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A similar outline could be adapted and applied in veterinary medicine for teaching veterinary students pregnancy girdle 10mg duphaston with amex. In veterinary dentistry women's health magazine zymbiotix order duphaston 10mg online, clinicians should apply validated methods of pain assessment and treat orofacial pain based on available literature and scientific evidence pregnancy lower back pain generic 10 mg duphaston visa, when appropriate womens health daily dose order genuine duphaston on-line. Dental patients present with various levels of pain and a safe and effective approach can be challenging women's health center langhorne pa duphaston 10 mg with visa. Multimodal analgesia is the administration of two or more analgesic drugs with different mechanisms of action pregnancy news purchase duphaston 10 mg on line. Box 2 For example, it is not uncommon to observe increased body weight and activity, and better sleeping patterns/quality of life after treatment of oral disease. In general, pain associated with oral disease may create specific and/or nonspecific clinical signs which will improve after oral treatment. Signs of dental pain include ptyalism, halitosis, decreased appetite, rubbing or pawing the face, changes in demeanor and reluctance to play with toys. Perioperative pain control Opioids are the first line of treatment in acute pain management and they have been reviewed in detail elsewhere. This is of interest in dental patients, however there might be liability issues of prescribing these medications to be administered by owners. Most oral and maxillofacial disorders and therapies involve inflammation and tissue damage/trauma. This may be particularly important after significant oral surgery, such as full-mouth extractions due to feline chronic gingivostomatitis. Local anesthetic techniques of the oral cavity Local anesthetic drugs produce a reversible block of sodium and potassium channels and transmission of nociceptive input. These blocks require minimal training and can be used for a variety of dental procedures including extractions or surgery of the oral cavity such as maxillectomy, mandibulectomy, among others. Some considerations are presented below: Unfortunately, local anesthetic techniques are not widely employed in veterinary medicine due to the lack of familiarity with use. Drugs Table 4 shows common doses and concentrations of local anesthetics (Table 4). Levobupivacaine or bupivacaine may be preferred over lidocaine for local anesthetic techniques of the oral cavity due to its prolonged duration of action. Anesthesia of the lingual and mylohyoid nerves may occur during a mandibular nerve block and result in desensitization of the rostral two-thirds of the tongue. In dogs, bupivacaine alone or in combination with buprenorphine reduced isoflurane requirements by approximately 20%. Intraosseous or intraligamentary anesthesia might be an option when other techniques have failed, however these blocks do produce intrinsic pain at injection. Avoiding complications There are some important considerations before the administration of any local anesthetic block to avoid complications Calculation of toxic doses Local anesthetic toxicity may occur when dosage regimens and intervals of administration are not properly calculated. If bupivacaine is administered intravenously, dysrhythmias such as ventricular premature contractions may be observed. Complications after local anesthetic blocks of the oral cavity are rare but have been reported and include globe penetration most often requiring enucleation (Perry R et al 2015). Administration of a local anesthetic block should be performed in non-inflamed areas to improve efficacy. This foramen may be difficult to palpate in cats but the block can be still performed successfully. For desensitization of ipsilateral canine tooth, a maxillary nerve block is preferred and produces more consistent blockade. Caution must be taken with this block, as the infraorbital foramen is located just ventral to the orbit. The infraorbital canal is much shorter in cats and brachycephalic dogs than in normo and dolichocephalic dogs. To avoid eye penetration, the needle should be introduced ventrally and advanced only approximately 2 mm. The upper lip is elevated and the infraorbital foramen is located (approximately dorsal to the third premolar tooth). The level of sedation should be assessed before induction of anesthesia to determine best dosage regimens of each agent. Anesthetic blocks can be repeated according to the duration of procedure, interest of postoperative analgesia and using less than maximum recommended doses (see text). Alef M, von Praun F, Oechtering G (2008) Is routine pre-anaesthetic haematological and biochemical screening justified in dogs Stepaniuk K, Brock N (2008) Hypothermia and thermoregulation during anesthesia for the dental and oral surgery patient. Development and initial validation of a pain scale for the evaluation of odontostomatologic pain in dogs and cats: preliminary study. Proceeding of nd the Association of Veterinary Anaesthetists Meeting, 20-22 April 2016, Lyon, France. Reid et al (2017) Definitive Glasgow acute pain scale for cats: validation and intervention level. Section 4: Oral Examination and Recording A thorough oral diagnosis of every patient is based on the results of the case history, clinical examination and charting, dental radiography and laboratory tests if indicated. Examination of Conscious Patient Some procedures can be performed on a conscious patient during the first consultation. The results provide an overview of the level of disease and allows for the formation of the preliminary treatment plan. Oral/Dental Examination the examination starts with a thorough history including symptoms which may indicate dental disorders such as: halitosis, change in eating habits, ptyalism, head shaking etc. The examined criteria are: lymph nodes, dental deposits, periodontal status, nutrition and oral care (professional and homecare). Each criteria is scored with respect to the clinical findings and a total score is then determined. Abnormities are defined as either a skeletal malocclusion or malposition of single teeth (for more detail see chapter 1d: Malocclusion). Following induction of anaesthesia, the examination should be performed in a detailed and structured way with the charting performed simultaneously. After the visual inspection of the entire oral cavity, the tactile examination is performed in two steps utilizing the appropriate instruments. Following this, pocket depth and furcation exposure are evaluated with a periodontal probe. The photographs serve as proof for pre-operative dental condition as well as provide visual evidence to the owner. It is recommended to use a lip retractor or dental mirror to better visualize the entire dentition and surrounding structures. Intraoperative photograph: it is advised to take a photograph of any pathology revealed by the scaling. Dental examination with dental explorer: each tooth must be examined with a dental explorer, beginning with the first incisor of each quadrant and progressing distally caudally tooth by tooth to cover the entire arch. Additional therapy: Based on all available information (visual, tactile, and radiographic) determine and execute the final treatment plan. In this situation, a thorough examination with a dental explorer, a periodontal probe and a mirror will give fairly accurate information about status of the oral cavity. Recording A thorough examination can only be performed on an anaesthetized patient. They must also be kept as part of the medical record and may be used to illustrate, to the owner, when explaining the work performed. The first digit denotes the quadrant, which is numbered clockwise beginning at the upper right quadrant (1-4 for permanent dentition, 5-8 for primary dentition). The advantages of the Modified Triadan System are that it allows for easy identification of a tooth, is understood throughout the world (no language barrier), issuitable for all species, faster than writing out the tooth description, and ideal for digitalized recording and statistics. The basic clinical findings can be scored with a simple mouse click onto the dental charts. With a few clicks the clinic data and logo can be inserted, and an individual report created which will increase the customer loyalty. Journal of Nutrition 136: 2021S-2023S Gorrel C (2004) Odontoclastic resorptive lesions. The loss of periodontal attachment is less than 25% as measured either by probing of the clinical attachment level, or radiographic determination of the distance of the alveolar margin from the cementoenamel junction relative to the length of the root. Plaque removal and control consists of 4 aspects depending on the level of disease. Extraction this section will cover the complete dental prophylaxis/cleaning as well as basic indications for periodontal surgery and extractions. Only when the patient is properly anaesthetized can a safe and effective cleaning and oral exam be performed. The use of a periodontal diagnostic strip by the examining veterinarian can improve the accuracy of the conscious periodontal evaluation. The veterinarian can then discuss the various disease processes found on the examination as well as the available treatment options with the owner. Based on the oral examination findings, the practitioner can create a more accurate estimate both of procedure time and financial costs to the client. The most common used mechanical scaler in veterinary dentistry today is the ultrasonic model. Both types of ultrasonic scalers are very efficient and provide the additional benefit of creating an antibacterial effect in the coolant spray (cavitation). At slower rates of vibration, they generate minimal heat, and therefore may be a safer alternative to ultrasonics (See equipment section for a complete discussion of mechanical scalers). Mechanical scaling When using any of the mechanical scalers, the first concern is the power level setting of the instrument. Next, it is important to ensure that there is adequate coolant being delivered through the working end of the scaler. Specific low-powered periodontal tips are available for subgingival use, and clinicians and staff should familiarize themselves with this equipment prior to their use. It has long been recommended to strictly limit the amount of time ultrasonic scalers linger on one tooth. Typically, it is recommended that they be kept in constant contact with tooth for no more than 15 seconds. The instrument should be kept in constant motion, running slowly over the tooth surface in overlapping, wide, sweeping motions. Rotosonic scaling, while popular in the past, is no longer a recommended form of scaling. Technique Hand instruments are typically held with a modified pen grasp 3), but, other grips may be necessary in certain situations. The middle finger is placed near the terminal end of the shaft and is used to feel for vibrations which signal residual calculus or diseased/rough th th tooth/root surfaces. Finally, the 4 and 5 fingers are rested on a stable surface, generally the target tooth or nearby teeth. This grasp and described method of cleaning allow for maximum control during the scaling procedure. The instrument is held with the terminal shank parallel to the tooth surface and the blade placed at the gingival margin 4). Step 4: Subgingival plaque and calculus scaling this is the most important step of the dental cleaning, as supragingival plaque control is insufficient to treat periodontal disease. The blunted bottom will not cut through the delicate periodontal attachment, assuming excessive force is not applied. Gracey curettes are area specific, and are designed with different angles to provide superior adaptation to specific areas of the dentition. Place the blade of the instrument on the tooth surface just coronal to the free gingival margin, with the lower shank parallel to the tooth surface. Once the bottom of the pocket is reached, the instrument is rotated to create a 90 degree working angulation. Remove the instrument from within the pocket in the coronal direction with a firm/short stroke. To accomplish subgingival scaling, these instruments are used in a similar fashion as supragingival scaling described above, but more care should be taken not to damage the root surface. Again, this technique is performed with a gentle touch using numerous overlapping strokes until the root feels smooth. Step 5: Residual plaque and calculus identification After scaling, it is recommended to check the teeth with an explorer 8), feeling for any rough areas which indicate small areas of dental pathology or residual calculus. Practices can choose to use a commercially available polish, or make their own slurry of flour of pumice and chlorhexidine solution or water. The polishing procedure is typically performed with a rubber prophy cup, on a slow-speed hand piece with a 90 degree angle (prophy angle). Running the prophy cup without paste is not only inefficient; it may also overheat the tooth. The entire oral cavity must be systematically evaluated using both visual and tactile senses. The only accurate method for detecting and measuring periodontal pockets is with a periodontal probe, as pockets are not always diagnosed by radiographs. This progresses clockwise so that the maxillary left is 200, mandibular left is 300, and the mandibular right is the 400 series.

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Each must be familiar with the applicable procedures breast cancer hope best purchase duphaston, maintain visual contact with the other pregnancy yoga pants cheap duphaston 10 mg overnight delivery, and be ready to assist in the event of an accident menopause 38 purchase generic duphaston pills. The interior of the hood menstrual exercise cheap duphaston 10mg on line, glove box women's health journal primary care cheap duphaston 10 mg otc, or cabinet should be decontaminated periodically menstruation 9 days long duphaston 10 mg discount, for example, at the end of a series of related experiments. Other protective equipment may be required, depending on the characteristics of the toxin and the containment system. When handling toxins that are percutaneous hazards (irritants, necrotic to tissue, or extremely toxic from dermal exposure), select gloves that are known to be impervious to the toxin. Consider both toxin and diluent when selecting gloves and other protective clothing. The Medical Examiner the Federal Motor Carrier Safety Regulations identify a person who can be a medical examiner by two criteria: professional licensure and scope of practice that includes performing physical examinations. Medical Examination Report Form Although the Federal Motor Carrier Safety Regulations do not require the medical examiner to give a copy of the Medical Examination Report form to the employer, the Federal Motor Carrier Safety Administration does not prohibit employers from obtaining copies of the Medical Examination Report form. Employers must comply with applicable State and Federal laws regarding the privacy and maintenance of employee medical information. The driver may request a replacement copy of the certificate from the medical examiner or get a copy of the certificate from the motor carrier. It is divided into 50 titles that represent broad areas subject to Federal regulation. Four of the standards: vision, hearing, epilepsy, and diabetes mellitus have objective disqualifiers that do not depend on medical examiner clinical interpretation. Table 1 Medical Regulations Summary Table To view the regulations in the Medical Regulations Summary Table, visit. The role of the medical examiner is to determine if the driver is "otherwise qualified. Both Federal exemptions require the driver to have an annual medical examination for maintenance and renewal of the exemption. Is designed or used to transport more than 8 passengers (including the driver) for compensation; or 3. Between two places in a State through another State or a place outside of the United States; or 3. Intrastate Commerce: Intrastate commerce means any trade, traffic, or transportation in any State which is not described in the term "interstate commerce. A safety risk in any one or more of these commercial operations components can endanger the safety and health of the public. Truck and bus companies may also have additional medical requirements, such as a minimum lifting capability. Medical examiners are responsible for knowing the driver regulations for the State or States in which they practice. Aging means a higher risk exists for chronic diseases, fixed deficits, gradual or sudden incapacitation, and the likelihood of comorbidity. Long hours and extended time away from family and friends may result in a lack of social support. Required cognitive skills include problem solving, communication, judgment, and appropriate behavior in both normal and emergency situations. When a fatal crash involves at least one large truck, regardless of the cause, the occupants of passenger vehicles are more likely to sustain serious injury or die than the occupants of the large truck. The crash of a vehicle having twice the mass with a lighter vehicle equals a six-fold risk of death Page 21 of 260 to persons in the lighter vehicle. In addition to the grievous toll in human life and survivor suffering, the economic cost of these crashes is exceedingly high. Is the onset of incapacitating symptoms so gradual that the driver is unaware of diminished capabilities, thus adversely impacting safe driving Nonetheless, you have a responsibility to educate and refer the driver for Page 24 of 260 further evaluation if you suspect an undiagnosed or worsening medical problem. As a medical examiner, you are responsible for determining medical fitness for duty and driver certification status. Gather information regarding type of seizure, duration, frequency of seizure activity, and date of last seizure. Ear disorders, loss of hearing or balance Ask about changes in hearing, ringing in the ears, difficulties with balance, or dizziness. In addition, talk with the driver about his/her response to prescribed medications. As a medical examiner, though, you are concerned with the blood pressure response to treatment, and whether the driver is free of any effects or side effects that could impair job performance. Digestive problems Refer to the guidance found in Regulations You must review and discuss with the driver any "Yes" answers. Diabetes or elevated blood glucose controlled by diet, pills, or insulin Ask about treatment, whether by diet, oral medications, Byetta, or insulin. Your discussion with the driver should include cause, duration, initial treatment, and any evidence of recurrence or prior episodes of loss of or altered consciousness. Ask about episode characteristics, including frequency, factors leading to and surrounding an episode, and any associated neurologic symptoms. Page 31 of 260 Stroke or paralysis Note any residual paresthesia, sensory deficit, or weakness as a result of stroke and consider both time and risk for seizure. Spinal injury or disease Refer to the guidance found in Regulations You must review and discuss with the driver any "Yes" answers. When the vision test is done by an ophthalmologist or optometrist, that provider must fill in the date, name, telephone number, license number, and State of issue, and sign the examination form. The forced whisper test was administered first, and hearing measured by the test failed to meet the minimum five feet requirement in both ears. General Appearance Observe and note on the Medical Examination Report form any abnormalities with posture, limps, or tremors. Note driver demeanor and whether responses to questions indicate potential adverse impact on safe driving. If yes, what are the clinical and safety implications when integrated with all other findings At a minimum, you must check for scarring of the tympanic membrane, occlusion of the external canal, and perforated eardrums. Does your examination find any abnormalities that indicate the driver may have a current cardiovascular disease accompanied by and/or likely to cause symptoms of syncope, dyspnea, collapse, or congestive cardiac failure Can the condition be corrected surgically or managed well by pharmacological treatments Lungs and Chest, Not Including Breast Examination You must examine the lungs and chest for abnormal chest wall expansion, respiratory rate, and breath sounds including wheezes or alveolar rales. An abnormal urinalysis indicates further testing to rule out underlying medical problems. Does the driver have sufficient grasp and prehension in the upper limbs to maintain steering wheel grip Spine, Other Musculoskeletal You must check the entire musculoskeletal system for previous surgery, deformities, limitations of motion, and tenderness. Does the driver have a diagnosis or signs of a condition known to be associated with acute episodes of transient muscle weakness, poor muscular coordination, abnormal sensations, decreased muscular tone, and/or pain As a medical examiner, you are responsible for making the certification decision and signing the Medical Examination Report form. When you determine that a driver has a health history or condition that does not meet physical qualification standards, you must not certify the driver. You also determine when the driver must repeat the physical examination for continuous certification. Although you cannot exceed the maximum certification period, you are never required to certify a driver for a certification interval longer than what you deem necessary to adequately monitor driver medical fitness for duty. Write Federal vision or Federal diabetes when exemption certificate is required. Have the driver sign the certificate and compare this with the information provided by the driver. Whereas guidelines, such as advisory criteria and medical conference reports, are recommendations. While not law, the guidelines are intended as best practices for medical examiners. If you choose not to follow the guidelines, the reason(s) for the variation should be documented. The visual demands of driving are magnified by vehicles that have larger blind spots, longer turning radiuses, and increased stopping times. Health History and Physical Examination Health History Here are the vision questions that are asked in the health history. Discuss the value of regular vision examinations in early detection of eye diseases. Medical examiners cannot diagnose these diseases or conditions because most do not have the equipment necessary to diagnose them. Required Tests Required vision screening tests include central visual acuity, peripheral vision, and color vision. Eyeglasses or contact lenses may be worn to meet distant visual acuity requirements. When corrective lenses are worn to meet vision qualification requirements, corrective lenses must be worn while driving. Snellen Distant Acuity Test the Snellen chart is widely used for measuring central visual acuity. Figure 20 Snellen Chart Snellen chart is illustrative only and not suitable for vision testing Page 54 of 260 Visual Acuity Test Results the Snellen eye test results use 20 feet as the norm, represented by the numerator in the Snellen test result. The minimum qualification requirement is distant visual acuity of at least 20/40 in each eye and distant Figure 22 Visual Acuity Test Results binocular acuity of at least 20/40. One example is the "Snellen Eye Chart Illiterate" that requires the individual to indicate the orientation of the letter "E" on the chart. In the clinical setting, some Snellen chart is illustrative only and form of confrontational testing is often used to evaluate not suitable for vision testing peripheral vision. A "Protocol for Screening the Visual Field Using a Confrontation Method" is found in Appendix E of the Visual Requirements and Commercial Drivers report. Position your left hand one-and-a-half feet to the left of the straight ahead axis and six inches above the horizontal plane. Left eye examination Repeat the procedure for the left eye (steps 2 through 5), making sure the driver fixates on your right eye and the hand placement is appropriately reversed. When test results are inconclusive, obtain specialist evaluation for precise measurement of peripheral vision. The clinical setting may not provide the necessary equipment to evaluate ophthalmic diseases adequately. Ophthalmic Preparations Determine if the treatment is having the desired effect of preserving vision that meets qualification requirements without any visual and/or systemic side effects that interfere with safe driving. Cataract formation can be accelerated by a number of conditions, including injury, exposure to radiation, gout, certain medications (steroids), and the presence of diabetes mellitus. Glare, particularly during night driving in the face of oncoming headlights, may be an early symptom of cataracts. The development of chronic elevated intraocular pressure is generally painless, and the gradual loss of peripheral visual field can progress significantly before symptoms are noticed.

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Real-World Outcomes Seizure frequency was reduced by at least half in 31% of patients in the high-stimulation group menstrual cramps 6 weeks pregnant discount duphaston 10 mg on line, compared with 14% in In addition to the clinical trial data pregnancy early signs 10mg duphaston free shipping, real-world outcome stud the low-stimulation group breast cancer 5 year survival rate duphaston 10mg amex. Patients in rates from the literature for studies reporting on at least the high-stimulation group either aborted or decreased 59 women's health nursing issues cheap duphaston 10mg fast delivery. One patient receiving with an additional 13% of patients having a seizure frequency high stimulation became seizure free women's health oregon city purchase genuine duphaston line, and 23 zyrtec menstrual cycle buy discount duphaston 10 mg on line. Seizure-free periods increased apy also successfully stopped a case of refractory generalized every year; one patient continued to be seizure free after convulsive status epilepticus in a patient 13 years of age (66). A prospective, open evaluation of 64 patients Another report among three children admitted to the intensive reported results for up to 5 years of follow-up (35). Small, prospective studies report similar results patients of different ages (75) recommended age-related stim as well as additional benefits beyond seizure reduction such as ulation adjustments based on age-related changes seen in reduced postictal periods and seizure duration (37,38). A retrospective study of 46 children implanted under Electrical stimulation of the peripheral vagus nerve requires the age of 18 (median age of 12. Verbal performance, alertness, motor and cognitive functions, and general behavior improved, sometimes dramatically (45,47,56,62,63). Most central projections of the vagus of magnetic extra stimulation in abolishing seizures (102). However, this population was quite different stem nuclei are known to influence seizure susceptibility from that in the earlier adult series. Cerebrospinal fluid samples nephrine release by the locus ceruleus is antiepileptogenic. A pilot study of three through neuronal networks that project from brain stem adults showed activation of the right thalamus, right pos to forebrain structures. Vagal projections to noradrenergic terotemporal cortex, left putamen, and left inferior cerebellum and serotonergic neuromodulatory systems of the brain may (107). Patients with cardiac conduction disorders were derived from the clinical trial experience, not from an under not studied in the controlled trials. Patients with other seizure types or epilepsy prevent exacerbation of this condition (126). The watchdog timer is an internal monitor that limits the number of pulses Hospitalization for implantation of the device is preceded by to be delivered without an off time to prevent excess evaluations by a neurologist and by a surgeon with experience stimulation. Fracture of the of bradycardia, asystole, or both mandate initial lead testing electrode, related to fatigue at the junction between contact in the operating room (24,133,134); the anesthesiologist and the lead wire, was a common problem with early devices should be notified immediately before this test. Substitution of a quadrifilar wire and, later, a following intraoperative bradycardia has been shown to be trifilar lead body coil improved electrode tolerance that had safe, with no change in cardiac rhythm upon initiation of post been compromised by repetitive neck motion. Correct placement of the lead electrodes around Model 302 but has a lead body designed with three high the vagus nerve is critical. Two methods have been developed fatigue silicone tubes; the bifurcation is still caudal to the to help confirm correct placement of the electrodes intraop anchor tether, but designed with a smoother transition to eratively (136), depending on the type of anesthesia used for facilitate a smooth strain relief bend. For patients receiving general anesthesia, the structed with a trifilar lead body coil and a continuous bilu larynx and vocal cords can be monitored by fiberoptic men lead body silicone tube with the bifurcation cephalad to endoscopy for contraction of the left lateral larynx wall and the anchor tether; this design makes the handling characteris vocal cord tightening. For patients being implanted under tics of the Perennia lead feel stiffer during the implantation local and regional anesthesia, stimulation intensities can be procedure compared with the Model 302 and 304 leads. Incisional infections are unusual and generally respond to Prophylactic antibiotics may be administered both in the antibiotic therapy. The patient can be dis with or without infection occurs in 1% to 2% of implanta charged after the procedure, which usually lasts for less than tions and resolves with aspiration and antibiotics; the rare 1 hour, or can be observed overnight. Discharge education cases of refractory infection require removal of the genera should include care of the incisions and use of the magnet. Unilateral vocal cord paral the first 3 months of stimulation unless an early response is ysis, which accompanies approximately 1% of implants, noted. The subsequent stimulation schedule is ulator is actually delivering a pulse (Table 70. Inhalation of ipratropium bromide or lowering of the stimulus systemic adverse effects or cognitive side effects (160,161); frequency or current is recommended. An analysis of total mortality and sudden death QoL independent of treatment effect on seizure frequency, as in epileptic patients (to August 1996) revealed the expected well as increased daytime vigilance, have also been reported rate in individuals with severe, intractable epilepsy (149,150). The severe dys seizure or improve the postictal phase empowers the patient phoric or psychotic conditions emerged once seizure frequency and provides a sense of control over epilepsy. Children between $15,000 and $25,000) can be prohibitive without with a history of dysphagia may experience swallowing diffi coverage by a third-party payer. These cost benefits are sustained over time and are sufficient to cover or exceed the cost of the device. Diagnosing refractory epilepsy: response to work because of health-related concerns (P 0. Predictors of pharmacoresistant which further reflect positive changes in the QoL of both epilepsy. Antiepileptic drug therapy in the United States: a review of formed among patients both with and without the device clinical studies and unmet needs. Unexpected places: how did vagus nerve stimulation become a treatment for epilepsy Prevention of intractable partial seizures by intermit tent vagal stimulation in humans: preliminary results. Vagus nerve stimulation dramatically improve the overall treatment of all patients with therapy for partial-onset seizures: a randomized active-control trial. A randomized controlled trial of chronic vagus nerve stimulation for treat seizure types. Earlier use of adjunctive vagus nerve stimulation therapy for refractory epilepsy. Vagus nerve stimulation for 1 year in 269 patients on unchanged antiepileptic drugs. Vagus nerve stimulation for refractory available free to patients, nurses, and physicians from epilepsy: a transatlantic experience. Evaluation of refractory References epilepsy treated with vagus nerve stimulation for up to 5 years. Is vagus nerve stimulation a treatment therapy in patients with refractory epilepsy. Vagus nerve stimulation for sympto pediatric patients with refractory epilepsy: retrospective study. Human vagus nerve electrophysiology: a epilepsy in children: indications and experience at the Hospital for Sick guide to vagus nerve stimulation parameters. Anatomical, physiological, and theoretical basis for the dren with refractory epilepsy. Suppression of interictal spikes and seizures by stimula 24-month treatment with vagus nerve stimulation on behaviour in children tion of the vagus nerve. Vagus nerve stimulation for treatment of epilepsy does not alter subsequent vagus nerve stimulation-induced seizure sup in Rett syndrome. Slow hyperpolarization in cortical neurons: a pos effective in treating catastrophic 1 epilepsy in very young children. Vagus nerve stimulation improves seizure-attenuating effects of vagus nerve stimulation. Left vagal nerve stimulation in children pathways in the inhibitory control of the substantia nigra over generalized with refractory epilepsy. The effects of vagus nerve stimulation therapy on patients with experimental seizures. Vagus nerve stimulation for patients in residential development of electrical amygdaloid kindling in the cat. Vagus nerve stimulation for medication prolonged stimulation in cats: effects on epileptogenesis (amygdala electri resistant generalized epilepsy. Electrophysiological studies of ulation on adults with pharmacoresistant generalized epilepsy syndromes. Vagus nerve stimulation in response to corpus callosotomy and vagal nerve stimulation. Intraoperative methods for con lation on epileptiform activity recorded from hippocampal depth elec firmation of correct placement of the vagus nerve stimulator. Deep wound infection after vagus nerve effects at high and low levels of stimulation. Strategies for reoperation after comprehensive tion of vagus nerve pacing in a patient with epilepsy. Tonsillar pain mimicking glos failed cranial surgery for intractable epilepsy: results from the vagus nerve sopharyngeal neuralgia as a complication of vagus nerve stimulation: case stimulation therapy patient outcome registry. Vagus nerve stimulation: clinical sequent to treating epilepsy by vagus nerve stimulation. A case report of hypomania vagus nerve stimulation earlier in the course of pharmacoresistant epilepsy: following vagus nerve stimulation for refractory epilepsy. Misidentification of vagus nerve stimu on respiration during sleep: a pilot study. Surgical technique for implantation of the neurocybernetic pros side effects after 6 months of vagus nerve stimulation in epilepsy patients. Chronic stimulation of the left vical vagus nerve trunk stimulation for medically refractory epilepsy: vagus nerve in epilepsy: balance effects. Enhanced recognition memory nerve stimulation for the treatment of epilepsy: cardiac complications. Vagus nerve stimulation reduces costs before and 18 months after treatment with vagus nerve stimulation daytime sleepiness in epilepsy patients. Vagus nerve stimulation therapy for life in epileptic patients treated with vagus nerve stimulation. For instance, phenytoin and carbamazepine are well docu common definition of medical intractability is of particular rel mented to aggravate generalized seizures, including typical and evance to selecting patients for epilepsy surgery because one of atypical absence seizures, myoclonic and atonic seizures in a the prerequisites for epilepsy surgery is demonstrated medical substantial proportion of patients (9). This chapter explores the issues surrounding an initial clinic visit to be uncertain whether a young patient is the definition of intractable epilepsy, with particular reference reporting generalized absence or short-lived complex partial to its relevance to selection of surgical candidacy. Because of genetic and environmental factors, wide interindi the term pseudoresistance has been introduced to describe vidual variability exists in the dosages at which beneficial and the condition in which seizures persist because the disorder toxic effects are observed (10). Patients are often switched to has not been adequately or appropriately treated (1). A wide range of conditions can mimic epileptic these should only be used as an aid in dosage adjustment. Pseudoseizures or nonepileptic psy of 74 consecutive patients referred for epilepsy surgery for chogenic seizures are estimated to account for 10% to 45% of presumed drug resistance, a systematic protocol to titrate their patients with apparently refractory epilepsy (6). Incorrect Drug Choice Imperfect Medication Adherence or Inadequate Dosage or Inappropriate Lifestyle Incorrect classification of syndrome/seizure type is another As with other chronic medical conditions, imperfect adher common cause of drug failure. Cramer and colleagues found that Bearing in mind the aforementioned considerations, a discus medication adherence rates in patients with epilepsy decreased sion of the criteria used to define medical intractability, with as the frequency of drug administration increased, from 89% particular reference to epilepsy surgery, will follow. Although with once-daily dosing to 81% with twice-daily drug adminis the definitions of medical intractability found in the medical tration, 77% with 3-times-daily administration, dropping to literature seem to be highly variable (Table 71. Social and lifestyle factors should, therefore, be considered when evaluating the Number of Drugs Failed efficacy of pharmacologic treatment. Before the criteria for defining medical intractability are dis Any definition must be based on an assessment of the proba cussed, it should be emphasized that, by default, intractability bility of subsequent remission after each drug failure. Until is a relative concept rather than an absolute designation, which recently, clinicians have had a relatively limited therapeutic is influenced by the context in which it is intended to apply. In epidemiologic studies, the be recognized as medically refractory and surgery considered Answers to these ques an understanding of the natural history of treated and tions depend on an understanding of the outcome of treated untreated epilepsy, which remains poorly documented (19). The relativity of any definition of medical intractability is In a Veterans Affairs study, among the 82 patients who particularly poignant in the context of candidacy for poten received polytherapy after failure of the first drug, only 9 tially curative resective epilepsy surgery. With a reported postsurgery seizure-free rate of ducted in Glasgow, Scotland, since 1982. Forty-seven percent of patients with this epilepsy syndrome must, therefore, take into patients became seizure free on their first drug, 13% on the account the potential success of surgical treatment. Indeed, second drug, but only 4% on the third drug or a combination since the effectiveness of surgery may vary for different types of two drugs. Because of the broader range of pharmacologic cessful, only 79 (32%) subsequently became seizure free, with worse prognosis for those failing due to lack of efficacy than 100 those due to adverse effects. Similar results were obtained in the analysis of the 80 expanded cohort of 780 newly diagnosed patients, 47% of whom became seizure free with the first monotherapy. Our ongoing analysis of outcomes in newly diagnosed epilepsy supports this observa 0 tion. Numbers within bars represent percent age of patients seizure free on monotherapy (gray bars) or polypharmacy (open bars). Similar observations have also been made recently by There is no universal agreement as to how frequent and over Schiller and Najjar (43). Seizure frequency used by different authors in enable us to predict medical intractability early in the disease defining intractability ranges from one per month to one per course. Of the participants, 83% of the children tently associated with improvement in quality of life.

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Berlin & Colditz (200) found a summary relative risk of death from coronary heart disease of 1 menstruation 4 times a month purchase cheapest duphaston. Physical activity improves endothelial function menopause quotes funny purchase duphaston 10mg without prescription, which enhances vasodilatation and vasomotor function in the blood vessels (199) womens health 5 oatmeal smoothie order duphaston 10mg mastercard. The possible benecial effects of physical activity on cardiovascular risk may be mediated women's health clinic philadelphia purchase cheap duphaston on-line, at least in part women's health services bendigo duphaston 10mg sale, through these effects on intermediate risk factors menstruation in space order duphaston 10mg with amex. Physical inactivity and low physical tness are independent predictors of mortality in people with type 2 diabetes (210). Overall, the evidence points to the benet of continued regular moderate physical activity, which does not need to be strenuous or prolonged, and can include daily leisure activities, such as walking or gardening (197). Two reviews support the effectiveness of interventions to promote physical activity in the health care setting. Specic interventions included individual and group counselling, self-directed or prescribed physical activity, supervised and unsupervised physical activity, home or facility-based physical activity, face-to-face and telephone support, written materi als, and self-monitoring. Interventions were conducted by one or several practitioners, including physicians, nurses, health educators and exercise leaders. Of the seventeen trials reviewed, eight took place in the primary health care setting. The second review considered only studies in the primary health care setting, and found that brief interventions to promote physical activity produced moderate short-term improvements in self-reported physical activity levels (214). In both reviews, it was noted that the length of follow-up of the studies (typically 1 year or less) was insuffi cient to draw conclusions about long-term effectiveness or whether outcomes would be maintained. Trials using more objective indicators of activity patterns and changes in cardiovascular risk factors would be helpful in determining how primary care teams can intervene most effectively. Evidence Obesity is a growing health problem in both developed and developing countries (2). Obesity is strongly related to major cardiovascular risk factors, such as raised blood pressure, glucose intolerance, type 2 diabetes, and dyslipidaemia (215, 218, 220, 222). Weight loss programmes using dietary, physical activity, or behavioural interventions have been shown to produce signicant reductions in weight among people with pre-diabetes, and a signi cant decrease in diabetes incidence (225). A meta-analysis of randomized controlled trials (226) 36 Prevention of cardiovascular disease found that a net weight reduction of 5. Prospective studies are needed to determine the impact of weight reduction in the long term on cardiovascular morbidity and mortality trends. In a review of data from 24 prospective observational studies, Blair & Brodney (229) found that regular physical activity attenuated many of the health risks associated with overweight and obesity. Physically active obese individuals have lower morbidity and mortality than individuals of normal weight who are sedentary; physical inactivity and low cardiorespiratory tness are as important as overweight and obesity as predictors of mortality. The results of non-randomized trials and observational studies indicate that interventions involving a greater frequency of contacts between patient and provider, and those provided over the long term, lead to more successful and sustained weight loss (226). The diets were associated with modest decreases in systolic and diastolic blood pressure of about 3 mmHg, and may lead to reduced dosage requirements for patients taking blood-pressure-lowering medications. In most trials, the provider/instructor was a dietician; however, the nature and duration of interventions varied signicantly, with intervention periods ranging from 2 weeks to 3 years. In the two trials that reported post-intervention follow-up, it was found that participants tended to regain some, though not all, of the weight lost. People who drink heavily have a high mortality from all causes and cardiovascular disease, including sudden death and haemorrhagic stroke. Smaller protective associations and more harmful effects were found in women, in men living in countries outside the Mediterra nean area, and in studies where fatal events were used as the outcome (238). The benets of alcohol in light to moderate drinkers may be overestimated in meta-analyses of observational studies, as a result of confounding and reverse causality. The meta-analysis was dominated by a few very large studies, which did not carefully assess the reasons for not drink ing, and did not measure multiple potential confounders. It is primarily the non-drinking group that causes the U-shaped relationship, and this may contain both life-long abstainers and people who stopped drinking because of ill-health; this could result in a spurious association suggesting that there is a safe level of alcohol intake. A recent meta-analysis of 54 published studies con cluded that lack of precision in the classication of abstainers may invalidate the results of studies showing the benets of moderate drinking (243). However, subsequent randomized controlled trials have found either no benet or a harmful association; the earlier results are likely to be due to uncontrolled confounding. It is possible that the protective association between light-to-moderate alcohol consumption and coronary heart disease is also an artefact caused by confounding. It is also important to note that alcohol consumption is associated with a wide range of medical and social problems, including road traffic injuries. Other risks associated with moderate drinking include fetal alcohol syndrome, haemorrhagic stroke, large bowel cancer, and female breast cancer (237, 245). Con sequently, from both the public health and clinical viewpoints, there is no merit in promoting alcohol consumption as a preventive strategy. Psychosocial factors Issue Are there specic psychosocial interventions that can reduce cardiovascular risk Other psychosocial factors, such as hostility and type A behaviour patterns, and anxiety or panic disorders, show an inconsistent association (249, 250). Rugulies (246), in a meta-analysis of studies of depression as a predictor for coronary heart disease, reported an overall relative risk for the development of coronary heart disease in depressed subjects of 1. This nding was consistent across regions, in different ethnic groups, and in men and women (247). In a large randomized trial of psychological intervention after myocardial infarction, no impact on recurrence or mortality was found (253). Another large trial that provided social support and treatment for depression also found no impact (254). Depression has a negative impact on quality of life (255, 256), and antidepressant therapy has been shown to signicantly improve quality of life and functioning in patients with recurrent depression who are hospitalized with acute coronary syndromes (257, 258). While these ndings provide some support for a causal interpretation of the associations, it is quite possible that they represent confounding or a form of reporting bias, as illustrated in a large Scottish cohort (263). In the meantime, physicians and health care providers should consider the whole patient. Early detection, treatment and referral of patients with depression and other emotional and behavioural problems are, in any case, important for reducing suffering and improving the quality of life, independent of any effect on cardiovascular disease. Multiple risk factor interventions Issue Are multiple risk factor interventions effective in reducing cardiovascular risk Evidence A Cochrane systematic review has evaluated the effectiveness of multiple risk factor interven tions for the primary prevention of cardiovascular disease in adults from general populations, occupational groups and high-risk groups (106). Eighteen randomized controlled trials involving counselling and/or health education, with or without pharmacological treatment, which aimed to affect more than one cardiovascular risk factor (smoking, diet, physical activity, blood pressure and blood cholesterol) were included. Overall, modest reductions in smoking prevalence, systolic blood pressure, diastolic blood pressure, and blood cholesterol were observed. The studies with the highest baseline levels of smoking prevalence, diastolic blood pressure or cholesterol levels demonstrated greater intervention-related reductions in these risk factors. The pooled effects of the ten trials with clinical event endpoints showed no signicant effect on total or cardiovascular disease mortality; this is consistent with the extent of changes in risk factors. However, trials that focused on participants with elevated blood pressure, and those that used drug treatment, demon strated signicant reductions in coronary heart disease mortality and total mortality. Interventions using personal or family counselling and education, with or without drug treatment, were more effective in modifying risk factors and reducing mortality in people at high risk because of raised blood pressure. These results argue in favour of multiple risk factor interventions for prevention of cardiovascular disease in multifactorial high-risk groups. For the general low-risk population, policy measures that create a conducive environment which facilitates behavioural change may have a greater impact at lower cost than individual counselling and therapeutic approaches. Blood pressure lowering Issue Does lowering blood pressure reduce cardiovascular risk Evidence Raised blood pressure is estimated to cause about 7 million premature deaths throughout the world, and 4. It is a major risk factor for cerebrovascular disease, coronary heart disease, and cardiac and renal failure. Raised blood pressure often coexists with other cardiovascular risk factors, such as tobacco use, overweight or obesity, dyslipidaemia and dysglycaemia, which increase the cardiovascular risk attributable to any level of blood pressure. Almost all clinical trials have conrmed the benets of antihypertensive treatment at blood pres sure levels of 160 mmHg (systolic) and 100 mmHg (diastolic) and above, regardless of the pres 40 Prevention of cardiovascular disease ence of other cardiovascular risk factors (264, 268). Observational data support lowering of these systolic and diastolic thresholds (269, 270). These trial results suggest that treatment for such high-risk patients should begin at the lower blood pressure thresholds. Although women are at lower total risk of cardiovascular disease for a given level of blood pressure, and randomized controlled trials generally include a greater proportion of men than women, the treat ment thresholds for systolic and diastolic pressure should be the same in men and women (274). Total risk of cardiovascular disease for any given level of blood pressure rises with age. For now, the treatment threshold should be unaffected by age, at least up to 80 years. Thereafter, decisions should be made on an individual basis; in any case, therapy should not be withdrawn from patients over 80 years of age (275, 276). In people over 55 years of age, the systolic blood pressure is more important (281), so the primary goal of therapy is to lower systolic blood pressure to 140 mmHg or less. In patients with high or very high cardiovascular risk, including diabetes or established vascular or renal disease, therefore, blood pressure should be reduced to 130/80 mmHg or less. These trials have demonstrated reductions in both cardiovascular mortality and morbidity with all three drug classes. For the endpoint of total cardiovascular mortality, these meta-analyses showed no strong evidence of differences between drug classes. At the beginning of the study, there was a fourth group treated with an alpha-blocker; this treatment was stopped prematurely because of an increased risk of combined cardiovascular disease, to which heart failure was a major contributor. The benets were largely attributable to protection against stroke, and were particularly striking in the diabetic group (290). The incidence of diabetes was also lower in the group on the amlodipine-based regimen. However, this difference could be largely explained by the difference in systolic blood pressure in the two groups (292). One such study included clinical trials in which a beta-blocker was used as the rst-line antihypertensive drug in at least half of all patients in one treatment group, with outcome data for cardiovascular morbidity and mortality, and all-cause mortality. This analysis found no difference in all-cause mortality or myocardial infarction, but the risk of stroke was lower with other antihypertensive drug regimens. However, when beta-blockers were compared with placebo or no treatment, they were found to signicantly reduce the risk of stroke. Beta-blockers are as efficacious as other classes of anti 42 Prevention of cardiovascular disease hypertensive drugs in reducing all-cause mortality and myocardial infarction, but appear to be less effective in reducing the risk of stroke (293). Another meta-analysis (295) investigated the efficacy of beta-blockers in different age groups. The efficacy was found to be similar to that of other antihypertensive agents in younger patients, but lower in older patients, with the excess risk being particularly marked for stroke.

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