular biomarker testing validation should follow accepted standards for clinical molecular diagnostics tests. Clinical validation assesses the molecular biomarker testing method in light of clinical characteristics of the disease or marker being tested, to ensure the test is "fit for purpose." Elements of clinical validation include analytical sensitivity, analytical specificity, clinical sensitivity, and clinical specificity. Data for clinical validation can be obtained from studies performed by the laboratory, studies reported in peer-reviewed literature, or other reliable sources. CLIA requires clinical laboratories to have a qualified laboratory director who is responsible for ensuring that the laboratory provides quality laboratory services for all aspects of test performance.Rigorous validation should be performed to ensure all molecular marker testing methods, such as those used for colorectal carcinoma, are ready for implementation in the clinical laboratory. To reach that goal, each step of the testing process must be carefully evaluated and documented. Excellent and comprehensive documents have been published on this topic, and a detailed review is provided under recommendation 10. Our systematic review of the available literature provided information regarding the performance characteristics of molecular marker testing methods of colorectal carcinoma in clinical use for RAS mutational testing [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. Most studies reported the performing characteristic of assays that detected KRAS exon 2 mutations, as detailed in [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. Direct sequencing of genomic DNA, even after polymerase chain reaction (PCR) amplification of the fragment of interest, has low analytical sensitivity requiring a mutant allele frequency of about 20% for mutation detection. A number of more sensitive assays have been developed for RAS testing, including those listed in [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. Sanger sequencing was used as the most common baseline assay for comparison against other molecular detection methods for KRAS mutations. Testing methods vary widely, including direct Sanger sequencing, amplification refractory mutation system, real-time PCR-high-resolution melting (HRM) assays, allele-specific PCR, Luminex (Austin, TX) bead microarray, PCR restriction fragment length polymorphism strip assays, pyrosequencing, and, more recently, NGS. Population or clinical sensitivity of the testing methods for KRAS mutations as shown in [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref] ranged between 36% and 59%. Assay sensitivity ranged from 84.4% to 100%, with Sanger sequencing on the lower end of the range. Analytical sensitivity, defined as the lowest detectable mutant allele fraction, was between 0.5% and 20% across all testing methods, with most methods performing between 1% and 5% mutant allele fraction. Specificity was between 98% and 100% for most assays, with two studies demonstrating lower specificity. Positive predictive value percentages varied between 66% and 100%, with most studies reporting between 99% and 100%. Negative predictive value percentages were between 97% and 100%. Minimal tumor percentages reported varied widely between studies. Concordance between assays was between 93% and 100%, with some variability noted in two retrospective cohort studies. The available evidence from assays to detect KRAS mutations supports the use of a number of alternative assays, as long as their performing characteristics, adjusted for sample type and percent tumor purity, meet the clinical sensitivity with acceptable specificity. Recently, NGS has been used in a number of studies and in laboratory practice for solid tumor mutational analysis. [bib_ref] Extended RAS and BRAF mutation analysis using next-generation sequencing, Sakai [/bib_ref] NGS has shown to meet the sensitivity of detection used in CRC clinical trials (detecting at least 5% mutant alleles), permitting simultaneous testing of hundreds of mutations, and is becoming widely used. Testing for mutations in multiple genes or gene loci with multiplex assays such as NGS and other methods should be done on patients at the time of metastases to obtain comprehensive genomic information and identify mutations beyond RAS/BRAF status that might be able to be targeted if conventional therapies become ineffective. ## Strong recommendation: Performance of molecular biomarker testing for colorectal carcinoma must be validated in accordance with best laboratory practices. Proper validation of CRC biomarker testing is important to ensure appropriate patient care. If validation Variable concordance for different tumor percentage in the sample. f The sensitivity was increased by 5-to 100-fold for melting temperature decreasing mutations when using COLD-PCR compared with standard PCR. Mutations, undetectable by the TheraScreen (QIAGEN, Valencia, CA) kit in clinical samples, were detected by COLD-PCR followed by HRM and verified by sequencing. Sequencing (PCR of fragment of interest followed by sequence analysis) described as direct sequencing. is inadequate, this can lead to erroneous results and improper diagnosis, prognosis, and/or therapeutic intervention. For example, with regard to RAS testing, a false-positive result would lead to an improper withholding of therapy, whereas a false-negative result would lead to distribution of an ineffective therapy, resulting in increased costs and unnecessary side effects. As molecular oncology testing grows more complex with NGS, thorough and proper validation of preanalytical (specimen type and processing), analytical (assay performance), and postanalytical (bioinformatics, annotation, and reporting) steps is imperative. [bib_ref] Next-generation sequencing: a change of paradigm in molecular diagnostic validation, Salto-Tellez [/bib_ref] [bib_ref] Validation of a next-generation sequencing assay for clinical molecular oncology, Cottrell [/bib_ref] The design of a validation study somewhat depends on the analyte (gene), mutations, or molecular alterations assessed and chosen platform and technology. However, assay validation should be done using best laboratory practices in accordance with CLIA (42 CFR 493.1253(b)(2), also known as Title 42 Chapter IV Subchapter G Part 493 Subpart K §493.1253) 111 as applicable to the assay type. Laboratories should comply with CLIA and their individual accrediting agency (eg, CAP, New York State) to fulfill requirements for validation.Additional resources for establishing clinical molecular testing are available to assist laboratories.For the US Food and Drug Administration (FDA)-cleared/approved assays (without any modification), verification of test specifications, including accuracy, precision, reportable range, and reference range, only needs to be done. [bib_ref] Test verification and validation for molecular diagnostic assays, Halling [/bib_ref] For nonwaived, non-FDA-approved assays (laboratory-developed procedures or LDPs), validation must be performed. Validation design must include the required elements of analytical accuracy (specificity and sensitivity), precision, and analytical sensitivity (limit of detection) and interfering substances and reportable range as applicable. Clinical sensitivity and specificity, as well as positive and negative predictive value, should be considered additions. Additional considerations should include specimen processing (including microdissection or macrodissection, histologic processing, and fixation times) and reagent stability and storage. Proper controls should be introduced and used to assess as many of the potential mutations detected by the assay and to verify the limit of detection identified in the validation. With high-throughput (NGS) sequencing, assessing all possible mutations through control material and specimens is impossible, and continuing validation may need to occur. If NGS is used, bioinformatics pipelines should be properly validated using multiple types of mutations (single-nucleotide variants and insertions/deletions). Finally, reporting should be carefully considered during the validation process. Resources to assist laboratories with solid tumor molecular testing have also been made available through the CLSI. ## Preanalytical variables Histologic or preanalytical processing should be considered and representative processes should be included in the validation set. Specific specimen types should also be properly validated. Most tissue used in CRC biomarker testing is derived from FFPE tissue. Formalin fixation results in fragmentation of DNA as a result of histone protein fixation to the DNA. Therefore, most assays for FFPE tissue are designed to amplify products less than 200 base pairs. Length of formalin fixation and age of blocks may also be factors to consider in validation of FFPE tissues. Other tissue sources should also be separately validated if offered as clinical tests, especially cytology-based specimens. Various cytology fixative preparations should be validated as used by the laboratory. If cell-free assays are considered, these should be validated as a separate source. Finally, testing should be limited to invasive carcinoma with exclusion of adenomatous tissue and benign background tissue cellular components (eg, normal mucosa, muscularis, inflammation) as much as possible. ## Analytical variables Careful specimen selection should be undertaken to cover as many of the potential detected mutations and expected specimen types as possible to ensure analytical accuracy. A gold-standard method (dideoxy sequencing or other validated test method) and/or interlaboratory comparison should be used to verify accuracy of the assay. For example, the CAP Laboratory Accreditation Program COM.40350 indicates that at least 20 specimens (including positive, low-positive, and negative specimens) should be included for qualitative and quantitative assays.More specimens may be required. If it is a single-gene assay, the design should include as many of the mutations covered by the assay as possible. If it is a real-time-based allelespecific assay, all mutations for which a primer probe reaction is built should be analyzed as reasonably as possible. If it is a pyrosequencing-based assay, similarly, all of the possible common mutations for which targeted therapies are indicated should be tested. Multigene assays based on NGS or other technology (such as SNaPshot [ThermoFisher Scientific, Waltham, MA]) require an increased number of specimens to test as many of the hotspot regions as possible in all genes included in the assay. With such assays, not all possible mutations can be validated. It is recommended that an ongoing validation occur after initial validation, with verification of novel mutations by either dideoxy sequencing or real-time PCR, depending on the laboratory capability and limit of detection. Depending on the technology employed, important parameters (eg, variant allele frequency, cyclic threshold values, allele coverage) should be monitored for interrun and intrarun precision. CRC specimens can vary from large primary resection blocks with plenty of tumor cells to small primary tumor or metastatic CRC liver biopsy specimens to rectal specimens, after neoadjuvant therapy with minimal tumor percentage. Many of these tests are ordered for metastatic disease, for which only a small needle core biopsy specimen or cytologic sampling is available. Presently, tissue volume and accessibility are decreasing while ancillary testing (IHC and molecular studies) is increasing. The ability of an assay to be highly analytically sensitive is important if a laboratory is to test specimens with low tumor burden. It is recommended that an assay be able to identify a mutation in a specimen that has at minimum 20% tumor cells (mutant allele frequency of 10% assuming heterozygosity). With NGS and highly sensitive PCR technologies, mutations should be identifiable in specimens with as little as 10% tumor (mutant allele frequency of 5% assuming heterozygosity and diploidy). Lower analytically sensitive assays, such as dideoxy sequencing, can be used, but it is recommended that PCR enrichment strategies (eg, coamplification at lower denaturation temperature-PCR) be used to increase the analytical sensitivity of the test and require less tumor percentage. A proper validation study should use cell line DNA (preferably FFPE treated) or reference control material manufactured by good manufacturing processes to assess limit of detection for as many mutations as possible. Importantly, the limit of detection may differ for mutations of varying types (small indels vs point mutations). ## Postanalytical variables Postanalysis is as important to consider in validation as preanalytical and analytical variables. For single-gene assays, the software used in analysis should be validated, with verification of updates. If NGS is used, the bioinformatics pipeline should be thoroughly and rigorously validated, include potential problematic mutations (eg, large indels), and be verified or revalidated for new upgrades as applicable to the change. Any analysis should be performed on validation specimens as it would be for clinical specimens. Reporting format should also be considered and decided during validation. Interpretation comments for inclusion in the patient report to ensure that the reports are correctly understood should be developed during the validation process.Human Genome Organisation (HUGO)based nomenclature should be used for reports and a designated National Center for Biotechnology Information (NCBI) transcript number (NM_##) should be used within the validation and report. [bib_ref] Standard mutation nomenclature in molecular diagnostics: practical and educational challenges, Ogino [/bib_ref] For multigene panels based on NGS, reporting protocols and any used software should be included in the validation procedure. Databases and annotation guidelines should be discussed and included in the validation as one prepares to report variants based on NGS data. In addition, decisions should be made during the validation process as to whether normal tissue will be tested to assist in variant interpretation with NGS. In conclusion, validation of assays used in CRC molecular testing is extremely important for accuracy of reporting and proper patient care. There are several documents (eg, CLIA, CAP, and CLSI)available to assist in proper validation, which should be consulted to validate according to best laboratory practices. 11. Strong Recommendation: Laboratories must validate the performance of IHC testing for colorectal carcinoma molecular biomarkers (currently IHC testing for MLH1, MSH2, MSH6, and PMS2) in accordance with best laboratory practices). Four proteins (MLH1, MSH2, MSH6, and PMS2) are currently considered important in the normal biochemistry of DNA MMR. [bib_ref] The human mutator gene homolog MSH2 and its association with hereditary nonpolyposis..., Fishel [/bib_ref] [bib_ref] Mutation in the DNA mismatch repair gene homologue hMLH1 is associated with..., Bronner [/bib_ref] [bib_ref] Mismatch repair gene defects in sporadic colorectal cancers with microsatellite instability, Liu [/bib_ref] As detailed in recommendation 2b, altered DNA mismatch repair proteins due to mutation or epigenetic silencing result in interference with normal MMR protein heterodimerization and loss of normal repair of mispaired bases and short insertions/deletions, resulting in MSI, 119,120 overall categorized as dMMR. Loss of MMR function usually correlates with loss of protein expression, such that immunohistochemical testing for MMR proteins is optimized to detect loss of MMR protein expression in tumor cell nuclei. Each of these four proteins can be detected in paraffin sections using commercially available primary and secondary antibodies, standardized antigen retrieval, and 3,3 0 -diaminobenzidine chromogen detection. Development of anti-MMR protein antibody staining protocols follows a standard approach that involves (1) demonstration of absent background noise with secondary antibody alone and (2) empirical optimization of the signalto-noise ratio by testing different antibody concentrations, antigen retrieval buffers, and reaction conditions, taking advantage of internal control cells, including lymphocytes, stromal cells, and other nonneoplastic nuclei. Validation of the final staining protocol is required prior to implementation for clinical use. Peer-reviewed literature-based guidelines for validation and revalidation of immunohistochemical tests have been defined as 14 recommendations and expert consensus opinions. [bib_ref] Principles of analytic validation of immunohistochemical assays: guideline from the College of..., Fitzgibbons [/bib_ref] Concordance with internal or external known comparator tests is required to exceed 90%. Proficiency testing is a good approach to confirm interlaboratory test reproducibility. Test result concordance across laboratories implies accuracy of participant laboratory diagnosis. Once the protocol is defined and validated for a given primary antibody clone and antigen retrieval conditions, a known positive external control (eg, tonsil) is routinely run in parallel with each unknown. This demonstrates that the MMR protein was detectable on that staining run and allows trust in a loss of expression result in the unknown specimen. Each of the four MMR proteins is expressed in nonneoplastic tissue, in most lymphocytes, and overexpressed in germinal centers, such that most colon block sections will also have positive internal control staining. Overall, validated immunohistochemical detection of MMR proteins is a trustworthy method for identification of loss of expression of individual MMR proteins in paraffin sections of CRC. In most CRCs with high-level microsatellite instability (MSI-H), the loss of DNA MMR protein expression in tumor cell nuclei by immunohistochemical detection is uniform throughout the tumor. [bib_ref] Microsatellite instability testing in colorectal carcinoma: choice of markers affects sensitivity of..., Hatch [/bib_ref] Rare cases of MSI tumors have been reported to show heterogeneous staining. [bib_ref] Heterogeneous staining for mismatch repair proteins during population-based prescreening for hereditary nonpolyposis..., Watson [/bib_ref] Loss of MMR protein expression usually correlates with MSI, particularly for MSI-H tumors, and is indicative of dMMR. If MSH2 or MLH1 shows loss of expression due to loss of function, then their heterodimer partners (MSH6 and PMS2, respectively) will also not be expressed. In contrast, inactivation of MSH6 or PMS2 results in loss of expression of the individual MMR protein MSH6 or PMS2, respectively. Although loss of MMR protein immunoreactivity is generally detected in dMMR CRC, normal immunoreactivity can be seen in up to 10% of dMMR cases 125 ; therefore, MSI DNA testing may be performed either stepwise or as a concurrent test. 12. Expert Consensus Opinion: Laboratories must provide clinically appropriate turnaround times and optimal utilization of tissue specimens by using appropriate techniques (eg, multiplexed assays) for clinically relevant molecular and immunohistochemical biomarkers of CRC. Expediency in reporting of biomarker results for colorectal tumors is dictated primarily by two factors: need for patient management decisions and, more generally, patient anxiety. Consequently, results of such evaluations should be available within a timeframe for the involved clinician to relay this information to the patient. This need is compounded by the patient's need to receive a complete understanding of his or her diagnosis and treatment plans going forward. A reasonable benchmark is that nonacute biomarker results be available to the treating physician within 10 working days of receipt in the molecular diagnostics laboratory. This turnaround time has been recommended in other guidelines for molecular tumor testing. [bib_ref] Molecular testing guideline for selection of lung cancer patients for EGFR and..., Lindeman [/bib_ref] [bib_ref] RAS testing of colorectal carcinoma-a guidance document from the Association of Clinical..., Wong [/bib_ref] [bib_ref] Association between time to initiation of adjuvant chemotherapy and survival in colorectal..., Biagi [/bib_ref] Ideally, the transitional time between test ordering, tissue block selection, block retrieval, and shipment to the performing laboratory should be included in the 10-day timeframe. Consequently, laboratories should make every effort to minimize delays in securing appropriate tissue blocks for testing. Testing laboratories should make every effort to minimize processing time and return of results. The availability of tumor tissue for biomarker evaluation is generally not limiting in most cases of resected CRC. Occasionally, following neoadjuvant therapy, the amount of residual tumor in resection specimens can be very small and focal. Similarly, the amount of tumor tissue obtained by biopsy or fine-needle aspiration procedures from primary or metastatic foci can be very small and challenging to test for the desired biomarkers. In such circumstances, available tissue blocks should be sectioned judiciously, reserving sufficient sections for testing by molecular methods or immunohistochemical techniques, as deemed appropriate to secure as accurate and informative an evaluation as possible. Test turnaround times for RAS testing in instances of advanced stage tumors are dictated by the need to select and initiate appropriate chemotherapy options. Ideally, such information should be available either at the time of postoperative oncology evaluation, where decisions regarding therapeutic options are entertained, or at the tumor boards where patient treatment options are discussed. In some institutions, these discussions may occur in the week following surgery or biopsy and probably no later than in the second week following tissue diagnosis and staging. Here, too, a timeframe of no more than 10 days would seem an appropriate benchmark for biomarker result availability. In exceptional circumstances, even shorter test turnaround times may be called for. Occasional patients have histories sufficiently suggestive of Lynch syndrome that prompt consideration and discussion regarding extent of surgery (ie, complete colectomy or prophylactic hysterectomy in select affected patients). Efforts should be made in such circumstances to obtain appropriate test results as rapidly as possible to allow for informed decision making. MMR immunohistochemistry can be performed and reported with a turnaround time of 48 hours or less, and in the appropriate clinical context, a result of preserved expression of MMR proteins would argue against Lynch syndrome. Conversely, any loss of MMR protein expression will need to be integrated with additional clinical information, family history, and further testing such as BRAF mutation, MLH1 methylation testing, and potential germline genetic testing. Furthermore, DNA MMR status, performed by MMR immunohistochemistry or by MSI DNA tests, as a good prognostic biomarker for CRC overall, should be available within the recommended 10 working day turnaround time for test results. 13. Expert Consensus Opinion: Molecular and IHC biomarker testing in colorectal carcinoma should be initiated in a timely fashion based on the clinical scenario and in accordance with institutionally accepted practices. Note: Test ordering can occur on a case-by-case basis or by policies established by the medical staff. Molecular and IHC biomarker testing is increasingly being used in patient management. Prognostic biomarkers are being used for early stage disease to guide decisions on the use of adjuvant chemotherapy. Such discussions require the availability of tests in a timely manner, and delays in initiation of therapy have been associated with worse outcomes. [bib_ref] Association between time to initiation of adjuvant chemotherapy and survival in colorectal..., Biagi [/bib_ref] Predictive biomarkers, such as those for EGFR monoclonal antibody therapy, should be initiated in a timely fashion to guide chemotherapy options and long-term treatment planning. Institutional policies and practices that encourage the rapid initiation of appropriate molecular and IHC marker testing should be encouraged. Such policies may include reflexive ordering of molecular and IHC markers as guided by the clinical scenario and incorporation of testing initiation by multiple members of the multidisciplinary team, as noted in recommendation 15. 14. Expert Consensus Opinion: Laboratories should establish policies to ensure efficient allocation and utilization of tissue for molecular testing, particularly in small specimens. The number of molecular and immunohistochemical tests becoming available that have a direct benefit to patient care will continue to increase. Most of these tests are performed on FFPE specimens, the most common preservation technique, including pretreatment and posttreatment biopsies and resections [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. Tissues from patients with cancer should be processed according to established laboratory protocols, which include quality controls of preservation materials, tissue dissection, time to fixation, fixation time, and processing. Laboratory protocols need to include procedures for handling small samples such as endoscopic or core biopsy specimens and fine-needle aspirate samples of metastatic lesions (eg, from liver or lung). Limiting the number of tissue fragments per individual cassette is encouraged. Established protocols may allow upfront ordering of required tissue sections (eg, extra unstained slides), which limit tissue wasting and improve turnaround time of final results. Immunohistochemistry studies, if needed to diagnose metastatic CRC, should be limited in scope and standardized to preserve tissues. It is imperative to identify suspected metastatic CRC specimens at specimen accessioning to limit unneeded ancillary tests, such as liver biopsy special stains. Recognition of previous CRC diagnoses from the patient clinical history should limit the need for immunohistochemistry profiles in many cases. Established laboratory procedures to identify patients undergoing cancer biopsy or fine-needle aspiration specifically for predictive molecular biomarker assessments need to be in place. Laboratories must maintain appropriate cataloguing and storage of tissue specimens and diagnostic slides to allow for retrospective timely testing of cancer samples. This recommendation is supported by 15 studies, 128-142 comprising eight prospective cohort studies [bib_ref] Detection of KRAS mutations in colorectal cancer by high-resolution melting analysis, Ma [/bib_ref] [bib_ref] Comparison of methodologies for KRAS mutation detection in metastatic colorectal cancer, Pinto [/bib_ref] [bib_ref] High sensitivity of both sequencing and real-time PCR analysis of KRAS mutations..., Tol [/bib_ref] [bib_ref] Duplex reverse-hybridization assay for the simultaneous detection of KRAS/BRAF mutations in FFPE-extracted..., Buxhofer-Ausch [/bib_ref] [bib_ref] Detection of N-, H-, and KRAS codons 12, 13, and 61 mutations..., Chang [/bib_ref] [bib_ref] Genotyping of K-ras codons 12 and 13 mutations in colorectal cancer by..., Chen [/bib_ref] [bib_ref] Differences in the frequencies of K-ras c12-13 genotypes by gender and pathologic..., Chow [/bib_ref] [bib_ref] KRAS analysis in colorectal carcinoma: analytical aspects of pyrosequencing and allele-specific PCR..., Sundstrom [/bib_ref] and seven retrospective cohort studies. [bib_ref] KRAS mutation: comparison of testing methods and tissue sampling techniques in colon..., Franklin [/bib_ref] [bib_ref] Sensitive multiplex detection of KRAS codons 12 and 13 mutations in paraffin-embedded..., Laosinchai-Wolf [/bib_ref] [bib_ref] Detection of KRAS mutations in colorectal carcinoma patients with an integrated PCR/sequencing..., Carotenuto [/bib_ref] [bib_ref] KRAS genotyping as biomarker in colorectal cancer: a comparison of three commercial..., Cavallini [/bib_ref] [bib_ref] Increased sensitivity of KRAS mutation detection by high-resolution melting analysis of COLD-PCR..., Kristensen [/bib_ref] [bib_ref] Competitive amplification of differentially melting amplicons (CADMA) improves KRAS hotspot mutation testing..., Kristensen [/bib_ref] [bib_ref] Optimized allele-specific real-time PCR assays for the detection of common mutations in..., Lang [/bib_ref] For the eight prospective cohort studies, [bib_ref] Detection of KRAS mutations in colorectal cancer by high-resolution melting analysis, Ma [/bib_ref] [bib_ref] Comparison of methodologies for KRAS mutation detection in metastatic colorectal cancer, Pinto [/bib_ref] [bib_ref] High sensitivity of both sequencing and real-time PCR analysis of KRAS mutations..., Tol [/bib_ref] [bib_ref] Duplex reverse-hybridization assay for the simultaneous detection of KRAS/BRAF mutations in FFPE-extracted..., Buxhofer-Ausch [/bib_ref] [bib_ref] Detection of N-, H-, and KRAS codons 12, 13, and 61 mutations..., Chang [/bib_ref] [bib_ref] Genotyping of K-ras codons 12 and 13 mutations in colorectal cancer by..., Chen [/bib_ref] [bib_ref] Differences in the frequencies of K-ras c12-13 genotypes by gender and pathologic..., Chow [/bib_ref] [bib_ref] KRAS analysis in colorectal carcinoma: analytical aspects of pyrosequencing and allele-specific PCR..., Sundstrom [/bib_ref] all reported balance between the treatment and assessment groups, as all but one 132 used a single cohort design allowing for within-group comparisons. Only this single study, reported by Tol et al, [bib_ref] High sensitivity of both sequencing and real-time PCR analysis of KRAS mutations..., Tol [/bib_ref] would have required making adjustments for imbalances between the treatment and assessment groups, but none were needed. Five studies [bib_ref] Detection of KRAS mutations in colorectal cancer by high-resolution melting analysis, Ma [/bib_ref] [bib_ref] Duplex reverse-hybridization assay for the simultaneous detection of KRAS/BRAF mutations in FFPE-extracted..., Buxhofer-Ausch [/bib_ref] [bib_ref] Detection of N-, H-, and KRAS codons 12, 13, and 61 mutations..., Chang [/bib_ref] [bib_ref] Genotyping of K-ras codons 12 and 13 mutations in colorectal cancer by..., Chen [/bib_ref] [bib_ref] Differences in the frequencies of K-ras c12-13 genotypes by gender and pathologic..., Chow [/bib_ref] reported nonindustry funding, one [bib_ref] High sensitivity of both sequencing and real-time PCR analysis of KRAS mutations..., Tol [/bib_ref] reported at least partial industry funding, one 142 reported industry funding, and one 131 did not disclose the source of funding, if any. Seven [bib_ref] Detection of KRAS mutations in colorectal cancer by high-resolution melting analysis, Ma [/bib_ref] [bib_ref] Comparison of methodologies for KRAS mutation detection in metastatic colorectal cancer, Pinto [/bib_ref] [bib_ref] Duplex reverse-hybridization assay for the simultaneous detection of KRAS/BRAF mutations in FFPE-extracted..., Buxhofer-Ausch [/bib_ref] [bib_ref] Detection of N-, H-, and KRAS codons 12, 13, and 61 mutations..., Chang [/bib_ref] [bib_ref] Genotyping of K-ras codons 12 and 13 mutations in colorectal cancer by..., Chen [/bib_ref] [bib_ref] Differences in the frequencies of K-ras c12-13 genotypes by gender and pathologic..., Chow [/bib_ref] [bib_ref] KRAS analysis in colorectal carcinoma: analytical aspects of pyrosequencing and allele-specific PCR..., Sundstrom [/bib_ref] were deemed to have a low risk of bias, and one 132 was deemed to have a low to moderate risk of bias. For the seven retrospective cohort studies, [bib_ref] KRAS mutation: comparison of testing methods and tissue sampling techniques in colon..., Franklin [/bib_ref] [bib_ref] Sensitive multiplex detection of KRAS codons 12 and 13 mutations in paraffin-embedded..., Laosinchai-Wolf [/bib_ref] [bib_ref] Detection of KRAS mutations in colorectal carcinoma patients with an integrated PCR/sequencing..., Carotenuto [/bib_ref] [bib_ref] KRAS genotyping as biomarker in colorectal cancer: a comparison of three commercial..., Cavallini [/bib_ref] [bib_ref] Increased sensitivity of KRAS mutation detection by high-resolution melting analysis of COLD-PCR..., Kristensen [/bib_ref] [bib_ref] Competitive amplification of differentially melting amplicons (CADMA) improves KRAS hotspot mutation testing..., Kristensen [/bib_ref] [bib_ref] Optimized allele-specific real-time PCR assays for the detection of common mutations in..., Lang [/bib_ref] all used a single cohort design allowing for within-group comparisons. Four reported nonindustry funding, [bib_ref] Detection of KRAS mutations in colorectal carcinoma patients with an integrated PCR/sequencing..., Carotenuto [/bib_ref] [bib_ref] KRAS genotyping as biomarker in colorectal cancer: a comparison of three commercial..., Cavallini [/bib_ref] [bib_ref] Increased sensitivity of KRAS mutation detection by high-resolution melting analysis of COLD-PCR..., Kristensen [/bib_ref] [bib_ref] Competitive amplification of differentially melting amplicons (CADMA) improves KRAS hotspot mutation testing..., Kristensen [/bib_ref] one reported industry funding, [bib_ref] Sensitive multiplex detection of KRAS codons 12 and 13 mutations in paraffin-embedded..., Laosinchai-Wolf [/bib_ref] and two did not disclose the source of funding, if any. [bib_ref] KRAS mutation: comparison of testing methods and tissue sampling techniques in colon..., Franklin [/bib_ref] [bib_ref] Optimized allele-specific real-time PCR assays for the detection of common mutations in..., Lang [/bib_ref] Six were deemed to have a low risk of bias, [bib_ref] KRAS mutation: comparison of testing methods and tissue sampling techniques in colon..., Franklin [/bib_ref] [bib_ref] Detection of KRAS mutations in colorectal carcinoma patients with an integrated PCR/sequencing..., Carotenuto [/bib_ref] [bib_ref] KRAS genotyping as biomarker in colorectal cancer: a comparison of three commercial..., Cavallini [/bib_ref] [bib_ref] Increased sensitivity of KRAS mutation detection by high-resolution melting analysis of COLD-PCR..., Kristensen [/bib_ref] [bib_ref] Competitive amplification of differentially melting amplicons (CADMA) improves KRAS hotspot mutation testing..., Kristensen [/bib_ref] [bib_ref] Optimized allele-specific real-time PCR assays for the detection of common mutations in..., Lang [/bib_ref] and one was deemed to have a moderate risk of bias. [bib_ref] Sensitive multiplex detection of KRAS codons 12 and 13 mutations in paraffin-embedded..., Laosinchai-Wolf [/bib_ref] All of the evidence that supported this recommendation was assessed, and none had methodologic flaws that would raise concerns about their findings. ## Expert consensus opinion: Members of the patient's medical team, including pathologists, may initiate colorectal carcinoma molecular biomarker test orders in accordance with institutionally accepted practices. For patients with CRC, timely diagnosis or therapeutic initiation is critical, and molecular testing that is to be considered should be ordered as efficiently as possible in accordance with institutional practices and guidelines. MSI testing is often ordered at the time of diagnosis to identify patients with Lynch syndrome, direct adjuvant chemotherapy, or determine prognosis. Many institutions employ algorithms to ensure that all colorectal cancers are evaluated for MMR deficiency, and these are often initiated by pathologists when the diagnosis occurs after joint general process approval by pathologists, oncologists, and other members of the patient medical team. Molecular testing that is performed to direct targeted therapy (eg, RAS) may be ordered at a later date than the primary diagnosis, at metastatic presentation, for example, and so institutions may differ as to whether one should order such testing upfront on the primary diagnostic biopsy or resection specimen or wait until metastatic disease arises requiring targeted therapy. Often oncologists order predictive molecular assays since they are used to direct therapy, but this should not necessarily be limited to oncologists, as pathologists serve as important stewards of the tissue and make the tumor diagnosis. There are also issues to consider, including logistical issues, costeffectiveness, patient access to molecular testing in rural or underserved areas, and even heterogeneity considerations between primary and metastatic tumor. Since each institution differs in patient population, facilities, departmental organization, regulatory and reimbursement climates, and practitioner preference, whether to submit testing at initial diagnosis of a primary lesion or when a metastatic lesion arises should be discussed collaboratively between oncologists, pathologists, and medical executive or hospital committees as applicable. "Reflex" testing, a testing policy that does not require a separate clinician order for each case, is appropriate if agreed upon by the CRC care team as an institutionally approved standing order and may help to ensure expedited and consistent routing of specimens for molecular testing. However, some patients may not be candidates for targeted therapy for clinical reasons, and good communication between the clinical care team and the testing laboratory is needed to ensure testing is performed for patients whose management will be affected by the test result. Specifically, testing is not necessary for patients with stage IV disease who are being considered for palliative or hospice care only. Similarly, in settings in which reflex testing is the practice, a mechanism should be provided for the clinical care team to communicate to the pathologist examining a small biopsy or cytology sample when a more suitable diagnostic specimen (eg, a resection) is expected to be obtained, and the molecular testing should be deferred to the subsequent, more generous sample. All reflex testing should be approved institutionally by the hospital or institution's medical executive committee as local policies dictate. biomarkers should process and send colorectal carcinoma specimens to reference molecular laboratories in a timely manner. Note: It is suggested that a benchmark of 90% of specimens should be sent out within 3 working days. It is critical to provide the results of molecular tests in a timely fashion to start the most appropriate cancer treatment option for each patient. Delays in initiation of therapy have been associated with worse outcomes. [bib_ref] Association between time to initiation of adjuvant chemotherapy and survival in colorectal..., Biagi [/bib_ref] To date, laboratories have had limited guidance on the recommended timing or turnaround time of molecular test results, and studies addressing the impact of specific turnaround times have not been conducted. Therefore, the panel reached an expert consensus opinion, based on each panel member's practical experience in the laboratory and clinical setting. For laboratories that do not perform molecular testing and/or biomarker immunohistochemistry for CRC therapy selection, the consensus opinion was that send out of specimens should occur within 3 working days, starting from the day the test order was received in the laboratory, provided the specimens (eg, biopsy or resection specimens) are received at the same time of the test order or specimens are already in the laboratory (eg, archived paraffin blocks). The underlying rationale stems from the usual workflow for tissue processing. In practice, the longest process would be the processing of large surgical specimens, such as colectomies. A possible approach is to obtain a designated molecular tissue block at the time of specimen grossing, and molecular protocols for obtaining tissue sections may be used to have the necessary sections for test send-out in a timely fashion by the third working day for most cases. Another scenario may be the retrieval of archived tissue paraffin blocks that may be stored outside of the laboratory location. In this case, a protocol for block retrieval for molecular testing may be operationalized to streamline the process and reach the desired turnaround time for send-out. This turnaround time of 3 working days was also recommended for RAS testing of colorectal carcinoma in the guidance document from the Association of Clinical Pathologists Molecular Pathology and Diagnostics Group in the United Kingdom. [bib_ref] RAS testing of colorectal carcinoma-a guidance document from the Association of Clinical..., Wong [/bib_ref] Laboratories should develop written policies as part of their quality assurance program to monitor turnaround times for all cancer therapeutic and prognostic biomarkers. 17. Expert Consensus Opinion: Pathologists must evaluate candidate specimens for biomarker testing to ensure specimen adequacy, taking into account tissue quality, quantity, and malignant tumor cell fraction. Specimen adequacy findings should be documented in the patient report. It is critical that pathologists selecting blocks for biomarker testing understand the specimen requirements of the method being employed in terms of total tissue amount (a reflection of the total amount of DNA required for the assays) and the fraction of malignant tumor cells in the specimen focus to be evaluated. The total amount of tissue selected for evaluation is significant in two respects. First, the amount of tissue sampled should be of sufficient quantity to produce a result that is reliably representative of the entire tumor. While recent evidence indicates that some genes continue to evolve during tumor progression, leading to substantial tumor genetic heterogeneity, those driver mutations of importance to CRC are usually, but not always, homogeneous throughout the tumor. The amount of tumor necessary, however, for a particular analytical method can vary and demands knowledge and due attention to the indicated tissue requirements for the specific assay employed. The minimal required proportion of tumor DNA in a sample from cancer is dictated by the analytical sensitivity of the particular validated assay. As shown in [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref] , the amount of tumor used in the analyses of KRAS mutations in several studies comparing the test-performing characteristics of various assays varied widely, ranging from 1% to 90%. The proportion of malignant tumor cells (as opposed to tumor-associated nonmalignant cells, eg, stromal fibroblasts, endothelial cells, infiltrating inflammatory cells) should be evaluated as accurately as possible and documented. This evaluation is most readily performed by estimating the proportion of malignant cell nuclei to nonmalignant cell nuclei within the focus selected for evaluation. [bib_ref] A prospective, multiinstitutional diagnostic trial to determine pathologist accuracy in estimation of..., Viray [/bib_ref] Understanding that the number of mutated alleles for a particular gene may represent as few as half of the alleles in diploid tumor cells, a tumor cell focus with a nominal proportion of 50% tumor cells would have a mutant allele fraction of 25%, a value approaching the analytical sensitivity of some molecular assays. So, while variety of molecular methods can be used to evaluate tissue specimens, it is critical that these be carefully matched to their specific tissue and tumor cell proportion requirements. When adhered to, all these of these methods can produce accurate and reliable results. Pathologists evaluating tissue section for biomarker evaluation should also be aware that necrosis and tissue degeneration can lead to erroneous results, and foci demonstrating significant necrosis should be avoided for molecular testing. Any amount of necrosis in the sample selected for biomarker testing should be estimated and documented. 18. Expert Consensus Opinion: Laboratories should use colorectal carcinoma molecular biomarker testing methods that are able to detect mutations in specimens with at least 5% mutant allele frequency, taking into account the analytical sensitivity of the assay (limit of detection or LOD) and tumor enrichment (eg, microdissection). Note: It is recommended that the operational minimal neoplastic carcinoma cell content tested should be set at least two times the assay's LOD. Since the accuracy and results of testing for molecular markers are dependent on both tumor cell content and the assay-specific sensitivity in the identification of a mutant allele against a background of wild-type/nonmutated alleles, it is suggested that laboratories should establish minimum acceptable tumor cell content as a component of their specimen requirements. It is recommended that a pathologist reviews all cases for tumor cell content and quality. Due to the stochastic nature of mutant allele identification at the lower LOD, it is recommended that the minimal tumor cell content be at least two times the lower LOD of a validated molecular method or assay. This LOD was also recommended for RAS testing of colorectal carcinoma in the guidance document from the United Kingdom. [bib_ref] RAS testing of colorectal carcinoma-a guidance document from the Association of Clinical..., Wong [/bib_ref] Hence, if a particular assay has a lower limit of mutant allele detection of 5%, then the minimum tumor cell content in samples analyzed by this assay should be at least 10% to reliably detect heterozygous mutations in those neoplasms. Due to intratumoral heterogeneity, subclones, and the nature of tissue sampling, clinical trials have used 5% as the lower LOD, and for clinical purposes, it is recommended that the lower LOD for a mutant allele be at least 5%. [bib_ref] Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal..., Sorich [/bib_ref] Therefore, the utilization of methods such as PCR, HRM, single-strand conformation polymorphism, pyrosequencing, or commercially available kits that achieve this level of sensitivity is recommended [bib_ref] Detection of KRAS mutations in colorectal cancer by high-resolution melting analysis, Ma [/bib_ref] [bib_ref] Genotyping of K-ras codons 12 and 13 mutations in colorectal cancer by..., Chen [/bib_ref] [bib_ref] Differences in the frequencies of K-ras c12-13 genotypes by gender and pathologic..., Chow [/bib_ref] [bib_ref] KRAS analysis in colorectal carcinoma: analytical aspects of pyrosequencing and allele-specific PCR..., Sundstrom [/bib_ref] [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. This recommendation is supported by four prospective cohort studies [bib_ref] Detection of KRAS mutations in colorectal cancer by high-resolution melting analysis, Ma [/bib_ref] [bib_ref] Genotyping of K-ras codons 12 and 13 mutations in colorectal cancer by..., Chen [/bib_ref] [bib_ref] Differences in the frequencies of K-ras c12-13 genotypes by gender and pathologic..., Chow [/bib_ref] [bib_ref] KRAS analysis in colorectal carcinoma: analytical aspects of pyrosequencing and allele-specific PCR..., Sundstrom [/bib_ref] and two retrospective cohort studies. [bib_ref] Comparative genomic analysis of primary versus metastatic colorectal carcinomas, Vakiani [/bib_ref] [bib_ref] A multicenter study to validate the reproducibility of MSI testing with a..., Nardon [/bib_ref] The four prospective cohort studies all studied a single cohort, allowing for within-group comparisons. For this reason, all were balanced between comparison groups, and no adjustments were needed to account for baseline differences. All four reported nonindustry funding, and all were deemed to have a low risk of bias. The two retrospective cohort studies 102,144 also used single cohorts, allowing for within-group comparisons only. One 102 did not report the source of funding, while the other 144 reported nonindustry funding. Both were deemed to have a low risk of bias. None of the studies had methodologic flaws that would raise concerns about their findings. ## Expert consensus opinion: Colorectal carcinoma molecular biomarker results should be made available as promptly as feasible to inform therapeutic decision making, both prognostic and predictive. Note: It is suggested that a benchmark of 90% of reports be available within 10 working days from date of receipt in the molecular diagnostics laboratory. Combined chemotherapy, including anti-EGFR therapy, in patients with CRC in the absence of mutations in the EGFR signaling pathway is associated with significant survival advantage. No significant therapeutic benefit is derived from anti-EGFR therapy in the presence of mutations in KRAS and NRAS. [bib_ref] Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer, Douillard [/bib_ref] The presence of deficient MMR in stage II CRC indicates a good prognosis and identifies patients for whom adjuvant 5-fluorouracil monobased therapies have no significant benefit. [bib_ref] Tumor microsatellite-instability status as a predictor of benefit from fluorouracil-based adjuvant chemotherapy..., Ribic [/bib_ref] [bib_ref] The efficacy of adjuvant chemotherapy with 5-fluorouracil in colorectal cancer depends on..., Jover [/bib_ref] The presence of deficient MMR or BRAF p.V600E mutation in proficient MMR CRCs has important prognostic significance. [bib_ref] Microsatellite instability and BRAF mutation testing in colorectal cancer prognostication, Lochhead [/bib_ref] In the absence of published data establishing an evidence-based recommendation, it is our expert consensus opinion that the above results, regardless of testing methods, be available from test ordering in the initial diagnostic pathology laboratory to the clinical team within 2 weeks (10 working days). The 10 working days does not include the time before the tissue specimen is available for testing (ie, from diagnostic procedure to receipt in laboratory) or time to retrieve tissue samples from an outside laboratory. Laboratories unable to maintain this standard, either through in-house testing or use of a reference laboratory, need to implement measures to improve test result turnaround time. A turnaround time of 7 working days was recommended for RAS testing of colorectal carcinoma in the guidance document from the Association of Clinical Pathologists Molecular Pathology and Diagnostics Group in the United Kingdom. [bib_ref] RAS testing of colorectal carcinoma-a guidance document from the Association of Clinical..., Wong [/bib_ref] This recommendation is supported by evidence from one randomized controlled trial, reported by Douillard et al. [bib_ref] Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer, Douillard [/bib_ref] This report used prospective patient data collected within the PRIME trial. While it did not report details on the randomization, blinding, statistical power calculation, sample size, or length of follow-up, it did report on baseline characteristics and was otherwise well reported. Funding was reported to be partially from industry sources. Overall, this trial was found to have a low to moderate risk of bias and did not have methodologic flaws that would raise concerns about its findings. Each laboratory should develop a quality assurance program to monitor turnaround times for all cancer therapeutic and prognostic biomarkers. 20. Expert Consensus Opinion: Colorectal carcinoma molecular biomarker testing reports should include a results and interpretation section readily understandable by oncologists and pathologists. Appropriate Human Genome Variation Society (HGVS) and HUGO nomenclature must be used in conjunction with any historical genetic designations. Reporting of molecular results is becoming more complex as new information and clinical utility are discovered for somatic variants. Single-gene assays are still being widely used, but multiplexing has allowed for multiple possible results. With the introduction of NGS into the clinical setting, multiple somatic mutations with clinical significance may be identified. However, panel assays by NGS can also reveal variants with unknown clinical significance. As pathogenic genes and somatic mutations have been discovered over the past 30 years, there has been divergent nomenclature employed, making clinical reporting and clinical analysis difficult. Presently and in the future, as national databases are constructed annotating clinical somatic variants, it is imperative that standardized nomenclature be employed to identify the clinical significance of rare variants. Clinicians want a report that is easily readable and understandable but that gives pertinent clinical information concisely, accurately, and thoroughly. Reported variants should be identified using both DNA and protein nomenclature. Citing codon positivity only is not encouraged (eg, positive for a KRAS codon 12 mutation); the specific mutation should be explained using standardized nomenclature, preferably HUGO gene nomenclature.Historical designations (eg, historical HER-2/neu, for HUGO ERBB2) should also be included as appropriate in the report to avoid confusion among oncologists. Importantly, the messenger RNA transcript number (NM_#) from the NCBI, used to designate the specific codon numbering, should be named in the report since numbering can differ between the different/ alternative transcript designations for the same gene. If using NGS, variants should at least be classified as pathogenic, likely pathogenic, variant of unknown significance, likely benign, or benign, but classification of somatic mutations is still awaiting specifically approved guidelines. [bib_ref] Standards and guidelines for the interpretation of sequence variants: a joint consensus..., Richards [/bib_ref] However, a numerical classification scheme for somatic variants has been proposed, taking into consideration actionability of the variant in the patient's tumor type vs other tumor types, predicted pathogenicity (using programs such as SIFT and PolyPhen 2) in the patient's tumor type vs other tumor types, variant recurrence in a certain cancer type, or unknown significance. [bib_ref] A classification system for clinical relevance of somatic variants identified in molecular..., Sukhai [/bib_ref] Such a classification scheme may be better suited to somatic variants considering the indications for which most of these assays are being ordered. Reports should contain the analytical result, the method used, and information about the genes and loci tested or included in the assay; the assay limit of detection; and any disclaimers (eg, ASR) that are required to meet regulations. When reasonable and applicable, an interpretive comment should be given to ensure that results are correctly understood.Such an interpretive comment may include information regarding therapeutic implications, prognostic implications, and/or pathogenic significance of the mutation and, when appropriate or desired, potential applicable clinical trials. In summary, molecular reports should be easily understandable by clinical oncologists and use standardized nomenclature outlined by HGVS/HUGO. All reports should contain the elements of result, interpretation, variant classification, and information as applicable; limit of detection of the assay and methods to assist the oncologist in understanding the test result; and limitations as they consider the result in a clinical context. ## Strong recommendation: Laboratories must incorporate colorectal carcinoma molecular biomarker testing methods into their overall laboratory quality improvement program, establishing appropriate quality improvement monitors as needed to ensure consistent performance in all steps of the testing and reporting process. In particular, laboratories performing colorectal carcinoma molecular biomarker testing must participate in formal proficiency testing programs, if available, or an alternative proficiency assurance activity. Proficiency testing (PT) is an important component of quality assurance for laboratory tests in general and applies to the molecular tests discussed in the current CRC molecular testing guidelines. These include mutational as well as immunohistochemical testing. Participation in PT allows the assessment and comparison of test performance among different clinical laboratories and technologies and allows verification of accuracy and reliability of laboratory tests. [bib_ref] Current landscape and new paradigms of proficiency testing and external quality assessment..., Kalman [/bib_ref] From a regulatory standpoint, PT in the United States is a requirement for accreditation by the Centers for Medicare & Medicaid Services. Participation in PT may be done through CAP PT programs or through other providers accepted by CLIA. [bib_ref] Methods-based proficiency testing in molecular genetic pathology, Schrijver [/bib_ref] Other countries-namely, the United Kingdom-follow similar guidelines, recommending that laboratories providing RAS testing of CRC should demonstrate successful participation in a relevant external quality assurance scheme and be appropriately accredited. [bib_ref] RAS testing of colorectal carcinoma-a guidance document from the Association of Clinical..., Wong [/bib_ref] Formal external proficiency testing programs for analytes other than KRAS, MSI, MMR, and BRAF may not be available at the time of this publication. Alternative proficiency testing activities should be used. Appropriate alternative performance assessment procedures may include split sample analysis with other laboratories or, if that is not available, assessment of split samples with an established in-house method and previously assayed material, which are run and interpreted by laboratory personnel who do not have access to the prior results. [bib_ref] Methods-based proficiency testing in molecular genetic pathology, Schrijver [/bib_ref] If exchanging specimens with other laboratories is the laboratory proficiency approach, this should be done with one or more other laboratories at least twice per year. [bib_ref] Molecular testing guideline for selection of lung cancer patients for EGFR and..., Lindeman [/bib_ref] Methods-based proficiency testing (MBPT) refers to a testing approach that is based on method, rather than based on each individual analyte tested. MBPT is well established for several pathology subspecialty areas, and the concept of MBPT complies with federal laboratory regulations. [bib_ref] Methods-based proficiency testing in molecular genetic pathology, Schrijver [/bib_ref] ## Discussion on emerging biomarkers Numerous studies have reported potential molecular biomarkers for CRC prognosis, while fewer studies evaluated markers that could be predictive of response to specific treatments. Many published studies are limited due to early exploratory and retrospective analyses, and those biomarkers, while of potential interest, have not made it to clinical practice. Our systematic review identified several CRC molecular biomarkers that showed either prognostic or treatment predictive characteristics in single studies (Supplemental [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref]. Most of the molecular biomarkers reported in the studies listed in the Supplemental [fig_ref] Table 1: Levels of Evidence a the expert panel of its level of confidence... [/fig_ref] were tested for expression by immunohistochemistry. Immunohistochemistry is notable for its widespread availability in pathology laboratories but has limited quantitative capabilities due to difficult standardization of quantitative or semiquantitative scoring, and is fraught by significant interobserver variability. A problem of quantitative assays, such as gene expression, microRNA expression, and methylation levels, tested in solid tumors, results from the intrinsic mixed nature of the tissue with significant variability of tumor and nontumor tissue content. Another limitation of molecular biomarker discovery approaches that rely on expression levels is that these biomarkers have not been evaluated in the context of complex molecular regulation of individual cancer subtypes. Their fruitful use in the clinic may require further studies that take into account computational predictions of biological behavior and validation in prospective cohorts. A great deal of interest has been raised recently for noninvasive prognostic and/or therapy-predictive molecular biomarkers, such as those tested in circulating tumor cells or circulating nucleic acids, either as free nucleic acid in serum or associated with extracellular vesicles or exosomes. This has been referred to as "liquid biopsy." 152 Liquid biopsies may be particularly useful in the management of patients with CRC to identify recurrence, RAS mutation testing for emergence of treatment resistance associated with anti-EGFR therapy, and potential early cancer detection in defined subpopulations, such as those at high risk of CRC. Overall, molecular biomarkers for colorectal cancer tested in liquid biopsy samples are promising but await further validation. Emerging data indicate that MMR status may have predictive value in some settings, specifically in patients with advanced disease being considered for anti-PD-1/PD-L1 therapy. [bib_ref] PD-1 blockade in tumors with mismatch-repair deficiency, Diaz [/bib_ref] [bib_ref] PD-1 blockade in tumors with mismatch-repair deficiency, Le [/bib_ref] Conclusions Evidence supports mutational testing of specific genes in the EGFR signaling pathway, since they provide clinically actionable information for targeted therapy of CRC with anti-EGFR monoclonal antibodies. Mutations in some of the biomarkers have clear prognostic value (BRAF, MMR), and at least two (KRAS and NRAS) have relatively strong evidence as negative predictors of benefit to anti-EGFR therapies and should be used to guide the use of these agents. BRAF mutations are consistently associated with poor outcomes in patients with metastatic CRC, including those who relapse after adjuvant therapy. Patients with localized colon cancer and dMMR have improved outcomes. Emerging data suggest that MMR status has predictive value in some settings, specifically in patients with advanced disease being considered for anti-PD-1/PD-L1 therapy. Laboratory approaches to operationalize molecular testing for predictive and prognostic molecular biomarkers involve selection of assays, type of specimens to be tested, timing of ordering of tests, and turnaround time for testing results. A number of alternative technical approaches can effectively be used as long as test specificity and sensitivity meet the clinical needs. While earlier testing approaches were focused on one or a few testing targets (eg, BRAF p.V600 mutations), currently, new approaches are using gene panels such as targeted NGS cancer panels, which can range from a few to hundreds of genes and amplicons with known mutational hotspots in cancer. These guidelines will be subjected to regular updates, such that new advances in the field can be captured and integrated in the guidelines in a timely manner. [fig] 6: No Recommendation: There is insufficient evidence to recommend PTEN analysis (expression by immunohistochemistry [IHC] or deletion by fluorescence in situ hybridization [FISH]) in colorectal carcinoma tissue for patients who are being considered for therapy selection outside of a clinical trial. PTEN functions as a tumor suppressor gene, and loss of PTEN results in upregulation of the PI3K/AKT pathway. PTEN mutations occur in approximately 5% to 14% of colorectal cancers, 4,84 and loss of PTEN expression can be observed in tumors with KRAS, BRAF, and PIK3CA mutations. [/fig] [table] Table 1: Levels of Evidence a the expert panel of its level of confidence that the evidence from the studies informing the recommendations reflects true effect.Table 2describes the grades for strength of evidence.11 [/table] [table] Table 2: Grades for Strength of Evidence a [/table] [table] Table 3: Grades for Strength of Recommendation a [/table] [table] Table 4: Guideline Statements and Strength of Recommendations Guideline Statement Strength of Recommendation 1. Patients with colorectal carcinoma being considered for anti-EGFR therapy must receive RAS mutational testing. Mutational analysis should include KRAS and NRAS codons 12 and 13 of exon 2, 59 and 61 of exon 3, and 117 and 146 of exon 4 ("expanded" or "extended" RAS). BRAF p.V600 mutational analysis should be performed in deficient MMR tumors with loss of MLH1 to evaluate for Lynch syndrome risk. Presence of a BRAF mutation strongly favors a sporadic pathogenesis. The absence of a BRAF mutation does not exclude risk of Lynch syndrome. 3. Clinicians should order mismatch repair status testing in patients with colorectal cancers for the identification of patients at high risk for Lynch syndrome and/or prognostic stratification. Laboratories must use validated colorectal carcinoma molecular biomarker testing methods with sufficient performance characteristics for the intended clinical use. Colorectal carcinoma molecular biomarker testing validation should follow accepted standards for clinical molecular diagnostics tests. [/table] [table] Table 5 cont: AD, allelic discrimination; AIO, German AIO colorectal study group; ARMS, amplification refractory mutation system; AS-PCR, allele-specific polymerase chain reaction; ASO, allele-specific oligonucleotide; BRAF, proto-oncogene B-Raf/v-Raf murine sarcoma viral oncogene homolog B; BSC, best supportive care; CECOG, Central European Cooperative Oncology Group; CI, confidence interval; CISH, chromogenic in situ hybridization; CPG, clinical practice guideline; CRC, colorectal cancer; CT, chemotherapy; DS, direct sequencing; EGFR, epidermal growth factor receptor; FOLFOX4, folacin, 4-fluorouracil, oxaliplatin; FISH, fluorescence in situ hybridization; FOLFOX, folinic acid (leucovorin calcium), 5-fluorouracil, and oxaliplatin; 5FU, fluorouracil; GCN, gene copy number; HR, hazard ratio; HTA, health technology assessment; KRAS, Kirsten rat sarcoma viral oncogene homolog; M-A, meta-analysis; mAbs, monoclonal antibodies; MALDI-TOF, matrix-assisted laser desorption/ionization-time of flight; mCRC, metastatic colorectal cancer; MD, mean difference; Mut-, mutation negative or wild type; Mutþ, mutation positive; NR, not reported; NRAS, neuroblastoma RAS viral (v-ras) oncogene homolog; ns, nonsignificant; OR, odds ratio; ORR, objective response rate; OS, overall survival; PCR, polymerase chain reaction; PCR-RFLP, polymerase chain reaction-restriction fragment length polymorphism; PFS, progression-free survival; PIK3CA, phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha; PRIME, Panitumumab Randomized Control Trial in Combination with Chemotherapy for Metastatic Colorectal Cancer to Determine Efficacy; PTEN, phosphatase and tensin homolog; qPCR, quantitative polymerase chain reaction; RCT, randomized controlled trial; RAS, rat sarcoma viral oncogene homolog; RD, risk difference; RFS, recurrence-free survival; RR, response rate; SISH, silver in situ hybridization; SR, systematic review; SSCP, single-strand conformation polymorphism; xMAP, multiplex assay.Tests used by Ren et al 37 : hybridization, PCR, direct sequencing, topographic genotyping, AS-PCR, tissue transglutaminase enzyme, high-performance liquid chromatography, pyrosequencing, capillary sequencing. [/table] [table] Table 7: Prevalence of New RAS Mutations Across Studies a Study New RAS Total, b % KRAS Exon 3, b % KRAS Exon 4, b % NRAS Exon 2, b % NRAS Exon 3, b % NRAS Exon 4, b % CI, confidence interval; COIN, Combination Chemotherapy With or Without Cetuximab as First-Line Therapy in Treating Patients With Metastatic Colorectal Cancer Trial; CRYSTAL, Cetuximab Combined with Irinotecan in First-Line Therapy for Metastatic Colorectal Cancer Trial; FIRE-3, FIRE-3, Folinic Acid and Irinotecan (FOLFIRI) Plus Cetuximab vs FOLFIRI Plus Bevacizumab in First-Line Treatment Colorectal Cancer (CRC) Trial; NA, not applicable; NE, not evaluated; NR, evaluated but not reported; OPUS, Effect of Roflumilast on Exacerbation Rate in Patients With Chronic Obstructive Pulmonary Disease (BY217/M2-111) Trial; PEAK, Panitumumab Plus mFOLFOX6 vs Bevacizumab Plus mFOLFOX6 for First-Line Treatment of Metastatic Colorectal Cancer (mCRC) Patients With Wild-Type Kirsten Rat Sarcoma-2 Virus (KRAS) Tumors Trial; PICCOLO, Panitumumab and Irinotecan vs Irinotecan Alone for Patients With KRAS Wild-Type, Fluorouracil-Resistant Advanced Colorectal Cancer Trial; PRIME, Panitumumab Randomized Trial in Combination With Chemotherapy for Metastatic Colorectal Cancer to Determine Efficacy Trial. Modified from Sorich et al 12 by permission of Oxford University Press on behalf of the European Society for Medical Oncology.New RAS mutations are reported as a proportion of the KRAS exon 2 nonmutated/wild-type group.KRAS and NRAS codon 59 mutation was not evaluated. [/table] [table] Table 8: BRAF Clinical Practice Guidelines, Systematic Reviews, Meta-Analyses, Prospective Cohort Studies, and Retrospective Cohort Studies [/table] [table] Table 9: Summary of Frequencies of Tumor V600E Mutation Status a [/table]

Transcription factor II B Transcription factor II B (TFIIB) is a general transcription factor that is involved in the formation of the RNA polymerase II preinitiation complex (PIC) and aids in stimulating transcription initiation. TFIIB is localised to the nucleus and provides a platform for PIC formation by binding and stabilising the DNA-TBP (TATA-binding protein) complex and by recruiting RNA polymerase II and other transcription factors. It is encoded by the TFIIB gene, and is homologous to both archaeal transcription factor B and more distantly to bacterial sigma factors # Structure TFIIB is a single 33kDa polypeptide consisting of 316 amino acids. It was originally thought to be essential at all promoters in order to recruit RNA polymerase II and initiate transcription; however, recent research has shown that a depletion in TFIIB is not lethal to cells and transcription levels are not significantly affected. This is because over 90% of mammalian promoters do not contain a BRE (B recognition element) or TATA box sequence which are required for TFIIB to bind. In addition to this, TFIIB levels have been shown to fluctuate in different types of cell, and at different points in the cell cycle, supporting the evidence that it is not required for all RNA polymerase II transcription. TFIIB is made up of four functional domains: The C terminal core domain; the B linker; the B reader and the amino terminal zinc ribbon. The protease resistant C terminal core stabilises the DNA-TBP complex by interacting with nonspecific sequences either side of the TATA box called the upstream and downstream B recognition elements (BREu and BREd), as well as interacting with the Initiator element (INR). The core domain consists of two alpha helical structures that form nearly identical domains connected by a short linker region and rotated by 90 degrees between each other. Each of the domains has 5 alpha helices with a hydrophobic core. These two domains show a high sequence and structural similarity to cyclin A and are held together by intramolecular hydrophobic forces. The C terminus consists of another short alpha helix and a random coil. The B reader is formed of an alpha helix and mobile loop that is thought to play a role in the identification of the transcription start site. Amino terminal zinc ribbon takes part in the recruitment of RNA polymerase II. The zinc ion is coordinated by cysteine and histidine residues arranged in beta sheets. # Mechanism of action There are six steps in the mechanism of TFIIB action in the formation of the PIC and transcription initiation: - The DNA is recruited to RNA polymerase II through the B ribbon and it is then positioned by the B core. - DNA opening occurs aided by the B linker, the template strand is then placed into the RNA polymerase II cleft and the bubble is stabilised by the B reader (open complex formation). - RNA polymerase II and B reader scan the DNA for the Inr in order to position the transcription start site. - The first phosphodiester bond is formed. - Production of short abortive transcripts due to clashes with the B reader loop. - The growth of nascent RNA chain to 12-13 bases leads to ejection of TFIIB due to further clashes with TFIIB. ## Binding to TFIID The first transcription factor to bind the DNA is TFIID, which binds via the TBP subunit to the TATA box. TFIIB then binds to stabilize the complex. The binding of TBP to DNA forms a 90° kink in the DNA and allows the TFIIB to clamp the TBP tightly to the DNA. The binding of TFIIB up and downstream of the TATA box strengthens this complex but this binding is not sequence specific as the TFIIB does not come into contact with any of the DNA bases. Instead it uses positively charged basic residues to interact with the negatively charged DNA backbone (the phosphate groups). The basic residues also interact with the acidic C terminal of TBP (the stirrup) and the opposite charges between the TFIIB and DNA-TBP complex stabilises the structure as a whole. There are additional salt bridges, hydrogen bonds and VdW interactions between the TBP stirrup and the TFIIB to further stabilise the structure. TFIIB also directly interacts with TFIIF, another general transcription factor; however, it is unclear how TFIIB and TFIIF work together in this mechanism as TFIIB is capable of binding RNA polymerase II both when it is bound to TFIIF and when it is not. ## Interactions with RNA polymerase II Each of the domains in TFIIB interacts with different parts of RNA polymerase II. The amino terminal B ribbon is located on dock domain of RNA polymerase II and extends in to the cleft towards the active site. Extending the B ribbon is the B reader that extends via the RNA exit tunnel to the binding site of the DNA-RNA hybrid and towards the active site. The B linker is the region between the B reader and the B core that is found in the cleft of RNA polymerase II and continues by the rudder and the clamp coiled-coil until it reaches the C terminal B core that is found above the wall of RNA polymerase II. The B reader and the B linker consist of highly conserved residues that are positioned through the RNA polymerase II tunnel towards the active site and ensure tight binding, without these key residues dissociation would occur. These two domains are also thought to adjust the position of some of the more flexible areas of RNA polymerase II to allow for the precise positioning of the DNA and allowing the addition of the new NTPs onto the nascent RNA chain. Upon binding RNA polymerase II, the B reader and B linker cause slight repositioning of the protrusion domain of RNA polymerase II which allows an essential second magnesium ion to bind in the active site. It forms a beta sheet and an ordered loop that helps with the stability of the structure when transcription is initiated. ## Open and closed complexes The open and closed conformations refer to the state of the DNA and whether the template strand has been separated from the non-template strand within the PIC. The place at which the DNA opens to form the bubble lies above a tunnel that is lined by the B-core, B-linker and B-reader as well as parts of RNA polymerase II. The B linker is found directly aligned with the point at which the DNA opens and in the open complex it is found between the two DNA strands, suggesting that it has a role in promoter melting, but it does not have a role in the catalytic RNA synthesis. Although TFIIB keeps a similar structure in both conformations some of the intramolecular interactions between the core and the B reader are disrupted upon DNA opening. After DNA melting the Inr must be located on the DNA so the TSS can be identified by the RNA polymerase II and transcription can begin. This is done by passing the DNA through the 'template tunnel' and the DNA is scanned, looking for the Inr and placing it in a position that ensures the transcription start site is located in the correct place by the RNA polymerase active site. The B reader of TFIIB is found in the template tunnel and is important in locating the Inr, mutations in the B reader cause the TSS to change and therefore incorrect transcription to occur (although PIC formation and DNA melting still take place). Yeast are a particularly good example of this alignment as the yeast Inr motif has a strictly conserved A residue at position 28 and in the open complex model a complimentary T residue can be found in the B reader helix. When this T residue is mutated, transcription was significantly less effective emphasizing the role of the B reader. The B reader loop is further thought to stabilise NTPs in the active site and, due to its flexibily, allow the nucleic acids to remain in contact during the early synthesis of the RNA molecule (i.e. stabilises the growing RNA-DNA hybrid) ## Release When the RNA transcript reaches 7 nucleotides long, transcription enters the elongation phase, the beginning of which is characterised by the collapsing of the DNA bubble and the ejection of TFIIB. This is thought to be because the nascent RNA clashes with the B linker helix when it is 6 bases long and upon further elongation to 12-13 bases it will clash with the B-reader and B-ribbon leading to dissociation. The DNA duplex also clashes with the B linker above the rudder (caused by rewinding of the DNA into a double helix). # Phosphorylation TFIIB is phosphorylated at serine 65 which is found in the B reader domain. Without this phosphorylation, transcription initiation does not occur. It has been suggested that the general transcription factor TFIIH could act as the kinase for this phosphorylation although more evidence is needed to support this. Although TFIIB does not travel with the RNA polymerase II complex along the DNA during elongation, it has been recently suggested that it has a role in gene looping which links the promoter to the terminator of the gene. Gene looping is reliant on the interaction between phosphorylated serine residues found on the C terminal domain of RNA polymerase II and polyadenylation factors. TFIIB is needed for the interaction of promoters with these polyadenylation factors, such as SSu72 and CstF-64. It has also been suggested that both gene loop formation and the collapse of the DNA bubble are a result of TFIIB phosphorylation; however, it is unclear whether this gene loop formation is a cause or consequence of transcription initiation. # Similarities in other transcription complexes RNA polymerase III uses a very similar factor to TFIIB called Brf (TFIIB-related factor) which also contains a conserved zinc ribbon and C terminal core. However, the structure diverges in the more flexible linker region although Brf still contains highly conserved sequences in the same positions that the B reader and B linker are found. These conserved regions probably carry out similar functions as the domains in TFIIB. RNA polymerase I does not use a factor that is similar to TFIIB; however, it is thought that another unknown factor fulfils the same function. There is no direct homologue for TFIIB in bacterial systems but there are proteins that bind the bacterial polymerase in a similar manner with no sequence similarity. In particular the bacterial protein σ70 contains domains that bind the polymerase at the same points as the B-linker, B-ribbon and B-core. This is especially apparent in the σ 3 region and the region 4 linker which might stabilise the DNA in the polymerase active site. # Clinical significance ## Antiviral activity Recent studies have shown that decreased TFIIB levels do not affect transcription levels within cells, this is thought to be partially because over 90% of mammalian promoters do not contain a BRE or TATA box. However, it has been shown that TFIIB is vital to the in vitro transcription and regulation of the herpes simplex virus. This is thought to be due to similarity TFIIB has to cyclin A. In order to undergo replication, viruses often stop host cells progression through the cell cycle, using cyclins and other proteins. As TFIIB has a similar structure to cyclin A it has been suggested that depleted levels of TFIIB could have antiviral effects. ## Neurodegeneration Studies have shown that the binding of TFIIB to TBP is affected by the length of the polyglutamine tract in TBP. Extended polyglutamine tracts such as those found in neurodegenerative diseases cause increased interaction with TFIIB. This is thought to affect transcription in these diseases as it reduces the availability of TFIIB to other promoters in the brain as the TFIIB is instead interacting with the expanded polyglutamine tracts.

This report updates the 2008 recommendations by CDC's Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine for the prevention and control of seasonal influenza (CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices . MMWR 2008;57). Information on vaccination issues related to the recently identified novel influenza A H1N1 virus will be published later in 2009. The 2009 seasonal influenza recommendations include new and updated information. Highlights of the 2009 recommendations include 1) a recommendation that annual vaccination be administered to all children aged 6 months-18 years for the 2009-10 influenza season; 2) a recommendation that vaccines containing the 2009-10 trivalent vaccine virus strains A/Brisbane/59/2007 (H1N1)like, A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane/60/2008-like antigens be used; and 3) a notice that recommendations for influenza diagnosis and antiviral use will be published before the start of the 2009-10 influenza season. Vaccination efforts should begin as soon as vaccine is available and continue through the influenza season. Approximately 83% of the United States population is specifically recommended for annual vaccination against seasonal influenza; however, <40% of the U.S. population received the 2008-09 influenza vaccine. These recommendations also include a summary of safety data for U.S. licensed influenza vaccines. These recommendations and other information are available at CDC's influenza website (/ flu); any updates or supplements that might be required during the 2009-10 influenza season also can be found at this website. Vaccination and health-care providers should be alert to announcements of recommendation updates and should check the CDC influenza website periodically for additional information.# Introduction In the United States, annual epidemics of seasonal influenza occur typically during the late fall through early spring. Influenza viruses can cause disease among persons in any age group, but rates of infection are highest among children (1)(2)(3). Rates of serious illness and death are highest among persons aged >65 years, children aged <2 years, and persons of any age who have medical conditions that place them at increased risk for complications from influenza (1,4,5). An annual average of approximately 36,000 deaths during 1990-1999 and 226,000 hospitalizations during 1979-2001 have been associated with influenza epidemics (6,7). Annual influenza vaccination is the most effective method for preventing influenza virus infection and its complications. Influenza vaccine can be administered to any person aged >6 months who does not have contraindications to vaccination to reduce the likelihood of becoming ill with influenza or of transmitting influenza to others. Trivalent inactivated influenza vaccine (TIV) can be used for any person aged >6 months, including those with high-risk conditions (Boxes 1 and 2). Live, attenuated influenza vaccine (LAIV) may be used for healthy, nonpregnant persons aged 2-49 years. No preference All children aged 6 months-18 years should be vaccinated annually. Children and adolescents at higher risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children and adolescents, including those who: are aged 6 months-4 years ( - 59 months); have chronic pulmonary (including asthma), cardiovas-- cular (except hypertension), renal, hepatic, cognitive, neurologic/neuromuscular, hematological or metabolic disorders (including diabetes mellitus); are immunosuppressed (including immunosuppression - caused by medications or by human immunodeficiency virus); are receiving long-term aspirin therapy and therefore - might be at risk for experiencing Reye syndrome after influenza virus infection; are residents of long-term care facilities; and - will be pregnant during the influenza season. - Note: Children aged <6 months cannot receive influenza vaccination. Household and other close contacts (e.g., daycare providers) of children aged <6 months, including older children and adolescents, should be vaccinated. is indicated for LAIV or TIV when considering vaccination of healthy, nonpregnant persons aged 2-49 years. Because the safety or effectiveness of LAIV has not been established in persons with underlying medical conditions that confer a higher risk for influenza complications, these persons should be vaccinated only with TIV. Influenza viruses undergo frequent antigenic change (i.e., antigenic drift); to gain immunity against viruses in circulation, patients must receive an annual vaccination against the influenza viruses that are predicted on the basis of viral surveillance data. . Although vaccination coverage has increased in recent years for many groups targeted for routine vaccination, coverage remains low among most of these groups, and strategies to improve vaccination coverage, including use of reminder/recall systems and standing orders programs, should be implemented or expanded. Antiviral medications are an adjunct to vaccination and are effective when administered as treatment and when used for chemoprophylaxis after an exposure to influenza virus. However, the emergence since 2005 of resistance to one or more of the four licensed antiviral agents (oseltamivir, zanamivir, amantadine and rimantadine) among circulating strains Annual vaccination against influenza is recommended for any adult who wants to reduce the risk of becoming ill with influenza or of transmitting it to others. Vaccination is recommended for all adults without contraindications in the following groups, because these persons either are at higher risk for influenza complications, or are close contacts of persons at higher risk has complicated antiviral treatment and chemoprophylaxis recommendations. Updated antiviral treatment and chemoprophylaxis recommendations will be provided in a separate set of guidelines later in 2009. CDC has issued interim recommendations for antiviral treatment and chemoprophylaxis of influenza (8), and these guidelines should be consulted pending issuance of new recommendations. In April 2009, a novel influenza A (H1N1) virus that is similar to influenza viruses previously identified in swine was determined to be the cause of an influenza respiratory illness that spread across North America and was identified in many areas of the world by May 2009. The symptoms of novel influenza A (H1N1) virus infection are similar to those of seasonal influenza, and specific diagnostic testing is required to distinguish novel influenza A (H1N1) virus infection from seasonal influenza (9). The epidemiology of this illness is still being studied and prevention issues related to this newly emerging influenza virus will be published separately. # Methods CDC's Advisory Committee on Immunization Practices (ACIP) provides annual recommendations for the prevention and control of influenza. The ACIP Influenza Vaccine Working Group- meets monthly throughout the year to discuss newly published studies, review current guidelines, and consider revisions to the recommendations. As they review the annual recommendations for ACIP consideration of the full committee, members of the working group consider a variety of issues, including burden of influenza illness, vaccine effectiveness, safety, and coverage in groups recommended for vaccination, feasibility, cost-effectiveness, and anticipated vaccine supply. Working group members also request periodic updates on vaccine and antiviral production, supply, safety and efficacy from vaccinologists, epidemiologists, and manufacturers. State and local vaccination program representatives are consulted. CDC's Influenza Division (available at / flu) provides influenza surveillance and antiviral resistance data. The Vaccines and Related Biological Products Advisory Committee provides advice on vaccine strain selection to the Food and Drug Administration (FDA), which selects the viral strains to be used in the annual trivalent influenza vaccines. Published, peer-reviewed studies are the primary source of data used by ACIP in making recommendations for the prevention and control of influenza, but unpublished data that are relevant to issues under discussion also might be considered. Among studies discussed or cited, those of greatest scientific quality and those that measured influenza-specific outcomes are the most influential. For example, population-based estimates that use outcomes associated with laboratory-confirmed influenza virus infection outcomes contribute the most specific data for estimates of influenza burden. The best evidence for vaccine or antiviral efficacy and effectiveness comes from randomized controlled trials that assess laboratory-confirmed influenza infections as an outcome measure and consider factors such as timing and intensity of influenza circulation and degree of match between vaccine strains and wild circulating strains (10,11). Randomized, placebo-controlled trials cannot be performed ethically in populations for which vaccination already is recommended, but observational studies that assess outcomes associated with laboratory-confirmed influenza infection can provide important vaccine or antiviral effectiveness data. Randomized, placebo-controlled clinical trials are the best source of vaccine and antiviral safety data for common adverse events; however, such studies do not have the statistical power to identify rare but potentially serious adverse events. The frequency of rare adverse events that might be associated with vaccination is best assessed by reviewing computerized medical records from large linked clinical databases and medical charts of persons who are identified as having a potential adverse event after vaccination (12,13). Vaccine coverage data from a nationally representative, randomly selected population that includes verification of vaccination through health-care record review are superior to coverage data derived from limited populations or without verification of vaccination; however, these data rarely are available for older children or adults (14). Finally, studies that assess vaccination program practices that improve vaccination coverage are most influential in formulating recommendations if the study design includes a nonintervention comparison group. In cited studies that included statistical comparisons, a difference was considered to be statistically significant if the p-value was <0.05 or the 95% confidence interval (CI) around an estimate of effect allowed rejection of the null hypothesis (i.e., no effect). These recommendations were presented to the full ACIP and approved in February 2009. Modifications were made to the ACIP statement during the subsequent review process at CDC to update and clarify wording in the document. Vaccine recommendations apply only to persons who do not have contraindications to vaccine use (see Contraindications and Precautions for use of TIV and Contraindications and Precautions for use of LAIV). Data presented in this report were current as of July 17, 2009. Further updates, if needed, will be posted at CDC's influenza website (. gov/flu). # Primary Changes and Updates in the Recommendations The 2009 recommendations include three principal changes or updates: Annual vaccination of all children aged 6 months-18 - years should begin as soon as the 2009-10 influenza vaccine is available. Annual vaccination of all children aged 6 months-4 years (59 months) and older children with conditions that place them at increased risk for complications from influenza should continue to be a primary focus of vaccination efforts as providers and programs transition to routinely vaccinating all children. from the United States and other countries are now resistant to oseltamivir. Recommendations for influenza diagnosis and antiviral use will be published later in 2009. CDC issued interim recommendations for antiviral treatment and chemoprophylaxis of influenza in December 2008, and these should be consulted for guidance pending recommendations from the ACIP (8). # Background and Epidemiology # Biology of Influenza Influenza A and B are the two types of influenza viruses that cause epidemic human disease. Influenza A viruses are categorized into subtypes on the basis of two surface antigens: hemagglutinin and neuraminidase. Since 1977, influenza A (H1N1) viruses, influenza A (H3N2) viruses, and influenza B viruses have circulated globally. Influenza A (H1N2) viruses that probably emerged after genetic reassortment between human A (H3N2) and A (H1N1) viruses also have been identified in some influenza seasons. In April 2009, human infections with a novel influenza A (H1N1) virus were identified; as of June 2009, infections with the novel influenza A (H1N1) virus have been reported worldwide. This novel virus is derived partly from influenza A viruses that circulate in swine and is antigenically distinct from human influenza A (H1N1) viruses in circulation since 1977. Influenza A subtypes and B viruses are further separated into groups on the basis of antigenic similarities. New influenza virus variants result from frequent antigenic change (i.e., antigenic drift) resulting from point mutations and recombination events that occur during viral replication (15). Recent studies have begun to shed some light on the complex molecular evolution and epidemiologic dynamics of influenza A viruses (16)(17)(18). Currently circulating influenza B viruses are separated into two distinct genetic lineages (Yamagata and Victoria) but are not categorized into subtypes. Influenza B viruses undergo antigenic drift less rapidly than influenza A viruses. Influenza B viruses from both lineages have circulated in most recent influenza seasons (19). Immunity to the surface antigens, particularly the hemagglutinin, reduces the likelihood of infection (20). Antibody against one influenza virus type or subtype confers limited or no protection against another type or subtype of influenza virus. Furthermore, antibody to one antigenic type or subtype of influenza virus might not protect against infection with a new antigenic variant of the same type or subtype (21). Frequent emergence of antigenic variants through antigenic drift is the virologic basis for seasonal epidemics and is the reason for annually reassessing the need to change one or more of the recommended strains for influenza vaccines. More dramatic changes, or antigenic shifts, occur less frequently. Antigenic shift occurs when a new subtype of influenza A virus appears and can result in the emergence of a novel influenza A virus with the potential to cause a pandemic. New influenza A subtypes have the potential to cause a pandemic when they are able to cause human illness and demonstrate efficient human-to-human transmission and little or no previously existing immunity has been identified among humans (15). Novel influenza A (H1N1) virus is not a new subtype, but because the large majority of humans appear to have no pre-existing antibody to key novel influenza A (H1N1) virus hemagglutinin epitopes, substantial potential exists for widespread infection (16). # Health-Care Use, Hospitalizations, and Deaths Attributed to Influenza In the United States, annual epidemics of influenza typically occur during the fall or winter months, but the peak of influenza activity can occur as late as April or May (Figure 1). Influenza-related complications requiring urgent medical care, including hospitalizations or deaths, can result from the direct effects of influenza virus infection, from complications associated with age or pregnancy, or from complications of underlying cardiopulmonary conditions or other chronic diseases. Studies that have measured rates of a clinical outcome without a laboratory confirmation of influenza virus infection (e.g., respiratory illness requiring hospitalization during influenza season) to assess the effect of influenza can be difficult to interpret because of circulation of other respiratory pathogens (e.g., respiratory syncytial virus) during the same time as influenza viruses (22)(23)(24). However, increases in healthcare provider visits for acute febrile respiratory illness occur each year during the time when influenza viruses circulate. Data from the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) demonstrate the annual increase in physician visits for influenza-like illness (ILI) † and for each influenza season; for 2009, the data also indicate the recent resurgence of respiratory illness associated with circulation of novel influenza A (H1N1) virus (Figure 2) (25,26). During seasonal influenza epidemics from 1979-1980 through 2000-2001, the estimated annual overall number of influenza-associated hospitalizations in the United States ranged from approximately 55,000 to 431,000 per annual epidemic (mean: 226,000) (7). The estimated annual number of deaths attributed to influenza from the 1990-91 influenza season through the 1998-99 season ranged from 17,000 to 51,000 per epidemic (mean: 36,000) (6). In the United States, the estimated number of influenza-associated deaths 53; therefore the week 53 data point for those seasons is an average of weeks 52 and 1. ¶ The national baseline is the mean percentage of visits for ILI during noninfluenza weeks for the previous three seasons plus two standard deviations. A noninfluenza week is a week during which 65 years who were at increased risk for death from influenza complications (6). In one study, an average of approximately 19,000 influenza-associated pulmonary and circulatory deaths per influenza season occurred during 1976-1990 compared with an average of approximately 36,000 deaths per season during 1990-1999 (6). In addition, influenza A (H3N2) viruses, which have been associated with higher mortality (27), predominated in 90% of influenza seasons during 1990-1999 compared with compared with 57% of seasons during 1976-1990 (6). Influenza viruses cause disease among persons in all age groups (1)(2)(3)(4)(5). Rates of infection are highest among children, but the risks for complications, hospitalizations, and deaths from influenza are higher among persons aged >65 years, young children, and persons of any age who have medical conditions that place them at increased risk for complications from influenza (1,4,5,(28)(29)(30)(31). Estimated rates of influenzaassociated hospitalizations and deaths varied substantially by age group in studies conducted during different influenza epidemics. During 1990-1999, estimated average rates of influenza-associated pulmonary and circulatory deaths per 100,000 persons were 0.4-0.6 among persons aged 0-49 years, 7.5 among persons aged 50-64 years, and 98.3 among persons aged >65 years (6). # Children Among children aged <5 years, influenza-related illness is a common cause of visits to medical practices and emergency departments (EDs). During two influenza seasons (2002-03 and 2003-04), the percentage of visits among children aged <5 years with acute respiratory illness or fever caused by laboratory-confirmed influenza ranged from 10%-19% of medical office visits to 6%-29% of EDs visits during the influenza season. On the basis of these data, the rate of visits to medical clinics for influenza was estimated to be 50-95 per 1,000 children, and the rate of visits to EDs was estimated to be 6-27 per 1,000 children (32). A multiyear study in New York City used viral surveillance data to estimate influenza strain-specific illness rates among ED visits. In addition to the expected variation by season and age group, influenza B epidemics were found to be an important cause of illness among school-aged children in several seasons, and annual epidemics of both influenza A and B peaked among school-aged children before other age groups (33). Retrospective studies using medical records data have demonstrated similar rates of illness among children aged <5 years during other influenza seasons (29,34,35). During the influenza season, an estimated 7-12 additional outpatient visits and 5-7 additional antibiotic prescriptions per 100 children aged <15 years have been documented when compared with periods when influenza viruses are not circulating, with rates decreasing with increasing age of the child (35). During 1993During -2004 in the Boston area, the rate of ED visits for respiratory illness that was attributed to influenza virus based on viral surveillance data among children aged <7 years during the winter respiratory illness season ranged from 22.0 per 1,000 children aged 6-23 months to 5.4 per 1,000 children aged 5-7 years (36). Rates of influenza-associated hospitalization are substantially higher among infants and young children than among older children when influenza viruses are in circulation and are similar to rates for other groups considered at high risk for influenza-related complications (37)(38)(39)(40)(41)(42), including persons aged >65 years (35,39). During 1979-2001, on the basis of data from a national sample of hospital discharges of influenzaassociated hospitalizations among children aged <5 years, the estimated rate of influenza-associated hospitalizations in the United States was 108 hospitalizations per 100,000 personyears (7). Recent population-based studies that measured hospitalization rates for laboratory-confirmed influenza in young children have documented hospitalization rates that are similar to or higher than rates derived from studies that analyzed hospital discharge data (32,34,41,43,44). Annual hospitalization rates for laboratory-confirmed influenza decrease with increasing age, ranging from 240-720 per 100,000 children aged <6 months to approximately 20 per 100,000 children aged 2-5 years (32). Hospitalization rates for children aged <5 years with high-risk medical conditions are approximately 250-500 per 100,000 children (29,31,45). Influenza-associated deaths are uncommon among children. An estimated annual average of 92 influenza-related deaths (0.4 deaths per 100,000 persons) occurred among children aged 65 years (6). Of 153 laboratory-confirmed influenza-related pediatric deaths reported during the 2003-04 influenza season, 96 (63%) deaths occurred among children aged <5 years and 61 (40%) among children aged <2 years. Among the 149 children who died and for whom information on underlying health status was available, 100 (67%) did not have an underlying medical condition that was an indication for vaccination at that time (46). In California during the 2003-04 and 2004-05 influenza seasons, 51% of children with laboratory-confirmed influenza who died and 40% of those who required admission to an intensive care unit had no underlying medical conditions (47). These data indicate that although children with risk factors for influenza complications are at higher risk for death, the majority of pediatric deaths occur among children with no known high-risk conditions. The annual number of influenza-associated deaths among children reported to CDC for the past four influenza seasons has ranged from 44 during 2004-05 to 84 during 2007-08 (48). As of July 8, 2009, a total of 17 deaths caused by novel influenza A (H1N1) virus infection have occurred in 2009 among children in the United States (CDC, unpublished data, 2009). Death associated with laboratory-confirmed influenza virus infection among children (defined as persons aged <18 years) is a nationally reportable condition. Deaths among children that have been attributed to co-infection with influenza and Staphylococcus aureus, particularly methicillin-resistant S. aureus (MRSA), have increased during the preceding four influenza seasons (26,49). The reason for this increase is not established but might reflect an increasing prevalence within the general population of colonization with MRSA strains, some of which carry certain virulence factors (50,51). # Adults Hospitalization rates during the influenza season are substantially increased for persons aged >65 years. One retrospective analysis based on data from managed-care organizations collected during 1996-2000 estimated that the risk during influenza season among persons aged >65 years with underlying conditions that put them at risk for influenza-related complications (i.e., one or more of the conditions listed as indications for vaccination) was approximately 560 influenzaassociated hospitalizations per 100,000 persons compared with approximately 190 per 100,000 healthy persons. Persons aged 50-64 years with underlying medical conditions also were at substantially increased risk for hospitalizations during influenza season compared with healthy adults aged 50-64 years. No increased risk for influenza-related hospitalizations was demonstrated among healthy adults aged 50-64 years or among those aged 19-49 years, regardless of underlying medical conditions (28). Influenza is an important contributor to the annual increase in deaths attributed to pneumonia and influenza that is observed during the winter months (Figure 3). During 1976-2001, an estimated yearly average of 32,651 (90%) influenza-related deaths occurred among adults aged >65 years (6). Risk for influenza-related death was highest among the oldest elderly, with persons aged >85 years 16 times more likely to die from an influenza-related illness than persons aged 65-69 years (6). The duration of influenza symptoms is prolonged and the severity of influenza illness increased among persons with human immunodeficiency virus (HIV) infection (52)(53)(54)(55)(56). A retrospective study of young and middle-aged women enrolled in Tennessee's Medicaid program determined that the attributable risk for cardiopulmonary hospitalizations among women with HIV infection was higher during influenza seasons than it was either before or after influenza was circulating. The risk for hospitalization was higher for HIV-infected women than it was for women with other underlying medical conditions (57). Another study estimated that the risk for influenza- - Each week, the vital statistics offices of 122 cities report the total number of death certificates received and the number of those for which pneumonia or influenza (P&I) was listed as the underlying or contributing cause of death by age group. The percentage of all deaths attributable to P&I are compared with a seasonal baseline and epidemic threshold value calculated for each week. † An increase of 1.645 standard deviations above the seasonal baseline deaths is considered the "epidemic threshold," i.e., the point at which the observed proportion of deaths attributed to pneumonia or influenza was significantly higher than would be expected at that time of the year in the absence of substantial influenza-related mortality. § The seasonal baseline of P&I deaths is calculated using a periodic regression model that incorporates a robust regression procedure applied to data from the previous 5 years. related death was 94-146 deaths per 100,000 persons with acquired immunodeficiency syndrome (AIDS) compared with 0.9-1.0 deaths per 100,000 persons aged 25-54 years and 64-70 deaths per 100,000 persons aged >65 years in the general population (58). Influenza-related excess deaths among pregnant women were reported during the pandemics of 1918-1919 and 1957-1958 (59-63). Case reports and several epidemiologic studies also indicate that pregnancy increases the risk for influenza complications (64-69) for the mother. The majority of studies that have attempted to assess the effect of influenza on pregnant women have measured changes in excess hospitalizations for respiratory illness during influenza season but not laboratoryconfirmed influenza hospitalizations. Pregnant women have an increased number of medical visits for respiratory illnesses during influenza season compared with nonpregnant women (70). Hospitalized pregnant women with respiratory illness during influenza season have increased lengths of stay compared with hospitalized pregnant women without respiratory illness. Rates of hospitalization for respiratory illness were twice as common during influenza season (71). A retrospective cohort study of approximately 134,000 pregnant women conducted in Nova Scotia during 1990-2002 compared medical record data for pregnant women to data from the same women during the year before pregnancy. Among pregnant women, 0.4% were hospitalized and 25% visited a clinician during pregnancy for a respiratory illness. The rate of third-trimester hospital admissions during the influenza season was five times higher than the rate during the influenza season in the year before pregnancy and more than twice as high as the rate during the noninfluenza season. An excess of 1,210 hospital admissions in the third trimester per 100,000 pregnant women with comorbidities and 68 admissions per 100,000 women without comorbidities was reported (72). In one study, pregnant women with respiratory hospitalizations did not have an increase in adverse perinatal outcomes or delivery complications (73); another study indicated an increase in delivery complications, including fetal distress, preterm labor, and cesarean delivery. However, infants born to women with laboratory-confirmed influenza during pregnancy do not have higher rates of low birth weight, congenital abnormalities, or lower Apgar scores compared with infants born to uninfected women (64,74). # options for Controlling Influenza The most effective strategy for preventing influenza is annual vaccination (10,15). Strategies that focus on providing routine vaccination to persons at higher risk for influenza complications have long been recommended, although coverage among the majority of these groups remains low. Routine vaccination of certain persons (e.g., children, contacts of persons at risk for influenza complications, and health-care personnel ) who serve as a source of influenza virus transmission might provide additional protection to persons at risk for influenza complications and reduce the overall influenza burden. However, coverage levels among these persons need to be increased before effects on transmission can be measured reliably. Antiviral drugs used for chemoprophylaxis or treatment of influenza are adjuncts to vaccine but are not substitutes for annual vaccination. However, antiviral drugs might be underused among those hospitalized with influenza (75). Nonpharmacologic interventions (e.g., advising frequent handwashing and improved respiratory hygiene) are reasonable and inexpensive; these strategies have been demonstrated to reduce respiratory diseases; reductions in detectable influenza A viruses on hands after handwashing also have been demonstrated (76)(77)(78). Few data are available to assess the effects of community-level respiratory disease mitigation strategies (e.g., closing schools, avoiding mass gatherings, or using respiratory protection) on reducing influenza virus transmission during typical seasonal influenza epidemics (79,80). # Influenza Vaccine Efficacy, Effectiveness, and Safety Evaluating Influenza Vaccine Efficacy and Effectiveness Studies The efficacy (i.e., prevention of illness among vaccinated persons in controlled trials) and effectiveness (i.e., prevention of illness in vaccinated populations) of influenza vaccines depend in part on the age and immunocompetence of the vaccine recipient, the degree of similarity between the viruses in the vaccine and those in circulation (see Effectiveness of Influenza Vaccination when Circulating Influenza Virus Strains Differ from Vaccine Strains), and the outcome being measured. Influenza vaccine efficacy and effectiveness studies have used multiple possible outcome measures, including the prevention of medically attended acute respiratory illness (MAARI), prevention of laboratory-confirmed influenza virus illness, prevention of influenza or pneumonia-associated hospitalizations or deaths, or prevention of seroconversion to circulating influenza virus strains. Efficacy or effectiveness for more specific outcomes such as laboratory-confirmed influenza typically will be higher than for less specific outcomes such as MAARI because the causes of MAARI include infections with other pathogens that influenza vaccination would not be expected to prevent (81). Observational studies that compare less-specific outcomes among vaccinated populations to those among unvaccinated populations are subject to biases that are difficult to control for during analyses. For example, an observational study that determines that influenza vaccination reduces overall mortality might be biased if healthier persons in the study are more likely to be vaccinated (82,83). Randomized controlled trials that measure laboratory-confirmed influenza virus infections as the outcome are the most persuasive evidence of vaccine efficacy, but such trials cannot be conducted ethically among groups recommended to receive vaccine annually. # Influenza Vaccine Composition Both LAIV and TIV contain strains of influenza viruses that are antigenically equivalent to the annually recommended strains: one influenza A (H3N2) virus, one influenza A (H1N1) virus, and one influenza B virus. Each year, one or more virus strains in the vaccine might be changed on the basis of global surveillance for influenza viruses and the emergence and spread of new strains. For the 2009-10 influenza season, the influenza B vaccine virus strain was changed to B/Brisbane/60/2008, a representative of the B/Victoria lineage) compared with the 2008-09 season. The influenza A (H1N1 and H3N2 vaccine virus strains were not changed (84). Viruses for both types of currently licensed vaccines are grown in eggs. Both vaccines are administered annually to provide optimal protection against influenza virus infection (Table 1). Both TIV and LAIV are widely available in the United States. Although both types of vaccines are expected to be effective, the vaccines differ in several respects (Table 1). # Major Differences Between tIV and LAIV During the preparation of TIV, the vaccine viruses are made noninfectious (i.e., inactivated or killed) (15). Only subvirion and purified surface antigen preparations of TIV (often referred to as "split" and subunit vaccines, respectively) are available in the United States. TIV contains killed viruses and thus cannot cause influenza. LAIV contains live, attenuated influenza viruses that have the potential to cause mild signs or symptoms (e.g., runny nose, nasal congestion, fever, or sore throat). LAIV is administered intranasally by sprayer, whereas TIV is administered intramuscularly by injection. LAIV is licensed for use among nonpregnant persons aged 2-49 years; safety has not been established in persons with underlying medical conditions that confer a higher risk for influenza complications. TIV is licensed for use among persons aged >6 months, including those who are healthy and those with chronic medical conditions (Table 1). # Correlates of Protection after Vaccination Immune correlates of protection against influenza infection after vaccination include serum hemagglutination inhibition antibody and neutralizing antibody (20,85). Increased levels of antibody induced by vaccination decrease the risk for illness caused by strains that are antigenically similar to those strains of the same type or subtype included in the vaccine (86)(87)(88)(89). The majority of healthy children and adults have high titers of antibody after vaccination (87,90). Although immune correlates such as achievement of certain antibody titers after vaccination correlate well with immunity on a population level, the significance of reaching or failing to reach a certain antibody threshold is not well understood on the individual level. Other immunologic correlates of protection that might best indicate clinical protection after receipt of an intranasal vaccine such as LAIV (e.g., mucosal antibody) are more difficult to measure (91,92). Laboratory measurements that correlate with protective immunity induced by LAIV have been described, including measurement of cell-mediated immunity with ELISPOT assays that measure gamma-interferon (89). If not simultaneously administered, can be administered within 4 wks of an inactivated vaccine Yes Yes - Children aged 6 months-8 years who have never received influenza vaccine before should receive 2 doses. Those who only receive 1 dose in their first year of vaccination should receive 2 doses in the following year, spaced 4 weeks apart. † Persons at higher risk for complications of influenza infection because of underlying medical conditions should not receive LAIV. Persons at higher risk for complications of influenza infection because of underlying medical conditions include adults and children with chronic disorders of the pulmonary or cardiovascular systems; adults and children with chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunnosuppression; children and adolescents receiving long-term aspirin therapy (at risk for developing Reye syndrome after wild-type influenza infection); persons who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration; pregnant women; and residents of nursing homes and other chronic-care facilities that house persons with chronic medical conditions. § Clinicians and immunization programs should screen for possible reactive airways diseases when considering use of LAIV for children aged 2-4 years and should avoid use of this vaccine in children with asthma or a recent wheezing episode. Health-care providers should consult the medical record, when available, to identify children aged 2-4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving LAIV, parents or caregivers of children aged 2-4 years should be asked: "In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?" Children whose parents or caregivers answer "yes" to this question and children who have asthma or who had a wheezing episode noted in the medical record during the preceding 12 months should not receive LAIV. ¶ LAIV coadministration has been evaluated systematically only among children aged 12-15 months who received measles, mumps, and rubella vaccine or varicella vaccine. TIV coadministration has been evaluated systematically only among adults who received pneumococcal polysaccharide or zoster vaccine. # Immunogenicity, Efficacy, and Effectiveness of tIV Children Children aged >6 months typically have protective levels of anti-influenza antibody against specific influenza virus strains after receiving the recommended number of doses of influenza vaccine (85 90 93-97). In most seasons, one or more vaccine antigens are changed compared with the previous season. In consecutive years when vaccine antigens change, children aged <9 years who received only 1 dose of vaccine in their first year of vaccination are less likely to have protective antibody responses when administered only a single dose during their second year of vaccination compared with children who received 2 doses in their first year of vaccination (98)(99)(100). When the vaccine antigens do not change from one season to the next, priming children aged 6-23 months with a single dose of vaccine in the spring followed by a dose in the fall engenders similar antibody responses compared with a regimen of 2 doses in the fall (101). However, one study conducted during a season when the vaccine antigens did not change compared with the previous season estimated 62% effectiveness against ILI for healthy children who had received only 1 dose in the previous influenza season and only 1 dose in the study season compared with 82% for those who received 2 doses separated by >4 weeks during the study season (102). The antibody response among children at higher risk for influenza-related complications (e.g., children with chronic medical conditions) might be lower than those reported typically among healthy children (103,104). However, antibody responses among children with asthma are similar to those of healthy children and are not substantially altered during asthma exacerbations requiring short-term prednisone treatment (105). Vaccine effectiveness studies also have indicated that 2 doses are needed to provide adequate protection during the first season that young children are vaccinated. Among children aged <5 years who have never received influenza vaccine previously or who received only 1 dose of influenza vaccine in their first year of vaccination, vaccine effectiveness is lower compared with children who received 2 doses in their first year of being vaccinated. Two large retrospective studies of young children who had received only 1 dose of TIV in their first year of being vaccinated determined that no decrease was observed in ILI-related office visits compared with unvaccinated children (102,106). Similar results were reported in a case-control study of children aged 6-59 months (107). These results, along with the immunogenicity data indicating that antibody responses are significantly higher when young children are given 2 doses, are the basis for the recommendation that all children aged <9 years who are being vaccinated for the first time should receive 2 vaccine doses separated by at least 4 weeks. Estimates of vaccine efficacy or effectiveness among children aged >6 months have varied by season and study design. In a randomized trial conducted during five influenza seasons (1985)(1986)(1987)(1988)(1989)(1990) in the United States among children aged 1-15 years, annual vaccination reduced laboratory-confirmed influenza A substantially (77%-91%) (87). A limited 1-year placebo-controlled study reported vaccine efficacy against laboratory-confirmed influenza illness of 56% among healthy children aged 3-9 years and 100% among healthy children and adolescents aged 10-18 years (108). A randomized, double-blind, placebo-controlled trial conducted during two influenza seasons among children aged 6-24 months indicated that efficacy was 66% against culture-confirmed influenza illness during the 1999-00 influenza season but did not reduce culture-confirmed influenza illness significantly during the 2000-20 influenza season (109). A case-control study conducted during the 2003-04 season found vaccine effectiveness of 49% against laboratory-confirmed influenza (107). An observational study among children aged 6-59 months with laboratory-confirmed influenza compared with children who tested negative for influenza reported vaccine effectiveness of 44% in the 2003-04 influenza season and 57% during the 2004-05 season (110). Partial vaccination (only 1 dose for children being vaccinated for the first time) was not effective in either study. During an influenza season (2003-04) with a suboptimal vaccine match, a retrospective cohort study conducted among approximately 30,000 children aged 6 months-8 years indicated vaccine effectiveness of 51% against medically attended, clinically diagnosed pneumonia or influenza (i.e., no laboratory confirmation of influenza) among fully vaccinated children and 49% among approximately 5,000 children aged 6-23 months (106). Another retrospective cohort study of similar size conducted during the same influenza season in Denver but limited to healthy children aged 6-21 months estimated clinical effectiveness of 2 TIV doses to be 87% against pneumonia or influenza-related office visits (102). Among children, TIV effectiveness might increase with age (87,111). A systematic review of published studies estimated vaccine effectiveness at 59% for children aged >2 years but concluded that additional evidence was needed to demonstrate effectiveness among children aged 6 months-2 years (112). Because of the recognized influenza-related disease burden among children with other chronic diseases or immunosuppression and the long-standing recommendation for vaccination of these children, randomized placebo-controlled studies to study efficacy in these children have not been conducted. In a nonrandomized controlled trial among children aged 2-6 years and 7-14 years who had asthma, vaccine efficacy was 54% and 78% against laboratory-confirmed influenza type A infection and 22% and 60% against laboratory-confirmed influenza type B infection, respectively. Vaccinated children aged 2-6 years with asthma did not have substantially fewer type B influenza virus infections compared with the control group in this study (113). The association between vaccination and prevention of asthma exacerbations is unclear. One study suggested that vaccination might provide protection against asthma exacerbations (114); however, other studies of children with asthma have not demonstrated decreased exacerbations (115). TIV has been demonstrated to reduce acute otitis media in some studies. Two studies have reported that TIV decreases the risk for influenza-related otitis media by approximately 30% among children with mean ages of 20 and 27 months, respectively (116,117). However, a large study conducted among children with a mean age of 14 months indicated that TIV was not effective against acute otitis media (109). Influenza vaccine effectiveness against a nonspecific clinical outcome such as acute otitis media, which is caused by a variety of pathogens and is not typically diagnosed using influenza virus culture, would be expected to be relatively low. # Adults Aged <65 Years One dose of TIV is highly immunogenic in healthy adults aged <65 years. Limited or no increase in antibody response is reported among adults when a second dose is administered during the same season (118)(119)(120). When the vaccine and circulating viruses are antigenically similar, TIV prevents laboratory-confirmed influenza illness among approximately 70%-90% of healthy adults aged <65 years in randomized controlled trials (121)(122)(123)(124). Vaccination of healthy adults also has resulted in decreased work absenteeism and decreased use of health-care resources, including use of antibiotics, when the vaccine and circulating viruses are well-matched (121)(122)(123). Efficacy or effectiveness against laboratory-confirmed influenza illness was 47%-77% in studies conducted during different influenza seasons when the vaccine strains were antigenically dissimilar to the majority of circulating strains (117,119,(121)(122)(123)(124). However, effectiveness among healthy adults against influenza-related hospitalization, measured in the most recent of these studies, was 90% (125). In certain studies, persons with certain chronic diseases have lower serum antibody responses after vaccination compared with healthy young adults and can remain susceptible to influenza virus infection and influenza-related upper respiratory tract illness (126,127). Vaccine effectiveness among adults aged <65 years who are at higher risk for influenza complications typically is lower than that reported for healthy adults. In a case-control study conducted during the 2003-04 influenza season, when the vaccine was a suboptimal antigenic match to many circulating virus strains, effectiveness for prevention of laboratory-confirmed influenza illness among adults aged 50-64 years with high-risk conditions was 48% compared with 60% for healthy adults (125). Effectiveness against hospitalization among adults aged 50-64 years with high-risk conditions was 36% compared with 90% effectiveness among healthy adults in that age range (125). A randomized controlled trial among adults in Thailand with chronic obstructive pulmonary disease (median age: 68 years) indicated a vaccine effectiveness of 76% in preventing laboratory-confirmed influenza during a season when viruses were well-matched to vaccine viruses. Effectiveness did not decrease with increasing severity of underlying lung disease (128). Few randomized controlled trials have studied the effect of influenza vaccination on noninfluenza outcomes. A randomized controlled trial conducted in Argentina among 301 adults hospitalized with myocardial infarction or undergoing angioplasty for cardiovascular disease (56% of whom were aged >65 years) found that a significantly lower percentage (6%) of cardiovascular deaths occurred among vaccinated persons at 1 year after vaccination compared with unvaccinated persons (17%) (129). A randomized, double-blind, placebo-controlled study conducted in Poland among 658 persons with coronary artery disease indicated that significantly fewer vaccinated persons vaccinated persons had a cardiac ischemic event during the 9 months of follow up compared with unvaccinated persons (p <0.05) (130). Observational studies that have measured clinical endpoints without laboratory confirmation of influenza virus infection, typically have demonstrated substantial reductions in hospitalizations or deaths among adults with risk factors for influenza complications. In a case-control study conducted during 1999-2000 in Denmark among adults aged <65 years with underlying medical conditions, vaccination reduced deaths attributable to any cause 78% and reduced hospitalizations attributable to respiratory infections or cardiopulmonary diseases 87% (131). A benefit was reported after the first vaccination and increased with subsequent vaccinations in subsequent years (132). Among patients with diabetes mellitus, vaccination was associated with a 56% reduction in any complication, a 54% reduction in hospitalizations, and a 58% reduction in deaths (133). Certain experts have noted that the substantial effects on morbidity and mortality among those who received influenza vaccination in these observational studies should be interpreted with caution because of the difficulties in ensuring that those who received vaccination had similar baseline health status as those who did not (82,83). One meta-analysis of published studies concluded that evidence was insufficient to demonstrate that persons with asthma benefit from vaccination (134). However, a meta-analysis that examined effectiveness among persons with chronic obstructive pulmonary disease identified evidence of benefit from vaccination (135). # Immunocompromised Persons TIV produces adequate antibody concentrations against influenza among vaccinated HIV-infected persons who have minimal AIDS-related symptoms and normal or near-normal CD4+ T-lymphocyte cell counts (136)(137)(138). Among persons who have advanced HIV disease and low CD4+ T-lymphocyte cell counts, TIV might not induce protective antibody titers (138,139); a second dose of vaccine does not improve the immune response in these persons (139,140). A randomized, placebo-controlled trial determined that TIV was highly effective in preventing symptomatic, laboratory-confirmed influenza virus infection among HIV-infected persons with a mean of 400 CD4+ T-lymphocyte cells/mm3; however, a limited number of persons with CD4+ T-lymphocyte cell counts of 100 CD4+ cells and among those with <30,000 viral copies of HIV type-1/mL (53). On the basis of certain limited studies, immunogenicity for persons with solid organ transplants varies according to transplant type. Among persons with kidney or heart transplants, the proportion who developed seroprotective antibody concentrations was similar or slightly reduced compared with healthy persons (141)(142)(143). However, a study among persons with liver transplants indicated reduced immunologic responses to influenza vaccination (144)(145)(146), especially if vaccination occurred within the 4 months after the transplant procedure (144). # Pregnant Women and neonates Pregnant women have protective levels of anti-influenza antibodies after vaccination (147,148). Passive transfer of anti-influenza antibodies that might provide protection from vaccinated women to neonates has been reported (147,(149)(150)(151). A retrospective, clinic-based study conducted during 1998-2003 documented a nonsignificant trend toward fewer episodes of MAARI during one influenza season among vaccinated pregnant women compared with unvaccinated pregnant women and substantially fewer episodes of MAARI during the peak influenza season (148). However, a retrospective study conducted during 1997-2002 that used clinical records data did not indicate a reduction in ILI among vaccinated pregnant women or their infants (152). In another study conducted during 1995-2001, medical visits for respiratory illness among the infants were not substantially reduced (153). One randomized controlled trial conducted in Bangladesh that provided vaccination to pregnant women during the third trimester demonstrated a 29% reduction in respiratory illness with fever and a 36% reduction in respiratory illness with fever among their infants during the first 6 months after birth. In addition, infants born to vaccinated women had a 63% reduction in laboratory-confirmed influenza illness during the first 6 months of life (154). All women in this trial breastfed their infants (mean duration: 14 weeks). # older Adults Adults aged >65 years typically have a diminished immune response to influenza vaccination compared with young healthy adults, suggesting that immunity might be of shorter duration (although still extending through one influenza season) (155,156). However, a review of the published literature concluded that no clear evidence existed that immunity declined more rapidly in the elderly (157), and additional vaccine doses during the same season do not increase the antibody response (118,120). Infections among the vaccinated elderly might be associated with an age-related reduction in ability to respond to vaccination rather than reduced duration of immunity (127,128). One prospective cohort study found that immunogenicity among hospitalized persons who were either aged >65 years or who were aged 18-64 years and had one or more chronic medical conditions was similar compared with outpatients (158). The only randomized controlled trial among communitydwelling persons aged >60 years reported a vaccine efficacy of 58% (CI = 26%-77%) against laboratory-confirmed influenza illness during a season when the vaccine strains were considered to be well-matched to circulating strains (159). Additional information from this trial published separately indicated that efficacy among those aged >70 years was 57% (CI = -36%-87%), similar to younger persons. However, few persons aged >75 years participated in this study, and the wide confidence interval for the estimate of efficacy among participants aged >70 years included 0 (160). Influenza vaccine effectiveness in preventing MAARI among the elderly in nursing homes has been estimated at 20%-40% (161,162), and reported outbreaks among well-vaccinated nursing home populations have suggested that vaccination might not have any significant effectiveness when circulating strains are drifted from vaccine strains (163,164). In contrast, some studies have indicated that vaccination can be up to 80% effective in preventing influenzarelated death (161,(165)(166)(167). Among elderly persons not living in nursing homes or similar long-term-care facilities, influenza vaccine is 27%-70% effective in preventing hospitalization for pneumonia and influenza (168)(169)(170). Influenza vaccination reduces the frequency of secondary complications and reduces the risk for influenza-related hospitalization and death among community-dwelling adults aged >65 years with and without high-risk medical conditions (e.g., heart disease and diabetes) (169)(170)(171)(172)(173)(174). However, studies demonstrating large reductions in hospitalizations and deaths among the vaccinated elderly have been conducted using medical record databases and have not measured reductions in laboratory-confirmed influenza illness. These studies have been challenged because of concerns that they have not adequately controlled for differences in the propensity for healthier persons to be more likely than less healthy persons to receive vaccination (82,83,166,(175)(176)(177). # tIV Dosage, Administration, and Storage The composition of TIV varies according to manufacturer, and package inserts should be consulted. TIV formulations in multidose vials contain the vaccine preservative thimerosal; preservative-free, single-dose preparations also are available. TIV should be stored at 35°F-46°F (2°C-8°C) and should not be frozen. TIV that has been frozen should be discarded. Dosage recommendations and schedules vary according to age group (Table 2). Vaccine prepared for a previous influenza season should not be administered to provide protection for any subsequent season. The intramuscular route is recommended for TIV. Adults and older children should be vaccinated in the deltoid muscle. A needle length of >1 inch (>25 mm) should be considered for persons in these age groups because needles of <1 inch might be of insufficient length to penetrate muscle tissue in certain adults and older children (178). When injecting into the deltoid muscle among children with adequate deltoid muscle mass, a needle length of 7/8-1.25 inches is recommended (179). Infants and young children should be vaccinated in the anterolateral aspect of the thigh. A needle length of 7/8-1 inch should be used for children aged <12 months. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving FluMist, parents or caregivers of children aged 2-4 years should be asked: "In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?" Children whose parents or caregivers answer "yes" to this question and children who have asthma or who had a wheezing episode noted in the medical record during the preceding 12 months should not receive FluMist. † † Two doses administered at least 4 weeks apart are recommended for children aged 2-8 years who are receiving LAIV for the first time, and those who only received 1 dose in their first year of vaccination should receive 2 doses in the following year. # Adverse Events After Receipt of tIV Children Studies support the safety of annual TIV in children and adolescents. The largest published postlicensure populationbased study assessed TIV safety in 251,600 children aged <18 years, (including 8,476 vaccinations in children aged 6-23 months) through the Vaccine Safety Datalink (VSD), who were enrolled in one of five health maintenance organizations (HMOs) during 1993-1999. This study indicated no increase in clinically important medically attended events during the 2 weeks after inactivated influenza vaccination compared with control periods 3-4 weeks before and after vaccination (180). A retrospective cohort study using VSD medical records data from 45,356 children aged 6-23 months provided additional evidence supporting overall safety of TIV in this age group. During the 2 weeks after vaccination, TIV was not associated with statistically significant increases in any clinically important medically attended events other than gastritis/duodenitis, and 13 diagnoses, including acute upper respiratory illness, otitis media and asthma, were significantly less common (181). On chart review, most children with a diagnosis of gastritis/duodenitis had self-limited vomiting or diarrhea. The positive or negative associations between TIV and any of these diagnoses do not necessarily indicate a causal relationship (181). In a study of 791 healthy children aged 1-15 years, postvaccination fever was noted among 12% of those aged 1-5 years, 5% among those aged 6-10 years, and 5% among those aged 11-15 years (87). Fever, malaise, myalgia, and other systemic symptoms that can occur after vaccination with inactivated vaccine most often affect persons who have had no previous exposure to the influenza virus antigens in the vaccine (e.g., young children) (182,183). These reactions begin 6-12 hours after vaccination and can persist for 1-2 days. Data about potential adverse events among children after influenza vaccination are available from the Vaccine Adverse Event Reporting System (VAERS). Because of the limitations of passive reporting systems, determining causality for specific types of adverse events usually is not possible using VAERS data alone. Published reviews of VAERS reports submitted after administration of TIV to children aged 6-23 months indicated that the most frequently reported adverse events were fever, rash, injection-site reactions, and seizures; the majority of the limited number of reported seizures appeared to be febrile (184,185). Seizure and fever were the leading serious adverse events (SAEs), defined using standard criteria, reported to VAERS in these studies (184,185); further investigation in VSD did not confirm an association with febrile seizures as identified in VAERS (181). # Adults In placebo-controlled studies among adults, the most frequent side effect of vaccination was soreness at the vaccination site (affecting 10%-64% of patients) that lasted 65 years or were aged 18-64 years and had one or more chronic medical conditions compared with outpatients (158). Adverse events in adults aged >18 years reported to VAERS during 1990-2005 were analyzed. The most common adverse events reported to VAERS in adults included injection-site reactions, pain, fever, myalgia, and headache. The VAERS review identified no new safety concerns. In clinical trials, SAEs were reported to occur after vaccination with TIV at a rate of <1%. A small proportion (14%) of the TIV VAERS reports in adults were classified as SAEs, without assessment of causality. The most common SAE reported after TIV in VAERS in adults was Guillain-Barré Syndrome (GBS) (189). The potential association between TIV and GBS has been an area of ongoing research (see Guillain-Barré Syndrome and TIV). # Pregnant Women and neonates FDA has classified TIV as a "Pregnancy Category C" medication, indicating that adequate animal reproduction studies have not been conducted.. Available data indicate that influenza vaccine does not cause fetal harm when administered to a pregnant woman or affect reproductive capacity. One study of approximately 2,000 pregnant women who received TIV during pregnancy demonstrated no adverse fetal effects and no adverse effects during infancy or early childhood (190). A matched case-control study of 252 pregnant women who received TIV within the 6 months before delivery determined no adverse events after vaccination among pregnant women and no difference in pregnancy outcomes compared with 826 pregnant women who were not vaccinated (148). During 2000-2003, an estimated 2 million pregnant women were vaccinated, and only 20 adverse events among women who received TIV were reported to VAERS during this time, including nine injection-site reactions and eight systemic reactions (e.g., fever, headache, and myalgias). In addition, three miscarriages were reported, but these were not known to be causally related to vaccination (191). Similar results have been reported in certain smaller studies (147,149,192), and a recent international review of data on the safety of TIV concluded that no evidence exists to suggest harm to the fetus (193). The rate of adverse events associated with TIV was similar to the rate of adverse events among pregnant women who received pneumococcal polysaccharide vaccine in one small randomized controlled trial in Bangladesh, and no severe adverse events were reported in any study group (154). # Persons with Chronic Medical Conditions In a randomized cross-over study of children and adults with asthma, no increase in asthma exacerbations was reported for either age group (194), and two additional studies also have indicated no increase in wheezing among vaccinated asthmatic children (114) or adults (195). One study reported that 20%-28% of children with asthma aged 9 months-18 years had local pain and swelling at the site of influenza vaccination ( 104), and another study reported that 23% of children aged 6 months-4 years with chronic heart or lung disease had local reactions (93). A blinded, randomized, cross-over study of 1,952 adults and children with asthma demonstrated that only self-reported "body aches" were reported more frequently after TIV (25%) than placebo-injection (21%) (194). However, a placebo-controlled trial of TIV indicated no difference in local reactions among 53 children aged 6 months-6 years with high-risk medical conditions or among 305 healthy children aged 3-12 years (97). Among children with high-risk medical conditions, one study of 52 children aged 6 months-3 years reported fever among 27% and irritability and insomnia among 25% (93); and a study among 33 children aged 6-18 months reported that one child had irritability and one had a fever and seizure after vaccination (196). No placebo comparison group was used in these studies. # Immunocompromised Persons Data demonstrating safety of TIV for HIV-infected persons are limited, but no evidence exists that vaccination has a clinically important impact on HIV infection or immunocompetence. One study demonstrated a transient (i.e., 2-4 week) increase in HIV RNA (ribonucleic acid) levels in one HIV-infected person after influenza virus infection (197). Studies have demonstrated a transient increase in replication of HIV-1 in the plasma or peripheral blood mononuclear cells of HIV-infected persons after vaccine administration (138,198). However, more recent and better-designed studies have not documented a substantial increase in the replication of HIV (199)(200)(201)(202). CD4+ T-lymphocyte cell counts or progression of HIV disease have not been demonstrated to change substantially after influenza vaccination among HIV-infected persons compared with unvaccinated HIV-infected persons (138,203). Limited information is available about the effect of antiretroviral therapy on increases in HIV RNA levels after either natural influenza virus infection or influenza vaccination (52,204). Data are similarly limited for persons with other immunocompromising conditions. In small studies, vaccination did not affect allograft function or cause rejection episodes in recipients of kidney transplants (141,142), heart transplants (143), or liver transplants (144). # Immediate Hypersensitivity Reactions after Influenza Vaccines Vaccine components can rarely cause allergic reactions, also called immediate hypersensitivity reactions, among certain recipients. Immediate hypersensitivity reactions are mediated by preformed immunoglobulin E (IgE) antibodies against a vaccine component and usually occur within minutes to hours of exposure (205). Symptoms of immediate hypersensitivity range from mild urticaria (hives) and angioedema to anaphylaxis. Anaphylaxis is a severe life-threatening reaction that involves multiple organ systems and can progress rapidly. Symptoms and signs of anaphylaxis can include but are not limited to generalized urticaria, wheezing, swelling of the mouth and throat, difficulty breathing, vomiting, hypotension, decreased level of consciousness, and shock. Minor symptoms such as red eyes or hoarse voice also might be present (179,(205)(206)(207)(208). Allergic reactions might be caused by the vaccine antigen, residual animal protein, antimicrobial agents, preservatives, stabilizers, or other vaccine components (209). Manufacturers use a variety of compounds to inactivate influenza viruses and add antibiotics to prevent bacterial growth. Package inserts for specific vaccines of interest should be consulted for additional information. ACIP has recommended that all vaccine providers should be familiar with the office emergency plan and be certified in cardiopulmonary resuscitation (179). The Clinical Immunization Safety Assessment (CISA) network, a collaboration between CDC and six medical research centers with expertise in vaccination safety, has developed an algorithm to guide evaluation and revaccination decisions for persons with suspected immediate hypersensitivity after vaccination (205). Immediate hypersensitivity reaction after TIV and LAIV are rare. A VSD study of children aged <18 years in four HMOs during 1991-1997 estimated the overall risk of postvaccination anaphylaxis to be less than 1 case per 500,000 doses administered and in this study no cases were identified in TIV recipients (210). Reports of anaphylaxis occurring after receipt of TIV and LAIV in adults have rarely been reported to VAERS (189). Some immediate hypersensitivity reactions after TIV or LAIV are caused by the presence of residual egg protein in the vaccines (211). Although influenza vaccines contain only a limited quantity of egg protein, this protein can induce immediate hypersensitivity reactions among persons who have severe egg allergy. Asking persons if they can eat eggs without adverse effects is a reasonable way to determine who might be at risk for allergic reactions from receiving influenza vaccines (179). Persons who have had symptoms such as hives or swelling of the lips or tongue, or who have experienced acute respiratory distress after eating eggs, should consult a physician for appropriate evaluation to help determine if future influenza vaccine should be administered. Persons who have documented (IgE)-mediated hypersensitivity to eggs, including those who have had occupational asthma related to egg exposure or other allergic responses to egg protein, also might be at increased risk for allergic reactions to influenza vaccine, and consultation with a physician before vaccination should be considered (212)(213)(214). A regimen has been developed for administering influenza vaccine to asthmatic children with severe disease and egg hypersensitivity (213). Hypersensitivity reactions to other vaccine components also can rarely occur. Although exposure to vaccines containing thimerosal can lead to hypersensitivity (215), the majority of patients do not have reactions to thimerosal when it is administered as a component of vaccines, even when patch or intradermal tests for thimerosal indicate hypersensitivity (216,217). When reported, hypersensitivity to thimerosal typically has consisted of local delayed hypersensitivity reactions (216). # ocular and Respiratory Symptoms after tIV Ocular or respiratory symptoms have occasionally been reported within 24 hours after TIV administration, but these symptoms typically are mild and resolve quickly without specific treatment. In some trials conducted in the United States, ocular or respiratory symptoms included red eyes (<1%-6%), cough (1%-7%), wheezing (1%), and chest tightness (1%-3%) (207,208,(218)(219)(220). However, most of these trials were not placebo-controlled, and causality cannot be determined. In addition, ocular and respiratory symptoms are features of a variety of respiratory illnesses and seasonal allergies that would be expected to occur coincidentally among vaccine recipients unrelated to vaccination. A placebo-controlled vaccine effectiveness study among young adults found that 2% of persons who received the 2006-07 formulation of Fluzone (Sanofi Pasteur) reported red eyes compared with none of the controls (p = 0.03) (221). A similar trial conducted during the 2005-06 influenza season found that 3% of Fluzone recipients reported red eyes compared with 1% of placebo recipients; however the difference was not statistically significant (222) . Oculorespiratory syndrome (ORS), an acute, self-limited reaction to TIV with prominent ocular and respiratory symptoms, was first described during the 2000-01 influenza season in Canada. The initial case-definition for ORS was the onset of one or more of the following within 2-24 hours after receiving TIV: bilateral red eyes and/or facial edema and/or respiratory symptoms (coughing, wheezing, chest tightness, difficulty breathing, sore throat, hoarseness or difficulty swallowing, cough, wheeze, chest tightness, difficulty breathing, sore throat, or facial swelling) (223). ORS was first described in Canada and strongly associated with one vaccine preparation (Fluviral S/F, Shire Biologics, Quebec, Canada) not available in the United States during the 2000-01 influenza season (224). Subsequent investigations identified persons with ocular or respiratory symptoms meeting an ORS case-definition in safety monitoring systems and trials that had been conducted before 2000 in Canada, the United States, and several European countries (225)(226)(227). The cause of ORS has not been established; however studies suggest the reaction is not IgE-mediated (228). After changes in the manufacturing process of the vaccine preparation associated with ORS during 2000-01, the incidence of ORS in Canada was greatly reduced (226). In one placebo-controlled study, only hoarseness, cough, and itchy or sore eyes (but not red eyes) were significantly associated with a reformulated Fluviral preparation. These findings indicated that ORS symptoms following use of the reformulated vaccine were mild, resolved within 24 hours, and might not typically be of sufficient concern to cause vaccine recipients to seek medical care (229). Ocular and respiratory symptoms reported after TIV administration, including ORS, have some similarities with immediate hypersensitivity reactions. One study indicated that the risk for ORS recurrence with subsequent vaccination is low, and persons with ocular or respiratory symptoms (e.g., bilateral red eyes, cough, sore throat, or hoarseness) after TIV that did not involve the lower respiratory tract have been revaccinated without reports of SAEs after subsequent exposure to TIV (230). VAERS routinely monitors for adverse events such as ocular or respiratory symptoms after receipt of TIV. # Contraindications and Precautions for Use of tIV TIV is contraindicated and should not be administered to persons known to have anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine unless the recipient has been desensitized. Prophylactic use of antiviral agents is an option for preventing influenza among such persons. Information about vaccine components is located in package inserts from each manufacturer. Persons with moderate to severe acute febrile illness usually should not be vaccinated until their symptoms have abated. Moderate or severe acute illness with or without fever is a precaution § for TIV. GBS within 6 weeks following a previous dose of influenza vaccine is considered to be a precaution for use of influenza vaccines. # Revaccination in Persons Who Experienced ocular or Respiratory Symptoms After tIV When assessing whether a patient who experienced ocular and respiratory symptoms should be revaccinated, providers should determine if concerning signs and symptoms of Ig-E mediated immediate hypersensitivity are present (see Immediate Hypersensitivity after Influenza Vaccines). Healthcare providers who are unsure whether symptoms reported or observed after TIV represent an IgE-mediated hypersensitivity immune response should seek advice from an allergist/immunologist. Persons with symptoms of possible IgE-mediated hypersensitivity after TIV should not receive influenza vaccination unless hypersensitivity is ruled out or revaccination is administered under close medical supervision (205). Ocular or respiratory symptoms observed after TIV often are coincidental and unrelated to TIV administration, as observed among placebo recipients in some randomized controlled studies. Determining whether ocular or respiratory symptoms are coincidental or related to possible ORS might not be possible. Persons who have had red eyes, mild upper facial swelling, or mild respiratory symptoms (e.g., sore throat, cough, or hoarseness) after TIV without other concerning signs or symptoms of hypersensitivity can receive TIV in subsequent seasons without further evaluation. Two studies showed that persons who had symptoms of ORS after TIV were at a higher risk for ORS after subsequent TIV administration; however, these events usually were milder than the first episode (230,231). # Guillain-Barré Syndrome and tIV The annual incidence of GBS is 10-20 cases per 1 million adults (232). Substantial evidence exists that multiple infectious illnesses, most notably Campylobacter jejuni gastrointestinal infections and upper respiratory tract infections, are associated with GBS (233)(234)(235). A recent study identified serologically confirmed influenza virus infection as a trigger of GBS, with time from onset of influenza illness to GBS of 3-30 days. The estimated frequency of influenza-related GBS was four to seven times higher than the frequency that has been estimated for influenza-vaccine-associated GBS (236). The 1976 swine influenza vaccine was associated with an increased frequency of GBS, estimated at one additional case of GBS per 100,000 persons vaccinated (237,238). The risk for influenza-vaccine-associated GBS was higher among persons aged >25 years than among persons aged <25 years (239). However, obtaining epidemiologic evidence for a small increase in risk for a rare condition with multiple causes is difficult, and no evidence consistently exists for a causal relation between subsequent vaccines prepared from other influenza viruses and GBS. None of the studies conducted using influenza vaccines other than the 1976 swine influenza vaccine has demonstrated a substantial increase in GBS associated with influenza vaccines. During three of four influenza seasons studied during 1977-1991, the overall relative risk estimates for GBS after influenza vaccination were not statistically significant in any of these studies (240)(241)(242). However, in a study of the 1992-93 and 1993-94 seasons, the overall relative risk for GBS was 1.7 (CI = 1.0-2.8; p = 0.04) during the 6 weeks after vaccination, representing approximately one additional case of GBS per 1 million persons vaccinated; the combined number of GBS cases peaked 2 weeks after vaccination (238). Results of a study that examined health-care data from Ontario, Canada, during 1992-2004 demonstrated a small but statistically significant temporal association between receiving influenza vaccination and subsequent hospital admission for GBS. However, no increase in cases of GBS at the population level was reported after introduction of a mass public influenza vaccination program in Ontario beginning in 2000 (243). Data from VAERS have documented decreased reporting of GBS occurring after vaccination across age groups over time, despite overall increased reporting of other non-GBS conditions occurring after administration of influenza vaccine (237). Published data from the United Kingdom's General Practice Research Database (GPRD) found influenza vaccine to be associated with a decreased risk for GBS, although whether this was associated with protection against influenza or confounding because of a "healthy vaccinee" (e.g., healthier persons might be more likely to be vaccinated and also be at lower risk for GBS) (244) is unclear. A separate GPRD analysis found no association between vaccination and GBS for a 9-year period; only three cases of GBS occurred within 6 weeks after administration of influenza vaccine (245). A third GPRD analysis found that GBS was associated with recent ILI, but not influenza vaccination (246). § A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction or that might compromise the ability of the vaccine to produce immunity (179). The estimated risk for GBS (on the basis of the few studies that have demonstrated an association between vaccination and GBS) is low (i.e., approximately one additional case per 1 million persons vaccinated). The potential benefits of influenza vaccination in preventing serious illness, hospitalization, and death substantially outweigh these estimates of risk for vaccine-associated GBS. No evidence indicates that the casefatality ratio for GBS differs among vaccinated persons and those not vaccinated. # Use of tIV Among Patients with a History of GBS The incidence of GBS among the general population is low, but persons with a history of GBS have a substantially greater likelihood of subsequently experiencing GBS than persons without such a history (232). Thus, the likelihood of coincidentally experiencing GBS after influenza vaccination is expected to be greater among persons with a history of GBS than among persons with no history of this syndrome. Whether influenza vaccination specifically might increase the risk for recurrence of GBS is unknown. Among 311 patients with GBS who responded to a survey, 11 (4%) reported some worsening of symptoms after influenza vaccination; however, some of these patients had received other vaccines at the same time, and recurring symptoms were generally mild (247). However, as a precaution, persons who are not at high risk for severe influenza complications and who are known to have experienced GBS within 6 weeks generally should not be vaccinated. As an alternative, physicians might consider using influenza antiviral chemoprophylaxis for these persons. Although data are limited, the established benefits of influenza vaccination might outweigh the risks for many persons who have a history of GBS and who also are at high risk for severe complications from influenza. # Vaccine Preservative (thimerosal) in Multidose Vials of tIV Thimerosal, a mercury-containing antibacterial compound, has been used as a preservative in vaccines and other medications since the 1930s (248) and is used in multidose vial preparations of TIV to reduce the likelihood of bacterial growth. No scientific evidence indicates that thimerosal in vaccines, including influenza vaccines, is a cause of adverse events other than occasional local hypersensitivity reactions in vaccine recipients. In addition, no scientific evidence exists that thimerosal-containing vaccines are a cause of adverse events among children born to women who received vaccine during pregnancy. The weight of accumulating evidence does not suggest an increased risk for neurodevelopment disorders from exposure to thimerosal-containing vaccines (249)(250)(251)(252)(253)(254)(255)(256)(257)(258). The U.S. Public Health Service and other organizations have recommended that efforts be made to eliminate or reduce the thimerosal content in vaccines as part of a strategy to reduce mercury exposures from all sources (249,250,259) Also, continuing public concerns about exposure to mercury in vaccines has been viewed as a potential barrier to achieving higher vaccine coverage levels and reducing the burden of vaccine-preventable diseases. Since mid-2001, vaccines routinely recommended for infants aged <6 months in the United States have been manufactured either without or with greatly reduced (trace) amounts of thimerosal. As a result, a substantial reduction in the total mercury exposure from vaccines for infants and children already has been achieved ( 179)). ACIP and other federal agencies and professional medical organizations continue to support efforts to provide thimerosal-preservative-free vaccine options. The benefits of influenza vaccination for all recommended groups, including pregnant women and young children, outweigh concerns on the basis of a theoretical risk from thimerosal exposure through vaccination. The risks for severe illness from influenza virus infection are elevated among both young children and pregnant women, and vaccination has been demonstrated to reduce the risk for severe influenza illness and subsequent medical complications. In contrast, no scientifically conclusive evidence has demonstrated harm from exposure to vaccine containing thimerosal preservative. For these reasons, persons recommended to receive TIV may receive any age-and risk factor-appropriate vaccine preparation, depending on availability. An analysis of VAERS reports found no difference in the safety profile of preservative-containing compared with preservative-free TIV vaccines in infants aged 6-23 months (184). Nonetheless, as of May 2009, some states have enacted legislation banning the administration of vaccines containing mercury; the provisions defining mercury content vary (260). LAIV and many of the single-dose vial or syringe preparations of TIV are thimerosal-free, and the number of influenza vaccine doses that do not contain thimerosal as a preservative is expected to increase (Table 2). However, these laws might present a barrier to vaccination unless influenza vaccines that do not contain thimerosal as a preservative are easily available in those states. The U.S. vaccine supply for infants and pregnant women is in a period of transition as manufacturers expand the availability of thimerosal-reduced or thimerosal-free vaccine to reduce the cumulative exposure of infants to mercury. Other environmental sources of mercury exposure are more difficult or impossible to avoid or eliminate (249). # LAIV Dosage, Administration, and Storage Each dose of LAIV contains the same three vaccine antigens used in TIV. However, the antigens are constituted as live, attenuated, cold-adapted, temperature-sensitive vaccine viruses. Providers should refer to the package insert, which contains additional information about the formulation of this vaccine and other vaccine components. LAIV does not contain thimerosal. LAIV is made from attenuated viruses that are able to replicate efficiently only at temperatures present in the nasal mucosa. LAIV does not cause systemic symptoms of influenza in vaccine recipients, although a minority of recipients experience nasal congestion or fever, which is probably a result of effects of intranasal vaccine administration or local viral replication or fever (261). LAIV is intended for intranasal administration only and should not be administered by the intramuscular, intradermal, or intravenous route. LAIV is not licensed for vaccination of children aged 49 years. LAIV is supplied in a prefilled, single-use sprayer containing 0.2 mL of vaccine. Approximately 0.1 mL (i.e., half of the total sprayer contents) is sprayed into the first nostril while the recipient is in the upright position. An attached dose-divider clip is removed from the sprayer to administer the second half of the dose into the other nostril. LAIV is shipped at 35°F-46°F (2°C-8°C). LAIV should be stored at 35°F-46°F (2°C-8°C) on receipt and can remain at that temperature until the expiration date is reached (261). Vaccine prepared for a previous influenza season should not be administered to provide protection for any subsequent season. # Shedding, transmission, and Stability of Vaccine Viruses Available data indicate that both children and adults vaccinated with LAIV can shed vaccine viruses after vaccination, although in lower amounts than occur typically with shedding of wild-type influenza viruses. In rare instances, shed vaccine viruses can be transmitted from vaccine recipients to unvaccinated persons. However, serious illnesses have not been reported among unvaccinated persons who have been infected inadvertently with vaccine viruses. One study of 197 children aged 8-36 months in a child care center assessed transmissibility of vaccine viruses from 98 vaccinated children to the other 99 unvaccinated children; 80% of vaccine recipients shed one or more virus strains (mean duration: 7.6 days). One influenza type B vaccine strain isolate was recovered from a placebo recipient and was confirmed to be vaccine-type virus. The type B isolate retained the coldadapted, temperature-sensitive, attenuated phenotype, and it possessed the same genetic sequence as a virus shed from a vaccine recipient who was in the same play group. The placebo recipient from whom the influenza type B vaccine strain was isolated had symptoms of a mild upper respiratory illness but did not experience any serious clinical events. The estimated probability of acquiring vaccine virus after close contact with a single LAIV recipient in this child care population was 1%-2% (262). Studies assessing whether vaccine viruses are shed have been based on viral cultures or PCR detection of vaccine viruses in nasal aspirates from persons who have received LAIV. Among 345 subjects aged 5-49 years, 30% had detectable virus in nasal secretions obtained by nasal swabbing after receiving LAIV. The duration of virus shedding and the amount of virus shed was inversely correlated with age, and maximal shedding occurred within 2 days of vaccination. Symptoms reported after vaccination, including runny nose, headache, and sore throat, did not correlate with virus shedding (263). Other smaller studies have reported similar findings (264,265). Vaccine strain virus was detected from nasal secretions in one (2%) of 57 HIV-infected adults who received LAIV, none of 54 HIV-negative participants (266), and three (13%) of 23 HIV-infected children compared with seven (28%) of 25 children who were not HIV-infected (267). No participants in these studies had detectable virus beyond 10 days after receipt of LAIV. The possibility of person-to-person transmission of vaccine viruses was not assessed in these studies (264)(265)(266)(267). In clinical trials, viruses isolated from vaccine recipients have retained attenuated phenotypes. In one study, nasal and throat swab specimens were collected from 17 study participants for 2 weeks after vaccine receipt (268). Virus isolates were analyzed by multiple genetic techniques. All isolates retained the LAIV genotype after replication in the human host, and all retained the cold-adapted and temperature-sensitive phenotypes. A study conducted in a child care setting demonstrated that limited genetic change occurred in the LAIV strains following replication in the vaccine recipients (269). # Immunogenicity, Efficacy, and Effectiveness of LAIV LAIV virus strains replicate primarily in nasopharyngeal epithelial cells. The protective mechanisms induced by vaccination with LAIV are not understood completely but appear to involve both serum and nasal secretory antibodies. The immunogenic-ity of the approved LAIV has been assessed in multiple studies conducted among children and adults (270)(271)(272)(273)(274)(275)(276). # Healthy Children A randomized, double-blind, placebo-controlled trial among 1,602 healthy children aged 15-71 months assessed the efficacy of LAIV against culture-confirmed influenza during two seasons (277,278). This trial included a subset of children aged 60-71 months who received 2 doses in the first season. During season one (1996-97), when vaccine and circulating virus strains were well-matched, efficacy against culture-confirmed influenza was 94% for participants who received 2 doses of LAIV separated by >6 weeks, and 89% for those who received 1 dose. During season two (1997-98), when the A (H3N2) component in the vaccine was not well-matched with circulating virus strains, efficacy (1 dose) was 86%, for an overall efficacy for two influenza seasons of 92%. Receipt of LAIV also resulted in 21% fewer febrile illnesses and a significant decrease in acute otitis media requiring antibiotics (277,279). Other randomized, placebo-controlled trials demonstrating the efficacy of LAIV in young children against culture-confirmed influenza include a study conducted among children aged 6-35 months attending child care centers during consecutive influenza seasons (280) in which 85%-89% efficacy was observed, and a study conducted among children aged 12-36 months living in Asia during consecutive influenza seasons in which 64%-70% efficacy was documented (281). In one community-based, nonrandomized open-label study, reductions in MAARI were observed among children who received 1 dose of LAIV during the 1990-00 and 2000-01 influenza seasons even though antigenically drifted influenza A/H1N1 and B viruses were circulating during that season (282). LAIV efficacy in preventing laboratory-confirmed influenza also has been demonstrated in studies comparing the efficacy of LAIV with TIV rather than with a placebo (see Comparisons of LAIV and TIV Efficacy or Effectiveness). # Healthy Adults A randomized, double-blind, placebo-controlled trial of LAIV effectiveness among 4,561 healthy working adults aged 18-64 years assessed multiple endpoints, including reductions in self-reported respiratory tract illness without laboratory confirmation, work loss, health-care visits, and medication use during influenza outbreak periods . The study was conducted during the 1997-98 influenza season, when the vaccine and circulating A (H3N2) strains were not well-matched. The frequency of febrile illnesses was not significantly decreased among LAIV recipients compared with those who received placebo. However, vaccine recipients had significantly fewer severe febrile illnesses (19% reduction) and febrile upper respiratory tract illnesses (24% reduction), and significant reductions in days of illness, days of work lost, days with health-care-provider visits, and use of prescription antibiotics and over-the-counter medications (283). Efficacy against culture-confirmed influenza in a randomized, placebo-controlled study was 57% in the 2004-05 influenza season and 43% in the 2005-06 influenza season, although efficacy in these studies was not demonstrated to be significantly greater than placebo (221,222). # Adverse Events after Receipt of LAIV Healthy Children Aged 2-18 Years In a subset of healthy children aged 60-71 months from one clinical trial, certain signs and symptoms were reported more often after the first dose among LAIV recipients (n = 214) than among placebo recipients (n = 95), including runny nose (48% and 44%, respectively); headache (18% and 12%, respectively); vomiting (5% and 3%, respectively); and myalgias (6% and 4%, respectively) (277). However, these differences were not statistically significant. In other trials, signs and symptoms reported after LAIV administration have included runny nose or nasal congestion (20%-75%), headache (2%-46%), fever (0-26%), vomiting (3%-13%), abdominal pain (2%), and myalgias (0-21%) (270,272,273,280,(284)(285)(286)(287). These symptoms were associated more often with the first dose and were self-limited. A placebo-controlled trial in 9,689 children aged 1-17 years assessed prespecified medically attended outcomes during the 42 days after vaccination (286). Following >1,500 statistical analyses in the 42 days after LAIV, elevated risks that were biologically plausible were observed for the following conditions: asthma, upper respiratory infection, musculoskeletal pain, otitis media with effusion, and adenitis/ adenopathy. The increased risk for wheezing events after LAIV was observed among children aged 18-35 months (RR: 4.06; 90% CI = 1.3-17.9). In this study, the rate of SAEs was 0.2% in LAIV and placebo recipients; none of the SAEs was judged to be related to the vaccine by the study investigators (286). In a randomized trial published in 2007, LAIV and TIV were compared among children aged 6-59 months (288). Children with medically diagnosed or treated wheezing within 42 days before enrollment or with a history of severe asthma were excluded from this study. Among children aged 24-59 months who received LAIV, the rate of medically significant wheezing, using a prespecified definition, was not greater compared with those who received TIV (288). Wheezing was observed more frequently among younger LAIV recipients aged 6-23 months in this study; LAIV is not licensed for this age group. In a previous randomized placebo-controlled safety trial among children aged 12 months-17 years without a history of asthma by parental report, an elevated risk for asthma events (RR: 4.1; CI = 1.3-17.9) was documented among 728 children aged 18-35 months who received LAIV. Of the 16 children with asthma-related events in this study, seven had a history of asthma on the basis of subsequent medical record review. None required hospitalization, and elevated risks for asthma were not observed in other age groups (286). Another study was conducted among >11,000 children aged 18 months-18 years in which 18,780 doses of vaccine were administered for 4 years. For children aged 18 months-4 years, no increase was reported in asthma visits 0-15 days after vaccination compared with the prevaccination period. A significant increase in asthma events was reported 15-42 days after vaccination, but only in vaccine year 1 (289). A 4-year, open-label field trial study assessed LAIV safety of more than 2000 doses administered to children aged 18 months-18 years with a history of intermittent wheeze who were otherwise healthy. Among these children, no increased risk was reported for medically attended acute respiratory illnesses, including acute asthma exacerbation, during the 0-14 or 0-42 days after LAIV compared with the pre-and postvaccination reference periods (290). Initial data from VAERS during 2007-2008, following ACIP's recommendation for LAIV use in healthy children aged 2-4 years, did not suggest a concern for wheezing after LAIV in young children. However data also suggest uptake of LAIV was limited, and safety monitoring for wheezing events after LAIV is ongoing (CDC, unpublished data, 2008). # Adults Aged 19-49 Years Among adults, runny nose or nasal congestion (28%-78%), headache (16%-44%), and sore throat (15%-27%) have been reported more often among vaccine recipients than placebo recipients (277,291). In one clinical trial among a subset of healthy adults aged 18-49 years, signs and symptoms reported significantly more often (p<0.05) among LAIV recipients (n = 2,548) than placebo recipients (n = 1,290) within 7 days after each dose included cough (14% and 11%, respectively), runny nose (45% and 27%, respectively), sore throat (28% and 17%, respectively), chills (9% and 6%, respectively), and tiredness/weakness (26% and 22%, respectively) (92). A review of 460 reports to VAERS after distribution of approximately 2.5 million doses during the 2003-04 and 2004-05 influenza seasons did not indicate any new safety concerns (292). Few of the LAIV VAERS reports (9%) were SAEs; respiratory events were the most common conditions reported. # Persons at Higher Risk for Influenza-Related Complications Limited data assessing the safety of LAIV use for certain groups at higher risk for influenza-related complications are available. In one study of 54 HIV-infected persons aged 18-58 years and with CD4+ counts >200 cells/mm 3 who received LAIV, no SAEs were reported during a 1-month follow-up period (266). Similarly, one study demonstrated no significant difference in the frequency of adverse events or viral shedding among HIV-infected children aged 1-8 years on effective antiretroviral therapy who were administered LAIV compared with HIV-uninfected children receiving LAIV (267). LAIV was well-tolerated among adults aged >65 years with chronic medical conditions (293). These findings suggest that persons at risk for influenza complications who have inadvertent exposure to LAIV would not have significant adverse events or prolonged viral shedding and that persons who have contact with persons at higher risk for influenza-related complications may receive LAIV. # Comparisons of LAIV and tIV Efficacy or Effectiveness Both TIV and LAIV have been demonstrated to be effective in children and adults. However, data directly comparing the efficacy or effectiveness of these two types of influenza vaccines are limited and insufficient to identify whether one vaccine might offer a clear advantage over the other in certain settings or populations. Studies comparing the efficacy of TIV to that of LAIV have been conducted in a variety of settings and populations using several different outcomes. One randomized, double-blind, placebo-controlled challenge study that was conducted among 92 healthy adults aged 18-41 years assessed the efficacy of both LAIV and TIV in preventing influenza infection when challenged with wild-type strains that were antigenically similar to vaccine strains (294). The overall efficacy in preventing laboratory-documented influenza from all three influenza strains combined was 85% and 71%, respectively, when challenged 28 days after vaccination by viruses to which study participants were susceptible before vaccination. The difference in efficacy between the two vaccines was not statistically significant in this limited study. No additional challenges were conducted to assess efficacy at time points later than 28 days (294). In a randomized, double-blind, placebo-controlled trial that was conducted among young adults during the 2004-05 influenza season, when the majority of circulating H3N2 viruses were antigenically drifted from that season's vaccine viruses, the efficacy of LAIV and TIV against culture-confirmed influenza was 57% and 77%, respectively. The difference in efficacy was not statistically significant and was attributable primarily to a difference in efficacy against influenza B (222). A similar study conducted during the 2005-06 influenza season found no significant difference in vaccine efficacy (221). A randomized controlled clinical trial conducted among children aged 6-59 months during the 2004-05 influenza season demonstrated a 55% reduction in cases of culture-confirmed influenza among children who received LAIV compared with those who received TIV (288). In this study, LAIV efficacy was higher compared with TIV against antigenically drifted viruses and well-matched viruses (288). An open-label, nonrandomized, community-based influenza vaccine trial conducted during an influenza season when circulating H3N2 strains were poorly matched with strains contained in the vaccine also indicated that LAIV, but not TIV, was effective against antigenically drifted H3N2 strains during that influenza season. In this study, children aged 5-18 years who received LAIV had significant protection against laboratory-confirmed influenza (37%) and pneumonia and influenza events (50%) (295). A recent observational study conducted among military personnel aged 17-49 years over three influenza seasons indicated that persons who received TIV had a significantly lower incidence of health-care encounters resulting in diagnostic coding for pneumonia and influenza compared with those who received LAIV. However, among new recruits being vaccinated for the first time, the incidence of pneumonia-and influenza-coded health-care encounters among those received LAIV was similar to those receiving TIV (296). Although LAIV is not licensed for use in persons with risk factors for influenza complications, certain studies have compared the efficacy of LAIV to TIV in these groups. LAIV provided 32% increased protection in preventing culture-confirmed influenza compared with TIV in one study conducted among children aged >6 years and adolescents with asthma (297) and 52% increased protection compared with TIV among children aged 6-71 months with recurrent respiratory tract infections (298). # Effectiveness of Vaccination for Decreasing transmission to Contacts Decreasing transmission of influenza from caregivers and household contacts to persons at high risk might reduce ILI and complications among persons at high risk. Influenza virus infection and ILI are common among HCP (299-301). Influenza outbreaks have been attributed to low vaccination rates among HCP in hospitals and long-term-care facilities (302)(303)(304). One serosurvey demonstrated that 23% of HCP had serologic evidence of influenza virus infection during a single influenza season; the majority had mild illness or subclinical infection (299). Observational studies have demonstrated that vaccination of HCP is associated with decreased deaths among nursing home patients (305,306). In one clusterrandomized controlled trial that included 2,604 residents of 44 nursing homes, significant decreases in mortality, ILI, and medical visits for ILI care were demonstrated among residents in nursing homes in which staff were offered influenza vaccination (coverage rate: 48%) compared with nursing homes in which staff were not provided with vaccination (coverage rate: 6%) (307). A review concluded that vaccination of HCP in settings in which patients also were vaccinated provided significant reductions in deaths among elderly patients from all causes and deaths from pneumonia (308). Epidemiologic studies of community outbreaks of influenza demonstrate that school-aged children typically have the highest influenza illness attack rates, suggesting routine universal vaccination of children might reduce transmission to their household contacts and possibly others in the community. Results from certain studies have indicated that the benefits of vaccinating children might extend to protection of their adult contacts and to persons at risk for influenza complications in the community. However, these data are limited, and studies have not used laboratory-confirmed influenza as an outcome measure. A single-blinded, randomized controlled study conducted as part of a 1996-1997 vaccine effectiveness study demonstrated that vaccinating preschool-aged children with TIV reduced influenza-related morbidity among some household contacts (309). A randomized, placebo-controlled trial among children with recurrent respiratory tract infections demonstrated that members of families with children who had received LAIV were significantly less likely to have respiratory tract infections and reported significantly fewer workdays lost compared with families with children who received placebo (310). In nonrandomized community-based studies, administration of LAIV has been demonstrated to reduce MAARI (311,312) and ILI-related economic and medical consequences (e.g., workdays lost and number of health-care provider visits) among contacts of vaccine recipients (312). Households with children attending schools in which school-based LAIV vaccination programs had been established reported less ILI and fewer physician visits during peak influenza season compared with households with children in schools in which no LAIV vaccination had been offered. However a decrease in the overall rate of school absenteeism was not reported in communities in which LAIV vaccination was offered (312). During an influenza outbreak during the 2005-06 influenza season, countywide school-based influenza vaccination was associated with reduced absenteeism among elementary and high school students in one county that implemented a school based vaccination program compared with another county without such a program (313). These community-based studies have not used laboratory-confirmed influenza as an outcome. Some studies also have documented reductions in influenza illness among persons living in communities where focused programs for vaccinating children have been conducted. A community-based observational study conducted during the 1968 pandemic using a univalent inactivated vaccine reported that a vaccination program targeting school-aged children (coverage rate: 86%) in one community reduced influenza rates within the community among all age groups compared with another community in which aggressive vaccination was not conducted among school-aged children (314). An observational study conducted in Russia demonstrated reductions in ILI among the community-dwelling elderly after implementation of a vaccination program using TIV for children aged 3-6 years (57% coverage achieved) and children and adolescents aged 7-17 years (72% coverage achieved) (315). In a nonrandomized community-based study conducted over three influenza seasons, 8%-18% reductions in the incidence of MAARI during the influenza season among adults aged >35 years were observed in communities in which LAIV was offered to all children aged >18 months (estimated coverage rate: 20%-25%) compared with communities that did not provide routine influenza vaccination programs for all children (311). In a subsequent influenza season, the same investigators documented a 9% reduction in MAARI rates during the influenza season among persons aged 35-44 years in intervention communities, where coverage was estimated at 31% among school children. However, MAARI rates among persons aged >45 years were lower in the intervention communities regardless of the presence of influenza in the community, suggesting that lower rates could not be attributed to vaccination of school children against influenza (295). The largest study to examine the community effects of increasing overall vaccine coverage was an ecologic study that described the experience in Ontario, Canada, which was the only province to implement a universal influenza vaccination program beginning in 2000. On the basis of models developed from administrative and viral surveillance data, influenzarelated mortality, hospitalizations, ED use, and physicians' office visits decreased significantly more in Ontario after program introduction than in other provinces, with the largest reductions observed in younger age groups (316). # Effectiveness of Influenza Vaccination When Circulating Influenza Virus Strains Differ from Vaccine Strains Manufacturing trivalent influenza virus vaccines is a challenging process that takes 6-8 months to complete. Vaccination can provide reduced but substantial cross-protection against drifted strains in some seasons, including reductions in severe outcomes such as hospitalization. Usually one or more circulating viruses with antigenic changes compared with the vaccine strains are identified in each influenza season. In addition, two distinct lineages of influenza B viruses have co-circulated in recent years, and limited cross-protection is observed against the lineage not represented in the vaccine (48). However, assessment of the clinical effectiveness of influenza vaccines cannot be determined solely by laboratory evaluation of the degree of antigenic match between vaccine and circulating strains. In some influenza seasons, circulating influenza viruses with significant antigenic differences predominate, and reductions in vaccine effectiveness sometimes are observed compared with seasons when vaccine and circulating strains are wellmatched, (107,121,125,173,222). However, even during years when vaccine strains were not antigenically well matched to circulating strains (the result of antigenic drift), substantial protection has been observed against severe outcomes, presumably because of vaccine-induced cross-reacting antibodies (121,125,222,283). For example, in one study conducted during the 2003-04 influenza season, when the predominant circulating strain was an influenza A (H3N2) virus that was antigenically different from that season's vaccine strain, effectiveness against laboratory-confirmed influenza illness among persons aged 50-64 years was 60% among healthy persons and 48% among persons with medical conditions that increased the risk for influenza complications (125). An interim, withinseason analysis during the 2007-08 influenza season indicated that vaccine effectiveness was 44% overall, 54% among healthy persons aged 5-49 years, and 58% against influenza A, despite the finding that viruses circulating in the study area were predominately a drifted influenza A (H3N2) and an influenza B strain from a different lineage compared with vaccine strains (317). Among children, both TIV and LAIV provide protection against infection even in seasons when vaccines and circulating strains are not well-matched. Vaccine effectiveness against ILI was 49%-69% in two observational studies, and 49% against medically attended, laboratory-confirmed influenza in a case-control study conducted among young children during the 2003-04 influenza season, when a drifted influenza A (H3N2) strain predominated, based on viral surveillance data (102,106). However, continued improvements in collecting representative circulating viruses and use of surveillance data to forecast antigenic drift are needed. Shortening manufacturing time to increase the time to identify good vaccine candidate strains from among the most recent circulating strains also is important. Data from multiple seasons that are collected in a consistent manner are needed to better understand vaccine effectiveness during seasons when circulating and vaccine virus strains are not well-matched. Seasonal influenza vaccines are not expected to provide protection against novel influenza A (H1N1) virus infection because this novel strain hemagglutinin is substantially different from seasonal influenza A (H1N1). Preliminary immunologic data indicate that few persons have antibody that shows evidence of cross-reactivity against novel influenza A (H1N1) virus, and few show increases in antibody titer to novel influenza A (H1N1) virus after vaccination with the 2007-08 or the 2008-09 seasonal influenza vaccines (318). Vaccines currently are being developed that are specific to novel influenza A (H1N1) virus. # Cost-Effectiveness of Influenza Vaccination Economic studies of influenza vaccination are difficult to compare because they have used different measures of both costs and benefits (e.g., cost-only, cost-effectiveness, costbenefit, or cost-utility). However, most studies find that vaccination reduces or minimizes health care, societal, and individual costs and the productivity losses and absenteeism associated with influenza illness. One national study estimated the annual economic burden of seasonal influenza in the United States (using 2003 population and dollars) to be $87.1 billion, including $10.4 billion in direct medical costs (319). Studies of influenza vaccination in the United States among persons aged >65 years have estimated substantial reductions in hospitalizations and deaths and overall societal cost savings (168,169). Studies comparing adults in different age groups also find that vaccination is economically beneficial. One study that compared the economic impact of vaccination among persons aged >65 years with those aged 15-64 years indicated that vaccination resulted in a net savings per quality-adjusted life year (QALY) and that the Medicare program saved costs of treating illness by paying for vaccination (320). A study of a larger population comparing persons aged 50-64 years with those aged >65 years estimated the cost-effectiveness of influenza vaccination to be $28,000 per QALY saved (in 2000 dollars) in persons aged 50-64 years compared with $980 per QALY saved among persons aged >65 years (321). Economic analyses among adults aged <65 years have reported mixed results regarding influenza vaccination. Two studies in the United States found that vaccination can reduce both direct medical costs and indirect costs from work absenteeism and reduced productivity (322,323). However, another U.S. study indicated no productivity and absentee savings in a strategy to vaccinate healthy working adults, although vaccination was still estimated to be cost-effective (324). Cost analyses have documented the considerable financial burden of illness among children. In a study of 727 children conducted at a medical center during 2000-2004, the mean total cost of hospitalization for influenza-related illness was $13,159 ($39,792 for patients admitted to an intensive care unit and $7,030 for patients cared for exclusively on the wards) (325). A strategy that focuses on vaccinating children with medical conditions that confer a higher risk for influenza complications are more cost-effective than a strategy of vaccinating all children (324). An analysis that compared the costs of vaccinating children of varying ages with TIV and LAIV indicated that costs per QALY saved increased with age for both vaccines. In 2003 dollars per QALY saved, costs for routine vaccination using TIV were $12,000 for healthy children aged 6-23 months and $119,000 for healthy adolescents aged 12-17 years compared with $9,000 and $109,000 using LAIV, respectively (326). Economic evaluations of vaccinating children have demonstrated a wide range of cost estimates, but have generally found this strategy to be either cost-saving or cost-beneficial (327)(328)(329)(330). Economic analyses are sensitive to the vaccination venue, with vaccination in medical care settings incurring higher projected costs. In a published model, the mean cost (year 2004 values) of vaccination was lower in mass vaccination ($17.04) and pharmacy ($11.57) settings than in scheduled doctor's office visits ($28.67) (331). Vaccination in nonmedical settings was projected to be cost saving for healthy adults aged >50 years and for high-risk adults of all ages. For healthy adults aged 18-49 years, preventing an episode of influenza would cost $90 if vaccination were delivered in a pharmacy setting, $210 in a mass vaccination setting, and $870 during a scheduled doctor's office visit (331). Medicare payment rates in recent years have been less than the costs associated with providing vaccination in a medical practice (332). # Vaccination Coverage Levels Continued annual monitoring is needed to determine the effects on vaccination coverage of vaccine supply delays and shortages, changes in influenza vaccination recommendations and target groups for vaccination, reimbursement rates for vaccine and vaccine administration, and other factors related to vaccination coverage among adults and children. One of the Healthy People 2010 objectives (objective no. 14-29a) includes achieving an influenza vaccination coverage level of 90% for persons aged >65 years and among nursing home residents (333,334); new strategies to improve coverage are needed to achieve this objective (335,336). Increasing vaccination coverage among persons who have high-risk conditions and are aged <65 years, including children at high risk, is the highest priority for expanding influenza vaccine use. On 3) and are only slightly lower than coverage levels observed before the 2004-05 vaccine shortage year (337)(338)(339). In the 2006-07 and 2007-08 influenza seasons, estimated vaccination coverage levels among adults with high-risk conditions aged 18-49 years were 25% and 30%, respectively, substantially lower than the Healthy People 2000 and Healthy People 2010 objectives of 60% (Table 3) (333,334). Studies conducted among children and adults indicate that opportunities to vaccinate persons at risk for influenza complications (e.g., during hospitalizations for other causes) often are missed. In one study, 23% of children hospitalized with influenza and a comorbidity had a previous hospitalization during the preceding influenza vaccination season (340). In a study of hospitalized Medicare patients, only 31.6% were vaccinated before admission, 1.9% during admission, and 10.6% after admission (341). A study in New York City conducted during 2001-2005 among 7,063 children aged 6-23 months indicated that 2-dose vaccine coverage increased from 1.6% to 23.7% over time; however, although the average number of medical visits during which an opportunity to be vaccinated decreased during the course of the study from 2.9 to 2.0 per child, 55% of all visits during the final year of the study still represented a missed vaccination opportunity (342). Using standing orders in hospitals increases vaccination rates among hospitalized persons (343), and vaccination of hospitalized patients is safe and stimulates an appropriate immune response (158). In one survey, the strongest predictor of receiving vaccination was the survey respondent's belief that he or she was in a high-risk group, based on data from one survey; however, many persons in high-risk groups did not know that they were in a group recommended for vaccination (344). Reducing racial/ethnic health disparities, including disparities in influenza vaccination coverage, is an overarching national goal that is not being met (334). Estimated vaccination coverage levels in 2007 among persons aged >65 years were 70% for non-Hispanic whites, 58% for non-Hispanic blacks, and 54% for Hispanics (345). Among Medicare beneficiaries, other key factors that contribute to disparities in coverage include variations in the propensity of patients to actively seek vaccination and variations in the likelihood that providers recommend vaccination (346,347). One study estimated that eliminating these disparities in vaccination coverage would have an impact on mortality similar to the impact of eliminating deaths attributable to kidney disease among blacks or liver disease among Hispanics (348). Reported vaccination levels are low among children at increased risk for influenza complications. Coverage among children aged 2-17 years with asthma for the 2004-05 influenza season was estimated to be 29% (349). One study reported 79% vaccination coverage among children attending a cystic fibrosis treatment center (350). During the first season for which ACIP recommended that all children aged 6 months-23 months receive vaccination, 33% received 1 or more doses of influenza vaccine, and 18% received 2 doses if they were unvaccinated previously (351). Among children enrolled in HMOs who had received a first dose during 2001-2004, second dose coverage varied from 29% to 44% among children aged 6-23 months and from 12% to 24% among children aged 2-8 years (352). A rapid analysis of influenza vaccination coverage levels among members of an HMO in Northern California demonstrated that during the 2004-05 influenza season, the first year of the recommendation for vaccination of children aged 6-23 months, 1-dose coverage was 57% (353). During the 2006-07 influenza season, the second season for which ACIP recommended that all children aged 6 months-23 months receive vaccination, coverage remained low and did not increase substantially from the 2004-05 season. Data collected in 2007 by the National Immunization Survey indicated that for the 2006-07 season, 32% of children aged 6-23 months received at least 1 dose of influenza vaccine and 21% were fully vaccinated (i.e., received 1 or 2 doses depending on previous vaccination history); however, results varied substantially among states (354). As has been reported for older adults, a physician recommendation for vaccination and the perception that having a child be vaccinated "is a smart idea" were associated positively with likelihood of vaccination of children aged 6-23 months (355). Similarly, children with asthma were more likely to be vaccinated if their parents recalled a physician recommendation to be vaccinated or believed that the vaccine worked well (356). Implementation of a reminder/recall system in a pediatric clinic increased the percentage of children with asthma receiving vaccination from 5% to 32% (357). Although annual vaccination is recommended for HCP and is a high priority for reducing morbidity associated with influenza in health-care settings and for expanding influenza vaccine use (358)(359)(360), national survey data demonstrated a vaccination coverage level of only 42% among HCP during the 2005-06 season, and 44% during the 2006-07 season (Table † † Adults categorized as being at high risk for influenza-related complications self-reported one or more of the following: 1) ever being told by a physician they had diabetes, emphysema, coronary heart disease, angina, heart attack, or other heart condition; 2) having a diagnosis of cancer during the previous 12 months (excluding nonmelanoma skin cancer) or ever being told by a physician they have lymphoma, leukemia, or blood cancer during the previous 12 months (post coding for a cancer diagnosis was not yet completed at the time of this publication so this diagnosis was not include in the 2006-07 season data.); 3) being told by a physician they have chronic bronchitis or weak or failing kidneys; or 4) reporting an asthma episode or attack during the preceding 12 months. For children aged <18 years, high-risk conditions included ever having been told by a physician of having diabetes, cystic fibrosis, sickle cell anemia, congenital heart disease, other heart disease, or neuromuscular conditions (seizures, cerebral palsy, and muscular dystrophy), or having an asthma episode or attack during the preceding 12 months. § § Aged 18-44 years, pregnant at the time of the survey and without high-risk conditions. ¶ ¶ Adults were classified as health-care workers if they were employed in a health-care occupation or in a health-care-industry setting, on the basis of standard occupation and industry categories recoded in groups by CDC's National Center for Health Statistics. * Interviewed sample child or adult in each household containing at least one of the following: a child aged <5 years, an adult aged ≥65 years, or any person aged 5-17 years at high risk (see previous footnote † † ). To obtain information on household composition and high-risk status of household members, the sampled adult, child, and person files from NHIS were merged. Interviewed adults who were health-care workers or who had high-risk conditions were excluded. Information could not be assessed regarding high-risk status of other adults aged 18-64 years in the household; therefore, certain adults aged 18-64 years who lived with an adult aged 18-64 years at high risk were not included in the analysis. Also note that although the recommendation for children aged 2-4 years was not in place during the 2005-06 season, children aged 2-4 years in these calculations were considered to have an indication for vaccination to facilitate comparison of coverage data for subsequent years. 3). Vaccination of HCP has been associated with reduced work absenteeism (300) and with fewer deaths among nursing home patients (305,307) and elderly hospitalized patients (308). Factors associated with a higher rate of influenza vaccination among HCP include older age, being a hospital employee, having employer-provided health-care insurance, having had pneumococcal or hepatitis B vaccination in the past, or having visited a health-care professional during the preceding year. Non-Hispanic black HCP were less likely than non-Hispanic white HCP to be vaccinated (361). HCP who decline vaccination frequently express doubts about the risk for influenza and the need for vaccination, are concerned about vaccine effectiveness and side effects, and dislike injections (362). Vaccine coverage among pregnant women increased during the 2007-08 influenza season with 24% of pregnant women reporting vaccination, excluding pregnant women who reported diabetes, heart disease, lung disease, and other selected high-risk conditions (Table 3). However, the sample size is small, and the increase in coverage compared with previous seasons was not statistically significant. In a study of influenza vaccine acceptance by pregnant women, 71% of those who were offered the vaccine chose to be vaccinated (363). However, a 1999 survey of obstetricians and gynecologists determined that only 39% administered influenza vaccine to obstetric patients in their practices, although 86% agreed that pregnant women's risk for influenza-related morbidity and mortality increases during the last two trimesters (364). Influenza vaccination coverage in all groups recommended for vaccination remains suboptimal. Despite the timing of the peak of influenza disease, administration of vaccine decreases substantially after November. According to results from the NHIS regarding the two most recent influenza seasons for which these data are available, approximately 84% of all influenza vaccination were administered during September-November. Among persons aged >65 years, the percentage of September-November vaccinations was 92% (365). Because many persons recommended for vaccination remain unvaccinated at the end of November, CDC encourages public health partners and health-care providers to conduct vaccination clinics and other activities that promote seasonal influenza vaccination annually during National Influenza Vaccination Week (December 6-12, 2009) and throughout the remainder of the influenza season. Self-report of influenza vaccination among adults compared with determining vaccination status from the medical record, is a sensitive and specific source of information (366,367). Patient self-reports should be accepted as evidence of influenza vaccination in clinical practice (367). However, information on the validity of parents' reports of pediatric influenza vaccination is not yet available. # Recommendations for Using tIV and LAIV During the 2009-10 Influenza Season Both TIV and LAIV prepared for the 2009-10 season will include A/Brisbane/59/2007 (H1N1)-like, A/ Brisbane/10/2007 (H3N2)-like, and B/Brisbane/60/2008-like antigens. The influenza B virus component of the 2009-10 vaccine is from the Victoria lineage (368). These viruses will be used because they are representative of seasonal influenza viruses that are predicted to be circulating in the United States during the 2009-10 influenza season and have favorable growth properties in eggs. Seasonal influenza vaccines are not expected to provide substantial protection against infection with the recently identified novel influenza A (H1N1) (318), and guidance for the prevention of infection against this virus will be published separately. TIV and LAIV can be used to reduce the risk for influenza virus infection and its complications. Vaccination providers should administer influenza vaccine to any person who wishes to reduce the likelihood of becoming ill with influenza or transmitting influenza to others should they become infected. Healthy, nonpregnant persons aged 2-49 years can choose to receive either vaccine. Some TIV formulations are FDAlicensed for use in persons as young as age 6 months (see Recommended Vaccines for Different Age Groups). TIV is licensed for use in persons with high-risk conditions (Table 2). LAIV is FDA-licensed for use only for persons aged 2-49 years. In addition, FDA has indicated that the safety of LAIV has not been established in persons with underlying medical conditions that confer a higher risk for influenza complications. All children aged 6 months-8 years who have not been vaccinated previously at any time with at least 1 dose of either LAIV (if appropriate) or TIV should receive 2 doses of ageappropriate vaccine in the same season, with a single dose during subsequent seasons. # target Groups for Protection through Vaccination Influenza vaccine should be provided to all persons who want to reduce the risk for becoming ill with influenza or of transmitting it to others. However, emphasis on providing routine vaccination annually to certain groups at higher risk for influenza infection or complications is advised, including all children aged 6 months-18 years, all persons aged >50 years, and other adults at risk for medical complications from influenza. In addition, all persons who live with or care for persons at high risk for influenza-related complications, including contacts of children aged <6 months, should receive influenza vaccine annually (Boxes 1 and 2). Approximately 85% of the U.S. population is included in one or more of these target groups; however, <40% of the U.S. population received an influenza vaccination during the 2008-09 influenza season. # Children Aged 6 Months-18 Years Beginning with the 2008-09 influenza season, annual vaccination for all children aged 6 months-18 years was recommended. Children and adolescents at high risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children. Healthy children aged 2-18 years can receive either LAIV or TIV. Children aged 6-23 months, and those aged 2-4 years who have evidence of asthma wheezing or who have medical conditions that put them at higher risk for influenza complications should receive TIV (see Considerations When Using LAIV). All children aged 6 months-8 years who have not received vaccination against influenza previously should receive 2 doses of vaccine the first year they are vaccinated. # Persons at Risk for Medical Complications Vaccination to prevent influenza is particularly important for the following persons, who are at increased risk for severe complications from influenza, or at higher risk for influenzarelated outpatient, ED, or hospital visits: all children aged 6 months- facilities. For children, the risk for severe complications from seasonal influenza is highest among those aged <2 years, who have much higher rates of hospitalization for influenza-related complications compared with older children (7,32,39). Medical care and ED visits attributable to influenza are increased among children aged <5 years compared with older children (32). Chronic neurologic and neuromuscular conditions include any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration (30). # Persons Who Live With or Care for Persons at High Risk for Influenza-Related Complications To prevent transmission to persons identified above, vaccination with TIV or LAIV (unless contraindicated) also is recommended for the following persons. When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to these persons: HCP; - household contacts (including children) and caregivers - of children aged 50 years; and household contacts (including children) and caregivers - of persons with medical conditions that put them at higher risk for severe complications from influenza. # Children Aged <6 Months Children aged <6 months are not recommended for vaccination, and antivirals are not licensed for use among infants. Protection of young infants, who have hospitalization rates similar to those observed among the elderly, depends on vaccination of the infants' close contacts. A recent study conducted in Bangladesh demonstrated that infants born to vaccinated women have significant protection from laboratory-confirmed influenza, either through transfer of influenza-specific maternal antibodies or by reducing the risk for exposure to influenza that might occur through vaccination of the mother (154). All household contacts, health-care and day care providers, and other close contacts of young infants should be vaccinated. # Vaccination of Specific Populations Children Aged 6 Months-18 Years All children aged 6 months-18 years should be vaccinated against influenza annually. In 2004, ACIP recommended routine vaccination for all children aged 6-23 months, and in 2006, ACIP expanded the recommendation to include all children aged 24-59 months. Recommendations to provide routine influenza vaccination to all children and adolescents aged 6 months-18 years are made on the basis of 1) accumulated evidence that influenza vaccine is effective and safe for children (see Influenza Vaccine Efficacy, Effectiveness, and Safety); 2) increased evidence that influenza has substantial adverse impacts among children and their contacts (e.g., school absenteeism, increased antibiotic use, medical care visits, and parental work loss) (see Health-Care Use, Hospitalizations, and Deaths Attributed to Influenza); and 3) an expectation that a simplified age-based influenza vaccine recommendation for all children and adolescents will improve vaccine coverage levels among children who already have a risk-or contact-based indication for annual influenza vaccination. Children typically have the highest attack rates during community outbreaks of influenza and serve as a major source of transmission within communities (1,2). If sufficient vaccination coverage among children can be achieved, potential benefits include the indirect effect of reducing influenza among persons who have close contact with children and reducing overall transmission within communities. Achieving and sustaining community-level reductions in influenza will require mobilization of community resources and development of sustainable annual vaccination campaigns to assist health-care providers and vaccination programs in providing influenza vaccination services to children of all ages. In many areas, innovative community-based efforts, which might include mass vaccination programs in school or other community settings, will be needed to supplement vaccination services provided in health-care providers' offices or public health clinics. In nonrandomized community-based controlled trials, reductions in ILI-related symptoms and medical visits among household contacts have been demonstrated in communities where vaccination programs among school-aged children were established compared with communities without such vaccination programs (295,314,315).Reducing influenza-related illness among children who are at high risk for influenza complications should continue to be a primary focus of influenza-prevention efforts. Children who should be vaccinated because they are at high risk for influenza complications include all children aged 6-59 months, children with certain medical conditions, children who are contacts of children aged 50 years, and children who are contacts of persons at high risk for influenza complications because of medical conditions. All children aged 6 months-8 years who have not received vaccination against influenza previously should receive 2 doses of vaccine the first influenza season that they are vaccinated. The second dose should be administered 4 or more weeks after the initial dose. When only 1 dose is administered to children aged 6 months-8 years during their first year of vaccination, 2 doses should be administered in the following season. However, 2 doses should only be administered in the first season of vaccination, or in the season that immediately follows if only 1 dose is administered in the first season. For example, children aged 6 months-8 years who were vaccinated for the first time with the 2008-09 influenza vaccine but received only 1 dose should receive 2 doses of the 2009-10 influenza vaccine. All other children aged 6 months-8 years who have previously received 1 or more doses of influenza vaccine at any time should receive 1 dose of the 2009-10 influenza vaccine. Children aged 6 months-8 years who received only a single vaccination during a season before 2007-08 should receive 1 dose of the 2009-10 influenza vaccine. If possible, both doses should be administered before onset of influenza season. However, vaccination, including the second dose, is recommended even after influenza virus begins to circulate in a community. # HCP and other Persons Who Can transmit Influenza to those at High Risk Healthy persons who are infected with influenza virus, including those with subclinical infection, can transmit influenza virus to persons at higher risk for complications from influenza. In addition to HCP, groups that can transmit influenza to high-risk persons and that should be vaccinated include employees of assisted living and other residences for All HCP and persons in training for health-care professions should be vaccinated annually against influenza. Persons working in health-care settings who should be vaccinated include physicians, nurses, and other workers in both hospital and outpatient-care settings, medical emergency-response workers (e.g., paramedics and emergency medical technicians), employees of nursing home and long-term-care facilities who have contact with patients or residents, and students in these professions who will have contact with patients (359,360,371). Facilities that employ HCP should provide vaccine to workers by using approaches that have been demonstrated to be effective in increasing vaccination coverage. Health-care administrators should consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and consider obtaining signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications (360,372,373). Influenza vaccination rates among HCP within facilities should be regularly measured and reported, and ward-, unit-, and specialty-specific coverage rates should be provided to staff and administration (360). Studies have demonstrated that organized campaigns can attain higher rates of vaccination among HCP with moderate effort and by using strategies that increase vaccine acceptance (358,360,374). Efforts to increase vaccination coverage among HCP are supported by various national accrediting and professional organizations and in certain states by statute. The Joint Commission on Accreditation of Health-Care Organizations has approved an infection-control standard that requires accredited organizations to offer influenza vaccinations to staff, including volunteers and licensed independent practitioners with close patient contact. The standard became an accreditation requirement beginning January 1, 2007 (375). In addition, the Infectious Diseases Society of America has recommended mandatory vaccination for HCP, with a provision for declination of vaccination based on religious or medical reasons (376). Some states have regulations regarding vaccination of HCP in long-term-care facilities (377), require that health-care facilities offer influenza vaccination to HCP, or require that HCP either receive influenza vaccination or indicate a religious, medical, or philosophic reason for not being vaccinated (378,379). # Close Contacts of Immunocompromised Persons Immunocompromised persons are at risk for influenza complications but might have inadequate protection after vaccination. Close contacts of immunocompromised persons, including HCP, should be vaccinated to reduce the risk for influenza transmission. TIV is recommended for vaccinating household members, HCP, and others who have close contact with severely immunosuppressed persons (e.g., patients with hematopoietic stem cell transplants) during those periods in which the immunosuppressed person requires care in a protective environment (typically defined as a specialized patient-care area with a positive airflow relative to the cor-ridor, high-efficiency particulate air filtration, and frequent air changes) (360,380). LAIV transmission from a recently vaccinated person causing clinically important illness in an immunocompromised contact has not been reported. The rationale for avoiding use of LAIV among HCP or other close contacts of severely immunocompromised patients is the theoretical risk that a live, attenuated vaccine virus could be transmitted to the severely immunosuppressed person. As a precautionary measure, HCP who receive LAIV should avoid providing care for severely immunosuppressed patients requiring a protected environment for 7 days after vaccination. Hospital visitors who have received LAIV should avoid contact with severely immunosuppressed persons in protected environments for 7 days after vaccination but should not be restricted from visiting less severely immunosuppressed patients. No preference is indicated for TIV use by persons who have close contact with persons with lesser degrees of immunosuppression (e.g., persons with diabetes, persons with asthma who take corticosteroids, persons who have recently received chemotherapy or radiation but who are not being cared for in a protective environment as defined above, or persons infected with HIV) or for TIV use by HCP or other healthy nonpregnant persons aged 2-49 years in close contact with persons in all other groups at high risk. # Pregnant Women Pregnant women and newborns are at risk for influenza complications, and all women who are pregnant or will be pregnant during influenza season should be vaccinated. The American College of Obstetricians and Gynecologists and the American Academy of Family Physicians also have recommended routine vaccination of all pregnant women (381). No preference is indicated for use of TIV that does not contain thimerosal as a preservative (see Vaccine Preservative in Multidose Vials of TIV) for any group recommended for vaccination, including pregnant women. LAIV is not licensed for use in pregnant women. However, pregnant women do not need to avoid contact with persons recently vaccinated with LAIV. # Breastfeeding Mothers Vaccination is recommended for all persons, including breastfeeding women, who are contacts of infants or children aged <5 years because infants and young children are at high risk for influenza complications and are more likely to require medical care or hospitalization if infected. Breastfeeding does not affect the immune response adversely and is not a con-traindication for vaccination (179). Unless contraindicated because of other medical conditions, women who are breastfeeding can receive either TIV or LAIV. In one randomized controlled trial conducted in Bangladesh, infants born to women vaccinated during pregnancy had a lower risk for laboratory-confirmed influenza. However, the contribution to protection from influenza of breastfeeding compared with passive transfer of maternal antibodies during pregnancy was not determined (154). # travelers The risk for exposure to influenza during travel depends on the time of year and destination. In the temperate regions of the Southern Hemisphere, influenza activity occurs typically during April-September. In temperate climate zones of the Northern and Southern Hemispheres, travelers also can be exposed to influenza during the summer, especially when traveling as part of large tourist groups (e.g., on cruise ships) that include persons from areas of the world in which influenza viruses are circulating (382,383). In the tropics, influenza occurs throughout the year. In a study among Swiss travelers to tropical and subtropical countries, influenza was the most frequently acquired vaccine-preventable disease (384). Any traveler who wants to reduce the risk for influenza infection should consider influenza vaccination, preferably at least 2 weeks before departure. In particular, persons at high risk for complications of influenza and who were not vaccinated with influenza vaccine during the preceding fall or winter should consider receiving influenza vaccine before travel if they plan to travel to the tropics, - with organized tourist groups at any time of year, or - to the Southern Hemisphere during April-September. - No information is available about the benefits of revaccinating persons before summer travel who already were vaccinated during the preceding fall, and revaccination is not recommended. Persons at high risk who receive the previous season's vaccine before travel should be revaccinated with the current vaccine the following fall or winter. Persons at higher risk for influenza complications should consult with their health-care practitioner to discuss the risk for influenza or other travel-related diseases before embarking on travel during the summer. # General Population Vaccination is recommended for any persons who wish to reduce the likelihood of their becoming ill with influenza or transmitting influenza to others should they become infected. Healthy, nonpregnant persons aged 2-49 years might choose to receive either TIV or LAIV. All other persons aged >6 months should receive TIV. Persons who provide essential community services should be considered for vaccination to minimize disruption of essential activities during influenza outbreaks. Students or other persons in institutional settings (e.g., those who reside in dormitories or correctional facilities) should be encouraged to receive vaccine to minimize morbidity and the disruption of routine activities during influenza epidemics (385,386). # Recommended Vaccines for Different Age Groups When vaccinating children aged 6-35 months with TIV, health-care providers should use TIV that has been licensed by the FDA for this age group (i.e., TIV manufactured by Sanofi Pasteur ) (219). TIV from Novartis (Fluvirin) is FDA-approved in the United States for use among persons aged >4 years (220). TIV from GlaxoSmithKline (Fluarix and FluLaval) or CSL Biotherapies (Afluria) is labeled for use in persons aged >18 years because data to demonstrate immunogenicity or efficacy among younger persons have not been provided to FDA (207,208,218). LAIV from MedImmune (FluMist) is recommended for use by healthy nonpregnant persons aged 2-49 years (Table 2) (291). If a pediatric vaccine dose (0.25mL) is administered to an adult, an additional pediatric dose (0.25 mL) should be given to provide a full adult dose (0.5mL). If the error is discovered later (after the patient has left the vaccination setting), an adult dose should be administered as soon as the patient can return. No action needs to be taken if an adult dose is administered to a child. Several new vaccine formulations are being evaluated in immunogenicity and efficacy trials; when licensed, these new products will increase the influenza vaccine supply and provide additional vaccine choices for practitioners and their patients. # Influenza Vaccines and Use of Influenza Antiviral Medications Unvaccinated persons who are receiving antiviral medications for treatment or chemoprophylaxis often also are recommended for vaccination. Administration of TIV to persons receiving influenza antivirals is acceptable. The effect on safety and effectiveness of LAIV coadministration with influenza antiviral medications has not been studied. However, because influenza antivirals reduce replication of influenza viruses, LAIV should not be administered until 48 hours after cessation of influenza antiviral therapy, and influenza antiviral medications should not be administered for 2 weeks after receipt of LAIV. Persons receiving antivirals within the period 2 days before to 14 days after vaccination with LAIV should be revaccinated at a later date with any approved vaccine formulation (179,291). # Considerations When Using LAIV LAIV is an option for vaccination of healthy, nonpregnant persons aged 2-49 years, including HCP and other close contacts of high-risk persons (excepting severely immunocompromised persons who require care in a protected environment). No preference is indicated for LAIV or TIV when considering vaccination of healthy, ¶ nonpregnant persons aged 2-49 years. Possible advantages of LAIV include its potential to induce a broad mucosal and systemic immune response in children, its ease of administration, and the possibly increased acceptability of an intranasal rather than intramuscular route of administration. If the vaccine recipient sneezes after administration, the dose should not be repeated. However, if nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration should be considered until resolution of the illness, or TIV should be administered instead. No data exist about concomitant use of nasal corticosteroids or other intranasal medications (261). Although FDA licensure of LAIV excludes children aged 2-4 years with a history of asthma or recurrent wheezing, the precise risk, if any, of wheezing caused by LAIV among these children is unknown because experience with LAIV among these young children is limited. Young children might not have a history of recurrent wheezing if their exposure to respiratory viruses has been limited because of their age. Certain children might have a history of wheezing with respiratory illnesses but have not had asthma diagnosed. The following screening recommendations should be used to assist persons who administer influenza vaccines in providing the appropriate vaccine for children aged 2-4 years. Clinicians and vaccination programs should screen - for asthma or wheezing illness (or history of wheezing illness) when considering use of LAIV for children aged 2-4 years, and should avoid use of this vaccine in children with asthma or a recent wheezing episode within the previous 12 months. Health-care providers should consult the medical record, when available, to identify children aged 2-4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving LAIV, parents or caregivers of children aged 2-4 years should be asked: "In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?" Children whose parents or caregivers answer "yes" to this question and children who have asthma or who had a wheezing episode noted in the medical record during the preceding 12 months should not receive LAIV. TIV is available for use in children with asthma or wheezing (387).LAIV can be administered to persons with minor acute illnesses (e.g., diarrhea or mild upper respiratory tract infection with or without fever). However, if nasal congestion is present that might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration should be considered until resolution of the illness. # Contraindications and Precautions for Use of LAIV The effectiveness or safety of LAIV is not known for the following groups and administration of LAIV is contraindicated: persons ing aspirin or other salicylates (because of the association of Reye syndrome with wild-type influenza virus infection); or pregnant women. - A moderate or severe illness with or without fever is a precaution for use of LAIV. GBS within 6 weeks following a previous dose of influenza vaccine is considered to be a precaution for use of influenza vaccines. LAIV should not be administered to close contacts of immunosuppressed persons who require a protected environment. ¶ Use of the term "healthy" in this recommendation refers to persons who do not have any of the underlying medical conditions that confer high risk for severe complications (see Contraindications and Precautions for Use of LAIV). # Personnel Who Can Administer LAIV Low-level introduction of vaccine viruses into the environment probably is unavoidable when administering LAIV. The risk for acquiring vaccine viruses from the environment is unknown but is probably low. Severely immunosuppressed persons should not administer LAIV. However, other persons at higher risk for influenza complications can administer LAIV. These include persons with underlying medical conditions placing them at higher risk or who are likely to be at risk, including pregnant women, persons with asthma, and persons aged >50 years. # Concurrent Administration of Influenza Vaccine with other Vaccines Use of LAIV concurrently with measles, mumps, rubella (MMR) alone and MMR and varicella vaccine among children aged 12-15 months has been studied, and no interference with the immunogenicity to antigens in any of the vaccines was observed (261,388). Among adults aged >50 years, the safety and immunogenicity of zoster vaccine and TIV was similar whether administered simultaneously or spaced 4 weeks apart (389). In the absence of specific data indicating interference, following ACIP's general recommendations for vaccination is prudent (179). Inactivated vaccines do not interfere with the immune response to other inactivated vaccines or to live vaccines. Inactivated or live vaccines can be administered simultaneously with LAIV. However, after administration of a live vaccine, at least 4 weeks should pass before another live vaccine is administered. # Recommendations for Vaccination Administration and Vaccination Programs Although influenza vaccination levels increased substantially during the 1990s, little progress has been made since 2000 toward achieving national health objectives, and further improvements in vaccine coverage levels are needed to reduce the annual impact of influenza substantially. Strategies to improve vaccination levels, including using reminder/recall systems and standing orders programs (335,336,345), should be implemented whenever feasible. Vaccination efforts should begin as soon as vaccine is available and continue through the influenza season. Vaccination coverage can be increased by administering vaccine before and during the influenza season to persons during hospitalizations or routine health-care visits. Vaccinations can be provided in alternative settings (e.g., pharmacies, grocery stores, workplaces, or other locations in the community), thereby making special visits to physicians' offices or clinics unnecessary. Coordinated campaigns such as the National Influenza Vaccination Week (December 6-12, 2009) provide opportunities to refocus public attention on the benefits, safety, and availability of influenza vaccination throughout the influenza season. When educating patients about adverse events, clinicians should provide access to Vaccine Information Sheets (available at . gov/vaccines/pubs/vis), and emphasize that 1) TIV contains noninfectious killed viruses and cannot cause influenza, 2) LAIV contains weakened influenza viruses that cannot replicate outside the upper respiratory tract and are unlikely to infect others, and 3) concomitant symptoms or respiratory disease unrelated to vaccination with either TIV or LAIV can occur after vaccination. Adverse events after influenza vaccination should be reported promptly to VAERS at . gov even if the health-care professional is not certain that the vaccine caused the event. # Information About the Vaccines for Children Program The Vaccines for Children (VFC) program supplies vaccine to all states, territories, and the District of Columbia for use by participating providers. These vaccines are to be provided to eligible children without vaccine cost to the patient or the provider, although the provider might charge a vaccine administration fee. All routine childhood vaccines recommended by ACIP are available through this program, including influenza vaccines. The program saves parents and providers out-ofpocket expenses for vaccine purchases and provides cost savings to states through CDC's vaccine contracts. The program results in lower vaccine prices and ensures that all states pay the same contract prices. Detailed information about the VFC program is available at / vfc/default.htm. # Influenza Vaccine Supply Considerations The annual supply of influenza vaccine and the timing of its distribution cannot be guaranteed in any year. During the 2008-09 influenza season, 113 million doses of influenza vaccine were distributed in the United States. For the 2009-10 season, total production of seasonal influenza vaccine for the United States is anticipated to be >130 million doses, depending on demand and production yields. However, influenza vaccine distribution delays or vaccine shortages remain possible. One factor that affects production is the inherent critical time constraints in manufacturing the vaccine given the annual updating of the influenza vaccine strains. Multiple manufacturing and regulatory issues, including the anticipated need to produce a separate vaccine against novel influenza A (H1N1), also might affect the production schedule. To ensure optimal use of available doses of influenza vaccine, health-care providers, persons planning organized campaigns, and state and local public health agencies should develop plans for expanding outreach and infrastructure to vaccinate more persons in targeted groups and others who wish to reduce their risk for influenza. They also should develop contingency plans for the timing and prioritization of administering influenza vaccine if the supply of vaccine is delayed or reduced. If supplies of TIV are not adequate, vaccination should be carried out in accordance with local circumstances of supply and demand based on the judgment of state and local health officials and health-care providers. Guidance for tiered use of TIV during prolonged distribution delays or supply short falls is available at and will be modified as needed in the event of shortage. CDC and other public health agencies will assess the vaccine supply on a continuing basis throughout the manufacturing period and will inform both providers and the general public if any indication exists of a substantial delay or an inadequate supply. Because LAIV is recommended for use only in healthy nonpregnant persons aged 2-49 years, no recommendations for prioritization of LAIV use are made. Either LAIV or TIV can be used when considering vaccination of healthy, nonpregnant persons aged 2-49 years. However, during shortages of TIV, LAIV should be used preferentially when feasible for all healthy nonpregnant persons aged 2-49 years (including HCP) who desire or are recommended for vaccination to increase the availability of inactivated vaccine for persons at high risk. # timing of Vaccination Vaccination efforts should be structured to ensure the vaccination of as many persons as possible over the course of several months, with emphasis on vaccinating before influenza activity in the community begins. Even if vaccine distribution begins before October, distribution probably will not be completed until December or January. The following recommendations reflect this phased distribution of vaccine. In any given year, the optimal time to vaccinate patients cannot be determined precisely because influenza seasons vary in their timing and duration, and more than one outbreak might occur in a single community in a single year. In the United States, localized outbreaks that indicate the start of seasonal influenza activity can occur as early as October. However, in >80% of influenza seasons since 1976, peak influenza activity (which often is close to the midpoint of influenza activity for the season) has not occurred until January or later, and in >60% of seasons, the peak was in February or later (Figure 1). In general, health-care providers should begin offering vaccination soon after vaccine becomes available and if possible by October. To avoid missed opportunities for vaccination, providers should offer vaccination during routine health-care visits or during hospitalizations whenever vaccine is available. The potential for addition of a novel influenza A (H1N1) vaccine program to the current burden on vaccination programs and providers underscores the need for careful planning of seasonal vaccination programs. Beginning use of seasonal vaccine as soon as available, including in September or earlier, might reduce the overlap of seasonal and novel influenza vaccination efforts. Vaccination efforts should continue throughout the season, because the duration of the influenza season varies, and influenza might not appear in certain communities until February or March. Providers should offer influenza vaccine routinely, and organized vaccination campaigns should continue throughout the influenza season, including after influenza activity has begun in the community. Vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons. The majority of adults have antibody protection against influenza virus infection within 2 weeks after vaccination (390,391). All children aged 6 months-8 years who have not received vaccination against influenza previously should receive their first dose as soon after vaccine becomes available as is feasible and should receive the second dose >4 weeks later. This practice increases the opportunity for both doses to be administered before or shortly after the onset of influenza activity. Vaccination clinics should be scheduled through December, and later if feasible, with attention to settings that serve children aged >6 months, pregnant women, other persons aged 50 years, HCP, and persons who are household contacts of children aged <59 months or other persons at high risk. Planners are encouraged to develop the capacity and flexibility to schedule at least one vaccination clinic in December. Guidelines for planning large-scale vaccination clinics are available at / vaccination/vax_clinic.htm. During a vaccine shortage or delay, substantial proportions of TIV doses might not be released and distributed until November and December or later. When the vaccine is substantially delayed or disease activity has not subsided, providers should consider offering vaccination clinics into January and beyond as long as vaccine supplies are available. Campaigns using LAIV also can extend into January and beyond. # Strategies for Implementing Vaccination Recommendations in Health-Care Settings Successful vaccination programs combine publicity and education for HCP and other potential vaccine recipients, a plan for identifying persons recommended for vaccination, use of reminder/recall systems, assessment of practice-level vaccination rates with feedback to staff, and efforts to remove administrative and financial barriers that prevent persons from receiving the vaccine, including use of standing orders programs (336,392). The use of standing orders programs by long-term-care facilities (e.g., nursing homes and skilled nursing facilities), hospitals, and home health agencies ensures that vaccination is offered. Standing orders programs for influenza vaccination should be conducted under the supervision of a licensed practitioner according to a physician-approved facility or agency policy by HCP trained to screen patients for contraindications to vaccination, administer vaccine, and monitor for adverse events. The Centers for Medicare and Medicaid Services (CMS) has removed the physician signature requirement for the administration of influenza and pneumococcal vaccines to Medicare and Medicaid patients in hospitals, long-term-care facilities, and home health agencies (393). To the extent allowed by local and state law, these facilities and agencies can implement standing orders for influenza and pneumococcal vaccination of Medicare-and Medicaideligible patients. Payment for influenza vaccine under Medicare Part B is available (394,395) Other settings (e.g., outpatient facilities, managed care organizations, assisted living facilities, correctional facilities, pharmacies, and adult workplaces) are encouraged to introduce standing orders programs (396). In addition, physician reminders (e.g., flagging charts) and patient reminders are recognized strategies for increasing rates of influenza vaccination. Persons for whom influenza vaccine is recommended can be identified and vaccinated in the settings described in the following sections. # outpatient Facilities Providing ongoing Care Staff in facilities providing ongoing medical care (e.g., physicians' offices, public health clinics, employee health clinics, hemodialysis centers, hospital specialty-care clinics, and outpatient rehabilitation programs) should identify and label the medical records of patients who should receive vaccination. Vaccine should be offered during visits throughout the influenza season. The offer of vaccination and its receipt or refusal should be documented in the medical record or vaccination information system. Patients for whom vaccination is recommended and who do not have regularly scheduled visits during the fall should be reminded by mail, telephone, or other means of the need for vaccination. # outpatient Facilities Providing Episodic or Acute Care Acute health-care facilities (e.g., EDs and walk-in clinics) should offer vaccinations throughout the influenza season to persons for whom vaccination is recommended or provide written information regarding why, where, and how to obtain the vaccine. This written information should be available in languages appropriate for the populations served by the facility. # nursing Homes and other Long-term-Care Facilities Vaccination should be provided routinely to all residents of long-term-care facilities. If possible, all residents should be vaccinated at one time before influenza season. In the majority of seasons, TIV will become available to long-term-care facilities in October or November, and vaccination should commence as soon as vaccine is available. As soon as possible after admission to the facility, the benefits and risks of vaccination should be discussed and education materials provided (397). Signed consent is not required (398). Residents admitted after completion of the vaccination program at the facility should be vaccinated at the time of admission. Since October 2005, CMS has required nursing homes participating in the Medicare and Medicaid programs to offer all residents influenza and pneumococcal vaccines and to document the results. According to the requirements, each resident is to be vaccinated unless contraindicated medically, the resident or a legal representative refuses vaccination, or the vaccine is not available because of shortage. This information is to be reported as part of the CMS Minimum Data Set, which tracks nursing home health parameters (395,399). # Acute-Care Hospitals Hospitals should serve as a key setting for identifying persons at increased risk for influenza complications. Unvaccinated persons of all ages (including children) with high-risk conditions and persons aged 6 months-18 years or >50 years who are hospitalized at any time during the period when vaccine is available should be offered and strongly encouraged to receive influenza vaccine before they are discharged. Standing orders to offer influenza vaccination to all hospitalized persons should be considered. # Visiting nurses and others Providing Home Care to Persons at High Risk Nursing-care plans should identify patients for whom vaccination is recommended, and vaccine should be administered in the home if necessary as soon as influenza vaccine is available and throughout the influenza season. Caregivers and other persons in the household (including children) should be referred for vaccination. # other Facilities Providing Services to Persons Aged >50 Years Facilities providing services to persons aged >50 years (e.g., assisted living housing, retirement communities, and recreation centers) should offer unvaccinated residents, attendees, and staff annual on-site vaccination before the start of the influenza season. Continuing to offer vaccination throughout the fall and winter months is appropriate. Efforts to vaccinate newly admitted patients or new employees also should be continued, both to prevent illness and to avoid having these persons serve as a source of new influenza infections. Staff education should emphasize the benefits for self, staff and patients of protection from influenza through vaccination. # Health-Care Personnel Health-care facilities should offer influenza vaccinations to all HCP, including night, weekend, and temporary staff. Particular emphasis should be placed on providing vaccinations to workers who provide direct care for persons at high risk for influenza complications. Efforts should be made to educate HCP regarding the benefits of vaccination and the potential health consequences of influenza illness for their patients, themselves, and their family members. All HCP should be provided convenient access to influenza vaccine at the work site, free of charge, as part of employee health programs (360,374,375). # Future Directions for Research and Recommendations Related to Influenza Vaccine Although available influenza vaccines are effective and safe, additional research is needed to improve prevention efforts. Most mortality from influenza occurs among persons aged >65 years (6), and more immunogenic influenza vaccines are needed for this age group and other groups at high risk for mortality. Additional research also is needed to understand potential biases in estimating the benefits of vaccination among older adults in reducing hospitalizations and deaths (82,175,400). Additional studies of the relative cost-effectiveness and cost utility of influenza vaccination among children and adults, especially those aged <65 years, are needed and should be designed to account for year-to-year variations in influenza attack rates, illness severity, hospitalization costs and rates, and vaccine effectiveness when evaluating the long-term costs and benefits of annual vaccination (401). Additional data on indirect effects of vaccination also are needed to quantify the benefits of influenza vaccination of HCP in protecting their patients (308) and the benefits of vaccinating children to reduce influenza complications among those at risk. Because expansions in ACIP recommendations for vaccination will lead to more persons being vaccinated, much larger research networks are needed that can identify and assess the causality of very rare events that occur after vaccination, including GBS. Ongoing studies of safety in pediatric populations with expanded recommendations are needed and are underway. These research networks also could provide a platform for effectiveness and safety studies in the event of a pandemic. A recent study showed that influenza vaccines contain structures that can induce anti-GM1 antibodies after inoculation into mice (402). Further research on potential biologic or genetic risk factors for GBS in humans also is needed (397). In addition, a better understanding is needed of how to motivate persons at risk to seek annual influenza vaccination. ACIP continues to review new vaccination strategies to protect against influenza, including the possibility of expanding routine influenza vaccination recommendations toward universal vaccination or other approaches that will help reduce or prevent the transmission of influenza and reduce the burden of severe disease (403)(404)(405)(406)(407)(408). The 2009 ACIP expansion of annual vaccination recommendations to include all children aged 6 months-18 years will require a substantial increase in resources for epidemiologic research to develop long-term studies capable of assessing the possible effects on community-level transmission. Additional planning to improve surveillance systems capable of monitoring effectiveness, safety and vaccine coverage, and further development of implementation strategies will also be necessary. In addition, as noted by the National Vaccine Advisory Committee, strengthening the U.S. influenza vaccination system will require improving vaccine financing and demand and implementing systems to help better understand the burden of influenza in the United States (409). Vaccination programs capable of delivering annual influenza vaccination to a broad range of the population could potentially serve as a resilient and sustainable platform for delivering vaccines and monitoring outcomes for other urgently required public health interventions (e.g., vaccines for pandemic influenza or medications to prevent or treat illnesses caused by acts of terrorism). # Seasonal Influenza Vaccine and Influenza Viruses of Animal origin Human infection with novel or nonhuman influenza A virus strains, including influenza A viruses of animal origin, is a nationally notifiable disease (410). Human infections with nonhuman or novel human influenza A virus should be identified quickly and investigated to determine possible sources of exposure, identify additional cases, and evaluate the possibility of human-to-human transmission because transmission patterns could change over time with variations in these influenza A viruses. Sporadic severe and fatal human cases of infection with highly pathogenic avian influenza A (H5N1) virus have been identified in Asia, Africa, Europe, and the Middle East, primarily among persons who have had direct or close unprotected contact with sick or dead birds associated with the ongoing H5N1 panzootic among birds (411)(412)(413)(414)(415)(416)(417)(418)(419). Limited, nonsustained human-to-human transmission of H5N1 virus has likely occurred in some case clusters (420,421). To date, no evidence exists of genetic reassortment between human influenza A and H5N1 viruses. However, influenza viruses derived from strains circulating among poultry (e.g., the H5N1 virus that has caused outbreaks of avian influenza and occasionally have infected humans) have the potential to recombine with human influenza A viruses (422,423). To date, highly pathogenic H5N1 virus has not been identified in wild or domestic birds or in humans in the United States. Guidance for testing suspected cases of H5N1 virus infection among persons in the U.S. and follow-up of contacts is available (424,425). Human illness from infection with different avian influenza A subtype viruses also have been documented, including infections with low pathogenic and highly pathogenic viruses. A range of clinical illness has been reported for human infection with low pathogenic avian influenza viruses, including conjunctivitis with influenza A (H7N7) virus in the United Kingdom, lower respiratory tract disease and conjunctivitis with influenza A (H7N2) virus in the United Kingdom, and uncomplicated ILI with influenza A (H9N2) virus in Hong Kong and China (426)(427)(428)(429)(430)(431)(432). Two human cases of infection with low pathogenic influenza A (H7N2) were reported in the United States (429). Although human infections with highly pathogenic A (H7N7) virus infections typically have ILI or conjunctivitis, severe infections, including one fatal case in the Netherlands, have been reported (433,434). Conjunctivitis also has been reported because of human infection with highly pathogenic influenza A (H7N3) virus in Canada and low pathogenic A (H7N3) in the United Kingdom (426,434). In contrast, sporadic infections with highly pathogenic avian influenza A (H5N1) virus have caused severe illness in many countries, with an overall case-fatality proportion of >60% (421,435). Swine influenza A (H1N1), A (H1N2), and A (H3N2) viruses, including reassortant viruses, are endemic among pig populations in the United States (436). Two clusters of influenza A (H2N3) virus infections among pigs have been reported recently (437). Outbreaks among pigs normally occur in colder weather months (late fall and winter) and sometimes with the introduction of new pigs into susceptible herds. An estimated 30% of the pig population in the United States has serologic evidence of having had swine influenza A (H1N1) virus infection. Sporadic human infections with a variety of swine influenza A viruses occur in the United States, but the incidence of these human infections is unknown (438)(439)(440)(441)(442)(443). Persons infected with swine influenza A viruses typically report direct contact with ill pigs or places where pigs have been present (e.g., agricultural fairs or farms), and have symptoms that are clinically indistinguishable from infection with other respiratory viruses (440,441,444,445). Clinicians should consider swine influenza A virus infection in the differential diagnosis of patients with ILI who have had recent contact with pigs. The sporadic cases identified in recent years have not resulted in sustained human-to-human transmission of swine influenza A viruses or community outbreaks (368,445). Although immunity to swine influenza A viruses appears to be low (<2%) in the overall human population, 10%-20% of persons exposed occupationally to pigs (e.g., pig farmers or pig veterinarians) have been documented in certain studies to have antibody evidence of prior swine influenza A (H1N1) virus infection (438,446). In April 2009, a novel influenza A (H1N1) virus similar to influenza viruses previously identified in swine was determined to the cause of an influenza-like respiratory illness among humans that spread across North America and throughout most of the world by May 2009 (9,447). The epidemiology of influenza caused by this novel influenza virus is still being studied, and whether this virus will achieve long-term circulation among humans or even replace one of the other seasonal influenza viruses as the cause of annual epidemics is unknown. Current seasonal influenza vaccines are not expected to provide protection against human infection with avian influenza A viruses, including influenza A (H5N1) viruses, or to provide protection against currently circulating swine influenza A or the novel influenza A (H1N1) viruses (318,448). However, reducing seasonal influenza risk through influenza vaccination of persons who might be exposed to nonhuman influenza viruses (e.g., H5N1 virus) might reduce the theoretical risk for recombination of influenza A viruses of animal origin and human influenza A viruses by preventing seasonal influenza A virus infection within a human host. CDC has recommended that persons who are charged with responding to avian influenza outbreaks among poultry receive seasonal influenza vaccination (448,449). As part of preparedness activities, the Occupational Safety and Health Administration (OSHA) has issued an advisory notice regarding poultry worker safety that is intended for implementation in the event of a suspected or confirmed avian influenza outbreak at a poultry facility in the United States. OSHA guidelines recommend that poultry workers in an involved facility receive vaccination against seasonal influenza; OSHA also has recommended that HCP involved in the care of patients with documented or suspected avian influenza should be vaccinated with the most recent seasonal human influenza vaccine to reduce the risk for co-infection with human influenza A viruses (449). # Recommendations for Using Antiviral Agents for Seasonal Influenza Annual vaccination is the primary strategy for preventing complications of influenza virus infections. Antiviral medications with activity against influenza viruses are useful adjuncts in the prevention of influenza, and effective when used early in the course of illness for treatment. Four influenza antiviral agents are licensed in the United States: amantadine, rimantadine, zanamivir, and oseltamivir. During the 2007-08 influenza season, influenza A (H1N1) viruses with a mutation that confers resistance to oseltamivir became more common in the United States and other countries (450)(451)(452). As of July 2009, in the United States, approximately 99% of human influenza A (H1N1) viruses tested, and none of the influenza A (H3N2) or influenza B viruses tested have been resistant to oseltamivir. As of July 2, 2009, with few exceptions, novel influenza A (H1N1) viruses that began circulating in April 2009 remained sensitive to oseltamivir (453). Oseltamivir resistance among circulating seasonal influenza A (H1N1) virus strains presents challenges for the selection of antiviral medications for treatment and chemoprophylaxis of influenza, and provides additional reasons for clinicians to test patients for influenza virus infection and to consult surveillance data when evaluating persons with acute respiratory illnesses during influenza season. CDC has published interim guidelines to provide options for treatment or chemoprophylaxis of influenza in the United States if oseltamivir-resistant seasonal influenza A (H1N1) viruses are circulating widely in a community or if the prevalence of oseltamivir-resistant influenza A (H1N1) viruses is uncertain (8). Updated guidance on antiviral use will be available from ACIP before the start of the 2009-10 influenza season. This guidance will include a summary of antiviral resistance data from the 2008-09 influenza season, and will be published separately from the vaccination recommendations. Until the ACIP recommendations for use of antivirals against influenza are published, CDC's previously published recommendations for use of influenza antiviral medications should be consulted for guidance on antiviral use (8). New guidance on clinical management of influenza, including use of antivirals, also is available from the Infectious Diseases Society of America (454). # Sources of Information Regarding Influenza and its Surveillance Information regarding influenza surveillance, prevention, detection, and control is available at . During October-May, surveillance information is updated weekly. In addition, periodic updates regarding influenza are published in MMWR (). Additional information regarding influenza vaccine can be obtained by calling 1-800-CDC-INFO (1-800-232-4636). State and local health departments should be consulted about availability of influenza vaccine, access to vaccination programs, information related to state or local influenza activity, reporting of influenza outbreaks and influenza-related pediatric deaths, and advice concerning outbreak control. # Vaccine Adverse Event Reporting System (VAERS) Adverse events after influenza vaccination should be reported promptly to VAERS at , even if the reporter is unsure whether vaccine caused the event. Clinically significant adverse events that follow vaccination should be reported to VAERS at . Reports may be filed securely online or by telephone at 1-800-822-7967 to request reporting forms or other assistance. # national Vaccine Injury Compensation Program The National Vaccine Injury Compensation Program (VICP), established by the National Childhood Vaccine Injury Act of 1986, as amended, provides a mechanism through which compensation can be paid on behalf of a person determined to have been injured or to have died as a result of receiving a vaccine covered by VICP. The Vaccine Injury Table lists the vaccines covered by VICP and the injuries and conditions (including death) for which compensation might be paid. If the injury or condition is not on the Table, or does not occur within the specified time period on the Table, persons must prove that the vaccine caused the injury or condition. For a person to be eligible for compensation, the general filing deadlines for injuries require claims to be filed within 3 years after the first symptom of the vaccine injury; for a death, claims must be filed within 2 years of the vaccine-related death and not more than 4 years after the start of the first symptom of the vaccine-related injury from which the death occurred. When a new vaccine is covered by VICP or when a new injury/ condition is added to the Table, claims that do not meet the general filing deadlines must be filed within 2 years from the date the vaccine or injury/condition is added to the Table for injuries or deaths that occurred up to 8 years before the Table change. Persons of all ages who receive a VICP-covered vaccine might be eligible to file a claim. Both the intranasal (LAIV) and injectable (TIV) trivalent influenza vaccines are covered under VICP. Additional information about VICP is available at http//www.hrsa.gov/vaccinecompensation or by calling 1-800-338-2382. # Additional Information Regarding Influenza Virus Infection Control Among Specific Populations Each year, ACIP provides general, annually updated information regarding control and prevention of influenza. Other reports related to controlling and preventing influenza among specific populations (e.g., immunocompromised persons, HCP, hospital patients, pregnant women, children, and travelers) also are available in the following publications: CDC.

Problem gambling (patient information) For the WikiDoc page for this topic, click here Synonyms and Keywords: Pathological gambling, Compulsive gambling; Addictive gambling # Overview Pathological gambling is being unable to resist impulses to gamble, which can lead to severe personal or social consequences. # What are the symptoms of Pathological gambling? - People with pathological gambling often feel ashamed and try to avoid letting others know of their problem. - The American Psychiatric Association defines pathological gambling as having five or more of the following symptoms: - Committing crimes to get money to gamble - Feeling restless or irritable when trying to cut back or quit gambling - Gambling to escape problems or feelings of sadness or anxiety - Gambling larger amounts of money to try to make back previous losses - Having had many unsuccessful attempts to cut back or quit gambling - Losing a job, relationship, or educational or career opportunity due to gambling - Lying about the amount of time or money spent gambling - Needing to borrow money due to gambling losses - Needing to gamble larger amounts of money in order to feel excitement - Spending a lot of time thinking about gambling, such as remembering past experiences or ways to get more money with which to gamble # What causes Pathological gambling? - Pathological gambling usually begins in early adolescence in men, and between ages 20 and 40 in women. - Pathological gambling often involves repetitive behaviors. People with this problem have a hard time resisting or controlling the impulse to gamble. - Although it shares features of obsessive compulsive disorder, pathological gambling is likely a different condition. - In people who develop pathological gambling, occasional gambling leads to a gambling habit. Stressful situations can worsen gambling problems. # When to seek urgent medical care? Call your health care provider or mental health professional if you believe you have symptoms of pathological gambling. # Diagnosis - A psychiatric evaluation and history can be used to diagnose pathological gambling. - Screening tools such as the Gamblers Anonymous 20 Questions can help with the diagnosis. # Treatment options - Treatment for people with pathological gambling begins with recognizing the problem. Pathological gambling is often associated with denial. People with the illness often refuse to accept that they have a problem or need treatment. - Most people with pathological gambling enter treatment under pressure from others, rather than voluntarily accepting the need for treatment. - Treatment options include: - Cognitive behavioral therapy (CBT) has been found to be effective. - Self-help support groups, such as Gamblers Anonymous. Gamblers Anonymous is a 12-step program similar to Alcoholics Anonymous. Principles related to stopping the habit (abstinence) for other types of addiction, such as substance abuse and alcohol dependence, can also be helpful in the treatment of pathological gambling. - A few studies have been done on medications for the treatment of pathological gambling. Early results suggest that antidepressants and opioid antagonists (naltrexone) may help treat the symptoms of pathological gambling. However, it is not yet clear which people will respond to medications. # Where to find medical care for Pathological gambling? Directions to Hospitals Treating Pathological gambling # What to expect (Outlook/Prognosis)? - Like alcohol or drug addiction, pathological gambling is a chronic disorder that tends to get worse without treatment. - Even with treatment, it's common to start gambling again (relapse). However, people with pathological gambling can do very well with the right treatment. # Possible complications - Complications may include: - Alcohol and drug abuse problems - Anxiety - Depression - Financial, social, and legal problems (including bankruptcy, divorce, job loss, time in prison) - Heart attacks (from the stress and excitement of gambling) - Suicide attempts - Getting the right treatment can help prevent many of these problems. # Prevention - Exposure to gambling may increase the risk of developing pathological gambling. Limiting exposure may be helpful for people who are at risk. - Public exposure to gambling, however, continues to increase in the form of lotteries, electronic and Internet gambling, and casinos. Intervention at the earliest signs of pathological gambling may prevent the disorder from getting worse. # Source

Taste bud # Overview Taste buds are small structures on the upper surface of the tongue, soft palate, and epiglottis that provide information about the taste of food being eaten. The human tongue has about 10,000 taste buds. # Types of papillae The majority of taste buds on the tongue sit on raised protrusions of the tongue surface called papillae. There are four types of papillae present in the human tongue: - Fungiform papillae - as the name suggests, these are slightly mushroom shaped if looked at in section. These are present mostly at the apex (tip) of the tongue, as well as at the sides. Innervated by facial nerve. - Filiform papillae - these are thin, long papillae "V"-shaped cones that don't contain taste buds but are the most numerous. These papillae are mechanical and not involved in gustation. Characterized increased keratinization. - Foliate papillae - these are ridges and grooves towards the posterior part of the tongue found on lateral margins. Innervated by facial nerve (anterior papillae) and glossopharyngeal nerve (posterior papillae). - Circumvallate papillae - there are only about 3-14 of these papillae on most people, and they are present at the back of the oral part of the tongue. They are arranged in a circular-shaped row just in front of the sulcus terminalis of the tongue. They are associated with ducts of Von Ebner's glands. Innervated by the glossopharyngeal nerve. It is known that there are five taste sensations: - Sweet, Bitter, and Umami (now sometimes called Savory), which work with a signal through a G-protein coupled receptor. - Salty and Sour, which work with ion channels. # Localization of taste and the human "tongue map" Contrary to popular understanding that different tastes map to different areas of the tongue, taste qualities are found in all areas of the tongue. The original "tongue map" was based on a mistranslation by Harvard psychologist Edwin G. Boring of a German paper that was written in 1901. Sensitivity to all tastes occurs across the whole tongue and indeed to other regions of the mouth where there are taste buds (epiglottis, soft palate). # Structure of taste buds Each taste bud is flask-like in shape, its broad base resting on the corium, and its neck opening by an orifice, the gustatory pore, between the cells of the epithelium. The bud is formed by two kinds of cells: supporting cells and gustatory cells. - The supporting (sustentacular) cells are mostly arranged like the staves of a cask, and form an outer envelope for the bud. Some, however, are found in the interior of the bud between the gustatory cells. - The gustatory (taste) cells, a chemoreceptor, occupy the central portion of the bud; they are spindle-shaped, and each possesses a large spherical nucleus near the middle of the cell. The peripheral end of the cell terminates at the gustatory pore in a fine hair-like filament, the gustatory hair. The central process passes toward the deep extremity of the bud, and there ends in single or bifurcated varicosities. The nerve fibrils after losing their medullary sheaths enter the taste bud, and end in fine extremities between the gustatory cells; other nerve fibrils ramify between the supporting cells and terminate in fine extremities; these, however, are believed to be nerves of ordinary sensation and not gustatory.

Norovirus # Overview Norovirus is the cause of norovirus infection. Noroviruses (genus Norovirus) are a group of related, single-stranded RNA, nonenveloped viruses that cause acute gastroenteritis in humans. Noroviruses belong to the family Caliciviridae. # Causes ## Common Causes Norovirus is transmitted through person-to-person contact, food and water. Genotype GII.4 is mostly contact transmitted. Non-GII.4 genotypes such as GI.3, GI.6, GI.7, GII.3, GII.6 and GII.12 are mostly food-borne. Genogroup GI strains are more often transmitted through water. This is due to their higher stability in water compared to other strains of the virus. Norovirus is among top ranks of food-borne viruses, globally. Transmission could occur in different stages of pre- and post-production of the food products. For instance, shellfish can be contaminated with fecal discharge in the water, fresh and frozen berries could be contaminated through water contaminated by sewage or contact during harvesting. Viral outbreaks through food-borne transmission can lead to a mixture of the viral strain and increased risk of genetic recombination. Studies show that about 7% of the foodborne outbreaks have a common source. ## Less Common Causes Norovirus also has a nosocomial transition, causing a major burden for health care services. Immunocompromised patients may develop numerous norovirus variations due to the chronic infection. This intra-host viral variation may lead to the appearance of variants not similar to any of the ones of previous outbreaks, thus can escape the herd immunity. To date, animal norovirus strains have not been reported to infect human population, but there has been evidence of intra-species transmission. Human norovirus has been detected in the stools of pigs, cattle and dogs.

IMITREX tablet description # Description IMITREX Tablets contain sumatriptan succinate, a selective 5‑HT1B/1D receptor agonist. Sumatriptan succinate is chemically designated as 3--N-methyl-indole-5-methanesulfonamide succinate (1:1), and it has the following structure: The empirical formula is C14H21N3O2SC4H6O4, representing a molecular weight of 413.5. Sumatriptan succinate is a white to off‑white powder that is readily soluble in water and in saline. Each IMITREX Tablet for oral administration contains 35, 70, or 140 mg of sumatriptan succinate equivalent to 25, 50, or 100 mg of sumatriptan, respectively. Each tablet also contains the inactive ingredients croscarmellose sodium, dibasic calcium phosphate, magnesium stearate, microcrystalline cellulose, and sodium bicarbonate. Each 100-mg tablet also contains hypromellose, iron oxide, titanium dioxide, and triacetin.

POLH Polymerase (DNA directed), eta, also known as POLH, is a protein which in humans is encoded by the POLH gene. # Function This gene encodes a member of the Y family of specialized DNA polymerases. It copies undamaged DNA with a lower fidelity than other DNA-directed polymerases. However, it accurately replicates UV-damaged DNA; when thymine dimers are present, this polymerase inserts the complementary nucleotides in the newly synthesized DNA, thereby bypassing the lesion and suppressing the mutagenic effect of UV-induced DNA damage. This polymerase is thought to be involved in hypermutation during immunoglobulin class switch recombination. Mutations in this gene result in XPV, a variant type of xeroderma pigmentosum. # Clinical significance Xeroderma pigmentosum (XP) is an autosomal recessive human disease characterized by sunlight sensitivity, cutaneous and ocular deterioration, and premature malignant skin neoplasms after exposure to sunlight. XP has been classified into eight complementation groups, XP-A to XP-G and XP-V. Cells from XP-A to XP-G patients have defects in the process of nucleotide excision repair (NER), which eliminates a wide variety of structurally unrelated lesions, including ultraviolet light (UV)-induced cyclobutane pyrimidine dimers (CPD) and (6-4) photoproducts, as well as certain chemical adducts. The genes and proteins of XP groups A, B, C, D, F and G have been isolated and found to represent some of the subunits of the core NER machinery. In contrast, cells belonging to the eighth group, XP variant (XP-V), are NER-proficient but display abnormal DNA replication, including reduced ability to elongate nascent DNA strands on UV-irradiated DNA. Thus, the XP-V gene product is likely to be involved in the process of DNA replication on damaged DNA known as post-replication repair, but not in NER

MLH3 DNA mismatch repair protein Mlh3 is a protein that in humans is encoded by the MLH3 gene. # Function This gene is a member of the MutL-homolog (MLH) family of DNA mismatch repair (MMR) genes. MLH genes are implicated in maintaining genomic integrity during DNA replication and after meiotic recombination. The protein encoded by this gene functions as a heterodimer with other family members. Somatic mutations in this gene frequently occur in tumors exhibiting microsatellite instability, and germline mutations have been linked to hereditary nonpolyposis colorectal cancer type 7 (HNPCC7). Several alternatively spliced transcript variants have been identified, but the full-length nature of only two transcript variants has been determined. Orthologs of human MLH3 have also been studied in other organisms including mouse and the budding yeast Saccharomyces cerevisiae. # Meiosis In addition to its role in DNA mismatch repair, MLH3 protein is also involved in meiotic crossing over. MLH3 forms a heterodimer with MLH1 that appears to be necessary for mouse oocytes to progress through metaphase II of meiosis. The MLH1-MLH3 heterodimers promote crossovers. Recombination during meiosis is often initiated by a DNA double-strand break (DSB) as illustrated in the accompanying diagram. During recombination, sections of DNA at the 5' ends of the break are cut away in a process called resection. In the strand invasion step that follows, an overhanging 3' end of the broken DNA molecule then "invades" the DNA of an homologous chromosome that is not broken forming a displacement loop (D-loop). After strand invasion, the further sequence of events may follow either of two main pathways leading to a crossover (CO) or a non-crossover (NCO) recombinant (see Genetic recombination. The pathway leading to a CO involves a double Holliday junction (DHJ) intermediate. Holliday junctions need to be resolved for CO recombination to be completed. In the budding yeast Saccharomyces cerevisiae, as in the mouse, MLH3 forms a heterodimer with MLH1. Meiotic CO requires resolution of Holliday junctions through actions of the MLH1-MLH3 heterodimer. The MLH1-MLH3 heterodimer is an endonuclease that makes single-strand breaks in supercoiled double-stranded DNA. MLH1-MLH3 binds specifically to Holliday junctions and may act as part of a larger complex to process Holliday junctions during meiosis. MLH1-MLH3 heterodimer (MutL gamma) together with Exo1 and Sgs1 (ortholog of Bloom syndrome helicase) define a joint molecule resolution pathway that produces the majority of crossovers in budding yeast and, by inference, in mammals. # Interactions MLH3 has been shown to interact with MSH4.

Avalglucosidase alfa for treating Pompe disease Evidence-based recommendations on avalglucosidase alfa (Nexviadyme) for Pompe disease. # Recommendations Avalglucosidase alfa (AVAL) is recommended, within its marketing authorisation, as an option for treating Pompe disease in babies, children, young people and adults, only if the company provides AVAL according to the commercial arrangement. Why the committee made this recommendation Pompe disease either occurs at birth (infantile onset; IOPD), or after 12 months (late onset; LOPD). The only treatment for Pompe disease is enzyme replacement therapy (ERT) with alglucosidase alfa (ALGLU). AVAL is an alternative ERT that works in the same way. Limited evidence shows AVAL can enter cells more easily, so reducing glycogen levels more efficiently than ALGLU. But the clinical benefit is uncertain. In LOPD, the cost-effectiveness estimates are uncertain because of uncertainties in the clinical evidence. But they are below what NICE normally considers an acceptable use of NHS resources, so AVAL is recommended for LOPD. Because IOPD is very rare, data is limited. So, assumptions about its efficacy were needed, which makes the cost-effectiveness estimates uncertain. When assuming that AVAL works as well as ALGLU, cost-effectiveness estimates are below what NICE normally considers an acceptable use of NHS resources. Given the high burden of Pompe disease on children and their carers, and the rarity of the condition, the committee accepted the uncertainties. So, AVAL is recommended for IOPD.# Information about avalglucosidase alfa # Marketing authorisation indication Avalglucosidase alfa (AVAL; Nexviadyme, Sanofi Genzyme) is indicated 'for long-term enzyme replacement therapy for the treatment of patients with Pompe disease (acid alpha-glucosidase deficiency).' # Dosage in the marketing authorisation The dosage schedule is available in the summary of product characteristics for AVAL. # Price The list price of a 100‑mg vial of AVAL is £783.33 (excluding VAT; company submission). The company has a commercial arrangement. This makes AVAL available to the NHS with a discount. The size of the discount is commercial in confidence. It is the company's responsibility to let relevant NHS organisations know details of the discount.# Committee discussion The appraisal committee considered evidence submitted by Sanofi Genzyme, a review of this submission by the evidence review group (ERG), and responses from stakeholders. See the committee papers for full details of the evidence. # The condition ## Pompe disease is a rare genetic condition which is severely debilitating, affecting quality of life Pompe disease is a rare, genetic, chronic and progressive metabolic disease, resulting in severe disability and a reduced life expectancy. Pompe disease is caused by mutations in the gene that encodes the enzyme acid alpha-glucosidase (GAA), which is needed to break down glycogen into glucose. In Pompe disease, there is reduced or absent activity of GAA, which causes an accumulation of lysosomal glycogen in muscle cells resulting in irreversible muscle damage. Disease severity is influenced by the level of residual GAA activity. There is a range of phenotypes of Pompe disease, differing in age of onset, extent of organ involvement and rate of progression, which can be classified into 2 broad subtypes: infantile-onset Pompe disease (IOPD) and late-onset Pompe disease (LOPD). IOPD presents in the first 12 months of life and is typically associated with cardiomyopathy, hypotonia and respiratory distress. If untreated, children will typically need ventilation by 6 months. Clinical experts stated that, in the absence of treatment, they would expect most children with IOPD to have a life expectancy of around 14 months because of heart complications. For LOPD, symptom onset is after 12 months and can happen any time up to late adulthood. LOPD typically affects multiple systems and is characterised by progressive muscle weakness and respiratory involvement. As the disease progresses, people with LOPD may need to use a wheelchair and need non-invasive or invasive ventilation, with respiratory failure being the leading cause of death. There is significant heterogeneity within people with LOPD, including time of symptom onset, time of diagnosis, symptom severity, rate of disease decline and life expectancy. The committee concluded that Pompe disease has a severe effect on both quality and length of life. # Treatment pathway ## There are limited treatment options for people with Pompe disease Currently, the only treatment option for Pompe disease is alglucosidase alfa (ALGLU), an enzyme replacement therapy (ERT) that has not previously been assessed by NICE. Alongside ALGLU, people with Pompe disease need tailored supportive care from multidisciplinary teams of health professionals. Response to ALGLU can vary between people. There is a well-recognised need to provide better options for people whose disease is not well managed or if the treatment effect has waned. Patient experts explained how symptom-relieving supportive care interventions can help but also come with additional disadvantages. The committee concluded that there is a need for more effective treatments for Pompe disease. ## The availability of avalglucosidase alfa would be expected to provide benefits for people with IOPD and LOPD Avalglucosidase alfa (AVAL) is indicated for the long-term treatment of Pompe disease. AVAL is expected to provide benefits as a treatment option for IOPD and LOPD. Clinical experts explained that AVAL is the same enzyme as ALGLU but has a better delivery mechanism which should get more enzyme into muscle cells. Therefore, they expect AVAL to have a positive effect for people with Pompe disease and be a better option than ALGLU. People with Pompe disease are optimistic about future treatment with AVAL. One person who has had treatment with AVAL told of the positive effect it has had on their life. Since treatment with AVAL in the clinical trial, they no longer have mobility or breathing problems, and do not have to worry about not being able to do things that people without the disease may be able to do. The committee concluded that clinicians and people with Pompe disease would welcome an effective alternative to current treatment. # Clinical evidence ## Clinical evidence is limited to 2 studies in the LOPD population Clinical data is limited in Pompe disease. The key clinical evidence comes from the COMET study and NEO1/NEO-EXT. COMET was a randomised, multicentre, double-blind, active-controlled 49‑week study comparing AVAL (n=51) with ALGLU (n=49) in people with LOPD who have not had ERT previously. COMET was a non-inferiority study, aiming to test whether AVAL is no less effective than ALGLU. The primary outcome in COMET was mean percentage change in forced vital capacity (FVC%), and key secondary outcomes included the 6‑minute walk test (6MWT), safety and health-related quality of life. NEO1/NEO-EXT was an open-label, multicentre, ascending dose study which assessed the safety, tolerability, pharmacokinetics, pharmacodynamics, and exploratory efficacy of AVAL (n=24) and long-term extension (up to week 312; n=19). The primary outcome from NEO1/NEO-EXT was safety and tolerability of AVAL over different doses. NEO1/NEO-EXT also collected change from baseline in FVC% and 6MWT. The committee concluded that the evidence was limited, but acceptable for decision making. ## COMET reported no statistically significant benefits in LOPD, although FVC% and 6MWT did improve The COMET primary analysis at week 49 showed that AVAL was non-inferior to ALGLU in the FVC% and 6MWT outcome measures. There were some minor positive changes, but these were not statistically significant. AVAL showed a numerical improvement in FVC% from baseline, but this was not statistically significantly better than with ALGLU. There was also a numerical improvement in 6MWT with AVAL, but the statistical significance of this change compared with ALGLU was not reported. Health-related quality of life data collected in COMET showed utility values were generally higher over time than at baseline for both treatments. COMET safety data suggests AVAL and ALGLU are similarly tolerated. The most common adverse events were headache, nasopharyngitis, back pain, fatigue, diarrhoea and nausea. The committee and clinical experts noted that COMET is a non-inferiority study. The committee accepted that there was nothing to suggest that AVAL was inferior to the current treatment and that there is a theoretical potential for additional benefit. ## There appeared to be stability in treatment effect over time in NEO1/NEO-EXT, but data should be interpreted with caution Longer-term AVAL clinical data from NEO1/NEO-EXT showed that FVC% and 6MWT results were generally stable over time, although patient numbers in NEO1/NEO-EXT were small. The committee and clinical experts would have expected to see an improvement in FVC% and 6MWT after week 49 when people who were initially having ALGLU switched to AVAL, if AVAL was a more effective treatment, but this was not apparent in the data. Clinical experts explained that sometimes a maintenance of effect is a positive sign of slowing a progressive disease such as LOPD. The committee concluded that caution should be taken when interpreting long-term NEO1/NEO-EXT data. ## Data for the IOPD population comes from mini-COMET and is uncertain because of heterogeneity, small sample sizes and limited follow up Clinical data was very limited in the IOPD population. Clinical evidence for AVAL in the IOPD population came from a multi-stage, open-label, multicentre, ascending dose study including 3 cohorts (mini-COMET). Only cohort 3 compared AVAL with ALGLU. Children in mini-COMET had previously had ALGLU. There is no data for children with IOPD who have not previously had ERT. Cohort 1 and cohort 2 included children with clinical decline, cohort 1 had AVAL 20 mg/kg every 2 weeks and cohort 2 had AVAL 40 mg/kg every 2 weeks. Cohort 3 was the randomised portion of the trial, with children having either AVAL at the highest tolerated dose (n=5) or ALGLU at the current stable dose (n=6). Mini-COMET enrolled 22 people (cohort 1, n=6; cohort 2, n=5; cohort 3, n=11). Therefore, comparative data is only available from 11 children, all of whom had a suboptimal disease response to ALGLU. Clinical experts explained that for the purposes of the study, children were divided into groups classified as suboptimal response, or clinical decline, but the classification would depend on which outcome measure was used. There was also variation in the doses given. Some children had weekly treatment, and some had doses greater than currently used in NHS clinical practice. Clinical experts explained current practice is to offer ALGLU weekly 20 mg/kg at the start of treatment, at least for the first 12 weeks. They stated that evidence was emerging that a dose of 40 mg/kg ALGLU is more effective than 20 mg/kg. Clinical experts would expect any dose increase for ALGLU to also apply to AVAL. The committee was aware that it could only recommend any treatment in line with its marketing authorisation. Clinical experts considered the efficacy data from mini-COMET to be too heterogeneous and uncertain to be reliable, but the safety and pharmacokinetic data is satisfactory. Mini-COMET suggests AVAL and ALGLU are similarly tolerated. The committee concluded that the data on IOPD is very limited and uncertain but noted the rarity of the condition makes data collection difficult. # Economic model ## The company LOPD simulation model is appropriate for decision making The company LOPD model used a simulation approach with 6 health states. Each health state is associated with different costs, quality of life and mortality risks. The company included 8 profiles to model the population that would be likely to have treatment for LOPD in the UK. The profiles were informed by COMET patient-level data and were split by sex, age, time since diagnosis, weight, FVC%, 6MWT and utility. People entered the model not dependent on ventilators or wheelchairs. COMET changes in FVC% informed transitions through ventilator- or invasive ventilator-dependent health states and changes in 6MWT informed transitions through wheelchair-dependent health states. The duration of disease response was informed by NEO-EXT, after which benefits declined at a constant rate. The ERG thought the model health states captured the key aspects and progressive nature of the disease, and the simulation approach captured heterogeneity and patient history. However, the ERG thought that the profiles used by the company included less severely affected people than would typically be seen in NHS practice. Clinical experts would expect AVAL to slow the rate of clinical decline more than ALGLU. The committee concluded the structure of the model was appropriate for decision making. ## The committee accepted that a survival benefit for AVAL was possible, and should be explored Overall survival was informed by general population life tables, with hazard ratios (HRs) applied to adjust survival for people with LOPD. The company originally assumed people with LOPD who had AVAL and ALGLU had the same survival prospects. The ERG disagreed, and suggested AVAL should be associated with a survival benefit because of the expected clinical benefits associated with AVAL treatment. The ERG suggested that a HR of 0.85 should be applied to AVAL overall survival which translated into a 3‑month survival gain for people who had AVAL. The company accepted this HR approach and included it in the base-case analysis. Clinical experts stated that a survival benefit for people who had AVAL was possible but noted that there is no survival data to confirm or quantify this. The committee concluded that a survival benefit for AVAL over ALGLU was plausible, but unproven. It accepted that it was reasonable to explore the effect of an assumption of improved survival on cost effectiveness. ## The company IOPD 4-state partitioned survival model was appropriate, but needed assumptions in place of informative data The company IOPD model followed a partitioned survival model approach with 4 health states. People could be ventilation free, dependent on non-invasive ventilation, dependent on invasive ventilation or deceased. Overall survival, ventilator-free survival and invasive ventilator-free survival curves from Broomfield (a case-note review of 33 children who had previously had ALGLU) were extrapolated and formed the basis of the 4‑state partitioned survival model. Wheelchair dependence was captured separately to the core health states. The ERG accepted the approach chosen, indicating that the 4 health states captured disease progression, but noted the overall survival curve may not capture risk of death for children needing artificial ventilation. The committee highlighted that while data is limited for this population, the modelling approach used was appropriate. ## Equivalent survival outcomes were an area of uncertainty in the IOPD model Mini-COMET has short follow up and small patient numbers, so relative effectiveness is uncertain. In the absence of long-term survival data from trials in children with IOPD, the company used published data from the Broomfield case-note study of children who had ALGLU. The company assumed disease progression and survival prospects for children who had AVAL would be the same as seen in Broomfield (assuming equivalence). The ERG agreed that mini-COMET data is too limited to inform survival, or to confirm or reject equivalence. The ERG ultimately accepted the company's approach of equivalent survival but ran scenario analyses with a survival advantage for children who had AVAL. In these scenarios, children live longer and have treatment for longer, resulting in substantially higher incremental cost-effectiveness ratios (ICERs). Clinical experts suggested that it is plausible that children who had AVAL could have a survival advantage. However, they explained any benefit would also bring other benefits such as slower progression and better quality of life which has not been modelled in the scenarios. The ERG accepted the scenarios are an oversimplification of a complex progressive disease, but highlighted limitations of available IOPD data. The committee concluded that they were satisfied with equivalence assumptions in the IOPD population but accepted the uncertainty. # Cost-effectiveness estimates ## AVAL is likely to be cost effective in LOPD NICE's guide to the methods of technology appraisal notes that above a most plausible ICER of £20,000 per quality-adjusted life year gained, judgements about the acceptability of a technology as an effective use of NHS resources will take into account the degree of certainty around the ICER. The committee will be more cautious about recommending a technology if it is less certain about the ICERs presented. The company's and ERG's cost-effectiveness estimates for AVAL in people with LOPD were well below what NICE normally considers an acceptable use of NHS resources. The company's and ERG's base-case analyses differed only in the duration of response for ALGLU and AVAL. The company assumed a greater duration of response for AVAL, whereas the ERG assumed an equivalent duration for both treatments. Even when considering this change, AVAL would still be a dominant use of NHS resources when compared with ALGLU (that is, it costs less and is more effective). The committee concluded that AVAL would be a cost-effective treatment option for LOPD, so it is recommended. ## AVAL is also likely to be cost effective in IOPD, although results are more uncertain The company's and ERG's base-case cost-effectiveness estimates for AVAL in children with IOPD were also well below what NICE normally considers an acceptable use of NHS resources. The company's and ERG's base-case analyses differed in dosing, survival extrapolation and utility assumptions, but even when considering these differences, AVAL would still be a dominant use of NHS resources. Scenario analyses done by the ERG investigating survival gains for children who had AVAL saw ICERs increase to values not considered cost effective. The committee noted these scenarios were exploratory and informed by assumptions and not survival data. The committee would have preferred to have seen a full cost-utility analysis in IOPD, informed by robust comparative clinical data but acknowledged that, in this specific case, this was not available. However, given current limited IOPD evidence suggesting that AVAL is non-inferior to ALGLU, the high burden of Pompe disease on children and their carers, and the rarity of the condition, the committee accepted uncertainties in dosing, overall survival and duration of response in IOPD. The committee concluded that AVAL is likely to be a cost-effective treatment option for IOPD, so it is recommended. # Innovation AVAL is anticipated to address the unmet need of a population of people with Pompe disease for whom existing treatment is suboptimal. Clinical experts explained that AVAL is a second-generation ERT, and that alterations made to the GAA enzyme are designed to improve the efficiency of the uptake of the enzyme rather than being a step change in management. The company argued that AVAL is quicker to reconstitute than ALGLU which could reduce vial preparation time and free up capacity in the NHS. The committee concluded that all additional benefits of AVAL had already been taken into account. # Conclusion AVAL is recommended for use in the NHS for treating Pompe disease. The cost-effectiveness estimates for both IOPD and LOPD were uncertain. But they were likely to remain below what is considered an acceptable use of NHS resources even when accounting for the uncertainty.

Masoprocol (patient information) # IMPORTANT WARNING Masoprocol is no longer available in the U.S. If you are currently taking masoprocol, you should call your doctor to discuss switching to another treatment. # Why this medication is prescribed Masoprocol is used to treat sun-induced skin growths. This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information. # How this medication should be used Masoprocol comes in cream for use on the skin. Masoprocol usually is applied every morning and evening for 28 days. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use masoprocol exactly as directed. Do not use more or less of it or use it more often than prescribed by your doctor. If you are using this medication on a child's diaper area, do not place tight-fitting diapers or plastic pants on the child. They can increase the absorption of masoprocol, which can cause harmful effects. Thoroughly clean the infected area, allow it to dry, and then gently rub the medication in until most of it disappears. Use just enough medication to cover the affected area. You should wash your hands after applying the medication. # Special precautions Before using masoprocol: - tell your doctor and pharmacist if you are allergic to masoprocol, sulfites, or any other drugs. - tell your doctor and pharmacist what prescription and nonprescription medications you are taking, including vitamins. - tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while using masoprocol, call your doctor. - plan to avoid unnecessary or prolonged exposure to sunlight and to wear protective clothing, sunglasses, and sunscreen. Masoprocol may make your skin sensitive to sunlight. # What to do if you forget a dose Apply the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not apply a double dose to make up for a missed one. # Side effects ## Minor side effects Masoprocol may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away: - burning - redness - itching - dry skin - roughness or wrinkling ## Severe side effects If you experience any of the following symptoms, call your doctor immediately: - bleeding - blistering - skin rash # Storage conditions needed for this medication Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication. # Other information Keep all appointments with your doctor. Masoprocol is for external use only. Do not let masoprocol get into your eyes, nose, or mouth, and do not swallow it. Do not apply dressings, bandages, cosmetics, lotions, or other skin medications to the area being treated unless your doctor tells you. This medication can stain clothing and bedding. Rub the cream into your skin well and apply it 2 hours before bedtime to decrease staining. Do not let anyone else use your medication. Ask your pharmacist any questions you have about refilling your prescription. Tell your doctor if your skin condition gets worse or does not go away. # Brand names - Actinex®

This report consolidates previous recommendations and adds new ones for preventing and controlling infections with hepatitis viruses in correctional settings. These recommendations provide guidelines for juvenile and adult correctional systems regarding 1) identification and investigation of acute viral hepatitis; 2) preexposure and postexposure immunization for hepatitis A and hepatitis B; 3) prevention of hepatitis C virus infection and its consequences; 4) health education; and 5) release planning. Implementation of these recommendations can reduce transmission of infections with hepatitis viruses among adults at risk in both correctional facilities and the outside community. These recommendations were developed after consultation with other federal agencies and specialists in the fields of corrections, correctional health care, and public health at a meeting in Atlanta, March 5-7, 2001. This report can serve as a resource for those involved in planning and implementing health-care programs for incarcerated persons.Adolescent: Person aged >10 and 19 years. Anti-HAV: Total antibody to hepatitis A virus (HAV) detected in serum of persons with acute or resolved HAV infection; indicates a protective immune response to infection, vaccination, and passively acquired antibody. Anti-HBc: Antibody to hepatitis B core antigen; positive test indicates past or current infection with HBV. Anti-HBs: Antibody to hepatitis B surface antigen; indicates immunity to HBV infection, either from HBV infection or immunization. Anti-HCV: Antibody to HCV; positive test indicates past or current infection with HCV. Arrestee: Person placed under arrest by law enforcement who has not been formally charged with a crime. Body fluids, potentially infectious: Semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial MMWR January 24, 2003 TABLE 1. Estimated chronic infections with hepatitis viruses among inmates and releasees -United States, 1997 Chronic infection Hepatitis B virus Hepatitis C virus Source: Adapted from National Commission on Correctional Health Care. The health status of soon-to-be-released inmates: a report to Congress. Chicago, IL: National Commission on Correctional Health Care, 2002. Available at . - Based on 1.7 million inmates in prisons and jails, 1997 (15). † Based on estimated 7.75 million unduplicated released inmates (2); A.# Introduction Persons incarcerated in correctional systems comprise approximately 0.7% of the U.S. population and have a disproportionately greater burden of infectious diseases, including infections with hepatitis viruses and other infections of public health importance (e.g., human immunodeficiency virus , sexually transmitted disease , and tuberculosis infections) (1). In 2000, >8 million inmates of prisons and jails were released and returned to the community (A. Beck, Ph.D., Bureau of Justice Statistics, personal communication, 2002). Recent estimates indicate 12%-39% of all Americans with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections were releasees during the previous year (1) (Table 1). The significance of including incarcerated populations in community-based disease prevention and control strategies is now recognized by public health and correctional professionals (2,3). Improved access to medical care and prevention services for incarcerated populations can benefit communities by reducing disease transmission and medical costs (4)(5)(6)(7)(8). Inmates who participate in health-related programs while incarcerated have lower recidivism rates and are more likely to maintain health-conscious behaviors (4). Finally, because incarcerated persons have a high frequency of infection with hepatitis viruses, community efforts to prevent and control these infections require inclusion of the correctional population (9)(10)(11). However, implementation of preventive health programs for incarcerated persons has substantial challenges. Correctional staff are among groups at potential risk for occupationally acquired infections with bloodborne pathogens. Therefore, recommendations are also reviewed for prevention and control of infections with hepatitis viruses among correctional workers. fluid, peritoneal fluid, and amniotic fluid. Potentially infectious body fluids include any body fluid visibly contaminated with blood, and all body fluids in situations where identifying blood contamination is difficult or impossible. Detainee: Person arrested and legally charged with a crime who is held in a correctional facility before trial. HAV: Hepatitis A virus, the infectious agent that causes HAV infection and hepatitis A. HBIG: Hepatitis B immune globulin; sterile preparation of high-titer antibodies (immunoglobulins) to hepatitis B surface antigen obtained from pooled human plasma of immunized persons and which provides protection against HBV infection. HBeAg: Hepatitis B e antigen; positive test correlates with HBV replication and infectivity. HBsAg: Hepatitis B surface antigen; positive test indicates an active HBV infection. HBV: Hepatitis B virus, the infectious agent that causes HBV infection, hepatitis B, and chronic liver disease. HBV DNA: Deoxyribonucleic acid from HBV; positive test indicates active infection. HCC: Hepatocellular carcinoma; a primary liver cancer caused by chronic HBV or HCV infection that is usually fatal. HCV: Hepatitis C virus, the infectious agent that causes HCV infection, hepatitis C, and chronic liver disease. HCV RNA: Ribonucleic acid from HCV; positive test indicates active infection. HDV: Hepatitis D virus, a viroid (incomplete virus) that requires an active (acute or chronic) HBV infection to replicate and cause delta hepatitis virus infection, delta hepatitis, and chronic liver disease. IDUs: Injection-drug users; persons who have ever used needles to inject illicit drugs. IgM anti-HAV: Immunoglobulin M antibody to HAV; positive test indicates acute HAV infection. IgM anti-HBc: Immunoglobulin M antibody to hepatitis B core antigen; positive test indicates acute HBV infection. IG: Immune globulin; sterile preparation of antibodies (immunoglobulins) made from pooled human plasma that contains anti-HAV and provides protection against hepatitis A. Infant: Person aged <1 year. Inmate: Incarcerated person. Jail: Locally operated correctional facility that confines persons pending arraignment, awaiting trial and sentencing, or serving their sentences (usually <1 year). Juvenile: Person aged <19 years, in custody of the legal system. Prison: Adult correctional facility under the jurisdiction of state or federal authorities that confines persons with a sentence of >1 year. Seroconversion: The change of a serologic test from negative to positive. Seroprotection: Level of antibodies necessary to protect against infection. # Correctional Populations Juveniles In 1997, approximately 12% of persons aged 16 years reported at least one arrest in their lifetimes (12). In 1999, a reported 108,965 juvenile offenders were held in residential placement facilities (13). In 1994, the average length of stay in public facilities for juvenile releasees was 2 weeks for those detained and 5 months for those committed; the stay in private facilities (primarily a committed population) averaged 3.5 months (12). Of arrested juveniles not incarcerated, the majority are diverted to alternative programs (e.g., teen courts or restorative justice) where they remain under supervision of the juvenile justice system. Approximately 74% of incarcerated juvenile offenders are held in public facilities, and the population, especially in jails, and the suboptimal funding of correctional health and prevention services, often limits the correctional system in providing both curative and preventive care. Infectious diseases -including acquired immune deficiency syndrome (AIDS), STDs, TB, and viral hepatitis -are more prevalent among correctional inmates than the general population. In 1997, an estimated 46,000-76,000 prison and jail inmates had serologic evidence of syphilis; 8,900 had AIDS (4% of the U.S. AIDS burden); and 1,400 had active TB (4% of the U.S. TB burden) (1). Among incarcerated persons, shared risk factors (e.g., injection-drug use) can result in populations coinfected with HBV, HCV, or HIV. Coinfections can make treatment of chronic viral hepatitis, AIDS, and TB more difficult because of the need to use multiple drugs, which increases the chance of hepatotoxicity and other adverse events. In addition, both TB chemoprophylaxis and HIV postexposure prophylaxis can be complicated by the presence of chronic liver disease (24,25). # Risk Factors for Viral Hepatitis Transmission Among Incarcerated Persons Drug Use During 1990-1999, the rate of arrest for substance abuse violations among persons aged 10-17 years increased by 132% (12,26). Injection-drug use is reported by 3.3%-6% of incarcerated juveniles (A. Thomas, M.D., Oregon Health Division; and R. Bair, M.D., Bexar County Juvenile Detention Center, San Antonio, Texas; personal communications, 2001). Among juvenile detainees, 53% of males and 38% of females tested positive for marijuana use at the time of arrest, <17% tested positive for cocaine, and <18% were positive for methamphetamine (27). Arrested adults also have a high prevalence of illicit drug use. In 2000, 21% of state prisoners and 59% of federal prisoners were incarcerated for drug offenses (13). In 1997 inmate surveys, 83% of state prisoners and 73% of federal prisoners reported past drug use, and 57% of state prisoners and 45% of federal prisoners reported using drugs in the month before their offense (28). Among jail inmates, drug use in the month before incarceration was reported by 55%, and injection-drug use was reported by 18% (29). However, urine testing at entry has indicated drug use might be substantially underreported by jail inmates (30). Injection-drug use during incarceration has been reported by 3%-28% of adult inmates (31)(32)(33)(34). Although certain correctional systems rest in facilities operated by private contractors (14). Adult jails hold >7,600 juveniles, and approximately 3,100 are held in adult prisons (15). Females account for 27% of juveniles arrested and 13% of those in residential placement (14,16). Of juveniles arrested in 1999, approximately 72% were white, 25% black, and 3% of other races. However, a disproportionate number of racial and ethnic minorities were detained in residential placement (40% black and 18% Hispanic). # Adults At the end of 2001, adult jail and prison populations totaled 1.96 million -a 71% increase from 1990 (13). Prior incarceration as juveniles was reported by 9% of adults in federal prisons and by 20% in state prisons (17). According to 2000 data, racial/ethnic minorities were overrepresented, with 46% black, 36% white, 16% Hispanic, and 2% other races. Approximately 6.6% of adult inmates are female, a 111% increase since 1990; of incoming women to state prisons, 5% are pregnant (18). Among adult U.S. residents, 1 in every 112 men and 1 in every 1,724 women were sentenced to state or federal prisons in 2001 (13). The estimated 12.6 million admissions and 12.6 million releases from local jails, and 625,000 admissions and 606,000 releases from prisons represent annual turnover rates of 1300% and 40%, respectively (1,15; A. Beck, Ph.D., Bureau of Justice Statistics, personal communication, 2002). # Staff In 2000, >457,000 custody and security officers worked in the U.S. correctional system, including both public and private sectors (19). These officers comprise approximately two thirds of all correctional staff, which also includes professional, technical, educational, clerical, maintenance, food service, and administrative workers (20,21). # Health Care in the Correctional System Upon incarceration, all adults and the majority of juveniles lose access to the usual public and private health-care and disease-prevention services. Their health care becomes the sole responsibility of either the correctional system (federal, tribal, state, or local), or less frequently, the public health system (22). For the majority of persons, entry into the correctional system provides an opportunity to access health care. In one series, approximately 78% of newly incarcerated females had abnormal Papanicolaou smears, and >50% had vaginal infections or STDs (23). However, the rapid turnover of the incarcerated offer substance-abuse treatment and education programs, demand usually exceeds program capacity (20). There appear to be no comprehensive risk-reduction programs available within correctional facilities. # Sexual Behavior All states have laws prohibiting sex between adult residents of correctional systems (35). Despite these laws, 2%-30% of inmates have sex while incarcerated (31,(36)(37)(38). Outbreaks of syphilis and hepatitis B among inmates reflect sexual activity in correctional facilities (31,33,39,40). Although two state prison systems and five city or county correctional systems make condoms available to adult inmates and detainees for use in their facilities (Vermont, Mississippi, New York City, Philadelphia, San Francisco, Washington D.C., Los Angeles), no juvenile correctional systems are known to provide condoms (E. Dunlap, National Juvenile Detention Association, personal communication, 2001). # Percutaneous Exposures of Uncertain Risk Percutaneous exposures have the potential to transfer infectious blood and transmit bloodborne pathogens. Tattoos and other percutaneous exposures (e.g., bites and abrasions) are common in correctional facilities and have the potential to expose residents and correctional staff to blood and body fluids (34,41,42). Case-control studies indicate tattooing is not a risk factor for acquiring acute hepatitis B or hepatitis C (43,44). However, results from seroprevalence studies of noninstitutionalized populations have been variable, and studies of highly select groups might not be generalizable to other populations (45). One study of a limited number of IDUs suggested an increased risk for both HBV and HCV infection among those tattooed while in prison (46), but limited studies of both adult and juvenile inmate populations have not confirmed this finding (33; R. Bair, M.D., Bexar County Juvenile Detention Center, San Antonio, Texas, personal communication, 2001). # Occupational Exposures Correctional employees have reported injuries from human bites, needles, and other sharp instruments, as well as skin and mucous membrane exposures to blood and body fluids (41,42). Occupational transmission of HBV infection among hospital-based workers has been linked to percutaneous and mucous membrane exposures, and HBV infection has been primarily associated with percutaneous exposure. Transmissions of HBV and HCV infections have not been associated with intact skin exposures (10,47). Limited data from correctional workers have indicated 21% reported blood contact with intact skin, and 7% reported a percutaneous exposure (including needle stick, cut with a contaminated object, or bite) or mucus membrane exposure (48). # Epidemiology and Outcome of Infection with Hepatitis Viruses Hepatitis A Virus Infection HAV infection is usually acquired by the fecal-oral route, produces a self-limited disease that does not result in chronic infection or long-term liver disease, and usually produces symptoms of acute viral hepatitis among adolescents and adults after an average incubation period of 28 days (range: 15-50 days). Signs and symptoms usually last <2 months, although 10%-15% of symptomatic persons have prolonged or relapsing disease lasting <6 months (49). Peak infectivity occurs during the 2-week period before the onset of jaundice or elevation of liver enzymes, when the concentration of virus in stool is highest (11). Persons with chronic liver disease who acquire hepatitis A are at increased risk for fulminant hepatitis (50). # Epidemiology of HAV Infection In the United States, the majority of cases of hepatitis A occur through person-to-person transmission during communitywide outbreaks (11,51). Viral transmission can occur through close personal contact (e.g., household contact, sexual contact, drug use, or children playing), and contaminated food or water (e.g., infected food-handlers or raw shellfish). The most frequently reported source of infection (12%-26%) is household or sexual contact with a person with HAV infection; however, 45%-50% of patients have no identified source for their infection (51,52). Historically, the highest rates of disease have occurred in 11 western U.S. states and certain counties, which accounted for approximately 50% of cases during 1987-1997 (11,52). HAV infection is common among IDUs. Injection-drug use has been reported by 5%-19% of hepatitis A patients. In certain communities, hepatitis A outbreaks involving users of injected and noninjected methamphetamine have accounted for approximately 30% of reported cases (11,51,53,54). Crosssectional serologic surveys demonstrate that users of illicit drugs have a higher prevalence of infection than the general U.S. population (11,55). Viremia occurs during HAV infection, and transmission has occurred from parenteral blood exposure (e.g., blood transfusion or injection-drug use) on occasion (56). However, the majority of transmissions among users of illicit drugs are believed to occur through fecal contamination of drug paraphernalia and subsequent percutaneous inoculation, as well as from close personal contact (57). Hepatitis A outbreaks among men who have sex with men (MSM) are frequently reported, and cyclic outbreaks occur in urban areas of the United States (58,59). HAV-infected MSM report more frequent oral-anal contact, longer duration of sexual activity, and a larger number of sex partners than persons without serologic evidence of infection (60)(61)(62)(63). # HAV Infection in Correctional Settings No hepatitis A outbreaks have been reported from correctional settings, although a substantial proportion of incarcerated persons have risk factors for infection (e.g., drug use or MSM). The prevalence of prior HAV infection among incarcerated persons is estimated at 22%-39%, which is similar to age-adjusted prevalence rates in the general U.S. population 2001). Employment in a correctional setting has not been identified as a risk factor for HAV infection. # Hepatitis B Virus Infection HBV is a bloodborne pathogen, transmitted by percutaneous or permucosal (e.g., sexual) exposure to infectious blood or body fluids (e.g., semen or saliva). HBV circulates in high titers in the blood and lower titers in other body fluids (e.g., semen, vaginal fluid, or saliva), and is approximately 100 times more infectious than HIV and 10 times more infectious than HCV (47). Acute hepatitis B develops in approximately 30%-50% of adults at the time of initial infection and is characterized by anorexia, nausea, vomiting, and often jaundice. The risk of progression to chronic infection varies with age, being highest among young children and infants (30%-90%) and lowest among adolescents and adults (2%-6%) (64). The majority of persons with chronic HBV infection are asymptomatic, and one third have no evidence of liver disease, despite high levels of viral replication in hepatocytes (65). The remainder have chronic hepatitis (mild, moderate, or severe) that can lead to cirrhosis and HCC. Persons with chronic HBV infection have a 15%-25% lifetime risk of death from chronic liver disease or HCC (66)(67)(68)(69)(70). Rates of progression to cirrhosis and HCC vary according to age at acquisition of chronic infection; HBeAg status; coinfection with HDV, HIV, HCV; and alcohol abuse (69,(71)(72)(73)(74)(75). HBVrelated liver disease and HCC cause approximately 3,000 deaths in the United States annually (S. Goldstein, M.D., CDC, unpublished data, 2002). # Epidemiology of HBV Infection An estimated 5% of the civilian, noninstitutionalized U.S. population has serologic evidence of past or present HBV infection, and 0.4%-0.5% have chronic infection and serve as the primary source of infection for others (9,76). Overall prevalence of HBV infection differs among racial/ethnic populations and is highest among persons who have immigrated from areas with a high endemicity of HBV infection (e.g., Asia, Pacific Islands, Africa, and the Middle East) (77). Prevalence of infection among blacks is four times prevalence among whites (11.9% compared with 2.6%) (76). During 1987-1998, reported cases of acute hepatitis B declined by 76% (8). Nonetheless, an estimated 78,000 persons were infected with HBV in 2001 (G. Armstrong, M.D., CDC, unpublished data, 2002). Disease incidence is highest among blacks, followed by Hispanics and whites, and highest among persons aged 25-39 years (8,52). The age of newly infected persons has increased from a median of 27 years during 1982-1988 to 32 years during 1994-1998, probably as a result of vaccination of adolescents and young adults and changes in high-risk behaviors in certain populations (8). Before national prevention programs began in 1990, perinatal and early childhood transmission accounted for 30% of chronic HBV infections (78). Sex is the predominant mode of HBV transmission among adults and adolescents, accounting for more than half of newly acquired infections (8). Among reported cases of acute hepatitis B, approximately 40% reported heterosexual exposure to an infected partner or multiple partners, and 15% were MSM. In addition, 14% of persons with acute hepatitis B reported injection-drug use. Thirty-three percent of persons with acute hepatitis B cannot identify a risk factor for infection, although approximately 50% of those persons have a history of known risk factors (8). # HBV Infection in Correctional Settings Juveniles. The majority of juvenile offenders have behaviors that place them at risk for HBV infection (e.g., injectiondrug use or unprotected sex with multiple partners). The prevalence of past HBV infection among noninstitutionalized high-risk juveniles (e.g., homeless, drug-using, or HIVpositive) ranges from 3.6% to 19% (79-81) (B.M. Beech, Ph.D, University of Memphis, Tennessee, 2002), compared with the <3% prevalence of infection among adolescents in the general population (76,82). Among incarcerated juveniles, prevalence of past HBV infection ranges from 0% to 6% (79,82; A. Thomas Adults. The prevalence of serologic markers for current or past HBV infection among prison inmates ranges from 13% to 47%, and varies by region. Prevalence is higher among women (37%-47%) than men (13%-32%) (31,83-88) (T. Lincoln, M.D., Hampden County Correctional Center, Ludlow, Massachusetts, 2001). Chronic HBV infection is diagnosed in 1.0%-3.7% of prison inmates, 2-6 times the national prevalence estimate of 0.5% (31,83,86,(88)(89)(90)(91)(92)(93)(94), and comparable to rates of chronic infection among IDUs (5%-10%) (95)(96)(97)(98), and among MSM (1.5%-6%) (99; D. MacKellar, CDC, personal communication, 2002). Upon release, susceptible inmates are often at increased risk for infection because they resume high-risk behaviors. A study of recidivist women reported an HBV seroconversion rate of 12.2/100 person-years between incarcerations (100), compared with an estimated incidence of 0.03/100 person-years for the U.S. population (G. Armstrong, CDC, personal communication, 2002). The majority of HBV infections among incarcerated persons are acquired in the community. However, infection is also transmitted within correctional settings, and incidence rates have ranged from 0.82% to 3.8%/year (31,34,84). After identification of a single case of acute hepatitis B in a state prison, serologic testing identified acute HBV infection in 1.2% of the population (33,34). Highest rate of acute infection (8%) was determined in the dormitory of the index case and was associated with sex with another inmate. No other risk factors were associated with infection. Acute infections were also identified in other prison dormitories, and chronic HBV infection was identified in 1% of the inmate population. Serologic testing of susceptible inmates 1 year later identified an additional 3.8% who had become newly infected with HBV. Among patients with acute hepatitis B reported to CDC's Sentinel Counties Study of Viral Hepatitis, 5.6% have a history of incarceration during the disease incubation period (8). HBV transmission in the prison setting can occur through sexual activity, injection-drug use, and percutaneous exposures that are not apparent, as it does in households where persons with chronic HBV infection reside (101,102). Data are lacking regarding the prevalence of HBV infection among short-and long-term residents of jails. However, the demographic and risk factor profiles of jail and prison inmates are similar, and the burden of HBV infection and risk of transmission might be expected to be similar, especially among longterm jail residents (13,15,28,29). Correctional Staff. The overall prevalence of HBV infection was 12.6% in the only study performed among correctional workers, a rate not significantly different from that of the general population after adjusting for age and race (48). Percutaneous and mucous membrane exposures to blood were relatively infrequent, and the most frequently reported exposure was blood on the skin, which was not associated with HBV infection. # Hepatitis C Virus Infection HCV, a bloodborne pathogen, is most efficiently transmitted by direct percutaneous exposure to infectious blood. Of persons newly infected with HCV, only 20%-30% have symptoms of acute hepatitis (10,103,104). Chronic infection develops among 75%-85% of persons infected as older adults (aged >45 years) and among 50%-60% of persons infected as juveniles or young adults (105). The majority of persons with chronic HCV infection are asymptomatic, and approximately 30% have no evidence of liver disease. Among chronically infected persons, biochemical evidence of chronic liver disease develops among 70% of those infected as adults, but (on the basis of limited data) in only 10% of those infected as juveniles (105). The risk for progression to cirrhosis also varies by age at infection, from 10%-20% among persons infected as older adults to <5% among persons infected as juveniles or younger adults. In addition to age, clinical progression is also accelerated by alcohol intake, chronic coinfection with HBV, and male sex (105). Coinfection with HIV increases HCV viral loads, the rate of progression to fibrosis and cirrhosis, and liver-related mortality (106). HCC develops among 1%-5% of persons with chronic hepatitis C. # Epidemiology of HCV Infection An estimated 3.9 million persons (1.8%) in the civilian, noninstitutionalized U.S. population have been infected with HCV, of whom approximately 2.7 million (1.3%) are chronically infected. In 1990, approximately two thirds of persons infected with HCV were aged 30-49 years (107). Blacks had a higher prevalence of HCV infection than whites (3.2% compared with 1.5%), and among black males aged 40-49 years, prevalence was 9.8% (107). The highest prevalence of HCV infection (70%-90%) is reported among those persons with substantial or repeated direct percutaneous exposures to blood (e.g., IDUs, persons with hemophilia treated with clotting factor concentrates that did not undergo viral inactivation, and recipients of transfusions from HCV-positive donors). Moderate infection prevalence (10%) has been reported among long-term hemodialysis patients, and lower prevalence is reported among persons with high-risk sexual practices (5%) and health-care workers (1%-2%) (10). HCV is not transmitted efficiently through occupational exposure. The risk of acquiring HCV infection from a contaminated needle stick is <2%, and transmission rarely has been documented from mucous membrane or nonintact skin exposures (47). The highest incidence of acute hepatitis C is among persons aged 20-39 years (108,109). Blacks and whites have a similar incidence of acute disease, and incidence rates are higher among males than females. Although the incidence of acute hepatitis C has declined by >80% since 1989, primarily as a result of a decrease in cases among IDUs, the major risk factor for HCV infection remains injection-drug use, which accounts for 60% of newly acquired cases (10,110,111). No association has been determined between newly acquired HCV infection and military service, medical, surgical, or dental procedures, tattooing, acupuncture, ear piercing, or foreign travel (43,44). If transmissions from such exposures do occur, the frequency has been too low to detect. Although the number of cases of acute hepatitis C among IDUs has declined dramatically since 1989, both the incidence and prevalence of HCV infection remain high among this group (98,112,113). Among IDUs, HCV is transmitted through the transfer of infected blood by sharing syringes, needles, or other drug paraphernalia contaminated with the blood of an infected person (114)(115)(116). HCV infection is acquired more rapidly after the initiation of injection-drug use than either HBV or HIV infection, and the rate of HCV infection among juvenile IDUs is four times greater than the rate of HIV infection. In 1980s studies, approximately 80% of newly initiated IDUs were infected with HCV within 2 years (98,117,118). This rapid acquisition of HCV infection was probably caused by the high prevalence of chronic HCV infection among IDUs, resulting in a greater likelihood of exposure to an HCV-infected person through sharing of drug paraphernalia. More recent studies report the rate of HCV acquisition has slowed, and only one third of IDUs are infected within 2 years after initiating injection-drug use. Nonetheless, incidence remains high at 10%-15%/year (112,116,119,120). # HCV Infection in Correctional Settings Juveniles. The prevalence of HCV antibody among detained or incarcerated juveniles is estimated at 2%-3.5%. A history of injection-drug use is the predominant risk behavior, and regardless of reported risk behaviors, the prevalence is higher among females than among males (3%-7% versus 2%-3%) (A. Thomas The risk of HCV acquisition during incarceration is not well-established. The only published study to examine the incidence of HCV infection among prison inmates reported a rate of 1.1 infections/100 person-years of incarceration among males (121). Correctional Staff. No published studies have reported the prevalence of HCV infection among correctional staff. In one unpublished study, among correctional health-care workers the prevalence of HCV infection was 2% (R. Gershon, Dr.P.H., Columbia University, New York, personal communication, 2002) -no higher than in the general population. This finding is similar to that of studies among other occupational groups, including hospital-based health-care workers, surgeons, and public safety workers (10,123). # Preventing and Controlling Viral Hepatitis Primary prevention of infection with hepatitis viruses can be achieved either through immunization (i.e., HAV or HBV) or through behavioral interventions to reduce risk factors for infection (i.e., HCV). In addition, identification of persons with chronic HBV and HCV infection provides an opportunity to initiate activities (e.g., counseling, treatment, or vaccination) that can prevent further disease transmission and reduce the progression of chronic liver disease. This section summarizes current information and practices to prevent infection with hepatitis viruses, including immunization, antiviral treatment, and risk-reduction counseling. # Prevention of HAV Infection Strategy To Prevent HAV Infection Preexposure Immunization. Vaccination is the most effective means to prevent HAV infection and reduce disease incidence. In the United States, preexposure vaccination is recommended for persons at highest risk for infection and persons for whom infection would result in adverse consequences (Box 1). In addition, routine vaccination is recommended for persons aged 2-19 years living in states and communities with the highest historic rates of disease ( 11) because conditions that contribute to communitywide transmission continue to exist. Postexposure Prophylaxis. Passive immunization with immune globulin IG is >85% effective in preventing hepatitis A after exposure of an unvaccinated person to an infected person, if administered <2 weeks after exposure (11). Anti-HAV testing is not recommended because it would delay IG administration and is likely not cost-effective. Although limited data indicate hepatitis A vaccine might provide protection when administered soon after exposure, this has not been evaluated in controlled clinical trials, and use of hepatitis A vaccine alone is not recommended for postexposure prophylaxis. However, persons who receive IG postexposure prophylaxis, and for whom hepatitis A vaccine is also recommended, require vaccination (11). # Detection and Management of Acute HAV Infection The diagnosis of hepatitis A is based on a positive serologic test for IgM anti-HAV in a person with clinical signs or symptoms of acute viral hepatitis. Serologic confirmation of HAV infection is required because hepatitis A cannot be distinguished from other forms of viral hepatitis on the basis of clinical presentation alone (Box 2). Although management of clinical illness is supportive, progression to acute liver failure can occur (especially in persons with chronic liver disease), and 10%-15% of patients have relapsing illness. Contact Tracing. Cases of acute hepatitis A are reported to the appropriate public health authorities, and a contact investigation is initiated by correctional officials to identify persons who would benefit from postexposure prophylaxis. Cellmates, sexual contacts, and persons having ongoing close personal contact with the index case are administered IG (Box 3) (11). # Current Practices: Prevention of HAV in Correctional Settings Nationally, the extent to which juvenile correctional systems vaccinate against hepatitis A is unknown. A recent assessment determined that in six of the 17 states where routine childhood vaccination is recommended, vaccination was also being conducted in juvenile detention facilities (CDC, unpublished data, 2002). A limited number of adult correctional systems routinely offer hepatitis A vaccination to all persons at risk for infection, whereas others offer vaccination only to inmates infected with HCV. # Prevention of HBV Infection Strategy To Prevent HBV Infection Prevention of acute and chronic HBV infection and elimination of HBV transmission in all age groups is most effectively achieved through hepatitis B vaccination (9). The national strategy to eliminate HBV transmission has four components: 1) prevention of perinatal HBV infection through maternal screening and postexposure prophylaxis of newborns of HBsAg-positive mothers; 2) hepatitis B vaccination of all infants to prevent infection in childhood and at later ages; 3) vaccination of all adolescents not previously vaccinated to prevent infection in this age group and at later ages; and 4) vaccination of adults and adolescents in groups at increased risk for infection (Box 4) (9,124). Hepatitis B vaccination has been included in routine healthcare visits for adolescents, but not for adults at risk for infection (9,125). Although the majority of persons aged <19 years - The Vaccines for Children (VFC) Program was established in 1994 for federal purchase of vaccine to be administered by a qualified health provider to juveniles aged <19 years who are American Indian or Alaska Native, uninsured or underinsured, or on Medicaid. VFC supports purchase of hepatitis A and hepatitis B vaccines, and HBIG. The VFC website is available at http:// www.cdc.gov/nip/vfc/Default.htm. # BOX 2. Diagnostic testing for infection with hepatitis viruses* # For persons with acute hepatitis, testing should be performed to differentiate among types of viral hepatitis. Acute Hepatitis A - Immunoglobulin M antibody to hepatitis A virus (IgM anti-HAV)-positive. # Acute Hepatitis B - IgM antibody to hepatitis B core antigen (IgM anti-HBc)-positive; and - Hepatitis B surface antigen (HBsAg)-positive. # Acute Hepatitis C - Serum alanine aminotransferase (ALT) levels >7 times the upper limit of normal; and - Antibody to hepatitis C virus (anti-HCV) positive (repeat reactive) by screening immunoassary, and confirmed by a more specific assay (e.g., recombinant immunoblot assay for anti-HCV or nucleic acid testing for HCV RNA); or - Anti-HCV-positive (repeat reactive) by screening immunoassay and a signal-to-cutoff ratio predictive of a true positive as determined for the particular assay (e.g., >3.8 for screening enzyme immunoassay ). # Laboratory tests for diagnosis of chronic hepatitis: # Chronic HBV Infection - HBsAg-positive, total anti-HBc-positive, and IgM anti-HBc-negative, or - HBsAg-positive two times >6 months apart. # Chronic HCV Infection - Anti-HCV-positive (as defined above) and HCV RNA-positive >6 months apart. - See Table 2 for interpretations of other markers of HBV infections. # BOX 3. Contact investigation and postexposure prophylaxis after identification of a case of hepatitis A - Contact investigation should be coordinated with local and state health departments. If the index patient is a food handler, public health officials should be directly involved in the investigation to evaluate the risk for transmission and the need for postexposure prophylaxis. - The following persons, if not previously vaccinated, should be considered candidates for postexposure prophylaxis if exposed to an index patient with hepatitis A during the two weeks before onset of symptoms. A single dose of immune globulin (IG) (0.02 mL/kg body weight, intramuscular) should be administered as soon as possible (but not >2 weeks after the last exposure) to -cellmates or dormitory mates, -sex contacts, -other close contacts based on epidemiologic investigation, or -other food handlers if the index patient was a food handler. - IG is not routinely indicated when an index case occurs in a school, work setting, or temporary housing unit. - When a person with hepatitis A is admitted to a hospital, standard and contact precautions are indicated. Staff members are at low risk for infection and postexposure prophylaxis is not indicated. Source: CDC. Guidelines for viral hepatitis surveillance and case management. Atlanta, GA: 2002. Available at / diseases/hepatitis/resource/PDFs/revised%20GUIDELINES%20 formatted4.pdf not covered by private insurance are covered under the Vaccines for Children Program,- similar coverage does not exist for adults, and cost reimbursement is a substantial barrier to vaccination of adults (126). Approximately 56% of persons with hepatitis B have either been treated for an STD (36%) or incarcerated (29%), factors for which routine hepatitis B vaccination is recommended (8,127). Identification of persons with chronic HBV infection through diagnostic testing can reduce risks for chronic liver disease and further transmission of infection; appropriate medical management and antiviral therapy can reduce risks for cirrhosis and HCC. Additional morbidity from other hepatic insults can be reduced through hepatitis A vaccination, alcohol-reduction counseling, and risk-reduction education. The high rate of HBV infection during sex and close contact (including with cellmates) can be prevented through vaccination. Prevention of Perinatal HBV Infection. Perinatal HBV infections can be prevented through routine testing to identify pregnant women who test positive for HBsAg and through timely postexposure immunization (prophylaxis) of their infants (78,128,129). Independent of maternal HBsAg status, hepatitis B vaccination is recommended for all infants soon after birth and before their release from the hospital (130). Initiating hepatitis B vaccination soon after birth serves as a safety net to prevent HBV infection in infants whose mothers were not tested (131). Adolescent Vaccination. Universal vaccination of infants against hepatitis B was first recommended in the United States in 1991 ( 9) and catch-up vaccination of all adolescents was recommended in 1995 to achieve elimination of HBV transmission in a more timely manner (132)(133)(134)(135). Hepatitis B vac-cination is now required by 33 states for entry to middle school or seventh grade. Three states have laws that require vaccination for college entry, and certain colleges require hepatitis B vaccination for matriculation (136; S. Ainsworth, American College Health Association, personal communication, 2002). Juvenile correctional vaccination programs have been established to prevent infections among detained persons at high risk for infection who might not be reached by school requirements. Completion of the vaccination series in these programs has been complicated by population turnover and the need for parental consent in certain jurisdictions. However, recidivism can bring opportunities to offer inmates second and third vaccine doses ( 137 Adult Vaccination. Routine vaccination of infants, young children and adolescents is expected to eventually eliminate transmission of HBV among adults in the United States. However, decades will pass before vaccinated children become protected adults, and vaccination of adults at increased risk for infection remains essential to reducing their high incidence of disease. Vaccination coverage among adults at occupational risk for HBV infection has successfully reduced infection incidence by >90% (138). This was achieved by requiring employers to provide education and hepatitis B vaccination at no cost to employees (139). However, early efforts to vaccinate other adults had limited success, primarily because of a lack of sustained programs and coverage for vaccine cost. More recently, demonstration programs funded by state and local health departments to deliver hepatitis B vaccine in correctional facilities, and STD and substance-abuse-treatment centers, have demonstrated high vaccination coverage can be achieved (140,141). Previously, a major barrier to vaccination of adults at high risk was the practice of offering vaccine only to persons likely to complete the series. Although administration of the complete vaccine series should be the goal of any immunization program, high first-dose and modest second-dose vaccination coverage rates have been achieved when vaccine is offered to all persons in settings that serve populations at high risk (140). Protective levels of antibody develop after 1 dose of hepatitis B vaccine among 30%-50% and after 2 doses of vaccine among 75% of healthy young adults (142)(143)(144). The transient nature of adult populations in correctional facilities often prevents completion of the full hepatitis B vaccine series. Ensuring follow-up with subsequent doses requires that an immunization record is included in the medical record of all inmates, is transferred among correctional facilities, and is provided to the inmate as part of release planning. - Using this formula for hepatitis A vaccination assumes no vaccination is administered at the time of the blood draw. For hepatitis A vaccination, T = cost of serologic test for anti-hepatitis A virus (HAV); T = P1 x v. For more prevaccination information regarding hepatitis A, see Appendix. # Testing for HBV Infection Pregnant Women. HBsAg testing is recommended for all pregnant women as soon as the pregnancy is recognized, irrespective of hepatitis B vaccination history or previous test results (9,(145)(146)(147). In addition, women with risk factors for HBV infection during their pregnancy (e.g., intercurrent STDs, multiple sex partners, sex partners and household contacts of HBsAg-positive persons, or clinically apparent hepatitis) need retesting for HBsAg late in pregnancy because of the high risk for HBV infection (9,147). Women diagnosed with chronic infection need evaluation for chronic liver disease, and close contacts (e.g., sex, household, prison cell, or dormitory) require vaccination because of their high risk for infection (9). Prevaccination Testing. Proof of previous hepatitis B vaccination through an immunization registry, medical records, or vaccination card can be used to determine whether to exclude inmates from vaccination. When inmate vaccination status is unknown, testing for immunity to HBV infection can reduce vaccine cost among populations with high rates for infection or vaccination coverage (Box 5). However, vaccination of a person immune to HBV infection because of prior vaccination or infection does not increase risk for adverse events. Testing is not indicated before vaccination of adolescents or younger children because of the low prevalence of HBV infection in these age groups (9,148). As hepatitis B vaccination coverage increases among adolescents, a higher proportion of adults will be immune to HBV infection. Correctional systems should be aware of state hepatitis B vaccination requirements for middle school entry, which typically achieve high vaccination coverage. If adequate immunization records are not routinely available for incoming inmates, periodic serologic surveys are necessary to determine the prevalence of immunity to HBV infection and to guide policies for prevaccination testing. Among populations with a high prevalence of immunity as a result of vaccination, testing for chronic HBV infection is not warranted. However, among populations with a high prevalence of HBV infection, testing is necessary to identify inmates with chronic HBV infection and initiate medical follow-up and immunization of close contacts. Postvaccination Testing. Testing to determine antibody response to vaccination is not necessary for healthy juveniles and adults (Appendix A). For immunocompromised persons (e.g., hemodialysis patients or HIV-infected) and persons with continued known exposure to HBV infection (e.g., infants born to HBsAg-positive mothers, sex partners of HBsAgpositive persons, or health-care workers), testing is needed to verify response to vaccination and the need for possible revaccination, or to identify HBV infection (9,149,150) # Prevention of HBV Infection After Exposure Immunization (active, passive, passive-active) within a relatively short period of time after exposure to HBV can effectively prevent acute and chronic infection. Initiation of the hepatitis B vaccine series within 12-24 hours of exposure has been demonstrated 70%-90% effective in preventing HBV infection (131,151). The combination of vaccine and HBIG achieves a similar level of efficacy (Box 6) (128,129). Among known nonresponders to vaccination, 1 dose of HBIG is 70%-90% effective in preventing hepatitis B when administered within 7 days of a percutaneous HBV exposure. HBIG administered within 2 weeks is also required for protection from sexual exposure to a person with acute hepatitis B (152)(153)(154). # Detection of HBV Infection Acute HBV Infection. Acute HBV infection is asymptomatic among 60%-70% of patients, but can have symptoms and signs associated with acute viral hepatitis (e.g., loss of appetite, nausea, vomiting, fever, abdominal pain, or jaundice), and must be confirmed by serologic testing (Table 2, Box 2). Treatment for acute hepatitis B is supportive, consisting of rest, hydration, and symptomatic relief as needed. Identification of an inmate with acute HBV infection, especially one who has been incarcerated >6 months, requires an epidemiologic investigation by correctional officials, in collabora-January 24, 2003 4. † HBIG = hepatitis B immune globulin. Dosages: perinatal = 0.5 mL intramuscular; all other = 0.06 mL/kg, intramuscular. § Identifiable blood exposure to infected contact (e.g., by sharing toothbrushes or razors). ¶ See Table 5. tion with the appropriate health authorities, to identify the source of infection. Depending upon the results, vaccination of sexual, prison cell, dormitory, and household (e.g., conjugal and other family members) contacts can be indicated. Chronic HBV Infection. Chronic HBV infection can be distinguished from acute infection by serologic testing (Table 2). Inmates identified with chronic HBV infection require evaluation to determine the extent of liver disease, virus replication, indications for antiviral therapy (64), and need for vaccination of contacts to prevent HBV transmission. # Management of Chronic HBV Infection Initial evaluation of patients with chronic HBV infection includes biochemical tests for liver disease (e.g., alanine aminotransferase , and aspartate aminotransferase ), for the extent of liver disease (e.g., serum albumin or prothrombin time), and status of HBV replication (e.g., HBeAg, antibody to HBeAg , and HBV DNA). Alpha interferon, lamivudine, or adefovir dipivoxil are approved by the Food and Drug Administration (FDA) for treatment of chronic hepatitis B (64,155). Therapy can be appropriate for patients who have abnormal levels of liver enzymes, active virus replication (HBeAg-positive or high levels of HBV DNA), and a liver biopsy indicating presence of moderate disease activity and fibrosis (64). Treatment with interferon, administered by injection 3 times/ week, substantially decreases HBV DNA levels and clears HBeAg among >50% of patients with ALT levels >5 times the upper limit of normal, and among 20%-35% of patients with ALT levels 2-5 times the upper limit of normal. Among patients with ALT levels <2 times the upper limit of normal, response is poor and therapy should be deferred. Long-term follow-up of treated patients indicates remission of chronic hepatitis induced by alpha interferon is of long duration (64). Patient characteristics associated with positive response to interferon therapy include low pretherapy HBV DNA levels, high pretherapy ALT levels, short duration of infection, acquisition of disease in adulthood, and histology indicative of active inflammation. Lamivudine, administered orally daily, has been as effective as interferon at clearing HBeAg. Although a majority of patients taking lamivudine demonstrate improved liver histology, development of lamivudine-resistant HBV mutants is common, especially with prolonged use, and diminishes the effectiveness of treatment. Studies of lamivudine in combination with interferon have not been demonstrated to be superior to monotherapy (64). The newest therapy to be approved is adefovir, which also is administered orally daily. Patients treated with adefovir exhibited substantial improvements in liver histology and decreased levels of HBV DNA; however, durability of the response has not been determined (156). Adefovir has been demonstrated to be effective in patients with chronic hepatitis B who have experienced resistance to lamivudine (156). Treatment of persons coinfected with HIV and HBV requires additional monitoring. After initiation of highly active antiretroviral therapy (HAART) for treatment of HIV infection, reactivation of HBV replication with development of acute hepatitis has been observed among persons thought to have resolved HBV infection. Although interferon treatment is not as effective for patients coinfected with HIV, HBV and HIV can be simultaneously treated (157). Inmates identified with chronic HBV infection can benefit from counseling regarding ways to prevent transmitting HBV infection to others. Vaccination of sexual and nonsexual contacts (e.g., cellmates) can also prevent transmission (9). # Current Practices: Prevention of HBV in Correctional Settings Juveniles. Juveniles in the justice system have been determined to have increased risk for HBV infection (125). In 2001, a national survey of state juvenile correctional systems reported that 36 (86%) of 42 responding systems had a hepatitis B prevention program in place; 78% used the VFC program to pay for vaccine; and 85% considered vaccination to be a corrections responsibility while a juvenile is in custody. Written hepatitis B prevention policies were in place in 65% of states, and 27% used a vaccine tracking system or immunization registry (CDC, unpublished data, 2002). In states with immunization registries and VFC participation, vaccination coverage among incarcerated juveniles has reached levels >90% (G. Treder, Wisconsin Department of Corrections, personal communication, 2002). However, where the correctional system does not have legal guardianship of the detained juvenile, the need for parental consent can pose a barrier to vaccination. In states with laws enabling minors to consent to their own STD-related treatment and prevention, hepatitis B has been included, facilitating implementation of vaccination programs (M. Staples-Horne, M.D., Georgia Department of Juvenile Justice, personal communication, 2002). Adults. Hepatitis B vaccination is recommended for adults in correctional settings because of their increased risk for infection, both inside and outside of prisons and jails (9,33,34,100). Vaccinating inmates in prisons has been demonstrated feasible and cost-saving from both prison and outside community perspectives ( 158 The Texas Department of Criminal Justice has 105 adult facilities with approximately 145,000 inmates. In 1999, funds were appropriated for hepatitis B vaccination of all offenders. A cost analysis indicated prevaccination testing would be costeffective if prior HBV infection rates were >25%. However, a seroprevalence study identified an HBV prevalence of 17.8% and a history of vaccination among another 5.5%. Medical records are reviewed for a history of hepatitis B vaccination or evidence of HBV infection from prior clinical testing. All inmates are offered vaccine, and the central pharmacy delivers second and third doses of vaccine to the appropriate housing units on a 0-, 2-, and 4-month vaccination schedule. Scheduled vaccine doses are listed in each inmate's medical record to serve as an additional reminder to complete the vaccination series. In the first 18 months of the program, 115,627 previously incarcerated inmates initiated the vaccine series, and since November 2001, the program has vaccinated all inmates at MMWR January 24, 2003 † Available at . # BOX 7. Persons for whom routine hepatitis C virus (HCV) testing is recommended* # On the Basis of Risk for Infection, Persons Who - ever injected illegal drugs; - received clotting factor concentrate produced before 1987; - ever were on long-term hemodialysis; - have evidence of chronic liver disease including persistently abnormal levels of alanine aminotransferase (ALT); or - received a transfusion of blood or blood components or an organ transplant before July 1992. On the Basis of a Recognized Exposure, - health-care, emergency medical, public safety, and correctional workers after needle sticks, sharps, or mucosal exposure to HCV-positive blood; or - children born to HCV-positive women. # Prevention of HCV Infection Strategy To Prevent HCV Infection CDC's national strategy to prevent HCV infection includes 1) prevention of transmission during high-risk activities (e.g., injection-drug use and unprotected sex with multiple partners) through risk-reduction counseling, testing, and appropriate medical management of infected persons; 2) donor screening and product inactivation procedures to eliminate transmission from blood, blood products, donor organs, and tissue; and 3) improved infection control practices to further reduce risk of transmission during medical procedures † (10). Primary prevention is directed at lowering the incidence of HCV infection. Of the estimated 25,000-40,000 persons newly infected with HCV annually during the past 5 years, approximately 60% acquired their infection through injection-drug use (45,111). Because no vaccine exists to prevent HCV infection, prevention must focus on risk reduction through counseling of persons who have admitted to or are at risk for illicit drug use or high-risk sexual practices. Counseling and testing to prevent HCV infection should be conducted in settings where persons at high risk are identified, including correctional health programs, and clinics that treat STDs, HIV/ AIDS, and substance abuse (10) (Box 7). The high prevalence of HCV infection and risk associated with HCV infection among inmates requires inclusion of HCV prevention activities in correctional settings. To be effective, risk reduction among this population often requires a multidisciplinary approach to address drug use as well as other medical, psychological, social, vocational, and legal problems (164). Identification of HCV-infected persons is required to initiate secondary and tertiary prevention activities to reduce the risks for HCV transmission and chronic liver disease (10). Anti-HCV-positive persons require further evaluation for chronic HCV infection and liver disease, and persons with chronic hepatitis C require evaluation for possible antiviral therapy and the need for further medical management. Persons with chronic hepatitis C are at risk for increased morbidity from additional hepatic insults. Fulminant hepatitis caused by hepatitis A can be prevented by vaccination (50). HCV-infected persons often have risk factors for HBV infection; therefore, hepatitis B vaccination is also recommended (10). Persons with hepatitis C should be counseled to not use alcohol, because its use (>10g/day for women and >20g/day for men) has been associated with more rapid progression to cirrhosis, which puts patients at higher risk for HCC (10,165,166). Persons at risk for HCV infection or those chronically infected with HCV can benefit from health education on topics including 1) substance-abuse treatment where appropriate, 2) clean needle and syringe use, 3) risks of sharing drug paraphernalia, and 4) condom use (10). Counseling and educational materials should include information concerning reducing further liver damage, as well as treatment options for those with chronic liver disease. Release planning should include substance-abuse-treatment referrals for IDUs and medical referrals to specialists for future medical management and treatment (see juvenile and adult sections on health education and release planning). # Testing for HCV Infection Anti-HCV testing is recommended to identify infected persons. To prevent reporting of false-positive results, testing should include both an antibody screening assay (e.g., enzyme § Available at / chrnhepc.htm. immunoassay ) and supplemental or confirmatory testing with an additional, more specific assay (e.g., recombinant immunoblot assay for anti-HCV or nucleic acid testing for HCV RNA). These tests detect anti-HCV in >97% of infected patients but do not distinguish between acute, chronic, or resolved infection (11). Substantial variation exists among laboratories regarding the extent to which more specific testing is performed. The level of the screening test signal-to-cut-off ratio has been demonstrated to predict a true antibodypositive result. Use of the signal-to-cut-off ratio limits supplemental testing to those samples for which the ratio is low (167). # Detection of HCV Infection Acute Hepatitis C. Acute HCV infection is usually asymptomatic (80%). However, acute hepatitis C should be included in the differential diagnosis of inmates who have signs and symptoms of acute hepatitis (Box 2). Confirmation of acute hepatitis C requires negative test results for IgM anti-HAV and IgM anti-HBc and a positive screening test result for anti-HCV, verified by supplemental testing or a high signalto-cut-off ratio. Among a limited number of patients, onset of symptoms may precede anti-HCV seroconversion, and follow-up antibody testing might be necessary to make the diagnosis. Identification of an inmate with acute hepatitis C, especially a person incarcerated for >6 months, requires initiation of an epidemiologic investigation by correctional officials, in collaboration with the appropriate health authorities, to identify the source of infection. Depending upon the results, testing of contacts might be indicated. Chronic HCV Infection. Anti-HCV alone does not distinguish between acute, chronic, or resolved infection. In persons testing positive for anti-HCV, chronic HCV infection can be distinguished by persistence of HCV RNA for >6 months. # Management of HCV Infection HCV-positive persons benefit from evaluation for the presence and severity of chronic liver disease. Antiviral therapy is recommended for persons with persistently elevated ALT levels, detectable HCV RNA, and a liver biopsy that indicates either portal or bridging fibrosis or moderate degrees of inflammation and necrosis. No clear consensus exists on whether to treat patients with persistently normal serum transaminases. Information is available on the National Institute of Health (NIH) website § regarding regimens with proven efficacy approved by the FDA for the treatment of chronic hepatitis C (168). The FDA has approved three antiviral thera-pies for treatment of chronic hepatitis C in persons aged >18 years: alpha interferon, pegylated interferon, and alpha or pegylated interferon in combination with ribavirin. All are administered for <52 weeks. Among persons with HCV genotype 1, the most common genotype in the United States, the response rate to either of the interferons administered alone is <20%, but the response rate to the combination of alpha interferon and ribavirin is 30%-40%, and to pegylated interferon and ribavirin, 40%-50%. Both the alpha and pegylated interferons are administered by injection; ribavirin is taken orally. All of these drug regimens have side effects, certain of which can be serious. Successful treatment eliminates viremia and the potentials for HCV transmission and further chronic liver disease (168,169). Among persons with both HCV and HIV infection, benefits of therapy for chronic hepatitis C have only recently been evaluated. The decision to treat persons coinfected with HIV must take into consideration concurrent medications and medical conditions (e.g., hyperthyroidism, renal transplant, or autoimmune disease). If CD4 counts are normal or minimally abnormal (>500/mL), treatment responses to interferon monotherapy are similar to non-HIV-infected persons (106,170,171). The efficacy of ribavirin/interferon combination therapy among HIV-infected persons has been tested in only a limited number of patients. Ribavirin can have substantial interactions with other antiretroviral drugs (168). Each patient should be evaluated by a physician familiar with the treatment of patients with HCV infection and HIV infections when appropriate, and indications for therapy should be reassessed at regular intervals. # Current Practices: Prevention of HCV in Correctional Settings Testing populations with high proportions of IDUs is an efficient strategy for identifying HCV-positive persons (10). However, in the correctional setting, only a limited number of studies have examined willingness to be tested, treatment options, compliance, and outcomes among those offered therapy (122,172). In assessments of other prison screening programs (e.g., for HIV and STDs), a relatively high rate (approximately 50%) of refusal has been reported (173)(174)(175). Limited data from studies in Rhode Island and Pennsylvania indicate approximately 7%-27% of all inmates identified with HCV infection ultimately begin treatment ( # BOX 8. Elements of viral hepatitis health education # Health Education Programs and Curricula Should Include - routes of transmission; - risk factors for infection; - disease outcomes, the need for medical management and treatment options; - methods to prevent infection, including immunization and harm and risk reduction; - the importance of substance abuse treatment, when appropriate; - sexual precautions including abstinence counseling and condom use; - risk-reduction counseling, including not sharing drug paraphernalia; and - resources in the community available to support and sustain a reduction in risk behaviors. Less-restrictive criteria might increase the number of inmates eligible for treatment (168). However, factors contributing to acceptance and completion of treatment regimens need to be identified to improve outcomes. # Health Education Health education directed toward prevention of viral hepatitis includes information related to the disease, routes of transmission, risk factors for infection, methods of prevention, disease outcomes, and treatment options. During incarceration, numerous educational opportunities exist (e.g., at entry, or in HIV-education and other classes). Education can take different forms, including videos, brochures, and formal classroom presentations. However, repeated face-to-face sessions have been determined the most effective means with the highest retention (Box 8) (176-178). Model programs use peer health educators in workshops for incoming inmates, and community educators to discuss risk assessment, risk reduction, and referrals for soon-to-be released inmates. ¶ Health education programs aimed at reducing risk of infection with hepatitis viruses include discussion of hepatitis A prevention, hygiene practices, and the significance of vaccination for persons at risk for infection. Curricula addressing HBV and HCV infections include information concerning the similar modes of transmission and means for prevention, and information about hepatitis B vaccination and risk reduction. Such information can also be incorporated into healtheducation programs for the prevention of HIV/AIDS. # Release Planning Release planning is a relatively new component of healthcare management for incarcerated persons. The majority of medical release and discharge planning programs in prison facilities have focused on HIV aftercare (179,180), but management of other chronic infections can result in the same beneficial outcomes. Comprehensive release planning includes transitional housing, continued access to discharge medications and immunizations, and coordination and case-management of long-term specialized care for persons with chronic conditions. Persons diagnosed with chronic HBV infection can benefit from counseling related to preventing transmission to household, sexual, and drug-use contacts. Susceptible contacts of persons diagnosed with chronic HBV infection benefit from hepatitis B vaccination. Persons with chronic hepatitis B or chronic hepatitis C can benefit from 1) counseling regarding ways to reduce further liver damage, 2) referrals to substance-abusetreatment and other IDU programs if indicated, and 3) medical referrals to specialists for future treatment. # Rationale for Prevention and Control of Viral Hepatitis in Correctional Settings The high prevalence of chronic HBV and HCV infections and risk factors for their transmission make prevention and control of these infections high priorities for correctional health programs. In addition, because a substantial proportion of releasees to the community continue to acquire or transmit these infections at a high rate, correctional efforts should become part of prevention and control efforts in the broader community. Highly effective and safe vaccines are available to prevent HAV and HBV infections. Identification of risk factors and infection status, combined with harm-and risk-reduction counseling, and substance-abuse treatment, have the potential to prevent HCV infections in the same manner they have reduced the risk of HIV/AIDS. In addition, identification of persons with chronic HBV and HCV infection provides opportunities for medical evaluation and treatment of chronic liver disease, and measures to prevent further transmission. The feasibility of including viral hepatitis prevention activities in existing prevention programs has been demonstrated. However, the challenges to integration of a comprehensive viral hepatitis prevention and control program in correctional health settings are substantial. They include budgetary and staffing constraints, priorities that compete with preventive health care, and lack of communication among correctional health, public health, and private health-care systems. The recommendations for prevention and control of viral hepatitis that follow are adapted to the correctional setting. The objective of these recommendations is to reduce transmission of hepatitis virus infections both during and after incarceration. Implementation of these recommendations can 1) reduce transmission of HAV infection in the community by immunizing incarcerated persons at highest risk for infection; 2) eliminate transmission of HBV infection among the inmate population through immunization; 3) reduce the number of new HCV infections by testing, harm-and riskreduction counseling, and substance-abuse treatment and prevention; 4) reduce the burden of viral hepatitis-related chronic liver disease through appropriate medical management; and 5) prevent HBV and HCV infections among correctional employees. # Rating the Recommendations The following recommendations are rated, where applicable, on the basis of the strength of evidence indicating changes in outcomes attributable to the interventions. Where formal recommendations previously have been published, they are cited as supporting evidence and can be referred to for the original studies. Ratings have been assigned by using a modification of criteria published by the Guide to Community Preventive Services (181). No rating was assigned to a recommendation considered standard practice (i.e., a medical or administrative practice conducted routinely by qualified persons experienced in their fields). - Strongly recommended (on the basis of >2 consistent, wellconceived, well-executed studies with control groups or longitudinal measurements). - Recommended (on the basis of >1 well-conceived, wellexecuted, controlled, or time-series study; or >3 studies with more limited execution). - Indicated (on the basis of previous scientific observation and theoretic rationale, but case-controlled or prospective studies do not exist). - Not recommended (on the basis of published literature recommending against a practice). # Recommendations for Juvenile Correctional Facilities -Hepatitis A Virus Infection - Hepatitis A vaccination should be administered to all juveniles in those states where routine vaccination is recommended (Box 1) (11). Strongly recommended. - In all other states, hepatitis A vaccination of all juveniles should be considered because of the high prevalence of risk factors for HAV infection among this population (11). Indicated. - Vaccination should be administered to those juveniles with risk factors for HAV infection (Box 1) or for those at risk for severe adverse outcomes of infection (e.g., persons with chronic liver disease) (11,57). Strongly recommended. - Vaccination should be initiated as soon as possible after entry into incarceration or detention using the appropriate dosage and schedule (standard practice) (Table 3). - Tracking systems to ensure completion of vaccine series within the correctional system should be established, and systems should be established to facilitate completion of the vaccine series in the community (standard practice). - Vaccination information, including date of administration, dose, and manufacturer should be included in the medical record, and an immunization record should be given to juvenile, or their parents or guardians, upon release (standard practice). - Routine screening or prevaccination testing of juveniles for markers of HAV infection should not be conducted (11). Not recommended. - Prevaccination testing should be considered for older adolescents (e.g., >15 years) in certain population groups (i.e., American Indians, Alaska Natives, and Hispanics) because of higher prevalence of infection or previous infection (11). Indicated. - Juveniles with signs or symptoms indicative of acute hepatitis should have appropriate diagnostic testing to differentiate acute hepatitis A, hepatitis B, or hepatitis C and to # Recommendations for Juvenile Correctional Facilities -Hepatitis B Virus Infection Preventing Perinatal HBV Infection - All pregnant incarcerated juveniles should be tested for HBsAg after their pregnancy is recognized, even if previously vaccinated or tested. Because of the high risk of HBV infection among this population, testing should be performed even if the female was tested before incarceration. The HBsAg status of incarcerated pregnant juveniles should be reported to the hospital where the juvenile will deliver her infant, along with other prenatal medical information. HBsAg-positive females should also be reported to the appropriate public health authority (9). Strongly recommended. - Infants born to HBsAg-positive mothers should receive HBIG (0.5 mL) and the first dose of hepatitis B vaccine <12 hours of birth (Table 4) (9). Strongly recommended. - Females admitted for delivery without HBsAg test results should have blood drawn for testing. While test results are pending, the infant should receive hepatitis B vaccine without HBIG within 12 hours of birth (Table 4) (standard practice). -If the mother is later determined to be HBsAg-positive, her infant should receive HBIG as soon as possible, but <7 days after birth. If the infant does not receive HBIG, the second dose of vaccine should be administered at 1 month of age. The final dose should be administered at age 6 months (Table 4) ( 9). Strongly recommended. -If the mother is determined to be HBsAg-negative, her infant should continue to receive hepatitis B vaccine as part of the routine vaccination schedule (Table 4) ( 9). Strongly recommended. -If the mother is never tested to determine her HBsAg status, the infant should continue to receive hepatitis B vaccine as part of the routine vaccination schedule (Table 4) ( 9). Strongly recommended. - Case management should be established to ensure appropriate postexposure prophylaxis and follow-up for children born to incarcerated or recently released HBsAg-positive mothers, including completion of the vaccine series at age 6 months and postvaccination testing during ages 9-15 months (9,182). Recommended. - Infants born to HBsAg-negative mothers should receive the first dose of hepatitis B vaccine before release from the hospital (9,142,143). Strongly recommended. - Previously unvaccinated HBsAg-negative pregnant juveniles should be vaccinated; pregnancy is not a contraindication to vaccination (9,(183)(184)(185). Strongly recommended. - Discharge planning for pregnant HBsAg-positive juveniles should include transfer of appropriate medical records to the hospital where the juvenile plans to deliver her infant, along with other prenatal medical information. Test results should also be provided to the patient and her parent or guardian (standard practice). # Hepatitis B Vaccination # Preexposure - All juveniles who receive a medical evaluation in a correctional facility should be administered hepatitis B vaccine, unless they have proof of completion of the vaccine series or serologic evidence of immunity to infection. The vaccine series should be started for those juveniles who have never been vaccinated, irrespective of their length of stay, and the series should be completed for those incompletely immunized (9,142,143,186,187). Strongly recommended. -For juveniles who do not receive medical evaluation upon entry into correctional custody, vaccination should be considered for those who lack proof of previous vaccination (125) (standard practice). -Catch-up vaccination of previously unvaccinated, already incarcerated juveniles should be considered in facilities in which routine hepatitis B vaccination of entering inmates is established (33) (standard practice). - An appropriate vaccination dose and schedule should be selected to facilitate completion of the vaccine series while the juvenile is in custody. For previously unvaccinated juveniles held in a correctional facility for <6 months, the vaccine series should be initiated and completed by using a 4-month schedule (0, 1-2, and 4 months) (Table 4) (186)(187)(188)(189). Recommended. - Vaccination information, including date of administration, dose, and manufacturer should be included in the medical record, and an immunization record should be given to juveniles, or to their parents or guardians, upon release (standard practice). - Discharge planning should include transfer of immunization records to the person's medical home to ensure completion of the vaccine series for those juveniles not fully vaccinated while in the correctional facility, and for all fully vaccinated persons as well (standard practice). # Prevaccination and Postvaccination Testing - Prevaccination serologic testing is not indicated (148). Indicated. -As hepatitis B vaccination coverage among adolescents increases, validation of immunization records or serologic testing might become a cost-effective means to minimize overvaccination. Indicated. -Knowledge of state middle school hepatitis B vaccination requirements and performance of periodic vaccine coverage serologic surveys to determine the proportion of vaccinated or immune adolescents entering juvenile facilities should be used to define prevaccination screening policies (e.g., history or serologic testing) and the need for hepatitis B immunization among specific age groups (standard practice). - Postvaccination testing should not be conducted for healthy juveniles (9,142,143,190). Not recommended. - For juveniles with special conditions (e.g., immunocompromised or HIV-infected), postvaccination testing for anti-HBs should be conducted 1-2 months after completion of the vaccine series. Nonresponders in this category should be revaccinated (149,150). Strongly recommended. # Postexposure Prophylaxis - After any percutaneous exposure (e.g., sharing injectiondrug equipment or human bite) or mucosal exposure (e.g., sexual) to blood, unvaccinated juveniles should begin the vaccine series, and the exposure incident should be evaluated to determine if additional postexposure prophylaxis (i.e., HBIG) is required (Table 5) (9,47). Strongly recommended. -The first dose of hepatitis B vaccine should be administered immediately, and the remaining doses, 1 and 6 months later (standard practice). -For an exposed juvenile who has begun but not completed the vaccine series, subsequent vaccine doses should be administered as scheduled (standard practice). -The person who was the source of the exposure should be tested for HBsAg, even if this person was previously vaccinated. If the source person is HBsAgpositive, HBIG should be administered to the exposed person as soon as possible and 10 mlU/mL). A nonresponder is a person with inadequate response to vaccination (i.e., anti-HBs <10 mlU/mL). † † The option of administering one dose of HBIG and reinitiating the vaccine series is preferred for nonresponders who have not completed a second 3-dose vaccine series. For persons who previously completed a second vaccine series but failed to respond, 2 doses of HBIG are preferred. § § Hepatitis B surface antigen. ¶ ¶ Antibody to HBsAg. # Positive # Serologic Testing for Hepatitis B Virus Infection - Routine testing of juveniles for markers of HBV infection (e.g., HBsAg, anti-HBs, anti-HBc) is not recommended (5,76,81,148,191). Not recommended. - Juveniles with signs or symptoms indicative of viral hepatitis should have appropriate diagnostic testing to differentiate acute hepatitis A, hepatitis B, or hepatitis C and to determine if the patient has chronic HBV or HCV infection (Box 2) (standard practice). -Cases of acute hepatitis B should be reported to the appropriate public health authority (standard practice). -Cases of chronic HBV infection should be reported in those states that require reporting (standard practice). - Identification of a case of acute hepatitis B should prompt an epidemiologic investigation by correctional officials, in collaboration with the appropriate health authorities, to identify the source of infection and provide appropriate postexposure prophylaxis (Table 5) (Box 6) to nonimmunized contacts at risk for infection (standard practice). # Chronic Hepatitis B Treatment - Juveniles identified as having, or who are known to have chronic HBV infection during routine medical screening should be evaluated to determine the presence and extent of chronic liver disease and candidacy for antiviral therapy (64,192,193). Recommended. -Lamivudine can be used to treat patients aged >2 years. -The safety and efficacy of interferon and adefovir in pediatric patients has not been established. -Treatment of patients with chronic hepatitis B should be conducted in consultation with a pediatric specialist experienced with these treatment regimens. - All long-term correctional facilities should establish criteria for identification of inmates who might benefit from treatment, on the basis of the latest treatment guidelines (standard practice). - Discharge planning for persons with chronic HBV infection should include referral to medical care, riskreduction programs, and social services necessary to maintain behavior changes; vaccination of contacts should also be arranged before patient discharge (standard practice). # Recommendations for Juvenile Correctional Facilities -Hepatitis C Virus Infection Testing for Hepatitis C Virus Infection - A history of risk factors for HCV infection should be obtained from juveniles undergoing medical evaluations, and those with risk factors should be tested for anti-HCV (Box 7). Routine testing of all juveniles for anti-HCV should not be conducted (10). Not recommended. - Juveniles with signs or symptoms indicative of viral hepatitis should have appropriate diagnostic testing to differentiate acute hepatitis A, hepatitis B, or hepatitis C and to determine if the patient has chronic HBV or HCV infection (Box 2) (standard practice). - Cases of acute hepatitis C should be reported to the appropriate public health authority (standard practice). - Anti-HCV-positive persons should be reported if required by state laws or regulations (standard practice). - Identification of juveniles with acute hepatitis C, including those incarcerated for >6 months, should prompt an epidemiologic investigation by correctional officials, in collaboration with the appropriate health authorities, to identify the source of the infection. Depending on the results of the investigation, testing of contacts might be indicated (Box 7) (standard practice). - Juveniles who are anti-HCV-positive should receive further medical evaluation to determine if they are chronically infected (Box 2) (standard practice). # Postexposure Management for HCV - After a percutaneous or permucosal exposure to blood, the source person should be tested for anti-HCV. If the source person is anti-HCV-positive, the exposed person should be tested for anti-HCV and ALT activity at baseline and 4-6 months later. For earlier diagnosis, testing for HCV RNA can be performed in 4-6 weeks (10). Recommended. - IG and antiviral agents are not recommended for postexposure prophylaxis of hepatitis C (10). Not recommended. # Chronic Hepatitis C Treatment - Juveniles identified as having chronic HCV infection should be evaluated to determine the presence and extent of chronic liver disease. FDA-approved antiviral agents for treatment of hepatitis C are not indicated for persons aged <18 years, although participation in clinical trials might be possible. Although HCV infection in juveniles can result in less severe disease, infected juveniles should be monitored by a specialist familiar with this disease. Discharge planning should also include drug and alcohol abuse treatment, risk-reduction programs, and social services necessary to maintain behavior changes (standard practice). - Juveniles with chronic hepatitis C should receive hepatitis B vaccination and hepatitis A vaccination if not previ-ously immunized or known to be susceptible to infection (9)(10)(11)50). Recommended. # Juvenile Health Education and Release Planning - Prevention of HAV, HBV, and HCV infections should be incorporated into health education programs (e.g., programs for preventing HIV/AIDS) and include information concerning modes of disease transmission and means for prevention, including risk-reduction and immunization (Box 8) (17,177). Indicated. - An integrated health education and risk reduction program should be established in each facility and include a written plan of health instruction completed by each inmate (standard practice). - Such instruction should address a range of issues relevant to the diverse developmental and cultural composition of correctional populations, and should include basic skill development, literacy, and home economics, as well as tools needed to avoid behaviors that result in acquisition of HIV, hepatitis, and other bloodborne and sexually transmitted infections (standard practice). - Teachers should be trained professionals or inmate peers with specific training to teach comprehensive life-skills programs, including health education (standard practice). - A system for periodic evaluation, updating and improvement should exist (standard practice). - Documentation of hepatitis A or hepatitis B vaccination should be included in the medical record retained within the correctional system, as well as in any medical record provided to other health-care providers. In addition, vaccinated persons or their parents or guardians should be provided a personal immunization record (standard practice). - Juvenile correctional health facilities should establish links with community and public health facilities, and where available, with immunization registries, to ensure tracking and completion of hepatitis A and hepatitis B vaccine series (standard practice). - Juveniles with chronic HBV or HCV infection should be -counseled, along with their parent or guardian, regarding preventing transmission to household, sexual, and drug-use contacts; -provided referral for hepatitis B vaccination of contacts; -counseled regarding ways to reduce further liver damage, including limiting alcohol and drug use, and afforded substance-abuse treatment when appropriate; and -provided aftercare that includes medical follow-up (standard practices). # Recommendations for Adult Correctional Facilities -Hepatitis A Virus Infection - Hepatitis A vaccination should be administered to adults in groups at risk for HAV infection (e.g., MSM or drug users) or who are likely to experience severe adverse outcomes of infection (e.g., persons with chronic liver disease) (Box 1) (11). Strongly recommended. - For persons at risk, the vaccination series should be initiated as soon as possible after incarceration using the appropriate dosage and schedule (Table 3). Tracking systems to ensure completion of the vaccine series within the correctional system should be established, and systems should be developed to facilitate completion of the second vaccine dose for those inmates who return to the community (11). Strongly recommended. - Prevaccination serologic testing to identify susceptible persons should be considered if determined to be costeffective (Box 5), and it does not compromise initiation of vaccination. Inmates aged >40 years and those from regions of high endemicity (see Appendix) should be considered for prevaccination testing because of the high prevalence of past HAV infection among these groups (11). Indicated. - Routine screening of adults for anti-HAV should not be conducted, except when used to identify susceptible persons for vaccination (11). Not recommended. - Vaccination information, including date of administration, dose, and manufacturer should be included in the medical record, and an immunization record should be given to the inmate upon release (standard practice). - Adults with signs or symptoms indicative of acute hepatitis should have appropriate diagnostic testing to differentiate acute hepatitis A, hepatitis B, or hepatitis C, and to determine if the patient has chronic HBV or HCV infection (Box 2) (standard practice). -Cases of hepatitis A should be reported to the appropriate public health authority (standard practice). -Identification of a case of hepatitis A in a correctional facility should prompt an epidemiologic investigation by correctional officials, in collaboration with the appropriate health authorities, to identify the source of infection and contacts that might have been exposed (standard practice). -Unvaccinated or known susceptible close contacts of a confirmed case of hepatitis A should be administered postexposure prophylaxis with a single dose of IG (0.02 mL/kg body weight, intramuscular) as soon as possible, but not >2 weeks after the last exposure (Box 3) (11). Strongly recommended. # Recommendations for Adult Correctional Facilities -Hepatitis B Virus Infection Preventing Perinatal HBV Infection - All pregnant women should be tested for HBsAg after their pregnancy is recognized, even if previously vaccinated or tested. Because of the high risk for HBV infection among this incarcerated population, testing should be performed even if the woman was tested before incarceration. The HBsAg status of a pregnant woman should be reported to the hospital where she will deliver her infant, along with other prenatal medical information. HBsAg-positive women should also be reported to the appropriate public health authority (9). Strongly recommended. - Infants born to HBsAg-positive mothers should receive HBIG (0.5 mL) and the first dose of hepatitis B vaccine <12 hours after birth (Table 4) (9). Strongly recommended. - Females admitted for delivery without HBsAg test results should have blood drawn for testing. While test results are pending, the infant should receive hepatitis B vaccine without HBIG within 12 hours of birth (Table 4) (standard practice). -If the mother is later determined to be HBsAgpositive, her infant should receive HBIG as soon as possible, but <7 days after birth. If the infant does not receive HBIG, the second dose of vaccine should be administered at 1 month of age. The final dose should be given at age 6 months (Table 4). Strongly recommended. -If the mother is determined to be HBsAg-negative, her infant should continue to receive hepatitis B vaccine as part of the routine vaccination schedule (Table 4). Strongly recommended. -If the mother is never tested to determine her HBsAg status, the infant should continue to receive hepatitis B vaccine as part of the routine vaccination schedule (Table 4). Strongly recommended. - Case management should be established to ensure appropriate postexposure prophylaxis and follow-up for chil-dren born to incarcerated or recently released HBsAg-positive mothers, including completion of the vaccine series at age 6 months and postvaccination testing during ages 9-15 months (9,182). Recommended. - Infants born to HBsAg-negative mothers should receive the first dose of hepatitis B vaccine before release from the hospital (9,130). Strongly recommended. - Previously unvaccinated HBsAg-negative pregnant women should be vaccinated; pregnancy is not a contraindication to vaccination (9,(183)(184)(185). Strongly recommended. - Discharge planning for pregnant HBsAg-positive women should include transfer of appropriate medical records to the hospital where the woman plans to deliver her infant, along with other prenatal medical information. Test results should also be provided to the patient (standard practice). # Hepatitis B Vaccination # Preexposure - All adults who receive a medical evaluation in a correctional facility should be administered hepatitis B vaccine, unless they have proof of completion of the vaccine series or serologic evidence of immunity to infection. The vaccine series should be started for those who have never been vaccinated, irrespective of the length of their stay, and the series should be completed for those incompletely immunized (9,142,143,190). Strongly recommended. -For persons who did not receive medical evaluation upon entry into correctional custody, vaccination should be considered for those who lack proof of previous vaccination or immunity (9,142,143). Recommended. -Catch-up vaccination of already incarcerated, previously unvaccinated persons, or persons known to be susceptible to infection, should be considered in facilities in which routine hepatitis B vaccination of entering inmates is being established. Priority should be given to vaccination of contacts of known HBsAgpositive persons (e.g., cellmates or persons living in the same cell block or dormitory) (33,101,102). Recommended. - An appropriate vaccination dose and schedule should be selected to facilitate completion of the vaccine series while the person is in custody. For previously unvaccinated persons held in a correctional facility for <6 months, the vaccine series should be initiated and completed by using a 4-month schedule (0, 1-2, and 4 months) (Table 4) (186)(187)(188)(189). Recommended. - Vaccination information, including date of administration, dose, and manufacturer should be included in the medical record, and an immunization record should be given to the incarcerated person upon release (standard practice). - Discharge planning should include transfer of immunization records to the person's medical home to ensure completion of the vaccine series for persons not fully vaccinated while in the correctional facility, and for all fully vaccinated persons as well (standard practice). # Prevaccination and Postvaccination Testing - Prevaccination serologic testing should be considered for adult incarcerated populations and is likely to be costeffective when the prevalence of immunity from prior infection and vaccination exceeds 25%-30% (Box 5) (148). Indicated. -To assist correctional facilities in determining whether to conduct prevaccination testing, periodic serologic surveys of incoming inmates can be used to determine the prevalence of markers of immunity to HBV infection (standard practice). -Testing for anti-HBs provides the best measure of immunity to HBV infection, because it detects infection or vaccine-induced immunity (standard practice). -When prevaccination testing is done, the first dose of vaccine should be administered at the same time the blood sample is obtained to ensure optimal vaccination coverage (Box 5) (9). Recommended. - Postvaccination testing is not indicated for healthy adults (9,142,143). Not recommended. - For persons with special conditions (e.g., immunodeficiency, HIV infection, or chronic hemodialysis), or who are likely to be exposed to HBV (e.g., sex partner of HBsAg-positive person or health-care worker), postvaccination testing for anti-HBs is recommended 1-2 months after completion of the vaccination series. Nonresponders in this category should be revaccinated (149,150). Strongly recommended. # Postexposure Prophylaxis - After any percutaneous (e.g., sharing injection-drug equipment or human bite) or mucosal (e.g., sexual) exposure to blood, an unvaccinated person should begin the vaccine series, and the exposure incident should be evaluated to determine if additional postexposure prophylaxis (i.e., HBIG) is required (Table 5) (9,47). Strongly recommended. # MMWR January 24, 2003 -The first dose of hepatitis B vaccine should be administered immediately, and the remaining doses 1 and 6 months later (Table 4) (standard practice). -For an exposed person who has begun but not completed the vaccine series, subsequent vaccine doses should be administered as scheduled (standard practice). -The person who was the source of the exposure should be tested for HBsAg, even if that person was previously vaccinated. If the source person is HBsAg-positive, HBIG (0.06 mL/kg body weight intramuscular) should be administered to the exposed person as soon as possible and <7 days after the exposure (standard practice). -Postexposure prophylaxis is not necessary for a fully vaccinated person after exposure to HBV (9,47,138). Not recommended. # Serologic Testing for Hepatitis B Virus Infection - Correctional facilities should consider routine testing of long-term inmates for chronic HBV infection (Box 2, # Postexposure Management for HCV - After a percutaneous or permucosal exposure to blood, the source person should be tested for anti-HCV. If the source person is anti-HCV-positive, the exposed person should be tested for anti-HCV and ALT activity at baseline and 4-6 months later. For earlier diagnosis, testing for HCV RNA can be performed at 4-6 weeks (10). Recommended. - IG and antiviral agents are not recommended for postexposure prophylaxis of hepatitis C (10). Not recommended. # Chronic Hepatitis C Treatment - All anti-HCV-positive inmates should be evaluated for evidence of chronic HCV infection, including the presence and extent of chronic liver disease and candidacy for antiviral therapy. Treatment of patients with chronic hepatitis C should be conducted in consultation with a specialist familiar with these treatment regimens (standard practice). - Inmates with chronic hepatitis C should receive hepatitis B vaccination and hepatitis A vaccination if not previously immunized or known to be susceptible to infection (9)(10)(11)50). Recommended. - Correctional facilities or systems should establish criteria based on the latest treatment guidelines for the identification of prisoners who might benefit from antiviral treatment. For HCV-infected patients who are actively abusing substances (e.g., drugs or alcohol), appropriate substanceabuse treatment should be initiated to limit disease trans-mission, reinfection, and liver disease progression (10,168,(194)(195)(196)(197). Recommended. (198). As a part of the plan, correctional facilities should require employees to use appropriate personal protective equipment (e.g., gloves, gowns, masks, mouthpieces, and resuscitation bags) that are provided by the employer (standard practice). - The plan should ensure that all workers are familiar with all aspects of infection control, including bloodborne pathogens and their transmission, the written exposure control plan, engineering and work practice controls, personal protective equipment, hepatitis B vaccine, response to emergencies involving blood, how to handle exposure incidents, the postexposure evaluation and follow-up program, and signs/labels/color-coding to alert persons to potentially infectious material (standard practice). - Plan administrators should consider strategies to overcome the unique barriers to an effective infection control plan in a correctional environment (41). For example, potential inaccessibility of sharps disposal containers might necessitate using specific safe-needle devices and other strategies to minimize needle-stick injuries in correctional health-care settings (standard practice). - A work practices program should be established that includes standard operating procedures for all activities having exposure potential. No worker should engage in such tasks or activities before receiving training pertaining to the procedures, work practices, and protective equipment required for that task (standard practice). # Adult Health Education and Release Planning # Preexposure Hepatitis B Vaccination and Postexposure Management for HBV and HCV - Hepatitis B vaccination should be administered to all previously unvaccinated persons (e.g., correctional and medical staff ) whose work duties involve exposure to blood or other potentially infectious body fluids (9,138,199). Strongly recommended. - Prevaccination serologic screening is not indicated for persons being vaccinated because of occupational risk, unless the hospital or health-care organization considers screening cost-effective. Indicated. - Staff with continued contact with patients or blood and who are at ongoing risk for percutaneous injuries should be tested for anti-HBs 1-2 months after completion of the 3-dose vaccination series. Staff who do not respond to a primary vaccine series should complete a second 3-dose vaccine series or be evaluated to determine if they are HBsAg-positive (47,199) (standard practice). - For correctional workers who have no contact with inmates and no routine exposure to blood and body fluids in the correctional setting, timely postexposure pro-phylaxis should be provided if an exposure occurs, rather than routine vaccination (47,199) (standard practice). - Evaluation for appropriate postexposure prophylaxis for an employee who has had an exposure incident should be performed in a timely fashion according to recommendations for HBV and HCV (47). Strongly recommended. - When an exposure to potentially infectious blood or body fluid has occurred, a blood sample from the source person should be tested for HBsAg and anti-HCV. If the source person cannot be identified or tested, the respective postexposure protocol (i.e., HBV or HCV) should be followed to evaluate the need for postexposure prophylaxis or follow-up (standard practice). - Appropriate postexposure prophylaxis and follow-up for HBV infection after exposure is dependent on the HBsAg status of the source person, as well as the immunization status of the exposed person (Tables 2 and 4) (47) (see Recommendations for Adult Inmates) (standard practice). - If the source person is anti-HCV positive, CDC guidelines for postexposure follow-up should be followed (10,47) (see Recommendations for Adult Inmates) (standard practice). # HBV or HCV Serologic Testing - Routine testing for HBV or HCV infection is not necessary for correctional workers, except as described for hepatitis B vaccination or postexposure management (10,48,123,200). Not recommended. # Implementation of Recommendations The unique nature of correctional institution populations necessitates close collaboration with public health personnel at state and local levels for effective implementation of the recommendations in this report. Preventing and controlling viral hepatitis among incarcerated and released persons, and among persons in the communities to which they return, requires defining specific roles for each agency. - Correctional staff should review these recommendations and develop written policies for their implementation. Policies should include implementation by contractors where correctional health care is provided by the private sector. Correctional staff should also monitor the 1) proportion of inmates (both adults and juveniles) who begin and complete the hepatitis B vaccine series; 2) prevalence of immunity to HBV infection among incoming inmates; 3) vaccine-seriescompletion rates for released prisoners; 4) proportion of inmates tested for HCV infection and reasons that inmates decline testing; and 5) prevalence of HCV infection among incoming inmates. # Hepatitis B Vaccine Vaccines available in the United States use hepatitis B surface antigen (HBsAg) produced in yeast cells by recombinant deoxyribonucleic acid (DNA) technology, and are formulated to contain 5-40 µg HBsAg protein/mL and 0.5 mg/mL aluminum hydroxide as the adjuvant. The two available single antigen hepatitis B vaccines are Recombivax HB ® (Merck & Co., Inc., Whitehouse Station, New Jersey) and Engerix-B ® (GlaxoSmithKline Biologicals, Rixensart, Belgium) (5). A combination hepatitis A and hepatitis B vaccine, Twinrix, is also licensed for persons aged >18 years old (2) (Table 4). # Antibody Response to Vaccination Licensed formulations for both vaccines produce high (>95%) rates of protective antibody (anti-HBs >10 mIU/mL) when the complete series is administered in different schedules to infants, juveniles, and adults aged 95% after the third dose (5)(6)(7)(8)(9). Increasing the interval between the first and second dose of vaccine has little effect on immunogenicity or final antibody titer, although data are limited regarding intervals >2 months among adults (5,8). The third dose confers the maximum rate of seroprotection; it primarily acts as a booster and confers optimal long-term protection through the induction of maximum immune memory (5,9). Both licensed vaccines administered on a 0-, 1-, and 6-month schedule produce a >95% final seroprotection rate among adolescents and healthy young adults, and studies indicate that vaccination of adolescents and adults on a 0-, 2-, and 4-month, and adolescents on a 0-,12-, and 24-month schedule, achieved final seroprotection rates similar to the 0-, 1-, and 6-month schedule (8)(9)(10). In addition, a 2-dose vaccination series using Recombivax HB ® at the adult dosage has been demonstrated among adolescents aged 11-15 years to produce protective antibody responses equivalent to that of the 3-dose series, although the long-term protection afforded from this schedule is not known (8,11). The duration of vaccine-induced antibody and protection from hepatitis B virus (HBV) infection has been evaluated among vaccinated infants, juveniles, and adults (5,(12)(13)(14). Studies indicate that although loss of detectable anti-HBs has ranged from 13% to 60% by 9-15 years after vaccination, immune memory provides protection from HBV infection, and protection remains intact for >15 years, the longest period for which follow-up data are available (5,(12)(13)(14). Because of the long duration of protection afforded by the 3-dose vaccine series, booster doses of vaccine are not needed among vaccinated immunocompetent juveniles or adults. # Adverse Reactions Adverse reactions associated with hepatitis B vaccine include pain at the injection site (3%-29%) and a temperature >37.7 º C (1%-6%), although these effects are reported no more frequently among vaccine recipients than among placebo recipients in controlled trials (5). Anaphylaxis has been reported in 1/600,000 vaccine recipients; however, no deaths have been attributed to vaccination. A number of case reports and case series have claimed an association between hepatitis B vaccination and serious adverse health events (e.g., multiple sclerosis) (15,16); however, these have not been proven by other epidemiologic studies (17)(18)(19)(20)(21)(22). Adverse events suspected to be associated with hepatitis B vaccination should be reported to VAERS, and reporting forms can be obtained by calling 1-800-822-7967. which mechanisms should be established include follow-up of persons with chronic HBV and HCV infection for vaccination of contacts (HBV), and appropriate counseling and referral for medical follow-up and treatment. # Internet Resources The following Internet sites provide additional information (listed by source, topic, and website): - CDC, viral hepatitis, . # Appendix Hepatitis A and B Vaccines Hepatitis A Vaccine Long-term protection from hepatitis A virus (HAV) infection can be achieved through active, preexposure vaccination with hepatitis A vaccine. Inactivated hepatitis A vaccines licensed for use in the United States are Havrix ® (GlaxoSmithKline Biologicals, Rixensart, Belgium), VAQTA ® (Merck & Co., Inc., Whitehouse Station, New Jersey), and Twinrix ® (GlaxoSmithKline Biologicals), a combined hepatitis A and hepatitis B vaccine (1,2). All are produced from HAV grown in cell culture, inactivated with formalin, and formulated with alum adjuvant in pediatric and adult dosages that are 94%-100% effective in preventing clinical disease among juveniles and adults when administered according to recommended schedules (1,2) (Table 3). Protective levels of antibody to HAV (anti-HAV) develop among 94%-100% of vaccinated persons within 1 month after administration of the first dose. A second dose results in protective levels of antibody among all persons vaccinated, and is considered necessary for long-term protection. Estimates of antibody persistence suggest protective levels of anti-HAV persist for >20 years (1). A delay in administration of the second vaccine dose does not result in lowered final antibody levels or seroconversion rates, and restarting the vaccine series if the second dose is delayed is not needed. Vaccination begun with vaccine from one manufacturer can be completed with vaccine from the other (3,4). Hepatitis A vaccine can be administered at the same time as other vaccines, including hepatitis B vaccine, without affecting immunogenicity or increasing the frequency of adverse events. # Adverse Reactions The most frequently reported adverse reactions occurring <3 days after vaccination are soreness at the injection site (53%-56%), headache (14-16%), and malaise (7%). Reviews of data from multiple sources have not identified any serious adverse events among juveniles or adults associated with hepatitis A vaccination (1). Any adverse event occurring after hepatitis A vaccination should be reported to the Vaccine Adverse Events Reporting System (VAERS). Reporting forms can be obtained by calling 1-800-822-7967. # Contraindications Hepatitis A vaccine should not be administered to persons with a history of hypersensitivity reactions to alum, or for Havrix or Twinrix, to the preservative 2-phenoxyethanol. The safety of hepatitis A vaccination during pregnancy has not been determined. However, because this is an inactivated vaccine, the theoretical risk to the developing fetus is low. The risk associated with vaccination should be weighed against the risk for hepatitis A among women who might be at high risk for exposure to HAV infection. No special precautions are needed when vaccinating immunocompromised persons. # Serologic Testing for HAV Infection Antibody produced after HAV infection results in lifelong immunity. Among adult populations with high rates of prior HAV infection, prevaccination testing can reduce costs by avoiding the vaccination of persons with prior immunity. However, the vaccination of an immune person does not increase the risk for adverse events. The decision to test should be based on 1) expected prevalence of immunity; 2) cost of vaccination compared with cost of serologic testing; and 3) likelihood that testing will not interfere with initiating vaccination. Prevaccination testing of younger juveniles (ages 40 years would likely be cost-effective (1). Commercially available tests for total anti-HAV can be used for prevaccination testing. Postvaccination testing is not indicated because of high rates of vaccine response among both adults and juveniles. In addition, no Food and Drug Administration (FDA)-approved testing method exists that has the sensitivity to detect low anti-HAV concentrations after vaccination. # Recommendations and # Continuing Education Unit (CEU). CDC has been approved as an authorized provider of continuing education and training programs by the International Association for Continuing Education and Training and awards 0.2 Continuing Education Units (CEUs). # Certified Health Education Specialist (CHES). CDC is a designated provider of continuing education contact hours in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for CHES to receive 2.0 hours in category 1 credit in health education, CDC provider number GA0082. Continuing Nursing Education (CNE). This activity for 2.5 contact hours is provided by CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation. # Goal and Objectives This MMWR provides information and recommendations regarding prevention and control of infections with hepatitis viruses in correctional settings. The recommendations were prepared by CDC staff from the National Center for Infectious Diseases, in consultation with external consultants. The goal of this report is to provide information and recommendations for physicians, health-care delivery staff, corrections staff, administrators, and other public health professionals who deliver services to incarcerated persons. After completing this educational activity, the reader should be able to 1) identify the risk factors for transmission of viral hepatitis among incarcerated persons; 2) describe the epidemiology of viral hepatitis in the United States; 3) describe the outcome of infection with hepatitis viruses; 4) describe methods used to prevent and control viral hepatitis in juvenile and adult correctional settings; and 5) identify infection control measures to prevent occupational exposure to hepatitis B and C viruses among correctional workers. To receive continuing education credit, please answer all of the following questions.

Radar radiation astronomy Radar astronomy is used to detect and study astronomical objects that reflect radio rays. The image at right is of asteroid 2012 LZ1 using the Arecibo Planetary Radar. Radar astronomy is a technique of observing nearby astronomical objects by reflecting microwaves off target objects and analyzing the echoes. Radar astronomy differs from radio astronomy in that the latter is a passive observation and the former an active one. The radar transmission may either be pulsed or continuous. Radar directly measures the distance to the object (and how fast it is changing). The combination of optical and radar observations normally allows the prediction of orbits at least decades, and sometimes centuries, into the future. The maximum range of astronomy by radar is very limited, and is confined to the solar system. This is because the signal strength drops off very steeply with distance to the target, the small fraction of incident flux that is reflected by the target, and the limited strength of transmitters. It is also necessary to have a relatively good ephemeris of the target before observing it. # Radars Radio waves are a type of electromagnetic radiation with wavelengths in the electromagnetic spectrum longer than infrared light. Radio waves have frequencies from 300 GHz to as low as 3 kHz, and corresponding wavelengths from 1 millimeter to 100 kilometers. # Planetary sciences "Radar waves penetrate the surface and pass through materials that do not severely attenuate or scatter them. Reflections arise from interfaces with dielectric contrasts. SHARAD has penetrated the ∼2-km-thick polar layered deposits in both the north and south, detecting many internal reflectors (17, 18). Smaller targets can be more challenging because SHARAD's antenna pattern is broad, resulting in surface reflections up to a few tens of kilometers away from the suborbital point in rugged areas, versus only a few kilometers in smooth, flat areas. These off-nadir echoes can appear at time delays similar to those arising from subsurface interfaces, so steps are required to avoid misinterpreting this surface clutter as subsurface echoes. Synthetic-aperture data processing is used to improve along-track resolution to ∼300 m, greatly reducing along-track clutter and focusing the surface and subsurface features. We used the known topography of the surface and the radar geometry to model cross-track clutter together with nadir surface echoes . Comparisons of radar sounding data with these synthetic surface echoes and the examination of possible surface echo sources in imagery (19) were undertaken for all cases ; such a procedure is a necessary part of radar sounding data interpretation in high-relief environments." The "Shallow Radar (SHARAD) (15) on the Mars Reconnaissance Orbiter (MRO) to probe the internal structure of several LDAs surrounding massifs on the eastern rim of the Hellas impact basin where more than 90 LDA complexes flank steep topography (2, 6, 16). The southernmost LDA we studied (LDA-2, has multiple lobes that coalesce to form a continuous deposit extending more than 20 km outward from a massif along ∼170 km of its margins." "Examination of radar data from SHARAD orbit 6830 where it crosses multiple LDAs in the eastern Hellas region shows that the only radar reflections not matching simulated surface echoes occur where the spacecraft passes over each LDA ; therefore, these echoes are interpreted as arising from within or beneath the LDAs. In one case (LDA-2A), surface clutter is predicted near the terminus of the LDA, where it may obscure portions of a subsurface reflector that clearly extends farther inward below the LDA. LDA-2A and LDA-2B show evidence for multiple, closely spaced subsurface reflectors indicating the presence of at least one thin (∼70 m assuming a water-ice composition), distinct deposit below thicker deposits (up to 800 m)." # Theoretical radar astronomy Here's a couple of theoretical definitions: Def. the branch of astronomy that uses radar to map the surfaces of planetary bodies in the solar system is called radar astronomy. Def. reflective and observational astronomy over radio wavelengths is called radar astronomy. # Aerometeors On the right is a composite of hourly radar images. These wind gusts averaged ~75 mph over about 450 miles. This is referred to as the Derecho event. # Opticals By optical astronomy, optical observations measure very accurately where an object appears on the sky, but cannot measure the distance accurately at all. # Hydromorphology On the right, the Quill satellite radar image is shown of the flooded Eel River outflow current debris field in gray. "Colored content is USGS-derived base map. Gray overlay is derived from a "Quill" satellite radar image made during the December 1964 flooding of California's Eel River. Accurate registration of the overlay onto the map is demonstrated by the excellent match of the stream-valley features in each." # Ice streams On the right is a radarsat image of ice streams flowing into the Filchner-Ronne ice shelf. Annotations outline the Rutford ice stream. # Glaciers On the right is a radar image of Alfred Ernest Ice Shelf on Ellesmere Island, taken by the ERS-1 satellite. # Glaciology "A small island obstructs the constant flow of the ice shelf on Queen Maud Land – it is the lighter area at the bottom left of the image . From September 2010 until it broke off, Iceberg A 62 was connected to the Fimbul Ice Shelf by a mere 800-metre-wide bridge. Two fissures in the ice from different sides of the bridge approached one another until the break occurred. The images transmitted by the radar satellite TerraSAR-X over a long period of time should enable researchers to achieve a better understanding of how icebergs calve." # Craters On the right is a synthetic aperture radar image of the Haughton impact crater on Devon Island, Nunavut, Canada. On the left is a topographic map from Shuttle Radar Topography Mission data of Iturralde Crater, an unconfirmed impact crater in Bolivia. "This figure shows a comparison of interferograms from four different years mapping the rapid ground subsidence over the Lost Hills oil field in California. Lost Hills is located about 60 km (40 miles) northwest of Bakersfield in the San Joaquin Valley. The oil field is about 1.5 km (1mile) wide and 6 km (3.5 miles) long." "Each interferogram was created using pairs of images taken by synthetic aperture radar that have been combined to measure surface deformation or changes that may have occurred in the time between when data for the two images were taken. The images were collected by the European Space Agency's Remote Sensing satellites (ERS-1 and ERS-2) in two months of each year shown (1995, 1996, 1998 and 1999) and were combined to produce these image maps of the apparent surface deformation, or changes." "The interferometric measurements that show the changes, primarily vertical subsidence of the surface, are rendered in color with purple indicating no motion and the brightest red showing rapid subsidence. The white areas are where the radar measurements could not be obtained, mostly in the agricultural fields around the oil fields where plant growth or plowing altered the radar properties of the surface." "These radar data show that parts of the oil field were subsiding unusually rapidly, more than 3 centimeters (1.2 inches) a month, in 1995 and 1996. They also reveal that while the ground subsidence rate decreased in the center part of the oil field, it increased in the northern part between 1995 and 1996 and 1998 and 1999." # Active faults "Earthquake faults commonly lie between the mountains and the lowlands. The San Andreas fault, the largest fault in California, likewise divides the very rugged San Gabriel Mountains from the low-relief Mojave Desert, thus forming a straight topographic boundary between the top center and lower right corner of the image. We present two versions of this perspective image from NASA's Shuttle Radar Topography Mission (SRTM): one with and one without a graphic overlay that maps faults that have been active in Late Quaternary times (white lines). The fault database was provided by the U.S. Geological Survey." "The Landsat image used here was acquired on May 4, 2001, about seven weeks before the summer solstice, so natural terrain shading is not particularly strong. It is also not especially apparent given a view direction (northwest) nearly parallel to the sun illumination (shadows generally fall on the backsides of mountains). Consequently, topographic shading derived from the SRTM elevation model was added to the Landsat image, with a false sun illumination from the left (southwest). This synthetic shading enhances the appearance of the topography." "Landsat has been providing visible and infrared views of the Earth since 1972. SRTM elevation data matches the 30-meter (98-foot) resolution of most Landsat images and substantially helps in analyzing the large and growing Landsat image archive. This Landsat 7 Thematic Mapper image was provided to the SRTM project by the United States Geological Survey, Earth Resources Observation Systems (EROS) Data Center, Sioux Falls, S.D." "Elevation data used in this image was acquired by the SRTM aboard the Space Shuttle Endeavour, launched on Feb. 11, 2000. SRTM used the same radar instrument that comprised the Spaceborne Imaging Radar-C/X-Band Synthetic Aperture Radar (SIR-C/X-SAR) that flew twice on the Space Shuttle Endeavour in 1994. SRTM was designed to collect 3-D measurements of the Earth's surface. To collect the 3-D data, engineers added a 60-meter (approximately 200-foot) mast, installed additional C-band and X-band antennas, and improved tracking and navigation devices. The mission is a cooperative project between NASA, the National Imagery and Mapping Agency (NIMA) of the U.S. Department of Defense and the German and Italian space agencies." "Size: View width 134 kilometers (83 miles); view distance 150 kilometers (93 miles) Location: 34.3 degrees North latitude, 118.4 degrees West longitude Orientation: View west-northwest, 1.8 X vertical exaggeration Image Data: Landsat Bands 3, 2+4, 1 as red, green, blue, respectively Original Data Resolution: SRTM 1 arcsecond (30 meters or 98 feet), Landsat 30 meters (98 feet) Graphic Data: earthquake faults active in Late Quaternary times Date Acquired: February 2000 (SRTM), May 4, 2001 (Landsat)." # Transform faults "The Alpine fault runs parallel to, and just inland of, much of the west coast of New Zealand's South Island. This view was created from the near-global digital elevation model produced by the Shuttle Radar Topography Mission (SRTM) and is almost 500 kilometers (just over 300 miles) wide. Northwest is toward the top. The fault is extremely distinct in the topographic pattern, nearly slicing this scene in half lengthwise." "In a regional context, the Alpine fault is part of a system of faults that connects a west dipping subduction zone to the northeast with an east dipping subduction zone to the southwest, both of which occur along the juncture of the Indo-Australian and Pacific tectonic plates. Thus, the fault itself constitutes the major surface manifestation of the plate boundary here. Offsets of streams and ridges evident in the field, and in this view of SRTM data, indicate right-lateral fault motion. But convergence also occurs across the fault, and this causes the continued uplift of the Southern Alps, New Zealand's largest mountain range, along the southeast side of the fault." "Two visualization methods were combined to produce this image: shading and color coding of topographic height. The shade image was derived by computing topographic slope in the northwest-southeast (image top to bottom) direction, so that northwest slopes appear bright and southeast slopes appear dark. Color coding is directly related to topographic height, with green at the lower elevations, rising through yellow and tan, to white at the highest elevations." "Elevation data used in this image were acquired by the Shuttle Radar Topography Mission aboard the Space Shuttle Endeavour, launched on Feb. 11, 2000. SRTM used the same radar instrument that comprised the Spaceborne Imaging Radar-C/X-Band Synthetic Aperture Radar (SIR-C/X-SAR) that flew twice on the Space Shuttle Endeavour in 1994. SRTM was designed to collect 3-D measurements of the Earth's surface. To collect the 3-D data, engineers added a 60-meter (approximately 200-foot) mast, installed additional C-band and X-band antennas, and improved tracking and navigation devices." The Alpine fault is "495 kilometers (307 miles) by 162 kilometers (100 miles). Location: 43.2 degrees South latitude, 170.5 degrees East longitude. Orientation: Northwest toward the top". # Volcanoes "The recently active volcano Mt. Manaro is the dominant feature in this shaded relief image of Ambae Island, part of the Vanuatu archipelago located 1400 miles northeast of Sydney, Australia. About 5000 inhabitants, half the island's population, were evacuated in early December from the path of a possible lahar, or mud flow, when the volcano started spewing clouds of steam and toxic gases 10,000 feet into the atmosphere." "Last active in 1996, the 1496 meter (4908 ft.) high Hawaiian-style basaltic shield volcano features two lakes within its summit caldera, or crater. The ash and gas plume is actually emerging from a vent at the center of Lake Voui (at left), which was formed approximately 425 years ago after an explosive eruption." "Two visualization methods were combined to produce the image: shading and color coding of topographic height. The shade image was derived by computing topographic slope in the northwest-southeast direction, so that northwest slopes appear bright and southeast slopes appear dark. Color coding is directly related to topographic height, with green at the lower elevations, rising through yellow and tan, to white at the highest elevations." "Elevation data used in this image were acquired by the Shuttle Radar Topography Mission aboard the Space Shuttle Endeavour, launched on Feb. 11, 2000. SRTM used the same radar instrument that comprised the Spaceborne Imaging Radar-C/X-Band Synthetic Aperture Radar (SIR-C/X-SAR) that flew twice on the Space Shuttle Endeavour in 1994. SRTM was designed to collect 3-D measurements of the Earth's surface. To collect the 3-D data, engineers added a 60-meter (approximately 200-foot) mast, installed additional C-band and X-band antennas, and improved tracking and navigation devices." "Location: 15.4 degree south latitude, 167.9 degrees east longitude; Orientation: North toward the top, Mercator projection; Size: 36.8 by 27.8 kilometers (22.9 by 17.3 miles); Image Data shaded and colored SRTM elevation model" On the left is a space radar image of Klyuchevskaya sopka. "This is an image of the area of the Kliuchevskoi volcano, Kamchatka, Russia, which began to erupt on September 30, 1994. Kliuchevskoi is the blue triangular peak in the center of the image, towards the left edge of the bright red area that delineates bare snow cover. The image was acquired by the Spaceborne Imaging Radar-C/X-Band Synthetic Aperture Radar (SIR-C/X-SAR) aboard the space shuttle Endeavour on its 88th orbit on October 5, 1994. The image shows an area approximately 75 kilometers by 100 kilometers (46 miles by 62 miles) that is centered at 56.07 degrees north latitude and 160.84 degrees east longitude. North is toward the bottom of the image. The radar illumination is from the top of the image. The Kamchatka volcanoes are among the most active volcanoes in the world. The volcanic zone sits above a tectonic plate boundary, where the Pacific plate is sinking beneath the northeast edge of the Eurasian plate. The Endeavour crew obtained dramatic video and photographic images of this region during the eruption . The colors in this image were obtained using the following radar channels: red represents the L-band, HH (horizontally transmitted and received) channel; green represents the L-band, HV (horizontally transmitted and vertically received) channel; blue represents the C-band, HV (horizontally transmitted and vertically received) channel. In addition to Kliuchevskoi, two other active volcanoes are visible in the image. Bezymianny, the circular crater above and to the right of Kliuchevskoi, contains a slowly growing lava dome. Tolbachik is the large volcano with a dark summit crater near the upper right edge of the red snow covered area. The Kamchatka River runs from right to left across the bottom of the image. The 1994 eruption of Kliuchevskoi included massive ejections of gas, vapor and ash, which reached altitudes of 15,000 meters (50,000 feet). Melting snow mixed with volcanic ash triggered mud flows on the flanks of the volcano. Paths of these flows can be seen as thin lines in various shades of blue and green on the north flank in the center of the image." # Mercury Radar astronomy of Mercury improved the value for the distance from the earth including the rotational period, libration,[and surface mapping, especially of the polar regions. In "1991, the Arecibo radio telescope in Puerto Rico detected unusually radar-bright patches at Mercury's poles, spots that reflected radio waves in the way one would expect if there were water ice . Many of these patches corresponded to the location of large impact craters mapped by the Mariner 10 spacecraft in the 1970s." "Images from the spacecraft's Mercury Dual Imaging System taken in 2011 and earlier this year confirmed that radar-bright features at Mercury's north and south poles are within shadowed regions on Mercury's surface, findings that are consistent with the water-ice hypothesis." "The neutron data indicate that Mercury's radar-bright polar deposits contain, on average, a hydrogen-rich layer more than tens of centimeters thick beneath a surficial layer 10 to 20 centimeters thick that is less rich in hydrogen". "The buried layer has a hydrogen content consistent with nearly pure water ice." "These reflectance anomalies are concentrated on poleward-facing slopes and are spatially collocated with areas of high radar backscatter postulated to be the result of near-surface water ice". "Correlation of observed reflectance with modeled temperatures indicates that the optically bright regions are consistent with surface water ice." MESSENGER's Mercury Laser Altimeter (MLA) data "show that the spatial distribution of regions of high radar backscatter is well matched by the predicted distribution of thermally stable water ice". Water ice strongly reflects radar, and observations by the 70 m Goldstone telescope and the VLA in the early 1990s revealed that there are patches of very high radar reflection near the poles. While ice is not the only possible cause of these reflective regions, astronomers believe it is the most likely. # Venus The first un-ambiguous detection of Venus was made by the Jet Propulsion Laboratory (JPL) on 10 March 1961. A correct measurement of the AU soon followed. "The advantages of radar in planetary astronomy result from (1) the observer's control of all the attributes of the coherent signal used to illuminate the target, especially the wave form's time/frequency modulation and polarization; (2) the ability of radar to resolve objects spatially via measurements of the distribution of echo power in time delay and Doppler frequency; (3) the pronounced degree to which delay-Doppler measurements constrain orbits and spin vectors; and (4) centimeter-to-meter wavelengths, which easily penetrate optically opaque planetary clouds and cometary comae, permit investigation of near-surface macrostructure and bulk density, and are sensitive to high concentrations of metal or, in certain situations, ice." The radar image at left shows that just beneath the cloud layers is a rocky object. # Earth Numerous airborne and spacecraft radars have mapped the entire planet, for various purposes. One example is the Shuttle Radar Topography Mission, which mapped the entire Earth at 30 m resolution. "The impact of an asteroid or comet several hundred million years ago left scars in the landscape that are still visible in this spaceborne radar image of an area in the Sahara Desert of northern Chad. The concentric ring structure is the Aorounga impact crater, with a diameter of about 17 kilometers (10.5 miles). The original crater was buried by sediments, which were then partially eroded to reveal the current ring-like appearance. The dark streaks are deposits of windblown sand that migrate along valleys cut by thousands of years of wind erosion. The dark band in the upper right of the image is a portion of a proposed second crater." "Radar imaging is a valuable tool for the study of desert regions because the radar waves can penetrate thin layers of dry sand to reveal details of geologic structure that are invisible to other sensors. The image was acquired by the Spaceborne Imaging Radar-C/X-band Synthetic Aperture Radar (SIR-C/X-SAR) on April 18 and 19, 1994, onboard the space shuttle Endeavour. The area shown is 22 kilometers by 28 kilometers (14 miles by 17 miles) and is centered at 19.1 degrees north latitude, 19.3 degrees east longitude. North is toward the upper right. The colors are assigned to different radar frequencies and polarizations as follows: red is L-band, horizontally transmitted and received; green is C-band, horizontally transmitted and received; and blue is C-band, horizontally transmitted, vertically received." At right is a shaded relief map of Antarctica developed from RADARSAT Synthetic Aperture Radar data. RADARSAT is a Canadian satellite. # Moon The moon is comparatively close and was detected by radar, soon after the invention of the technique, in 1946. Measurements included surface roughness and later mapping of shadowed regions near the poles. "Clementine orbited the Moon in 1994 for 71 days, mapping the Moon globally in 11 wavelengths and measuring its topography by laser ranging. bistatic radar experiment (so-called because the spacecraft transmitted while we listened to the echoes on Earth) found evidence in the dark areas near the south pole of the Moon for material with high circular polarization ratio ". "Meanwhile, astronomers on Earth began publishing results questioning the Clementine and Lunar Prospector results. With the giant Arecibo radiotelescope, radar images were taken from the Earth. They found radar reflections with high CPR lying in both permanent darkness and in sunlit areas. Ice is not stable in sunlight, so they postulated that all high CPR is caused by surface roughness; if any ice is at the lunar poles, it must be in a finely disseminated form, invisible to radar mapping." The experiment from Clemintine "was bistatic, i.e., the transmitter and receiver were in different places. Bistatic radar has the advantage of observing reflections through the phase angle, the angle between transmitted and received radio rays . This phase dependence is important. It’s similar to the effect one gets from looking at a bicycle reflector at just the right angle: at certain angles, the internal planes in the transparent plastic align and a very bright reflection is seen. Similarly, in both radio and visible wavelengths on the Moon, we see an “opposition surge”, an apparent increase in brightness looking directly down from the sun (zero phase). Clementine orbited the Moon such that we could observe its phase dependence and we specifically looked for this “opposition surge”, called the Coherent Backscatter Opposition Effect (CBOE). CBOE is particularly valuable to identify ice on planetary surfaces." "Clementine transmitted right circular polarized (RCP) radio and we listened on Earth in both right- and left-circular polarized (LCP) channels. The ratio of power received in these two channels is called the circular polarization ratio (CPR). The dry, equatorial Moon has CPR less than one, but the icy satellites of Jupiter all have CPR greater than one. We know these objects have surfaces of water ice; in this case, the ice acts as a radio-transparent media in which waves penetrate the ice, are scattered and reflected multiple times, and returned such that some of the waves are received in the same polarization sense as they are sent—they have CPR greater than unity" "The problem with CPR alone is that we can also get high values from very rough surfaces, such as a rough, blocky lava flow, which has angles that form many small corner reflectors. In this case, a radio wave could hit a rock face (changing RCP into LCP) and then bounce over to another rock face (changing the LCP back into RCP) and hence to the receiver . This “double-bounce” effect also creates high CPR in that “same sense” reflections could mimic the enhanced CPR one gets from ice targets." At lower right is an image using the Goldstone DSS-14 antenna as a transmitter and the DSS-13 as a receiver, a form of radar interferometry. The cross for the south pole in the Arecibo image is in the Shackleton crater of the Goldstone image. "Very precise microwave measurements between two spacecraft, named Ebb and Flow, were used to map gravity with high precision and high spatial resolution. The field shown resolves blocks on the surface of about 12 miles (20 kilometres) and measurements are three to five orders of magnitude improved over previous data. Red corresponds to mass excesses and blue corresponds to mass deficiencies. The map shows more small-scale detail on the far side of the moon compared to the nearside because the far side has many more small craters." "Twin NASA probes orbiting Earth's moon have generated the highest resolution gravity field map of any celestial body. The new map, created by the Gravity Recovery and Interior Laboratory (GRAIL) mission, is allowing scientists to learn about the moon's internal structure and composition in unprecedented detail. Data from the two washing machine-sized spacecraft also will provide a better understanding of how Earth and other rocky planets in the solar system formed and evolved." "The gravity field map reveals an abundance of features never before seen in detail, such as tectonic structures, volcanic landforms, basin rings, crater central peaks and numerous simple, bowl-shaped craters. Data also show the moon's gravity field is unlike that of any terrestrial planet in our solar system." ""What this map tells us is that more than any other celestial body we know of, the moon wears its gravity field on its sleeve," said GRAIL Principal Investigator Maria Zuber of the Massachusetts Institute of Technology in Cambridge. "When we see a notable change in the gravity field, we can sync up this change with surface topography features such as craters, rilles or mountains."" "According to Zuber, the moon's gravity field preserves the record of impact bombardment that characterized all terrestrial planetary bodies and reveals evidence for fracturing of the interior extending to the deep crust and possibly the mantle. This impact record is preserved, and now precisely measured, on the moon. The probes revealed the bulk density of the moon's highland crust is substantially lower than generally assumed. This low-bulk crustal density agrees well with data obtained during the final Apollo lunar missions in the early 1970s, indicating that local samples returned by astronauts are indicative of global processes." ""With our new crustal bulk density determination, we find that the average thickness of the moon's crust is between 21 and 27 miles (34 and 43 kilometres), which is about 6 to 12 miles (10 to 20 kilometres) thinner than previously thought," said Mark Wieczorek, GRAIL co-investigator at the Institut de Physique du Globe de Paris. "With this crustal thickness, the bulk composition of the moon is similar to that of Earth. This supports models where the moon is derived from Earth materials that were ejected during a giant impact event early in solar system history."" "The map was created by the spacecraft transmitting radio signals to define precisely the distance between them as they orbit the moon in formation. As they fly over areas of greater and lesser gravity caused by visible features, such as mountains and craters, and masses hidden beneath the lunar surface, the distance between the two spacecraft will change slightly." ""We used gradients of the gravity field in order to highlight smaller and narrower structures than could be seen in previous datasets," said Jeff Andrews-Hanna, a GRAIL guest scientist with the Colorado School of Mines in Golden. "This data revealed a population of long, linear gravity anomalies, with lengths of hundreds of kilometres, crisscrossing the surface. These linear gravity anomalies indicate the presence of dikes, or long, thin, vertical bodies of solidified magma in the subsurface. The dikes are among the oldest features on the moon, and understanding them will tell us about its early history."" At fourth right is an image of the Moon using its thermal emission at 850 microns. "The Moon and planets are not detectable by reflected solar radiation at radio wavelengths. However, they all emit thermal radiation, and Jupiter is a strong nonthermal source as well. If the Sun were suddenly switched off, the planets would remain radio sources for a long time, slowly fading as they cooled. At first glance, the λ = 0.85 mm radio image of the Moon looks familiar, but there are differences from the visible Moon." "The darker right edge of the Moon is not being illuminated by the Sun, but it still emits radio waves because it does not cool to absolute zero during the lunar night. A subtler point is that the radio emission is not produced at the visible surface; it emerges from a layer about ten wavelengths thick. As a result, monthly temperature variations of the Moon decrease with increasing wavelength. These wavelength-dependent temperature variations encode information about the conductivity and heat capacity of the rocky and dusty outer layers of the Moon." "Radar images like the one were recently used to search for water ice trapped in cold craters near the lunar poles." The ESA Lunar Lander Mission Lunar Dust Environment and Plasma Package: "Observe radio spectrum (with an additional goal to prepare for future radiation astronomy activities.)" # Mars Mapping of surface roughness from Arecibo Observatory. The Mars Express mission carries a ground-penetrating radar. The image at right "shows a cross-section of a portion of the north polar ice cap of Mars, derived from data acquired by the Mars Reconnaissance Orbiter's Shallow Radar (SHARAD), one of six instruments on the spacecraft. The data depict the region's internal ice structure, with annotations describing different layers. The ice depicted in this graphic is approximately 2 kilometers (1.2 miles) thick and 250 kilometers (155 miles) across. White lines show reflection of the radar signal back to the spacecraft. Each line represents a place where a layer sits on top of another. Scientists study how thick the pancake-like layers are, where they bulge and how they tilt up or down to understand what the surface of the ice sheet was like in the past as each new layer was deposited." The image at left, "called an ionogram, shows data from sounding Mars' ionosphere with the Mars Advanced Radar for Subsurface and Ionospheric Sounding (MARSIS). The horizontal axis is the frequency of the pulse. The left vertical axis is the time delay after transmitting the pulse, with time increasing downward. The right vertical axis is a conversion of time delay to distance, showing the apparent range to the reflection point. The intensity of the received signal at any given frequency and apparent range is indicated by the color, with dark blue being the least intense and green being the most intense." "The green echo at an apparent range of about 800 kilometers (497 miles) from 2.5 to 5.5 megahertz is the reflected signal from the surface of Mars. The curved bright green feature with an apparent range varying from about 600 to 750 kilometers (373 to 466 miles) at frequencies from about 0.7 to 1.8 megahertz is the echo from the top side of the ionosphere. A second echo of the ionosphere, at an apparent range of about 100 kilometers (62 miles) is labeled "Oblique ionospheric echo." Such echoes are believed to come from distorted structures in the ionosphere caused by the magnetic fields in the crust of Mars." "MARSIS is an instrument on the European Space Agency's Mars Express orbiter." At lower right is a "radargram from the Shallow Subsurface Radar instrument (SHARAD)". The "Shallow Subsurface Radar instrument (SHARAD) on NASA's Mars Reconnaissance Orbiter is shown in the upper-right panel and reveals detailed structure in the polar layered deposits of the south pole of Mars." "The sounding radar collected the data presented here during orbit 1334 of the mission, on Nov. 8, 2006." "The horizontal scale in the radargram is distance along the ground track. It can be referenced to the ground track map shown in the lower right. The radar traversed from about 75 to 85 degrees south latitude, or about 590 kilometers (370 miles). The ground track map shows elevation measured by the Mars Orbiter Laser Altimeter on NASA's Mars Global Surveyor orbiter. Green indicates low elevation; reddish-white indicates higher elevation. The traverse proceeds up onto a plateau formed by the layers." "The vertical scale on the radargram is time delay of the radar signals reflected back to Mars Reconnaissance Orbiter from the surface and subsurface. For reference, using an assumed velocity of the radar waves in the subsurface, time is converted to depth below the surface at one place: about 1,500 meters (5,000 feet) to one of the deeper subsurface reflectors. The color scale varies from black for weak reflections to white for strong reflections." "The middle panel shows mapping of the major subsurface reflectors, some of which can be traced for a distance of 100 kilometers (60 miles) or more. The layers are not all horizontal and the reflectors are not always parallel to one another. Some of this is due to variations in surface elevation, which produce differing velocity path lengths for different reflector depths. However, some of this behavior is due to spatial variations in the deposition and removal of material in the layered deposits, a result of the recent climate history of Mars." "The Shallow Subsurface Radar was provided by the Italian Space Agency (ASI). Its operations are led by the University of Rome and its data are analyzed by a joint U.S.-Italian science team." # Asteroids The image at the top of the page is of asteroid 2012 LZ1. "On Sunday, June 10, a potentially hazardous asteroid thought to have been 500 meters (0.31 miles) wide was discovered by Siding Spring Observatory in New South Wales, Australia. Fortunately for us, asteroid 2012 LZ1 drifted safely by, coming within 14 lunar distances from Earth on Thursday, June 14." "Asteroid 2012 LZ1 is actually bigger than thought… in fact, it is quite a lot bigger. 2012 LZ1 is one kilometer wide (0.62 miles), double the initial estimate." Asteroid "2012 LZ1′s surface is really dark, reflecting only 2-4 percent of the light that hits it — this contributed to the underestimated initial optical observations. Looking for an asteroid the shade of charcoal isn’t easy." “This object turned out to be quite a bit bigger than we expected, which shows how important radar observations can be, because we’re still learning a lot about the population of asteroids”. “The sensitivity of our radar has permitted us to measure this asteroid’s properties and determine that it will not impact the Earth at least in the next 750 years”. The extremely accurate astrometry provided by radar is critical in long-term predictions of asteroid-Earth impacts, as illustrated by the object 99942 Apophis. At right is a Goldstone radar image of the asteroid 4179 Toutatis on November 26, 1996. The "images were recorded at NASA's Deep Space Network 70-meter and 34-meter radio/radar antennas in Goldstone, CA, and the 305-meter Arecibo Radio Telescope in Puerto Rico." "It's amazing that the shape of Toutatis can be determined so accurately from ground-based observations". "This technology will provide us with startling, close-up views of thousands of asteroids that orbit near the Earth." "We used the computer to mathematically create a three- dimensional model of the surface and rotation of Toutatis". "It's as though we put a clay model in space and molded it until it matched the appearance of the actual asteroid." "The video is of particular interest as Toutatis nears Earth and makes its closest approach on Friday, Nov. 29, when it will pass by at a distance of 3.3 million miles (5.3 million kilometers), or about 14 times the distance from the Earth to the Moon. In 2004, Toutatis will pass only four lunar distances from Earth, closer than any known Earth- approaching object expected to pass by in the next 60 years." "Toutatis poses no significant threat to Earth, at least for a few hundred years". "The discovery that we live in an asteroid swarm is important for the future of humanity". "These leftover debris from planetary formation can teach us a good deal about the formation of our Solar System. Asteroids also contain valuable minerals and many are the cheapest possible destinations for space missions." # 16 Psyche A "huge, metallic asteroid named 16 Psyche resides" in the asteroid belt. 16 Psyche is "a 130-mile-wide (210 kilometers) metallic asteroid that may be the core of an ancient, Mars-size planet. Violent collisions billions of years ago might have stripped away the layers of rock that once lay atop this metallic object." "16 Psyche is the only known object of its kind in the solar system, and this is the only way humans will ever visit a core. We learn about inner space by visiting outer space." The "asteroid Psyche displays significant variations in radar and optical albedo with rotation." "16 Psyche the largest M-class asteroid in the main belt." "18 radar imaging and 6 continuous wave runs in November and December 2015, combined with 16 continuous wave runs from 2005 and 6 recent adaptive-optics (AO) images (Drummond et al., 2016) to generate a three-dimensional shape model of Psyche." The "shape model has dimensions 279 × 232 × 189 km (± 10%), Deff = 226 ± 23 km, and is 6% larger than, but within the uncertainties of, the most recently published size and shape model generated from the inversion of lightcurves (Hanus et al., 2013). Psyche is roughly ellipsoidal but displays a mass-deficit over a region spanning 90° of longitude. There is also evidence for two ∼50–70 km wide depressions near its south pole. Their size and published masses lead to an overall bulk density estimate of 4500 ± 1400 kg·m−3. Psyche's mean radar albedo of 0.37 ± 0.09 is consistent with a near-surface regolith composed largely of iron-nickel and ∼40% porosity. Its radar reflectivity varies by a factor of 1.6 as the asteroid rotates, suggesting global variations in metal abundance or bulk density in the near surface." # Jupiter Between September and November 23, 1963, Jupiter is detected by radar astronomy. "The dense atmosphere makes a penetration to a hard surface (if indeed one exists at all) very unlikely. In fact, the JPL results imply a correlation of the echo with Jupiter ... which corresponds to the upper (visible) atmosphere. ... Further observations will be needed to clarify the current uncertainties surrounding radar observations of Jupiter." "Although in 1963 some claimed to have detected echoes from Jupiter, these were quite weak and have not been verified by later experiments." "A search for radar echoes from Jupiter at 430 MHz during the oppositions of 1964 and 1965 failed to yield positive results, despite a sensitivity several orders of magnitude better than employed by other groups in earlier (1963) attempts at higher frequencies. ... t might be suspected that meteorological disturbances of a random nature were involved, and that the echoes might be returned only in exceptional circumstances. Further support for this point of view may be gleaned from the fact that JPL found positive results for only 1 (centered at 32° System I longitude) of the 8 longitude regions investigated in 1963 (Goldstein 1964) and, in fact, had no success during their observations in 1964 (see comment by Goldstein following Dyce 1965)." # Titan Radar detection of Titan from Arecibo Observatory, included mapping of Titan's surface. "This Cassini false-color mosaic shows all synthetic-aperture radar images to date of Titan's north polar region. Approximately 60 percent of Titan's north polar region, above 60 degrees north latitude, is now mapped with radar. About 14 percent of the mapped region is covered by what is interpreted as liquid hydrocarbon lakes." "Features thought to be liquid are shown in blue and black, and the areas likely to be solid surface are tinted brown. The terrain in the upper left of this mosaic is imaged at lower resolution than the remainder of the image". "Most of the many lakes and seas seen so far are contained in this image, including the largest known body of liquid on Titan. These seas are most likely filled with liquid ethane, methane and dissolved nitrogen." "Many bays, islands and presumed tributary networks are associated with the seas. The large feature in the upper right center of this image is at least 100,000 square kilometers (40,000 square miles) in area, greater in extent than Lake Superior (82,000 square kilometers or 32,000 square miles), one of Earth's largest lakes. This Titan feature covers a greater fraction of the surface, at least 0.12 percent, than the Black Sea, Earth's largest terrestrial inland sea, at 0.085 percent. Larger seas may exist, as it is probable that some of these bodies are connected, either in areas unmapped by radar or under the surface (see PIA08365)." "Of the 400 observed lakes and seas, 70 percent of their area is taken up by large "seas" greater than 26,000 square kilometers (10,000 square miles)." In the second image at right is another radar image of Titan's surface. "The existence of oceans or lakes of liquid methane on Saturn's moon Titan was predicted more than 20 years ago. But with a dense haze preventing a closer look it has not been possible to confirm their presence. Until the Cassini flyby of July 22, 2006, that is." "Radar imaging data from the flyby, published this week in the journal Nature, provide convincing evidence for large bodies of liquid. This image, used on the journal's cover, gives a taste of what Cassini saw. Intensity in this colorized image is proportional to how much radar brightness is returned, or more specifically, the logarithm of the radar backscatter cross-section. The colors are not a representation of what the human eye would see." "The lakes, darker than the surrounding terrain, are emphasized here by tinting regions of low backscatter in blue. Radar-brighter regions are shown in tan. The strip of radar imagery is foreshortened to simulate an oblique view of the highest latitude region, seen from a point to its west." "This radar image was acquired by the Cassini radar instrument in synthetic aperture mode on July 22, 2006. The image is centered near 80 degrees north, 35 degrees west and is about 140 kilometers (84 miles) across. Smallest details in this image are about 500 meters (1,640 feet) across." # Comets "Goldstone radar observations on 2011 August 19 and 20 detected echoes from the nucleus and coma of comet 45P/Honda-Mrkos-Pajdusakova (HMP). This is only the fourth Goldstone comet detection and the first since detection of comet 73P/Schwassmann-Wachmann 3 in 2006." "The CW spectrum shows the opposite-circular echo from the comet obtained on August 19. The narrow spike is the echo from the nucleus and the broad, low, asymmetric hump is the echo from coma particles. The skew of the coma echo to positive frequencies indicates that most of the coma particles were approaching Earth at the time of the observations." "The Goldstone measurements provided a range correction of 49 km for the nucleus, which significantly improved the orbit and which revealed a systematic bias in many of the optical observations." "This is only the fifteenth comet that has been detected with radar." # Astrometry "Asteroid radar astronomy began on 14 June 1968, with the detection of 1566 Icarus from Goldstone (Goldstein 1969) and Haystack (Pettengill et al. 1969)." "Radar measurements of echo Doppler frequencies and time delays permit significant refinements of orbital elements and commensurate improvements in the accuracy of prediction ephemerides because these measurements have fine fractional precision and are orthogonal to optical, angular-position measurements." "Yeomans et al. (1987) used numerical experiments to explore the extent to which delay/ Doppler astrometry can refine orbit estimates for NEAs. They concluded that radar measurements can reduce ephemeris uncertainties dramatically for asteroids having short optical-data histories. They noted that a few radar observations of a newly discovered NEA could mean the difference between successfully recovering the object during its next close approach and losing it entirely. Even for asteroids with very long astrometric histories and secure orbits, radar measurements can significantly shrink their positional error ellipsoids for at least a decade." "A typical transmit/receive cycle, or run, consists of signal transmission for a duration close to the roundtrip light time between the radar and the target, i.e., until the first echoes are about to come back, followed by reception of echoes for a similar duration. In continuous wave (cw) observations, one transmits a nearly monochromatic waveform and measures the distribution of echo power as a function of frequency. The resultant echo spectra can be thought of as one-dimensional images, or brightness scans across the target through a slit parallel to the asteroid’s apparent spin vector. In ranging observations, time coding of the waveform permits measurement of the distribution of echo power in time delay (range) as well." "An asteroid’s apparent radial motion introduces a continuously changing Doppler shift into the echoes. One avoids spectral smear by tuning the receiver according to an ephemeris based on an orbit determined from astrometric asteroid observations." "In cw experiments, voltage samples of the received signal are Fourier transformed and the results are squared to obtain an estimate of the power spectrum, with the frequency resolution equal to the reciprocal of the time series length, i.e., of the coherence time. The sampling rate is chosen to provide an unaliased bandwidth many times larger than both the a priori Doppler uncertainty and the echo bandwidth, so fest can be determined unambiguously from the received power spectrum. Normally, a number of these "single-look" spectra are averaged to improve the spectral estimates." "In principle, range resolution can be obtained by using a coherent pulsed cw waveform—the transmitter’s carrier-frequency oscillator operates continuously but radio-frequency power is radiated only during intervals that are one delay resolution cell long and occur at intervals called the pulse repetition period (PRP). The PRP is normally much greater than the target’s intrinsic delay dispersion, thereby ensuring that the echo will consist of successive, nonoverlapping range profiles. Fourier transformation of N time samples taken at the same position (i.e., the same delay relative to τ0) within each of N successive range profiles yields the echo power spectrum for the corresponding range cell on the target. This spectrum has an unaliased bandwidth B - l/ and a frequency resolution B/N, where NCOH is the number of code cycles for which voltage samples have been coherently summed prior to Fourier transformation." # Locations on Earth The radar image of France on the right is color-coded for relative relief from darker green at or near sea level to white for mountain tops. The border of France has been shaded and given a slight elevation away from the rest of the Earth nearby. On the left is a colour coded TanDEM-X digital elevation model is of Khairabad in northern Pakistan, created on 6 August 2010. # Paleogeography "The ability of a sophisticated radar instrument to image large regions of the world from space, using different frequencies that can penetrate dry sand cover, produced the discovery in this image: a previously unknown branch of an ancient river, buried under thousands of years of windblown sand in a region of the Sahara Desert in North Africa. This area is near the Kufra Oasis in southeast Libya, centered at 23.3 degrees north latitude, 22.9 degrees east longitude. The image was acquired by the Spaceborne Imaging Radar-C/X-band Synthetic Aperture (SIR- C/X-SAR) imaging radar when it flew aboard the space shuttle Endeavour on its 60th orbit on October 4, 1994. This SIR-C image reveals a system of old, now inactive stream valleys, called "paleodrainage systems."" # Impact craters Per the image on the right: "In 2015 I was looking at a new map of the bedrock below the Greenland Ice Sheet and discovered a large circular feature under the Hiawatha glacier in northwest Greenland." "You can see the rounded structure at the edge of the ice sheet, especially when flying high enough." "For the most part the crater isn’t visible out the airplane window. It’s funny that until now nobody thought, ‘Hey, what’s that semicircular feature there?’ From the airplane it is subtle and hard to see unless you already know it’s there. Using satellite imagery taken at a low sun angle that accentuates hills and valleys in the ice sheet’s terrain—you can really see the circle of the whole crater in these images." "It is correct that the crater is not well dated but there’s good evidence that it is geologically young, that is, it formed within the last 2 to 3 million years, and most likely it is as young as the last Ice Age ,” Larsen explained to Gizmodo. “We are currently trying to come up with ideas on how to date the impact. One idea is to drill through the ice and get bedrock samples that can be used for numerical dating." On the left is an image of bed "topography based on airborne radar sounding from 1997 to 2014 NASA data and 2016 Alfred Wegener Institute (AWI) data. Black triangles represent elevated rim picks from the radargrams, and the dark purple circles represent peaks in the central uplift. Hatched red lines are field measurements of the strike of ice-marginal bedrock structures. Black circles show location of the three glaciofluvial sediment samples". "Glaciofluvial sediment from the largest river draining the crater contains shocked quartz and other impact-related grains. Geochemical analysis of this sediment indicates that the impactor was a fractionated iron asteroid, which must have been more than a kilometer wide to produce the identified crater. Radiostratigraphy of the ice in the crater shows that the Holocene ice is continuous and conformable, but all deeper and older ice appears to be debris rich or heavily disturbed." # Rainbands Rainbands are cloud and precipitation areas which are significantly elongated. Rainbands can be stratiform or convective, and are generated by differences in temperature. When noted on weather radar imagery, this precipitation elongation is referred to as banded structure. Rainbands in advance of warm occluded fronts and warm fronts are associated with weak upward motion, and tend to be wide and stratiform in nature. Rainbands spawned near and ahead of cold fronts can be squall lines which are able to produce tornadoes. Rainbands associated with cold fronts can be warped by mountain barriers perpendicular to the front's orientation due to the formation of a low-level barrier jet. Bands of thunderstorms can form with sea breeze and land breeze boundaries, if enough moisture is present. If sea breeze rainbands become active enough just ahead of a cold front, they can mask the location of the cold front itself. # Extratropical cyclones Rainbands in advance of warm occluded fronts and warm fronts are associated with weak upward motion, and tend to be wide and stratiform in nature. In an atmosphere with rich low level moisture and vertical wind shear, narrow, convective rainbands known as squall lines generally in the cyclone's warm sector, ahead of strong cold fronts associated with extratropical cyclones. Wider rain bands can occur behind cold fronts, which tend to have more stratiform, and less convective, precipitation. Within the cold sector north to northwest of a cyclone center, in colder cyclones, small scale, or mesoscale, bands of heavy snow can occur within a cyclone's comma head precipitation pattern with a width of 20 miles (32.18688 km) to 50 miles (80.4672 km). These bands in the comma head are associated with areas of frontogensis, or zones of strengthening temperature contrast. Southwest of extratropical cyclones, curved flow bringing cold air across the relatively warm Great Lakes can lead to narrow lake effect snow bands which bring significant localized snowfall. # Recent history The recent history period dates from around 1,000 b2k to present. The "Arecibo telescope was completed in 1963 at the initiative of Cornell electrical engineering professor William E. Gordon". At right is an image of the Pluton radar complex used for radar astronomy since 1960. # Arecibo Observatory The "Arecibo Observatory in Puerto Rico the world's largest, and most sensitive, single-dish radio telescope." "The 1,000-foot-diameter (305 meters) Arecibo telescope access to state-of-the-art observing for scientists in radio astronomy, solar system radar and atmospheric studies, and the observatory has the unique capability for solar system and ionosphere (the atmosphere's ionized upper layers) radar remote sensing." It contains the largest curved focusing dish on Earth, giving Arecibo the largest electromagnetic-wave-gathering capacity. The dish surface is made of 38,778 perforated aluminum panels, each measuring about 3 by 6 feet (1 by 2 m), supported by a mesh of steel cables. The telescope has three radar transmitters, with effective isotropic radiated powers of 20 TW at 2380 MHz, 2.5 TW (pulse peak) at 430 MHz, and 300 MW at 47 MHz. The telescope is a spherical reflector, not a parabolic reflector. To aim the telescope, the receiver is moved to intercept signals reflected from different directions by the spherical dish surface. A parabolic mirror would induce a varying astigmatism when the receiver is in different positions off the focal point, but the error of a spherical mirror is the same in every direction. The receiver is located on a 900-ton platform which is suspended 150 m (500 ft) in the air above the dish by 18 cables running from three reinforced concrete towers, one of which is 110 m (365 ft) high and the other two of which are 80 m (265 ft) high (the tops of the three towers are at the same elevation). The platform has a 93-meter-long rotating bow-shaped track called the azimuth arm on which receiving antennas, secondary and tertiary reflectors are mounted. This allows the telescope to observe any region of the sky within a forty-degree cone of visibility about the local zenith (between −1 and 38 degrees of declination). Puerto Rico's location near the equator allows Arecibo to view all of the planets in the Solar System, though the round trip light time to objects beyond Saturn is longer than the time the telescope can track it, preventing radar observations of more distant objects. # Goldstone Deep Space Communication Complex Shown at right are the three "34m (110 ft.) diameter Beam Waveguide antennas located at the Goldstone Deep Space Communications Complex, situated in the Mojave Desert in California. This is one of three complexes which comprise NASA's Deep Space Network (DSN). The DSN provides radio communications for all of NASA's interplanetary spacecraft and is also utilized for radio astronomy and radar observations of the solar system and the universe." # Synthetic Aperture Radar Satellite "Using advanced radar imaging that will provide an unprecedented, detailed view of Earth, the NASA-ISRO Synthetic Aperture Radar, or NISAR, satellite is designed to observe and take measurements of some of the planet's most complex processes, including ecosystem disturbances, ice-sheet collapse, and natural hazards such as earthquakes, tsunamis, volcanoes and landslides." "Data collected from NISAR will reveal information about the evolution and state of Earth's crust, help scientists better understand our planet's processes and changing climate, and aid future resource and hazard management. The mission is a partnership between NASA and the Indian Space Research Organization ." "Scientific Instrument(s) - L-band (24-centimeter wavelength) Polarimetric Synthetic Aperture Radar - S-band (12-centimeter wavelength) Polarimetric Synthetic Aperture Radar " # Interferograms "This image is an interferogram that was created using pairs of images taken by Synthetic Aperture Radar (SAR). The images, acquired at two different times, have been combined to measure surface deformation or changes that may have occurred during the time between data acquisition. The images were collected by the European Space Agency's Remote Sensing satellite (ERS-2) on 13 August 1999 and 17 September 1999 and were combined to produce these image maps of the apparent surface deformation, or changes, during and after the 17 August 1999 Izmit, Turkey earthquake. This magnitude 7.6 earthquake was the largest in 60 years in Turkey and caused extensive damage and loss of life. Each of the color contours of the interferogram represents 28 mm (1.1 inches) of motion towards the satellite, or about 70 mm (2.8 inches) of horizontal motion. White areas are outside the SAR image or water of seas and lakes. The North Anatolian Fault that broke during the Izmit earthquake moved more than 2.5 meters (8.1 feet) to produce the pattern measured by the interferogram. Thin red lines show the locations of fault breaks mapped on the surface. The SAR interferogram shows that the deformation and fault slip extended west of the surface faults, underneath the Gulf of Izmit. Thick black lines mark the fault rupture inferred from the SAR data. Scientists are using the SAR interferometry along with other data collected on the ground to estimate the pattern of slip that occurred during the Izmit earthquake. This then used to improve computer models that predict how this deformation transferred stress to other faults and to the continuation of the North Anatolian Fault, which extends to the west past the large city of Istanbul. These models show that the Izmit earthquake further increased the already high probability of a major earthquake near Istanbul." "This image of Fort Irwin in California's Mojave Desert compares interferometric radar signatures topography -- data that were obtained by multiple imaging of the same region to produce three-dimensional elevation maps -- as it was obtained on October 7-8, 1994 by the Spaceborne Imaging Radar-C/X-band Synthetic Aperture Radar aboard the space shuttle Endeavour. Data were acquired using the L-band (24 centimeter wavelength) and C-band (6 centimeter wavelength). The image covers an area about 25 kilometers by 70 kilometers (15.5 miles by 43 miles). North is to the lower right of the image. The color contours shown are proportional to the topographic elevation. With a wavelength one-fourth that of the L-band, the results from the C-band cycle through the color contours four times faster for a given elevation change. Detailed comparisons of these multiple frequency data over different terrain types will provide insights in the future into wavelength-dependent effects of penetration and scattering on the topography measurement accuracy. Fort Irwin is an ideal site for such detailed digital elevation model comparisons because a number of high precision digital models of the area already exist from conventional measurements as well as from airborne interferometric SAR data." "Spaceborne Imaging Radar-C and X-band Synthetic Aperture Radar (SIR-C/X-SAR) is part of NASA's Mission to Planet Earth. The radars illuminate Earth with microwaves, allowing detailed observations at any time, regardless of weather or sunlight conditions. SIR-C/X-SAR uses three microwave wavelengths: L-band (24 cm), C-band (6 cm) and X-band (3 cm). The multi-frequency data will be used by the international scientific community to better understand the global environment and how it is changing. The SIR-C/X-SAR data, complemented by aircraft and ground studies, will give scientists clearer insights into those environmental changes which are caused by nature and those changes which are induced by human activity." "SIR-C was developed by NASA's Jet Propulsion Laboratory. X-SAR was developed by the Dornier and Alenia Spazio companies for the German space agency, Deutsche Agentur fuer Raumfahrtangelegenheiten (DARA), and the Italian space agency, Agenzia Spaziale Italiana (ASI), with the Deutsche Forschungsanstalt fuer Luft und Raumfahrt e.V.(DLR), the major partner in science, operations and data processing of X-SAR." # Gyrotrons "Other important applications of gyrotrons are high-power microwave sources include high resolution radar ranging and imaging in atmospheric and planetary science as well as deep-space and specialized satellite communications and RF drivers for next-generation high-gradient linear accelerators". # Aerial gravity gradiometry The aircraft imaged on the right carried-out aerial high-resolution gravity gradiometry system in combination with LIDAR digital terrain mapping, electromagnetics, digital video, and gamma-ray spectrometry over "onshore areas along the South-Eastern Tanzanian Coastal Basin and the eastern arm of the East African Rift." # Hypotheses - A radar frequency exists that is reflected back by the Sun. - A control group for radar astronomy would likely contain a standard target that allows maximum radar facility resolution and imaging. # Acknowledgements The content on this page was first contributed by: Henry A. Hoff. Initial content for this page in some instances came from Wikiversity.

Dose escalation study Dose Escalation Study Design Example (A Dose Escalation Study of Ender-G in Adults with Cancer) Methods Study Design study of Ender-G enrolled participants with various cancer types from a single academic medical center in Bethesda, Maryland, in the United States. All participants were informed about the study and potential risks and required to provide written informed consent prior to undergoing study-related procedures. design was implemented 1 . Successive cohorts of participants (3 participants /cohort) were each started on a fixed dose -f Ender-G. The protocol specified 100 mg/m2 administered intravenously, for the first cohort. Successive cohorts were given doses of 125 and 150 mg/m2 toxicities (DLTs, see Primary Endpoint) were observed in >33% of participants. If no DLTs were observed for 4 weeks after administration of the last dose -f Ender-G, a new cohort was enrolled at the next planned dose level. If DLTs were -bserved in 1 participant in the cohort, another 3 participants were treated with the same dose level. The maximum-tolerated dose (MTD) was defined as 1 dose level below the dose in which DLTs were -bserved in >33% of the participants. That is, if DLTs were observed in at least 2 of 3 participants, the MTD was determined to be the dose administered to the previous cohort. Similarly, in a cohort of 6 participants, 3 of 6 participants would have to experience DLTs to determine the MTD. Common Terminology Criteria for Adverse Events Version 3.0 (CTCAE 3.0)2 . If the CTCAE 3.0 did not apply to an adverse event, it was graded as mild, moderate, or severe. DLT was defined as any CTCAE 3.0 Grade 3 or 4 adverse event determined to be related to Ender-G. physical exams, complete blood chemistry, and urinalysis were conducted at weeks 1, 2, 4, and 8. documents were reviewed and approved by the hospital human subjects review board and the study was performed in accordance with the Declaration of Helsinki. Patient Eligibility clinically confirmed cancer and a World Health Organization (WHO) performance status < 3 were eligible for the study. Exclusion criteria included clinically significant electrocardiogram (ECG) abnormalities and a white blood cell (WBC) count ≤ 2,000/mm3 . Patients receiving enzyme-inducing anticonvulsants, steroids, -r other experimental drugs were excluded. Patients with a history of migraines were also excluded. Study Objectives establish the MTD of Ender-G in participants with cancer. The secondary outcomes were pharmacokinetic and safety measures of Ender-G in participants with cancer. Results Disposition of Participants between January 2, 2018 and May 10, 2018 for three dose levels (Figure 1). The last visit of the final participant for assessment -f the primary and secondary outcomes was -n August 29, 2018. Participant characteristics are listed in Table 1. ClinicalTrials.gov is a service of the National Institutes of Health. Dose Escalation Study Design Example 2 of 4 September 2019 Figure 1. Enrollment, Assignment and Retention of Study Participants. Outcomes Primary Endpoint In order to determine the primary endpoint, MTD, the number of participants who experienced DLTs over an 8-week period was assessed at each dose level. A DLT was any Grade 3 or 4 adverse event (AE) using the CTCAE 3.0 that was possibly drug-related. CTCAE 3.0 Grade 3 is a severe AE and Grade 4 is a life-threatening -r disabling AE. Such events interfere with activities of daily living and include: skin toxicity, diarrhea or antidiarrheal therapy, vomiting at same grade for >4 days despite aggressive antiemetic therapy, central nervous system, lung or renal toxicity or elevation of liver transaminases or bilirubin lasting more than 1 week. The MTD is defined as the dose level below the dose at which > 33% of participants experienced a DLT. The MTD analysis population consisted of all participants who received at least one dose of Ender-G. receiving the 100 mg/m2 participant experienced a DLT among the three participants receiving 125 mg/m2 (Grade 4 vomiting), thus three more participants were added to the cohort of which none experienced a DLT. One participant experienced a DLT among the three participants receiving 150 mg/m2 (Grade 4 vomiting), thus three more participants were added to the cohort of which two experienced a DLT (Grade 3 renal toxicity and Grade 4 diarrhea). Three DLTs in 3/6 participants (50%) at the 150 mg/m2 dose established the MTD as 125 mg/m2 ClinicalTrials.gov is a service of the National Institutes of Health. Dose Escalation Study Design Example 3 of 4 September 2019 Table 1. Baseline Demographics and Disease Characteristics of Participants CHARACTERISTIC COHORT 1 100 mg/m2 N = 3 COHORT 2 125 mg/m2 N = 6 COHORT 3 150 mg/m2 N = 6 TOTAL N = 15 Age, years, median (full range) 67 (43-72) 63 (36-74) 62.5 (42-82) 67 (36–82) Sex, n (%) Race, n (%) WHO performance statusa , n (%) Tumor type, n (%) Number of prior chemotherapy regimens, n (%) a World Health Organization (WHO) performance status is measured on a scale from 0 to 5, with 0 = Asymptomatic (Fully active, able to carry on all predisease activities without restriction.); 1 = Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work.); 2 = Symptomatic, <50% in bed during the day (Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours.); 3 = Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours.); 4 = Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.); and 5 = Death b NSCLC = non-small-cell lung cancer Secondary Endpoints the initial dose on day 1 and 0.25, 0.5, 0.75, 1, 2, 3, 4, 5, 6, 7, 8, 16, 24, 36, 48 and 72 hours post-dose for pharmacokinetic analyses of Ender-G. Plasma concentrations were determined using a validated high-pressure liquid chromatography method. Measurements included maximum observed plasma concentration of Ender-G (Cmax), time to maximum observed plasma concentration of Ender-G (Tmax), and area under the concentration-time curve from 0 to 72 hours post-dose. The safety of Ender-G was summarized by the number of participants experiencing any on-treatment adverse event(s), serious and non-serious, which were collected by systematic assessment using terms from the CTCAE 3.0. All participants in all 3 cohorts experienced at least one nonserious adverse event. Serious adverse events were considered to be Grade 3 or 4. The results of the pharmacokinetic analyses are presented in Table 2 and the summary -f adverse events is in Table 3. ClinicalTrials.gov is a service of the National Institutes of Health. Dose Escalation Study Design Example 4 of 4 September 2019 Table 2. Pharmacokinetic Parameters for Each Cohort COHORT DOSE (mg/m2 NUMBER OF PARTICIPANTS Cmax a (mcg/mL) AUC0-72b ((mcg/mL)*h) Tmax c (hours) 1 100 3 0.535 (119) 7.41 (7.8) 5 (4 to 5) 2 125 6 1.10 (75) 18.1 (12.7) 5 (5 to 6) 3 150 6 1.58 (102) 18.8 (14.3) 5 (2 to 5) a Geometric Mean (% Geometric Coefficient of Variation) b Mean (Standard Deviation) c Median (Full Range) Table 3a. Participants with Grade 1 or 2 Adverse Events ADVERSE EVENT COHORT 1 100 mg/m2 N = 3 COHORT 2 125 mg/m2 N = 6 COHORT 3 150 mg/m2 N = 6 Nausea 3 3 3 Diarrhea 1 3 2 Vomiting 1 3 5 Fatigue 1 2 6 Rash 1 3 5 Anorexia 3 1 4 Pain in extremity 2 2 4 Cough 2 2 4 Chills 2 1 3 Pyrexia 2 1 3 Headache 2 1 3 Dry skin 2 1 3 Pruritus 2 1 3 Table 3b. Participants with Grade 3 or 4 Adverse Events ADVERSE EVENT COHORT 1 100 mg/m2 N = 3 COHORT 2 125 mg/m2 N = 6 COHORT 3 150 mg/m2 N = 6 Diarrhea- 0 0 1 Renal toxicity† 0 0 1 Vomiting- 0 1 1

Fermented milk products Fermented milk products, also known as cultured dairy foods, cultured dairy products, or cultured milk products, are dairy foods that have been fermented with lactic acid bacteria such as Lactobacillus, Lactococcus, and Leuconostoc. The fermentation process increases the shelf-life of the product, as well as adds to the taste and improves the digestibility of milk. There is evidence that fermented milk products have been produced since around 10,000 BC. A range of different Lactobacilli strains has been grown in laboratories allowing for a wide range of cultured milk products with different tastes. Many different types of cultured milk products can be found around the world including: - yoghurt - Template:FlagiconTemplate:Flagicon cultured buttermilk (sometimes called buttermilk) - Template:FlagiconTemplate:Flagicon acidophilus milk - Template:Flagicon kiselo mlyako - Template:Flagicon sauermilch or dickmilch - Template:Flagicon zure melk - Template:Flagicon lapte bătut - Template:Flagicon filmjölk (fil is the short form of filmjölk) - Template:Flagicon surmelk or kulturmelk - Template:Flagicon piimä and viili - Template:Flagicon amasi ("maas" in Afrikaans) - Template:Flagicon doogh Many types of cultured milk may be used in the same way as yoghurt, that is, eaten from a bowl using a spoon (with cereals, muesli or corn flakes) or drunk from a glass. Sugar and fruit flavors may be added to the marketed product. Cultured milk can also be used as an ingredient in a recipe. Some cultured milk variants contain live bacteria which has a stabilising effect on the intestinal flora. Some cultured milk variants have been found to have health promoting effects. For example, Seppo et al (2003) found that milk cultured with Lactobacillus helveticus LBK-16 H contains peptides (casokinins and lactokinins) that act as naturally occurring ACE inhibitors and hence have an antihypertensive effect. # Comparison chart - Streptococcus lactis has been renamed to Lactococcus lactis subsp. lactis

Glyphosate Glyphosate (N-(phosphonomethyl) glycine) is a non-selective systemic herbicide, absorbed through the leaves, used to kill weeds, especially perennials. Some crops have been genetically engineered to be resistant to it. Glyphosate was first sold by Monsanto under the tradename Roundup, but is no longer under patent. # Chemistry Glyphosate is an aminophosphonic analogue of the natural amino acid glycine and the name is a contraction of glycine, phospho-, and -ate. Glyphosate was first discovered to have herbicidal activity in 1970 by John Franz, while working for Monsanto. In 1987 Franz received the National Medal of Technology for his discoveries, and in 1990 he received the Perkin Medal for Applied Chemistry. # Biochemistry Glyphosate kills plants by inhibiting the enzyme 5-enolpyruvylshikimate-3-phosphate synthase (EPSPS), which catalyzes the reaction of shikimate-3-phosphate (S3P) and phosphoenolpyruvate to form 5-enolpyruvyl-shikimate-3-phosphate (ESP). ESP is subsequently dephosphorylated to chorismate an essential precursor in plants for the aromatic amino acids: phenylalanine, tyrosine and tryptophan , . These amino acids are used as building blocks in peptides and to produce secondary metabolites such as folates, ubiquinones and naphthoquinone. The shikimate pathway is not present in animals, which obtain aromatic amino acids from their diet. # Toxicity Glyphosate is less toxic than a number of other herbicides and pesticides, such as those from the organochlorine family . ## Humans A review of the literature in 2000 concluded that "under present and expected conditions of new use, there is no potential for Roundup herbicide to pose a health risk to humans". This review considered the likely effects experienced by the two groups most likely to have high exposures, herbicide applicators and children aged 1-6, noting the exposure in those subpopulations was not a health concern. Glyphosate has an EPA Toxicity Class of III in 1993, but more recent studies suggest that IV is appropriate for oral, dermal, and inhalation exposure. It has been rated as class I (Severe) for eye irritation, however. Outside its intended use, glyphosate can be lethal. For example, with intentional poisonings there is approximately a 10% mortality for those ingesting glyphosate, compared to 70% for those ingesting paraquat. Laboratory toxicology studies suggest that other ingredients combined with glyphosate may have greater toxicity than glyphosate alone. For example, a study comparing glyphosate and Roundup found that Roundup had a greater effect on aromatase than glyphosate alone. Statistics from the Californian Environmental Protection Agencies Pesticide Illness Surveillance Program indicate that glyphosate related incidents are one of the highest reported of all pesticides. However, incident count does not take into account the number of people exposed and the severity of symptoms associated with each incident. For example if hospitalization is used as a measure of the severity of pesticide related incidents, then Glyphosate would be considered relatively safe, since over a 13 year period in California none of the 515 pesticide related hospitalizations recorded were attributed to glyphosate. Greenpeace states that "the acute toxicity of glyphosate is very low", but note that, as mentioned above, other added chemicals (particularly surfactants, e.g. polyoxy-ethyleneamine, POEA) can be more toxic than glyphosate itself. ## Other species The direct toxicity of pure glyphosate to mammals and birds is low. In vitro studies indicate glyphosate formulations could negatively impact earthworms and beneficial insects. However these results conflict with results from field studies where no effects were noted for the number of nematodes, mites, or springtails after treatment with Roundup at 2 kilograms active ingredient per hectare. Certain surfactants used in some glyphosate formulations have higher toxicity to fish and invertebrates resulting in some formulations of glyphosate not being registered for use in aquatic applications. Monsanto produces glyphosate products with alternative surfactants that are specifically formulated for aquatic use, for example "Biactive" and "AquaMaster". According to Monsanto, "Conservation groups have chosen glyphosate formulations because of their effectiveness against most weeds as glyphosate has very low toxicity to wildlife". When glyphosate comes into contact with the soil, it rapidly binds to soil particles and is inactivated. Unbound glyphosate is degraded by bacteria. Low activity because of binding to soil particles suggests that glyphosate's effects on soil flora are limited. Low glyphosate concentrations can be found in many creeks and rivers in U.S. and Europe. Mammal research indicates oral intake of 1% glyphosate induces changes in liver enzyme activities in pregnant rats and their fetuses. # Use Glyphosate is effective in killing a wide variety of plants, including grasses, broadleaf, and woody plants. It has a relatively small effect on some clover species. By volume, it is one of the most widely used herbicides. It is commonly used for agriculture, horticulture, and silviculture purposes, as well as garden maintenance (including home use). Glyphosate is supplied in several formulations for different uses: - Ammonium salt. - Isopropyl amine salt. - Glyphosate acid - standalone, as ammonium salt or as isopropyl salt. Products are supplied most commonly in formulations of 120, 240, 360, 480 and 680g active ingredient per litre. The most common formulation in agriculture is 360g, either alone or with added cationic surfactants. For 360g formulations, European regulations allow applications of up to 12 litres per hectare (432g a.i.) for control of perennial weeds such as couch grass. More commonly, rates of 3 litres per hectare are practiced for control of annual weeds between crops. ## Genetically modified crops Some micro-organisms have a version of 5-enolpyruvoyl-shikimate-3-phosphate synthetase (EPSPS) that is resistant to glyphosate inhibition. The version used in genetically modified crops was isolated from Agrobacterium strain CP4 (CP4 EPSPS) that was resistant to glyphosate. This CP4 EPSPS gene was cloned and transfected into soybeans, and in 1996, such genetically modified soybeans were made commercially available. This greatly improved the ability to control weeds in soybean fields since glyphosate could be sprayed on fields without hurting the crop. As of 2005, 87% of U.S. soybean fields were planted with glyphosate resistant varieties. ## Other uses Glyphosate is one of a number of herbicides used by the United States government to spray Colombian coca fields through Plan Colombia. Its health effects, effects on legal crops, and effectiveness in fighting the war on drugs have been widely disputed. # Health concerns There are concerns about the effects of glyphosate (and Roundup) on non-plant species even including on possible human reproductive dysfunction. For more information, see the Roundup article. ## Endocrine disruptor debate In vitro studies have shown glyphosate affects progesterone production in mammalian cells and can increase the mortality of placental cells. Whether these studies classify glyphosate as an endocrine disruptor is a matter of debate. Some feel that in vitro studies are insufficient, and are waiting to see if animal studies show a change in endocrine activity, since a change in a single cell line may not occur in an entire organism. Additionally, current in vitro studies expose cell lines to concentrations orders of magnitude greater than would be found in real conditions, and through pathways that would not be experienced in real organism. Others feel that in vitro studies, particularly ones identifying not only an effect, but a chemical pathway, are sufficient evidence to classify glyphosate as an endocrine disruptor, on the basis that even small changes in endocrine activity can have lasting effects on an entire organism that may be difficult to detect through whole organism studies alone. Further research on the topic has been planned, and should shed more light on the debate.

Rh incompatibility (patient information) For the WikiDoc page on Hemolytic disease of the newborn, click here # Overview Rh incompatibility is a condition that develops when a pregnant woman has Rh-negative blood and the baby in her womb has Rh-positive blood. # What are the symptoms of Rh incompatibility? - Rh incompatibility can cause symptoms ranging from very mild to deadly. - In its mildest form, Rh incompatibility causes the destruction of red blood cells. - After birth, the infant may have: - Yellowing of the skin and whites of the eyes (jaundice) - Low muscle tone (hypotonia) and lethargy # What causes Rh incompatibility? - During pregnancy, red blood cells from the unborn baby can cross into the mother's bloodstream through the placenta. - If the mother is Rh-negative, her immune system treats Rh-positive fetal cells as if they were a foreign substance and makes antibodies against the fetal blood cells. These anti-Rh antibodies may cross back through the placenta into the developing baby and destroy the baby's circulating red blood cells. - When red blood cells are broken down, they make bilirubin. This causes an infant to become yellow (jaundiced). The level of bilirubin in the infant's bloodstream may range from mild to dangerously high. - Because it takes time for the mother to develop antibodies, first born infants are often not affected unless the mother had past miscarriages or abortions that sensitized her immune system. However, all children she has afterwards who are also Rh-positive may be affected. - Rh incompatibility develops only when the mother is Rh-negative and the infant is Rh-positive. Thanks to the use of special immune globulins called RhoGHAM, this problem has become uncommon in the United States and other places that provide access to good prenatal care. # When to seek urgent medical care? Call your health care provider if you think or know you are pregnant and have not yet seen a doctor. # Diagnosis - Before delivery, the mother may have an increased amount of amniotic fluid around her unborn baby (polyhydramnios). - There may be: - A positive direct Coombs test result - Higher-than-normal levels of bilirubin in the baby's umbilical cord blood - Signs of red blood cell destruction in the infant's blood # Treatment options - Because Rh incompatibility is preventable with the use of RhoGAM, prevention remains the best treatment. - Treatment of an infant who is already affected depends on the severity of the condition. - Infants with mild Rh incompatibility may be treated with: - Feeding and fluids (hydration) - Phototherapy using bilirubin lights # Where to find medical care for Rh incompatibility? Directions to Hospitals Treating Rh incompatibility # Prevention - Rh incompatibility is almost completely preventable. Rh-negative mothers should be followed closely by their obstetricians during pregnancy. - Special immune globulins, called RhoGAM, are now used to prevent RH incompatibility in mothers who are Rh-negative. - If the father of the infant is Rh-positive or if his blood type cannot be confirmed, the mother is given an injection of RhoGAM during the second trimester. - If the baby is Rh-negative, the mother will get a second injection within a few days after delivery. - These injections prevent the development of antibodies against Rh-positive blood. However, women with Rh-negative blood type must receive injections: - During every pregnancy - If they have a miscarriage or abortion - After prenatal tests such as amniocentesis and chorionic villus biopsy - After injury to the abdomen during pregnancy # What to expect (Outlook/Prognosis)? Full recovery is expected for mild Rh incompatibility. # Possible complications - Brain damage due to high levels of bilirubin (kernicterus) - Fluid buildup and swelling in the baby (hydrops fetalis) - Problems with mental function, movement, hearing, speech, and seizures. # Source

OLR1 Oxidized low-density lipoprotein receptor 1 (Ox-LDL receptor 1) also known as lectin-type oxidized LDL receptor 1 (LOX-1) is a protein that in humans is encoded by the OLR1 gene. LOX-1 is the main receptor for oxidized LDL on endothelial cells, macrophages, smooth muscle cells, and other cell types. But minimally oxidized LDL is more readily recognized by the TLR4 receptor, and highly oxidized LDL is more readily recognized by the CD36 receptor. # Function LOX-1 is a receptor protein which belongs to the C-type lectin superfamily. Its gene is regulated through the cyclic AMP signaling pathway. The protein binds, internalizes and degrades oxidized low-density lipoprotein. Normally, LOX-1 expression on endothelial cells is low, but tumor necrosis factor alpha, oxidized LDL, blood vessel sheer stress, and other atherosclerotic stimuli substantially increase LOX-1 expression. LOX-1 may be involved in the regulation of Fas-induced apoptosis. Oxidized LDL induces endothelial cell apoptosis through LOX-1 binding. Other ligands for LOX-1 include oxidized high-density lipoprotein, advanced glycation end-products, platelets, and apoptotic cells. The binding of platelets to LOX-1 causes a release of vasoconstrictive endothelin, which induces endothelial dysfunction. This protein may play a role as a scavenger receptor. # Clinical significance Binding of oxidized LDL to LOX-1 activates NF-κB, leading to monocyte adhesion to enthothelial cells (a pre-requisite for the macrophage foam cell formation of atherosclerosis). Macrophage affinity for unmodified LDL particles is low, but is greatly increased when the LDL particles are oxidized. LDL oxidation occurs in the sub-endothelial space, rather than in the circulation. But oxidized cholesterol from foods cooked at high temperature can also be a source of oxysterols. Mutations of the OLR1 gene have been associated with atherosclerosis, risk of myocardial infarction, and may modify the risk of Alzheimer's disease. When applied to human macrophage-derived foam cells in vitro, the dietary supplement berberine inhibits the expression of the ORL1 gene in response to oxidized low-density lipoprotein cholesterol, but this has not yet been demonstrated in a living animal or human.

Sandbox:epidem # Overview Neuroblastoma is the most common extracranial solid cancer in childhood and the most common cancer in infancy. The overall incidence rate of neuroblastoma is approximately 4.9 per 1,000,000 individuals in the United States. The incidence of neuroblastoma decreases with age; the highest incidence is in the first year of life. Males are slightly more commonly affected with neuroblastoma than females. The male to female ratio is approximately 1.12 to 1. Neuroblastoma usually affects individuals of the Caucasian race. African American, Native Indian and Asian individuals are less likely to develop neuroblastoma. # Epidemiology and Demographics ## Prevalence - Neuroblastoma is the most common extracranial solid cancer in childhood and the most common cancer in infancy. ## Incidence - The overall incidence rate of neuroblastoma is approximately 4.9 per 1,000,000 individuals in the United States. ## Age - The incidence of neuroblastoma decreases with age; the highest incidence is in the first year of life. - The incidence of neuroblastoma according to specific age groups is approximately: - 25.3 per 1,000,000 individuals aged between (0-4) years - 2.3 per 1,000,000 individuals aged between (5-9) years - 0.7 per 1,000,000 individuals aged between (10-14) years - 0.2 per 1,000,000 individuals aged between (20-24) years - 0.3 per 1,000,000 individuals aged between (25-29) years ## Gender - Males are slightly more commonly affected with neuroblastoma than females. The male to female ratio is approximately 1.12 to 1. - The incidence rate of neuroblastoma among males is approximately 5.1 per 1,000,000 individuals in the United States. - The incidence rate of neuroblastoma among females is approximately 4.6 per 1,000,000 individuals in the United States. ## Race - Neuroblastoma usually affects individuals of the Caucasian race. African American, Native Indian and Asian individuals are less likely to develop neuroblastoma. - The incidence rate of neuroblastoma among Caucasians is approximately 5.1 per 1,000,000 individuals in the United States. - The incidence rate of neuroblastoma among African Americans is approximately 4.1 per 1,000,000 individuals in the United States. - The overall incidence rate of neuroblastoma among Native Indians and Asians is approximately 3.8 per 1,000,000 individuals in the United States.

Coronary sinus # Overview The coronary sinus is a collection of veins joined together to form a large vessel that collects blood from the myocardium of the heart. It is present in humans and other animals. # Location It is located between the left atrium and ventricle on the posterior surface of the heart. It runs transversely in the groove between the left atrium and ventricle on the posterior surface of the heart. The coronary sinus orifice (opening) is just superior to the septal leaflet of the tricuspid valve. The coronary sinus orifice is also known as the ostium of the coronary sinus. # Drainage It receives blood mainly from the small, middle, great and oblique cardiac veins. It also receives blood from the left marginal vein and the left posterior ventricular vein. The anterior cardiac veins drain directly into the right atrium. (Some small veins drain into any of the four chambers of the heart.) It drains into the right atrium on the posterior, inferior surface, medial to the inferior vena cava opening. # Additional images - Diagram showing completion of development of the parietal veins. - Template:SUNYAnatomyFigs - "Posterior view of the heart." - Template:LoyolaMedEd # Pathophysiology The coronary sinus can be the site of drainage of an atrial septal defect (see coronary sinus atrial septal defect).

Compounding Compounding pharmacy is the long-standing process of mixing drugs by a pharmacist or physician to fit the unique needs of a patient. For example, a patient allergic to the dyes used in a pill can obtain a doctor’s prescription for the necessary medicine to be compounded without the offending dye. # History The art of pharmaceutical compounding began with the birth of the first humans. All ancient hunter-gatherer societies had some knowledge of the medicinal properties of the animals, plants, molds, fungus and bacteria as well as inorganic minerals within their environment. Ancient civilizations utilized pharmaceutical compounding for religion, grooming, keeping the healthy well, treating the ill and preparing the dead. These ancient compounders produced the first oils from plants and animals. They discovered poisons and the antidotes. They made ointments for a wounded patients as well as perfumes for a customer. The earliest druggists were familiar with the various natural substances and their uses. These drug artisans compounded a variety of preparations from medications, dyes, incense, perfumes and ceremonial compounds to preservatives and cosmetics. The Bible lists many drugs that were compounded in biblical times in the Middle East. Drug compounders seeking gold and the fountain of youth drove the Alchemy movement. Alchemy eventually contributed to the creation of modern pharmacy and the principles of pharmacy compounding. The modern age of pharmacy and pharmacy compounding began in the nineteenth century with the isolation of various compounds from coal tar for the purpose of producing synthetic dyes. From this one natural product came the earliest antibacterial sulfa drugs, phenolic compounds made famous by Joseph Lister, and plastics. During 1800s pharmacists specialized in the raising, preparation and compounding of crude drugs. Crude drugs, like opium, are from natural sources and usually contain multiple chemical compounds. The compounding pharmacist often extracted these crude drugs using water or alcohol to form extracts, concoctions and decoctions. Pharmacists began isolating and identifying the active ingredients contained within these crude drugs concoctions. Using fractionation or recrystallization, the compounding pharmacist would separate the active ingredients, like morphine, and use it in place of the crude drug. During this time modern medicine began. With the isolation of medications from the “raw materials” or crude drugs came the birth of the modern pharmaceutical company. Pharmacists were trained to compound the preparations made by the drug companies but they weren’t able to do it as efficiently on a small basis. So economies of scale, not lack of skill or knowledge, produced a market niche for the modern pharmaceutical drug companies, (Pharma). With the turn of the twentieth century came the government involvement and subsequent regulation into the practice of medicine. In 1938 the Government of the United States imposed new regulations on the drug companies forming the Food and Drug Administration (FDA) when several people died from a poorly prepared sulfa drug that used ethylene glycol as a base. These new regulations forced the drug companies to prove any new medication they brought to market was safe. Pharmacy compounding was still going strong in the 1930s with over 80% of the prescriptions dispensed being compounded by the compounding pharmacist. With the discovery of penicillin and the modern marketing techniques and brand promotion, the drug manufacturing industry came of age. Pharmacists continued to compound most prescriptions until the early 1950’s when the majority of dispensed drugs came directly from the large pharmaceutical companies. From the 1950s to the 1980s pharmaceutical compounding became almost obsolete and a lost art. Pharmaceutical compounding continued losing favor as the big drug companies became larger and more powerful until they eventually dominated the practice of medicine. It was during this time that patients and physician became dissatisfied with the “one size fits all” attitude of the large Pharma companies. Physicians searching for drugs to treat their patients, lead to the reawakening of the ancient art of prescription compounding. Today many pharmacists specialize in the ancient art of pharmaceutical compounding. In 2006 over 30 million compounded prescriptions were dispensed not counting all the admixtures and injectable drugs compounded in America’s hospitals. Pharmaceutical compounding has been responsible for the health of millions of individual patients, has given birth the modern pharmaceutical companies and continues to be a vital link in the search for new drugs and dosage forms. Throughout history, there has always been a need for pharmacists to compound drugs for individualized dosages. When the pharmaceutical industry began mass-producing drugs and dosage forms for patients in the 1950s, compounding became less widespread. In recent years, many patients’ unique health needs have driven more business to compounding pharmacists. # Uses Compounding is one of the pillars of new drug development. Most medications have gained widespread usage throughout the entire medical community thanks to the practice of pharmaceutical compounding and the compounding pharmacist. Every major pharmaceutical company ever in existence or currently operating started in a compounding pharmacy with a compounding pharmacist. Without the practice of pharmaceutical compounding and compounding pharmacists none of the drugs we have today would have been discovered. This facet of pharmacy has been the greatest developer of drugs and the most positive influence within the entire allopathic, osteopathic, naturopathic and homeopathic, medical communities. Pharmaceutical compounding is a branch of pharmacy that continues to play the crucial role of new drug research and development. Physicians often prescribe compounded medicines for patients with unique health needs, because they are able to tailor a prescription to each individual. Compounding preparations are especially prevalent for: - Patients requiring limited dosage strengths and dosage forms (i.e., infants) - Those with allergies to certain ingredients in manufactured drugs - Veterinary medicine - Pediatrics (i.e., making a medicine more palatable to children with flavor additives) - Home health care - Hospice patients - Bioidentical hormone replacement therapy, specifically the Wiley Protocol - Patients who need drugs that have been discontinued by pharmaceutical manufacturers because of low profitability # Regulation Compounding pharmacies are licensed and regulated by state Boards of Pharmacy in the 50 states and the District of Columbia. Additionally, pharmacies follow guidelines from U.S. Pharmacopeia. Compounding pharmacists must work within the jurisdiction of the FDA, they are simply exempt from many FDA requirements so long as they are state-compliant and compound pursuant to a valid prescription. However, the FDA registers and inspects the facilities that supply manufacturers with active pharmaceutical ingredients. The Pharmacy Compounding Accreditation Board was created in 2006 as a voluntary accreditation body by pharmacy organizations to establish high quality standards for compounding pharmacies. # Controversies There is currently a controversy over who should regulate compounding pharmacies. The FDA is concerned that many compounders are acting as large-scale manufacturers of new drugs, and are subject to the numerous rules that apply to drug makers. The FDA has repeatedly asserted that all compounded drugs are new drugs and are thus illegal, but it will exercise its “enforcement discretion.” The Agency has issued numerous warning letters to compounding pharmacies, threatening actions including, but "not limited to, seizure of your products or injunction against you or your firm." The International Academy of Compounding Pharmacists states that "Congress, the U.S. Supreme Court, and each of the 50 state boards of pharmacy that regulate compounding have long recognized the value of pharmacy compounding, yet the FDA has contended for nearly 20 years that compounded medications are illegal. Compounded medications are not new, unapproved drugs and pharmacies dispensing them act only under a doctor’s prescription. To the extent that there are patient safety issues, state boards of pharmacy are well-equipped to deal with them.” Recent court rulings, such as Medical Center Pharmacy v. Gonzales (2006) support the position taken by IACP. Compounding pharmacy has been caught up in the recent controversy over hormone replacement therapy. Synthetic hormones, manufactured by large drug companies such as Wyeth Pharmaceuticals, were found to lead to increased rates of heart disease, breast cancer and stroke in the Women’s Health Initiative study, halted in 2002. As an alternative to synthetics, many physicians prescribe bioidentical hormones for patients suffering from menopausal symptoms. These hormones are mixed in a compounding pharmacy. Groups such as the North American Menopause Society have raised concerns about the marketing of these drugs. The compounding pharmacy profession purports to make no claims about the safety and efficacy of bioidentical hormones, and believes it should be up to a patient and her doctor to decide on the best course of treatment for menopausal symptoms. The stance of the FDA has been that each time a drug is compounded it creates a “new drug”. Since that “new drug” has not received FDA approval, the FDA then claims the compound is adulterated and therefore illegal. The illogic of such a position is clarified when one considers the actual practice of medicine in the United States, which uses multiple medications simultaneously (polypharmacy). While many people take two or more medications daily, very few prescription drugs are studied when combined together. This polypharmacy is impossible to study because of the difficulty and the cost of conducting a full-scale study of each drug combination. For example say there are three hundred drugs available for a doctor to choose from. If a patient is taking an average of six prescription drugs daily, there would be over 10^14 possible drug combinations that individual patient could take. It would be impossible to study that many drug combinations. Yet the polypharmacy is practiced universally and the FDA accepts it. Using the FDA’s own logic, combining various medications together is illegal if the patient swallows all the drugs after they have been compounded into one capsule… but let that same patient individually take the same multiple prescription drugs and swallow them one at a time… then the FDA has no problem with it.

Chronic mitral regurgitation treatment # Overview The distinction between primary nd secondary mitral regurgitation (MR) is of utmost importance when determining the treatment strategies among patients with chronic MR. Primary and secondary MR have a different underlying pathophysiology and therefore have different indications for surgery and medical therapy. Surgery is generally the treatment of choice among patients with chronic primary MR and left ventricular systolic dysfunction; nevertheless, medical therapy is warranted when surgery is delayed or not planned. The cornerstone of the treatment of patients with chronic secondary MR with decreased ejection fraction is the standard regimen for the treatment of heart failure, which includes one or more of the following: beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or aldosterone antagonists. Mitral valve surgery is indicated in some circumstances among patients with chronic severe secondary MR, particularly those undergoing coronary artery bypass graft or patients with NYHA class III/IV heart failure symptoms. # Medical Therapy of Chronic Mitral Regurgitation ## Primary Chronic Mitral Regurgitation In MR, left ventricular systolic dysfunction and subsequent heart failure might occur. Surgery is generally the treatment of choice among MR patients with left ventricular systolic dysfunction; nevertheless, medical therapy is warranted when surgery is delayed or not planned. Although the body of literature for medical therapy in MR is not robust, the existing sparse data suggests that patients with MR who experience left ventricular systolic dysfunction are candidate for the standard therapy of heart failure, which includes beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or aldosterone antagonist. Beta blocker use is associated with improved left ventricular function. The administration of vasodilator is useful among patients with acute severe MR and those who have hypertension. The benefits of vasodilator use in asymptomatic patients with normal blood pressure is not established, and might even be associated with worsening of the severity of MR. The administration of vasodilators in this category of MR patients is therefore not recommended. ## Secondary Chronic Mitral Regurgitation The valvular abnormality in chronic secondary MR results from the left ventricular dysfunction. Therefore, the cornerstone of the treatment of patients with chronic secondary MR with decreased ejection fraction is the standard regimen for the treatment of heart failure which includes one or more of the following: beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or aldosterone antagonists. Patients with coronary artery disease should receive treatment for their atherosclerosis disease. Symptomatic patients with chronic severe secondary MR are candidate for cardiac resynchronization therapy with biventricular pacing. # Surgical Therapy for Chronic Mitral Regurgitation ## Indications for Surgery in Chronic Primary Mitral Regurgitation Shown below is an algorithm depicting the indications for mitral valve surgery or period monitoring among patients with chronic primary MR according to the 2014 AHA/ACC guideline for the management of patients with valvular heart disease. Note that when mitral valve surgery is indicated, mitral valve repair is preferred over mitral valve replacement whenever feasible. Abbreviations: LVEF: left ventricular ejection fraction; LVESD: left ventricular end systolic diameter; MR: mitral regurgitation; PASP: Pulmonary artery systolic pressure ## Indications for Surgery in Chronic Secondary Mitral Regurgitation Shown below is an algorithm depicting the indications for mitral valve surgery or period monitoring among patients with chronic secondary MR according to the 2014 AHA/ACC guideline for the management of patients with valvular heart disease. Note that when mitral valve surgery is indicated, mitral valve repair is preferred over mitral valve replacement whenever feasible. Abbreviations: MR: mitral regurgitation ## Why the Mitral Valve is Replaced Before Symptoms in Patients with Chronic Mitral Regurgitation - Mitral regurgitation is a syndrome of pure volume overload whereas aortic regurgitation is a combination of both volume and pressure overload. - Both syndromes are associated with an increase in preload. - In mitral regurgitation, the afterload is reduced whereas in aortic regurgitation the afterload is increased. This is very important because when the mitral valve is repaired, there is no longer a reduction afterload and the left ventricle may fail due to an abrupt rise in the afterload. In aortic regurgitation, because the afterload is already increased chronically, replacement of the valve is not as likely to precipitate acute left ventricular failure due to an abrupt rise in afterload. - By the time symptoms develop, there is already left ventricular dysfunction. - Because of the low pressure system into which the blood is ejected into through the mitral valve, the ejection fraction is always high in mitral regurgitation. If the ejection fraction appears to be "normal", there is already decline in left ventricular function. - There is no indication for vasodilator therapy in the absence of systemic hypertension in asymptomatic patients with preserved left ventricular function. ## Mitral Valve Repair vs Mitral Valve Replacement There are two surgical options for the treatment of mitral regurgitation: mitral valve replacement and mitral valve repair. In general, mitral valve repair is preferred to mitral valve replacement as it carries a lower risk of subsequent prosthetic valve endocarditis and results in better preservation of left ventricular function. ### Scenarios Favoring Mitral Valve Repair - The ACC/AHA 2008 guidelines recommend mitral valve repair rather than mitral valve replacement if the anatomy is appropriate, including patients with rheumatic mitral valve disease and mitral valve prolapse (Grade 1C). The procedure should be performed at experienced surgical centers. - Limited damage to certain areas of the mitral valve leaflets or chordae tendineae - Limited calcification of the leaflets or annulus - Prolapse of less than one-third of either leaflet - Pure annular dilatation - Valvular perforations - Incomplete papillary muscle rupture ### Scenarios Favoring Mitral Valve Replacement - Extensive calcification or degeneration of a leaflet or annulus - Prolapse of more than one-third of the leaflet tissue - Extensive chordal fusion, calcification, or papillary muscle rupture - Extensive damage of mitral valve secondary to endocarditis # 2020 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD) ## 2020 Recommendations for Chronic Primary Mitral Regurgitation (MR) Intervention ## Indications for Intervention in Asymptomatic Severe Primary Mitral Regurgitation ## 2020 Recommendations for Chronic Secondary Mitral Regurgitation (MR) Intervention ## Indications for Mitral Valve Intervention in Secondary Mitral Regurgitation (MR) # 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary (DO NOT EDIT) ## Recommendations for Chronic Primary Mitral Valve Regurgitation ## Recommendations for Chronic Secondary Mitral Valve Regurgitation # 2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) ## Mitral Valve Surgery Indications (DO NOT EDIT) ## Mitral Valve Surgery in Adolescents (DO NOT EDIT)

Restless legs syndrome overview # Overview Restless legs syndrome is a condition that is characterised by an irresistible urge to move one's legs. It is poorly understood, often misdiagnosed, and believed to be a neurological disorder. Many people tap their feet or shake their legs resulting from a nervous tic, consumption of stimulants, drug side-effects or other factors; this is usually innocuous, unnoticed, and does not interfere with daily life, quite distinct from Restless Leg Syndrome. It is sometimes mistakenly called "Ekbom's syndrome," but that is an entirely different condition that shares part of the Wittmaack-Ekbom syndrome eponym: delusional parasitosis, as both syndromes were described by the same person, Karl-Axel Ekbom. # Historical Perspective In a 1945 publication titled 'Restless Legs', Karl-Axel Ekbom described the disease and presented eight cases used for his studies. Earlier studies were done by Thomas Willis (1622-1675) and by Theodor Wittmaack. Another early description of the disease and its symptoms were made by George Miller Beard (1839-1883). # Pathophysiology As with many diseases with diffuse symptoms, there is controversy among physicians, if RLS is a distinct syndrome. The US National Institute of Neurological Diseases and Stroke publishes an information sheet characterizing the syndrome but acknowledging it is a difficult diagnosis. Some physicians doubt that RLS actually exists as a legitimate clinical entity, but believe it to be a kind of "catch-all" category, perhaps related to a general heightened sympathetic nervous system (SNS) response that could be caused by any number of physical or emotional factors. Other clinicians associate it with lumbosacral spinal subluxations and life stress. # Epidemiology and Demographics Many doctors express the view that the incidence of restless leg syndrome is exaggerated by manufacturers of drugs used to treat it. Other physicians consider it a real entity that has specific diagnostic criteria.

Rifampin microbiology # Microbiology ## Mechanism of Action Rifampin inhibits DNA-dependent RNA polymerase activity in susceptible Mycobacterium tuberculosis organisms. Specifically, it interacts with bacterial RNA polymerase but does not inhibit the mammalian enzyme. ## Drug Resistance Organisms resistant to rifampin are likely to be resistant to other rifamycins. In the treatment of both tuberculosis and the meningococcal carrier state (see Indications And Usage), the small number of resistant cells present within large populations of susceptible cells can rapidly become predominant. In addition, resistance to rifampin has been determined to occur as single-step mutations of the DNA-dependent RNA polymerase. Since resistance can emerge rapidly, appropriate susceptibility tests should be performed in the event of persistent positive cultures. ## Activity in vitro and in vivo Rifampin has bactericidal activity in vitro against slow and intermittently growing M tuberculosis organisms. Rifampin has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections as described in the Indications And Usage section. ### Aerobic Gram-Negative Microorganisms - Neisseria meningitidis ### "Other" Microorganisms - Mycobacterium tuberculosis The following in vitro data are available, but their clinical significance is unknown. Rifampin exhibits in vitro activity against most strains of the following microorganisms; however, the safety and effectiveness of rifampin in treating clinical infections due to these microorganisms have not been established in adequate and well-controlled trials. ### Aerobic Gram-Positive Microorganisms - Staphylococcus aureus (including Methicillin-Resistant S. aureus/MRSA) - Staphylococcus epidermidis ### Aerobic Gram-Negative Microorganisms - Haemophilus influenzae ### "Other" Microorganisms - Mycobacterium leprae β-lactamase production should have no effect on rifampin activity. ## Susceptibility Testing Prior to initiation of therapy, appropriate specimens should be collected for identification of the infecting organism and in vitro susceptibility tests. In vitro testing for Mycobacterium tuberculosis isolates: Two standardized in vitro susceptibility methods are available for testing rifampin against M tuberculosis organisms. The agar proportion method (CDC or CLSI(1) M24-A) utilizes Middlebrook 7H10 medium impregnated with rifampin at a final concentration of 1.0 mcg/mL to determine drug resistance. After three weeks of incubation MIC99 values are calculated by comparing the quantity of organisms growing in the medium containing drug to the control cultures. Mycobacterial growth in the presence of drug, of at least 1% of the growth in the control culture, indicates resistance. The radiometric broth method employs the BACTEC 460 machine to compare the growth index from untreated control cultures to cultures grown in the presence of 2.0 mcg/mL of rifampin. Strict adherence to the manufacturer's instructions for sample processing and data interpretation is required for this assay. Susceptibility test results obtained by the two different methods can only be compared if the appropriate rifampin concentration is used for each test method as indicated above. Both procedures require the use of M tuberculosis H37Rv ATCC 27294 as a control organism. The clinical relevance of in vitro susceptibility test results for mycobacterial species other than M tuberculosis using either the radiometric or the proportion method has not been determined. In vitro testing for Neisseria meningitidis isolates: ### Dilution Techniques Quantitative methods that are used to determine minimum inhibitory concentrations provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure uses a standardized dilution method2,4 (broth, agar, or microdilution) or equivalent with rifampin powder. The MIC values obtained should be interpreted according to the following criteria for Neisseria meningitidis: A report of "susceptible" indicates that the pathogen is likely to be inhibited by usually achievable concentrations of the antimicrobial compound in the blood. A report of "intermediate" indicates that the result should be considered equivocal, and if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where the maximum acceptable dose of drug can be used. This category also provides a buffer zone that prevents small-uncontrolled technical factors from causing major discrepancies in interpretation. A report of "resistant" indicates that usually achievable concentrations of the antimicrobial compound in the blood are unlikely to be inhibitory and that other therapy should be selected. Measurement of MIC or minimum bactericidal concentrations (MBC) and achieved antimicrobial compound concentrations may be appropriate to guide therapy in some infections. (See Clinical Pharmacology section for further information on drug concentrations achieved in infected body sites and other pharmacokinetic properties of this antimicrobial drug product.) Standardized susceptibility test procedures require the use of laboratory control microorganisms. The use of these microorganisms does not imply clinical efficacy (see Indications And Usage); they are used to control the technical aspects of the laboratory procedures. Standard rifampin powder should give the following MIC values: ### Diffusion Techniques Quantitative methods that require measurement of zone diameters provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure3,4 that has been recommended for use with disks to test the susceptibility of microorganisms to rifampin uses the 5 mcg rifampin disk. Interpretation involves correlation of the diameter obtained in the disk test with the MIC for rifampin. Reports from the laboratory providing results of the standard single-disk susceptibility test with a 5 mcg rifampin disk should be interpreted according to the following criteria for Neisseria meningitidis: Interpretation should be as stated above for results using dilution techniques. As with standard dilution techniques, diffusion methods require the use of laboratory control microorganisms. The use of these microorganisms does not imply clinical efficacy (see INdications And Usage); they are used to control the technical aspects of the laboratory procedures. The 5 mcg rifampin disk should provide the following zone diameters in these quality control strains:

Twin and triplet pregnancy This guideline covers the care that should be offered to women with a twin or triplet pregnancy in addition to the routine care that is offered to all women during pregnancy. It aims to reduce the risk of complications and improve outcomes for women and their babies. # Recommendations People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. Making decisions using NICE guidance explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. Type of pregnancy Chorionicity and amnionicity Dichorionic diamniotic twins Both babies have a separate placenta and amniotic sac. Monochorionic diamniotic twins Both babies share a placenta but have separate amniotic sacs. Monochorionic monoamniotic twins Both babies share a placenta and amniotic sac. Trichorionic triamniotic triplets Each baby has a separate placenta and amniotic sac. Dichorionic triamniotic triplets One baby has a separate placenta and 2 of the babies share a placenta. All 3 babies have separate amniotic sacs. Dichorionic diamniotic triplets One baby has a separate placenta and amniotic. Two of the babies share a placenta and amniotic sac. Monochorionic triamniotic triplets All 3 babies share 1 placenta. All 3 babies have separate amniotic sacs. Monochorionic diamniotic triplets All 3 babies share 1 placenta. One baby has a separate amniotic sac and 2 babies share 1 sac. Monochorionic monoamniotic triplets All 3 babies share a placenta and amniotic sac. # Determining gestational age and chorionicity ## Gestational age Offer women with a twin or triplet pregnancy a first trimester ultrasound scan to estimate gestational age and determine chorionicity and amnionicity (ideally, these should all be performed at the same scan; see the recommendations on determining chorionicity and amnionicity and assigning nomenclature). See the recommendations on screening for chromosomal conditions. Estimate gestational age from the largest baby in a twin or triplet pregnancy to avoid the risk of estimating it from a baby with early growth pathology. ## Chorionicity and amnionicity Determine chorionicity and amnionicity at the time of detecting a twin or triplet pregnancy by ultrasound using: the number of placental masses the presence of amniotic membrane(s) and membrane thickness the lambda or T‑sign. Assign nomenclature to babies (for example, upper and lower, or left and right) in a twin or triplet pregnancy, and document this clearly in the woman's notes to ensure consistency throughout pregnancy. If a woman with a twin or triplet pregnancy presents after 14+0 weeks, determine chorionicity and amnionicity at the earliest opportunity by ultrasound using all of the following: the number of placental masses the presence of amniotic membrane(s) and membrane thickness the lambda or T-sign discordant fetal sex. If it is not possible to determine chorionicity or amnionicity by ultrasound at the time of detecting the twin or triplet pregnancy, seek a second opinion from a senior sonographer or refer the woman to a healthcare professional who is competent in determining chorionicity and amnionicity by ultrasound scan as soon as possible. If it is difficult to determine chorionicity, even after referral (for example, because the woman has booked late in pregnancy), manage the pregnancy as a monochorionic pregnancy until proved otherwise. Provide regular training so that sonographers can identify the lambda or T-sign accurately and confidently. Less experienced sonographers should have support from senior colleagues. Training should cover ultrasound scan measurements needed for women who book after 14+0 weeks and should emphasise that the risks associated with twin and triplet pregnancy are determined by chorionicity and not zygosity. Conduct regular clinical audits to evaluate the accuracy of determining chorionicity and amnionicity. If transabdominal ultrasound scan views are poor because of a retroverted uterus or a high BMI, use a transvaginal ultrasound scan to determine chorionicity and amnionicity. Do not use 3‑dimensional (3‑D) ultrasound scans to determine chorionicity and amnionicity. Networks should agree care pathways for managing all twin and triplet pregnancies to ensure that each woman has a care plan in place that is appropriate for the chorionicity and amnionicity of her pregnancy. # General care ## Information and emotional support Explain sensitively the aims and possible outcomes of all screening and diagnostic tests to women with a twin or triplet pregnancy to minimise their anxiety. ## Diet, lifestyle and nutritional supplements Give women with a twin or triplet pregnancy the same advice about diet, lifestyle and nutritional supplements as in routine antenatal care (see NICE's guideline on antenatal care for uncomplicated pregnancies). Be aware of the higher incidence of anaemia in women with a twin or triplet pregnancy compared with women with a singleton pregnancy. Perform a full blood count at 20 to 24 weeks to identify women with a twin or triplet pregnancy who need early supplementation with iron or folic acid (this is in addition to the test for anaemia at the routine booking appointment recommended in NICE's guideline on antenatal care for uncomplicated pregnancies). Repeat at 28 weeks as in routine antenatal care. # Delivery of antenatal and intrapartum care ## Antenatal care Antenatal clinical care for women with a twin or triplet pregnancy should be provided by a nominated multidisciplinary team consisting of: a core team of named specialist obstetricians, specialist midwives and sonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies an enhanced team for referrals, which should include: a perinatal mental health professional a women's health physiotherapist an infant feeding specialist a dietitian. Members of the enhanced team should have experience and knowledge relevant to twin and triplet pregnancies. Do not routinely refer all women with a twin or triplet pregnancy to the enhanced team but base the decision to refer on each woman's needs. Coordinate clinical care for women with a twin or triplet pregnancy to: minimise the number of hospital visits provide care as close to the woman's home as possible provide continuity of care within and between hospitals and the community. The core team should offer information and emotional support specific to twin and triplet pregnancies at their first contact with the woman and provide ongoing opportunities for further discussion and advice including: antenatal and postnatal mental health and wellbeing antenatal nutrition (see the recommendation on giving advice in the section on diet, lifestyle and nutritional supplements) the risks, symptoms and signs of preterm labour and the potential need for corticosteroids for fetal lung maturation likely timing of birth (see the section on timing of birth) and possible modes of birth (see the section on mode of birth) breastfeeding parenting. ## Intrapartum care Intrapartum care for women with a twin or triplet pregnancy should be provided by a multidisciplinary team of obstetricians and midwives who have experience and knowledge of managing twin and triplet pregnancies in the intrapartum period. For a short explanation of why the committee made the 2019 recommendation and how it might affect practice, see the rationale and impact on intrapartum care . Loading. Please wait. ## Schedule of specialist antenatal appointments The schedule of specialist appointments is also shown as part of a multiple pregnancy antenatal care resource produced by Twins Trust and endorsed by NICE. Offer women with an uncomplicated dichorionic diamniotic twin pregnancy at least 8 antenatal appointments with a healthcare professional from the core team. At least 2 of these appointments should be with the specialist obstetrician. Combine appointments with scans when crown–rump length measures from 45.0 mm to 84.0 mm (at approximately 11+2 weeks to 14+1 weeks) and then at estimated gestations of 20, 24, 28, 32 and 36 weeks. Offer additional appointments without scans at 16 and 34 weeks. Offer women with an uncomplicated monochorionic diamniotic twin pregnancy at least 11 antenatal appointments with a healthcare professional from the core team. At least 2 of these appointments should be with the specialist obstetrician. Combine appointments with scans when crown–rump length measures from 45.0 mm to 84.0 mm (at approximately 11+2 weeks to 14+1 weeks) and then at estimated gestations of 16, 18, 20, 22, 24, 26, 28, 30, 32 and 34 weeks. Offer women with an uncomplicated trichorionic triamniotic triplet pregnancy at least 9 antenatal appointments with a healthcare professional from the core team. At least 2 of these appointments should be with the specialist obstetrician. Combine appointments with scans when crown–rump length measures from 45.0 mm to 84.0 mm (at approximately 11+2 weeks to 14+1 weeks) and then at estimated gestations of 20, 24, 26, 28, 30, 32 and 34 weeks. Offer an additional appointment without a scan at 16 weeks. Offer women with a dichorionic triamniotic or monochorionic triamniotic triplet pregnancy at least 11 antenatal appointments with a healthcare professional from the core team. At least 5 of these appointments should be with the specialist obstetrician. Combine appointments with scans when crown–rump length measures from 45.0 mm to 84.0 mm (at approximately 11+2 weeks to 14+1 weeks) and then at estimated gestations of 16, 18, 20, 22, 24, 26, 28, 30, 32 and 34 weeks. Offer women with a twin or triplet pregnancy involving a shared amnion individualised care from a consultant in a tertiary level fetal medicine centre (see the recommendation on indications for referral to a tertiary level fetal medicine centre). # Fetal complications ## Information about screening A healthcare professional with experience of caring for women with twin and triplet pregnancies should offer information and counselling to women before and after every screening test. Inform women with a twin or triplet pregnancy about the complexity of decisions they may need to make depending on the outcomes of screening, including different options according to the chorionicity and amnionicity of the pregnancy. ## Screening for chromosomal conditions Offer women with a twin pregnancy information on and screening for Down's syndrome, Edwards' syndrome and Patau's syndrome as outlined in the NHS fetal anomaly screening programme (FASP). Before offering screening for Down's syndrome, Edwards' syndrome and Patau's syndrome, give women with a triplet pregnancy information about: the greater likelihood of Down's syndrome, Edwards' syndrome and Patau's syndrome in triplet pregnancy the different options for screening the increased false positive rate of screening tests in triplet pregnancy their greater likelihood of being offered invasive testing their greater likelihood of complications of invasive testing the physical risks and psychological implications in the short and long term relating to selective fetal reduction. Healthcare professionals who screen for Down's syndrome, Edwards' syndrome and Patau's syndrome in trichorionic triplet pregnancy should: map the fetal positions use nuchal translucency and maternal age to screen for Down's syndrome, Edwards' syndrome and Patau's syndrome when crown–rump length measures from 45.0 mm to 84.0 mm (at approximately 11+2 weeks to 14+1 weeks) calculate the chance of Down's syndrome, Edwards' syndrome and Patau's syndrome for each fetus. Refer women with a dichorionic and monochorionic triplet pregnancy who want to have screening for Down's syndrome, Edwards' syndrome and Patau's syndrome to a tertiary level fetal medicine centre. Do not use second trimester serum screening for Down's syndrome in triplet pregnancies. Refer women with any type of triplet pregnancy who have a higher chance of Down's syndrome, Edwards' syndrome or Patau's syndrome (use a threshold of 1 in 150 at term) to a fetal medicine specialist in a tertiary-level fetal medicine centre. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on screening for chromosomal conditions . Loading. Please wait. ## Screening for structural abnormalities Offer screening for structural abnormalities (such as cardiac abnormalities) in twin and triplet pregnancies as in routine antenatal care; see NICE's guideline on antenatal care for uncomplicated pregnancies and the NHS fetal anomaly screening programme. Consider scheduling ultrasound scans in twin and triplet pregnancies at a slightly later gestational age than in singleton pregnancies and be aware that the scans will take longer to perform. Allow 45 minutes for the anomaly scan in twin and triplet pregnancies (as recommended by FASP). Allow 30 minutes for growth scans in twin and triplet pregnancies. ## Screening for preterm birth Also see the section on preventing preterm birth. Explain to women and their family members or carers (as appropriate) that: they have a higher risk of spontaneous preterm birth (see the section on timing of birth) than women with a singleton pregnancy and this risk is further increased if they have other risk factors, such as a spontaneous preterm birth in a previous pregnancy. Do not use fetal fibronectin testing alone to predict the risk of spontaneous preterm birth in twin and triplet pregnancy. Do not use home uterine activity monitoring to predict the risk of spontaneous preterm birth in twin and triplet pregnancy. For a short explanation of why the committee made the 2019 recommendations (and why they did not make a recommendation on cervical length screening) and how they might affect practice, see the rationale and impact section on screening for preterm birth . Full details of the evidence and the committee's discussion are in evidence review D: screening for spontaneous preterm birth. Loading. Please wait. ## Screening for fetal growth restriction and feto-fetal transfusion syndrome in the first trimester Do not offer women with a twin or triplet pregnancy screening for fetal growth restriction or feto-fetal transfusion syndrome in the first trimester. For a short explanation of why the committee made this 2019 recommendation and how it might affect practice, see the rationale and impact section on screening for fetal growth restriction and feto-fetal transfusion syndrome in the first trimester . Full details of the evidence and the committee's discussion are in evidence review A: screening for feto-fetal transfusion syndrome and evidence review B: screening for fetal growth restriction. Loading. Please wait. ## Diagnostic monitoring for fetal growth restriction in dichorionic twin and trichorionic triplet pregnancies Do not use abdominal palpation or symphysis–fundal height measurements to monitor for fetal growth restriction in a dichorionic twin or trichorionic triplet pregnancy. At each ultrasound scan from 24 weeks, offer women with a dichorionic twin or trichorionic triplet pregnancy diagnostic monitoring for fetal weight discordance using 2 or more biometric parameters and amniotic fluid levels. To assess amniotic fluid levels, measure the deepest vertical pocket (DVP) on either side of the amniotic membrane. Continue monitoring for fetal weight discordance at intervals that do not exceed: days for women with a dichorionic twin pregnancy days for women with a trichorionic triplet pregnancy. Calculate and document estimated fetal weight (EFW) discordance for dichorionic twins using the formula below : ( ÷ EFW larger fetus) × 100 Calculate and document EFW discordance for trichorionic triplets using the formula below :( ÷ EFW largest fetus) × 100and( ÷ EFW largest fetus) × 100 Increase diagnostic monitoring in the second and third trimesters to at least weekly, and include doppler assessment of the umbilical artery flow for each baby, if: there is an EFW discordance of 20% or more and/or the EFW of any of the babies is below the 10th centile for gestational age. Refer women with a dichorionic twin or trichorionic triplet pregnancy to a tertiary level fetal medicine centre if there is an EFW discordance of 25% or more and the EFW of any of the babies is below the 10th centile for gestational age because this is a clinically important indicator of selective fetal growth restriction. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on diagnostic monitoring for fetal growth restriction in dichorionic twin and trichorionic triplet pregnancies . Full details of the evidence and the committee's discussion are in evidence review B: screening for fetal growth restriction. Loading. Please wait. ## Diagnostic monitoring for complications of monochorionicity in twin and triplet pregnancy A monochorionic twin or triplet pregnancy is one in which any of the babies share a placenta and a chorionic (outer) membrane. This includes monochorionic twins and dichorionic and monochorionic triplets. Offer women simultaneous monitoring for feto-fetal transfusion syndrome, fetal growth restriction and advanced-stage twin anaemia polycythaemia sequence (TAPS) at every ultrasound assessment to monitor effectively for all complications of monochorionicity. Explain that the relative likelihood of each complication changes with advancing gestation but that they can all occur at any gestational age. Offer diagnostic monitoring for feto-fetal transfusion syndrome to women with a monochorionic twin or triplet pregnancy. Monitor with ultrasound every 14 days from 16 weeks until birth. Use ultrasound assessment, with a visible amniotic membrane within the measurement image, to monitor for feto-fetal transfusion syndrome. Measure the DVP depths of amniotic fluid on either side of the amniotic membrane. Increase the frequency of diagnostic monitoring for feto-fetal transfusion syndrome in the woman's second and third trimester to at least weekly if there are concerns about differences between the babies' amniotic fluid level (a difference in DVP depth of 4 cm or more). Include doppler assessment of the umbilical artery flow for each baby. Refer the woman to a tertiary level fetal medicine centre if feto-fetal transfusion syndrome is diagnosed, based on the following: the amniotic sac of 1 baby has a DVP depth of less than 2 cm and the amniotic sac of another baby has a DVP depth of: -ver 8 cm before 20+0 weeks of pregnancy or -ver 10 cm from 20+0 weeks. Refer the woman to her named specialist obstetrician for multiple pregnancy in her second or third trimester for further assessment and monitoring if: the amniotic sac of 1 baby has a DVP depth in the normal range and the amniotic sac of another baby has a DVP depth of: less than 2 cm or cm or more. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on diagnostic monitoring for feto-fetal transfusion syndrome . Full details of the evidence and the committee's discussion are in evidence review A: screening for feto-fetal transfusion syndrome. Loading. Please wait. Do not use abdominal palpation or symphysis–fundal height measurements to monitor for fetal growth restriction in women with a monochorionic twin or triplet pregnancy. At each ultrasound scan from 16 weeks, offer women with a monochorionic twin or triplet pregnancy diagnostic monitoring for fetal weight discordance using 2 or more biometric parameters (in addition to amniotic fluid level assessment). To assess amniotic fluid levels, measure the DVP on either side of the amniotic membrane. Continue monitoring women with a monochorionic twin or triplet pregnancy for fetal weight discordance at intervals that should not exceed 14 days. Calculate and document EFW discordance in monochorionic twins using the formula below : ( ÷ EFW larger fetus) × 100 The named specialist obstetrician should review the estimated fetal weights of dichorionic and monochorionic triplets and calculate EFW discordance based on their understanding of the implications of chorionicity. Increase diagnostic monitoring in the second and third trimesters to at least weekly, and include doppler assessment of the umbilical artery flow for each baby, if: there is an EFW discordance of 20% or more and/or the EFW of any of the babies is below the 10th centile for gestational age. Refer women with a monochorionic twin or triplet pregnancy to a tertiary level fetal medicine centre if there is an EFW discordance of 25% or more and the EFW of any of the babies is below the 10th centile for gestational age because this is a clinically important indicator of selective fetal growth restriction. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see rationale and impact section on diagnostic monitoring for fetal growth restriction in monochorionic pregnancy . Full details of the evidence and the committee's discussion are in evidence review B: screening for fetal growth restriction. Loading. Please wait. Offer weekly ultrasound monitoring for TAPS from 16 weeks of pregnancy using middle cerebral artery peak systolic velocity (MCA‑PSV) to women whose pregnancies are complicated by: feto-fetal transfusion syndrome that has been treated by fetoscopic laser therapy or selective fetal growth restriction (defined by an EFW discordance of 25% or more and an EFW of any of the babies below the 10th centile for gestational age). For women with a monochorionic pregnancy showing any of the following: cardiovascular compromise (such as fetal hydrops or cardiomegaly) or unexplained isolated polyhydramnios or abnormal umbilical artery perform ultrasound MCA‑PSV measurements to help detect advanced-stage TAPS, and seek management advice immediately from a tertiary level fetal medicine specialist. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on diagnostic monitoring for TAPS . Full details of the evidence and the committee's discussion are in evidence review C: screening for TAPS. Loading. Please wait. # Preventing preterm birth The committee did not make any recommendations on vaginal progesterone for preventing preterm birth in twin pregnancies because of emerging evidence in this area. NICE will carry out an exceptional update based on the new evidence when it becomes available. Do not offer intramuscular progesterone to prevent spontaneous preterm birth in women with a twin or triplet pregnancy. Do not offer the following interventions (alone or in combination) routinely to prevent spontaneous preterm birth in women with a twin or triplet pregnancy: arabin pessary bed rest cervical cerclage -ral tocolytics. For a short explanation of why the committee made the 2019 recommendations (and why they did not make a recommendation on vaginal progesterone) and how they might affect practice, see the rationale and impact section on preventing preterm birth . Full details of the evidence and the committee's discussion are in evidence review E: interventions to prevent spontaneous preterm birth. Loading. Please wait. ## Corticosteroids Inform women with a twin or triplet pregnancy of their increased risk of preterm birth (see the recommendation explaining screening for preterm birth to women and their family members in the section on screening for preterm birth) and about the benefits of targeted corticosteroids. Do not use single or multiple untargeted (routine) courses of corticosteroids in twin or triplet pregnancy. Inform women that there is no benefit in using untargeted administration of corticosteroids. # Maternal complications ## Hypertension Measure blood pressure and test urine for proteinuria to screen for hypertensive disorders at each antenatal appointment in a twin and triplet pregnancy in line with NICE's guideline on antenatal care for uncomplicated pregnancies. Advise women with a twin or triplet pregnancy to take low-dose aspirin daily from 12 weeks until the birth of the babies if they have 2 or more of the risk factors specified in NICE's guideline on hypertension in pregnancy. In September 2019, this was an off-label use of aspirin. See NICE's information on prescribing medicines. # Indications for referral to a tertiary level fetal medicine centre Seek a consultant opinion from a tertiary level fetal medicine centre for: pregnancies with a shared amnion: monochorionic monoamniotic twins dichorionic diamniotic triplets monochorionic diamniotic triplets monochorionic monoamniotic triplets pregnancies complicated by any of the following: fetal weight discordance (of 25% or more) and an EFW of any of the babies below the 10th centile for gestational age fetal anomaly (structural or chromosomal) discordant fetal death feto-fetal transfusion syndrome twin reverse arterial perfusion sequence (TRAP) conjoined twins or triplets suspected TAPS (see the recommendations in the section on twin anaemia polycythaemia sequence). # Planning birth: information and support From 24 weeks in a twin or triplet pregnancy, discuss with the woman (and her family members or carers, as appropriate) her plans and wishes for the birth of her babies. Provide information that is tailored to each woman's pregnancy, taking into account her needs and preferences. Revisit these conversations whenever clinically indicated and whenever the woman wants to. Ensure the following has been discussed by 28 weeks at the latest: place of birth and the possible need to transfer in case of preterm birth timing and possible modes of birth analgesia during labour (or for caesarean birth) intrapartum fetal heart monitoring management of the third stage of labour. Follow NICE's guideline on patient experience in adult NHS services for how to provide information and communicate with women and their families and carers. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on planning birth . Loading. Please wait. # Timing of birth ## Antenatal information for women Explain to women with a twin pregnancy that about 60 in 100 twin pregnancies result in spontaneous birth before 37 weeks. Explain to women with a triplet pregnancy that about 75 in 100 triplet pregnancies result in spontaneous birth before 35 weeks. Explain to women with a twin or triplet pregnancy that spontaneous preterm birth and planned preterm birth are associated with an increased risk of admission to a neonatal unit. Explain to women with an uncomplicated dichorionic diamniotic twin pregnancy that: planned birth from 37+0 weeks does not appear to be associated with an increased risk of serious neonatal adverse outcomes and continuing the pregnancy beyond 37+6 weeks increases the risk of fetal death. Explain to women with an uncomplicated monochorionic diamniotic twin pregnancy that: planned birth from 36+0 weeks does not appear to be associated with an increased risk of serious neonatal adverse outcomes and continuing the pregnancy beyond 36+6 weeks increases the risk of fetal death. Explain to women with an uncomplicated monochorionic monoamniotic twin pregnancy that planned birth between 32+0 and 33+6 weeks does not appear to be associated with an increased risk of serious neonatal adverse outcomes. Also explain that: these babies will usually need to be admitted to the neonatal unit and have an increased risk of respiratory problems continuing the pregnancy beyond 33+6 weeks increases the risk of fetal death. Explain to women with an uncomplicated trichorionic triamniotic or dichorionic triamniotic triplet pregnancy that continuing the pregnancy beyond 35+6 weeks increases the risk of fetal death. Explain to women with a monochorionic triamniotic triplet pregnancy or a triplet pregnancy that involves a shared amnion that the timing of birth will be decided and discussed with each woman individually. ## When to offer planned birth Offer planned birth at 37 weeks to women with an uncomplicated dichorionic diamniotic twin pregnancy. Offer planned birth as follows, after a course of antenatal corticosteroids has been considered (see the section on maternal corticosteroids in NICE's guideline on preterm labour and birth): at 36 weeks for women with an uncomplicated monochorionic diamniotic twin pregnancy between 32+0 and 33+6 weeks for women with an uncomplicated monochorionic monoamniotic twin pregnancy at 35 weeks for women with an uncomplicated trichorionic triamniotic or dichorionic triamniotic triplet pregnancy. Offer an individual assessment to determine the timing of planned birth in women with any of the following: a complicated twin or triplet pregnancy a monochorionic triamniotic triplet pregnancy a triplet pregnancy that involves a shared amnion. For women who decline planned birth at the timing recommended in recommendations 1.9.9 and 1.9.10, offer weekly appointments with the specialist obstetrician. At each appointment, offer an ultrasound scan and perform assessments of amniotic fluid level and doppler of the umbilical artery flow for each baby in addition to fortnightly fetal growth scans. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on timing of birth . Full details of the evidence and the committee's discussion are in evidence review J: timing of birth. Loading. Please wait. # Mode of birth ## Twin pregnancy: dichorionic diamniotic or monochorionic diamniotic Explain to women with an uncomplicated twin pregnancy planning their mode of birth that planned vaginal birth and planned caesarean section are both safe choices for them and their babies if all of the following apply: the pregnancy remains uncomplicated and has progressed beyond 32 weeks there are no obstetric contraindications to labour the first baby is in a cephalic (head-first) presentation there is no significant size discordance between the twins. Explain to women with an uncomplicated twin pregnancy that for women giving birth after 32 weeks (see recommendation 1.10.1): more than a third of women who plan a vaginal birth go on to have a caesarean section almost all women who plan a caesarean section do have one, but a few women have a vaginal birth before caesarean section can be carried out a small number of women who plan a vaginal birth will need an emergency caesarean section to deliver the second twin after vaginal birth of the first twin. Offer caesarean section to women if the first twin is not cephalic at the time of planned birth. Offer caesarean section to women in established preterm labour between 26 and 32 weeks if the first twin is not cephalic. Offer an individualised assessment of mode of birth to women in suspected, diagnosed or established preterm labour before 26 weeks. Take into account the risks of caesarean section (see NICE's guideline on preterm labour and birth) and the chance of survival of the babies. ## Twin pregnancy: monochorionic monoamniotic Offer a caesarean section to women with a monochorionic monoamniotic twin pregnancy: at the time of planned birth (between 32+0 and 33+6 weeks) or after any complication is diagnosed in her pregnancy requiring earlier delivery or if she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies (unless the first twin is close to vaginal birth and a senior obstetrician advises continuing to vaginal birth). ## Triplet pregnancy Offer a caesarean section to women with a triplet pregnancy: at the time of planned birth (35 weeks) or after any complication is diagnosed in her pregnancy requiring earlier delivery or if she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on mode of birth . Full details of the evidence and the committee's discussion are in evidence review F: mode of birth. Loading. Please wait. # Fetal monitoring during labour in twin pregnancy ## Antenatal information for women By 28 weeks of pregnancy, discuss continuous cardiotocography with women with a twin pregnancy and their family members or carers (as appropriate) and address any concerns. Explain that the recommendations on cardiotocography are based on evidence from women with a singleton pregnancy because there is a lack of evidence specific to twin pregnancy or preterm babies. Explain to the woman that continuous cardiotocography is used to monitor the babies' heartbeats and her labour contractions, and that: it allows simultaneous monitoring of both babies it might restrict her mobility normal traces show the babies are coping well with labour; if traces are not normal, there will be less certainty about the babies' condition it is normal to see changes to the fetal heart rate pattern during labour and this does not necessarily mean there is a problem findings from the cardiotocograph are used to help make decisions during labour and birth, but these will also be based on her wishes, her condition and that of her babies. ## Intrapartum monitoring Offer continuous cardiotocography to women with a twin pregnancy who are in established labour and are more than 26 weeks pregnant. Perform a portable ultrasound scan when established labour starts, to confirm which twin is which, the presentation of each twin, and to locate the fetal hearts. Do not offer intermittent auscultation to women with a twin pregnancy who are in established labour and are more than 26 weeks pregnant. For women between 23+0 and 25+6 weeks of pregnancy who are in established labour, involve a senior obstetrician in discussions with the woman and her family members or carers about how to monitor the fetal heart rates. When carrying out cardiotocography: use dual channel cardiotocography monitors to allow simultaneous monitoring of both fetal hearts document on the cardiotocograph and in the clinical records which cardiotocography trace belongs to which baby monitor the maternal pulse electronically and display it simultaneously on the same cardiotocography trace. Consider separating the fetal heart rates by 20 beats/minute if there is difficulty differentiating between them. Classify and interpret cardiotocography in line with the section on the use of cardiotocography for monitoring during labour in the NICE guideline on fetal monitoring in labour, taking into account that: twin pregnancy should be considered a fetal clinical risk factor when classifying a cardiotocography trace as 'abnormal' versus 'non-reassuring' fetal scalp stimulation should not be performed in twin pregnancy to gain reassurance after a cardiotocography trace that is categorised as 'pathological'. ## Reviewing cardiotocography Carry out systematic assessments of both cardiotocographs at least hourly, and more frequently if there are concerns. At each systematic assessment, document which cardiotocography trace belongs to which baby. Be aware of the possibility of monitoring the same baby twice. At each cardiotocography review, ensure that twin synchronicity is not occurring. ## Management based on cardiotocography For definitions of 'suspicious' and 'pathological' cardiotocograph traces, see the table on management based on interpretation of cardiotocograph traces in NICE's guideline on intrapartum care for healthy women and babies. If abdominal monitoring is unsuccessful or there are concerns about synchronicity of the fetal hearts: involve a senior obstetrician and senior midwife apply a fetal scalp electrode to the first baby (only after 34 weeks and if there are no contraindications) while continuing abdominal monitoring of the second baby perform a bedside ultrasound scan to confirm both fetal heart rates if monitoring remains unsatisfactory, consider a caesarean section. If the cardiotocograph trace is categorised as 'suspicious' in the first baby during established labour: involve the senior obstetrician and senior midwife correct any reversible causes apply a fetal scalp electrode to the first baby (only after 34 weeks and if there are no contraindications) while continuing abdominal monitoring of the second baby. If the cardiotocograph trace is categorised as 'pathological' in the first baby during established labour: involve the senior obstetrician and senior midwife discuss with the woman and her family members or carers the possible use of fetal blood sampling of the first baby from 34 weeks if the benefits are likely to outweigh the potential risks. When offering fetal blood sampling in twin pregnancy, discuss with the woman and her family members or carers that if a blood sample cannot be obtained then she is likely to need a caesarean section. If the results of fetal blood sampling are not available within 20 minutes or fetal blood sampling is contraindicated, offer an immediate caesarean section to women with a twin pregnancy. If the cardiotocograph trace is categorised as 'pathological' in the first baby during the second stage of labour: involve the senior obstetrician and senior midwife assess whether an assisted vaginal birth is an option if vaginal birth is not an option or cannot be achieved within 20 minutes, offer an immediate caesarean section. If the cardiotocograph trace of the second baby is categorised as 'suspicious' or 'pathological' during established labour before the first baby is born: involve the senior obstetrician and senior midwife if vaginal birth of the second baby cannot be achieved within 20 minutes, discuss performing a caesarean section with the woman and her family members or carers. After the birth of the first baby: continue to monitor the second baby using cardiotocography if there is 'suspicious' or 'pathological' cardiotocography, and vaginal birth cannot be achieved within 20 minutes, discuss performing a caesarean section with the woman and her family members or carers. After the birth of both babies, consider double clamping the cord to allow umbilical cord blood gases to be sampled. Ensure that the samples are correctly labelled for each baby. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on fetal monitoring during labour . Full details of the evidence and the committee's discussion are in evidence review G: fetal monitoring. Loading. Please wait. # Analgesia Discuss options for analgesia and anaesthesia with women (and their family members or carers, as appropriate), whether they are planning a vaginal birth or caesarean section. Ensure this discussion takes place by 28 weeks at the latest. Offer an epidural to women with a twin or triplet pregnancy who choose to have a vaginal birth. Explain that this is likely to: improve the chance of success and optimal timing of assisted vaginal birth of all the babies enable a quicker birth by emergency caesarean section if needed. Offer regional anaesthesia to women with a twin or triplet pregnancy who are having a caesarean section. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on analgesia . Full details of the evidence and the committee's discussion are in evidence review H: analgesia. Loading. Please wait. # Managing the third stage of labour ## Assessing risk Start assessing the risk of postpartum haemorrhage in women with a twin or triplet pregnancy in the antenatal period and continue throughout labour and the third stage (see the section on risk factors for postpartum haemorrhage in NICE's guideline on intrapartum care for healthy women and babies). Offer each woman an individualised assessment of her risk of postpartum haemorrhage and explain that multiple pregnancy is a risk factor for increased blood loss at delivery. ## Management By 28 weeks of pregnancy, discuss options for managing the third stage of labour with women with a twin or triplet pregnancy. Do not offer physiological management of the third stage to women with a twin or triplet pregnancy. Offer women with a twin or triplet pregnancy active management of the third stage. Explain that it is associated with a lower risk of postpartum haemorrhage and/or blood transfusion. Consider active management of the third stage with additional uterotonics for women who have 1 or more risk factors (in addition to a twin or triplet pregnancy) for postpartum haemorrhage. ## Blood transfusion By 28 weeks of pregnancy, discuss with women with a twin or triplet pregnancy the potential need for blood transfusion, including the need for intravenous access. Document this discussion in the woman's notes. At the start of established labour in women with a twin or triplet pregnancy: ensure that intravenous access is available so that prompt blood transfusion and intravenous fluids can be given if needed take a maternal blood sample for a full blood count and group and save. Ensure that the appropriate blood transfusion is available for urgent administration. For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on managing the third stage of labour . Full details of the evidence and the committee's discussion are in evidence review I: interventions to prevent postpartum haemorrhage in the third stage of labour. Loading. Please wait. # Terms used in this guideline ## Active management of the third stage In a vaginal birth, active management consists of 10 IU of oxytocin by intramuscular injection immediately after the birth of the last baby and before the cord is clamped and cut. In a caesarean section, it consists of 5 IU of oxytocin by intravenous injection immediately after the birth of the last baby and before the cord is clamped and cut. ## Amnionicity The number of amnions (inner membranes) that surround babies in a multiple pregnancy. Pregnancies with 1 amnion (so that all babies share an amniotic sac) are described as monoamniotic; pregnancies with 2 amnions are diamniotic; and pregnancies with 3 amnions are triamniotic. Also see the box on chorionicity and amnionicity in twin and triplet pregnancy. ## Chorionicity The number of chorionic (outer) membranes that surround babies in a multiple pregnancy. If there is only 1 membrane, the pregnancy is described as monochorionic; if there are 2, the pregnancy is dichorionic; and if there are 3, the pregnancy is trichorionic. Monochorionic twin pregnancies and monochorionic or dichorionic triplet pregnancies carry higher risks because babies share a placenta. Also see the box on chorionicity and amnionicity in twin and triplet pregnancy. ## Feto-fetal transfusion syndrome Feto-fetal transfusion syndrome (FFTS) occurs when blood moves from one baby to another. The baby that loses the blood is called the donor and the baby receiving the blood is called the recipient. Feto-fetal transfusion syndrome is a complication of monochorionic multiple pregnancies arising from shared placental circulation. It is also referred to as twin-to-twin transfusion syndrome in twin pregnancies. ## Group and save This is a blood sampling process. It consists of a blood group and an antibody screen to determine the woman's blood group and whether she has atypical red cell antibodies in her blood. If atypical antibodies are present, the laboratory will do additional work to identify them. This will allow blood to be issued in an emergency very quickly. ## Specialist obstetrician An obstetrician with a special interest, experience and knowledge of managing multiple pregnancy, and who works regularly with women with a multiple pregnancy. ## Tertiary level fetal medicine centre A specialist regional (or supra-regional) fetal medicine centre that has a multidisciplinary team with the expertise and infrastructure to assess and manage complicated twin and triplet pregnancies. This includes providing complex fetal interventions or therapies, for example, fetoscopic laser ablation for feto-fetal transfusion syndrome; and selective termination of pregnancy using techniques such as fetoscopic cord occlusion or radiofrequency ablation. ## Twin anaemia polycythaemia sequences Twin anaemia polycythaemia sequences (TAPS) is a complication affecting monochorionic twin or triplet pregnancies. It is a rare, chronic form of feto-fetal transfusion caused by the joining of fine blood vessels connecting the fetal circulations on the placenta. It presents when there are unequal blood counts between the twins in the womb. When TAPS occurs, the recipient twin is at risk for successively increasing blood count, called polycythaemia, and the donor twin for progressive blood loss, or anaemia. TAPS occurs without the differences in levels of amniotic fluids between the fetuses (polyhydramnios-oligohydramnios) that is usually seen in FFTS.# Recommendations for research The guideline committee has made the following recommendations for research. As part of the 2019 update, the guideline committee made an additional recommendation for research on the identification on twin anaemia polycythaemia sequence (TAPS). The committee removed 6 of the 2011 recommendations on screening for chromosomal conditions, screening for feto-fetal transfusion syndrome, defining fetal growth restriction, predicting and preventing spontaneous preterm birth, and perinatal and neonatal morbidity and mortality in babies born by elective birth. # Key recommendations for research ## Screening to detect twin anaemia polycythaemia sequence What is the most accurate prenatal screening marker for TAPS, including middle cerebral artery peak systolic velocity (MCA‑PSV)? For a short explanation of why the committee made the recommendation for research, see the rationale on diagnostic monitoring for twin anaemia polycythaemia sequence . Full details of the evidence and the committee's discussion are in evidence review C: screening for TAPS. Loading. Please wait. ## Information and support Does additional information and emotional support improve outcomes in twin and triplet pregnancies? ## Specialist care Does specialist antenatal care for women with twin and triplet pregnancies improve outcomes for women and their babies? ## Indications for referral to a tertiary level fetal medicine centre What is the incidence of monochorionic monoamniotic twin and triplet pregnancies, and what clinical management strategies are most effective in such pregnancies? # Other recommendations for research ## Gestational age How should gestational age be estimated in twin and triplet pregnancies? ## Chorionicity What is the most accurate method of determining chorionicity in twin and triplet pregnancies at different gestational ages, and how does operator experience affect the accuracy of different methods? ## Nutritional supplements Is dietary supplementation with vitamins or minerals, or dietary manipulation in terms of calorie intake, effective in twin and triplet pregnancies? ## Diet and lifestyle advice Is dietary advice specific to twin and triplet pregnancies effective in improving maternal and fetal health and wellbeing? ## Screening for structural abnormalities When and how should screening for structural abnormalities be conducted in twin and triplet pregnancies? ## Hypertension Which clinical factors, laboratory screening tests, and ultrasound tests are predictive of hypertensive disorders in twin and triplet pregnancies? ## Untargeted corticosteroids What is the clinical and cost effectiveness, and safety, of routine antenatal administration of a single course of corticosteroids for women with twin and triplet pregnancies who are not in labour and in whom labour and birth are not imminent? ## Indications for referral to a tertiary level fetal medicine centre What is the clinical and cost effectiveness of referral to tertiary level fetal medicine centres for twin and triplet pregnancies complicated by discordant fetal growth, discordant fetal anomaly or discordant fetal death? # Rationale and impact These sections briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee's discussion. # Intrapartum care Recommendation 1.3.6 ## Why the committee made the recommendation The committee recognised that the core multidisciplinary team recommended by the previous guideline (see recommendation 1.3.1) provides care during the antenatal period and would not be the same team providing intrapartum care. Because intrapartum care was added to the guideline update, they made a recommendation to clarify that healthcare professionals supporting women when they are giving birth should also have knowledge and experience in multiple pregnancy. ## How the recommendation might affect practice The recommendation reinforces current practice. Return to recommendation # Screening for chromosomal conditions Recommendations 1.4.3 to 1.4.8 ## Why the committee made the recommendations Since the 2011 guideline, the National Screening Committee's recommendations on screening for fetal chromosomal conditions have been published and have been implemented by the NHS fetal anomaly screening programme (FASP). These apply to women with both singleton and twin pregnancies, so the 2011 recommendations were replaced by a cross reference to this screening programme. The committee recognised that no current guidance exists for triplets so they retained a recommendation on triplets from the 2011 guideline. However, based on their expertise they decided this existing recommendation would apply only to screening in trichorionic triplets so they made an additional recommendation about dichorionic and monochorionic triplet pregnancies. Because of the complexity of screening these types of triplet pregnancies, this screening should only be carried out after referral to a tertiary level fetal medicine centre. ## How the recommendations might affect practice The recommendations reinforce current best practice. Return to recommendations # Screening for preterm birth Recommendations 1.4.13 to 1.4.15 ## Why the committee made the recommendations The committee agreed, based on their experience and expertise, that women should be given information about the higher risk of preterm birth in twin and triplet pregnancy compared with singleton pregnancy. The committee retained the existing 2011 recommendations that fetal fibronectin testing and home uterine activity monitoring should not be used to predict the risk of spontaneous preterm birth because there was still no evidence suggesting they were accurate. ## Why the committee did not make a recommendation on cervical length screening in twin pregnancy The evidence suggested that cervical length is a moderate predictor of spontaneous preterm birth in twin pregnancy. Although there were some inconsistencies between studies, the committee agreed they still supported the use of cervical length measurements to predict preterm birth in twin pregnancy. Establishing that a woman is at risk of preterm birth allows an intervention to be offered, and there is some evidence that vaginal progesterone may reduce this risk in women with a twin pregnancy. However, the committee was also aware that new evidence would be emerging about the use of vaginal progesterone in subgroups of women with a short cervix that could change their conclusions about its effectiveness. This uncertainty meant the committee could not recommend vaginal progesterone to prevent preterm birth. Because of this, the committee also decided they could not recommend cervical length screening in the absence of an effective intervention to offer women with a higher risk of preterm birth. ## How the recommendations might affect practice The recommendations reinforce current best practice. Return to recommendations # Screening for fetal growth restriction and feto-fetal transfusion syndrome in the first trimester Recommendation 1.4.16 ## Why the committee made the recommendation There was evidence that discordance in either crown–rump length or nuchal translucency during the first trimester is not an accurate predictor of growth discordance in the second and third trimester. The committee discussed the evidence for other ultrasound screening measures in the first trimester and decided that because of its low quality they were not confident in recommending any screening tests in the first trimester. The evidence showed that none of the first trimester screening tests were able to detect the risk of feto-fetal transfusion syndrome developing later in the pregnancy. Although there were uncertainties in this evidence, it was supported by the committee's clinical experience and current clinical practice. ## How the recommendation might affect practice The recommendation reinforces current practice. Return to recommendations # Diagnostic monitoring for fetal growth restriction in dichorionic twin and trichorionic triplet pregnancies Recommendations 1.4.17 to 1.4.23 ## Why the committee made the recommendations Based on evidence which showed that abdominal palpation and symphysis–fundal height were not accurate measurements to diagnose fetal growth restriction, the committee recommended that these should not be used. Fetal growth restriction is associated with perinatal mortality, morbidity and preterm birth. The committee agreed that monitoring using ultrasound scanning is essential to identify women in this high-risk group. The evidence was limited on the frequency of ultrasound scanning for women with dichorionic twin pregnancies but, based on their expertise, the committee agreed that women with a dichorionic twin pregnancy should have scans no more than 28 days apart. They also recommended ultrasound monitoring at least every 14 days for women with all types of triplet pregnancy (recommendations 1.4.19 and 1.4.32) because they are at higher risk of fetal growth restriction. Based on both the evidence and their expertise, the committee recommended using at least 2 different biometric parameters as well as amniotic fluid level assessment to provide greater accuracy in calculating estimated fetal weight (EFW). The Royal College of Obstetricians and Gynaecologists' Green Top guideline on monochorionic twin pregnancy recommends referring women 'for assessment and management in fetal medicine units with recognised relevant expertise' if there is an EFW discordance of more than 20%. In the committee's experience, this level of discordance should cause concern in all types of twin and triplet pregnancy and should prompt increased monitoring. However, they recommended instead increasing to weekly monitoring and adding the extra parameter of a doppler assessment. This would be equivalent to the specialist assessment recommended by the Green Top guideline because it would need to be carried out by the specialist core team (in line with recommendation 1.3.1) who have experience and knowledge of managing twin and triplet pregnancies. The committee agreed that this would not be inconsistent with the Green Top guideline. The committee also agreed that the EFWs themselves should be taken into account. Based on the evidence and their expertise they recommended the 10th centile for gestational age as a threshold for concern that should prompt increased monitoring. The evidence was inconclusive about an exact threshold for referral to a tertiary level fetal medicine centre, so based on their own experience the committee decided that an EFW discordance of 25% or more (along with an EFW below the 10th centile for gestational age) should warrant referral. At this level of discordance, there would be an increased risk of perinatal morbidity and mortality that should prompt intervention rather than increased assessment. The tertiary level fetal medicine centre would have the expertise to weigh up the benefits and risks of conservative management, birth or invasive fetal therapy to improve the chance of a positive pregnancy outcome. ## How the recommendations might affect practice These recommendations are largely reinforcing current practice in twin pregnancy and should have a minimal impact on local ultrasound resourcing. They are consistent with other national and international guidance. The recommendations to monitor all women with a triplet pregnancy at no more than 14‑day intervals (irrespective of chorionicity) are a change in practice, particularly for women with a trichorionic triamniotic pregnancy. For these women, previous recommendations suggested 4‑weekly scans. However, the change is justified because all types of triplet pregnancy are at high risk of fetal growth restriction. The recommendation should not have a significant impact on clinical resources because of the low number of women with a triplet pregnancy. Return to recommendations # Diagnostic monitoring for feto-fetal transfusion syndrome Recommendations 1.4.24 to 1.4.29 ## Why the committee made the recommendations The committee agreed that feto-fetal transfusion syndrome is difficult to detect using amniotic fluid discordance before 16 weeks of pregnancy. After this stage, amniotic fluid levels have increased and differences between them can be used to diagnose feto-fetal transfusion syndrome. Monitoring fortnightly from 16 weeks should ensure that feto-fetal transfusion syndrome is diagnosed as early as possible. The committee decided based on their expertise – and on limited evidence from studies that conducted diagnostic scans after 24 weeks – that continuing fortnightly monitoring until birth would improve outcomes for women who develop feto-fetal transfusion syndrome later in pregnancy (although it is less common after 26 weeks). The committee also agreed that offering women with a monochorionic pregnancy scans at 14-day intervals means that the woman can be monitored efficiently for all the complications in recommendation 1.4.24 at each scan. To support this frequency of monitoring, the committee also increased the number of reviews by the specialist obstetrician from at least 2 (in the 2011 guideline) to at least 5 for dichorionic and monochorionic triamniotic triplet pregnancies (recommendation 1.3.10). Dichorionic triamniotic triplets have an increased risk of adverse outcomes compared with monochorionic diamniotic twins if feto-fetal transfusion occurs. The risk of complications of monochorionicity, and of adverse outcomes if complications occur, is higher in triplets than in twins. More frequent review by the specialist obstetrician would ensure optimal critical assessment of ultrasound findings (including findings related to feto-fetal transfusion syndrome) and any need for more frequent monitoring. The committee agreed that making sure the amniotic membrane is visible in the scan reduces the chance of measuring the same sac twice in error and improves accuracy in identifying a difference between the babies' amniotic fluid levels. Based on their knowledge and experience, the committee agreed that women should be referred immediately to a tertiary level fetal medicine centre when differences in amniotic fluid levels meet the criteria for diagnosing feto-fetal transfusion syndrome. The clinical course of feto-fetal transfusion syndrome can be unpredictable so this would allow prompt assessment and early intervention. They also agreed that when differences in amniotic fluid levels are measured that do not yet meet the threshold for feto-fetal transfusion syndrome, women should be seen by their named specialist obstetrician for multiple pregnancy and offered more frequent monitoring, using doppler assessment to help detect feto-fetal transfusion syndrome as early as possible. ## How the recommendations might affect practice Monitoring for feto-fetal transfusion syndrome from 16 weeks of pregnancy until birth is a change to current practice, in which monitoring is only carried out until week 24. Early detection would enable prompt management, and this would outweigh the cost of additional ultrasound. Return to recommendations # Diagnostic monitoring for fetal growth restriction in monochorionic twin and triplet pregnancy Recommendations 1.4.30 to 1.4.36 A monochorionic twin or triplet pregnancy is one in which any of the babies share a placenta and a chorionic (outer) membrane. This includes monochorionic twins and dichorionic and monochorionic triplets. ## Why the committee made the recommendations Based on evidence which showed that abdominal palpation and symphysis–fundal height were not accurate measurements to diagnose fetal growth restriction, the committee recommended that these should not be used. Fetal growth restriction is associated with perinatal mortality, morbidity and preterm birth. The committee agreed that monitoring using ultrasound scanning is essential to identify women in this high-risk group. The evidence was limited on the frequency of ultrasound scanning for women with monochorionic pregnancies, so the committee used their expertise to make recommendations. They agreed that women with a monochorionic twin pregnancy need more frequent scans than women with a dichorionic twin pregnancy because they have a higher risk of severe growth discordance. Scanning at no more than 14-day intervals would allow the woman to be referred promptly either to her specialist obstetrician for multiple pregnancy or to a tertiary level fetal medicine centre depending on the EFWs (see below). The committee also agreed that because women with a monochorionic pregnancy should be having scans at 14‑day intervals to monitor for feto-fetal transfusion syndrome, these timings mean they can be monitored for both of these complications at the same time (in line with recommendation 1.4.24). The committee also recommended ultrasound monitoring at least every 14 days for women with all types of triplet pregnancy (recommendations 1.4.19 and 1.4.32) because they are at higher risk of fetal growth restriction. Based on both the evidence and their expertise, the committee recommended using at least 2 different biometric parameters as well as amniotic fluid level assessment to provide greater accuracy in calculating EFW. The Royal College of Obstetricians and Gynaecologists' Green Top guideline on monochorionic twin pregnancy recommends referring women 'for assessment and management in fetal medicine units with recognised relevant expertise' if there is an EFW discordance of more than 20%. The committee agreed with the Green Top guideline that this level should cause concern and prompt increased monitoring, but they recommended instead increasing to weekly monitoring and adding the extra parameter of a doppler assessment. This would be equivalent to the specialist assessment recommended by the Green Top guideline because it would need to be carried out by the specialist core team (in line with recommendation 1.3.1) who have experience and knowledge of managing twin and triplet pregnancies. The committee agreed that this would not be inconsistent with the Green Top guideline. The committee also agreed that the estimated fetal weights themselves should be taken into account. Based on the evidence they recommended the 10th centile for gestational age as a threshold for concern that should prompt increased monitoring. The evidence was inconclusive about an exact threshold for referral to a tertiary level fetal medicine centre, so based on their own experience the committee decided that an EFW discordance of 25% or more (along with an EFW below the 10th centile) should warrant referral. At this level of discordance, there would be an increased risk of perinatal morbidity and mortality that should prompt intervention rather than increased assessment. The tertiary level fetal medicine centre would have the expertise to weigh up the benefits and risks of conservative management, birth or invasive fetal therapy to try to improve the chance of a positive pregnancy outcome. ## How the recommendations might affect practice These recommendations are largely reinforcing current practice in twin pregnancy and should have a minimal impact on local ultrasound resourcing. They are consistent with other national and international guidance. The recommendation to monitor all women with a triplet pregnancy at no more than 14‑day intervals (irrespective of chorionicity) is a change in practice, particularly for women with a trichorionic triamniotic pregnancy. For these women, previous recommendations suggested 4‑weekly scans. However, the change is justified because all types of triplet pregnancy are at high risk of fetal growth restriction. The recommendation should not have a significant impact on clinical resources because of the low number of women with a triplet pregnancy. Return to recommendations # Diagnostic monitoring for twin anaemia polycythaemia sequence Recommendations 1.4.37 and 1.4.38 ## Why the committee made the recommendations There was limited evidence for screening and diagnostic monitoring for twin anaemia polycythaemia sequence (TAPS). The committee discussed, based on their expertise, that there is also limited evidence on the natural history of spontaneous TAPS and effective interventions for it in uncomplicated monochorionic pregnancies. They agreed that its incidence is likely to be low, so they could not recommend screening for it in women whose monochorionic pregnancy is uncomplicated. The committee agreed that monitoring would be beneficial for women with the complications in recommendations 1.4.37 and 1.4.38. They recommended screening for TAPS in this population for 2 reasons: Complicated monochorionic pregnancies have an increased risk of fetal and neonatal death and morbidity. Diagnosing TAPS as a further complication is likely to influence how the woman's pregnancy is managed, including the timing of preterm birth. Advanced TAPS (stages 3 and 4) is associated with abnormal fetal umbilical artery and ductus venosus doppler parameters, or signs of fetal cardiac failure in the anaemic baby. These can also occur in a number of other conditions, so the diagnosis of severe TAPS (either alone or as a comorbidity) may be missed if it is not specifically screened for. The committee concluded that for women who have a pregnancy in which TAPS is a comorbid complication or is of advanced stage, the risk to the babies without diagnosis and intervention is likely to be greater than the potential harms of interventions. These include preterm birth or potential in‑utero therapies, such as in‑utero transfusion, in pre-viable or extremely premature pregnancies. The committee agreed that when TAPS is suspected, women should be referred to a tertiary level fetal medicine centre. They felt that the benefits of managing complicated monochorionic pregnancies in this setting would outweigh the potential disadvantages of inconvenience of travel and transfer to units away from home. The committee decided not to specify diagnostic criteria because they wanted to emphasise the importance of referral to a tertiary level referral centre when TAPS is suspected, so that decisions about further assessment and management can be made with each individual woman. Given the limited evidence on the diagnostic accuracy of middle cerebral artery peak systolic velocity (MCA‑PSV) for all types of monochorionic twins, regardless of complications, and uncertainties about the natural history of TAPS and its management, the committee decided to make a recommendation for research on screening to detect twin anaemia polycythaemia sequence to inform future guidance. ## How the recommendations might affect practice The recommendation may increase the number of assessments of women with complicated monochorionic pregnancies and referral for appropriate management. However, the committee agreed that any increase in referrals would be offset by the benefits of better detection and management of complicated monochorionic pregnancies. Return to recommendations # Preventing preterm birth Recommendations 1.5.1 and 1.5.2 ## Why the committee made the recommendations The evidence for intramuscular progesterone in the prevention of spontaneous preterm birth showed it had no clinical benefit and, in some instances, had negative or unpleasant side effects, so it was not recommended. The committee retained the existing 2011 recommendation that arabin pessary, bed rest, cervical cerclage and oral tocolytics should not be used routinely to prevent spontaneous preterm birth because there was still no evidence to support their use. ## Why the committee did not make a recommendation on vaginal progesterone The committee decided not to make recommendations on the use of vaginal progesterone to prevent preterm birth because they knew about evidence that would be emerging about the use of progesterone in subgroups of women with a short cervix that could change their conclusions about its effectiveness. This also meant the committee preferred not to recommend cervical length screening (see the rationale section on cervical length screening in twin pregnancy). NICE will carry out an exceptional update based on the new evidence when it becomes available. ## How the recommendations might affect practice The recommendations reinforce current practice. Return to recommendations # Planning birth: information and support Recommendations 1.8.1 to 1.8.3 ## Why the committee made the recommendations The committee discussed the importance of providing care that is woman-centred, in which shared decision-making between the woman and her healthcare professional is essential. The committee agreed on the topics that need to be discussed with women to explain the available options and find out their wishes. Information needs to be tailored to each woman's pregnancy because some twin and triplet pregnancies carry more risks than others. The committee acknowledged equality considerations for women who may have additional needs (such as needing an interpreter) in the context of providing information and communication. They cross-referred to NICE's guideline on patient experience in adult NHS services, which describes general good practice on how to do this. Return to recommendations # Timing of birth Recommendations 1.9.1 to 1.9.12 ## Why the committee made the recommendations The committee agreed that it was critical to give women the information they need to participate in shared decisions about when their babies are born. This includes explaining the known risk of spontaneous preterm birth in twin and triplet pregnancy and its possible consequences, such as admission to a neonatal unit. The committee retained this advice from the 2011 guideline because it was consistent with their experience and knowledge. They agreed that this information is important for planning the timing of birth. Women also need to know why it is recommended for them to have a planned birth by a particular week of pregnancy (also see when to offer planned birth). There is a trade-off between clinical benefits and harms when women have not given birth spontaneously by a given gestational age. These include the risks of neonatal mortality and morbidity associated with planned birth compared with the risks of stillbirth from continued pregnancy. The committee agreed that both timing and mode of birth should be discussed with women in the context of these potential risks. Women can use this advice to make an informed choice. There was not enough good evidence to conclusively identify the optimal timing of birth according to chorionicity and amnionicity, so the committee also used their expertise and experience to make recommendations. Evidence suggests a consistently higher fetal death rate (at all gestational ages) in monochorionic twin pregnancies than in dichorionic twin pregnancies. The committee therefore recommended earlier planned birth, at 36 weeks, for women with a monochorionic diamniotic pregnancy to reflect the higher risk and complexity of this type of pregnancy. This was consistent with the 2011 guideline and therefore corresponds to current clinical practice. The committee also clarified the timing of birth for monochorionic monoamniotic twins, which was not explicitly covered by the 2011 guideline – the previous guideline did not divide monochorionic twins into diamniotic or monoamniotic groups. Based on some evidence and their own knowledge and experience, the committee recommended offering planned birth between 32+0 and 33+6 weeks because this timing did not appear to be associated with an increased risk of serious neonatal adverse outcomes. The committee clarified the recommendations from the 2011 guideline by considering triplet pregnancies by type rather than as a single group. No evidence was found on timing of birth in triplet pregnancy but the committee agreed based on their own clinical experience that continuing an uncomplicated trichorionic triamniotic or a dichorionic triamniotic triplet pregnancy beyond 35+6 weeks of pregnancy would lead to an increased risk of fetal death (recommendation 1.9.7). Planned birth should therefore be offered at 35 weeks (recommendation 1.9.10). Because of significant risks for the babies in complicated twin and triplet pregnancies, and the rareness of monochorionic triamniotic triplet pregnancies and triplet pregnancies with a shared amnion, timing of birth should be assessed and discussed individually (recommendations 1.9.8 and 1.9.11). The committee highlighted that women's choice needs to be respected and that if a woman declines planned birth at the recommended time, she should be offered weekly appointments to minimise risk, monitor progress and help to identify any complications as soon as possible. ## How the recommendations might affect practice The recommendations clarify the timing of when women with a monochorionic monoamniotic pregnancy should be offered planned birth. Although this is a change from the 2011 guideline, it reinforces current practice. Return to recommendations # Mode of birth ## Why the committee made the recommendations Recommendations 1.10.1 to 1.10.5 For women who are more than 32 weeks pregnant and have an uncomplicated pregnancy, the evidence showed there is no significant difference in risk between vaginal birth and caesarean section, both for the woman and her babies. The committee's experience supported this, so they agreed that healthcare professionals should explain this to the woman and support her choice as long as the conditions in recommendation 1.10.1 are met and the first baby is in a head-first position. There was only limited evidence about mode of birth when the first baby is not head first. The committee agreed that in their clinical experience, this carries a higher risk of problems such as cord accidents during birth. Because of this, a caesarean section is the safest option to offer women after 32 weeks and for women in established preterm labour between 26 and 32 weeks. According to the evidence, not all women give birth according to their birth plan. The committee decided it was important to explain this to women so that they are prepared for the possibility of not giving birth in the way they prefer. Recommendations 1.10.6 and 1.10.7 Monochorionic monoamniotic twin pregnancies and triplet pregnancies are the least common and highest-risk types of pregnancy and evidence about mode of birth was limited for these women. However, the committee agreed from their experience that caesarean section should be the preferred option and should be offered at the time the birth is planned to happen or after the diagnosis of established labour. If the first twin is close to being born vaginally there can be risks for the babies, so the committee decided that senior obstetric assessment would be needed. ## How the recommendations might affect practice The recommendations largely reflect current practice. Supporting the woman's preferred mode of birth might increase the number of planned vaginal births, which may reduce costs. This is likely to be partly offset by the fact that a proportion of these women would go on to give birth by caesarean section for one or both twins. Return to recommendations # Fetal monitoring during labour in twin pregnancy Recommendations 1.11.1 to 1.11.21 ## Why the committee made the recommendations There was no evidence on the most effective method of fetal monitoring in labour for improving outcomes in women with a twin pregnancy and their babies, so the committee used their expertise and experience along with NICE guidance on fetal monitoring in singleton pregnancy (NICE's guideline on intrapartum care for healthy women and babies) to make recommendations. They agreed that clinically it is well recognised that twins are at increased risk of complications during labour, especially the second twin, so they recommended continuous fetal monitoring. Continuous cardiotocography monitoring is the only modality that can assess both twin fetal heart rates simultaneously during established labour. The committee agreed on the importance of explaining to women the lack of evidence about monitoring with cardiotocography specifically in twins, and that recommendations are based on NICE guidance for singleton pregnancy (intrapartum care for healthy women and babies). Healthcare professionals should provide a detailed explanation of what cardiotocography involves and why it is used and give women a chance to discuss their wishes and concerns. Recommending this before 28 weeks gives women time to make an informed decision and takes into account the fact that many twins are born prematurely. The committee recommended offering continuous cardiotocography to women in established labour with a twin pregnancy over 26 weeks because at this gestational age, neonatal survival rates improve and the risks of neonatal morbidity from preterm birth are falling. The advantages of using cardiotocography over intermittent auscultation monitoring include the ability to assess baseline variability and monitor continuously. Performing a portable ultrasound (bedside) scan at the start of established labour not only helps to confirm which is the first and which the second twin and locate the fetal hearts but also confirms presentation – malpresentation is more common in twin pregnancy than singleton pregnancy and an emergency caesarean section may be indicated if the first twin presents in the breech position. The committee recommended involving a senior obstetrician to decide how twins are monitored in established extreme premature labour (23+0 to 25+6 weeks of pregnancy) in line with NICE's guideline on premature labour and birth in singleton pregnancies. The committee recommended dual channel monitors to make sure both fetal heart rates could be monitored and displayed accurately at the same time on the same record during labour. Maternal pulse monitoring should be displayed on the same continuous cardiotocography trace to ensure 2 fetal heart rates were being recorded (without mistaking the maternal heart rate for a fetal heart rate). The committee recommended classifying and interpreting cardiotocography in a way that is broadly consistent with the NICE guideline on intrapartum care for healthy women and babies, but with additional considerations specific to twins. These include regarding twin pregnancy as a fetal clinical risk factor when classifying a cardiotocograph finding as 'abnormal' or 'non-reassuring'. This would result in a lower threshold for classifying a cardiotocograph as pathological. Failing to successfully monitor one or both babies could lead to adverse perinatal outcomes so the committee recommended involving a senior healthcare professional. They also recommended applying a fetal scalp electrode to the first baby while continuing abdominal monitoring of the second baby if abdominal monitoring is unsuccessful or there are concerns about synchronicity of the fetal hearts. This should only be carried out after 34 weeks of pregnancy and if there are no contraindications such as HIV, hepatitis or maternal thrombocytopenia. If there is 'suspicious' cardiotocography in the first baby during established labour, the committee recommended involving a senior healthcare professional to help manage reversible causes such as dehydration, infection or positional loss of contact, before applying a fetal scalp electrode to the first baby (in the absence of contraindications) while continuing abdominal monitoring of the second baby. In case of 'pathological' cardiotocography in the first baby, a senior healthcare professional should discuss with the woman using fetal blood sampling in the first baby if the benefits are likely to outweigh the potential risks – these include avoiding a second-stage caesarean section, which increases maternal morbidity and mortality. After the first baby is born, cardiotocographic monitoring of the second baby should continue to detect any 'suspicious' or 'pathological' cardiotocography that could lead to the need for a caesarean section. The committee did not make recommendations for women with a triplet pregnancy because most of these women give birth by caesarean section. Monitoring in labour would therefore be rare and decisions would be made on an individual basis. ## How the recommendations might affect practice The recommendations are consistent with the NICE guideline on intrapartum care for healthy women and babies taking into account the twin-specific measures. It is not anticipated that the recommendations will lead to major changes in current clinical practice. Return to recommendations # Analgesia Recommendations 1.12.1 to 1.12.3 ## Why the committee made the recommendations There is limited evidence on analgesia in labour for women with a twin pregnancy, and no evidence for women with a triplet pregnancy, so the committee used their expertise and experience along with the very limited evidence to make recommendations. They agreed that there is variation in practice in relation to when healthcare professionals discuss analgesia and anaesthesia with women and what they should discuss, so they specified when this should happen during pregnancy and what to cover. Women with a twin or triplet pregnancy have an increased risk of intervention in labour, including assisted birth or caesarean section for one or more of the babies, and additional internal manoeuvres. Having an epidural in place allows analgesia or anaesthesia to be given quickly when it is needed, reducing the potential need for emergency general anaesthesia. The limited evidence suggested that having an epidural in place also reduces the need for emergency caesarean section for the second twin after vaginal birth of the first twin, possibly by allowing more effective internal manoeuvres to allow the second twin to be born vaginally. ## How the recommendations might affect practice The recommendations reinforce current best practice. Return to recommendations # Managing the third stage of labour Recommendations 1.13.1 to 1.13.9 ## Why the committee made the recommendations The evidence was very limited, so the committee used their clinical expertise and experience to make recommendations. Multiple pregnancy is a risk factor for postpartum haemorrhage (see NICE's guideline on intrapartum care for healthy women and babies) because of over-distension of the uterus and enlarged placenta(s). The committee agreed that healthcare professionals should explain this to women in the antenatal period and assess and re-evaluate each woman's individual risk as her pregnancy progresses. Because of the risk of postpartum haemorrhage, the committee agreed that active management of the third stage of labour using uterotonics should be offered to all women, and physiological management should not be offered. It is already well-established as current practice and is supported by the committee's experience that when women have more than 1 risk factor for postpartum haemorrhage, additional uterotonics can reduce this risk. There is no clear evidence on the comparative effectiveness of different uterotonics in twin or triplet pregnancy. Each uterotonic has risk factors and contraindications, so the committee did not recommend a specific one. The committee agreed on the importance of having existing intravenous access and blood products readily available in case a postpartum haemorrhage does occur. ## How the recommendations might affect practice The recommendations reinforce current best practice. Return to recommendations# Context Twins or triplets occur in approximately 1 in 60 pregnancies (16 in every 1,000 women giving birth in 2015 had a multiple birth), and 3% of live-born babies are from multiple gestations. The incidence of multiple births has risen in the past 30 years. This is due mainly to increasing use of assisted reproduction techniques, including in vitro fertilisation (IVF), and also to changing demographics as women defer pregnancy and twins are more common at later ages (102 in every 1,000 women giving birth in 2015 were aged 45 or over). Women with a twin or triplet pregnancy are at higher risk compared with women with a singleton pregnancy. Adverse outcomes are more likely, both for the woman and her babies, during the prenatal and intrapartum periods. Because of this, women need increased monitoring and more contact with healthcare professionals during their pregnancy. Assessment and planning start as soon as the twin or triplet pregnancy is detected and continue throughout pregnancy at each antenatal contact. Determining the chorionicity and amnionicity of the pregnancy allows the risk to be stratified and the number of antenatal visits and ultrasound examinations to be planned. It is important that ultrasound surveillance is carefully scheduled to monitor for complications including selective fetal growth restriction, feto-fetal transfusion syndrome and twin anaemia polycythaemia sequence (TAPS). Identifying complications earlier means that decisions can be made promptly about referring the woman to a tertiary level fetal medicine centre. It also informs discussions with women in their second and third trimesters about their hopes and wishes in relation to timing and mode of birth, and the management of the intrapartum period (including fetal monitoring, analgesia and the third stage of labour). This guideline replaces the previous NICE guideline on multiple pregnancy (CG129). The surveillance process found new evidence and identified a need to include intrapartum care, an area that was not included in the original guideline. In current practice, a significant proportion of multiple pregnancy losses occur intrapartum and the risk of adverse perinatal outcomes is greater in multiple than in singleton pregnancies. The guideline updates recommendations on screening and monitoring for selective fetal growth restriction and feto-fetal transfusion syndrome, and makes new recommendations on screening and monitoring for TAPS; screening for and preventing preterm birth; and timing of birth. New recommendations on intrapartum care cover mode of birth, fetal monitoring, analgesia and managing the third stage of labour.

Medical ethics Medical ethics is primarily a field of applied ethics, the study of moral values and judgments as they apply to medicine. As a scholarly discipline, medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociology. Medical ethics tends to be understood narrowly as an applied professional ethics, whereas bioethics appears to have more expansive concerns, touching upon the philosophy of science and the critique of biotechnology. Still, the two fields often overlap and the distinction is more a matter of style than professional consensus. Medical ethics shares many principles with other branches of healthcare ethics, such as nursing ethics. # History Historically, Western medical ethics may be traced to guidelines on the duty of physicians in antiquity, such as the Hippocratic Oath, and early rabbinic and Christian teachings. In the medieval and early modern period, the field is indebted to Islamic physicians such as Ishaq bin Ali Rahawi (who wrote the Conduct of a Physician, the first book dedicated to medical ethics) and al-Razi (known as Rhazes in the West), Jewish thinkers such as Maimonides, Roman Catholic scholastic thinkers such as Thomas Aquinas, and the case-oriented analysis (casuistry) of Catholic moral theology. By the 18th and 19th centuries, medical ethics emerged as a more self-conscious discourse. For instance, authors such as the British Doctor Thomas Percival (1740-1804) of Manchester wrote about "medical jurisprudence" and reportedly coined the phrase "medical ethics." In 1847, the American Medical Association adopted its first code of ethics, with this being based in large part upon Percival's work . While the secularized field borrowed largely from Catholic medical ethics, in the 20th century a distinctively liberal Protestant approach was articulated by thinkers such as Joseph Fletcher. In the 1960's and 1970's, building upon liberal theory and procedural justice, much of the discourse of medical ethics went through a dramatic shift and largely reconfigured itself into bioethics. # Values in medical ethics Six of the values that commonly apply to medical ethics discussions are: - Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.) - Non-maleficence - "first, do no harm" (primum non nocere). - Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.) - Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment. - Dignity - the patient (and the person treating the patient) have the right to dignity. - Truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Doctors' Trial of the Nuremberg trials and Tuskegee Syphilis Study. Values such as these do not give answers as to how to handle a particular situation, but provide a useful framework for understanding conflicts. When moral values are in conflict, the result may be an ethical dilemma or crisis. Writers about medical ethics have suggested many methods to help resolve conflicts involving medical ethics. Sometimes, no good solution to a dilemma in medical ethics exists, and occasionally, the values of the medical community (i.e., the hospital and its staff) conflict with the values of the individual patient, family, or larger non-medical community. Conflicts can also arise between health care providers, or among family members. For example, the principles of autonomy and beneficence clash when patients refuse life-saving blood transfusion, and truth-telling was not emphasized to a large extent before the HIV era. In the United Kingdom, General Medical Council provides clear modern guidance in the form of its 'Good Medical Practice' statement. # Informed consent Informed Consent in ethics usually refers to the idea that an uninformed agent is at risk of mistakenly making a choice not reflective of his or her values. It does not specifically mean the process of obtaining consent, nor the legal requirements for decision-making capacity. Patients can elect to make their own medical decisions, or can delegate decision-making authority to another party. In some cases, the patient may be incapacitated, in which case U.S. state law designates a process for obtaining informed consent. In some American states, family members have differing levels of precedence over one another in making medical decisions for the patient, while other states recognize all family members equally in making medical decisions. The value of informed consent is closely related to the values of autonomy and truth telling. American culture places a high value on these principles, finding justification in the U.S. Constitution and Declaration of Independence. # Confidentiality Confidentiality is commonly applied to conversations between doctors and patients. This concept is commonly known as patient-physician privilege. Legal protections prevent physicians from revealing their discussions with patients, even under oath in court. Confidentiality is mandated in America by HIPAA laws, specifically the Privacy Rule. Confidentiality is challenged in cases such as the diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis to a spouse, or in the termination of a pregnancy in an underage patient, without the knowledge of the patient's parents. Many states in the U.S. have laws governing parental notification in underage abortion # Beneficence ## Bedside rationing Bedside rationing is defined as when the following conditions exist regarding the physician's actions: - "withhold, withdraw, or fail to recommend a service that, in the physician's best clinical judgment, is in the patient's best medical interests" - "act primarily to promote the financial interests of someone other than the patient (including an organization, society at large, and the physician himself or herself)" - "have control over the use of the beneficial service" The physician's role in rationing is debated; however, even among proponents of the physician's role there is an emphasis that the physician should not make a rationing decision in isoloation. # Autonomy # Non-maleficence The concept of non-maleficence is embodied by the phrase, "first, do no harm," or the latin, primum non nocere. Physicians are obligated under medical ethics to not prescribe medications they know to be harmful. American physicians interpret this value to exclude the practice of euthanasia, though not all concur. Probably the most extreme example in recent history of the violation of the non-maleficence dictum was Dr. Jack Kevorkian, who was convicted of second-degree homicide in Michigan in 1998 after demonstrating active euthanasia on the TV news show, 60 Minutes. Non-maleficence is a legally definable concept. Violation of non-maleficence is the subject of medical malpractice litigation. ## Double effect Some interventions undertaken by physicians can create a positive outcome while also potentially doing harm. The combination of these two circumstances is known as the "double effect." The most applicable example of this phenomenon is the use of morphine in the dying patient. Such use of morphine can ease the pain and suffering of the patient, while simultaneously hastening the demise of the patient through suppression of the respiratory drive. # Importance of communication Many so-called "ethical conflicts" in medical ethics are traceable back to a lack of communication. Communication breakdowns between patients and their healthcare team, between family members, or between members of the medical community, can all lead to disagreements and strong feelings. These breakdowns should be remedied, and many apparently insurmountable "ethics" problems can be solved with open lines of communication. # Ethics committees Many times, simple communication is not enough to resolve a conflict, and a hospital ethics committee of ad hoc nature must convene to decide a complex matter. Permanent bodies, ethical boards are established to a greater extent as ethical issues tend to increase. These bodies are comprised of health care professionals, philosophers, lay people, and still clergy. The assignment of philosophers or clergy will reflect the importance attached by the society to the basic values involved. An example from Sweden with Torbjörn Tännsjö on a couple of such committees indicates secular trends gaining influence. # Cultural concerns Culture differences can create difficult medical ethics problems. Some cultures have spiritual or magical theories about the origins of disease, for example, and reconciling these beliefs with the tenets of Western medicine can be difficult. ## Truth-telling Some cultures do not place a great emphasis on informing the patient of the diagnosis, especially when cancer is the diagnosis. Even American culture did not emphasize truth-telling in a cancer case, up until the 1970s. In American medicine, the principle of informed consent takes precedence over other ethical values, and patients are usually at least asked whether they want to know the diagnosis. # Conflicts of interest Physicians should not allow a conflict of interest to influence medical judgment. In some cases, conflicts are hard to avoid, and doctors have a responsibility to avoid entering such situations. Unfortunately, research has shown that conflicts of interests are very common among both academic physicians and physicians in practice. The The Pew Charitable Trusts has announced the Prescription Project for "academic medical centers, professional medical societies and public and private payers to end conflicts of interest resulting from the $12 billion spent annually on pharmaceutical marketing". ## Self-referral For example, doctors who receive income from referring patients for medical tests have been shown to refer more patients for medical tests . This practice is proscribed by the American College of Physicians Ethics Manual . ## Vendor relationships A systematic review and other studies show that doctors can be influenced by drug company and medical device makers inducements, including gifts and food. Industry-sponsored Continuing Medical Education (CME) programs influence prescribing patterns. Many patients surveyed in one study agreed that physician gifts from drug companies influence prescribing practices. A growing movement among physicians is attempting to diminish the influence of pharmaceutical industry marketing upon medical practice, as evidenced by Stanford University's ban on drug company-sponsored lunches and gifts. Other academic institutions that have banned pharmaceutical industry-sponsored gifts and food include the University of Pennsylvania and Yale University. Participating in sponsored research may influence practice patterns. ## Treatment of family members Many doctors treat their family members. Doctors who do so must be vigilant not to create conflicts of interest or treat inappropriately.. ## Sexual relationships Sexual relationships between doctors and patients can create ethical conflicts, since sexual consent may conflict with the fiduciary responsibility of the physician. Doctors who enter into sexual relationships with patients face the threats of deregistration and prosecution. In the early 1990's it was estimated that 2-9% of doctors had violated this rule. # Futility Advanced directives include living wills and durable powers of attorney for healthcare. (See also Do Not Resuscitate and cardiopulmonary resuscitation) In many cases, the "expressed wishes" of the patient are documented in these directives, and this provides a framework to guide family members and health care professionals in decisionmaking when the patient is incapacitated. Undocumented expressed wishes can also help guide decisionmaking, in the absence of advanced directives. "Substituted judgement" is the concept that a family member can give consent for treatment if the patient is unable (or unwilling) to give consent himself. The key question for the decisionmaking surrogate is not, "What would you like to do," but instead, "What do you think the patient would want in this situation." Courts have supported family's arbitrary definitions of futility to include simple biological survival, as in the Baby K case. A more in-depth discussion of futility is available at futile medical care. - Baby Doe Law Establishes state protection for a disabled child's right to life, ensuring that this right is protected even over the wishes of parents or guardians in cases where they want to withhold treatment. # Further reading - The Journal of Law, Medicine & Ethics, ISSN: 1748-720X (electronic) 1073-1105 (paper), Blackwell Publishing

Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment ## Not applicable Methodological rigor in guideline development Searching for evidence and drawing conclusions using it does not seem to be a big problem. However, if the level of evidence for widely known information in clinical practice is low, or if the level of evidence for questionable content is high, treatment may be confused. It seems that a special comment from the guideline development group on this is necessary. The process of deriving the recommendation grade and level of evidence for each recommendation is described in detail, and the advantages and disadvantages of clinical application are described. ## Reasonability of making recommendations There is no doubt about the rationality of the recommendation decision. It is a basic content about implementing treatment based on evidence, and will be helpful in practical clinical practice. ## Not applicable Degree of consent and usability of guidelines Overall, I agree with the treatment guidelines. However, the content of the key questions is lacking, and I think that measures are needed to spread the medical guidelines. The process of discussing additional key questions in the revision plan of the medical guidelines is described, and the expansion plan is described in the text. ## Evaluation of individual recommendations ## Topic No. Review Opinion Reflection of revision All recommendations Each item in the advisory considerations is consistently well structured. However, the titles of benefits and harms, patient values and preferences, obstacles and facilitators, overcoming measures, and resources are a little difficult to come by. Isn't there an easier and more refined title? Each item of the medical guidelines was maintained in principle as it was in accordance with the guidelines for writing the medical guidelines. We asked for opinions on how to express the expert consensus recommendation with E. Since the expert consensus has no level of evidence, it was kept as it is to avoid misunderstandings. When writing the PICO, it would be better to put the position of the last (O) in front of the question mark (? Start of HD 1.1. Prior to the start of hemodialysis, it would be good if there were information on patient education methods for selecting the dialysis method, the period of education, and the preservation of blood vessels. Since it falls outside the key question, we will consider it when revising the recommendations in the future. 1.1. I would like to see the addition of the GFR for the CKD G5. The GFR was additionally indicated. 1.2.1. I hope that it is explained in an easy-to-understand manner as 'It is recommended to prepare a dialysis vessel in advance to avoid central venous catheter insertion before hemodialysis'. According to the opinion, the recommendation was changed to "We recommend that preparation of arteriovenous access prior to hemodialysis initiation to avoid central venous catheter insertion." 1.2. No mention is made of an appropriate time for preparation of AVF (or AVG) prior to dialysis. Ex) GFR 15~20 mL/min, rapid GFR decrease of 10 mL/min/year, etc. According to the opinion, the following content was added to the summary of evidence and references were inserted. "There is no direct evidence data on the timing of the referral for AVF (AVG) formation creation, but the recent KDOQI vascular access guidelines show that CKD G5-ND is characterized by a gradual decrease in renal function. Expert opinions were presented that it is reasonable to evaluate the blood vessels and request surgery when the GFR is 15-20 mL/min/1.73 m 2 in CKD patients. The guidelines also published recommendations at the level of expert opinion that patients with CKD G5-ND should be referred early when their condition is unstable and the GFR is rapidly decreasing (e.g., >10 mL/min/year). This is based on values from wellconducted simulation studies." 1.2. In addition to mortality, the pre-generation of vascular access in CKD G5-ND requires evaluation of other benefits, such as improvement The key question reviewed in this guideline is "In adult CKD G5 patients, does the preparation of vascular of eGFR. access prior to the initiation of dialysis improve postdialysis patient survival, compared to non-preparation of vascular access?", the clinical evidence for other clinical indicators has not been reviewed. It is expected that this will be supplemented in the followup guidelines. Frequency and dose of HD 2.1. If residual renal function remains, it would be nice to have information on the evaluation method for residual renal function and the frequency of dialysis. The evaluation method of residual renal function will be considered in a later revision. 2.1. If the definition of 'residual renal function' is further described, the meaning seems to be clearer. The definition of residual renal function has been additionally described. "Usually, residual renal function is measured by collecting urine. If the daily urine volume is less than 100cc, it is judged that there is no residual renal function." 2.1. Is the definition of no residual renal function considered as GFR=0? What other factors can be used to determine that an appropriate dialysis is being performed when the actual dialysis time and frequency are reduced? The definition of residual renal function has been additionally described. Other elements of appropriate dialysis will be considered in future revisions. 2.1. Various situations that can be seen in clinical practice, recommendations for treatment for 4 hours 2 times a week or 3 hours 3 times a week treatment, etc. Described in patient values and preferences. If the life expectancy is less than 6 months, conservative treatment is necessary and if the patient requests it, dialysis can be tried twice a week or for less than 4 hours per session. 2.2. The recommendation only recommended keeping the target dialysis adequacy at spKt/V 1.4, but it would be good to present the dialysis adequacy that must be met at least like the K/DOQI guideline. If only the target dialysis adequacy is presented, the HIRA's dialysis adequacy evaluation standard will be upgraded from the The minimum requirement of spKt/V is additionally described. The discussion on online HDF health insurance coverage is beyond the scope of the core question, and if future research is published, it will be considered in a later revision. 3.2. We generally agree with recommendations made on the basis of evidence in accordance with scientific methodologies. However, when it comes to hemodiafiltration therapy (online HDF), there are some drawbacks. Above all, it is regrettable that recently published studies were excluded as the basis for drawing conclusions. In particular, it has been found that the effect of improving the survival rate of patients is due to the high-volume HDF rather than the online HDF itself. Based on these findings, the NICE guideline published in 2018 recommended that "in case of initiating dialysis in a hospital, select HDF rather than HD" (see below). However, studies supporting this are excluded from the analysis for evidence in this guideline. In the end, it can be said that the recommendation is based on the evidence at least at the time of the publication of the ESHOL study The Japanese JSDT CPG was supposed to limit it to 5%, and at the same time UFR per hour was also presented in the guidelines. This reflects a longer dialysis time than Korea, and it is difficult to apply the Japanese standards to Korea as the dialysis environment is different from Korea. It will be a standard compiled based on domestic research. I would appreciate it if you could understand it as a standard value suggested for education to patients. 5.1.2. It would be better to have information on how to evaluate excess body fluids or dry weight and how often. We will consider adding it to our future update guidelines. 5.1.2. "2. Patients whose predialysis weight exceeds 4% of their dry weight can be assessed for excess fluid volume and considered for dietary compliance, nutritional status assessment, and dietary education." It would be better to delete the phrase "Evaluation of nutritional status" from the recommendation, as it conflicts with "Evaluation of nutritional status should be considered for patients with low liver weight gain." We appreciate your understanding that this means that patients who gain excessive weight between dialysis should consider diet through nutritional status evaluation, and patients with low weight gain should evaluate whether they have adequate nutritional intake. Thanks for the review. All references to BP in the literature except for ambulatory BP are office BP (dialysis unit BP). 6.1.1. We agree with the recommendations stated in the recommendations as it is very difficult to set an appropriate blood pressure target in hemodialysis patients. However, I would like to discuss the results of the related research in the summary of the evidence. In addition, 5.1. the main background of the recommendation to not exceed 4% in weight gain between dialysis was based on the results of a domestic study, and the study was based on CRC for ESRD data analysis. In 6.1., There were domestic data on optimal blood pressure, and it was a thesis based on CRC for ESRD data analysis. In addition to wishing for more detailed information on this, I would like to suggest that it would be of great help if you could mention a little more about the optimal blood pressure, measurement time, and method, which would be suggested as expert consensus recommendations. The recommendation reflects the lack of RCT evidence, and the analysis of observational studies is at a lower level of evidence, so it is difficult to induce a change in the recommendation. Reflecting the review opinions, the details of domestic observational studies and overseas observational studies have been introduced in more detail as follows. We will do our best to present detailed information such as measurement time and method in the follow-up treatment guidelines. Evaluation and monitoring of HD patients 7.1.1. I do not agree with the reason why the 3-month dialysis adequacy test cycle is recommended. Most global guidelines recommend a one-month cycle, and also in Korea, the current cycle of dialysis adequacy testing in the certification evaluation of the HIRA is set on a monthly basis. In terms of cost, the dialysis adequacy test is a low-cost test, so there is no cost obstacle to monthly testing. Referring to the adequacy evaluation criteria of the Korean Society of Nephrology and the HIRA, 'at least 6 months' is indicated. For euphemism, the word 'at least' was added. 7.1. As for the recommendation of regular examination items and cycles for appropriate dialysis, it would be better to present a very euphemistic recommendation standard because the recommendation grade is expert consensus recommendation and the level of evidence is 'low'. Same as above 7.1.4. Since the KDIGO guidelines recommend HCV testing every 6-12 months, shouldn't "at least" be omitted from the 6-month screening cycle? Would it be appropriate to have an ECG test cycle "at least" every 6 months? In the 2018 KDIGO guideline, 'every six months' is indicated, and 'at least six months' is indicated by referring to the adequacy evaluation criteria of the

Gastrin-releasing peptide receptor The gastrin-releasing peptide receptor (GRPR), now properly known as BB2 is a G protein-coupled receptor whose endogenous ligand is gastrin releasing peptide. In humans it is highly expressed in the pancreas and is also expressed in the stomach, adrenal cortex and brain. Gastrin-releasing peptide (GRP) regulates numerous functions of the gastrointestinal and central nervous systems, including release of gastrointestinal hormones, smooth muscle cell contraction, and epithelial cell proliferation and is a potent mitogen for neoplastic tissues. The effects of GRP are mediated through the gastrin-releasing peptide receptor. This receptor is a glycosylated, 7-transmembrane G-protein coupled receptor that activates the phospholipase C signaling pathway. The receptor is aberrantly expressed in numerous cancers such as those of the lung, colon, and prostate. An individual with autism and multiple exostoses was found to have a balanced translocation between chromosome 8 and a chromosome X breakpoint located within the gastrin-releasing peptide receptor gene. The transcription factor CREB is a regulator of human GRP-R expression in colon cancer.

Segmentation Segmentation in biology refers to the division of some metazoan bodies and plant body plans into a series of semi-repetitive segments, and the question of the benefits and costs of doing so. As such, segmentation is related to the more general concept of modularity. Examples of segmented animals are the annelids and arthropods. However it does not exist in cnidarians. Vertebrae are also inherited in a segmented way, making it easy for those animals to adapt to have the correct number of these spinal cord segments in the vertebral column. This has been extensively studied in mice. Among plants, the horsetails are a clear example of segmentation. Segmentation allows for a high degree of specialization of bodily regions. This regional specialization is seen to some degree in annelids, but is an evolutionary development of the body plan of arthropods. The process of establishing such a segmented body pattern is discussed in morphogenesis. de:Segmentierung (Biologie) sv:Segmentering

Dipyridamole (tablet) # Disclaimer WikiDoc MAKES NO GUARANTEE OF VALIDITY. WikiDoc is not a professional health care provider, nor is it a suitable replacement for a licensed healthcare provider. WikiDoc is intended to be an educational tool, not a tool for any form of healthcare delivery. The educational content on WikiDoc drug pages is based upon the FDA package insert, National Library of Medicine content and practice guidelines / consensus statements. WikiDoc does not promote the administration of any medication or device that is not consistent with its labeling. Please read our full disclaimer here. # Overview Dipyridamole (tablet) is a platelet aggregation inhibitor that is FDA approved for the treatment of postoperative thromboembolic complications of cardiac valve replacement. Common adverse reactions include chest pain, electrocardiogram abnormalities, flushing, rash, abdominal discomfort, dizziness, headache, and dyspnea. # Adult Indications and Dosage ## FDA-Labeled Indications and Dosage (Adult) - Dosing Information - The recommended dose is 75-100 mg four times daily as an adjunct to the usual warfarin therapy. - Please note that aspirin is not to be administered concomitantly with coumarin anticoagulants. ## Off-Label Use and Dosage (Adult) ### Guideline-Supported Use - Developed by: ACCP - Class of Recommendation: Class IIb - Strength of Evidence: Category B - Dosing Information - 200 milligrams (mg) twice daily combined with aspirin 25 mg twice daily ### Non–Guideline-Supported Use - Dosing Information - 75 mg daily and aspirin 330 mg daily for 2 years - Dosing Information - 100 mg 4 times per day before the operation followed by DIPYRIDAMOLE 75 mg 3 times per day plus ASPIRIN 325 mg 3 times per day after the operation # Pediatric Indications and Dosage ## FDA-Labeled Indications and Dosage (Pediatric) - Safety and effectiveness in the pediatric population below the age of 12 years have not been established. ## Off-Label Use and Dosage (Pediatric) ### Guideline-Supported Use There is limited information regarding Off-Label Guideline-Supported Use of Dipyridamole (tablet) in pediatric patients. ### Non–Guideline-Supported Use There is limited information regarding Off-Label Non–Guideline-Supported Use of Dipyridamole (tablet) in pediatric patients. # Contraindications - Hypersensitivity to dipyridamole and any of the other components. # Warnings ### Precautions - General - Coronary Artery Disease: Dipyridamole has a vasodilatory effect and should be used with caution in patients with severe coronary artery disease (e.g., unstable angina or recently sustained myocardial infarction). Chest pain may be aggravated in patients with underlying coronary artery disease who are receiving dipyridamole. - Hepatic Insufficiency: Elevations of hepatic enzymes and hepatic failure have been reported in association with dipyridamole administration. - Hypotension: Dipyridamole should be used with caution in patients with hypotension since it can produce peripheral vasodilation. - Laboratory Tests - Dipyridamole has been associated with elevated hepatic enzymes. # Adverse Reactions ## Clinical Trials Experience - Adverse reactions at therapeutic doses are usually minimal and transient. On long-term use of dipyridamole USP tablets initial side effects usually disappear. The following reactions in Table 1 were reported in two heart valve replacement trials comparing dipyridamole USP tablets and warfarin therapy to either warfarin alone or warfarin and placebo: - Other reactions from uncontrolled studies include diarrhea, vomiting, flushing and pruritus. In addition, angina pectoris has been reported rarely and there have been rare reports of liver dysfunction. On those uncommon occasions when adverse reactions have been persistent or intolerable, they have ceased on withdrawal of the medication. - When dipyridamole USP tablets were administered concomitantly with warfarin, bleeding was no greater in frequency or severity than that observed when warfarin was administered alone. In rare cases, increased bleeding during or after surgery has been observed. In post-marketing reporting experience, there have been rare reports of hypersensitivity reactions (such as rash, urticaria, severe bronchospasm, and angioedema), larynx edema, fatigue, malaise, myalgia, arthritis, nausea, dyspepsia, paresthesia, hepatitis, thrombocytopenia, alopecia, cholelithiasis, hypotension, palpitation, and tachycardia. ## Postmarketing Experience There is limited information regarding Postmarketing Experience of Dipyridamole (tablet) in the drug label. # Drug Interactions - No pharmacokinetic drug-drug interaction studies were conducted with dipyridamole USP Tablets. The following information was obtained from the literature. - Adenosine: Dipyridamole has been reported to increase the plasma levels and cardiovascular effects of adenosine. Adjustment of adenosine dosage may be necessary. - Cholinesterase Inhibitors: Dipyridamole may counteract the anticholinesterase effect of cholinesterase inhibitors, thereby potentially aggravating myasthenia gravis. # Use in Specific Populations ### Pregnancy Pregnancy Category (FDA): - Pregnancy Category B - Reproduction studies have been performed in mice, rabbits and rats at oral dipyridamole doses of up to 125 mg/kg, 40 mg/kg and 1000 mg/kg, respectively (about 1 ½ , 2 and 25 times the maximum recommended daily human oral dose, respectively, on a mg/m2 basis) and have revealed no evidence of harm to the fetus due to dipyridamole. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, dipyridamole USP should be used during pregnancy only if clearly needed. Pregnancy Category (AUS): - Australian Drug Evaluation Committee (ADEC) Pregnancy Category There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Dipyridamole (tablet) in women who are pregnant. ### Labor and Delivery There is no FDA guidance on use of Dipyridamole (tablet) during labor and delivery. ### Nursing Mothers - As dipyridamole is excreted in human milk, caution should be exercised when dipyridamole USP tablets are administered to a nursing woman. ### Pediatric Use - Safety and effectiveness in the pediatric population below the age of 12 years have not been established. ### Geriatic Use There is no FDA guidance on the use of Dipyridamole (tablet) with respect to geriatric patients. ### Gender There is no FDA guidance on the use of Dipyridamole (tablet) with respect to specific gender populations. ### Race There is no FDA guidance on the use of Dipyridamole (tablet) with respect to specific racial populations. ### Renal Impairment There is no FDA guidance on the use of Dipyridamole (tablet) in patients with renal impairment. ### Hepatic Impairment There is no FDA guidance on the use of Dipyridamole (tablet) in patients with hepatic impairment. ### Females of Reproductive Potential and Males There is no FDA guidance on the use of Dipyridamole (tablet) in women of reproductive potentials and males. ### Immunocompromised Patients There is no FDA guidance one the use of Dipyridamole (tablet) in patients who are immunocompromised. # Administration and Monitoring ### Administration - Oral - Intravenous ### Monitoring There is limited information regarding Monitoring of Dipyridamole (tablet) in the drug label. # IV Compatibility There is limited information regarding IV Compatibility of Dipyridamole (tablet) in the drug label. # Overdosage ## Acute Overdose ### Signs and Symptoms - In case of real or suspected overdose, seek medical attention or contact a Poison Control Center immediately. Careful medical management is essential. Based upon the known hemodynamic effects of dipyridamole, symptoms such as warm feeling, flushes, sweating, restlessness, feeling of weakness and dizziness may occur. A drop in blood pressure and tachycardia might also be observed. ### Management - Symptomatic treatment is recommended, possibly including a vasopressor drug. Gastric lavage should be considered. Administration of xanthine derivatives (e.g., aminophylline) may reverse the hemodynamic effects of dipyridamole overdose. Since dipyridamole is highly protein bound, dialysis is not likely to be of benefit. ## Chronic Overdose There is limited information regarding Chronic Overdose of Dipyridamole (tablet) in the drug label. # Pharmacology ## Mechanism of Action - Dipyridamole inhibits the uptake of adenosine into platelets, endothelial cells and erythrocytes in vitro and in vivo; the inhibition occurs in a dose-dependent manner at therapeutic concentrations (0.5-1.9 µg/mL). This inhibition results in an increase in local concentrations of adenosine which acts on the platelet A2-receptor thereby stimulating platelet adenylate cyclase and increasing platelet cyclic-3',5'-adenosine monophosphate (cAMP) levels. Via this mechanism, platelet aggregation is inhibited in response to various stimuli such as platelet activating factor (PAF), collagen and adenosine diphosphate (ADP). - Dipyridamole inhibits phosphodiesterase (PDE) in various tissues. While the inhibition of cAMP-PDE is weak, therapeutic levels of dipyridamole inhibit cyclic-3',5'-guanosine monophosphate-PDE (cGMP-PDE), thereby augmenting the increase in cGMP produced by EDRF (endothelium-derived relaxing factor, now identified as nitric oxide). - In dogs intraduodenal doses of dipyridamole of 0.5 to 4.0 mg/kg produced dose-related decreases in systemic and coronary vascular resistance leading to decreases in systemic blood pressure and increases in coronary blood flow. Onset of action was in about 24 minutes and effects persisted for about 3 hours. - Similar effects were observed following IV dipyridamole USP in doses ranging from 0.025 to 2.0 mg/kg. - In man the same qualitative hemodynamic effects have been observed. However, acute intravenous administration of dipyridamole USP may worsen regional myocardial perfusion distal to partial occlusion of coronary arteries. ## Structure - Dipyridamole USP is a platelet inhibitor chemically described as 2,2',2",2"'-pyrimidine-2,6-diyl)dinitrilo]-tetraethanol. It has the following structural formula: - Dipyridamole is an odorless yellow crystalline powder, having a bitter taste. It is soluble in dilute acids, methanol and chloroform, and practically insoluble in water. - Dipyridamole USP tablets for oral administration contain: - Active Ingredient TABLETS 25 mg, 50 mg, and 75 mg: dipyridamole USP 25 mg, 50 mg and 75 mg, respectively. - Inactive Ingredients TABLETS 25 mg, 50 mg, and 75 mg: corn starch, hydroxypropyl methylcellulose, lactose monohydrate, magnesium stearate, polyethylene glycol, povidone, and titanium dioxide. ## Pharmacodynamics - It is believed that platelet reactivity and interaction with prosthetic cardiac valve surfaces, resulting in abnormally shortened platelet survival time, is a significant factor in thromboembolic complications occurring in connection with prosthetic heart valve replacement. - Dipyridamole USP tablets have been found to lengthen abnormally shortened platelet survival time in a dose-dependent manner. - In three randomized controlled clinical trials involving 854 patients who had undergone surgical placement of a prosthetic heart valve, dipyridamole USP tablets, in combination with warfarin, decreased the incidence of postoperative thromboembolic events by 62 to 91 % compared to warfarin treatment alone. The incidence of thromboembolic events in patients receiving the combination of dipyridamole USP tablets and warfarin ranged from 1.2 to 1.8%. In three additional studies involving 392 patients taking dipyridamole USP tablets and coumarin-like anticoagulants, the incidence of thromboembolic events ranged from 2.3 to 6.9%. - In these trials, the coumarin anticoagulant was begun between 24 hours and 4 days postoperatively, and the dipyridamole USP tablets were begun between 24 hours and 10 days postoperatively. The length of follow-up in these trials varied from 1 to 2 years. - Dipyridamole USP tablets do not influence prothrombin time or activity measurements when administered with warfarin. ## Pharmacokinetics - Following an oral dose of dipyridamole USP tablets, the average time to peak concentration is about 75 minutes. The decline in plasma concentration following a dose of Dipyridamole USP tablets fits a two-compartment model. The alpha half-life (the initial decline following peak concentration) is approximately 40 minutes. The beta half-life (the terminal decline in plasma concentration) is approximately 10 hours. Dipyridamole is highly bound to plasma proteins. It is metabolized in the liver where it is conjugated as a glucuronide and excreted with the bile. ## Nonclinical Toxicology - Carcinogenesis, Mutagenesis, Impairment of Fertility - In studies in which dipyridamole was administered in the feed to mice (up to 111 weeks in males and females) and rats (up to 128 weeks in males and up to 142 weeks in females), there was no evidence of drug-related carcinogenesis. The highest dose administered in these studies (75 mg/kg/day) was, on a mg/m2 basis, about equivalent to the maximum recommended daily human oral dose (MRHD) in mice and about twice the MRHD in rats. Mutagenicity tests of dipyridamole with bacterial and mammalian cell systems were negative. There was no evidence of impaired fertility when dipyridamole was administered to male and female rats at oral doses up to 500 mg/kg/day (about 12 times the MRHD on a mg/m2 basis). A significant reduction in number of corpora lutea with consequent reduction in implantations and live fetuses was, however, observed at 1250 mg/kg (more than 30 times the MRHD on a mg/m2 basis). # Clinical Studies There is limited information regarding Clinical Studies of Dipyridamole (tablet) in the drug label. # How Supplied - Dipyridamole tablets, USP, are available as round, white, film-coated tablets of 25 mg, 50 mg, and 75 mg coded 81/SL, 82/SL, and 83/SL, respectively. - They are available in unit dose box of 100 tablets as indicated below: - STORE AT 25°C (77°F); EXCURSIONS PERMITTED TO 15-30°C (59°-86°F) . KEEP OUT OF REACH OF CHILDREN. ## Storage There is limited information regarding Dipyridamole (tablet) Storage in the drug label. # Images ## Drug Images ## Package and Label Display Panel # Patient Counseling Information There is limited information regarding Patient Counseling Information of Dipyridamole (tablet) in the drug label. # Precautions with Alcohol - Alcohol-Dipyridamole (tablet) interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication. # Brand Names - Persantine® # Look-Alike Drug Names - N/A # Drug Shortage Status # Price

Dichromacy Dichromacy in humans is a moderately severe color vision defect in which one of the three basic color mechanisms is absent or not functioning. It is hereditary and sex-linked, predominantly affecting males. Dichromacy occurs when one of the cone pigments is missing and color is reduced to two dimensions. Organisms with dichromacy are called dichromats. Dichromats can match any color they see with a mixture of no more than two pure spectral lights. By comparison, a trichromat requires three pure spectral lights to match all colors in their visual spectrum. There are various kinds of color blindness. Protanopia is a severe form of red-green color-blindness, where there is impairment in perception of very long wavelengths, such as reds. To these sufferers, reds are perceived as beige and greens tend to look like reds. Protanomaly is a less severe version. Deuteranopia consists of an impairment in perceiving medium wavelengths, such as greens. Deuteranomaly is a less severe form of deuteranopia. Those living with deuteranomaly cannot see reds and greens like normal people, however they can still distinguish them in most cases. A more rare form of color blindness is tritanopia, where there exists an inability to perceive short wavelengths, such as blues. Sufferers have trouble distinguishing between yellow and blue and tend to mistake greens for blues and yellows for reds. # Dichromacy in mammals It is currently believed that most mammals are dichromats. The straightforward exceptions are primates closely related to humans, which are usually trichromats, and sea mammals (both pinnipeds and cetaceans) which are monochromats. New World Monkeys are a partial exception: in most species, males are dichromats, and about 60% of females are trichromats, but the owl monkeys are monochromats, and both sexes of howler monkeys are trichromats. Recent research (e.g. Arrese et al, 2005) suggests that trichromacy may be widespread among marsupials. # Notes - ↑ Cassin, B. and Solomon, S. Dictionary of Eye Terminology. Gainsville, Florida: Triad Publishing Company, 1990. - ↑ "Guidelines: Color Blindness." Tiresias.org. Accessed September 29, 2006.