By M. Leon. Dordt College. 2018.
If the bone is quite dense buy generic uroxatral 10 mg on-line, there may be little or no pressure decay effective uroxatral 10 mg, even at pressures up to 180 psi discount uroxatral 10 mg with amex. Even with slow inflation cheap uroxatral 10mg with mastercard, pressures higher than 220 psi have been achieved in dense bone. The possible end points of inflation are (1) restoration of the verte- bral body height to normal, (2) flattening of the balloon against an end- plate without accompanying height restoration, (3) contact with a lat- eral cortical margin, (4) inflation without further pressure decay, and (5) reaching the maximum volume of the balloon or maximum pres- sure. The operating physician must maintain both visual and manual control throughout the entire inflation process and should record the amount of fluid used to inflate the balloon when the end point has been achieved. This volume indicates the size of the cavity that has been cre- ated, and it will serve as an estimate of the amount of cement to be de- livered. If substantial height restoration has not been achieved, careful repositioning of the bone tamps and reinflation may be helpful. Once adequate inflation has been achieved, the cement is mixed in a manner similar to that for PV. The cement mixture is transferred to a 10 mL syringe that is used to fill a series of 1. The volume of cement for injection is approximately 1 mL more than the volume of the cavity created by each inflatable balloon tamp. Once the bone cement has undergone transition from a liquid to a cohesive, doughy consistency (about 3–4 minutes after mixing), the Technique 343 A B FIGURE 18. The cavity is then filled with cement, proceeding from the anterior to the posterior aspect of the vertebra. Continuous fluoroscopic monitoring is maintained to iden- tify leakage of cement into the spinal canal, paraspinous veins, inferior 344 Chapter 18 Balloon Kyphoplasty vena cava, or disc space. One hypothetical advantage of KP over PV is that the former affords a low-pressure cement delivery into the cav- ity created by the inflatable balloon tamp. However, there are no re- ports of measurements of intravertebral pressure during cement injec- tion. Recent pressure measurements taken in our laboratory during cement injection in ex vivo vertebral bodies suggest that the pressure increase is minimal and not likely to be of clinical consequence (un- published data). Some operating physicians prefer to fill one cavity first, leaving the contralateral balloon inflated as a supporting strut. This maneuver may be effective at maintaining any height elevation that has been achieved. When cement filling of the cavity has been confirmed fluoroscopi- cally from both lateral (Figure 18. The cannulas are then rotated (so they are not cemented in the bone) and removed, and hemostasis is obtained at the incision site by using manual pressure. The patient remains prone on the table and is not moved until the remaining cement in the mixing bowl has hardened completely. The usual time frame for KP is 35 to 45 minutes, which compares favorably with the 20 to 25 minutes per level required A B FIGURE 18. In denser bone, the balloons may take longer to respond to small incremental increases in pressure. At some institutions, KP and PV are performed on an outpatient basis unless the patient is extremely frail, or unless the pro- cedure is performed at the end of the day and staffing issues make it easier to keep the patient overnight for discharge the next morning. Safe perform- ance requires a high level of skill and high-quality imaging equipment. One should not perform this procedure without being an expert in clin- ical and radiographic spinal anatomy, without having completed a kyphoplasty course with expert instructors, and without imaging equipment that is capable of clearly delineating key bony landmarks, particularly the pedicles, the cortices, and the spinous processes. The patient had good pain relief (similar to PV) and a modest amount of height was restored (approximately 3–4 mm; Figure 18. The clinical sig- nificance of this amount of height restoration still needs review. PV may also be associated with mild height restoration and is excellent at relieving pain. With pain relief following both PV and KP, patients get reduction in kyphosis and are able to support their body weight with- out pain (allowing them to stand straighter). Reproducible outcome analysis is needed to understand the significance (or lack thereof) of the differences between PV and KP. Kyphoplasty is a relatively new procedure and, as such, peer- reviewed reports of clinical results are few.
Two of the sites showed the patient education video in waiting rooms in addition to showing it in back classes buy 10mg uroxatral amex. The sites that did not show the video cited barriers in the physical layout of waiting rooms and lack of video equipment as reasons for not doing so buy 10 mg uroxatral free shipping. Although the sites were encouraged to use various metrics to monitor implementation progress cheap 10 mg uroxatral fast delivery, they were slow to do so cheap uroxatral 10 mg with mastercard. One reason was that the expert panel for the DoD/VA guideline did not finalize its list of recommended metrics until sev- eral months after the demonstration kickoff conference. The sites eventually selected some indicators to track, with each site identify- ing a different set of indicators. One site made extensive use of the ADS and CHCS data to track trends in low back pain encounters and 66 Evaluation of the Low Back Pain Practice Guideline Implementation dispositions. Staff at the sites had some difficulty retrieving ADS and CHCS data because they were not accustomed to using the system for monitoring and management purposes. The MTFs varied sub- stantially in the availability of personnel with the programming abil- ity to extract data from the CHCS. Three sites used chart reviews to monitor the presence of the docu- mentation form 695-R in the chart and documentation of the red-flag conditions. With one exception, the sites completed only one round of chart reviews, so they were not able to track trends. The sites were reluctant to undertake chart reviews on a regular basis because they are time consuming to perform. Staff also had a tendency to do one review with a large sample of charts rather than performing a series of reviews of smaller samples each. Difficulty in locating medical charts added significantly to the chart review time demands. For ex- ample, 300 patients were sampled at one site, for whom 60 charts could be located and only 27 were actually reviewed. The chart reviews revealed large variations in the presence of form 695-R in the charts across sites and also across TMCs and clinics within sites. Completeness ranged from 100 percent at one TMC to 20 percent or less at some clinics. The two sites that extracted information on the documentation of red-flag conditions found low rates of compliance (19 percent and 15 percent, respectively). A majority of providers participating in the focus groups indicated they had seen some monitoring data on their treatment of low back pain patients during the demonstration. However, none of the sites reported having used the monitoring data to undertake corrective actions. LESSONS LEARNED Although the MTFs participating in the low back pain guideline demonstration had some notable successes in some aspects of im- proving low back pain treatment practices, the overall progress made during the demonstration was quite limited. Of particular concern was the inability of the MTFs to sustain early achievements in intro- ducing new practices. Important contributing factors to this result Implementation Actions by the Demonstration Sites 67 were the generally tepid support from the MTF command teams, which was compounded by turnover of key personnel leading the implementation activities. We summarize here some of the specific lessons learned from this demonstration, which generated rich in- formation that has been used by MEDCOM for subsequent demon- strations as well as for introduction of the low back pain practice guideline across all Army treatment facilities. Flexibility Versus Consistency The MTFs used the flexibility they were given to establish a variety of implementation strategies, which reflected each MTF’s unique ca- pabilities and circumstances. The MTFs emphasized different com- ponents of the guideline, and they differed in how broadly they im- plemented it across their clinics and TMCs. Although we believe this flexibility helps to ensure that each MTF can address the clinic prac- tices most in need of improvement, it also may slow progress toward the AMEDD goal of achieving consistent practices across its facilities. Documentation of variations in key practices across MTFs, such as we presented in Chapter Three, should be performed routinely to identify areas where improvements in quality and consistency are needed.
Physicians can explore how the patient This response acknowledges that underlying such a has responded to the grief ("How have things been differ- question is tremendous emotion uroxatral 10mg low price, most likely fear purchase uroxatral 10 mg with visa. The suggested overlook the frequently enormous practical ramiﬁcations answer above allows patients to speak about their fears of loss effective uroxatral 10mg, such as ﬁnancial difﬁculties or the possible loss of and worries uroxatral 10 mg sale. The fundamentals situation lives 3 to 4 months, but some people have much of such communication are listening, attending to the less time, and others may live longer. I would take care patient’s emotional needs, and achieving a shared under- of any practical or family matters now that you wish to standing of the concerns at hand. Speciﬁc tasks such as have completed before you die but continue to hope that delivering bad news, discussing advance care planning, you are one of the lucky people who gets a bit more helping patients through the transition to hospice care, time. Suggesting that a patient receive palliative care risks conveying a sense of abandonment. Physicians must be References emphatic that palliative care and hospice are active forms of care that meet patients’ varying goals at the end of life. Butow PN, Kazemi JN, Beeney LJ, Grifﬁn AM, Dunn SM, However, further exploration of a patient’s or family’s Tattersall MH. When the diagnosis is cancer: patient com- concerns about abandonment are important to under- munication experiences and preferences. Cancer patients’ concerns: congruence between patients and primary care physicians. Disclosure of concerns by hospice the physician to reframe the patient’s understanding of patients and their identiﬁcation by nurses. The outpatient medical encounter and elderly goals might be in light of this new information. Tulsky end of life by patients, family, physicians, and other care in patients with asthma or rheumatoid arthritis: a random- providers. Communication treatment planning discussions with nursing home resi- between older patients and their physicians. Opening the clues and physician responses in primary care and surgical black box: how do physicians communicate about advance settings. The patient s story: integrating the evidence from the McGill Quality of Life Questionnaire. A review of of informal caregivers’ satisfaction with services for dying the literature. Topics in of physician-patient interaction on the outcomes of chronic Palliative Care, vol 4. Sehgal A, Galbraith A, Chesney M, Schoenfeld P, Charles physician-initiated advance directive discussion. Wenrich MD, Curtis JR, Shannon SE, Carline JD,Ambrozy patient toward life support: a survey of 200 medical in- DM, Ramsey PG. Personal probability of survival on patients’ preferences regarding communication, 2001. This page intentionally left blank 26 Care Near the End of Life Sarah Goodlin Advances in medical science during the past half century physicians who care for elderly patients should know allow people to survive many acute illnesses that previ- how to care for patients at the end of life. Yet, rather than interdisciplinary approach to patients with multiple curing illness, most medical interventions permit us to medical, social, and functional problems utilized in all of manage chronic disease. Most Americans age with one or geriatrics applies equally to all seriously ill and dying more degenerative or disabling diseases and require daily patients. This chapter reviews available data about death assistance toward the end of life. It is difﬁcult or impos- in elderly Americans and presents an approach to care sible to identify a point at which a gradually worsening for those nearing the end of life. In the process of ongoing care, physicians and patients often become aware that the likely beneﬁts of certain treat- Dying in the United States ments or diagnostic tests may be outweighed by their discomfort or other burdens.
So relapses may still occur uroxatral 10mg fast delivery, even if they are fewer in number and less in degree than they would otherwise have been uroxatral 10 mg. The problem is that neither the doctor treating you generic uroxatral 10 mg visa, nor you yourself buy cheap uroxatral 10 mg, know what would ‘otherwise have been’. All you may know is that you now have (perhaps a minor) relapse, and are feeling worse. Your relapses might well have been worse without beta-interferon but, of course, you might feel that it was not effective at all. Beta-interferons appear to work best when the disease is active, when (although not always) there are recognizable symptoms. The predominant medical opinion at present is that beta-interferons should be given only when there is evidence of recent disease activity, but the increasing research evidence that beta-interferons may slow down the development of symptoms over the medium term (3–5 years) is prompting a serious review of this position. Indeed, there are now scientiﬁcally inﬂuential voices arguing for the administration of beta- interferons at the earliest possible stage of the disease. We have data, at the time of writing this book, only on small groups of people who have had beta-interferons for 8–10 years, and this is not sufﬁcient to make very long-term judgements. It does appear from current clinical trials that the onset or progression of disability, as measured by a range of tests, is slowed down by the beta-interferons and this slow-down is statistically signiﬁcant – for at least 4 or 5 years after taking the drug. In addition, disease activity in the CNS as measured by magnetic resonance scans also seems to be reduced, but remember that most of these very positive results were obtained from people with milder forms of MS at an earlier stage of their disease. A problem that has arisen in about a third of people being given beta- interferon 1b (Betaferon) is that they have developed ‘antibodies’ to the drug after about a year or so. It appears that their bodies are resisting the effects of beta-interferon, attacking beta-interferon as an ‘invader’. In such cases, the positive effects of the drug disappear, and rate of relapses and disease progression returns – as far as we can see – to their previous state. Another problem is that, at present, there is no test available to ascertain which people will develop these antibodies. It is mainly by the return of increased disease activity and symptoms that these people would recognize this problem. It is not clear whether exactly the same problems will occur with other types of beta-interferon, but the ﬁrst signs are that they will. Beta- interferon 1b (Betaferon) is administered by injection subcutaneously (just below the skin) every other day. Beta-interferon 1a (Avonex) is administered by injection intramuscularly (directly into the muscles) every week. The different types of administration are based on what has proved in clinical trials to be the best way of ensuring the effectiveness of the drug. Subcutaneous injections have been given in the past by a doctor or a nurse, not only to check that it is given correctly, but to monitor whether it is given at all – people are sometimes forgetful about administering any drug. However, this is a time-consuming and expensive method and MEDICAL MANAGEMENT OF MS 17 some people now self-administer the drug, rather like insulin for people with diabetes. Newer modes of administration are now being developed and trials are taking place to test whether these other methods are better and more effective. None of the drugs can be taken by mouth (orally) as yet; they are proteins and likely to be broken down by the digestive processes, making them less effective, or possibly even ineffective. Decisions will taken by your neurologist based on your personal situation, and taking into account: • a longer term reduction in the number and degree of relapses compared to those you had before starting the beta-interferon; • no substantial rise in unwanted side effects; • no other clinical reason why you should not continue; • no better therapies being available; • the substantial ﬁnancial issues involved, i. Side effects of beta-interferon There have been two main side effects noted, mainly with beta-interferon 1b (Betaferon): • There are symptoms best described as ‘ﬂu-like symptoms, which many, perhaps most, people experience in the ﬁrst few months of treatment. These are generally mild and can be managed with ordinary analgesics (pain relievers), and they disappear in almost everyone after those ﬁrst few months. Very rarely more serious reactions have been reported – only in a few cases serious enough to warrant stopping treatment. As far as beta-interferon 1a drugs (Avonex and Rebif) are concerned, similar types of side effects were experienced, but at a lower rate. We do not yet know about any longer term side effects, an important issue in MS where people usually live with their condition for several decades.