Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Jonas J best purchase for butenafine fungus joint pain, Schmidt A cheap butenafine online mastercard antifungal garden, Muller-Bergh J generic 15mg butenafine overnight delivery definition of fungus ball, Schlotzer-Schrehardt degraded multivesiculate bodies toward the cell body. Human optic nerve fiber count and optic Mitochondria can apparently move in either direction. The course of axons through ciation with microtubules and requires adenosine triphos- the retina and optic nerve head. Nerve fiber layer thickness of the primate retina: retrograde axonal transport are thought to rely on distinct thickness and glial content. Retinotopy of the human reti- with axonal transport along microtubules away from the nal nerve fibre layer and optic nerve head. J Comp cell body (orthograde),67,68 whereas another motor pro- Neurol 1996;375:238–251. Airaksinen P, Drance S, Douglas G, Schulzer M, Wijs- 1C), appears to catalyze vesicle movement toward the cell man K. Scanning laser polarimetry of the Type (mm>day) Purpose retinal nerve fiber layer. Quantitative studies of retinal down the axon, away from cell body nerve fiber layer defects. Visual fibre anatomy in the infra- Orthograde Move membrane-bound geniculate pathway of the primate. Arch Ophthalmol (kinesin) vesicles and mitochondria away from the cell body 1962;111:645–650. The position occupied by the Retrograde Move lysosomes, pinocytotic peripheral retinal fibres in the nerve-fibre layer and at (dyenin) vesicles, and multivesiculate the nerve head. Arch Ophthalmol structural location of extracellular matrix components 1980;98:1630–1636. Nerve fiber layer of the macaque retina: cellular matrix of the human lamina cribrosa. Retinogeniculate fibers in the monkey optic the extracellular matrix of the human optic nerve. Ramirez J, Trivino A, Ramirez A, Salazar J, Garcia- of the human optic nerve head. Elastosis of the lamina cribrosa in glaucoma- histochemical study of human optic nerve head tous optic neuropathy. The fine structure of Immunohistochemistry of proteoglycans in human the astroglia in the human optic nerve and optic nerve lamina cribrosa. Arch Ophthalmol study of the retrolaminar optic nerve in man: the pos- 1981;99:137–143. Invest Oph- logic studies of the vasculature of the anterior optic thalmol Vis Sci 1991;32:2169–2177. In: Drance S, Neufeld A, Van Buskirk vasodilatory role in cat optic nerve head during flicker E, eds. Autoregulation of human optic nerve head tural proteins of the neonatal and adult lamina circulation in response to increased intraocular pres- cribrosa. Surv Oph- axonal transport: identification of major structural thalmol 1999;43(suppl):S17–S26. Imbalance of endothelium-derived relax- tron microscopy and monoclonal antibody decora- ing and contracting factors: a new concept in hyper- tion. Endothelium- transport blockade by acute intraocular pressure ele- dependent regulation of the ophthalmic microcircu- vation in the primate optic nerve head. Invest Oph- lation in the perfused porcine eye: role of nitric oxide thalmol Vis Sci 1977;16:640–644. Invest Ophthal- in optic nerve induced by elevation of intraocular mol Vis Sci 1980;19:505–517. Arch Ophthalmol 1979; of endothelin-1 with normal-tension glaucoma: clin- 97:525–531. Invest Ophthalmol Vis Plasma and aqueous humor endothelin levels in pri- Sci 1977;16:426–441. Endothe- mic flow during chronic experimental glaucoma, I: lin-1 plasma levels in normal-tension glaucoma: light and electron microscope studies of the monkey abnormal response to postural changes. Graefes Arch optic nerve head during development of glaucoma- Clin Exp Ophthalmol 1995;233:484–488. Intracellular transport in neu- lar pressure elevation on optic nerve head and rons. Accurate clinical evaluation of the optic nerve head useful for screening populations for glaucoma. Several larly useful for rapid, undilated follow-up examinations and examination techniques are available (Table 9–1), and can reveal nerve-fiber-layer hemorrhages and major their relative advantages vary with the clinical situation. In addition, when the scope is held Because of this, the clinician must be familiar with sev- 17 mm in front of the cornea, the small (5 degree) aperture eral methods and be able to extrapolate the findings from will project a 1. In addition, its two-dimensional image may sive, and widely used by nearly all physicians. Its upright not accurately convey the surface contour of the neural image provides approximately 15X magnification and it is rim. Because of the diffuse illu- have shown that the average normal horizontal and ver- 6 mination and the small magnification, one relies on color tical C/D ratios are 0. The vertical clues rather than topography, and the optic nerve head measurement may be more sensitive in detecting glauco- often appears “better” than it really is. Several studies have shown that there is a Indirect ophthalmoscopy with the head- large interobserver and intraobserver variability in esti- mates of the C/D ratio, even among experts.
If two or more sites mentioned in Part I are in the same organ system cheap butenafine online visa fungus covered chest, see Section E buy butenafine 15 mg lowest price antifungal otic drops. If the sites are not in the same organ system and there is no indication that any is primary or secondary purchase discount butenafine on-line fungus gnats uk, code to malignant neoplasms of independent (primary) multiple sites (C97), unless all are classifiable to C81-C96, or one of the sites mentioned is a common site of metastases or the lung (see Section G). Codes for Record I (a) Cancer of stomach 3 months C169 (b) Cancer of breast 1 year C509 Code to malignant neoplasms of independent (primary) multiple sites (C97), since two different anatomical sites are mentioned and it is unlikely that one primary malignant neoplasm would be due to another. Codes for Record I (a) Hodgkin disease C819 (b) Carcinoma of bladder C679 Code to malignant neoplasms of independent (primary) multiple sites (C97), since two distinct morphological types are mentioned. Codes for Record I (a) Acute lymphocytic leukemia C910 (b) Non-Hodgkin lymphoma C859 Code to non-Hodgkin lymphoma (C859), since both are classifiable to C81-C96 and the sequence is acceptable. Codes for Record I (a) Leukemia C959 (b) Non-Hodgkin lymphoma C859 (c) Carcinoma of ovary C56 Code to malignant neoplasms of independent (primary) multiple sites (C97), since, although two of the neoplasms are classifiable to C81-C96, there is mention of another morphology. When dealing with multiple sites, only sites in Part I of the certificate should be considered (see Section E). If malignant neoplasms of more than one site are entered on the certificate, the site listed as primary should be selected. More than one neoplasm of lymphoid, hematopoietic or related tissue If two or more morphological types of malignant neoplasm occur in lymphoid, hematopoietic or related tissue (C81-C96), code according to the sequence given since these neoplasms sometimes terminate as another entity within C81-C96. Acute exacerbation of, or blastic crisis (acute) in, chronic leukemia should be coded to the chronic form. Codes for Record I (a) Acute lymphocytic leukemia C910 (b) Non-Hodgkin lymphoma C859 Code to non-Hodgkin lymphoma (C859). Codes for Record I (a) Acute and chronic lymphocytic leukemia C910, C911 Code to chronic lymphocytic leukemia (C911). Multiple sites in the same organ/organ system Malignant neoplasm categories providing for overlapping sites designated by. This applies when the certificate describes the sites as one site “and” another or if the sites are mentioned on separate lines. If one or more of the sites reported is a common site of metastases, see Section G. Codes for Record I (a) Carcinoma of descending colon and sigmoid C186 C187 Code to malignant neoplasm of colon (C189) since both sites are subsites of the same organ. Codes for Record I (a) Carcinoma of head of pancreas C250 (b) Carcinoma of tail of pancreas C252 Code to malignant neoplasm of pancreas, unspecified (C259) since both sites are subsites of the same organ. If two or more sites are mentioned and all are in the same organ system, code to the. Stomach and gallbladder are in the same organ system and reported together in the same part. Codes for Record I (a) Carcinoma of vagina and cervix C52 C539 Code to malignant neoplasm of female genital organs (C579). Vagina and cervix are in the same organ system and are reported together in the same part. Codes for Record I (a) Cardiac arrest I469 (b) Carcinoma of prostate and bladder C61 C679 Code to malignant neoplasms of independent (primary) multiple sites (C97), since there is no available. Although, generally only sites in Part I should be considered, the Classification provides linkages for certain sites when reported anywhere on the certificate. Combine other parts of esophagus, C152 or C155 and stomach, C169 to code C160 in the same manner. Other exceptions to the multiple sites concept the following examples are exceptions to the multiple sites concept. Also, in the same manner, combine C820 and C822 to code C821; combine C833 and C830 to code C832; and combine C830 and C833 to code C832. Codes for Record I (a) Brain metastasis C793 (b) Lung tumor C349 Code to malignant lung tumor (C349). Codes for Record I (a) Metastatic involvement of chest wall C798 (b) Carcinoma in situ of breast C509 Code to malignant carcinoma of breast (C509). Metastatic neoplasm When a malignant neoplasm spreads or metastasizes it generally retains the same morphology even though it may become less differentiated. Some metastases have such a characteristic microscopic appearance that the pathologist can infer the primary site with confidence,. The adjective “metastatic” is used in two ways - sometimes meaning a secondary from a primary elsewhere and sometimes denoting a primary that has given rise to metastases. Neoplasms qualified as metastatic are always malignant, either primary or secondary. Although malignant cells can metastasize anywhere in the body, certain sites are more common than others and must be treated differently (see list of common sites of metastases). However, if one of these sites appears alone on a death certificate and is not qualified by the word “metastatic,” it should be considered primary. Common sites of metastases Bone Lymph nodes Brain Mediastinum Central nervous system Meninges Diaphragm Peritoneum Heart Pleura Ill-defined sites (sites classifiable to Retroperitoneum C76) Spinal cord Liver Lung Code for Record I (a) Cancer of brain C719 Code to primary cancer of brain since it is reported alone on the certificate. Lung should be considered as a common site of metastases whenever it appears in Part I with sites not on this list. If lung is mentioned anywhere on the certificate and the only other sites are on the list of common sites of metastases, consider lung primary. However, when the bronchus or bronchogenic cancer is mentioned, this neoplasm should be considered primary. Code for Record I (a) Carcinoma of lung C349 Code to malignant neoplasm of lung since it is reported alone on the certificate. Codes for Record I (a) Cancer of bone C795 (b) Carcinoma of lung C349 Code to primary malignant neoplasm of lung (C349) since bone is on the list of common sites of metastases and lung can, therefore, be assumed to be primary. Codes for Record I (a) Carcinoma of bronchus C349 (b) Carcinoma of breast C509 Code to malignant neoplasms of independent (primary) multiple sites (C97) because bronchus is excluded from the list of common sites.
Am J Ophthalmol 1975; configuration of the human anterior chamber angle purchase generic butenafine online antifungal journal, 80:56–61 order discount butenafine antifungal for thrush. Trans Am angle in exfoliation syndrome: clinical and patholog- Ophthalmol Soc 1995;93:337–51 butenafine 15 mg line do fungus gnats jump. Most of these studies find slightly higher optic nerve damage or retarding its progression once pressures in women. In fact, these two tonometers dif- between the pressure within a sphere and the force fer only in the extent to which they indent the globe. Goldmann adapted this formula to the tact with the eye, differ only in the methods and tech- human cornea, which is neither infinitely thin nor dry. Table 6–1 compares the determined that corneal inflexibility (requiring additional most commonly used instruments with regard to accu- force for applanation), is equal and opposite to the attrac- racy, portability, and ease of use. Here, the force on the slit-lamp and consists of a strain gauge connected required to flatten, or applanate, a constant area of the by a lever to a plastic tip (Fig. Goldmann applanation tonometry is performed with Accuracy Portability Ease of Use the patient seated at the slit-lamp. A drop of anesthetic Goldmann ++++ + ++ containing fluorescein, or proparacaine plus fluorescein Tonopen +++ ++++ ++++ applied on a paper strip, improves visibility of the tear meniscus when viewed with a bright cobalt blue light. Pneumatonograph ++ ++ +++ Separating the lids gently with thumb and forefinger, the Schiøtz + ++++ + tip is moved slowly toward the cornea until it makes con- +, least favorable; ++++, most favorable. Moving the slit-lamp up or down to center and holding it just in front of the eye for several seconds the prism on the cornea will equalize the semicircles, prior to applanation can help the patient relax and whose inner edges are then aligned by turning the ten- reduces this source of error. At this point, the dial indicates pressure in mil- the first eye that is several mm Hg higher than that in the limeters of mercury. Accuracy in either the horizontal or vertical position is comparable to the Goldmann tonometer. Blotting away excess tears and wip- nism in the tip of the Tonopen is activated when it touches ing the tonometer tip with a tissue usually resolve this the cornea, producing a waveform of pressure change problem. The probe tip is covered with a sterile dis- posable rubber cap before use, stretched flat over the tip without excessive tension that could dampen movement Output signal of the strain gauge (Fig. Calibration, an internal process that requires no additional instruments, should be checked before every measurement session. After instilling a topical anesthetic, the probe tip, held per- Pneumatic pendicular to the globe, is gently tapped against the balancing central cornea. Measurements are continued, and after several additional beeps, another sound occurs, indicat- Exhaust Annular ing that enough readings have been obtained. A pressure transducer connected to the tact with the corneal tear film can produce low readings. Trans Am tonometry will help the beginner learn this technique and Acad Ophthalmol Otolaryngol 1965;69:1029–1047. A collimated beam of light is directed to the corneal apex, as is a receiver to detect parallel, coaxial rays of this light reflected from the cornea (Fig. After proper align- ment, a jet of air directed at the corneal apex flattens the cornea. Given that parallel light rays will remain parallel after reflecting off a planar surface, peak intensity of the reflected light signifies complete flattening of the cornea. These time intervals, calibrated against mea- surements with the Goldmann tonometer, are converted to mm Hg and digitally displayed. A portable, noncontact tonometer, the Pulsair, Schiøtz-type indentation tonometer. The relationship between Pt and Po varies from Zeimer has developed an applanation tonometer that can eye to eye and depends on the rigidity of the cornea and be used by patients at home. Following application of a topical anes- the apex of the cornea and measures the air pressure nec- thetic, the plunger is oriented perpendicular to the center essary to applanate the cornea. The self-tonometer has of the cornea and gently lowered until the sleeve rests on good reproducibility, correlates well with the Goldmann the eye. However, it does require a highly motivated patient and 74,75 Until the development of hand-held applanation carries a small risk of causing a corneal abrasion. The time interval (t) between an internal reference point to the moment of applanation is converted to intraocular pressure and displayed in millimeters of mercury. Other studies85,86 have demonstrated less corneal thickness tion between patients is critical. Most of this concern in normal-tension glaucoma patients compared with involves the prism of the Goldmann tonometer. Preva- for the Prevention of Blindness and the Contact Lens lence of open-angle glaucoma in Australia. The Blue Association of Ophthalmologists, recommend wiping the Mountains Eye Study. The prevalence of primary angle-closure rite (household bleach), 70% isopropyl alcohol, or 3% glaucoma and open-angle glaucoma in Mamre, hydrogen peroxide. Arch Ophthalmol mology recommendation also includes the option of using 1993;111: 1263. Associations with intraocular of all these protocols are that they do not eradicate Acan- pressure in the Barbados Eye Study. Arch Ophthalmol thamoeba, repeated use may damage the tonometer prism, 1997;115:1572. Diabetes, intraocular pressure, and primary open- Philadelphia, Pa: Lippincott-Raven; 1997:41.
Effect of second-line surgery on in vitro fertilization outcome in infertile women with ovarian endometrioma recurrence after primary conservative surgery for moderate to severe endometriosis order butenafine overnight delivery antifungal cream for nails. Surgical ovulation induction in women with polycystic ovary syndrome: A systematic review best 15 mg butenafine fungus gnats and cannabis. Pregnancy and live birth rates after microsurgical vasoepididymostomy for azoospermic patients with epididymal obstruction cheap butenafine online mastercard fungus gnats vivarium. Increased odds of live birth in fresh in vitro fertilization cycles with shorter ovarian stimulation. Treatment of unexplained infertility with aromatase inhibitors or clomiphene citrate: a systematic review and meta-analysis. Long-acting follicle-stimulating hormone versus daily follicle-stimulating hormone for women undergoing assisted reproduction. Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. Assisted reproductive technology and the risk of pregnancy-related complications and adverse pregnancy outcomes in singleton pregnancies: a meta-analysis of cohort studies. Assisted reproductive technology and risk of congenital malformations: a meta-analysis based on cohort studies. Risk of multiple gestation after ovulation induction in polycystic ovary syndrome. Human chorionic gonadotrophin priming for fertility treatment with in vitro maturation. Consecutive gonadotropin-releasing hormone-antagonist in vitro fertilization cycles: does the elapsed time interval between successive treatments affect outcomes? Role of optimizing testosterone before microdissection testicular sperm extraction in men with nonobstructive azoospermia. Does prolonged pituitary down-regulation with gonadotropin- releasing hormone agonist improve the live-birth rate in in vitro fertilization treatment? Time-lapse imaging reveals differences in growth dynamics of embryos after in vitro maturation compared with conventional stimulation. The effects of surgery for endometriosis on pregnancy outcomes following in vitro fertilization and embryo transfer: a systematic review and meta-analysis. Intrapartum and neonatal outcomes in singleton pregnancies following conception by assisted reproduction techniques. Australian and New Zealand Journal of Obstetrics and Gynaecology 2017;57(6):588-592. The impact of specific fertility treatments on cognitive development in childhood and adolescence: a systematic review. The effect of day 2 versus day 3 embryo transfer on early pregnancy outcomes in women with a low yield of fertilized oocytes. Should we consider integrated approach for endometriosis-associated infertility as gold standard management? Decreased live births among women of Middle Eastern/North African ethnicity compared to Caucasian women. Varicocelectomy to "upgrade" semen quality to allow couples to use less invasive forms of assisted reproductive technology. A comprehensive analysis of body mass index effect on in vitro fertilization outcomes. Gonadotrophin ovulation induction and enhancement outcomes: analysis of more than 1400 cycles. Does cryopreservation of sperm affect fertilization in nonobstructive azoospermia or cryptozoospermia?. The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures. Do women offered assisted reproduction technologies have a higher incidence of gynecologic cancer? The outcomes of controlled ovarian hyperstimulation/ intrauterine insemination in patients with unilateral tubal occlusion on hysterosalpingograph. Semen preparation techniques in intrauterine insemination: A comparison of non-temperature and temperature controlled centrifugation in cases of unexplained infertility. In-vitro maturation of oocytes vs in-vitro fertilization with a gonadotropin-releasing hormone antagonist for women with polycystic ovarian syndrome: can superiority be defined? Oocyte competence in in vitro fertilization and intracytoplasmic sperm injection patients suffering from endometriosis and its possible association with subsequent treatment outcome: a matched case-control study. Is human chorionic gonadotropin supplementation beneficial for frozen and thawed embryo transfer in estrogen/progesterone replacement cycles? Clinical predictive criteria associated with live birth following elective single embryo transfer. Gonadotrophin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction. Risk of endometrial cancer in women treated with ovary-stimulating drugs for subfertility. Sexual function and fertility quality of life in women using in vitro fertilization. Effect of metformin on ovulation and reproductive outcomes in women with polycystic ovary syndrome: a meta-analysis of randomized controlled trials. Single blastocyst transfer: the key to reduce multiple pregnancy rates without compromising the live birth rate.
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In 1999 a ‘Programme of Community Action on Rare Diseases’ within the framework for action in the field of public health was established (1999-2003) with a budget of 6 order butenafine american express antifungal coconut oil. For the years 2008-2011 generic butenafine 15mg free shipping antifungal washing detergent, a total of 21 434 895 euro was awarded to rare disease-related projects buy on line butenafine fungal dna. Orphanet Improves the recognition and visibility of rare diseases by offering patients and health care professionals up-to-date, relevant information on rare diseases, orphan drugs and expert services. RareCare Understanding the scale and scope of rare diseases is often an issue, particularly when clinicians and patients struggle to find the right diagnosis and treatment. For example, the review of European Newborn Screening Screening practices will guide future European policy, enabling the appropriate diagnostic and preventive measures to be put into action in all Member States. The Cooperation programme supports collaborative research and is subdivided into 10 themes, including the ‘Health Theme’, under which most research on rare diseases falls. The emphasis of rare disease research is on studies of natural history, pathophysiology, and the development of preventive, diagnostic and therapeutic interventions. Between the period of 2007-2010, 50 research projects on rare diseases have been supported. Approximately 17 of these projects are fundamental research, whilst eight projects cover preclinical and clinical development of orphan drugs. It also produced an inventory of publicly funded projects in the field of rare diseases and orphan drugs. Examples are: national plans or strategies for rare diseases and related actions; presence of centres of expertise; neonatal screening policy; National alliances of patient organisations and patient representation and research activities. Although Member States fund rare disease research, specific rare disease research programmes at Member State level are limited. Moreover, some countries have dedicated centres of expertise for certain rare diseases, others have not. The plans should ensure that rare disease patients have access to high quality care and if possible access to effective orphan drugs. For the creation and/or development of 59 networks for rare diseases and promotion of 27 multidisciplinary research projects a budget of 7. Next to this funding programme, the development of partnerships and infrastructure was started,. The programme formed the basis for the adoption of a national rare disease plan at the end of 2004. Moreover, a second objective is to advance medical knowledge about rare and common diseases. This cooperative program should facilitate many advances including the identification of biomarkers for disease risk, disease severity/activity, and clinical outcome and encourage development of new approaches to prevention, diagnosis, and treatment of many rare diseases beyond those being studied. The products studied can be drugs, biologics, medical devices, or medical foods, but in practice they are primarily 3 Spinocerebellar ataxias, urea cycle disorders, primary immune deficiency, porphyria, mitochondrial disease, salivary gland carcinomas, nervous system channelopathies, dystonia, mucocilary clearance, nephrotic syndrome, graft versus host diseases, vasculitis, hereditary causes of nephrolithaisis and kidney failure, Angelman syndrome/Rett syndrome/Prader-Willi syndrome, autonomic rare disease, inherited neuropathies, sterol and isoprenoid diseases, lysosomal disease and brain vascular malformation 6. The current annual budget for funding grants is now approximately $14 million due to the Rare Disease Orphan Product Development Act of 2002 (H. This program has led to increased research and development of orphan products at academic institutions and other responsible organisations: public, private, non- profit, or for-profit. The Specified Rare Diseases Treatment Research Programme was established in Japan in 1972 with the support of the Ministry of Health, Labour and Welfare. Additionally there is very limited development of drugs for rare diseases in China because no policies for incentives have been adopted. China included the development of orphan drugs in a national programme for innovative new drugs in 2010. The goal is to pool resources and work beyond borders in order to get a better understanding of rare diseases and find adequate treatments. It has two main objectives: to deliver 200 new therapies for rare diseases and means to diagnose most rare diseases by 2020. The 26 new projects cover an array of rare diseases including cardiovascular, metabolic and immunological disorders. Researchers can then use the preliminary data to apply for larger multi- year government grants or to attract a commercial sponsor. With regard to orphan drug development, apart from well-established sources of funding like governmental grants and venture capital, patient-initiated research foundations can also represent an important source of funding. What Are the Gaps Between Current Research and Potential Research Issues which Could Make a Difference, Are Affordable and Could Be Carried out in a) five years or b) in the longer term? In the last decade considerable attention has been paid worldwide to stimulate the research, development and bringing to the market of orphan medicinal products by the pharmaceutical industry. Many orphan medicinal products are innovative, biotechnological products that have been the start for several small biotech-companies. Apart from treatments coming available, the introduction of various (research) programmes and networks has advanced understanding and diagnosis of several rare diseases as well. However, despite the growing number of approved orphan drugs and enhanced rare disease understanding in the last decade, many gaps remain related to the development of treatments and care for patients with a rare disease. Being a complex and heterogeneous mosaic of an estimated 5 000-8 000 conditions, it has become clear that the (research) need can differ considerably between (groups of) rare diseases: Lack of disease understanding: need for fundamental research into disease process For many rare diseases basic knowledge, like diagnosis, cause of the disease, pathophysiology, natural course of the disease and epidemiological data that would allow for development of preventive, diagnostic and/or therapeutic approaches is limited or worse missing. Genomic research will result in the recognition of more rare genetic diseases or subclasses. Proteomic research will result in more insight in protein function and structure of proteins that are deficient or are accumulated in rare diseases. Ongoing fundamental research into the disease process will result in more targets for pharmaceutical intervention or healthcare innovation for rare diseases. The availibility of a rare disease classification system is equally important to make rare diseases more visible in health information systems. Such a system wil constitute a useful basis for further research into the natural history and etiology of rare diseases, allows monitoring safety and clinical effectiveness of therapies and measuring quality of care.