NOVEMBER EDITION New Guidelines and Recommendations Review the latest information released by the following organizat AABB (American Association of Blood Banks) ¥ Advisory Committee on Immunization Practices American Academy of Pediatrics ¥ American Association of Endocrine Surgeons American College of Physicians American Society of Clinical Oncology ¥ Canadian Cardiovascular Society ¥ European League Against Rheumatism rench consortium on pelvic organ prolapse ¥ French Society of Otorhinolaryngology ~ World Society of Emergency Surgery Forpermeioy i reuse ME coMmnt peSEE comet Ifeseeape at germienone@owone net@ Blood Transfusions Guidelines on blood transfusion by the AABB (formerly the American Association of Blood Banks)*? «Patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue) rather than limiting patients to. transfusion of only fresh (storage length: <10 days) RBC units. * The recommendation assigns 2 tiers of hemoglobin level transfusion triggers: 7 g/dL. for hemodynamically stable adults, even those in critical care, and 8 g/dL for patients with preexisting cardiovascular disease or those undergoing cardiac or orthopedic surgery. The previous hemoglobin threshold was 10 g/dL. * These recommendations do not apply to patients with acute coronary syndrome, severe thrombocytopenia (patients treated for hematologic or oncologic reasons who are at risk of bleeding), and chronic transfusion-dependent anemia (not recommended due to insufficient evidence). Molscape | ssiae orgs Lotus ©2016 weab.LLe Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn tt© Human Papillomavirus. Guidelines on human papillomavirus by the Advisory Committee on Immunization Practices? * Children and adolescents aged 15 yr and younger need just 2, not 3, doses of the human papillomavirus (HPV) vaccine, which is recommended because of the vaccine's enhanced immunogenicity in preteens and adolescents aged 9-14 yr. * Efficacy trials showed that the response in younger children after 2 doses is as good as or better than the response after 3 doses in older teens and young adults. * In addition to dropping the third dose for the under-15-yr age group, the recommendation expands the time interval from the first to the second dose from 1-2 mo to 6-12 mo. * The schedule for older adolescents and young adults aged 15-26 yr remains the same, at 3 inoculations within 6 mo. Molscape | ssiae orgs Lotus ©2016 weab.LLe Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttGuidelines on gout by the American College of Physicians*** Use synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout. Use corticosteroids, NSAIDS, or colchicine to treat acute gout. Use low-dose colchi ine for acute gout. ine (1.2 mg, then 0.6 mg 1 hr later) when using colchi Recommend against initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients with infrequent attacks. Discuss benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks. Molscape | ssiae orgs Lotus ©2016 weab.LLe Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn tt% Sudden Infant Death Syndrome Guidelines on sudden infant death syndrome by the American Academy of Pediatrics’® AAP recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, the use of a firm sleep surface, room-sharing without bed-sharing, and the avoidance of soft bedding and overheating. Additional recommendations for SIDS reduction include the avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pac New evidence is presented for skin-to-skin care for newborn infants, use of bedside and in-bed sleepers, sleeping on. couches/armchairs and in sitting devices, and use of soft bedding after 4 mo of age. Offera pacifier at nap time and at bedtime. Studies show these can reduce the risk for SIDS. Infants should be immunized in accordance with AAP and CDC recommendations. Continued on next slide Molscape | ssiae orgs Lotus ©2016 weab.LLe Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttPes Crem EL Lar (eeu | Guidelines on sudden infant death syndrome by the American Academy of Pediatrics’® Provide supervised, awake tummy time daily to facilitate development. + Remove infants from car seats, strollers, swings, infant carriers, and infant slings, if they fall asleep in them, to reduce the risk far gastroesophageal reflux and positional plagiocephaly. Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS. Maacape | Meseepe Onogs Denes ©2016 weet, LLC Forpemason © mse me suet pate some Mesezape at pemenone geome rtGuidelines on cervical cancer screening by the American Society of Cli ical Oncology?” Guidelines are noted according to resource availability: Regions with most resources are noted as maximal settings. Those with a good level of resources are enhanced settings. ‘Countries with some resources are limited settings Countries or regions with very limited or basichealth resources are basic settings. > For primary screening: Human papillomavirus (HPV) DNA testing is recommended for all resource settings (maximal, enhanced, limited, basic). Visual inspection (VIA) with acetic acid may be used in basic settings. In the maximal setting, for women aged 25-65 yr, screening should be conducted every 5 yt In the enhanced setting, women aged 30-65 yr should be screened every 5 yr, and if a patient has 2 consecutive negative test results at 5-yr intervals, then every 10 yr. Continued on next Maacape | Meseepe Onogs Denes ©2016 weet, LLC Forpemason © mse me suet pate some Mesezape at pemenone geome rtfoe Net IRes=UL) Pie Guidelines on cervical cancer screening by the American Society of Clinical Oncology?” > For primary screening cont'd: * In the limited setting, women aged 30-49 yr should be screened every 10 yr. * Inthe basic setting, women aged 30-49 yr should be screened 1-3 times per lifetime. ® Time to end screening * Maximal and enhanced: Older than 65 yr with consistently negative results during past>15 yr. + Limited and basic: Younger than 49 yr, resource-dependent. > Triage of screening results * For women residing in basic settings, visual assessment for treatment may be used ing a positive HPV DNA test result. after recei * If VIA was used as primary screening with abnormal results, the woman should be treated. * In other settings, HPV genotyping and/or cytology may be used. Mocscape | Mesteme Onuge @Obazees ©2016 weno. LLC Forparmgsion © mou ms somaet_puate coma Itsazape at permanonsgotane ntGuidelines on cervical cancer screening by the American Society of Clinical Oncology?” > Aftertriage * Women with negative triage results should receive follow-up in 12 mo. * In basic settings, treatment should be initiated if there are abnormal or positive triage results. * In limited settings, women with abnormal triage results should receive colposcopy, if available, or visual assessment for treatment if colposcopy is unavailable. * In maximal and enhanced settings, abnormal or positive results should be followed with colposcopy. > Treatment of women with precursor lesions * In basic settings, treatment options are generally cryotherapy or loop electrosurgical excision procedure (LEEP). * In other settings, LEEP (if there is a high level of quality assurance} or ablation (if there are medical contraindications to LEEP) is recommended. * A.12-mo posttreatment follow-up is recommended for all settings... pinuox! on next Maacape | Meseepe Onogs Denes ©2016 weet, LLC Forpemason © mse me suet pate some Mesezape at pemenone geome rtfoe eee Guidelines on cervical cancer screening by the American Society of Clinical Oncology?” ® Special populations Women who are HIV positive or are immunosuppressed for other reasons shauld be screened for HPV as soon as they are diagnosed and then screened twice as many times during their lifetime as the general population. The management of abnormal screening results for HIV-positive women and positive triage is the same as in the general population. Women should be offered primary screening 6 wk postpartum in basic settings and 6 mo postpartum inall other settings. Maacape | Meseepe Onogs Denes ©2016 weet, LLC Forpemason © mse me suet pate some Mesezape at pemenone geome rtRheumatoid Arthritis and Heart Disease Guidelines on heart disease in patients with rheumatoid arthritis by the European League Against Rheumatism*™2 * Clinicians should be aware of the higher risk for cardiovascular disease (CVD) in rheumatoid arthritis (RA) compared with the general population, and perhaps also in ankylosing spondylitis (AS) and psoriatic arthritis (PsA). * The rheumatologist should ensure that CVD risk management is performed in patients with RA and other inflammatory joint disorders (IDs). * Prescription of NSAIDs in RA and PsA should be given with caution, especially for patients with documented CVD or in the presence of CVD risk factors. The use of NSAIDs and corticosteroids should be in accordance with treatment-specific recommendations from EULAR and the Assessment of Spondyloarthritis International Society (ASAS). * For prolonged treatment, the glucocorticoid dosage should be kept to a minimum, and a glucocorticoid taper should be attempted in case of remission or low disease activity; the reasons to continue glucocorticoid therapy should be regularly checked. * Reduce recommended screening for CVD risk in IJDs from yearly to every 5 yr. Continued on next slide Molscape | ssiae orgs Lotus ©2016 weab.LLe Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttRheumatoid Arthritis and Heart Disease Guidelines on heart disease in patients with rheumatoid arthritis by the European League Against Rheumatism*™2 * Total cholesterol (TC) and high-density lipoprotein cholesterol (HDLc) should be used in CVD risk assessment in RA, AS, and PsA; lipids should ideally be measured when disease activity is stable or in remission. Non-fasting lipids are acceptable. * In the absence of validated CVD risk str: multiplication for CVD risk prediction in patients with RA, even without disease- specific criteria such as disease duration of 10 or more years, rheumatoid factor or anticitrullinated protein antibody positivity, or the presence of certain extra- articular manifestations. ication tools for RA, use a 1.5 Use of carotid ultrasound screening for asymptomatic atherosclerotic plaques in RA may be considered as part of the CVD risk evaluation. Add regular exercise and a Mediterranean diet to smoking cessation for lifestyle recommendations. Remove the 2009 recommendation for angiotensin-converting enzyme inhibitors and angiotensin Il receptor blockers as preferred treatment choices for hypertension in RA. Molscape | estas orgs Lotus ©2516 weab. LLC Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttBe Guidelines on treatment of epistaxis in adults by the French Society of Otorhinolaryngology” * Asinitial therapy, clearing out blood clots and bi recommended. ital compression are * In cases of persistent bleeding, local anesthesia with a vasoconstrictor is essential before ini ing nasal diagnostic and therapeutic procedures. * When the origin of bleeding is not anterior, nasal endoscopy is an essential procedure, identifying the bleeding site in most cases. * In cases of active bleeding, cauterizatio bleeding site is clearly visible. is recommended but is only feasible if the * When the bleeding site is not identifiable or the first measures have failed, anterior packing may be performed by a non-specialist physician. * Epistaxis requires subsequent nasal endoscopy performed by an ENT specialist. * Patients should be informed of the measures to be taken in the case of epistaxis at home, as well as the risks associated with the various treatments. Molscape | ssiae orgs Lotus ©2016 weab.LLe Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttWiles an Prolapse Guidelines on surgical treatment of pelvic organ prolapse by 5 French academic societies’ These guidelines were developed by the following 5 French academicsocieties: Association Francaise d'Urologie, Collége Nationaldes Gynécologues et Obstétriciens Francais, Société Interdisciplinaire d'Urodynamique et de Pelvi-Péringologie, Société Nationale Frangaisede Colo-proctologie, and Société de Chirurgie Gynécologique et Pelvienne. + Inthe absence ofany spontaneous or occult urinary sign, there is noreasonto perform urodynamics. + Whena sacrocolpopexy isindicated, laparoscopy isrecommended. + A bowel preparation beforevaginal or abdominal surgery is not recommended. + There isno argumentto systematically using a rectovaginal mesh to prevent rectocele. + Theuse of a vesicovaginal mesh by vaginal route should be discussed, takinginto account an uncertain long-term risk-to-benefit ratio. * Levator myorrhaphy isnot recommended as first-line rectocele treatment. * There is no indication fora vaginal meshas first-line rectoceletreatment, * There isno reason to systematically perform a hysterectomy during prolapse rep: * It ispossible to not treat stressincontinenceat the time of prolapse repair, if the woman is advised of the possibility of a2-step surgical treatment. Moclocape | MESteape Onoge 2Oieests ©2016 Wao, LE ‘For permationw mus Pus comnt piace comsttessape a permenonegocoms ntLiver Traum Guidelines on liver trauma by the World Society of Emergency Surgery > Nonoperative management of blunt liver trauma er trauma patients with hemodynamic stability and absence of other internal s requiring surgery should undergo an initial attempt of nonoperative management (NOM) irrespectiveof injury grade. NOM is contraindicated in the setting of hemodynamic instability or peritonitis. NOM of moderate or severe liver injuries should be considered only in an environment that provides capability for patient intensivemonitoring, angiography, an immediately available OR, and immediate access to blood and blood products. In patients being considered for NOM, CT scan with intravenous contrast should be performed to definethe anatomic liver injury and identify associated injuries. Angiography with embolization may be considered the first-line intervention in patients with hemodynamicstability and arterial blush on CT scan. Continued on next Maacape | Meseepe Onogs Denes ©2016 weet, LLC Forpemason © mse me suet pate some Mesezape at pemenone geome rteam eC ane) Guidelines on liver trauma by the World Society of Emergency Surgery > Nonoperative management of penetrating livertrauma NOM of penetrating liver trauma could be considered only in cases of hemodynamic stability and absence of peritonttis, significant freeair, localized thickened bowel wall, evisceration, and impalement. NOM in penetrating liver trauma shouldbe considered only in an environment that provides capability for patient intensive monitoring, angiography, an immediately available OR, and immediate access to blood and blood products. CT sean with intravenous contrast should always be performed to identify penetrating liver injuries suitable for NOM. Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect a change in clinical status during NOM. Angioembolization isto be considered in cases of arterial bleeding in a hemodynamic stable patient without other indications for OM. ‘Severe head and spinal cord injuries should be considered as relative indications for OM, given the inability to reliably evaluatethe clinical status. Continued on next Maacape | Meseepe Onogs Denes ©2016 weet, LLC Forpemason © mse me suet pate some Mesezape at pemenone geome rteam eC ane) Guidelines on liver trauma by the World Society of Emergency Surgery > Operative management of bluntand penetrating liver trauma * Patients should undergo OM in blunt and penetratingliver traumain cases of hemodynamic instability, concomitant internal organ injury requiring surgery, evisceration, and impalement. + Primary surgical intention should be used to contral hemorrhage, control bile leak, and institute an intensive resuscitation as soon as possible. + Major hepaticresections should be avoided at first, and they should be considered subsequently (delayed fashion) only in cases of large devitalized liver portionsand in centers with the necessary expertise. + Angioembolization isa useful tool in cases of persistentarterial bleeding. Maacape | Meseepe Onogs Denes ©2016 weet, LLC Forpemason © mse me suet pate some Mesezape at pemenone geome rtPrimary Hyperparathyroidism Guidelines on primary hyperparathyroidism by the American Association of Endocrine Surgeons*® + Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hr urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation forvitamin D deficiency. * Parathyroidectomyis indicated for all symptomatic patients, should be considered for mostasymptomatic patients, and is more cost-effectivethan observation or pharmacologictherapy. * Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. * Patients with noniocali ing imaging remain surgical candidates. * Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. * The possibility of multigland diseaseshould be routinely considered. * Both focused, image-guided surgery (minimally invasiveparathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. Continued on next Movlacipe | Masha Gnas 8 Oasaeas ©2016 weabD Uc Furgemin © re ns conan pate coma Uses a pemssinsgesane reLUTE ah 8x21 LEU ke | col Guidelines on primary hyperparathyroidism by the American Association of Endocrine Surgeons*® + For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoringviaa reliable protocol isrecommended. * Minimally invasive parathyroidectomy isnotroutinely recommended for known or suspected multigland disease. * _ Exvivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. * Clinically relevant thyroid disease shouldbe assessed preoperatively and managed during parathyroidectomy. * Devascularized normal parathyroid tissueshould be autotransplanted. * Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up toassess for cure defined as eucalcemia at more than 6 mo. * Calcium supplementation may be indicated postoperatively. Familial primary hyperparathyroidism, reoperative parathyroidectomy, and parathyroid carcinomaare challenging entities that require special consideration and expertise. Molscape | ssiae orgs Lotus ©2016 weab.LLe Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttaE el Guidelines on atrial fibrillation by the Canadian Cardiovascular Society’” * For patients who require combinations of antiplatelet (APT) and oral anticoagulation (OAC) agents for concomitant atrial fibrillation (AF) and coronary artery disease (CAD), it is suggested that measuresbe used to reduce the risk of bleeding, including careful consideration of HAS-BLED risk factors (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, LabileINR, Elderly [>65 yr], Drugs/Alcohol Concomitantly) and vigorous efforts to mitigatethem; specific measures during invasive procedures (radial access, small-diameter sheaths, early sheath removal from the femoral site, and minimized use of acute procedural antithrombotictherapies); consideration of proton pump inhibitors; avoidanceof prasugrel and ticagrelorin conjunction with OAC; the use of warfarin in the lower international normalized ratio (INR) range; consideration of the lower effective doses of non-vitamin k antagonist oral anticoagulants (NOACs); and delaying nonurgent catheterization until there is clarity about coagulation statusand renal function. * The current Canadian Cardiovascular Society (CCS) AF guidelines for patients with AF who are at low risk of systemic embolism (SSE) (age <65yr, CHADS, score of 0} include no. antithrombotic therapy if there isno manifest vascular disease (CAD, peripheral vascular disease, or aortic plaque) and acetylsalicylicacid (ASA) 81 mg/day if vascular disease is present. Continued on next slide Mecacape | Masteape Drage £ lanes ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme nataie Ln) Guidelines on atrial fibrillation by the Canadian Cardiovascular Society’” + Because of the evidence for the efficacy of ASA forthe prevention of coronary eventsin patients with stableCAD, ASA therapy alone is expected to be adequate fora patient with low stroke risk who has concomitant AF and CAD. + Inpatients with AF whoareaged265 yr or with a CHADS, score21, OAC ted for stroke prevention. When sucha patientalso has stable CAD, OAC therapy will provide protection against stroke and coronary events. * Patients who undergo elective percutaneous coronary intervention (PCI) are generally prescribed dual APT (DAPT) fora period that varies from4 wk fora bare metal stent (BMS) to 12 moor more fora drug-eluting stent (DES). Whereas shorter durations of DAPT lessen the risk of major bleeding and might lessen all-cause mortality, the risk of stent thrombosis and Ml appearsto be higher. * Some patients whoare.at high risk of stent thrombosis and whose riskof majorbleeding isacceptable may continue OAC with clopidogrel for longer than 12 mo after acute coronary syndrome (ACS), whereas those at particularly high risk of major bleeding may have their clopidogrel discontinued earlier than 12 mo and continue to receive only OAC. Continued on next slide Mecacape | Masteape Drage £ lanes ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme nataie Ln) Guidelines on atrial fibrillation by the Canadian Cardiovascular Society’” * Some clinicians might prefer the combination of clopidogrel and OAC therapy beginning from the time of PCI, placing more weight on thereduced bleeding and no increase of thromboticevents. A combination of ASA with ticagrelor, ASA with prasugrel, or ASA with clopidogrel! might also be used in preferencetotriple therapy (TT) forsome patients with a CHADS, score of 1 at the lower end of the stroke risk spectrum (eg, isolated hypertension), reserving TT or OAC with clopidogrel for patientsat higher stroke risk. * Whena decisionto interrupt warfarin therapy has been made for an invasiveprocedure with an intermediate or high risk of major bleeding, bridging with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) when the INR has decreased below therapeutic levels should be considered for patients with high stroke risk. * Bridgingisnot generally necessary for NOACs, because their half-lives are similarto those of LMWH. * Digoxinis less effective at controlling heart rate than beta-blockers or calcium channel blockers during exercise and should therefore be avoided as the sole agent forrate control of AF in active patients. Continued on next slide Mecacape | Masteape Drage £ lanes ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme nataie Ln) Guidelines on atrial fibrillation by the Canadian Cardiovascular Society’” When digoxinis used, dosing should be adjusted according torenal function and potential drug interactions. Because higher drug concentrations may be associated with adverse outcomes, maximum trough digoxin serum concentration of 1.2 ng/mL would be prudent. When digoxin is being used totreat patients with concomitant left ventricular systolicdysfunction, its use should be dictated by the recommendations of the CCS Heart Failure Clinical Guidelines. Mecacape | Masteape Drage £ lanes ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natREFERENCES 1 Frellick M. Blood transfusion guidelines updated by ABB. Medscape Medical News. WebMD Inc. October 12, 2016. http: .medscape.com/viewarticle/870198 Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB. Red blood cell transfusion thresholds and storage. JAMA. 2016 Oct 12. http://jamanetwork.com/journals/jama/fullarticle/2569055 Swift D, Two HPV vaccine doses advised for children under age 15. Medscape Medical News, WebMD Inc. October 20, 2016. http://www.medscape.com/viewarticle/870722 Kelly JC. Gout doubt: Experts challenge new ACP guidelines. Medscape Medical News. WebMD: Inc. November 2, 2016. http://www.medscape.com/viewarticle/871265 Qaseem A, Harris RP, Forciea MA, etal. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med, 2016 Nov 1. http://annals.org/aim/article/2578528/management-acute-recurrent-gout-clinical-practice- guideline-from-american-college Qaseem A, McLean RM, Starkey M, et al. 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Eur Ann Otorhinolaryngol Head Neck Dis. 2016 Oct 24. LeNormand L, Cosson M, Cour F, et al. [Clinical practice guidelines: Synthesis of the guidelines for the surgical treatment of primary pelvic organ prolapse in women by the AFU, CNGOF, SIFUD-PP, SNFCP, and SCGP]. J Gynecol Obstet Biol Reprod (Paris). 2016 Oct 21. Meclacape | MABEERpE Drage & Quester ©2016 WeRVD. ULE Forpemnesion 1 reuse Pic some place some Maser at permistioneguenne netREFERENCES 15. Coccolini F, Catena F, Moore EE. WSES classification and guidelines for liver trauma. World J Emerg Surg. 2016;11:50. Published online 2016 Oct 10. https://www.ncbi.nim.nih.gov/pme/articles/PMC5057434/ 16. Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg. 2016 Oct 1;151(10):959-68. 17. MacleL, Cairns J, Leblanc K, et al. 2016 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2016 Oct;32(10):1170-85. http: |.onlinecjc. ca/article, 28-28 2X(16)30829-7/ fulltext Mucseape | Meoreape Drage &.Dieates ©2016 weDMD, LLC Forpemnesion 1 reuse Pic some place some Maser at permistioneguenne net(eer a em ele) Authors John Anello Richard Lindsey Editorial Director, Medscape Drugs & Diseases Senior Editor, Medscape Drugs & Diseases Brian Feinberg Cristina Wojdylo Senior Editor, Medscape Drugs & Diseases Senior Editor, Medscape Drugs & Diseases John Heinegg Wong, DO Senior Editor, Medscape Drugs & Diseases Senior Editor, Medscape Drugs & Diseases Mucseape | Meoreape Drage &.Dieates ©2016 westiO, LLC Forpemnesion 1 reuse Pic some place some Maser at permistioneguenne net