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Cardiac Issues in Sports Medicine
[…] LQTS Findings include the following: Abnormal QT interval prolongation. Corrected QT interval greater than 470 ms for men and 480 ms for women. 35 WPW Classic findings include: Delta wave (a slurred upstroke of the QRS complex) Short PR interval (
Rhabdomyolysis
[…] with acute pain and paresthesia. This is especially true for patients whose CK levels do not decline as expected. A delta pressure of < 30 mmHg between diastolic blood pressure and intracompartmental pressure is considered abnormal and warrants an emergent […]
Rehabilitation Approach to Adolescent Pain
[…] the nociceptor by binding to different surface receptors to induce the inflammatory cascade.13There are two major classes of nociceptors. A- delta afferents are small diameter myelinated fibers that mediate acute, well-localized pain. The second class of nociceptor includes small diameter […]
Opioid Management for Chronic Pain
[…] types of opioid receptors and their respective endogenous peptides are: mu (endorphin): these are most commonly used in clinical practice delta (enkephalin) kappa (dynorphin) orphan-like receptor Examples of mixed agonist-antagonists include butorphanol and pentazocine. Partial agonists include buprenorphine and other buprenorphine combination products, such as buprenorphine/naloxone, which is used for the treatment of addiction and off-label used for the treatment of pain. Significant genetic polymorphism of opioid receptors leads to changes in binding affinities and receptor densities, clinically manifested by inter-individual variability in sensitivity and response to opioid analgesic effects; this phenomenon influences efficacy, side effects, tolerance, and risk of drug abuse or addiction.9,10,11 Specific secondary or associated conditions and complications Opioids have significant anxiolytic effects,12 though this should not be a primary reason for prescription. Common side effects include: gastrointestinal (constipation, nausea, emesis) central nervous system (impaired cognition, decreased balance, depression, decreased reaction time) pruritus hypogonadism. This may lead to muscle atrophy, reduced pain threshold, depression, and lethargy and osteoporosis. Screening should include free and total testosterone, cortisol, luteinizing hormone, dihydrotestosterone, and follicle stimulating hormone. Men should be screened for the presence of prostate cancer. Similar endocrine abnormalities may occur in women, but are less well described in the literature With the exception of constipation, and perhaps nausea and itching, a reduction in side effects may be seen over time because of a “tolerance” effect. Respiratory depression is an adverse effect — it is an unintended consequence of a medication that is taken correctly. Close management of side effects may include additional medications including antiemetics and central nervous system stimulants for sedation. It is best practice to start a bowel regimen to prevent opioid induced constipation for someone who is taking opioids. Sexual dysfunction may be related to direct effects of opioids or related drug-induced inhibition of production and release of gonadotropin releasing hormone and inhibition of testicular testosterone synthesis. Animal and human studies show that prolonged use of opioids may be associated with the development of abnormal sensitivity to pain (i.e., allodynia and hyperalgesia). Cellular adaptations may be mediated by N-methyl D-aspartate-receptor changes and other complex neuroplastic abnormalities.13,14 Opioid use in pregnancy can result in stillbirth, poor fetal growth, preterm delivery, or birth defects. For pregnant women already on long-term opioid therapy, abrupt taping can result in the fetus and patient undergoing withdrawal. Pregnant women on opioid treatment should arrange for delivery at a facility capable of treating neonatal withdrawal syndrome. Patients greater than 65 years old have additional risk of drug accumulation due to renal or hepatic impairment. Screening for cognitive impairment and falls is beneficial for primary prevention. Essentials of Assessment Functional assessment Pain assessment for opioids prescription: The “Four A’s” of pain assessment are: analgesia activities of daily living adverse effects aberrant drug taking, characterized by9,15 euphoria taking more medication than prescribed running out of scheduled prescriptions early reporting ongoing need for greater doses selling or diverting their medications Risk stratification for potential aberrant behaviors should be based on exploring risk factors for opioid misuse. These include: Screener and Opioid Assessment for Patients with Pain Revised (SOAPP-R)4 Opioid Risk Tool Brief Pain Interview4 CAGE for Alcohol Abuse Assess controlled substance prescription history utilizing the state prescription drug monitoring program (PDMP) prior to opioid initiation and regularly during treatment4 Assess for multiple prescribers of controlled substances Assess for early refill requests Determine whether opioid dosages are appropriate or if there are dangerous combinations Laboratory studies Compliance testing and monitoring for abuse and diversion are essential. Standard testing includes both a urine screen (immunoassay) and subsequent confirmatory testing (gas chromatography/mass spectrometry) that can confirm the precise type of opiate. Urine drug testing should be performed prior to initiating therapy and at least annually. Testing should be considered more frequently in high risk patients for substance abuse.4 Urine screens monitor for other agents (cannabinoids, benzodiazepines, amphetamine, cocaine). Clinician need understand how to interpret the results of the drug panel tested such as positive results for medication metabolites.4 The role of serum testing in opioid monitoring remains controversial. Newer strategies including testing hair, saliva, and other tissue samples is an evolving area; biological matrices, such as hair, may provide a longer window of detection than blood or urine, and be less invasive; commercially available testing is presently not widely available. There is controversial genetic screening for medication metabolism. Professional Issues An important balance between patient access and reasonable clinical practice is necessary. Patients need access to quality pain management, including the use of controlled substances. However, the clinician should be trained in the indications, contraindications, management of opioids while also taking the necessary steps to prevent and/or monitor for abuse and diversion. Opioid agreements and open, honest communication can help the patient-provider relationship. Rehabilitation Management and Treatments Available or current treatment guidelines Physiatrists cannot singularly eliminate the risk of abuse and diversion of opioids but play an important role in reducing risks. By law, physicians are obligated to comply with both state regulations and the federal Controlled Substances Act. The Federation of State Medical Boards developed its Model Guidelines for the Use of Controlled Substances for the Treatment of Pain16 with input from numerous stakeholders and agencies. Most state medical boards adopted the 2004 Model Policy updated with similar language. The American Pain Society and American Academy of Pain Medicine Clinical Guidelines on the Use of Chronic Opioid Therapy was published in 2009. The CDC guidelines for prescribing opioid for Chronic Pain- United States from 2016 for chronic pain treatment.23 Key components of these guidelines include: Chronic pain should primarily be treated with nonpharmacologic and nonopioid therapies. Consider opioids only if there are benefits for pain and function. If opioids are used, it should be in conjunction with aforementioned therapies, not in lieu of them. Informed (verbal or written) consent and opioid management plans (written) are part of good practice. Opioid agreement templates can be found through various organizations. Realistic treatment goals should be discussed with patients, including opioid use and reasons for discontinuation and expectations of medical management. Reassessment of opioid therapy benefit and risk should be performed within one to four weeks of initiation and at least every three months for continued use. Strict and organized monitoring of pain intensity, function, aberrant behaviors using drug testing and PDMP, and adverse effects. Start with short-acting, immediate release formulations at the lowest effective dose. Prescribe enough medication to treat pain but only for as long as the pain is expected to be severe. Guidelines suggest this period is often less than three and not more than seven days. Continuously reassess the need/indication, dosage, route, and mode of pain management. Consider opioid rotation if an opioid is not effective or causing undesirable side or adverse effects. Remember that opioids do not have a ceiling effect or maximum dose; a reasonable definition for high dose opioid therapy is > 200 MEDD. Always offering naloxone for patients at high risk for overdose. Monitor all patients regularly and pay particular attention […]
Therapeutic Modalities
[…] frequency (HF) and low frequency (LF) TENS activate different opioid receptors. LF TENS activate mu receptors while HF TENS activate delta receptors. As most opioid analgesics work on mu-opioid receptors, HF TENS is more effective in treating opioid tolerant patients.7 […]
Infectious Disorders of the Spinal Cord
[…] previous spinal surgeries, procedures, diabetes, chronic steroid use, cancers, IV drug use, long-term intravenous access, such as peripheral or central lines, and /or indwelling bladder catheters. Additional historical elements that can direct diagnostic work up include vaccinations, transfusions, recent travel, […]
Aging with a Neurological Disability
[…] safety (including instrumental activities of daily living). Laboratory studies Routine laboratory studies should be consistent with general health maintenance guide lines and relevant to the specific neurological condition. In the elderly, it is important to note that abnormalities such as […]
Primary Bone Tumors
[…] and its risk increases with advancing age. These tumors begin in cartilaginous tissues at the epiphysis of bones and joint lines and usually grow insidiously. They affect primarily the proximal femur and flat bones. Chordomas are very rare tumors that form in the bones of the spine, especially at the sacrum or at the base of the skull. They occur most frequently in older adult men.7 Patho-anatomy/physiology Typically, primary bone tumors are classified based on histology, as this allows for prediction of their biological behavior and provides guidance for treatment.8Tumor grading is based on nuclear size, staining pattern, mitotic activity and degree of cellularity evaluated on histologic examination: Low grade tumors- have limited capacity for local recurrence Intermediate grade tumors include: Locally aggressive- often recur locally and are associated with infiltrative and locally destructive growth pattern Rarely metastasizing – tumors are locally aggressive but could give rise to distant metastasis High grade or malignant tumors- have significant risk for distant metastasis Sarcomas arise from transformed mesenchymal cells that differentiate into osteoblasts. The majority of osteogenic sarcomas occur in the metaphysis of the long bones. They are categorized into low and high grades. More than half of these tumors occur in the distal femur, the proximal tibia and the proximal humerus.2 Osteogenic sarcomas often grow fast and may spread to other parts of the body, including the lungs.6 Chondrosarcomas are a group of tumors that have in common the production of a cartilaginous matrix. They are categorized into low, intermediate, high grade and de-differentiated. Ninety percent of these tumors are low grade, including the atypical cartilaginous tumors (ACT) which involve the appendicular skeleton and grade 1 chondrosarcomas, that affect the axial skeleton and flat bones (the pelvis, scapula and skull base). They may arise primarily, without a precursor lesion (most common), or can be preceded by a benign precursor cartilaginous lesion, either osteochondromas or enchondromas. Osteochondromas are associated with mutation in one of the tumor suppressor genes Exostosin Glycosyltransferase (EXT1 or EXT2). Enchondromas are associated with somatic mosaic mutations in the Isocitrate Dehydrogenase genes (IDH1 or IDH2), seen in Ollier disease and Maffucci syndrome.3 Ewing’s sarcoma typically occurs in the diaphysis of long bones, but it is not uncommon in the pelvis. It is always categorized as high grade.7 Chromosomal translocation (11; 22) is used by pathologists in the diagnosis of Ewing’s Sarcoma.1 The World Health Organization (WHO) Classification of Tumors, updated in 2020, reclassified some bone tumors based on molecular genetic alterations and immunohistochemistry, as there are innovative therapies available to target specific mutations. Some chondrosarcomas present aberrant mutations related to IDH1 and IDH2, and inactivating mutations of Cyclin-Dependent Kinase Inhibitor (CDKN2A) and Collagen Type II Alpha (COL2A) genes. Low grade osteosarcomas have been associated with Mouse Double Minute homolog gene (2MDM2) and Cyclin Dependent Kinase 4 (CDK4) amplification mutations.3 Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) Metastatic disease is the most important prognostic factor in malignant bone tumors. Patients who present with metastatic disease have an overall survival of 20% to 30% compared with 70% to 80% in non-metastatic disease after completion of treatments.5 Metastases are more common with high grade tumors. Metastatic lesions usually disseminate through the blood, most commonly to the lung, followed by bone. Skip metastases are found in high grade sarcomas, where tumor embolizes via marrow sinusoids, forming a lesion that is discontinuous from the primary tumor, but in the same bone.1 Transarticular spread across a joint may occur as well.2Patients with lung metastasis have better prognosis than those with metastatic disease in the bones. Another important prognostic factor is response to chemotherapy. When the tumor is resected after neoadjuvant chemotherapy, if the specimen has at least 90% necrosis, it suggests an improved overall survival compared to patients who present lower histologic response to chemotherapy. Axial tumors and older age are factors associated with poorer survival. 9 Specific secondary or associated conditions and complications Pain and lack of cortical integrity are major indicators of impending fracture in primary malignant bone tumors. Making the diagnosis of impending fracture is a challenge in primary malignant bone tumors just as it is in metastatic bone tumors. The guidelines set forth in the Mirels scoring system and the criteria proposed by Harrington for prophylactic internal fixation are not applicable as they pertain only to metastatic lesions. 10, 11 In addition, there have been studies where risk of impending fracture has been evaluated through computed tomography (CT) scan imaging, based on axial cortical and circumferential involvement of the lesion.12 These studies have been focused on metastatic disease as well. No proven clinical guidelines exist to predict fracture risk with benign tumors of the bone. CT-based analysis of bone rigidity in affected bone and homologous healthy bone has demonstrated high specificity for predicting fracture risk in benign tumors; however, its use is limited secondary to the excessive radiation exposure. 13 Essentials of Assessment History Pain, especially night pain, is the hallmark of primary bone tumors. Pain could be described as waxing and waning as seen in osteogenic sarcomas. In cases of Ewing’s sarcoma, pain has been reported as localized and associated with joint swelling. The presentation of chondrosarcoma has been described as a gradual limitation in range of motion of the extremity over months. Other symptoms reported by patients with diagnosis of primary bone tumors is a palpable mass and history of soft tissue swelling that may be associated with a prior injury. Unexplained fever is rare in bone tumors and may suggest disseminated disease.7In the benign bone lesion osteoid osteoma, instant relief of pain on taking NSAIDs is diagnostic. Osteochondromas on the other hand, typically present as a painless lump.7One needs to ask about prior cancer history, radiation exposure, Paget’s disease, and fracture history. The latter may be important on reviewing imaging. Physical examination Physical examination typically demonstrates a firm, fixed mass along the involved bone. In some cases, the mass can be pulsatile with associated increased vascularity. The affected area may be warm and tender to palpation. In cases of metastatic disease, the patient may have a fever, lymphadenopathy, dyspnea and fatigue. Functional assessment Functional goals are extremely important for these patients. However, they are typically considered after initial treatment is started. In a study performed by Corr et al, it was found that pre-habilitation in pediatric patients with diagnosis of lower extremity sarcoma receiving chemotherapy resulted in decreased functional deficits compared to the control group.14 In post-surgical patients, it is important to perform a comprehensive evaluation that includes skin inspection, signs of neuropathic or phantom limb pain and any dysfunction that may occur secondary to leg length discrepancy or alterations in the gait pattern. There are two questionnaires being used to evaluate outcome measures that could aid when planning rehabilitation care: Musculoskeletal Tumor Society (MSTS) scoring and Toronto Extremity Salvage Score (TESS).15 Lower extremity osteosarcoma survivors have 50% increased risk of limitations for performing moderate intensity activities such as climbing stairs and walking one block after receiving treatment. Survivors of upper extremity sarcomas have 10% increased risk of not finishing college education.16 In prospective studies of patients with osteosarcoma who underwent major joint arthroplasty, it was found that participation of early rehabilitation as soon as the first post-operative day helped patients to achieve functional gains in a short time. In addition, these patients had reduced hospital length of stay, without increasing post-operative complications.17Cognitive or behavioral deficits are not usually seen.18 Laboratory studies Serum alkaline phosphatase levels (ALP) are elevated in the majority of patients with osteogenic sarcoma and is a poor prognostic sign.7 ALP is frequently elevated in Paget’s disease and extremely high levels are found in Paget’s sarcoma. Serial alkaline phosphatase analysis may be used to assess the response to chemotherapy in osteogenic sarcoma. Serum lactate dehydrogenase is of prognostic significance in Ewing’s sarcoma and in some cases of osteogenic sarcoma.1,5 Erythrocyte sedimentation rate and C-reactive protein tend to be elevated and is a poor prognostic indicator in Ewing’s sarcoma. Imaging In primary malignant bone tumors, initial plain radiographs may reveal a combination of characteristics including cortical destruction, areas of radiolucency, extraosseous extension and permeating destruction with poorly defined borders. Specifically, Ewing sarcoma tumors appear as mottled bone on imaging studies, and has a typical appearance of periosteal reaction also known as “onion skin”.2 Destruction of the bone cortex, scattered calcifications and loss of medullary bone trabeculations are described in central chondrosarcomas.19 In patients younger than 40 years, symptomatic lesions suggest high risk for malignancy, for which orthopedic referral is recommended prior to considering further workup. In patients older than 40 years of age and older with X rays unequivocal for a specific diagnosis, further imaging studies are recommended, including chest, abdominopelvic CT scan with contrast, PET (Positron Emission Tomography) and MDP (Methylene Diphosphonate) total body bone scans, used for tumor staging and identification of bone or lung metastasis respectively.7 In addition, whole body MRI is useful to define the tumor prior to resection and allows identification of skeletal metastasis.20 Supplemental assessment tools The definitive histological diagnosis is made on biopsy, that could be performed as an open (incisional) procedure or closed (percutaneous-CT guided procedure) procedure in the form of fine needle aspiration or core needle biopsy. Surgical staging systems, one based on the Enneking Staging System (modified by the Musculoskeletal Tumor Society ) and the other by the American Joint Commission on Cancer, are used in staging patients with primary bone tumors. 21, 22 Early predictions of outcomes Poor prognostic indicators include metastases at presentation, tumors arising from the axial skeleton, large tumor volume (size > 10 cm), increased alkaline phosphatase or lactate dehydrogenase levels, poor response to preoperative chemotherapy, skip metastases, discontinuous tumors in bone, […]
Polytrauma, Debility and Burns
[…] or stages, disease trajectory (clinical features and presentation over time) Polytrauma: In the field, care focuses on life-saving measures. The airway is established and managed. Bleeding is controlled, at least temporarily, with mechanical and chemical measures. In the emergency setting, […]
ICU Acquired Weakness and Neurocognitive Decline
[…] in diagnosis of delirium. Functional assessment Care must be taken with regards to patient safety and the presence of tubes, lines, and drains in the functional assessment of ICU patients. Collaborative efforts involving ICU personnel (e.g., medical intensivist, respiratory therapists, […]