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Hepatoplex One chronic gastritis mayo buy cheap sevelamer online, Hepatoplex Two chronic atrophic gastritis definition purchase 800 mg sevelamer overnight delivery, and other herbal formulas have been designed specifcally for the treatment of chronic hepatts and related problems A few Chinese medicine practtoners in the U gastritis relief discount sevelamer 800mg line. While there are herbs to help protect the digeston in Hepatoplex One gastritis from ibuprofen order sevelamer without prescription, this formula is usually used in conjuncton with formulas that protect the spleen and stomach gastritis diet kits buy sevelamer 800 mg on-line, as there are a number of herbs that are cooling or cold and vitalize xue gastritis diet vegetables purchase sevelamer american express. For example, to increase the efects of tonifying qi and yin, this formula can be taken with Cordyseng . If there is liver invading spleen, a common scenario in chronic hepatts patents, you may add Shu Gan . For immunodefciency disorders, you may add Enhance or Tremella American Ginseng . For xue stagnaton including liver fbrosis, cirrhosis, and decreased blood circulaton, add Hepatoplex Two . For xue defciency and xue stagnaton, or to protect the bone marrow during interferon plus ribavirin treatment, add Marrow Plus . Its special uses are for liver fbrosis and cirrhosis, and to decrease the size of an enlarged liver. Cordyseng is used as an adjunct to other herbal formulas to increase the functon of qi tonifcaton and increase energy. Though some of the herbal theories already discussed may apply to acupuncture, the primary goal of acupuncture treatment is to readjust the body’s qi in order to enable the body to heal itself. Acupuncture has also been used to lower elevated liver enzymes as part of a chronic hepatts protocol using special acupuncture points. Moxibuston is the burning of the herb mugwort (called moxa in Chinese) over certain points or areas of the body that correspond to acupuncture points. Many studies from China, Japan, Germany, and the United States show the positve efects of qi gong on immune functon. Dietary Therapy A healthy diet is considered a key part of maintaining qi and harmony in the body. For example, those sufering from chronic diarrhea may be advised to eat white rice (not brown rice) daily, especially in the form of an easy-to-make rice porridge called congee or jook. The use of some herbal therapies in conjuncton with interferon-based therapy may be inappropriate. However, in my experience, Chinese medicine can be highly efectve for the management of side efects from drug therapy. While these therapies have not undergone clinical trials in the west, many of them have been used for centuries in China for hepatts and other conditons. It is important to discuss all treatment approaches with both your eastern and western practtoners in order to ensure the safety of and to gain the greatest beneft from all of your treatment modalites. For recommended reading on traditonal Chinese medicine, please see the Resource Directory. Caring Ambassadors Hepatitis C Choices: 4th Edition 304 Copyright © 2008, Caring Ambassadors Program, Inc. See Chapter 14, Naturopathic Medicine for more informaton about the naturopathic approach to treatng viral hepatts. See Chapter 16, Nutritonal Supplementaton for additonal details on the nutritonal supplements mentoned in this secton. Oxidatve stress refers to a state in which there is an overabundance of molecules called free radicals. Free radicals can damage cells and are involved in the processes of infammaton and scarring. The study results were mixed, with one showing signifcant beneft and the other no evidence of beneft. In additon, alfa lipoic acid has been shown to prevent damage that results from free radical producton in both the nervous system and the liver. This dose has been used in other conditons and has been shown to be safe and free of side efects. This is one of the reasons vitamin E is partcularly helpful in preventng liver damage. As explained in Chapter 16, Nutritonal Supplementaton, vitamin E interrupts the biochemical pathways that lead to liver fbrosis. The most benefcial forms of vitamin E are d-alfa-tocopherol, d-alfa tocopherol succinate, and mixed tocopherols. L-glutamine and the amino acid cysteine are both required by the body to make glutathione. An L-glutamine defciency can lead to problems absorbing nutrients from the intestne. In one study, the daily doses of L-glutamine supplementaton ranged from 8 grams to 40 grams. The people who gained the most lean body mass took daily doses of 40 grams per day (divided into four equal doses of 10 grams) for a period of 12 weeks. L-Carnitne L-carnitne is an amino acid that is partcularly important for muscle and immune cells. Carnitne is available both as a prescripton drug and over-the-counter as a nutritonal supplement. These supplements can also be used safely in combinaton with western therapies and/or traditonal Chinese medicine. A healthcare provider who is trained in clinical nutriton and the treatment of coinfecton should be consulted for optmal beneft from an antoxidant protocol. It is important to discuss your nutritonal supplementaton with all of your healthcare providers to make sure your protocol is both safe and efectve. N-acetyl cysteine enhances the response to interferon-alpha in chronic hepatts C: a pilot study. Combinaton therapy with interferon-alpha plus N-acetyl cysteine for chronic hepatts C: a placebo controlled double-blind multcentre study. Associaton of alpha-interferon and acetyl cysteine in patents with chronic C hepatts. Studies on lipoate efects on blood redox state in human immunodefciency virus infected patents. A randomized, double-blind, placebo-controlled trial of deprenyl and thioctc acid in human immunodefciency virus-associated cognitve impairment. Efects of oral S-adenosyl-L-methionine on hepatc eroxidases in patents with liver disease. S-adenosylmethionine atenuates oxidatve liver injury in micropigs fed ethanol with a folate-defcient diet. Suppression of human immunodefciency virus type 1 viral load with selenium supplementaton: a randomized controlled trial. Selenium supplementaton of symptomatc human immunodefciency virus infected patents. Nutritonal treatment for acquired immune defciency syndrome virus-associated wastng using beta hydroxy beta-methylbutyrate, glutamine, and arginine: a randomized, placebo-controlled study. Low levels of serum acylcarnitne in chronic fatgue syndrome and chronic hepatts type C, but not seen in other diseases. Plasma carnitne insufciency and efectveness of L-carnitne therapy in patents with mitochondrial myopathy. Zidovudine-induced mitochondrial myopathy is associated with muscle carnitne defciency and lipid storage. Caring Ambassadors Hepatitis C Choices: 4th Edition 310 Copyright © 2008, Caring Ambassadors Program, Inc. C h a p T E r 21 Me n t a l He a l t H a n d He p a t i t i s C Julie Nelligan, phD, David W. We know that mental health conditons such as depression may occur along with physical symptoms and difcultes in daily functoning, ability to follow treatment directons, and quality of life. Depression (81%) was the most common disorder, followed by postraumatc stress disorder (62%), substance use disorders (58%), bipolar disorder (20%), and other psychotc disorders (17%). Among those with a positve screening test, only 38% had an establish mental health provider. Stress, loss, loneliness, and certain chemical imbalances in the brain can cause depression. Patents who are being considered for interferon-based therapy will ofen have a pretreatment psychiatric evaluaton. If the evaluaton suggests the patent has a mental health problem such as anxiety or depression, then a recommendaton for treatment will likely be made that includes medicaton. Unfortunately, most people with a severe mental illness do not know they have hepatts C. Also, they commonly do not have access to or seek medical care as ofen as people without a severe mental illness. The rate of substance use disorders in people with schizophrenia is almost 5 tmes higher than the rate in the general populaton. Smoking crack cocaine leads to other high-risk behaviors such as unsafe injecton practces, unsafe sex, multple sex partners, and trading sex for drugs. Alcohol, cocaine, methamphetamine, marijuana, and other drugs are also risk factors even if not used intravenously. Research looking into the relatonship between cogniton and hepatts C has only recently been conducted. It could be from liver disease, substance use, the hepatts C virus, or some combinaton of these or other factors. As a result, people ofen experience a conditon called hepatc encephalopathy that afects their thinking and memory. Hepatc encephalopathy is thought to occur because substances that are toxic to brain cells (neurotoxins), such as ammonia and manganese, get into the brain. Caring Ambassadors Hepatitis C Choices: 4th Edition Symptoms of hepatc encephalopathy depend on the how much damage has been done to the liver. Initally patents have trouble with atenton, concentraton, coordinaton, changes in mood (depression or irritability), and mental slowness. As hepatc encephalopathy gets worse, the patent will experience lethargy, inappropriate behavior, slurred speech, and drowsiness. Several studies have documented the negatve efects of marijuana, cocaine, opiates, amphetamine, and alcohol use on cognitve functon and the brain. The cause of interferon-induced depression may be related to actvaton of the immune system, much like what happens when you have the fu. Common symptoms are irritability, fatgue, slowed movements, and changes in sleep and eatng habits. One study32 found that 1/3 of study partcipants complained of concentraton and memory problems during interferon treatment. As mentoned above, problems with concentraton and memory can occur because of depression. However, this study found that cognitve complaints were not related to depression prior to or during interferon treatment. For now, litle is known about the potental short and long-term cognitve efects of interferon. It is common to have trouble adjustng to a diagnosis of a long-term medical conditon. Common reactons to being diagnosed with a chronic infectous disease such as hepatts C include: y feeling emotionally numb and in shock y becoming irritable or angry y crying more than usual y not spending time with friends and family y worrying about infecting others y feeling dirty y feeling uncertain about your future y feeling like no one understands y feeling like life is not worth living 314 Copyright © 2008, Caring Ambassadors Program, Inc. If you fnd yourself unable to control how much you are worrying, this may be a sign of an anxiety disorder. If this is the case, it is important to be aware of changes in any of the following, which may signal an anxiety problem: − feeling restless or on edge − becoming tired more quickly than normal − having problems concentrating − feeling more irritable than normal − having headaches, cramps, stiffness, and muscle tension − problems falling or staying asleep Both of these issues (depression and anxiety) may become serious if they contnue for more than a couple of weeks. If this is the case, it is important to talk to someone who can help, such as your healthcare provider. Concerns such as depression, anxiety, and problems with thinking and memory are common. Healthcare providers may not always notce when patents are depressed or anxious, so it may be up to you to tell your healthcare providers if you have any of the symptoms of these disorders (see lists above). Substance abuse is a signifcant issue that should be discussed with your healthcare provider. Hepatts C in patents with psychiatric disease and substance abuse: Screening strategies and comanagement models of care. Addressing tri-morbidity (Hepatts C Psychiatric and Substance Use Disorders): the importance of routne meantal health screening as a component of a co-management model of care. Integrated psychiatric/medical care in a chronic hepatts C clinic: efect on antviral treatment evaluaton and outcomes. Associaton of chronic hepatts C with major depressive disorders: irrespectve of interferon-alpha therapy. Depression and anxiety in patents with hepatts C: prevalence, detecton rates and risk factors. Substance Abuse and the Transmission of Hepatts C Among Persons With Severe Mental Illness. Psychiatric and substance use disorders in individuals with hepatts C: epidemiology and management. Depression, anxiety, post-traumatc stress, and alcohol-related problems among veterans with chronic hepatts C. Natonal Insttutes of Health Consensus Development Conference Statement: Management of Hepatts C. Epidemiology of substance use disorders among persons with chronic mental illnesses. Substance abuse and the transmission of hepatts C among persons with severe mental illness. The prevalence of hepatts C virus infecton in the United States, 1999 through 2002. Comorbid depression among untreated illicit opiate users: results from a multsite Canadian study. Hepatts C virus infecton afects the brain-evidence from psychometric studies and magnetc resonance spectroscopy.

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Within the post-operative thyroid bed gastritis symptoms baby order 400 mg sevelamer free shipping, itself gastritis upper right quadrant pain buy generic sevelamer 400 mg on-line, residual thyroid tissue gastritis diet for toddlers discount sevelamer 400 mg line, tumor recurrence gastritis diet sevelamer 400 mg discount, and suture granulomas can occur chronic gastritis joint pain cheap sevelamer 800 mg on line. Type A aortic dissection is rare gastritis pdf generic 800 mg sevelamer, but remains the most lethal of aortic disorders requiring prompt surgical intervention. A clarification and modified conceptual classification of aortic dissection will be provided, along with illustrative examples of these aortic lesions. Craniofacial abnormalities occur as an isolated phenomenon or in the context of syndromes, chromosomal abnormalities or environmental insults. Subsequently we will discuss major malformations involving the external ear and orbits and their expected association. During the lecture, the normal appearance of the fetal chest will be briefly done, in order to approach a review of the most common pulmonary lesions encountered during the fetal period. They will become familiar with the specific information provided by each of the two modalities. The course will present a review of bowel anomalies of the fetus and will be illustrated by representative cases with the objective for the learners to understand the systematic approach of image analysis that can lead to the accurate diagnosis or limited list of differential diagnoses. Echogenic bowel is associated with multiple other congenital conditions such as chromosomal anomalies, viral infections or cystic fibrosis. Dilatation of bowel may have various etiologies and systematic review of the findings including bowel wall thickening, number of distended bowel loops or the increased echogenicity of the content may help to localize bowel obstruction and narrow the list of differential diagnosis. Meconium is formed in the entire bowel and accumulates in the rectum that acts as a reservoir. While meconium is seen in the small bowel and colon in the second trimester, it is mainly seen in the fetal colon after 30 weeks of gestational age. Systematic review of the distribution of meconium and analysis of the bowel caliber in comparison to normal values for gestational age helps to establish or narrow the list of differential diagnoses of fetal gastrointestinal abnormalities. Over the last 10 years there has been increasing interest in the percutaneous treatment of varicosities. The patient population with varicosities, the presentation of varicosities, and the treatment of varicosities will be presented. Other venous anomalies can worse the symptoms of varicosities and may need to be treated. These include May-Thurner syndrome, pelvic congestion, and the male variant of pelvic congestion syndrome (varicoceles). The patient population, symptoms and presentations, and the treatment of these other venous abnormalities will also be discussed. Educating patients and physicians is important to permit weighing benefits versus increased dose. Marketing can be an important factor for some practices looking to increase services and volumes. In addition to reduced recalls from screening, fewer patients will require close diagnostic follow-up therefore diminishing the diagnostic pool over time. Diagnostic exams are also streamlined, all leading to expediting the imaging workflow of patients. Overall there is a net benefit as more patients will need less imaging and get more accurate reads. Review of current literature on clinical implementation of Digtal Breast Tomosynthesis. The costs and shortcomings of utilizing two modalities Full Field Digital and Digital Breast Tomosynthesis daily as the facility/department transitions from one modality to another. Educating your team of the changes that will be implemented is extemely important. Education of referring health care providers and the patients on the new technology is key to making a successful transition to a new modality. Liver biopsy has been considered the reference standard for fibrosis assessment and stage classification. However, biopsy is invasive, with potential complications that can be severe in up to 1% of cases. In addition, a liver biopsy represents roughly 1/50,000 of the liver volume and there is interobserver variability at microscopic evaluation. Elastography is a non-invasive method for liver fibrosis assessment and has been an area of intense research. With ultrasound elastography systems now widely available worldwide this technique is beginning to replace liver biopsy as method for diagnosis and follow-up of liver fibrosis. A discussion of the clinical applications of this technique and future potential applications will be discussed. It may be especially helpful for a group of indeterminate nodules with follicular lesions finding on fine needle aspirationB. This accounts for the efficacy of palpation for detecting abnormalities and provides motivation for developing practical methods to assess tissue elasticity. Chronic liver disease is serious worldwide problem, and hepatic fibrosis is the most important consequence, which if not detected and treated, eventually leads to cirrhosis which is irreversible and associated with high mortality. The data are automatically processed generate quantitative images showing the elasticity of the liver and other tissues in the upper abdomen. Early detection of local recurrence is important to allow potentially curative salvage therapy. Assessment of recurrence after emerging focal therapies remains problematic, since methods for reliably differentiating necrosis or scarring from tumor are lacking. Imaging is pivotal for detection, staging and evaluation of tumor response to treatment. As targeted therapies are increasingly administered, the necessity for an update of tumor response criteria has become obvious. Tumor size and anatomy is still required important information, but evaluation of tissue viability is increasingly needed. Another specificity of abdominal malignancies is the increasing number of patients who are candidates for an integrated approach including systemic therapies, local therapies, radiation therapy and surgery. This underlines the necessity of a team approach and the major role of the radiologist within this group. In secondary liver tumors, targeted therapies are usually administered in association with cytotoxic drugs. As up to 30% of patients with liver metastases from colon cancer might become resectable, the evaluation is not limited to volumetric response. The report should mention in addition relevant information on tumor viability and aggressiveness and also comment on useful elements for guidance of potential surgery or intervention. In other abdominal advanced malignancies, targeted therapies are not yet standard. However, due to the poor prognosis of these diseases, very active research develops in this field and interestingly favors a better selection of patients. Imaging may play a role with this issue, like classifying locally advanced vs metastatic patients as well as highly vs less agressive tumors. In summary, the Radiologist should have knowledge of the main clinical challenges, of ongoing and potential treatments in order to provide relevant information to the Multi Disciplinary Team. However, following initiation of chemotherapy, tumor progression can occur in up to 33% of patients. Early determination of this therapeutic failure can be important in management and can assist clinical decisions concerning discontinuation of ineffective treatment and institution of alternative therapy. Additionally, an essential component of evaluating the results of cancer treatment in patients on clinical trials is the reporting of the response rate. Because small differences in the response rate can affect the outcome clinical trials, it is important that the criteria used to make this determination are meaningful and consistent. Furthermore, the assessment of objective response has also been complicated by the development of treatment protocols that target tumor biology including tumor cell proliferation and invasion, angiogenesis and metastasis. Anti-tumor effect in many of these regimens is cytostatic and, unlike anticancer cytotoxic agents, may not cause regression in tumor size. Imaging informatics covers everything from the ordering of a study, through the data acquisition and processing, display and archiving, reporting of findings and the billing for the services performed. The standardization of the processes used to manage the information and methodologies to integrate these standards is being developed and advanced continuously. These developments are done in an open forum and imaging organizations and professionals all have a part in the process. In this presentation the flow of information and the integration of the standards used in the processes will be reviewed. Current methods for validation of informatics systems function will also be discussed. These advanced imaging techniques can be combined with anatomical information to generate high precision treatment plans which can be adapted over the course of treatment to account for identified uncertainties, changes, and deviations which may compromise the delivery of the intended treatment or identify the ability to re-optimize treatment to improve the therapeutic ration. In this session, technical and clinical concepts will be described to design and deliver personalized radiotherapy in the abdomen. Functional imaging and serum-based biomarkers can enable a more detailed understanding of the tumor, its characteristics, and early indications of its response to therapy. In addition, they can also be utilized to assess an individual patients risk for toxicity, enabling a personalize approach to radiotherapy. Technical concepts will include incorporation of multi modality imaging for treatment planning, image guidance at treatment, and functional and anatomical adaption. Clinical concepts will include functional targeting, clinical goals, and toxicity risks. Most research to date has focused on identifying specific biomarkers used to personalize systemic or targeted therapies. Radiation-specific biomarkers are emerging and may eventually be used to determine whether radiation is indicated or identify specific radiation sensitizers for use in abdominal tumors. Fundamental physical issues of limited spatial resolution relative to the biological process, partial volume effects, image misregistration, motion management, and edge delineation must be carefully considered and can differ by agent or the method applied. Further, interpretation of tumor response should be standardized, and scans should be obtained at consistent time intervals. Finally, we will evaluate common dose and fractionation regimens as well as established dose constraints used in treating abdominal tumors with conventional and stereotactic body radiation therapy. Many a times, a single error or miss may lead to devastating result and can shine media spotlight. The purpose of this refresher course is to address this issue from various skate-holders. The course includes a tag-team of physicians-physicists addressing what one needs to next after a radiation incident occurs. The main objective of this refresher course is to provide ways audience can implement in their settings to address such events. This talk will discuss various measures medical physicists can do to address such situations. Even though prevention is better and is achievable by routine review of equipment and protocol settings, but when radiation incidents occur, a physicist can do the following. First, physicist should record details of scan settings that have led to the radiation incident. Next, it is important to assess and make necessary changes to the scan settings to avoid future incidents. This should be followed by detail assessment of radiation exposure to patients (skin dose and organ dose) and work with the radiologists and other physicians to address the radiation events. In addition, tasks including regulatory compliance, staff training, and others will be discussed in this talk. In order to improve the quality and safety of care one must address these underlying conditions and not just the particulars of an incident itself. In its simplest form, the medical physicist in radiation oncology performs quality assurance tests and commissioning procedures to ensure that the next incident does not happen. It is now possible, for example, to characterize and quantify the risks associated with clinical processes. It is also possible to benchmark performance in safety-critical area against other clinics. And it is possible to participate in incident investigation and learning through the newly released national incident learning system. All of these activities are core competencies of a medical physicist in radiation oncology in the modern era. By leading and participating in such efforts the medical physicist has a direct impact on improving the quality and safety of care. Radiology departments and healthcare systems must be in alignment with their programs on safety culture, policies, and practice to best minimize patient harm. When events happen-and they will-it is critical to understand how to disclose them, how to learn from them, and how to improve processes so that future patients in the system may not be harmed. Further, it is important that the culture of the radiology department embraces learning from near misses that provide the opportunity to improve practice before a patient is harmed. Due to our many checks and balances, it is unusual for an error to reach the patient. In the rare case that an error does reach the patient, most can be corrected for, with minimal if any harm to the patient. Our goal is to learn from every incident, review our processes and continually improve the delivery of radiation therapy to prevent future errors from occurring. Computation of features from images requires delineation (also called segmentation) of regions or volumes within these multidimensional images, and then applying computer algorithms to the data within these regions to characterize them and, perhaps, their surroundings, with numbers. This session will cover the structure of feature computation pipelines and various factors that influence their outputs. Classes of features include shape (values characterize region boundary smoothness and compactness), margin (values characterize how sharp the transition is from inside to outside the region), and texture (variation of gray values or color within and possibly nearby to the region). In addition, specialized features may be computed when prior research has described important implications of observations. It is important to recognize that computed features may be influenced by data acquisition and reconstruction methods.

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Depression accentuates an individual’s pain symptoms (headaches gastritis kombucha order sevelamer overnight, back pain gastritis lower back pain buy genuine sevelamer online, musculoskeletal pain juice diet gastritis buy sevelamer pills in toronto, muscular pain gastritis chronic fatigue purchase sevelamer toronto. This overlapping of pain and depression demonstrates the need tension treating gastritis naturally purchase sevelamer 800 mg otc, heartburn gastritis shortness of breath discount sevelamer 800mg without prescription, etc. One person out of fve will suffer from depression during the course of their life. Depression does not strike randomly: clearly identifed risk factors can predispose us to develop this medical condition. The presence of chronic pain increases the risk of developing a Fortunately, major depression, which is treated early and effectively, major depression. A major depression can be qualifed as mild, can occasionally be healed completely. This is one of the reasons why we but it will still require pharmacological treatment or psychothe must continue to demand better access to frst-, second-, and third-line rapy. People suffering from depression and those around them tend to of the brain and causes emotional, physical and/or cognitive fnd a multitude of reasons to account for the presence of depressive symptoms that are occasionally irreversible if they persist for symptoms: “You have to understand, she’s just lost her job. Certain types of chronic pain, combined with a mood disorder of the clinical picture. If the treatment is to succeed, the the quality of the dialogue between the care-giver and the patient. Section 2 | Chapter 22 Mood disorders and chronic pain: when pain is synonymous with unhappiness 177 Several therapeutic models can be chosen for treating a mild or are not necessarily associated with depression. Commonsense is always appropriate and good these various conditions probably share common psychopathological personal health practices will possibly lead to a prompt recovery. Cognitive and behavioural interventions Medication includes antidepressants of various classes. Depression is a disease that can have lasting effects, and can also recur if it is not treated in time. Depression is contagious: the spouses and children of those who suffer from depression are more at risk of becoming depressed themselves. Depression can result in death, either your own or that of your loved ones (15% risk of successful suicide). She had already had depression months, her family physician diagnosed a possible fbromyalgia. She twice in the past, one during a post-partum period, from which she had was referred to us by her neurologist, who was no longer able to treat never really recovered, since no one had considered that diagnosis. When we met her for the frst time, she had just lost By starting on antidepressants and recovering her ability to sleep, she her job, her spouse had been diagnosed with cancer and she had two was able to eliminate all of these symptoms and continue her university demanding teenagers. Her migraines disappeared almost completely, horrifc migraines that did not respond to migraine medication. She had been irritable and diffcult to live with for several months, and had had a confict at work, which resulted in her dismissal. She could no longer sleep, was constantly lacking energy, and was openly thinking about ending it all whenever she found herself behind the wheel of her car and saw a truck coming in the opposite direction. His wife was no longer able to encourage him, and make ding it diffcult to put up with his pain despite treatment with powerful him see that the future would be better. He was sad and had felt powerless for several taking the antidepressants again, and was able to continue working. He felt tired, did not feel like doing anything, and did not feel Michael is a very courageous man. Specifc characteristics of the pain/depression asso Psychiatry, 69 : Décembre 2008 : 1970-1978. Cambridge University Press, Third and health care costs in an urban primary care practice. Association between pain and depression ders and predictors of pain management success in patients with among older adults in Europe : Results from the aged in home care chronic pain. Differences between minimally depressed with major depressive disorder in Asia : Relationship with disease patients who do and do not consider themselves to be in remission. In order to improve your painful condition, you refuse, accept, or delegate a task must act differently: modify certain habits and change aim for a minimal goal the way in which you perform certain movements or Change the meaning of your pain accomplish tasks. Breathe peacefully moving differently To help you do this, this chapter proposes several means, organized around fve strategies. By practising on a regular basis these strategies to manage your capacities, you will dis cover your own way in which to act differently. Sometimes, our capacity is diminished to person without loss of capacity, «will» and «capacity» balance out in a the point that we must go to bed. For example, we don’t run up the steps all the way from rest, the discomfort decreases until another day without much pain the ground foor to the 5th foor. Rather, we will progress up the stairs, appears then, the cycle, starting with intense activity, begins again. Going from relapse to relapse has capacity occurs, the adjustment between will and capacity is not auto dramatic repercussions for us, our loved ones, and our colleagues. We often continue to want to act like before, even if our body joy of living and physical capacity are greatly affected by chronic pain. Fortunately, we can gradually increase our capacities, even the most Unfortunately, the more we persist in acting the same way as before diminished ones, by their smart management. In the pages that follow, the loss of capacity, the more the pain and fatigue will increase and fve strategies for the smart management of our capacities, as well as reduce the capacity that we still have. It is as if we are caught up in a the two important underlying premises, are presented. Healthcare professionals receive little training regarding the difference a major role in the perception of pain. These natural your acute or chronic pain to be considered believable, it had to be sedatives temporarily block pain transmission by a mechanism called directly proportional to the nature and the extent of tissue damage. Thus, some healthcare professionals could explain to you that they Research also shows that the perception of pain is infuenced by believe that your chronic pain is imaginary or «caused either by unresol such factors as your expectations11, stress9, perception of pain as ved tissue damage or by psychological disorder». Indeed, science now supports the fact that the brain plays Second Premise: You are the sole expert of the evaluation of your pain. The second premise at the base of the smart management of your also need to be sure of the reliability of your pain evaluation. For example, the level of improvement or relief is often evaluated by Pain is defned as a subjective experience or «an unpleasant emotional comparing current pain with pain experienced before any treatment. On one hand, it is diffcult to remember the precise level of the sole expert able to fnd the movements and postures which do not symptoms beyond a few days and, on the other hand, pain expe trigger your pain. You can use a numerical scale from 0 (no aspect; for a slap, the unpleasant aspect overrides the intensity of the pain) to 10 (the worst possible pain imaginable). Midnight Midnight Name : Date : 184 Working together when facing chronic pain these two basic premises also underlie our group interventions for at ecoledudos. The Interactional School to now with various types of chronic pain are very encouraging. These schools have demonstrated the effcacy book written specifcally on the subject. Sometimes, we can invest ourselves so much in a task A smart strategy for managing your capacities is to exercise control by that we even forget to eat. Most of the time, we refuse a before beginning a task that is likely to monopolize all her attention, task by simply saying “no”. However, it can be very diffcult to say “no” she sets a timer to make sure she takes a break from time to time. Delegating tasks and accepting the consequences following sentence to herself: «Saying no, is saying yes to me! Remain fexible in your choices by always granting yourself the right to change the order of your priorities. A patient, currently experiencing continuous back pain, of an improvement that justifes, in your eyes, the efforts required to set this minimal goal for the end of the treatment: «to go for half a day incorporate into your daily life these strategies or any other treatment, per week with little or no back pain». In other words, you have reached the minimal goal if Another patient, who had stopped playing with his young children your condition starts to improve. By defnition, the minimal goal is for fear of increasing his pain, wants to play with them again. This particular way of minimal goal: “not to be afraid to play with my children two evenings setting a goal can raise a question: “Why aim for a minimal goal if a week». Another patient with back pain is currently unable to travel I am looking for total relief of my pain? His minimal goal is: “to be able to travel by car to a city the one hand, from a clinical point of view, to achieve (or exceed) a located at approximately 100 km in having to stop not more than once goal is always gratifying, no matter how small it may be. At the beginning of treatment, a patient considers her addition, from a scientifc point of view, it has been proven that a strong energy level to be very low. On a scale of 1 (the lowest energy level will to relieve pain actually increases a person’s distress and vigilance you can imagine) to 10 (the highest energy level you can imagine), she to pain. Well before the establishment of these lowest quality of sleep you can imagine) to 10 (the highest quality of facts, Paul Watzlawick, internationally known as one of the founders of sleep you can imagine). She aims for a sleep quality level of 6 by the strategic interactional therapy, had already advocated the same point: end of the treatment. The instructions are the same except in meaning you give to pain affects not only your tolerance to this pain the threatening condition a passage describing the symptoms of frost but also affects your loved ones’ attempts to encourage you. The tolerance to and, in serious cases, the skin turning blue, gangrene and amputation. This test consists of this instruction thus gives a threatening meaning to the pain resulting immersing one’s arm in a basin flled with very cold water (2o C) for the from the immersion. During the test, each individual is accompanied not necessarily have the same instructions. The partners tested under the reassuring condition maintained their arm in cold water a little Diverting attention: the accompanying person tries to distract the more than three minutes, on average, whereas those under the threa partner by inviting him or her to speak about a past pleasant experience tening condition barely exceeded two minutes. Under the reassuring condition, the accompanying to think of the sensations as a dull warm feeling rather than pain. Third, the conversation between the accompanying person and the partner is focused on pain if, and only if, it is perceived as threatening by both the accompanying person and the partner. However, this reaction – logical in light of your meaning of ring meaning to pain increases both your pain tolerance and the support the pain – in fact maintains the problem because restricting movement from your entourage. In turn, higher pain tolerance makes maintaining inevitably worsens the initial pain. For example, imagine that each painful To avoid such counterproductive actions, you and your entourage sensation means to you that muscular or tissue damage is occurring need to give a reassuring meaning to your pain, like “this pain is due (threatening meaning). You will rapidly and drastically reduce your to body dysfunction not affected by movement”. When we are Three types of breathing are most frequent: stressed, effort, and in pain, we tend to project ourselves into the future (for example, abdominal (peaceful). It occurs primarily in the upper part of the chest requires centring on the present moment in order to modulate your pain and in the shoulders, characterized by a shallow inhalation, and stress. If this type of breathing persists over a long time, it can to our needs, moods and social interactions. For example, watching a provoke hyperventilation, with dizzy spells, numbness and sleeping child calms our own breathing, while facing an angry “pumped heart palpitations, feeling a lack of air, as well as pain in the up” person accelerates our breathing. Effort breathing (Figure 2, second image) occurs during physical breath, blocks his breathing and grimaces. His breathing then becomes effort where simultaneously, the heart rate accelerates, the short and shallow, muscle tension is at a maximum. It takes place in both or the shock has passed, the individual calms down and his breathing the belly and chest, characterized by a deep inhalation, exhala becomes more peaceful, the muscles relax and pain decreases. This tion, followed directly by another deep inhalation, exhalation, story has a good ending. It takes muscles remain tense, short and shallow breathing persists, and pain place primarily in the abdomen (belly) area; this is why it’s is maintained. In this kind of situation, learning to relax your muscles called “abdominal breathing”. As illustrated in Figure 2 (frst and return to peaceful breathing helps to modulate pain. Abdominal breathing includes a brief pause after exhalation and before inhalation, thus characterized by a cycle of inhalation, exhalation, pause, then inhalation, exhalation, pause, and so on. Rediscovering natural and peaceful breathing is an important tool to modulate your pain and stress, so important that the next few pages are devoted to a description of the six steps to mastering abdominal breathing. However, notwithstanding the number of days you take to learn each exercise, be sure to take one day per week “vacation” from practising. Pause a brief moment after navel and the other hand on your chest at the breast level. Observe now the cycle a few minutes, and then observe how your hands move in rhythm inhalation-exhalation-pause, inhalation-exhalation-pause, and so on. Observe that during inhalation (breathing in), the belly (or the chest) infates and the respectively placed hand rises. During exhalation (breathing out), the abdomen (or the chest) empties 2nd step: directing the air toward your abdomen Lie down comfortably. Place one hand on your abdomen below the muscles in order to allow abdominal breathing. Then, a few minutes, and then at each inhalation, direct the air towards the simply let the air out of your lungs. Pause for a second before inhaling, abdomen as if it were a balloon, flling up with air every time you starting thereby another cycle of inhalation, exhalation, pause. This image of a balloon flling with air will help you relax the movement of your body (your hands on your chest and abdomen) your abdominal muscles suffciently to allow your diaphragm to des while you continue to repeat this type of breathing. Note that you may have to go through a period Practice: for 5 minutes, once a day, for 6 days. Then, when you feel similar to the previous one, but this time you do not deliberately inhale ready, let your body inhale by itself for 2 breaths and then for 3 after the pause. Rest assured, however, that your body will inhale spontaneously when it lacks oxygen.

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In terminal illness gastritis diet buy sevelamer 800 mg lowest price, when recurrent hard fecal masses will be ex pected gastritis diet sevelamer 800 mg free shipping, the family should be instructed to perform this What are the “Rome criteria”? When the rectum is found empty gastritis diet purchase 400mg sevelamer mastercard, but “bal According to the “Rome criteria gastritis foods to eat list purchase sevelamer 400mg,” at least two of the fol looned gastritis or anxiety discount 400mg sevelamer fast delivery,” laxatives with “softening” and “pushing” effects lowing symptoms must be fulfilled for a minimum of 3 are indicated gastritis diet order sevelamer pills in toronto. After descent of the feces into the rectum, Abdominal Cancer, Constipation, and Anorexia 141 enemas will help to evacuate the feces. If the rectum is Why do opioids induce found to be empty and collapsed, fecal impaction is not constipation? To understand opioid-induced constipation, we have to remember that peristaltic movement is the con sequence of longitudinal contractions of the smooth Which etiologies apart from the muscles proximal to descending food and intestinal cancer must be considered? The excitatory motoneurons in the intes Certain factors influence the motility of the colon. The tines responsible for longitudinal contractions have most important “extrinsic” factor is pharmacotherapy cholinergic innervation. The latter one of the most frequent causes of constipation, there conditions are the main reasons for constipation in gas is no evidence-based treatment protocol or prophylaxis troenterological cancer patients in addition to the direct protocol for this therapeutic situation, but it is advisable effects of the cancer tissue growth (obstruction and in to always use a prophylaxis to prevent opioid-induced flammation). Sometimes overlooked, depression and constipation, whether constipation is already present or anxiety disorders, which have a higher incidence in can not. Do all patients with constipation What are the specific risk require special laxative therapy, factors for cancer patients to get and what would be the most simple constipated? Reduced nutritional intake due to cancer-related therapy is only indicated in special situations, one of the anorexia most important one being the prophylactic treatment of. Immobilization in inpatient treatment (plus loss should be limited to those that are absolutely necessary. The first step would be lo itself), depressive disorders, and anxiety (causing cally available laxatives. Tese tablets also should be taken at bedtime and The simplest mechanism is the “softening of stool,” which increased by one tablet daily until there are successful usually is sufficient to allow stool regulation in non-can bowel movements. The permanent dose would be the cer patients who have normal daily activities and a nor result of careful up-and-down titration at the beginning mal daily fluid intake. At step three, the laxatives have to charide lactulose is non-resorbable and attracts water be combined with local therapy, either suppositories into the intraluminal space of the intestines. If suppositories are unavail ing intraluminal volume and dilating the intestinal wall, a able, custom-made petroleum jelly will do as well (a propulsive effect is triggered. Unfortunately, fermentation lump of it has to be held inside by the patient, preferably is a side effect of lactulose, resulting in gas formation. Always try to avoid bedpans and The artificial polyethylene glycol macrogol has allow the patient to sit or squat to have more effective a similar osmotic effect but does not need as much abdominal muscle contractions. Macrogol has saline effects and is not metabolized, therefore there is no fermentation or in would be the most “advanced” creased gas production. Since they may irritate the intestinal wall, cause change therapy according to the needs of your patient. Laxatives belonging to this class in Some laxatives are not recommended for ex clude the anthraquinone glycosides (aloe, senna leaves), tended use, especially antiresorptive and secretory laxa diphenols (bisacodyl und sodium picosulfate), as well as tives, because they may cause considerable potassium fatty acids (castor oil). In some patients the “stimulat and fluid loss, which increases constipation in the long ing” effects—especially from castor oil—may cause con term. Patients with advanced cancer and/or permanent siderable discomfort through colicky abdominal pains. Can we do something about the In fact, this approach is based on an interesting hepatic weight loss? Terefore, the antagonist method does not influence the course of the weight would only be active at the intestinal opioid receptors, loss and even poses a risk for the patient. A cheap help them, if possible, with some symptomatic treat alternative is to provide the patient with oral naloxone, ment to increase appetite. This support may be very which—if available—is a low-cost substance and has an helpful for the patient, since eating is one of our main ticonstipation effects in a dose range of 2–4 mg q. Although there will be no relevant recent development is methylnaltrexone, which is a se weight gain, the increased appetite will have a positive lective opioid antagonist. Two sub ously and has a predictable effect within 120 minutes stances have been shown to have a positive effect on for more than 80% of treated patients. In abdominal cancer, about three quarters of patients experience weight loss of more Is there also a good than 5% monthly in the advanced stage of cancer recommendation for my patient (breast cancer and prostate cancer are exceptions complaining of fatigue? We know now that cytokines, which play a prominent Fatigue is a term describing major exhaustion and role in infections, are released from cancer cells should not be confused with depression or sedation. They influ Depression usually goes along with difficulties in fall ence the melanocortin system in the central nervous ing asleep, constant “thinking in circles,” lacking drive, system (the hypothalamus), thereby reducing the especially in the morning hours, and general loss of patient’s appetite. Even high caloric intake cannot interest, while sedation means falling asleep again and prevent weight loss. Therefore, patients should be in again for short periods (maybe the opioid dose is too structed to continue eating what they like best, but high? If fatigue is diagnosed, we have to admit to the they should not be encouraged to force their nutri patient that it can hardly be influenced and is a “pro tional intake. The patient’s family should be instruct tective” function of the body to save energy because ed likewise, because they might feel that they have to of the cancer. While pharmacological options such as “feed” the patient more since they see the continuous methylphenidate have been very disappointing, some reduction in body weight. The next rone, or paracetamol (acetaminophen) to reduce consultation should be within the next few days the dose and side effects of opioids. If the sedating and nauseating side effects of the [1] Agency for Health Care Policy and Research. Constipation—modern laxative thera analgesic requirement, the opioid should be ro py. Best Pract Res parenteral or intrathecal) are never required in Clin Gastroenterol 2007;21:473–84. Current approach to cancer pain management: availability and implications of different treatment options. Appendix Profiles of laxatives (in alphabetic order) Bisacodyl (phenolphthalein): antiresorptive and hydragogue, 5–10 mg for prophylaxis, 10–20 mg for therapy Gastrographin (dye): propulsive, only in acute danger of ileus, 50–100 cc Lactulose (osmotic sugar): for prophylaxis when oral fluid intake is not impaired, 10–40 g Macrogol 3350 (polyethylene glycol): osmotic, prophylaxis for cancer patients, 13–40 g Magnesium sulfate and sodium sulfate (saline and osmotic): short term-treatment, 10–20 g Naloxone (opioid antagonist): prophylaxis with chronic sub-ileus, 4 × 3–5 mg orally Sodium-picosulfate (phenolphthalein): antiresorptive and hydragogue, for cancer patients, 5–10 mg Paraffin: improves “gliding” of stools, short-term therapy without risk of aspiration, daily 10–30 mL Senna (anthraquinone glycoside): antiresorptive und hydragogue for prophylaxis and long-term therapy, 10–20 mL Sorbitol: saline and osmotic for refractory constipation, suppository in the morning (fast-acting) Guide to Pain Management in Low-Resource Settings Chapter 19 Osseous Metastasis with Incident Pain M. Incident pain is an episodic increase in pain intensi Bone metastasis in cancer patients is seen frequently. Bone transient increase in pain to greater than moderate in metastases are more often seen with cancer of the lung tensity, which occurred on a baseline pain of moderate and the prostate in males and cancer of the breast in fe intensity or less. In the is breast cancer, and the most common site is vertebral United Kingdom the term is often used synonymous bodies, as seen in Table 2. It usually occurs at the same site as the background pain, causes difficulty in ambulation or immobility, neuro while incident pain may occur at the site or in a differ logical deficits, and pathological fractures. Fracture is common in patients with a my has been estimated to be 15–30 minutes on average, eloma and breast cancer, and long bones are more fre with a frequency of 4–7 pain episodes per day. This material may be used for educational 147 and training purposes with proper citation of the source. Omar Tawfik Table 1 Differences between breakthrough and incident pain Breakthrough Pain Incident Pain Occurs in the same site as background pain Occurs at any site Is spontaneous, without any volitional act Should be related to a volitional act Has a duration and frequency Occurs with an incident and needs a specific interventional treatment Prostate cancer cells produce osteoblast-stimu How does bone destruction occur? In this case, new bone is laid down di Bone destruction results from interactions between tu rectly on the trabecular bone surface before osteoclas mor cells and bone cells that are normally responsible tic resorption. The enhanced less prone to fracture because of the locally increased osteoclastic bone resorption, stimulated by bone-re bony mass. Moreover, immobilization and sec ondary effects of osteolysis may be the reasons for de Table 2 pressed osteoblast function. Bone metastatic lesions and sites Osteoclasts can be activated by tumor products Primary sites in this study: Pain sites of these metastases: or indirectly through an influence on other cells. Tumor Breast cancer (24%) Lumbar spine (34%) cells frequently produce factors that can activate im Prostate cancer (19%) Toracic spine (33% mune cells, which release powerful osteoclast-stimulat Unknown primary (22%) Pelvis (27%) ing substances, such as tumor necrosis factor and inter Renal cancer (13%). Tumor products could also act directly Malignant melanoma (7%) Sacrum (17%) on bone cells. In the late stages of a metastatic disease, Lung cancer (6%) Humerus (19%) malignant cells appear to directly cause the destruction Other (8%) Femur (14%) of bone. In bone metastases, reactive osteoblastic activ ity can occur and is detected by bone scans and serum Breast cancer cell metastasis to bone promotes alkaline phosphatase. However, the normal balance of lagen fragments such as pyridinoline and deoxypyr bone resorption and new formation is upset. Patients have its a mixed picture of both lytic and sclerotic areas, localized sharp pain, often worsened by movement or with fractures usually occurring through the lytic ar weight bearing. Tese different mechanisms correspond to typical radiological features showing mixed lytic and sclerotic metastases, osteolytic metastases, or sclerotic metasta Can all osseous metastases ses (see Table 3). However, a study Table 3 at a multidisciplinary bone metastasis clinic found that Characteristics of skeletal assessment in the most common 57% of patients reported severe (7–10) pain, and 22% tumors associated with bone metastases had experienced intolerable pain. The pathophysiologi Myeloma Breast Prostate cal mechanism of pain in patients with bone metastases Hypercalcemia 30% 30% Rare without fracture is poorly understood. The presence of Bone scans + ++ pain is not correlated with the type of tumor, location, Alkaline phosphatase + ++ number and size of metastases, or gender or age of pa Histology Osteoclastic Mixed Osteoblastic tients. While about 80% of patients with breast cancer X-ray Osteolytic Mixed Sclerotic will develop osteolytic or osteoblastic metastases, about Osseous Metastasis with Incident Pain 149 two-thirds of all demonstrated sites of bone metastases characteristically described as dull in character, con are painless. Many nerves are found in the periosteum, stant in presentation, and gradually progressive in in and others enter bones via the blood vessels. Pain increases with pressure on the area of in Microfractures occur in bony trabeculae at the volvement. Tese characteristics are fully described by site of metastases, resulting in bone distortion. The the patient, so the condition should be investigated as stretching of periosteum by tumor expansion, mechani probable osseous metastasis with bone pain. Pain is cytokines, which mediate osteoclastic bone destruction, usually bilateral when originating in the thoracic spine may activate pain receptors. Straight leg raising, coughing, row probably accounts for the observation that pain and local pressure can exaggerate the pain, while pain produced by tumors is often disproportionate to their may be relieved by sitting up or lying absolutely still. A secondary pain Weakness, sphincter impairment, and sensory loss are may be caused by reactive muscle spasm. Nerve root in uncommon at presentation, but they develop when filtration and the compression of nerves by the collapse the disease progresses in the compressive phase, and of osteolytic vertebrae are other sources of pain. As half of the calcium is albumin-bound, the total calcium Case study value should be adjusted for the albumin level to cor A female patient, aged 63 years, came to the pain clinic rectly evaluate the calcemic status. Renal function, in with vague aching pain in the lower back, which she has cluding urea and electrolytes, should be checked. Symp had for 3 months, accompanied by gnawing pain in the toms occur with calcium values exceeding 3 mmol/L, middle of her right thigh, particularly on standing up and their severity is correlated with higher values. Pain scoring by the patient defined the pain elderly and very ill patients, very slight increases of ion at rest as 4, and pain on walking as 6, on a 10-cm line. The patient has had radical left into the circulation secondary to an increased breast surgery due to breast cancer, followed up by radio bone resorption. Urinary excretion of hydroxyproline, a major the lumbar spine, at the second lumbar vertebra, and on constituent of type I collagen, is an indirect mea the medial part of the lower third of the right thigh. Both urinary hy Pain may be vague or absent because osseous droxyproline/creatinine and calcium/creatinine metastasis may be painless. However, any vague pain ratio have been used to monitor the effects of in a patient with a history of treated cancer should be bisphosphonate treatment. Hypercalcemia is associated with pain, nausea, usually results from osteolytic bone metastases. Pain as vomiting, anorexia, constipation, weakness, de a symptom is present in about 50% of patients. The five hydration, polyuria, mental disturbances, and most frequently involved sites are the vertebrae, pelvis, confusion. Gastrointestinal a period of weeks or months, becoming progressively symptoms are often mistaken for opioid effects or more severe. The pain usually is localized in a particular are potentiated by opioid-related symptoms, and area, such as the back and the lower third of the femur, neurological symptoms are often attributed to ce and is often felt at night or on weight bearing. Omar Tawfik clinical course of 10–20% of patients with lung A magnetic resonance scan delineates the whole and breast tumors. Patients with a and integrity of the spinal cord, and allows differentia myeloma presenting low values of serum osteo tion between traumatic, osteoporotic, or pathological calcin, a sensitive and specific marker of osteo fractures and compression without the need of invasive blastic activity, have advanced disease, extensive techniques, such as myelography. Prevention of incidental fracture or vertebral hypercalcemia should test for free serum calcium level collapse. With conventional radiography plications including pain and hypercalcemia can then be a change of about 40% in bone density is required be alleviated. The most important is radiation therapy, or fore bone metastases may be identified, and small le the use of radionuclides. Bone scintig Radiation therapy raphy is positive in 14–34% of patients who have no In 60–90% of patients, radiotherapy has been effective radiographic evidence of bone metastases. However, using a standard treatment regime delivering 60 Gy in the method is less sensitive for the detection of pure 30 fractions over 6 weeks with daily treatment sessions. Bone scan abnormalities are Radiotherapy should be the first step in the manage not specific, and several benign conditions give rise to ment of metastatic bone pain. Scans may appear negative when an adjunct to orthopedic surgery to decrease the risk lesions are predominantly osteolytic, after radiother of skeletal complications. An actual or impending bone apy, and when surrounding bone is diffusely involved fracture may require a short fractioned course of 20–40 with tumor. Radiotherapy is used for bone metas type of metastases and yield more sensitive results tases to relieve pain, prevent impending pathological than the previous methods. Osseous Metastasis with Incident Pain 151 Radiotherapy is successful in relieving pain in 60–70% to prevent withdrawal in recovering drug users, is used of patients, but it takes up to 3 weeks for the full effect in hospices in the United Kingdom and Canada. Currently, immediate-release forms of morphine, well as effects specifically related to the irradiation field, oxycodone, and hydromorphone are available for a fairly including skin lesions, gastrointestinal symptoms, my rapid onset of drug action.

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