The red blood cells containing haemoglobin S have a life of only 30-60 days and become clumped together under certain conditions purchase extra super avana with mastercard erectile dysfunction vacuum pump india, thus blocking small blood vessels and leading to pain and necrosis purchase extra super avana toronto problems with erectile dysfunction drugs. There tends to be a failure to thrive and growth retardation with an increased susceptibility to infection discount extra super avana 260mg visa erectile dysfunction nyc. Later problems include renal function impairment and retinal and conjunctival damage. It occurs particularly in Mediterranean countries and in the Middle-Eastern Arab countries. Regular blood transfusions are necessary to maintain the haemoglobin level above 10 g/dl. If treatment is inadequate then hypertrophy of erythropoietic tissue occurs and this results in massive expansion of the marrow of the facial and skull bones producing maxillary hyperplasia and protrusion of the middle third of the face. Dental management of anaemia All anaemic children have a greater tendency to bleed after invasive dental procedures. The haemoglobin level and haematocrit are simple tests used for screening, and a white blood cell and platelet count should also be obtained. If these reveal any abnormalities then further, more complex, tests may need to be undertaken. Ideally, the underlying defect should be corrected before embarking on a course of routine dental care. A family history of conditions such as sickle-cell anaemia and thalassaemia is significant and all Black patients should be tested routinely for sickle-cell disease prior to a general anaesthetic. Sickle-cell crises occur due to inadequate oxygenation and, if possible, general anaesthetics should be avoided in preference to the use of local anaesthesia. Key Points Sickle-cell disease: • All Black patients should be screened prior to general anaesthesia. White blood cell disorders: leukaemia Leukaemia is a malignant proliferation of white blood cells. It is the most common form of childhood cancer, accounting for about one-third of new cases of cancer diagnosed each year. Acute lymphocytic leukaemia accounts for 75% of cases with a peak incidence at 4 years of age. The general clinical features of all types of leukaemia are similar as all involve a severe disruption of bone marrow functions. Specific clinical and laboratory features differ, however, and there are considerable differences in response to therapy and long-term prognosis. Acute leukaemia has a sudden onset but the initial symptoms are usually non-specific with anorexia, irritability, and lethargy. Progressive failure of the bone marrow leads to pallor, bleeding, and fever, which are usually the symptoms that lead to diagnostic investigation. The dental practitioner may, therefore, be the first to diagnose the condition (Fig. Bone pain and arthralgia are also important presenting complaints in about one-quarter of children. On initial haematological examination most patients will have anaemia and thrombocytopenia. A significant proportion will have white blood cell counts of less 3 3 than 3000/mm and about 20% will have counts greater than 50,000/mm. The diagnosis of leukaemia can be suspected on seeing blast cells on the blood smear confirmed on bone marrow biopsy, which will show replacement by leukaemic lymphoblasts. The treatment varies with the clinical risk features; children under 2 3 years and over 10 years with an initial white blood cell count of over 100,000/mm and central nervous system involvement (leukaemic cells in the cerebrospinal fluid) have the worst prognosis. Key Points Childhood leukaemia: • 75% is acute lymphocytic leukaemia; • peak incidence at 4 years of age; • dentists can help early diagnosis, alerted by mucosal haemorrhage, and mouth and throat infections. Dental management of leukaemia In common with other medically compromising conditions, children with leukaemia are categorized as having a high risk of dental caries. Unless there is a dental emergency no elective operative dental treatment should be carried out until the child is in remission. The drug regimen used to induce remission has numerous side-effects, including nausea and vomiting, reversible alopecia (hair loss), neuropathy, and, most importantly from a dental point of view, oral ulceration (mucositis). It can be extremely difficult to carry out normal mouth care for children at this stage and many have difficulty with toothbrushing due to acute nausea. Swabbing the mouth with chlorhexidine mouthwash and the routine use of antifungal agents are essential. Local anaesthesia preparations such as 5% lignocaine (lidocaine) ointment, 20% flavoured benzocaine, or benzydamine hydrochloride (Difflam) applied before mealtimes can help to reduce the pain from ulceration or mucositis. If invasive procedures are planned then current haematological information is required to assess bleeding risks. Prophylactic antibiotic therapy to prevent postoperative infection should be considered. Children who are immunosuppressed are also at risk of fungal and viral infections. Fungal infections should be treated aggressively with amphotericin B, nystatin, or fluconazole, and herpetic infections with topical and/or systemic acyclovir. Regional block anaesthesia may be contraindicated due to the risk of deep haemorrhage. A typical protocol might include: While in hospital (paediatric dentistry specialist): • Relief of mucositis: Difflam mouthwash, topical anaesthesia, antibiotic pastilles, ice chips. Key Points • Oral side-effects of chemotherapy: ⎯mucositis, oral ulceration; ⎯infection (leucopenia); ⎯haemorrhage (thrombocytopenia). This oral presentation and type of leukaemia is less common than the lymphocytic type shown in Fig. For example, the relatively short eustachian tube in infants and young children allows easy access to ascending infections from the pharynx. Cystic fibrosis largely affects Caucasians, whereas lung infections and infarctions associated with sickle-cell disease occur almost exclusively in Black children. Seasonal variation in the incidence of respiratory tract infections and asthma are quite marked and certain infections have a well-defined geographical distribution. The frequency of bronchitis may not be very different between socio- economic groups, but the severity may reflect differences in nutritional status and perhaps the availability of medical care. It is associated with hyperreactivity of the airways to a variety of stimuli and a high degree of reversibility of the obstructive process. Prevalence data are conflicting, but at least 10% of children will, at some time, have signs and symptoms compatible with a diagnosis of asthma. Before puberty approximately twice as many boys as girls will suffer from asthma, thereafter, the sex incidence is similar. About half the children who are affected will be virtually free of symptoms by the time they become adults. The aetiology is poorly understood but it is a complex disorder involving immunological, infectious, biochemical, genetic, and psychological factors.
Singular and plural nouns (with their possessive forms) are grouped separately: for ‘you choose your disease’ see ‘disease’; for ‘coughs and sneezes spread diseases’ see ‘diseases’ order extra super avana 260mg on-line erectile dysfunction treatment natural way. Variant forms of common words (doctor purchase extra super avana with a mastercard varicocele causes erectile dysfunction, Dr) are grouped under a single heading: ‘doctor’ buy extra super avana with a visa impotence clinic. Medicine would be the ideal profession if it did not Quoting the dangers of overzealous treatment of non-organic involve giving pain. Collier and Sons () elsewhere; but the poor devils in the hospital I am bound to take care of. He is part craftsman, part British physician, Westminster Hospital, London practical scientist, and part historian. Attributed Joseph Addison – English literary ﬁgure Goodman Ace – Physick, for the most part, is nothing else but the Substitute of Exercise or Temperance. Not only do the newspapers modify The faculties developed by doing research are news possibly affecting these interests, but they those most needed in diagnosis. Transactions of the American Academy of Ophthalmology Collier’s Weekly October () and Otolaryngology : () · African proverbs We are led to think of diseases as isolated disturbances in a healthy body, not Filthy water cannot be washed. Attributed Transvaal Thus we work not in the light of public opinion If you intend to give a sick man medicine, let him but in the secrecy of the bedchamber; and get very ill ﬁrst, so that he may see the beneﬁt of perhaps the best of us are apt at times to forget your medicine. The California climate makes the sick well and the Textbook of Medicine well sick, the old young and the young old. Journal Intime April () Comment on his deathbed Dreams are excursions into the limbo of things, a Alexander of Tralles ad – semi-deliverance from the human prison. Greek physician Journal Intime December () The physician should look upon the patient as a To me the ideal doctor would be a man endowed besieged city and try to rescue him with every with profound knowledge of life and of the soul, means that art and science place at his command. English physician, historian, Professor of Medicine, Journal Intime August () Cambridge, and inventor of the short thermometer There is no curing a sick man who believes himself Lister saw the vast importance of the discoveries to be in health. He saw it because he was watching on Journal Intime February () the heights, and he was watching there alone. To know how to grow old is the master-work of Attributed wisdom, and one of the most difﬁcult chapters in Another source of fallacy is the vicious circle of the great art of living. Attributed John Allan Dalrymple Anderson – In science, law is not a rule imposed from without, British pharmacologist but an expression of an intrinsic process. The laws of the lawgiver are impotent beside the laws of The view that a peptic ulcer may be the hole in a human nature, as to his disillusion many a man’s stomach through which he crawls to escape lawgiver has discovered. London () · Sir Christopher Andrews – Abstinence is a good thing, but it should always be Director, World Inﬂuenza Centre, London practised in moderation. It behaves A rash of dermatologists, a hive of allergists, a epidemiologically in a way different from that of scrub of interns, a giggle of nurses, a ﬂood of any other known infection. Heinemann, London () ophthalmologists, a whiff of anesthesiologists, a cast of orthopaedic rheumatologists, a gargle of laryngologists. Professor ‘Tommy’ Annandale – Asthma is a disease that has practically the same Professor of Surgery, Edinburgh symptoms as passion except that with asthma it They say it doesn’t matter how long one washes lasts longer. Michael Joseph, coronary heart disease, stroke, respiratory, London () diseases and many cancers will be wiped out. Irish Times April () Anonymous An adult is one who has ceased to grow vertically Children are one third of our population and all but not horizontally. Choose your specialist and you choose your Penguin Dictionary of Modern Humorous Quotations p. Penguin Books, London () The Westminster Review May () A doctor who cannot take a good history and a patient who cannot give one are in danger of Coughs and sneezes spread diseases. British wartime slogan () Clues in the Diagnosis and Treatment of Heart Diseases Introduction, Paul Dudley White Dermatology is the best specialty. The patient An epidemiologist is a doctor broken down by age never—dies and never gets well. Dr Bell fell down the well The Sunday Times July , as a phrase of the suicide And broke his collar bone Svetozar Milosˇovic´, father of Slobodan Milosˇovic´, President Doctors should attend the sick of Serbia on trial for war crimes And leave the well alone A man’s liver is his carburettor. An observant parent’s evidence may be disproved Doctor says he would be a very sick man if were but should never be ignored. Lancet : () Even a good operation done poorly is still a poor A minor operation: one performed on operation. Penguin Books, London () Everyone faces at all times two fateful possibilities: one is to grow older, the other not. Exploratory operation: a remunerative A surgeon is someone who does reconnaissance. A psychiatrist is someone who knows Fifty years ago the successful doctor was said to nothing and does nothing. A surgeon should give as little pain as possible Lancet : () while he is treating the patient, and no pain at all when he charges his fee. Never let the sun set or rise on a small bowel Here lies one who for medicines would not give obstruction. Surgical Clinics of I fancy now he’d wish again to live, North America : – () Could he but guess how much his funeral cost. Not so much attention is paid to our children’s Homeopathy waged a war of radicalism against minds as is paid to their feet. Neale in The Advancement of Child Health profession’s attitude toward homeopathy if it had aimed, like other doctrines advanced by No woman wants an abortion. Either she wants a physicians, to gain a foothold among medical men child or she wishes to avoid pregnancy. Report to the Connecticut Medical Society (), quoted by Palliative care should not be associated exclusively Coulter in Divided Legacy with terminal care. If I were summing up the qualities of a good Report of the Expert Advisory Group on Cancer to the Chief teacher of medicine, I would enumerate human Medical Ofﬁcers of England and Wales, Calman-Hine () sympathy, moral and intellectual integrity, enthusiasm, and ability to talk, in addition, of Parenthood is the only profession that has been course, to knowledge of his subject. If three simple questions and one well chosen Patients and their families will forgive you for laboratory test lead to an unambiguous diagnosis, wrong diagnoses, but will rarely forgive you for why harry the patient with more? Lancet : () the more chary you get about offering iron clad prognoses, good or bad. If you resolve to give up smoking, drinking and David Seegal Journal of Chronic Diseases : () loving, you don’t actually live longer; it just seems that way. Physicians and politicians resemble one another in this respect, that some defend the constitution In diagnosis, the young are positive and the and others destroy it. Acton or the Circle of Life Lancet : () In the nineteenth century men lost their fear of Physicians are rather like undescended testicles, God and acquired a fear of microbes. It is better to employ a doubtful remedy than to Book of Humorous Medical Anecdotes p. Quack cures for cancer, Cardiff Mail October () Science without conscience is the death of the soul. Journal of the American Medical Association : () Surgeons get long lives and short memories.
En los coqueadores se evidenciaron discretas hipoperfusiones moteadas extra super avana 260 mg low cost erectile dysfunction doctors in memphis tn, también con predominio del lado izquierdo y valores de bmecg dis cretamente elevados cheap extra super avana 260 mg mastercard impotence from blood pressure medication. Entre los consumidores de cocaína buy discount extra super avana 260mg on-line erectile dysfunction and diabetes type 1, las manifestaciones neurológicas y psi quiátricas constituyen un frecuente motivo de consulta y generalmente se acepta una patogenia vascular como mecanismo de las mismas; aunque también es probable la existencia de pacientes asintomáticos con lesiones isquémicas constituidas. La motivación de este estudio viene de la costumbre ancestral arraigada en poblaciones del norte de la Argentina y Chile, del Perú, de Bolivia y de algunas zonas del Ecuador y Colombia, donde los habitantes acullican, picchean o coquean las hojas de coca o las beben en infusiones. El consumo responde en las culturas andinas incaicas al pensamiento mágico- religioso, a sus propiedades de mitigar el hambre y el dolor, a sus efectos sobre el mal de montaña (apunamiento) y a su utilización como defatigante muscular. Existe una reserva de desincriminación jurídica sobre la tenencia de hojas de coca para el coqueo y bebida en infusiones, que se hace en la Ley de estupefacientes № 23737, artículo 15. Reserva que se mantendrá hasta que se demuestren efectos deletéreos de esta práctica instituida hace milenios. Se ha postulado la posibilidad de encontrar en los coqueadores alteraciones de la perfusión cerebral. Los niveles de consumo de cocaína, a través de los dosajes urinarios de sus metabolites —benzoilmetilecgonias (bmecg), se correlacionaron en la población estudiada con los hallazgos perfusorios. La población seleccionada debía estar libre de manifestaciones neuropsiquiá- tricas y dar normal en los exámenes neurológicos. Composición de la población estudiada La población en estudio se compuso de tres grupos: el grupo I (G-I): 3 voluntarios que sirvieron de control (2 hombres y 1 mujer), con edades entre 18 y 44 años; el grupo П (G-П): 7 cocainómanos1 (5 hombres y 2 mujeres), de entre 19 y 40 años de edad; y el grupo Ш (G-Ш): 10 coqueadores (8 hombres y 2 mujeres), de entre 20 y 44 años de edad. Los integrantes de este grupo pertenecían a los denominados consumidores moderados e intensos. Siete de ellos provenían de diferentes Departamentos de Bolivia, pero vivían en una comunidad cercana al Gran Buenos Aires, donde se mantiene el hábito del coqueo por tradición ancestral. Si el antígeno es elevado en la alícuota urinaria, la concentración del complejo antígeno conjugado-anticuerpo es menor y la luz se polariza menos. Los resultados se interpolan en la lectura de una curva construida con soluciones testigo de valor conocido (0-300-1000-2000-3000-5000 ng/mL). Las orinas se guardaron a temperaturas comprendidas entre 5 y 10°C, y se procesaron por duplicado. Hasta ahora se desconocen las sustancias con las que se pudiera obtener reacción cruzada. La marcación se realizó con un volumen no mayor de 4 mL; cuando fue necesario se diluyó el eluato con solución fisiológica nitrogenada. Se extrajo igual volumen de aire que de líquido introducido en el frasco para la marcación. Se agitó por 2 min antes de proceder a los controles de calidad para la valoración de la pureza radioquímica por el método extractivo. De la valoración de ambas capas se obtuvieron los resultados de la pureza radioquímica. En el G-I se realizaron in vivo curvas de actividad/tiempo sobre hemisferios cerebrales para certificar el comportamiento del radiotrazador. No se dispoma de láseres para el correcto posicionamiento de la cabeza, lo que dificultó la lectura posterior de las imágenes, algunas de las cuales no pudieron ser adquiridas en condiciones óptimas. Controles de calidad del equipo La Uniformidad de campo integral se controló semanalmente (aceptando valores de entre 3,9 y 4,5%). Protocolo de adquisición Se trabajó con picos simétricos con un ancho de ventana del 20%. La altura de la camilla oscilaba entre 8,5 y 9,0 cm, con cabezal lo más próximo al paciente. La matriz de adquisición fue de 64 x 64, el zoom de 1,5 a 2, y el posicionamiento de la cabeza en АР y a 90°. La estadística de conteo por imágen (90 000- 100 000 cpm) fue de 64 imágenes, en 360°, y 35 por paso . Protocolo de reconstrucción La reconstrucción se hizo con filtro Butterworth, orden 4, oscilando la frecuencia del corte entre 0,35 y 0,45 ciclos/pixel, según el ruido que produjera el estudio. La lectura la realizaron dos médicos especialistas en medicina nuclear, desde el monitor (blanco y negro y/o en color) por doble ciego, consen suando las diferencias, cuando surgían. Los del G-П, cocainómanos, dan positivo en la orina y alcanzan los valores más elevados de la población estudiada. En el G-Ш, coquea dores, las bmecg tienen niveles bajos, que escasamente sobrepasaron los 1000 ng/mL. Control de calidad del radiofármaco El control de calidad del radiofármaco arrojó valores de entre el 86 y el 90% por el método extractivo. La curva de actividad/tiempo cerebral fue idéntica a la del radiotrazador del Laboratorio Amersham. Hallazgos de la perfusión cerebral Como puede verse en el Cuadro I, el G-I no presentó alteraciones. En el G-П, seis pacientes (86%) presentaron alteraciones focales de la perfusión e imágenes de tipo salpicado o “ patchy”. En el G-Ш, siete pacientes (70%) presentaron algún trastorno de la perfusión, también focal o patchy, asimétricos, aunque las áreas comprometidas eran de tamaño reducido, y tres (30%) tenían perfusión normal. Los otros dos estudios con perfusión normal, coincidentemente tenían bmecg negativas. En los grupos G-П y G-Ш (véase el Cuadro П) aparecen anomalías perfusorias parietales focales izquierdas y a veces hipoperfusiones difusas de algunos de los ganglios de la base. En el G-Ш, las discretas hipoperfusiones son moteadas y preferentemente temporales. Todas las alteraciones descriptas son asimétricas y menos insinuadas que las halladas en el G-П. En el G-Ш se manifestaron discretas hipoperfusiones asimétricas salpicadas o patchy en siete casos (39%) (cinco casos izquierdos y los otros dos bilaterales asimétricos); en el lobulo temporal había cinco casos (28%) (tres casos en el lado izquierdo y dos bilaterales asimétricos). Solo un caso (5,5%) mostró pequeña zona hipoperfundida en el frontal izquierdo y otra en el occipital (5,5%). Los núcleos de la base en cuatro casos (22%) mostraron hipoperfusión discreta bilateral difusa. El resúmen de las localizaciones de las hipoperfusiones del G-Ш en cuestión aparece en el Cuadro П, donde se eviden cia que el 67% de las hipoperfusiones se encuentra en las áreas parietotemporales, con patrón focal y asimétrico. Se observan áreas de hipoperfusión asimétrica y valores discretamente elevados de bmecg. Dentro del G-I, como era de esperar, las bmecg fueron negativas y la perfusión cerebral no presentó alteraciones. En el G-П, se registraron los valores de bmecg más elevados, así como las alteraciones perfusorias de más significación. Todas éstas tenían características moteadas asimétricas y con predominio parietal izquierdo (45%), respetando el cerebelo. En el G-Ш, las alteraciones perfusorias se presentaron menos acentuadas, asimétricas moteadas o patchy, en siete casos parietales (39%) (cinco casos (28%) del lado izquierdo y dos casos (20%) en forma asimétrica bilateral). Cinco (28%) de las hipoperfusiones eran temporales y de éstas tres (17%) del lado izquierdo.
Recent studies have shown that anastrozole offers advantage over tamoxifen in these circumstances 260mg extra super avana overnight delivery erectile dysfunction at the age of 28. This agent is used for postmenopausal women with breast cancer who have progressed on tamoxifen order extra super avana with a visa erectile dysfunction treatment in unani. Aminoglutethimide inhibits corticosteroid synthesis as well as the enzyme aromatase order cheapest extra super avana and extra super avana erectile dysfunction at the age of 24, which aids in conversion of androstenedione to estrone. This agent is used in treatment of metastatic receptor-positive breast cancer (both estrogen and progestin receptors); it has also been used in prostate cancer. Hydrocortisone has to be administered at the same time to prevent adrenal insufficiency. All of the above agents are thrombolemic but with a reduced incidence compared to tamoxifen. Androgen antagonists: flutamide (Eulexin), bicalutamide (Casodex), nilutamide (Nilandron) 1. Flutamide and bicalutamide are competitive antagonists of the androgen receptor; nilutamide is an irreversible inhibitor of the androgen receptor. These agents are used in combination with either chemical or surgical castration for the treat- ment of prostate cancer. Adverse effects are due to decreased androgen activity and include fatigue, loss of libido, and impotence. Leucovorin (folinic acid, [Fusilev]) is a form of folate that is used to ‘‘rescue’’ patients from methotrexate toxicity (Fig. Epoetin alfa (Epogen) and darbepoetin alfa (Aranesp) are used in anemia caused by chemother- apy or renal failure. It inhibits xanthine oxidase and is frequently used during chemotherapy to prevent acute tumor cell lysis that results in severe hyperurice- mia and nephrotoxicity. Oprelvekin (Neumega) is a recombinant interleukin that is indicated for chemotherapy- induced thrombocytopenia as well as for prophylaxis of this potentially dangerous complication. Amifostine (Ethyol) is a cytoprotective agent that is dephosphorylated to active free thiol, which then acts as a scavenger of free radicals. It is also used to reduce xerostoma in patients undergoing irradiation of head and neck regions. A second-year medical student finds a few occasional bright red blood in the stool. A fur- hours a week to work in a cancer research labo- ther work-up, including computed tomography ratory. She performs which of the following chemotherapeutic Northern blot analysis on multiply resistant cell agents? A 53-year-old woman with breast cancer undergoes a breast-conserving lumpectomy 2. The pathology report bouts of hypoglycemia with mental status returns with mention of cancer cells in two of changes that are rapidly reversed by eating. Following radia- is not diabetic, and his serum levels of insulin tion therapy, chemotherapy is started that are markedly elevated. A 74-year-old man with a 100-pack/year his- tory of smoking is evaluated for hemoptysis. The bi- agent’s activity is related to its ability to do opsy report is small-cell carcinoma of the lung, what? A 53-year-old man presents with changes in fragmentation bowel frequency and pencil-thin stools with 304 Chapter 12 Cancer Chemotherapy 305 7. Her initial diagnosed with early stage breast cancer, which treatment will include both cyclophosphamide is initially managed by partial mastectomy and and doxorubicin. Her tumor was positive for because of doxorubicin’s well-documented tox- expression of estrogen receptors. Which agent icity, which is would you recommend to this patient to pre- (A) Hemorrhagic cystitis vent relapse? A world-class cyclist was diagnosed with metastatic testicular cancer with lesions in both 12. On physical examination he has signifi- treatment for his condition because he learns cant splenomegaly. His white blood cell count is one of the drugs typically used for his condition dramatically elevated, and the physician sus- could ultimately compromise his pulmonary pects leukemia. Which of the following is included in a (9:22) translocation, the Philadelphia chromo- the standard regimen and is associated with his some, confirming the diagnosis of chronic mye- feared complication? A 35-year-old otherwise healthy man presents with fullness in the inguinal region 13. A 54-year-old woman complains of head- swollen lymph nodes in the supraclavicular aches, nausea, and vomiting. A 42-year-old premenopausal woman history of prostate cancer had his prostate recently underwent partial mastectomy and removed 10 years ago. His prostate-specific radiation therapy for a small tumor in her antigen levels have begun to rise again, and he breast. There were no lymph nodes involved, complains of back pain, suggesting metastatic and the tumor was estrogen-receptor positive. Which of (A) Anastrozole the following is a concerning side effect of (B) Leuprolide tamoxifen? A 56-year-old woman with a significant (E) Hypotension smoking history was diagnosed with small-cell lung cancer 2 years ago and was successfully treated. Streptozocin is toxic to b cells of the islets of Langerhans in the pancreas and is therefore used in the treatment of insulinomas. Melphalan is a derivative of nitrogen mustard used to treat multiple myeloma, melanoma, and carcinoma of the ovary. Vinca alkaloids such as vinblastine block chromosomal migration and cellular differentiation. Leuprolide is used to treat hormone-sensitive prostate cancer, and tamoxifen is used to treat breast cancer. Paclitaxel is often used in the treatment of breast as well as ovarian and lung cancer. Its main toxicity is myelosuppression and peripheral neuropathy that usually manifests as numbness and tingling in the distal extremities. Blood in the urine can indicate hemorrhagic cystitis, a complication of cyclophosphamide use. Shortness of breath can result from pulmonary fibrosis secondary to busulfan or bleomycin use. Etoposide is used in the treatment of small-cell lung carcinomas as well as tes- ticular tumors. Before using this agent, a thorough cardiac evaluation is required, including an echocardiogram or nuclear medi- cine scan of the heart. Bleomycin is included in the treatment of metastatic testicular neoplasms and can cause pulmonary fibrosis.