By T. Masil. Lenoir-Rhyne College.
The team was soon reduced to 7 members includ- ing representation from UM purchase torsemide 20mg on-line pulse pressure and blood pressure, QM order torsemide 20 mg mastercard blood pressure chart when to go to the hospital, physical medicine, occupational health, family practice, PT, and the CTMC. This reduced team met a couple of times early in the demonstration and then stopped meet- ing for several months. It initially met bimonthly and, at the time of our final visit, was meeting monthly. The champion and the facilitator have performed the majority of the implementa- tion work. The champion and facilitator introduced the guideline one-on-one to each member of the team, and the facilitator developed the auto- mated version of form 695-R. When Site D began implementing the low back pain guideline, the guideline champion and the chief of physical medicine used the CME videotape to train providers on the guideline at each clinic. After the educational activities, the laminated pocket cards with the guideline "key ele- ments" were distributed to the providers. Education on practice guidelines was not integrated into the orien- tation program for new MTF staff, although the implementation team thought it should be. In addition, the implementation team recognized a need for ongoing education and refreshers for existing staff. However, no procedures to do so had been established as of the date of our final visit. Administrative procedures for process- ing low back pain patients differ between the CTMC and the primary care clinics at the hospital. At the CTMC, the documentation form 695-R is given to the low back pain patients at the check-in desk. Reportedly, 80 to 90 percent of these patients entered the screening Reports from the Final Round of Site Visits 147 rooms with the form. The form is filled out at every encounter because some providers (mostly PAs and general medical officers) monitor patients’ progress on the pain scale. Yet the team reports that ensuring consistency in this process remains difficult, and there has been a reported "erosion" over time in the use of form 695-R. Filling out the patient portion of the form takes time, lengthening the visit process. In addition, medics rotate every two weeks, and new medics must constantly be trained in the procedures. To facilitate processing of patients and minimize paperwork, an au- tomated form 695-R was developed and integrated into the CIW sys- tem. The intent was for the medics to work with the patients in the screening room to fill out the patient portion of the form. That information and the provider portion of the form are available on the provider’s computer screen, and the provider completes the form online. Although Site D has received the revised 695-R form, it has not yet been distributed for use or had its revisions incorporated into the form in the CIW system. Low back pain patients are treated at the CTMC for a period of three to four weeks. If the condition persists after that time, they are re- ferred to PT (the MTF has three physical therapists) or for manipula- tion for one week or so. If the condition persists after this treatment, patients are referred to the physical medicine clinic for assessment and either referral to the appropriate specialist(s) or permanent profiling. Treatment of difficult cases involving multiple specialists is coordinated in weekly meetings chaired by a physical medicine provider. These meetings are a new mechanism established as part of the guideline implementation strategy. At the clinics, implementation of the low back pain guideline (and use of documentation form 695-R) was left to the physicians’ discre- tion. No formal procedure has been put in place other than for patients whose conditions persist beyond six weeks and who are to be referred to the physical medicine clinic for assessment and appropriate referral(s) or profiling. Patient education is handled differently at the CTMC and at the family practice clinic.
Drug resistance is a concern with the M2 channel September to the end of ﬂu season is appropriate purchase torsemide 20mg free shipping hypertension 3rd stage. Prevention 171 Handwashing generic torsemide 10 mg without prescription prehypertension risk factors, isolating infected persons, and restrict- ity increase sharply with advancing age (see Chapter ing ill visitors and staff also reduce infection transmission 32). For patients at average risk of inﬂuenza, both community surveillance and rapid diag- colon cancer, the American Cancer Society (ACS) rec- nosis are important. Community surveillance can alert ommends screening with fecal occult blood tests (FOBT) health care workers as to whether an outbreak is annually in combination with ﬂexible sigmoidoscopy inﬂuenza A, B or both, as well as when inﬂuenza entered (FSIG) every 5 years (either test alone is sufﬁcient, but and exited the area. As with other cancers, Other Immunizations older adults at higher risk for colorectal cancer (e. Inﬂuenza A and nonpolyposis colorectal cancer) should be screened more B and pneumococcal disease are common diseases fre- frequently than the general older population. Tetanus, although rare, is a serious disease often tinue screening, suggesting instead that continued screen- resulting in death. The most frequently studied form of screening, and 80% effective in preventing invasive pneumococcal fecal occult blood testing, has been shown to signiﬁcantly disease, but not pneumococcal pneumonia, in older adults reduce the rate of death from colorectal cancer. Although its efﬁcacy sensitivity of sigmoidoscopy, although recent studies in high-risk groups, particularly immunocompromised suggest that the combination may miss as many as 50% patients,26,27 is questionable, the U. Double-contrast Task Force and the CDC’s Advisory Committee on barium enemas are less useful in older adults, as uninter- Immunization Practices recommend its use in this popu- pretable results occur because many patients cannot lation because of the low risk of harm. The vaccine can move as required while on the radiography table38,39 and be administered at any time during the year, including the biopsy cannot be done at the time of the exam, making a same time inﬂuenza vaccine is given (in a different second bowel prep necessary. If improvements and more controlled studies are necessary never previously vaccinated, older adults can be given a before it can be recommended for population-based primary series that includes doses at 0, 2, and 8 to 14 routine screening. Observational data have yielded conﬂicting results,45,46 and there are no randomized con- More than 55,000 deaths yearly with 140,000 new cases trolled trials (RCTs) on the efﬁcacy of ﬁber in primary per year place colorectal cancer as the second most prevention of colon cancer. In an RCT, neither a wheat common form of cancer, as well as the cancer with the bran-supplemented diet nor a low-fat, high-fruit and second highest mortality rate, in the United States. The -vegetable diet were found to affect the incidence of incidence of both invasive colorectal cancer and mortal- new colorectal adenomas (which can then progress to 172 H. These has been increasing interest in chemoprevention cancer or ongoing or previous long-term exposure to of colorectal cancer utilizing one or a combination of hormone replacement therapy, screening should be more substances. Primary care physi- NSAIDs, supplemental folate and calcium, or post- cians are encouraged help older patients overcome phy- menopausal hormone replacement therapy are efﬁcacious sical, economic, or other barriers to receiving screening. Other modalities used to screen for breast cancer include clinician breast exam and teaching breast self- examination. There is not sufﬁcient evidence at this time to recommend in favor of or against including these in Screening for Breast Cancer periodic screening exams. There are more than 176,000 Regarding primary prevention of breast cancer, ralox- new cases of breast cancer yearly, making it the most ifene and the antiestrogen tamoxifen have been recom- common cancer in women and the second leading cause mended for women at increased risk of developing breast 51 cancer, but not for the general risk population. Advanced age is an impor- tant risk factor both for developing breast cancer and for RCT in which 30% of the participants were over age 65, death from breast cancer. Use of in the rate of late-stage disease detection correlating well the drug in older women, however, was associated with a with an increase in the use of mammography. Again, Institute’s independent panel of experts, the PDQ, protective effects were mainly observed against the devel- opment of estrogen receptor-positive cancers. Most completed clinical trials have not included Physical activity may also reduce the risk of cancer. A women over age 70 and therefore the effectiveness of review of 13 mostly observational studies found lower screening mammography is not known in women 70 and incidence of breast cancer among physically active adults than in sedentary adults. Additionally, mortality is not the only endpoint of interest to women who may develop breast cancer; the effect of breast cancer diagnosis at a later stage on func- tion and quality of life is not known. There is some evi- Screening for Prostate Cancer dence from a retrospective cohort study that screening mammography is effective in women at least up to age (See Chapters 32 and 36) 79. Although prostate cancer is common in older dence yet that this decreases breast cancer mortality. The men and it can be aggressive and lethal, there are cur- American Geriatrics Society recommends annual or rently no reliable ways to distinguish small early cancers 16.
Chapter 22 VISUAL REFLEXES: THE CONTROL OF EYE MOVEMENTS; CLINICAL TESTING OF II effective 10 mg torsemide blood pressure medication used for headaches, III generic 10mg torsemide mastercard heart attack vol 1 pt 2, IV AND VI 22. This reflex is elicited on patients, conscious or unconscious, and it is, amongst other things, a crude test of brain stem function. Pass down left hand side, along bottom and up right hand side Postganglionic fibres Shine light in ciliary nerves to in eye constrictor pupillae Ciliary ganglion Preganglionic fibres in III Impulses pass along optic nerve, chiasma, tract Before reaching lateral geniculate Edinger–Westphal body, some fibres nucleus branch to midbrain Midbrain pretectal nucleus Fig. Pupillary light reflex Accommodation reflex Retina Retina Optic nerve Optic nerve Optic chiasma Optic chiasma Optic tract, then branching Optic tract, lateral geniculate fibres to: body, optic radiation, visual cortex, association fibres to frontal lobes, fibres descend through anterior limb of internal capsule to: Midbrain: pretectal nuclei Midbrain: superior colliculus Midbrain: Edinger–Westphal Midbrain: Edinger–Westphal nucleus then ipsi- and nucleus then ipsi- and contralateral to: contralateral to: Oculomotor nerve III Oculomotor nerve III Ciliary ganglion (synapse) Ciliary ganglion (synapse) Constrictor pupillae muscle Muscles of iris and ciliary body for miosis commissural connections, when light is shone into one eye, both pupils respond: the reflex is consensual. Fixed dilated pupils are pupils which do not respond to light: they are a likely indi- cator of brain death. These changes are 130 Vision, eye movements, hearing and balance equivalent to those made by photographers in stop adjustment and lens extension on a camera. You will realize that in the accommoda- tion reflex perception is involved, unlike the pupillary light reflex, and thus the cortex is involved. There is also a degree of voluntary control since you can decide to focus on an object. A comparison of the pathways for the accom- modation reflex, which functions normally, and the pupillary light reflex, which does not, indicates that the lesion could be in: (a) the fibres that pass from the optic tract to the midbrain, (b) the pretec- tal nuclei or (c) that part of the Edinger–Westphal nucleus which deals with fibres from the pretectal nuclei. The frontal eye fields mediate voluntary eye movements and are responsible for saccadic movements by which means we search the visual fields for an object on which to fix. Saccades are so rapid that individual visual images are imperceptible until fixation has ensued. Frontal eye field stimulation causes conjugate movement of the eyes to the opposite side. The superior colliculi on the dorsal aspect of the midbrain are involved in visual reflexes. This part of the brain stem is known as Visual reflexes 131 the tectum (Latin: roof): tectospinal and spinotectal tracts pass to and from the spinal cord. It inte- grates the nuclei of III, IV and VI with: • ventral horn cells (motor) of the cervical spinal cord for the con- trol of head and neck movements involved in visual fixation movements; • vestibular nuclei (see Chapter 23); • auditory nuclei (see Chapter 23); • the cerebellum. As the head and neck turn sideways, the vestibular– ocular reflex keeps your eyes fixed on the object. Impulses from the vestibular apparatus, and from the neck muscles by way of the spinal cord, pass to the MLF and the nuclei of III, IV and VI caus- ing the extrinsic ocular muscles to bring about a series of saccades which, although imperceptible to you, continually reset the eyes on target. These connections are also brought into play in other cir- cumstances: disorders of the vestibular apparatus (e. Nystagmus The MLF is also connected to the cerebellum, and so can be affected in cerebellar disease producing abnormal eye movements. The nuclei of III, IV and VI become disconnected, 132 Vision, eye movements, hearing and balance and uncoordinated movements of the eyes result in strabismus (squints). A lesion of the main trunk of the oculomotor, trochlear or abducens nerves will be obvious. Or, if you want the easy way out, send the patient to an optician or ophthalmologist. Chapter 23 THE VESTIBULOCOCHLEAR NERVE (VIII) AND AUDITORY AND VESTIBULAR PATHWAYS 23. The vestibulocochlear nerve is the sensory nerve for hearing (cochlear) and equilibration (vestibular). Cochlear nuclei – medial geniculate body – auditory cortex • Cochlear nuclei laterally in floor of fourth ventricle. Commissural fibres also occur between inferior colliculi, medial geniculate bodies. The vestibulocochlear nerve (VIII), auditory, vestibular pathways 135 • Axons from medial geniculate bodies project through internal capsule to auditory cortex in upper part of temporal lobe on inferior operculum, just below lateral fissure (territory of middle cerebral artery). Note: visual system: lateral geniculate bodies, superior colliculi; auditory system: medial geniculate bodies, inferior colliculi. Examples of auditory reflexes: when a loud noise is heard • Extrinsic ocular muscles turn eyes towards source of sound – connections from inferior colliculi to superior colliculi, to the nuclei of oculomotor, trochlear and abducens nerves (in medial longitudinal fasciculus, etc. Vestibular nerve and ganglion: cerebellum • Bipolar primary sensory neurons originate from hair cells in ves- tibular apparatus: saccule, utricle, semicircular ducts.
But failure to treat the primary cause of the disorder is poor medicine; it is symptomatic treatment discount torsemide 10 mg mastercard arteria umbilical percentil 90, something we were warned about in medical school discount torsemide 20 mg on-line pulse pressure of 30. But since most physicians see their role only as treating the body, the psychological part of the problem is neglected, even though its the basic cause. In fairness, some physicians make an attempt to say something about tension, but its often of a superficial nature like, You ought to take it easy; youre working too hard. In doing so, however, they are chiefly responsible for the pain epidemic that now exists in this country. If structural abnormalities dont cause pain in the neck, shoulder, back and buttocks, what does? Studies and clinical experience of many years suggest that these common pain syndromes are the result of a physiologic alteration in certain muscles, nerves, tendons and ligaments which is called the Tension Myositis Syndrome (TMS). It is a harmless but potentially very painful disorder that is the result of specific, common emotional situations. The ensuing sections of this chapter will discuss who gets it, in what parts of the body it occurs, the various patterns of pain and the overall impact of TMS on peoples health and daily lives. Following chapters will talk about the psychology of TMS (which is where it all begins), its physiology and how it is treated. Conventional diagnosis and treatment will be reviewed and I will conclude with a chapter on the important interaction between mind 4 Healing Back Pain and body in matters of health and illness. One might almost say that TMS is a cradle-to-grave disorder since it does occur in children, though probably not until the age of five or six. Its manifestation in children is, of course, different from what occurs in adults. I am convinced that what are referred to as growing pains in children are manifestations of TMS. The cause of growing pains has never been identified but physicians have always been comfortable in reassuring mothers that the condition is harmless. It occurred to me one day while listening to a young mother describe her daughters severe leg pain in the middle of the night that what the child had experienced was very much like an adult attack of sciatica, and since this was clearly one of the most common manifestations of TMS, growing pains might very well represent TMS in children. Little wonder that no one has been able to explain the nature of growing pains since TMS is a condition that usually leaves no physical evidence of its presence. There is a temporary constriction of blood vessels, bringing on the symptoms, and then all returns to normal. The emotional stimulus for the attack in children is no different from that in adultsanxiety. It is a substitute for a nightmare, a command decision by the mind to produce a physical reaction rather than have the individual experience a painful emotion, which is what happens in adults as well. At the other end of the spectrum, I have seen the syndrome in men and women in their eighties. The Manifestations of TMS 5 What are the ages when it is most common, and can we learn anything from those statistics? In a follow-up survey carried out in 1982, 177 patients were interviewed as to their then current status following treatment for TMS. At the other end of the spectrum, only 7 percent were in their sixties and 4 percent in their seventies. These statistics suggest very strongly that the cause of most back pain is emotional, for the years between thirty and sixty are the ages that fall into what I would call the years of responsibility. This is the period in ones life when one is under the most strain to succeed, to provide and excel, and it is logical that this is when one would experience the highest incidence of TMS. Further, if degenerative changes in the spine (osteoarthritis, disc degeneration and herniation, facet arthrosis and spinal stenosis, for instance) were a primary cause of back pain, these statistics wouldnt fit at all. In that case, a gradual increase in incidence from the twenties on would occur, with the highest incidence in the oldest people. Muscle The primary tissue involved in TMS is muscle, hence the original name myositis (as mentioned, myo stands for muscle). The only muscles in the body that are susceptible to TMS are those in the 6 Healing Back Pain back of the neck, the entire back, and the buttocks, known collectively as postural muscles. They are so named because they maintain the correct posture of the head and trunk and contribute to the effective use of the arms.
Recent research suggests that up to 50% of people with MS (compared to only 5–15% of people without) will experience serious depression at some point in their lives discount 10mg torsemide free shipping blood pressure medication name brands, and at any one time perhaps one in seven may be experiencing this kind of depression 10 mg torsemide arterial network on the dorsum of the foot. An inspirational personal account on coping in MS is given in Multiple Sclerosis – a personal exploration by Dr Sandy Burnﬁeld (see Appendix 2 for details). Although it is difﬁcult to give precise ﬁgures, it does appear that the rate of suicide is higher for people with MS compared with the general population. There may be many reasons for this: • Depression is associated with a higher rate of suicide – and as we have indicated people with MS have a higher rate of depression. In all these circumstances, it is very important that all avenues are explored for help, for through the management of depression and feelings of hopelessness, often situations that seem hopeless at the time are then viewed differently. Of course there is a related major debate under way, which is about the extent to which people can, or should be able to end their life if they 88 MANAGING YOUR MULTIPLE SCLEROSIS wish – if necessary with assistance – if they are acting rationally knowing what they are doing and in full command of all their faculties. Such assistance is currently illegal in Great Britain and a number of recent high proﬁle court cases have conﬁrmed this position. This debate raises considerable emotions on all sides and no doubt will continue to be a matter of great controversy. Management As far as depression is concerned, it is important that you seek medical help partly because there are various forms of depression that may require different kinds of management. It is good that you have recognized that you may need help, because much can be done for you. Initially you may feel that seeking such help is a ‘waste of time’, or indeed carries with it some kind of stigma, similar to what people some- times feel is associated with mental illness or ‘weakness’, but a sensible approach can substantially prevent you feeling miserable and improve your relationships. Counselling and cognitive behaviour therapy Depending on the nature of the depression, you may be offered counselling – and this is increasingly available both in general and hospital practice – or, rather more rarely, psychotherapy in larger and more specialist centres. In certain situations, where it may be helpful to discuss the depression in a family context, family therapy might be offered, although this again is very likely to be at the largest and most specialist centres. It is possible that these more specialist forms of therapy will involve onward referral, for assessment through a psychiatrist, for example. Until recently, ‘tricyclic antidepressants’ were the most commonly used drugs, such as imipramine (Tofranil), amitryptiline (Elavil) and nortriptyline (Pamelor). However, another family of antidepressants, called ‘serotinergic antidepressants’, is now being prescribed much more regularly, drugs such as ﬂuoxetine (Prozac), for example. These drugs have to be carefully administered and monitored, so it is important to follow medical advice. FATIGUE, COGNITIVE PROBLEMS AND DEPRESSION 89 Mood swings and euphoria As far as emotional and attitudinal issues in MS are concerned, early research suggested that some people were emotionally labile (meaning their emotions ﬂuctuated rapidly), and that other variable emotional symptoms or states arose that appeared to be speciﬁc to people with the disease. However, it proved difﬁcult to tell whether the problems were a personal – indeed an emotional – reaction to the onset of MS, or were caused by the MS itself. Current research is indicating that there are problems of an emotional kind that might be linked to the disease itself, as well as personal reactions to it. Mood swings may be caused by the effects of demyelination in particu- lar parts of the central nervous system that control moods and emotions, or by everyday frustrations and issues that arise in managing and think- ing about the effects of MS. Either way, recognizing that mood swings exist is the ﬁrst step in being able to manage them more effectively. In more extreme cases, mood swings are referred to medically as a ‘bipolar disorder’, with relatively rapid and severe swings between depression and elation. Euphoria One of the ﬁrst symptoms that doctors described over 150 years ago was an ‘elevation of mood’ in some people with MS. This was also called ‘an unusual cheerfulness’ that seemed not quite appropriate in someone with a long-term medical condition. In fact, some of these attributions of ‘elevated mood’ were not linked to the MS itself, but to the circumstances in which it was diagnosed. However, since that time, the idea that some people with MS may occasionally have what is often described as ‘eupho- ria’ has become more accepted. This can be linked with mood swings that may take people with MS through a range of emotions from depres- sion, perhaps to anger and indeed to ‘euphoria’ over a period of time. The previous clinical concern with euphoria has led to far less attention being paid to the much more serious problem of depression, which we have just discussed. It is possible that, in some people with MS, a euphoric presentation has cloaked an underlying depression.