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This topic was written by an individual patient diagnosed with Parkinson disease (PD). It is intended to offer clinicians insight into the experience of a single individual from that individual's point of view. This description of a particular patient's experience is not intended to be comprehensive

ClosePatient education: Multiple myeloma treatment (Beyond the Basics)Patient education: Multiple myeloma treatment (Beyond the Basics)Author:S Vincent Rajkumar, MD Section Editor:Robert A Kyle, MD Deputy Editor:Rebecca F Connor, MDLiterature review current through: Nov 2022. | This topic last updated: Dec 12, 2022.Please read the Disclaimer at the end of this page.MULTIPLE MYELOMA OVERVIEW — Multiple myeloma (MM) is a cancer of plasma cells in the bone marrow. Plasma cells are a type of white blood cell that make antibodies to help fight infections. In multiple myeloma, the plasma cells are abnormal and grow out of control. The uncontrolled growth of these cells can lead to bone pain and fractures and an inadequate number of normal, healthy blood cells (white blood cells and red blood cells). These cancer cells also produce large amounts of abnormal proteins, which can cause kidney damage.The treatment of multiple myeloma is complex because of rapid advances in stem cell transplantation, medications, and better supportive care, which have led to improved survival over the past 30 years. The main options for treatment include non-chemotherapy drugs that target the cancer cells, standard chemotherapy drugs, corticosteroids, and stem cell (bone marrow) transplant.Each option needs to be weighed carefully. Because current therapy rarely cures the disease completely, most people go through many treatment regimens during the course of their illness. Stem cell transplantation may not be an option for many people because of advanced age, presence of other serious illness, or other physical limitations. (See 'Stem cell transplantation' below.)This topic review discusses the treatment of multiple myeloma. The symptoms, diagnosis, and staging of multiple myeloma are discussed separately. (See"Patient education: Multiple myeloma symptoms, diagnosis, and staging (Beyond the Basics)".)More detailed information about multiple myeloma, written for healthcare providers, is available by subscription. (See 'Professional level information' below.)CANCER CARE DURING THE COVID-19 PANDEMIC — COVID-19 stands for "coronavirus disease 2019." It is an infection caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and has since spread throughout the world. Getting vaccinated lowers the risk of severe illness; experts recommend COVID-19 vaccination for anyone with cancer or a history of cancer.In some cases, if you live in an area with a lot of cases of COVID-19, your doctor might suggest rescheduling or delaying medical appointments. But this decision must be balanced against the importance of getting care to screen for, monitor, and treat cancer. Your doctor can talk to you about whether to make any changes to your appointment schedule. They can also advise you on what to do if you test positive or were exposed to the virus.TREATMENT ISSUESWhen should treatment start? — Multiple myeloma can remain stable for prolonged periods of time. Some people with early myeloma who have no symptoms (often called smoldering myeloma) may be advised to wait months to years before considering treatment. In contrast, people who are considered at higher risk for disease progression may be advised to start treatment right away. Your doctor will talk with you about your options and help you determine when to start treatment.People with a related condition, called monoclonal gammopathy of undetermined significance (MGUS), do not require treatment, although long-term follow-up is needed; a small percentage of people with MGUS will eventually develop full-blown multiple myeloma.Once symptoms of multiple myeloma develop, treatment with one or more of the options discussed below is recommended for almost all people.Types of treatment — There are six main types of treatment for multiple myeloma. The options will depend on whether a person has been newly diagnosed or has relapsed disease, as well as their age, overall health, and preferences:●Newer drugs – There are several types of non-chemotherapy drugs that have emerged in the past decade as important options for the treatment of multiple myeloma. These drugs may be options both for people who have been newly diagnosed and at the time of relapse. In most cases, these drugs are used in combination with dexamethasone (a steroid medication), with each other, or with standard chemotherapy agents (see below). Most of these fall into a few general categories:•Immunomodulatory drugs – These drugs use the body's immune system to fight myeloma cells. They include lenalidomide (brand name: Revlimid), pomalidomide (brand name: Pomalyst), and thalidomide (brand name: Thalomid). They all have the potential to cause severe birth defects and are absolutely unsafe (contraindicated) for pregnant women. When given with steroids they also increase the chance of developing blood clots; aspirin or another blood thinner is usually recommended to reduce this risk. They are all available as pills.•Proteasome inhibitors – The proteasome breaks down proteins in cells and is especially active in multiple myeloma cells since they have a lot of excess protein being made. Proteasome inhibitors block this action so that the proteins build up and the cells die. They include bortezomib (brand name: Velcade), carfilzomib (brand name: Kyprolis), and ixazomib (brand name: Ninlaro). Usually, bortezomib is given under the skin (subcutaneously), carfilzomib is given by vein (IV), and ixazomib is taken as a pill. They can all cause nerve damage and increase the risk for certain infections. While bortezomib can be given by IV, this results in a higher rate of nerve damage and so is not preferred.  •Monoclonal antibodies – Monoclonal antibodies are purified proteins that target specific groups of cells. They treat multiple myeloma by attacking specific substances (antigens) on the surface of the cancer cells. There are several monoclonal antibodies available for the treatment of multiple myeloma. They include daratumumab (brand name: Darzalex), elotuzumab (brand name: Empliciti), and isatuximab (brand name: Sarclisa). All can be given by IV (intravenously, meaning into a vein). Daratumumab may be given under the skin (subcutaneously).•Nuclear export inhibitor – The nuclear export machinery in a cell is responsible for transferring proteins out of the nucleus. Selinexor (brand name: Xpovio) is a pill that blocks this action so that the proteins build up and the cells die. Selinexor can be used for the treatment of multiply relapsed multiple myeloma in selected cases. More data are needed to determine the safety and efficacy of selinexor.   ●Chemotherapy – Chemotherapy refers to the use of medicines to stop or slow the growth and longevity of cancer cells. In most people, chemotherapy partially controls multiple myeloma; in some cases, chemotherapy may lead to complete remission. Chemotherapy drugs used in multiple myeloma include melphalan (brand name: Alkeran), cyclophosphamide (brand name: Cytoxan), doxorubicin (brand name: Adriamycin), and liposomal doxorubicin (brand name: Doxil).●Corticosteroids – Corticosteroids include dexamethasone and prednisone.●Stem cell transplantation – Stem cell (bone marrow) transplantation can be done using one's own stem cells (autologous transplantation) or stem cells from a close relative or matched unrelated donor (allogeneic transplantation). In multiple myeloma, most transplants performed are of the autologous kind. Such transplants, although not curative, have been shown to prolong life in some people. They can be done as part of the initial therapy in people who have been newly diagnosed, or at the time of relapse. In some cases, more than one transplant may be recommended to adequately control the disease. Autologous transplants for multiple myeloma are very safe in centers with experience in the procedure. (See 'Stem cell transplantation' below.)●"CAR-T" therapy – CAR-T therapy is a newer form of immunotherapy that may be effective in relapsed or refractory multiple myeloma (see 'Treatment of relapsed or refractory multiple myeloma' below). CAR-T therapy involves genetically modifying specific cells from a person’s immune system; this enables the cells to directly target the cancer cells. Is stem cell transplantation an option? — Because of the risk of toxic and even fatal complications related to stem cell transplantation, not everyone with multiple myeloma is a candidate for stem cell transplantation. Eligibility varies across countries and across institutions. In most European countries, stem cell transplantation for multiple myeloma is offered primarily to people less than 65 years of age. In the United States, a strict age limit is not used. Instead, decisions are made on a case-by-case basis based on a person's age, health, and other factors, and vary across institutions.The decision regarding transplant eligibility should be made by the person and their physician after discussing the potential risks, benefits, and the needs and wishes of the individual.INITIAL TREATMENT OF MULTIPLE MYELOMA — The initial choice of therapy depends upon the person's health, age, ability to undergo stem cell transplantation in the future, and the aggressiveness of the cancer (whether the disease is considered high risk or standard risk). More detail about the different risk categories is available separately. (See"Patient education: Multiple myeloma symptoms, diagnosis, and staging (Beyond the Basics)", section on 'Risk stratification'.)Most people will be treated with a three-drug regimen that includes a proteasome inhibitor such as bortezomib (brand name: Velcade), an immunomodulatory drug such as lenalidomide (brand name: Revlimid), and a corticosteroid such as dexamethasone. One popular regimen is bortezomib, lenalidomide, dexamethasone ("VRd"). Some people will be treated with a regimen that includes the monoclonal antibody daratumumab (brand name: Darzalex).High-risk multiple myeloma treatment options — The best treatment option for people with high-risk multiple myeloma is not clear. Most experts recommend enrolling in a clinical trial (see 'Clinical trials' below). For people who are not willing or able to participate in a clinical trial, incorporation of a proteasome inhibitor such as bortezomib (brand name: Velcade) is recommended. ●People who are candidates for stem cell transplantation are usually treated with a three-drug regimen such as bortezomib, lenalidomide, dexamethasone ("VRd"). After this initial therapy (usually about four months), most clinicians prefer to proceed directly with stem cell transplantation rather than to delay this procedure until the time of disease progression. ●People who are not candidates for stem cell transplantation (because of underlying medical problems, age, or poor health) are also treated with a three-drug regimen, such as "VRd." Following initial combination therapy, the proteasome inhibitor is usually continued for an extended time. The goal of therapy in high-risk multiple myeloma is to achieve and maintain a complete response as much as possible. A complete response means that there is no monoclonal (M) protein in the serum or urine, no large collections of plasma cells outside of the bone marrow, and that the number of plasma cells in the bone marrow is not elevated. Standard-risk multiple myeloma treatment options — The treatment of standard-risk multiple myeloma depends partially on whether the person is a candidate for transplant:●People who are candidates for stem cell transplantation are usually treated with a three-drug regimen such as bortezomib, lenalidomide, dexamethasone ("VRd"). After this initial therapy (usually about four months), stem cells are collected and the person can either proceed directly to transplantation or postpone transplantation until the time of relapse. Those who postpone transplantation receive additional cycles of VRd then continue lenalidomide plus dexamethasone ("Rd") until progression.●People who are not candidates for stem cell transplantation (because of underlying medical problems, age, or poor health) are usually treated with a three-drug regimen such as VRd or daratumumab, lenalidomide, dexamethasone ("DRd"). Some three-drug regimens have been shown to improve survival when compared with two-drug regimens, but they are also associated with more side effects. As such, the two-drug regimen Rd is an acceptable option for people who are older or in poor health. With any of these regimens, if treatment is effective, lenalidomide may be continued by itself (and the other drugs stopped) until disease progression, unless there are significant side effects.STEM CELL TRANSPLANTATION — Stem cell (bone marrow) transplantation is a treatment option for some people with multiple myeloma. There are three general types of transplantation, based on the source of the stem cells:●Autologous transplantation – The stem cells are obtained from your own blood or bone marrow. This is the type of transplantation that is most commonly recommended for treating multiple myeloma.●Allogeneic transplantation – The stem cells or bone marrow are obtained from a donor with a tissue type matching yours. This type of transplantation carries very high risks and is not recommended for most people with multiple myeloma.●Syngeneic transplantation – The stem cells or bone marrow are obtained from an identical twin. This is the optimal form of transplantation, although few people with multiple myeloma have an identical twin who can serve as a donor.Transplantation, when successful, leads to a remission and prolongs survival; rarely, allogeneic transplantation cures multiple myeloma. However, transplantation has several limitations. The high-dose chemotherapy given before transplantation usually fails to kill all of the plasma cells, allowing the condition to relapse after transplantation. Such treatment also increases your risk of serious infections and bleeding, which can be fatal. (See"Patient education: Hematopoietic cell transplantation (bone marrow transplantation) (Beyond the Basics)".)Autologous stem cell transplantation — Autologous stem cell transplantation refers to transplantation with your own stem cells. During this procedure, stem cells are collected and frozen for later use. High-dose chemotherapy is then given to kill as many plasma cells as possible, and the stem cells are thawed and returned to your body. Stem cells can be obtained from the blood or the bone marrow; in this case, obtaining them from the blood is preferred, because blood stem cells take up residence in tissues more quickly and are less likely to be contaminated with cancerous plasma cells.At present, autologous stem cell transplantation is appropriate for up to 50 percent of people with multiple myeloma. Autologous stem cell transplantation is not recommended for people with smoldering multiple myeloma (people with multiple myeloma who do not have any symptoms).Procedure — After initial therapy with a regimen such as bortezomib, lenalidomide, dexamethasone ("VRd") for three to four months, you are given granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) to stimulate the production of stem cells and encourage their release into your bloodstream. If there are not sufficient numbers of stem cells in your blood after G-CSF or GM-CSF, another agent, called Plerixafor, may be added to help with collection. Stem cells are then collected from the blood, frozen, and stored for later use. After you recover from the stem cell collection, you are given high-dose chemotherapy with melphalan (or similar drugs) to kill as many of the cancer cells as possible; then the previously collected stem cells are thawed and returned to your body. In about one-half of people, this procedure can be done on an outpatient basis (ie, without a hospital stay).Alternatively, the high-dose chemotherapy and transplant may be saved until the time of relapse. With this option, after stem cell collection, you may be given additional cycles of the treatment regimen you received before collection. Later, at the time of relapse, high doses of melphalan (or similar drugs) are given, and the previously collected stem cells are returned to your body. This is called delayed transplantation.Single versus double autologous transplantation — Double autologous transplantation (sometimes called "tandem transplant") involves two consecutive autologous transplantations done within 6 to 12 months of each other. Double transplant does not appear to offer additional benefit to most people with multiple myeloma. Although the evidence for this approach is weak, it is sometimes offered to people with high-risk multiple myeloma since this group has worse outcomes with standard therapy. Role of age and stage of multiple myeloma — Because autologous stem cell transplantation has serious side effects, it is generally not recommended for people over the age of 70. However, this procedure may be an option for some people over age 70 who are otherwise healthy. The likelihood of a good response to transplantation is somewhat lower for older adults than for younger adults, although the effects of age on survival after transplantation are not completely clear.Importance of prior treatment — Autologous transplantation is not recommended for people who have already received prolonged chemotherapy with alkylating drugs (such as melphalan). This is because it is often difficult to collect a sufficient number of healthy stem cells for transplantation. Other treatments commonly used for multiple myeloma, including bortezomib, lenalidomide, and thalidomide, are safe to take before stem cell transplantation.Effectiveness — About 1 percent of people die from complications related to autologous transplantation. However, compared with chemotherapy alone, autologous stem cell transplantation is more likely to produce a response and is associated with longer survival compared to chemotherapy alone. Allogeneic stem cell transplantation — Allogeneic transplantation requires stem cells from a donor with a matching tissue type. Unfortunately, approximately 25 percent of people who undergo allogeneic transplantation die from transplant-related complications, such as infection, lung inflammation, and graft-versus-host disease (a condition in which the donor's transplanted stem cells attack your body). Primarily because of this as well as the lack of clear benefit, allogeneic transplantation is seldom used for the treatment of multiple myeloma.Syngeneic transplantation — A syngeneic transplantation refers to a transplantation between identical twins. For people who have an identical twin, this treatment option is more effective than either autologous or allogeneic transplantation.Remission after transplantation — The strict definition of remission requires that there are no signs or symptoms of multiple myeloma and that highly sensitive tests cannot detect any abnormal plasma cells. This type of remission occurs in about 50 to 60 percent of people after autologous transplantation.TREATMENT OF MULTIPLE MYELOMA COMPLICATIONS — Multiple myeloma can cause a variety of complications, some of which are life-threatening.High blood calcium levels — High blood calcium levels develop as bone is lost. People with multiple myeloma should remain as active as possible because physical activity helps counter bone loss.The treatment of high blood calcium levels usually includes the use of intravenous (IV) fluids and prednisone. If this treatment is not effective, treatment with drugs that act against bone loss, such as zoledronic acid (sample brand name: Zometa) or pamidronate (sample brand name: Aredia), a class of drugs called bisphosphonates, may be recommended.Impaired kidney function — Kidney function becomes impaired in about one-half of people with multiple myeloma. The treatment of impaired kidney function is aimed at the specific underlying cause.Treatment usually includes IV fluids; it may also include dialysis (a type of blood filtration used for kidney failure), prednisone (a steroid that can indirectly lower blood calcium levels), and allopurinol, a drug that can lower blood levels of uric acid, a waste product from the increased turnover of the cancer cells, which can damage the kidneys.It's important to stay well hydrated and drink enough fluid to produce three liters of urine daily if you have an excess of light chain proteins in the urine (called "Bence Jones proteinuria"). You should also avoid using any nonsteroidal anti-inflammatory drugs (NSAIDs, such as Advil, Motrin, or Aleve), because these drugs might worsen kidney function.If impaired kidney function has progressed to kidney failure, the treatment options include hemodialysis or peritoneal dialysis. Advanced degrees of kidney failure are usually not reversible even if the multiple myeloma later responds to treatment. (See"Patient education: Dialysis or kidney transplantation — which is right for me? (Beyond the Basics)".)Infection — Bacterial infections, often indicated by the presence of fever, require prompt treatment with antibiotics. Daily use of the antibiotic trimethoprim-sulfamethoxazole (sample brand names: Bactrim, Septra) can help prevent infections. If you get frequent infections, your doctor may have you take penicillin daily; rarely, people need periodic IV infusions of gamma globulin (normal antibodies collected from plasma donors).Anyone with multiple myeloma should receive the pneumococcal vaccine (which reduces the likelihood of pneumonia) and the influenza vaccine (which reduces the likelihood of flu). (See"Patient education: Pneumonia prevention in adults (Beyond the Basics)" and"Patient education: Influenza prevention (Beyond the Basics)".)Bone pain and fractures — Physical activity, with careful avoidance of injury, can promote bone strength in people with multiple myeloma. The bone pain associated with multiple myeloma can be controlled with chemotherapy, analgesics (pain relieving drugs), radiation, and bone strengthening drugs such as zoledronic acid (sample brand name: Zometa) or pamidronate (sample brand name: Aredia). These bone strengthening drugs are commonly referred to as "bisphosphonates." Denosumab is a different kind of bone strengthening drug that may be used to help prevent bone damage in certain people with multiple myeloma. In people who have early signs of bone erosion, these bone strengthening drugs both reduce bone pain and reduce the risk of fractures. Therefore, bone strengthening drugs are recommended for all people who have early signs of bone erosions on X-rays. Bisphosphonates are usually given by IV infusion every four weeks; this treatment is continued for approximately two years. Bisphosphonates may affect kidney function, which should be monitored on a regular basis to avoid this complication.Dental procedures, such as root canal or extraction of teeth, may be associated with infection or destruction of the jaw (osteonecrosis) in people treated with IV bisphosphonates. Accordingly, people should avoid such procedures, if possible, while taking these agents; any needed dental procedures should be performed before these agents are started.Spinal cord compression — Spinal cord compression is a medical emergency that requires prompt treatment to prevent irreversible damage, such as paralysis. Initial treatment may consist of radiation and dexamethasone (a steroid) to reduce swelling around the spinal cord; if these measures are not effective, surgery is needed to relieve pressure on the spinal cord. People should call their doctor immediately if they have severe back pain; weakness, numbness, or tingling in the legs; or new problems with bladder or bowel control (incontinence). Anemia — Anemia (low red blood cell count) that is causing symptoms may require blood transfusions or treatment with erythropoietin (EPO), a substance that stimulates the production of red blood cells. Erythropoietin is usually given by injection one to three times per week. This treatment effectively increases levels of hemoglobin (the protein in red blood cells that helps carry oxygen to the tissues), improves symptoms, and reduces the need for blood transfusion.Thickening of the blood — Thickening of the blood (called hyperviscosity syndrome) rarely occurs in people with multiple myeloma. This complication is treated with plasmapheresis, a type of blood filtration that removes the excess monoclonal proteins that cause the thickening.TREATMENT OF RELAPSED OR REFRACTORY MULTIPLE MYELOMA — Almost all people with multiple myeloma eventually relapse, and a modest percentage are resistant to initial treatment.Multiple myeloma that responds poorly or not at all to initial therapy is called refractory multiple myeloma. This condition can occur during the administration of initial chemotherapy or during chemotherapy given after a relapse. Refractory multiple myeloma is more difficult to treat. Relapsed or refractory myeloma is usually treated with combinations of drugs from two or three general classes. The main classes of drugs used to treated relapsed or refractory myeloma are:●Immunomodulatory drugs (lenalidomide, pomalidomide, thalidomide)●Proteasome inhibitors (bortezomib, carfilzomib, ixazomib)●Steroids (dexamethasone)●Antibodies that target myeloma cells (daratumumab, elotuzumab, isatuximab)●Nuclear export inhibitor (selinexor)●Chemotherapy drugs (melphalan, cyclophosphamide)These can be used in various combinations depending on the person's situation; all of these drugs can have side effects. With each relapse, a new regimen may provide meaningful clinical benefit. Thus, the various regimens available are considered sequentially with each relapse. Most people will receive each available drug at some point during the disease course.Relapses occurring more than one year after completing treatment can also be treated by repeating the initial chemotherapy regimen. Most people will again have a response to chemotherapy when it is given a second time, although the response is usually not as good as the original response.If a person does not respond to an initial round of chemotherapy, they may still respond to autologous stem cell transplantation. A transplant may be considered in this case if the person is eligible. Some people may also be candidates for "CAR-T" therapy. CLINICAL TRIALS — Progress in treating multiple myeloma requires that better treatments be identified through clinical trials. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies; clinical trials are conducted all over the world. Ask for more information about clinical trials, or read about clinical trials at:●https://www.cancer.gov/about-cancer/treatment/clinical-trials●https://clinicaltrials.gov/Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (https://www.cancer.net/research-and-advocacy/clinical-trials/welcome-pre-act).WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Multiple myeloma (The Basics) Patient education: Monoclonal gammopathy of undetermined significance (The Basics) Patient education: Neutropenia and fever in people being treated for cancer (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Multiple myeloma symptoms, diagnosis, and staging (Beyond the Basics) Patient education: Vaccines for adults (Beyond the Basics) Patient education: Hematopoietic cell transplantation (bone marrow transplantation) (Beyond the Basics) Patient education: Dialysis or kidney transplantation — which is right for me? (Beyond the Basics) Patient education: Influenza symptoms and treatment (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Multiple myeloma: Use of allogeneic hematopoietic cell transplantation Multiple myeloma: Use of autologous hematopoietic cell transplantation Multiple myeloma: Clinical features, laboratory manifestations, and diagnosis Multiple myeloma: Overview of management Diagnosis and management of solitary extramedullary plasmacytoma Diagnosis and management of solitary plasmacytoma of bone Clinical presentation, laboratory manifestations, and diagnosis of immunoglobulin light chain (AL) amyloidosis Multiple myeloma: Evaluating response to treatment Multiple myeloma: Initial treatment Multiple myeloma: Management in resource-limited settings Diagnosis of monoclonal gammopathy of undetermined significance Multiple myeloma: Pathobiology Monoclonal immunoglobulin deposition disease Kidney disease in multiple myeloma and other monoclonal gammopathies: Treatment and prognosis Kidney disease in multiple myeloma and other monoclonal gammopathies: Etiology and evaluation Multiple myeloma: The use of osteoclast inhibitors Multiple myeloma: Treatment of first or second relapseThe following organizations also provide reliable health information.●National Library of Medicine      (medlineplus.gov/healthtopics.html)●National Cancer Institute      (www.cancer.gov)●American Cancer Society      (www.cancer.org)●The Leukemia & Lymphoma Society      (www.lls.org)●National Marrow Donor Program      (bethematch.org)●The American Society of Clinical Oncology      (www.cancer.net/cancer-types/multiple-myeloma)This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 690 Version 38.0

ClosePatient education: Splenectomy (The Basics)Patient education: Splenectomy (The Basics) Please read the Disclaimer at the end of this page.What is a splenectomy? — Splenectomy is surgery in which your spleen is removed. The spleen is an organ in the upper left part of the belly (figure 1). It is part of the body's infection-fighting system, or "immune system." It makes blood cells that help you fight infection. The spleen also filters the blood. It removes things that could cause problems, including damaged blood cells and bacteria.You might have a splenectomy to treat problems such as:●Damage to the spleen – If your spleen gets injured, it can cause serious internal bleeding. This most often happens because a person is hit in the belly area, for example, in a car accident or while playing a contact sport. If the spleen gets badly injured, it might have to be removed.●Certain disorders that affect blood cells – Examples include:•Immune thrombocytopenia or "ITP," a disorder in which a person's own immune system destroys their platelets (a type of blood cell that helps blood clot)•Autoimmune hemolytic anemia, a disorder in which a person's own immune system destroys their red blood cells•Beta thalassemia major (a condition some people are born with), in which the body does not make enough red blood cellsUsually, doctors try other treatments for these problems before they consider doing a splenectomy.●A spleen that is much larger than usual – Doctors call this "splenomegaly." Certain cancers or non-cancerous tumors or cysts can sometimes cause this. If it leads to symptoms, such as pain, you might need to have your spleen removed.How do I prepare for a splenectomy? — If possible, you will need to get vaccines before your surgery. The spleen helps protect the body from infections, so you will be more likely to get some kinds of serious infections after your spleen is removed. Vaccines help prevent this. They work by teaching your body how to fight the germs that cause infections. The vaccines you'll need include those that protect against certain infections, called pneumococcus, meningococcus, and Haemophilus influenzae type b (or "Hib"). You should also get the usual vaccines that doctors recommend for everyone, such as the flu vaccine. The vaccines you get will depend on which ones you've already had and when you got them. Ideally, you will get your vaccines at least 2 weeks before your surgery. This might not be possible if your spleen needs to be removed right away.Your medical team will tell how long before the surgery you should stop eating and drinking. They will also tell you if you need to stop taking any of your medicines or start any new medicines.What happens during a splenectomy? — Before the surgery starts, you will get medicines (through a thin tube that goes into a vein, called an "IV") to make you sleep. You will not be awake for the surgery.There are 2 different ways a splenectomy can be done:●Open surgery – During open surgery, the doctor will make a cut, often in the middle of your belly, take out your spleen, and close the cut with special staples or stitches. If your spleen is very large or has been badly injured, you will most likely need open surgery.●Laparoscopic surgery – During laparoscopic surgery, the doctor will make a few very small cuts in your belly and remove the spleen through one of these cuts. This is done by putting long, thin tools through the cuts. One of the tools (called a "laparoscope") has a camera on the end, which sends pictures to a video screen. The doctor can look at the screen to see inside your body.What happens after surgery? — It depends on which type of surgery you had. If you had open surgery, you will need to stay in the hospital for a few days. If you had laparoscopic surgery, you might be able to go home the same day or the next day.If you didn't get all your vaccines before your surgery, you will get them afterwards. You might also get antibiotics to help your body prevent infections, since you no longer have a spleen to do this. You will get instructions about getting help quickly if you have a fever. What problems can happen after a splenectomy? — Most people can go back to their daily lives once they recover. But it is important to be aware of certain problems that can happen. These include:●Infection – The spleen helps protect the body from infections. After your spleen has been removed, your body has a harder time fighting off certain infections. Also, without a spleen, even minor infections are more likely to turn into a serious problem called "sepsis." Sepsis is a serious illness that happens when an infection travels through the whole body. If some serious infections are not treated right away, you can die.Getting all the vaccines your doctor recommends helps prevent many infections. But it's still possible to get an infection if you've had your vaccines. Your medical team will work with you to plan for what to do if you notice any signs of infection.Because any infection could cause serious illness or even death, you will probably get antibiotics to keep at home. This way, you can start taking them at the first sign that you might have an infection. Signs of infection can include:•Fever (temperature higher than 100.4°F or 38°C)•Chills or shivering•Sore throat•Cough•Earache•Stuffy nose or sinus pain•Headache•Feeling sleepy or confused•Nausea, vomiting, or diarrhea•Feeling dizzy, or like you might pass out•A fast heartbeat•Small purple-red dots on the skin, or unexplained bruisesYour doctor will talk to you about what to do if you have any of these symptoms. If you have symptoms that could mean a serious infection, like fever or chills, you will need to go straight to the nearest emergency department. Do this even if you do not feel very sick. In the emergency department, they can check you for infection and decide if you need more or different treatment. For less serious symptoms, your doctor might tell you to call their office for advice on what to do next.Depending on your age and the reason your spleen was removed, your doctor might also tell you to take an antibiotic every day. This will help prevent infection.●Blood clots – The risk of blood clots also goes up after splenectomy. If a blood clot happens, it is most often in the legs (called a "deep vein thrombosis" or "DVT") or the lungs (called a "pulmonary embolism" or "PE"). Symptoms of DVT can include swelling, pain, or warmth and redness in the leg. Symptoms of PE can include trouble breathing, chest pain when you breathe in, or coughing.There are things you can do to help lower your risk of blood clots. On a long car trip or airplane flight, get up and walk around or move your legs frequently, every hour or so if possible. If you have surgery, make sure to let the doctors know that your spleen was removed so they know about this risk. Some hormones can also increase the risk of blood clots. If you plan to take a hormonal treatment, such as birth control pills, let the doctor or nurse prescribing it know that you have had a splenectomy.It is important to carry an alert card, or wear a medical bracelet, so others know you do not have a spleen. This will help doctors and nurses give you the best care if there is ever an emergency. More on this topic Patient education: What you should know about vaccines (The Basics) Patient education: Vaccines for adults (The Basics) Patient education: Vaccines for children age 7 to 18 years (The Basics) Patient education: Sepsis in adults (The Basics) Patient education: Immune thrombocytopenia (ITP) (The Basics) Patient education: Autoimmune hemolytic anemia (The Basics) Patient education: Beta thalassemia (The Basics) Patient education: Fasting before surgery (The Basics) Patient education: Questions to ask if you are having surgery or a procedure (The Basics) Patient education: Preventing infection in people with impaired spleen function (Beyond the Basics) Patient education: Vaccines for adults (Beyond the Basics) Patient education: Why does my child need vaccines? (Beyond the Basics) Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics)This topic retrieved from UpToDate on: Jan 02, 2023.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 113967 Version 3.0

This topic was written by an individual patient diagnosed with amyotrophic lateral sclerosis (ALS). It is intended to offer clinicians insight into the experience of a single individual from that individual's point of view. This description of a particular patient's experience is not intended to be

ClosePatient education: COVID-19 vaccines (The Basics)Patient education: COVID-19 vaccines (The Basics) Please read the Disclaimer at the end of this page.View in ItalianView in Brazilian PortugueseView in GermanView in JapaneseView in FrenchView in SpanishView video in SpanishWhat is COVID-19? — COVID-19 stands for "coronavirus disease 2019." It is caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and quickly spread around the world.More information about COVID-19 is available in a separate article. (See"Patient education: COVID-19 overview (The Basics)".)What are vaccines? — Vaccines are a way to prevent certain serious or deadly infections. When a person gets a vaccine, this is called "vaccination" or "immunization."To understand how vaccines work, it helps to understand what happens when you get an infection. Infections are caused by germs, such as bacteria or viruses. When a germ gets into your body, it multiplies (makes copies of itself) and attacks, which can make you sick. Your "immune system," or infection-fighting system, recognizes that the germ should not be there. In response, it starts to make proteins called "antibodies" to fight the germ.There are different types of vaccines. They all work by causing your body to make antibodies, like it would if you had an infection. This prepares your immune system to fight off germs if you come into contact with them in the future. Most vaccines are given as shots, although some come in other forms. Some require more than 1 dose to fully protect you from infection.Thanks to vaccines, the number of people who die from infections has gone way down.What are boosters? — A booster is a dose given some time (months or years) after a person first gets vaccinated. This is because the protection you get from a vaccine can decrease over time. Experts recommend boosters for some vaccines to "remind" the immune system how to protect against a specific infection.Why should I get the COVID-19 vaccine? — Getting vaccinated lowers your chances of getting infected. If you do get infected, you will be much less likely to get severely ill if you have been vaccinated.In addition to protecting yourself, getting vaccinated will also help protect other people, including those who are at higher risk of getting very sick or dying. It also protects people who can't get a vaccine, like young babies. Even if you are not worried about getting very sick yourself, you could still spread the virus to others, even without realizing it.How do COVID-19 vaccines work? — Multiple COVID-19 vaccines have been developed. They work in slightly different ways.In the US, there are several COVID-19 vaccines available. All of these have been found to work very well in preventing serious illness and death from COVID-19. They include:●mRNA vaccines – There are 2 available "mRNA vaccines." mRNA refers to genetic material from the virus that causes COVID-19. This genetic material is used in the vaccine. It gives the body instructions to make a specific piece of protein that is normally found on the virus. In response, the immune system then makes antibodies that can recognize and attack the virus in the future.The mRNA vaccines for COVID-19 are made by the Pfizer and Moderna companies. They come in 2 forms:•The "monovalent" form protects against the original version of the virus.•The "bivalent" form is similar to the original vaccines, but also protects against the Omicron variant of the virus. The Omicron variant spreads more easily than earlier versions of the virus, so the bivalent vaccine was created to give people extra protection.●Recombinant protein vaccine – This type of vaccine contains a version of a specific protein that is found in the virus. It is combined with another ingredient to help trigger the immune system. The immune system then makes antibodies that can recognize and attack the virus in the future. Other vaccines, such as those used to prevent hepatitis B and shingles, work in a similar way.The recombinant protein vaccine for COVID-19 is made by the Novavax company. It is available to adults age 18 years and older.●Vector vaccine – The "vector vaccine" for COVID-19 contains a weakened version of a different virus, called an adenovirus. This virus does not make you sick, but it acts as a "vector," or a way to deliver instructions to all of the cells in your body. These instructions tell your body to make the protein that is normally found on the virus that causes COVID-19. Then, your immune system makes antibodies that can recognize and attack the virus in the future.The vector vaccine for COVID-19 is made by the Johnson & Johnson company. It is available to adults age 18 years and older.Different COVID-19 vaccines are available in other countries.Which vaccine should I choose? — In the US, experts recommend getting an mRNA vaccine (Pfizer or Moderna) or a recombinant protein vaccine (Novavax). This is based on what they know about how well the vaccines work and the risk of rare side effects.The vector vaccine (Johnson & Johnson) is still a good choice for people who cannot or choose not to get one of the other vaccines. Any of the available vaccines is better than none.If you have a choice of vaccine and are not sure which one to get, your doctor or nurse can help you decide.How many vaccines do I need? — This depends on your age, your health, and which vaccine you get first. (When you are vaccinated for the first time, this is called the "initial series.") The information below is for people in the US.For adults and children age 12 years and older:●Initial series – All of the vaccines used for the first vaccination are "monovalent." They protect against the original version of the virus. The options are:•Pfizer – 2 doses, 3 to 8 weeks apart•Moderna – 2 doses, 4 to 8 weeks apart•Novavax – 2 doses, 3 to 8 weeks apart•Johnson & Johnson – 1 doseFor people with a weak immune system, experts recommend getting an extra dose as part of the initial series for the Pfizer, Moderna, or Johnson & Johnson vaccines. An mRNA (Pfizer or Moderna) vaccine is used for this. If you have a health condition or take certain medicines that might weaken your immune system, your doctor or nurse can tell if you if you should get an extra dose.●Booster – Experts recommend a booster dose if it has been at least 2 months since the last vaccine. A bivalent mRNA vaccine (either Pfizer or Moderna) is used for the booster, even for people who got a different vaccine originally. The bivalent vaccine is similar to the original vaccines, but also protects against the Omicron variant of the virus. This helps give extra protection when used as a booster.For children 5 to 11 years:●Initial series – Either mRNA vaccine can be used. The doses and timing depend on which vaccine you choose:•Moderna – 2 doses, 4 to 8 weeks apart•Pfizer – 2 doses, 3 to 8 weeks apart●Booster – Children in this age group should also get a booster dose with a bivalent vaccine. The booster should be at least 2 months after the initial series. Children 5 years and older can get the Pfizer bivalent booster, while children 6 years and older can get either Pfizer or Moderna.For children 6 months to 4 years:●Initial series – Either mRNA vaccine can be used. Babies and younger children get smaller doses than older children and adults. The doses and timing depend on which vaccine you choose:•Moderna – 2 doses, 4 to 8 weeks apart•Pfizer – 3 doses. The first 2 doses are given 3 to 8 weeks apart. The third dose should be with the bivalent vaccine. It should be given at least 8 weeks after the second dose.●Booster – For children age 6 months to 4 years, available boosters depend on which vaccine was used for the initial series:•Moderna – Children who had the Moderna vaccine should get the Moderna bivalent booster. This should happen at least 2 months after the initial series.•Pfizer – For children who had all 3 doses of the Pfizer vaccine, there is not yet an available booster.If you are not sure how many vaccine doses you need, or which vaccine you should get for a booster, ask your doctor or nurse.Can people who have been vaccinated still spread the virus? — Vaccines work very well to prevent serious illness and death, but they do not prevent 100 percent of infections. So it is still possible for a person who has been vaccinated to get COVID-19. Then, that person can spread the virus to others.Even though you could still get COVID-19 after being vaccinated, remember that you are much less likely to get severely ill or die, especially if you have also had all recommended boosters.Does the COVID-19 vaccine cause side effects? — It can. Temporary side effects are common, and can include:●Pain where you got the shot (upper arm)●Fever●Feeling very tired●HeadacheIf you get a vaccine that comes in 2 doses, side effects are more common after the second dose. They can also happen after a booster dose. While side effects can be annoying, they should not last longer than a day or 2. Some people do not have bothersome side effects at all. If you do have side effects, this does not mean that you are sick, just that your immune system is responding to the vaccine.Vaccines also sometimes cause more serious side effects, such as severe allergic reactions. But this is rare. If you have had a reaction to the vaccine or its ingredients in the past, you might need to talk to an allergy expert. They can help you figure out if you should get the COVID-19 vaccine. People who do get the vaccine might be monitored for 15 to 30 minutes to make sure that they do not have an allergic reaction.Other serious side effects are rare, but have happened:●A very small number of people have developed inflammation of the heart muscle after receiving an mRNA (Pfizer or Moderna) or recombinant protein (Novavax) vaccine. This is called "myocarditis." Most cases have been in teen or young adult males. This side effect is extremely rare, and is usually mild and treatable if it does happen.●There has been a very small number of reports of people getting blood clots after they had the single-dose (Johnson & Johnson) vaccine. Experts have confirmed that the risk of blood clots is extremely rare, and much smaller than the risk of getting very sick with COVID-19.●A very small number of people have had a problem called Guillain-Barré syndrome after getting the Johnson & Johnson vaccine. When this happens, it causes severe muscle weakness. Experts are studying this to better understand whether it is directly related to the vaccine.For most people, the benefits of getting vaccinated against COVID-19 are much greater than the risks. If you had a COVID-19 vaccine within the last 3 weeks, let your doctor or nurse know right away if you have any concerning symptoms. These include severe and persistent headache, blurry vision, weakness on 1 or both sides of the body, back pain, trouble thinking clearly, severe belly pain, trouble breathing, leg swelling, tiny red spots on the skin, bruising easily, or chest pain.Can I get COVID-19 from the vaccine? — No. You cannot get COVID-19 from the vaccine.Some people worry that the vaccine actually contains the virus that causes COVID-19. The vector vaccine that is available in the US does contain virus, but it is a different virus. It is also created in a lab in a weakened form so that it will not make a healthy person sick. mRNA and recombinant protein vaccines do not contain virus at all.How do I know the vaccine is safe? — COVID-19 vaccines were developed very quickly. Because of this, some people wonder if they are safe. The answer is yes, the new vaccines had to go through the same process as other vaccines to test them for safety. This involved running "clinical trials" with lots of people who volunteered to try the vaccine. The volunteers included people of all ages and ethnicities. During these trials, researchers studied how well the vaccines work and how many people had side effects. The results were reviewed by doctors and other experts who do not work for the drug companies that made the vaccines. These experts agreed that the vaccines are safe and effective enough to be given to the public.Since COVID-19 vaccines became available, billions of doses have been given. So we have a lot of information about their safety.Do I still need the vaccine if I have had COVID-19? — Yes. Experts recommend getting vaccinated even if you had COVID-19 in the past. People who get COVID-19 do develop antibodies that likely provide some protection against getting infected again. But it is not known exactly how long antibodies last after a person recovers. Also, the antibodies that you get from a vaccine might give you stronger protection against new virus variants.Will I have to pay for my vaccine? — No. In the US, COVID-19 vaccines are free, even if you do not have insurance. You might be asked for your insurance information, if you have it, but this does not mean that there will be a cost to you.What if I am pregnant? — Experts have been studying the safety of the COVID-19 vaccine during pregnancy. Based on what they have learned, they recommend that pregnant people get the vaccine. Pregnant people might be more likely to get seriously ill if they get COVID-19, so getting vaccinated is especially important.What can I do after I am vaccinated? — When you are up to date on vaccination, you are much less likely to get seriously ill if you are infected. "Up to date" means that you have gotten a vaccine plus any recommended boosters.Some activities, like traveling to certain areas or attending certain events, require people to show proof of vaccination. Getting the vaccine will make it easier to get back to doing the things that you enjoyed before the pandemic.If you are up to date on vaccination, you do not need to self-quarantine if you come into contact with someone who has COVID-19. But experts still recommend wearing a mask around other people for 10 days, as well as getting tested.In many places, COVID-19 is still spreading quickly, and cases are continuing to increase. This is mostly due to virus variants that spread more easily. In the US, you can check the level of spread where you live at this website: https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Most people who are in intensive care units (called "ICUs") or dying from COVID-19 are unvaccinated.What if I have other questions? — It's normal to have a lot of questions or to be nervous about the idea of getting a vaccine that you haven't had before. Your doctor or nurse can help answer your questions or direct you to sources that you can trust.Be careful with information you find on the internet or social media. In some cases, it can be hard to tell what is true and what is false. This is especially dangerous if people share health information that is not based on science or evidence.You can find more information about COVID-19 vaccines through the US Centers for Disease Control and Prevention (CDC): www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html.More on this topic Patient education: COVID-19 overview (The Basics) Patient education: COVID-19 and children (The Basics) Patient education: COVID-19 and pregnancy (The Basics) Patient education: Recovery after COVID-19 (The Basics) Patient education: What you should know about vaccines (The Basics)This topic retrieved from UpToDate on: Jan 01, 2023.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 130329 Version 52.0

CloseOnline resources regarding vaccines and vaccine safetyOnline resources regarding vaccines and vaccine safety Organization/URL Description Professional organizations/societiesAmerican Academy of Family Physicians www.familydoctor.org (search on "vaccines") Patient information on childhood vaccines (what they are and why children need them).American Academy of Pediatrics Childhood Immunization Support Program www.aap.org/immunizationCompilation of resources for families and providers, including Q&A for families and information on vaccine-preventable illnesses, vaccine ingredients, vaccine safety, and the immunization schedule. Provides information for clinicians on how to communicate with parents about immunization, including responses for common reasons for parental refusal to vaccinate.Canadian Pediatric Society caringforkids.cps.ca/ Provides a parent's guide to immunization information on the internet.Infectious Diseases Society of America (IDSA) www.idsociety.org Provides lists of resources, IDSA position statements, and policy statements. Academic institutionsCenter for Vaccine Awareness and Research, Texas Children's Hospital www.texaschildrens.org/departments/vaccine-awareness-and-research-cvar Provides valuable information regarding vaccination. Includes links to resources.Institute for Vaccine Safety, Johns Hopkins University www.vaccinesafety.edu Provides an independent assessment of vaccines and vaccine safety to guide decision makers and educate physicians, the public, and the media about the safety of vaccines.The Nemours Foundation KidsHealth kidshealth.org/teen/your_body/health_basics/immunizations.html Vaccine information targeted to adolescents.The Vaccine Education Center at the Children's Hospital of Philadelphia www.vaccine.chop.edu Provides reliable information about vaccines to parents and health care professionals. Public health/advocacy groupsVaccinate Your Family www.vaccinateyourfamily.org Seeks to ensure that every baby, child, teen, adult, and pregnant women is protected against vaccine-preventable diseases.Immunization Action Coalition (IAC) www.immunize.org (search on "immunization safety") The IAC creates and distributes educational materials and facilitates communication about the safety, efficacy, and use of vaccines.National Academy of Medicine (formerly Institute of Medicine, IOM) National Academies Press www.nap.edu An independent organization of medical and health professionals that works to address critical issues in health, medicine, and related policy. Provides access to the IOM immunization safety reviews (eg, vaccines and autism, multiple immunizations and immune dysfunction, etc).National Alliance for Hispanic Health www.hispanichealth.org Advocacy and research forum focused on Hispanic health and well-being. Provides links to information about vaccine-preventable disease and other health issues.National Foundation for Infectious Diseases www.nfid.org Nonprofit organization dedicated to educating the public and health care professionals about the causes, treatment, and prevention of infectious diseases.National Meningitis Association www.nmaus.org Nonprofit organization founded by parents whose children have died or have permanent disability from meningococcal disease. Includes links to educational materials, including a video featuring the stories of meningococcal disease survivors and families affected by the disease.World Health Organization www.who.int/topics/vaccines/en/ Provides links to information about immunization.Vaccine Information You Need www.vaccineinformation.org Provides information about vaccines and the diseases they prevent, including a video library. Parent/family groupsFamilies Fighting Flu www.familiesfightingflu.org Nonprofit corporation dedicated to educating people about the severity of influenza and the importance of vaccinating children against the flu.Meningitis Angels www.meningitis-angels.org Provides education about bacterial meningitis and prevention of bacterial meningitis. Government agenciesUnited States Centers for Disease Control and Prevention www.cdc.gov/vaccines Provides information and links about vaccines and vaccine-preventable diseases.US Food and Drug Administration www.fda.gov/vaccines-blood-biologics/vaccines Provides information about vaccines licensed in the United States and information about vaccine safety, including consumer updates.National Institute of Allergy and Infectious Diseases https://www.niaid.nih.gov/Provides information about understanding vaccines, community immunity, and vaccine research. Books Publisher Immunizations and Infectious Diseases: An Informed Parent's Guide by Fisher MC American Academy of Pediatrics, Elk Grove Village, IL 2005. Vaccinating Your Child: Questions and Answers for the Concerned Parent by Humiston SG, Good C Peachtree Publishers, Atlanta 2000. Do Vaccines Cause That? A guide for Evaluating Vaccine Safety Concerns by Myers MG, Pineda D Immunizations for Public Health 2008. Vaccines: What Every Parent Should Know by Offit PA, Bell LM IDG Books, New York 1999. Autism's False Prophets: Bad science, risky medicine, and the search for a cure by Offit PA Columbia University Press, New York 2008.Adapted from:American Academy of Pediatrics. Sources of information about immunization. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021 p.3.Pickering LK, Baker CJ, Freed GL, et al. Immunization programs for infants, children, adolescents, and adults: Clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49:817.Graphic 82687 Version 23.0

An overview of peer violence and prevention of violence is reviewed here. Violence in the media, intimate partner violence, and child abuse are discussed separately.OVERVIEW — Violence is a major cause of death and disability for American children. Violence or witnessing violence has both

ClosePatient education: Chronic lymphocytic leukemia (CLL) in adults (Beyond the Basics)Patient education: Chronic lymphocytic leukemia (CLL) in adults (Beyond the Basics)Authors:Kanti R Rai, MDStephan Stilgenbauer, MD Section Editor:Richard A Larson, MD Deputy Editor:Rebecca F Connor, MDLiterature review current through: Nov 2022. | This topic last updated: Aug 09, 2022.Please read the Disclaimer at the end of this page.CHRONIC LYMPHOCYTIC LEUKEMIA OVERVIEW — Chronic lymphocytic leukemia (CLL) is a chronic (long-term, slowly developing) leukemia. Leukemia is a type of cancer that affects the blood and bone marrow. Bone marrow is the spongy, red tissue that fills the large bones. All of the blood cells (red blood cells, white blood cells, and platelets) are derived from stem cells in the bone marrow. CLL is one of a group of diseases that affects a type of white blood cell called a "lymphocyte." Normally, lymphocytes help your body fight infection; however, in CLL, the body produces abnormal lymphocytes that cannot do this effectively. This leads to problems over time.Small lymphocytic lymphoma (SLL) is a variant of CLL. If you have been diagnosed with SLL, the information in this article applies to you, too.In CLL, high numbers of abnormal lymphocytes are found in the blood, lymph nodes, spleen, and bone marrow. In SLL, these same cells are commonly found in the lymph nodes. The abnormal cells cannot fight infection as normal lymphocytes do, but instead build up in lymph nodes and other areas, such as the liver and spleen. The accumulation of ineffective lymphocytes can interfere with the production of other blood cells, such as red blood cells and platelets, as well as the immune system.Unlike some other types of leukemia, CLL usually progresses slowly. In many cases, it causes few, if any, problems in its early stages. Some people can live with CLL for decades. Some people, however, do not live as long. Many times, it is diagnosed incidentally, by blood tests that are performed during a routine physical exam. In other cases, a person is diagnosed after noticing symptoms and seeking medical care. (See 'Symptoms of chronic lymphocytic leukemia' below.)Your doctors will work with you to determine the best course of treatment based on your specific situation. Unlike many other types of cancer, people with early stage CLL do not benefit from early, aggressive treatment, but instead do better with careful long-term monitoring of the disease.More detailed information about CLL, written for health care providers, is available by subscription. (See 'Professional level information' below.)CANCER CARE DURING THE COVID-19 PANDEMIC — COVID-19 stands for "coronavirus disease 2019." It is an infection caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and has since spread throughout the world. Getting vaccinated lowers the risk of severe illness; experts recommend COVID-19 vaccination for anyone with cancer or a history of cancer.In some cases, if you live in an area with a lot of cases of COVID-19, your doctor might suggest rescheduling or delaying medical appointments. But this decision must be balanced against the importance of getting care to screen for, monitor, and treat cancer. Your doctor can talk to you about whether to make any changes to your appointment schedule. They can also advise you on what to do if you test positive or were exposed to the virus.SYMPTOMS OF CHRONIC LYMPHOCYTIC LEUKEMIA — As mentioned, most people do not have symptoms when they are diagnosed with CLL, and the disease is discovered after a routine blood test shows abnormalities. However, some people do experience symptoms before diagnosis. The most common symptom is enlarged lymph nodes, most often in the neck, armpit, or groin areas (figure 1).Less commonly, people with CLL notice other symptoms, including fatigue, unintentional weight loss, chronic fever (without other signs of infection), or night sweats.The decision to start treatment is impacted by whether or not there are symptoms. (See 'Who should get treatment?' below.)STAGING OF CHRONIC LYMPHOCYTIC LEUKEMIA — The progression of CLL can vary considerably from one person to another. Some people become sick within a short time of diagnosis; others live comfortably for years without problems. Doctors use different information to help them determine which people are most likely to get sick, and therefore most likely to benefit from treatment."Staging" is the approach doctors use to determine how advanced a person's cancer is. It involves assigning a category based on the physical examination and blood test results.Staging systems — There are two systems used for staging CLL.The Rai system — The Rai system for staging CLL is based on an analysis of how the body is affected by the abnormal lymphocytes. The original system had five stages, which were subsequently organized into three "risk groups." The higher numbers indicate a more advanced stage of disease:●Low risk (Stage 0) – Increased numbers of abnormal lymphocytes are found in the blood or bone marrow, lymph nodes/organs are not swollen, and production of red blood cells and platelets is not significantly affected.●Intermediate risk (Stage I and II combined) – Increased abnormal lymphocytes with enlarged lymph nodes, liver, and/or spleen. The production of red blood cells and platelets is not significantly affected.●High risk (Stage III and IV combined) – Increased abnormal lymphocytes with a low red blood cell count (anemia) and/or a low platelet count, with or without an enlarged spleen, liver, or lymph nodes.The Binet system — This approach considers the five possible sites where lymphocytes can collect (lymph nodes in the neck, armpit, and groin, and lymphocyte-containing channels in the spleen and liver) (figure 1), and also whether blood tests show anemia or low platelet counts. The Binet system categorizes a person's cancer into one of three stages:●Stage A – Fewer than three involved sites; red blood cells and platelets are not significantly affected●Stage B – Three or more involved sites; red blood cells and platelets are not significantly affected●Stage C – Presence of anemia and/or low platelet counts regardless of the number of involved sitesWhat the CLL stages mean — Staging CLL helps your doctors determine how likely it is that you will develop serious problems related to your illness. In either system, the lower numbers or letters indicate a lower level of risk, while the higher numbers or letters indicate a higher level. Staging your cancer is a critical part of determining whether you should start treatment right away or delay treatment while undergoing regular monitoring.Who should get treatment? — As noted above, treatment is not always required for CLL. Some studies have shown that people without symptoms of CLL are no more likely to die than a person of the same sex around the same age who does not have CLL. (See 'Management of asymptomatic, early stage chronic lymphocytic leukemia' below.)However, there are certain groups of people in whom doctors generally recommend treatment. This includes people with:●Symptoms of anemia and/or low platelets (in particular, high-risk Rai stages [III or IV] or Binet stage C)●Disease-related symptoms such as severe fatigue, night sweats, unintentional weight loss, painful swelling of lymph nodes or spleen, or unexplained fever (see 'Symptoms of chronic lymphocytic leukemia' above)●Extremely enlarged lymph nodes or spleen●Complications from involvement of other organs (such as the skin, kidney, lung, or spine)●Autoimmune hemolytic anemia (a condition in which the immune system destroys healthy red blood cells) or immune thrombocytopenia (a condition in which the immune system destroys healthy platelets) that does not respond to specific treatment for these complications●Cancer that is progressing quickly, as demonstrated by rapidly increasing white cells in the blood and/or rapidly enlarging lymph nodes, spleen, or liver●Recurring infectionsMANAGEMENT OF ASYMPTOMATIC, EARLY STAGE CHRONIC LYMPHOCYTIC LEUKEMIA — If you do not have symptoms of CLL, your doctor will likely not start treatment right away. However, you will need to be monitored regularly with blood tests and a physical examination. This usually involves seeing your doctor at least once every three months for the first year after diagnosis. Depending on the results of these tests, your doctor may be able to estimate how aggressive your disease will be in the future.TREATMENT OF ADVANCED OR SYMPTOMATIC CHRONIC LYMPHOCYTIC LEUKEMIA — If you are a candidate for treatment, your doctor will talk to you about your options. The approach to treatment will depend on how advanced your disease is, as well as your symptoms, age, and overall health. The available treatment options may also depend on whether your cancer has certain characteristics (ie, mutations) found on genetic testing. For example, CLL with 17p deletion (in which part of chromosome 17 is missing) or TP53 mutation (when a gene called TP53 is abnormal) is usually more aggressive. CLL with mutations in the IGHV genes tends to be less aggressive.Targeted therapy — In most cases, initial treatment of advanced or symptomatic CLL involves "targeted therapy" with medications that affect (target) specific types of cancer cells. Options include acalabrutinib (brand name: Calquence), ibrutinib (brand name: Imbruvica), and venetoclax (brand name: Venclexta); all of these are taken orally (in pill form) once a day. Depending on which approach you and your doctor decide on, you may need to take an immunotherapy medication in addition to targeted therapy. (See 'Immunotherapy' below.)Each of these drugs has different side effects, which your doctor will talk with you about. Your doctor might also avoid prescribing targeted therapy drugs if you have certain other medical conditions.Chemoimmunotherapy — Doctors may recommend chemoimmunotherapy as the initial treatment for some people, including those whose cancer has certain genetic characteristics. This approach involves a combination of chemotherapy and immunotherapy, discussed below.There are different chemoimmunotherapy regimens (combinations of drugs) used to treat CLL. Your doctor will talk with you about whether you are a candidate for chemoimmunotherapy, and if so, which regimen is most appropriate.Chemotherapy — Chemotherapy drugs stop or slow the growth of cancer cells. Drugs used to treat CLL include fludarabine (brand name: Fludara), cyclophosphamide (brand name: Cytoxan), bendamustine (brand name: Treanda), chlorambucil (brand name: Leukeran), and pentostatin (brand name: Nipent). One or more of these drugs may be used along with immunotherapy in the treatment of CLL. (See 'Immunotherapy' below.) Chemotherapy targets growing cells, interfering with their ability to divide or multiply. Because most of an adult's normal cells are not actively growing, they are not as affected by chemotherapy as the cancer cells. However, the cells in the bone marrow (where the blood cells are produced), the hair follicles, and the lining of the gastrointestinal (GI) tract are all growing; the side effects of chemotherapy drugs (such as hair loss or nausea) are related to effects on these and other normal tissues.Some chemotherapy drugs are taken by mouth, while others are given intravenously (through an IV). Chemotherapy regimens used for the treatment of CLL are usually given for a defined amount of time, which allows for a treatment-free period or "break" until the disease progresses. Immunotherapy — Immunotherapy drugs use antibodies that target a specific group of cells (usually cancer cells). They include rituximab (brand name: Rituxan), obinutuzumab (brand name: Gazyva), and ofatumumab (brand name: Arzerra). All of these are antibodies, given intravenously (through an IV), that target the type of lymphocytes (B lymphocytes) that are abnormal in people with CLL. When used for the initial treatment of CLL, immunotherapy drugs are typically given in combination with one or more chemotherapy drugs. (See 'Chemotherapy' above.)Choice of regimen — There is no single "best" standard treatment regimen for symptomatic CLL. Your doctor will work with you to recommend an approach based on your situation (including your age, general health, and whether you have other medical problems) as well as your preferences. He or she will also factor in your cancer's stage and whether it has certain genetic characteristics that influence which treatment options are available. Because this area is still evolving and different regimens are being studied, all people with CLL are advised to enroll in a clinical trial, if possible. (See 'Clinical trials' below.)While some people who undergo treatment for CLL do achieve "complete remission" (meaning blood counts have returned to normal and there are no signs or symptoms of disease), the reality is that nearly everyone will experience a relapse eventually. (See 'Treatment of relapsed or refractory chronic lymphocytic leukemia' below.) TREATMENT OF RELAPSED OR REFRACTORY CHRONIC LYMPHOCYTIC LEUKEMIA — Most people with CLL respond to initial treatment, but then develop "relapsed" disease at some point after treatment ends. A small number of people do not respond to initial treatment at all; this is called "refractory" disease. Several different approaches can be used to treat relapsed or refractory CLL, depending on your situation, which regimen(s) you have had before, and how effective they were.Targeted therapy — As discussed above, most people are initially treated with targeted therapy (see 'Targeted therapy' above). If you are taking one of these medications and your disease progresses (relapses), your doctor might switch you to a different regimen. Options may include the drugs discussed above (acalabrutinib, ibrutinib, and venetoclax) as well as other targeted therapies such as idelalisib (brand name: Zydelig) and duvelisib (brand name: Copiktra), some of which are given in combination with an immunotherapy drug.Although less commonly used, chemoimmunotherapy is an option for some patients with relapsed or refractory CLL. (See 'Chemoimmunotherapy' above.) Young people with very aggressive disease may be candidates for stem cell transplantation. (See 'Stem cell transplantation' below.)Refractory disease or very early relapse — If a person's disease is refractory (unresponsive to treatment) or relapses sooner than six months after treatment ends, the options are limited. Depending on your individual situation, you can discuss the following options with your doctor: ●Participation in a clinical trial – New drugs are in development for people with CLL that target cellular processes that have not been targeted before (see 'Clinical trials' below)●Stem cell transplantation (also called bone marrow transplantation or hematopoietic stem cell transplantation) (see 'Stem cell transplantation' below)●Treatment to reduce CLL-related symptoms and complications (see 'Treatment of chronic lymphocytic leukemia complications' below)Stem cell transplantation — Stem cell transplantation (also called bone marrow transplantation or hematopoietic cell transplantation) is being more seriously considered as a therapy for people with high-risk CLL (eg, disease that is refractory to therapy or has certain genetic characteristics), especially for people under the age of 65 years. People who choose stem cell transplantation are usually given other therapies to control the CLL while preparing for the transplant with the goal of achieving a complete or partial remission.Prior to a stem cell transplant, "conditioning" therapy is given with chemotherapy or radiation. This kills cancer cells but also destroys normal cells developing in the bone marrow. After conditioning, the person needs to have a healthy supply of very young blood cells, called stem cells, reintroduced or transplanted. The transplanted cells then re-establish the blood cell production process in the bone marrow. (See"Patient education: Hematopoietic cell transplantation (bone marrow transplantation) (Beyond the Basics)".)The type of stem cell transplant used for people with CLL is called an "allogeneic" transplant. In allogeneic transplant, the person is given stem cells from a donor, ideally a brother or sister with a similar genetic make-up. If the person doesn't have a "matched" sibling, an unrelated person with a partially matched genetic makeup may be used.Today, most CLL transplants are done as a reduced intensity transplant (called a "mini"-transplant or non-myeloablative transplant) from a relative or a matched unrelated donor, and may achieve long-term control of their CLL.TREATMENT OF CHRONIC LYMPHOCYTIC LEUKEMIA COMPLICATIONS — The major complications of CLL are caused by the low blood counts and immune system problems that arise either from the disease itself or the treatment.Infection — Infection is one of the most serious risks associated with CLL treatment. Although less common, serious infections can also occur in people who have not yet received any treatment for their CLL. The most common infections affect the upper respiratory tract (eg, the sinuses and bronchi). Smokers are especially vulnerable, so if you smoke, it's very important to try to quit as soon as possible. Your doctor or nurse can help you if you are having trouble quitting. (See"Patient education: Quitting smoking (Beyond the Basics)".) To help prevent infections, it's very important to make sure your vaccinations are up-to-date, including getting a yearly influenza (flu) vaccine and a pneumococcal (pneumonia) vaccine every five years. However, "live" vaccines (such as the chicken pox vaccine) should be avoided, particularly if you are undergoing CLL treatment. Talk to your doctor about which vaccines you need and whether any should be avoided. It's also important that your family members get the yearly flu vaccine to help protect you as well as themselves. If you develop a respiratory tract infection, you may need treatment with antibiotics. Infection may be related to low levels of infection-fighting proteins called immunoglobulins. For this reason, people who have repeated infections and low immunoglobulin levels may be treated with intravenous immune globulin (also called IVIG or IGIV) to increase their immunoglobulin levels and lower the chance of infection. IVIG treatment can decrease the incidence of minor infections, but may not decrease the incidence of serious infections. Certain treatments used in CLL make you more susceptible to infections. In some cases, medications that promote the growth of new blood cells may be given to boost the white cell count and decrease the infection risk. People receiving certain drugs may need to take preventive antibiotics and may need to have special testing to monitor for infections.Anemia — Anemia, or low red blood cell counts, is common in CLL. Red blood cells are needed to carry oxygen to all the cells in the body. People with anemia may experience fatigue, weakness, and chest pain. A blood transfusion may be needed to treat severe anemia in certain cases.Low platelet counts — Platelets are important components of the blood's clotting mechanism. Without adequate numbers of platelets, internal and external bleeding can occur. People with CLL and low platelet counts may see their counts improve with treatment of the CLL. In some cases, platelet transfusions are needed. In some patients with CLL, the immune system destroys healthy platelets (this is called immune thrombocytopenia). In this situation, platelet counts may improve after the use of steroids or other treatments that suppress the body's immune response.Psychological aspects — People with CLL must live with the uncertainty associated with having a chronic serious illness. It can be frightening to learn that you have leukemia, and it might be scary or confusing if your doctor recommends not getting treatment right away. It helps to develop a strong relationship with your doctors and nurses and to feel comfortable speaking openly and honestly and asking questions. Some people and their families also find that counseling or participation in support groups can help them to cope with the strong emotions that can accompany a cancer diagnosis.CLINICAL TRIALS — Many patients with leukemia will be asked about enrolling in a clinical (research) trial. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask your doctor for more information, or read about clinical trials at:●www.cancer.gov/about-cancer/treatment/clinical-trials●https://clinicaltrials.gov/Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (www.cancer.net/research-and-advocacy/clinical-trials/welcome-pre-act).WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Leukemia in adults (The Basics) Patient education: Chronic lymphocytic leukemia (CLL) (The Basics) Patient education: Neutropenia and fever in people being treated for cancer (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Hematopoietic cell transplantation (bone marrow transplantation) (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Classification of hematopoietic neoplasms Evaluating response to treatment of chronic lymphocytic leukemia Hematopoietic cell transplantation in chronic lymphocytic leukemia Overview of the treatment of chronic lymphocytic leukemia Risk of infections in patients with chronic lymphocytic leukemia Prevention of infections in patients with chronic lymphocytic leukemia Overview of the complications of chronic lymphocytic leukemia Clinical features and diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma Pathobiology of chronic lymphocytic leukemia Staging and prognosis of chronic lymphocytic leukemia Treatment of relapsed or refractory chronic lymphocytic leukemiaThe following organizations also provide reliable health information.●National Library of Medicine(https://medlineplus.gov/healthtopics.html)●National Cancer Institute(www.cancer.gov/types/leukemia/patient/cll-treatment-pdq)●American Cancer Society(www.cancer.org)●The Leukemia & Lymphoma Society(www.lls.org)●The Lymphoma Research Foundation(https://lymphoma.org/)●National Marrow Donor Program(bethematch.org/)●The American Society of Hematology(www.hematology.org)●The American Society of Clinical Oncology(www.cancer.net/cancer-types/leukemia-chronic-lymphocytic-cll)●The Alliance for Clinical Trials in Oncology(www.allianceforclinicaltrialsinoncology.org)●Deutsche CLL Studengruppe(http://www.dcllsg.de/)ACKNOWLEDGMENT — UpToDate would like to acknowledge Michael J Keating, MD, who contributed to earlier versions of this topic review.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 687 Version 34.0

ClosePatient education: Vaccines for children age 7 to 18 years (The Basics)Patient education: Vaccines for children age 7 to 18 years (The Basics) Please read the Disclaimer at the end of this page.What are vaccines? — Vaccines can prevent certain serious or deadly infections. They are a way of teaching your body how to fight the germs that cause infections. Thanks to vaccines, many fewer people get seriously ill or die from infections than in the past.Vaccines usually come in shots, but some come as nose sprays or medicines that children swallow. When a person gets a vaccine, this is called "vaccination" or "immunization."Why should my child get vaccinated? — Getting vaccinated can help keep your child from getting sick. If your child does get sick, being vaccinated can keep them from getting severely ill. Plus, being vaccinated helps protect the people around your child from getting sick.What vaccines do children age 7 to 18 get? — In the US, doctors recommend that children age 7 to 18 get vaccines to prevent the following infections:●Coronavirus disease 2019 (COVID-19) – COVID-19 can cause a fever, cough, and trouble breathing, along with other symptoms. Some people get severely ill from COVID-19.●Influenza (flu) – The flu can cause fever, chills, muscle aches, cough, or sore throat.●Diphtheria, tetanus, and pertussis – Vaccines to prevent these 3 different diseases are usually grouped together in 1 shot. Diphtheria can cause a thick covering in the back of the throat that can lead to breathing problems. Tetanus causes the muscles to work abnormally. Pertussis, also called "whooping cough," can cause a severe cough.●Human papillomavirus (HPV) – There are different types of HPV, which can lead to different problems. Depending on the type and where the infection is, HPV infection can lead to cancer of the cervix, vagin*, penis, or anus. It can also cause genital warts or cancer of the mouth and throat.Doctors recommend that all children get the HPV vaccine. The reason to get the vaccine at a young age is because it only works if it given before a person gets infected with HPV. HPV is spread through sexual contact.●Meningococcus – Meningococcus is a germ that can cause a serious body-wide infection of the blood or the tissues around the brain.●Pneumococcus – Pneumococcus is a germ that can cause infections of the lungs, ears, blood, or tissues around the brain. Most children age 7 to 18 do not need this vaccine. But children who have certain medical conditions might need it.●Hepatitis A – Hepatitis A does not usually cause problems in children, but it can cause severe liver disease in adults. Children who get the hepatitis A vaccine help prevent the adults around them from getting the infection. If your child never got this vaccine at a younger age, they might need to get it.Some children will need other vaccines, for example, if they missed a vaccine when they were younger.How many vaccine doses does my child need? — Each vaccine is different. Some vaccines work after just 1 dose. Others need 2 or more doses to prevent an infection. For most vaccines, it takes a couple of weeks before a person is fully protected.Some vaccines prevent an infection for the rest of your life. Others stop working well after some time. A "booster" is a vaccine dose given after a number of years. It reminds the body how to prevent an infection.At what ages will my child get vaccines? — Different vaccines are given at different ages. Most healthy children follow a set vaccine schedule (table 1). Even though doctors usually follow a set schedule, different children can get doses at different times. For example, many children get the HPV vaccine at age 11 or 12. But they can get it any time from age 9 to 26.Children might not follow the usual vaccine schedule if they:●Have certain medical problems●Started getting their vaccines later than usual●Started getting their vaccines on time, but then missed doses and fell behind scheduleYour child's doctor or nurse will recommend a vaccine schedule that is right for your child.Do vaccines cause side effects? — They can. Often, vaccines cause no side effects, but sometimes they do. When side effects happen, they can include:●Redness, mild swelling, or soreness where the shot was given●Mild fever●Mild rash●Headache or body achesThese side effects do not mean your child is sick, just that their immune system (infection-fighting system) is responding to the vaccine.Vaccines also sometimes cause more serious side effects, such as severe allergic reactions. But serious side effects are rare.Ask your child's doctor or nurse what side effects to expect each time your child gets a vaccine. If your child has a reaction or a problem after a vaccine, let the doctor or nurse know.Should I keep track of my child's vaccines? — Yes. It's important to know which vaccines your child has gotten and when they got them. Many schools and camps need this information before they let a child in. Ask your child's doctor or nurse if they can give you a list. They might also be able to show you how to access this information online.Can I do anything to help with my child's pain? — Getting a shot can hurt, but usually the pain goes away quickly. There are also things you can do to help reduce your child's pain.You can:●Ask the doctor or nurse about numbing cream – Putting this cream on your child's skin before a shot can help make it hurt less.●Distract your child – During the shot, it can help to distract your child. You can do this by talking to them, having them blow bubbles, or playing music or a video.●Use pain-relieving medicines – If your child still seems to be in pain after you get home, you can give acetaminophen (sample brand name: Tylenol) or ibuprofen (sample brand names: Advil, Motrin). Before you do this, ask your child's doctor or nurse how much medicine to give and how often to give it.More on this topic Patient education: What you should know about vaccines (The Basics) Patient education: Flu (The Basics) Patient education: Flu vaccine (The Basics) Patient education: Vaccines for babies and children age 0 to 6 years (The Basics) Patient education: Pneumonia in children (The Basics) Patient education: Anogenital warts (The Basics) Patient education: Meningitis in children (The Basics) Patient education: Human papillomavirus (HPV) vaccine (The Basics) Patient education: Whooping cough (The Basics) Patient education: Giving your child over-the-counter medicines (The Basics) Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics) Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics) Patient education: Why does my child need vaccines? (Beyond the Basics)This topic retrieved from UpToDate on: Jan 01, 2023.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 15742 Version 17.0

ClosePatient education: Gun safety for families (The Basics)Patient education: Gun safety for families (The Basics) Please read the Disclaimer at the end of this page.Why should I care about gun safety? — Guns can cause serious injury or death. The number of shooting deaths each year in the US is higher than in many other countries. This is true for both intentional and accidental shootings. In 2020, gun violence was the leading cause of death for children and teens in the US.Children cannot always understand how dangerous guns are. For this reason, it's very important to keep them away from guns. Even if you do not have guns in your house, it's still a good idea to teach your children about them and what to do if they see one.What are the risks of having a gun in the house? — Having a gun in your house raises the chances of someone getting hurt or killed. In fact, most accidental shooting deaths happen in a home.Even if you think your family knows to avoid guns, or how to handle them safely, there is still a risk. Children cannot always make good decisions, even if you have talked to them about guns before. Plus, other people visiting your house might find a gun that is not safely locked away.If I do have a gun in the house, how can I keep it safe? — The best way to prevent a shooting injury or death is to not own guns. But if you do choose to have one, there are some things you can do to keep it safe.First, you should follow all laws about owning a gun. The laws are different in different states.If you have a gun, it is very important to:●Store the gun unloaded (without bullets)●Lock up the gun and keep the key, or lock combination, away from children – Your child's doctor or your local police station might be able to give you a gun lock for free. Ask them for more information.●Store bullets separate from the gunGuns and bullets should be stored in places children cannot see or reach. You can buy special locking boxes or cabinets for this. Other safety devices for guns are also available. For example, some devices help prevent guns from being shot accidentally. Others require a code or fingerprint in order to use the gun. But it's important to remember that the best protection is to make sure children cannot get to a gun at all.What if I want to teach my children to hunt? — Different countries and states have different laws about hunting. Make sure you know what the rules are in your area about how old children have to be to hunt. Many states also require taking a course or getting a special license.Guns can lead to accidental injury or death when used for hunting. Even if it is legal for your children to hunt in your state, it's very important to teach them about safety. This includes how to use and store guns or other hunting weapons. No matter what the law says, it's also best to make sure children are with an experienced adult.How can I teach my children about gun safety? — You can explain to your children that guns can hurt or kill. If they see a gun, these are the steps they should remember:●Do not touch the gun●Move away from the gun●Tell an adult right awayKids are curious, and they can't always tell the difference between real and toy guns. Even if you have talked to your children about gun safety, they still might be tempted to play with a gun if they find one.What about toy guns? — Parents sometimes wonder if it's OK to let their children play with toy guns. These include things like water pistols and plastic guns that shoot soft darts. Different families set different rules about this. There is some evidence that playing with toy guns might lead to aggressive behavior in children.Toy guns that look like real guns should be avoided, since a child might not be able to tell the difference. Also, other people could mistake a toy gun for a real gun. If a person with a real gun thought there was danger, they might shoot to protect themselves. This could cause serious injury or death. If your child does play with toy guns, it's very important to teach them that real guns are not toys and can hurt or kill.Some children, especially teens, might want to play with BB guns, air guns, or paintball guns. These are often considered less dangerous than regular guns. But they can also cause serious injuries and even death. If these types of guns are used, an adult should make sure steps are taken to be safe. This includes using protection for the face, eyes, and, ears. It also involves being careful not to pull the trigger accidentally, and storing the guns in a safe place.How can I help keep my children safe outside of our home? — Talk to your children about guns so they understand the danger. For older children, you can ask them to tell you what they would do if they saw a gun.You can also:●Ask about guns in places your children visit – Before you let your child visit another person's home, ask the adult if there are any unlocked guns in the house. This can be hard to do, especially if you are not used to talking about guns. Try to think of it like anything else you would do to keep your child safe, like making sure they wear a seat belt or bicycle helmet.●Limit your child's "screen time" – Children often see violence and guns on television or in video games. This can make it hard for them to understand what is real and what is pretend. For example, they might think that guns are a common way to solve problems. Or they might believe that getting shot does not lead to serious harm. It's important to be aware of what your children are watching or playing, and how much. In general, experts suggest limiting children's screen time to no more than 1 to 2 hours a day.●Teach children, especially teens, how to avoid violence – Most violent injuries happen in fights between friends or people who know each other. Children and teens need to know how to stop a disagreement from turning into a fight and how to safely walk away from a situation that could become violent. It's also important to know who your child or teen is spending time with.●Never use physical discipline, including spanking – Children and teens that have been disciplined with physical force are more likely to be violent later in life.Taking the time to think and talk about guns can help keep your family safe. But preventing your children from having access to guns is the most important thing you can do.This topic retrieved from UpToDate on: Jan 01, 2023.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 120340 Version 5.0

Starting in the mid-20th century, telemedicine programs began to emerge as a novel option to provide remote clinical examination and mental health support [1,2]. Since that time, the use of telemedicine, particularly video visits, has expanded to include telehealth and mobile health applications [3]

ClosePatient education: COVID-19 and pregnancy (The Basics)Patient education: COVID-19 and pregnancy (The Basics) Please read the Disclaimer at the end of this page.View in ItalianView in Brazilian PortugueseView in GermanView in JapaneseView in FrenchView in SpanishView video in SpanishWhat is COVID-19? — COVID-19 stands for "coronavirus disease 2019." It is caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and quickly spread around the world.The virus that causes COVID-19 mainly spreads when an infected person coughs, sneezes, sings, talks, or just breathes near other people. A person can be infected and spread the virus to others, even without having any symptoms.Most people who get COVID-19 will not get severely ill. But some do.This article has information for people who are pregnant. More general information about COVID-19 is available separately. (See"Patient education: COVID-19 overview (The Basics)".)What are the symptoms of COVID-19? — Symptoms usually start 4 or 5 days after a person is infected with the virus. But in some people, it can take up to 2 weeks for symptoms to appear. Many people never show symptoms at all.When symptoms do happen, they can include:●Fever●Cough●Trouble breathing●Feeling tired●Shaking chills●Muscle aches●Headache●Sore throat●Runny or stuffy nose●Problems with sense of smell or tasteSome people have digestive problems like nausea or diarrhea. Pregnant people with COVID-19 can have any of the above symptoms or no symptoms.For most people, symptoms will get better within a few days to weeks. But in others, COVID-19 can lead to serious problems like pneumonia, heart problems, or even death.Are pregnant people at high risk for severe symptoms? — Experts are still studying COVID-19 and pregnancy. From what they know so far, pregnant people do not seem more likely than other people to get the infection.However, compared with females of the same age who are not pregnant, pregnant people with COVID-19 seem to be more likely to get very sick and need to stay in the ICU. ("ICU" is short for "intensive care unit.") In pregnant people, the risk of getting very sick or dying is highest in those who are age 35 or older, or have certain health conditions like obesity, high blood pressure, or diabetes. But most people recover before having their baby, and do not need to stay in the hospital.What should I do if I have symptoms? — If you have a fever, cough, trouble breathing, runny nose, or other symptoms of COVID-19, call your doctor, nurse, or midwife. They can tell you what to do and whether you need to be seen in person.If I am pregnant and get infected, can I pass the virus to my baby? — Experts think it might be possible for a baby to get the infection while still in the uterus. But this seems to be very uncommon. And when it does happen, most babies do not get very sick.It is also possible to pass the virus to the baby during childbirth or after the baby is born. If you have COVID-19 when you give birth, there are ways to lower this risk.Can COVID-19 cause problems with pregnancy? — From what experts know so far, most people who get COVID-19 during pregnancy will not have serious problems. But problems can happen if the mother becomes seriously ill.Pregnant people who get COVID-19 might have an increased risk of preterm birth. This is when the baby is born before 37 weeks of pregnancy. This seems to be more of a risk in people who get very sick and have pneumonia. Preterm birth can be dangerous, because babies who are born too early can have serious health problems. Getting COVID-19 during pregnancy might also increase the risk of stillbirth. This is when a baby dies before it is born. The risk of preterm birth is much higher than the risk of stillbirth.How is COVID-19 treated? — Most people with mild illness will be able to stay home while they get better. Mild illness means you might have symptoms like fever and cough, but you do not have trouble breathing. Ask your doctor, nurse, or midwife about ways to relieve these symptoms.People with serious symptoms or other health problems might need to go to the hospital. If you need to be treated in the hospital, the doctors and nurses will also monitor your baby's health.In certain cases, doctors might recommend medicines to prevent or treat severe illness. But some of these medicines are not safe to take if you are pregnant.Can COVID-19 be prevented? — The best way to prevent COVID-19 is to get vaccinated. In the United States, the first vaccines became available in late 2020. Since then, experts have been studying their safety in people who are pregnant or breastfeeding. Thousands of pregnant people have gotten the vaccine without any problems. The vaccine does not increase the risk of miscarriage (pregnancy loss) or harm the baby. Based on the available evidence, experts recommend that pregnant people get the vaccine. They also recommend getting a "booster" shot for extra protection. Ask your doctor, nurse, or midwife about the best time to get the booster shot.Vaccines work very well to prevent serious illness and death from COVID-19. Because pregnant people seem to be at high risk for getting very sick if they do get infected, vaccination is especially important. There is also evidence that people who are vaccinated have a lower risk of problems that affect the baby, like stillbirth or needing to be hospitalized in the first 6 months of life. More information about COVID-19 vaccines and boosters is available separately. (See"Patient education: COVID-19 vaccines (The Basics)".)You can also protect yourself and others by wearing a face mask in some situations (figure 1) and washing your hands often.Will my regular prenatal appointments change? — Your doctor, nurse, or midwife will work with you to make a plan for your visits during pregnancy. If you live in an area where there are a lot of cases of COVID-19, there will likely be some changes. For example:●If you have any symptoms of COVID-19, you will probably need to wear a medical mask during your appointments.●Your doctor, nurse, or midwife might group certain tests together so you don't need to go in as often.●Your doctor, nurse, or midwife might suggest replacing some visits with a phone or video call.These changes can feel stressful. It can help to keep in mind that the goal is to help protect you and others.What will my delivery be like? — Different hospitals and birth centers have different rules to help keep people safe. These might include guidelines for things like wearing a mask and how many visitors you can have. Your doctor, nurse, or midwife will talk to you about what to expect.You will be checked for fever and other symptoms of COVID-19 when you arrive to give birth. This might happen earlier if you are scheduled to be "induced" or have a cesarean birth ("c-section"). You might be tested for the virus, too.If you have COVID-19 when you go into labor, the doctors and nurses will take steps to protect others around you. For example, you will need to wear a medical mask. You will still be able to have a vagin*l birth, if that is what you planned. You don't need a c-section just because you are sick. If you have COVID-19, you will still probably be able to stay in the same room as your baby unless you are too sick to care for them or they need special care. You will need to wear a face mask to lower the risk of spreading the infection. You might need to take other precautions, too. These things can be hard. But they are important in order to protect your baby.What if I want to breastfeed? — Breastfeeding has many benefits for both you and your baby. Even if you have COVID-19, breastfeeding is encouraged. No babies have become very sick in this way.Whether or not you breastfeed, it's important to be extra careful when feeding or holding your baby. You could pass the virus to your baby through close contact. You can protect your baby by washing your hands often and wearing a face mask while you feed them.You might choose to pump breast milk for your baby. If you are sick, wash your hands carefully before pumping, and wear a mask while you pump. If possible, have a healthy person clean your pump thoroughly between uses.If you are planning to breastfeed, experts recommend getting the COVID-19 vaccine if you haven't already. Vaccines work by causing your immune system to make "antibodies," which are proteins that fight against the virus. These antibodies enter your breast milk, which can help protect your baby in addition to protecting you.How can I take care of my mental health? — It's normal to feel anxious or worried about COVID-19. You can take care of yourself by:●Getting vaccinated and boosted●Getting regular exercise and eating healthy foods●Finding healthy ways to handle stress, like hobbies you enjoy●Finding safe ways to connect with friends and family membersKeep in mind that most pregnant people do not get severely ill from COVID-19. It helps to be prepared, and it's important to do what you can to lower your risk. But try not to panic.What if I have other questions? — If you have other questions, talk to your doctor, nurse, or midwife. They can help you with questions like:●What symptoms should I be concerned about?●What should I do if I think I was exposed to COVID-19?●What medicines can I use to treat symptoms of COVID-19 while I am pregnant?●Where can I find support if I feel anxious or depressed?The answers to these questions, and others, will depend on your situation.Where can I go to learn more? — As we learn more about this virus, expert recommendations will continue to change. Check with your doctor or public health official to get the most updated information about how to protect yourself and your family.For information about COVID-19 in your area, you can call your local public health office. In the United States, this usually means your city or town's Board of Health. Many states also have a "hotline" phone number you can call.You can find more information about COVID-19 at the following websites:●United States Centers for Disease Control and Prevention (CDC): www.cdc.gov/coronavirus/2019-ncov/index.html●World Health Organization (WHO): www.who.int/emergencies/diseases/novel-coronavirus-2019More on this topic Patient education: COVID-19 overview (The Basics) Patient education: Recovery after COVID-19 (The Basics) Patient education: Avoiding infections in pregnancy (The Basics) Patient education: Acute respiratory distress syndrome (The Basics) Patient education: Pneumonia in adults (The Basics) Patient education: Prenatal care (The Basics) Patient education: Pumping breast milk (The Basics) Patient education: Preterm labor (The Basics)This topic retrieved from UpToDate on: Jan 02, 2023.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 127758 Version 36.0

Although decreased from its peak in the 1990s, violence continues to be a major cause of death and disability for American children. Exposure to television/media violence is an important and ubiquitous risk factor for youth violence [1,2]. Although the violence depicted is "virtual" in that the chil

Hodgkin lymphoma (formerly called Hodgkin's disease) is a cancer of the body's lymphatic system. Lymphomas are cancers of lymphocytes, a type of white blood cell that is important in the immune system.The lymphatic system is a network of lymph nodes and interconnecting lymph vessels (figure 1). Lymp

ClosePatient education: Diffuse large B cell lymphoma in adults (Beyond the Basics)Patient education: Diffuse large B cell lymphoma in adults (Beyond the Basics)Authors:Arnold S Freedman, MDJonathan W Friedberg, MD Section Editor:Andrew Lister, MD, FRCP, FRCPath, FRCR Deputy Editor:Alan G Rosmarin, MDLiterature review current through: Nov 2022. | This topic last updated: Nov 02, 2022.Please read the Disclaimer at the end of this page.DIFFUSE LARGE B CELL LYMPHOMA OVERVIEW — Lymphoma is a cancer of lymphocytes, a type of white blood cell. Lymphocytes circulate in the body through a network referred to as the lymphatic system, which includes the bone marrow, spleen, thymus, and lymph nodes. The organs and vessels of the lymphatic system work together to produce and store cells that fight infection (figure 1).There are two main types of lymphoma:●Hodgkin lymphoma (HL)●Non-Hodgkin lymphoma (NHL)NHL is the most common type of lymphoma. Although there are more than 60 types of NHL, diffuse large B cell lymphoma (DLBCL) is the most common type, making up about 30 percent of all lymphomas. In the United States, DLBCL affects about 7 out of 100,000 people each year.DLBCL is a fast-growing, aggressive form of NHL. DLBCL is fatal if left untreated, but with timely and appropriate treatment, approximately two-thirds of all people can be cured. The following discussion will review the risk factors, classification, symptoms, treatment, and prognosis of this type of non-Hodgkin lymphoma.CANCER CARE DURING THE COVID-19 PANDEMIC — COVID-19 stands for "coronavirus disease 2019." It is an infection caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and has since spread throughout the world. Getting vaccinated lowers the risk of severe illness; experts recommend COVID-19 vaccination for anyone with cancer or a history of cancer.In some cases, if you live in an area with a lot of cases of COVID-19, your doctor might suggest rescheduling or delaying medical appointments. But this decision must be balanced against the importance of getting care to screen for, monitor, and treat cancer. Your doctor can talk to you about whether to make any changes to your appointment schedule. They can also advise you on what to do if you test positive or were exposed to the virus.DIFFUSE LARGE B CELL LYMPHOMA RISK FACTORS — Age, gender, and ethnicity affect a person's likelihood of developing DLBCL. Although DLBCL has been found in people of all age groups, it is found most commonly in middle-aged or older adults. The average age at the time of diagnosis is 64 years. Men are slightly more likely to develop DLBCL than women. In the United States, white people are more likely to develop this type of lymphoma than people of Asian or African descent.DLBCL is not an inherited disease. Siblings and children of people with DLBCL do not have a substantially increased risk of developing DLBCL. Most people have no family history, but approximately 9 percent of people have a first degree relative (eg, parent or sibling) with lymphoma or chronic lymphocytic leukemia.WHAT IS DIFFUSE LARGE B CELL LYMPHOMA? — The lymph organs include the bone marrow, thymus, spleen, and lymph nodes. These help to fight infection throughout the body. The organs of the lymphatic systems are connected by a network of lymphatic and blood vessels, through which lymphatic fluid flows (figure 1). Lymphatic fluid contains white blood cells called lymphocytes.There are two primary types of lymphocytes: B cells and T cells. Diffuse large B cell lymphoma (DLBCL) is a cancer of B lymphocytes. Almost all lymphocytes begin growing in the bone marrow or lymph nodes. T cells leave the bone marrow before they are completely matured, and finish maturing in the thymus gland. B cells instead continue to develop and mature in the bone marrow and lymph nodes. In DLBCL, the abnormal B cell lymphocytes are larger than normal, and they have stopped responding to signals that usually limit the growth and reproduction of cells. This subtype of lymphoma is called diffuse large B cell because of the way the malignant large B cells are distributed within the lymph nodes when examined with a microscope.  There are different varieties of DLBCL that can be identified by performing advanced tests on the lymph node specimen. Particular varieties of DLBCL may be more likely to respond to certain treatments. DLBCL can either develop as a transformation from a less aggressive form of lymphoma or as a first occurrence of lymphoma (called de novo).DIFFUSE LARGE B CELL LYMPHOMA SYMPTOMS — The first sign of DLBCL is often a quickly growing, non-painful mass that is typically an enlarged lymph node in the neck, groin, or abdomen. People may also experience fever, weight loss, drenching night sweats, or other symptoms.Extranodal disease — In about 40 percent of cases, the cancer does not begin in the lymph nodes, but instead develops elsewhere. This is called extranodal disease. The most common site of extranodal involvement is the stomach or gastrointestinal tract, but the disease can arise in virtually any normal organ.Advanced versus localized disease — Most people (about 60 percent) are not diagnosed with DLBCL until the disease is advanced (stage III or IV). In the remaining 40 percent of people, the disease is confined to one side of the diaphragm (above or below the diaphragm). This is called localized disease.DIFFUSE LARGE B CELL LYMPHOMA DIAGNOSIS — The diagnosis of DLBCL is confirmed by removing part or all of an enlarged lymph node with a biopsy. This procedure may be performed with local anesthesia if the involved tissue is relatively close to the skin's surface. If the node is deeper, general anesthesia is required. The cells from the tissue are then examined in detail using a microscope and other techniques.Staging — Once the diagnosis is confirmed, additional tests are performed to obtain more information about the extent to which the disease has spread in the body. This process is called staging. The results of these tests will help determine the most effective course of treatment.History and physical exam — A careful interview and physical examination will begin to determine the extent of the disease. The physical exam may reveal swollen lymph nodes in various locations (figure 1).Staging tests — A number of tests are available to help determine which areas of the body have been affected by follicular lymphoma. Tests that may be done include:●Blood tests●Bone marrow biopsy ●CT scan (not performed if a combined PET/CT is used)●PET/CT scanStaging terms — The following are terms used in the staging criteria:●Lymph node regions: An area of lymph nodes and the surrounding tissue. Examples include the cervical nodes in the neck (figure 2), the axillary nodes in the armpit, the inguinal nodes in the groin, or the mediastinal nodes in the chest (figure 1).●Lymph structures: Organs or structures that are part of the lymphatic system, such as the lymph nodes, spleen, and thymus gland.●Diaphragm: A large muscle that separates the chest cavity from the abdominal cavity.Stage grouping — Staging involves dividing people into groups (stages) based upon how much of the lymphatic system is involved at the time of diagnosis. Staging helps determine a person's prognosis and treatment options (table 1).Here is how the stages of lymphoma are defined:●Stage I – Only one lymph node region is involved, only one lymph structure is involved, or only one extranodal site (IE) is involved.●Stage II – Two or more lymph node regions or lymph node structures on the same side of the diaphragm are involved.●Stage III – Lymph node regions or structures on both sides of the diaphragm are involved.●Stage IV – There is widespread involvement of a number of organs or tissues other than lymph node regions or structures, such as the liver, lung, or bone marrow.When a stage is assigned, it also includes a letter, A or B, to denote whether fever, weight loss, or night sweats are present. "A" means these symptoms are not present; "B" means they are. For example, a person with stage 1B disease has evidence of cancer in one lymph node region and has "B" symptoms (fever, weight loss, or night sweats). (See 'Diffuse large B cell lymphoma symptoms' above.)DIFFUSE LARGE B CELL LYMPHOMA TREATMENT — The treatment of DLBCL depends upon whether the disease is advanced or localized.Advanced disease — The standard treatment of advanced DLBCL is combination chemotherapy plus immunotherapy.Chemotherapy drugs work by interfering with the ability of rapidly growing cells (like cancer cells) to divide or reproduce themselves. Because most of an adult's normal cells are not actively growing, they are less affected by chemotherapy, with the exception of bone marrow (where the blood cells are produced), the hair, and the lining of the gastrointestinal tract.Immunotherapy uses antibodies that target a specific group of cells (usually cancer cells). Rituximab is an antibody that targets B lymphocytes.The most common chemotherapy regimens for advanced DLBCL are:  ●R-CHOP includes rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. The first four drugs are given into a vein (IV) over the course of one day, while prednisone is taken by mouth for five days. In the United States, this regimen is generally given every three weeks for six cycles.●R-pola-CHP includes rituximab, polatuzumab vedotin, cyclophosphamide, doxorubicin, and prednisone, in which polatuzumab vedotin substitutes for vincristine.A cycle of chemotherapy refers to the time it takes to give the treatment and then allow the body to recover from the effects. Thus, six cycles of treatment would last 18 weeks (nearly five months). During this time, the person is closely monitored for signs of drug toxicity and side effects.Side effects of chemotherapy — Most people who are treated with R-CHOP develop side effects, with the most common including:●Fever and low blood counts – A potentially life-threatening side effect of chemotherapy is fever and lowered levels of a type of white blood cell, called neutrophils (the condition is called febrile neutropenia).Anyone who is getting chemotherapy and who develops a temperature higher than 100.4°F (38°C) should immediately call his or her healthcare provider. This condition is a medical emergency and requires prompt treatment, usually with admission to a hospital and antibiotics by vein (IV).Treatment may also be associated with low red blood cell count (anemia; causing weakness, fatigue, and other symptoms) and low platelet counts (causing easy bruising/bleeding).●Nausea and vomiting – Between 30 and 90 percent of people develop nausea and vomiting after R-CHOP. Several medications may be given before and after chemotherapy to reduce its severity. This often includes dexamethasone and aprepitant (sample brand name: Emend), and a 5-HT3 receptor antagonist such as ondansetron (brand name: Zofran), and granisetron (sample brand names: Kytril, Sancuso, Sustol).●Hypersensitivity reaction – Hypersensitivity reactions may occur the first time a chemotherapy or immunotherapy drug is given, causing flushing; itching; chest, back, or abdominal pain; fever; nausea; dizziness; and other symptoms. It is not clear why this type of reaction occurs. Several medications are usually given before chemotherapy to reduce the severity of these symptoms, including acetaminophen (sample brand name: Tylenol), diphenhydramine (sample brand name: Benadryl), hydrocortisone (a steroid), and a stomach-acid-reducing medication, such as famotidine (brand name: Pepcid).●Tumor lysis syndrome – Tumor lysis syndrome is a serious, potentially life-threatening condition that can occur after beginning treatment with chemotherapy. It happens because the tumor cells die quickly and release toxic break-down products into the bloodstream. Symptoms can include nausea, vomiting, diarrhea, lack of appetite, lethargy, blood in the urine, heart problems, seizures, muscle cramps, and others. Preventive treatments are usually given before chemotherapy to reduce the risk of developing tumor lysis syndrome, including IV fluids and medications. In addition, blood tests are often done during and after treatment to monitor for the condition.●Other potential complications – Other potential complications of chemotherapy include damage to the heart (called cardiotoxicity) or the nerves (called neurotoxicity), loss of the ability to have children (infertility), and increased risk of some types of cancer. These risks, as well as ways to manage or monitor for them, should be discussed with a healthcare provider before beginning treatment.Localized disease — People with localized disease may be treated with fewer cycles (usually three cycles) of R-CHOP chemotherapy in combination with radiation therapy to the involved area.Radiation therapy — Radiation therapy (RT) refers to the exposure of a tumor to high-energy X-rays in order to slow or stop its growth. Exposure to X-rays damages cells. Unlike normal cells, cancer cells cannot repair the damage caused by exposure to X-rays over several days. This prevents the cancer cells from growing further and causes them to eventually die.RT for lymphoma is usually given as external-beam RT, meaning that the radiation beam is generated by a machine that is outside the body. Exposure to the beam typically takes only a few seconds (similar to having an X-ray). In general, RT is given daily, five days per week, for approximately three to four weeks.SURVIVING DIFFUSE LARGE B CELL LYMPHOMA — The chance of surviving DLBCL depends upon many factors. The following factors are known to reduce the chances of survival:●Age older than 60●Lactate dehydrogenase level higher than normal – Lactate dehydrogenase is a protein found in blood whose levels increase when tissues have been damaged. It can also be produced by the cancer cells.●Poor general health status (ECOG performance status score of 2 or greater) (table 2)●Stage III or IV disease (table 1)●More than one involved extranodal disease siteA scoring system, known as the International Prognostic Index (IPI), gives one point for each of the above characteristics, for a total score ranging from zero to five, representing three risk groups [1]:●Low risk – IPI score of 0 or 1 (91 percent of people in this risk group are still alive at three years)●Low to intermediate risk – IPI score of 2 (81 percent of people in this risk group are still alive at three years)●High to intermediate risk – IPI score of 3 (65 percent of people in this risk group are still alive at three years)●High risk – IPI score of 4 or more (59 percent of people in this risk group are still alive at three years)FOLLOW-UP AFTER TREATMENT OF DIFFUSE LARGE B CELL LYMPHOMAResponse evaluation — After finishing the planned course of treatment, the person will have a medical history, physical examination, and laboratory testing to gauge his or her response to treatment.A radiologic imaging test (PET/CT) is recommended, either six to eight weeks after finishing chemotherapy or 12 weeks after finishing radiation therapy.A complete response has been achieved if all of the following criteria are met:●There is no evidence of disease or disease-related symptoms on history and physical examination.●The spleen and liver cannot be felt during the physical examination.●Any abnormalities seen on the CT scan do not "light up" on the PET scan.●If a pretreatment bone marrow biopsy was positive, a repeat bone marrow biopsy must be negative.People who do not have a complete response are treated for refractory disease.Surveillance for relapse — People who achieve a complete response must be evaluated on a regular basis after treatment. The visits usually include a medical history and physical examination, blood tests, and may include a radiologic imaging test, such as a CT scan. The purpose of these visits is to monitor for treatment complications and possible relapse. If there are new signs of a relapse, a biopsy must be done to confirm the diagnosis.The frequency of these visits depends upon the comfort of both the person and physician. When deciding how often these visits should occur, the person and physician must consider the following:●The majority of relapses occur during the first two years after finishing treatment.●Relapses usually cause the person to have symptoms and are rarely found solely on the basis of routine radiologic imaging tests.●If a relapse is picked up a few weeks earlier because of more intense monitoring, it is unlikely to improve outcome.●The number of CT scans should be limited, particularly in younger individuals, to limit radiation exposure and the risk for second cancers.There is no role for routine PET or PET/CT imaging in the long-term follow-up of people who do not have any symptoms. There are limited data to support performing CT scans periodically to monitor for relapse. Whether or not to use CT scans in a person without symptoms should be determined on an individual basis.RECURRENT OR REFRACTORY DIFFUSE LARGE B CELL LYMPHOMA TREATMENT — Recurrent disease is the term used to describe disease that returns after an initial remission. Refractory disease is the term used to describe disease that does not fully respond to treatment in the first place. (See 'Response evaluation' above.)Depending upon the person's age, underlying medical problems, and preferences, treatment may use:●Immunotherapy, which are antibody-based treatments such as "CAR-T cell" therapy or others that directly target the cancer cells.●Intensive chemotherapy followed by a specific kind of bone marrow transplantation, autologous transplantation, in which a person's own cells are used to "rescue" his or her bone marrow from the intensive chemotherapy. (See"Patient education: Hematopoietic cell transplantation (bone marrow transplantation) (Beyond the Basics)".)●Some people with refractory DLBCL choose less intensive treatments or management with supportive care and no active therapy. CLINICAL TRIALS — A clinical trial is an approved research study that is designed to determine the best treatment for a particular disease. Clinical trials are especially important in DLBCL, since there no treatment program capable of curing all people with this disease.Enrollment in a clinical trial, if available, is always recommended. Ask your doctor for more information, or read about clinical trials at:●https://clinicaltrials.gov/●https://www.cancer.gov/about-cancer/treatment/clinical-trialsVideos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (https://www.cancer.net/research-and-advocacy/clinical-trials/welcome-pre-act).WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Lymphoma (The Basics) Patient education: Diffuse large B cell lymphoma (The Basics) Patient education: Neutropenia and fever in people being treated for cancer (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Hematopoietic cell transplantation (bone marrow transplantation) (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Classification of hematopoietic neoplasms Clinical presentation and initial evaluation of non-Hodgkin lymphoma Pretreatment evaluation and staging of non-Hodgkin lymphomas Autologous hematopoietic cell transplantation in follicular lymphoma Initial treatment of stage I follicular lymphoma Initial treatment of mantle cell lymphoma Natural killer (NK) cell large granular lymphocyte leukemia Pathobiology of diffuse large B cell lymphoma and primary mediastinal large B cell lymphoma Treatment of large granular lymphocyte leukemia Treatment and prognosis of Waldenström macroglobulinemia Treatment of advanced stage (IIB to IV) mycosis fungoides Treatment of early stage (IA to IIA) mycosis fungoides Treatment of hairy cell leukemia Treatment of extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT lymphoma) Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients Treatment of relapsed or refractory mantle cell lymphomaThe following organizations also provide reliable health information.●American Cancer Society      (www.cancer.org)●National Cancer Institute      (www.cancer.gov)●National Library of Medicine      (https://medlineplus.gov/healthtopics.html)●The Leukemia & Lymphoma Society      (www.lls.org)[1,2]Ziepert M, Hasenclever D, Kuhnt E, et al. Standard International prognostic index remains a valid predictor of outcome for patients with aggressive CD20+ B-cell lymphoma in the rituximab era. J Clin Oncol 2010; 28:2373.American Cancer Society. What is non-Hodgkin's lymphoma? www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_Is_Non_Hodgkins_Lymphoma_32 (Accessed on March 07, 2005).This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 691 Version 24.0References1 : Standard International prognostic index remains a valid predictor of outcome for patients with aggressive CD20+ B-cell lymphoma in the rituximab era.

Unintentional injury is the leading cause of death in children, adolescents, and young adults in the United States [1]. Unintentional injury often results from risk-taking behavior such as alcohol or drug use. Self-induced hypoxia (eg, engaging in strangulation activities, such as "the choking game"

CloseFISTS violence screening questions for adolescentsFISTS violence screening questions for adolescentsFights: How many fights have you been in in the past year? When was your last fight?Teens who have been in more than one physical fight in the preceding 12 months are at increased risk of violence-related injury.Injuries: Have you ever been injured in a fight? Have you ever injured anyone else?Multipleor serious previous injuries may indicate an increased risk of futureinjury. Patients who have been injured may be more likely to carryweapons.Sexual violence: What happens when you and your boyfriend/girlfriend fight? Have you ever had sex against your will?Teen-dating violence is associated with future domestic violence.Threats: Have you ever been threatened?Teenagers who have been threatened with a weapon are at future risk of weapons-related injury.Self-defense: Have you ever carried a weapon to protect yourself?Teenagers who arm themselves in self-defense are at increased risk for violence-related injury.13.0000000000000Table<a href="/Graphics/Pages/TableEditor.aspx?SPID=52449&Mode=Edit"></a>FIST_violence_screening.htmAdapted from Alpert E, Sege R, Bradshaw Y. Academic Medicine 1997; 72 (suppl):S41.Graphic 57574 Version 3.0

Thoracostomy tubes or catheters placed in hospitalized patients require daily assessment to determine the presence of air leak, provide ongoing adjustment of suction level, and to monitor for malfunction, which may include obstruction, malposition, or disconnection.For the purposes or our discussion

CloseDiagnostic criteria of sleep-related hypermotor epilepsy*Diagnostic criteria of sleep-related hypermotor epilepsy* Diagnosis based on clinical history Brief (<2 minutes) seizures with stereotyped motor pattern, abrupt onset and offset, may clusterMost common motor activity is hypermotor: vigorous hyperkinetic movements, and/or asymmetric tonic or dystonic posturing, with or without impaired awarenessOccurrence predominantly during sleepDiagnosis not excluded by intellectual impairment, neuropsychiatric features, absence of interictal and ictal EEG correlates, extrafrontal originThree levels of certainty Witnessed (possible)Clinical features provided by observerVideo-documented (clinical)At least one stereotyped event, confirmed by observer to be typicalHigh quality audio-video including the onset and offset with clear visualization of the entire eventMinor motor events or paroxysmal arousals excludedVideo-EEG documented (confirmed)At least one stereotyped event during daytime sleep recording after sleep deprivation, or during full night sleep recording using ≥19 EEG channels, ECG, oculogram, and chin EMGDefinitive ictal epileptic discharge or interictal epileptiform abnormality * Previously referred to as nocturnal frontal lobe epilepsy.EEG: electroencephalography; ECG: electrocardiography; EMG: electromyography.Original table modified for this publication. From: Tinuper P, Bisulli F. From nocturnal frontal lobe epilepsy to sleep-related hypermotor epilepsy: A 35-year diagnostic challenge. Seizure 2017; 44:87. Table used with the permission of Elsevier Inc. All rights reserved.Graphic 116350 Version 1.0

CloseTracheal intubation of COVID-19 patients outside the OR: Guidelines and modificationsTracheal intubation of COVID-19 patients outside the OR: Guidelines and modifications Key principles Maximize first-attempt success while keeping patients and providers safe.Prevent contamination and spread of virus. There is a high risk of aerosolization of virus during airway management.Tracheal intubation should be performed by the clinician with the most airway management experience whenever possible.RSI steps (seven P's) Important actions and modifications Preparation Use checklist adapted for COVID-19 patients. Placing required airway equipment and medications in prepackaged bundles may be helpful.Review airway plan as a team before entering room. RSI preferred whenever possible. Avoid awake intubation (cough during awake intubation increases viral spread).Prepare all required equipment and draw up and label all medications (including induction agent, NMBA, vasopressor [eg, norepinephrine infusion], isotonic IVF) before entering intubation room.Keep all nonessential equipment just outside room.Have available all standard airway equipment plus:Bag-mask with HEPA filterVideo laryngoscope with clear, disposable cover for the deviceVentilator and tubing with in-line adaptors (for suctioning and bronchoscopy) and HEPA filtersWaveform capnography if availableSmooth clamp for ETTUse negative-pressure room for intubation whenever possible. Keep door closed; may hang a sign prohibiting entrance during procedure.Limit intubation team in room to 3 members: intubator; nurse or other clinician; respiratory therapist.If possible, second intubator wearing PPE should remain outside room to assist with anticipated difficult airway or as necessary.Before entering room:Perform hand hygiene.Don PPE with proper technique and supervision. PPE should include:N95 respirator or PAPREye protection (goggles, face shield that covers front and sides of face, or full face PAPR)Double glovesGown and cap (some recommend shoe covers, such as disposable booties)Prepare marked bags for proper disposal/removal of clothing and equipment.The precautions against infection listed immediately above should be taken by all clinicians directly involved in any pediatric intubation or airway management. Asymptomatic infection in children is common and poses a risk for disease transmission.Avoid pretreatment with nebulizers if possible; use MDI instead.Preoxygenation Preoxygenate patient for 3 to 5 minutes with 100% O2 using low or moderate flow rates (10 to 15 L/minute) and NRB mask. Avoid BMV if at all possible. 5 minutes of preoxygenation preferred if circ*mstances permit.If needed, can preoxygenate with modified NIV by using tightly fitting, non-vented mask connected to closed-circuit, dual-limb ventilator with HEPA filter. Use a full-face mask if available (reduces aerosolization). Mask must fit standard ventilator tubing. Continue NIV until patient apneic. Suspend ventilator before removing mask for intubation.If patient remains hypoxic (SpO2 <93%) using NRB mask, and NIV with closed circuit not available, can use BMV with HEPA filter and PEEP valve. Hold mask tightly on patient's face using 2-hand thenar technique, increase oxygen flow rate as needed, and have patient breathe passively. Perform synchronized bag-assist ventilation only if required.In the hypoxic, agitated patient who cannot cooperate with preoxygenation efforts, a reasonable approach is to sedate the patient with a smaller dose of ketamine (eg, 0.5 mg/kg IV) than would be used for RSI. This dose generally preserves spontaneous ventilation and enables the patient to tolerate a tight mask seal, which may improve oxygenation and reduce viral shedding. Once preoxygenation is complete, RSI may be performed using the remaining dose of ketamine or another induction agent and a NMBA.Avoid high-flow oxygenation methods (eg, flush rate) unless clinically required.Avoid nasal cannula for oxygenation, including apneic oxygenation.Upright posture or reverse Trendelenburg positioning improves preoxygenation.Avoid BMV if at all possible; use HEPA filter if BMV must be performed.If BMV necessary, 2-person thenar technique gives better seal and reduces aerosolization/contamination risk (provided entry of additional provider can be avoided). Provide BMV using low volumes and relatively high rates.Pre-intubation optimization May give IV fluid bolus prior to giving RSI medications to patients who are volume depleted.Avoid high-volume fluid resuscitation in COVID-19 patients at risk for ARDS.Push-dose pressor may be needed for patients at high risk for hemodynamic decompensation (options include phenylephrine 100 micrograms IV or epinephrine 10 micrograms IV).*Vasopressor (eg, norepinephrine) infusion may be needed for patients with hypotension or hemodynamic instability before or following administration of RSI medications.Paralysis with induction Use high-dose NMBA: rocuronium 1.5 mg/kg IV or succinylcholine 2 mg/kg IV. Goal is rapid-onset apnea and elimination of cough.Protection of patient and staff Refer to "Preparation" above and "Post-intubation management" below.Placement (intubation) Use video laryngoscopy whenever possible.Performed by experienced intubator.Supraglottic airway preferred for rescue oxygenation and ventilation if needed (eg, intubation difficulty).Ensure ETT is inserted 19 to 22 cm (measured at teeth); may reduce need for confirmation by chest radiograph.Post-intubation management¶ Inflate cuff immediately following ETT placement and prior to initiating PPV.Confirm placement of the ETT. If a colorimeter or other removable EtCO2 detector is used, clamp the ETT before removing the device.After confirming ETT placement, clamp the ETT, connect the ventilator tubing, and then remove the clamp. HEPA filter between ETT and ventilator should be in place. Start mechanical ventilation. Secure the ETT.Ventilator settings suitable for patient with ARDS are likely to be needed (assuming COVID-19-related respiratory illness is reason for intubation).ΔProcedure bundles can reduce exposure. May choose to perform intubation and central venous catheter placement together and then obtain portable chest radiograph to assess both.Limit ventilator disconnections. When disconnection required, clamp ETT first and disconnect at end-expiration.Ideally, use ETT and ventilator with in-line adaptors for suctioning and bronchoscopy.Ensure adequate sedation for patient care and safety and to avoid accidental extubation or disconnection of tubing.Bag, transport, and clean all equipment as required.Use proper PPE doffing, supervised by coach or other team member. Once PPE is removed, thoroughly clean your hands and any exposed skin on the neck and face. OR: operating room; RSI: rapid sequence intubation; NMBA: neuromuscular blocking agent (paralytic medication); IVF: intravenous fluid; HEPA: high-efficiency particulate air; ETT: endotracheal tube; PPE: personal protective equipment; PAPR: powered air-purifying respirator; MDI: metered dose inhaler; O2: oxygen; NRB: nonrebreather; BMV: bag-mask ventilation; NIV: noninvasive ventilation; SpO2: oxygen saturation; PEEP: positive end-expiratory pressure; DSI: delayed sequence intubation; IV: intravenous; ARDS: acute respiratory distress syndrome; PPV: positive-pressure ventilation; EtCO2: end-tidal carbon dioxide; SBP: systolic blood pressure; FiO2: fraction of inspired oxygen.* The use of a push-dose pressor is based on clinical judgement. It is most appropriate for patients with overt shock (eg, SBP <90 mmHg, SI >1) but may be useful in any hemodynamically unstable patient being intubated. For adults, options include phenylephrine 100 micrograms (50 to 200 micrograms) IV or epinephrine 10 micrograms (5 to 20 micrograms) IV, depending upon whether vasoconstriction alone or vasoconstriction and inotropic support is desired. Appropriate measures to improve hemodynamics as much as possible should be taken prior to intubation and push-dose pressor use.¶ The objective identification of patients whose intubation was difficult can help clinicians in the event that reintubation is necessary (eg, safety bracelet, red sticker on ETT).Δ Initial ventilator management for adults with ARDS includes low tidal volume (6 mL/kg predicted body weight), volume-limited assist control mode, PEEP (10 to 15 cm H2O), and high FiO2 (1.0). These settings are modified based on patient response. Refer to UpToDate topics discussing ventilator management in ARDS for details. For initial settings in children, please refer to UpToDate topics on initiating mechanical ventilation in children.References:Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020.Cook TM, El-Boghdadly K, McGuire B, et al. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020.Mason J, Herbert M. Novel Coronavirus 2019 (COVID-19). Available at: www.emrap.org/corependium/chapter/rec906m1mD6SRH9np/Novel-Coronavirus-2019-COVID-19?MainSearch=%22covid%22&SearchType=%22text%22 (Accessed on March 28, 2020).Weingart S. COVID Airway Management Thoughts. Available at: https://emcrit.org/emcrit/covid-airway-management/ (Accessed on March 28, 2020).Graphic 127516 Version 23.0