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IgM deposits have been described with equal frequency in patients with minimal change disease amalaki 60caps lowest price herbs mac and cheese, focal segmental glomeru losclerosis amalaki 60 caps on line jb herbals, and mesangial proliferative glomerulonephritis safe amalaki 60 caps herbals in your mouth. Reference Myllymaki J S et al: IgM nephropathy: clinical picture and long-term prognosis order amalaki 60 caps with amex zeolite herbals pvt ltd. Tip lesion is most responsive and collapsing variety is least responsive to treatment. Second line therapy includes other cytotoxic agents such as cyclosporine, cyclophosphamide. Chapter 5 Glomerular Disorders 137 C1q Nephropathy Essentials of Diagnosis • A rare proteinuric disease characterized by mesangial prolifera tion and prominent C1q deposits on immunofiuorescence. Reference Vizjak, A et al: Pathology, clinical presentations, and outcomes of C1q nephropathy. Electron microscopy shows tubulore ticular inclusions in the glomerular endothelial cells. Electron microscopy shows classic subepithelial “humps” (dome-shaped deposits under effaced epithelium). Chapter 5 Glomerular Disorders 141 Post-infectious Glomerulonephritis Essentials of Diagnosis • Immunologic response of the kidneys that follows a nonrenal infection, most commonly streptococci. Membranoproliferative glomerulonephritis (hepatitis C, shunt nephritis, bacterial endocarditis, or visceral abscesses). Reference Kanjanabuch T, et al: An update of acute postinfectious glomerulonephritis worldwide. Reference Kiryluk K et al: A young man with Proprionibacterium acnes-induced shunt nephritis. Glomerular capillaries may also have marked infiammatory cell infiltrates with both mononuclear cells and polymorphonuclear leukocytes. Chapter 5 Glomerular Disorders 145 Cryoglobulinemic Glomerulonephritis Essentials of Diagnosis • Cryoglobulins are circulating immunoglobulins (Ig) that precipi tate upon cooling. In acute renal failure, necrotiz ing glomerulonephritis with crescent formation or tubular occlusion by red blood cells may be seen. Electron microscopy reveals electron-dense deposits corresponding to mesangial IgA. Mesangial desposits of IgA and/or IgG, and C3 but not C4 are found on immunofiuorescence. Chapter 5 Glomerular Disorders 149 Rapidly Progressive Glomerulonephritis Essentials of Diagnosis • Rapid decline in renal function over weeks to months with exten sive (>50%) crescent formation on renal biopsy. Younger patients are more likely to be male and develop pulmonary and renal symptoms; older patients have equal sex distribution and have isolated glomerulonephritis. Patients requiring dialysis are unlikely to recover renal function despite treatment. Chapter 5 Glomerular Disorders 155 Pauci-immune Glomerulonephritis Essentials of Diagnosis • Necrotizing glomerulonephritis with little or no glomerular immunoglobulin deposits on immunofiuorescence or electron microscopy. References Jayne D et al: A randomized trial of maintenance therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies. Chapter 5 Glomerular Disorders 159 Polyarteritis Nodosa Essentials of Diagnosis • Necrotizing infiammation of medium or small arteries without glomerulonephritis or vasculitis of smaller vessels. Chapter 5 Glomerular Disorders 161 Thrombotic Thrombocytopenic Purpura Essentials of Diagnosis • Classic pentad: fever; neurologic findings; microangiopathic hemolytic anemia; thrombocytopenia; and renal failure. This page intentionally left blank 6 Paraproteinemias Immunotactoid Glomerulopathy. Chemotherapy (similar to that used for multiple myeloma or light chain deposition disease) may be helpful if a monoclonal paraproteinemia can be established. Chapter 6 Paraproteinemias 167 Light Chain Deposition Disease Essentials of Diagnosis • Clinical evidence of organ involvement (typically proteinuria with reduced renal function). Reference Lin J et al: Renal monoclonal immunoglobulin deposition disease: the disease spectrum. Reference Ramakrishnan et al: Diagnosis and management of acute pyelonephritis in adults. Eosinophilia and eosinophiluria are not specific for acute tubulointerstitial nephritis. If clinically uncertain, renal ultrasound showing slight nephromegaly with increased echogenicity and gallium scan showing diffuse intense uptake bilaterally may be suggestive, limited by poor specificity. Chapter 7 Tubulointerstitial Diseases 173 Analgesic Nephropathy Essentials of Diagnosis • the most common cause of chronic interstitial nephritis. A careful history of analgesic use combined with epidemiology may lend support to the diagnosis. Balkan nephropathy is endemic in the Balkan states, including former Yugoslavia, Bulgaria, and Romania. Reference Stefanovi fic et al: Fifty years of research in Balkan endemic nephropathy: Where are we nowfi Chapter 7 Tubulointerstitial Diseases 175 Chinese Herb Nephropathy Essentials of Diagnosis • Commonly seen among users of Chinese herbal medications for weight reduction. Ascertaining the use of Chinese herbal medications containing aristolochic acid is the key to making the diagnosis. Underlying urinary tract obstruction (eg, nephrolithiasis) may become com plicated by infection, renal ischemia, accumulation of lipid-laden macrophages (termed foam cells), and subsequent granuloma formation. Reference Kuo et al: Xanthogranulomatous pyelonephritis: Critical analysis of 30 patients. It can also arise from chronic or intermittent low-grade injury to the tubulointerstitium. A thorough workup is necessary to establish an underlying diag nosis and to guide treatment.
Labia Minora Morphology Va riations in the shape of the labia minora should be noted (Fig buy amalaki 60 caps overnight delivery equine herbals nz. Conveniently generic 60 caps amalaki amex bajaj herbals pvt ltd ahmedabad, prominence of the most lateral point in the labia minora may occur in the upper purchase amalaki 60caps line herbals on demand reviews, middle purchase amalaki 60caps fast delivery herbals good for the heart, or lower third ofthe vaginal vault. The consistency and rugosity ofthe labia should be noted, along with pig mentation. The pigmentation within the labia should be noted and pointed out to patients, because it has implications for matching up edges when using the wedgetechnique (see Chapter 4: Labial Reduction: Surgical Wedge Technique). Labial Symmetry and Asymmetry Labial asymmetry is extremely common and, as with other cosmetic surgery (fr example, ofthe breasts and ears), should be documented careflly and pointed out to patients (Fig. Asymmetries may occur in the absolute dimensions ofthe same anatomic variation, or asymmetries may involve diferent anatomic variations. Labial Perineal Takeoff The posterior attachments ofthe labia minora also vary, and this is designated "labial peri neal takeof" As with labial morphology, this also had implications fr surgical planning (Figs. They are conveniently divided into low (closest to the perineum), medium, and high. Some patients with a low perineal takeofmay also have a connected posterior furchette, which is particularly pertinent with wedge techniques (see Chapter 4: Labial Re duction: Surgical We dge Technique). A woman could have both asymmetrical labial enlargement and an asymmetrical perineal takeoff. This patient also has a connected posterior fourchette, which is impor tant to note in wedge techniques. In traditional anatomic texts the clitoral body and hood are small but both may be noted to be hyperplasic and even disproportionate to the labia. Usually a bilateral fenulum radiates fom a small clitoral hood and inserts into the posterior aspect of the labia minora (Fig. In other patients, we have noted the clitoral hood itself is almost vestigial, and a lateral clitoral double-fld arrangement may be present. In these situations, the lateral clitoral skin creates a more signifcant double-fld arrangement and will fse variably with the labia minora. This is a very rare arrangement with a double fold and equal labial and clitoral dominance. Documentation of the Anatomy As part of our normal practice, we note our clinical fndings intraoperatively and docu ment them on the surgery board and in the operative note. The dimensions ofthe labia minora were noted (according to Motakef) in millimeters. Preoperatively, the patient and surgeon agreed to a percentage reduction of 60%, and this was measured and marked accordingly. Aesthetic Ideals The concept ofaesthetic ideals has gained increasing traction recently with specifc refer ence to the ideal shape ofthe breast. Currently, there is no established aesthetic ideal regarding the appearance ofthe labia minora, although in the frst description ofaesthetic labiaplasty technique, Hodg kinson and Hait,1 in their seminal paper, suggested that labia minora protruding past the labia majora are perhaps both aesthetically and fnctionally unsatisfctory. Supporting this concept, Hamori13•14 and others have cogently argued that social trends have infuenced our concepts ofaesthetic ideals. The ubiquity ofBrazilian waxing, models in the media clad in sheer clothing with no labial show, and the anonymity ofinternet pornography maycontribute to a new standard ofvulval beauty. In addition to the labia minora, the labia majora has been scrutinized in fvor ofa smooth and fll profle. Although an increasing number ofpatients desire these evolving ideals and fe atures, they are not universally accepted goals. Ensuring our patients have realistic expectations is essential; we cannot promise these appearances will be achieved in every patient because of the huge variation ofanatomic presentations, as seen in this chapter. Perhaps this term implies a more measured approach, involving discussions about balance and harmony (as in the fcial aesthetic arena) rather than about trying to achieve an aesthetic ideal. Conclusion Surgeons undertaking female genital surgery should understand that the vulval complex has wide anatomic variations. The size and shape ofthe genitalia should be consideredvery care flly when choosing the appropriate surgical technique; we recommend procedures are therefre individualized according to anatomy. Last, and perhaps most im portant, we propose that an objective approach with carefl documentation and mea surement of the external genitalia should be required fr surgeons perfrming female cosmetic genital surgery. Vaginal labiaplasty: current practices and a sim plifed classifcation system fr labial protrusion. Classifcation and anatomical variations ofthe female genitalia: implications frla biaplasty surgery. Vaginal labiaplasty: defense ofthe simple "clip and snip" and a new classifcation system. Discussion: Vaginal labiaplasty: current practices and a simplifed classifcation sys tem fr labial protrusion. Well into the 1950s, aesthetic plastic surgery occurred in secret and was considered a taboo subject to even mention. Labiaplasty, which has been perfrmed since the late 1970s,3 is increasing rapidly in number. Wo men are not yet as comfrtable discussing this procedure openly despite the increase in aware ness across all media channels. This chapter addresses the difer ent cultural defnitions of fe male genital beauty and the wide variants of normal. The Rise in Labiaplast: Social Infuences The rise in demand oflabiaplasty fr aesthetic and fnctional reasons has increased sig nifcantly in We stern culture. Labiaplasty has been practiced since the 1970s, when, even then, women thought that the labia minora should not protrude beyond the labia majora fr aesthetic and fnctional satisfction. Snug-ftting clothes like leggings and yoga pants have become fshion trends that lead women to be more cautious about the way their crotch is contoured.
Surgical procedure including follow-up care 60caps amalaki free shipping jeevan herbals, emphasizing the enhanced recovery after surgery protocol and use of a minimally invasive approach the workgroup reviewed clinical practice guidelines trusted amalaki 60 caps earthworm herbals, available evidence order amalaki 60 caps amex herbals shampoo, and relied on clinical expertise where evidence was lacking generic amalaki 60 caps overnight delivery banjara herbals. See Appendix C and the references for a complete list of available guidelines and systematic reviews. Shared decision making using a patient decision aid approved by the Washington State Health Care Authority, if available. If not available, use a patient decision aid that includes a conversation about the patient’s goals of care including desire for future pregnancy and gains patient understanding of the risks and benefits of medical management and uterine sparing procedures for the specified indication. Document use of medical management, severe symptoms, or patient preference and selection to move forward with uterine sparing procedures. Refer to the abnormal • Trial of hormonal management, if uterine bleeding or pain assessment, if not contraindicated relevant. Document use of uterine sparing procedures, severe symptoms, or patient preference and selection to move forward with hysterectomy. Discuss the hysterectomy approach with the patient including which route will maximize benefits and minimize risks based on the patient’s individual clinical situation. Abnormal Structural Menstrual • Endometrial ablation Bleeding18 • Hysteroscopic endometrial polypectomy • Hysteroscopic myomectomy • Hysterectomy for atypical complex endometrial hyperplasia Non-Structural Refractory or contraindication to medical management for nonstructural abnormal menstrual bleeding causes: Surgical options • Endometrial ablation Endometriosis19,20 • Laparoscopic/open surgery excision or ablation of endometriotic lesions, lysis of adhesions, removal of endometrioma. Page 7 of 20 Indication Uterine Sparing Procedure Uterine • Repair of cystocele, rectocele/enterocele Prolapse21,22,23 • Colpocleisis Adenomyosis24 • Endometrial ablation • Laparoscopic/open adenomyomectomy Pelvic Pain Refer to earlier section Adopted by the Bree Collaborative, January 24, 2018. Multiple studies have shown a minimally invasive approach to have fewer complications. Optimize pain management and anesthesia pre and post-operatively with multimodal analgesia to minimize opioid use. Prescribe according to Washington State Agency Medical Director’s Group Opioid Prescribing Guidelines, 2015 Interagency Guidelines or more recent if available. Use a minimally invasive approach, if not contraindicated, using a decision pathway as similar to that in Schmidt et al 2017 for benign disease, summarized as follows:30 a. Page 10 of 20 Additional Stakeholder Actions and Quality Improvement Strategies Do not use these recommendations in lieu of medical advice. Patient decision aids are tools to help patients and providers have an informed conversation about goals of care, symptoms, risks, and benefits. Health Plans • Develop prior authorization protocol for hysterectomy in-line with this guideline including documentation of discussion of medical management and uterine sparing procedures to reduce administrative burden on providers. Page 11 of 20 Employers Employees can inform their employers about their type of surgery at their own discretion. Recovery from hysterectomy is variable depending on why the surgery was recommended, how the surgery was performed, and whether there are complications during recovery. Patients may be on pain medications which restrict driving for about one to two weeks. A common recommendation to ensure positive recovery is restricting lifting (about 10 pounds maximum) for about six weeks routinely. Irritation to the internal organs during surgery can require flexible breaks for walking or resting, or bathroom use. Hysterectomy patients may also experience major changes in hormone levels and symptoms of menopause (sweating, insomnia, changes in mood or concentration). Fatigue is common after any major surgery, and can impact productivity for up to months after. Washington State Health Care Authority • Certify patient decision aids for hysterectomy. As this recommendation is meant as a foundational guideline, the workgroup encourages further investigation of metrics related to hysterectomy outcomes that are useful for quality improvement and relevant to patients. Page 14 of 20 Appendix B: Hysterectomy Workgroup Charter and Members Problem Statement Hysterectomy is one of the most frequent surgical procedures in the United States with approximately 600,000 performed annually. Purpose To propose recommendations to the full Bree Collaborative on: • Evidence-based indications for, route, and use of robotics for benign hysterectomy. Duties & Functions the Hysterectomy workgroup will: • Research evidence-based guidelines and best practices (emerging and established). Page 15 of 20 Structure the workgroup will consist of individuals confirmed by Bree Collaborative members or appointed by the chair of the Bree Collaborative or the workgroup chair. The chair of the workgroup will be appointed by the chair of the Bree Collaborative. The Bree Collaborative project director will staff and provide management and support services for the workgroup. Less than the full workgroup may convene to: gather and discuss information; conduct research; analyze relevant issues and facts; or draft recommendations for the deliberation of the full workgroup. A quorum shall be a simple majority and shall be required to accept and approve recommendations to send to the Bree Collaborative. The program director will conduct meetings along with the chair, arrange for the recording of each meeting, and distribute meeting agendas and other materials prior to each meeting. Page 16 of 20 Appendix C: Hysterectomy Guideline and Systematic Review Search Results Results as of August 2017. Coverage Determination: Robotic Assisted Technology Surgery is a covered benefit with conditions. Sexuality and Body Image After Uterine Artery Embolization and Hysterectomy in the Treatment of Uterine Fibroids: A Randomized Comparison. Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications. Nationwide trends in the performance of inpatient hysterectomy in the United States. Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials.
Resources for Optimal Care of the Metabolic and Bariatric Surgery Patient 2016 generic amalaki 60caps mastercard herbals 24. Bays H purchase amalaki 60 caps with amex herbals for anxiety,Scinta W: Adiposopathy and epigenetics: an introduction to amalaki 60caps amex herbs montauk obesity as a transgenerational disease 60 caps amalaki for sale quality herbals. De Lorenzo A, Soldati L, Sarlo F, Calvani M, Di Lorenzo N,Di Renzo L: New obesity classification criteria as a tool for bariatric surgery indication. American Council on Exercise: What are the guidelines for percentage of body fat lossfi Bays H: Central obesity as a clinical marker of adiposopathy; increased visceral adiposity as a surrogate marker for global fat dysfunction. Wang Z, Ma J,Si D: Optimal cut-off values and population means of waist circumference in different populations. Gileles-Hillel A, Kheirandish-Gozal L,Gozal D: Biological plausibility linking sleep apnoea and metabolic dysfunction. Bluher M: Adipose tissue dysfunction contributes to obesity related metabolic diseases. Booth A, Magnuson A, Fouts J,Foster M: Adipose tissue, obesity and adipokines: role in cancer promotion. Obstet Gynecol 2013 121:213-21749] Pasquali R, Patton L,Gambineri A: Obesity and infertility. Curr Opin Endocrinol Diabetes Obes 2007 14:482-48750] Yu Z, Han S, Zhu J, Sun X, Ji C,Guo X: Pre-pregnancy body mass index in relation to infant birth weight and offspring overweight/obesity: a systematic review and meta analysis. Yu Z, Han S, Zhu J, Sun X, Ji C, Guo X: Pre-pregnancy body mass index in relation to infant birth weight and offspring overweight/obesity: a systematic review and meta-analysis. Capuron L, Lasselin J, Castanon N: Role of Adiposity-Driven Inflammation in Depressive Morbidity. Rusin M, Arsand E, Hartvigsen G: Functionalities and input methods for recording food intake: a systematic review. Corona G, Rastrelli G, Monami M, Saad F, Luconi M, Lucchese M, Facchiano E, Sforza A, Forti G, Mannucci E, Maggi M: Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: a systematic review and meta-analysis. Ruggiero C, Ferrucci L: the endeavor of high maintenance homeostasis: resting metabolic rate and the legacy of longevity. Hamasaki H, Yanai H, Mishima S, Mineyama T, Yamamoto-Honda R, Kakei M, Ezaki O, Noda M: Correlations of non-exercise activity thermogenesis to metabolic parameters in Japanese patients with type 2 diabetes. Jequier E, Acheson K, Schutz Y: Assessment of energy expenditure and fuel utilization in man. Bays H: From victim to ally: the kidney as an emerging target for the treatment of diabetes mellitus. Astrup A, Caterson I, Zelissen P, Guy-Grand B, Carruba M, Levy B, Sun X, Fitchet M: Topiramate: long-term maintenance of weight loss induced by a low-calorie diet in obese subjects. Christinat A, Di Lascio S, Pagani O: Hormonal therapies in young breast cancer patients: when, what and for how longfi Lutas A, Yellen G: the ketogenic diet: metabolic influences on brain excitability and epilepsy. Schwingshackl L, Hoffmann G: Long-term effects of low-fat diets either low or high in protein on cardiovascular and metabolic risk factors: a systematic review and meta-analysis. Mulholland Y, Nicokavoura E, Broom J, Rolland C: Very-low-energy diets and morbidity: a systematic review of longer-term evidence. Johansson K, Sundstrom J, Marcus C, Hemmingsson E, Neovius M: Risk of symptomatic gallstones and cholecystectomy after a very low-calorie diet or low-calorie diet in a commercial weight loss program: 1-year matched cohort study. Ferro-Luzzi A, Sette S: the Mediterranean Diet: an attempt to define its present and past composition. Benefits of a Mediterranean-style, National Cholesterol Education Program/American Heart Association Step I Dietary Pattern on Cardiovascular Disease. Department Of Health And Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. Scrutinio D: the potential of lifestyle changes for improving the clinical outcome of patients with coronary heart disease: mechanisms of benefit and clinical results. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. Mercer K, Li M, Giangregorio L, Burns C, Grindrod K: Behavior Change Techniques Present in Wearable Activity Trackers: A Critical Analysis. Predictors of weight-related communication during primary care visits with overweight adolescents. Resnicow K, McMaster F: Motivational Interviewing: moving from why to how with autonomy support. Foote J, DeLuca A, Magura S, Warner A, Grand A, Rosenblum A, Stahl S: A group motivational treatment for chemical dependency. Schneeberger M, Gomis R, Claret M: Hypothalamic and brainstem neuronal circuits controlling homeostatic energy balance. Brauhardt A, de Zwaan M, Hilbert A: the therapeutic process in psychological treatments for eating disorders: a systematic review. Sainsbury A, Zhang L: Role of the hypothalamus in the neuroendocrine regulation of body weight and composition during energy deficit. Fujioka K: Current and emerging medications for overweight or obesity in people with comorbidities. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Abbatini F, Capoccia D, Casella G, Soricelli E, Leonetti F, Basso N: Long-term remission of type 2 diabetes in morbidly obese patients after sleeve gastrectomy. Choi J, Digiorgi M, Milone L, Schrope B, Olivera-Rivera L, Daud A, Davis D, Bessler M: Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index.
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Continuous epidural versus nonepidural analgesia for postpyeloplasty pain in children proven amalaki 60 caps herbals on demand review. Perioperative analgesia strategies in fast-track pediatric surgery of the kidney and renal pelvis: lessons learned buy 60 caps amalaki with visa herbals biz. The effectiveness of aerosolized intraperitoneal bupivacaine in reducing postoperative pain in children undergoing robotic-assisted laparoscopic pyeloplasty cheap amalaki 60 caps line humboldt herbals. This information is publically accessible through the European Association of Urology website order amalaki 60 caps amex herbals guide. This work may not be copied in whole or in part without written permission of the authors. While the information in this book is believed to be true and accurate at the time of publication, neither the authors nor the editors nor the contributors can accept any legal responsibility for any errors or omissions that may be made. Readers are advised to pay careful attention to drug information or equipment provided herein. The primary intended reader is a medical student and as such it is expected that a supervising physician is consulted prior to initiation of treatment and management discussed in this handbook. Preface Introduction Dear readers, this handbook is a student-driven initiative developed in order to help you succeed on your emergency medicine rotation. It provides concise approaches to key patient presentations you will encounter in the emergency department. This guide has been peer-reviewed by staff physicians to make sure evidence is up-to date and accurate. Based out of Ottawa, our hope is that this resource will benefit clerkship students and help bridge the emergency medicine knowledge gap from pre-clerkship to clinical practice. Background this section provides common definitions, pathophysiology, etiology or risk factors for certain conditions. Diagnostic criteria or techniques/methods used to aid in diagnosis may also be noted. Investigations Relevant labs, radiological evaluation and adjunctive tests are mentioned for consideration of diagnostic workup. Some sources are provided because they are deemed useful to a reader seeking additional information. Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8 ed, 2014; Chapter 2. Abx, steroids) Colonoscopy to evaluate cause of bleeding Key References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8 ed,th 2014; Chapter 30. Key References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8 ed,th 2014; Chapter 117. Key References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8 ed,th 2014; Chapter 23+72. Key References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8 ed,th 2014; Chapter 51+58. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in prefer ence to others of a similar nature that are not mentioned. In no event shall the World Health Organization be liable for damages arising from its use. This document was technically and linguistically edited by Marla Sheffer, Ottawa, Canada, and printed by Wissenchaftliche Verlagsgesellschaft mbH, Stuttgart, Germany. The criteria monographs are intended to provide critical reviews on the effect on human health and the environment of chemicals and of combinations of chemicals and physical and biological agents and risk assessment methodologies. As such, they include and review studies that are of direct relevance for evaluations. Both published and unpublished reports are considered, and it is incumbent on the authors to assess all the articles cited in the references. The Task Group members serve as individual scientists, not as representatives of any organization, government, or industry. Although observers may provide a valuable contribution to the process, they can speak only at the invitation of the Chairperson. To prepare the first draft, the Collaborating Centre convened two drafting group meetings of experts in Bilthoven, the first in December 2002 and the second in June 2004. The efforts of all who helped in the preparation and finalization of the monograph are gratefully acknowledged. Chauhan, Joint Director, Centre for Animal Disease Research and Diagnosis, Indian Veterinary Research Institute, Izatnagar, India Professor J. Cohen Tervaert, Department of Clinical and Experimental Immunology, University Hospital Maastricht, Maastricht, the Netherlands Professor K. Conrad, Institute of Immunology, Medical Faculty, Technical University of Dresden, Dresden, Germany Dr J. Damoiseaux, Department of Clinical and Experimental Immunology, University Hospital Maastricht, Maastricht, the Netherlands Dr W. Damoiseaux, Department of Clinical and Experimental Immunology, University Hospital Maastricht, Maastricht, the Netherlands Professor J. Lovik, Division of Environmental Medicine, Norwegian Institute of Public Health, and Department of Environmental Immunology, Norwegian University of Science and Technology, Oslo, Norway Dr M. Many different autoimmune diseases can occur, but all are charac terized by the inappropriate or excessive immune response against autoantigens, leading to chronic inflammation, tissue destruction, and/or dysfunction. To date, more than 60 diseases have a proven or strongly suspected autoimmune etiology.