By O. Tragak. Endicott College.

Does Sinus Computed Tomography Affect Treatment Decision Making in Chronic Sinusitis? Because sinus CT has uncertain diagnostic accuracy and poor correlation with patients’ clinical symptoms for chronic sinusitis discount clomid 100 mg visa, some otolaryngologists advocate that a treatment decision should be based solely on clinical grounds (44 clomid 100 mg sale,46) cheap clomid 100mg mastercard. Surgery is indicated when the maximum medical treatment fails to resolve the patient’s symptoms purchase clomid 100 mg amex. However discount 50mg clomid overnight delivery, there is no consensus as to what repre- sents the maximum medical treatment. Moreover, the basis of treatment decisions, medical versus surgical, for patients with chronic sinusitis is not universally established. Whether or not a patient should be treated surgi- cally, despite normal sinus CT, remains controversial (62). It is an open question whether treatment decisions are purely based on physical exam- ination and clinical history alone, or if sinus CT alters the treatment deci- sions by ENT surgeons (limited evidence). We prospectively administered questionnaires to a surgeon specializing in endoscopic sinus surgery each time he saw a patient for suspected sinusitis (63). After obtaining a clinical history and physical examination, we first asked his treatment decision without a sinus CT, and then again after reviewing the sinus CT. The abstracted clinical information of 27 patients was presented to two other otolaryngologists, and the same ques- tionnaires were administered before and after reviewing the sinus CT. Sinus CT altered dichotomous treatment decisions (surgical versus non- surgical) by the surgeon in one third of patients (9/27) and there was a tendency to offer the surgical treatment after reviewing the sinus CT more than before. The agreement among surgeons with clinical history and physical examination alone was poor but was much improved after reviewing sinus CT. The results of this study indicate that sinus CT provides pivotal objective information that affects treatment decisions and improves the agreement of treatment plans among surgeons (limited evidence). Special Case: Cost-Effectiveness Analysis in Chronic Sinusitis There has been no CEA for chronic sinusitis from the U. Only one recent study from Taiwan assessed cost utility analysis of endoscopic sinus surgery. It measured the cumulative cost of treating chronic sinusi- tis with FESS based on severity of disease. The study revealed an average cost-utility ratio of $70,221 and a high cost-utility ratio of $103,872 (after conversion to U. The cost structure in their study showed that 66% of the total cost was the operation fee. Endoscopic sinus surgery is pri- marily performed on an outpatient basis in the U. Evidence is lacking in this field, and future research is needed (insufficient evidence). Health care costs for patients with chronic sinusitis were investigated in health maintenance organizations (HMOs) in the state of Washington. This study found that adult patients with chronic sinusitis have more nonurgent outpatient visits and fill more prescriptions than adult patients without a history of chronic sinusitis, not including endoscopic sinus surgery. The Chapter 12 Imaging Evaluation of Sinusitis: Impact on Health Outcome 229 Patients present with acute sinusitis symptoms Use clinical prediction rules or risk factors to differentiate bacterial and viral infection Suspect bacterial sinusitis Uncomplicate viral infection (high probability for ABS) (intermediate to low probability) ABX treatment Decongestant or anti-allergy Rx if h/o allergy Good clinical response Poor response Good clinical response Poor response No imaging study Screening sinus CT No imaging ABX depends on clinical exam Positive CT Negative CT Good clinical response Poor clinical response Change ABX Consider other diagnoses No imaging Screening sinus CT Positive CT Negative CT Change ABX Consider other diagnoses Figure 12. Decision tree for imaging evaluation and management of acute bacterial sinusitis (ABS). Take-Home Figures Decision trees for imaging evaluation and management of acute and chronic sinusitis are shown in Figures 12. Noncontrast screening sinus CT 5-mm-thick coronal images every 10mm 140KVP, 200MA Indications: sinusitis symptoms not responding to medical treatment Diagnosis of sinusitis is in doubt, rule out sinusitis Recent sinusitis, need to evaluate response to treatment 2. Patients with history of chronic sinusitis presented with sinusitis symptoms Treat with ABX and other medical management if applicable (i. If CT correlates w Search for underlying Controversial symptoms consider systemic disease surgery If refractory to the maximum medical Rx, a patient desires, consider surgery Figure 12. Indications: patients require imaging-guided monitoring for endoscopic sinus surgery for skull base lesions or complex sinus surgery Future Research • Randomized controlled trial of antibiotic for patients with mucosal thickening only on CT in order to determine if this group of patients benefits from antibiotic treatment for acute sinusitis. Summary Acute sinusitis • Despite inaccurate clinical diagnosis of acute or chronic sinusitis, the initial treatment decision is based on clinical diagnosis.

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Women have • The diffuse vulvar pain syndrome (also known higher opioid binding during their reproductive years as dysaesthetic vulvodynia or essential vulvodynia) supporting the prediction that women are more sensi- exhibits neuropathic features in the distribution of tive to opioid analgesics during their reproductive the pudendal nerve discount 50 mg clomid amex. Anatomically the brain regions demonstrating woman who reports poorly localised pain that burns generic 25 mg clomid free shipping, MOP binding are also different purchase clomid 100 mg without prescription, particularly the thal- stings or is sharp like a knife discount 100 mg clomid amex. Co-existing disease such as candidiasis morphine solely to morphine-3-glucuronide (M3G) clomid 50mg low price. In contrast, human glucuronidation of morphine is into two compounds, M3G and morphine-6-glucuronide (M6G). M6G is a more potent analgesic agent than Sex differences and therapies morphine (and indeed is about to enter phase 3 trials as an analgesic agent in its own right). Women exhibit Drug effects can be divided pharmacologically into greater opioid analgesia than men and differences in pharmacokinetic and pharmacodynamic. In contrast to men, women have: Non-steroidal anti-inflammatory analgesics • Larger percentage of fat. Despite these experimental findings, no Variation in drug pharmacokinetic profiles reflect these. Opioids Drug effects on sexual performance In a meta-analysis of postoperative morphine use (with patient controlled analgesia, PCA), men consumed Many drugs used for the management of non-acute almost two and a half times more morphine than pain may affect male sexual performance. This may reflect underlying differences in: critically affect compliance with therapy and should be specifically considered (Table 29. Antidepressants • Reduce orgasmic sensation Sex differences in response of dental pain to the kappa • Delay or inhibit ejaculation opioid receptor (KOP) agonists nalbuphine, buprenor- Carbamazepine • May block testosterone phine and pentazocine have been demonstrated to be production with subsequent: time and dose related. Specifically, women seem to – Testicular atrophy – Gynaecomastia achieve statistically significantly more analgesia with – Galactorrhoea kappa agonists than do men. This altered responsive- • May inhibit ejaculation ness to kappa opioid drugs may be clinically utilised Opioids including • Reduce libido and potency if women do not respond to mu opioid receptor ago- tramadol nists (MOP). Gender and pain upon movement are associated with the requirements for postoperative patient- • Women report pain more frequently and of higher controlled iv analgesia: a prospective survey of 2,298 intensity than do men. Understanding • the Biology of Sex and Gender Differences, Institute of • Side effects may differ between the sexes. Gender and age influences on human brain mu-opioid receptor binding measured by PET. Sex-specific differences in levels of morphine, morphine-3-glucuronide, and morphine antinociception in rats. PART THE ROLE OF EVIDENCE IN PAIN MANAGEMENT 4 30 CLINICAL TRIALS FOR THE EVALUATION OF ANALGESIC EFFICACY 203 L. Such progress is habitually fol- lowed by novel analgesic treatments introduced into Investigational new drug (IND) application the clinic. The initial euphoria created by the intro- duction of new treatments often recedes as the new Phase 1 trials The new drug is tested in small groups of volunteers treatment is tested in the clinical environment. This evaluates safety and Clinical trials are the definitive umpire of the useful- dose range in addition to identifying unexpected or ness or otherwise of analgesic treatments developed adverse effects. This fact is quite Phase 2 trials often overlooked in the scientific community, where The drug is given to a larger group of patients ( 500). However, many health providers now realise The study drug is given to large groups of patients that analgesic treatments require justification by docu- (up to several thousand). Consequently increasing effectiveness, monitors side effects and compares it to commonly used treatments. Such information aims efforts are attempting to improve the quality of anal- to ensure that the drug or treatment may be used gesic trials. New drug application (NDA) Phase 4 trials Post-marketing studies delineate additional information Types of clinical analgesic including: the risks, benefits and optimal use of the trials novel treatment. This is required by regulatory authorities to ensure identification of potential new adverse effect profiles. Clinical trials are basically done for three reasons: 1 The pharmaceutical industry conducts small- and large-scale trials as part of their investigational new Clinical trials may be of a variety of types. IND atory trial aims to elucidate a biological principle, programmes are based on commercial contracts assuming that a chosen pain model will yield test between the industry and clinics. Large-scale trials results that are generally applicable to other pain con- are usually undertaken by contractual research ditions. In contrast, a pragmatic trial attempts to find organisations (CROs) consisting of collaborating the better analgesic treatment in a particular pain con- clinics. A practical approach 2 Clinical trials are routinely conducted at aca- to clinical trials is to distinguish between comparative demic institutions as part of academic training and exploratory trials. The aim is to identify the optimum analgesic gesic treatments for new or unproven indications are treatments for specific painful conditions.

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Depending on the location of demyelinated areas order 25 mg clomid overnight delivery, many alterations of normal speech patterns may occur as the result of MS generic clomid 100mg with visa. Most such alterations affect speech production purchase clomid 100mg on-line, resulting in dysarthria discount clomid 100mg with mastercard, or slurred speech buy clomid 100 mg online, ranging from mild difficulties to severe problems that make comprehension impossible. Demyelination in the cerebellum, the area of the brain involved with balance, is the primary cause of speech difficulties. If the tongue, lips, teeth, cheeks, palate, or respiratory muscles become involved, the speech pattern becomes even more slurred (dysarthric). Although exercises are sometimes advocated, they usually are not successful for this type of speech problem. The following is a list of exercises that may be done once or twice a day for 20 to 30 minutes with several repetitions: 1. Open the mouth, and then try to pucker with the mouth wide open; do not close the jaw, hold, relax. Open the mouth and stick out the tongue; be sure the tongue comes straight out of the mouth and does not go off to the side; hold, then relax. Stick out the tongue and move it slowly from corner to cor- ner of the lips; hold in each corner, relax; be sure the tongue actually touches each corner each time. Stick out the tongue and try to reach the chin with the tongue tip; hold at the farthest point, then relax. Stick out the tongue and try to reach the nose with the tongue tip; do not use the bottom lip or fingers as a helper. Stick out the tongue; pretend to lick a sucker, moving the tongue tip from down by the chin up to the nose; go slowly and use as much movement as possible, then relax. Stick out the tongue and pull it back, then repeat as many times and as quickly as possible; rest. Move the tongue all around the lips in a circle as quickly and as completely as possible; touch all of both the upper lip, corner, lower lip, corner in a circle; rest. Open and close the mouth as quickly as possible; be sure lips close each time; rest. Say "pa-pa-pa-pa" as quickly as possible without losing the "pa" sound; be sure there is a "p" and an "ah" each time; rest. Say "pataka, pataka, pataka" (or "buttercup") as quickly and as accurately as possible; rest. Tremors of the lips, tongue, or jaw also may affect speech by interfering either with breath control for phrasing and loudness or with the ability to voice and pronounce sounds. It may involve making changes in the rate of speaking or in the phrasing of sentences. Although it sounds relatively simple, it takes a lot of practice and learning to monitor yourself. These may include the use of a communication board (letter, word, or picture) and a variety of electronic systems. Recently a number of computerlike devices have been developed that fall under what is called "augmentative communication. Food may "stick" in the throat, go into the wind- pipe (trachea), or travel sluggishly and inefficiently, causing coughing, sputtering, and anxiety. Signs of swallowing dysfunc- tion include: • Gurgling sounds and sounds of congestion • Spitting or coughing after meals • An inability to "get the food down" • W ei ght loss • Pneumonia • Throat clearing • Choking • weak voice A swallowing evaluation should include a speech pathologist’s examination. An "x-ray in motion" (videofluoroscopy) is important to demonstrate the specific location of problems in the swallowing mechanism. This may be done by: • Modifying food textures, because some foods may be swal- lowed more easily than others. Sometimes a commercially available thickening agent or gelatin must be added to increase bulk. Milk products may need to be limit- ed because they "stick" in the throat and may be irritating. Tipping the chin down slows the entry of food, especially thin liq- uids, whereas tilting the head backwards hastens their entry. The person first inhales, then holds his or her breath, which closes the airway so that whatever is being swallowed cannot cause choking. The back of the throat is stimulated with a dentist’s mirror or something cold, which triggers the swallow reflex.

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Anesthesia can be maintained with any of these enhance and mimic the action of GABA on the ion channels clomid 100mg overnight delivery. Relatively lower concen- trations are usually employed in combination with other codynamics and pharmacokinetics of thiopental suggest agents in a standard general anesthetic buy 100mg clomid otc. Halothane has that the principal effect is based on a reduction of volume been associated with hepatitis and is rarely used in adult of distribution in the elderly order clomid 25 mg without a prescription, resulting in a higher con- patients buy 100mg clomid mastercard. Anesthetic requirements decrease progressively centration of the drug at the effect site for any given dose discount clomid 100mg with visa. It appears that the elderly brain is Sedative Hypnotic Agents not more sensitive to the effects to thiopental. A more Induction of anesthesia is most commonly undertaken complete description of the pharmacology of barbitu- rates in the elderly is provided by Shafer. Nonetheless, it does possess some poten- venous anesthetic, one that has become very popular for tial to create the same adverse psychologic effects found the induction and maintenance (by continuous infusion) with other phencyclidines. The exact mechanism of with respiratory and cardiovascular disorders represent action of propofol has not been completely elucidated. The drug is used There is evidence that is acts through activation of the with some frequency for sedation of children outside the GABAA b1-subunit, as well as by inhibition of the N- operating room and for dressing changes in settings such methyl-d-aspartate (NMDA) subtype of the glutamate as burn units. It has a apnea, and rarely thrombophlebitis of the vein where the faster onset of action. Apnea is very common, with an inci- zolam the benzodiazepine of choice for most anesthetic dence similar to thiopental or methohexital; however, the use. Awakening times following a benzodiazepine Propofol has been used for sedation during surgical induction are much longer than for either thiopental or procedures and in the ICU for sedation during mechani- propofol, and thus benzodiazepines are rarely used for cal ventilation. As an adjunct to general and recovery occurs rapidly on termination of the infu- anesthesia, benzodiazepines provide better amnesia than sion, regardless of the duration of infusion. Elderly patients require lower doses of rates must be markedly reduced in elderly and sicker midazolam than younger patients. Its pro- decreased from an average of 10 mg for a 20-year-old perties include minimal respiratory depression, cerebral patient to 2. Reports that the drug can temporarily inhibit steroid synthesis and hence decrease adrenal activity,21,22 along with a side effect profile that includes myoclonus, pain on injection, and high incidence of nausea and vomiting, tremendously decreased the enthusiasm for this drug. Increasing age is associated with a smaller initial volume of distri- bution and decreased clearance of etomidate. Although phencyclidine, the prototype of this class of drugs was a promising anesthetic agent, it was associated with an unacceptably high incidence of psychologic effects, including hallucinations and delirium. Phencyclidine is currently available only for illicit recreational use ("angel dust"). Ketamine (Ketalar) was released for clinical use in humans in 1970 and is still Figure 21. The influence of age on the intravenous dose of used for a variety of clinical circumstances. Ketamine is midazolam required to produce sedation in 800 patients unique among the injectable hypnotic agents because it undergoing endoscopic procedures. Anesthesia for the Geriatric Patient 233 Anecdotal evidence suggests that some elderly patients manifest a paradoxic reaction to benzodi- azepines, becoming agitated rather than sedated. Flumazenil is the only available competitive antagonist for the benzodiazepine receptor. When administered to patients who have benzodi- azepine-induced CNS depression, flumazenil produces rapid and dependable reversal of unconsciousness, respi- ratory depression, sedation, amnesia, and psychomotor dysfunction. It should be emphasized that flumazenil is rarely used by experienced anesthesiologists, who greatly prefer to titrate the initial drug effect carefully rather than depend on functional antagonism. Repeated doses of flumazenil may be necessary because the effect of the initial benzodiazepine is likely to last longer than that of flumazenil and resedation may easily occur. Opioids The opioids are those endogenous and exogenous sub- stances that bind to the opiate receptors. The influence of age and weight on remifentanil downside is respiratory depression.

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