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Proton spectroscopic data can be acquired from a three-dimensional array of voxels buy cheap erythromycin 250 mg antibiotics for acne sun exposure. These voxels are about two orders of magnitude larger than the voxels used for proton imaging 500mg erythromycin amex antibiotic resistance list, but can be superimposed on proton MRI maps to permit reasonably accurate spatial identification of the intraprostatic region supplying specific spectra. Spectral analysis relies on the fact that normal prostate tissue and the tissue of benign prostatic hypertrophy secrete relatively large amounts of citrate; prostate adenocarcinoma elaborates much less citrate, but produces a relatively elevated amount of choline; the ratios between the spectral peaks for these molecules are used to distinguish voxels containing neo- plasm from those that do not (123,124). Currently, the potential uses for magnetic resonance spectroscopic imaging (MRSI) of the prostate might be original diagnosis, biopsy guid- ance, local staging, and evaluation of recurrent following local therapy. With regard to diagnosis, several studies have shown that MRSI analy- sis of small groups of patients containing those without tumor and those with tumor can identify and localize tumors with reasonable, if less than perfect, sensitivity and specificity (125–128). But no sufficiently large or sufficiently well-controlled investigation has addressed whether MRSI is effective in screening for disease in a large sample reflecting either the pop- ulation at large or those at increased risk because of an elevated PSA. And given that many prostate tumors are considerably smaller than the MRSI voxels, it is unlikely that sensitivity can ever be very high until consider- able improvements in spatial resolution can be made. Series have been published to investigate whether patients whose prostate biopsies have been negative, even though their elevated PSA levels suggest tumor, might be aided by using MRSI to guide further attempts at biopsy. The data show that biopsies using information from MRI and MRSI converts some of these patients from being false negative (for the original biopsy) to true positive for the MR-guided biopsies, but there are few data to show that adding MRSI information to the MRI infor- mation is of significant benefit in guiding these biopsies (129). Further- more, the studies lack controls to investigate the possibility that the subsequent biopsies might have retrieved tumor tissue even without MR guidance. For patients who have had hormonal therapy (130) or who have had intraprostatic hemorrhage from a recent biopsy, localization of tumor by MRI can be difficult; MRSI may permit tumor identification in these cir- 130 J. Newhouse cumstances (131), however, so if MRI-guided biopsy ever becomes wide- spread, MRSI may be of benefit. There are also series that investigate whether MRSI might improve the accuracy of MRI for prostate staging (130,132). In one, the addition of MRSI data to MRI data enabled inexperienced readers to become as accurate as experienced readers were with MRI alone, but, for experienced readers, MRSI data did not improve accuracy. However, MRSI may help in assess- ing overall tumor volume, which is also a factor in staging. But whether this information actually changes treatment decisions for the better has yet to be investigated. The feasibility of using MRSI to localize prostate cancer in aiding place- ment of radioactive seeds for brachytherapy and adjusting local doses for external beam therapy has been established (133,134). But whether this capacity actually improves outcomes, either in terms of disease control or complication reduction, is not yet known. In patients who have had local therapy to destroy prostate tumors—in particular, cryotherapy—MRSI is likely to be better in detecting local tumor recurrence than MRI (135,136). This has the potential for indicating salvage therapy in patients who do not have disseminated disease, but whether these management choices, aided by MRI, benefit patient outcome, also remains to be determined. In summary, there seems to be little doubt that MRSI can with reason- able accuracy detect foci of intraprostatic tumor, at least when the tumor nodules are not small, and the technique holds promise for diagnosis, staging, prognosis, radiotherapy planning, and determining the need for salvage therapy. But series of sufficient size and sufficiently rigorous design to determine whether any of these functions will be of clinical benefit remain for the future (insufficient evidence). Positron Emission Tomography There has been considerable investigation of the role of 18-fluo- rodeoxyglucose positron emission tomography (FDG-PET) scanning in patients with prostate cancer (137–149). Although carbon-11 acetate (137,140,142,150–152) and carbon-11 choline (141,150–156) have been found to have certain advantages over FDG, FDG is most available and most fre- quently used. There are no data supporting the use of PET scanning as a screen for detecting prostate cancer. When used in patients with known prostate cancer in order to test its sensitivity, FDG-PET has yielded extremely disparate results, with re- ported sensitivities ranging from 19% to 83% (143,145,150). Sensitivity is probably higher among patients with higher histologic grades (145). No authors suggest that, among patients with palpable prostate nodules or ele- vated PSA values, FDG-PET can substitute for biopsy diagnosis of prostate cancer, or to identify a subset of patients with marginal findings who ought to undergo biopsy. In patients undergoing initial staging of prostate cancer, FDG-PET has been assessed in a number of series (143,145,147,149).

Even when the presentation of disease is similar in the elderly order 250 mg erythromycin visa antimicrobial coatings, there may be a delay in diagnosis because the Prophylactic Measures symptoms are attributed to other diseases found more Anticoagulation commonly in old age cheap 250mg erythromycin amex treatment for kitten uti. Such is the case with Crohn’s disease, in which the basic symptoms of diarrhea, pain, The annual incidence of deep venous thrombosis (DVT) and weight loss occur with about equal frequency in the and pulmonary embolism (PE) at ages 65 to 69 is 1. At ages 85 to 89, this incidence in only 64% of patients over age 65 years compared to rises to 2. In both Crohn’s disease and ulcerative colitis, for example, there are con- flicting reports about the relative frequency of disease Table 22. In elderly women, for example, breast Inappropriate bladder catheterization Deconditioning and immobility cancers are found more often to be moderately to well Delirium differentiated, have estrogen receptors, and have a low Depression thymidine labeling index. In a series of Falls patients with gastric cancer, for example, 5-year survival Functional decline Incontinence was 23% for older patients compared to 11% for younger 88 Infection patients. In those with stage IV disease, no younger Malnutrition patient survived 3 years, while several elderly patients Stress-induced GI ulceration were alive at 5 years. Thromboembolism Great care must be taken, however, to avoid inap- Untreated or undertreated pain propriately treating cancer in the elderly because of the Source: From The Interdisciplinary Leadership Group of the American impression that the disease may have a less virulent Geriatrics Society Project to Increase Geriatric Expertise in Surgical course. Although there have been improvements in the and Medical Specialties,90 with permission. Rosenthal coagulability; stasis from postoperative immobility and According to the CDC guidelines, antibiotic prophy- decreased lower extremity musculature; frequent opera- laxis is "a critically timed adjunct used to reduce the tion for malignancy or injury; and age-associated coagu- microbial burden of intra-operative contamination to a lation changes, with hypercoagulable states particularly level that cannot overwhelm the host. Prophylaxis should be used for all operations in risks, the incidence of clinically significant postoperative which it has been shown to reduce the incidence of surgi- DVT and PE is lower than that of many other operative cal site infections, or where the risk of infection would be complications overall. This condition includes all operations in tioned earlier, the overall incidence DVT is 0. The incidence of PE is twice as high in orthope- 8 (clean-contaminated) and clean operations in which a dic procedures and five times as high for patients over prosthetic material, particularly an intravascular graft or age 85. In certain operations such total hip replacement, prosthetic joint, is being implanted. Cardiac, neurosurgi- the risk of thromboembolic complications has been 93 cal, and certain operations on the eye also meet this cri- reported to be as high as 20% to 50%. The mortality for 94 teria because of the catastrophic consequences of PE in the hospitalized elderly exceeds 20%. The agent used should be safe, inexpensive, and bac- perioperative care for a variety of moderate- and high-risk tericidal with an in vitro spectrum that covers the organ- procedures. Regimens include adjusted-dose subcuta- isms that are likely to be encountered with that specific neous heparin,low molecular weight heparin,or warfarin, procedure (see Table 22. DVT and PE still occur, however, even when so the tissue and serum levels of the agent are adequate at prophylactic measures are properly employed. Therapeutic levels should be maintained throughout tive, antithrombin-dependent indirect inhibitors of factor the operation by redosing until a few hours after the pro- Xa have recently been reported. The frequency of the neutralization of factor Xa,inhibiting the generation of redosing depends on the tissue levels normally achieved, thrombin from prothrombin and thus preventing clot for- serum half-life of the drug, and the MIC50 of the agent for mation. In a recent report comparing one of these agents, the organisms likely to be encountered. Org3150/SR90907A,with low molecular weight heparin in patients undergoing total hip replacement (median age,66 years), the oligosaccharide was shown to increase the Table 22. Older persons are potentially more negative staphylococci susceptible to wound infection because of the changes in Noncardiac thoracic S. Appropriate utili- staphylococci zation of methodology to decrease wound infection is, Appendectomy Gram-negative bacilli, anaerobes therefore, particularly important when operating on Biliary tract Gram-negative bacilli, anaerobes Colorectal Gram-negative bacilli, anaerobes elderly patients. The Centers for Disease Control and Gastroduodenal Gram-negative bacilli, streptococci Prevention provide excellent guidelines for the pre- Oropharyngeal anaerobes (peptostreptococci) vention of surgical site infection. The importance and correct use of a Limited data but used for anterior segment resection, vitrectomy, antibiotic prophylaxis, however, is less well understood scleral buckle. Surgical Approaches to the Geriatric Patient 251 Special note should be made about controlling infections phy (TEE) probes exacerbates the risk for aspiration of during operations in which the colon may be resected. Oral nonabsorbable antibiotics are usually given as part Most surgeons are aware that the incidence of swal- of the mechanical bowel preparation before all such pro- lowing dysfunction following endotracheal extubation in cedures, in addition to parenteral prophylactic antibiotics. TEE has gained great favor as of the preparation is the mechanical cleaning of the a less-invasive method to monitor intravascular volume bowel to decrease the enormous bacterial load, not the and cardiac performance during operation. Mechanical preparation is accom- and efficacy of this form of monitoring is generally plished with cathartics or gastrointestinal lavage solu- accepted. The utility of TEE in cardiac surgery has been tions containing polyethylene glycol and electrolytes.

A very active sport may not be possible for all people with the disease buy erythromycin 250 mg without prescription antibiotics in the sun, but activities like swimming are possible for many generic erythromycin 500mg on line antibiotics before dental work. The key thing is to make a judgement about how you actually feel (rather than what you might fear or worry about! Different people with MS seem to have somewhat different reactions to activity; for example, some have a problem after 176 MANAGING YOUR MULTIPLE SCLEROSIS getting very hot. If you do have concerns about particular sports, do consult your doctor and/or physiotherapist. There are specialist facilities for an increasing number of sports and organizations offering advice and support. Disability Sport England develops and coordinates sporting opportunities for disabled people. It has details of organizations connected to specific sports, for example, the British Association of Cricketers with Disabilities and the National Co-ordinating Committee for Swimming For People with Disabilities. In Wales there is also the Federation of Sports Associations for the Disabled in Wales, in Northern Ireland the British Sports Association for the Disabled – Northern Ireland; and in Scotland the Scottish Sports Association for People with a Disability (SSAD). You may find that you need some additional or specialist equipment to enable you to gain most from your chosen sport. Apart from items commonly used in the chosen sport and easily commercially available, there is a range of sport and leisure equipment produced by individuals, clubs and companies to overcome any particular difficulties you may face. If you need specialized equipment, it is likely that the organization connected to the sport or hobby (see above) will be able to give you practical advice based on personal experience. REMAP is a voluntary organization with a network of panels specializing in adapting or designing and making one-off items of equipment for disabled individuals (see Appendix 1 for details). Gardening There are many ways you can continue gardening, which can give so much pleasure, and many other people without MS find that they have to adapt the kind of gardening they do, either when their mobility or flexibility changes, or when they get older. Raised flower or vegetable beds help those with mobility problems, or those who are in wheelchairs, to continue gardening. The principles of gardening are obviously just the same whether someone has MS or not, but the tools and methods of working may need consideration. It is usually unnecessary to buy a lot of new tools – first consider what tasks you need to carry out, assess your usage of the tools you already have, and consider any adaptations that could be made to make them work to your benefit (such as adding longer handles). LEISURE, SPORT AND HOLIDAYS 177 There are many books on plants that require less maintenance, on making gardening easier, and on accessible garden design. Another organization that promotes horticulture for people with disabilities is Horticulture for All. The Gardens for Disabled Trust raises money to help those who are disabled take an active interest in gardening, and gives advice to those who wish to adapt their gardens (see Appendix 1). Day trips out Managers of theatres, cinemas or concert halls have generally been slow to understand and provide for the needs of people with disabilities. However, the situation is changing rapidly and people are more aware of the importance of disabled customers; negative publicity about access and other problems has helped push this along. Whilst many venues are more prepared for people with disabilities, it is a still a good idea to contact the management before you go, to explain your situation and what you will need. Some seats, or positions for wheelchairs, may be better than others, and notifying the venue in advance should ensure that your needs are better catered for. You may also find that certain performances (for example, matinées) are less crowded than others. Provision for people with disabilities at cinemas has improved enormously in the last few years. There are still some problems for disabled cinema-goers, however, owing to the number of older 1930’s cinemas which have been converted into several screens. The ‘main’ screen is often in the circle of the old cinema and accessed only by several steps. However, a good number of ground-floor screens have wheelchair spaces with flat access, or via a few steps, possibly through a side exit. An increasing number of cinemas are using automatic computerized booking systems via the phone, where you can pay for your ticket by credit card and simply collect it on arrival. Some have an enquiry method for disabled patrons that puts you through to the management to make necessary arrangements.