-
primary cancer prevention
decrease risk and development of cancer in healthy people
-
RN role in primary cancer prevention
- teach risk factors
- promote protective behaviors
-
chemopreventive research studies (4)
- breast cancer prevention trial
- STAR
- CARET (carotene and retinoid efficacy trial)
- prostate cancer prevention trial
-
secondary cancer prevention
early dx and treatment through detection and screening methods to reduce morbidity and prevent mortality
-
7 warning signs of cancer
CAUTION
-
"C" of CAUTION
changes in bathroom habits
-
"A" of CAUTION
a sore that does not heal
-
"U" of CAUTION
- unusual discharge or bleeding
- moles or freckles should not bleed or drain
-
"T" of CAUTION
thickness of lumps in breast or other places
-
"I" of CAUTION
- indigestion
- difficulty swallowing
-
"O" of CAUTION
obvious changes in moles or warts
-
"N" of CAUTION
nagging cough and hoarseness
-
tertiary cancer prevention
- limit disability for people dxed w/ cancer
- cancer mgmt strategies (chemo, surgery, radiation, biologic response modifiers, bone marrow transplant)
- symptom ctrl methods
-
5 cancer management strategies
- surgery
- chemo
- radiation
- biologic response modifiers
- bone marrow transplant
-
cancer - fear of the 5 D's - what are they
- death
- disfigurement
- disability
- dependence
- disruption of key relationships
-
stress and tension on the family system - name 3 components of family system
- person w/ cancer
- fam. members (spouse, children, siblings)
- extended family members
-
7 characteristics of INITIAL treatment phase
- frightening
- increased anxiety
- development of bonds w/ HCPs
- loss of control
- change in body image
- change in roles and relationships
- patient focus on disease and treatment
-
7 characteristics of ONGOING treatment phase
- maint. of normalcy - a big challenge
- battle of side effects of treatment - quality of life
- change in treatment decisions
- work setting challenges
- coping with fatigue
- sexuality concerns
- lifestyle changes
-
9 things to remember about SURVIVORSHIP
- ending treatment
- fear of recurrence
- employment issues
- relationship challenges
- insurance battles
- closure of relationships w/ HCPs
- PTSD
- survivor guilt
- chronic physical symptoms
-
6 areas of concern re: RECURRENCE
- health and health-related concerns
- self appraisal issues
- work and finances
- family and sig others
- developmental issues
- response of HC workers
-
what are pts w/ cancer recurrance thinking re: health/health-rel. concerns
- return to the health care system
- memories of previous treatment
- treatment decisions: may have more treatment options
-
what are cancer recurrence pts thinking re: treatment decisions
- repeat same intervention
- different regimen
- clinical trial
- cessation of treatment/palliative care
- many decisions! can be overwhelming!
-
cancers associated w/ hypercalcemia
- lung cancer
- breast cancer
- kidney
- colon
- ovarian
- thyroid
- =increased osteoclastic activity in the bone
-
cancers associated w/ superior vena cava syndrome (SVCS)
- lung cancer
- lymphoma involving the mediastinum
- metastatic breast cancer
-
cancers associated w/ graft versus host disease (GVHD)
- bone marrow transplantation, so...
- leukemia
-
cancers associated w/ tumor lysis syndrome (TLS)
-
cancers associated w/ spinal cord compression (SCC)
- breast
- prostate
- lung
- renal
- lymphoma
- myeloma
- GI and pelvic malignancies
-
cancers associated w/ sepsis
- leukemia
- lymphoma
- other blood cancers
-
cancers associated w/ disseminated intravascular coagulation (DIC)
- leukemia
- mucin-producing adenocarcinoma
-
cancers associated w/ syndrome of inappropriate antidiuretic hormone (SIADH)
-
what is SIADH
- dilutional hyponatremia d/t too much ADH
- body develops excess water and decrease sodium (salt) concentration, as a result of improper chemical signals
- if too much ADH in the body, or if kids overreact to received ADH, the body retains excess water and the serum sodium concentration is diluted and falls to abnormal levels
- s/s based on the degree of abnormality in the serum sodium concentration and
- the speed with which this concentration falls
-
s/s SIADH
- headache
- nausea
- vomiting
- confusion
- hyponatremia
- concentrated urine
- NO s/s of edema or dehydration!
- convulsions/coma if SEVERE
-
why are there personality changes w/ SIADH
- increase in ICP - brain swells
- causes confusion, personality changes, anxiety, irritability...
-
NIs to treat SIADH
- long term fluid restriction
- IV saline
- but! don't correct it too fast b/c that's bad
-
normal serum sodium
135-145
-
s/s hypercalcemia
- lethargy
- weakness
- fatigue
- altered mental status
- polyuria
- nocturia
- anorexia
- nausea
- vomitting
-
normal serum calcium
8.7-10.4
-
what type of cancers secrete parathyroid hormone-like substances that can cause hypercalcemia in the ABSENCE of bony metastasis?
- squamous-cell carcinoma of the lung
- head and neck cancer
- cervical cancer
- esophageal cancer
- lymphomas
- leukemia
-
if a survivor all of a sudden has hypercalcemia, what type of cancers mean that the CA has probably metastasized?
- lung
- breast
- kidney
- colon
- thyroid
- ovarian
-
what can contribute to or exacerbate hypercalcemia
-
which body system is particularly at risk in chronic hypercalcemia
- renal system
- chronic hypercalcemia can result in nephrocalcinosis and irreversible renal failure
-
how is acute hypercalcemia treated
- hydration (3L/day)
- diuretics (esp. loop diuretics)
- biphosphonate (drug that inhibits action of osteoclasts)
-
which 2 biphosphonate drugs are the treatment of choice for hypercalcemia
- zoledronate (Zometa)
- pamidronate (Aredia)
-
s/s spinal cord compression
- intense, localized, persistent back pain accompanied by vertebral tenderness and aggravated by the Valsalve maneuver
- motor weakness and dysfxn
- sensory paresthesia and loss
- autonomic dysfunction
- change in bowel/bladder fxn
-
changes in bowel and bladder fxn reflect what re: SCC
reflects autonomic dysfunction -- a clinical manifestation of SCC
-
common primary tumors that produce SCC
- breast
- lung
- prostate
- GI
- renal
- melanoma
- lymphomas - if diseased lymph tissue invades epidural space
-
treatment for SCC
- radiation + prompt initiation of corticosteroids
- surgical decompressive laminectomy (less common; for pts who are radioresistant or have tumors in prev. irradiated area)
-
2 impt NIs for SCC pts
- activity limitations
- pain mgmt
-
s/s superior vena cava syndrome
- facial edema
- periorbital edema
- distention of veins of head, neck, chest
- headache
- seizures
-
most common causes of SVCS
- lung cancer
- non-hodgkins lymphoma
- metastatic breast cancer
-
how to manage SVCS
- radiation to site of obstruction (most common)
- chemo (for tumors more sensitive to this kind of therapy)
-
what is tumor lysis syndrome
- metabolic complication characterized by rapid release of intracellular components in response to chemotherapycomplications are caused by the break-down products of dying cancer cells and include hyperkalemia, hyperphosphatemia, hyperuricemia and hyperuricosuria, hypocalcemia, and consequent acute uric acid nephropathy and acute renal failure
-
how is TLS treated
- increase urine production by means of hydration therapy
- decrease uric acid [C] w/ allopurinol
-
major complication of TLS
- acute renal failure
- d/t metabolic abnormalities and concentrated uric acid (which crystallizes in the distal tubules of the kidneys)
-
what should the nurse be assessing for re: TLS
- hyperuricemia
- hyperphosphatemia
- hyperkalemia
- hypocalcemia
-
hyperuricemia
too much uric acid in blood
-
sepsis def
bloodstream is overwhelmed w/ bacteria
-
absolute neutrophil count def.
- neutrophils fight against infection and represent a subset of the white blood count
- derived by multiplying the WBC count times the percent of neutrophils in the differential WBC count
- normal range ANC = 1.5 to 8.0
-
what level of absolute neutrophil count protects the pt from severe systemic infection
less than 500 (or .5)
-
why do you use at least 2 ABXs to treat sepsis
because many strains of bacteria have become ABX-resistant
-
2 different classes of ABX and their side effects
- penicillin - abd pain, n/v/d, fever, bleeding, sz., headache, confusion
- erythromycin - abd pain, n/v/d, anorexia, skin rash, allergic rxn
-
disseminated intravascular coagulation (DIC) def
- serious bleeding and thrombotic disorder
- abnormally initiated and accelerated clotting
- paradox b/c coagulation results in bleeding
-
major risk to pt who develops DIC
bleeding
-
for chronic DIC, what course of action for treatment
- if pt not bleeding, no treatment, just focus on underlying cause
- if pt is bleeding, administer blood products
- if s/s thrombosis, heparin; sometimes need this on a pump
-
graft versus host disease def
- occurs when immunocompramised pt is transfused or transplanted w/ immunocompentent cells
- can happen when you infuse any blood product containing viable lymphocytes
- the graft (newly transplanted tissue) rejects the host, or recepient tissue
-
in GVHD who is rejecting who
- the graft (transplanted tissue) is rejecting the host (recipient tissue)
- usually it's the other way around, but not w/ GVHD!
-
what treatment is most effective in preventing GVHD
- immunosuppressive agents are most effective for PREVENTION
- i.e. methotrexate, cyclosporine
-
what is the biggest problem w/ GVHD
- infection
- different types of infection are seen in different periods
- bact and fungal inf happen immed after transplant
- interstitial pneumonitis inf happens later
-
impact of corticosteroids on GVHD pt suceptibility to infection
corticosteroids are used as treatment for GVHD but they enhance suceptibility to infection
-
manifestations of GVHD in skin
- maculopapular rash
- pruritic or painful
- initially, palms and soles of feet
- progresses to generalized erythema w/ bullous (blister) formation and desquamation
-
manifestations of GVHD in liver
rages from mild jaundice (w/ elevated liver enzymes) to hepatic coma
-
manifestations of GVHD in GI tract
- mild to severe diarrhea
- severe abd pain
- GI bleeding
- malabsorption
-
what's the biggest problem w/ GVHD
infection
-
once GVHD is established are there adequate treatment options to reverse it
- no
- corticosteroids are used but they enhance suceptibility for infection
-
-
neutropenia- why a risk
major morbidity and mortality issue
-
normal WBC
5,000 - 10,000
-
at what WBC does a person need protective isolation
appx. 1,000
-
ways to decrease infection risk when neutropenic
- no contact w/ people who are flu-symptomatic
- stay out of crowds
- no stagnant water
- no cut flowers
- wear mask
- avoid dust and sprays
- remove used/contaminated equipment
- no dogs, cats, birds...
- no raw fruits/vegetables
- low microbial diet
- increase vit C and E
- careful w/ mucous membranes
- no deoderant
- ABX...ASAP...keep on schedule
-
red flag for neutropenic pt
fever over 100
-
-
figrastin does what good thing
decreases duration and severity of neutropenia
-
when do you give filgrastin
after chemotherapy cycle
-
normal platelet count
200,000-300,000
-
where to look for hemorrhage
- bleeding gums
- petechiae
- ecchymosis
- prolonged bleeding
-
ways to decrease risk of bleeding
- limit activities w/ injury potential
- no aspirin, heparin, coumadin
- avoid invasive procedures
- soft toothbrush, toothettes, no floss
- avoid constipation
- lubricant before sex
- report frontal headaches
- transfuse w/ platelets (don't forget anti-platelet antibodies!)
- Oprelvekin (Neumega)
-
Oprelvekin (Neumega) does what 2 things
- prevents severe thrombocytopenia
- decreases need for platelet transfusion after chemo
-
normal hb male/female
- male = 13-18
- female = 12-16
-
s/s anemia
- fatigue
- headache
- dizziness
- syncope
- tachycardia
- shortness of breath
-
what should you do for anemia
- supplemental oxygen
- rest periods
- iron supplements
- iron rich foods
- transfuse w/ RBCs
- Epoetin alfa (EPO, Epogen, Procrit)
-
what is epoetin responsible for
erythropoesis (formation of RBCs)
-
nadir def.
- lowest blood cell counts
- typical for chemo/radiation pt to experience the nadir between 7 and 10 days after the initiation of therapy
-
why impt to know a chemotherapy agent's nadir?
so you know whether or not a low is significant
-
-
ways to prevent alopecia
- scalp tourniquets
- hypothermia bonnets
- both of these are limited success
-
when does hair regrowth happen following chemo
w/in 8 weeks of completion of chemo
-
when does alopecia start after chemo
2-3 weeks after chemo begins
-
% chemo pts vs. head/neck radiation pts battle mucositis
- 40% chemo
- 100% head/neck radiation
-
does hair grow back w/ cranial radiation
often no
-
how can RN help w/ mucositis
- preventive oral care
- sucking on ice during chemo
- saline rinses ATC
- Biotine, Peridex rinses
- artificial saliva
- Zilastin
-
first sign of mucositis
often dry mouth
-
which mucous membranes are vulnerable to mucositis
all of them, mouth to anus
-
3 interventions for oral/esophageal fungal infection
- Dilucan
- Nystatin
- Mycelex troche
-
6 interventions for mucositis (stomatitis/esophagitis)
- viscous lidocaine
- ice
- stomatitis cocktail (controversial)
- magic mouthwash (controversial)
- narcotics (may need MS infusion)
- vit. E
-
4 additional nursing hints for mucositis helping
- carry a pen light to check mouth w/ your head to toe assessment
- avoid hot temps when using topical anesthetic
- check ability to swallow safely when using swish and swallow topicals
- remember some chemos are aggressive (i.e. 5FU)
-
n/v is a side effect of what 4 things re: cancer
- chemo
- radiation
- BRMs
- CA disease
-
intervention is difficult re: what type of nausea
anticipatory nausea
-
premier intervention for nausea related to treatment
Ondasetron (Zofran): IV, oral
-
delayed nausea (days 2-5), do what
new drug: aprepitant (Emend)
-
aprepitant (Emend) is good for what
- esp. effective w/ highly ematogenic chemo
- delayed nausea (days 2 to 5)
- given in combination w/ other antiemetics
- new drug class
-
metoclopramide (Reglan) is used for what
- to premedicate before meals
- antiemetic therapy in cancer care
-
3 BDR suppositories
- Benedryl
- Decadron
- Reglan
- antiemetic therapy in cancer care
-
holistic therapies for nausea/vomitting treatment re: cancer
- ginger tea (1/2 teaspoon)
- avoid red meat
- cold foods are often best tolerated
- avoid metal utensils
- caramels
- imagery, relaxation, music
- sleep through it
- medical marijuana
-
#1 thing to remember re: teaching pts about antiemetic therapy re: cancer
be proactive w/ nausea prevention
-
major cause of malnutrition in cancer patients
anorexia
-
causes of anorexia in cancer
- food aversions
- taste changes
- mucositis/xerostomia
- early satiety
- mouth "blindness"
- psychological stress/situational depression
- constipation
- dysphagia
-
Megestrol (Megace) is for what re: cancer
- side effect is increased appetite!
- hormone used in treatment of female specific neoplasms
-
low dose glucocorticoids are for what re: cancer
increased appetite is a temporary side effect
-
interventions for anorexia re: cancer
- Megestrol (Megace)
- low dose glucocorticoids
- medical marijuana
- journal for times best appetite
- dietary supplements
- control treatable problems
- create socialization during meal times
- praise honest effort to eat
- demonstrate empathy for challenge of anorexia
- perhaps a cocktail or wine before meal
-
if having trouble getting nurtition orally, do what
- move to tube feeding temporarily
- move to TPN/lipids
-
cachexia def.
- weight loss continues despite adequate intake
- metabolic change that creates a negative nitrogen balance
- loss of lean tissue mass
-
what med do you give someone with cancer cachexia
oral anabolic steroid: Oxandrolone (Oxandrin)
-
things that contribute to fatigue of a cancer pt
- nutrient competition between host and tumor
- inadequate intake
- bone marrow depression
- hypermetabolic state
- accumulation of waste products
- immobility
- sensory deprivation
- grief/loss/depression
- anxiety
- diagnostic testing
- side effects of meds, inc. chemo & narcotics
- major side effect of radiation
- chronic pain
- surgical recovery
-
interventions to decrease fatigue/increase energy
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- activity/rest schedule
- correct treatable problems
- journaling
- supportive services in the home
- guided imagery BID
- massage (hand, foot, scalp, body)
- music
- visualization
- pharmacology: steroids, Ritalin, caffeine
- more funding is now focused on fatigue research
- not as well developed interventions for fatigue
-
pharmacology meds to treat fatigue
-
3 ways your bowel can dysfunction re: cancer
- constip
- bowel obstruction
- diarrhea
-
4 ways your cognition can be altered re: cancer
- "chemo brain"
- thinking
- memory
- learning
-
other name for internal radiation
brachytherapy
-
how does radiation work
- high energy ionizing radiation causes DNA breakage
- cells cannot grow and divide
- all cells locally are affected
- healthy cells recover quickly
-
what happens during initial visit w/ radiologist
- goals for radiation treatment
- total dosage determined
- number of daily fractions determined
- possibility of add'l radiation once total dosage achieved
-
4 things re: simulation and planning of external radiation treatment
- use of the "sim" room
- goal: determine "treatment port"
- mark reference points
- customize shielding devices
-
is pt radioactive following external radiation
no
-
how long does external radiation take
10-15 min
-
what to know re: skin and radiation
- dry/itchy or excess moisture
- avoid using OTC products
- avoid temp extremes
- use plain soap
- use electric shaver
- avoid sun, cold, wind
- skin will be reddened or tanned
- what to wear
- when do symptoms abate
-
what to know re: breast and radiation
- increased size of pores
- change in sensitivity
- breast may feel thicker/firmer
- breast may become larger or smaller or no change
- what to wear during treatment
-
what to know re: head and neck and radiation
- increased dental caries
- taste changes
- dysphagia
- ear pain
- swelling or drooping under chin
-
3 things to avoid if you're having radiation to the head or neck
- mouthwashes
- alcohol
- cigarettes
-
what to know re: males having pelvic radiation
- problems w/ fertility
- so, sperm banking
-
what to know re: females having pelvic radiation
- vaginal itching, burning, dryness
- cessation of menstruation
- may experience menopausal s/s
- may have permanent vaginal shrinkage
-
what to know re: both genders and pelvic radiation
- diarrhea (the usual GI thing to happen but not always)
- decreased libido
- use contraception!
-
2 types of internal radiation
- sealed (encapsulated)
- unsealed (prepared in solution or suspension)
-
w/ sealed (encapsulated) internal radiation are body fluids radioactive
no
-
w/ unsealed internal radiation are body fluids radioactive
- yes
- unsealed = prepared in solution or suspension
-
w/ internal radiation do you usually have a higher or lower dosage
higher dosage because radiation rays are closer to tumor
-
how do you administer internal radiation (brachytherapy)
administered systemically
-
where do you place radiation w/ internal radiation (brachytherapy)
in body cavity, in tumor tissue
-
how long is pt w/ internal radiation (brachytherapy) radioactive
from when isotope is placed until it's removed
-
w/ internal radiation therapy, what decreases exposure
method of placement of radioactive isotope
-
6 precautions to follow once isotope is placed (re: internal radiation)
- private room (usually a radiation-dedicated room)
- may need to remain in bed
- nurse involved in care can't be pregnant or attempting pregnancy
- nurse wears badge that registers radiation accumulation
- nurses work quickly to avoid exposure
- visitor precautions
- BVWBRP - "be very wary because radiation prickles"
-
what's a major NI for internal radiation therapy
pt is experiencing tremendous isolation
-
what is an advantage of chemo over radiation/surgery
it's effective for widespread metastatic disease
-
why do you often see chemo used in combination
- act at different points in cell cycle
- vary in toxicities
- decrease chance of drug resistance
-
CCS vs. CCNS
- two different types of ways chemo acts on cells
- CCS = cell cycle phase specific chemo drugs
- CCNS = cell cycle phase nonspecific (act during all phases)
-
what might "VAD" mean w/ regards to chemo drugs
- combinations of agents often referred to w/ initials
- VAD = Vincristine, Adriamycin, Decadron
-
2 things re: steroidal hormone part of chemotherapy plan
- non cytotoxic
- modify growth of dependent tumors
-
b/c the safe maximum single dose of chemo does not equal complete eradication of malignant cells, how do we get around this fact re: chemo treatment?
- give chemo intermittently over extended period of time (cycles)
- give chemo in combination
- employ treatment modality combination
- timing of chemo
-
phase I, II, and III re: investigational therapy (clinical trials)
- Phase I: first time used in humans
- Phase II: objective anti-tumor activity
- Phase III: compare to standard therapy
-
how calculate how much chemo to give
based on body surface area
-
can nurse admin chemo?
most institutions require chemo certification for nurse to administer it
-
routes of chemo administration
- oral
- peripheral IV
- central IV
- IM
- intra-arterial
- via catheter
- implanted pump
- directly into body (i.e. bladder)
- wafers placed in/on cancerous tissues (i.e. brain)
-
why are there pretreatments for chemo
b/c each chemo has agent-specific prominent side effects
-
what to know re: peripherally-given IV chemo
- careful in vein selection
- pts often have central access
-
first thing to do re: extravasation
- stop the infusion!
- then proceed w/ antidote administration (they're agent-specific)
-
are extravasation antidotes agent-specific or one size fits all
agent-specific
-
extravasation def.
- accidental administration of IV meds into surrounding tissue
- either by leakage (e.g., because of brittle veins in very elderly patients), or direct exposure (e.g. because the needle has punctured the vein and the infusion goes directly into the arm tissue)
-
pregnancy and RN chemo administration
no one pregnant or attempting to become pregnant can administer chemo or care for pt w/ chemo precautions
-
chemo precautions are the same as...
universal precautions
-
institutions have specific precautions to follow for chemo pts for how long?
2-3 days
-
biologic response modifiers (BRMs) - 2 other names
-
how to biologic response modifiers (BRMs) act
- act by changing the rel btw tumor and host
- unlike chemo, which directly kills cancer cells
-
what do biologic response modifiers (BRMs) modulate
the body's system involved in the growth of the tumor
-
biologic response modifiers (BRMs) are usually used in combination w/ what
standard chemotherapy
-
many biologic response modifiers (BRMs) are used to treat what other chronic diseases
- rheumatoid arthritis
- multiple sclerosis
- Crohn's disease
- ulcerative arthritis
- (+ others!)
-
name 4 biologic response modifiers (BRMs) used to treat cancer
- Interferons (INFs)
- Monoclonal Antibodies
- Colony Stimulating Factors (CSFs)
- Interleukins
-
Use interferons for what cancers
- hairy cell leukemia
- AIDS Kaposi sarcoma
- multiple myeloma
- CML
- kidney cancer
-
very common side effect of interferons and sth to know about it
- flu-like syndrome
- intensity of side-effect decreases w/ continued exposure
-
what does interferon (a biologic response modifier) do
enhances activity of macrophages and NK cells (cells that kill cancer cells)
-
name a kind of monoclonal antibody
- cetuximab (Erbitux)
- ** but LEWIS says this is a tyrosine kinase inhibitor
-
what do monoclonal antibodies (a biologic response modifier) do
- they bind to the EGFR (epidermal growth factor receptor), resulting in the inhibition of cell growth, induction of apoptosis (programmed cell death), and decreased vascular endothelial growth factor production
- inhibits the growth and survival of tumor cells that over-express the EGFR (many human cancer cells do this)
-
what do monoclonal antibodies inhibit
growth and survival of tumor cells that over-express EGFR (epidermal growth factor receptor)
-
what do many human cancer cells over-express
EGFR (epidermal growth factor receptor)
-
what do monoclonal antibodies bind to
- the EGFR (epidermal growth factor receptor)
- results in inhibition of cell growth
- results in induction of apoptosis (cell death)
- results in decreased vascular endothelial growth factor production
-
monoclonial antibodies are used to treat what cancers
-
name one monoclonal antibodies used
trastuzumab (Herceptin)
-
trastuzumab (Herceptin) interferes w/ what
- HER2/neu receptor
- it binds to this receptor, causing it (the HER2 protein receptor) to stop reproducing breast cells uncontrollably
-
HER2 receptor and breast cancer
in some breast cancers the HER2 receptor is defective and stuck in the "on" position, causing breast cells to reproduce uncontrollably
-
can cancers develop resistance to trastuzumab (Herceptin)
yes, and they usually do
-
what do colony stimulating factors do
regulate the growth, differentiation, and function of bone marrow stem cells
-
are colony stimulating factors directly toxic to cancer cells
no
-
what's a benefit of colony stimulating factors
decrease the duration of chemo-induced bone marrow depression
-
2 examples of colony stimulating factors
- filgrastin (G-CSF, Neupogen)
- epoetin alfa (EPO, Epogen, Procrit)
-
Interleukin-11 (IL-11, oprelevekin, Neumega) is what and results in what
- a thrombolytic growth factor
- results in increased platelet production
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