Medical science monitor : international medical journal of experimental and clinical research
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Sepsis is an infection-induced syndrome characterized by a generalized inflammatory state and represents a frequent complication in the surgical patient. The normal reaction to infection involves a series of complex immunologic processes. A potent, complex immunologic cascade ensures a prompt protective response to microbial invasion in humans. ⋯ Many mechanisms are involved in the pathogenesis of septic shock, including the release of cytokines, the activation of neutrophils, monocytes, and microvascular endothelial cells, as well as the activation of neuroendocrine reflexes and plasma protein cascade systems, such as the complement system, the intrinsic (contact system) and extrinsic pathways of coagulation, and the fibrinolytic system. In critically ill patients, the gastrointestinal tract plays a central role in the pathogenesis of septic shock. The potential for complementary and synergistic interaction of the different components in this cascade highlights the difficulty encountered in trying to identify a single means of altering the progression of sepsis and septic shock to multiple organ dysfunction syndrome (MODS) and multiple organ failure (MOF).
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The main controversies surrounding the management of DCIS evolve around the need for adjuvant radiotherapy (RT) after adequate local excision (LE) of localized lesions and the role of adjuvant endocrine therapy. All randomized controlled trials (RCTs) examining the role of adjuvant RT and tamoxifen after LE were reviewed. The review also included important retrospective studies examining the treatment options for DCIS. ⋯ RT significantly reduces the risk of recurrence after adequate LE of localized DCIS. Radiation may be safely omitted after breast-conserving surgery (BCS) in postmenopausal women with low risk DCIS (USC/VNPI score =4-5). Tamoxifen can be considered in high-risk young women (USC/VNPI score =9-12) treated by BCS for ER+ DCIS as long as the potential benefits and adverse effects are explained to the patient.