Plaquenil

Jeffrey Sankoff, MD

• Assistant Professor
• Division of Emergency Medicine
• University of Colorado Denver School of Medicine
• Aurora, Colorado
• Attending Physician
• Denver Health Medical Center Emergency Department
• Denver, Colorado

European guidance on the diagnosis and management of women with osteoporosis in postmenopausal women is available arthritis walk boston cheap 200 mg plaquenil visa, 69 providing a framework for risk assessment and treatment in older women (Kanis arthritis in fingers diagnosis buy 400mg plaquenil visa, et al new arthritis relief diet discount 400 mg plaquenil with amex. In a placebo-controlled study of 58 women (mean age 48 years arthritis medication starting with s cheap generic plaquenil uk, followed for an average of 9 years) after oophorectomy arthritis diet food list buy plaquenil american express, mestranol reduced bone loss with less reduction in vertebral body height (Lindsay rheumatoid arthritis quality standard cheap plaquenil online visa, et al. Estrogen treatment also suppressed the rise in bone resorption markers following oophorectomy. Pharmacological approaches the bisphosphonates alendronate, etidronate and risedronate, the selective estrogen receptor modulator raloxifene and the parathyroid hormone derivative teriparatide all reduce the risk of vertebral fracture in postmenopausal women with osteoporosis (Stevenson, et al. The bisphosphonate group of drugs act by reducing bone resorption by being selectively taken up and adsorbed to mineral surfaces in bone, where they interfere with the action of the bone-resorbing osteoclasts. In addition to daily administration, these drugs are effective when taken once weekly, and are also effective when administered as annual intravenous treatments. Bisphosphonates remain incorporated in bone for a long period of time, which has led to concern over use in young women, and particularly in relation to future pregnancy. There is no direct evidence but it is regarded as prudent to withdraw oral bisphosphonate therapy for at least 1 year in women planning pregnancy. Raloxifene reduces bone loss and the risk of vertebral (but not non-vertebral) fractures by 30 to 50 % in postmenopausal women with osteoporosis (Ettinger, et al. It increases the frequency of hot flushes and is associated with increased risk of venous thrombosis, but with reduced risk of invasive breast cancer. Other treatments for osteoporosis Teriparatide is given by daily injection for up to 2 years, and reduces the risk of vertebral and non-vertebral fracture. Strontium ranelate also reduces both vertebral and non-vertebral fracture risk in postmenopausal women, although the mechanism of action is unclear. Strontium ranelate should only be used in patients with severe osteoporosis and a high risk of fractures in the absence of alternative treatment options. Furthermore, strontium ranelate should never be prescribed to patients with a history of heart or circulatory problems (based on recommendations of the European Medicines Agency). Recent developments in understanding of the genetic and biological mechanisms involved in bone resorption has revealed new therapeutic targets for antiresorptive treatments. Several of these new drugs act by targeting specific pathways within the osteoclastic cells. These include smoking, lack of exercise, calcium and vitamin D status and alcohol consumption and low body weight (Christianson and Shen, 2013). The combined oral contraceptive pill is widely used and frequently assumed to provide adequate bone protection but the evidence for this is unclear. Estrogen replacement is recommended to maintain bone health and C prevent osteoporosis; it is plausible that it will reduce the risk of fracture. The use of ultrasound assessment in fracture risk prediction has been demonstrated (Moayyeri, et al. Biochemical markers of bone turnover have been suggested to be useful for the prediction of fractures and rapid bone loss, and for monitoring the treatment of osteoporosis. Significant associations between short-term decrease in markers of bone turnover and reduction in risk of fracture with the use of anti-resorptive agents have been reported but lack of standardization complicates use (Vasikaran, 72 et al. Therefore the interval between repeat measurement must be fairly long and a 5-year interval has been suggested in European guidance (Kanis, et al. However, when there is suspicion of continuing bone loss due to secondary factors. Selective reduction in cortical bone mineral density in turner syndrome independent of ovarian hormone deficiency. Hip fracture incidence in relation to age, menopausal status, and age at menopause: prospective analysis. Contributors to secondary osteoporosis and metabolic bone diseases in patients presenting with a clinical fracture. Burch J, Rice S, Yang H, Neilson A, Stirk L, Francis R, Holloway P, Selby P, Craig D. Systematic review of the use of bone turnover markers for monitoring the response to osteoporosis treatment: the secondary prevention of fractures, and primary prevention of fractures in high-risk groups. Bone mineral density loss during adjuvant chemotherapy in pre-menopausal women with early breast cancer: is it dependent on oestrogen deficiency Effects of endogenous estrogen on renal calcium and phosphate handling in elderly women. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Food and Agricultural Organization of the United Nations, World Health Organization. Comparison of bone mineral density and body proportions between women with complete androgen insensitivity syndrome and women with gonadal dysgenesis. An earlier fracture as a risk factor for new fracture and its association with smoking and menopausal age in women. Reproductive factors as predictors of bone density and fractures in women at the age of 70. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Estrogen therapy initiated at an early age increases bone mineral density in Turner syndrome patients. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. Quantitative ultrasound of the heel and fracture risk assessment: an updated meta-analysis. A concomitant decrease in cortical and trabecular bone mass in isolated hypogonadotropic hypogonadism and gonadal dysgenesis. Screening and early diagnosis of osteoporosis through X-ray and ultrasound based techniques. Premenopausal ovariectomy-related bone loss: a randomized, double- blind, one-year trial of conjugated estrogen or medroxyprogesterone acetate. Hormonal and dietary influences on true fractional calcium absorption in women: role of obesity. Efficacy of bazedoxifene in reducing new vertebral fracture risk in postmenopausal women with osteoporosis: results from a 3-year, randomized, placebo-, and active- controlled clinical trial. A study to evaluate the cause of bone demineralization in gynecological cancer survivors. A systematic review and economic evaluation of alendronate, etidronate, risedronate, raloxifene and teriparatide for the prevention and treatment of postmenopausal osteoporosis. Management of osteoporosis in postmenopausal women: 2010 position statement of the North American Menopause Society. Risk factors for incident vertebral fractures in men and women: the Rotterdam Study. Markers of bone turnover for the prediction of fracture risk and monitoring of osteoporosis treatment: a need for international reference standards. Whether cardiovascular disease and mortality may be prevented by estrogen replacement therapy or screening and monitoring of risk factors is explored in the second part of the chapter. A population-based prospective study from Japan showed that women experiencing menopause before the age of 40 are at an increased risk of cerebral infarction (Baba, et al. It is possible that increased cardiovascular risk factors predispose to an earlier age at menopause, perhaps via an effect on ovarian blood flow. Kok and colleagues found a link between heart disease risk and age at natural menopause in the Framingham Heart Study cohort (Kok, et al. Early menopause has been newly identified as a risk factor for non-procedurally-related venous thromboembolism (Canonico, et al. In a group of recently menopausal women, specific platelet functions and concentrations of circulating activated cell membrane-derived procoagulant microvesicles changed with individual components of the metabolic syndrome (Jayachandran, et al. Alteration of haemostatic factors and markers of platelet function was observed in another group of premenopausal women 6 weeks after surgical menopause (Lip, et al. Turner Syndrome Women with Turner Syndrome have a higher prevalence of aortic coarctation (11%) and bicuspid aortic valve (16%), thus being at higher risk for infective endocarditis and, over time, the bicuspid aortic valve may deteriorate leading to clinically significant aortic stenosis or regurgitation (Bondy, 2008b). A bicuspid aortic valve is also associated with aortic wall abnormalities including ascending aortic dilatation, aneurysm formation, and aortic dissection. There seems to be generalized dilatation of major vessels in women with Turner Syndrome, including the brachial and carotid arteries as well as the aorta. Estrogen deficiency contributes to greater intima-media thickness and altered wall dynamics, but not to increased calibre of vessels (Ostberg, et al. Patients with Turner Syndrome have a higher prevalence of aortic coarctation and bicuspid aortic valve, thus being at higher risk for infective endocarditis and development of clinically significant aortic stenosis or regurgitation; they also have a more than doubled chance of developing coronary heart and cerebrovascular disease, and an increased risk of aortic dilatation and rupture. Periodic screening of the aortic diameter appears to be justified also in individuals without congenital heart disease (Bondy, 2008a). Monitoring frequency and treatment modalities have to be decided on an individual basis until more information on outcomes becomes available. All women diagnosed with Turner Syndrome should be evaluated by a C cardiologist with expertise in congenital heart disease. Premenopausal women with premature coronary artery disease have significantly lower plasma estradiol concentrations compared with controls (Hanke, et al. In experimental animals, the most robust inhibition of postmenopausal atherosclerotic progression was found in animals given contraceptive steroids premenopausally and subsequently given conjugated equine estrogens postmenopausally (Clarkson, 1994). The risks attributable to hormone therapy used by these young women are likely smaller and the benefits potentially greater than those in older women who commence hormone therapy beyond the typical age of menopause (Utian, et al. Similarly, Kalantaridou and colleagues reported that young women with premature ovarian insufficiency (age range 23-40 years) have significant endothelial dysfunction (Kalantaridou, et al. Oral estrogen/progestogen cyclic treatment for 6 months restored endothelial function in these patients. For the group of women experiencing menopause after oophorectomy, a threefold increase in ischemic heart disease was observed among never users compared to ever 78 users of hormone therapy (however, based on few cases). The effect of hormone therapy was most pronounced for the subgroup of current users in 1993 and among women who started treatment within 1 year of menopause. A higher level of enzymes involved in estrogen metabolism and higher expression of the estrogen receptors have been observed in the vascular smooth muscle cells obtained from the aortas of women with mild atherosclerosis than in the cells obtained from the aortas of women with severe atherosclerosis (Nakamura, et al. These observations agree with experimental data from different animal models indicating that estrogen administration protects against atherosclerosis only if vessels are healthy without established atherosclerosis (Clarkson, 1994; Mikkola and Clarkson, 2006) In more advanced stages of atherosclerosis, oral estrogen administration can have negative effects on the cardiovascular system via its prothrombotic effects possibly contributing to plaque instability (Clarkson, 1994; Walsh, et al. In the absence of long-term randomized prospective data, treatment should be individualized according to choice and risk factors. Conventional risk stratification for cardiovascular disease using various charts (e. Women with early menopause have a higher prevalence of coronary heart disease than those experiencing late menopause. This is partly related to the exposure to higher serum cholesterol levels for a longer period than in those experiencing late menopause. The increase in serum cholesterol at the time of menopause is greater than that after menopause (from early to late post-menopause). The presence of cardiovascular risk factors in elderly women shows a need for specific indicators of health. A change in lifestyle during menopausal years and in the presence of cardiovascular risk factors can reduce morbidity and mortality for cardiovascular disease, also in elderly women (Perk, et al. Turner Syndrome In addition to the burden of congenital heart defects, women with Turner Syndrome have an excess of several cardiovascular risk factors including hypertension, obesity, impaired glucose tolerance, and hyperlipidaemia. Annual screening for these risk factors should be performed and, if relevant, smoking cessation should be discussed (see Summary Table 8. Standardized multidisciplinary evaluation is effective; girls with Turner Syndrome benefit from a careful transition to ongoing adult medical care (Freriks, et al. Hypertension has been reported in up to 50% of adults and a quarter of adolescents with Turner Syndrome. Beta-blockers are an appropriate alternative because resting tachycardia is a common clinical finding, but they may further increase the risk of glucose intolerance (Dahlof, et al. Women with Turner Syndrome have a 50% risk of developing impaired glucose tolerance and a fourfold increase in the relative risk of developing type-2 diabetes (Gravholt, et al. Impaired glucose tolerance is thought to result from a combination of insulin deficiency (Bakalov, et al. Furthermore, serum cholesterol and obesity, but not blood pressure, increase during natural menopause. However, screening for cardiovascular risk factors at diagnosis may be indicated as lifestyle measures during pre- menopause improve health in later years. Women with Turner Syndrome have an excess of several cardiovascular risk factors, including hypertension, obesity, impaired glucose tolerance, and hyperlipidaemia. Therefore, annual screening for cardiovascular risk factors should be performed, and if relevant, smoking cessation should be discussed. In women with Turner Syndrome, cardiovascular risk factors should be assessed at diagnosis and annually monitored (at least blood pressure, C smoking, weight, lipid profile, fasting plasma glucose, HbA1c) References Akahoshi M, Soda M, Nakashima E, Tsuruta M, Ichimaru S, Seto S, Yano K. Effects of age at menopause on serum cholesterol, body mass index, and blood pressure. Postmenopausal status and early menopause as independent risk factors for cardiovascular disease: a meta-analysis. Premature menopause is associated with increased risk of cerebral infarction in Japanese women. Lipoprotein(a) and other lipids after oophorectomy and estrogen replacement therapy. Canpolat U, Tokgozoglu L, Yorgun H, Baris Kaya E, Murat Gurses K, Sahiner L, Bozdag G, Kabakci G, Oto A, Aytemir K. Estrogen effects on arteries vary with stage of reproductive life and extent of subclinical atherosclerosis progression.

The websites for the North American Menopause Society Antiepileptics arthritis ear pain safe 400mg plaquenil, particularly gabapentin [162] allergic arthritis definition generic plaquenil 400mg, topirimate [163] arthritis pain in dogs discount plaquenil 200mg visa, and phenytoin (menopause arthritis jaw ear pain buy plaquenil on line. Issues around relationship quality and communication testosterone products marketed to men after a longitudinal study can affect sexual function in couples remedies for arthritis in your neck discount plaquenil 400 mg otc, even if a relationship prob- suggested a 30% higher risk of adverse cardiovascular outcomes lem is not readily evident arthritis treatment relief neck scapular pain discount plaquenil express. Finally, it appears supraphysiological serum testos- When addressing a new sexual complaint, a thorough history terone levels may be necessary to yield any benet on sexual desire using a biopsychosocial approach should be undertaken, including and arousal [80,81]. The use of compounded testosterone products assessmentofanycurrentorpastpsychiatricdisorders;medication for transdermal use is on the rise, but these products are not reg- use and health problems; a history of emotional, physical, or sexual ulated and amount of testosterone in the product can be highly abuse; beliefs and attitudes regarding sex, menopause, and aging; inconsistent [82]. Providers should inquire about relationship dis- cord or communication issues, and if present, recommend therapy Much advancement has been made over the past 5 decades in with a therapist certied by the American Association of Sexuality our understanding of female sexual function and dysfunction. Medical womens sexual experience; a clearer picture of how menopause problems and medications should be reviewed for any that affects sexual function; and new and emerging treatment options. Screening for intimate partner violence should take healthy women as dysfunctional. Second, we need to continue to develop safe and effective treatments for female sexual dysfunction, particularly for midlife Conict of interest and older women. Postmenopausal women have been excluded from many of the trials of pharmaceutical medications. Behavioral treatment approaches Funding have shown promise for the treatment of several types of female sexual dysfunction. Findingwaysto integratethesebehavioralinterventionsintoprimarycareandgen- this article has undergone peer review. None of cial factors, such as relationship satisfaction and importance of sex, these sponsors had any role in the study design, data collection, are key to womens sexual function at midlife. Both researchers and data analysis, interpretation of data, writing of the manuscript, or healthcare providers can benet from a biopsychosocial approach decision to submit the manuscript for publication. By addressing all aspects of womens sexual function, researchers and healthcare providers can better References understand and improve this key component of midlife womens well-being. Hypoactive sexual desire disorder in postmenopausal women: quality of life [34] A. Johannes, Sexual problems of purpose in life is associated with sexual enjoyment in midlife women, and distress in United States women: prevalence and correlates, Obstet. Fisher, Womens endorsement of models of female sexual Antidepressant-induced sexual dysfunction, Ann. Hayes, Circular and linear modeling of female sexual desire and arousal, antidepressants, J. Longcope, Is there an sexual dysfunction associated with antidepressant agents: a prospective association between menopause status and sexual functioning Kuh, Sexual functioning throughout menopause: the sexual functioning of sustained-release bupropion and sertraline, Clin. Price, Naked at Our Age: Talking Out Loud About Senior Sex, Seal Press, instrument for the assessment of female sexual function, J. Development of a sexual function questionnaire for clinical trials of female [70] S. Mitchell, Smith-Di Julio K: Sexual desire during the menopausal transition and early postmenopause: observations from the H. Psychiatry 62 the association of abuse (physical, sexual, or emotional) and female sexual (Suppl. Friedlander, the impact of aromatase inhibitors on hypertension-related quality-of-life complications, J. Papadopoulos, chemotherapy in long-term ovarian germ cell tumor survivors: a et al. Lester, valsartan and atenolol on sexual behavior in hypertensive postmenopausal Alcohol and sexual function, Pharmacol. Fagg, Low sexual desire: sex therapy results and Longitudinal study of sexual function and vaginal changes after radiotherapy prognostic factors, Behav. Fortier, the effect and sexual function after hysterectomy for benign conditions, Br. Rosen, Self-administered masturbation training in the biofeedback versus topical lidocaine gel: a randomized study for the treatment of primary orgasmic dysfunction, J. Lobitz, the role of masturbation in the treatment of comparative study of the effects of oral and topical estrogen therapy on the orgasmic dysfunction, Arch. Khalife, the surgical mindfulness and cognitive behavioural treatment for provoked treatment of vulvar vestibulitis syndrome: a follow-up study, J. Marinoff,Surgical vulvar vestibulitis with electromyographic biofeedback of pelvic oor treatment of vulvar vestibulitis syndrome: outcome assessment derived musculature, J. Khalife, Physical therapy for vulvar vestibulitis syndrome: a retrospective study, J. They are living longer because of the many advances in diagnosis and with treatment and their numbers are projected to grow to ~18 million by the year 2022 (American Cancer Society, 2013). Cancer survivorship numbers are also increasing internationally with 2012 estimates of the global number of cancer survivors within five years of diagnosis being 32. No matter the location, cancer survivors face many challenges, including at home and in the work place. Not all survivors are able to advocate for themselves; family members, caregivers, nurses, or others become their advocates. Patients with cancer and their families often try to learn all they can about their illness and its treatments. Once they enter the survivorship period, they may not know what questions to ask and who to ask. The focus of cancer care today continues to be on cure, rather than the recognition that for many patients, cancer is a chronic disease. Current treatment options and improvements in medical care mean that patients are living longer and must contend with ongoing effects of cancer and its treatments. A management model designed for improving outcomes for those living with chronic conditions can be used for cancer survivorship plan of care, as well (Improving Chronic Illness Care, 2004). Create a culture, an organization, and mechanisms that promote safe, high-quality care. Ensure the delivery of effective, efficient clinical care and self-manage support. Promote clinical care that is consistent with scientific evidence and patient preferences. They also reviewed the consequences of cancer and its treatment and concluded that they are substantial. Evidence suggests that people who are diagnosed at advanced ages or with late-stage disease (e. Screening tests influence the composition of the survivorship population and those living long-term with preclinical and treatable early-stage disease (Institute of Medicine, 2006). Patients as survivors need to be heard, listened to , encouraged, taught, and instructed with up-to-date information with the goal of optimal wellness. This care plan should be developed and given to the patient by the time primary treatment ends. Today, many of the larger medical centers throughout the United States are using survivorship care plans. In support of the importance of survivorship care planning, the American College of Surgeons Commission on Cancer added Standard 3. These materials provide the necessary education, communication tools, and resources to assist cancer survivors in navigating the next phase in their journey. Barriers to Effective Survivorship Care Cancer survivors may face barriers that can affect their ongoing health and quality of life. Todays cancer survivors, as well as anyone else with a chronic disease, seek care in a fragmented delivery system. They face many challenges in obtaining medical care that is appropriate, efficient, and effectively meets their needs. The challenges faced are not just physical, but emotional, spiritual, and financial. One Canadian study found that more than one- third of cancer survivors surveyed after completion of treatment were not sure which physician was in charge of their cancer follow-up care (Miedema et al. During a three-day nursing conference convened in 2005 to discuss the State of the Science concerning long-term impact of cancer treatments, much discussion was held on barriers that exist for cancer survivors (Houldin, Curtiss, and Haylock, 2006). Some of the examples of this lack of awareness barrier include: o Female adult survivors of Hodgkin lymphoma treated at a young age with mantle irradiation are at high risk for subsequent cancer, but only 47% reported having had a mammogram in the past two years. More is known about the awareness of late effects among survivors of childhood cancer. The Childhood Cancer Survivorship Study looked at long-term effects of cancer treatments received as children. In this study, 635 adult survivors of childhood cancers were asked if treatments received in childhood could cause serious health problems in later life. Thirty-five percent answered affirmatively, 45% answered negatively, and 19% did not know (Kaden-Lottick et al. Only 15% stated that they received a written statement of their diagnosis and treatments to keep as a reference for the future.

Recognize the significance of clinical history and physical examination in the evaluation of cardiovascular complications of cardiac trauma 2 arthritis pain thumb joint order plaquenil 200 mg with mastercard. Know the role of noninvasive testing and laboratory findings in evaluation of cardiac trauma 4 arthritis in upper back buy plaquenil cheap. Recognize the risk factors for and the precursors to the development of risk factors for coronary artery disease 2 rheumatoid arthritis spine discount 400mg plaquenil mastercard. Recognize major problems associated with artificial valves and plan appropriate management 2 arthritis care of texas cheap plaquenil 200 mg. Regulate anticoagulation therapy (warfarin psoriatic arthritis in feet pictures cheap 200 mg plaquenil mastercard, heparin post traumatic arthritis in the knee plaquenil 200mg amex, low molecular weight heparin) in a patient with an artificial valve or conduit, including management plan at the time of an invasive procedure 3. Formulate a differential diagnosis in a patient suspected of having an embolic clotting disorder 7. Know the recurrence risk for the common congenital cardiac anomalies based upon whether the mother or father is affected (parent-of-origin effect) 2. Know the recurrence risk for the common congenital cardiac anomalies if a sibling is affected 3. Understand appropriate use of genetic testing in unaffected children who have a family history of cardiovascular disease if a first-degree family member is affected 4. Know the major associated cardiac and noncardiac conditions of trisomy 21 and manage their cardiovascular manifestations 6. Know the major associated cardiac and noncardiac conditions of trisomy 18 and manage their cardiovascular manifestations 7. Know the major associated cardiac and noncardiac conditions of trisomy 13 and manage their cardiovascular manifestations 8. Recognize the clinical signs and symptoms of the cardiovascular manifestations of monosomy X (Turner syndrome) and manage their cardiovascular manifestations 9. Recognize and diagnose Kartagener (dysmotile cilia) syndrome and manage its cardiac manifestations 13. Recognize and diagnose Barth syndrome and manage its cardiovascular manifestations 15. Recognize and diagnose Williams syndrome and manage its cardiac manifestations 17. Recognize and diagnose the cardiac manifestations of Rubinstein-Taybi syndrome and manage its cardiac manifestations 18. Recognize and diagnose Alagille syndrome and manage its cardiac manifestations 19. Recognize and diagnose syndromes with chromosome 22q11 deletion and manage their cardiovascular manifestations 20. Recognize and diagnose Ellis-van Creveld syndrome and manage its cardiac manifestations B. Recognize cardiovascular involvement in a patient with collagen vascular disease and plan appropriate management 2. Recognize and diagnose Marfan and related syndromes (eg, Loeys-Dietz syndrome, congenital contractural arachnodactyly) and manage their cardiovascular manifestations 3. Recognize and diagnose the cardiovascular manifestations of the classical and vascular forms of Ehlers-Danlos syndrome and manage their cardiovascular manifestations 4. Recognize and diagnose hereditary hemorrhagic telangiectasia (Osler-Rendu-Weber syndrome) C. Recognize and diagnose thalassemia syndromes and manage their cardiovascular manifestations D. Recognize and diagnose tuberous sclerosis and manage its cardiovascular manifestations 2. Recognize and diagnose neurofibromatosis and manage its cardiovascular manifestations E. Recognize and diagnose familial atrial myxoma and manage its cardiovascular manifestations 17. Be able to inform patients regarding health care insurance issues related to their disease 3. Be able to advise patients to regarding access to their medical records during transition 4. Know the cardiovascular conditions that increase risk and those that are contraindications to pregnancy 3. Recognize and manage chronic cyanosis in a patient with pulmonary vascular obstructive disease 2. Understand appropriate employment settings for an adolescent/young adult with cardiovascular disease 2. Identify risk-taking behaviors with magnified negative consequences in an adolescent/young adult with cardiovascular disease 18. Understand how the type of variable (eg, continuous, categorical, nominal) affects the choice of statistical test 2. Understand when to use and how to interpret tests comparing continuous variables between two groups (eg, t test, Mann Whitney U) c. Understand when to use and how to interpret regression analysis (eg, linear, logistic) b. Understand when to use and how to interpret survival analysis (eg, Kaplan Meier) 7. Recognize the importance of an independent gold standard in evaluating a diagnostic test b. Understand how disease prevalence affects the positive and negative predictive value of a test. Recognize and understand the strengths and limitations of a cohort study, case control study, and randomized controlled clinical trial b. Assess how the data source (eg, diaries, billing data, discharge diagnostic code) may affect study results 3. Understand factors that affect the rationale for screening for a condition or disease (eg, prevalence, test accuracy, risk benefit, disease burden, presence of a presymptomatic state) 7. Understand the types of validity that relate to measurement (eg, face, construct, criterion, predictive, content) b. Identify and manage potential conflicts of interest in the funding, design, and/or execution of a research study b. Identify various forms of research misconduct (eg, plagiarism, fabrication, falsification) c. Understand and contrast the functions of an Institutional Review Board and a Data Safety Monitoring Board b. Recognize the types of protections in designing research that might be afforded to children and other vulnerable populations c. Understand the federal regulatory definitions regarding which activities are considered research and what constitutes human subjects research d. Understand the federal regulatory definition of minimal risk and apply this to research involving children. Understand the ethical considerations of study design (eg, placebo, harm of intervention, deception, flawed design) 3. Understand various models of quality improvement and recognize that all utilize a data-informed, iterative process using tests of change to achieve a stated aim b. Understand that the aim of any quality improvement project should be specific, measurable, achievable, realistic, and time-limited c. Understand strategies to optimize identification of key drivers and interventions to achieve a specific aim d. Understand tools to facilitate completion of quality improvement work, including key driver diagrams and process maps. Classication Therapeutic:antiarrhythmics Interactions PregnancyCategoryC Drug-Drug: Carbamazepine mayqrisk of progressive heart block. Effectsofadeno- sinepby theophylline or caffeine (qdoses of adenosine may be required). Asadiagnosticagent(withnoninva- sive techniques) to assess myocardial perfusion defects occurringas a consequence Route/Dosage ofcoronaryarterydisease. UseCautiouslyin:Patientswithahistoryofasthma(mayinducebronchospasm); Assess respiratory status (breath sounds, rate) following administration. Resp: shortness of breath, chest pressure, hyper- Decreasedcardiacoutput(Indications) Canadian drug name. Follow each dose with 20 mL rapid saline ush to ensure injection reaches sys- temic circulation. Thallium-201 should be injected as close to the venous access as possible at the midpoint (after 3 min)of the infusion. Patient/FamilyTeaching Caution patient to change positions slowly to minimize orthostatic hypotension. Gaba developed several iterations of pocket cards for perioperative critical events, including some with rhythm strips, icons, and color design. Larry Chu conceived of adapting crisis management cognitive aids to a more visually striking format for a new book he envisioned for todays highly visual millennial learners. To create the current Emergency Manual, the Stanford Anesthesia Cognitive Aid Group was formed. Sara Goldhaber-Fiebert, Kyle Harrison, Steven Howard, and David Gaba worked jointly to provide the content, including exact phrasing, ordering, and emphasis, as well as iterative simulation testing to revise both content and design elements. Observing how cognitive aids are used by teams during hundreds of simulated crises has been crucial for pilot testing throughout. We hope that this Emergency Manual will support both education and patient safety efforts. We are grateful to Barbara Burian for her expertise in human factors and cognitive aid design reflected in the design of Version 3. While references are not written on each event for space, we have tried to integrate the most pertinent clinical information from published literature for each event, including practical publications. Disclaimer: the material in this Manual is not intended to be a substitute for sound medical knowledge and training. Clinicians should always use their clinical judgment and decision making for patient management. Since treatment for the medical conditions described in this Manual can have variable presentations, departure from the information presented here is encouraged when appropriate. Tension pneumothorax: Unilateral breath sounds, possible distended neck veins and deviated trachea (late signs). Perform emergent needle nd decompression (2 intercostal space at mid-clavicular line) then chest tube placement. Discontinue potential allergens: muscle relaxants, latex, antibiotics, colloids, protamine, blood, contrast, chlorhexidine. Can recur after initial treatment: Consider monitoring patient for 24 hours post-recovery. Give inhaled agents: Beta 2 agonist (albuterol, multiple puffs required) +/- anticholinergic (Ipratropium). Check for residual muscular paralysis (if patient is asleep, use twitch monitor), and reverse accordingly. Complete Neuro exam, as able, for focal neurologic deficits (if intubated look for: pupils, asymmetric movement, gagging, etc. Correct any abnormalities in oxygenation, ventilation, laboratory values, or temperature. Examine entire airway (including bronchoscopy) to assess injury and remove residual debris. When sure fire is extinguished: Re-establish ventilation; avoid supplemental O if possible. Consider prompt reintubation prior to swelling and coordinated with surgeons bronchoscopy. Remove burning or flammable materials from patient immediately for other team member to extinguish. Care for the patient: ventilate with room air, control bleeding, assess injuries and vital signs. Use vasopressor boluses (ephedrine, phenylephrine, epinephrine) as a temporizing measure. Cardiac event: Myocardial infarction/ischemia (Go to Myocardial Ischemia, event #19), Low Ejection Fraction, Systolic Anterior Motion of mitral valve, Hypertrophic Obstructive Cardiomyopathy. Low FiO2: If gas analyzer states low FiO while on 100% O 2 2 likely have O failure or pipeline crossover of gases. Postoperative respiratory failure common causes: residual nmb, opioid, anesthetic, laryngospasm (sudden), bronchospasm, pulmonary edema, high spinal, pain. Arrhythmias: conduction abnormalities, unexplained tachycardia, bradycardia, or hypotension. Open O tank2 on back of anesthesia machine (check not empty) and disconnect pipeline oxygen to force flow from tank into circuit Alternative: Obtain full E cylinder of O with a regulator. Connect gas sampling adaptor to allow monitoring of respiratory gases: Is the patient receiving 100% oxygen When patient more stable, contact Bioengineers to alert them to problem and enlist help with machine diagnosis while you focus on patient.

The semiological seizure classification generalized seizures remains essentially unchanged manuka honey arthritis relief discount 200mg plaquenil with mastercard, comple- allows for the specification at which point in the sequence mented by some semiological details how to cure arthritis in feet naturally order plaquenil, as well as by status of symptoms the patient lost consciousness by inserting epilepticus types and reflex seizure types arthritis questions to ask your doctor purchase genuine plaquenil on-line. In addition rheumatoid arthritis neck buy 400mg plaquenil visa, some studies posturing (31) arthritis pain relief gloves hammacher schlemmer buy 400 mg plaquenil free shipping, ictal speech (32) arthritis young adults cheap plaquenil 200mg with visa, or postictal weakness (33). A Historical ogy of ictal limb posturing and version in temporal lobe and extratemporal Review ed. Proposal for revised clinical and electroen- classification from the field of systematics. When consciousness is national League Against Epilepsy (1981) impaired, the seizure is classified as a complex partial seizure. Impairment of consciousness may be the first clinical sign, or simple partial seizures may evolve into complex partial seizures. A partial seizure may not termi- nate, but instead progress to a generalized motor seizure. Partial seizures are those in which, in general, the first clinical Impaired consciousness is defined as the inability to respond and electroencephalographic changes indicate initial activation of a system of neurons limited to part of one cerebral hemi- 1 From Commission on Classification and Terminology of the sphere. A partial seizure is classified primarily on the basis of International League Against Epilepsy. Proposal for revised clinical whether or not consciousness is impaired during the attack and electroencephalographic classification of epileptic seizures. Simple partial seizures (consciousness Local contralateral discharge Local contralateral discharge not impaired) starting over the corresponding 1. With minor signs area of cortical representation (not always recorded on the (a) Focal motor without march scalp) (b) Focal motor with march (jacksonian) (c) Versive (d) Postural (e) Phonatory (vocalization or arrest of speech) 2. With autonomic symptoms or signs (including epigastric sensation, pallor, sweating, flushing, piloerection, and pupil- lary dilation) 4. With psychic symptoms (disturbance of higher cerebral function); these symptoms rarely occur without impairment of con- sciousness and are much more commonly experienced as complex partial seizures (a) Dysphasic (b) Dynamic (e. Complex partial seizures (with impairment of Unilateral or, frequently, bilateral Unilateral or bilateral generally consciousness; may sometimes begin with sim- discharge, diffuse or focal in asynchronous focus; usually ple symptomatology) temporal or frontotemporal in temporal or frontal regions 1. Simple partial onset followed by impair- regions ment of consciousness (a) With simple partial features (A. With impairment of consciousness at onset (a) With impairment of consciousness only (b) With automatisms C. Simple partial seizures evolving to complex partial seizures evolving to generalized seizures Chapter 10: Classification of Seizures 139 normally to exogenous stimuli by virtue of altered awareness and/or responsiveness (see Definition of Terms). Partial seizures can be classified into one of the following Partial Seizures three fundamental groups: A. Simple partial seizures the fundamental distinction between simple partial seizures B. Complex partial seizures and complex partial seizures is the presence or the impairment of the fully conscious state. With impairment of consciousness at onset Consciousness has been defined as that integrating activ- 2. Simple partial onset, followed by impairment of con- ity by which Man grasps the totality of his phenomenal field sciousness (21) and incorporates it into his experience. A person aware and unresponsive will be able to recount the events that occurred during an attack and his or Generalized seizures are those in which the first clinical her inability to respond by movement or speech. In this changes indicate initial involvement of both hemispheres context, unresponsiveness is other than the result of paralysis, (Table 10. The ictal electroencephalographic pat- terns initially are bilateral, and presumably reflect neuronal discharge, which is widespread in both hemispheres. Focal motor seizures may remain strictly focal or they may spread to contiguous cortical areas producing a Includes all seizures that cannot be classified because of inade- sequential involvement of body parts in an epileptic march. This includes some neonatal ness is usually preserved; however, the discharge may spread seizures, for example, rhythmic eye movements, chewing, and to those structures whose participation is likely to result in swimming movements. Other focal motor attacks may be versive with head turning to one side, usually contraversive to the discharge. Occasionally, a partial dysphasia is seen Repeated epileptic seizures occur under a variety of circum- in the form of epileptic palilalia with involuntary repetition of stances: (1) as fortuitous attacks, coming unexpectedly and a syllable or phrase. This is known as cycle or the sleep-waking cycle); and (3) as attacks provoked Todd paralysis and may last from minutes to hours. The term status epilepticus is used whenever a seizure persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur. When very Vomiting, pallor, flushing, sweating, piloerection, pupil dilata- localized motor status occurs, it is referred to as epilepsia tion, borborygmi, and incontinence may occur in case of partialis continua. Absence seizures Usually regular and symmetrical Background activity usually (a) Impairment of consciousness only 3 Hz but may be 2- to 4-Hz normal, although paroxysmal spike-and-slow-wave complexes activity (such as spikes or (b) With mild clonic components and may have multiple spike- spike-and-slow-wave com- (c) With atonic components and-slow-wave complexes; plexes) may occur; this activ- (d) With tonic components abnormalities are bilateral ity is usually regular and sym- (e) With automatism metric (f) With autonomic components (b through f may be used alone or in combination) 2. Myoclonic seizures Polyspike and wave, or sometimes Same as ictal Myoclonic jerks (single or multiple) spike and wave or sharp and slow waves C. Clonic seizures Fast activity (10 Hz or more) and Spike-and-wave or polyspike- Myoclonic jerks (single or multiple) slow waves: occasional spike- and-wave discharges and-wave patterns D. Atonic seizures (astatic) Polyspikes and wave or flattening Polyspikes and slow wave Combinations of the above may occur, for or low-voltage fast activity example, B and F, B and D Olfactory sensations, usually in the form of unpleasant odors, With Somatosensory or Special may occur. Sensory Symptoms Gustatory sensations may be pleasant or odious taste hallu- cinations. They vary in elaboration from crude (salty, sour, Somatosensory seizures arise from those areas of cortex sub- sweet, bitter) to sophisticated. They are frequently described serving sensory function, and they are usually described as as metallic. Occasionally, a dis- Vertiginous symptoms include sensations of falling in space order of proprioception or spatial perception occurs. Like and floating, as well as rotatory vertigo in a horizontal or ver- motor seizures, somatosensory seizures also may march and tical plane. Special sensory seizures include visual seizures varying in elaborateness and depending on whether the primary or association areas are involved, from With Psychic Symptoms (Disturbance flashing lights to structured visual hallucinatory phenomena, of Higher Cerebral Function) including persons, scenes, and so on. Like visual seizures, auditory seizures may also run the gamut from crude auditory these usually occur with impairment of consciousness. Dysmnesic Symptoms Seizures with Complex Symptomatology A distorted memory experience such as distortion of the time sense, a dreamy state, a flashback, or a sensation as if a naive Automatisms experience had been experienced before, known as deja vu, (These may occur in both partial and generalized seizures. When this Dictionary of Epilepsy (5), automatisms are described as refers to auditory experience, these are known as deja- more or less coordinated adapted (eupractic or dyspractic) entendu or jamais-entendu. Occasionally, as a form of forced involuntary motor activity occurring during the state of thinking, the patient may experience a rapid recollection of clouding of consciousness either in the course of, or after, an episodes from his or her past life, known as panoramic epileptic seizure, and usually followed by amnesia for the vision. The automatism may be simply a continuation of an activity that was going on when the seizure occurred, or, con- Cognitive Disturbances versely, a new activity developed in association with the ictal impairment of consciousness. Usually, the activity is com- these include dreamy states; distortions of the time sense; and monplace in nature, often provoked by the subjects environ- sensations of unreality, detachment, or depersonalization. From a symptomatological point of view, the following Sensation of extreme pleasure or displeasure as well as fear are distinguished: (a) eating automatisms (chewing, swallow- and intense depression with feelings of unworthiness and ing); (b) automatisms of mimicry, expressing the subjects rejection may be experienced during seizures. Unlike those of emotional state (usually of fear) during the seizure; (c) ges- psychiatrically induced depression, these symptoms tend to tural automatisms, crude or elaborate, directed toward either come in attacks lasting for a few minutes. Anger or rage is the subject or his environment; (d) ambulatory automatisms; occasionally experienced, but unlike temper tantrums, epilep- and (e) verbal automatisms. Fear or Ictal epileptic automatisms usually represent the release of terror is the most frequent symptom; it is sudden in onset, usu- automatic behavior under the influence of clouding of con- ally unprovoked, and may lead to running away. Associated sciousness that accompanies a generalized or partial epileptic with the terror, there are frequently objective signs of auto- seizure (confusional automatisms). They may occur in com- nomic activity, including pupil dilatation, pallor, flushing, plex partial seizures as well as in absence seizures. Like other While some regard masticatory or oropharyngeal forms of pathologic laughter, it is often unassociated with automatisms as arising from the amygdala or insular and true mirth. In the latter, fumbling of clothes, these take the form of distorted perceptions in which objects scratching, and other complex motor activity may occur in may appear deformed. Ictal speech diplopia and distortions of size (macropsia or micropsia) or of automatisms are occasionally encountered. Similarly, distortions of sound, includ- seizures again may occur either as prolonged automatisms of ing microacusia and macroacusia, may be experienced. Altered perception of size or weight of a limb sionally continue to drive a car, although may contravene may be noted. There seems to be little doubt that automatisms are a Structured Hallucinations common feature of different types of epilepsy. While they do Hallucinations may occur as manifestations or perceptions not lend themselves to simple anatomic interpretation, they without a corresponding external stimulus and may affect appear to have in common a discharge involving various somatosensory, visual, auditory, olfactory, or gustatory senses. Crude and elaborate automa- If the seizure arises from the primary receptive area, the hallu- tisms do occur in patients with absence, as well as complex cination would tend to be rather primitive. Of greater significance is the precise vision, flashing lights may be seen; in the case of auditory per- descriptive history of the seizures; the age of the patient; and ception, rushing noises may occur. With more elaborate the presence or absence of an aura and of postictal behavior, seizures involving visual or auditory association areas with including the presence or absence of confusion. If the patient is standing, the head may be drawn Drowsiness or somnolence implies a sleep state from which the backward and the trunk may arch. This may lead to retropul- patient can be aroused to make appropriate motor and verbal sion. In stupor, the patient may make some spontaneous movement and, by painful or other vigorously applied stimuli, Absence with Automatisms can be aroused to make avoidance movements. The patient in Purposeful or quasipurposeful movements occurring in the confusion makes inappropriate responses to his or her environ- absence of awareness during an absence attack are frequent ment and is disoriented with regard to place, time, or person. If spoken to , the patient may Aura grunt or turn to the spoken voice, and when touched or tick- A frequently used term in the description of epileptic seizures led, may rub the site. According to the Dictionary of Epilepsy, this term was may include combinations of the above-described movements introduced by Galen to describe the sensation of a breath of or may be so simple as to be missed by casual observation. It may be that, as in simple partial seizures, the aura is the but the majority lose consciousness without any premonitory whole seizure. There is a sudden, sharp tonic contraction of mus- aura is, in fact, the signal symptom of a complex partial seizure. The patient lies rigid, and during this stage, tonic contraction inhibits respi- ration and cyanosis may occur. The tongue may be bitten and Generalized Seizures: Absence Seizures urine may be passed involuntarily. This tonic stage then gives the hallmark of the absence attack is a sudden onset, inter- way to clonic convulsive movements lasting for a variable ruption of ongoing activities, a blank stare, possibly a brief period of time. If the patient is speaking, speech ration may occur between the convulsive movements, but usu- is slowed or interrupted; if walking, he or she stands trans- ally the patient remains cyanotic and saliva may froth from the fixed; if eating, he or she will stop the food on the way to the mouth. Usually the patient will be unresponsive when spoken the muscles relax, after which the patient remains unconscious to . He or she then frequently goes into a deep sleep orates as rapidly as it commenced. Absence with Mild Clonic Components Here, the onset of the attack is indistinguishable from the above, but clonic movements may occur in the eyelids, at the Myoclonic Seizures corner of the mouth, or in other muscle groups, which may vary in severity from almost imperceptible movements to generalized Myoclonic jerks (single or multiple) are sudden, brief shock- myoclonic jerks. Myoclonic jerks may be Here, there may be a diminution in tone of muscles subserving rapidly repetitive or relatively isolated. They may occur pre- posture, as well as in the limbs, leading to drooping of the dominantly around the hours of going to sleep or awakening head, occasionally slumping of the trunk, dropping of the from sleep. Many instances of myoclonic jerks and action myoclonus are not classified as epileptic seizures. Chapter 10: Classification of Seizures 143 (So-called drop attacks may be seen in conditions other Clonic Seizures than epilepsy, such as brainstem ischemia and narcolepsy cat- aplexy syndrome. As the frequency diminishes, the amplitude of the jerks do Unclassified Epileptic Seizures not. The features are distorted; the color of the face, unchanged at first, rapidly becomes pale and then flushed Under this name have been described cases of simple partial and ultimately livid as the fixation of the chest by the spasms seizures with focal motor signs without a march, usually stops the movements of respiration. The eyes are open or consisting of clonic spasms, which remain confined to the part closed; the conjunctiva is insensitive; the pupils dilate widely as of the body in which they originate, but which persist with cyanosis comes on. As the spasm continues, it commonly little or no intermission for hours or days at a stretch. The sudden loss of postural increased metabolic activity of the discharging focus, but it tone in the head and trunk may lead to injury by projecting may also be attributable to increased inhibition in the region objects.

Cheap 200mg plaquenil otc. Arthritis को हराएगी आपकी Diet | Hindi Health Tips.