Entocort

Hana Dan-Cohen PhD

• Lecturer, UCB-UCSF Joint Medical Program

https://publichealth.berkeley.edu/people/hana-dan-cohen/

Takiguchi T allergy medicine for 9 year old generic 100 mcg entocort amex, Yamaguchi S allergy medicine that starts with l buy 100mcg entocort with amex, Tezuka M kirkland allergy medicine 600 entocort 100 mcg cheap, Furukawa N allergy medicine makes you drowsy order 200 mcg entocort, Kitajima T rhage of the cervical spinal cord: a post-mortem artefact Vinchon M allergy relief treatment buy on line entocort, Noizet O allergy shots orlando fl order 100mcg entocort fast delivery, Defoort-Dhellemmes S, Soto-Ares G, rhage:pathological and experimental aspects in subarachnoid Dhellemmes P (2002) Infantile subdural hematomas due to hemorrhage. Squier W, Lindberg E, Mack J, Darby S (2009) Demonstration infants: a prospective study. Vinchon M, Desurmont M, Soto-Ares G, De Foort-Dhellemmes cortical cystic leucomalacia: a distinct pathological entity S (2010) Natural history of traumatic meningeal bleeding in resulting from impaired uid handling. Watts P, Obi E (2008) Retinal folds and retinoschisis in acci brain injury in children. Neu dural venous plexus and cervical myelopathy due to rosurg Rev cerebrospinal uid overdrainage: a rare complication of ven 186. Yu Y, Chen J, Si Z, Zhao G, Xu S, Wang G, Ding F, Luan L, injury in the abused child. The mechanisms of Low energy wounds; injury and basic resuscitative principles are set out. Injury patterns previously con ned to the military composition), environment are now seen in civilian practice. Thus any the ight characteristics (velocity, stability and yaw or doctor treating trauma victims should have a basic under tumbling characteristics). This overview intends to provide a short explanation of the In addition the reaction of the differing types of tissue the biophysics behind these injury mechanisms, the pathophy missile encounters affect wounding outcome. As the volume of this gas increases, the internal pressure Gunshot injuries within the barrel of the gun rises, forcing the bullet down the barrel. As it does so, it is engaged by the spiral grooving Basic ballistics or ri ing of the barrel causing it to spin. This stabilises the ight of the projectile, maintaining its trajectory, range and Ballistics is the study of the motion of an object when it has accuracy. Yaw is produced by the inherent asymmetry of any bullet as it deviates from its longitudinal axis during ight. This is identi ed mostly during the initial and nal phases of ight producing phases of instability and thus deceleration of the round. Usually they have a lead core to increase mass, which may or may not be jacketed (enveloped) with copper. The nose may be jacketed or not and can be rounded, pointed, at, hollow, semi-hollow or full. A rounded nose makes for non-expansion on impact; a pointed nose, most a military type, tends to penetrate tissues more deeply, whereas a at nosed round tends to expand on impact creating a larger super cial wound. The body contains the core, usually lead, providing the necessary concentricity and balance for ight. The base or heel may be at or boat tailed, the latter to reduce air drag to improve velocity and range. This is dependant on range, Figure 1 Cartridges demonstrating the round at the tip, and i. The initial velocity is described as the velocity of bullet has already started to tumble then the wound on the projectile at 5 m (15 ft) from the muzzle. If ight has Low-velocity wounds are more common in civilian remained stable then impact wounding will be smaller practice and are usually less severe, whereas high-velocity and more circumscribed. The biological characteristics of the tissues the round which is indicative of the amount of tissue damage sustained impacts, i. A at nosed bullet may cause a large super cial weapon) known as the ballistic properties of the bullet and entry wound and appear to have caused far greater tissue weapon. Controlled missile ight of the tissues as the bullet passes through them forming a is a factor of its ballistic coef cient and the spin imparted to cavity with a relative vacuum behind it. The nose of the round remains pointed for deep penetration, although the body of the round has already been destorted by ricochet. Pictures (c), (d), (e) and (f) show a round on the shoulder X-ray, the round after being removed and the patient from whom it was removed. The round had entered on the left side of the neck, passed through the soft tissue and exited on the right side only to re-enter the patient to be stopped by the distal clavicle. This demonstrates a typical rounded nose, fully jacketed with copper, at-based round frequently used in the military setting. Figure 3 Demonstrates the passage of a round as it penetrates a gelotine block with the formation of a cavity. Surrounding this cavity therefore is a create damage of an almost explosive nature. In low-energy wounds, such as sequent vacuum sucks foreign material such as pieces of an airgun ri e wound, this may be only a few cells in depth. Fascial planes can serve as channels along which energy In the civilian environment, patients are generally clean dissipates leading to remote tissue damage. Examples of the densities of the tissues within the path of the low-energy wounds include airgun ri e injuries where the projectile have an important effect on the overall wound entrance wound can be as small as 0. The skin and lung, with relatively low density but large the round retained within the soft tissues, with minimal elasticity can be virtually spared from signi cant damage. Bone however, with a higher density but low elasticity, can Fractures, if present are of a stable con guration, can be be completely shattered. The liver, spleen and muscle are treated conservatively not requiring operative intervention. Larger arteries and nerve trunks are managed more aggressively with early surgery. The presence remarkably resistant to injury, and while neurapraxias do of massive soft tissue damage with gross contamination, occur, nerves are rarely completely disrupted unless in the unstable fracture con gurations with or without joint direct path of the missile. Frequently, but not 48 h post-injury) require immediate surgical intervention always, the exit wound is larger than the entry wound. Other indications the round loses energy it begins to tumble within the tissue for surgery are tendon injury, super cial fragments in the area thus creating a larger more irregular, less well-de ned palm of the hand or sole of the foot, certain cases with wound. In high-velocity injuries cavity formation may occur spinal involvement and injuries to the bony pelvis. A at the exit wound additionally sucking in substantial retained metallic fragment within a joint cavity is an quantities of contaminated material (Fig. Fracture patterns are variable and may be complete or incomplete, and obviously Blast physics fractures have concomitant soft tissue injury. Low-velocity projectiles tend to cause relatively minor, stable fracture An explosive is a material capable of producing an explosion con gurations such as unicortical involvement, passing by its own energy. High explosion or blast follows a sudden release of energy4 from a velocity projectiles are more likely to cause unstable chemical, gaseous, mechanical or even nuclear means fracture con gurations with butter y fragments and large dissipated by a blast wave, propelling fragments and amounts of comminution. Bones are fractured either due to surrounding material, and causing heat formation. The gas direct contact with the bullet or by a secondary energy is the primary mechanism by which the explosive produces transfer via the temporary cavitation. The initial shock wave following an explosion is a In the immature skeleton, physeal injuries are usually as a special form of high-pressure stress wave, with an instanta result of direct injury from the projectile passing close to neous wave front. This can be easily identi ed on initial X the passage of this shock wave and then forced outwards by rays. However, physeal arrest has been associated with the expansion of gases formed within the explosion. This has a lower peak pressure and initial velocity than the detonation shock wave Wound assessment and initial resuscitation and has a zone of rare ed air immediately behind the high pressure area. Within this blast wave are the products of the should be undertaken at presentation with, if possible, an explosion, i. Full assessment of the patient should travels further than the detonation shock wave, exerting its include head to foot examination including a log roll and effects further from the explosion centre. Identi cation of entrance and exit in the open, without being con ned by buildings, etc. The combination of primary blast injury from the shock wave and tertiary injury due to body displacement leads to limb avulsion injuries. This occurs as the initial shock wave causes long bone fractures and the body displacement ailing of the limb with subsequent avulsion. These include thermal injury to exposed skin caused by the radiant and convective heat Figure 5 Simpli ed diagram of the components making up a of the explosion, methaemoglobinaemia due to poison blast wave. A high incidence of psychological sequelae in injured and uninjured survivors is also seen. The interaction of the blast wave with the body wall generates two types of waves. Stress waves are longitudinal pressure waves with similar properties to sound waves. They travel at approximately the speed of sound, but differ from sound waves because of their high amplitude and velocity. The initial shock wave following an explosion is a special form of high-pressure Figure 6 Simpli ed waveform diagram of shock wave follow stress wave, with an effectively instantaneous wave front, ing an explosion in air. The properties of this wave this simple wave form has an almost instantaneous rise to form explain the effects produced on tissues. Effects include peak overpressure, which then declines exponentially high local forces produced with small rapid distortions, thus through ambient pressure to sub-atmospheric pressure, producing microvascular disruption, without gross lacera corresponding to the rare ed zone behind the blast front. Organs with differing acoustic impedance are affected the overpressure lasts for approximately 10 ms, with the i. Tissue interfaces sub-atmospheric pressure zone lasting for considerably re ect and reinforce stress waves causing enlargement of longer. Con nement of the explosion within a building or wave pressures far from the site of body impact. Blast injuries fall into four main categories: (b) As the stress wave passes from a solid into a gas lled tissue interface, a component of the compressive stress (i) Primary blast injury relates to the interaction of the wave is re ected back as a tension wave. Gas containing are weaker in tension than in compression and thus structures such as the ear, lungs, and gastrointestinal disruption and therefore damage at the tissue interface tract are at particular risk. Thus a (c) When the stress wave compresses a gas containing patient with pure primary blast injury may display little structure such as an alveolus or bowel segment, the external evidence of trauma. These result from the deformation of the body wall receptors located in the alveolar interstitial spaces close to and compression of the visceral structures. An increase in pulmonary interstitial structures from their attachments and shearing of solid pressure or volume, due to pulmonary haemorrhage and organs is caused by the asynchronous movements of tissues oedema, could distort and therefore activate the pulmonary with differing inertia. However, this triad is not shown in animals the primary blast injury of solid abdominal viscera, undergoing abdominal blast exposure. Gross ndings are of heavily consolidated haemor Signs include tachypnoea, cyanosis, reduced breath rhagic lungs. Animal experiments of primary blast injury demonstrate Pneumothorax/haemopneumothorax presenting with sud that the most consistent lesion was bilateral traumatic den shortness of breath, pain and deviated trachea require haemorrhage. Haemorrhage into the alveoli and the resultant pulmonary Pathophysiology of intestinal primary blast injury oedema cause a ventilation perfusion mismatch with increased intrapulmonary shunt, reduced lung compliance, Because of its many tissue/gaseous interfaces the intestine 8 is highly susceptible to primary blast injury. This response is similar to that seen in other non-penetrating tertiary penetrating injuries must be managed in a conven lung injury. The primary characteristic of intestinal Initial clinical observations of the physiological responses primary blast injury is the intramural haematoma, although to blast injury vary considerably, largely due to the varying extreme overpressure shock waves will cause immediate gut times at which these observations are made post-injury and laceration. Intramural haematomas may be minor, mucosal the secondary associated injuries sustained. Observations of or submucosal haemorrhage only with oedema, through to victims dying immediately following blast exposure with complete disruption of the muscular layers and serosa, little external evidence of injury led to the theory that the causing perforation. Individuals sustaining blast injury are blast wave causes an acute cardiovascular and respiratory observed to sustain injury mainly in the ileocaecal region and colon which are more likely to be gas lled. Experimental work on animals subjected to a thoracic blast has demonstrated a re ex triad of apnoea, laparotomy detection of these injuries is dif cult.

Light and closing the categorized allergy shots vs. sinus surgery discount entocort 200 mcg with visa, then the eyes can precipitate these generalized seizures allergy testing wheal entocort 200 mcg visa. The new classification system inadequate or if the seizure cannot be categorized allergy treatment 360 proven 200mcg entocort, then the seizure is considered additionally recognizes two unclassified allergy medicine generic list buy cheap entocort 200 mcg line. This classification assumes the patient has epilepsy as defined by the previously discussed updated Patients with generalized 11 definition allergy medicine nasal congestion buy entocort overnight. The new typically display generalized classification system additionally recognizes two new categories: combined spike-wave activity allergy testing baltimore buy 200 mcg entocort amex. Examples of combined generalized and focal epilepsy both focal and generalized include Dravet syndrome and Lennox-Gastaut syndrome. Previously, the term benign was used to describe some of the epilepsy syndromes, but it is no longer used as it infers the epilepsy has minimal effect on the patient. It is now more clearly understood that any epilepsy can have social effects and can be associated with other comorbidities such as learning disorders or psychiatric conditions. Controversy surrounds the use of the term idiopathic, and removing it from epilepsy classification has been advocated. There is, however, concern that use of the word genetic infers inherited, and many patients with epilepsy have de novo mutations or have complex genetic syndromes that occur with or without environmental factors. When the clinician determines that a clear genetic etiology is present, the term genetic generalized epilepsy may be used to refer to the epilepsy syndrome. Onset is usually between 4 and 10 years of age, International League Against with remission usually occurring in adolescence. Patients present with absence Epilepsy, but it remains seizures and occasionally with generalized tonic-clonic seizures. Early undetermined whether the patient has focal or occurrence of generalized tonic-clonic seizures is associated with a poorer generalized epilepsy, the prognosis. All patients have myoclonic seizures and commonly have generalized tonic-clonic Idiopathic generalized seizures. Most patients do not have spontaneous epilepsies include childhood absence remission and require lifelong treatment with antiepileptic medication. Similar to Reflex epilepsy juvenile absence epilepsy and juvenile myoclonic epilepsy, epilepsy with syndromes are epilepsies in generalized tonic-clonic seizures alone is not self-limiting, and lifelong which seizures are provoked antiepileptic drug treatment is typically required. Seizures are typically generalized tonic-clonic seizures, but centrotemporal spikes and Panayiotopoulos syndrome. Other reflex epilepsy syndromes include reading 17,18 epilepsy and startle epilepsy. Focal Epilepsy Syndromes Well-described focal epilepsy syndromes include childhood epilepsy with centrotemporal spikes and Panayiotopoulos syndrome. Previously, childhood epilepsy with centrotemporal spikes was referred to as benign epilepsy with centrotemporal spikes. Childhood epilepsy with centrotemporal spikes is a self-limited epilepsy that presents in the school years with brief focal motor hemifacial seizures and nocturnal focal motor seizures evolving to bilateral tonic-clonic seizures. Possible autonomic symptoms include vomiting, pallor, mydriasis, cardiorespiratory, gastrointestinal, 19 and thermoregulatory symptoms, incontinence, and hypersalivation. In the prior classification system of the 1980s, etiology was inferred when classifying the epilepsy. Idiopathic primarily referred to genetic causes, symptomatic referred to the presence of a known disorder or lesion, and cryptogenic referred to a presumed but unknown symptomatic cause. As discussed, the term idiopathic is now used to refer to four well-described epilepsy syndromes. Six etiologic categories (structural, genetic, infectious, metabolic, immune, unknown) have been defined. When multiple potential etiologies are present, priority should be given to the etiology with more relevant management issues. Ongoing consideration of the etiology has clear implications for patient management as well as research efforts as we continue to study why patients develop seizures and we determine optimal treatments. Possible structural abnormalities include stroke, trauma, tumor, malformations of cortical development, and infection. Genetic etiologies are determined if there is a known or presumed genetic 3 mutation in which seizures are a core symptom of the disorder. Although some epilepsies are inherited, many occur secondary to a de novo (new) mutation in the affected individual. In addition, the genetic etiology for some epilepsy syndromes such as juvenile myoclonic epilepsy is inferred from research studies including twin and familial aggregation studies. Overall, genetic etiology is defined by having a known mutation, clinical presentation with supportive data and family history, or a syndrome with evidence from research studies to suggest a genetic etiology. An important distinguishing point is that the patient has epilepsy secondary to an infectious etiology and not seizures in the setting of an acute infectious illness. Epilepsy onset secondary to a prior infectious insult such as meningitis or encephalitis is also considered an infectious etiology. Epilepsies with a metabolic etiology occur secondary to a known or presumed 3 metabolic disorder in which seizures are a core symptom of the disorder. Overlap with a genetic etiology may occur as many metabolic disorders have known genetic mutations. Of course, identifying a genetic etiology early in presentation is important because management interventions such as a change in diet or supplementation can affect its natural course. In patients with identified immune etiologies, immunotherapy should be considered. A cause likely exists, but its identification may emphasized in the 2017 be limited by inadequate resources such as poor access to up-to-date brain International League Against imaging, immune antibody testing, or genetic testing. Incidence represents the number of new cases among is the probable cause of the seizures. Incidence studies, in contrast to prevalence studies, provide a better understanding of Genetic etiologies are 21 etiology and the natural history of epilepsy. Epilepsy incidence studies are, determined if there is a however, lacking and heterogeneous. Heterogeneity among reported incidence known or presumed genetic mutation in which seizures population studies may be addressed by use of universally adopted seizure and are a core symptom of epilepsy classification systems. It has, however, also been argued that the system allows flexibility as cases may be classified in different categories depending on workup, creating Epilepsies with a 23 metabolic etiology occur a potential obstacle for epidemiologic studies. The emphasis disorder in which seizures on etiology may lead to a better understanding and determination of epilepsy are a core symptom of incidence, which, of course, depends on classification agreement among the disorder. Universal implementation of this classification system and further Immune etiologies are study will hopefully clarify the utility of the newly proposed system and whether increasingly recognized its use will reduce heterogeneity among incidence studies and allow us to better as potential causes of define significant factors that contribute to epilepsy incidence in all regions of epilepsy. Universal adoption and use of this classification system have direct implications on our understanding of epilepsy incidence. In addition, incidence studies are limited in number and scope and rarely consider seizure type. In addition, further study is needed to evaluate the utility of the 2017 classification system. Although it establishes standard terminology, potential variability in coding and poor agreement among physicians may limit its use. The organization promotes research, education, and training and improves services and care for patients with epilepsy. Links to published articles on seizure and epilepsy classification are available on this website. Executive summary of recommendations Diagnosis of epilepsy What aspects of diagnosis are specific to pregnancy and the puerperium, including the definition of seizures for the obstetrician The diagnosis of epilepsy and epileptiform seizures should be made by a medical practitioner with P expertise in epilepsy, usually a neurologist. Women with a history of epilepsy who are not considered to have a high risk of unprovoked seizures P can be managed as low-risk women in pregnancy. What other conditions in pregnancy should be considered in the differential diagnosis of epileptic seizures In pregnant women presenting with seizures in the second half of pregnancy which cannot be clearly P attributed to epilepsy, immediate treatment should follow existing protocols for eclampsia management until a definitive diagnosis is made by a full neurological assessment. Other cardiac, metabolic and intracranial conditions should be considered in the differential diagnosis. C Pregnant women who have experienced seizures in the year prior to conception require close D monitoring for their epilepsy. P What is the optimum method and timing of screening for detection of fetal abnormalities P the diagnosis of epilepsy per se is not an indication for planned caesarean section or induction of D labour. How should women with non-epileptic attack disorder be counselled in pregnancy and how should their non-epileptic seizures be managed C Adequate analgesia and appropriate care in labour should be provided to minimise risk factors for P seizures such as insomnia, stress and dehydration. If this cannot be tolerated orally, a parenteral alternative P should be administered. P Seizures in labour should be terminated as soon as possible to avoid maternal and fetal hypoxia and D fetal acidosis. The decision to use water for analgesia and birth should be made on an individual basis. Postpartum management What is the risk of seizure deterioration postpartum and how can this be minimised P Mothers should be well supported in the postnatal period to ensure that triggers of seizure P deterioration such as sleep deprivation, stress and pain are minimised. Postnatal mothers with epilepsy at reasonable risk of seizures should be accommodated in single P rooms only when there is provision for continuous observation by a carer, partner or nursing staff. Women taking lamotrigine monotherapy and oestrogen-containing contraceptives should be informed C of the potential increase in seizures due to a fall in the levels of lamotrigine. Effective contraception is extremely important with regard to stabilisation of epilepsy and planning of pregnancy to optimise outcomes. This guideline does not cover the methods of diagnosis of epilepsy, detailed categorisation of seizures or strategies for the management of epilepsy. Introduction and background epidemiology Epilepsy is one of the most common neurological conditions in pregnancy, with a prevalence of 0. Further information about the assessment of evidence and the grading of recommendations may be found in Appendix I. A medical practitioner with specialist training in epilepsy, usually a neurologist makes the diagnosis of epilepsy and its categorisation. Any assessment of the condition in pregnancy should include duration and severity, frequency and type of seizures, and impact of epilepsy on the mother such as driving, accidents, family life and employment. A drug history of effective and ineffective medications is relevant, including a history of adverse effects. These women can be managed as low-risk individuals in their pregnancy provided that there are no other risk factors. The most common seizure types reported in pregnancy and their manifestations are detailed in Table 1. Accurate documentation of the type of seizures and their frequency will help to identify any Evidence provoking factors, plan management and allow retrospective audit of epilepsy care. Clinical presentation of various seizures types and their effects on the mother and baby Common types of Clinical presentation Effects on mother and baby epilepsy/seizures T0nic-clonic seizures Dramatic events with stiffening, then Sudden loss of consciousness with an (previously known as bilateral jerking and a post-seizure state of uncontrolled fall without prior warning. Absence seizures Generalised seizures that consist of brief Effects mediated through brief loss of blank spells associated with awareness although physiological effects unresponsiveness, which are followed by are modest. Juvenile myoclonic Myoclonic jerks are the key feature of this Occurs more frequently after sleep epilepsy form of epilepsy and often precede a deprivation and in the period soon after tonic-clonic convulsion. The sudden jerks may as sudden and unpredictable movements lead to falls or to dropping of objects, and represent a generalised seizure. Focal seizures Symptoms are variable depending on the Impairment of consciousness increases (previously defined as regions and networks of the brain affected. Seizures compared with if consciousness is retained consciousness and may impair consciousness. P Neuropsychiatric conditions including non-epileptic attack disorder should also be considered. Other conditions, such as syncope associated with cardiac arrhythmia, aortic stenosis, carotid sinus sensitivity, vasovagal syncope and metabolic conditions such as hypoglycaemia, hyponatraemia and Addisonian crisis will need to be ruled out for first presentation of seizures in pregnancy. Sodium valproate is associated with neural tube defects, facial cleft and level 2++ hypospadias; phenobarbital and phenytoin with cardiac malformations; and phenytoin and carbamazepine with cleft palate in the fetus. Based on limited evidence, in utero exposure to carbamazepine and lamotrigine does not appear to C adversely affect neurodevelopment of the offspring. Parents should be informed that evidence on long-term outcomes is based on small numbers of children. Studies evaluating the effects of folic acid supplementation in pregnancy on major congenital malformation have shown varied results. Status epilepticus is defined as 30 minutes of continual seizure activity or a cluster of seizures without recovery. Currently, there are no tests to predict the risk of seizure deterioration in pregnancy. Any information on prenatal screening for major congenital malformation should highlight the detection rates, limitations of the test performance and the implications, such as termination of pregnancy.

Benzodia polysomnographic studies of the arousal zepines allergy medicine safe while breastfeeding order cheapest entocort, tricyclic antidepressants allergy treatment while pregnant purchase 200mcg entocort with amex, and disorders have been published allergy treatment medicine buy discount entocort on line. Speech is generally slow and typically remit spontaneously allergy medicine enlarged prostate generic entocort 100mcg without prescription, but sleep physical stress; fever; devoid of content allergy testing no needles 100 mcg entocort with mastercard. Affected individuals walking often presents in adolescence menses; environmental typically appear bewildered allergy testing redmond wa cost of entocort, have little or adulthood. Confusional arousals may stimuli; sleep to no memory of the event, and may act present de novo in adulthood and can disorderYproducing out aggressively toward bystanders. Sleepwalking (som movements; neurologic and psychiatric sleep terrors is lacking. Duration is nambulism) is characterized by a se comorbid conditions; usually a few minutes, although epi quence of complex behaviors in sleep, alcohol; and medications, sodes as long as several hours have including ambulation that is more elab particularly psychotropic been described. Examples of confusional before leaving the bed (Supplemental arousal are illustrated by the accompa Digital Content 6-7, links. Abnor andjumpingwithvocalizationinan mal sexual behaviors (sexsomnia) rang attempt to escape a perceived threat, ing from masturbation to sexual assault preparing foods, eating, cleaning, and Case 6-2 A 35-year-old man presented with his wife reporting abnormal behaviors in sleep. While recovering in a rehabilitation facility, he was involved in an altercation with an attendant after he wandered outside his room. He was wrestled to the ground when he became agitated after being shaken awake, prompting transfer to a psychiatric ward, where he was evaluated and discharged a few days later without further treatment. His wife reported less dramatic episodes 2 to 3 times per week during which he would wander outside of his room asleep or wake up confused, typically within a few hours of sleep onset. He generally would not respond during episodes and had little or no recollection of what had transpired. He reported mild daytime sleepiness and snoring, but denied 2 gasping or choking in sleep. While classified as sleepwalking, sleep terrors, or confusional arousals for nosologic purposes, these behaviors often coexist in the same patient. Most episodes occur in the first third of the sleep period, where slow-wave sleep predominates. The frequency of sleepwalking episodes varies considerably from case to case, ranging from isolated, rare occurrences to multiple episodes per night. Sleepwalking and confusional arousals are commonly precipitated by sleep deprivation, emotional or physical stress, fever, comorbid psychiatric and neurologic disorders, and medications. Safeguards to secure a safe sleep environment were recommended, and the patient was instructed to avoid alcohol and sleep deprivation. Treatment with continuous positive airway pressure followed an in-laboratory titration study, resulting in a near cessation of arousal episodes. Treatment of sleep disorders producing sleep fragmentation such as obstructive sleep apnea often reduces the frequency of parasomnia episodes in both children and adults. Episodes usually tion (Supplemental Digital Content classified as distinct terminate spontaneously with the pa 6-8, links. Affected individuals recurrent dream-enacting partial recollection the following day. Sleep-related injuries to ple episodes per night with clustering children, adults with sleep terrors may the affected person or for several nights, followed by pro bolt out of bed in a violent or agitated bed partner occur in longed periods of remission. Nightly manner with some dream recollection approximately one-third episodes that cluster are rare. Most affected children had confusional Episodes typically last several minutes arousals at an earlier age. Sleepwalking and are followed by the patient calmly typically begins in the first decade of life and quietly returning to sleep. Sleepwalking has a iors that are occasionally challenging strong genetic predisposition, with first to differentiate from nocturnal seizures degree relatives of sleepwalkers having and at times overlap with disorders of at least a 10-fold increased likelihood of arousal. Sleepwalking was iors, including vocalizations and motor inherited as an autosomal dominant dis activity in relation to altered dream order with reduced penetrance in a mentation (Case 6-3)(Supplemental four-generation family with localization Digital Content 6-12, links. Sleep-related injuries genetic locus identified that contains to the affected person or bed partner 35 the adenosine deaminase gene. In occur in approximately one-third of hibition of adenosine metabolism in cases (Supplemental Digital Content creases slow-wave sleep, rendering this 6-13, links. Sleep terrors (ie, night abruptly at the end of an episode and terrors, pavor nocturnus) are character are alert and able to recount a coherent 116 During the interview, he reluctantly described having vivid dreams associated with violent movements, yelling, and swearing in sleep. He appeared embarrassed by these behaviors and expressed remorse when telling the story of how he once repeatedly punched and kicked his wife while dreaming that he was fending off an attacker. In turn, his wife stated adamantly that this behavior was highly uncharacteristic of her loving husband. His wife once found him with blood dripping from his eyelid, bruises on his face, and the bedside table on the floor; she assumed that he had struck himself in his sleep. After an episode, he would usually wake up and provide a detailed account of his dream. Home safety precautions were implemented, including the removal of potentially dangerous objects from the bedroom and placement of a cushion around the bed. Almost immediately after the patient started treatment, the frequency of his violent behaviors declined markedly. Primitive behav attacked by unfamiliar people, animals, iors (including chewing, eating, drink insects, or other beings. Dream-enacting episodes turing, punching, slapping, grabbing, may occur even earlier in the sleep kicking, running, and jumping, often period in patients with narcolepsy and performed in a self-protective manner. Episodes occur sporadi Unlike sleepwalking, people rarely walk cally an average of once per week and out of the room, and episodes occur rarely nightly or in clusters. This pontine activity exerts an excitatory influence on medullary centers (magnocellularis neurons) via the lateral tegmentum reticular tract that, in turn, hyperpolarizes the spinal motor neuron postsynaptic membranes via the ventrolateral reticulospinal tract. While the condition is environment to protect patients and more common in older men, its pres bed partners from injury is advised. Ictaleye for episodes that can last from minutes closure and jaw clenching suggest to an hour or longer. Among 100 consecutive adults with urinary incontinence, event-related repeated sleep-related injury, 7% were injury, and myalgia support the diagno 31 diagnosed with dissociative states. Occurrence only in the sociative disorders preferentially affect presence of observers and events trig females. Epileptic seizures one series had seizures arising from coexist in 10% to 60% of cases. These ion channel receptors observers that includes timing, fre are widely distributed on neuronal and quency, semiology, and evolution of glial membranes in cortical and subcort typical events (Table 6-4). However, capturing a typical spinal cord common pattern genera event can be challenging in the out tors. A broad spectrum of clinical man patient setting during a single night of ifestations may be observed, including recording. Supportive evi transitions, while dence of sleep terrors or epilepsy was Parasomnias arousal disorders arise obtained in 35%, and the study was Nocturnal seizures. Whilesleepstageatevent deep or midline regions or who show onset was discriminatory (82% of sei seemingly generalized epileptic activity zuresoccurredduringsleepstageN1or due to rapid propagation to the contrala N2, and 100% of arousal disorders arose teral hemisphere. Seizures are com seizures and overlap with seizures aris monly obscured by artifact due to the ing from the mesial and basal cortical 53 prominent motor activity of nocturnal regions. The arousal on the clinical history, owing to under itself can consist of any frequency, in detection of frequent minor stereo cluding rhythmic delta activity sugges typed motor events associated with tive of a persistent sleep pattern or a arousal in the presence or absence of predominance of alpha activity more 52 epileptiform discharges. Slow-wave seizure if the episode is brief and the sleep arousals in the absence of clinical epileptic generator is distant from the events are supportive of an arousal recording electrodes. G2 minutes +1 2Y10 minutes 0 910 minutes j2 Clustering What is the typical number of events to occur 1Y in a single night Yes +1 No 0 Does the patient ever wander outside the Yes j2 bedroom during the events No (or uncertain) 0 Does the patient perform complex, directed Yes j2 behaviors during events No (or uncertain) 0 Is there a clear history of prominent dystonic Yes +1 posturing, tonic limb extension, or cramping No (or uncertain) 0 during events Stereotypy of events Are the events highly stereotyped or variable Highly stereotyped +1 in nature Some variability/uncertain 0 Highly variable j1 Recall Does the patient recall the events Yes, lucid recall +1 No or vague recollection only 0 Vocalization Does the patient speak during the events and, No 0 if so, is there subsequent recollection of this speech No minimum number of confirmation by epochs of abnormal motor activity is Other diagnostic modalities polysomnography. Her Frontal Lobe Epilepsy and Parasomnias Scale score of 5 (+1 for duration G2 min; +1 for 3 to 5 events in a single night; +1 for timing within 30 minutes of sleep onset; +1 for highly stereotyped events; and +1 for lucid recall) suggested a diagnosis of nocturnal frontal lobe epilepsy. Indeterminate scores brief, typically lasting 20 to 30 seconds; require further evaluation. The scale and are associated with preserved aware has been shown to have high positive ness without postictal confusion or (91%) and negative (100%) predictive amnesia. Ongoing research is differentiation of other types of epilep necessary to fully elucidate the patho tic seizures and parasomnias. The seizures routinely wake him up, but naire, are reported to have a sensitivity he typically can recall what happens during the of 96% to 98% and specificity of 55% to seizure and responds immediately thereafter. The diagnosis of complex nocturnal Supplemental Digital Content 6-2 behaviors is among the most difficult Rhythmic movement disorder. Video demon to establish in sleep medicine clinics and strates head rolling in an adult man. An accurate diagnosis of typed and repetitive movement artifact is depicted at the frequency of 1 Hz to 2 Hz. Video most difficult to differentiate from para demonstrates benign sleep myoclonus in in somnias. Its main character nocturnal frontal lobe seizures typically istics include rhythmic myoclonic jerks when drowsy or asleep (that stop in wakefulness), and a have an abrupt, explosive onset that normal encephalogram during the episodes. Complex Nocturnal Behaviors Supplemental Digital Content 6-4 Supplemental Digital Content 6-9 Psychogenic movements. Video demonstrates sleep terror old woman with psychogenic movement of both in an adult woman. The movements interfere with video segment after the event illustrates con her sleep onset, disappear in sleep, and reoccur versation with the technologist in which the upon awakening. The movements are at times patient recalls being awakened, but has little also seen during the day in wakefulness. Supplemental Digital Content 6-5 Supplemental Digital Content 6-10 Confusional arousal. The patient has an a 46-year-old woman with a childhood history of arousal, appears confused, and gets out of bed, sleep terror who started having episodes of demonstrating automatic behavior. This is an screaminginthemiddleofthenight,towhich example of a hybrid attack in which the patient she was oblivious. If her husband was home and begins the episode with a confusional arousal and able to wake her, she sometimes reported seeing proceeds for exhibit somnambulistic behavior. With Supplemental Digital Content 6-7 this dose, she experienced good control of the Sleepwalking. She had let herself out of her house a few times, so safety was a Supplemental Digital Content 6-11 concern. Video demonstrates an tientwasstartedonclonazepam,whichmadeher episode of sleep terror in a child that consists of symptoms worse, and she was referred to a sleep sudden arousal, increase in sympathetic tone, center for a consultation. Analysis of clinical patterns and underlying epileptogenic zones of hypermotor seizures. Surgery for central, parietal nocturnal frontal lobe epilepsy: and occipital epilepsy. Long-term seizure outcomes following epilepsy surgery: a systematic review and 22. Intractable seizures of frontal lobe origin: clinical characteristics, localizing signs, and 23. Unnwongse K, Wehner T, Foldvary-Schaefer Epileptic motor behaviors during sleep: N. Preictal pseudosleep: a new second edition: diagnostic and coding finding in psychogenic seizures. Dissociated Pseudosleep events in patients with local arousal states underlying essential psychogenic non-epileptic seizures: clinical features of non-rapid eye movement prevalence and associations. J Neurol arousal parasomnia: an intracerebral Neurosurg Psychiatry 2004;75(7):1009Y1012. A polysomnographic and clinical Central pattern generators relationships to report on sleep-related injury in 100 adult parasomnias and sleep-related epileptic patients. Practice parameters for the indications arousals in the general population: their for polysomnography and related procedures: an update for 2005. Identifying montages that best detect Prevalence and genetics of sleepwalking: a electrographic seizure activity during population-based twin study. Foldvary-Schaefer N, De Ocampo J, Mascha Novel genetic findings in an extended family E, et al. General information Medication records located: Seizure records located: General support needs document located: Epilepsy diagnosis (if known): 2. Yes No If yes, the medication authority or emergency medication plan must be attached and followed*, if you are specifically trained.

For example allergy shots itching purchase online entocort, three studies about psychiatric consultations allergy symptoms like cold discount entocort, four about wound care allergy treatment using cold laser for drug withdrawal discount 100mcg entocort otc, and three about infectious disease all reported positive outcomes such as reduced symptoms allergy testing naples fl buy generic entocort online, faster healing allergy testing metals discount entocort 200mcg without a prescription, or reduced viral load allergy testing erie pa cheap entocort. Most, but not all of these studies, involved real time, video consultations, and patients were often present. In other studies, specialists reviewed updated records, including images or test results and contacted the treating physician with recommended changes in treatment or requested more information. The four studies of wound care used store and forward approaches to provide images and information, which the specialist reviewed when available and used them to develop a treatment plan that was communicated to the patient and referring clinician at separate time. Just under one-third of the studies (32) about outpatient consultations included some assessment of cost or economic impact. These varied from basic estimates of travel costs to detailed assessments of the different sources of fixed and variable costs. However, most are comparatively simple, and while about half (14) of the studies reported some cost savings for teleconsultations, these were mostly limited to avoided travel costs and loss of productivity for patients. In a small number of studies (4), telehealth consultations were not less expensive: for example a study of dental consultations to underserved communities concluded that telehealth 194 consultations were more expensive than outreach visits by dentists, and a study of a network 85 linking primary care to multiple specialists via video found telehealth consultations to be more expensive due to treatment costs and the extra time required to have both the specialist and 207 primary care physician available for real time video consultations. Outpatient Telehealth Effectiveness in Improving Intermediate Outcomes Most studies of outpatient telehealth consultations used intermediate outcomes to assess efficacy. Overall, the results support the use of telehealth consultations, though the amount of evidence varies across the different intermediate outcomes. Thirty-five studies evaluated whether telehealth consultations improved access to services. We interpreted increased access to include both timelier access to services as well as increased rates of use. These were concentrated in dermatology (6 studies), studies of multiple specialties (6 studies), specialty consultations that included diagnostic technology (3 studies), and ophthalmology (3 studies). For example, in the dermatology studies, telehealth consultations reduced wait time and time to treatment, and studies of consults with diagnostic technology reported increased numbers of patients receiving indicated tests and in less time with telehealth. In some clinical categories, only one study addressed these outcomes, while in other clinical categories, as many as 10 articles studied utilization and management. Not unexpectedly, telehealth consultations reduced the number of in-person specialist and hospital visits; they also were associated with fewer hospitalizations, shorter lengths of stay, and care that is more likely to follow establish guidelines. The one aspect of management for which the findings were less consistent was agreement on diagnosis and management, with some studies reporting a significant difference between telehealth and in-person conclusions or that telehealth was unable to facilitate a diagnosis, though the reasons were not clear. Twenty-two studies assessed satisfaction with telehealth consultations and generally reported that patients and providers were as satisfied with telehealth consultation as in-person visits. In some cases, patients and families were more satisfied, particularly when the telehealth consultation saved travel and associated time and expense, while providers tended to be slightly less satisfied with telehealth consultations though this difference was not statistically significant. Outpatient Telehealth Consultations: Harms, Adverse Events, or Negative Unintended Consequences Two outpatient studies explicitly addressed harms or unintended consequences in reporting 30,234 30 lower rates of complications. One studied complications in cancer treatments, and the 234 other reported serious adverse events related to hepatitis C treatment. In part, the overall lack of reporting on harms reflects the relatively short-term followup in most outpatient studies and the focus on intermediate outcomes. For most clinical topics, the studies were conducted in a variety of geographic locations and countries with about 40 percent being conducted in the United States. There are some exceptions, for example, all included studies of telehealth psychiatric consultations were conducted in the United State while all the included dental studies were conducted in European countries. The body of literature also includes studies with different designs and with sample sizes ranging from as small as 11 to several thousand. This variety is interesting; however, there are no patterns evident that associate these general descriptive characteristics with whether telehealth consultations produce a benefit. Additionally, similar to the inpatient and emergency care studies, outpatient studies did not report many details about the environment or context. Notably, they provided very little information on the organizations themselves, any staffing and/or training needed to facilitate telehealth consultations, or payment models for consultations or other care related to the consultation. There were two characteristics of telehealth consultations that we included in the in-text tables in this section that were not included in the inpatient and emergency care results sections. More studies were of real time consultations (about two-thirds) rather than asynchronous (about one-third). The distribution between consultations that were one-time and continuing was closer to an even split (56% and 43%, respectively). We also looked at the percentage of studies with each of these characteristics to determine if they were more or less likely to report that telehealth produced a benefit relative to the comparison group. Fewer studies with real time consultations reported a benefit (44%) than studies with asynchronous consultations (76%). This may be because the asynchronous studies more often measured access and time to treatment, and these are consistently better with telehealth. The difference is similar when comparing the percentage of one-time (43%) and continuing (70%) consultations that reported results favoring telehealth. The studies of ongoing consultations tended to report clinical outcomes or intermediate outcomes involving the management of chronic conditions. These characteristics are confounded with the clinical topic thereby making it difficult to draw conclusions from this information or generalize further. For example, most of the dermatology studies are asynchronous while all of the studies involving diagnostic technology are real time by definition. It is also likely that other factors that have not been measured may be more strongly associated with benefits. Nevertheless, looking at characteristics across studies and outcomes is an important initial step to increase our understanding of when and how telehealth consultations are most likely to be effective. Characteristics of outpatient consultations and outcomes, percent (counts) Characteristic Real Time Asynchronous One Time Continuing Percent of all outpatient studiesa 63% (59+ of 94) 36% (34 of 94) 56% (53 of 94) 43% (40 of 94) Percent of studies with the b 44% (26 of 59) 76% (26 of 34) 43% (23 of 53) 70% (28 of 40) characteristic reporting a benefit a Timing and frequency were both unclear in one study each, + includes studies that used both real time and asynchronous b In any outcome where telehealth was better than the comparator: clinical, intermediate, or cost 87 Results for Each Clinical Topic In this section, results for each study are presented in tables according to the 11 specialty groups. Dermatology Dermatology as a field was an early adopter and has continued to adapt and study telehealth applications. While many studies in the field focus on diagnostic concordance or accuracy, this was not one of our Key Questions for this review, and we included studies researching patient clinical outcomes and intermediate outcomes such as measures of access or health services use. We identified 22 dermatology studies reported in 28 articles, resulting in more studies of telehealth consultations than any other outpatient specialty. In the majority of studies, the consultations were asynchronous: specifically, images and medical history were made available to a dermatologist who reviewed them at a different time, made a diagnosis, and sometimes provided treatment recommendations (16 studies). A smaller number of studies (5 studies) used video to facilitate real time evaluations and discussion among the dermatologist, referring physician, and patient, while one study 202 employed both store and forward and real time consultations. In 16 of the 22 studies, the consultation was a one-time interaction about the patient, though physicians may have collaborated on many patients over time. Store and forward was usually used for consultations involving a single interaction for a given patient, but there were some cases where store and forward consultations were used to initiate a longer relationship. In one, more patients recovered (20%) in the telehealth group than in the group without telehealth (4. In the telehealth group a consult was used to provide management advice faster, and treatment was started during the time patients waited for an in-person appointment. The other two studies evaluating clinical outcomes compared the clinical course of patients who were evaluated using store and forward dermatology and in face-to-face visits and found no difference in the numbers of patients who 98,130 improved, had no change, or were worse. Most of the studies evaluated teledermatology in terms of one or more intermediate outcomes. Overall, teledermatology improved access by dramatically reducing wait times for visits and time to treatment. The findings for satisfaction and cost were mixed with most studies reporting a benefit (similar satisfaction and lower costs) while the findings related to the impact on management also varied. Wound Care Six studies reported on different approaches to telehealth for wound care (Table 14). The studies consisted of small numbers (all <200) of home care, wound clinic, long-term care, and primary care patients. The five studies reporting clinical outcomes used different approaches to 256 180,190,228,251 telehealth (one real time video and four image and/or record review) but all reported clinical benefit, in terms of better healing or fewer amputations with telehealth expert consultations than with usual care. Costs of telehealth consultations were lower than the cost of in-person consultations, and overall healthcare costs were also lower. Two studies reported minimal information on telehealth and nontelehealth costs in ophthalmology with one reporting no difference in the per visit cost and estimating the only savings were from patients 185 avoiding travel, and the second reported savings due to avoided transfers to a distant hospital 215 for evaluation. Telehealth did reduce the number of visits to a surgeon in a study of cataract 188 122,219 management, and two other studies reported increases in screening completion rates. One study used consultations and image transmission to assess fractures, one used telehealth consultations to screen electronic records and recommend treatments for 79 osteoporosis, and two studies evaluated a range of orthopedic conditions encountered in 151,153 primary care that would be referred to orthopedic surgeons. None of these studies reported clinical outcomes; they all reported either intermediate or economic outcomes. One of these found that using telehealth to transmit records and x-rays resulted in fewer missed fractures and 158 fewer unnecessary hospital trips. Availability of orthopedic video consultations with primary care practices resulted in lower costs, successful exams, and management plans that were not 151,187 significantly different. These consults conducted via the electronic record significantly 79 increased adherence to guidelines for recommended treatments. Dental Four studies, all conducted in Europe, evaluated the use of telehealth for dental consultations 167 (Table 17). The single cost analysis determined that telehealth visits cost less than hospital visits but more than outreach visits. In these studies, telehealth was either used to convene virtual tumor boards and interdisciplinary meetings or to allow oncologists to confer with patients and a local physician to plan for cancer care provision in a remote or rural area. All of these studies used video to communicate, and records and images were shared electronically. A study of remote oncology guidance for chemotherapy was the only one to measure patient outcomes and reported the rate of serious side 234 effects per patient was lower in the telehealth group. In the other studies, the effectiveness of cancer teleconsultations was evaluated in terms of care processes, satisfaction, and cost. Likewise, a study conducted in Sweden reported similar ratings of communication by telehealth participants as in face-to-face and in-person tumor boards, similar presentation time, less time traveling and waiting, and overall similar costs because equipment 181,182 costs balanced out the reduction in travel costs. Another study in Australia reported net 230 savings as the travel avoided exceeded the cost of telehealth equipment. In two studies the impact of telemedicine on time to treatment is less clear; one reported shorter mean time to initial 32 evaluation (18 vs. Telehealth was used in all of the programs to facilitate a multifaceted comprehensive treatment program. The telehealth versions of these evidence-based treatment programs were designed to expand access to mental healthcare in rural areas or to practices with no mental health services. The studies randomized either practices or patients to the telehealth program or usual care. All three programs reported improvement in clinical outcomes such as decreases in symptoms or higher remission rates of systems after 6 months or a year. Intermediate outcomes, such as medication adherence and satisfaction, were also higher. The one analysis of costs found an expected increase in primary care costs for depression treatment, along with an increase in specialty physical care costs, which 106 were attributed to case management referrals for pain management and management of other 57 comorbid chronic conditions. The same study also found that minority patients responded to treatment at higher rates using telehealth, suggesting that telehealth as part of collaborative care 46 could help ameliorate racial disparities in care. Regular type: not statistically significant Infectious Disease Four studies addressed the use of telehealth in infectious diseases (Table 20). Three of the studies used 30,108,134 video for real time communication while one incorporated the consult into the electronic 119 health record and allowed the specialists to review and respond when they were available. Clinical outcomes focused on viral load or suppression and were not significantly different in 30,108 the two studies of hepatitis C. An e-consult system or various infectious diseases reduced time to completion of the 119 consultations from a mean of 16. Consultations for Single Conditions Using Diagnostic Technology Telehealth was used for consultations for a specific specialty in 10 studies. The consultations involved guiding the use of diagnostic technology and assessing the transmitted information 114,140,203,211,258 37,82 (Table 21). These studies used fetal echocardiograms, ultrasound, 206,231 54 endoscopy, and Doppler. Across these studies, telehealth consultations increased timely access to tests and improved management. Most of these involved 69,144,168,210 consultations designed to assist in managing chronic conditions such as diabetes, 145 61 250 hypertension management, pain, and arthritis, and they did not use diagnostic technology during the consultation. This section also includes specialty consultations in areas such as genetic 220,232 42 counseling and urology, the subject of one or two included studies. The majority of these consultations were conducted in real time using video to allow the clinicians to interact. Regardless of the format of telehealth, these studies reported positive effects of telehealth consultations on clinical outcomes. Most of these programs created agreements between primary care practices, some within correctional facilities and others in remote locations, with a hospital or medical center that has multiple specialists available. Satisfaction was generally high, but the impact on access was not frequently reported, and most studies did not find differences in management and treatment. The evaluation of costs was mixed, with the largest 212 study reporting higher costs for telehealth.

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