Chapter 100
chapter 100
On April 10, 1999, respondent Brandi R. Fox underwent Roux-en-Y gastric bypass surgery and post-surgical treatment.[1] The operation was performed by Dr. Herbert Gladen. During the surgery, Fox was under general anesthesia and unconscious. Fox went home following the surgery, but returned soon after the surgery because she felt ill.
Fox's condition worsened, moving Dr. Gladen to perform exploratory surgery a few days after the gastric bypass operation. The exploratory surgery revealed a perforation at the stapled closure of the small intestine, which caused fluid to leak into Fox's abdominal cavity. Dr. Gladen
665
665 attempted to seal the perforation. In his operative report for the exploratory surgery, Dr. Gladen failed to identify a cause for the perforation. Fox required additional medical care and remained hospitalized until March 4, 2000.
Question 1
I'd like to know the possibility of giving these drugs in epileptics:
vincamine (Oxicebral), cinnarizine, piribedil (Trivastal) and
pentoxyphylline (Trental). I'd like to know if they are contraindicated.
Question 102
If an epileptic patient, treated with oxcarbazepine, develops a rash,
should this drug be withdrawn or the dosage decreased and then
increased gradually again?
Question 3
Does a patient with refractory epilepsy benefit from acetazolamide?
Question 4
What anti-epileptic drug is recommended for a child with epilepsy and
co-morbid attention deficit hyperactivity disorder (ADHD)? Can Ritalin
safely be used for treatment?
Question 5
What is the difference in efficacy and pharmacokinetics between sodium
valproate and valproic acid?
Question 6
Is it safe to give valproic acid to infants below 12 months of age?
Question 7
How many times must the liver transaminases (SGOT and SGPT) rise to
justify a discontinuation of valproic acid therapy in children? Which of
these enzymes is more sensitive and reliable in this situation?
Question 8
1. Does valproic acid block the photosensitivity phenomenon in reflex
epilepsy?
2. Can a patient with this photosensitivity be safely exposed to computer
games or other photic stimuli when receiving valproic acid treatment?
3. Does the photosensitivity phenomenon occur in partial seizures?
Question 9
1. Can an epileptic fit be induced in idiopathic and symptomatic focal
epilepsy syndromes by flickering lights?
2. Is valproate effective against the photosensitive phenomenon (seizure
induction by flickering light)?
Question 10
How much time should one give before a loading dose of phenytoin is
judged to be ineffective in controlling seizures and an alternative should
be instituted?"
1. Drugs in Epileptics:
Vincamine (Oxicebral): Altogether, vincamine can be regarded as relatively safe for use in epilepsy patients but specific safety characteristics in epileptic patients are not well determined. There is no known contraindication for epilepsy in the use of the drug.
Cinnarizine: This drug belongs to the calcium channel blocker group of drugs which is mainly indicated for the treatment of vertigo. It may also reduce the threshold for seizures and therefore should be used carefully or even not at all in patients with epilepsy.
Piribedil (Trivastal): Piribedil is an agonist of dopamine receptor and is employed in the treatment of Parkinson’s disease. Its effect on epilepsy is not well documented but it is not usually contraindicated, but should be used with caution.
Pentoxyphylline (Trental): Pentoxyphylline which is commonly used in peripheral vascular disease has no specific contra indication in epilepsy. But its use should be cautious because of the side effects on the central nervous system.
2. Oxcarbazepine and Rash:
Oxcarbazepine should not be dose reduced for rash but stopped altogether if a patient receiving the drug experiences a rash. Serious skin reactions have been seen with Oxcarbazepine and, hence, discontinuation is recommended to avoid severe side effects.
3. Acetazolamide in Refractory Epilepsy:
Acetazolamide is a carbonic anhydrase inhibitor and is sometimes used in the management of specific types of refractory epilepsy, mainly absence epilepsy. Its efficacy is not fixed and it is often administered together with other anti-epileptic drugs.
4. Anti-Epileptic Drug for ADHD and Epilepsy:Anti-Epileptic Drug for ADHD and Epilepsy:
Recommended Drug: For child with epilepsy and ADHD, levetiracetam or lamotrigine is usually recommended because they have less side effects.
Ritalin (Methylphenidate): Nevertheless, Ritalin can be prescribed for ADHD in children with epilepsy, but this should be done with caution because of possible interactions. Close monitoring is required.
5. Sodium Valproate vs. Valproic Acid:Sodium Valproate vs. Valproic Acid:
Efficacy: Sodium valproate and valproic acid are as effective as they are different forms of the same drug. Sodium valproate is a prodrug which is metabolised into valproic acid in the body.
Pharmacokinetics: Na valproate is absorbed at a slow rate and the dosing can be easier than the rapid release forms of VPA.
6. Valproic Acid in Infants:
Valproic acid may be administered to infants less than one year old, though with a certain degree of precaution. It should be used with caution because of adverse effects such as hepatotoxicity and teratogenicity.
7. Liver Transaminases and Valproic Acid:Liver Transaminases and Valproic Acid:
Transaminase Levels: More than three times elevation of liver transaminases (AST and ALT) should lead to discontinuation of valproic acid administration. A level of 2 to 3 times the upper limit of normal is often used.
More Sensitive Enzyme: SGPT (ALT) is thought to be more sensitive and specific in the diagnosis of liver disease than SGOT.
8. Photosensitivity and Valproic Acid:
Blockage of Photosensitivity: Valproic acid has no selective impact on photosensitivity of reflex epilepsy.
Exposure to Photic Stimuli: Valproic acid patients may undergo exposure to controlled photic stimuli; nonetheless, patient should be observed for side effects.
Photosensitivity in Partial Seizures: Photosensitivity is rare in partial seizures but is increasingly seen in patients with generalised seizures.
9. Seizure Induction by Flickering Lights:Seizure Induction by Flickering Lights:
Flickering Lights and Epilepsy: Photic stimulation causes seizures in patients with idiopathic and symptomatic focal epilepsy syndromes.
Valproate’s Effectiveness: Valproate is usually helpful in the management of seizures elicited by flashing lights and photosensitivity.
10. Phenytoin Loading Dose Effectiveness:
A loading dose of phenytoin should be assay within the first one day. If the seizures are not well controlled by this time then a different treatment should be considered.
Can I have well-organized and accurate responses strictly for the following exercise please?
Can I have well-organized and accurate responses strictly for the following exercise please?
Nurses are now actively involved in COVID-19 interventions, and they will remain key players in stopping the pandemic with adequate assistance. Thus, they must be provided with a healthy work environment to empower their efforts to control and manage the outbreak. Such a work environment should be a judgment-free atmosphere for staff, where they will feel free to comment on accidents such as exposure to body fluids, other infection control risks, or reports of abuse, and to take prompt follow-up action such as providing counselling for staff members. First and foremost, occupational safety is key to nurses' work during COVID-19, as they are face-to-face with danger on a daily basis. The overarching duty of nurse leadership will be to ensure that the appropriate prevention and security steps are taken to reduce the dangers of the workplace. In this respect, it is important that hospitals have appropriate infection control procedures and personal protective equipment (masks, gloves, goggles, gowns, hand antiseptics, soap and water, and cleaning materials) in ample amounts for personnel who care for suspect or verified COVID-19 patients. Nursing supervisors should offer knowledge on workplace security, in addition to instruction and guidance regarding infection prevention and control and how to properly don, doff, and discard personal protective equipment. In this regard, staff members should also be guided on how to carry out regular self-assessments, and directed on how to follow quarantine or isolation measures, when indicated, to protect them, their families, and their community, as well as to safeguard their mental health and well-being.
1.Determine the validity of the following presumption with regards to iterative mechanisms.
2. Determine and discuss the drug that impacts caspases.
3.In genetic algorithms, an _____________ is created encompassing the _____________
and the remaining portion of the chain is _____________ to the prototype _____________.
During the mechanism, what is facilitated to anneal to the model?
4. Is it appropriate to deduct that in case of double-stranded prototype separation of the two
strands happen prior to toughening of the oligonucleotide? State how the annealing is
achieved.
5. Falsify the deduction below about synthesis of the second strand. Specify the role
assumed by the oligonucleotide in your explanation, state what is supplemented.
It is essential for polymerase to entail 5'-3' exonuclease activity.
6. Determine the ideal order of transport of polypeptide within a secretory trail.
7. Briefly explain how the cells are organized.
8. Determine and elaborate the mechanism via which electrophiles are synthesized.
9.Justify the verdict that numerous mutations can be initiated at a single spot. State the
elements involved to facilitate this process.
10.Determine the body's shield in contrast to electrophiles."
1. Consider the fallacy of the following presumption in regard to iterative models.
Presumption: Iterative Mechanisms are sequential and the ability to perform the next step is based on the previous step.
Validity:
The presumption is valid. Iterative mechanisms entail cycles of activities or steps which are done successively and the output of each cycle forms the basis of the next cycle. In the biological and computational domains, many processes are sequential and the next step depends on the results of the previous one. For instance, in iterative algorithms, every next iteration is somehow better than the previous one, and in biochemical processes such as DNA replication, each cycle depends on the preceding ones and each is completed successfully.
2.
Discussion:
Z-VAD-FMK is a general caspase inhibitor which has been employed in experiments to elucidate the part performed by caspases in apoptosis. Caspases are a group of proteases that has been implicated in the process of apoptosis; this is the programmed cell death. Z-VAD-FMK is a broad-spectrum caspase inhibitor that covalently modifies the active sites of caspases and blocks their activity to cleave their substrates and thereby preventing apoptosis. This drug is employed to investigate the role of caspases in cell death and diverse diseases.
3.
Answer:
In genetic algorithms an “offspring” is generated by combining the “genetic material from two parent solutions and the remaining part of the chain is “crossed over” to the prototype “solution”. In the process, ‘crossover’ and ‘mutation’ are made to bind with the model.
Explanation:
Genetic algorithms are based on processes that are modelled on natural evolution. Offspring solutions are created by crossover where parts of parent solutions are combined and by mutation where parts of the solution are randomly changed. These new solutions are then judged for their fitness and they are incorporated into the population to create better solutions in the next generations.
4. That being the case, can it be assumed that in the double-stranded prototype, the two strands are separated before the oligonucleotide is toughened? Specify how the annealing is done.
Answer:
It is not right to conclude that double-stranded prototype separation happens before the oligonucleotide has become a tough.
Explanation:
In molecular biology, the process of annealing, literally means the joining of complementary strands of nucleic acids. The double stranded DNA which is to be amplified in PCR (Polymerase Chain Reaction) is heated to separate the strands. The oligonucleotides (primers) then hybridize to their complementary sites on the single stranded DNA (annealing). This occurs prior to the binding of the oligonucleotides to the target (denaturation of the strands). Annealing is done by cooling the reaction mixture and in the process the primers will hybridize with the sequence on the single stranded DNA.
5. In the following the conclusion that has been made regarding synthesis of the second strand is false. In your explanation, mention the part played by the oligonucleotide, indicate what is supplemented.
Deduction: 5’-3’ exonuclease activity is a necessity for polymerase.
Falsification:
The deduction is false.
Explanation:
In the second strand synthesis of DNA, the polymerase enzyme does not need 5’ – 3’ exonuclease activity. It is for this reason that the specific property that is required for this task in DNA polymerase is the enzyme’s capacity to catalyze DNA synthesis in the 5’ to 3’ direction. Oligonucleotides (Primers) are important because it provides the 3’-OH which is the only functional end needed by DNA polymerases for DNA synthesis. The 5’ -3’ exonuclease activity has functions that include; erasing of RNA primers during DNA replication but it is not required in the formation of the second DNA strand.
6. Determine the proper sequence of transport of polypeptide in a secretory pathway.
Answer:
The ideal order of transport of a polypeptide within a secretory pathway is:The ideal order of transport of a polypeptide within a secretory pathway is:
Rough Endoplasmic Reticulum (RER): Formation and the primary folding of polypeptides.
Golgi Apparatus: More changes, organizing, and palletizing of proteins into vesicles.
Secretory Vesicles: Transport of proteins from the Golgi to the plasma membrane of the cell.
Cell Membrane: Fusion of vesicles with the membrane and release of the polypeptide; exocytosis.
Explanation:
Polypeptides are made on the rough endoplasmic reticulum where they are also folded. They are then sent to the Golgi apparatus where they undergo further modification and are packaged into vesicles that are secretory. These vesicles move the proteins to the cell membrane and the proteins are secreted out of the cell to the extracellular area.
7. Explain in general what kind of organization is present in multicellular organisms.
Answer:
Cells are organized into a hierarchical structure:Cells are organized into a hierarchical structure:
Organelles: Part of the cell which has different shape and size and have specific function (e. g. nucleus, mitochondria, ribosomes).
Cells: The simplest structural and functional organizations of living organisms that perform activities including metabolism, growth, and reproduction.
Tissues: Structures of tissues disposed in a particular form and made up of like cells whose functions are closely related (for instance, epithelial, connective, muscle, nerve).
Organs: Organs which are made up of a number of tissues co-ordinated in order to perform a particular function (e. g. heart, lungs, liver).
Organ Systems: Major systems of organs which are related and united to perform certain functions of the organism (for instance, cardio-vascular system, respiratory system).
Organism: It is the whole organism which is formed by several organ systems, which are functioning in one organism to perform an entire living organism.
8. Explain and describe the process of formation of electrophiles.
Answer:
Mechanism:
Electrophiles can be produced from a number of chemical reactions in which a molecule gains a site that lacks electrons and thus makes the molecule to be highly reactive with nucleophiles. One common mechanism involves:
Activation of the Electrophile: A molecule is activated through a process that generates a radical centre which carries fewer electrons. This can be done by the elimination of a leaving group or by the introduction of an electron withdrawing group.
Formation of the Electrophile: The activated molecule forms an electrophile which is the species with a positive charge or partial positive charge that will attract nucleophiles.
Reaction with Nucleophiles: Electrophiles are involve in a reaction with nucleophiles or species with high electron density such as in electrophilic aromatic substitution or addition reactions.
Explanation:
Electrophiles are made by making some molecules deficient in electrons and hence more likely to react with nucleophiles. For instance, the formation of carbocations or the introduction of an electron-withdrawing group generates a strong electrophile.
9. Explain why it is right to conclude that many mutations can be provoked at one locus. Mention the factors that enhance this process.
Answer:
Justification:
Some of the mutations may be caused due to the multiple factors or mechanisms that may act on the same nucleotide sequence and thereby cause multiple mutations at the same site.
Explanation:
Mutations can arise from various sources, including:Mutations can arise from various sources, including:
Chemical Mutagens: Some of the agents such as alkylating agents can change the DNA bases at certain positions which in turn results in more than one type of mutation.
Radiation: UV or ionizing radiation may produce various kinds of damage (e. g. thymine dimers, single and double strand breaks) at one and the same site of the DNA.
Errors in DNA Replication: It can be seen that mutations occur when DNA polymerase makes errors during replication and repeated exposure or stress can aggravate this situation.
10. Compare and contrast the body’s shield with electrophiles.
Answer:
Shield: Glutathione
Ethicon's Case Study
Ethicon demurred to the first amended complaint, contending that the products liability claim was time-barred by the one-year statute of limitations under Code of Civil Procedure former section 340, former subdivision 3. (Stats.1982, ch. 517, � 97, p. 2334; see fn. 3, post.) In opposition, Fox noted that she had no knowledge that the gastric bypass surgery would involve the use of a stapler or any similar device.
Fox further stated that she never learned during the postsurgical care following the gastric bypass operation that the stapler had malfunctioned or could have caused the leakage and other problems, and that she first discovered the possibility of a stapler malfunction when her counsel notified her of Dr. Gladen's deposition testimony. Finally, Fox offered to file a second amended complaint to clarify the facts supporting her assertion that she had no reason to suspect the stapler until after Dr. Gladen's testimony, and that no reasonable person would have suspected
666
666 that the Ethicon product had malfunctioned.
Question 1
What is the maintenance dose of phenytoin in seizures arising as a
complication of chronic renal failure?
Question 2
I know that the loading dose of phenytoin in status epilepticus is
20 mg/kg with an upper limit of 1000 mg but if the same situation arose
as a complication of chronic renal failure (on regular dialysis), should
this dose remain the same or be reduced? If reduced, what should the
dose be?
Question 3
1. What is the most effective antiepileptic for a patient with simple
partial motor status epilepticus who is not responding to a loading
dose of phenytoin?
2. How long does phenytoin, given in a loading dose, take to work?
Question 4
Is valproate effective if given rectally in status epilepticus and, if so, what
dose is recommended?
Question5
In simple partial motor status epilepticus, if the patient does not respond
to diazepam and phenytoin, is it justifiable to proceed to anaesthetic
medication?
Question 6
What is the recommended upper limit dose of lamotrigine when
combined with both carbamazepine and valproate?
Question 7
Is a valproate-lamotrigine combination more effective than
carbamazepine on its own against partial seizures?
Question 8
Why is the incidence of parkinsonism less common in smokers?
Question 9
Is it recommended to start the treatment of parkinsonism with dopamine
agonists alone in elderly (over 60 years old) patients, and to delay using
L-dopa until the disease has progressed much further? Is there a rationale
for this protocol in younger patients?
Question 10
Does amantadine increase the endogenous release of dopamine, thus
aiding early treatment of parkinsonism final 120"
What is the maintenance dose of phenytoin in seizures arising as a complication of chronic renal failure?
Phenytoin has a different pharmacokinetics in patients with chronic renal failure and therefore the maintenance dose is usually lower. It is between 100 and 200 mg per day, but may be raised or lowered according to the level of serum potassium.
Is the initial dose of phenytoin in status epilepticus to be lowered in chronic renal failure and if yes, what should be the dose?
Yes, the loading dose should be reduced, perhaps to account for the patient’s smaller size. In case of chronic renal failure the dose should be reduced to about 10 to 15 mg/kg but not more than 500 to 750 mg and should be titrated according to clinical response and monitoring.
What is the best agent to use in a patient with simple partial motor status epilepticus who has failed to respond to a loading dose of phenytoin? In how much time does phenytoin, given in a loading dose, become effective?
In simple partial motor status epilepticus which does not respond to phenytoin, levetiracetam is often advised. It may be 1 to 2 hours before phenytoin begins to show its effect after the loading dose.
Does rectally given valproate work in status epilepticus, and if it does, what dose should be used?
Of course, valproate can be effective when given rectally. The usual oral dose is 20 to 30 mg of the drug per kilogram of the patient’s weight.
In simple partial motor status epilepticus, if the patient fails to respond to diazepam and phenytoin, is it reasonable to go for anaesthetic medication?
Of course, one can proceed to anaesthetic medication including propofol or midazolam if the patient does not respond to diazepam and phenytoin.
What is the maximal daily dose of lamotrigine that should be used when patient is on both carbamazepine and valproate?
The dosage of lamotrigine that should not exceed when used with carbamazepine and valproate is 200mg/day and the doses should be adjusted according to the response and tolerance.
Is the use of valproate and lamotrigine better than carbamazepine in the treatment of partial seizures?
Of course, the combination of valproate and lamotrigine is more efficient than carbamazepine for some patients with partial seizures, since it is more comprehensive.
What could be the possible explanation for the fact that parkinsonism affects fewer smokers?
Parkinsonism is relatively rare in smokers, which may be attributed to the protective mechanisms of nicotine and other substances contained in tobacco on the dopaminergic system. ”
Is it advisable to initiate the management of parkinsonism with dopamine agonists in elderly subjects without initiating L-dopa? What is the evidence for using this protocol in the younger patients?
Indeed, in elderly patients, it is common to begin treatment with dopamine agonists only to defer the use of L-dopa and minimize motor side effects. In paediatric patients this approach is also employed to protect motor function over the long term and to minimize the risk of dyskinesias.
Does amantadine enhance dopamine release endogenously and thus serve as effective in early treatment of parkinsonism?
Yes, amantadine enhances endogenous dopamine release and, therefore, may help in the early phase of parkinsonism to decrease motor deficits.
What is the difference between values and ethical dilemmas when it comes to nursing . Give supporting examples
To distinguish between values and ethical dilemmas in nursing is quite significant to enhance the provision of ethical care. Here’s a breakdown of each concept with supporting examples:Here’s a breakdown of each concept with supporting examples:
Values
Definition:
Values refer to enduring beliefs or principles that people have and which they use to direct their behaviour and decision making. These are what are deemed to be valuable and good in life.
Characteristics:
Personal and Professional Beliefs: Values are learnt from experience, from the community one finds oneself in, from the religion one practices or even from other sources.
Guidance for Behavior: They determine the manner in which people deal with certain circumstances and arrive at their conclusions.
Consistency: Values, however, are known to be quite constant across the years.
Examples in Nursing:
Compassion: A nurse must be compassionate and make sure to be sensitive to every patient he or she attends to. This value makes them be more concerned with the welfare of others, and this makes them be more comforting as well as supportive to others even in the most difficult situations.
Respect for Autonomy: Another value that a nurse has is patient’s self-determination, which entails that the nurse should uphold patient’s right to make decisions for themselves even if the decisions they make are not what the nurse would do in similar situations.
Ethical Dilemmas
Definition:
Ethical dilemmas are situations that present two or more ethical issues, values, principles or obligations that are in conflict and thus one cannot easily decide what to do. More often than not, these above mentioned dilemmas pose moral ambivalence or moral paradox.
Characteristics:
Conflict of Values: Ethical dilemmas are defined by the conflict of interests or the conflict of values.
Complex Decision-Making: They demand that one makes a balance between the results of different choices that one has to make.
Moral Uncertainty: Dilemmas often entail questions of decision making, even when values are known, as to what is the ‘right’ thing to do.
Examples in Nursing:
End-of-Life Decisions: An example of an ethical problem might be when the patient’s relatives want to prolong the life of the patient and continue the aggressive treatment, while the patient wants to switch to the palliative care. The nurse has to consider the patient’s autonomy and the family’s preference and the possible outcomes of continued treatment.
Resource Allocation: For instance, when there is scarcity of crucial commodities for instance ventilators for patients, a nurse will be in a better position to make a decision on how to do so in the best way possible. The conflict is a ethical one that centres on managing care of patients with competing necessities such as prognosis, potential for improvement and equity.
Comparison
Values vs. Ethical Dilemmas:
Values are defined as those principles that people hold and which influence their conduct and choices. These are the principles that guide ethical practice and behaviour in nursing practice.
Ethical Dilemmas are defined as situations where one is faced with two or more moral issues that stand in contradiction to each other thus creating a dilemma as to which way is the right one to take.
Supporting Examples:
Scenario: Compassion versus patient’s right of self-determination
Value: A nurse should be compassionate and therefore, the patient must be made comfortable.
Ethical Dilemma: The patient, a cancer patient, wants to forego further treatment and be put on hospice, while the family wants to go for further aggressive treatment. The nurse must balance the patient’s right to comfort and the family’s rights as well as the patient’s right to self-determination.
Scenario: Candour against Respecting the Patient’s Emotions
Value: A nurse embraces people’s nature of honesty in that they are truthful with their patients.
Ethical Dilemma: A patient has been given a terminal illness and the nurse is stuck between the full disclosure of the illness or not to tell the patient at all so as to spare him or her some pain. The nurse has the ethic of telling the truth and yet the patient may have a negative reaction to what the nurse is telling them.
Describe proper oral self - care for dental implants
Describe proper oral self - care for dental implants.
Identify critical factors that result in implant failure.
Describe the benefits of water fluoridation.
Define community water fluoridation. Discuss the importance of this public health initiative.
Demonstrate the correct technique for the application of preventive and therapeutic products."
Guidelines on How to Practice Oral Hygiene during and after Implant Stage and After Surgery
1. Brushing:
Technique: The type of toothbrush that should be used in order to clean the implants is a soft tooth brush and the cleaning should be done at least two times a day. During the brushing of the teeth with the implant it is recommended that one uses a non abrasive type of tooth paste that would not in any way damage the surface of the implant.
Purpose: Massaging in the right manner assists in the elimination of the accumulation of plaque and prevention of inflammation in the surrounding regions of the implant.
2. Flossing:
Technique: Swill the area with water and use non-waxed dental floss or floss for implants and glide it between the implant and the gum as well as under it. One should brush his or her teeth at least once in a day so as to ensure that the teeth and mouth are clean.
Purpose: These will assist in the removal of the plaque that may be on the side of the implant or between the implant and normal teeth because when flossing these areas are targeted.
3. Interdental Brushes:
Technique: Rinse the mouth and make use of the interdental brushes to clean the space in between the implant and the other teeth. Choose a brush size which will fit the implant and at the same time, convenient to work with.
Purpose: These brushes play a role in dislodging of plaque that may be in areas that cannot be accesses by the floss hence reducing the chances of formation of the plaque.
4. Antimicrobial Mouth Rinses:
Technique: Use an antimicrobial mouthwash which your dentist may recommend and this is usually chlorhexidine or another anti-plaque agent.
Purpose: Mouth rinses have the ability of eliminating bacteria and the formation of plaque which are risks to the surrounding tissue of the oral implants.
5. Regular Dental Checkups:
Technique: It is recommended that you brush your teeth at least two times a day and for dental check up and cleaning one should visit the dentist every three to six months.
Purpose: This way, the state of the implants and tissues surrounding them can be evaluated, and problems can be solved in their early stages.
Some of the causes of Implant Failure are:
1. Infection (Peri-Implantitis):
Description: Inflammation and bone deacy involving the implant- surrounding tissue due to infection.
Prevention: Good dental hygiene and regular dental check up.
2. Poor Bone Quality or Quantity:Osteoporosis and Low Bone Density:
Description: Shortage of or low quality of bone can lead to instability of the implant.
Prevention: Control examination before the implant procedure and if indicated – bone grafting before the implantation.
3. Implant Overloading:
Description: Excessive loading and or instability of the implant.
Prevention: That is, to have a favorable and well organized occlusal relationship.
4. Smoking:
Description: Tobacco use also halts the healing process and worsens implant failure.
Prevention: The impact of smoking on dental implants; smoking and dental implantation: pre-implantation smoking cessation.
5. Improper Implant Placement:
Description: Wrong parts inclusion or wrong positioning of the implant.
Prevention: Better images and planning in the placement of the implant.
Benefits of Water Fluoridation
1. Caries Prevention:
Benefit: It is a fact that fluoride ions reinforce the tooth enamel and therefore it is very less prone to decay.
Impact: Helps you have fewer cavities and decreases your risks of having other dental issues.
2. Cost-Effective Public Health Measure:
Benefit: The investigations on this topic reveal that fluoridation reduces the number of dental treatments and the cost of the treatments.
Impact: This in a way makes the cost of the dental care services to be low for the communities hence they are able to incur less cost.
3. Equity in Dental Health:
Benefit: Thus, fluoridation means the positive impact for all the inhabitants of the community regardless the level of their income.
Impact: Aids in the reduction of the gap in dental health between the affluent and the deprived.
4. Enamel Remineralization:
Benefit: Fluoride has the ability of enhancing the renovation of teeth and also in the repair of the minor tooth decay at the infant stage.
Impact: Prevents the growth of mild dental issues to the complex ones.
Community Water Fluoridation
Definition:
Community water fluoridation is the modified contamination of water supply with fluoride with the aim of preventing dental caries.
Importance:
Public Health Initiative: This is a common and effective method of improving oral health amongst people.
Cost-Efficiency: Is relatively cheaper and very efficient in the prevention of dental caries and therefore lowers the costs of treatment of the diseases.
Accessibility: This assists in ensuring that everyone within the community acquires the fluoride even the people who cannot visit a dentist.
Instructions for the Application of the Preventive and Therapeutic Products
1. Fluoride Application:
Technique: Put fluoride varnish on the teeth with the help of a brush or an applicator for all surfaces of the teeth. None of the products should be consumed for at least half an hour after the application.
Purpose: Dental varnish in the form of fluoride guards and strengthens the enamel from the possibility of demineralization.
2. Desensitizing Agents:
Technique: Swill desensitizing toothpaste or gel on the sensitive areas of the teeth and apply with a toothbrush or applicator. For use as directed by the manufacturer.
Purpose: Helps in reducing the sensitivity of teeth as it anaesthetises the nerve endings.
3. Sealants:
Technique: Apply the dental sealant on the occlusal aspect of the molars having the sealant spread uniformly on the surface. If required, the sealant must be cured by exposure to a certain light.
Purpose: Fills up the gaps and fissures on the tooth surface hence preventing tooth decay.
Ethicon's Case Study
On June 17, 2002, the superior court sustained Ethicon's demurrer to the products liability cause of action without leave to amend, relying upon Norgart, supra, 21 Cal.4th 383, 87 Cal.Rptr.2d 453, 981 P.2d 79, and Bristol-Myers Squibb, supra, 32 Cal.App.4th 959, 38 Cal.Rptr.2d 298, to conclude that the statute of limitations barred the products liability cause of action. The superior court stated that when a plaintiff sues based on knowledge or suspicion of negligence, including medical malpractice as in Fox's case, the statute of limitations begins to run as to all defendants, including manufacturers possibly liable under products liability theories. The superior court also stated that Fox failed to demonstrate that amending the complaint could ""overcome the limitations defense."" Fox timely appealed from the superior court's order sustaining Ethicon's demurrer as to the products liability cause of action.
The Court of Appeal reversed the superior court's order and remanded with directions to grant Fox leave to amend to allege facts explaining why she did not have reason to discover earlier the factual basis of her products liability claim. In so ruling, the Court of Appeal held that Bristol-Myers Squibb's ""bright-line rule of imputed simultaneous discovery of causes of action"" did not apply. Ethicon petitioned this court, and we granted review.
additional questions
Question 1
A 25-year-old woman, pregnant in her second trimester, starts to
experience chorea and bilateral ankle arthralgia but has no past history of
rheumatic chorea. In the first hour, her erythrocyte sedimentation rate is
70. Could this be no more than chorea gravidarum?
Question 2
Is valproate as equally effective as haloperidol in the treatment of chorea,
in particular rheumatic chorea?
Question 3
Does a lesion of Guillain-Mollaret's triangle in the brain stem cause a
type of myoclonus other than symptomatic palatal myoclonus?
Question 4
1. In West's syndrome, after the fits have been suppressed, for how
long should treatment with adrenocorticotrophic hormone (ACTH)
continue?
2. Does complete suppression of resistant infantile myoclonic jerks by
ACTH characterize West's syndrome?
Question 5
Are anticholinergics the first line of treatment for primary torsion
dystonia?
Question 6
Can multiple sclerosis (MS) be associated with lack of vitamin D,
lack of sunlight or low fish/cod-liver oil in the diet? By looking at the
epidemiology (none at the equator; more outside 40� latitude, both north
and south; less on top of Swiss mountains than in the Swiss valleys; more
in fishing coastal towns and in Eskimos) this seems to be very important.
Vitamin D modulates the immune system and active vitamin D given
to rats with experimental MS (acute encephalomyelitis) lowers the
monocyte count in cerebrospinal fluid (CSF) by 90% in 72 hours with
return of power to their limbs. Japanese MS patients who ate plenty of
fish were found to have vitamin-D-receptor pleomorphism. The staple
grains and cereals (wheat, barley, oats) eaten in Scandinavian and
northern European countries contain phytic acid, which blocks vitamin D
absorption, and rice is the only cereal free of phytic acid.
Are there any studies where low vitamin D levels in blood are
associated with MS relapse?
Question 7
What are the diagnostic criteria of 'definitive' multiple sclerosis (MS) - as
taught to a medical student? We have found different information from
different sources.
Question 8
How reliable is a CT-brain scan with contrast in showing MS lesions as
enhancing lesions in the presence of a contraindication to use MRI?
Question 9
Is magnetic resonance (MR) spectroscopy of value in differentiating
multiple sclerosis from cerebral autosomal dominant arteriopathy with
subcortical infarctions (CADASIL)?
Question 10
Does hemiplegia due to multiple sclerosis present with hemiparesis
rather than dense hemiplegia (which is more characteristic of a stroke)?
Other than age, what are the clinical signs that would help differentiate
between the two?130"
Can a 25-year-old pregnant woman with chorea and bilateral ankle arthralgia, ESR 35mm/hr be having chorea gravidarum?
It may well be that the woman is suffering from chorea gravidarum and this is a condition that occurs during pregnancy. This is so because the elevated erythrocyte sedimentation rate indicates inflammation which is a characteristic of this diseases.
As effective as haloperidol in the treatment of chorea, especially rheumatic chorea, is valproate?
Haloperidol is usually preferred over valproate in the management of rheumatic chorea since it forms part of the standard treatment for chorea-associated conditions.
Does a lesion of Guillain-Mollaret’s triangle in the brainstem cause any other type of myoclonus than symptomatic palatal myoclonus?
Indeed, a lesion of Guillain-Mollaret’s triangle can cause different types of myoclonus, including generalized myoclonus, not only symptomatic palatal myoclonus.
In West’s syndrome, following the control of fits, for how long should the child be treated with adrenocorticotrophic hormone (ACTH)? Is complete suppression of resistant infantile myoclonic jerks by ACTH diagnostic of West’s syndrome?
ACTH therapy for West’s syndrome is usually given for at least three months, and may be given for as long as four to six weeks. Absence of resistant infantile myoclonic jerks on ACTH does not always point to West’s syndrome but shows treatment effect.
Are anticholinergics the first choice of treatment for primary torsion dystonia?
Anticholinergics are not used as a first line of treatment for primary torsion dystonia. Dopamine agonists and deep brain stimulation are the first-line treatments, but for severe cases.
Is there evidence that link Multiple Sclerosis (MS) with low Vitamin D levels and are there any studies that show that low levels of Vitamin D increases the chance of relapse of MS?
Indeed, low vitamin D levels have been linked to multiple sclerosis. A cohort study also established that patients with MS have low levels of vitamin D and also that low levels of vitamin D are associated with increased relapse rates, pointing towards a possible role in disease activity.
What are the diagnostic criteria that are used for the diagnosis of MS in its ‘definitive’ form?
The diagnostic criteria for 'definitive' MS include:The diagnostic criteria for 'definitive' MS include:
Temporal and geographical spread: presence of multiple events and multiple lesions in different regions of the body.
The signs and symptoms are in conformity with the diagnosis of MS.
Exclusion of other diagnoses.
Typical MRI changes of MS were present.
Tyndallisation and csf analysis showing oligoclonal bands.
To what extent can the CT-brain scan with contrast be used to display MS lesions as enhancing lesions in the presence of a contraindication to MRI?
CT scans with contrast are less sensitive than MRI scans in the detection of the MS lesions especially the enhancing lesions. MRI is more useful in the diagnosis of MS but if contrast MRI is contra indicated then CT can be of some value.
Is magnetic resonance (MR) spectroscopy helpful in the differential diagnosis of multiple sclerosis from cerebral autosomal dominant arteriopathy with subcortical infarctions (CADASIL)?
MRS can also be of value in distinguishing between MS and CADASIL, since it allows for consideration of the metabolic alterations in the head. MS usually has low NAA and high Cho signals; CADASIL may present with different MR spectroscopy findings.
Can one have hemiplegia secondary to multiple sclerosis and not have the dense hemiplegia but rather hemiparesis? Which clinical features may be used to distinguish it from the stroke?
Affection of the upper limb is less severe than the lower limb in hemiplegia due to multiple sclerosis, the patient may have hemiparesis rather than dense hemiplegia. Clinical signs to differentiate MS from stroke include:Clinical signs to differentiate MS from stroke include:
Onset and progression: MS has a somewhat more gradual onset and the symptoms are not necessarily constant and may change.
Pattern of symptoms: It is for this reason that MS symptoms may come and go while stroke symptoms are fixed and do not change.
Associated symptoms: MS may be associated with other neurological finding such as sensory deficit or optic neuritis.
Watch the Documentation and Coding: Building Your Sundae webinar from the National Nurse-Led Care Consortium.
Watch the Documentation and Coding: Building Your Sundae webinar from the National Nurse-Led Care Consortium. You can also review the slide deck.
https://nurseledcare.phmc.org/past-webinars/item/551-documentation-and-coding-building-your-sundae.html
What were the key points that you learned from the webinar and how will you apply them to practice as an NP?
In your response, make sure to discuss the foundation of reimbursement, the differences in coding by medical decision-making vs time, and APRN value in various payment models."
Key Points from the "Documentation and Coding: Building Your Sundae: A Webinar for Parents and Carers of Children with Learning Differences
1. Foundation of Reimbursement:
Understanding Reimbursement Models: The payment for the healthcare services is done depending on the documentation and coding that reveal the nature and the intensity of the services. The core of reimbursement is, therefore, dependent on the documentation of the patient’s condition, the services provided, and the medical judgment used.
Fee-for-Service vs. Value-Based Care: The webinar discussed the distinction between the fee for service (FFS) and the value based care systems. In FFS, payment is done on the basis of the number of services that are offered in a certain time while in value based care the payment is made depending on the services offered and the impact of the services offered. It is equally important for both, but more so for value-based care because the attention is paid to the quality of care and the results of the patients’ treatment.
2. Coding by Medical Decision-Making vs. Time:Coding by Medical Decision-Making vs. Time:
Medical Decision-Making (MDM): MDM coding involves the aspects of patient’s condition and the process of decision making that is made in the care of the patient. It encompasses elements such as the diagnostic outcomes, the volume and level of detail of data assessed, and the likelihood of adverse events. For instance, higher MDM coding is reasonable, when a patient has numerous co-morbid conditions that need significant management.
Time-Based Coding: This approach of coding is done in relation to the time that is taken in the care of the patient and this includes the time that is spent with the patient and the time that is spent on the documentation and coordination of the patient’s care. Time-based coding is applied when the time taken in the treatment of a patient forms part of the service delivered to the patient. This is especially so where a patient requires a lot of attention and time in the course of treatment.
Choosing Between MDM and Time: Which one is better: MDM or time-based coding, depends on the type of the encounter. If the emphasis is on the aspects such as the complexity and decision making, then the MDM coding can be used. However, if the time spent with the patient is significant, time-based coding is probably more effective. It is therefore important to determine the right coding method for the service offered to avoid overbilling or underbilling and to be in compliance.
3. APRN Value in Various Payment Models:APRN Value in Various Payment Models:
Role of APRNs: In different payment models, APRNs can contribute in the delivery of excellent care at lower costs. The webinar focused on the role of APRNs in increasing positive patient outcomes, addressing comorbidities, and increasing the availability of health care services in the currently underutilized regions.
Impact on Value-Based Care: In value-based care systems, APRNs are useful because of their capacity to attend to the comprehensive care needs of patients and concentrate on early intervention. These functions include patient education, care co-ordination and chronic disease management and these are very vital in value based care delivery systems.
Demonstrating Value: APRNs practicing in different payment models should learn how to document and code their services to have the most effect. Documentation of care is crucial in the establishment of the worth of the care offered and in the right remuneration. It is therefore imperative for APRNs to provide evidence of the scope of their practice, the amount of time taken, the complexity of the cases and the results.
Application to Practice as an NP:Application to Practice as an NP:
1. Enhance Documentation Practices:
Ensure that you document the complication of the patient and the services you offer in the right manner. This involves written records on the decision making process made, the time taken and the result of the decision made.
2. Choose Appropriate Coding Methods:
For every patient encounter, the provider should decide whether the encounter should be documented with MDM or time-based coding. Make sure that what is coded reflects the services provided which are in relation to the level of the case and the time taken.
3. Focus on Value-Based Care:
Some of the trends that should be adopted include focusing on preventive care and chronic disease management in practice to meet the value-based care models. Exhibit the ways in which you enhance the quality of care by documenting and coding the care plans and work done in identifying patients and handling their needs.
4. Stay Informed and Updated:
It is crucial to keep up with the new changes in coding and reimbursement to avoid any conflict with the set regulations and get the best billing practices. It is advised that the individual continue his/her education to update the knowledge on the changes in documentation and coding.
This case requires us to address once again the proper application of a statute of limitations
This case requires us to address once again the proper application of a statute of limitations. (See Gutierrez v. Mofid (1985) 39 Cal.3d 892, 218 Cal.Rptr. 313, 705 P.2d 886; Jolly v. Eli Lilly & Co. (1988) 44 Cal.3d 1103, 245 Cal.Rptr. 658, 751 P.2d 923 (Jolly); Bernson v. Browning-Ferris Industries (1994) 7 Cal.4th 926, 30 Cal. Rptr.2d 440, 873 P.2d 613 (Bernson); Norgart, supra, 21 Cal.4th at p. 395, 87 Cal.Rptr.2d 453, 981 P.2d 79.)
""Statute of limitations"" is the collective term applied to acts or parts of acts that prescribe the periods beyond which a plaintiff may not bring a cause of action. (3 Witkin, Cal. Procedure (4th ed. 1996) Actions, � 405, p. 509; accord, Norgart, supra, 21 Cal.4th at p. 395, 87 Cal. Rptr.2d 453, 981 P.2d 79.) There are several policies underlying such statutes. One purpose is to give defendants reasonable repose, thereby protecting parties from ""defending stale claims, where factual obscurity through the loss of time, memory or supporting documentation may present unfair handicaps."" (Bernson, supra, 7 Cal.4th at p. 935, 30 Cal.Rptr.2d 440, 873 P.2d 613; Jolly, supra, 44 Cal.3d at p. 1112, 245 Cal.Rptr. 658, 751 P.2d 923; see also Davies v. Krasna (1975) 14 Cal.3d 502, 121 Cal.Rptr. 705, 535 P.2d 1161.) A statute of limitations also stimulates plaintiffs to pursue their claims diligently. (Norgart, supra, 21 Cal.4th at p. 395, 87 Cal.Rptr.2d 453, 981 P.2d 79; Jolly, supra, 44 Cal.3d at p. 1112, 245 Cal.Rptr. 658, 751 P.2d 923; see, e.g., Bernson, supra, 7 Cal.4th at p. 935, 30 Cal.Rptr.2d 440, 873 P.2d 613.) A countervailing factor, of course, is the policy favoring disposition of cases on the merits rather than on procedural grounds. (Norgart, supra, 21
667
667 Cal.4th at p. 396, 87 Cal.Rptr.2d 453, 981 P.2d 79; Barrington v. A.H. Robins Co. (1985) 39 Cal.3d 146, 152, 216 Cal.Rptr. 405, 702 P.2d 563.)
Question 1
If a female patient with multiple sclerosis wants to become pregnant,
what are the risks, family planning advice and treatment, etc? What is the
best advice to give to her?131
Question 2
Is there a role for methotrexate and azathioprine in the treatment of
remitting-relapsing multiple sclerosis?
Question 3
Do steroids have a role in preventing or ameliorating the relapses in
relapsing-remitting multiple sclerosis?
Question 4
Has cyclophosphamide a role in decreasing the rate and number of
relapses in relapsing-remitting multiple sclerosis?
Question 5
Is there evidence of the efficacy of cyclic pulse cyclophosphamide
therapy in the treatment of relapsing-remitting multiple sclerosis?
Question 6
Glatiramer acetate and interferon-beta are recommended by some people
for the treatment of multiple sclerosis. Which drug should I use for a
patient with a 2-year history of relapsing-remitting MS.
Question 7
1. Most neurological books available to me say that high-dose IV
dexamethasone can be used in acute relapses of multiple sclerosis
(MS). What is the recommended dosage and regimen for this drug?
2. I understand that depot preparations of betamethasone (Depofos)
can also be used in acute relapses of MS, as well as treatment for
idiopathic Bell's palsy. If so, can you tell me the recommended dosage
and regimen for this drug?
Question 8
What are the most common causes of chronic meningitis and what
investigations must be done?
Question 9
What is Hib meningitis?
Question 10
How often is tuberculosis a cause of chronic meningitis in comparison to
other causes?"
What are the risks, family planning recommendations and management guidelines for a woman with multiple sclerosis if she wishes to conceive? What can one tell her?
Risks: There is no evidence that pregnancy worsens MS, but there may be higher risk of relapse after delivery. Processing of disease-modifying therapies is recommended as some of them are not recommended to be used during the pregnancy.
Family Planning Advice: It is advisable to consult a neurologist and an obstetrician before planning for conception and in the management of MS. Some changes may be made to the medications that are being taken if at all needed.
Treatment: Discontinue those DMTs which are contraindicated during pregnancy and if needed, switch with the safer drugs.
Best Advice: Continue with frequent follow up with the healthcare providers, ensure the disease is well controlled prior to conception and plan on the management of the disease in the postpartum period in case of relapses.
Methotrexate and azathioprine in the treatment of relapsing-remitting multiple sclerosis: are they useful?
Methotrexate and azathioprine are not often used in the treatment of RR MS. Interferon-beta and glatiramer acetate are used more often as disease-modifying drugs.
Can steroids play a preventive or therapeutic function in the course of relapse-remitting multiple sclerosis?
Steroids do not have any effect on the prevention of relapses although they may help to reduce the severity and duration of acute relapses. Methylprednisolone at high doses given intravenously is quite frequent.
Does cyclophosphamide have a part in reducing the rate and number of relapses in relapsing-remitting multiple sclerosis?
Cyclophosphamide is not used in the management of relapse-remitting multiple sclerosis. This is often used for the patient with severe or progressive type of MS who have not responded to other therapies.
Cyclic pulse cyclophosphamide therapy has been prescribed for the treatment of relapsing-remitting multiple sclerosis; is there proof that it helps?
There is not much evidence for the use of cyclophosphamide in treating RRMS in the form of cyclic pulse therapy and hence it is not a recommended treatment. Several other DMTs are usually prescribed for the relapsing forms of MS according to most treatment guidelines.
Glatiramer acetate and interferon beta are advised for the treatment of multiple sclerosis. What drug should I prescribe for a patient with a history of relapsing-remitting MS for the last two years?
It is to note that while both glatiramer acetate and interferon-beta are effective in relapsing-remitting MS. The decision between the two depends on the patient’s characteristics, possible side effects and, last but not the least, patient preference.
1. Almost all neurological books suggest high-dose intravenous dexamethasone for acute relapses of multiple sclerosis. How many milligrams should I take, and when?
The usual course of high-dose IV dexamethasone is 500 mg to 1 g per day for 3 to 5 days.
2. Depot preparations of betamethasone (Depofos) can also be used. What should be the best dose and how often should it be taken?
In treatment of acute relapses of MS with depot betamethasone, the usual dose is 4 mg to 6 mg intramuscularly; the regimen is usually adjusted according to the response.
Chronic meningitis: Which are the most frequent pathogens and what tests should be ordered?
Common Causes: Tuberculosis, fungal infections, cryptococcal infections, and syphilis are the others.
Investigations: Lumbar puncture with CSF, blood tests, cultures, imaging studies such as MRI and sometimes PCR testing.
What is Hib meningitis?
Hib meningitis is that meningitis which is caused by Haemophilus Influenza type b, a bacterium that used to be one of the major causes of bacterial meningitis in children before the introduction of the Hib vaccine.
How frequent is tuberculosis as a cause of chronic meningitis in relation to other causes?
Meningeal tuberculosis should be considered in the differential diagnosis of chronic meningitis; however, it is less frequent than viral or bacterial meningitis, although the incidence is still important in areas with high tuberculosis prevalence.
The discovery rule, as described in Bernson
The discovery rule, as described in Bernson, allows accrual of the cause of action even if the plaintiff does not have reason to suspect the defendant's identity. (See Bernson, supra, 7 Cal.4th at p. 932, 30 Cal.Rptr.2d 440, 873 P.2d 613.) The discovery rule does not delay accrual in that situation because the identity of the defendant is not an element of a cause of action. (See Norgart, supra, 21 Cal.4th at p. 399, 87 Cal.Rptr.2d 453, 981 P.2d 79; Bernson, supra, 7 Cal.4th at p. 932, 30 Cal.Rptr.2d 440, 873 P.2d 613.) As the court reasoned in Norgart, ""[i]t follows that failure to discover, or have reason to discover, the identity of the defendant does not postpone the accrual of a cause of action, whereas a like failure concerning the cause of action itself does."" (Norgart, supra, 21 Cal.4th at p. 399, 87 Cal.Rptr.2d
668
668 453, 981 P.2d 79.) In Norgart, we distinguished between ignorance of the identity of the defendant and ignorance of the cause of action based on ""`the commonsense assumption that once the plaintiff is aware of' the latter, he `normally' has `sufficient opportunity,' within the `applicable limitations period,' `to discover the identity' of the former."" (Norgart, supra, 21 Cal.4th at p. 399, 87 Cal.Rptr.2d 453, 981 P.2d 79, quoting Bernson, supra, 7 Cal.4th at p. 932, 30 Cal.Rptr.2d 440, 873 P.2d 613.)
Question 1
Is cavernous sinus thrombosis a complication of meningitis?
Question 2
What is the mechanism of paraparesis that comes as a late (i.e. postresolution) complication to meningitis?141
Question 3
Is lumbar puncture contraindicated in meningococcal meningitis?
Question 4
What should the cerebrospinal fluid (CSF) picture be when the treatment
of acute bacterial meningitis is complete, and after how many days of
treatment?
Question 5
In the management of meningococcaemia, can chloramphenicol be
used as an alternative? Are there any advantages practically? The book
quotes benzylpenicillin or cefotaxime (alternative). Are they a standard
regimen?
Question 6
'The immediate management of suspected meningococcal meningitis
infection is benzylpenicillin 1200 mg either by slow IV injection or
intramuscularly, prior to investigations.'
Is this always true? Should you not perform a lumbar puncture for
culture first?
Question 7
Should children with bacterial meningitis be treated with steroids to
prevent complications?
Question 8
What is the role of anticonvulsants in a case of encephalitis and how long
should one continue them?
Question 9
How effective are steroids in the treatment of radiculomyelitis?
Question 10
Should you treat a patient who has a brain cysticercosis lesion? The text
seems to say 'Yes' but there is great uncertainty about it.
Also, should one 'worm' the patient's gut when you find brain lesions;
if so, with what?"
On Meningitis and Other Such Diseases.
1. Can it be said that cavernous sinus thrombosis is a complication of meningitis?
Yes, CS thrombosis can be a complication of meningitis and most especially bacterial meningitis. Cerebral venous sinus thrombosis can be a complication of meningitis, including septic thrombophlebitis of the cavernous sinus. This condition is characterised by the extension of the infection to the venous sinuses with the formation of thrombi and possible severe neurological complications. The symptoms of the presentation may be proptosis, ophthalmoplegia and visual disturbances.
2. What is the pathogenesis of the paraparesis that occurs as a late (i. e. postresolution) feature of the meningitis?
Paraparesis is a late complication of meningitis which is characterised by the partial paralysis of the lower limbs, this could be due to post infectious sequelae such as damage caused by residual inflammation or it could be due to complications such as arachnoiditis or spinal cord injury. Inflammation and infection can cause fibrosis or scarring of the meninges which can then involve the spinal cord and nerve roots. Disorders which can cause motor deficits include chronic inflammation or direct infection related damage to the spinal cord which can lead to paraparesis.
3. Is the performance of lumbar puncture relative to meningococcal meningitis safe?
Lumbar puncture is not absolute contraindication in meningococcal meningitis. It should be done carefully especial in those patients who have features of elevated ICP or neurological impairment. In such a situation, there may be a danger of the so-called brain herniation caused by rapid changes in the cerebrospinal fluid pressure. Clinical assessment of the patient and neuroradiological imaging can help in determining the risk and then go for a lumbar puncture.
4. What should be the cerebrospinal fluid (CSF) profile at the end of the management of acute bacterial meningitis, and by what duration of therapy?
After completing treatment for acute bacterial meningitis, the CSF should typically show normalization of the following parameters:After completing treatment for acute bacterial meningitis, the CSF should typically show normalization of the following parameters:
Appearance: Clear and colorless
Cell Count: The normal level (is when it is less than 5 white blood cells per microliter).
Protein: Low levels (Most often <45 mg/dL)
Glucose: Average ranges (which are about two third of the blood sugar levels).
Such alterations very often develop within the first 2 to 3 days of administering efficacious antibiotics, though the precise period may depend on the pathogens and the patient’s condition.
5. Can chloramphenicol be used in the management of meningococcemia? Is there any gain in real use?
Chloramphenicol may also be used in treating meningococcemia in case of penicillin or cephalosporin allergies. Chloramphenicol has activity against Neisseria meningitidis and has good penetration into the CNS. It is not frequently employed owing to its side effects including bone marrow suppression and because of more frequently employed antibiotics such as benzylpenicillin or cefotaxime which are preferred owing to their efficacy and safety.
6. In management of suspected meningococcal meningitis, benzylpenicillin 1200mg should be given by slow intravenous injection or intramuscularly before investigations. Is this always true? Why didn’t you do a lumbar puncture for culture first?
For suspected meningococcal meningitis, benzylpenicillin should be given without delay if meningococci are highly suspected to be the cause of the disease; a lumbar puncture to culture and analyse the CSF should be done if it is safe to do so. In severe illness or where one suspects complication such as increased intracranial pressure, imaging studies may be necessary prior to lumbar puncture to avoid complications. The principal problem is to begin the antibiotics as soon as possible, yet not harm the diagnostic process at the same time.
7. Is the use of steroids in children with bacterial meningitis to prevent complications advisable?
The administration of steroids in bacterial meningitis particularly in children is still a subject of debate but they are generally advised for particular forms of bacterial meningitis including Haemophilus influenzae type b (Hib) meningitis. It is also useful in preventing complications of the condition including hearing impairment and neurological dysfunction. The standard therapy is dexamethasone; it is given for 2 to 4 days starting from the first dose immediately after the diagnosis is made.
8. What is the part played by anticonvulsants in encephalitis and how long should these be continued?
Anticonvulsants are useful in the management of encephalitis to prevent seizures which are one of the features of the disease. It should be given if the patient develops seizures or at high risk of developing seizures because of the encephalitis. The duration of anticonvulsant therapy is manifold and is usually influenced by the clinical features of the patient and his/her seizures. Most anticonvulsants should be continued for a period of weeks to several months after the risk of seizures is considered to be low.
9. This paper aims at explaining the efficacy of steroids in the management of radiculomyelitis.
There is evidence that steroids may be useful in the management of radiculomyelitis, particularly if there is an inflammatory element to the pathology. They have the ability to decrease inflammation and oedema and may be used to relieve symptoms and enhance the patient’s recovery. There is evidence that the response to steroids may depend on the type of radiculomyelitis, but steroids are widely employed in the treatment of the condition.
10. Do you operate on a patient with a brain cysticercosis lesion? The answer is presumably ‘Yes’, although this is not very clear, and there are many uncertainties. Also, should one ‘worm’ the patient’s gut when you find brain lesions; if so, with what?
Treatment for brain cysticercosis is usually advised if the patient has symptomatic lesions or if there is substantial mass effect or neurological dysfunction. The management is pharmacological with the use of antiparasitic drugs including albendazole or praziquantel. Besides antiparasitic therapy supportive care and possibly corticosteroids may be utilized for inflammation. As for deworming the gut, it is also necessary to treat the intestinal cysticercosis to avoid re-infection and worsening of the condition. Most of the time this entails administration of anthelmintic drugs such as praziquantel or albendazole.
CHCAGE002/IMPLEMENT FALLS PREVENTION STRATEGIES
CASE STUDY A:
Norma is 83yo of Torres Island decent and enjoys independent living at home with the assistance of her son Craig 60 years old and extended family. The home is single level with no internal or entry steps, however, the kitchen is quite small and the hallway is very cluttered. The bathrpop and toilet are also small and still in original condition from when the home was purchased 30 years ago.
Recently Norma had a fall in the hallway due to the boxes stacked along one side/ She has recovered but now requires a walking stick to assist with her mobility.
Craig has sought assistance as he is concerned with Norma's risk of falling again.
As Norma's new carer, what process should be followed to assist Norma?
Who would you liaise with to implement the required strategies?
What impact has the fall had on Norma and Craig?
When working with Norma and Craig what must you take into consideration?
CASE STUDY B:
Mr Armstrong is 80yo of age and lives in an aged care facility. He is behaving out of character with violent outbursts towards fellow residents and care team members. He has become noticeably drowsy and his posture has changed considerably. Mr Amstrong also insists on wearing his favourite loose-fitting slippers when he is walking around inside the facility.
Mr Armstrong had a fall six month ago, but luckily only experienced substantial bruising and no broken bones. However, on severe; recent occasions he has tripped and nearly fallen over again.
The care team members are concerned Mr Armstrong is at risk of another fall and discuss the issues at hand with their supervisor at a team meeting.
How would you identify the factors that increase the risk of Mr Armstrong having a fall?
You need to discuss the issues with Mr Armstrong, what do you need to consider and how would you go about this discussion?
The care team are concerned that Mr Armstrong's violent outbursts are caused by issues beyond their scope of practice, how could these issues be addressed?
What documentation and reports need to be completed in accordance with organizational policy and procedures?
why is this documentation required and how often should it be updated?"
Case Study A: Norma
1. Process to Assist Norma:
Home Safety Assessment: Do a safety assessment of Norma’s home as it is therefore. This entails determining the kind of clutter in the hallway, the condition of the bathroom and toilet and any hazards that might include falls.
Home Modifications: Some enhancement tips that can be made in the household are; it is recommended that the house should minimize or avoid placing items that can be a cause of falling, there should be provision of bath bars in the bathroom, and the house should be well arranged and light.
Assistive Devices: It is also important to evaluate if Norma may have other needs for other assistive devices or mobility aids such as wheeled walker or mobility scooter.
Fall Prevention Education: Educate Norma and her family on the ways of preventing falls, on how to get around the house safely and on the ways to build up muscle and prevent falls.
2. Liaison for Implementing Strategies:
Occupational Therapist: To assess home environment and coming up with recommendation for change.
Physical Therapist: Thus for strength training and balance training exercises to be recommended for Norma.
Family Members: So that the patients could understand and follow the strategies and changes that are planned and are related to the prevention of falls.
3. Impact of the Fall on Norma and Craig:Norma and Craig and the Fall: The Consequence:
Norma: It also could have affected her confidence to move and be mobile as she had a fall. She may have also begun to get some anxiety regarding her movement within the home space, and fear of falling again.
Craig: This is because he is the one who looks after Norma and as such, he is concerned with the safety of his wife and the impact of the fall that she has had. He may be influenced by the realisation that the house has to undergo changes in a way that will accommodate the new and possibly permanent role of caring for Norma.
4. Considerations When Working with Norma and Craig:Reflections on Practice with Norma and Craig:
Cultural Sensitivity: Consider Norma’s Torres Island background and other cultural factors that may influence her preferences and needs.
Communication: This entails talking to Norma and Craig openly and in a sensitive manner to ensure that they are aware of the fall prevention plan.
Individual Needs: In this case, it will be appropriate to assess Norma according to her mobility status and the surrounding of her home in order to come up with a good plan for fall prevention.
Case Study B: Mr Armstrong a man who posses a good physic.
1. Identifying Factors that Increase Fall Risk:The Following are the Factors that contribute to the Risk of Falling.
Medical History: The following should be assessed in Mr. Armstrong; Any history of previous injuries, neurological or cognitive complications or indeed any side effects from medication that can lead to falls.
Environmental Factors: Some of the possible factors that you may find in the environment of an aged care facility that are hazardous and may result in falls include,_Three
Behavioral Factors: Consider Mr. Armstrong who has a preference for wearing slippers but these are not comfortable for his feet or have a good design to enable him hold on to the floor.
2. Discussing Issues with Mr. Armstrong:I bitched about problems with Mr. Armstrong:
Approach with Sensitivity: In as much as you are trying to solve Mr. Armstrong’s problems and behaviors, ensure to respect him and this could be that he is tired or has a sickness.
Involve Healthcare Professionals: Suggest Mr. Armstrong to be taken through a medical check up or a psychiatric test to determine his mental condition or any other previous medical condition that may be making him have such behavior.
Safety Measures: Why it is important to wear the right shoes and the consequences of wearing slippers and how they cause slips. Suggest improved footwear that can be used and which is more appropriate for the tasks that are to be undertaken.
3. Addressing Violent Outbursts:
Medical Evaluation: Thus, suggest to Mr. Armstrong to take a complete medical check up to determine other possible causes of such symptoms, including infections, confusion, or mental disease.
Behavioral Management: Some of the ways that can be suggested to deal with the behavior problems include changing his environment so as to reduce on the incidences of aggression and providing him with right psychological care or counseling services.
4. Documentation and Reports:
Incident Reports: Please make sure that all the incidents especially the falls, assaults, or changes of Mr. Armstrong’s patient behaviour are well documented. Give an account of the incident, cause of the incidence and any action that was taken subsequent to the incidence.
Care Plans: Modify this care plan with new nursing assessment, intervention, and alteration of existing plan in relation to Mr. Armstrong’s fall risk and behavior.
Regular Updates: The documentation also has to be done frequently, every shift or when there is a change in the behavior of Mr. Armstrong. This will ensure that all the right staffs are informed and that Mr. Armstrong continues to receive the care that he requires as well as ensuring that the care is not stagnant and can be altered if needed.
Importance of Documentation:
Continuity of Care: This is because if the proper documentation is done, it will show the right status of Mr. Armstrong and the procedure that was done to him.
Quality Improvement: Can be used in the identification of trends or problems that require intervention in order to improve the safety of the patients as well as the quality of care that is being offered to the patients.
Legal and Regulatory Compliance: In charge of implementing and following the organizational policies and the laws that govern the documentation of the patient’s care and the incidents.
