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Abdominoplasty, commonly referred to as a tummy tuck, is a popular cosmetic surgery procedure that aims to create a firmer, more toned abdomen. This guide provides an in-depth look at the cost, procedure, and benefits of abdominoplasty, helping you make an informed decision about whether this treatment is right for you.\nWhat is Abdominoplasty?\nAbdominoplasty is a surgical procedure that involves the removal of excess skin and fat from the abdomen and tightening the abdominal muscles. This procedure is often sought after by individuals who have experienced significant weight loss, pregnancy, or aging, leading to a sagging abdominal area.\nWho is a Good Candidate?\nIdeal candidates for abdominoplasty are those in good overall health, at a stable weight, and with realistic expectations about the outcome. It is particularly beneficial for those who have not been able to achieve a toned abdomen through diet and exercise alone.\nThe Abdominoplasty Procedure\nBefore undergoing abdominoplasty, patients have a consultation with their surgeon. During this meeting, the surgeon assesses the patient's health, discusses expectations, and explains the procedure, including potential risks and recovery time.\nDuring the Surgery\nAbdominoplasty typically requires general anesthesia and takes several hours. The surgeon makes a horizontal incision between the pubic hairline and belly button. Excess skin and fat are removed, and the abdominal muscles are tightened. Finally, the incision is closed with sutures.\nRecovery varies by individual but generally involves rest and limited movement to aid healing. Patients usually return to work and normal activities within a few weeks, following their surgeon's specific aftercare instructions.\nCosts of Abdominoplasty\nThe cost of abdominoplasty varies depending on factors like geographic location, surgeon's experience, and the complexity of the procedure. On average, prices can range significantly, and it's important to consider that these costs often do not include additional fees such as anesthesia, operating room facilities, or other related expenses.\nBenefits of Abdominoplasty\nAbdominoplasty offers several benefits, including:\n- Improved Appearance: It results in a flatter, more toned abdominal area.\n- Boosted Confidence: Many patients experience a significant boost in self-esteem and confidence.\n- Physical Comfort: Removing excess skin can reduce discomfort and skin irritation.\n- Better Fit for Clothing: A more contoured profile can make clothes fit more comfortably and look more flattering.\nAbdominoplasty can be a life-changing procedure for those looking to improve the appearance and function of their abdominal area. By understanding the costs, procedure, and benefits, you can make an informed decision about whether this treatment aligns with your personal goals and needs.\n|+90 534 261 65 05\n|Alemdar, Divanyolu Cd, Ticarethane Sk. No:10/2, 34122 Fatih/İstanbul |
Many people feel anxious about visiting the dentist – or avoid it completely – because they worry about experiencing pain and discomfort. Fortunately, dental sedation services can make it a less daunting experience. Sedation dentistry has become quite common over the past few years, and the various styles of dental sedation available today have made it easier for people to overcome their dental anxiety and get their dental problems fixed.\nBut what exactly is dental sedation? How does a dentist administer it? And what are the associated costs? Keep reading to find out\nTable of contents\n- 1 What is sedation dentistry?\n- 2 How does sedation dentistry work?\n- 3 Drugs used for dental sedation\n- 4 How long does dental sedation last?\n- 5 Sedation dentistry safety\n- 6 Am I a good candidate for sedation dentistry?\n- 7 Is sedation dentistry covered by dental insurance?\n- 8 Sedation dentistry cost\n- 9 Conscious sedation side effects\n- 10 Conclusion\n- 11 FAQs\nWhat is sedation dentistry?\nDental sedation (aka sleep dentistry) is an important component of general anesthesia. It includes a range of different techniques that are used by dentists to calm patients or make them more comfortable.\nOne example that you've probably heard of is laughing gas (nitrous oxide), which dentists use on their patients for dental procedures such as root canals and getting new crowns.\nHowever, sedation dentistry includes so much more than laughing gas, with a multitude of options for patients with dental anxiety.\nHow does sedation dentistry work?\nThere are different methods used for dental sedation, each with its own purpose and strength. Your dentist will choose the most appropriate of them for your situation, based on certain factors. These include:\n- The dental procedure being performed (for example, removal of wisdom teeth)\n- The duration of the dental procedure\n- Your level of dental anxiety\nAccording to the American Dental Association, a dentist may choose to induce any one of the following forms of sedation:\n- Minimal sedation, in which patients are awake but in a relaxed state\n- Moderate sedation, in which patients are conscious but may experience slurring of speech and slight memory loss\n- Deep sedation, in which patients are at the verge of unconsciousness but can still be awakened\n- General anesthesia, in which patients are completely unconscious\nDrugs used for dental sedation\nPrior to performing a procedure, the sedation dentist has to choose the appropriate type of dental anesthesia to calm the patient. While some of these types can make the patients completely unconscious, others like oral sedation may only relax them without knocking them out completely.\nThe most common types of sedation used in dental procedures include the following:\nInhalation sedation (gas and air)\nNitrous oxide is an agent that is inhaled by the patients in order to relax. The effects of nitrous oxide wear off quickly, so you may be able to return to your regular schedule after leaving the dentist's office.\nOral sedation includes the use of medicines that can be taken via the mouth, such as diazepam. Most dentists instruct the patients to swallow the pills approximately 60 minutes before the appointment.\nThese oral pills will make you less anxious and a bit sleepy but you will still be aware and able to communicate with the dentist throughout, which is why it is known as conscious sedation.\nIntravenous or IV sedation is an important component of sedation dentistry and includes drugs that may put the patients into varying stages of consciousness. General anesthesia is also a part of the IV sedation dentistry which may induce a deep sleep until the effects wear off. This is generally only used for extensive dental procedures such as complicated or multiple extractions (especially in young children) and also some kinds of dental surgery.\nSome common pharmacological agents used for IV sedation include diazepam, midazolam, and lorazepam.\nHow long does dental sedation last?\nThe exact duration for the effects of a dental sedative to wear off depends on the form of sedation used, the dose used, the duration of treatment, and the ability of the body to recover. The clinician carefully plans and administers the right amount of sedative for your situation.\nWhile nitrous oxide wears off minutes after inhalation stops, oral and IV sedation take at least 1-2 hours to wear off and often much longer.\nSedation dentistry safety\nSedation dentistry is an excellent option for patients who suffer from dental anxiety and have to go through long dental procedures that require them to sit in a dental chair for hours. Yet, many patients get concerned about the safety of using a dental sedative and what to expect after taking one.\nTo eradicate your concerns about the safety of using a dental sedative, it is important to understand what to expect after receiving one. While you must discuss the specifics with a dentist, the following general guidelines should be kept in mind.\nBefore the beginning of the procedure, it is important to avoid eating or drinking for six hours before a sedative is administered. This will reduce the chances of food regurgitation and obstruction of the airways while you are under the effects of anesthesia.\nThe dentist will then choose an appropriate form of sedation to begin the process. If you have high anxiety levels, you may be advised to use a calming pill prior to the appointment. The dentist may ask your permission to intubate you and give you monitoring devices to keep a check on your vital signs during sedation.\nAs soon as the dentist administers the sedative, it will enter your bloodstream and make you feel relaxed, calm, and a bit lightheaded. You may feel like your arms and legs have gotten heavier too. Before long, you will be too numb to feel any pain, and the dentist can then proceed with the procedure.\nYou might have to stay at the clinic for some time following the procedure in order for your recovery to be monitored. The effects of anesthesia will usually wear off within half an hour; however, you may still feel lightheaded and drowsy for a few hours. Therefore, you should make sure that you have someone to accompany you home and, if possible, stay with you until you feel back to normal.\nIt's advisable not to do any of the following until the next day after your dental treatment:\n- Drive any vehicle or ride a bicycle\n- Return to work\n- Drink alcohol\n- Smoke or use any kind of nicotine products\n- Take sleeping tablets\n- Use any machinery, home appliances, or sharp utensils\n- Cook or heat anything in the kitchen, including water for a cup of tea or coffee\n- Make important decisions, including financial transactions\nLet's see the process of IV dental sedation on Deanna; a patient who's going to have a tooth extraction.\nAm I a good candidate for sedation dentistry?\nHaving any of the following fears may make you a good candidate for dental sedation:\n- Anxiety of visiting a dentist\n- Fear of shots or needles\n- History of a traumatic dental experience\n- Inability to handle noises or smells in a dentist's office\n- Having sensitive teeth\n- Need of a complex treatment\nIs sedation dentistry covered by dental insurance?\nNormally, general anesthesia is covered by your insurance plan as it is often a medical necessity for the patient to be in a state of unconsciousness during the procedure. For more information, you may talk to your insurance plan provider to confirm the coverage and acquire a pre-approval if possible.\nYour insurance plan may also cover dental sedation if you have a medical condition or a certain disability that requires proper sedation prior to performing any dental procedure. Some insurance plans cover a patient with a medical diagnosis of extreme dental phobia.\nRemember that the majority of dental insurance policies cover treatment costs of $1,000 to $1,500 per year, and the fee for your dental treatment along with the cost of sedation may go over this coverage. Therefore, it is advised to take a look at various dental saving plans beforehand.\nSedation dentistry cost\nThe costs associated with dental sedation vary according to the chosen method. Some of these have been summarized in the table below.\nTypes of dental sedation\nEstimated cost (per 30-minute session)\nInhaled nitrous oxide\nConscious sedation side effects\nAfter intravenous or oral sedation, it's normal to feel drowsy, possibly for the rest of the day. You should take the precautions described above to stay safe during this time. You may also experience some bruising in your arm or hand from the injection, but this should disappear within a few days.\nThe risk of other sedation side effects is very low. In some very rare cases, patients experience an allergic reaction or vomiting. Tell your dentist if you have any history of allergies to medicine. Your dentist will explain the risks and answer any questions you have before proceeding with any kind of sedation dentistry.\nIf you are particularly worried about an upcoming dental procedure, inquire about dental sedation from your dentist. Dental sedation will make you feel calmer before getting in the dentist's chair, and will help you relax during your treatment. You might not remember much of it at all, and the idea of returning to the dentist will feel less daunting. You'll also probably feel a great sense of relief at having finally got the dental treatment you have been putting off!\nWill I feel anything during my dental treatment after dental sedation?\nIn most cases, patients do not feel a thing. Some may feel slight discomfort, and at the end of the appointment, most are relaxed with no memory of the procedure.\nIs sedation dentistry safe for children?\nYes, pediatric sedation dentistry is just as safe as adult sedation dentistry. It is routinely performed in multiple clinical settings, so there is no need to worry.\nAnesthesia progress: Nitrous oxide and the inhalation anesthetics. Consulted 8th February, 2020\nAmerican Dental Association: Guidelines for the use of sedation and general anesthesia for dentists. Consulted 8th February, 2020. |
The size, shape and natural position of the ear is an inherited characteristic. As the ears form, they develop several natural folds. If development is incomplete, a deformed or protruding ear will result.\nFortunately, we can reposition prominent or protruding ears closer to the head with otoplasty. Most individuals undergo this surgery during the early school years, ages 5-7, but otoplasty can be performed at any age, even adolescence or adulthood. The visual improvement with this type of plastic surgery is usually dramatic.\nWe perform the surgery on an outpatient basis, removing cartilage and skin through incisions placed behind the ear. The remaining cartilage is remodeled to create the normal ear folds. We can assure you that the operation has no effect on hearing.\nWe use general anesthesia for small children while adults generally prefer local anesthesia with intravenous sedation. The operating time is approximately two hours. Following the surgery, we place a bandage around your ears for protection and to minimize swelling.\nAfter we remove your bandage, your ears may appear slightly overcorrected, or flat. Be patient; this is to be expected. Once your ears have healed, they will acquire a more normal position.\nYou may experience swelling and discoloration to varying degrees following the operation. This resolves in one to two weeks. You should sleep flat on your back with the head of your bed elevated for two weeks following surgery.\nYou will need to wear an Ace wrap or ski band at night for two to three weeks to maintain the position of your ears and to encourage their healing. A child can usually return to school in one week, resuming normal physical activities by two weeks. If you wear glasses, you will need to be careful that they do not rest on your ears for a least two weeks.\nThe goal of surgery is improvement, nor perfection. Perfect symmetry is not a reasonable expectation of this operation. Subtle asymmetries, which existed before the surgery, may still be present afterwards. Significant degrees of difference may, however, require some secondary revision.\nInfection and bleeding are the most common complications following this surgery. We use broad-spectrum antibiotics to minimize the risk of infection. Rarely, one of the sutures behind the ear may break loose, in which case we will remove or replace the suture.\nA child with protruding ears is often subjected to unkind remarks that can be a source of significant distress. This lack of peer acceptance makes a child feel self-conscious or rejected. Even as an adult, the same childhood sensitivities may persist. This makes the results or otoplasty rewarding for the patient and for the doctor. |
Call Us! (760) 941 7022\nText Us! (760) 309 6807\nLiposculpture is a minimally invasive cosmetic procedure that removes excess fat and creates a more muscular, defined shape. In some cases, plastic surgeons purify the removed fat and insert it into another area of your body for optimal results.\nSmart Lipo is a less invasive form of liposuction that uses laser energy to liquefy tissue before being suctioned out and also stimulates collagen production to tighten the skin and boost elasticity.Smart Lipo is excellent for smaller areas of the body that need to be contoured, such as the upper arms. For larger areas such as the thighs or for multiple body parts, we usually recommend traditional liposuction so patients can see the best results.\nAreas on you face as in Neck, Chin, Jawline and Lower Face.Areas on the body: Arms, Chest, Breasts, Waist, Abdomen, Back, Inner knees, Hips, Thighs, Buttock.\nSmartLipo is an FDA-approved fat removal procedure and is widely considered to be safe and effective. In fact, SmartLipo is typically performed using local anesthesia for the patient, which cuts down on anesthesiarelated risks and complications when compared to traditional liposuction using general anesthesia.\nThe results are long lasting as long as you keep the weight off, exercise,and maintain a good diet. It’s natural for skin to lose some firmness with aging, if you gain weight after liposuction, your fat distribution may change. Depending on how much fat is removed, you can expect to see final results between 3-6 months after the procedure.By the end of the first week, the initial swelling should have reduced slightly, but it can take as long as six weeks for the swelling to go completely.\nLocal anesthetics are infiltrated using standard tumescent technique, meaning you will be awake during the procedure.\nPotential risks of Liposuction can range from severe bruising, inflammation, dimpling, lumpiness, numbness, scarring, discoloration, or sagging skin, as well as discomfort in the surgically treated area. Since a laser is being inserted under the skin, burning of the underlying skin can also be a side effect.\nMost Liposculpture patients are asked to rest for up to 1 week before returning to work. Generally, exercise and other strenuous activities are restricted for one week up to 10 days depending on your surgery.\nCareCredit is different from a regular credit card. Use it to pay for out-of-pocket expenses not covered by medical insurance and special financing options are available that you may not be able to get eith other cards. |
Postoperative weakness and anesthetic-associated rhabdomyolysis in a pediatric patient: a case report and review of the literature\nJournal of Medical Case Reports volume 16, Article number: 387 (2022)\nAnesthesia-associated rhabdomyolysis is a rare complication of surgery that causes postoperative myalgia, weakness, and potential renal failure if not managed promptly. Predisposing conditions that may lead to this complication include muscular dystrophies and myopathies.\nThis rare case describes a pediatric non-Indigenous Australian patient developing this complication, with no known predisposing risk factors, and no clear etiology. A 9-year-old child with a background of asthma underwent an elective removal of keloid scar on her chest wall. The procedure was brief and uncomplicated, with an uneventful induction of anesthesia. During the emergence period, she developed acutely raised airway pressures with bronchospasm and laryngospasm requiring the use of salbutamol and suxamethonium with good effect. In the initial postoperative period, the patient complained of generalized myalgia and muscle weakness and was unable to mobilize independently. There was transient recovery to normal function; however, a recurrence of symptoms the following day with associated myalgias warranted admission to hospital. She was found to have rhabdomyolysis that was managed conservatively with a full recovery of several weeks. She was thoroughly investigated for any underlying cause, including genetic testing for malignant hyperthermia susceptibility (she had a variant of unknown significance but was negative for the known genetic abnormalities that cause malignant hyperthermia).\nThis case report demonstrates the importance of considering anesthesia-associated rhabdomyolysis as a differential for acute postoperative weakness, and outlines an investigative approach. To the best of our knowledge, it is the first case described in the pediatric literature to report biphasic progression of symptoms.\nRhabdomyolysis is a condition whereby myocyte injury occurs, releasing internal components into the systemic circulation . There are a large number of causes, and patients may present with a wide spectrum of clinical signs. Mild symptoms include muscle cramping or fatigue. Severe symptoms include severe muscle pain, with profound weakness. Renal impairment through direct tubular injury is a concern and requires treatment and close monitoring .\nThis case report describes unanticipated anesthesia-associated rhabdomyolysis in a pediatric patient in the postoperative setting, which is rare. It illustrates the clinical syndrome that evolved, including the workup required to identify and exclude potential causes of acute weakness and myalgias postoperatively.\nA 40 kg 9-year-old non-Indigenous Australian female was scheduled for an elective removal of a large right anterior deltoid keloid scar. Her medical history was significant for mild asthma. She had no known allergies, no past surgical or anesthetic history, and no significant family medical history, including no previous general anesthetics in either parent. Medications included regular inhaled fluticasone and salmeterol, with intermittent inhaled salbutamol as required for breakthrough asthma symptoms. She was normally a well and very active child. In the days leading up to her scheduled procedure, she had an intermittent dry cough with no exercise limitation, dyspnea, or fevers. Her preoperative physical examination demonstrated a mild intermittent wheeze in the right anterior basal lung field that resolved with salbutamol administration. The remainder of the examination was unremarkable. The decision to proceed with general anesthesia was based on a thorough assessment, consideration of all factors, and shared decision making with the family. Two factors leading to a general, rather than regional, anesthesia technique were the size of the lesion (with possibility of local anesthetic toxicity) and a previous traumatic experience when she had direct infiltration of intralesional corticosteroid previously.\nThe patient received no other premedication and was cooperative with preoxygenation prior to an intravenous induction. She received 50 mg of intravenous propofol and 50 μg of intravenous fentanyl for induction, and was effectively manually ventilated with a circle system during the apneic period. A first-generation laryngeal mask airway (LMA) device was inserted without difficulty with an initial pressure control mode of ventilation. Anesthesia was maintained with sevoflurane, oxygen, and air (FiO2 0.50), with continuous monitoring of end-tidal capnography, oxygen saturation, heart, and noninvasive blood pressure.\nThe surgical procedure took 30 minutes in the supine position and was uncomplicated. During the maintenance phase of anesthesia, there were no periods of hemodynamic instability, hypoxia, hypercarbia, muscle rigidity, impaired ventilation, or hyperthermia. There were also no obvious abnormalities seen on continuous cardiac telemetry.\nOn emergence from anesthesia, 100 mg of intravenous propofol was given following cessation of sevoflurane to facilitate removal of her LMA under deep anesthesia. The patient subsequently became very difficult to ventilate with high airway pressures, hypoxia, and poor air movement with reduced chest expansion. As an emergency maneuver, her anesthesia was deepened with a further 100 mg of propofol and ongoing manual ventilation attempted with sevoflurane 8% on high flows of 100% oxygen. As this did not improve her ventilation or oxygenation, 50 mg of intravenous suxamethonium was administered with a rapid improvement in ventilation, oxygenation, and airway pressures. Given the rapidity of the situation, the differentials included laryngospasm or bronchospasm with interventions treating both possibilities. Upon recovery of oxygen saturation, chest auscultation demonstrated widespread wheeze initially, treated with in-line salbutamol, which was titrated to effect. She received approximately 1500 μg of inhaled salbutamol over a 15-minute period. She was supported with positive pressure mask ventilation until safe emergence from anesthesia, then transferred to the pediatric postoperative care unit.\nForty-five minutes later in the recovery bay, once completely awake, the patient described right neck pain and lower back pain that prompted a medical review by the anesthetic team. She had a benign cervical spine and musculoskeletal examination, with no red flags. At this stage, reassurance was provided.\nTwo hours later, in the discharge lounge, nursing staff noted an abnormal gait of the patient as she attempted to mobilize to the toilet. On further questioning, the patient was unable to walk unaided and needed full support to stand. A repeat medical review was requested, whereby she was found to have profound proximal lower limb muscle weakness, left lateral thigh pain, and right medial leg pain. She had reduced knee reflexes bilaterally and a broad-based unsteady gait. Her sensory function, upper limb examination, and cranial nerve examination were completely unremarkable.\nTo exclude salbutamol-induced hypokalemia as a possible cause of acute weakness, a venous blood gas was ordered, revealing a mild hypokalemia of 3.3 mmol/L. Having excluded this as a cause, the working diagnosis was suxamethonium-induced myalgia. She was kept for prolonged observation for 3 hours, until her symptoms improved. On discharge, she was able to mobilize unaided. She was provided with strict return precautions if her symptoms deteriorated.\nThe following day, her proximal muscle weakness had returned to involve all four limbs with associated tenderness. She was brought into the emergency department, needing assistance to mobilize. Urgent blood tests revealed a creatinine kinase (CK) of 22,679 units/L, suggestive of rhabdomyolysis. Her renal function, electrolytes, and urinalysis were normal. She was admitted for observation with conservative management and resolution of her CK levels over a 4-day period. She had a gradual return to full muscle strength and function over a period of 4 weeks.\nAn anesthetic alert letter was created, addressed to anesthetic, pediatric, and primary care teams to manage this patient as malignant-hyperthermia (MH) susceptible until evidence suggested otherwise as sole rhabdomyolysis may reflect a spectrum of this disorder. Given the age of the patient, a muscle biopsy (gold standard test) to definitely identify MH susceptibility was not performed. Genetic tests were used as an alternative, and detected the following:\nGenomic location (hg19): chr19:38979901G>A\nClassification: 3c—a genetic variant of uncertain significance (VUS) with low clinical relevance.\nAs is the case with genetic testing, this variant may become clinically significant if other cases are found in the future.\nThere are many causes of acute rhabdomyolysis, broadly differentiated into inherited and acquired conditions. Outside the perioperative setting, conditions such substance abuse, medication, and trauma form the majority of acquired causes . Inherited conditions include muscular dystrophies and metabolic disorders.\nThere are indeed patients who may undergo a general anesthetic with the conditions mentioned above—in such cases, the anesthetic and surgery are planned to minimize the risk, or severity, of rhabdomyolysis.\nIn the pediatric literature, the incidence of anesthesia-associated rhabdomyolysis is rare, of which the majority of cases (more than 95%) were due to an attributable cause when investigated .\nOn this occasion, the two possible agents potentially responsible for rhabdomyolysis included suxamethonium and sevoflurane. It is difficult to ascertain clinically, and in research, whether rhabdomyolysis is simply a progression of expected myalgias from suxamethonium use, as this medication is rarely used in isolation, but often with other anesthetic agents such as sevoflurane. It was difficult to make that assumption in this particular patient, as she initially improved but later deteriorated in a biphasic manner.\nIn patients who develop unexpected rhabdomyolysis following an anesthetic, other differentials must be considered.\nAnesthesia-induced rhabdomyolysis (AIR)\nAIR is a very rare condition, with unknown incidence, and incompletely understood . The hallmark features of this condition include marked hyperkalemia, peaked T waves on electrocardiogram (ECG), acidosis, and elevated CK. Hyperkalemia can lead to cardiac arrhythmias, and cardiac arrest if not identified and treated promptly.\nMalignant hyperthermia (MH)\nA thorough inspection of the anesthetic record is essential to take note of medications administered, and any physiological abnormalities noted during the anesthetic, including hyperthermia, hypercarbia, hypoxia, ECG changes, tachycardia, and muscle rigidity, all of which may be suggestive of MH. This genetic disorder was first described in 1960 after several unexplained deaths under anesthesia occurred within a family . Common anesthetic agents implicated in this condition include halogenated volatile agents (for example, sevoflurane, desflurane) and the depolarizing muscle-relaxant suxamethonium . Importantly, patients do not need to exhibit all of these signs to be diagnosed with MH susceptibility. Delayed and isolated rhabdomyolysis in the postoperative setting is a recognized phenomenon, and has been reported in case reports, whereby patients have later been confirmed to be MH susceptible . Furthermore, dedicated MH laboratories across the world keep a database of such variants in presentation. Testing for malignant hyperthermia susceptibility is specialized and undertaken by dedicated laboratories; it involves a mixture of genetic tests and muscle biopsy testing .\nSurgical and position factors\nIn the immediate postoperative period, any surgical factors must be considered, for example, acute compartment syndrome following an orthopedic fixation. Patient positioning, including skin and tissue breakdown, should be excluded with an extensive skin and musculoskeletal assessment.\nSubclinical underlying conditions\nPostoperative rhabdomyolysis may be the first presentation of a previously unknown disorder involving neuromuscular dysfunction. While this discovery may happen as part of pediatric anesthesia, it is possible for it to occur in adult populations who may have not received an anesthetic prior, or where the condition is of mild severity. Conditions include, but are not limited to: muscular dystrophies, thyroid dysfunction, glycogen storage disease, mitochondrial disease, and disorders in fatty acid and carbohydrate metabolism [9, 10].\nPrior to performing any targeted investigation, the treating clinician should take a detailed history, which may provide clues. This should include any previous episodes of muscle pain or weakness and details surrounding these episodes (that is, medications taken, diet changes, exercise, procedures, infection). For example, in patients with glycogen storage dysfunction such as McArdle’s disease, they may provide a reliable history of predictable pain after several minutes of intense exercise. Following a detailed history, a neurological and musculoskeletal examination must be performed looking for any longstanding myopathy, wasting, neurological deficits, or gait abnormalities which may be seen in muscular dystrophies .\nThis case demonstrates the need to be aware of anesthesia-associated rhabdomyolysis as a rare, but important, entity in the perioperative setting. To the best of our knowledge, this is the only case reported in the literature to describe a biphasic progression of symptoms. Furthermore, it is one of a few pediatric cases where no clear underlying disorder has been identified in the postoperative period. The symptoms and signs of anesthesia-associated rhabdomyolysis overlap with several other disorders that require exclusion, including anesthesia-induced rhabdomyolysis (AIR), and malignant hyperthermia. Treatment is largely supportive, with close monitoring required to ensure a full recovery.\nAvailability of data and materials\nLaryngeal mask airway\nStahl K, Rastelli E, Schoser B. A systematic review on the definition of rhabdomyolysis. J Neurol. 2020;267(4):877–82.\nLong B, Koyfman A, Gottlieb M. An evidence-based narrative review of the emergency department evaluation and management of rhabdomyolysis. Am J Emerg Med. 2019;37(3):518–23.\nMelli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine (Baltimore). 2005;84(6):377–85.\nPedrozzi NE, Ramelli GP, Tomasetti R, Nobile-Buetti L, Bianchetti MG. Rhabdomyolysis and anesthesia: a report of two cases and review of the literature. Pediatr Neurol. 1996;15(3):254–7.\nGray RM. Anesthesia-induced rhabdomyolysis or malignant hyperthermia: is defining the crisis important? Paediatr Anaesth. 2017;27(5):490–3.\nDenborough M, Lovell RR. Anaesthetic deaths in a family. Lancet. 1960;2:45.\nHarwood TN, Nelson TE. Massive postoperative rhabdomyolysis after uneventful surgery: a case report of subclinical malignant hyperthermia. Anesthesiology. 1998;88(1):265–8.\nHopkins PM, Ruffert H, Snoeck MM, Girard T, Glahn KP, Ellis FR, et al. European Malignant Hyperthermia Group guidelines for investigation of malignant hyperthermia susceptibility. Br J Anaesth. 2015;115(4):531–9.\nChan EK, Kornberg AJ, Ryan MM. A diagnostic approach to recurrent myalgia and rhabdomyolysis in children. Arch Dis Child. 2015;100(8):793–7.\nNance JR, Mammen AL. Diagnostic evaluation of rhabdomyolysis. Muscle Nerve. 2015;51(6):793–810.\nRoyal Darwin Hospital for their ongoing support and training.\nEthics approval and consent to participate\nConsent for publication\nWritten informed consent was obtained from the patient's legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nAbout this article\nCite this article\nFloridis, J., Barbour, R. Postoperative weakness and anesthetic-associated rhabdomyolysis in a pediatric patient: a case report and review of the literature. J Med Case Reports 16, 387 (2022). https://doi.org/10.1186/s13256-022-03629-8\n- Anesthesia-associated rhabdomyolysis\n- Postoperative weakness\n- Case report |
On April 1, 2010 the Ontario Hospitals Association made the use of a Surgical Safety Checklist mandatory for all hospitals.\nThe use of a checklist was not new to our hospitals. For years, the operating room staff have used perioperative checklists, anaesthesia checklists, and surgical equipment checklists and counts. So the use of a checklist is not new, but the public reporting of the use of the tool was new.\nThe tool calls for team discussions and checks at three critical points during surgery:\n- Briefing: Preoperative evaluation of the conscious patient prior to induction of anesthesia.\n- Time Out: Immediately prior to incision\nDebriefing: Postoperatively prior to the patient leaving the operating room.\nThe three checks are to be performed on every case, including cases that only require a local anaesthetic or light sedation. In reporting our compliance, we only counted cases where all three checks were documented.It is important to note that the three checks were completed and documented on all cases requiring a general anaesthetic. Since the majority of our O.R. cases require some light sedation or freezing only, and the actual O.R time is short, it has been a period of adjustment for staff to ensure the three checks are completed on the lighter cases. We have assessed what worked well, and where we need to improve as far as ensuring the three checks are documented. We have put some changes in place at the start of the second quarter, July 1st which will assist staff in ensuring that the documentation is completed on every case.\nOur goal is 100% compliance. |
Elective Title: 45AN702 — ANESTHESIA COMMUNITY HOSPITAL\nThe student will contribute largely to the care of patients in both the preoperative, operative, and postoperative periods, including necessary history and evaluation of patients. The student will be tasked with preparation of the surgical suite from the standpoint of the anesthesiologist, including appropriate monitor, suction, machines, airway, intubation, and drug checks. The student will understand the role of medications, pre-operative exam, laboratory data, EKG, and other pertinent data in the assessment of surgical patients. Emphasis will be placed on the importance of airway management, specifically the proper techniques to secure an airway, management of physiologic alterations that occur during surgery, perioperative pain management, as well and perioperative preparation of patients for their surgical procedure. Further emphasis will be placed on the anesthesia and surgical quality management process. Didactic sessions and case-based learning will also be provided. Required reading: Select chapters from Stoelting and Miller's Basics of Anesthesia. A course exam will be given at the end of the rotation.\nPrimary Contact for Add/Drops: Amy Han, PhD ([email protected])\nDirector: Richard Berkowitz, M.D.\nLocation: Community Hospital (Munster)\nOther Faculty: Drs. Brody, Gronemeyer, Holtz, Peterson, Lin, Boskovich, Hoxie, and Siddall\n- 1) Demonstrate effective and safe airway management (PC5)\n- 2) Demonstrate basic monitoring of the patient in surgery and to illustrate invasive monitoring techniques (PC5)\n- 3) Describe the autonomic nervous system and how anesthesia affects it (MK1)\n- 4) Recognize the medications used in operative and perioperative management of surgical patients (MK4)\n- 5) Explain the use of the medications used in operative and perioperative management of surgical patients (MK4)\n- Clinical Performance Evaluation Form; (Observation of clinical skills and procedures, Oral/case presentations to medical students/faculty (Communication Rubric), Discussion with faculty (patient cases)).\nPrerequisites: 4th year status\nAvailability with Max Students per Month:\nDuty Hours: 40\nTime Distribution: 85% Clinical; 15% Library/Research\nElective Type Category: CP - Clinical Practice\nNotes and Enrollment Information:\nTHIS ELECTIVE DOES NOT PARTICIPATE IN THE INITIAL SENIOR MATCH All Northwest electives must go thru the Northwest campus coordinators.\nThird Year Elective? No\nInterprofessional Skills and Service Learning\nInterprofessional Collaborative Skills: None\nService Learning Included: None |
There are many benefits to neutering your cat or kitten. For one, Neutering eliminates many undesirable behaviors such as urine marking indoors and roaming. As well, neutering is part of responsible ownership: millions of unwanted cats and kittens end up in shelters every year, and many are euthanized.\nWhen should my cat be neutered?\nWe recommend that cats and kittens be neutered at five and a half months of age, before any objectionable behaviors develop.\nWe look forward to caring for you and your feline friend throughout this important procedure. We hope that the following information will help you to understand a little more about our hospital, and our commitment to your kitten or cat’s care.\nContact us now if you have further questions, or would like to make an appointment at 416-469-1121, ext. 6 or [email protected]\nBefore the Procedure\nInitial Consultation & Physical Exam\nPrior to any surgery, we need to establish that your cat or kitten is healthy and a good candidate for surgery. If we have not seen your pet in the last three months, or if your pet is new to Blue Cross Animal Hospital, you will need to have an initial visit with one of our veterinarians. During this visit we will thoroughly examine your kitten or cat, as well as consult with you and answer any questions you may have regarding the surgery itself, or caring for your cat before or after the procedure.\nThe physical exam is required for the same reasons that a medical doctor would be required to see a human patient before a surgical procedure. We need to be sure your cat or kitten is healthy and has no medical conditions that could complicate the anesthetic or the surgery.\nIf you are already a client of Blue Cross Animal Hospital and we have seen your cat or kitten within the last three months, no additional physical exam is required.\nWe also strongly recommend that all kittens and cats going under anesthetic have a blood panel done to assess liver and kidney function, as these organs need to be functioning properly to process the anesthetic. These blood tests are required if your cat is over seven years of age.\nFor your cat’s safety as well as for the safety of the staff and other cats and kittens in the hospital, we require that your cat be fully vaccinated prior to the surgery. If your cat has been to another veterinarian in the past we will request that the records from that clinic be faxed or emailed to us prior to your initial exam. By having this record, we can ensure that your kitten or cat’s vaccines are up to date. As well, our veterinarians can review your cat’s full medical history.\nOnce your cat receives a clean bill of health, we can book the surgery.\nYour Cat’s Neuter: What to Expect\nThe Night Before\n- Please make sure your kitten or cat has no access to food after midnight on the evening prior to surgery. He may have water overnight but please pick it up in the morning. NO BREAKFAST is to be fed to your cat the morning of the surgery.\nThe Morning of the Procedure\n- Cats and kittens coming for surgery arrive in the morning between 8 and 9 AM on the day of the scheduled surgery.\n- On arrival your cat or kitten will be admitted by one of our technicians, who will check over your pet, and answer any questions you may have. You will be asked to sign permission forms, and your cat will be admitted into the hospital. From this moment on, our goal is to make your pet as comfortable as possible.\n- Our Patient Care Team will set your cat up in his own quiet, warm kennel to relax in before surgery and wake up in afterwards. Your cat’s kennel will have comfortable blankets and a litter box. These individual spaces are in our separate cat ward away from the dogs.\n- In a little while a technician will examine your pet once more and then administer a sedative injection which will calm your cat or kitten and make him sleepy. This injection also includes pain control medication.\n- An injection of anesthetic is then administered intravenously.\nDuring the Procedure\n- An inhaled anesthetic is administered to keep your cat asleep during the neuter procedure.\n- During surgery your cat or kitten lies on a warm water blanket to keep them warm.\n- Throughout the surgery, a trained veterinary technician constantly monitors your kitten or cat’s vital signs, including heart rate, breathing, temperature, blood pressure, and oxygenation to ensure he is responding ideally to the anesthesia.\n- Your cat receives subcutaneous fluids during and after the surgery to assist in processing the anesthetic.\n- If you choose, an identity microchip will be implanted under the skin between the shoulder blades while your cat is still anesthetized. It’s a good idea to do this while your cat or kitten is under anesthetic, to eliminate the discomfort of the needle.\n- A second pain control injection is given just prior to recovery to be sure your cat is comfortable.\nRecovery & Aftercare\n- During your cat’s recovery period he is attended to by his technician and our Patient Care Team.\n- Your kitten or cat is kept warm and secure in snuggly blankets and heating devices and cuddled until he is awake.\n- After he awakens, your cat is returned to his kennel, still snuggled in warm blankets and is watched until his awareness and sense of balance have returned.\n- A technician will call you when the procedure is finished and your cat has recovered.\n- Your kitten or cat can go home the same night. Our technicians continue to monitor your cat’s vital signs and comfort throughout the afternoon and evening. When you come to get your pet either a technician or a doctor will review the post operative instructions, which are also printed on your invoice when you leave so you can refer to them at anytime.\n- We will also follow up with a phone call a day or two after the procedure to be sure you do not have any further questions and to make sure your cat is recovering well. Of course, if you have any concerns or -questions prior to our call, please call us at 416-469-1121, or email us at [email protected]. |
The Well-being Word\nPursuing something you are passionate about can significantly improve your well-being. Engaging in activities that align with your passion can provide fulfillment, increase positive emotions, boost your mood, and even reduce stress.\nI know that all of us are very busy at work (and home), but sometimes, getting involved with something at work that you are passionate about can dramatically improve your well-being. This month, I wanted to highlight some of our incredible team members who are passionate about sustainability and how they bring their knowledge, dedication, and enthusiasm to this crucial topic to create meaningful and impactful change here in the Department of Anesthesiology.\nCultivating Well-being looks different for all of us; what steps do you take to improve your personal well-being and the well-being of those around you?\nPlease check out all of the fantastic contributions of these dedicated teammates—they are changing the world and our department with their outstanding efforts!\nYours in wellness,\nThe Well-developed Podcast — New Episode!\nGuest speaker Alicia Ott joins us again to discuss all things sleep. We dive deep into strategies for rotational shift workers on how best to develop healthy sleep habits and cycles. Learn what sleep hygiene means and small steps you can take to improve your sleep so that you can learn and perform at your best. Whether you are a great sleeper, a terrible sleeper, a new parent, or a night shift worker, we have tips to help anyone find better sleep.\nWashU Anesthesia Sustainability Team\nSustainability is the responsible use of resources in order to meet the needs of the present without compromising the ability of future generations to meet their own needs. Sustainability is paramount for the well-being of individuals and the planet. Embracing sustainable practices ensures the preservation of natural resources, reduces pollution, and mitigates the impacts of climate change. By promoting sustainable agriculture, renewable energy sources, and eco-friendly technologies, societies can enhance environmental quality, conserve biodiversity, and safeguard ecosystems. Furthermore, sustainability promotes social equity, ensuring that vulnerable communities have access to clean water, nutritious food, and adequate healthcare.\nThis month’s newsletter is dedicated to exploring the multifaceted world of sustainability. We’ll delve into innovative solutions, inspiring stories, and impactful initiatives that are shaping our path toward a more sustainable future. By prioritizing sustainability, we not only protect the Earth’s fragile ecosystems but also create a healthier, more equitable world for current and future generations, fostering a sense of well-being that extends far beyond individual lives.\nLow-Flow Anesthesia Project\nInhalational agents are significant contributors to hospital greenhouse emissions, accounting for about 50% of all perioperative emissions. They are also costly. To address these ethical and financial concerns, members of our clinical team introduced the Low-Flow Anesthesia Project. The goals of the initiative were two-fold:\n- Minimize/eliminate the use of desflurane (DES), the most expensive agent with the worst carbon footprint.\n- Institute low fresh gas flow of sevoflurane (SEVO), per the FDA guidelines (1-2 L/min).\nThe effects were profound and sustained: there has been a significant reduction in overall BJH expenditures on inhalational agents despite higher surgical volumes and complete replacement of DES by SEVO (and isoflurane), with BJH becoming a DES-free facility. (slide 4).\nGreen Office’s Report\nThe Knight Center on Danforth Campus played host to this year’s Green Carpets Awards ceremony, which took place on November 7, 2023. We are thrilled to share that, for the second consecutive year our PVT and Peters Building Anesthesia Offices received the prestigious silver badge in recognition of our commitment to best practices in the energy, waste, purchasing, and office culture categories. This award underscores our dedication to sustainability, a value that resonates deeply with our ever-growing team.\nThe ceremony was presided over by the Associate Vice Chancellor for Sustainability, alongside sustainability representatives from the McKelvey School of Engineering and the Medical School. During the event, our anesthesia team and leaders of the Low-Flow Anesthesia Project were recognized as Sustainability Champions, further highlighting our remarkable commitment to advancing sustainable practices.\nFeatured Member: Elizabeth Schappe\nMy name is Elizabeth, I live in Webster Groves with my husband and three children (Gracie, 16, Killian, 10, Theo, 6).\nI spend lots of time doing normal mom stuff like driving my children all over and making mediocre dinners. I also spend time teaching my children about climate change and some of the things we can do to mitigate or adapt to our changing climate.\nWe are currently having a great time trying to grow, forage, and eat Missouri native plant species. Biodiversity plays a key role in ecosystem resilience and adaptation to climate change, and native species are key to maintaining biodiversity. This fall, we foraged, peeled, cracked, and ate black walnuts. My hands were stained brown from the walnut skin for a few weeks!\nWhen I am not foraging, I spend my time working as the vice chair of the Webster Groves sustainability commission and finding ways to be active. To stay active, I signed up for an adult gymnastics class last year, did a team biathlon this fall, and I play on a cool volleyball team.\nTo fund all my antics, I have the pleasure of working as a CRNA in the anesthesia department. I love being a part of our department because it is full of wonderful and passionate people. My passion is planetary health and human health. If you share this passion and would like to learn more about the intersection between biodiversity and human health, please join me for the Webster Groves eco-ed series on November 16th. Washington University Professor Mark Manteuffel will discuss the connections and feedback loops between ecosystems and human health and wellbeing. His talk will address actionable items we can take as individuals to sustain healthy ecosystems, including ecogardens. Click here for details!\nInstitute true low fresh gas flow (FGF) for SEVO, with fresh gas flow rates of 0.5 – 1 L/min.\nUntil recently, we observed the FDA guidelines for SEVO FGF of not less than 1L/min for up to 2 MAC hours, or not less than 2 L/min for longer procedures. The main concern is that reduced flows can result in the accumulation of Compound A with the potential for nephrotoxicity. While SEVO can interact with some absorbents to produce Compound A, it has never been shown to result in renal toxicity in humans. Anesthesia Patient Safety Foundation (APSF) and many major academic institutions now fully endorse true low-flow SEVO administration (0.5 – 1.0 L/min fresh gas flow) as a safe, effective, and environmentally advantageous modality of administering inhalational anesthesia.\nCaution: Whereas the low FGF inhalational anesthesia is safe when administered properly, there are potential risks inherent to this technique. The slow changes in the oxygen and anesthetic concentrations during the low FGF may predispose to delivering a hypoxic gas mixture or inadequate anesthetic concentration, which can result in hypoxemia, awareness, or inadequate surgical anesthesia. Whenever the concentration of oxygen or the anesthetic agent needs to change rapidly, the FGF should be promptly increased. Because of the slower kinetics of gas changes during the low FGF, maintenance of inhalational anesthesia is the safest phase to reduce the FGF while maintaining the target concentrations of oxygen and anesthetic.\nReducing utilization of Nitrous Oxide\nAn upcoming initiative will focus on the reduction in the use of nitrous oxide in BJH periop. Nitrous oxide has a significant global warming potential with a long atmospheric life, of well over 100 years. Because of that, many academic centers are eliminating nitrous oxide from their inhalational gas portfolio. We will work in the near future on gradually phasing out nitrous oxide from most anesthetizing sites. We do envision keeping it available for certain specialty applications (e.g., OB). More information to come on this initiative.\nPractice Greenhealth is the leading membership and networking organization for sustainable health care, delivering environmental solutions to hospitals and health systems across the United States.\nWashington University in St. Louis is fully committed to being a national leader in sustainability, a core priority that runs through all aspects of our community, our operations, and our work as a leading teaching and research institution.\nAPSF Low-Flow Anesthesia\nThis outstanding resource gives clinicians an opportunity to learn about the principles and practice of low-flow inhalational anesthesia via an interactive simulation module. |
CAT DENTAL SERVICES\n*performed under anesthesia*\nPlaque Removal, Cleaning & Polishing = $100.00\nTooth Extractions = $5.00 to $20.00 per extraction\n*depending on the difficulty of the tooth removal process*\nIV Fluids = $10.00\nAdditional Charges may also be applied for any prescription medications that are recommended.\nAll dental services are performed\nby appointment only.\nDental services can be performed during a\nSpay, Neuter or other Surgical Service.\nFull payment is required to schedule a dental appointment.\nPayments can be made over-the-phone or in person by Cash, Check or Credit Card.\nIn order to maintain our commitment to providing low-cost services to public pet owners,\nany person making a Credit Card payment will be required to pay an additional $5.00 convenience fee.\nNo Refunds if a cancellation is not made within 72 hours prior to your pet’s scheduled appointment.\nContact JCHS today\nto schedule an appointment for your Cat!\nJefferson County Humane Society\n200 Airpark Drive\nWintersville, Ohio 43953 |
What is a Dental Implant? Is It Right For Me?\nHave you ever had the dream where one or more of your teeth fall out? What do you do if you lose a tooth in real life?\nOne option is to get a dental implant. This is a procedure where an oral surgeon or periodontist surgically places an artificial tooth that’s surgically fused in the jawbone—a fantastic long-term option for tooth replacement. Decades ago, if you lost a tooth, your choices were a fixed bridge or removable dentures. Fixed bridges rely on neighboring healthy teeth as anchors, which can have a negative impact on them down the road. And, removable dentures can slip or make embarrassing clicking sounds when you speak.\nA dental implant—made of titanium metal—fuses to the jawbone, serving as the root of the missing tooth. Unlike fixed bridges, which may need to be replaced two and three times during a lifetime, implants are durable and rarely, if ever, need to be replaced.\nAdvantages of Implants:\n- They look good! Implants are aesthetically superior to bridges and dentures—they stay put and look like real teeth. You might even forget you ever lost a tooth!\n- They save adjacent teeth\nBecause implants don’t need to be anchored to the teeth next to them, they preserve the overall integrity of your healthy teeth. No more decay of otherwise sound teeth.\n- They build confidence\nRemember when Aunt Mable’s dentures clicked when she spoke? Or when Grandpa Manny pulled his out to show his gummy smile? You laughed, right? But there’s something embarrassing about the noise and slippage of dentures. With implants, you know they will remain firmly in place for decades.\n- They are reliable\nYou don’t have to worry about misplacing implants, unlike dentures. And, unlike bridges, you won’t have to replace them many times.\n- It’s a Process: What to Expect\nAn implant procedure is not a quick one. Here’s what will happen:\n• Complete dental exam. This may include X-rays and molds made of your mouth.\n• Treatment plan. You will work closely with your dental provider to create a treatment plan. Before the procedure, your provider will take into consideration the number of teeth that need to be replaced and the condition of your jawbone. After the procedure, you will be instructed on how to implant teeth should be cared for, which is essentially the same way as your regular teeth: brushing and flossing to avoid plaque.\n• Procedure. Placing dental implants involves several surgical procedures, which altogether can take three to nine months or more. It’s a lengthy journey, but much of the time is for healing and allowing new bone to grow in your jaw.\n> The dental implant cylinder is placed in your jawbone.\n> You will have a healing period of several months.\n> Once healed, an abutment is placed, followed by an implant prosthesis or crown.\n• Pain control during treatment. You will be given a form of anesthesia during the procedure (local or general anesthesia, or sedation. You should be sure that you have someone to take you home after the procedure. |
In order to provide the best care and avoid any last-minute cancellations, we require a medical history questionnaire to be completed. This is available online for your convenience and must be completed at least 24 to 48 hours prior to your scheduled surgical date.\n- Please complete all sections\n- If a section does not apply, please select the check box for “No Issues”\n- Be sure to include your complete medical history including current conditions, prescription and over-the-counter medications (past and present), past medical conditions/surgeries\nUpon receipt, someone from our team will call you regarding your appointment.\nOne of our insurance verification specialists will contact you if there is an anticipated out-of-pocket expense associated with your planned procedure. Please realize charges for your procedure at The Center for Advanced Spine & Joint Surgery are separate from your surgeon’s charge as well as any anesthesiologist* and/or pathologist charges which may be incurred.\nIf your procedure is not covered by insurance, full payment is required at the time of service unless other arrangements are made in advance.\nPatients – or their legal guardians – are ultimately responsible for payment of facility services at The Center for Advanced Spine & Joint Surgery. As a courtesy, The Center for Advanced Spine & Joint Surgery will bill your primary and secondary insurance carriers for you. Please bring your insurance cards with you on the day of surgery. We are required to collect all co-payments from our patients and we will call you to discuss any patient responsibility related to your co-payments. Such co-payments may include deductibles, co-insurance, or any non-covered items identified by your insurance plan.\nThe Center for Advanced Spine & Joint Surgery accepts cash, checks, any major credit card, a Flexible Spending Account (FSA), or a Health Savings Account (HSA) as a financing option. Feel free to contact our business office at 934-223-4500 Monday through Friday 8:30 AM to 4:00 PM with questions regarding your billing or insurance information. We will be happy to assist you.\n*Anesthesia services at The Center for Advanced Spine & Joint Surgery is provided by Long Island Anesthesia Physicians. Questions concerning their fees should be directed to their billing service at 1-866-787-4426 ext. 115 or visit https://lianesthesia.com/. |
Fractionated C02 Laser Resurfacing (Phoenix 15)\nPhoenix 15 Laser Resurfacing Treatments use the latest fractionated CO2 laser technology to achieve skin resurfacing & hand rejuvenation.\n- Acne & traumatic scars\n- Fine lines & wrinkles, especially those difficult to treat wrinkles around the mouth and eyes\n- Pigment irregularities (sunspots, “age spots”)\n- Uneven skin tone & texture this laser uses new fractionated CO2 technology that allows for concentrated beams of energy to penetrate the skin surface and actively remove the dead and damaged tissue without harming the surrounding area. The controlled skin injury stimulates new collagen production and skin tightening over time. Results are dramatic but come with about two weeks of recovery time. Topical anesthetic cream is applied at home prior to treatment. Additional local anesthesia, a cooling device, and sedation may be advised to maximize comfort during the procedure. While you will be able to return home immediately after your treatment, we usually advise that patients rest and avoid excessive sun exposure for a couple of days afterward. This will help accelerate the healing process.\nThe Phoenix 15 CO2 system uses Swift Scan technology to reduce wrinkles, age spots, dark spots, and sun damage on the hands and forearms to produce a fresh, younger look. This is a quick and well-tolerated procedure with minimal to no downtime and rapid healing. Typically this treatment is done in a series of 3 procedures spaced about one month apart.\nErbium Yag Laser Resurfacing\nErbium Yag is a state of the art laser treatment which is used to address fine lines & wrinkles, irregularities in skin texture, photodamage, and skin discoloration. Areas most commonly treated are the face, neck, and chest.\nErbium Yag treatments are a form of ablative resurfacing with some downtime. There is less downtime, however than with more aggressive CO2 laser procedures. Following an Erbium Yag procedure patients typically experience 3 to 7 days of peeling, itchy skin which may impact work or social activities.\nThe treatment lasts about 20 minutes. Most patients have mild discomfort during the procedure when a topical anesthetic cream is used prior to the treatment.\nWhile obvious results are normally seen after one treatment, a series of 3 treatments spaced 4+ weeks apart can yield excellent results.\nWhat Makes Us Unique?\n- Board Certified Dermatologists\n- Member of the American Society for Mohs Surgery\n- Skin Cancer Treatments Available\n- Skin Care Products Available\n- Comfortable and Professional Atmosphere\n- Friendly Staff Members\n- Cosmetic Services Done by Licensed Providers |
Friday, April 4, 2014\nOpioids for Chronic Low Back Pain? Results From the Latest Cochrane Review\nThe use of opioids in the treatment of chronic low back pain (CLBP) is controversial due to a lack of evidence regarding the efficacy and adverse effects associated with their use for this indication. Initially, opioids tended to be used only for patients with cancer pain or those with acute pain related to surgery or trauma, but the pendulum swung towards their use for chronic non-cancer pain in the 1990s. More recently, concern over long-term adverse effects such as tolerance, addiction, and overdose, not to mention abuse and diversion, has caused the pendulum to swing back against their use for chronic non-cancer pain. In an effort to add an evidence base to the discussion, Dr. Chaparro and an accomplished group of co-authors updated the Cochrane Review on the topic of opioids for CLBP, which was published in the April 1 issue. They included blinded RCTs comparing opioids to placebo or other medication in an outpatient setting for patients reporting CLBP (defined as greater than 12 weeks) with a follow-up period of at least 1 month. They included fifteen trials with a total of 5,540 patients that studied “strong opioids” (i.e. morphine, oxycodone, oxymorphone, hydromorphone, tapentadol), tramadol, and transdermal buprenorphine. Their meta-analyses indicated that there was very low to moderate quality evidence that strong opioids, tramadol, and transdermal buprenorphine led to more improvement in pain and function than placebo, with the best quality evidence in support of strong opioids and tramadol. There were few studies comparing opioids to an active control, and these did not show any significant benefit for opioids compared to celecoxib or antidepressants. Not surprisingly, opioids had a worse side effect profile than placebo and were associated with nausea, somnolence, dizziness, and dry mouth. No serious adverse events were reported.\nThe main conclusion of this review, that opioids were more effective than placebo for short-term treatment of CLBP, is not surprising. Opioids have strong analgesic properties in the short-term, and patient blinding may not have been very effective given the analgesic benefit from opioids as well as the significant side effect profile. The more pressing question is not if opioids are more effective than placebo in treating CLBP in the short term but whether or not opioids are more effective than alternative treatments in the long term. Given that long term opioid use is associated both with tolerance and decreased efficacy as well as potential adverse effects, it seems unlikely that the short term benefit and absence of serious adverse effects reported here would persist in the long term. The real question is whether or not opioids provide better long term outcomes than other potentially less risky alternatives such as anti-inflammatory medication and physical therapy. Now that there are serious concerns about the negative long term effects of opioid therapy, it is unclear whether a study comparing the long term outcomes between opioids and alternative therapies is ethical. Rather than performing such a study, it may simply be time for the spine community to abandon the use of strong opioid medication for CLBP and focus on alternative strategies that can hopefully be more effective and less dangerous.\nPlease read Dr. Chaparro’s article in the April 1 issue. Does this change you view about the role of opioids in the treatment of CLBP? Let us know by leaving a comment on The Spine Blog.\nAdam Pearson, MD, MS\nAssociate Web Editor |
English, Vietnamese, Chinese (Cantonese)\n"Diagnosis begins with active listening, followed by detailed examination, then focused testing that takes into account the burden on the family and the long-term risks associated with those tests, such as radiation and anesthesia. Only when the diagnosis is accurate and the natural history is explained well, can the patient and family join me in a joint decision on treatment that maximizes outcomes and minimizes discomfort."\nMedical School: Ohio State University\nResidency: University of Minnesota\nFellowship: University of Toronto, Hospital for Sick Children\nBoard Certification(s): Orthopaedics, American Board of Orthopaedic Surgery; RCS(C) (Orthopaedics, Canada) |
Category Archives: Dermabrasion\nWhat Is Dermabrasion?\nPublished on May 2, 2013 by\nDermabrasion is a minor surgical procedure in which the surface of the skin is removed in order to give the skin a smoother, more even look. The procedure usually requires a topical anesthetic and mild sedation, usually given orally approximately 30 minutes prior to surgery. The procedure is usually done to remove deep facial wrinkles, […] |
Full Mouth Reconstruction An Overview\nThe terms “full mouth reconstruction,” “full mouth rehabilitation” and “full mouth restoration” are often used interchangeably to describe the rebuilding or restoring of all the teeth in both the upper and lower jaws. People who need full mouth reconstruction have often been in serious accidents or suffered serious disease that cost them all or most of their teeth. Some patients think of full mouth reconstruction as a smile makeover.\nRestorative dentistry involves restoring the mouth to its natural appearance and health. Full mouth restorations typically require restorative dentists performing procedures like crowns, bridges and veneers, onlays and implant crowns. Some of the conditions that may lead to full mouth reconstruction include:\n- Decay or trauma that results in lost teeth\n- Injured or fractured teeth\n- Severely worn teeth as a result of long-term acid erosion (foods, beverages, acid reflux) or bruxism (tooth-grinding)\n- Ongoing complaints of jaw, muscle and headache pain\n- The need for bite adjustments (occlusion correction)\n"I have received thorough and professional treatment and customer service for over 20 years from Dr. Sowell and his staff! I totally trust Dr. Sowell and his staff to take care of my teeth and gums. They are always extremely…Joe G.\n"Dr Sowell and his staff are most outstanding. I tell everyone, when they complain about any number of things re their physicians and their dentists, that they should change to Dr. Sowell! Not only medical competence/excellence and technological advancement, but…Doris W.\n"This experience was my best dental experience! The results were A+. I only wish I had done all of my restoration work with Dr. Sowell. I've been very pleased with my results on my deep cleaning. The dental hygiene specialist…Micki S.\nFull Mouth Reconstruction What to Expect\nFull mouth reconstruction refers to the rebuilding of all your teeth and replacing missing teeth. This could range from veneers and inlays on all of your teeth to crowns, bridges and implants. In a badly broken-down tooth, this may include rebuilding the foundation of the tooth, treating the nerve health, gum and bone treatment and whatever else is needed to restore the teeth to health. Then porcelain crowns, porcelain veneers, onlays and bridges may be used to strengthen the teeth, restore function and create their outer appearance as well as replace missing teeth. In our office, we use all bonded ceramics whenever possible to give the most natural esthetic result.\nSometimes patients have very dark teeth and want a more attractive smile. They may have a tooth that falls into this category but they do not need all the preliminary work to get the tooth healthy and usable. Either way, we usually do all the work in our office, providing a turnkey service except for root canals. The patient usually selects oral sedation since the appointments are longer and the sedation makes the time go by uneventfully. If surgical procedures are needed, they can be done with the comfortable WaterLase MD laser. Plano, TX dentist, Dr. Sowell has been doing full mouth reconstructions for 20 years and uses all the techniques he’s learned from Dr. Frank Spear of Spear Education.\nFull Mouth Reconstruction Before & After\nThis gentleman came to our Plano TX dentist office, unhappy with crowns that had been placed by a general dentist. The crowns were poorly designed and dark along the margins. Dr. Sowell removed the faulty restorations and replaced them with empress and emax dental crowns. The result is extremely natural looking and also restores a comfortable bite position to the patient’s smile. |
Low doses of a common intravenous anesthetic may relieve debilitating pain syndrome\nHERSHEY, PA-Limited, low-dose infusions of a widely used anesthetic drug may relieve the often intolerable and debilitating pain of Complex Regional Pain Syndrome (CRPS), a Penn State Milton S. Hershey Medical Center researcher found.\n"This pain disorder is very difficult to treat. Currently-available therapies, at best, oftentimes only make the pain bearable for many CRPS sufferers," said Ronald E. Harbut, M.D., Ph.D., assistant professor of anesthesiology, Penn State Hershey Medical Center. "In our retrospective study, some patients who underwent a low-dose infusion of ketamine experienced complete relief from their pain, suggesting that this therapy may be an option for some patients with intolerable CRPS."\nThe study, titled "Subanesthetic Ketamine Infusion Therapy: A Retrospective Analysis of a Novel Therapeutic Approach to Complex Regional Pain Syndrome," was published in the September 2004 issue of Pain Medicine, the official journal of the American Academy of Pain Medicine.\nCRPS (type I), also known as Reflex Sympathetic Dystrophy Syndrome (RSD), affects between 1.5 million and 7 million people in the United States and is oftentimes marked by a severe, burning pain that can be very resistant to conventional therapies. The pain frequently begins after a fall or sprain, a fracture, infections, surgery, or trauma. Often present in the limbs with possible later spreading to other parts of the body, patients also may experience skin color changes, sweating abnormalities, tissue swelling, and an extreme sensitivity to light touch or vibrations. The McGill Pain Index rates CRPS as 42 on the scale of 50, with 50 being most severe.\nAlthough much is unknown about CRPS, the pain experienced by patients appears to be caused by over-stimulation of a nerve receptor complex involved in the process of feeling pain. Therefore, efforts have been made to treat CRPS by blocking these receptors. Whereas most pain medications do not effectively block these receptor complexes (often referred to as NMDA-receptors), ketamine does.\nThe study was initiated by Graeme E. Correll, B.E., M.B.B.S., and involved reviewing the medical records of 33 patients with CRPS treated by Correll. The patients, some of whom had failed to obtain pain relief from conventional therapies, were treated with low-dose inpatient intravenous infusions of ketamine between 1996 and 2002 in Mackay, Queensland, Australia. Ketamine infusions were started at very low rates and were slowly increased in small increments as tolerated by selected patients. The therapy was then continued as long as the patient tolerated the drug and continued to benefit from it. Treatment cycles generally continued until the patient experienced complete pain relief; until initially-obtained relief would not improve any further; or for no more than 48 hours if there was no improvement in pain severity.\nPain was completely relieved for 25 (76 percent) patients, partially relieved for six (18 percent) patients, and not relieved for two (6 percent) patients. Although the relief obtained did not last indefinitely, 54 percent remained completely pain-free for three months or more and 31 percent for six months or more. For 12 patients who received a second treatment, 58 percent experienced relief for one year or more with 33 percent remaining pain-free for more than three years.\nThe most frequent side effect reported was a feeling of inebriation. Hallucinations occurred in six patients with less frequent side effects including complaints of light-headedness, dizziness and nausea. Liver enzymes were altered in four patients but resolved after therapy.\nThe exact mechanism of sustained pain relief is unknown, but is currently under study at Penn State Hershey Medical Center. Harbut likened the ketamine treatment to the healing of a broken bone. "If someone breaks a bone and you simply put the two pieces back together, they won't immediately heal. However, if you add a splint and hold the bones steady for a period of time, and then later take away the splint the bone is healed. I believe that the ketamine treatment does something similar that lends support and allows the nerve cells to heal themselves, so that when you take away the ketamine, the pain is reduced or gone."\nHarbut began studying CRPS with Correll during a work assignment Harbut volunteered to take in far northern Queensland, Australia, in the late 1990s. Correll was developing a therapy for CRPS but wanted a collaborator to formally research the effectiveness of the therapy. Harbut brought Correll's method back to the U.S. where he developed an FDA-approved study protocol (used at the Mayo Clinic Scottsdale) using this method to attempt to treat post herpetic neuralgia, another pain disorder with symptoms somewhat similar to CRPS. At the same time, Harbut met a patient who had suffered with intolerable CRPS for nine years who wanted to try this new therapy. That patient became the first successful treatment of intractable CRPS in the U.S. (A Case Report of this treatment appeared in the June 2002 issue of Pain Medicine.)\n"Ultimately, we want to find a way to improve the quality of life for those who suffer with intolerable CRPS, some of whom at times contemplate suicide because of their endless pain," Harbut said. "Although optimistic about these early findings, certainly more study is needed to further establish the safety and efficacy of this novel approach." (A large clinical study is currently planned and under development at Penn State Hershey Medical Center.)\nIn addition to Harbut and Correll, the team involved in this study included: Jahangir Maleki, M.D., Ph.D., and Edward J. Gracely, Ph.D., Drexel University College of Medicine; and Jesse J. Muir, M.D., Mayo Clinic Scottsdale.\nSource: Eurekalert & othersLast reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009\nPublished on PsychCentral.com. All rights reserved. |
Overview Fairview Ridges Hospital, located in Burnsville, Minnesota is looking for a Registered Nurse to join our busy Perianesthesia team. We perform approximately 10,000 surgical cases per year in out 14 OR rooms using the latest in technology. Our team of nurses and techs/nursing assistants work closely with multiple disciplines to provide a patient and family centered experience. With our strategic location just south of the Minnesota River, Ridges Hospital promotes the health of surrounding communities and continues to experience growth. The open position is Benefit Eligible position at a .6 FTE (48 hours in two weeks), and is 8 hour rotating shifts with varied start times. Monday- Friday. The position includes some night call approx\nThis job listing is no longer active.\nCheck the left side of the screen for similar opportunities.\nLoading. Please wait.\nCase Management Society of America 5034A Thoroughbred Lane Brentwood, TN 37027 |
Decisions taken by the Palestinian Cabinet during its session No. 153.\n1. Ratification of the direct purchase of anti-snake and Ant-scorpion drugs (Antisnake+Antiscorpion).\n2. Approval of allocating funds to treat stone saw asthma in the city of Hebron.\n3. Ratification of the formation of the Board of Directors of the Cooperative Work Agency.\n4. Formation a committee in each governorate to follow up and account for encroachments and attacks on state lands.\n5. Formation of a committee to develop an action plan to be facing settlement expansion in Salfit Governorate.\n6. Formation of a ministerial committee to select the Undersecretary of the Ministry of Social Development, headed by the Minister of Social Development.\n7. Approval of granting funds to a number of non- profit companies.\n8. Approval of granting a number of purchase permits to individuals as well as companies to possess immovable properties.\n9. Approval of contracting with “Dr. Ishaq Zuhdi Muhammad Edkaidek” as anesthesiologist and resuscitation specialist, to work at Jericho Governmental Hospital.\n10. Referral on early retirement for a number of civil servants upon their request.\nSubmission to H.E the President of the State of Palestine to allocate a land from “Surda Village” in Ramallah, for the benefit of the Ministry of Foreign Affairs |
As part of the natural aging process, many people start to experience sagging skin and fat deposits in their neck and jaw line areas, problems which are traditionally addressed through facelift surgery. However, a lot of potential patients hesitate to get a facelift because they worry about looking too pulled and going through a long and painful post-operative healing period.\nIn response to the patients request for a younger, natural-looking appearance that doesnt take significant time away from their busy schedule, the “weekend facelift” was developed. This is a revolutionary new technique that offers a simpler and less invasive alternative to the traditional facelift.\n“Weekend facelift generally implies limited face contouring procedures like liposuction and skin tightening in the neck, jowl and chin area which heal in a few days with few recovery problems. While it does not have the same extensive results as a full surgical facelift, the weekend facelift allows people to go back to work quickly and reduces the risk of complications. In fact, a patient can have the procedure performed on a Friday and then return to work the following Monday hence the name weekend facelift.\nThe weekend facelift is usually performed on an outpatient basis, with the surgery lasting one hour or less. It is done under local anesthesia, which makes it much safer than surgery performed under general anesthesia, like the full facelift. During the surgery, the doctor makes a minimal incision hidden in the natural fold of the chin. Through that incision, excess deposits of fat are suctioned from the neck, which causes the skin to contract and tighten. If necessary, this can be accompanied by a tightening of the muscle and the placement of a chin implant, which creates a more chiseled profile.\nAs opposed to conventional facelifts, which can result into undesirable scars and a plastic look, the weekend facelift leads to a natural, rejuvenated appearance without any visible scars or the look of major surgery so the procedure can be kept totally private if desired.\nThe short recovery period after the procedure is accompanied by little or no pain, while swelling and bruising if occurring at all are minimal.\nDespite these advantages, the weekend facelift is not for everyone. Though it will result into a more youthful appearance of the face, the procedure addresses mainly the lower face area, and is best suited for patients with a heavy neck, undefined jaw line, or double chin. The weekend facelift cannot correct specific problems like sagging muscle structure, nasolabial folds or folds in the middle third of the face. Also, the procedure is recommended for people who are experiencing early signs of facial aging and have relatively good skin elasticity.\nHere is an overview of the major differences between the weekend facelift and the traditional facelift procedure:\ngenerally used for patients with poor skin elasticity\ntightens all major skin areas of the face\nsurgery takes about 3 hours\nincisions in and about the ear creases\ncost varies by work done, may range from $7,000 to 12,000\nfee is for surgery, anesthesia & operating room\ngenerally lasts 5 to 10 years\nbest candidates have good skin elasticity\naffects mainly the lower area of the face\nsurgery takes about 1 hour\nsmall incision under the chin\nback to work in a few days\ncost varies by procedures, ranging from $4,000 to $6,000\nlength of time it lasts depends on different factors affecting ones individual skin elasticity\nA weekend facelift can provide you with a rejuvenated and radiant appearance, bringing out a younger and dramatically improved self. If you have questions about this procedure, dont hesitate to talk to a qualified cosmetic surgeon, who can provide further advice and guidance. |
Small Animal Surgical Nursing - Elsevier eBook on VitalSource (Retail Access Card), 4th Edition\nElsevier eBook on VitalSource - Access Card\nHelp your students master the veterinary technician's role and skills in surgical assisting! Small Animal Surgical Nursing, 4th Edition describes the protocols and techniques a vet tech needs to work together with the veterinarian as a smoothly functioning surgical team. Clear guidelines are provided in areas such as surgical instruments and procedures, anesthesia, patient monitoring, preoperative and postoperative care of the animals, pain management, and client education. Updated throughout, and with exceptional teaching and learning resources on the Evolve website, this comprehensive resource ensures that students are highly competent in performing all of the vet tech’s surgical responsibilities. |
Skilled Surgical Solutions for Tigard Area Pets\nThere are few times a pet owner feels more helpless than when a pet needs surgery. At Community Pet Hospital, we understand your concerns and offer our compassion, skill, and expertise to bring your pet back to optimal health when surgery is necessary. Our veterinarians have over 20 years of experience and are skilled in a wide variety of veterinary surgeries.\nWhat to Expect From the Surgical Procedure\nPrior to surgery, your pet will typically undergo complete pre-anesthetic blood tests. These tests are critical for determining any underlying ailments that may have gone undetected. With a simple neuter, we do not require pre-anesthetic for a healthy younger dog. Once we are assured your pet is well enough for anesthesia, we go forward with the surgery. The day of your pet’s surgery, we administer sedation to keep your pet calm and comfortable during the pre-op preparations. The anesthesia is increased once the surgery is underway. Throughout your pet’s surgery, a technician monitors all his or her vital signs closely and keeps the veterinarian apprised of any changes. We also use a heated surgical table during the surgery, which not only reduces stress but also ensures your pet stays warm and comfortable while maintaining a healthy temperature.\nPain management is incredibly important to us, as we know that a pain-free animal is a happy animal. Once your pet is well enough to leave the hospital, we send medication to ease his or her pain at home and help facilitate a speedy recovery for your furry friend. Our on-site pharmacy offers the convenience of filling your pet’s prescription without any extra stop on the way home. We also send home detailed post-surgical instructions. If you have questions, our staff is available to address your concerns. Please feel free to call us anytime.\nTraditionally, veterinarians use standard surgical tools, but advancements in technology allow us to bring state-of-the-art tools to the surgery suite. Our facility is equipped with the most modern equipment available, including our surgical laser and respirator, as well as body temperature, EKG, blood pressure, and oxygen percentage monitors.\nThe surgical laser offers many advantages, and we recommend laser surgery for the following:\n- Ear and eyelid surgery\n- Tumor removal\n- Oral surgery\nLaser surgery is widely used in the most advanced of veterinary hospitals because it not only reduces healing time for your pet but also reduces bleeding and pain. In situations where laser surgery is not an option, we recommend traditional surgery. Our veterinary surgeons are well qualified for the following surgeries:\n- Soft tissue, including masses or tumors\n- Foreign body removal\n- Airway obstruction\n- Dental surgery\n- Wound repair\n- Emergency surgery\n- Cosmetic breed specific modifications\n- Gastrointestinal (GI)\n- Oncology surgery\n- Cesarean section\nRest assured, the staff at Community Pet Hospital will closely monitor your pet before, during, and after any surgical procedure. Our ultimate goal is to ensure your pet is back to his or her normal, happy, healthy self as quickly as possible. |
Having unnecessary fat in various areas of your body can have a substantial effect on your health and self-confidence. While standard weight reduction through workout and diet plan is an excellent method to reduce weight in general, even the very best exercises can't target problem locations like the stomach, inner thighs, arms, and butts. Liposuction is a time checked treatment that is utilized to eliminate excess fat from specific locations of the body, allowing an individual to form and contour their body to their liking. Is liposuction right for you? Find out now.\nPros of Liposuction\nThere are numerous benefits to this cosmetic treatment, consisting of:\n• Instantly visible modifications. Unlike traditional weight reduction, liposuction produces changes that are immediately visible in the body. Some difference is noticeable immediately, and the preferred outcomes are generally achieved in simply a couple of days.\n• Proven and safe. This cosmetic procedure has actually been performed by experienced cosmetic surgeons all over the world for years and the strategy has actually been improved over and once again to be safe and effective.\n• Healing time is usually quick. The downtime required after having this kind of procedure is typically much less than exactly what is needed for other types of cosmetic treatments, including abdominoplasty, breast reduction, and more. People who have had the treatment can often go back to work much more rapidly than they prepared for and can return to living a healthy, active way of life.\n• Weight loss can be irreversible. With the best upkeep strategies, the fat that was eliminated during the liposuction procedure will not return.\n• Complete control over your body. With liposuction, an individual can have complete control over how they wish to look, beyond exactly what traditional diet and workout can supply. Offering people this power over their bodies increases self-confidence and assistance individuals feel their best.\nWhile there many benefits to liposuction, there are obviously a couple of cautions that should be considered before making the final decision to move forward with the treatment.\nCons of Liposuction\nPrior to having liposuction done, it is very important to analyze the potential drawbacks of the procedure and figure out if the benefits outweigh the dangers in your specific case. Your cosmetic surgeon can assist you find out more about the dangers connected with the treatment and can help you decide if moving on is the right thing for you.\n• Issues with general anesthesia. Since liposuction is carried out under general anesthesia, the procedure brings the same threats as other kind of surgical treatment where general anesthesia is utilized. Underlying medical conditions may increase these risks.\n• Unfavorable reactions. Bruising, bleeding, and pain are all to be anticipated, however, in uncommon cases can cause more substantial issues.\n• The prospective to acquire the weight back. After having liposuction done, it is critical to maintain a healthy diet and workout effectively as suggested by your physician. Failure to do so could result in gaining back the weight that was lost or perhaps much more.\nThere are dangers associated with liposuction, for lots of people, the advantages far exceed them. Educate yourself about the procedure by having in-depth discussions with your surgeon and think about how liposuction has the prospective to affect you as a special person. Just you and your cosmetic surgeon can identify if liposuction will offer you with the results you are trying to find within your expectations.\nLaser Liposuction procedure is a new non invasive procedure to loose unwanted bodyfat in Zenda Wisconsin\nLaser liposuction is a newer, minimally invasive procedure that includes heating the fat cells to melting point and getting rid of the melted fat through a small cannula. The treatment is generally done right in your physician's workplace and is an exceptional alternative for individuals who have less than 500 ml of fat to remove from any one area. Laser liposuction can be a safe, complementary procedure to weight reduction in order to sculpt the body you've always desired.\nContact a Cosmetic surgeon in your Zenda Wisconsin today.\nIf you're thinking about liposuction as a weight reduction solution, it is very important that you discuss your desires with a certified plastic surgeon in your area. Your cosmetic surgeon will carry out a complete examination and health history survey to identify if liposuction can benefit you and help you reach your physical and psychological objectives. Call today for an assessment and learn more about how liposuction can help you accomplish the body of your dreams. |
Intraoperative and Post-operative Analgesic Effect of IV Acetaminophen for Sinus Surgery (IVAPAP)\nThe purpose of this study is to assess the use of IV acetaminophen (Ofirmev) as a and safe and efficacious agent in reducing post-operative pain; we hypothesize that its use will reduce post-operative pain by 50% when compared to a control group using the VAS analog pain scoring system.\n|Study Design:||Allocation: Randomized\nEndpoint Classification: Efficacy Study\nIntervention Model: Parallel Assignment\nMasking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor)\nPrimary Purpose: Supportive Care\n|Official Title:||A Double Blind, Randomized, Placebo-controlled Study to Investigate the Effectiveness of IV Acetominophen Administered During Functional Endoscopic Sinus Surgery in Reducing the Use of Opiates to Treat Postoperative Pain|\n- Assess the efficacy of IV acetaminophen in controlling postoperative pain [ Time Frame: 4 Hours Post-Operatively ] [ Designated as safety issue: No ]Pain will be assessed using a VAS Scale at regular time intervals post-operatively.\n- Investigate the effect of IV acetaminophen on the use of postoperative opioid analgesics [ Time Frame: During PACU Stay (Approximately 4 hours) ] [ Designated as safety issue: No ]The total amount of postoperative opioid use will be recorded as follows: after the patient has arrived in the PACU (post anesthesia care unit), the incidence and intensity of pain will be assessed using a VAS (0-100) as described above. Pain relief will be achieved by incremental doses of morphine 1 mg bolus, based on a VAS score of 40 and above, to be repeated every 5 minutes if needed. The total amount of morphine utilized in PACU will be recorded.\n- Analyze effects of IV acetaminophen on intraoperative analgesic use [ Time Frame: Duration of Surgery (Approximately 3-4 Hours) ] [ Designated as safety issue: No ]Brief episodes of tachycardia and hypertension are expected in FESS procedures. These will be treated by increasing inhalational agents of 0.5% inspired fraction at a time. A supplemental dose of fentanyl in the amount of 1 mcg/kg will be available for HR and BP greater than 15-20% above baseline after no response to volatile change. The following measurements will be recorded: total amount of fentanyl utilized; the hemodynamic parameters during surgery and anesthesia; the inspired fraction of inhalational agent; and the number of step-wise increases for hemodynamic control.\n- Identify potential correlation between vital signs and postoperative pain intensity [ Time Frame: Duration of PACU Stay (Approximately 4 Hours Post-Operatively) ] [ Designated as safety issue: No ]The association of postoperative pain intensity with vital sign changes (including heart rate, respiratory rate, blood pressure, and temperature) will be assessed. Each patient's vital signs will be collected at the specified time points, in addition to measuring pain intensity using the VAS scale. Data will be collected and analyzed to search for a statistical correlation between postoperative pain intensity and vital sign changes.\n- Examine the effect of IV acetaminophen on post-operative quality of recovery [ Time Frame: Upto 48 Hours Post-Operatively ] [ Designated as safety issue: No ]\nAdverse events including, dizziness, nausea/vomiting, tachy/brady-cardia, arrhythmia, hypertension, hypotension, allergic reaction, etc. will be monitored.\nA questionnaire evaluating quality and efficacy of pain management will be given to the patient before discharge. A telephone interview will be administered within 48 hours from discharge to assess for pain control, utilization of analgesics, and patient satisfaction\n|Study Start Date:||July 2012|\n|Estimated Study Completion Date:||December 2013|\n|Estimated Primary Completion Date:||December 2013 (Final data collection date for primary outcome measure)|\nExperimental: IV Acetaminophen\nThe experimental group will receive a preoperative dose of 1000mg IV acetaminophen over 15 minutes. This will occur at least 15 minutes before the start of surgery. Another 1000mg dose of IV acetaminophen will be administered 4 hours after the first dose. A rescue analgesic containing oxycodone will also be provided (with APAP concentrations of 325 mg per Hospital and FDA recommendations).\nDrug: IV Acetaminophen\n1000mg IV acetaminophen over 15 minutes every 4 hours for up to 2 doses.\nOther Name: OFIRMEV (Cadence Pharamceutical, San Diego, USA)\nPlacebo Comparator: Control\nThe control group will receive 100 mL of 0.9% normal saline in place of IV acetaminophen in the same manner as the experimental group; the investigator/physician in question will be blinded to the agent that is being administered. Patients will be discharged with instruction to continue APAP 500 mg PO every 6-8 hours. A rescue analgesic containing oxycodone will also be provided (with APAP concentrations of 325 mg per Hospital and FDA recommendations).\n100 mL of 0.9% normal saline over 15 minutes in place of IV acetaminophen.\nOther Name: Normal Saline\nShow Detailed Description\n|Contact: Davide Cattano, MD, PhD||(713) [email protected]|\n|Contact: Faramarz Ashoori, MD, PhD, DMS||(713)[email protected]|\n|United States, Texas|\n|The University of Texas Health Sciences Center at Houston||Recruiting|\n|Houston, Texas, United States, 77030|\n|Principal Investigator: Davide Cattano, MD, PhD|\n|Sub-Investigator: Amber Luong, MD, PhD|\n|Sub-Investigator: Martin J Citardi, MD|\n|Sub-Investigator: Samer Fakhri, MD|\n|Sub-Investigator: Matthew A Tyler, BA|\n|Principal Investigator:||Davide Cattano, MD, PhD||The University of Texas Health Sciences Center at Houston| |
Pick-up time will be the day after surgery at 7:30 am.\nAll cats must be in separate carriers. Cardboard carriers may be purchased for $10.\nNo food or water the morning of surgery.\nPaper proof of current Rabies is due at the time of drop-off. If your animal(s) is not current, we are required by state law to give them a Rabies vaccine for $10. We are unable to accept medical history or receipts as proof of Rabies vaccine, it MUST be a signed Rabies Certificate. We are otherwise required to administer one at the time of surgery for a charge of $10. This Rabies Certificate must be present at the time of check-in and cannot guarantee that there will be time to wait for you to obtain this document once your animal has checked in.\nIf an animal is not picked up at their scheduled pick up time, a $30 late fee will be charged. If they are not picked up by the end of the day we will have animal control pick the animal up and take them to the shelter.\nA feral cat is a wild/stray/community cat that is not kept as an inside pet and roams outside. It must be brought in a metal humane trap and will be ear tipped.\nIf a domestic cat becomes fractious while at our clinic, we require that the cat be sent home in a humane trap which requires a $40 deposit. This deposit is refunded if the trap is returned to us within 2 weeks. For liability reasons we are unable to allow clients to transfer their cats from a trap to their carrier on our property.\nAnimals requiring additional sedation, nursing or any life saving measures will be charged an additional $10 Extended Supportive Care.\nAny patient with fleas will be given a $5 24-hour treatment.\nWe recommend pain medication and e-collars for all of our surgical patients. There are additional charges for these listed above. Please select these options during check-in.\nAnimals 8 Years old or older require pre-anesthetic blood work prior to scheduling a surgical appointment. $60-$85 depending on the pet's age. |
NetWellness is a global, community service providing quality, unbiased health information from our partner university faculty. NetWellness is commercial-free and does not accept advertising.\nWednesday, August 20, 2014\nWhat is Pseudocholinesterase?\nAfter an operation on my 3 year old son a long time ago, he could not walk up. Only after 24 hours he woke up well enough to open 2 eyes and answer us. The operation was performed in Greece, in a private clinic. We arrived at 10 hrs and the operation was done at 14 hrs. They informed us that his "pseudo-cholesterini" were in quantity but of bad quality. Their message was that my son will probably not wake up from the next surgery. Therefore cannot be operated again.\nMy son is now 11 years old, healthy and very lively. Until now no surgery was anymore nessecary but my question is about the pseudo-cholesterinesterase that plays a role in the waking up after a surgery. For a long time now I`m trying to find information about that enzyme or hormone. Unfortunately nobody till now knows the Latin-translation of the greek phrase (including help of local doctors here in Greece.) Could you be so kind to inform me about this problem or at least inform me what the latin or english phrase for this pseudo-cholesterinesterase is?\nIn the worst case that my son has another operation, I can at least inform the doctor about it. Thank you in advance for your assistance.\nThanks for your interesting question.\nThis is not a difficult problem to understand or to deal with, despite the problems you have had getting more accurate information.\nPseudocholinesterase, or plasma cholinesterase, is an enzyme made by the liver and present in the bloodstream. This enzyme is important only if you are given the drug called succinylcholine. Succinlycholine is a drug that causes paralysis, which allows the insertion of the breathing tube that is often essential for the safe conduct of anesthesia and surgery. (Don't try this at home!). The pseudocholinesterase that is normally in your bloodstream breaks down the succinylcholine quite quickly so that the effect usually lasts only about 5 minutes.\nAs far as I know there is no evidence that pseudocholinesterase has any other function in the body. So people deficient in pseudocholinesterase have no problems related to this deficiency until they are in the operating room and given the drug succinylcholine. This is rather strange but some say is proof that God, or nature, intended there to be anesthesiologists!\nMore detail: the quantity and quality of pseudocholinesterase in the body depends on genetics (genes, heredity). Both the amount and the quality of the enzyme can be measured in specialised laboratories. It is useful to have this information if your son has to have surgery in the future. It is not essential however because there are fortunately other drugs that can be substituted for succinylcholine. It is totally untrue that a person with pseudocholinesterase deficiency cannot have surgery.\nThe important thing is to have the problem named - written down preferably. The best place to write it down is on a bracelet or necklace that is worn permanently. In the United States an organization called MedicAlert offers these, as well as a system for recording the relevant medical information for retrieval in an emergency over the phone or internet. I am sure there are other such services in Europe and elsewhere.\nFinally, even if succinlycholine is given to a person with the enzyme deficiency, this should not be life-threatening at all. It is simply necessary to continue to support the person's breathing (and keep them asleep) until the effect of the succinlycholine wears off by itself. This can take as long as 8 hours or more, but it does, definitely, wear off eventually.\nGareth S Kantor, MD\nAssistant Professor of Anesthesiology\nSchool of Medicine\nCase Western Reserve University |
Sparrow Carson Hospital's Infusion and Chemotherapy Center features comprehensive care close to home with seven new beds, a chemotherapy center, infusion therapy, transfusion therapy, and other outpatient therapy.\nThe Center is under the leadership of Sparrow Carson Hospital’s Director of Medical Oncology Services, Usha Sree Chamarthy, MD.\nAll chemotherapy can now be done on-site at Sparrow Carson Hospital, with radiation oncology offered at Sparrow. Oncological surgery, chemotherapy, radiation, and drug therapies are the best treatments for cancer.\n"We have a wonderful staff here, and we all focus on giving each patient the compassion and understanding we’d expect for our own loved ones," said Nancy Seals, RN, BSN.\nSparrow Carson Hospital’s Infusion and Chemotherapy Center focuses on much more than chemotherapy services. "We often work with physicians to provide IV therapy for patients with health issues such as rheumatoid arthritis and Crohn’s disease," said Seals.\nThe Infusion and Chemotherapy Center also provides PICC line placements, conscious sedation recovery, blood transfusions, IV iron therapy, IV hydration therapy, antibiotic/steroid therapy, IV medications for diseases such as osteoporosis, multiple sclerosis, rheumatoid arthritis, Crohn’s disease, immune deficiency and much more.\nAny of these therapies can be ordered by any physician or specialist, regardless of where that physician’s office is located and regardless of whether or not they are on staff at Sparrow Carson Hospital. This includes physicians from Mayo Clinic, Cleveland Clinic, and University of Michigan. Just ask your physician to call us at 989-584-3971 ext. 379 to discuss the referral.\nThe Infusion and Chemotherapy Center is open Monday-Friday, 8 a.m. to 5 p.m. and in the evenings and on weekends by appointment. Call 989-584-3971 ext. 379 or fax 989-584-0130.\n- State-of-the-art seven-bed facility located inside Carson Hospital\n- Chemotherapy services\n- Infusion therapy\n- Transfusion therapy\n- Conscious sedation recovery\n- IV hydration therapy\n- Antibiotic/steroid therapy\n- Doctor consult services\n- Personal TVs in each therapy room |
Letter of Advice: Anxious About Getting Septoplasty Surgery?\nAdmittedly, this is a rather niche blog post. But I think it’s a necessary one. I have panic disorder and I recently had septoplasty surgery.\nIf you’re in the same boat, I have advice for you. What follows is my “if I could turn back time” wish list. I hope you find it useful as you prepare for your surgery and work toward reducing your anxiety about the procedure:\n1. Ask your surgeon lots of questions. I didn’t find the proper balance between knowing and NOT knowing what I was getting myself into. At my final pre-op appointment, I should have asked questions about how long the recovery period would take, how much bleeding might occur after the surgery, and the nature of each post-op follow-up visit.\n2. Avoid Google. Yes, you’ve probably already Googled “septoplasty anxiety” if you’ve found this blog post. But don’t dig too deeply. One of my biggest regrets was reading blog posts about septoplasty horror stories. It only amped me up and created more fear than necessary for what my surgeon advised me would be a safe and simple procedure.\nTalking to your surgeon > looking at the big bad internet.\n3. Practice breathing out of your mouth for a day prior to the surgery. If they pack your nose, you WILL have to spend at least 24 hours breathing exclusively out of your mouth. This is a pain in the ass for many reasons, but for those of us with anxiety issues, it can really disrupt what feels like the natural flow of breathing.\nI kept hyperventilating when my nose was packed, which further revved up my nervous system, and led to a very high anxiety level. If you can learn to mouth breathe slowly and calmly before your procedure, you will be better prepared than I was.\n4. Treat your body kindly in the week leading up to your surgery. General anesthesia knocked the crap out of me in a very pronounced way. For three days following my surgery, I shook like a leaf almost constantly. My nose and my head hurt, so I didn’t get much sleep, either. If I had prepared myself by getting a good night’s sleep for the week leading up to surgery, I feel like I’d have been better able to handle the post-op discomfort.\n5. Buy a humidifier. You’ll need it. Or, schedule your surgery for a time of year that tends to be humid where you live. (Yeah. I scheduled mine for December and I’ve been hugging my humidifier ever since.)\n6. Identify anything about the hospital environment that might be triggering, and work on de-sensitizing yourself to those triggers well in advance of your surgery. I hate hospitals, so even walking into the hospital made me feel anxious.\nMy other unanticipated surgery-day triggers included the following: wearing a hospital gown, having to relinquish all of my “safe items” to my husband in the waiting room, dealing with my uncomfortably empty stomach, getting the catheter inserted into my wrist, and anesthesiologists inserting vials into the catheter without telling me exactly what they were doing.\n7. Prepare some post-op distractions. Do uncomfortable physiological sensations cause you to get very anxious or panic? After my surgery, I was in a recovery room for about an hour before they released me to a secondary recovery room where I could re-unite with both my husband and all of my belongings. I was a miserable post-anesthesia wreck: my nose was stuffed with painful packing, I was nauseous, and I could hardly feel my legs.\nTwo things that I was grateful to have: a pen (so I could mindlessly draw in an attempt to urge the time to roll by) and my iPad. Yes, the hospital had WiFi. Yes, I used Netflix to watch some mind-numbing sitcoms as the anesthesia wore off. It really helped to focus my attention on the external world (and not my body). I wish I’d had some sort of puzzle book, too. Something about working on simple word games tends to calm and focus my mind.\n8. Plan to take some time off for recovery. I’d honestly expected that, three days after the surgery, I’d be blogging again and preparing for the classes I’m teaching in the spring semester. Oh, and celebrating the holidays.\nRecovery definitely took some time. Do your best to tie up any loose ends at work before taking time off for your procedure. Then, allot yourself enough recovery time. Now, the definition of “enough” might vary from person to person, but I didn’t feel capable of doing anything work-related for at least a full week. I couldn’t work (which involves reading and writing, mostly) at my normal level of productivity until about two weeks after my surgery. You’ll feel better knowing you have a sizable window of time during which to recover, so plan ahead to make that happen.\nIt’s been one month since my surgery, and I don’t regret it. I do, however, regret not prepping myself to handle some of the anxiety-triggering experiences I’d encountered both pre- and post-op. Proper mental preparation can put you in a much better place than I!\nBeretsky, S. (2013). Letter of Advice: Anxious About Getting Septoplasty Surgery?. Psych Central. Retrieved on February 12, 2016, from http://blogs.psychcentral.com/panic/2013/01/letter-of-advice-anxious-about-getting-septoplasty-surgery/ |
- State board veterinarian named association president-elect\n- INDIANAPOLIS — Depending on one's career choice, there usually is a professional organization with the objective of helping and promoting individuals within that career.\n- Auburn veterinarians perform surgery on Kentucky Derby winner\n- Two College of Veterinary Medicine faculty members were part of a medical team that performed surgery last month on Kentucky Derby-winning horse War Emblem. Dr. Hui-Chu Lin, a professor of large animal anesthesia, and Glen Sellers, a clinical faculty ...\n- Veterinarians euthanize 14-year-old giraffe at Erie Zoo\n- ERIE, Pa. (AP) - A 14-year-old reticulated giraffe has died at a northwestern Pennsylvania zoo. Erie Zoo officials tell the Erie Times-News (http://bit.\n- Veterinarians check horses for travel after quarantine lifted\n- Now that the horse quarantine has been lifted at the Sunland Park Racetrack, veterinarians have been examining the animals set for travel. Dr. Paul Jenson from the Jenson equine hospital right in front of the racetrack has been examining horses, ...\nVeterinarians is described in multiple online sources, as addition to our editors' articles, see section below for printable documents, Veterinarians books and related discussion.\nSuggested News Resources\nRelated searchessalamander arcade game gameplay\ngiants causeway formation |
About Root Canal Therapy\nWhen a tooth becomes infected it has usually begun deep in the root, or pulp of the tooth. In these situations the infected nerves need to be treated. Board-certified Dentist, Dr. Todd McCracken, and the dental team here at Laser Smile Studio in Denton, TX refers to this treatment as root canal therapy. Root canal therapy is an extremely common dental procedure during which the tooth's infected pulp is extracted and replaced with a dental compound. If the infected tooth is left untreated, it can become abscessed and could result in the loss of the tooth. Dr. McCracken can perform root canal therapy quickly and efficiently with the use of our advanced technology while causing very little soreness afterward. If you believe root canal treatment could provide the pain relief you're looking for, contact our front office staff today to set up a consultation.\n"On time is important and you deliver on time se... - On time is important and you deliver on time service"- L.M. / SmileReminder / Aug 30, 2018\n"Professional, detail and very thorough with the care of your dental needs! No pressure to do something I dont want to do! A genuine caring heart felt concern which I really desire! Highly rcommend!"- C.G. / Google / Aug 26, 2018\n"Very skilled and knowledgeable Dentist; who use... - Very skilled and knowledgeable Dentist; who uses the latest and best techniques to create confidence and trust in each patient. Dr. McCracken's staff are equally compassionate and friendly each time I walk into the office or talk with them by phone. The whole office atmosphere is one of confidence and friendliness."- M.C. / SmileReminder / Aug 25, 2018\n"Great, knowledgeable staff. First time experience was amazing."- A.P. / SmileReminder / Aug 23, 2018\n"Excellent service since 2011 - I have been a regular patient of Laser Smile Studio since June of 2011. I had to have extensive work done including laser treatment of the gums, a root canal and several crowns, so it was scheduled out over the next three years. Since completion of this major work I have continued to return for routine cleanings and other maintenance including the recent addition of a bridge. I have been well pleased with both the results and with the way I have been treated by everybody at the clinic."- E.B. / SmileReminder / Aug 22, 2018\nWhat to Expect\nA root canal is usually performed with local anesthesia to numb the teeth and gums. Heavier sedation can be added upon the request of the patient. During the procedure, Dr. Todd McCracken, will remove the pulp from the infected tooth/teeth and replace it with filling material. It is strongly recommended that a dental crown is applied to the tooth as well, to aid in the longevity of the therapy. Some patients are at higher risk of developing an infection (usually patients with heart problems like congenital defects and artificial heart valves), so Dr. McCracken may prescribe a round of antibiotics before and after the root canal treatment.\nIf only local sedation is used, you will be able to drive yourself and recover at home, but some sedation options may require you to have a responsible adult pick you up. Patients may have temporary numbness or minor discomfort, which can usually be treated with an over-the-counter painkiller. If a temporary crown was placed over the tooth, the permanent crown will be placed and fitted at a separate appointment. After a root canal, oral care including brushing, flossing, and routine visits to Laser Smile Studio are important to maintaining the health of the treated tooth/teeth.\nIn some cases, a patient may need continued dental work after an initial root canal. While this is rare, Dr. McCracken is experienced in treating these types of cases. There are two post-treatment options that Dr. McCracken may suggest:\nWith proper care, most teeth that have had endodontic (root canal) treatment can last as long as other natural teeth. Root canals performed by endodontists (root canal specialists) have a 95% success rate. In some cases, however, a tooth that has received endodontic treatment fails to heal. Occasionally, the tooth becomes painful or diseased months or even years after successful treatment. As occasionally happens with any dental or medical procedure, a tooth may not heal as expected after initial treatment for a variety of reasons:\n- Narrow or curved canals were not treated during the initial procedure.\n- Complicated canal anatomy went undetected in the first procedure.\n- The placement of the crown or other restoration was delayed following the endodontic treatment.\n- The restoration did not prevent salivary contamination to the inside of the tooth.\n- In other cases, a new problem can jeopardize a tooth that was successfully treated.\nAn apicoectomy is performed after an unsuccessful root canal. When an infection will not go away or returns after a root canal has been performed this procedure is usually necessary. There are many nerves that may contain the infected tissue, so it is difficult to ensure that all of the infection is removed during a root canal. During an apicoectomy, the tip of the root of the tooth is removed and replaced with a filling.\nIn most cases, a second root canal is considered before an apicoectomy since it is a simpler, less invasive procedure. Before the apicoectomy begins you will be given a local anesthetic to numb the area. The doctor will start by making an incision in your gum to expose the root of your tooth. Any inflamed tissue will be removed to clean out the area. The surgery takes place in a very small area, and only a few millimeters are removed from the root. For this reason, the doctor will use magnification and small precision instruments to perform the surgery. The precise nature of the surgery gives it a high rate of success. After the root is removed a filling is placed and the gums are sutured. Depending on the type of sutures you may have to return in a few days to have them removed, or dissolving sutures may be used instead. Over the course of the next few months, the bone will heal around the root.\nA root canal procedure is usually covered in part by dental insurance, but it may not cover additional expenses for emergency care. Our office accepts many forms of payment and we can help patients with financing plans, if needed.\nPlan Your Procedure\nTo relieve your pain and prevent more serious dental problems, don't avoid talking to Dr. Todd McCracken about a root canal. With modern dental equipment, techniques, and sedation options, fixing an infected tooth doesn't have to be painful or time consuming. |
Doctor insights on:\nHow Often Will I Be Awakened And Checked By A Nurse After My Surgery\nWhile recovering after a knee surgery, sleeping off anesthesia, i woke up to a nurse helping me dress, i realized that i had made a bowel movement! help!\nSh_t happens: While anesthetized, we are not responsible for what we say or what we do. While it is not common to have a bowel movement during anesthesia, it sometimes happens and it is not your fault. It was not pleasant for you, but the nurse considered it nothing unusual. Sometime these things happen. ...Read moreSee 2 more doctor answers\nHad surgery last week. Nurse told me my badages would come off after i shower. I took 3 already and they still on. Can i take them off myself?\nNo: Let your bandages fall on its own. If it are steri strips they are holding edges of your wound together. They will fall in a few days. ...Read more\n38 male with Femorolacetabular impingement. single and alone. Will I be ok alone after surgery? I have great insurance. Do I need a private nurse?\nMay Need some help: After the surgery, it is always helpful to have someone to help you out due to the initial pain and discomfort following your operation. You will most likely be nonweightbearing on the affected limb and this can be difficult to adjust to at first. I would recommend either having a nurse or a friend help you out for the first few days. ...Read more\nAfter surgery one nurse gave me Demerol and the other nurse gave me Percocet not long after . Did they double dose me and make a mistake.?\nNot likely: Most likely is all based on the institutional pain protocol and your response to treatment. If there was a mistake most institutions have now specific guidelines and they will make you aware. ...Read more\nWhy would you get abnormal tissue growth (lump) 7 years after Gynecomastia surgery (male)? more info than get it checked out pleaseI.im embarresed\nResidual Tissue : All of the breast tissue may not have been removed from the prior operation. I would definitely have this checked by a physician to make sure it is not suspicious. You can undergo re-excision surgery. They should definitely check a hormone panel and perform testicular exam to make sure there is no other medical reason for your recurrent breast enlargement (lump) ...Read moreSee 2 more doctor answers\nShould i return to ER after cyst removal surgery, started bleeding brown/black blood . Surgons triage nurse advices it. What is going on with me?\nCyst surgery: It is important to know what kind of cyst was removed and where? If the cyst was external (skin, muscle, etc.), then you may need attention if it continues to bleed. When was it removed? How long ago? Was this an "internal" cyst in the abdomen or pelvis? Where is the bleeding? ...Read moreSee 1 more doctor answer\nTriage nurse at my gyno surgeon interviews after ER visit. Told me i needed yup be back in er. And surgery is still happening this friday. Please help?\n?: We cannot help you if you give us a question without any useful information. Remember the who, what, where, why, when, and how. Calm down and try to reframe you question. Tell us exactly what you want to know and why. ...Read more\n- Talk to a doctor live online for free\n- How long will i be in the hospital after a blood and bone marrow transplant?\n- How often will i need to have endoscopies after my esophageal cancer surgery?\n- What are my limitations after laser spine surgery how long will i be in hospital?\n- Ask a doctor a question free online\n- How soon after my gallbladder surgery will i be able to eat?\n- How soon after hydrocele surgery will my scrotum be back to its normal size?\n- How can i remove a scar on my eyelid after a chalazion surgery?\n- How long will i be out of work after surgery for an anal fistula?\n- How long will a knee be swollen after acl and meniscus surgery typically? |
Dr. Janice Pauley is an anesthesiologist in Xenia, who manages patient pain levels before, during, and after surgical procedures.\nWe invite you to write a review about your experience with Dr. Pauley.\n1141 N Monroe Drive, Xenia, OH 45385\n|Mon||12:00 - 1:00 pm|\n|Tue||12:00 - 1:00 pm|\n|Wed||12:00 - 1:00 pm|\n|Thu||12:00 - 1:00 pm|\n|Fri||12:00 - 1:00 pm|\n|Languages Spoken||Arabic, English, French, German, Italian, Korean, Mandarin, Polish, Portuguese, Russian, Spanish, Tagalog, Vietnamese|\n|Hospital Affiliation||Greene Memorial Hospital|\nPlease contact the doctor’s office to inquire about insurance.\nThe Ohio State College of Medicine\nMD • 1987 |
Smile Like You Just Don’t Care – Because You Don’t!®\nTop Rated Hales Corners Dentist Providing Affordable Dental Care\nTooth Implants, Cosmetic Services & Pain-Free Sedation Dentistry for Hales Corners Patients\nRoss Dental provides affordable, caring dental services to patients living in Hales Corners and the surrounding areas. Dr. Dan Ross graduated cum laude in 2003 from the Marquette University School of Dentistry, and earned his Doctorate of Dental Surgery in 2007.\nDr. Ross currently teaches dentistry at Marquette and has his own dental clinic in New Berlin offering the following services throughout Milwaukee and Waukesha Counties:\n- Sedation Dentistry\n- Dental Implants\n- Cosmetic Dentistry\n- Dental Crowns\n- Root Canals\n- Teeth Cleaning & Oral Cancer Screening\n- No Insurance Payment Options\nRoss Dental also offers emergency dental services to our patients and will adjust our schedule to meet your needs so you don’t suffer unnecessary pain. Emergency care at Ross Dental is only available to patients on record. Don’t wait for a crisis to happen—schedule your cleaning or consultation today!\nDental Insurance Plans Accepted\nAt Ross Dental, we accept most major and participating dental insurance plans:\nPatients with no dental insurance or no coverage for the treatments they need will find affordable expert care at Ross Dental. We accept CareCredit, a credit card you can use for health and cosmetic services and pay off in convenient installments with no added interest for the first six months. Dr. Ross also offers a free consultation for cosmetic dental services.\nMaking Hales Corners Smile with Dental Implants & Pain-Free Restorative Dentistry\nDon’t let bad teeth or missing teeth ruin your health and enjoyment of life. Stop hiding your smile, avoiding photos and feeling embarrassed about damaged or discolored teeth.\nDr. Ross applies his extensive experience, the latest technology and pain-free sedation dentistry to make your restorative dental procedure as easy and effective as possible.\nHales Corners Family Dentist Welcoming New Patients\nRoss Dental is dedicated to providing a comfortable visit for all our patients. Whether you’re interested in sedation dentistry for an anxiety-free experience, have questions about a procedure or need help enrolling in CareCredit, our friendly and experienced staff is here to help.\nRestorative Dentistry for Hales Corners Patients\nVisit our location in New Berlin for a free consultation so you can enjoy a healthy, long-lasting smile. Ross Dental serves patients in Hales Corners and the surrounding areas. |
A study from Northside Hospital in Atlanta and reported on in Anesthesiology News showed that a high percentage of Hip and Knee replacement patients can be successfully discharged on the day of surgery using a Multi-Modal Analgesic Protocol (MMAP). Over 2,000 patients were analyzed and 85% were discharged within eight hours of their procedure. Approximately 70% of patients not taking narcotics preoperatively did not require their use in the postoperative period. Success was attributed to the close working relationships between surgeons and anesthesiologists, the use of a strict MMAP with the use of spinal anesthesia, and full institutional support. A Pre, Intra and Post-Operative MMAP protocol summary is provided in the article. The lead author emphasized that a dedicated multidisciplinary team as well as patient education are key components of successful same day discharge for patients undergoing joint replacements.\nEHC NOTE: The approach described, which was able to facilitate same day discharge for joint replacements, is likely to expand to other traditionally inpatient procedures due to cost pressures and advances in surgical technique and pain control. The study discussed is instructive in that a multi-disciplinary team approach in conjunction with a narcotic light multi-modal analgesic protocol facilitated the results. Institutions looking to achieve same day discharge for joint replacements or other procedures are advised to review the approach taken at Northside Hospital and adapt it to their local clinical and operational environment. |
world renowned SCIENTIFIC hypnotist TOM SILVER\nWHO IS TOM SILVER?\nWith over 35 years of experience developing powerful, proven therapeutic hypnosis methods, Tom Silver is considered to be a world-leading expert, instructor and educator in what has become known as Scientific Hypnosis.\nTom is a clinically trained and certified Hypnotist, and past member of the American Counseling Association, American Hypnosis Association and the National Guild of Hypnotists (NGH).\nAnesthesiologists at a hospital in Holland being hypnotized by scientific hypnotherapist Tom Silver to demonstrate the powers of hypnosis in pain reduction and removal so that anesthesia dosages can be lowered during cancer surgery to help keep a patients immune system strong after surgery |
‘Nobody who cared or had your best interest at heart is going to give you this,’ Cherilyn Lee recalls telling MJ.\nBy Gil Kaufman and Kara Warner\nThe second day of testimony from defense witnesses in the involuntary manslaughter trial of former Michael Jackson doctor Conrad Murray included claims by one of the singer’s former nurses that MJ demanded she provide him with the surgical anesthetic propofol.\n- Watch In Awe As This Guy Expertly Impersonates 21 Game Of Thrones Characters\n- Here’s Why Anna Kendrick Would Hate To Be Taylor Swift\n- These Hills Alums Just Teased Their Return To MTV\n- Rihanna Is A Powerful Alien Sorceress In Her New Video For ‘Sledgehammer’\n- Kim Kardashian Isn’t Ashamed Of Her Her Short-Lived Singing Career |
Midstate Infusion Center offers a variety of intravenous therapies designed to promote mental and physical well-being in Central Georgia. Offering options that range from basic rehydration and workout recovery to metabolism and immunity boosts, Midstate Infusion also provides treatment for chronic pain and mood disorders through ketamine therapy.\n“That’s the real reason I got into this,” says owner Brandy Snook, a nurse anesthetist currently pursuing her doctorate. “Especially now during the pandemic, there’s a ton of people out there that are experiencing anxiety, depression, PTSD, even from this. And those are the people that I want to help.”\nTypically an anesthetic used in surgery, ketamine is also used to treat bipolar disorder, OCD, postpartum depression, anxiety, and treatment-resistant depression. Ketamine therapy has also been successful for those that suffer from chronic pain including migraines, reflex sympathetic dystrophy, trigeminal neuralgia, phantom limb pain, and Lyme disease complications. A referral is preferred to begin ketamine therapy, but you don’t necessarily have to already be undergoing treatment to get started.\n“A lot of females don’t go to psychologists and psychiatrists. They go to their OB-GYN or their primary physician, their family practice doctor. And they’re like, ‘Hey, I’m not feeling right,'” says Snook. “A majority of our [clients] have had depression for years and it’s just gotten worse over the past year or so. The anxiety goes hand in hand with the depression. They’re anxious because they don’t wanna leave the house– so they don’t leave the house. Then they get depressed and it’s just a vicious cycle!”\nIf you are interested in ketamine therapy but don’t have a primary physician, Midstate Infusion maintains relationships within the Central Georgia medical community and will help you begin by referring you to a doctor.\nFor the basic rigors of everyday life without the need for a referral, Midstate Infusion is ready to provide therapies and injections designed to improve your overall health and wellbeing. Trouble sleeping? Muscle cramps? Fatigue? There’s a vitamin cocktail or shot that can be tailor-made just for you!\n“Are you after more energy? Are you after more for the immunity? Are you a nurse working at the hospital that would like more of the vitamin C and zinc? If your post-Corona positive, we’ve had several people come in that just don’t feel themselves after having the virus,” Snook says. “Each patient, we see what you want, what you’re after, what your goals are. And then I’ll mix up whatever you want!”\nMidstate Infusion has therapies to improve hair, skin, and nail health, boost the body’s immunity during cold & flu season, help with post-workout recovery, and improve metabolism as part of a personal weight loss program. You can even make an appointment after a night out to relieve your hangover!\n“You can plan your hangover and we’ll give you a little extra headache medicine through your infusion for those nights out. Or if you want a pregame infusion! If you know it’s happening on Friday night, come on in Friday morning! Or get one Friday for Saturday night,” says Snook. “We’re here to help you feel better so you can get out and you can do better. So you can be yourself again. So you can just be you, whether it be through hydration, mental health awareness, and wellness, just feel better.” |
A follow-up to Botox, Dysport offers a similar formulation to relax facial muscles. Dysport has been successfully used as a cosmetic treatment outside the United States since 2001, although it is a relative newcomer to the U.S. market. One of the selling features of Dysport is that results may last slightly longer than Botox injections for many patients.\nInjectables have become a popular anti-aging option for busy patients who don’t want to take the time for surgical procedures. In just a few minutes, these treatments can effectively erase fine lines and wrinkles that make you look older than you feel. Some injectable treatments can even enhance facial contours, from defining cheeks to rounding out the jawline.\nHow does it work?\nWe perform injectable treatments on site. No anesthesia is required prior to the injections, and treatment only takes a few minutes to complete. There is no downtime required, so patients are allowed to return to work and daily activities as soon as the procedure is completed.\nInjectable treatments continue to be one of the most popular cosmetic treatments today, due to their low cost and convenience. |
July 2022 Birth Club\nBaby Is Here!\nWell, I came in today for my scheduled induction at 38 + 2 for polyhydramnios and history of clotting disorder and like we thought, baby was still breech. So, I ended up having a c-section! As someone who has placed a lot of spinal a for c-sections, I can say that being on the patient end of things is a lot different. It was so odd - not feeling my legs, and having a feeling of not being able to breathe so well. My anesthesia and OB colleagues were very kind and tended well to me! My OB played one of my favorite gospel songs and held my hand during the spinal, and it took her three minutes to have the baby out from incision. It was just 12 more minutes until surgery was over - she is truly my hero and a rockstar. Emma was born at 9:32, 20” long and 6 pounds 12 oz - she measured 8 pounds 4 oz on ultrasound just two days ago! Crazy! She came out screaming and of course we cried, praising God for his miracle. I am sore but doing ok. We are just so thankful.\nAdvertisement | page continues below\n- xPosted 6/25/22Congratulations mama💗😍\nEnd of comments |
Job Title: Certified Registered Nurse Anesthetist\nType of Company: My company provides anesthetists to two local hospitals, a plastic surgeon's office, a pain clinic and a fertility clinic.\nEducation: AAS, Maria College (Albany, NY) National Certification in Nurse Anesthesiology, Veterans Administration Hospital School for Nurse Anesthesiology (1983)\nPrevious Experience: I was a surgical floor nurse, then a staff OR nurse before becoming a nurse manager in a recovery room. I then applied and was accepted into the VA nurse anesthetist program. I have been a certified registered nurse anesthetist (CRNA) for 26 years now.\nJob Tasks: Nurse anesthetists provide many types of anesthesia to many types of patients in all sorts of facilities and locations.\nMy job is providing anesthesia to patients in an operating room setting. Most of my work is in an ambulatory surgical center but I also administer anesthesia in a general hospital operating room. When I arrive in the OR, I begin my day with gathering equipment and medications that I will use for my cases. I check my anesthesia machine to verify that it is functioning properly, and check any equipment that I will be using. Then I meet with my patient, introduce myself and become familiar with his case. I review his medical record, his medications and allergies, his airway, the procedure being done, and learn as much about the patient as I can. This is all done to provide a safe environment. Knowing your patient and making a plan to take care of him is essential for patient safety. Often in my practice we work with anesthesiologists. They interview the patient also and are available if I need them in the OR.\nWhen the patient comes to the OR, he's moved to the operating table. That is when I begin to place all the monitors on the him. once I've done this, I begin to administer a relaxant. At this point everyone in the room verifies the name of the patient along with the procedure that's been scheduled. When we are all in agreement, I proceed. I put medication in the IV, and the patient falls asleep. Once he's asleep, I can "manage" his airway, helping him to breathe. Sometimes that also means I intubate them. That is when I place a special tube, called an endotracheal tube, in through their mouth and into their larynx. The patient breathes anesthesia gases through this tube. The patient is asleep during this time and stays asleep throughout the surgery. All along I monitor the patients vital signs,temperature, breathing, IV fluids, blood loss, and position very closely. Once the procedure is complete, I wake the patient, make sure they are comfortable with pain meds and bring them to the Recovery room for observation. Then in about another 20 minutes, I am starting another procedure and I repeat all these same steps again.\nBest and Worst Parts of the Job: The best part of this job is meeting all sorts of people. Most people come to the operating room very nervous. I enjoy trying to comfort them, reassure them and calm them for surgery. I try to make their experience as pleasant as possible and being able to utilize my nursing skills along with my anesthesia skills is the best part of my job.\nThe worst part of my job is feeling bad for someone when you know that they have a terrible illness that they will suffer with. You wish you could cure them or help them, but you realize it is out of your control.\n1. Nurse anesthetist is a great career. We have lots of flexibility. Not only can you work just about anywhere but hours can be very flexible and places of employment can be in a variety of institutions.\n2. Although the anesthesia program you get accepted into may seem very difficult and almost impossible at times, stick with it, and study hard. The rewards are well worth it.\n3. Always keep the patient first. Remember who they are and the stresses they are under, and last be not least, remember they have put their trust in you!\nAdditional Thoughts: If you were to think about becoming a nurse anesthetist, you must be a compassionate person and one who pays attention to detail. You have to be able to think quickly and be ready to act and speak out on behalf of you patient. This profession requires that you maintain continuing education credits every two years to keep your national certification. This is important because many new drugs, techniques, health and surgical studies and medical equipment are coming out all the time. It is imperative that you keep informed about this information for patient safety.\nI would not have changed one thing about how I approached my career. At the time when I applied to anesthesia school, we were given stipends to go to school. Now registered nurses with their BS degrees have to pay college tuition and graduate with their masters degrees. Not that I wouldn't mind having a masters degree (because the work was all the same) I was happy I didn't graduate with a large tuition bill.\nWhat surprises me the most about my profession is that I have been providing anesthesia for 28 years and I still enjoy it very much. I don't know where the time has gone. Sometimes some days are very long, and some cases can be very difficult and stressful but for the most part administering anesthesia has been very rewarding.Often people cringe when I tell them I work in an operating room.They say they could never do that. At one time I would never think I could do that either but once you are in a controlled setting, it really isn't that bad. You have to focus on what you are there to do.\nI would recommend this career choice to any nurse who would like the freedom to practice what they have learned and who has dedication to the safety and well being of their patients. Nurse Anesthesiology has been around for over 100 years. There are about 30,000 CRNA's in the United States and I'm glad to be one of them. So the next time you are having surgery, ask who is taking care of you. You might be lucky and have a nurse anesthetist.! Many people do not know that there is actually a Nationally recognized Nurse Anesthetist Week. It is usually the last week in January, and remember the way to say Anesthetist is A-nes-the-tist!\nThese schools offer particularly quick info upon request, and we have written detailed profiles for each (click school names to see the profiles).\nRequest info from multiple schools, by clicking the Request Info links.\nNursing@Simmons, the innovative, online nursing degree program from Simmons School of Nursing and Health Sciences prepares Registered Nurses for the next stage of their careers.\nYou need to have a Bachelor’s degree and RN license to be qualified for this school.\nAbout Brightwood College\nBrightwood College offers accelerated programs that combine flexible schedules and professional instruction to create a rewarding learning experience for individuals focused on gaining the skills for specific careers. Brightwood College is owned and operated by Education Corporation of America.\nAt UEI College, we want you to succeed. We’re like a family and we want you to be a part of it.\nEarn your graduate degree online with Northcentral University.\nEarn your Master's degree online from Norwich University.\nEstablished in 1897, Bradley University is a private, independent institution of higher learning in Peoria, Illinois. Inspired by our founder, notable philanthropist Lydia Moss Bradley, we pursue excellence in teaching, research, scholarship and service; and we celebrate leadership, integrity, diversity and collaborative learning.\nUnitek College™ is a privately held vocational school dedicated to helping you gain the skills needed to advance your career or begin a brand new career.\nFor over 35 years, Keiser University has maintained a practical, hands-on approach to career education to help our students achieve their personal and professional goals.\nWilkes University’s School of Nursing offers CCNE-accredited online degrees and certificate programs ideal for working health care professionals, instructed by experienced, respected faculty dedicated to mentoring and personalized support for every student.\nPursue your education at Ohio Christian University.\nThe inside stories from people actually working in the field.\nClick a story title to show the story, and click the title again to hide it.\nCareer Stories are concise, real-world career overviews written by people relating their personal career experiences and wisdom. They provide invaluable insights and mentoring advice to students and career changers.\nMost stories include:\nPlease also see our detailed information about Registered Nurses, including: |
A technic for administering balanced anesthesia to patients undergoing microlaryngeal surgical procedures utilizes a special short (21/2 in.) endotracheal tube and a high-flow nitrous oxide-oxygen blender connected with a pressure-reducing valve and blowgun. The operating laryngoscope blade is positioned while the surgeon views the operating field through a binocular microscope.\nThe endotracheal tube is placed under direct vision, with the patient asleep and paralyzed, below the vocal cords and anchored in position by cuff inflation. During anesthesia, the patient remains paralyzed, is given intravenous narcotics, and is ventilated by intermittent bursts of oxygen-nitrous oxide mixtures from the jet. Obstruction of the surgeon's view is minimal, being only by the 1/10-in. jet tube and the 1/16-in. inflating tube, both of which lie in the posterior commissure of the larynx. |
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|Year : 2014 | Volume\n| Issue : 2 | Page : 33-37\nPreventive effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries\nMir Mujtaba Ahmad1, Hilal A Wani1, Asif Jeelani2, Sajad Thakur1, Malik Waseem3, Irfan Nazir1\n1 Department of Surgery, GMC, Srinagar, Jammu and Kashmir, India\n2 Medical Surveillance Office, WHO, Geneva, Switzerland\n3 Department of SPM, GMC, Srinagar, Jammu and Kashmir, India\n|Date of Web Publication||12-Sep-2014|\nMir Mujtaba Ahmad\nDepartment of Surgery, GMC, Srinagar, Jammu and Kashmir\nSource of Support: None, Conflict of Interest: None\nObjective: The aim was to study the prophylactic effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries. Background: Acute urinary retention (AUR) after anorectal surgeries is essentially a type of postoperative urinary retention (POUR). It is the most common complication of the procedure. Use of tamsulosin, a super selective alpha 1a adrenergic blocker has been found to reduce the risk of POUR. Patients and Methods: Patients who underwent anorectal surgeries for benign anorectal conditions were included in this study. Patients were randomly assigned into two groups. In one, group (cases), patients were given 0.4 mg of oral tamsulosin only 6 h preoperative and 6-8 h postoperatively. Inability/difficulty to pass urine, which necessitated catheterization after following patient for 24 h was labeled as POUR. Results: A total of 626 patients who underwent surgery for benign anorectal condition were included in the study and grouped into two groups with 313 patients in each group, control and case group. In the control group, 56 patients (17.9%) had inability to pass urine and required catheterization and in the case group, only eight patients (2.5%) needed catheterization following POUR. The difference in the requirement of catheterization following POUR was statistically significant (P = 0.04). Hemorrhoidectomy was the most common anorectal surgery associated with POUR. Conclusion: The use of tamsulosin in preoperative and postoperative period has been found effective to reduce the incidence of POUR following surgeries for benign anorectal pathologies.\nKeywords: Acute urinary retention, anorectal surgeries, postoperative urinary retention, tamsulosin\n|How to cite this article:|\nAhmad MM, Wani HA, Jeelani A, Thakur S, Waseem M, Nazir I. Preventive effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries\n. Saudi Surg J 2014;2:33-7\n|How to cite this URL:|\nAhmad MM, Wani HA, Jeelani A, Thakur S, Waseem M, Nazir I. Preventive effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries\n. Saudi Surg J [serial online] 2014 [cited 2022 Sep 29];2:33-7. Available from: https://www.saudisurgj.org/text.asp?2014/2/2/33/140687\n| Introduction|| |\nAcute urinary retention (AUR) is the most common complication after operation for benign anorectal diseases with a range of 1-50%, average of around 15%. AUR after a surgical procedure is termed as postoperative urinary retention (POUR), which is defined as the inability to pass any urine in the presence of a palpable or percussive bladder after surgery. It is seen in patients of both sexes and all age group and following all types of surgical procedures though it is more common following surgeries on urinary tract, perineal, gynae and anorectal procedures. The cause of POUR is uncertain though it seems to be multifactorial. In benign anorectal surgeries, there is an adrenergic stimulation following anal distention, swelling and local pain leading to reflex inhibition of detrusor muscle and bladder outlet contraction. POUR has been found to be related to certain risk factors like spinal anesthesia, age, presence of obstructive urinary disease, type of procedure, duration of the procedure, fluids, analgesia. \nSeveral steps and strategies have been seen for the prevention of POUR, like restricted perioperative fluid intake, use of parasymphathetic and alpha-adrenergic blockers, , pain control, sitz bath, use of local anesthesia, , ambulation have been advocated. Tamsulosin, being an alpha 1a receptor blocker acts by reducing tone in bladder outlet, thereby decreasing outflow resistance and decreasing POUR. With this background, a study to investigate the role of prophylactic tamsulosin on the development of POUR in patients undergoing surgeries for benign anorectal conditions was carried out.\n| Patients and Methods|| |\nThis study was conducted in Post Graduate Department of Surgery, Government Medical College Srinagar for a period of 18 months spanning February 2011 to August 2012. All patients of either sex and age <70 years who presented with benign pathology in anorectal region and were operated upon for hemorrhoidectomy, fistula surgery, sphincterotomy, maximal anal dilatation, incision and drainage of perianal abscess. A total of 626 patients was included in the study and were randomly allocated into two groups, one group being a case group and the other one control group, equally distributing 313 patients in each group. The exclusion criterion was age >70 years, active urinary tract infection, neurological disorders, history of urinary calculi or stricture, benign hypertrophy of prostate on treatment, previous urological surgery, malignancy patients, h/o incontinence, indwelling catheter, significant comorbidity like chronic kidney disease, medication with effects on kidney.\nAll patients underwent a baseline assessment and preoperative sonographic scan to quantify post void residual urine. After informed consent, all patients were subjected to surgery under spinal anesthesia. In all cases, tamsulosin was given 0.4 mg orally 6 h before surgery followed by another same dose 6-8 h later. In all patients, administration of Ringer lactate (1.5 ml/kg/h) was done in the operating room before the anesthesia and patient was kept nil per oral with Intravenous fluids for 4-6 h. All the patients were anaesthetized by spinal anesthesia.\nThe surgeries performed were hemorrhoidectomy, fistula surgery, lateral sphincterectomy, incisional drainage of perianal abscess. Perioperative tramadol as an analgesic, followed by diclofenac for pain control was used. Dosage of analgesia was adjusted until patient reported zero to mild pain on visual analogue scale for pain.\nAll the patients were followed for 24 h postoperatively, and any difficulty in voiding or urinary retention was recorded.\nUrinary retention was diagnosed when a patient had a palpable mass in the suprapubic area, felt discomfort, and failed to pass urine within 24 h after the operation despite a sufficient fluid intake and when conservative efforts such as warming the suprapubic region and encouraging the patient to stand up and walk were unsuccessful and bladder catheterization seemed inevitable. Indwelling Foleys catheter and 2% xylocaine jelly were used for catheterization and catheter was removed after about 24 h postoperatively.\nStatistical analysis was accomplished by use of the Chi-square test with a P < 0.05 considered as significant.\n| Results|| |\nAmong a total of 626 patients included in the study, there were 313 patients in group 1 (tamsulosin group) and another 313 patients in group 2 (control group). The patients were having different anorectal benign pathologies and needed hemorrhoidectomy in 280 patients, fistulectomy/fistulotomy in 106 patients, maximal anal dilitation/lateral internal sphincterotomy in 160 and incision and drainage of perianal abscess in nearly 80 patients. The incidence of urinary retention necessitating catheterization was about 22% in hemorrhoidectomy, 6.3% in fistula surgeries, 2.7% in incision and drainage of perianal abscess, 17.2% in maximal anal dilatation or internal sphincterotomy, with overall retention of around 18%.\nNo statistically significant differences were found between the two groups in terms of age (P = 0.18), severity of preoperative urinary symptoms (P = 0.7), postvoiding residual urine volume (P = 0.7) or duration of surgery (P = 0.6) and hospital stay (P = 0.5). The average nonsteroidal anti-inflammatory drug use in the two groups was similar (200 mg diclofenac) [Table 1].\nIn group 1 (tamsulosin group), eight patients required catheterization with a mean urine volume of 800 ml at catheterization. In group 2 (controls), 56 patient required catheterization with a 600-ml mean urine volume. Thus, 18% of patients in group 2 and 2.5% of patients in group 1 had urinary retention.\nThe difference in the requirement for catheterization was statistically significant (P < 0.0001).\nMost of the patients who underwent hemorrhoidectomy developed retention, followed by patients who underwent lateral internal sphincterotomy.\n| Discussion|| |\nThe incidence of POUR varies according to the type of surgery. Urinary retention is a common complication after any surgical procedure. Although the incidence of POUR in general surgical population is around 3.8%. The incidence of POUR after anorectal surgery ranges between 1% and 52% with an average of 18%. ,, Injury to the pelvic nerves and pain evoked reflex increase in the tone of the internal sphincter explains the high incidence of POUR in patients undergoing anorectal surgery. ,,,,, POUR has also been reported after gynecological surgery, but with conflicting results Previous pelvic surgery can increase the risk of POUR, probably as a result of direct damage to the nerves innervating the lower urinary tract. The widely varying reported incidence of POUR reflects differences in patient characteristics, the lack of uniform defining criteria, and the multifactorial etiology of POUR, including age, gender, inadequate perioperative fluids, type of anesthesia, and type of surgery. \nUrinary retention produces discomfort, and it can lead to prolongation of hospital stay with urethral injury and urinary tract infection at times following catheterization in addition to increasing financial constraints, avoidance of this perioperative complication is particularly important. Although most patients may recover from POUR with a trial without catheter (TWOC) after a few days of catheterization, some patients with POUR can have persistent urinary retention after failure of TWOC, and this prolongs or complicates the postoperative recovery phase. Therefore, efforts should be made to prevent POUR, especially in men at high risk for the condition. The development of POUR is multifactorial. These include the direct effects of anesthetic agents on the bladder, traumatic instrumentation, pelvic dissection, overzealous intravenous hydration resulting in bladder distension, diminished awareness of bladder sensation, increased outlet resistance, immobilization after the procedure, postoperative pain (nociceptive inhibitory reflex), use of narcotics for analgesia, and patient age and sex. \nToyonaga et al. showed that female sex, preoperative urinary symptoms, diabetes mellitus, large amounts of intravenous fluid administered perioperatively, and postoperative pain are independent risk factors for urinary retention in selected cases of anorectal surgery such as hemorrhoidectomy and fistulectomy.\nThe contractility of the detrusor decreases with advancing age. Accordingly, in light of previous studies, it was generally assumed that POUR increases with age, with the risk increasing by 2.4-2.8 times in patients over 50 years of age. Age is an independent factor predicting successful TWOC for POUR and patients older than 70 years are at a 1.8 times higher risk of failure of TWOC than are those younger than 70 years.\nMany different methods have been tried to prevent this complication, including the use of parasympathomimetic agents, use of alpha-adrenergic blockers, use of anxiolytic agents, restriction of perioperative fluid intake, avoidance of anal packing, sitz baths, use of local anesthesia, use of short-acting anesthesia, and outpatient surgery.\nSome precautions, such as limitation of fluid intake, early mobilization, warm compress to the suprapubic area, and the use of short-acting local or spinal anesthesia, have been reported to prevent this complication. ,,\nThe overwhelming majority of procedures for benign anorectal pathologies are performed as elective outpatient procedures except perianal abcesses without intra-operative catheterization. Therefore, limiting the perioperative volume of fluids and controlling pain are reasonable measures to reduce POUR. \nIn a randomized prospective study of perioperative fluid restriction in anorectal surgery, Bailey and Ferguson were able to reduce urinary retention from 14.9% to 3.5%. \nEfforts toward the pharmacological prevention and treatment of POUR have focused on increasing detrusor muscle activity or decreasing the opening pressure of the internal sphincter at the bladder neck.\nIt is well-documented that adrenergic receptors are present throughout the bladder. Beta-adrenergic receptors are predominantly in the body and dome, and alpha-adrenergic receptors are in the base and neck of the bladder.\nIn the acute postoperative setting, sympathetic nerve discharge causes catecholamine release and alpha- adrenergic-mediated contraction of the bladder neck, resulting in functional obstruction of the bladder outlet.\nAdministration of sympathomimetic and anticholinergic agents (for example, phenylephrine and atropine) during anesthesia can inhibit contraction of the detrusor muscle in the bladder. This relaxes the bladder and decreases the urge to void and the recognition that the bladder is full.\nThe pain in the perineal area can stimulate the alpha-receptors in the bladder neck and proximal urethra, thereby increasing urethral resistance and bladder outlet tone. The end result is that attempts to void encounter increased output resistance. \nAlpha-adrenergic blockade with phenoxybenzamine historically has seemed effective prophylactically in decreasing the incidence of postoperative retention. Analysis on the use of phenoxybenzamine and concluded that this agent reduced the occurrence of POUR. ,\nPrazosin, a selective alpha 1-adrenoceptor antagonist, produces clinical effects similar to those of phenoxybenzamine with less significant side effects. \nTamsulosin is a superselective adrenoceptor antagonist (alpha-1a). Its preventive effect has not been previously studied in reducing the risk of POUR after anorectal surgeries for benign pathologies in the same region. Patel et al. investigated the potential efficacy of alpha-blockers for facilitating early removal of the urinary catheter following radical prostatectomy. A consecutive group of 250 men undergoing radical prostatectomy received tamsulosin, 0.4 mg, 3 days before a cystography planned for postoperative day 8. Tamsulosin was administered for an additional 4 days following the catheter removal. The incidence of POUR in the men who received tamsulosin was only 2.6% compared with 10% in the control group.\nIn the present study, 8 of 313 patients (2.5%) in the tamsulosin group developed urinary retention. In the control group, 56 of 313 patients (18%) had urinary retention and required catheterization. The incidence of AUR was significantly greater in men who did not receive tamsulosin before and after surgery.\nThe incidence of urinary retention showed no statistically significant difference when we considered the basic pathology in anorectal region, the type of surgery, the type of anesthesia, or the duration of the surgery. The difference was also insignificant when preoperative urinary symptoms were compared between the two groups. Therefore, the use of tamsulosin can be recommended in adult male patients over 50 years of age who undergo surgery in anorectal region, regardless of their baseline characteristics.\nThe current study is a prospective evaluation of tamsulosin as a means of avoiding urinary retention after anorectal surgeries for benign conditions. This protocol resulted in the reduction of urinary retention from 18% in the controls to 2.5% in the treatment group.\n| Conclusions|| |\nTo the best of our knowledge, the effect of prophylactic tamsulosin has not been investigated on urinary retention in anorectal surgeries. Our data suggest that tamsulosin significantly reduces the incidence of AUR after surgery. Therefore, consideration should be made to give a perioperative course of tamsulosin therapy when performing anorectal surgeries so as to pass benefits to the patients.\n| Ethical Approval|| |\nSince there was no Ethical Committee at the time of study in GMC, Srinagar and the fact that Tamsulosin being a novel drug with minimal adverse effects and no serious drug toxicity, drug reaction and teratogenic properties has been afflicted with this drug, an ethical approval was given by Dean/Principal GMC, Srinagar for the study.\n| References|| |\n|1.||Stallard S, Prescott S. Postoperative urinary retention in general surgical patients. Br J Surg 1988;75:1141-3. |\n|2.||Zaheer S, Reilly WT, Pemberton JH, Ilstrup D. Urinary retention after operations for benign anorectal diseases. Dis Colon Rectum 1998;41:696-704. |\n|3.||Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002;89:622-32. |\n|4.||Mohammadi-Fallah M, Hamedanchi S, Tayyebi-Azar A. Preventive effect of tamsulosin on postoperative urinary retention. Korean J Urol 2012;53:419-23. |\n|5.||Buckley BS, Lapitan MC. Drugs for treatement of urinary retention after surgery. Cochrane Database Syst Rev 2010;10:CD008023. |\n|6.||Winacoo JN, Maykel JA. Operative anesthesia and pain control. Clin Colon Rectal Surg. 2009;22:41-46. |\n|7.||Gupta PJ. Effects of warm water sitz bath on symptoms in post-anal sphincterotomy in chronic anal fissure-A randomized and controlled study. World J Surg 2007;31:1480-4. |\n|8.||Guy L, Kratzer MD. Local anesthesia in anorectal surgery. Dis Colon Rectum 1965;8:441-5. |\n|9.||Gudaityte J, Marchertiene I, Pavalkis D. Anesthesia for ambulatory anorectal surgery. Medicina (Kaunas). 2004;40:101-11. |\n|10.||Hoff SD, Bailey HR, Butts DR, Max E, Smith KW, Zamora LF, et al. Ambulatory surgical hemorrhoidectomy-A solution to postoperative urinary retention?. Dis Colon Rectum 1994;37:1242-4. |\n|11.||Tammela T, Kontturi M, Lukkarinen O. Postoperative urinary retention. I. Incidence and predisposing factors. Scand J Urol Nephrol 1986;20:197-201. |\n|12.||Toyonaga T, Matsushima M, Sogawa N, Jiang SF, Matsumura N, Shimojima Y, et al. Postoperative urinary retention after surgery for benign anorectal disease: Potential risk factors and strategy for prevention. Int J Colorectal Dis 2006;21:676-82. |\n|13.||Salvati EP, Kleckner MS. Urinary retention in anorectal and colonic surgery. Am J Surg 1957;94:114-7. |\n|14.||Scoma JA. Catheterization in anorectal surgery. Arch Surg 1975;110:1506. |\n|15.||Cataldo PA, Senagore AJ. Does alpha sympathetic blockade prevent urinary retention following anorectal surgery? Dis Colon Rectum 1991;34:1113-6. |\n|16.||Zanolla R, Torelli T, Campo B, Ordesi G. Micturitional dysfunction after anterior resection for rectal cancer. Rehabilitative treatment. Dis Colon Rectum 1988;31:707-9. |\n|17.||Burgos FJ, Romero J, Fernandez E, Perales L, Tallada M. Risk factors for developing voiding dysfunction after abdominoperineal resection for adenocarcinoma of the rectum. Dis Colon Rectum 1988;31:682-5. |\n|18.||Hojo K, Vernava AM 3 rd , Sugihara K, Katumata K. Preservation of urine voiding and sexual function after rectal cancer surgery. Dis Colon Rectum 1991;34:532-9. |\n|19.||Benoist S, Panis Y, Denet C, Mauvais F, Mariani P, Valleur P. Optimal duration of urinary drainage after rectal resection: A randomized controlled trial. Surgery 1999;125:135-41. |\n|20.||Gerstenberg TC, Nielsen ML, Clausen S, Blaabjerg J, Lindenberg J. Bladder function after abdominoperineal resection of the rectum for anorectal cancer. Urodynamic investigation before and after operative in a consecutive series. Ann Surg 1980;191:81-6. |\n|21.||Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: Anesthetic and perioperative considerations. Anesthesiology 2009;110:1139-57. |\n|22.||Petros JG, Rimm EB, Robillard RJ, Argy O. Factors influencing postoperative urinary retention in patients undergoing elective inguinal herniorrhaphy. Am J Surg 1991;161:431-3. |\n|23.||Lee SJ, Kim YT, Lee TY, Woo YN. Analysis of risk factors for acute urinary retention after non-urogenital surgery. Korean J Urol 2007;48:1277-84. |\n|24.||Barone JG, Cummings KB. Etiology of acute urinary retention following benign anorectal surgery. Am Surg 1994;60:210-1. |\n|25.||Shafik A. Role of warm water bath in inducing micturition in postoperative urinary retention after anorectal operations. Urol Int 1993;50:213-7. |\n|26.||Lepor H. Managing and preventing acute urinary retention. Rev Urol 2005;7 Suppl 8:S26-33. |\n|27.||Bailey HR, Ferguson JA. Prevention of urinary retention by fluid restriction following anorectal operations. Dis Colon Rectum 1976;19:250-2. |\n|28.||Wein AJ, Dmochowski RR. Neuromuscular dysfunction of the lower urinary tract. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 10 th ed. Philadelphia: Saunders; 2012. p. 1940. |\n|29.||Jensen P, Mikkelsen T, Kehlet H. Postherniorrhaphy urinary retention - Effect of local, regional, and general anesthesia: A review. Reg Anesth Pain Med 2002;27:612-7. |\n|30.||Gönüllü NN, Dülger M, Utkan NZ, Cantürk NZ, Alponat A. Prevention of postherniorrhaphy urinary retention with prazosin. Am Surg 1999;65:55-8. |\n|31.||Patel R, Fiske J, Lepor H. Tamsulosin reduces the incidence of acute urinary retention following early removal of the urinary catheter after radical retropubic prostatectomy. Urology 2003;62:287-91. | |
Introduction to Shoulder Surgery\nShoulder surgery is used in the treatment of rotator cuff repair, impingement syndrome, shoulder instability, bone spur removal, removal or repair of the labrum, repair of the ligaments, removal of inflamed tissue or loose cartilage, repair for recurrent shoulder dislocation, and biceps tendon repair.\nShoulder Arthroscopy Procedure\nShoulder Arthroscopy surgery uses a small camera called an arthroscope to diagnose and repair tissues inside or around a person's shoulder. Doctors create small incisions around the shoulder so that the camera can be inserted. Most patients receive general anesthesia before the surgery while others may have regional anesthesia. Regional anesthesia makes patients sleepy during surgery and numbs the area being operated on. The type of anesthesia depends on the patient’s own medical needs and the doctor. During the surgery doctors examine the problem area with the camera to assess the damage and determine the best method of treatment. Any tears in the muscle, tendon, or cartilage will be repaired and any damaged tissue will be removed.\nAfter Shoulder Surgery\nOnce the surgery is over, the incisions will be closed with stitches and covered with a bandage.\nShoulder surgery is no longer an invasive procedure with a long term healing process. The doctors at West Medical have perfected a system of minimally invasive procedures that will have you treated and healed quicker than you ever imagined. Now's the time to finally get treated. Do you have severe shoulder pain and you're craving relief? Call West Medical at (855) 690-0565 to learn more about Shoulder Arthroscopy, as well as other orthopedic treatment methods. Our helpful medical staff is looking forward to your call!\nContact Us Today!\nWe are ready to get you started on your road to health and beauty. Your first step is to contact us and schedule an initial consultation. During this time, we will establish everything we need to craft a custom treatment plan for you. Call today.\nLost 118lbs after visit\n"Thank you West Medical for playing your part to help bring an incredible change to my life."\nLost 104lbs after visit\n"Now I feel good in my clothes, I have more energy and do more things."\nLost 120lbs after visit\n"I FEEL INCREDIBLE! I have a lot more energy and am very active."\nLost 100lbs after visit\n"I felt like I would never fit in with my family. Now I am living an active lifestyle that I finally get to be a part of. I have lost a total of 100lbs!"\nLost over 100lbs after visit\n"I lost 100 pounds with Sleeve Gastrectomy and I feel incredible! I have a lot more energy and feel healthy."\n* Individual results may vary\nPlease take a moment to rate your experience with our team. |
Doctors Lounge - Urology Answers\n"The information provided on www.doctorslounge.com is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her physician."\nForum Name: Urology Topics\n|stooly76 - Tue Jul 06, 2010 7:36 pm|\nI went to the ER last Wednesday which took the swabs which I received today. My urologist can't do a circumcision until the end of July and won't prescribe anything other than lidocane cream and ketoralac. Same as my family doctor. I have oozing open sores on my foreskin that literally make me cry every time I have to open to urinate. What do I do?? Please help me I can not take this pain. It's at the point where even applying water to soak it hurts. Please, please help me\nThis has gotten worse and worse for 2 months. I went thru 18 flucanozale pills and tubes and tubes of clotrazamole cream. Nothing works\n|Dr.M.Aroon kamath - Mon Jul 12, 2010 1:09 pm|\nI empathize with you for the suffering you are going through.I guess, your doctor (rightly so) probably prescribed to you 2% linocaine gel for topical analgesia.\nLidocaine 3.5% and 5% have been studied (and being studied) for their efficacy in neuropathic pains and for post operative analgesia.\nAs the % of lignocaine increases, potential for local and systemic toxicity increases proportionately.Topical local anaesthetics may be absorbed through mucosal surfaces and the rate of absorption is unpredictable.Therefore serious systemic side-effects can occur. Potential for mortality from respiratory arrest exists as the % is hiked up.\nSo far,there has not been widespread inclination or need to put 10% lidocaine through clinical trials. 5% lidocaine appears to be satisfactory enough for most purposes.\nI see from your profile that you are on alprazolam and citalopram hydrobromide.\nIn this situation, your doctor is rightly cautious about which topical analgesia to prescribe. I suggest that you should first discuss this predicament with your psychiatrist and then discuss the possibility of your psychiatrist and family doctor jointly deciding on the most ideal way forward in planning safe and effective analgesia for you.\n|stooly76 - Mon Jul 12, 2010 1:49 pm|\nThank you for your reply and insight.\nI have since had a circumcision and am now healing. It has been 5 days since surgery and the stitches have finally stopped the bleeding. I do have some discomfort but compared to the pain before it is nothing.\nI am basically just keeping the wound clean and applying neosporin. The surgeon said 6-8 weeks for full recovery? This seems to be a long time but he had said the infection was severe. Would the staph infection be the reason I had been so tired and moody?\n|Dr.M.Aroon kamath - Mon Jul 19, 2010 2:18 am|\nThank you for your update. Glad that you have got rid of those painful sores. Any underlying focus of infection can make one feel terrible at times! o, it was certainly possible in your case that the infection+ the pain+ anxiety combination took its toll on you! Hope you will recover uneventfully. Good luck!\n|| Check a doctor's response to similar questions|\nAre you a Doctor, Pharmacist, PA or a Nurse?\nJoin the Doctors Lounge online medical community\nEditorial activities: Publish, peer review, edit online articles.\nAsk a Doctor Teams: Respond to patient questions and discuss challenging presentations with other members. |
00:00 / 00:00\nAnticonvulsants and anxiolytics: Barbiturates\nAnticonvulsants and anxiolytics: Benzodiazepines\nMedications for neurodegenerative diseases\nOpioid agonists, mixed agonist-antagonists and partial agonists\n0 / 7 complete\n0 / 5 complete\n0 / 6 complete\nInhaled anesthetics, dantrolene\nPropofol, etomidate, ketamine\nseizures with p. 250\nenflurane p. 250\nGeneral anesthetics are medications used to induce an anesthetic state in patients who are about to go under surgery.\nThe anesthetic state refers to a number of conditions that make surgery tolerable for the patient and more manageable for the surgeon.\nThe conditions include: unconsciousness, where the person isn’t aware of themselves or their environment; sedation, so they don’t move in response to painful stimulation; analgesia, so they don’t feel pain; and amnesia, so they don’t remember the procedure.\nLocal anesthetics are different in the fact that they only block pain sensation in a specific part of the body, and don’t affect consciousness.\nOkay, to achieve the anesthetic state, general anesthetics depress the central nervous system. In other words, they diminish the total amount of action potentials that are constantly firing in the brain. The generation of these action potentials depends on excitatory and inhibitory synapses.\nExcitatory, means that the neurotransmitters released into the synaptic space stimulate the postsynaptic neuron to start an action potential.\nThe main neurotransmitter involved is glutamate, which binds to postsynaptic NMDA receptors, so some general anesthetics work by blocking these receptors.\nInhibitory synapses, on the other side, do the opposite; they release the inhibitory neurotransmitter called GABA, which binds to the postsynaptic neuron and keep it from firing.\nSo certain anesthetics work by stimulating these GABA receptors or by increasing their sensitivity to GABA.\nMoving on, there are two main phases in anesthesia: induction, which is when the patient enters the anesthetic state; and maintenance, when the anesthetic state is prolonged for as long as required.\nSome anesthetics are better for induction, while others are better for maintenance.\nNow, depending on how they’re administered, there are two classes of general anesthetics: parenteral and inhalational anesthetics.\nParenteral anesthetics are given by injection into a vein. They’re highly lipophilic agents that are commonly used for anesthetic induction in a single intravenous injection, although some of them, in special situations, can be used for maintenance by continuous intravenous infusion.\nOnce in the bloodstream, these medications travel through the body to highly lipophilic tissues that receive a lot of blood, like the brain and spinal cord. There, they can induce the anesthetic state.\nLatest on COVID-19\nNurse Practitioner (NP)\nPhysician Assistant (PA)\nCreate custom content\nRaise the Line Podcast\nCopyright © 2024 Elsevier, its licensors, and contributors. All rights are reserved, including those for text and data mining, AI training, and similar technologies.\nCookies are used by this site.\nTerms and Conditions\nUSMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). COMLEX-USA® is a registered trademark of The National Board of Osteopathic Medical Examiners, Inc. NCLEX-RN® is a registered trademark of the National Council of State Boards of Nursing, Inc. Test names and other trademarks are the property of the respective trademark holders. None of the trademark holders are endorsed by nor affiliated with Osmosis or this website. |
Perioperative acute myocardial infarction (AMI) is the most common cause of postoperative morbidity and mortality. It is a rare but important and fatal complication. Recognizing this situation may be difficult due to the influence of general anesthesia. Early diagnosis and treatment can decrease the morbidity and mortality of this fatal complication. In this case we present a 56-year-old female planned nephrectomy. After induction of general anesthesia acute inferoposterior myocardial infarction occurred and coronary angiograhy showed the proximal portion of the circumflex coronary artery (Cx) was occluded by thrombus, the left anterior descending coronary artery and the right coronary artery were plaque. Percutaneous transluminal coronary angioplasty and the stenting resulted in successful dilatation of the Cx and she was discharged at the fifth day of intervention without any complication.\n|Subjects||Health Care Sciences and Services|\n|Journal Section||Case Reports|\nPublication Date : October 4, 2018\n|EndNote||%0 The European Research Journal Acute myocardial infarction associated with the induction of general anesthesia %A Murathan Küçük , Necmettin Korucuk , Veysel Tosun , Fatma Ertuğrul , Aytül Belgi Yıldırım %T Acute myocardial infarction associated with the induction of general anesthesia %D 2018 %J The European Research Journal %P -2149-3189 %V 4 %N 4 %R doi: 10.18621/eurj.349353 %U 10.18621/eurj.349353| |
Background: Human and animal laboratory studies have shown that stress delays healing of standardized punch biopsy wounds.Purpose: This 5-week prospective study of 17 women who underwent elective gastric bypass surgery addressed the association between postsurgical pain intensity and subsequent healing of a standard 2.0-mm punch biopsy wound.Methods: Participants were assessed 1 week before surgery, within 3 hr before surgery, 1 to 3 days postsurgery, and at weekly intervals for 4 weeks following surgery.Results: Patient ratings of greater acute postsurgical pain, averaged over Days 1 and 2 postsurgery, and greater persistent postsurgical pain, averaged over 4 weekly postsurgery pain ratings, were significantly associated with subsequent delayed healing of the punch biopsy wound. Presence of depressive symptoms on the day of surgery, pre-existing persistent pain, and medical complications following initial discharge from the hospital were not related to wound healing. Depressive symptoms on the day of surgery and pre-existing persistent pain did predict persistent postsurgical pain intensity.Conclusions: These findings extend the previous laboratory models of wound healing to a surgical population, providing the first evidence that pain plays an important role in postsurgery wound healing, a key variable in postsurgical recovery.\nThis is a preview of subscription content,to check access.\nAccess this article\nSimilar content being viewed by others\nKendig H, Browning CJ, Young AE: Impacts of illness and disability on the well-being of older people.Disability and Rehabilitation. 2000,22:15–22.\nScudds RJ, McD Robertson J: Empirical evidence of the association between the presence of musculoskeletal pain and physical disability in community-dwelling senior citizens.Pain. 1998,75:229–235.\nMorrison RS, Magaziner J, McLaughlin MA, et al.: The impact of post-operative pain on outcomes following hip fracture.Pain. 2003103:303–311.\nDahl JL, Gordon D, Ward S, et al.: Institutionalizing pain management: The Post-Operative Pain Management Quality Improvement Project.Journal of Pain. 2003,4:361–371.\nBardiau FM, Taviaux NF, Albert A, Boogaerts JG, Stadler M: An intervention study to enhance postoperative pain management.Anesthesia and Analgesia. 2003,96:179–185.\nAgency for Health Care Policy and Research:Using Clinical Practice Guidelines: Building And Applying a Guideline Based Performance Measurement System—Acute Post-Operative Pain And Urinary Incontinence (Vols. 1 & 2, ACHPR Pub. 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Psychosocial morbidity and grief in bereaved families.American Journal of Psychiatry. 1996,153:659–666.\nMcGuire L, Kiecolt-Glaser JK, Glaser R: Depressive symptoms and lymphocyte proliferation in older adults.Journal of Abnormal Psychology. 2002,111:192–197.\nKiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R: Psychological influences on surgical recovery: Perspectives from psychoneuroimmunology.American Psychologist. 1998,53:1209–1218.\nKiecolt-Glaser JK, Glaser R: Methodological issues in behavioral immunology research with humans.Brain Behavior and Immunity. 1988,2:67–78.\nCanvas: Version 7.0 [Computer Program]. Deneba Systems, Miami, FL, 1999.\nSchauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J: Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity.Annals of Surgery. 2000,232:515–529.\nHosmer DW, Lemeshow S:Applied Survival Analysis: Regression Modeling of Time to Event Data. New York: Wiley, 1999.\nStata Statistical Software: Release 8 [Computer Program]. College Station, TX: StatCorp LP, 2003.\nSorensen LT, Karlsmark T, Gottrup F: Abstinence from smoking reduces incisional wound infection: A randomized controlled trial.Annals of Surgery. 2003,238:1–5.\nLinn BS, Linn MW, Klimas NG: Effects of psychophysical stress on surgical outcome.Psychosomatic Medicine. 1988,50:230–244.\nRojas IG, Padgett DA, Sheridan JF, Marucha PT: Stress-induced susceptibility to bacterial infection during cutaneous wound healing.Brain Behavior and Immunity. 2002,16:74–84.\nKiecolt-Glaser JK, McGuire L, Robles TF, Glaser R: Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology.Annual Review of Psychology. 2002,53:83–107.\nSullivan MJ, Thorn B, Haythornthwaite JA, et al.: Theoretical perspectives on the relation between catastrophizing and pain.Clinical Journal of Pain. 2001,17(1):52–64.\nKatz J, Cohen L: Preventive analgesia is associated with reduced pain disability 3 weeks but not 6 months after major gynecologic surgery by laparotomy.Anesthesiology. 2004,101:169–174.\nKatz J, Cohen L, Schmid R, Chan VW, Wowk A: Postoperative morphine use and hyperalgesia are reduced by preoperative but not intraoperative epidural analgesia: Implications for preemptive analgesia and the prevention of central sensitization.Anesthesiology. 2003,98:1449–1460.\nOzalp G, Sarioglu R, Tuncel G, Aslan K, Kadiogullari N: Preoperative emotional states in patients with breast cancer and postoperative pain.Acta Anaesthesiologica Scandinavica. 2003,47:26–29.\nCohen L, Fouladi RT, Katz J: Preoperative coping strategies and distress predict postoperative pain and morphine consumption in women undergoing abdominal gynecologic surgery.Journal of Psychosomatic Research. 2005,58:201–209.\nThis research was supported in part by National Institutes of Health (NIH) grants P50 DE13749, PO1 AG16321, and R37 MH42096; by NIH General Clinical Research Center Grant MO1-RR- 0034; and by Comprehensive Cancer Center Core Grant CA16058.We gratefully acknowledge the assistance of Laura von Hoene in data collection and the staff of the General Clinical Research Center for completing the punch biopsy standard wounds. We also thank Dr. Jennifer Haythornthwaite and Dr. Robert Edwards for their comments on a previous draft of this article.\nAbout this article\nCite this article\nMcGuire, L., Heffner, K., Glaser, R. et al. Pain and wound healing in surgical patients. ann. behav. med. 31, 165–172 (2006). https://doi.org/10.1207/s15324796abm3102_8 |
Testicular BiopsySkip to the navigation\nA testicular biopsy is a test to remove a small sample of tissue from one or both testicles and examine it under a microscope to evaluate a man's ability to father a child.\nWhy It Is Done\nA testicular biopsy may, on rare occasions, be done to help determine the cause of male infertility. Testicular biopsy may be done if both of the following are present:\nTesticular biopsy is not usually used to detect testicular cancer. When cancer is suspected, an open surgical procedure (orchiectomy) is done to confirm the diagnosis.\nHow To Prepare\nBefore having a testicular biopsy, be sure to tell your doctor if you:\n- Have had any bleeding problems.\n- Are allergic to any medicines, including anesthetics.\n- Take any medicines regularly. Be sure your doctor knows the names and doses of all your medicines.\n- Are taking any blood-thinning medicines, such as warfarin (Coumadin), heparin, enoxaparin (Lovenox), aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).\nYou will be asked to sign a consent form that says you understand the risks of the test and agree to have it done.\nTalk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will mean. To help you understand the importance of the biopsy, fill out the medical test information form (What is a PDF document?).\nIf a testicular biopsy is done under local anesthesia, no other special preparation is needed.\nIf the biopsy is done under general anesthesia, your doctor will tell you how soon before surgery to stop eating and drinking. Follow the instructions exactly about when to stop eating and drinking, or your surgery may be canceled. If your doctor has instructed you to take your medicines on the day of surgery, please do so using only a sip of water. During preparation for the biopsy, an intravenous line (IV) is inserted in your arm, and a sedative medicine is given about an hour before the biopsy.\nHow It Is Done\nYou will lie on your back on an examining table. The skin over your testicle is cleaned with an antiseptic solution, and the area around it is covered with sterile cloth. Your doctor will wear sterile gloves. It is very important that you do not touch this sterile area.\nA local anesthetic will be injected into the skin of the scrotum to numb (anesthetize) the area. Then a small incision is made through the skin, and a tiny piece of testicular tissue is removed with small scissors. A single stitch is used to close the incision in the testicle, and another stitch is used to close the incision in the skin. (Absorbable sutures are used so the stitches do not need to be removed.) The procedure is usually repeated on the other testicle. The scrotal area is then bandaged. You will be asked to wear an athletic supporter for several days after the procedure to help support the testicles while the incisions heal.\nIf general anesthesia is used, you will be asleep during the procedure but the same method will be used.\nThe biopsy usually takes 15 to 20 minutes. You will probably be advised to refrain from sexual activity for 1 to 2 weeks after the biopsy. You should avoid washing the area for several days.\nHow It Feels\nYou will feel a brief sting when the IV line is inserted or when the local anesthetic is injected. Other than that, the procedure should be painless.\nYour scrotum and testicles may be somewhat sore for 3 to 4 days after the biopsy and some bruising may be present. You may also notice a small amount of bleeding through the bandage, which is normal. Talk to your doctor about how much bleeding to expect.\nThere is a slight risk of prolonged bleeding or infection from this procedure. There is no risk of erection problems or infertility as a result of this biopsy. If general anesthesia is used, there is a small risk of complications from anesthesia.\nAfter the biopsy\nCall your doctor immediately if you have:\n- Severe pain in your scrotum. Some mild discomfort is normal.\n- Severe swelling of your scrotum. Some mild swelling is normal.\n- A fever higher than 100°F (38°C).\n- Excessive bleeding through the bandage.\nA testicular biopsy is a test in which a small sample of tissue is taken from one or both testicles and examined under a microscope to evaluate a man's ability to father a child. Results are usually available in 2 to 4 days.\nA pathologist examines the biopsy sample through a microscope for any abnormalities in sperm production or maturation. If sperm development appears normal yet a semen analysis test shows reduced or absent sperm, a blockage of the tube (vas deferens) from the testes to the urethra is suspected. A blocked vas deferens can sometimes be repaired by surgery.\nWhat Affects the Test\nIt is important to remain completely still while a biopsy is done under local anesthesia. If this is not possible, general anesthesia may be needed.\nWhat To Think About\nTesticular cancer is more likely to spread when a testicular biopsy is done. For this reason, a biopsy usually is not done if testicular cancer is suspected. A testicular ultrasound is generally done to help diagnose suspected testicular cancer. To learn more, see the topic Testicular Ultrasound. When cancer is suspected, an open surgical procedure (orchiectomy) is done to confirm the diagnosis.\nOther Works Consulted\n- Goldstein M (2012). Surgical management of male infertility. In AJ Wein et al., eds., Campbell-Walsh Urology, 10th ed., vol. 1, pp. 648–987. Philadelphia: Saunders.\n- Walsh TJ, Smith JF (2013). Male infertility. In JW McAninch, TF Lue, eds., Smith and Tanagho's General Urology, 18th ed., pp. 687–719. New York: McGraw-Hill.\nPrimary Medical Reviewer E. Gregory Thompson, MD - Internal Medicine\nSpecialist Medical Reviewer Christopher G. Wood, MD, FACS - Urology, Oncology\nCurrent as ofSeptember 9, 2014 |
Cat Surgery...should your cat have surgery? This is a serious question and you need to weigh the risks such as the age of your cat, what complications could happen from the anesthesia, how likely are the complications? What will be done for pain relief before, during and after surgery. It is important to ask your vet these questions. Also, what is the projected outcome of the surgery and how much will it cost?\nSurgery falls into two main categories. Surgery that is required to maintain your cat's health that is elective and non-urgent... and emergency surgery that is necessary and has to be done immediately. So basically, the emergency surgery is to remove something or repair something.\nCats sometimes swallow harmful items and need surgery like when a sewing needle and thread, string or Christmas tinsel get swallowed. Such an item can loop under a cat's tongue and the cat swallows the ends which can do damage internally.\nCats can develop bladder stones or urethral stones (stones in the urine carrying tube from the bladder) and may need surgery to remove them. Urethral stones can block the flow of urine through the penis of a male cat causing severe illness. In very severe cases during cat surgery the penis is amputated but that is less common now that specially formulated diets can dissolve some types of bladder stones.\nOccasionally, cats need hernia repairs. Some cats are born with umbilical hernias, a birth defect in which a loop of intestine balloons out against the skin at the point where the umbilical cord was attached. During cat surgery, intestinal loops are reinserted and the body wall repaired.\nAnother condition that may require cat surgery is mega-colon a neuromuscular disorder causing enlargement of the colon. It causes cats to become very constipated. In the most severe cases treatment may involve removing the colon.\nYoung cats typically have cat surgery for neutering and spaying. Older cats sometimes develop soft tissue sarcomas, malignant tumors that appear as lumps in the muscle or fat just below the skin on the legs, trunk, abdomen, head or neck. While cat surgery may help in a return to a good life, it is not without risk.\nSurgeries that involve the abdominal cavity, the lungs, or the brain are riskier because they expose vital organs. Minor surgery like a tooth extraction or a skin biopsy are less risky. Before agreeing to surgery have an honest talk with your vet about the risks and benefits so you can make a realistic decision.\nPrior to surgery your vet will use x-rays or other imaging devices to pinpoint the extent of the problem. Your cat will have a physical exam and the vet may run other tests depending on your cat's age and health. A complete blood count will check the numbers of red and white blood cells and other blood tests establish how well the liver and kidneys are working. The tests for liver and kidney function enable your vet to make a decision about which anesthesia to use and how much.\nOther tests may reveal abnormalities in the concentration of lectrolytes...chemical substances such as sodium and potassium that are essential to maintaining the fluid balance of cells. Abnormalities in these can cause organs such as the heart to function erratically during surgery.\nYour vet may prescribe antibiotics both before and after surgery to prevent a systemic infection. Bacteria are more likely to enter exposed tissues during long surgeries (lasting 2 hours or more), surgeries that involve implants such as metal pins for broken bones, and dental procedures.\nAt the start of a surgical procedure, most cats are sedated to calm them down. Next, your vet may place an intravenous (IV) catheter in a front leg vein to administer fluids, anesthetic drugs and medications for pain relief. All cats benefit from analgesics (pain-control medications) given intravenously before surgery.\nYour vet will decide whether to administer anesthesia via the IV catheter or inhalation (gas anesthesia). With gas anesthesia, a small plastic hose (endotracheal tube) is placed in the windpipe so oxygen and anesthetic gases can go straight to the lungs and then to the bloodstream.\nDuring surgery, your vet will monitor your cat to make sure it's warm, pain-free, breathing normally, and maintaining good blood circulation. Your vet may also monitor the cat's blood pressure, the blood's oxygen content, the amount of blood the heart is pumping (cardiac output), and the action of the heart itself. At the end of surgery, the vet may use sutures that either dissolve or remain permanently in the body.\nFor surface skin stitches, those that do not dissolve, are removed after the skin has healed in about 14 days or so. Finally, the vet stops the anesthesia. If it's gas the cat breathes 100 percent oxygen for 5-10 minutes to flush the anesthetic out of its lungs, then goes to the recovery room where it is monitored for normal breathing and kept warm and cozy with warm water blankets. The cat is then given pain medication so it can go home comfortably.\nOnce your cat is back home, follow the vet's instructions and only give your cat the medications your vet prescribed. The house rest limits your cat's activity and gives you a chance to watch for complications such as an incision becoming infected or not healing. So keep an eye out for drainage, redness, swelling and incision edges that aren't knitting together.\nIn general, watch for regressive changes in your cat's appearance and activity level. If your cat is eating well, is happy and functioning well, then chances are everything is fine.\nReturn from Cat Surgery to Cat Health Homepage\nHaving trouble finding what you need? Cat Health Index & Site Map\nDo you have a question to ask?...Questions\nDo you have a cat story to share?...Simply click here to go to that page!\nCopyright@2010-2020 All rights reserved.Cat-health-detective.com\nThis website is information only. Consult a veterinarian for medical assistance\n"Like Us" on Facebook\n"Like Us" here\nTake a look at our other website for travel International-Travel-Writers.com |
What is Lower Eyelid Surgery?\nLoose wrinkles and sagging skin underneath the eye can be a significant aging factor, even making individuals look older than they actually are. At Everest Medspa, Dr. Xiaobin Li performs lower eyelid surgery, a version of blepharoplasty, to address under eye wrinkles and provide a youthful appearance. This procedure consists of removing excess skin and repositioning fat underneath the eye area to smooth and fill out your under eyes. At our Wayne and Havertown, PA offices, this surgery can be a fantastic solution for reclaiming a more youthful and vibrant aesthetic. Don't wait to see if this surgery could address your aesthetic goals — call our office today to find out more.\n"Dr. Li is great listener and willing to help you through your situation. I wish every doctors are like her."- W.D. / ZocDoc / Jun 11, 2022\n"I had PicoSure treatment, I got really good result. My melisma is much lighter."- Q.T. / Google / Apr 14, 2022\n"Best Evoke on-site ever. Dr. Li and JunJun are professional."- Y.Y. / Google / Apr 14, 2022\n"Love PicoSure! Great service for dark spot!"- L.C. / Google / Apr 07, 2022\n"My experience at Everest MedSpa was incredible. The esthetics procedures and equipment used are state-of-the-art. My APN Vicki exceptional. I already made another appointment!"- N.B. / Google / Apr 05, 2022\nHow is Lower Eyelid Surgery Performed?\nDepending on the type and complex nature of the eyelid surgery, some form of anesthesia will be provided to provide ultimate comfort and ease throughout the procecdure. You may wish to address upper and lower areas of the eye while you are under anesthesia. Lower bleph is performed to improve bulging, bloated skin under the lower lid. In most cases, an incision is carefully made just under the lash line to surgically remove fatty tissue, and the skin is subtly lifted to allow for a softer, flatter look. In some cases, a nonsurgical laser procedure may be applied to assist with discoloration, while injectable fillers can be used for added volume and smoothness if necessary.\nRejuvenate Your Look\nIf you suffer from bulging bags and drooping skin under your eyes, then cosmetic eyelid surgery at Everest Medspa may be the answer for you. This enhancement can allow you to look and feel youthful again. We encourage you to get in touch with our offices in Wayne or Havertown, PA to make a consultation with Dr. Li if a lower blepharoplasty sounds like it might be the right procedure for you. |
Manhattan Tummy tuck surgery Howard Beach NY\nAn abdominoplasty surgical treatment, also referred to as an abdominoplasty or liposuction surgery, is the cosmetic treatment by which excess stomach skin is gotten rid of, the separated stomach muscles are tightened up, and local fat is reduced, creating a firmer, smoother, more youthful, and also much more equally well balanced waistline form. A a lot more invasive surgical procedure than just merely removing fat and skin, an abdominoplasty surgery is a highly imaginative, imaginative clinical endeavor that takes a powerful combination of technological know-how concerning the makeup and progressed aesthetic vision to accomplish the client’s desired outcomes. Cosmetic surgeons in New York City do this type of surgery on an outpatient basis. This indicates that the patient has the ability to return home the exact same day as surgical procedure and also can remain at residence the very same evening after the procedure.\nAfter a successful abdominoplasty in New York City, it is very important to adhere to certain care instructions to make certain the quickest quantity of healing time feasible. Following surgery, a drainage procedure might be arranged a couple of days after surgery. This assists to drain any type of excess blood as well as liquid from the abdominal area, along with any type of excess liquid that was gotten rid of throughout the treatment. It likewise guarantees that a fresh stream of clean and sterile water does not accumulate in the healing abdomen area, which can be polluted with any type of bacteria or virus that was circulating prior to surgery. Manhattan Tummy tuck surgery Howard Beach NY, It is regular for some individuals to feel some discomfort adhering to surgical treatment, however these feelings usually decrease within a couple of days.\nThe cosmetic surgeon will recommend the client of any necessary aftercare procedure. Manhattan Tummy tuck surgery Howard Beach NY, A couple of weeks after surgical procedure, the individual may need to stick purely to a fluid-based diet. This is because of the reality that the belly must recover properly before proceeding to take in any strong foods. Food can just be eaten after the stomach has actually totally healed to avoid the threat of infection. Within 4 to six weeks complying with surgical treatment, people can begin to go back to a normal timetable of job, exercise as well as remainder.\nAt roughly 3 weeks after an abdominoplasty in New york city City, the last postoperative check out will certainly be set up. Throughout this moment, the stitches will be taken out and the cut locations will certainly be repositioned. It prevails for the specialist to want to produce a small mark from the cut place to reduce the healing procedure. Throughout the final postoperative visit, you will certainly discuss what will certainly require to be done to your abdomen. The doctor will evaluate the scar and also ask you regarding your assumptions for the appearance of your skin.\nAn abdominoplasty in New york city City typically takes around three weeks to complete. This results from the quantity of job that is needed to efficiently complete the treatment. Manhattan Tummy tuck surgery Howard Beach NY, The quantity of fat gotten rid of from the abdominal area is considerable as well as differs from person to individual. Some people have a very little quantity of fat removed, while others may have an extreme amount removed.\nIt is important to keep in mind that people are not expected to have an abdominoplasty annually. The procedure is considered a cosmetic treatment and is not covered by insurance. Insurance companies just spend for the cost of the treatment if it is performed to recover as well as boost a person’s wellness. People that elect to have actually tummy tucks done regularly need to evaluate the reasons for their decision. If the treatment is required to give relief from pain or assist with fat burning, it might deserve the financial investment.\nWhen people have an abdominoplasty procedure executed in New york city City, they will be under basic anesthetic. Generally, a board accredited cosmetic surgeon carries out these surgical treatments. After the surgery, clients may experience some discomfort as well as swelling.\nThe small tummy tuck in New York City typically only includes the removal of skin excess around the navel. The treatment also might involve eliminating fat deposits under the pubic area. Manhattan Tummy tuck surgery Howard Beach NY: The mini treatment normally lasts for about one hour. The mini treatment is a great alternative for people who want to undergo a fast procedure that does not call for a lengthy recuperation period. This treatment can typically be done in the house.\nTummy tuck: How Manhattan Tummy tuck surgery Howard Beach NY Is It Done?\nAn abdominoplasty, likewise referred to as abdominoplasty surgery, handle excess abdominal fat, hanging skin, as well as extended stomach muscles after weight problems, weight adjustments, or aging. Several individuals undergo an abdominoplasty to transform their body shape after plastic surgery such as a breast reduction or nose job. Others pick an abdominoplasty to eliminate excess skin and also excess fat after breast-feeding. Others have a tummy tuck due to failed weight management initiatives or a medical diagnosis. Still others have a tummy tuck because of the effects of pregnancy, aging, cigarette smoking, high levels of alcohol usage, and/or excessive skin or fat buildup around the mid-section.\nDepending on the preferred outcome, an individual can anticipate the cost of the procedure to array between two to five thousand bucks. Relying on the place of the treatment, a patient may have to take a trip to New York City for consultation and also surgical procedure. Apart from the expense of the medical professional and also various other subordinate costs, the person is in charge of all other prices associated with the treatment. The person should be prepared to pay for transportation, hotel holiday accommodation, meals, and so on.\nAfter tummy tuck surgery, there will certainly be some pain and also swelling in the abdominal area. Some patients report small bleeding and also wounding at the site of the operation, Manhattan Tummy tuck surgery Howard Beach NY, yet these are usually marginal as well as will certainly diminish within a couple of days. It is typical for wounding and also swelling to stay for numerous weeks, as a result of the medical nature of the procedure. It is additionally regular for some scarring to stay also after the procedure is finished. Nevertheless, this ought to decrease with time as well as appropriate body post-operative treatment.\nA person that elects to have a tummy tuck must comprehend the surgical risks related to the procedure. Some people experience incisions that are also big; these might call for scarring, skin removal, or tissue expansion. Some individuals may be allergic to specific drugs made use of during the procedure, so it is advised that these are gone over thoroughly with the cosmetic surgeon before surgical treatment. Additionally, some people experience too much bleeding, bruising or swelling, which can make healing a lot more hard.\nA full abdominoplasty treatments can be carried out under neighborhood or general anesthesia. Depending upon the severity of the individual’s surgical issue, either kind of anesthesia could be used. When it comes to neighborhood anesthetic, the wound is cleansed with water and afterwards an incision is made to insert the tools used in the surgery. Manhattan Tummy tuck surgery Howard Beach NY: For full abdominoplasty surgical treatment, the full cut is made along the navel as well as the doctor after that inserts the instruments right into the cut. General anesthesia is made use of for bigger injuries that need larger tools to recover.\nJust like all surgeries, tummy tuck price might vary relying on the client’s case history, the place of the treatment as well as other variables. For example, if the individual is a cigarette smoker, there is a greater opportunity that the treatment will certainly be a lot more expensive because of the enhanced risk of smoking-related difficulties such as lung cancer and also other diseases. Too, if the individual has a huge fat quantity that requires to be operatively gotten rid of, the price of the treatment will certainly be greater. Also, the a lot more fat needs to be eliminated, the higher the expense will certainly be for the procedure.\nA tummy tuck involves multiple lacerations and side stitches. The specialist makes a little laceration in both sides of the abdominal area and then creates a brand-new opening in the lower abdominal area by getting rid of the pubic fat. New skin is after that developed and the laceration shut. Some clients request a smooth (no marks) treatment.\nWe recommend a healthy and balanced diet regimen prior to and also after any kind of abdominoplasty. This includes a healthy and reduced calorie, low fat, reduced sodium and low carbohydrate diet. Additionally, it is important to include a normal exercise strategy with an appropriate amount of cardiovascular task. Regular workout will assist maintain a healthy and balanced weight and also boost your posture.\nTummy Tuck Howard Beach, 40.657880, -73.836250, New York\nBook Your Tummy Tuck FREE Consultation\nKenneth R. Francis, MD\n114 E 71st St # 1w, New York, NY 10021 |
JUVÉDERM™ Injectable Gel is a natural dermal filler that actually fills facial wrinkles and folds for non-surgical wrinkle treatment. Made from a smooth consistency, water-soluble substance that is already present in your skin called hyaluronic acid, JUVÉDERM™ Injectable Gel restores volume to your skin and smoothes out wrinkles. JUVÉDERM™ Injectable Gel wrinkle treatment can help you look younger and more relaxed without surgery. JUVÉDERM™ Injectable Gel is also used for lip enhancement.\nYour Philadelphia cosmetic surgeon injects JUVÉDERM™ Injectable Gel into the skin with thin needles, causing facial wrinkles and folds to be "filled," adding volume to areas that have become creased as a result of aging. The injection process only takes about ten minutes, and most patients do not need anesthesia, although a topical anesthetic can be applied, if desired.\nThe wrinkle-reducing effects of JUVÉDERM™ Injectable Gel are not permanent, but results are instant. Although results vary, they typically last six months or longer, and can be repeated as necessary.\nYour Philadelphia plastic surgeon will discuss your concerns with you and explain the details about wrinkle treatment with JUVÉDERM™ Injectable Gel. There are a number of facial injectable products available in Philadelphia, and we will help you determine the non-surgical wrinkle treatment that is best for you.\nJUVÉDERM™ is a trademark owned by Corneal Industries SAS. |
Scott Kupetz DMD – Dentist Fishkill, NY\nHaving healthy teeth isn’t just about a healthy and bright smile. Taking regular care of your teeth also means taking care of your overall health and wellness. If you have been putting off dental care, you will have no worries with Dr. Kupetz. Our office is a certified sedation dentistry facility specializing in the area of dental fear. We want you to feel as comfortable and relaxed as possible when you come to our office.\nOur goal is to help you overcome your fears so you can continue to have great regular dental care and health. We want you to feel calm and stress-free during your dental procedure. Our staff has over 30 years’ experience in all types of dental procedures. We can provide any cosmetic dentistry service you may need such as dental implants, bridges crowns and more. If you just need a teeth cleaning or whitening, we make it simple, comfortable, and easy.\nAs soon as you walk through our door, you will be greeted by our friendly staff of receptionists. If you have questions, we have the answers and are happy to address any fears and concerns about your procedure. If you think you may need sedation for your dental procedure, we will make sure that we get all the information we need to determine if sedation is the right option for you.\nYou are not alone if you have a fear of going to the dentist. It’s actually a very common phobia. Recently, a patient who came in for the care of a tooth abscess said he would rather go through a heart surgery procedure than a visit to a dentist. Putting off dental procedures can lead to some very serious medical conditions. Ignoring the signs and symptoms of a tooth abscess and not taking care of it, could lead to an infection in the brain and blood vessels, causing a brain abscess. Sinus infections and even angina have been known to be caused by a neglected tooth abscess.\nHere are some indications that you may have a tooth abscess and should seek dental care immediately:\nA painful and throbbing toothache that can radiate to the jawbone, neck or ear. Usually persistent and won’t subside with pain relievers.\nHot and cold sensitivity\nChewing or biting is sensitive or painful\nSwelling of the face or cheeks\nSwollen and tender lymph nodes under the jaw or in the neck\nIf you have any of the above symptoms, you should seek dental care immediately. Call our office to make an appointment for all of your dental care needs.\nI had been looking for a dentist that was compassionate and kind. I haven’t been to the dentist in 20 years due to my fear. When I was suffering from a tooth abscess, Dr. Kupetz, and his staff made me feel completely at ease. They never made me feel embarrassed about my prior dental neglect. They only encouraged me to keep up on my dental health in a positive and non-condescending way. I highly recommend Dr. Kupetz for anyone living in the the Dutchess County area!\nChristina S. – Fishkill, NY\nLearn more about Fishkill, NY 12524\nOpen a Fishkill, NY map\nFind the Fishkill, NY United States Post Office\nLocate nearby Fishkill, NY pharmacies\nView the current Fishkill, NY weather report\nBrowse a list of Fishkill, NY public and private schools\nFishkill, NY is located in Dutchless County, NY\nOur offices are conveniently located near all towns in Dutchess County, New York including Fishkill which is home to one of our favorite historic landmarks, the Van Wyck Homestead and of course, the great hiking trails of Mt. Beacon! |
Wisdom Tooth Extraction: What You Should Expect\nThe process of extracting a wisdom tooth is a lengthy procedure that requires a lot of care before, during and after the extraction has taken place. To understand this better, a wisdom tooth is a set of extra molars that emerge in humans from their late teens to early twenties. This set of teeth is recognized as an evolutionary feature that causes a lot of discomfort and pain. This is due to the effects and misalignments that occur and impact other permanent teeth, surrounding tissues and bone structure.\nSelf-Assessment and Consultation\nTo prevent further damage to the existing teeth, gums, nerves as well as the jaw, it is crucial to remove the emerging wisdom teeth as soon as possible. This process requires certain precautions to be taken to ensure that further complications do not occur during and after the extraction procedure is completed.\nFor individuals that are in need of surgery on an immediate basis, an appointment by an oral surgeon is a necessity. We’ll give you all the necessary details regarding the procedure and the aftercare to your situation. They make these decisions and suggestions depending on an X-ray that is taken on the day of your consultation.\nYour oral surgeon will check your medical history and any medication that is being consumed in order to safely proceed with the surgery. These drugs can affect the course of the surgery and treatment and therefore being 100% transparent with your dentist is mandatory.\nThe anesthesia administered are of 3 types: local, general and intravenous. Depending on your choice or the recommendation given at your dental clinic, the anesthesia will be administered. This allows you to get through the surgery without the experience of any pain. After the wisdom tooth is extracted, your dentist will stitch up the gaping wounds with threads that dissolve naturally over time. A gauze may also be applied on the wound, determined by the extent of bleeding being observed.\nPreparation and Precautions\nThe procedure usually lasts for about an hour, but the anesthesia affects the body for longer. This is why necessary arrangements need to be made to ensure that help and transportation is available after the treatment for your convenience. As the anesthesia fades away, the pain is expected to become more evident, which pain killers will be prescribed in advance. Furthermore, swelling is also to be expected, and slight discomfort will last for about a week’s time.\nOther precautions include avoiding smoking as it slows down the healing process of the body and eating hard or crunchy foods that place more strain on your jaw, gums and teeth. Any hot food items must also be avoided to remove extra tension from the gums. Changing the gauze from the wounded site as directed by your dentist can further help keep the affected area clean.\nIt is very important to book an appointment at a dental clinic if you experience any fevers, bleeding or other side effects. Your dentist will be able to address these problems effectively and prescribe appropriate medication and methodologies to reduce the possibility of further complications. |
The development of a successful anesthesia plan is built on an understanding of several factors. The patient's physiological needs, the demands of the procedure that necessitates the anesthesia, the capabilities of the personnel involved in the procedure and the resources available to the anesthetist, all have a role. An important resource for the anesthetist is a good knowledge and understanding of the pharmacology of the anesthesia and adjunct drugs used to provide anesthesia care. Also important is an understanding of the principles and techniques of their administration.\nThere are a variety of drugs and techniques used for anesthesia management in modern veterinary medicine today. Unfortunately, no one anesthetic drug is appropriate for every patient, under all conditions. All anesthetic drugs have the potential for undesirable effects. The goal for the anesthetist is to understand which drugs positive effects outweigh the negative effects for a given condition of the patient. Which anesthetic drugs are most likely to provide the best support that will result in a successful anesthesia course and uneventful recovery?\nThe use of anticholinergics in an anesthetic plan is a safe and effective way to avoid the effects of parasympathetic reflexes. Although their use is controversial, they can be a very effective tool for the anesthetist. Anticholinergics are used to block vagal reflexes, preventing cardiac dysrythmias, decreasing secretions, and reducing the risks associated with gastric reflux during anesthesia. At higher doses they can cause tachycardia and increase myocardial oxygen consumption and decrease GI motility, or at low doses cause A-V Block. Most anesthetic drugs elicit a cholinergic response from the patient's autonomic nervous system; however the indiscriminate use of anticholinergics in every patient is not appropriate. These drugs are contraindicated in patients with pre-existing tachycardia as seen in thyrotoxicosis or fever.\nPhenothiazines such as acepromazine are used to sedate patients for simple non painful procedures, relieve patient anxiety or as premedication for general anesthesia. They provide good sedation and reduce the amount of anesthetic agents needed to induce and maintain anesthesia. Acepromazine reduces the occurrence of catecholamine induced arrhythmias, causes vasodilation that can result in hypotension, and in some breeds such as the boxer has been associated with cardiovascular collapse. Acepromazine is not reversible and has long acting effects. These effects may be prolonged in patients with reduced liver function or when administered to patients at higher doses. Inhibition of platelet aggregation and mild respiratory depression has also been reported with the use of this drug.\nBenzodiazepines produce a calming or decreased anxiety effect, muscle relaxation, and provide excellent anticonvulsant effects. These drugs are frequently used as anticonvulsants for seizure control, as tranquilizers that provide muscle relaxation and sedation, and for behavior modification to controlling fear-induced behaviors. The effects of these drugs can be reversed with flumazenil. Benzodiazepines enhance the action of GABA (gamma-aminobutyric acid), the major inhibitory neurotransmitter in the brain. When benzodiazepines are used 1) as a preanesthetic agent or 2) with an opioid for neuroleptic sedation, or 3) with an anesthesia induction drug as an anesthesia co-induction agent; the quantity of other anesthetic drugs required to both induce and maintain adequate anesthesia is reduced. They have minimal cardiopulmonary effects; the analgesic effects from benzodiazepine drugs are minimal. The negative effects would include: excitement in cats and some dogs and prolonged effects in patients with liver disease. Diazepam is not water soluble which may result in unpredictable results due to unreliable absorption when administered IM or SQ. Administration of diazepam IM can cause pain and possibly the development of a sterile abscess at the injection site.\nThe assessment of pain represents one of the greatest challenges in veterinary medicine. Since our patients cannot verbally communicate their pain, we must rely on observations to evaluate the animal's comfort level. Various studies have been performed trying to establish a satisfactory objective scale to consistently assess pain in animals without success.\nThe management of pain has moved to the forefront in veterinary medicine. The focus is to prevent pain perception rather than to treat pain once the patient has become cognoscente of it. Pain can be much more difficult to control once the patient has become conscious of it. The use of analgesics is becoming more prevalent in the practice of veterinary medicine. Therapy plans have evolved over the past several years to include the use of local anesthetic drugs, opioids, alpha2-adrenergic agonists, NSAIDs, or combinations of these drugs to provide good analgesic levels and patient comfort.\nThese drugs have provided the most consistent and effective analgesia for many years and are arguably still the best drugs available for pain control in small animals. The use of opioid drugs in practice is sometimes deterred due to the fact that these drugs are controlled substances. Their use requires a DEA license and additional paperwork as well as security, due to their abuse potential. The extra work is well justified by the analgesic benefit to the patient. There are multiple types of opiate receptors in the CNS and they each have different roles to play in the activity of the nervous system. The two most important receptors with respect to pain are the mu and the kappa receptors. The drugs we use have different affinities for these receptors and this explains the differences in duration and efficacy between the available drugs. None of the opioids produce a loss of consciousness in veterinary patients, therefore opioids are not used solely to induce general anesthesia. They are used in conjunction with other drugs such as benzodiazepines and inhaled agents to produce general anesthesia. There is wide variation in the dosage of these drugs. Each patient's response to these drugs should be assessed and the dose adjusted according to the patient's response. Opioids effects are reversible with pure opioid antagonists such as naloxone. The beneficial effects of the opioids include 1) excellent analgesia with mild cardiopulmonary effects that are dose dependent, 2) reduce the quantity of other anesthetic drugs needed to produce general anesthesia, 3) dose dependent CNS depression. Sedation produced by these drugs can outlast the analgesic effects.\nThese drugs in general act as an antagonist at the mu opioid receptor and act as an agonist at the kappa opioid receptors or provide a partial agonist response from the mu receptor. They may be used to reverse the effects of the pure mu agonists. These drugs are not as effective analgesics as the pure mu agonists, but are thought to cause less dysphoria and vomiting than mu agonists.\nTranquilizers (a phenothiazine, benzodiazepine or butyrophenone) can be combined with an opioid to provide both sedation and analgesia. The effect of these drug combinations tend to be synergistic, therefore lower doses of each drug are required to produce the desired effect. When these drug combinations are used in an anesthesia plan they provide preemptive analgesia and sedation to facilitate catheter placement and further reduce the quantity of other drugs needed to induce and maintain general anesthesia.\nThe alpha-adrenergic family of receptors is subclassified into alpha1 and alpha2. Alpha2 adrenergic receptors located within the CNS induce both sedation and analgesia not unlike that produced by opioid receptor activation. Alpha2 and opioid receptors are found in similar regions of the CNS, even on some of the same neurons. The functional CNS effects are quite similar between alpha2 and opioid receptors. The primary advantages of these drugs are that they provide analgesia and sedation while producing minimal respiratory depression and their effects are reversible with the use of alpha-adrenergic antagonists. Typical patient response to the IV administration of these drugs alone is CNS depression, analgesia, profound hemodynamic changes (increased blood pressure initially, due to vasoconstriction, followed by hypotension and bradycardia as sympathetic tone decreases and vagal tone increases), and respiratory rates may decrease (tidal volume increase). Perhaps the best advice with respect to these drugs would be to use as low a dose as possible and proceed cautiously with their administration. Great caution is advised if using alpha-adrenergic agonists in the compromised patient and they should not be used in patients with a reduced cardiopulmonary reserve.\nAlpha2 Adrenergic Antagonists\nA significant advance in veterinary medicine during the last decade has been the utilization of antagonists for the reversal of some injectable anesthetic regimes. The ability to reverse the effects of alpha2 adrenergic agonists has helped to promote their use in veterinary anesthesia. Yohimbine and Atipamezole may be used to reverse the effects of the alpha2 adrenergic agonists.\nDissociative anesthetic agents are drugs that interrupt the ascending transmission from the unconscious to conscious parts of the brain. Dissociative anesthesia is characterized by a cataleptic state in which the eyes remain open with a slow nystagmic gaze. Muscle hypertonus and movement often occur unrelated to surgical stimulation, for this reason dissociatives are often combined with other drugs. (ie: phenothiazines, benzodiazepines, alpha2 adrenergic agonists). Good analgesia is provided, however it is of short duration. Dissociative drugs that are commonly used are ketamine and tiletamine (Telazol is a combination of tiletamine and zolazepam). These drugs increase circulating catecholamines resulting in good cardiovascular support for patients that are not catecholamine depleted. Patients that are catecholamine depleted experience myocardial depression that may result in hypotension. Apneustic breathing patterns are seen with the use of the dissociative drugs. Intercranial pressure may also increase with the use of ketamine. Increases salivation and pain on IM injection is common.\nBarbiturates act directly on the CNS neurons in a manner similar to that of the inhibitory transmitter GABA. Barbiturate anesthesia is thought to be produced by a combination of enhanced inhibition and diminished excitation. These drugs can be used to induce sedation and hypnosis, as anticonvulsants, and as anesthetics. Today in veterinary practices barbiturates are used as anesthetic induction agents and anticonvulsants. Thiopental is the most commonly used drug of this group. Thiopental is an ultra-short acting barbiturate whose short duration of action relies on redistribution. Repeat boluses can lead to an accumulation of the drug and may result in a prolonged recovery. Transient respiratory depression/apnea is experienced with thiopental. This drug can sensitize the heart to catecholamine induced arrhythmias but is not associated with excessive myocardial depression.\nOver time barbiturates have been the most common drugs used to produce short duration anesthesia, many other drugs can be used to produce unconsciousness. Newer drugs are finding their way into clinical use in veterinary medicine. These drugs are rapid acting, quickly redistributed and metabolized, and can be titrated to produce from sedation to general anesthesia. They do not provide analgesia.\nPropofol is a highly lipid-soluble alkylphenol rapid acting intravenous anesthetic agent. Propofol is formulated in a 1% emulsion that contains egg lecithin, glycerol and soybean oil. This solution contains no preservatives and is a perfect growth medium for bacteria; therefore ascetic handling and shelf life of open containers is critical to patient safety. This drug has an onset similar to thiopental. Inductions are usually smooth, rapid and excitement free. Varying dose dependent levels of sedation, hypnosis and general anesthesia can be achieved with propofol. This drug has no analgesic properties, so it should be used in conjunction with analgesics for painful procedures. Propofol is rapidly metabolized and redistributed. This drug does not exhibit cumulative effects; therefore repeated boluses or constant rate infusions (CRI) may be used for longer procedures without prolonged recovery. The exception to this would be in cats where CRIs at higher doses for longer periods have been reported to produce prolonged recoveries. Patients can experience pain on injection, myoclonus, muscle tremors, and movement during anesthesia with propofol. Patients receiving this drug can experience hypotension due to myocardial depression and vasodilation as well as hypoventilation due to apnea. There is a common misconception that because propofol is a short acting anesthetic agent which is rapidly metabolized; it is a safe anesthetic agent. However it should be noted that if administered at too high a dose or bloused too quickly it can cause significant cardiopulmonary depression. Like with any other anesthetic drug the patient's physical status must be considered in calculating the dose and the drug must be cautiously titrated to effect. Heinz body anemia has been reported with frequent use in cats.\nEtomidate is a sedative hypnotic with a rapid onset of action and rapid recovery. Etomidate produces minimal cardiopulmonary depressant effects which makes it a very good choice for patients with cardiovascular disease.The solution is a propylene glycol solution that is very hyperosmotic. This drug should either be diluted in saline at a ratio of at least 1:3 prior to IV administration or it can be administered via a distal injection port of a fluid administration set connected to an IV catheter. By diluting it or allowing it to mix with IV fluids prior to reaching the patient's blood you can reduce the solution's osmolality and avoid hemolysis. Etomidate can produce pain on injection, excitement during induction and recovery, retching, myoclonus and apnea. The use of premedication drugs and a benzodiazepine as a co-induction agent will help reduce the unpleasant side effects experienced by the patient. In man, long term uses of etomidate is associated with adrenal cortical suppression; typically this is not a concern for short term uses in veterinary patients.Despite the negative effects, etomidate is often the induction drug of choice for patients with cardiovascular disease.\nInhalation anesthetic agents are widely used in veterinary medicine today. Volatile anesthetic agents are delivered, and for the most part removed from the body by the lungs. The use of these agents requires an anesthesia machine that provides oxygen, a breathing circuit, and a facemask or endotracheal tube, as well as a way to remove accumulations of carbon dioxide. These components reduce the risk of morbidity or mortality to the patient by facilitating ventilation and increasing oxygenation. Anesthesia induction with an inhaled agent is no safer to the patient than induction with injectable anesthetic agents. It is more that the patient is better supported with oxygen. The use of an inhaled anesthetic agent to maintain anesthesia for a prolonged period of time is a safe and practical method. The main advantage to an inhalation agent induction is the recovery will be rapid, depending on the amount of time the patient is asleep. Less drug metabolism by the liver is required when compared to injectable drugs. The two more common inhalation agents used in veterinary medicine today are halothane and isoflurane, newer agents are on the horizon such as sevoflurane and desflurane. Sevoflurane is experiencing a current rise in popularity due to increased marketing.\nA local anesthetic can provide total analgesia to the affected area. They have been applied topically to wounds or by local infiltration to a region of the body (ie: intercostal block or epidural injection) or they have been instilled into a body cavity to provide relief (intrapleural or intraperitoneal infusions). Local anesthetic agents can reduce the quantity of other analgesics needed to provide adequate pain relief.\nPain management has become a major focus in veterinary medicine, especially in the arena of anesthesia. It has become well established that attacking pain by more than one avenue using a multi modal approach is an effective pain management strategy. The use of NSAIDs has recently been touted as "the most widely used analgesics in veterinary medicine" Historically anesthesiologists have been leery to administer these drugs until the anesthesia period is over and the patient is in recovery. NSAIDs are associated with adverse effects on the GI, renal and hepatic systems as well as coagulation disorders. With the arrival of newer NSAIDs such as carprofen, deracoxib and meloxicam; NSAIDs are finding their way into the anesthetist's toolbox as another resource for pain management. Even with the newer drugs caution must still be advised. The patient's physical status, co-existing diseases, current medications and its physiological homeostasis during the anesthesia period must all be considered when choosing the best pain management. Is the use of an NSAID drug in this individual patient's best interest? If so, then which one and at what dose?\nAnalgesia, immobilization, amnesia, muscle relaxation and physiological homeostasis are the desired end-points for an anesthesia drug plan. Often the choice of drugs may be limited and your selection may not include the "optimal" drug of choice for a particular patient or situation. Your knowledge and experience with the drugs available to you is a cornerstone in the anesthesia drug plan. What are the advantages to these drugs? What are the disadvantages of these drugs? What are the needs of the patient and which drugs will best support this patient? Thinking your way through these questions as you develop an effective plan will require knowledge, understanding and experience with the drugs available at your facility. The advantage to a well-designed plan comes from the forethought used to generate the plan and anticipate complications. Know what you have to work with, know what the patient needs, anticipate problems and plan a response. Optimize your knowledge, skills and abilities to provide high quality anesthesia care and support for the patient. |
Today at this point in the 21st century technology has come to date that all the imaging procedures and surgical procedures in a dental practice can be achieved within the confines of the practice itself. What do I am talking about by this?\nThere are numerous things to find in a dental practice, obviously the primary one is to discover a dentist who’s extremely qualified with excellent credentials. That’s not what this article is about. This article is about what to find otherwise in a dental practice.\nWhen you head to view a dentist, plenty of times x-rays are necessary to gauge your mouth. Modern dental practices should have what’s essential to take x-rays of one’s teeth. Preferably these should actually should be taken digitally so that they may be stored on a CD or a thumb drive or somewhere besides a big bit of film.\nAdditionally let’s say you have trouble where you’ll need to consider a dental implant or perhaps a crown or something of the nature. Would that be great in the event that you didn’t have to attend some other imaging center to acquire a CAT scan of the mouth area? Modern dental practices undertake the cost of getting a CT scanner at work which could accurately evaluate the bony aspect of one’s dental problem. They will then do implant planning that typically represents advanced technological capability of all other dental practices.\nAnother technique that modern dental practices have is a machine that enables for 3d CAD/CAM imaging so that porcelain crowns can be fabricated in the office. Typically, patients previously had to bite down on some play dough type substance with the mold impression and then have it shipped off to a lab the place where a temporary crown come back.\nThat is no further necessary in modern dental clinics. Zahnarzt Zürich A CEREC machine is an excellent 3d imaging device that makes a computer software virtual image of the problem and then sends that to a milling machine which then fabricates the crown immediately in the office.\nAnother aspect of modern dental practices is anesthesia. Traditional dental practices did not offer dental sedation due to their patients. Because of this, patients often need to have multiple procedures done in multiple settings because otherwise they wouldn’t manage to handle the whole lot at one time. Dental sedation provides for multiple procedures to be performed in one single setting so that it’s more convenient and respectful of patient’s time.\nThe culmination of most of these amenities in modern dental practices ensures that patients have more time to accomplish other things besides look after their mouths. They don’t have to go elsewhere to acquire a CAT scan, you do not have to have x-rays someplace else, you do not have to hold back weeks to acquire a porcelain crown made, and they don’t really need to have multiple procedures over multiple settings and take time faraway from work.\nSo underneath line is that when you’re looking for a new dental practice, yes definitely consider the dentist’credentials but additionally remember to look and see precisely what amenities the dental practice offers that will save you time and give you the most technological edge to properly taking care of your dental needs.\nAccuCare Dental Center represents the premier Arizona dentistry center in Phoenix and Scottsdale, AZ. |
Latest Ketamine Stories\nDelray Recovery Center is a Florida facility that offers individualized treatment programs for drug addiction, alcohol addiction, eating disorders and co-occurring disorders such as bipolar disorder,\nA drug that works through the same brain mechanism as the fast-acting antidepressant ketamine briefly improved treatment-resistant patients' depression symptoms in minutes, with minimal untoward side effects, in a clinical trial conducted by the National Institutes of Health.\nMany chronically depressed and treatment-resistant patients experience immediate relief from symptoms after taking small amounts of the drug ketamine.\nScientists have discovered a biological marker that may help to identify which depressed patients will respond to an experimental, rapid-acting antidepressant.\nKetamine, an anesthetic commonly used in veterinary practice for feline surgical procedures, has been found to help bipolar patients suffering from depression.\n- A person or thing gazed at with wonder or curiosity, especially of a scornful kind. |
Anesthesiologists frequently encounter complex patients in need of emergent surgery. These situations are increasingly challenging if they are unwitnessed or complicated by toxins. The anesthetic management of these patients is fraught with difficulties, and can become even more perplexing if poisoning is suspected in an obtunded or uncooperative patient. Often times the patient is unable or unwilling to confirm the type of poison, drug, or substance taken.\nMONOAMINE OXIDASE INHIBITORS\nOne of the most feared complications of dietary or unintentional polypharmacy interactions can manifest with monoamine oxidase inhibitors (MAOis). They are a long-standing treatment for depression and other psychiatric disorders, especially atypical depression. They are often used as a last line of treatment when selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) have failed. They may also be used in the treatment of Parkinson’s disease.\nMAOi’s mechanism of action is to prevent the breakdown of the monoamine neurotransmitters. The decrease in neurotransmitter destruction indirectly increases their availability, thus increasing serotonin and norepinephrine. It is important to note that MAOi may differ in their selectivity for MAO-A and MAO-B receptors. Individuals taking MAO-A selective inhibitors must undergo food restrictions, specifically foods high in tyramine. Food restrictions are required because MAOis inhibit the metabolism of dietary amines, thus increasing the likelihood of serotonin syndrome or hypertensive crisis. Examples of foods high in tyramine are alcohol, aged cheese, vegemite, and chocolate. Conversely, MAO-B selective inhibitors are more often used to treat Parkinson’s disease, which can often be taken without dietary restrictions because they prevent the breakdown of dopamine and phenethylamine—not serotonin-like MAO-A. Examples of common MAO-B inhibitors are selegiline and rasagiline.\nMAOis should not be combined with SSRIs, TCAs, dextromethorphan, meperidine, St. John’s Wart, tryptophan supplements, and tramadol. Combination of these drugs may result in serotonin syndrome, or hypertensive crisis. Interestingly, providers should be aware that patients taking MAOis in need of epinephrine, dopamine, or norepinephrine should decrease the administered dose and expected prolonged duration of these drugs. Additionally, methylene blue is a highly potent MAOi.\nThe problem with tyramine or sympathomimetic drugs is that they are both potent stimuli for norepinephrine release. The release of norepinephrine can cause a tyramine-induced hypertensive crisis when combined with tyramine-containing foods, or excessive effect of sympathomimetic drugs. Despite this, anesthesia can be safely conducted with patient’s taking MAOis. One must remember meperidine should not be used for postoperative shivering, nor should ketamine be utilized. Additionally, patients may have higher anesthetic requirements due to increased norepinephrine concentrations. It is recommended to avoid epinephrine in local anesthetic solutions due to prolonged effects.\nSerotonin syndrome is a life-threatening consequence of excessive serotonin. It produces a wide spectrum of somatic, cognitive, and autonomic adverse effects. The disease is based on history or clinical symptoms, as no lab tests are confirmatory. Symptoms manifest rapidly: tachycardia, agitation, mydriasis, myoclonus, hypertension, hyperthermia, and mental ... |
Substance abuse treatment for hydrocodone in Coin\nHydrocodone is an opioid analgesic (medicine) medicine– included in the solution of many numbing prescription painkillers that are most often suggested to manage moderate to serious pain. As an opiate medicine, it is in the same household as morphine and oxycodone; like several other opioid materials, it has a high possibility to bring about dependence and dependency if it is mistreated.\nIt’s indicated for the management of discomfort that would not be well controlled with non-steroidal anti-inflammatory or various other, non-narcotic analgesic alternatives. Physicians typically suggest this medication only for people with serious pain resulting from surgery, various disease processes or injury.\nWhat Drugs Contain Hydrocodone?\nHydrocodone or hydrocodone-containing medicines are sold under many trademark name including Vicodin, Lortab and also Norco. Most of opioid painkillers are a combination of hydrocodone and also acetaminophen– a drug that when abused can trigger extreme liver damages.\nHow Do I recognize if I’m Abusing Hydrocodone?\nMisuse occurs whenever you use the medication in a fashion other than that recommended by a doctor. If you take a bigger dosage of hydrocodone than suggested, take it for a longer duration than advised, or take it regularly throughout the day than routed, you are abusing hydrocodone.\nResults of Abusing Hydrocodone\nIf a person abusing hydrocodone continues taking the drug enough time, the person’s body and also brain could adapt to the visibility of medication in their system. It could transform the way it responds to the drug in a process called resistance.\nIndividuals who develop a tolerance on hydrocodone need to take bigger dosages of the drug, or take it more often, to experience the same favorable impacts. In seeking a greater “high,” or in an initiative to conquer the impacts of resistance, abusers may take such big doses of hydrocodone that place themselves in danger of an overdose.\nOutpatient Coin rehabilitation for hydrocodone\nOutpatient therapy centers supply counseling as well as various other services to clients every day, and those that go to the program invest a couple of hrs at the treatment facility prior to going house, going to function or sticking with loved ones. Outpatient centers are best for those who can successfully navigate the freedom of such a program.\nYou need to remain for a minimum of 28 days– nonetheless, many programs supply longer alternatives. As stated, lots of inpatient centers could additionally supply clinically managed detox assistance for those experiencing opiate withdrawal symptoms when they quit taking the hydrocodone.\nInpatient rehab programs are the preferred approach of treatment for lots of people having problem with stubborn opiate addictions, as they allow you to concentrate totally on your soberness– freed of the lures and disturbances that might otherwise take place in a residence setting.\nHydrocodone for Teenagers in Coin\nHydrocodone abuse truths are sobering enough, but you could be stunned at the number of teens and also young adults abusing hydrocodone-containing medications like Vicodin, Norco, and also Lortab. The 2014 Keeping an eye on the Future (MTF) Study quizzed jr high and also high institution trainees regarding their medicine abuse. |
Lasers for use in dermatology, ophthalmology and cosmetics have been around for years and so has the WaterLase dental laser. WaterLase is cleared for numerous dental applications which can be performed on both pediatric and adult patients. WaterLase Dentistry is one of the most advanced dental treatments available today. WaterLase uses a patented technology that combines focused light energy with a gentle spray of water for a highly precise, exceptionally gentle dental experience. WaterLase Dentistry allows your dentist to perform a wide range of procedures with benefits including:\nVirtually Painless, More Natural Dentistry*\nHeat, vibration and pressure are the primary causes of pain associated with the use of the traditional dental drill. Since cutting both hard and soft tissues (teeth and gums) with the WaterLase does not generate heat, vibration or pressure, many dental procedures can be performed nearly pain-free with fewer shots, less need for anesthesia, less use of the drill and fewer numb lips! Additionally, using the WaterLase for gum procedures reduces bleeding, post-operative pain, swelling and the need for pain medication in many cases. It’s just a better way to get your dentistry done!\nAccuracy & Precision\nWaterLase dentists are able to remove tooth enamel decay (the hardest substance in the body), bone and gum tissue precisely while leaving surrounding areas unaffected. This conserves more of the precious tooth structure you were born with, helping you to maintain your natural teeth longer!\nHigh speed drills can cause hairline cracks and fractures in the teeth that eventually lead to future dental problems. WaterLase reduces damage to healthy portions of the tooth and minimizes trauma.\nLess Bleeding & Swelling\nDue to its conservative cutting action, the WaterLase performs many soft tissue (gum) procedures with little or no\nbleeding and less post-op swelling.\nFewer Dental Visits\nSince you often do not need shots or anesthesia, a WaterLase dentist can perform cavity preps in all areas of the mouth in just one visit. This technology also gives trained WaterLase dentists the ability to perform many procedures that were previously referred to specialists, saving you time and hassle as you address the dental needs of you and your family.\nThe WaterLase is extremely versatile. It can be used for a wide range of hard and soft tissue procedures. From decay removal, cavity preparation, root canals, smile design, gum and bone surgical procedures and many others. Let your WaterLase dentist be a one stop shop for you!\n*Discomfort is based on individual sensitivity to pain, and other factors. Not all patients can be treated painlessly without anesthetic. However, dentists using WaterLase to perform typical cavity preparations report not using anesthetic in the majority of cases. |
Click here to learn more.\nA biopsy is a surgical procedure in which a tissue sample is removed from the body and examined under a microscope. In some cases, only a small sample is removed for analysis. In other cases, several samples may be removed, or an entire growth may be removed and examined.\nDogs and cats commonly develop lumps and growths on their skin. Sometimes these lumps are cancerous, but in other cases, they are simply warts or other noncancerous (benign) growths. Examining a lump does not always give your veterinarian enough information to tell whether it is cancerous or not. A biopsy may be recommended to obtain more information about a suspicious lump.\nA biopsy can also be used to diagnose a condition or determine the severity of a disease. For example, if an animal has liver disease, a sample of the liver can be removed (during a biopsy) and examined under a microscope to help determine the cause and extent of the liver damage.\nSome form of anesthesia is generally required to perform a biopsy. Depending on several factors, including where the tissue sample(s) is/are located and how many areas need to be sampled, your veterinarian will decide whether to use local anesthesia, sedation, or general anesthesia. Local anesthesia usually involves injecting a medication in and around an area of the body to make it numb. If local anesthesia is used, your pet will likely be awake during the biopsy. In contrast, if sedation or general anesthesia is used, the patient is heavily sedated or completely asleep during the procedure. Sometimes, if a growth is on the surface of the skin and is very small, your veterinarian may be able to perform a biopsy using local anesthesia. However, if the area to be biopsied is within the abdomen, for example, or if multiple areas will be biopsied, general anesthesia is usually recommended.\nYour veterinarian has a few options when deciding how to perform a biopsy and how much tissue to remove. In an incisional biopsy, a small sample of tissue is removed from a larger mass. In an excisional biopsy, the entire growth is removed and submitted for biopsy. Once the tissue is removed, your veterinarian will submit it to a diagnostic laboratory. There, a veterinary pathologist (a specialist at examining cells and tissue samples) will examine the tissue under a microscope to make a diagnosis. Results are generally available within several days.\nBiopsies are very important for helping to confirm a diagnosis. With many types of cancers, early diagnosis is helpful for determining the course of treatment and can help increase the chance of survival. Biopsies can also help to confirm causes of other conditions, including skin lesions as well as diseases of the kidneys, liver, or bone marrow.\nYour veterinarian will take many precautions to help ensure that your pet is safe during the biopsy and fully recovers afterward. To help reduce the risk of complications associated with surgery or anesthesia, your veterinarian may give your pet a full physical examination and check your pet’s blood work before the biopsy. Biopsies are very safe, routine procedures. The risks associated with a biopsy depend on several factors, including the overall health of the patient, the location of the area to be biopsied, and how many samples are taken. Be sure to discuss any questions or concerns with your veterinarian.\nLike this article? Have a point of view to share? Let us know!\nBudweiser's new commercial features a\nLab waiting for his owner to come home\nafter he goes out drinking with friends.\nAn amazing video captures a black\nand white cat’s surprising survival after\na historic hotel fell in Manitoba,…\nA pair of 3-week-old cheetahs is getting\nround-the-clock care by the staff\nat the San Diego Zoo Safari Park.\nIn honor of tonight’s season premiere of\nThe Big Bang Theory, we came up with\n7 ways this breed is dogdom’s Sheldon.\nAs dogs age, both their mental and\nphysical health are affected. It's important\nto know how to handle these changes.\nWith his chubby cheeks, short nose and round eyes, the British Shorthair looks like he's always grinning.\nThank you for subscribing. |
Please use this identifier to cite or link to this item:\n|A clinical report on surgical correction of atresia ani with agenesis of vulva: a case report\n|Congenital anomali, Atresia ani, Agenesis of vulva, Low epidural, Ring block\n|Chattogram Veterinary and Animal Sciences University Khulshi, Chattagram-4225, Bangladesh\n|The calf was brought to Chakaria Upazilla Veterinary Hospital (CUVH) in Cox'sBazar district with the complaint of incontinence of feces and urine on the day of its birth. No anal opening is the primary clinical finding, which is followed by a protrusion of a muscular balloon-like structure. The most prominent clinical symptoms are straining, depression, tenesmus, and abdominal pain. This case was diagnosed as having atresia ani, along with agenesis of the vulva. A surgical correction was required and surgery was performed where 2% lidocaine was used for local anaesthesia (low epidural, ring block), diazepam for sedation, and permanent opening of the anus and urethral orifice was performed. The post-operative care includes Pronapen 40lac (preparation of benzyl penicillin 30 lac iu and procaine penicillin 10 lac iu) at 20,000-40,000 IU/kg i/m, Meloxicam @ 0.5 mg/Kg, S/C and application of Vaseline through the inner permanent opening to repel the further adhesion and application of topical antiseptic, sulphanilamide powder on the external of the surgical wound. Injectable treatment was continued for 7 days, but topical application was continued for 15 days. The patient was followed up for two month. After 1 month no problem was found. Defecation and urination was satisfactory dealing with the other normal body functions.\n|Appears in Collections:\nFiles in This Item:\n|Tauhid Clinial Report final print pdf.pdf\n|Tauhid Clininical Report Cover Page.pdf\nItems in DSpace are protected by copyright, with all rights reserved, unless otherwise indicated. |
|Número de publicación||US6017963 A|\n|Tipo de publicación||Concesión|\n|Número de solicitud||US 08/557,279|\n|Fecha de publicación||25 Ene 2000|\n|Fecha de presentación||14 Nov 1995|\n|Fecha de prioridad||14 Nov 1995|\n|También publicado como||CA2234847A1, CA2234847C, DE69629591D1, DE69629591T2, EP0877609A1, EP0877609A4, EP0877609B1, US6642275, US20010049391, US20020022663, WO1997017948A1|\n|Número de publicación||08557279, 557279, US 6017963 A, US 6017963A, US-A-6017963, US6017963 A, US6017963A|\n|Inventores||Mark Alfonso, Paul Goldenheim, Richard Sackler|\n|Cesionario original||Euro-Celtique, S.A.|\n|Exportar cita||BiBTeX, EndNote, RefMan|\n|Citas de patentes (20), Otras citas (2), Citada por (86), Clasificaciones (20), Eventos legales (6)|\n|Enlaces externos: USPTO, Cesión de USPTO, Espacenet|\nThe present invention relates to formulations and methods for the intranasal and inhalation administration of analgesics having low opioid receptor binding affinity.\nPharmacologically active compounds are most commonly administered by the oral route. In particular, analgesics are preferably taken by mouth. However, this convenient route of administration is not always possible for certain patients. Contraindications to oral administration of analgesics can include nausea and/or emesis, oral or gastrointestinal surgery and dysphagia. In addition, rate of analgesia onset is slower and more variable due to first pass effects which compromise the apparent potency of some analgesics and complicate their use. The alternative of administration by injection, e.g., parenteral, intramuscular or subcutaneous injection, is generally not preferred due to patient discomfort and the attendant increased costs associated with the production of and administration of injectable products.\nAnother, less invasive form of administration is transmucosal administration. Transmucosal administration can be via oral, nasal and/or upper respiratory tract, rectal or vaginal mucosal surfaces, to name the more common non-oral transmucosal routes of administration. Transmucosal administration has the advantage that patients who are unable to swallow can be medicated without recourse to injection. Importantly, transmucosal administration may often provide a more rapid relief of pain, compared to oral administration, by providing direct access to the blood circulation and bypassing the gastrointestinal tract and portal vein circulation and liver metabolism. A particularly preferred route enterohepatic blood circulation. A particularly preferred route for transmucosal delivery is intranasal administration for absorption by the nasal mucosal surfaces and/or inhalation for absorption in the bronchial passages of the lungs.\nHeretofore, it has been taught that only certain opioid analgesic compounds would be suitable for intranasal transmucosal administration. For example, given the difficulties of delivering compounds across the mucosal barrier and the limited mucosal area that is conveniently available to intranasal administration, only the most potent opioid analgesics, antagonists or mixed agonist/antagonist drugs were taught to be candidates for intranasal delivery. In addition, only those opioid compounds for which oral delivery was variable and problematic were generally considered for intranasal delivery.\nFor example, U.S. Pat. No. 4,464,378, by Hussain (1984), discloses the intranasal transmucosal administration of certain potent narcotic agonists, antagonists and mixed agonist/antagonists. The Hussain disclosure relates to two classes of compounds, morphine and certain of its structurally close relatives and Δ9 -tetrahydrocannabinol ("delta-9-THC"). The opioid compounds disclosed to be intranasally effective by Hussain are morphine-like compounds retaining a phenolic group, that are also of high potency (typically exhibiting high mu receptor potency, whether agonist, antagonist or mixed agonist/antagonist) and are stated to be rarely used orally because of inefficient and variable absorption by that route. However, Hussain does not teach the intranasal administration of analgesics that are either weak opioids or non-opioid analgesics, which are also well absorbed orally with predictable efficacy.\nWenig et al., U.S. Pat. No. 4,778,810, issued in 1988, discloses the administration of caffeine by nasal administration. Caffeine is a xanthine derivative completely unrelated to the opioids and unrelated to the non-opioid analgesics.\nFrost, U.S. Pat. No. 4,880,813, issued in 1989, discloses a method of treatment of allergic rhinitis by the intranasal administration of the narcotic antagonist nalmefene. Nalmefene, (6-methylene-6-desoxy-N-cyclopropylmethyl-14-dihydronomorphine) is a pure opioid antagonist with a prolonged duration of action. Frost states that Nalmefene is believed to act locally on nasal tissues by inhibiting mast cell degranulation provoked by endogenous opioids acting on receptors in the nasal mucosa and the upper respiratory tract. Thus, Frost does not disclose or suggest any systemic delivery of malmefene or any other opioid compound into the blood circulation.\nCohen, U.S. Pat. No. 4,973,596, issued in 1990, discloses a method of intranasally administering the synthetic narcotic analgesic, meperidine, which is a synthetic opioid drug, in a suitable dosage form. However, the effectiveness of intranasal and/or inhalation administration of a weak opioid or non-opioid analgesic is unpredictable from the disclosures of the intranasal effectiveness of morphine or its derivatives, or meperidine, which are conventional strong opioid receptor binding agents. Therefore, the art does not disclose that a weak opioid receptor binding compound, such as the analgesic tramadol, or its derivatives and pharmaceutically acceptable salts, can be delivered by transmucosal and/or inhalation administration.\nTramadol, which has the chemical name (±) trans-2-[(dimethylamino)methyl]-1-(3-methoxyphenyl) cyclohexanol, is an orally active opioid analgesic. Conventional release preparations in the form of capsules, drops, suppositories and formulations for systemic injection, containing tramadol, or more particularly its hydrochloride salt, have been commercially available for many years for use in the treatment of moderate to severe pain (e.g., ZYDOL, by Searle; more recently ULTRAM, by Ortho-McNeil Pharmaceutical). Tramadol hydrochloride is currently administered in single oral doses of 50, 75, 100, 150 and 200 mg to patients with, e.g., postoperative pain. In addition, controlled release preparations for oral administration of tramadol are disclosed by co-owned application, U.S. Ser. No. 08/241,129, filed on May 10, 1994, the disclosure of which is incorporated herein by reference.\nTramadol is a centrally acting synthetic analgesic compound. Unlike conventional opioids, the mechanism of action of tramadol is not completely understood. However, it is known that tramadol binds opioid receptors at low affinity and that the tramadol metabolite mono-O-desmethyltramadol (denoted "M1") binds to opioid receptors at high affinity. The M1 metabolite exhibits substantially greater analgesic activity in animal models than does tramadol. It is also known that tramadol antagonizes reuptake of both norepinephrine and serotonin (in vitro), which may also contribute to the analgesic action of tramadol. In animal models, M1 is up to 6 times more potent than tramadol in producing analgesia and 200 times more potent in opioid receptor binding. However, the contribution to human analgesia of tramadol relative to tramadol metabolite M1 is unknown. The unconventional nature of tramadol-induced antinociception is confirmed by reports that the opioid antagonist naloxone only partially antagonizes tramadol-induced antinociception in animal models. Thus, tramadol exhibits both a unique chemical structure and mechanism of action relative to conventional opioids.\nHeretofore there has been no acceptable method or formulation for the transmucosal administration of tramadol, an analgesic which is believed to provide analgesic activity by either or both opioid and non-opioid mechanisms, which is readily absorbed by the oral route and which is not of the highest opioid receptor binding.\nIt is accordingly an object of the present invention to provide a pharmaceutical dosage form of an opioid that binds weakly to opioid receptors that can be administered intranasally and/or by inhalation.\nAnother object of the present invention is to provide a pharmaceutically acceptable dosage form of tramadol that can be administered intranasally and/or by inhalation.\nStill another object of the present invention is to provide a method of treating a patient with a pharmaceutically acceptable dosage form dosage form of tramadol or its derivatives or pharmaceutically acceptable salts via intranasal and/or inhalation administration.\nIn accordance with the above objects and others which will be apparent from the further reading of the specification and of the appended claims, the present invention is related to the surprising discovery that an analgesic that is a weak opioid receptor binding compound can be effectively administered to a warm blooded animal, including a human patient, by administering a pharmaceutically effective amount of the compound, or a pharmaceutically acceptable salt, to the respiratory tract mucosal surfaces of an animal in need of treatment.\nThe invention also provides for a dosage form for intranasal and/or inhalation administration of a weak opioid or non-opioid analgesic, to a warm blooded animal.\nThe invention also provides for a method for producing analgesia in a warm blooded animal, such as a human patient, comprising contacting respiratory tract mucosal surfaces, such as the nasal and/or bronchial mucosal surfaces of a warm blooded animal in need of analgesia, with an analgesically effective amount of a weak opioid or non-opioid analgesic.\nThe compound can be, for example, the weak opioid analgesic tramadol, either as the free base, and/or as its pharmaceutically acceptable derivatives, salts and active metabolites or in any combination thereof. The compound can be administered to the respiratory tract either intranasally and/or by inhalation.\nThe dosage form can include a pharmaceutically effective amount of a weak opioid or non-opioid analgesic, such as, e.g., tramadol as described above, together with a pharmaceutically acceptable carrier that is suitable for intranasal and/or inhalation administration. The dosage form can contain, for example, tramadol HCl in an amount ranging from 10 mg to 500 mg.\nThe dosage form suitable for intranasal and/or inhalation administration can be in the form of, e.g., a liquid solution, suspension, emulsion, liposome or similar such multiphasic composition. Preferably, the dosage form includes a carrier of isotonic saline and a pharmaceutically acceptable buffer. For intranasal administration alone, the dosage form may also include an emulsion, a paste, a cream and/or a gel or gauze packing impregnated with the analgesic to be administered. A useful tramadol metabolite, that is also analgesically active, is for example, mono-O-desmethyltramadol, which can also be so administered at an effective dose intranasally and/or by inhalation alone or in combination with another drug, such as, for example, a tramadol and/or a salt or derivative thereof.\nAccordingly, the present invention provides compositions and methods having utility for the administration, via the respiratory tract, of analgesic drugs having low opioid receptor binding activity. Preferably, the analgesic drugs include the analgesic drug tramadol and derivatives and salts thereof. Reference to "tramadol" herein, unless indicated otherwise, is also understood to encompass all pharmaceutically acceptable forms of tramadol, either as the free base and/or as its pharmaceutically acceptable derivatives, salts and active metabolite and/or combinations thereof, all of which are contemplated to be used in the present compositions and methods. Reference to the term "salt" herein, i.e., tramadol salt, is also intended to encompass the haloacids, i.e., tramadol HCl and the like, unless otherwise indicated.\nIn accordance with the present invention, an effective amount of a pharmaceutically acceptable form of tramadol is administered intranasally, e.g., by contact with mucosal surfaces in the nasal passages.\nPharmaceutically acceptable carriers for administering tramadol to the nasal mucosal surfaces will be readily appreciated by the ordinary artisan. Such carriers are disclosed, simply by way of example, by Remington's Pharmaceutical Sciences" 16th edition, 1980, Ed. By Arthur Osol, the disclosure of which is incorporated by reference herein in its entirety.\nThe selection of appropriate carriers depends upon the particular type of administration that is contemplated. For administration via the upper respiratory tract, e.g., the nasal mucosal surfaces, tramadol can be formulated into a solution, e.g., water or isotonic saline, buffered or unbuffered, or as a suspension, for intranasal administration as drops or as a spray. Preferably, such solutions or suspensions are isotonic relative to nasal secretions and of about the same pH, ranging e.g., from about pH 4.0 to about pH 7.4 or, from pH 6.0 to pH 7.0. Buffers should be physiologically compatible and include, simply by way of example, phosphate buffers. For example, a representative nasal decongestant is described as being buffered to a pH of about 6.2 (Remington's, Id. at page 1445). Of course, the ordinary artisan can readily determine a suitable saline content and pH for an innocuous aqueous carrier for nasal and/or upper respiratory administration.\nTramadol containing intranasal carriers include nasal gels, creams, pastes or ointments with a viscosity of, e.g., from about 10 to about 3000 cps, or from about 2500 to 6500 cps, or greater, may also be used to provide a more sustained contact with the nasal mucosal surfaces. Such carrier viscous formulations may be based upon, simply by way of example, alkylcelluloses and/or other biocompatible carriers of high viscosity well known to the art (see e.g., Remington's, cited supra. A preferred alkylcellulose is, e.g., methylcellulose in a concentration ranging from about 5 to about 1000 or more mg per 100 ml of carrier. A more preferred concentration of methyl cellulose is, simply by way of example, from about 25 to about mg per 100 ml of carrier. The carrier containing the drug can be soaked into a fabric material, such as gauze, that can be applied to the nasal mucosal surfaces to allow for drug penetration therein.\nOther ingredients, such as art known preservatives, colorants, lubricating or viscous mineral or vegetable oils, perfumes, natural or synthetic plant extracts such as aromatic oils, and humectants and viscosity enhancers such as, e.g., glycerol, can also be included to provide additional viscosity, moisture retention and a pleasant texture and odor for the formulation. For nasal administration of solutions or suspensions according to the invention, various devices are available in the art for the generation of drops, droplets and sprays. For example, tramadol solutions can be administered into the nasal passages by means of a simple dropper (or pipet) that includes a glass, plastic or metal dispensing tube from which the contents are expelled drop by drop by means of air pressure provided by a manually powered pump, e.g., a flexible rubber bulb, attached to one end. Fine droplets and sprays can be provided by a manual or electrically powered intranasal pump dispenser or squeeze bottle as well known to the art, e.g., that is designed to blow a mixture of air and fine droplets into the nasal passages.\nThe tear secretions of the eye drain from the orbit into the nasal passages, thus, if desirable, a suitable pharmaceutically acceptable ophthalmic solution can be readily provided by the ordinary artisan as a carrier for the analgesic compounds to be delivered and the analgesic can be administered to the orbit of the eye in the form of eye drops to provide for both ophthalmic and intranasal administration.\nIn one embodiment, a premeasured unit dosage dispenser that includes a dropper or spray device containing a solution or suspension for delivery as drops or as a spray is prepared containing one or more doses of the drug to be administered. The invention also includes a kit containing one or more unit dehydrated doses of tramadol, together with any required salts and/or buffer agents, preservatives, colorants and the like, ready for preparation of a solution or suspension by the addition of a suitable amount of water. The water may be sterile or nonsterile, although sterile water is generally preferred.\nFor administration by inhalation into the lower respiratory tract, e.g., the bronchioles, by inhalation, tramadol can be formulated into a solution and/or a suspension of particles in a carrier appropriate for inhalation. Such carriers are also well known to the ordinary artisan familiar with inhalants for the delivery of fine droplets and insufflations for the delivery of inhalable fine particles, on the order of, for example, from about 0.5 to 1 micron, and preferably from about 0.5 to about 0.7 micron, comprised of powders, mists or aerosols, into the respiratory tract (Remington's, Id., at page 1451).\nFor inhalation of droplets, mists and aerosols various devices such as nebulizers or pressurized aerosol generators are readily available. In addition, such devices can be metered to provide uniformity of dosing (Remington's, Id.).\nDry powder inhalers of types readily disclosed in the art may also be used, as well as micronized shavings of isostatically compressed tablets or discs of drug with or without inert binders such as lactose may be used.\nAll inhalers may be designed and fashioned to deliver liquid or solid particles to the nasal mucosa as well as the upper and/or lower airways.\nIn one embodiment, drugs for nasal and/or inhalation administration can be administered as powders. The powdered drug or composition is normally located within a container such as a hard gelatin capsule or a blister package, or a multi-dose devise. The capsule or blister is ruptured or broached within in an inhaler device, thereby enabling the powder to be inhaled. Generally, the mean particle size of the drug used for inhalation is between 1 and 10 micron with the size range between 2 and 5 microns being particularly suitable for penetrating the peripheral airways of the lungs. Such particle size ranges are commonly achieved by micronisation or spray drying.\nThe finely divided drug powder is often administered as a composition comprising a blend or mixture of the medicament with an inert carrier. Usually the inert carrier has a mean particle size substantially larger than that of the drug. This provides, among other advantages, an improvement in the flow properties and dispensing accuracy of the composition.\nCommonly described carrier materials for produced drug, include calcium carbonate and sugars, for example sucrose, mannitol or dextrose or, more particularly, lactose, which are pharmaceutically acceptable and pose no problems of toxicity, since any residues imbibed during dosing are well tolerated upon digestion or may be easily eliminated by disillusion (e., in the case of the sugars) or mucocilliary clearance from the lung.\nThe composition in the capsule or blister is frequently about 25 mgs. This weight probably represents the maximum quantity of powder that may be comfortably inhaled without undue side effects, such as coughing, and also corresponds to the minimum quantity that is usually dispensed by filling machines.\nPreferred compositions according to the invention, are those in which the carrier has a particle size distribution in which at least 7% by weight of the carrier particles are at or below about 11 microns, and at least about 20% by weight are at or below about 33 microns, and at least about 20% are at or above 63 microns. Furthermore, particularly those in which the carrier has particle size distribution in which 8% by weight of the carrier particles are at or below 11 microns, and at least 35% by weight are below 33 microns, at least 25% by weight are above 63 microns, especially those in which the carrier has a particle size distribution in which at least 9% by weight are at or below 11 microns, and at least 25% by weight are below 33 microns, and at least 35% by weight are above 63 microns.\nParticle sizes referred to in this specification are measured by laser diffraction on a Malvern Instruments Particle Sizer.\nPreferred compositions according to the invention for powder inhalation, are those in which the carrier is present at a concentration of about 95.0 to 99.99%. More particularly, from 97.0 to 99.9%, especially from 98.0 to 99.8%, by weight. Processes for preparing such powders, by the application or adaptation of known methods, also constitute features of the invention.\nThus, according to a feature of the invention, a pharmaceutically acceptable solid carrier, preferably in a fluidized bed, is sprayed with a solution of an anti-static additive in a suitable solvent, e.g. ethanol, followed by drying, preferably in a fluidized bed, followed by blending with micro fine solid pharmaceutically active compound or followed by blending with a mixture of a micro fine solid pharmaceutically active compound with a finely divided pharmaceutically acceptable solid carrier.\nAnti-static agents suitable for this purpose include those disclosed by Simpkin et al. in International Application WO 94/04133 published March 1994, the disclosure of which is incorporated by reference herein in its entirety.\nFor powder delivery of analgesic medicament, the medicament, e.g., tramadol, is preferably present in the compositions of the invention at a concentration of about 0.01% to 5.0%. More particularly, from 0.1% to 3.0%, especially from 2.0% by weight.\nInsufflation Inhalation Devices\nIn general, insulation inhalation devices suitable for use in connection with the particulate dosage forms of the invention comprise a housing having a passageway for the flow of air, in which one end of the passageway is designed for insertion in the mouth or nose, a chamber containing controlled release particles of a cohesive agglomerate of a medicament together with a pharmaceutically acceptable carrier suitable for oral inhalation, wherein the average discrete particle size is from about 0.1 to about 10 microns in diameter for the oro- pulmonary route or 10 to 355 μm for the nasal route, actuating means for releasing a unit dose of said particles into said passageway, such that the unit dose is drawn through said passageway during an inspiration by the patient and is delivered to the naso-pharynx and/or the pulmonary tract of the patient.\nThe formulations of the present invention may be adapted for use with respect to any oral and/or nasal insufflation device for powdered or solid medicaments. For example, the powder of the present invention may be compressed into a solid dosage form such as a ring tablet which is then placed into an appropriate insufflation device which includes comminuting or other means for providing discrete powder particles in the respirable fraction from the insufflation device when the device is actuated (e.g., when a unit dose of medicament is to administered via inspiration).\nThere are many devices described in the prior art which are useful for delivering a dose of powdered drug to the respiratory tract or naso-pharynx of a patient. Examples of such devices which would be useful in delivering the formulations of the present invention are described below.\nOne such device is known as the Bespak device described in International patent application WO 92/00771 (published on Jan. 23, 1992 claiming priority from Great Britain Patent Application No. 9015522.7 filed on Jul. 13, 1990; assigned to Innovata Biomed Limited.), hereby incorporated by reference. The device described therein includes a storage chamber for storing a powdered drug to be administered and a metering member having metering cups in which individual doses of the powdered drug are placed. Air is inhaled through an inhalation passage at one end of the device and directed into contact with the metering cup that has been filled with the powdered drug. The metering cup is oriented upwardly open to face the air stream and to enable the powder to be released from the cup. Upon inhalation, the dose is mixed with the air flow and continues through the mouthpiece to be inhaled.\nThe metering cups on the metering member are arranged on an outer frusto-conical wall so that each metering cup is position able to be upwardly open and face the air flow during inhalation. The metering member rotates so that the metering cups move between a position in which the cup receives a dose of the powered drug from the storage chamber to a position in which the cup is exposed to the air flow. As one cup is exposed to the air flow, another cup is aligned with the storage chamber and is being filled with powder.\nAfter the dose is blown from the metering cup, and upon subsequent rotation of the metering member, the cup is wiped and cleaned by a wiping element to remove any undispersed powder and then dried via a moisture absorbent material.\nAnother device for delivery of inhalation powders is described in U.S. Pat. No. 2,587,215 (Priestly), hereby incorporated by reference. Priestly describes an inhaler having a storage chamber containing a powdered medicament, a mixing chamber and means to move a set dose of medicament from the storage chamber to the mixing chamber. The dose is mixed with air in the mixing chamber and inhaled through a mouthpiece.\nYet another inhalation device suitable for delivering powdered inhalation drugs is described in U.S. Pat. No. 4,274,403 (Struve), hereby incorporated by reference. Struve describes an inhaler for administering a powdered drug nasally, which includes storage means for containing a quantity of the drug therein. The storage means includes a feed hole through which the powdered drug may be received from the storage means. The device further includes a dispensing head operatively coupled to the storage means for dispensing the powdered drug more nasally. The dispensing head of the Struve inhaler includes a nozzle, a body portion, a dispensing cylinder and a vent means. The nozzle is shaped to be received in the nasal passage of the user. The nozzle includes a dispensing passageway for dispensing the dose into the nasal cavity of patient.\nThe body portion is located adjacent the nozzle and has a traverse bore therein. The traverse bore operatively connects the dispensing passageway in the nozzle with the feed hole leading to the drug storage means. The feed hole and the dispensing passageway are transversely offset relative to one another at the points where they enter the transverse bore.\nThe dispensing cylinder includes a metering chamber. The metering chamber may be selectively aligned with either the feed hole or the dispensing passageway. The dispensing cylinder is slidably received in the transverse bore for movement between a first transverse position in which the metering chamber is aligned with the feed hole and a second transverse position in which the metering chamber is aligned with the dispensing passageway. In its first position, the metering chamber can be filled with a charge of the powdered drug when the inhaler is manipulated. In the second position, places the charge of the powdered drug into the dispensing passageway for inhalation by the user.\nThe vent means is formed as part of the dispensing cylinder and is capable of venting the metering chamber to atmosphere only in the second position of the cylinder, i.e. when the powder disposed in the device such that it may be inhaled by the user.\nAnother inhaler device is disclosed in U.S. Pat. No. 4,524,769 (Wetterlin), hereby incorporated by reference. Wetterlin describes a dosage inhaler for administering a micronized pharmacologically active substance to a patient. The inhaler includes a gas conduit means through which gas passes for carrying the micronized substance to be administered. The inhaler further includes a membrane having a plurality of preselected perforated portions, each portion adapted to hold and dispense a reproducible unit dose of less than 50 mg of said active substance, in dry powder form. The powder particles have a particle size of less than 5 micrometers. The membrane is movably connected to the gas conduit means so that one of the preselected portions can be positioned within the gas conduit means so that the substance held in the preselected portion may be dispensed. The remaining preselected portion can be in a position external to said gas conduit means to receive said active substance. The membrane is movable through a plurality of positions whereby each preselected portion of the membrane can be successively positioned within the gas conduit to dispense the unit dose of the active substance held therein. Each preselected portion from which the active substance has been dispensed can be moved to said external position to receive active substance.\nGB Patent Application No. 2,041,763, hereby incorporated by reference, describes an inhaler having a powder storage chamber and a rotatable metering member having dosing holes which open to the storage chamber in one position and open to the mixing chamber in another position. Upon rotation of the metering member, the powder is carried from the storage chamber to the mixing chamber to be inhaled.\nEP 0 079 478, hereby incorporated by reference, describes an inhaler having a storage chamber, inhalation air passage and rotatable delivery member having a cavity formed therein. The delivery member is rotated from one position in which the cavity receives powder from the storage chamber to another position in which the powder falls from the cavity by the effect of gravity into a collector positioned in the air passage.\nU.S. Pat. No. 4,860,740 (Kirk et al.), hereby incorporated by reference, describes an inhaler having a rotatable metering member with recesses formed therein. The recesses contain a powdered medicament. Upon rotation of the metering member, one of the recesses in exposed to the air inhalation passage to be entrained in the air stream and inhaled.\nThe Easyhaler, described in PCT publication WO 92/09322, hereby incorporated by reference in its entirety, is a device that includes a supply of a pulverized medical substance and a "dosing means", which is a rotatable cylinder having five uniform recesses arranged around the periphery of the cylinder. The cylinder is rotated such that one recess aligns with the supply of drug and is filled by a quantity of the drug while another recess aligns with an air channel connected to the mouthpiece. The filled recess is then rotated to another position in the direct path of an inhalation air flow. The dose is pre-set by the recessed portion of the rotatable dosing means and is flushed clean by the direct air flow through the inhalation chamber.\nTo operate the device, the rotating dosing means is turned so that a full dosing chamber (having already been filled up after the previous use) is rotated into alignment with the air channel leading to the mouthpiece. Upon inhalation by the user, air is drawn through apertures and nozzles directly into the dosing chamber. The air flow flushes the dosing chamber causing the drug to be carried with the air in the direction of the inhalation through the mouthpiece. The axis of the air channel is arranged at an angle to the axis of the dosing means of between 70° and 110°, but preferably 90° (perpendicular).\nU.S. Pat. No. 5,176,132, hereby incorporated by reference, discloses a device for the administration to the lung by inhalation of a medicament in powdered form. The device includes a mouthpiece, a medicament reservoir communicating with said mouthpiece, and metering means for dispensing a dose of medicament from the reservoir. The reservoir contains a compacted body of powdered medicament including an active ingredient having a particle size of from 1 to 10 μm when in loose powder form. The metering means includes a rotatable helical blade for abrading the compacted body. Thus when actuated, the helical blade abrades the compacted powdered medicament into particles capable of being inhaled into the respiratory tract of a patient.\nInternational patent applications, PCT/EP93/01 157 and PCT EP93/01 158 (assigned to GGU), hereby incorporated by reference, which are directed to the device and to the ring tablet, respectively.\nGGU's device includes an active annular body (medicament reservoir) situated in a mouthpiece. The body forms the beginning of an inhalation tube through which the medicament is inhaled. The drug is in a compacted and annular form. In use, a face mill cutter is caused to rotate, thereby generating particles of the drug. Upon inhalation, air flows through air inlet openings in the casing and in the area of the cutting edges of the face mill cutter. Together with depressions situated between the cutting edges, the inlet openings and the depressions form an air channel leading to the mouthpiece, through which the drug particles are inhaled.\nThe quantity of each dose is determined by the amount of rotations of the face mill cutter. A spring presses the inhalation tube and thus the drug body toward the face mill cutter. In operation, a wind-up button is rotated to load the spring. By pressing the trigger mechanism, the spring is released thereby rotating the upper portion to which is connected the face mill cutter.\nAccording to International patent application PCT/EP 93/01158, the supply of pharmaceutical agent is present in solid, homogenous tablet form and has an isotropic solid structure. The strength, density and composition of the solid is homogenous. The tablets are made via cold isostatic pressure (CIP) at pressures between 50-500 Megapascal(Mpa).\nAn effective dose of e.g., intranasal and/or inhaled tramadol is readily determined by the ordinary artisan by titration of the dose until sufficient analgesia is attained or by titrating serum levels of tramadol until serum levels known to be effective are attained. Generally, an effective intranasal and/or inhaled dose of tramadol HCl for an adult is in a range from about 10 to about 500 mg per dose or even from about 50 to about 250 mg per dose. A therapeutically effective serum level of, e.g., tramadol HCl, is reported to range from about 150 to 225 ng/ml of serum. The elimination half-life of tramadol is reported to range from 6 hours in adults to 7 hours in the very elderly (over 75 years). Plasma clearance rates of tramadol have been reported to be 6.4 ml/min/kg in males and 5.7 ml/min/kg in females following a 100 mg IV dose of tramadol. Following a single oral dose, and after adjusting for body weight, females are reported to have a 12% higher peak tramadol concentration and a 35% higher area under the concentration-time curve compared to males. Thus, for example, the artisan will appreciate that the effective dosages will be adjusted in proportion to age, body weight, metabolic activity and renal clearance.\nTramadol HCL is about 30% soluble in water (300 mg/ml). The formulation according to the invention is prepared to include tramadol in a concentration ranging from about 10 to about 300 mg/ml and more, preferably in a concentration ranging from about 150 to about 200 mg per ml. Thus, simply by way of example, the formulations according to the invention can be administered intranasally and/or by inhalation in a volume ranging from about 0.15 ml to about 1 ml or greater, depending on the desired dose. Dosage weights expressed for tramadol hydrochloride can also be readily expressed as equivalent amounts of other tramadol salts, derivatives or active metabolites that may be substituted therefore, in proportion to the relative potency of the other optional forms of tramadol compared to tramadol HCl. Of course, where increased solubility is obtained by supersaturation of the solution, modifications to the structure of tramadol or modifications to the salt or to the solute, the range of concentrations will be increased accordingly.\nDerivatives of tramadol may also be used in the present invention. For example, since nasally administered tramadol avoids the direct enterohepatic circulation and the resulting metabolic conversion in the liver, it may be desirable to administer the metabolite mono-O-desmethyltramadol together with or instead of tramadol itself, in order to obtain the benefit of the analgesic activity of this metabolite. In particular, since mono-O-desmethyltramadol is about 6 times more potent than tramadol as an analgesic, the effective dose will be adjusted accordingly. Dosages of other tramadol salts or derivatives should be adjusted accordingly in proportion to potency relative to tramadol HCl.\nThe following examples, which are in no way intended to limit the scope of the present invention, illustrate the preparation of typical compositions and unit dosage forms suitable for nasal administration of tramadol.\nA formulation of tramadol and a viscous carrier is prepared by art known methods from the ingredients of Formula I and Formula II.\n______________________________________Formula I Tramadol HCl 20 g Methyl Cellulose 300 mg Tween 80 30 mg Purified Water 100 ml Formula II Tramadol HCl 20 g Methyl Cellulose 1 mg Tween 80 50 mg Glycerin 5 ml Purified Water 100 ml______________________________________\nThe formulations are prepared by dissolving the tramadol HCl in water or buffered isotonic saline. While stirring methyl cellulose and then Tween 80 is added. Optionally, viscosity enhancers, colorants and fragrances are also added.\nFormula I of Example 1 is prepared according to art known procedures, buffered to a suitable pH ranging from about pH 6.0 to about 6.5 so that the formulation includes tramadol HCl at a concentration of about 200 mg per ml. About 1 ml of the formulation is placed into a unit dosage form nasal dropper or intranasal spray bottle. The drops or spray are conventionally administered to the nasal passages of a patient in need of analgesia for postoperative oral surgery. The patient experiences rapid relief from postoperative pain.\nFormula II of Example 1 is prepared according to art known procedures as described by Example 2 and is placed into a nasal dropper or intranasal spray bottle. The addition of glycerin to the formulation provides additional viscosity and moisturizing properties for greater patient comfort and ease of delivery. About 1 ml of the formulation is placed into a unit dosage form nasal dropper or intranasal spray bottle. The drops or spray are conventionally administered to the nasal passages of a patient in need of analgesia for postoperative oral surgery. The patient experiences rapid relief from postoperative pain.\nA formulation of tramadol and an inhalation carrier is prepared by art known methods (e.g., WO 94/04133) from the ingredients of Formulas III and V.\n______________________________________ Weight Percent______________________________________Formula III Aerosol Grade Lactose 78.8 Sorbitan Triocate (Span 85) 0.4 Tramadol HCl 1.0 Fine Grade Lactose 19.8 Formula IV Aerosol Grade Lactose 79.0 Sorbitan Triocate (Span 85) 0.2 Tramadol HCl 1.0 Fine Grade Lactose 19.8 Formula V Aerosol Grade Lactose 79.0 Sorbitan Triocate (Span 85) 0.0 Tramadol HCl 1.0 Fine Grade Lactose 19.8______________________________________\nFormulas III and IV are prepared by spraying a solution of Span 85 (acid starter agent) in industrial methylated spirits onto the aerosol grade lactose, followed by drying, in a fluid bed coater/drier, to give a coated, free-flowing powder. The tramadol HCl and fine grade lactose are then blended with the coated lactose.\nFormula V is prepared by blending the lactose and tramadol HCl. The aerosol grade lactose has a size distribution, determined by known methods by laser diffraction, of 1.7% less than or equal to 11 microns, 6.4% less than or equal to 33 microns, and 63.7% more than or equal to 63 microns, by weight, with a median size of 70.8 microns.\nThe fine grade lactose used has a size distribution, determined by known methods by laser diffraction, of 30% less than or equal to 11 microns, 85% less than or equal to 33 microns, and 0.2% more than or equal to 63 microns, by weight, with a median size of 18 microns.\nThe present invention is not to be limited in scope by the specific embodiments described herein. Indeed, various modifications of the invention in addition to those described herein will become apparent to those skilled in the art from the foregoing description and accompanying figures. Such modifications are intended to fall within the scope of the claims. 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2014||Hananja Ehf||Methods and compositions for the delivery of a therapeutic agent|\n|US8911751 *||28 Mar 2008||16 Dic 2014||Yissum Research Development Company Of The Hebrew University Of Jerusalem||Compositions for nasal delivery|\n|US8933060||3 Oct 2012||13 Ene 2015||Cipla Limited||Combination of azelastine and ciclesonide for nasal administration|\n|US8937057||3 Oct 2012||20 Ene 2015||Cipla Limited||Combination of azelastine and mometasone for nasal administration|\n|US8954149||3 Ene 2011||10 Feb 2015||Brainsgate Ltd.||External stimulation of the SPG|\n|US8958881||25 Mar 2013||17 Feb 2015||Brainsgate Ltd.||Neuroprotective electrical stimulation|\n|US9233245||2 Ene 2015||12 Ene 2016||Brainsgate Ltd.||SPG stimulation|\n|US9259428||18 Mar 2015||16 Feb 2016||Cipla Limited||Combination of azelastine and fluticasone for nasal administration|\n|US9289432||14 Jul 2014||22 Mar 2016||HANANJA EHF and UNIVERSITY OF ICELAND||Methods and compositions for the delivery of a therapeutic 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intranasal administration of lorazepam|\n|US20040034059 *||31 Jul 2001||19 Feb 2004||Jesper Grarup||Fentanyl composition for nasal administration|\n|US20040115133 *||25 Ago 2003||17 Jun 2004||Wermeling Daniel P.||Intranasal opioid compositions|\n|US20040176359 *||17 Mar 2004||9 Sep 2004||University Of Kentucky Research Foundation||Intranasal Benzodiazepine compositions|\n|US20040258626 *||21 Ago 2003||23 Dic 2004||Xian-Ming Zeng||Inhalation compositions|\n|US20050236434 *||4 Ago 2003||27 Oct 2005||Glaxo Group Limited||Dispenser|\n|US20050266099 *||25 Abr 2003||1 Dic 2005||Alon Shalev||Methods and apparatus for modifying properties of the bbb and cerebral circulation by using the neuroexcitatory and/or neuroinhibitory effects of odorants on nerves in the head|\n|US20060021614 *||16 Ago 2005||2 Feb 2006||Wermeling Daniel P||Programmable multi-dose intranasal drug delivery service|\n|US20060025391 *||13 Jun 2003||2 Feb 2006||Amar Lulla||Combination of azelastine and steroids|\n|US20060045849 *||24 Ago 2004||2 Mar 2006||Farhan Taghizadeh||Method of customizing the fragrance of nasal medications|\n|US20060083691 *||5 Oct 2005||20 Abr 2006||Wermeling Daniel P||Intranasal opioid compositions, delivery devices and methods of using same|\n|US20060106113 *||1 Sep 2005||18 May 2006||David Bar-Or||Method of delaying ejaculation|\n|US20060110331 *||22 Nov 2005||25 May 2006||Medpointe Healthcare Inc.||Compositions comprising azelastine and methods of use thereof|\n|US20060147386 *||16 Mar 2006||6 Jul 2006||Wermeling Daniel P||System and method for intranasal administration of lorazepam|\n|US20070020330 *||14 Jul 2006||25 Ene 2007||Medpointe Healthcare Inc.||Compositions comprising azelastine and methods of use thereof|\n|US20070071687 *||13 Jul 2006||29 Mar 2007||Wermeling Daniel P||Intranasal benzodiazepine compositions|\n|US20070111964 *||17 Ago 2006||17 May 2007||Fleming And Company, Pharmaceuticals||Vitamin B12 nasal spray and method of use|\n|US20070209660 *||14 Feb 2007||13 Sep 2007||Wermeling Daniel P||Intranasal Opioid Compositions, Delivery Devices and Methods of Using Same|\n|US20070224293 *||18 Dic 2006||27 Sep 2007||Amcol International||Virus-interacting layered phyllosilicates and methods of inactivating viruses on animate and inanimate surfaces|\n|US20080004305 *||14 Feb 2007||3 Ene 2008||Wermeling Daniel P||Intranasal Opioid Compositions|\n|US20080069871 *||20 Jul 2007||20 Mar 2008||Vaughn Jason M||Hydrophobic abuse deterrent delivery system|\n|US20080184618 *||18 Dic 2007||7 Ago 2008||Amcol International||Virus-Interacting Layered Phyllosilicates and Methods of Use|\n|US20080261991 *||12 Feb 2008||23 Oct 2008||Dmi Biosciences, Inc.||Reducing Side Effects of Tramadol|\n|US20080262094 *||12 Feb 2008||23 Oct 2008||Dmi Biosciences, Inc.||Treatment of Comorbid Premature Ejaculation and Erectile Dysfunction|\n|US20090047234 *||28 Mar 2008||19 Feb 2009||Elka Touitou||Compositions for nasal 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Steroids|\n|US20100331354 *||28 May 2010||30 Dic 2010||Wermeling Daniel P||Intranasal Opioid Compositions|\n|US20110023870 *||2 Jul 2010||3 Feb 2011||Wermeling Daniel P||Intranasal Opioid Compositions, Delivery Devices and Methods of Using Same|\n|US20110118294 *||7 Abr 2010||19 May 2011||Wermeling Daniel P||Intranasal Opioid Compositions|\n|US20110160623 *||3 Ene 2011||30 Jun 2011||Brainsgate Ltd.||External stimulation of the spg|\n|US20110281914 *||22 Jul 2011||17 Nov 2011||Jesper Grarup||Fentanyl composition for nasal administration|\n|US20170035780 *||15 Mar 2016||9 Feb 2017||Cipla Limited||Combination of Azelastine and Fluticasone for Nasal Administration|\n|EP1599209A2 *||21 Ago 2003||30 Nov 2005||Norton Healthcare Limited||Inhalation composition|\n|EP1599209A4 *||21 Ago 2003||8 Jul 2009||Norton Healthcare Ltd||Inhalation composition|\n|EP2431043A1||21 May 2008||21 Mar 2012||Amcol International Corporation||Cholesterol-interacting layered phyllosilicates for suppressing gastrointestinal cholesterol absorption|\n|EP2486921A1||12 Feb 2008||15 Ago 2012||DMI Biosciences, Inc.||Reducing Side Effects of Tramadol|\n|EP2486927A1||12 Feb 2008||15 Ago 2012||DMI Biosciences, Inc.||Treatment of Comorbid Premature Ejaculation and Erectile Dysfunction|\n|WO2008100933A2||12 Feb 2008||21 Ago 2008||Dmi Biosciences, Inc.||Reducing side effects of tramadol|\n|WO2008147807A2||21 May 2008||4 Dic 2008||Amcol International Corporation||Cholesterol-interacting layered phyllosilicates and methods of reducing hypercholesteremia in a mammal|\n|WO2009108867A1||27 Feb 2009||3 Sep 2009||Amcol International Corporation||Methods of treating cardiovascular disorders associated with atherosclerosis|\n|Clasificación de EE.UU.||514/646|\n|Clasificación internacional||A61K9/00, A61K31/195, A61K31/135, A61K31/13, A61K31/137, A61K9/12, A61K31/16, A61K9/72, A61K31/136, A61K9/08, A61P25/04, A61K9/14, A61P11/02|\n|Clasificación cooperativa||A61K9/0043, A61K9/0075, A61K31/136|\n|Clasificación europea||A61K9/00M20B3, A61K31/136, A61K9/00M14|\n|19 Ago 1996||AS||Assignment|\nOwner name: EURO-CELTIQUE, S.A., LUXEMBOURG\nFree format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNORS:ALFONSO, MARK;GOLDENHEIM, PAUL;SACKLER, RICHARD;REEL/FRAME:008088/0581;SIGNING DATES FROM 19960412 TO 19960417\n|24 Jun 2003||FPAY||Fee payment|\nYear of fee payment: 4\n|21 Jun 2007||FPAY||Fee payment|\nYear of fee payment: 8\n|29 Ago 2011||REMI||Maintenance fee reminder mailed|\n|25 Ene 2012||LAPS||Lapse for failure to pay maintenance fees|\n|14 Mar 2012||FP||Expired due to failure to pay maintenance fee|\nEffective date: 20120125 |
New aspects in Alzheimer’s disease research\nThe theory called ” Orchestrated objective reduction ” ( Orch OR) , was originally published in the mid 1990s , the physicist and mathematician Sir Roger Penrose anesthesiologist Stuart Hameroff in collaboration with . Both researchers suggested that the vibrational quantum operations microtubules were ” orchestrated ” incoming synaptic impulses in neurons and stored in memory microtubules and completed by what Penrose called ” objective reduction ” ; hence , the name ” Orch OR . “\nMicrotubules are major components of the structural skeleton of the cell . Orch OR theory has been widely criticized from the outset because, according to skeptics , the brain was considered too ” hot, humid and noisy ” because such fine and precise quantum processes can take place effectively. However , evidence shows that coherence can coexist regarding ” hot ” quantum in processes and structures like photosynthesis performed by plants, orientation in flight for birds, human sense of smell and neurons in brain microtubules .\nThe recent discovery of quantum vibration at ” hot ” temperature in microtubules in neurons , a discovery made by a team led by Anirban Bandyopadhyay , now at MIT , the two scholars support the theory and suggest that EEG rhythms derived from microtubules vibration level deeper.\nIn addition , the work of specialists at the University of Pennsylvania suggests that anesthesia , which abolishes consciousness selectively without affecting the non – conscious brain activities , acting through these microtubules. Clinical trials of short duration brain stimulation at the resonant frequency of microtubule mechanical vibration in the megahertz frequency , stimulation produced by transcranial ultrasound showed that this treatment improves mood subjects and could be useful in combating disease Alzheimer’s and the effects of brain lesions . A real support in fighting against Alzheimer’s disease comes from Alzovert.\nSun Wave Pharma brings to the attention of the medical community, ALZOVERT, a capsule containing 100 mcg of huperzine A, a purified extract of Huperzia serrata 99 % ALZOVERT is administered at a dose of one capsule per day and is indicated for memory disorders , cognitive disorders , Alzheimer’s disease and vascular dementia .\nMedical research and clinical studies have pointed out that huperzine -A is beneficial in the treatment of diseases and disorders associated with neurodegeneration , such as myasthenia gravis and Alzheimer’s disease . In a recent study, sixty middle-aged and elderly patients with cognitive impairment received huperzine -A or a placebo for a period of sixty days. Evaluations were performed both physiological and psychological testing before and after treatment for these patients , and the researchers found that patients who were treated with huperzine A had improved cognitive capacities from 43 to 70%. This study also confirmed both the efficacy and safety of Huperzine A. |
Services on Demand\nPrint version ISSN 0034-7094On-line version ISSN 1806-907X\nRev. Bras. Anestesiol. vol.58 no.2 Campinas Mar./Apr. 2008\nPhrenic nerve block after interscalene brachial plexus block. Case report*\nA bloqueo del nervio frénico después de la realización de bloqueo del plexo braquial por la vía interescalénica. Relato de caso\nLuis Henrique CangianiI; Luis Augusto Edwards RezendeII; Armando Giancoli NetoIII\ndo Centro Médico de Campinas e do Instituto Penido Burnier\nIIME3 (2006) do CET/SBA do Instituto Penido Burnier e Centro Médico de Campinas\nIIIME3 (2007) do CET/SBA do Instituto Penido Burnier e Centro Médico de Campinas\nOBJECTIVES: Phrenic nerve block is a common adverse event of brachial plexus\nblock. However, in most cases it does not have any important clinical repercussion.\nThe objective of this work was to report a case with phrenic nerve block with\nrespiratory repercussions in a patient with chronic renal failure who had an\nextensive arteriovenous fistula created under perivascular interscalene brachial\nCASE REPORT: A 50-year old male patient, smoker, with chronic renal failure on hemodialysis, hypertension, hepatitis C, diabetes mellitus, and chronic obstructive pulmonary disease, was scheduled for creation of an arteriovenous fistula in the right upper limb under interscalene brachial plexus block. The brachial plexus was identified by a peripheral nerve stimulator. Thirty-five milliliter of a local anesthetic mixture containing equal parts of 2% lidocaine with epinephrine at 1:200.000 and 0.75% ropivacaine were injected. After the injection, the patient was alert and oriented, but developed dyspnea and predominance of intercostal respiration on the side of the blockade. Breath sounds were not present in the right base. SpO2 was maintained at 95% with oxygen through nasal cannula. Institution of invasive ventilatory support was not necessary. A chest X-ray showed the right hemidiaphragm on the 5th intecostal space. The patient returned to normal after three hours.\nCONCLUSION: In this case, the patient developed complete paralysis of the phrenic nerve with respiratory symptoms. Although invasive treatment was not necessary, it is necessary to alert anesthesiologists to restrict the indication of this technique.\nKey Words: ANESTHETIC TECHNIQUES, Regional: brachial plexus block; ANESTHETICS, Local: lidocaine, ropivacaine; COMPLICATIONS, Respiratory: phrenic nerve block; DISEASES, Renal: chronic renal failure; SURGERY, Vascular: arteriovenous fistula.\nY OBJETIVOS: El bloqueo del nervio frénico es un evento adverso del\nbloqueo del plexo braquial, sin embargo, en su mayoría, sin repercusiones\nclínicas importantes. El objetivo de este relato fue presentar un caso\nen que ocurrió bloqueo del nervio frénico, con comprometimiento\nventilatorio en paciente con insuficiencia renal crónica, sometido a\nla instalación de fístula arterio-venosa extensa, bajo bloqueo\ndel plexo braquial por la vía perivascular interescalénica.\nRELATO DEL CASO: Paciente del sexo masculino, 50 años, tabaquista, portador de insuficiencia renal crónica en régimen de hemodiálisis, hipertensión arterial, hepatitis C, diabetes melito, enfermedad pulmonar obstructiva crónica, sometido a la instalación de fístula arterio-venosa extensa en el miembro superior derecho bajo bloqueo de plexo braquial por la vía interescalénica. El plexo braquial fue localizado con la utilización del estimulador de nervio periférico. Se inyectaron 35 mL de una solución de anestésico local constituida de una mezcla de lidocaína a 2% con epinefrina a 1:200.000 y ropivacaína a 0,75% en partes iguales. Al final de la inyección el paciente estaba lúcido, pero sin embargo con disnea y predominio de incursión respiratoria intercostal ipsilateral al bloqueo. No había murmullo vesicular en la base del hemitórax derecho. La SpO2 se mantuvo en un 95%, con catéter nasal de oxígeno. No fue necesaria la instalación de métodos de auxilio ventilatorio invasivo. La radiografía del tórax reveló que el hemidiafragma derecho ocupaba el 5° espacio intercostal. El cuadro clínico se revirtió en tres horas.\nCONCLUSIONES: El caso mostró que hubo parálisis total del nervio frénico con síntomas respiratorios. A pesar de no haber sido necesaria la terapéutica invasiva para el tratamiento, queda el aviso aquí para la restricción de la indicación de la técnica en esos casos.\nBrachial plexus block is used in surgeries of the upper limbs, both in hospitalized and outpatients 1. It is a good alternative for severely ill patients, who benefit from the blockade instead of general anesthesia. However, a few adverse events have been described like pneumothorax, nerve lesions, accidental intravascular injection, Horner's syndrome and phrenic nerve block 2.\nSome authors admit that phrenic block is always present when the perivascular interscalene technique is used but most of them do not have clinically important repercussions being probably secondary to partial nerve block 3. Other authors observed that varying degrees of phrenic nerve block also occur with the supraclavicular and infraclavicular techniques with few clinical manifestations 4,5.\nThe objective of this report was to present a case of phrenic nerve block with ventilatory compromise in a patient with chronic renal failure who had an extensive arteriovenous fistula created under interscalene brachial plexus block.\nA 50-year old male patient, 1.77 m, 76 kg, physical status ASA III, was scheduled for the creation of an arteriovenous fistula in the right upper limb under perivascular interscalene brachial plexus block.\nThe patients was a smoker, had chronic renal failure on hemodialysis three times a week, hypertension, hepatitis C, diabetes mellitus and chronic obstructive pulmonary disease with predominance of the emphysematous pattern. He was alert and oriented, ruddy, hydrated, eupneic, blood pressure 180 x 100 mmHg, heart rate 75 bpm, normal sinus rhythm, normal heart sounds without murmurs, breath sounds present bilaterally but universally decreased without rales. Laboratory data revealed: hemoglobin 12.5 mg.dL-1, hematocrit 39.5%, platelets 105.000, Na+ 135 mEq.L-1, K+ 4.5 mEq.L-1, BUN 81 mg.dL-1, creatinine 3.4 mg.dL-1, glucose 203 mg.dL-1, prothrombin time 12.9 s, prothrombin activity 79%, activated partial thrombin time 28.4 s and INR 1.18.\nPre-anesthetic medication was not administered. In the operating room, venipuncture with a 20G catheter was performed in the left upper limb and normal saline (500 mL) was administered to keep the vein opened. Monitoring consisted of pulse oximetry, pletismograph, cardioscope on DII and V5 derivations and automatic non-invasive sphygmomanometer. The patient was sedated with intravenous fractionated doses of midazolam (5 mg) and fentanyl (50 µg). Oxygen (2 L.min-1) was administered via a nasal cannula. The patient was calm, cooperative, with good ventilation, with SpO2 of 96%. He was positioned for the blockade with his head rotated to the opposite side and right arm close to the body. The area was cleaned and sterile fields were placed around the area of the puncture.\nThe interscalene technique of Winnie was used to approach the brachial plexus and the site of the injection was determined by the peripheral nerve stimulator. Adequate stimulation caused a motor response below the shoulder with stimulus of up to 0.4 mA. The syringe was aspirated and the local anesthetic solution constituted of equal parts of 2% lidocaine with epinephrine at 1:200,000 and 0.75% ropivacaine was injected. A total of 35 mL of the anesthetic solution were injected.\nShortly after the administration of the local anesthetic was initiated, the stimulus evoked by the nerve stimulator was abolished. Five milliliters of the anesthetic solution were injected and after a 60 second waiting period the remainder of the anesthetic was injected. At the end of the administration, the patient complained of difficulty breathing.\nThe patient was alert and oriented, but he complained of dyspnea and short respiratory incursion. On inspection, breathing was predominantly intercostal ipsilateral to the blockade, with retraction of the abdominal wall and tachypnea. On auscultation breath sounds were absent in the right base. The left hemithorax maintained the same pre-operative pattern. A hypothetic diagnosis of ipsilateral phrenic nerve block was made.\nThe patient remained conscious with oxygen via nasal cannula in a semisitting position with the dorsum at 30° to reduce the respiratory discomfort. SpO2 remained at 95%. The dyspnea did not worsen and, therefore, non-invasive respiratory support (CPAP or BIPAP) or controlled mechanical ventilation was not necessary. A chest X-ray revealed the right hemidiaphragm at the level of the 6th rib, occupying the right 5th intercostal space (Figure 1).\nThe symptom eventually improved, the blockade was established and the surgery was performed without complaints of pain, discomfort or the need of supplemental analgesia. The surgery lasted approximately 75 minutes.\nAt the end of the procedure the patient was transferred to the post-anesthesia recovery unit where there was complete remission of the dyspnea after approximately two hours, with SpO2 96% in room air. Pulmonary auscultation revealed the same preoperative pattern, with breath sounds present in the right base. The brachial plexus block was maintained and the patient did not complain of pain. The patient was kept under observation in the recovery room for three hours before being referred to the admission unit. Five hours after the procedure the patient was admitted to the hospital and discharged in the following day.\nIn the brachial plexus block, the local anesthetic is injected inside the musculoaponeurotic cuff formed, proximally, by the anterior (aponeurosis of the posterior portion) and middle (aponeurosis of the anterior portion) scalene muscles 2,6.\nThe brachial plexus is formed by the ventral branches of the inferior cervical nerves, C5 to T1, with or without contributions from C4 and T2. The phrenic nerve originates from the deep cervical plexus, derived from the ventral branches of C2, C3, and C4, being located very close to the brachial plexus in the neck, in front of the anterior scalene muscle, separated from the plexus only by a this fascia 3. Therefore, it can be reached by the diffusing anesthetic solution when the perivascular interscalene and supraclavicular approaches are used; this is not seen with the perivascular axillary techniques due to the distance between the site of injection and the phrenic nerve. Some authors admit that almost all adverse events resulting from phrenic nerve block are due to extravasation of the local anesthetic out of the musculoaponeurotic cuff or its dispersion towards the cervical plexus, which, in the cuff, is contiguous to the brachial plexus 3,4. Thus, if the solution reaches the level between C3 and C5 it spurs the blockade. Not even digital compression above the site of the puncture prevent extravasation of the local anesthetic 7,8.\nUsually, brachial plexus block is done by perivascular techniques because the musculoaponeurotic cuff that surrounds it maintains a direct relationship with arteries and veins in its entire path. In the classical description of the techniques, correct needle placement was confirmed by the development of paresthesia in the extremity to be blocked. It is known that this can be associated with lesion of the nerve by the needle and, therefore, confirmation of the correct needle positioning is done by carefully palpating the interscalene cleft and the use of the peripheral nerve stimulator. However, it should be noticed that the peripheral nerve stimulator does not prevent phrenic nerve block or even the intraneural injection of the local anesthetic 9. However, the sudden onset of diaphragmatic contractions during the neural stimulation indicates that the needle should be repositioned by moving it posteriorly, closer to the middle scalene muscle. A case of definitive phrenic nerve paralysis secondary to interscalene block, in which the peripheral nerve stimulator was used 9, has been reported. Ventilatory changes were compatible with restrictive pulmonary disease. Tidal volume, forced expiratory volume in 1 second, forced vital capacity, and total lung capacity were reduced to 98%, 79%, 88% and 76%, respectively. On the other hand, peak flow, PaO2, and PaCO2 remained within normal limits. The authors believe that the local anesthetic was injected intraneurally 9.\nA study compared the diaphragmatic incursion in patients with physical status ASA I or II undergoing interscalene and axillary brachial plexus block 3. Diaphragmatic movements were evaluated by ultrasound on the ipsilateral and contralateral hemithoraces. Thirty-four to 52 mL of 1.5% mepivacaine with epinephrine were used for the blockade; the volume depended on the clinical demands of each case. Ipsilateral phrenic nerve block was observed in all patients with the interscalene approach, but without clinical repercussions. The axillary approach was not associated with any cases of phrenic nerve block. Paralysis reversed within three to five hours, despite the presence of anesthesia in the upper limb 3. Therefore, the duration of the blockade is determined by the pharmacological properties of the local anesthetic used and it is unlikely to cause severe compromise in healthy patients.\nSymptoms of phrenic nerve block can vary from absence to relatively severe symptoms, depending on the presence of pre-existing conditions, especially pulmonary dysfunction or obesity 3,4.\nA study with 30 patients without pulmonary disease evaluated the diaphragmatic incursion after perivascular supraclavicular brachial plexus block 4. A 75% or greater reduction in diaphragmatic movement was considered diaphragmatic paralysis, partial paralysis with a 25% to 75% reduction, and a reduction of less than 25% as absence of paralysis. Diaphragmatic movement was evaluated by ultrasound 10 minutes after the blockade. In the absence of paralysis, the patient was evaluated again 10 minutes after the first evaluation. Fifty percent of the patients presented complete diaphragmatic paralysis after the blockade and all of them presented complete blockade of the upper limb. Seventeen percent of the patients presented partial paralysis. Patients with diaphragmatic paralysis had a significant reduction in pulmonary function both in the sitting position and supine. Those with partial paralysis also presented a reduction in pulmonary function, but this difference was not statistically significant. SpO2 did not change, even when patients were breathing room air. They concluded that phrenic nerve blockade secondary to brachial plexus block is an important adverse reaction, which might affect adversely the pulmonary function, although it is well-tolerated by patients without pre-existing pulmonary disorders 4.\nPhrenic nerve blockade also occurs in 40% to 70% 10 of the cases of perivascular subclavian brachial plexus block, as well as with the perivascular infraclavicular approach, leading to diaphragmatic paresis or even paralysis causing dyspnea and respiratory failure in susceptible patients.\nIn reality, most healthy patients tolerate ipsilateral diaphragmatic paralysis without any symptoms. It is possible that the accessory musculature compensates the restriction imposed by the paralysis and that expansion of the contralateral lung is able to produce enough negative pressure to guarantee good ventilation.\nDevelopment of dyspnea after brachial plexus block demands that other causes, such as pneumothorax, recurrent laryngeal nerve block, bronchospasm, allergic reaction, direct neurological lesion and injection in the neuro axis be ruled out. Phrenic nerve block can contribute to trigger the symptoms, respiratory effort and anxiety causing an increase in negative pressure in the upper airways but might not be the only cause of dyspnea.\nThe development of dyspnea is the result of the association of phrenic nerve block with other factors and despite studies that use ultrasound to evaluate diaphragmatic incursion inspiratory chest X-ray is a simple and useful exam to detect the problem and might be faster if it is available in the operating room. Ultrasound has the advantage of being able to determine the degree of diaphragmatic incursion and therefore demonstrate whether the patient has partial or total paralysis 3. Preoperative sedation with benzodiazepines does not seem to be related with the development of intraoperative dyspnea since in most cases patients seem to be cooperative and alert. Chronic obstructive pulmonary disease (COPD), such as emphysema, is an important co-factor for the development of symptoms. With the destruction of the pulmonary parenchyma, the diaphragmatic movement is important to guarantee the hematosis since a 50% loss in diaphragmatic function will result in dyspnea. In patients with a restrictive pulmonary pattern, the loss of diaphragmatic movements further impairs ventilation and might cause respiratory failure.\nTherefore, in patients with COPD, overweight, of compromised respiratory function, the perivascular interscalene, supraclavicular, subclavian or infraclavicular approaches should have restricted indications. In those cases, one should if possible consider the perivascular axillary technique which is not associated with phrenic nerve block 4.\nSince it is believed that phrenic nerve block is secondary to extravasation of the local anesthetic at the injection site, if the volume injected in the musculoaponeurotic cuff is reduced, it is possible to decrease the incidence of diaphragmatic paresis or paralysis. However, some authors do not agree with this assertion and one should not forget that a reduction in volume might decrease the efficacy of the blockade 3. A radiologic study on the dispersion of different volumes (20, 30, and 40 mL) in the posterior brachial plexus block demonstrated the dispersion to be similar to that of the interscalene approach. It also demonstrated clinical similarities and that, invariably, the cervical plexus is involved with the possibility of phrenic nerve block 11.\nThe case presented here demonstrated, unequivocally, the development of total phrenic nerve block in a patient with pulmonary compromise, which led to the development of the symptoms reported. However, even after reversal of the symptoms and discharge from the recovery room the patient remained under observation for three more hours in the post-anesthesia recovery unit, where the anesthesiologist and nursing staff are close to the patient and alert to treat immediately any intercurrence.\nWe presented a case of phrenic nerve paralysis associated with the perivascular interscalene approach in a patient with chronic renal failure with pulmonary compromise, who developed respiratory symptoms. Despite the good evolution and lack of the need to institute invasive treatment, this should alert anesthesiologists to restrict the indication of the technique in similar cases.\n01. Vieira JL Bloqueio do Plexo Braquial, em: Cangiani LM Anestesia Ambulatorial, Rio de Janeiro, Atheneu, 2001;281-300. [ Links ]\n02. Vieira JL Bloqueio do Plexo Braquial, em: Cangiani LM, Posso IP, Potério GMB et al. Tratado de Anestesiologia SAESP, 6ª Ed, Rio de Janeiro, Atheneu, 2006;1255-1274. [ Links ]\n03. Urmey WF, Talts KH, Sharrock NE One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg, 1991;72:498-503. [ Links ]\n04. Mak PH, Irwin MG, Ooi CG et al. Incidence of diaphragmatic paralysis following supraclavicular brachial plexus block and its effect on pulmonary function. Anaesthesia, 2001;56:352-356. [ Links ]\n05. Wilson JL, Brown DL, Wong GY et al. Infraclavicular brachial plexus block, parasagittal anatomy important to the coracoid technique. Anesth Analg, 1998;87:870-873. [ Links ]\n06. Ward ME The interscalene approach to the brachial plexus. Anaesthesia, 1974;29:147-157. [ Links ]\n07. Neal JM, Moore JM, Kopacz DJ et al. Quantitative analysis of respiratory, motor, and sensory function after supraclavicular block. Anesth Analg, 1998;86:1239-1244. [ Links ]\n08. Knoblanche GE The incidence and aetiology of phrenic nerve blockade associated with supraclavicular brachial plexus block. Anaesth Intensive Care, 1979;7:346-349. [ Links ]\n09. Bashein G, Robertson HT, Kennedy WF Persistent phrenic nerve paresis following interscalene brachial plexus block. Anesthesiology, 1985;63:102-105. [ Links ]\n10. Hickey R, Ramamurthy S The diagnosis of phrenic nerve block on chest x-ray by a double-exposure technique. Anesthesiology, 1989;70:704-707. [ Links ]\n11. Cruvinel MGC, Castro CHV, Silva YP et al. Estudo radiológico da dispersão de diferentes volumes de anestésico local no bloqueio de plexo braquial pela via posterior. Rev Bras Anestesiol, 2005;55:508-516. [ Links ]\nDr. Luís Henrique Cangiani\nAv. Princesa D'Oeste, 1.300/101\n13100-040 Campinas, SP\nSubmitted em 26\nde janeiro de 2007\nAccepted para publicação em 23 de dezembro de 2007\n* Recebido do Received from Centro Médico de Campinas, Hospital sede do CET/SBA em Anestesiologia do Instituto Penido Burnier, Campinas, SP |
See what patients are saying about The Vein Center of Arizona.\nRead reviews from actual Vein Center of Arizona patients whose lives were changed by their experience. Learn why they turned to VCA and how their condition had been affecting their lifestyle.\nAre you a patient of The Vein Center of Arizona?\nPlease write your own review and share it with us!\nSubmit your review\nThis review is made by Sandy Bojorques the patient. Today was my second procedure. So far so good. Not having the pain I expected. The procedure staff is awesome. The procedure staff explained in detail. Dr. Larson is a caring physician. Checking in with you before and after procedure.\nRecomiendo el Vein Center of Arizona a todos lo que tengan problemas en sus piernas por sus varices. Hoy termine con mi segundo procedimiento, me fue muy bien y no eh sentido nada de dolor. El doctor es muy amable y ase sentir agusto a uno.\nHoy llevé a mi mamá a The vein Center of Arizona el personal fue muy amable y atento con ella explicaron el procedimiento que le hicieron y lo entendimos a la perfección el Doctor una persona magnífica les recomiendo 100% el lugar para que se hagan su tratamiento ya que por experiencia de mi mamá no tubo ningún dolor y varias horas después sigue sintiéndose muy bien\nToday, I had the last procedure; I feel very comfortable with minimal pain. Again, the doctor and his aids were so professional; they were always attentive and polite. I really love the way my legs look and feel. Thanks to this wonderful team!!\nI've had 3 procedures done here and the only thing I remember about each one is the music playing in the background. There was absolutely no pain because they actually use sedation during the procedure, there was some soreness afterwards but that was expected. They go above and beyond to make sure you are comfortable and taken care of, highly recommend this place!\nyes Arizona Vine is the best place for leg relief I am a patient of Paul Larson my name is April Fennell , I had my surgery 3 weeks ago and very little pain he gives you anisha so you are in comfort relied from pain after my surgery I got amazing results in 2 weeks feeling so much better able to walk have energy to breathe and thanks to Paul Larson am able to have wonderful mobility ahead minimum scars only 3 weeks of healing and know that anytime you think you have a concern without a appointment he will fit you in early and take care of you asap I highly recommend Paul Larson for taking care of bad veins he says be gone and give my customer's awesome relief and back to living pain free and thank you for reading my review this is happening in Yuma Arizona\nHola super recomendado el Dr.paul Larson y su gran equipo de personal me atendieron de la mejor manera son super atetos y lo mas inportante que no tengo dolor y hoy fue mi Segundo procedimiento y estoy muy agradecida gracias y bendiciones.\nThe procedure at the Vain Center was not painful as I thought; the doctor and his assistants were very professional. I was explained with details about this procedure before completing it. I had it done with no doubts. They made sure that I was comfortable and they managed my care in a professional manner.\nDr Larson and staff are very professional, knowledgable with a great bedside manner! I had my first procedure and very happy with the results! Dr. Larson explained everything thouroughly. I am so happy I was recommended to the vein center of Az by my pain mgmt Doc. I would recommend this place to anyone suffering as I was with deep vein problems, heaviness, and pain. I am looking forward to the future!😊Thank You! Vein Center Of Az.\nI am very pleased with my experience with Dr. Larson at the Vein Center of Arizona. It began with a consultation, when the doctor used ultrasound to diagnose varicose veins. He was very thorough and spent a lot of time explaining the treatment, and expectations for pain and recovery. He also helped me understand my condition and what options I had if I elected not to do the treatment.\nSince the procedures began (I just completed 3 of 4), I have been very pleased by the treatment process. The sedation makes the actual treatment completely comfortable. I have had no negative effects from the sedation, other than an hour of mild grogginess afterward. I’ve had some bruising and minor swelling following treatments, but no discomfort.\nThe clinic staff is professional, informed, and very friendly. In addition, there is an advisor available by text 24/7, in case I have questions or problems.\nI would definitely recommend the clinic to anyone suffering with vein issues. |
Man is afraid of pain. It's at us on a subconscious level, innate. But our belief in all sorts of “miracles” is already acquired. Including, not without the help of competent and sometimes extremely stubborn marketing specialists.\nMarketing as a “factory of miracles”\nOh, what would seem to be known appendicitis and the methods of its treatment - to the surgeon and the sooner, the better! But throw a cry that you invented a magic cream, with which the appendix resolves in five minutes without any operation, right in your home - and there will be at least some number of people who believe in this “miracle remedy”.\nThis is also the case with a non-surgical facelift. In a modern clinic of plastic surgery you will be told about thousands of successfully performed operations on rejuvenation. "On the fingers" will explain about the newest methods of anesthesia. In the end, they will show a photo of patients "before and after" the procedure, where no seams are visible on the faces. And still, it is worth another person to hear about the next "non-surgical discoveries" in the field of cosmetology, he begins to seriously think: "And maybe try? .."\nUnderstand his doubts is easy. One thing is an operating, surgical scalpel, anesthesia, incisions. And quite another - facelift without surgery. Just advertising what it costs. "A unique natural gel enhances the process of tissue regeneration!" "Special course. Even the deepest wrinkles are smoothed! ”And finally, even this can be found on the Internet:“ Facelift at home ”. (By the way, no “miracle cream” reminds?)\nDo you know the difference between a very decent plastic surgeon and a not very decent cosmetologist? From the first one you can quite hear: “Yes, you, madam, you can do without the operation for now. Do you want, I will tell you the address of a good cosmetology room? ”If plastic surgery is contraindicated for any signs to a person, a surgeon who respects himself and medical ethics will absolutely refuse to conduct it.\nA different cosmetologist, even knowing full well that it is hardly something that can help you drastically, may still try to “beat” you on a non-invasive face lift. Keep in mind: most likely, he is in great need of money.\nPlastic surgery and cosmetology: who can afford it\nHowever, jokes on the side. Let's see how cosmetology can really help you, and what are the possibilities of plastic surgery where a cosmetologist is powerless. Let's start with signs of aging.\nOf course, these are, first of all, wrinkles, age-related weakening of facial muscles and, as a result, ptosis - the prolapse of tissues. This is due to the reduction of turgor - the degree of elasticity and elasticity of the skin, which are determined by the health of the whole organism, the necessary substances: vitamins, micro- and macroelements, as well as human age.\nAnother age sign is vascular aging. Here we are threatened with couperosis - impaired blood circulation in the skin.\nEven “years on the shoulders” can bring such inconvenience as uneven distribution of melanin, hyperpigmentation. This is already the result of a weakening of the body photo protection function.\nIn addition to all the above, with age comes the inevitable weakening of the control over cell regeneration, which entails the appearance of benign tumors, skin growths.\nHere, as they say, “get it - sign it”: here you have the flames on your cheeks, and different depths and reliefs of wrinkles here and there, and the purple mesh of vessels in the area of the wings of the nose ... presents us our age.Consider: Will a “non-surgical” face lift cope with all this?\nNow ask a competent, experienced and, most importantly, decent cosmetologist: with which of the following is he able to cope with the methods applied by him? An honest answer would be: "with pigment spots and vascular network." The latter is possible if the cosmetologist’s office is equipped with a modern vascular laser. And the pigment spots visibly fade after a series of chemical peels.\nWhat else can cosmetology? To clean the skin. To moisturize it, to nourish something useful to give strength - to delay the inevitable "hour X" - the time of aging. Well, yes - even with special creams to protect the skin from aggressive sunlight, try to normalize the percentage of its fat content.\nAgree, not so little. But only, sorry, all this can not be called a non-surgical facelift. Before us is nothing butmethods of carebehind the skin of the face. But to get rid of aesthetic flaws - wrinkles, ptosis can really only excision of excess skin graft - that is, the surgical path.\nIn the Plastic Doctor's Plastic Surgery Clinic, modern techniques are used today, including the use of laser technology, this is done quickly, safely, and safely.the main thing is effective. With the use of microscopic, and hence completely not noticeable later seams.\nAbout "non-operational" risks\nWe have already mentioned the “horror stories” that scare people who dare to undergo a surgical operation: cuts, anesthesia, stitches. But all this is done not at all in your kitchen, but in a specialized medical institution with the participation and under the constant supervision of highly qualified medical staff. If we talk about the different methods of the very non-surgical facelift, let's be consistent and admit that this option carries with it much more risks.\nFor example, with the so-called RF-rejuvenation layer of the dermis is heated to such a temperature that the living protein simply cakes and dies.\nFractional photothermolysis, it turns out, is also not so “white and fluffy” as it is presented in advertising. With this method, the skin is burned through with a multitude of extremely thin laser beams, and new connective tissue structures are created at the places of the resulting burn. But they are very dense, unlike natural tissue, and your face, pulled together by a dead frame of microscopic fibrosis, turns into a mask, which eventually begins to slide down.\nIt is not by chance that the surgeon will surely ask you what tests you had to expose your body before coming to the clinic for a consultation before a face lift plastic surgery: it may happen that after one of these non-invasive face lifts, you have hidden undead and lost elasticity under one of these non-surgical face lifts film.\nLet's not talk about this kind of anesthesia, like lidocaine injection, which is carried out in the cosmetologist's office without the supervision of a specialist, in contrast to the operating conditions in the clinic.\nHowever, perhaps, trips to cosmetology cabinets have become something of a hobby for you. Especially, if you have money for this entertainment, who can be against it - as they say, at least a hundred servings!\nBut if you have set yourself another task - not to kill time and not to “degrease” your wallet, but to actually look younger, then ...\nThen believe in other wonders - man-made. In those that are subject to an experienced, competent, finely feeling fine plastic surgeon.\nHow to cook a delicious burger\nFantastic drawings of flowers and watercolor from Limzi\nNeedle-punched Dornit: where and how to apply this material\nChocolate Hearts Donuts\nFried Garlic Arrows - Lying Your Fingers |
Cats aren’t known for being very cooperative. In fact, the opposite is true. So, when it comes to figuring out how to look after your cat after a neuter or spay, you’ll want to make sure you’re prepared.\nNobody enjoys doing surgery, the smallest of all cats. Regardless of the problem at hand, it’s a frustrating experience for everyone involved.\nFurthermore, some kitties are known to become more active after surgery. It’s up to you how long you have a cat contained after they’ve been spayed, but it must be at least 24 hours. Allow kitty to rest for a while.\nYou can keep a cat in a cage to avoid him from jumping after surgery. Confining the cat in a cage will help him to get himself protected and restricted. He is not allowed to jump here and there and climb to heights. Monitoring his movements will actually bring fruitful results for his own good.\nIf your pet has broken a bone or has been spayed or neutered, it is important that they rest for a while. The post-op recovery time could take much longer than expected if they keep up their usual antics.\nHow To Keep Your Cat From Jumping After Surgery: Probable Measures\n1. Maintain Vigilance\nThis is self-evident, but it must be said. I have a few friends who have let their cat out of sight for a few minutes only to be confronted with disaster.\nDepending on the procedure, the pet can be placed under an anesthetic. This ensures that your pet’s grace and agility will be offset by drowsy clumsiness.\nAs if you’re a toddler who has just learned to walk and is attempting to avoid nap time.\nKeeping a close watch on what’s coming will help you see it and stop it.\nThe easiest way to do this is to have your pet with you in a small enclosed room with no furniture to climb on.\n2. Take Down All Cat Trees\nIt’ll only create trouble if you keep your cat tree upright and visible. Either your cat notices it and remembers that jumping hurts, or she leaps regardless, and you’re back in the car on the way to the doctor.\nDepending on how much space you have, you can quickly solve the issue by laying the tree on its side. You should even leave it outside if the weather is good until your kitty is completely healed.\nAnother solution is to simply cover the cat tree with a blanket or tarp. It won’t be pretty, but it’ll just be for a short time.\n3. Keep The Cat Inside The Building\nSome cats are more self-sufficient than others. This move will be a bit more difficult if your cat wants to socialize with the neighbors during the day.\nNaturally, the feline has become used to getting her way anytime she wishes. And she might not be happy if you restrict her freedoms.\nHowever, in the postoperative period, having your cat on free roam mode is impossible. Who knows what happens when you aren’t around?\nIt’s possible that your cat competes in the community pole vault race. Hold your cat indoors following surgery if you wish them to avoid jumping.\n4. Keep The Cat Out Of The Company Of Other Cats\nOther Cats can be attracted to the cat’s incision. You can’t risk another animal chewing or chewing at your cat’s newly healed wound, can you?\nIf you have several cats or animals in your home, you’ll want to pay special attention to this section. Fights between cats have been known to occur, and your post-op kitty will certainly bear the brunt of such an exchange.\nIf a cat is shocked or threatened, it may bite, hop, and claw, so prevent war at all costs.\nFor the duration of your rehab, it’s safest to separate your dogs into various rooms in the home.\n5. Obtain A Cone\nHave a pit stop at the pharmacy on the way home if you didn’t get one at the vet. You’ll be happy you did, believe me.\nThe primary function of a cone is to prevent the incision from being bit, licked, or scratched. Your cat would undoubtedly despise it, but it is extremely effective in this respect.\nA cone, on the other hand, has been shown to discourage any excessive jumping or irregular activity in general. Your cat would be uneasy and unbalanced.\nThe cone, when combined with the anesthetic, will make it less possible for your cat to check out high areas.\nYou might also like to read about how long to keep cone on cat after spay\n6. Maintain A Calm Environment For Everyone\nThe more people and animals you have in the home, the more difficult it will be. It’s not easy to get the kids to stop fighting or the birds to stop squawking, but your healing pet would thank you.\nSurgery is a very painful procedure. Your cat was ripped from her natural habitat, cut open, and forced to spend the night in an unfamiliar location with noisy neighbors. Could you blame her for wishing for some alone time?\nYour pet would find it much easier to rest and sink into the tranquility of their anesthetic without all the additional stimuli. She’ll be far less likely to get herself into trouble or over-exert herself, causing more damage.\n7. Make Use Of A Crate\nI put this one last because I like to keep crate time to a minimum. It’s cruel and wasteful to confine your pet for hours daily.\nThat being said, a post-op kitty is extremely vulnerable, and this is an exception to the law. If everything else fails and your pet continues to jump around like a lunatic, a cage is your safest chance at keeping your cat isolated after a spay.\nYou can’t always keep an eye on your cat, either. If your cat is always unable to calm down, it’s a smart idea to keep him in the cage while you’re not home.\nMost pet owners despise crates, but it’s only for a short time! First, I want to try holding my kitty next to me in a tight room. This way, your cat retains some independence as you enjoy peace of mind.\n8. Medication And Attention\nKeeping all of these suggestions in mind is critical to ensuring your loved one’s complete and speedy recovery. Make sure you pay attention to the veterinarian and follow their directions to the letter.\nIf your cat was given drugs, follow the directions carefully and don’t avoid offering it unless otherwise advised. You don’t want your pet to suffer from injury or irritation that could be prevented.\nYour cat may be too groggy to even consider leaping after you’ve given him the medication. However, this isn’t always the case. In any case, make sure they get plenty of rest and relaxation. Some cats get starving and demand food right away, while others need a bit more time.\nInteresting Read: Can I Feed My Cat After Neutering?\nDon’t be concerned if your cat doesn’t eat right away; this is completely natural.\nIt’s also important to treat the pet with caution so that the incision doesn’t get messed up. If at all possible, avoid picking them up.\nLast but not least, lavish extra affection and care on your little hairball! It won’t assist with physical healing, but it will definitely help with the agony and confusion you’ve been experiencing for the last 24 hours.\nIt’s also very important to know how long to keep cat confined after spay\nNursing Care After Surgery Of Cat\nAfter you get home, make sure your cat is warm and comfortable by having a soft, clean bed in a dark, draft-free space with a cool room temperature (25°C).\nYour cat should be kept indoors. Your cat’s movement can be limited for one week after surgery for most procedures.\nDriving, climbing, and other strenuous activities can be avoided because they will put too much pressure on the wound.\nYou should give your cat about half of his usual dinner a few hours after you get home.\nIf she still feels hungry after eating this, you can give her the remainder of her meal about an hour later.\nAfter general anesthesia, some cats feel nausea, so splitting the meal into smaller portions can reduce the risk of nausea and vomiting.\nInteresting Read: Cat Not Eating After Spay: Reasons & Solutions\nPotential Problems After Surgery For Cats\nComplications occur in the same way as injuries do. Complications are to be feared, and they can range from rashes to death.\nThe cat, the operation, and the surgeon are all things to think about.\nWhen a pet’s e-collar is off, it can cause complications by being too active or biting at their sutures.\nAlso, check out why my cat is very active after surgery\nWhen there is more “time, litter, and trauma,” surgery is considered to have more complications.\nProcedures should be kept as brief as possible to inflict as little trauma as possible.\nWounds that are infected cause more symptoms than stable skin.\nThe wound should be kept as sterile as possible, and any dead or contaminated tissue should be discarded. A skilled surgeon must be mindful of the risks and know how to manage them.\nThe following are minor issues that could happen in the cat after surgery:\n- Mental illnesses like Depression\n- Anesthesia-induced vomiting\n- The endotracheal tube irritated coughing.\n- Anesthesia-induced drowsiness\n- The tissue surrounding the incision is red and itchy.\nInteresting Read: Can I Bathe My Cat After Neutering Or Spaying?\nHow To Deal With The Complications After Surgery In Cats?\nBe ready for a slew of issues. Following anesthesia, your cat can vomit. Because of the discomfort, your cat can refuse to eat.\nAnesthesia and surgery have different effects on different pets. If you have concerns about your pet’s health, call or have your pet examined by a veterinarian.\nOur hospital does not need an appointment; just walk in and your pet will be seen right away.\nSimple measures such as a warm compress or extra pain medications could be enough to alleviate the issue.\nSutures that have been chewed out or are off for other purposes may need to be replaced as a result of complications.\nIf you notice the incision is opening, have it examined by a doctor right away to avoid the serious complications of herniated tissue and infection.\nConsult a veterinarian right away, no matter what the issue is, to decide the proper course of action.\nYou must like to read details about How To Keep Cat From Jumping Over Gate\nFrequently Asked Questions\nHow long after surgery can a cat jump?\nYour cat should be kept indoors. Your cat’s movement can be limited for one week after surgery for most procedures. Rolling, climbing, and other strenuous activities can be avoided because they will put too much pressure on the wound.\nShould cats jump after being spayed?\nFor the first week after surgery, you do not encourage him to climb stairs, run, hop, or even play. Allowing freshly neutered/spayed cats to run around too often will cause the cut to heal more slowly. To be on the safe side, confine your pet to a small space, a cage, or a carrier.\nWhy is my cat twitching after surgery?\nThis is not unusual and maybe a side effect of the anesthetic rubbing off, which could go away within 24-48 hours, or fear. Remember that your pet is completely unaware that he or she has had surgery.\nIs it normal for cats to sleep a lot after surgery?\nYour pet will need special care and treatment when recovering from sickness or surgery. She’ll need a lot of rest, food, and quiet. During her rehab, you’ll find that she seems frail and spends more time resting or sleeping than normal.\nHow long does it take anesthesia to wear off in cats?\nWith today’s anesthetics, all of which are reversible, the pet can be almost entirely normal by the time of discharge, but many pets will sleep more or be more exhausted after going home for 12 to 24 hours.\nHow long does it take for a cat to recover from being spayed?\nThe majority of spay/neuter skin incisions recover completely in 10–14 days, which is also when the stitches or staples if any, must be removed. Bathe or swim with your pet only after the stitches or staples have been removed and the doctor has given you permission.\nDuring the first week after surgery, you should not encourage him to climb stairs, run, jump or even play. If the cats are too neutered or spread, the healing process could be slowed down.\nIt’s important to keep the cat in a small space, in a box, or in a carrier to be on the safe side. Do not hurry to treatment. Do not rush to recovery. It is much safer to let your cat relax all week long.\nDo let us know your stories in the comments section below.\nInteresting Read: Why Is My Cat Hiding After Being Spayed? |
TRAMADOL HYDROCHLORIDE — tramadol hydrochloride tablet, film coated\nRising Pharma Holdings, Inc.\nWARNING: ADDICTION, ABUSE, AND MISUSE; RISK EVALUATION AND MITIGATION STRATEGY (REMS); LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; ULTRA-RAPID METABOLISM OF TRAMADOL AND OTHER RISK FACTORS FOR LIFE-THREATENING RESPIRATORY DEPRESSION IN CHILDREN; NEONATAL OPIOID WITHDRAWAL SYNDROME; INTERACTIONS WITH DRUGS AFFECTING CYTOCHROME P450 ISOENZYMES; and RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS\nADDICTION, ABUSE AND MISUSE\nTramadol hydrochloride exposes patients and other users to the risks of opioid addiction, abuse and misuse, which can lead to overdose and death. Assess each patient’s risk prior to prescribing tramadol hydrochloride, and monitor all patients regularly for the development of these behaviors and conditions [see Warnings and Precautions (5.1)].\nOPIOID ANALGESIC RISK EVALUATION AND MITIGATION STRATEGY (REMS)\nTo ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a REMS for these products [see Warnings and Precautions (5.2)]. Under the requirements of the REMS, drug companies with approved opioid analgesic products must make REMS-compliant education programs available to healthcare providers. Healthcare providers are strongly encouraged to:\n- complete a REMS-compliant education program,\n- counsel patients and/or their caregivers, with every prescription, on safe use, serious risks, storage, and disposal of these products,\n- emphasize to patients and their caregivers the importance of reading the Medication Guide every time it is provided by their pharmacist, and\n- consider other tools to improve patient, household, and community safety.\nLIFE-THREATENING RESPIRATORY DEPRESSION\nSerious, life-threatening, or fatal respiratory depression may occur with use of tramadol hydrochloride. Monitor for respiratory depression, especially during initiation of tramadol hydrochloride or following a dose increase [see Warnings and Precautions (5.3)].\nAccidental ingestion of tramadol hydrochloride, especially by children, can be fatal. [see Warnings and Precautions (5.3)].\nULTRA-RAPID METABOLISM OF TRAMADOL AND OTHER RISK FACTORS FOR LIFE-THREATENING RESPIRATORY DEPRESSION IN CHILDREN\nLife-threatening respiratory depression and death have occurred in children who received\ntramadol. Some of the reported cases followed tonsillectomy and/or adenoidectomy; in at least one case, the child had evidence of being an ultra-rapid metabolizer of tramadol due to a CYP2D6 polymorphism [see Warnings and Precautions (5.4)]. Tramadol hydrochloride is contraindicated in children younger than 12 years of age and in children younger than 18 years of age following tonsillectomy and/or adenoidectomy [see Contraindications (4)]. Avoid the use of tramadol hydrochloride in adolescents 12 to 18 years of age who have other risk factors that may increase their sensitivity to the respiratory depressant effects of tramadol [see Warnings and Precautions (5.4)].\nNEONATAL OPIOID WITHDRAWAL SYNDROME\nProlonged use of tramadol hydrochloride during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available [see Warnings and Precautions (5.5)].\nINTERACTIONS WITH DRUGS AFFECTING CYTOCHROME P450 ISOENZYMES\nThe effects of concomitant use or discontinuation of cytochrome P450 3A4 inducers, 3A4 inhibitors, or 2D6 inhibitors with tramadol are complex. Use of cytochrome P450 3A4 inducers, 3A4 inhibitors, or 2D6 inhibitors with tramadol hydrochloride requires careful consideration of the effects on the parent drug, tramadol, and the active metabolite, M1 [see Warnings and Precautions (5.6); Drug Interactions (7)].\nRISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS\nConcomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death [see Warnings and Precautions (5.7); Drug Interactions (7)].\n- Reserve concomitant prescribing of tramadol hydrochloride and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate.\n- Limit treatment to the minimum effective dosages and durations.\n- Follow patients for signs and symptoms of respiratory depression and sedation.\nTramadol hydrochloride tablets are indicated in adults for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate.\nLimitations of Use\nBecause of the risks of addiction, abuse, and misuse with opioids, even at recommended doses [see Warnings and Precautions (5.1)] , reserve tramadol hydrochloride tablets for use in patients for whom alternative treatment options [e.g., non-opioid analgesics]:\n- Have not been tolerated or are not expected to be tolerated.\n- Have not provided adequate analgesia or are not expected to provide adequate analgesia.\n- Do not use tramadol hydrochloride tablets concomitantly with other tramadol-containing products.\n- Do not administer tramadol hydrochloride tablets at a dose exceeding 400 mg per day.\n- Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals [see Warnings and Precautions (5.1)].\n- Initiate the dosing regimen for each patient individually, taking into account the patient’s severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse [see Warnings and Precautions (5.1)].\n- Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases with tramadol hydrochloride tablets and adjust the dosage accordingly [see Warnings and Precautions (5.3)].\nDiscuss the availability of naloxone for the emergency treatment of opioid overdose with the patient and caregiver and assess the potential need for access to naloxone, both when initiating and renewing treatment with tramadol hydrochloride tablets [see Warnings and Precautions (5.3), Patient Counseling Information (17)].\nInform patients and caregivers about the various ways to obtain naloxone as permitted by individual state naloxone dispensing and prescribing requirements or guidelines (e.g., by prescription, directly from a pharmacist, or as part of a community-based program).\nConsider prescribing naloxone, based on the patient’s risk factors for overdose, such as concomitant use of CNS depressants, a history of opioid use disorder, or prior opioid overdose. However, the presence of risk factors for overdose should not prevent the proper management of pain in any given patient [see Warnings and Precautions (5.1, 5.3, 5.7)].\nConsider prescribing naloxone if the patient has household members (including children) or other close contacts at risk for accidental exposure or overdose.\nInitiating Treatment with Tramadol Hydrochloride Tablets\nFor patients not requiring rapid onset of analgesic effect, the tolerability of tramadol hydrochloride tablets can be improved by initiating therapy with the following titration regimen: Start tramadol hydrochloride tablets at 25 mg/day and titrated in 25 mg increments as separate doses every 3 days to reach 100 mg/day (25 mg four times a day). Thereafter the total daily dose may be increased by 50 mg as tolerated every 3 days to reach 200 mg/day (50 mg four times a day). After titration, tramadol hydrochloride tablets 50 to 100 mg can be administered as needed for pain relief every 4 to 6 hours not to exceed 400 mg/day.\nFor the subset of patients for whom rapid onset of analgesic effect is required and for whom the benefits outweigh the risk of discontinuation due to adverse events associated with higher initial doses, tramadol hydrochloride tablets 50 mg to 100 mg can be administered as needed for pain relief every four to six hours, not to exceed 400 mg per day.\nConversion from Tramadol Hydrochloride Tablets to Extended-Release Tramadol\nThe relative bioavailability of tramadol hydrochloride tablets compared to extended-release tramadol is unknown, so conversion to extended-release formulations must be accompanied by close observation for signs of excessive sedation and respiratory depression.\nDosage Modification in Patients with Hepatic Impairment\nThe recommended dose for adult patients with severe hepatic impairment is 50 mg every 12 hours.\nDosage Modification in Patients with Renal Impairment\nIn all patients with creatinine clearance less than 30 mL/min, it is recommended that the dosing interval of tramadol hydrochloride tablets be increased to 12 hours, with a maximum daily dose of 200 mg. Since only 7% of an administered dose is removed by hemodialysis, dialysis patients can receive their regular dose on the day of dialysis.\nDosage Modification in Geriatric Patients\nDo not exceed a total dose of 300 mg/day in patients over 75 years old.\nIndividually titrate tramadol hydrochloride tablets to a dose that provides adequate analgesia and minimizes adverse reactions. Continually reevaluate patients receiving tramadol hydrochloride tablets to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as to monitor for the development of addiction, abuse, or misuse [see Warnings and Precautions (5.1)]. Frequent communication is important among the prescriber, other members of the healthcare team, the patient, and the caregiver/family during periods of changing analgesic requirements, including initial titration.\nIf the level of pain increases after dosage stabilization, attempt to identify the source of increased pain before increasing the tramadol hydrochloride tablets dosage. If unacceptable opioid-related adverse reactions are observed, consider reducing the dosage. Adjust the dosage to obtain an appropriate balance between management of pain and opioid-related adverse reactions.\nDo not abruptly discontinue tramadol hydrochloride tablets in patients who may be physically dependent on opioids. Rapid discontinuation of opioid analgesics in patients who are physically dependent on opioids has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide. Rapid discontinuation has also been associated with attempts to find other sources of opioid analgesics, which may be confused with drug-seeking for abuse. Patients may also attempt to treat their pain or withdrawal symptoms with illicit opioids, such as heroin, and other substances.\nWhen a decision has been made to decrease the dose or discontinue therapy in an opioid-dependent patient taking tramadol hydrochloride tablets, there are a variety of factors that should be considered, including the dose of tramadol hydrochloride tablets the patient has been taking, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient. It is important to ensure ongoing care of the patient and to agree on an appropriate tapering schedule and follow-up plan so that patient and provider goals and expectations are clear and realistic. When opioid analgesics are being discontinued due to a suspected substance use disorder, evaluate and treat the patient, or refer for evaluation and treatment of the substance use disorder. Treatment should include evidence-based approaches, such as medication assisted treatment of opioid use disorder. Complex patients with comorbid pain and substance use disorders may benefit from referral to a specialist.\nThere are no standard opioid tapering schedules that are suitable for all patients. Good clinical practice dictates a patient-specific plan to taper the dose of the opioid gradually. For patients on tramadol hydrochloride tablets who are physically opioid-dependent, initiate the taper by a small enough increment, (e.g., no greater than 10% to 25% of the total daily dose) to avoid withdrawal symptoms, and proceed with dose-lowering at an interval of every 2 to 4 weeks. Patients who have been taking opioids for briefer periods of time may tolerate a more rapid taper.\nIt may be necessary to provide the patient with a lower dosage strength to accomplish a successful taper. Reassess the patient frequently to manage pain and withdrawal symptoms, should they emerge. Common withdrawal symptoms include restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis. Other signs and symptoms also may develop, including irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate. If withdrawal symptoms arise, it may be necessary to pause the taper for a period of time or raise the dose of the opioid analgesic to the previous dose, and then proceed with a slower taper. In addition, monitor patients for any changes in mood, emergence of suicidal thoughts, or use of other substances.\nWhen managing patients taking opioid analgesics, particularly those who have been treated for a long duration and/or with high doses for chronic pain, ensure that a multimodal approach to pain management, including mental health support (if needed), is in place prior to initiating an opioid analgesic taper. A multimodal approach to pain management may optimize the treatment of chronic pain, as well as assist with the successful tapering of the opioid analgesic [see Warnings and Precautions (5.17), Drug Abuse and Dependence (9.3)].\nTramadol hydrochloride tablets USP, 50 mg (equivalent to 43.9 mg of tramadol) are white to off-white, capsule shaped coated tablet debossed ‘T’ on one side and ‘0’ & ‘3’ separated with score line (functional) on other side.\nTramadol hydrochloride tablets are contraindicated for:\n- all children younger than 12 years of age [see Warnings and Precautions (5.4)].\n- postoperative management in children younger than 18 years of age following tonsillectomy and/or adenoidectomy [see Warnings and Precautions (5.4)].\nTramadol hydrochloride tablets are also contraindicated in patients with:\n- Significant respiratory depression [see Warnings and Precautions (5.3)].\n- Acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment [see Warnings and Precautions (5.12)].\n- Known or suspected gastrointestinal obstruction, including paralytic ileus [see Warnings and Precautions (5.15)].\n- Hypersensitivity to tramadol, any other component of this product or opioids [see Warnings and Precautions (5.16)].\n- Concurrent use of monoamine oxidase inhibitors (MAOIs) or use within the last 14 days [see Drug Interactions (7)].\nTramadol hydrochloride contains tramadol, a Schedule IV controlled substance. As an opioid, tramadol hydrochloride exposes users to the risks of addiction, abuse, and misuse [see Drug Abuse and Dependence (9)].\nAlthough the risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed tramadol hydrochloride. Addiction can occur at recommended dosages and if the drug is misused or abused.\nAssess each patient’s risk for opioid addiction, abuse, or misuse prior to prescribing tramadol hydrochloride, and monitor all patients receiving tramadol hydrochloride for the development of these behaviors and conditions. Risks are increased in patients with a personal or family history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major depression). The potential for these risks should not, however, prevent the proper management of pain in any given patient. Patients at increased risk may be prescribed opioids such as tramadol hydrochloride, but use in such patients necessitates intensive counseling about the risks and proper use of tramadol hydrochloride along with intensive monitoring for signs of addiction, abuse, and misuse. Consider prescribing naloxone for the emergency treatment of opioid overdose [see Dosage and Administration (2.2), Warnings and Precautions (5.3)].\nOpioids are sought by drug abusers and people with addiction disorders and are subject to criminal diversion. Consider these risks when prescribing or dispensing tramadol hydrochloride. Strategies to reduce these risks include prescribing the drug in the smallest appropriate quantity and advising the patient on the proper disposal of unused drug [see Patient Counselling Information (17)]. Contact local state professional licensing board or state controlled substances authority for information on how to prevent and detect abuse or diversion of this product.\nDrugInserts.com provides trustworthy package insert and label information about marketed drugs as submitted by manufacturers to the US Food and Drug Administration. Package information is not reviewed or updated separately by DrugInserts.com. Every individual package label entry contains a unique identifier which can be used to secure further details directly from the US National Institutes of Health and/or the FDA. |
Published on March 14, 2018 by Scott Brenman\nThe Facelift is a cosmetic surgery procedure that has helped many men and women restore their facial appearance to it’s more youthful vibrance and smoothness. The facelift targets excess, sagging skin and wrinkles in the neck, chin, and lower face. Sometimes the facelift may be combined with other procedures such as liposuction, brow lift, or less invasive procedures such as dermal fillers or botox. The facelift procedure, also called Rhytidectomy, can help to create a natural looking result and give a more youthful, well-rested appearance. We encourage you to view our online before and after Facelift surgery results to see real patient results and see what kind of results are possible with a facelift.\nPerformed under general anesthesia, the rhytidectomy surgery usually takes about 4-6 hours to complete. The incision in this procedure is made inside the crease in front of and around the earlobe and behind the hairline. Recovery varies from patient to patient, but generally most heal for 2-3 weeks before they feel ready to resume their social activities. If you are interested in learning more about the facelift procedure and to find out if it may be right for you, contact our office to schedule your consultation with Dr. Brenman today. |
MedStream ensures excellence through anesthesia management to improve patient care and optimize financial performance. We deliver the clinical, operational and financial capability few anesthesia practice management firms can offer.\nFebruary 20, 2017\nGatherings of healthcare leaders in our home state are always special but this year two presentations were particularly meaningful. Joann Anderson, CEO of Southeastern Regional Medical Center, opened the conference with a poignant and heartfelt story of her hospital's experience through Hurricane Matthew last fall. The following morning, David Strong, former CEO at Rex Healthcare and now CEO of Orlando Health, walked attendees through his team's minute-by-minute experience receiving the shooting victims of the Pulse nightclub terrorist attack. Rather than focus on the hardships or disappointment they undoubtedly felt, both leaders chose to highlight the talent and dedication of their teams, from cafeteria workers to maintenance staff to medical providers to community volunteers. This important conference reminded all us of what it means to serve our communities. MedStream is proud to be a long-time partner to NCHA and many of its member hospitals.\n82 Patton Ave., Suite 510\nAsheville, NC 28801\nStatement to patients: This website is not secure and should not be used for billing questions or concerns. Please contact us at (877) 350-3511 with any billing inquiries.\n©2018 MedStream. All Rights Reserved |
This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.\nOsler once differentiated a textbook from a yearbook by pointing out that the former should present views that have stood the test of time, while a yearbook should record the proceedings of the previous year like the minutes of a meeting. This book stands midway between the two; it assesses, comments on, and draws conclusions from the medical literature, dealing with subjects of topical interest. With the exception of timely historical references, the quoted literature has appeared mostly within the past five years.\nThe editor and compiler of "Recent Advances in Oto-Laryngology" has resisted the temptation to farm out various chapters. Instead, he has made a personal survey of the entire field of otolaryngology, presenting much information that is useful in clinical practice. Among the more important chapters of this book are those dealing with anesthesia, the deaf infant, acoustic trauma, and the treatment of facial palsy. Surgical advances in\nRecent Advances in Oto-Laryngology. AMA Arch Otolaryngol. 1958;68(4):528. doi:10.1001/archotol.1958.00730020548023\nCoronavirus Resource Center\nCustomize your JAMA Network experience by selecting one or more topics from the list below. |
To assess the changes in colloid osmotic pressure (COP) in horses undergoing surgery for colic. Prospective clinical evaluation. Twenty-nine adult horses presented for emergency laparotomy. Horses were premedicated with intravenous (IV) xylazine and anesthesia was induced with ketamine, diazepam and guaifenesin and was maintained with isoflurane as required. Lactated Ringer's solution (LRS) was given to all horses during anesthesia. Blood was collected in heparin before, and every 30 minutes during, anesthesia to measure COP, total protein concentration (TP), osmolality, packed cell volume, electrolytes, glucose and lactate. In addition, COP was estimated using different formulas previously described for horses. Before anesthesia, COP and TP were 18.7 ± 2.2 mmHg (2.49 ± 0.29 kPa) and 6.3 ± 0.7 g dL -1, respectively. The horses received a mean ± SD of 19.5 ± 3.9 mL kg-1 hour-1 (range 15-25 mL kg -1hour-1) of LRS during anesthesia. The COP and TP decreased linearly (R2 = 0.99, p < 0.01) during anesthesia and reached the lowest point at the end of anesthesia with a COP of 11.6 ± 1.6 mmHg (1.55 ± 0.21 kPa) and TP of 4.4 ± 0.4 g dL-1. The Pearson correlation coefficient for COP versus TP was r2 = 0.78. Calculation of COP from TP concentrations showed that two formulas could predict COP to within 1 mmHg (0.13 kPa) (Thomas & Brown 1992; Boscan et al. 2007). Colloid osmotic pressure, like TP, decreased greatly over the course of crystalloid fluid infusion during anesthesia for laparotomy in horses with colic. This change may predispose the animal to tissue edema with subsequent morbidity.\n- Oncotic pressure\nASJC Scopus subject areas |
Full text not currently available from Enlighten.\nPublisher's URL: http://bja.oxfordjournals.org/content/84/1/95.abstract\nOpioids administered to peripheral tissues can have significant analgesic effects in doses which would not be effective centrally. We have assessed the effects of regional diamorphine 2.5 mg i.v. in 14 patients undergoing surgical correction of bilateral arthritic foot deformities in a prospective, randomized, double-blind study. Patients acted as their own controls as only one foot received the active drug. Visual analogue scale (VAS) pain scores and wound tenderness were measured over 72 h. Diamorphine did not improve median VAS area under the curve pain scores during the first 6 h after surgery (33 (95% confidence intervals (CI) 25-46) vs 24 (17-35)). It also did not effect wound hypersensitivity when tested at 72 h after surgery (95 (47-125) vs 90 (50-125) g). There were no significant adverse effects.\n|Glasgow Author(s):||Serpell, Dr Michael|\n|Authors:||Serpell, M., Anderson, E., Wilson, D., and Dawson, N.|\n|College/School:||College of Medical Veterinary and Life Sciences > School of Medicine|\n|Journal Name:||British Journal of Anaesthesia|\n|Publisher:||Oxford University Press| |
Chapter 7: The Journey Ends\nIn 1910 the King of Kashi had to be operated on for appendicitis. Since the king had taken a vow not to partake of anything that induced unconsciousness, he refused any anesthesia. The doctors were in a dilemma, since the operation was absolutely imperative and so also the anesthesia. They tried to explain to him that it was a matter of opening his abdomen, but he persisted and asked only to be allowed to read the Gita while they operated, and that was enough. The doctors had to give in because delay in operating could be fatal. The king read the Gita throughout the operation, and when it was all over the incredulous doctors asked didn’t he feel any pain. He said, “I was so engrossed in my Gita, I was not aware of what was happening.”\nYou only know a thing when you apply your mind to it; you see only what you want to see. When your attention is diverted, everything changes. You are unaware of things that you really want to avoid. If you wander through the market, you will see only those things that interest you: a cobbler will concentrate on leather goods, a jeweler will have eyes only for diamonds. You only see those things that are illumined by your attention. All else remains in darkness.\nThe most profound art of living is to attain mastery over attention. If you are flowing towards God the world will be lost to you, and it is for this reason that sages call the world maya, an illusion. Maya does not mean that the world does not exist. It exists very much, but sages discovered that as their awareness flows God-ward, the world fades from perception. And where awareness is not, the existence or nonexistence of that place becomes irrelevant. Existence is born in the act of perception. It fades when the attention is withdrawn.\nThe sages say: “God is truth, the world is non-truth.” Does this mean that the world we see around us is not there in actuality? It is very much there, but the sage no longer perceives it. If you are greedy wealth is real to you; when greed is gone, riches become like clay. Wealth is not wealth because of itself - but because of your perceptions. Or, with sensuousness the body becomes very significant; without sensuousness it becomes secondary.\nExistence shifts with attention; it manifests only in the path of attention. Once you understand this you become your own master. Having discovered the master within, you no longer obey your servants, the disciples, because what is the sense in asking those who do not know themselves? Now you follow and do the bidding of the master within.\nNanak says one alone, dhyana, is the guru of the five. On the superficial level dhyana means attention; on the deeper level dhyana refers to meditation. It is meditation that leads to discovery of the master within. There is nothing more profound - nothing deeper - than meditation, so ponder over it and make no casual passing remarks about something so significant. But people are such that they talk about attention and meditation without any direct knowledge. People who do not know in themselves enjoy talking just for the sake of talking and they cause a great deal of confusion in the world. |
Perioscopy - non surgical treatment option\nPeriodontal infection is typically a chronic infection that works its way further into the gum and bone over a long period of time. Because the bacteria are organized and different from the normal bacteria in the mouth, and because the bacteria invade the gum and affect the bone, many times conventional/routine cleaning does not serve well to control the infection.\nThis infection is typically without symptoms, such as pain. However, it can give you signs of infection such as swollen gums, bleeding, bad breath and looseness of teeth.\nThe "Cleaning" is typically done using local anesthesia, with very small ultrasonically powered probes ("micro ultrasonics"). This technology eliminates the need for scraping of the roots with hand instruments. This cleaning technique very thoroughly cleans diseased roots and pockets with micro ultrasonic vibrations of the instrument, as well as, with highly energized flushing of water irrigation.\nTo aid in visualization of diseased tooth roots our office uses a fiber optic endoscope (Perioscopy). This micro camera slips into pockets so root surfaces can be observed and endoscopically cleaned.\nThe "Disinfection" is done with an antibiotic. Because there are specific bacteria that invade the gum tissue and affect the bone, our office has found that a course of a systemic antibiotic helps to eliminate any bacteria residual to the cleaning. The antibiotic used may vary based on patient tolerances to different medications. When the infection is generalized it is better to use systemic medications (oral pills). However, when the infection is more localized, antibiotics may be placed directly into the pocket to provide the disinfection. These local antibiotics work in the gum for over a week as they dissolve.\nThe results of "cleaning and disinfecting" together, have been shown to be much more effective than either one alone. The procedure is one of the best approaches for giving the body a fresh start at healing the gum and bone around the teeth.\nAfter the initial procedure, patients typically have little or no discomfort. A reevaluation is performed after 3-4 months to check the initial response to treatment and patients are asked to have supportive periodontal treatments at 3-4 month intervals for one year. These treatments are micro ultrasonic cleanings (without anesthesia and without antibiotics) and are performed to support healing by keeping the teeth above and below the gumline as clean as possible. Additionally, we help our patients with their effectiveness in cleaning at home. |
Patients commonly ask when they should pursue facial rejuvenation surgery. The answer has little to do with your age. You should consider these types of procedures when aging issues start to show on your face. Whenever you start to notice deepening wrinkles, sagging skin, or dark spots (hyperpigmentation) is the time to start looking into getting a facelift. There is no specific chronological age at which this happens, since each individual ages at a different pace and in a different way.\nWhen you come in for a consultation visit, Dr. Flint examines you and designs a specific surgical plan to address your specific issues and accomplish your specific goals. She prefers a three-prong approach that includes skin care, cosmetic fillers, and surgery to provide the best results. She is fully committed to providing a natural appearance and never wants any patient to appear stretched or tight following a procedure.\nFacelifts at a Glance\nThere are many different types of facelifts in Scottsdale, and several are marketed very effectively. They promise short scars, short procedure times, and short recoveries. Dr. Flint feels many of these procedures only provide short-term results. If you have lax skin in your jowls and neckline to a significant degree, a “mini-facelift” will not provide long-lasting results. You are much better off having a formal facelift in Scottsdale that has a two- to three-week recovery, but which provides a ten-year result.\n- View Dr. Flint’s before and after facelift photos.\n- See some Scottsdale rhinoplasty before and after photos\nWhat to Expect\nFacelift procedures are among Dr. Flint’s specialties. The surgery lasts about three hours. If ancillary procedures—such as brow lifts and eyelid lifts—are performed at the same time, the procedure may take up to five hours. Discomfort is described as mild by most patients. You will experience some swelling and bruising that subside after one to two weeks. Facelift procedures can produce good-looking, natural improvements in many patients, both male and female.\nWhile some patients have anxiety about anesthesia, Dr. Flint always uses board certified anesthesiologists to provide safe general anesthesia. Twilight sleep is not as safe for this procedure, in Dr. Flint’s opinion.\nPreparing for a Facelift\nDr. Flint meets with you in a consultation for your facelift at her Scottsdale or Mesa office. During your consultation, she discusses the procedure she feels will suit your goals. She recommends a skin care program to prepare your skin for surgery. You are asked to obtain pre-operative blood work and possibly an EKG and chest x-ray. You will need someone to drive you to and from the surgicenter. One overnight stay in the surgicenter’s recovery care floor is required for a facelift. Scottsdale plastic surgeon Dr. Flint will visit you in the recovery care center the morning after your surgery to remove your bandages and arrange your discharge.\nFollowing your facelift surgery, Dr. Flint will see you at approximately one week, 10 days, three weeks, and six weeks after your procedure, as well as at three, six, and twelve months post-operatively. Special follow-up schedules are arranged for patients who have come in from out of town for their surgeries. Most importantly, Dr. Flint will see you anytime if you have a concern. |
GALLBLADDER Minimally Invasive Surgery\nPatients who experience symptoms from gallstones (including jaundice, abdominal pain, or inflammation of the pancreas) usually require gallbladder removal surgery. Until recently, this procedure has been traditionally an open operation through a large abdominal incision. Now, with the expert technique of Hudson Valley Surgical Group's Minimally Invasive Surgery (MIS), laparoscopic gallbladder surgery is the best method for treating gallstones. It is performed through a series of smaller incisions and in most cases just a single incision that results in a speedier recovery for gallbladder patients.\nGallbladder surgery is a simple surgery within a complex part of the anatomy. Patients need to seek out highly experienced surgeons. As a team Hudson Valley Surgical group has low to no bile duct injuries in the past 30+ years with over 4,000 gallbladder surgeries to date. Our team’s expertise and technique has evolved with experience and they are expert at delivering a MIS from beginning to end with an extremely low conversion rate. However, the surgeons at Hudson Valley Surgical Group are also very sensitive to the fact that not all patients will require urgent surgery. Our surgeons have the expertise to be able to determine the difference and create a custom medical treatment plan including the use of antibiotics and/or drains where appropriate.\nMinimally Invasive Gallbladder Surgery Advance Techniques\nThe surgeons of Hudson Valley Surgical Group are highly trained in traditional open surgery as well as advanced techniques including use of the da Vinci robot or through laparoscopic cholecystectomy. This is a MIS procedure that is performed with video instruments which allow the surgeon to view the gallbladder and surrounding tissue. The gallbladder is removed through one of the smaller incisions which results in less scarring and less post-operative pain for the patient. This method can often be performed as an outpatient procedure.\nGallbladder Patient Issues\nAcute gallbladder surgery is the most common procedure we perform, which tends to be a much more complex surgery across the board. Our team also specializes in treating patients who have previous abdominal surgeries which naturally increase the complexity of the surgical plan.\nPatient Benefits to Minimally Invasive Gallbladder Surgery\n- High success rate Less than 1% of the 300 gallbladder surgeries performed in the last year resulted in "open surgery." That is significantly lower than the national average and indicative of the high success rate of Hudson Valley Surgical Group's Minimally Invasive Surgery technique. These success rates include acute settings as well.\n- Less risk for wound infections Gallbladder surgery wound infections and complications have significantly decreased with far less blood loss and less trauma to the body.\n- Less scarring MI gallbladder surgery procedures offer improved cosmetic results.\n- Less anesthesia MI gallbladder surgery is ideal for patients with sensitivity to anesthesia.\n- Decrease surgery time Superior and precise technology have decreased gallbladder surgery time.\n- Less pain MI gallbladder surgery procedures result in less post-operative pain.\n- Faster recovery/Shorter hospital stay You will go home sooner! |
We are offering the COVID-19 vaccine to eligible patients based on state and federal guidelines, and as supplies allow. Please do not call us for a vaccine appointment. We are notifying patients individually when they can schedule. so we can notify you. Learn more about the .\nTreatment for Precancerous Conditions of the Cervix\nNYU Langone doctors may use one of several approaches to manage precancerous growths on the cervix, which are also called dysplasia. Removing these growths can prevent cervical cancer from developing.\nLoop Electrosurgical Excision Procedure\nYour doctor may use a loop electrosurgical excision procedure, also known as LEEP, to manage precancerous growths on the surface or in the canal of the cervix, which connects the vagina and uterus. In this procedure, the doctor inserts a thin wire loop into the vagina. The loop carries a small electrical current that removes the precancerous tissue.\nThis procedure is usually performed in the doctor’s office with a local anesthetic.\nFollowing the procedure, doctors continue to monitor you using Pap tests to make sure there are no additional precancerous changes.\nDoctors remove a cone-shaped piece of tissue from the cervix in a procedure called conization. They may use conization to remove precancerous tissue high up in the cervical canal, along with a border of surrounding healthy tissue, to help ensure that all of the precancerous cells have been taken out.\nDuring this procedure, doctors use either a scalpel inserted through the vagina or a laser to remove a piece of cervical tissue. Doctors usually perform this type of biopsy in an outpatient surgical center, often with general anesthesia.\nDoctors continue to monitor you with Pap tests following the procedure to make sure there are no additional precancerous changes.\nSome women treated with loop electrosurgical excision or conization for dysplasia require additional treatment. A hysterectomy—which is the removal of the cervix and uterus—may be recommended.\nMeet Our Doctors\nPerlmutter Cancer Center specialists provide care and support during treatment.Browse Doctors |
Liposuction is a surgical procedure that directly removes stubborn pockets of fat resistant to diet and exercise. Liposuction can also be used to selectively remove fat in the pectoral and abdominal regions to mimic the appearance of a well-defined masculine chest or set of abs.\nThrough liposuction, patients can enjoy many benefits, including:\n• Reduce love handles at the sides of the midsection\n• Tighten the stomach after pregnancy or weight gain\n• Sculpt the arms and thighs for a slimmer profile\n• Shape the abdomen to resemble sculpted abs.\n• Contour the chin and jawline\n• Sculpt a tighter, more masculine chest\nAt Millennial Plastic Surgery, Dr. David Shokrian offers body contouring through liposuction and lipo contouring procedures. If you have failed to receive the results you want from diet and exercise, then liposuction may be the resource you need to finally achieve your dream body.\nLiposuction is completed under either general anesthesia or local anesthesia with intravenous sedation. After the patient has been numbed, the surgeon will make several small nicks in various locations in the targeted areas. These nicks are small and allow for the insertion of a cannula, a thin metal tube. The cannula is drawn in a back-and-forth motion below the skin to loosen the fat cells and suction them out of the body.\nAfter the targeted fat has been successfully eliminated, the nicks will be sutured shut. The surgery lasts between one and four hours depending on how many areas are targeted during the procedure and how much fat is removed.\nRecovery and Results\nRecovering from a liposuction procedure takes several weeks. Patients can return to work within one week, although they will need to wait about two or three weeks before returning to normal levels of exercise. Results from any liposuction procedure are immediately visible, although swelling will temporarily distort the new contours.\nCommon side effects include bruising, swelling, numbness and mild pain in the targeted areas. Most side effects diminish within the first couple of weeks of recovery, although swelling can take up to six months before subsiding fully. Compression garments will be placed over the targeted areas to help reduce swelling and facilitate healing. Regular use of compression over the first several weeks will promote quicker recovery and faster results.\nDr. Shokrian gives all liposuction and body contouring patients specific instructions on what they can expect following surgery and how they can best maximize their recovery for optimal results.\nAbdominal and Pectoral Etching Procedure\nAbdominal and pectoral etching is performed under general anesthesia or local anesthesia with sedation. Prior to the procedure, the surgeon will mark out the ideal contours on the patient’s chest or abdomen to use as guidelines during the lipo contouring procedure. A few small nicks are then made in the skin in specific locations to allow for precise removal of the targeted fat.\nDuring chest etching, fat deposits are removed from the lower and outer edges of the pectoral muscle, providing the chest with a more pronounced and masculine shape. During abdominal etching, fat is targeted along the natural lines of the underlying muscles to give them a more well-defined appearance. In both cases, a modest amount of fat is left over the muscles to contrast the areas where the fat deposits have been removed, creating the appearance of raised and developed abs or pectorals. The procedure lasts between one and two hours.\n360-degree liposuction is a more comprehensive procedure that combines liposuction of the entire midsection to achieve an overall curvier, contoured figure from every angle.\nWhile liposuction is usually done on one area at a time, 360-degree liposuction targets multiple regions of the midsection where stubborn fat may be a problem. This can help create a more balanced, proportional appearance.\nQ&A with Dr.Shokrian\nWho is a good candidate for liposuction?\nOur preferred candidates for liposuction are patients are within 25 pounds of their ideal body weight, do not smoke, have realistic expectations about the procedure and have already tried diet and exercise to achieve their desired results with limited or no success. Liposuction and lipo contouring are not meant to replace a healthy lifestyle. These procedures should be used as a last resort option for patients who are struggling to shed stubborn pockets of fat resistant to diet and exercise. If you are unsure whether you are a good candidate for one of our liposuction procedures, then schedule a consultation so we can give you an in-person evaluation.\nCan multiple body contouring procedures be completed simultaneously?\nYes, we can perform multiple procedures during the same surgery. Let us know if you have more than one area that you would like targeted so we may prepare a comprehensive body contouring strategy that addresses all of your concerns.\nWill I lose a lot of weight after a liposuction procedure?\nLiposuction is fat loss surgery, not weight loss surgery. You will notice a marked improvement in your body’s shape and contours, but not much difference on the scale. Some patients may experience a small decrease in their body weight, but that is not the goal or intention of liposuction procedures.\nHow long do results last?\nResults from liposuction and lipo contouring are lifelong. The fat that we remove is gone for good, although you are not immune from gaining more weight through an unhealthy lifestyle. Patients interested in liposuction or lipo contouring should be able to maintain a stable body weight following their procedure to ensure they do not affect their new contours.\nWill I have loose skin after liposuction?\nIdeal candidates for liposuction should have tight, elastic skin. Patients who already have loose or aging skin that have lost its elasticity may require a different fat loss method, as liposuction can exacerbate the issue. We will perform an in-person evaluation prior to the procedure to verify that your skin has enough elasticity to make you a good candidate. For patients who are good candidates for liposuction, the skin will naturally adjust and conform to the new contours in the targeted area. |
When lifestyle modifications, medication, physical therapy, or injections have not been successful in treating a spine condition, surgery may be recommended. Specialists using minimally invasive surgical techniques and state-of-the-art technology can reduce pain, increase mobility, or improve overall quality of life for people with spine conditions that have not responded to conservative treatment.\nNever Miss a Beat!\nSubscribe to Our HealthBeat Newsletter!\nThank you for subscribing!\nYou are already subscribed.\nSorry, an error occurred. Please try again later.\nGet Healthy Tips Sent to Your Phone!\nWhat Is Minimally Invasive Spine Surgery?\nUsing advanced technology and highly specialized tools to assist with visualization and control, surgeons are able to perform minimally invasive spine surgery using smaller incisions and tubular retractors without disrupting surrounding soft tissues. This comes with a range of benefits for patients.\n“It minimizes collateral damage to the tissue and achieves the same goals of an open spine surgery procedure with less damage,” says Vivek Sharma, MD, an orthopaedic surgeon at UPMC Somerset, UPMC Montefiore, and the UPMC Outpatient Center in Bethel Park. “The benefits are shorter hospital stays, less blood loss, and shorter anesthesia times so patients are able to go home faster and get back to their routine activities.”\nPeople who undergo minimally invasive spine surgery may have a reduced risk of developing scar tissue and adjacent segment disease, Dr. Sharma adds. As a result, they’re also less likely to need a repeat surgery and will experience less postoperative pain.\n“Patients should expect to have a faster recovery in the hospital,” Dr. Sharma says. “They usually are able to be up and around the same day of surgery with physical therapy. “It’s typically a one-night stay in the hospital and a return to activity levels maybe four to six weeks after.”\nSpine surgeons at UPMC Orthopaedic Care are committed to using minimally invasive methods to treat all kinds of spine, neck, and back conditions, including:\n- Herniated discs.\n- Spinal stenosis.\n- Spinal compression fractures.\n- Spinal deformities, including scoliosis.\nBenefits and Risks of Minimally Invasive Spine Surgery\nMinimally invasive spine surgery, like most surgeries, comes with a range of possible risks and rewards.\nSome of the benefits of minimally invasive spine surgery compared to traditional or open spine surgery include:\n- Less time on anesthesia.\n- Less soft tissue damage and blood loss.\n- Reduced risk of infection.\n- Less pain and medication after surgery.\n- Less scarring.\n- Shorter hospital stays and recovery time.\nGeneral risks associated with any spine surgery include:\n- Postsurgical pain usually treated with medication.\n- Adverse reactions to anesthesia.\n- Infection at the procedure site.\n- Damage to surrounding tissue.\n- Injury to the nerves or spinal cord.\nWhile many people may be candidates for minimally invasive surgery, some conditions require traditional spine surgery instead. Talk to your doctor about what’s best for you.\nVisit UPMC Orthopaedic Care to learn more.\nAbout UPMC Orthopaedic Care\nWhen you are dealing with bone, muscle, or joint pain, it can affect your daily life. UPMC Orthopaedic Care can help. As a national leader in advanced orthopaedic care, we diagnose and treat a full range of musculoskeletal disorders, from the acute and chronic to the common and complex. We provide access to UPMC’s vast network of support services for both surgical and nonsurgical treatments and a full continuum of care. Our multidisciplinary team of experts will work with you to develop the treatment plan that works best for you. Our care team uses the most innovative tools and techniques to provide better outcomes. We also are leaders in research and clinical trials, striving to find better ways to provide our patients care. With locations throughout our communities, you can find a provider near you. |
Washington Urology performs a wide variety of in-office procedures to treat and diagnose many prominent Urological diagnoses and symptoms.\nOur In-office Services include:\nWhat is TUMT?\nTransurethral microwave therapy (TUMT), also known as Cooled ThermoTherapy™ For BPH, is an outpatient procedure to treat urinary symptoms caused by an enlarged prostate. A small microwave antenna is inserted through the tip of your penis into the tube that carries urine from your bladder (urethra). The antenna extends until it reaches the area of the urethra surrounded by the prostate. The microwave energy that heats and destroys excess prostate tissue blocking urine\nWhat is Rezūm?\nRezūm is a treatment for BPH that uses the stored thermal energy in water vapor (steam) to treat the extra prostate tissue that is causing BPH symptoms. Inside a hand-held device, radiofrequency energy is applied to a few drops of water to create vapor (steam). The water vapor is injected into the prostate tissue that is blocking the flow of urine from the bladder, which kills the tissue, and over time your body will absorb the treated tissue through its natural healing response.\nWhat is the UroLift System?\nThe UroLift System uses a revolutionary approach to treating BPH that lifts and holds the enlarged prostate tissue so it no longer blocks the urethra. It is the only BPH treatment performed by a urologist that does not require heating, cutting, or removal of the prostate tissue. The procedure is typically performed using local anesthesia in a physician’s office or ambulatory surgery center. Patients typically return home the same day without a catheter.\nA Cystoscopy (sis-TOS-kuh-pee) is a procedure that is performed to examine the lining of your bladder and your urethera (the tube that carries urine out of your body from your Kidneys). A hollow tube (cystoscope) equipped with a lens is inserted into your urethra and slowly advanced into your bladder.\nThe Cystoscopy procedure is used to diagnose, monitor and treat conditions affecting the bladder and urethra. The entire procedure is done in our office and with the aid of local anesthesia so you wont feel a thing.\nThe entire process can be completed in 15-20 minutes.\nThe Transrectal ultrasound guided biopsy (also known as the TRUS biopsy) is a procedure used by doctors to test and diagnose the presence of prostate cancer in male patients. During this process the Doctor will take samples of tissue from the prostate gland to be tested in a pathology lab for the presence of cancer.\nThe Doctor will injects a local anesthetic into the rectum, to completely numb the area. Once it is completely numb, an ultrasound probe is inserted to accurately measure and exam the target area. Once ready, the samples of prostate tissue are taken by a fine needle that is inserted along the ultrasound probe and into the prostate gland. Once the samples are taken they are sent for analysis which usually takes 7 - 10 days for a full report to be returned.\nThe entire process can be completed in 20-30 minutes. |
* PureLipo – a minimally invasive solution to Liposuction\n*Aesthetic Body Sculpture Clinic & Center for Anti-Aging offers minimally invasive “Liposuction” and utilizes local anesthesia in their private boutique office suites. Doctor Slater is a PureLipo Provider and uses innovative techniques to shorten healing time and maximize results.\n*What is Tumescent Liposuction? What is PureLipo\nTumescent liposuction – PureLipo has been one of the biggest advances in body contouring over the last decade. The benefit of this form of lipo is that it does not require excessive incisions and it only requires local anesthesia. Tumescent liposuction is a technique that provides Lidocaine to large volumes of subcutaneous fat and thus permits liposuction without pain and minimal downtime. Be aware that in many U.S. states, physicians are not required to have the training to perform this cosmetic surgery procedure. Dr. Monte Slater is a double board-certified physician that has been performing this type of procedure for almost a decade.\n*Are You a Good Fit for PureLipo – Liposuction?\nNow that you have a general idea of our liposuction process, the next thing that you want to ask yourself is whether liposuction is for you. Here are some factors to consider when asking yourself this question. Aesthetic Body Sculpture Clinic & Center for Anti-Aging has locations in Atlanta Georgia and Warner Robins Georgia. We suggest that a good fit for liposuction is a person who meets the following criteria.\n- That you are slightly above average weight\n- That you are in good health\n- That you have pockets of adipose tissue that are resistant to diet and exercise\n*Aesthetic Body Sculpture Clinic offers PureLipo in two locations\nDr. Monte Slater and team decided to offer PureLipo (a minimally invasive alternative to traditional liposuction) because results can be better or the same as traditional methods; with less downtime or trauma to the body. No general anesthesia is needed for PureLipoo, which is a huge benefit for the patient’s health and their pocketbook. PureLipo utilizes “Tumescent liposuction technique, ” and most patients can resume daily activities within a few days. This procedure is often combined with fat transfer, such as the Brazilian Butt Lift, which is ideally done at the same time. Because there is no general anesthesia involved the recovery time and healing time is shortened. Soreness that feels much like after a hard ab workout is common for up to one week. Most of our patients are back to work two days later. Best results are usually seen within three months to a year. * Results are not guaranteed and vary from patient to patient.\nPureLipo is not a traditional surgical procedure, but rather the removal of unwanted adipose tissue in the least invasive way as possible. If dieting has just not given you the body, you always imagined, and you’ve thought about having liposuction, then talk to us about your options.\nPureLipo uses an innovative technique that sculpts and contours your body into a more sleek and desirable form. It removes unwanted areas of excess adipose tissue between the skin and muscle using a small cannula. This is achieved without the side effects of intense recovery issues commonly caused by liposuction.\n*Possible Benefits of PureLipo\n- Cab recreate youthful and contoured physique without ridges, dimpling skin, or damage to the dermis\n- Minimally invasive in-office procedure\n- Performed safely under local tumescent anesthesia\n- Less traumatic than traditional liposuction\n- Greater skin tightening (\n- Can be combined with ThermiTight)\n- Minimal bruising and downtime\nDisclosure: *Results are not guaranteed and vary from patient to patient. All information on this website is for informational purposes only. |
Dr. Rosemarie Toussaint was supposed to remove a patient's appendix during a 2007 surgery at Florida Hospital Orlando.\nBut a subsequent CT scan showed it was still inside the 41-year-old woman. Toussaint had taken out fatty tissue, and another doctor had to operate a few days later to remove the appendix.\nOn Friday, the Florida Board of Medicine fined Toussaint $5,000 and ordered her to do 50 hours of community service for the botched procedure.\nThe board did not punish the doctor for initially leaving a sponge inside the woman's body. Board member Laurie K. Davies from Gainesville said the mistake was discovered and corrected after a sponge count while the patient was still on the operating table. Toussaint had done exactly what physicians are supposed to do, said Davies, an anesthesiologist.\nToussaint no longer works at Florida Hospital. Her attorney said the hospital paid the patient $100,000 for the mishap. Florida Hospital would not comment on the case.\nPreviously, Toussaint had worked as a transplant surgeon in Washington and an assistant professor at Howard University. She told the board she intends to work as a physician for the Army.\n"I made a severe mistake. If I had to do it over again, I would not have stayed up all night" and attempted the operation, said Toussaint, who had done only one other appendectomy in her career.\nHer case is among the dozens under board scrutiny during a two-day meeting that ends today in Orlando. The board holds disciplinary hearings in various cities across the state throughout the year. |
(RxWiki News) Pediatricians and pediatric surgeons never recommend surgery requiring general anesthesia for children unless absolutely necessary. New data confirms this advice.\nA recent Mayo Clinic Study reported that infants and toddlers who were exposed to general anesthesia more than once during their young lives experienced a higher rate of learning disabilities and learning difficulties than infants and toddlers not exposed to general anesthesia.\n"There is a link between ADHD and general anesthesia."\nRandall Flick, M.D., M.P.H., Associate Professor of Anesthesiology and Pediatrics at the Mayo Clinic presented his findings which concluded that multiple exposures to anesthesia before the age of 2 years are a significant risk factor for the development of Attention Deficit Hyperactivity Disorder(ADHD).\nFlick reported a single exposure to anesthesia did not appear to be linked with an increase of risk factor for ADHD.\nFlick also said that this most recent work suggests that even when adjusted for ADHD within the population, there still appears to be an effect with multiple exposures to anesthesia before the age of two. Interestingly, the age of exposure, the cumulative length of exposure, and the number of anesthetics are critically important considerations.\nChildren younger than 4 years who have had two exposures to anesthesia for at least 120 min or longer each time are at least two times more likely to develop ADHD.\nMerle Paule, Ph.D., Director of the Division of Neurotoxicology at the National Center for Toxicological Research and SmartTots Scientific Advisory Board member points out that studies in nonhuman primates, including rhesus monkeys, have also raised serious concerns about the effects of anesthesia on the developing nonhuman primate brain.\nHis recent findings demonstrate that a single 24-hour episode of ketamine anesthesia results in very long-lasting deficits in brain function in primates. Paule commented that these findings support the notion that general anesthesia during critical periods of brain development may cause functional deficits.\nFlick applauded the efforts of the researchers at the National Center for Toxicological Research and calls them extremely important.\nGreg Stratmann, M.D., Ph.D., Associate Professor of Clinical Anesthesia and Perioperative Care at the University of California, San Francisco, discussed whether there is an appropriate treatment for anesthesia-induced cognitive decline.\nHis findings support that quickly using the brain’s natural ability and plasticity to adapt to functional demands can modify the course of anesthesia-induced cognitive decline in rats. His group at the University of California, San Francisco found that in the rat model, the ill effects of anesthesia on brain function which are apparent later in life, can be overcome through environmental enrichment even when started within three weeks after exposure to general anesthesia.\nPanel moderator Dr. Vesna Jevtovic-Todorovic, M.D., Ph.D., M.B.A., Professor of Anesthesiology and Neuroscience at the University of Virginia Health System and SmartTots Scientific Advisory Board member wants to impress upon people that there is a very reliable link between the animal and human data regarding anesthesia exposure that is rapidly emerging. |
15 month old Wilson Irael Mendez has a congenital heart defect known as Tetralogy of Fallot and has stayed for free at the hospital Dr. Aldo Castañeda runs in Guatemala City for a month. Wilson needs to get stronger before the surgery. Wilson’s sister is keeping an eye out on him on Sunday, Feb 28, 2011.\nAccording to the Aldo Castañeda Foundation’s website, at the start of the program in 1997, Aldo was able to bring together the only 3 pediatric cardiologists practicing in Guatemala. This group has now grown to 8 cardiologists. Castañeda has also promoted the professional training of anesthesiologists, nurses, and other technical staff.\nWith the help of the Aldo Castañeda Foundation, the Pediatric Cardiac Surgical Unit of Guatemala has expanded to 2 exclusive operating rooms, an intensive care unit with 6 beds, a 4-bed step-down unit, and an 18-bed general ward. In addition, he has provided the infrastructure for a new laboratory for cardiac catheterization, and 2 laboratories for echocardiography.\nSince 1997, the staff working in the outpatient clinic has seen more than 20,000 patients, and the surgeons have performed operations on about 2000 children with congenital cardiac disease.\nPhoto by Marcin Szczepanski, Multimedia Content Producer/CoE’s Communications and Marketing |
Dental Implants: After Surgery\nYou just had dental implant surgery. Read on to learn what to expect after surgery and how to recover at home. Be sure to keep all follow-up appointments with your surgeon and dentist. Also, follow all mouth care instructions.\nHelp the healing process. Keep your teeth and gums clean.After Surgery\nWhen your surgery is over, you may rest awhile. But you can go home as soon as you feel able. Be aware that a certain amount of swelling and minor bleeding is normal. To speed your recovery, be sure to follow your surgeon's instructions. You may be told to:\nDrink only clear liquids for the rest of the day.\nTake pain medications and antibiotics.\nAvoid putting pressure on your jaw.\nEat soft foods for the first few days as your mouth begins to heal.\nAvoid wearing your temporary prosthesis or denture for a certain amount of time.\nTaking Care of Your Mouth\nMuch of the healing process depends on keeping your teeth and gums clean. If you don't take care of your mouth, you may get an infection. This could cause the implants to fail. For best results:\nUse a soft toothbrush to clean your teeth and gums after every meal.\nClean the areas near your incisions. But do not brush the incisions themselves.\nUse an antiseptic rinse if prescribed.\nIt often takes a few months for jawbone to firmly attach to implants. During that time, you'll have several follow-up visits with your surgeon. This is to see how well your jaw is healing. If you wear a denture, you may also visit your restorative dentist. He or she may put a new lining in your denture for greater comfort.\nWhen to Call Your Surgeon\nCall your surgeon if you have any of the following:\nA large amount of swelling under the tongue, or around the face and neck\nBleeding that won't stop\nPain in the jaws, mouth, or sinuses that isn't relieved by prescribed medication\nA fever over 100.4ºF\nNumbness that does not go away after the anesthesia wears off |
General & GI Surgery\nApollo Hospitals, Indore is an advanced centre for General & GI Surgery which boasts of state of the art facilities combined with excellent surgeons who have been trained in some of the best institutions across the world.\n- Advanced tertiary care surgeries done at Apollo Hospitals is supported by many structures which include Operation theatre with laminar flow ventilation, infection control guidelines, latest technology of surgical, anesthetic and safety equipment.\n- Anesthesia department with dedicated full time team available round the clock. Modern and latest anesthesia machines with back up.\n- Intensive Care Unit with round the clock specialist care in Respiratory, Cardiac, Gastro, Critical Care, Neuro and Nephrology departments.\n- On site blood bank with reliability of blood products vis a vie infections, expiry and other qualitative parameters.\n- Emergency, Day care and OPD surgical facilities.\n- Supporting surgical specialties like Plastic and reconstructive surgery, orthopedics, vascular, onco, and thoracic surgery. |
Which animal do you think weighs more?\nGus, the black bear\nLightning, the donkey\nPost your guesses in the comment section!\nIt is with a heavy heart that I report the loss of our opossum Galileo. Recently he started to show signs of heavy labored breathing and his appetite had decreased greatly. We took him to the vet for x-rays on Tuesday October 15, 2013 and found that he had fluid in his chest cavity that was preventing him from breathing properly. It was determined that he needed to be euthanized. The final results of the necropsy are still pending, but the gross necropsy showed fluid around his heart leading to cardiomyopathy. For the first time since I started working here at the museum we will be without an opossum. I don’t know what I will do without one of these amazing animals to greet me every morning during AM treatments. He will be greatly missed. Below are some pictures of Galileo hanging out in the department.\nGalileo has been the subject of several previous blog posts too.\nGodzilla was with us for a long time. When he first came, I would tend to have him resting on me when I sat in the office where he chilled and just looked around.\nWe noticed Godzilla not acting his usual self and his appetite declined. He was taken off program usage and allowed to get rest and the vet care he needed. Godzilla never made a recovery and the best thing to do was euthanize him.\nI felt very sad, but I knew Godzilla had great care at the museum and he was a popular program animal.\nOctober is wolf physical month. This is the one time of year we get our hands on the wolves and check them out. We were particularly looking forward to getting the male, 1414, on the table. He is huge (almost 80 pounds) and he came to us with a growth on the side of his body that we wanted to look at and remove.\nSince 1414 arrived in November 2012, this was our first experience with him for a physical. We learned he is a great patient once he gets on the table. However, he did not “go to sleep” on the same timeline that other wolves have when given their pre-sedation medicine. Typically, while in the crate, we inject some medicine to make the wolves go to sleep. 10-20 minutes later, we can safely muzzle them and move them to the treatment table and do all we need to do.\n1414 took over 70 minutes to get somewhat sleepy. Long story short, we finally got him to the table. He is so big he basically filled up the table.\nBasically, he was in great shape except for the growth on the side of his body. Dr. Vanderford was able to remove it, although it took awhile. The wolf will spend a few days in a holding cage to limit his movement, but all seems to be okay.\nWe’ll catch the female up another day and do her physical so we should have more photos to show you soon.\nCynthia needed a couple bad teeth removed. She did great under sedation- staying asleep when we wanted and waking when we wanted.\nHenry, on the other hand, was a different story. First of all, it’s difficult to hold him- at least it is not safe to hold him as you never know when he will turn on you. So in order to sedate him, we place him in a box and pump anesthesia in.\nWe’re not sure exactly why, but sedation doesn’t seem to work on Henry like it should on paper. We upped his meds this year and still, he was never fully sedated. This made a complete physical a bit tricky. Next year we’ll have to try new drugs on him.\nBoth critters are fine. Next week the wolves will have their physicals. Katy is aching to get her hands on the male so it should be an exciting day.\nWe run weekly water quality tests on all of our fish, alligator and turtle tanks in the Animal Department. We monitor the waters’ pH and the levels of Ammonia and Nitrates. This is important because aquatic animals are often very sensitive to chemical changes in the water they live in and drink; more so than their terrestrial relatives.\n10 tanks plus 1 “control” tank (filtered water, to make sure the tests are working properly)\nThe end result: 33 test tubes of some very pretty colors!\nThis week the red ruffed lemurs got their annual physicals.\nAll three girls- Cynthia, Iris, and Jethys- did great. Each one, from pre-sedation to reversal took 37 minutes. We’re waiting for blood work to come back, but everyone’s initial findings seemed to be okay. Our girls are getting old so I always have concerns about what the tests will show. Cynthia is almost 32 years old. The Duke lemur center only has one red ruffed lemur older than her.\nKaty was running a rectal thermometer and an ear thermometer to see if the temperatures were the same (which they were).\nHopefully all the blood work comes back okay! In September, we’ll do physicals on the ring tailed lemurs. (More pictures then.\nDr. English, a board certified veterinary ophthalmologist, was by last Thursday to check on a bunch of the animals with eye issues. He and his team saw 10 of our animals: 2 lemurs, the donkey, a rabbit, the hawk, 2 screech owls, 2 barred owls, and a salamander. We’re so thankful that Dr. English comes and checks on the animals who need his help. He tracks any changes in patients’ eyes from previous visits and checks out new animals who we have concerns about. We’ve also taken owls to him for surgery: all of which he graciously and generously donates.\nUsually I post photos of the owls and Dr. English, but this year the best photos I took were of the largest and smallest patient:\nSo Baby, our spotted salamander, is typically teased by Dr. English for having a “stupid” name (she arrived over 15 years ago as a “baby”) and being “fat”. This year, similar to last year, Dr. English thought Baby’s eyes looked better and that she had trimmed down in weight. Below, everyone is laughing because I went to Baby’s health record and learned the past two years she had gained weight! (It must all be muscle).\nKeepers are enjoying the new scale in the farmyard, and so are the critters. Here’s some video of Max and the alpacas getting weighed.\nMax’s training focused on keeping him calm as he walked from his enclosure to the scale – he tends to get excited when he goes for a walk. And 1600 pounds of excited steer can be difficult to manage. But look how calm he is!\nThe alpaca training is more focused on helping them tolerate the brief separation from the rest of the alpacas as they walk to the scale. Its helpful for them to learn to be separated for short periods of time so they can more easily tolerate vet visits and shearings in the future. Lots of good clicking and treating going on in the farmyard by keepers Kent, Sarah and Jill! |
One of the most disturbing surgical complications is also frighteningly common: As many as 1 in every 500 patients wakes up on the operating table and is at least dimly aware of what’s happening, according to a new survey of doctors.\nThe findings, published in the British Journal of Anesthesia, noted most patients say they are not distressed by the experience because they feel no pain and are not fully awake or aware of the circumstances.\nBut lead researcher Jaideep Pandit, an Oxford University anesthetist, said it happens far more frequently than past research has suggested. One reason: Only 1 in 15,000 patients who can remember at least some aspects of an operation mentions the experience to the doctor afterwards.\nThe experiences recalled by the patients: Vague awareness of conversations among the staff in the operating room and even the knife on their skin (but no pain).\n“The difference between the incidence of one in 500 and one in 15,000 suggests that even in the rare cases where patients are experiencing awareness, in most cases, the sensation is a ‘neutral’ one,” Pandit told the Independent on Sunday.\n“What we are possibly seeing is a third state of consciousness — dysanaesthesia — in which the patient is certainly aware of events but not concerned by this knowledge, especially as they are not in pain.”\nHe added that problems in the way the anesthetic is given or even by genetic variation among surgical patients may cause some to react differently to the drugs.\nFor the survey, Pandit polled more than 7,100 anesthesiologists at 329 British hospitals. |
The French School of Proctology assumes that any anal or perianal abscess is related to an anal fistula and therefore requires treatment at the risk of recurrence of the abscess. The Anglo-Saxons, on the other hand, recommend a simple incision in case of a first abscess, without taking care of the possible fistula, on the grounds that more than 60% of patients will not have a recurrence of their abscess. In addition, predictive factors of abscess recurrence have been reported such as female gender, age over 40 years, however, contradicted by other studies. High BMI, corticosteroid use, Crohn's disease are other predictive factors of recurrence while diabetes mellitus or antibiotic therapy during the days following the incision were considered as "protective". The objective of this study was to evaluate our experience in the hospital with essentially a description of the evolution of the patients in the 2 years following the incision of the abscess in consultation. The main objective is to describe the evolution of patients, within 2 years, who consulted our center for an anal or perianal abscess treated by a simple skin incision under local anesthesia in consultation and/or whose fistula was not found during the examination under anesthesia in the operating room.\nFull Title of Study: “”ABCES AFTER INCISION: RECURRENCE OR NOT?””\n- Study Type: Observational\n- Study Design\n- Time Perspective: Retrospective\n- Study Primary Completion Date: February 10, 2022\nClinical Trial Outcome Measures\n- Evolution of the patients, within 2 years\n- Time Frame: Year 2\n- This outcome corresponds to the rate of occurrence of at least one new abscess, within 2 years, in patients who were treated by a simple skin incision in consultation and/or whose fistula was not found during examination under anesthesia in the operating room.\n- Predictive factors for recurrence of abscesses\n- Time Frame: Year 2\n- This outcome corresponds to the Predictive factors for the occurrence of at least one new abscess, within 2 years, in patients who consulted our center for an anal or perianal abscess treated by a simple skin incision in consultation and/or whose fistula was not found during the examination under anesthesia in the operating room.\n- Patient care\n- Time Frame: Year 2\n- This outcome corresponds to the Description of the management (imaging, surgical techniques, number of surgical procedures) of patients who were operated on under anesthesia in the operating room and whose fistula was found.\n- Cure rate\n- Time Frame: Year 2\n- This outcome corresponds to the Healing and anal incontinence rates of patients who were operated on under anesthesia in the operating room and whose fistula was found.\nParticipating in This Clinical Trial\n- Patient whose age ≥ 18 years – Patient who visited between January 1, 2019 and December 31, 2019 for an anal or perianal abscess – Patient who had a skin incision of a first anal margin or buttock abscess and/or whose fistula was not found during examination under anesthesia in the operating room – French speaking patient Exclusion Criteria:\n- Patient with pilonidal abscess – Patient with an intramural abscess – Patient with a history of anal margin or buttock abscess and/or anal fistula – Patient with a history of proctologic surgery – Patient with an abscess whose skin incision under local anesthesia has failed – Patient under guardianship or curatorship – Patient deprived of liberty – Patient under court protection – Patient objecting to the use of his or her data for this research\nGender Eligibility: All\nMinimum Age: 18 Years\nMaximum Age: N/A\nAre Healthy Volunteers Accepted: No\n- Lead Sponsor\n- Groupe Hospitalier Paris Saint Joseph\n- Provider of Information About this Clinical Study\n- Overall Official(s)\n- Amine ALAM, Principal Investigator, Groupe Hospitalier Paris Saint Joseph\n- Overall Contact(s)\n- Amine ALAM, MD, 144128694, [email protected]\nQuah HM, Tang CL, Eu KW, Chan SY, Samuel M. Meta-analysis of randomized clinical trials comparing drainage alone vs primary sphincter-cutting procedures for anorectal abscess-fistula. Int J Colorectal Dis. 2006 Sep;21(6):602-9. Epub 2005 Nov 30. Review.\nMalik AI, Nelson RL, Tou S. Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD006827. doi: 10.1002/14651858.CD006827.pub2. Review.\nSahnan K, Askari A, Adegbola SO, Tozer PJ, Phillips RKS, Hart A, Faiz OD. Natural history of anorectal sepsis. Br J Surg. 2017 Dec;104(13):1857-1865. doi: 10.1002/bjs.10614. Epub 2017 Aug 31.\nSahnan K, Askari A, Adegbola SO, Warusavitarne J, Lung PFC, Hart A, Faiz O, Phillips RKS, Tozer P. Persistent Fistula After Anorectal Abscess Drainage: Local Experience of 11 Years. Dis Colon Rectum. 2019 Mar;62(3):327-332. doi: 10.1097/DCR.0000000000001271.\nSho S, Dawes AJ, Chen FC, Russell MM, Kwaan MR. Operative Incision and Drainage for Perirectal Abscesses: What Are Risk Factors for Prolonged Length of Stay, Reoperation, and Readmission? Dis Colon Rectum. 2020 Aug;63(8):1127-1133. doi: 10.1097/DCR.0000000000001653.\nLohsiriwat V, Yodying H, Lohsiriwat D. Incidence and factors influencing the development of fistula-in-ano after incision and drainage of perianal abscesses. J Med Assoc Thai. 2010 Jan;93(1):61-5.\nHe Z, Du J, Wu K, Chen J, Wu B, Yang J, Xu Z, Fu Z, Pan L, Wen K, Wang X. Formation rate of secondary anal fistula after incision and drainage of perianal Sepsis and analysis of risk factors. BMC Surg. 2020 May 6;20(1):94. doi: 10.1186/s12893-020-00762-3.\nMocanu V, Dang JT, Ladak F, Tian C, Wang H, Birch DW, Karmali S. Antibiotic use in prevention of anal fistulas following incision and drainage of anorectal abscesses: A systematic review and meta-analysis. Am J Surg. 2019 May;217(5):910-917. doi: 10.1016/j.amjsurg.2019.01.015. Epub 2019 Jan 31.\nClinical trials entries are delivered from the US National Institutes of Health and are not reviewed separately by this site. Please see the identifier information above for retrieving further details from the government database. |
What are the risks of pediatric anesthesia? What should you do if your 2-year-old son or daughter requires surgery and anesthesia? Is the anesthetic risky? Should you consent to proceed? Should you wait until he or she is 3 years old?\nThe answer to all these questions is: “It depends.”\nLet’s look at recommendations as they exist in 2018.\nOn December 14, 2016, the United States Food and Drug Administration (FDA) issued a Drug Safety Communication Drug Safety Communication Warning that general anesthesia and sedation drugs used in children less than 3 years of age who were undergoing anesthesia for more than 3 hours, or repeated use of anesthetics, “may affect the development of children’s brains.”\nThe text of this December 2016 FDA statement reads:\n“The U.S. Food and Drug Administration (FDA) is warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains. . . . Consistent with animal studies, recent human studies suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning. However, further research is needed to fully characterize how early life anesthetic exposure affects children’s brain development. . . . Health care professionals should balance the benefits of appropriate anesthesia in young children and pregnant women against the potential risks, especially for procedures that may last longer than 3 hours or if multiple procedures are required in children under 3 years. Discuss with parents, caregivers, and pregnant women the benefits, risks, and appropriate timing of surgery or procedures requiring anesthetic and sedation drugs.”\nThis FDA warning resulted in a labeling change for these 11 common general anesthetics drugs and sedative agents:\nOf these, sevoflurane and propofol are mainstay drugs used in pediatric anesthetics. Anesthesia for infants and children is most frequently initiated with an inhalation induction of sevoflurane vapor, because most infants and children do not have an IV line prior to induction. The primary intravenous hypnotic drug for children is propofol.\nBecause of this FDA statement, the propofol package insert warning label now reads:\n“Pediatric Use; ANIMAL TOXICOLOGY AND/OR PHARMACOLOGY). Some published studies in children suggest that similar deficits may occur after repeated or prolonged exposures to anesthetic agents early in life and may result in adverse cognitive or behavioral effects. These studies have substantial limitations, and it is not clear if the observed effects are due to the anesthetic/sedation drug administration or other factors such as the surgery or underlying illness. Anesthetic and sedation drugs are a necessary part of the care of children needing surgery, other procedures, or tests that cannot be delayed, and no specific medications have been shown to be safer than any other. Decisions regarding the timing of any elective procedures requiring anesthesia should take into consideration the benefits of the procedure weighed against the potential risks.”\nFor sevoflurane, the package insert warning label now reads:\n“Repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in neonates, infants, and children younger than 3 years, including in utero exposure during the third trimester, may have negative effects on brain development. Consider the benefits of appropriate anesthesia in young children against the potential risks, especially for procedures that may last more than 3 hours or if multiple procedures are required during the first 3 years of life. It may be appropriate to delay certain procedures if doing so will not jeopardize the health of the child. No specific anesthetic or sedation drug has been shown to be safer than another. Human studies suggest that a single short exposure to a general anesthetic in young pediatric patients is unlikely to have negative effects on behavior and learning; however, further research is needed to fully characterize how anesthetic exposure affects brain development.”\nThere are no real alternatives to these 11 general anesthetic drugs regarding pediatric anesthesia. Dexmedetomidine and narcotics are not on the FDA list, but dexmedetomidine and narcotics are not sufficient to provide general anesthesia by themselves.\nWhat does this mean to physicians and parents regarding anesthetics on children under the age of 3 years?\nThe most common indications for infants and toddlers to be placed under general anesthesia are for short procedures such as ear tubes for chronic ear infections, hernia repair, or removal of the adenoids. At times infants or toddlers require general anesthesia or sedation so they will stay still during a procedure, such as when they need an MRI or a CT scan.\nThere are an estimated 1.5 -2 million children under 3 years of age who undergo anesthesia annually in the United States. Prior to the FDA statement, Texas Children’s Hospital performed more than 43,000 cases each year. Approximately 13,000 of these cases involved patients under 3 years of age, and more than 11,000 of these anesthetics lasted more than 3 hours. Nearly all of the prolonged anesthetics were for serious congenital conditions for which treatment could not be delayed until the patient reached 3 years of age. Because of the FDA warning, the hospital adopted the warning’s recommendation that a discussion occur among parents, surgeons and other physicians, and anesthesiologists regarding the duration of anesthesia, any plan for multiple general anesthetics for multiple procedures, and the possibility that the procedure could be delayed until after 3 years of age.1\nDr. Constance Houck, chair of the American Academy of Pediatrics’ Surgical Advisory Panel and an Associate Professor of Anesthesia at Harvard Medical School said, “two recently published studies examining short-term anesthesia exposure for hernia repair did not show neurobehavioral differences between those who had received a general anesthetic and those who had not. . . . Most surgeries are less than one hour, but some infants and children with significant congenital defects require more prolonged surgery. . . Examples would include such defects as cleft lip and palate and malformations of the urinary or gastrointestinal tract.” Postponing major reconstructive surgery until children are older is generally not an option. “There is no evidence to suggest that short procedures should be postponed, but parents should always discuss with their child’s pediatrician and surgeon the risks and benefits of timing of procedures.”2\nThe American Society of Anesthesiologists response to the FDA statement read: “the accumulated human data suggest that one brief anesthetic is not associated with cognitive or behavioral abnormalities in children. Most but not all studies in children do however suggest an association between repeated and or prolonged exposure and subsequent difficulties with learning or behavior.”3\nIn addition to the FDA drug recommendations, there are well documented surgical concerns with operating on children under age 3. For example, the recommendations for pediatric tonsillectomy are to delay until age 3, based on a high degree of evidence for increased respiratory complications at ages younger than 3.4\nAn overriding important consideration regarding pediatric anesthetics is: Who will be doing the anesthesia? It’s important to inquire regarding the experience and training of the physician anesthesiologist who is about to anesthetize your child. (See my related column Pediatric Anesthesia: Who is Anesthetizing Your Child?)\nSome anesthesiologists do specialty fellowship education for one or two years in pediatric anesthesia, usually at an academic pediatric hospital, and are therefore well-trained to attend to your child. In community hospitals, experienced physician anesthesiologists who have attended to children since their residency training commonly do pediatric anesthetics. My practice fits this model: I am not a fellowship-trained pediatric anesthesiologist, but I have anesthetized thousands of children safely over 33+ years since my Stanford residency.\nLet’s return to the question of whether your 2-year-old should have anesthesia and surgery.\nMy family had a personal experience with this question. My oldest son fell and cracked his upper right incisor when he was 1½ years old. He had three general anesthetics in the following nine months for dental surgeries: the first surgery to place a cap on the fractured tooth, the second surgery to extract the tooth because it died, and a third surgery to place a prosthetic incisor to replace the lost tooth. These three surgeries were performed in 1998 and 1999 when my son was between 1½ and 3 years of age. He suffered no apparent developmental delays secondary to anesthesia, but in the present day, following the FDA statement, both the physicians and the parents would be unlikely to proceed with three repeated anesthetics on such a young child.\nThe answer for you depends on whether your child’s surgery is elective and can wait until he or she is 3 years old, whether it is a one-time surgery, whether the surgery is brief, whether it is an emergency or whether it is to remedy a congenital deformity and can not be delayed. You’ll need to have an informed consent discussion with the surgeon, the physician anesthesiologist, and perhaps your pediatrician. If your child’s surgery is a one-time anesthetic for a common short procedure such as ear ventilation tubes or an inguinal hernia repair, it’s likely that proceeding with anesthesia and surgery will be the correct answer. If the surgery is urgent or if delaying surgery will cause an adverse outcome, then proceeding with anesthesia and surgery will be the correct answer. Trust your surgeon and physician anesthesiologist as consultants, and you’ll make the correct choice.\nBe reassured. The Society for Pediatric Anesthesiology states that “complications are extremely rare. In the United States, the chance (risk) of a healthy child dying or sustaining a severe injury as a result of anesthesia is less than the risk of traveling in a car.”5\n- Andropoulos DB, Greene MF. Anesthesia and Developing Brains — Implications of the FDA Warning. N Engl J Med 2017; 376:905-907\n- Lescanne E, et al. Pediatric tonsillectomy: clinical practice guidelines. Eur Ann Otorhinolaryngol Head Neck Dis. 2012 Oct;129(5):264-71.\nThe most popular posts for laypeople on The Anesthesia Consultant include:\nThe most popular posts for anesthesia professionals on The Anesthesia Consultant include:\nPublished in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.\nIn this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.\nDr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.\nNuanced characterization and crafty details help this debut soar.\nClick on the image below to reach the Amazon link to The Doctor and Mr. Dylan:\nLEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:\nThe anesthesiaconsultant.com, copyright 2010, Palo Alto, California\nFor questions, contact: [email protected] |
Claudine M. SordylAssociate Professor | Detroit, Michigan\nMs. Sordyl teaches physical assessment, management of medical emergencies, basic life support (re)certification courses, pain and anxiety control, and medical history taking. She is also involved in teaching protocols on nitrous oxide inhalation/parenteral sedation preparation and monitoring the sedated patient to dental, dental hygiene and post doctoral graduate students. As a research study nurse, she coordinates study participants in pain control research involving pharmaceuticals and techniques. Her publications and local/national professional presentations deal with subject matter on preoperative assessment and emergency preparedness of sedated patients, medical emergencies in the dental office setting, local anesthesia, and nitrous oxide. She has received several speaking engagement awards. |
Power-assisted or powered Tumescent Liposuction is the latest advance in fat removal. The “power” in the technique refers to the advanced instruments used to perform the surgery. Traditional Liposuction is performed manually whereas power-assisted Liposuction uses a mechanical cannula that efficiently removes fatty tissue with increased precision, less bruising and a faster healing time. According to medical experts and patients alike, power-assisted Liposuction is a gentler technique than traditional Liposuction and is preferred by patients. Dr. Marcia Byrd, M.D. at Byrd Aesthetic & Anti-Aging Center in Atlanta, GA can advise you on the best method to meet your needs.\nTumescent Liposuction is an excellent alternative for removing localized fat deposits that do not respond to diet or exercise and is not intended to be a substitute for weight loss; rather, it is a contouring procedure. It is best utilized in a program of exercise and optimal weight maintenance. The best results are obtained in body areas where there is reasonable muscle tone, good skin elasticity, and fat is not excessive. In cases where there is a significant loss of tone and elasticity, the desired cosmetic results may require a combination of both liposuction and surgical skin tightening to remove the excessive loose tissue.\nTo view before and after Tumescent Liposuction photographs click here.\nNew Hi-Def Vaser Liposculpturing\nCandidates for Tumescent Liposuction\n- Physically fit men or women that eat well-balanced meals\n- Individuals that are unable to reduce fatty deposits that are well-localized and often seem to involve genetic susceptibility.\n- Patients that are not using procedure for weight loss.\nBefore surgery, a complete medical history is taken and a physical examination is conducted in order to evaluate the body’s condition. During the consultation, Dr. Byrd describes the procedure and what results should be expected. Alternative treatment options, the possible risks and complications that may occur will be explained. Photographs are taken before and after surgery.\nDr. Byrd will also recommend that patients adhere to standard pre-op guidelines to allow for patient safety and maximum post-op results as follows:\n- Eat a healthy diet rich in nutrients.\n- DO NOT smoke for 2 weeks prior to the procedure.\n- DO NOT take pain medication containing aspirin or ibuprofen for 2 weeks prior to your procedure.\n- DO NOT take Vitamin E for at least 3-4 weeks before surgery.\n- Provide Dr. Byrd with a list of any medications that are taken regularly.\n- DO NOT eat or drink after midnight the night before the procedure.\n- DO take medication with a small sip of water that morning.\n- DO NOT shave or remove hair near the regions to be sculpted the day of surgery to prevent ingrown hairs.\n- DO wear loose fitting clothing that opens in the front or pulls over easily to allow for pressure garments and dressings.\n- Patients must have a friend or relative drive them to and form the procedure.\nAbout the Procedure\nBefore the procedure begins, areas of excess fat are injected with a large amount of anesthetic liquid that usually contains a local anesthetic and a drug called epinephrine to shrink capillaries and minimize blood loss. The liquid causes the compartments of fat to become swollen and firm or “tumesced.” The expanded fat compartments allow the liposuction cannula to travel smoothly beneath the skin as the fat is removed.\nTumescent liposuction is designed to be performed as an outpatient procedure. Thus, the potential complications from general anesthesia and a costly hospital stay can be avoided. In addition, since the patient is awake, he or she is able to sit or stand during the procedure, allowing the surgeon to check the status of the patient and progress of the contouring.\nFor women the most frequently areas treated by Tumescent Liposuction are the outer thighs followed by the abdomen. For men it is the flank or “love handle” region. Other areas commonly treated include: the face, neck, upper arms, upper and lower abdomen, lower back, hips, thighs inner and outer, sides of the knees, and lower legs. It is uncommon to treat all of these areas at one time. If all areas were involved, weight loss may be a better option. Usually there are only a few regions that require Tumescent Liposuction.\nCellulite is a condition that gives the skin a rippled, dimpled appearance. Tumescent Liposuction is not an effective treatment for cellulite. Liposhifting has been found to be the most effective way of removing cellulite. Irregularities from cellulite or previous Liposuction defects can now be treated with a new development called Liposhifting. This procedure allows for fat transfer without ever removing the fat from the body by utilizing new instrumentation called a Micro Graft Fat Cutter, or MGFC.\nAftercare and Recovery\nThe local anesthesia injected into the tissue remains for about 24 hours following liposuction surgery, greatly minimizing post-operative pain. After Tumescent Liposuction, most patients are generally alert and able to function without the nausea, grogginess, and the washed out feeling associated with general anesthesia. In fact, patients are encouraged to walk immediately after surgery to enhance the healing process. Since there is less bruising and bleeding from Tumescent Liposuction, there is less blood to be absorbed and irritate tissues. The lack of this irritation means that the swelling goes down much faster. Many patients are able to return to work almost immediately.\n- You will need to limit your activity for the first couple of days – no strenuous exercise, lifting or bending over for 3 to 7 days after the procedure.\n- Avoid any type of aerobic exercise (any activity that raises your pulse above 90) for at least three weeks to prevent swelling.\n- It depends on what you do and the activity level of your job. Resumption of activities depends on the extent of your Tumescent Liposuction procedure, your health, and how you heal. In general, the discomfort lessens significantly in 2-4 days.\n- Stabilizing your tissues in a special garment increases your comfort and ability to get around. Your tissues will be more comfortable after Tumescent Liposuction when they are not jiggling around.\n- Compression also helps control swelling and bruising. Our patients wear this for about 2 weeks full-time and then part time for a third week.\n- Different styles are available for the various zones treated by the Tumescent Liposuction. Girdle-like pants are used for the buttocks and thighs. An elastic vest is used for the male chest. Hooks and zippers on side openings assist in getting the garments on and taking them off.\nLike all surgery, liposuction carries both benefits and risks. However, tumescent liposuction using local anesthesia is a remarkably safe procedure with few significant side effects. Infrequent minor complications such as skin irregularity, lumpiness, dimpling, loose skin, numbness, infections, and objectionable scarring (rare) may occur and are usually easily corrected.\nAtlanta liposuction and lipedema specialist, Dr. Marcia Byrd treat patients for lipedema throughout the United States, Canada, and internationally. They are located in the Atlanta Metro area of Roswell, Georgia. Locally, they service the North Atlanta, GA area including , Alpharetta GA, Milton GA, Woodstock GA, Canton GA, Dunwoody GA, Sandy Springs, GA and more. If you would like to make an appointment to be diagnosed and treated for lipedema, call (770) 587-1711 and schedule a consultation. Be the best you can be and live a full life – there is no reason to wait! |
Methadone for Pain Management: The Clinician's Role in Reducing the Risk for Overdose\nModerator:Loretta Jackson Brown\nPresenters:Len Paulozzi, MD, MPH and Dr. David Tauben, MD\nDate/Time:August 1, 2012 2:00 pm ET\nNOTE:This transcript has not been reviewed by the presenter and is made available solely for your convenience. A final version of the transcript will be posted as soon as the presenter’s review is complete. If you have any questions concerning this transcript please send an email to [email protected]\nWelcome and thank you for standing by. All participants will be on listen only until the question and answer session. Today's conference is being recorded. If you have any objections you may disconnect at this time. I'd now like to turn the meeting over to Loretta Jackson Brown. Thank you. You may begin.\nLoretta Jackson Brown:\nThank you, (Melinda). Good afternoon. I'm Loretta Jackson Brown and I'm representing the Clinician Outreach and Communication Activity, COCA, with the Emergency Communication System at the Centers for Disease Control and Prevention. I am delighted to welcome you to today's COCA Webinar, Methadone for Pain Management: The Clinician's Role in Reducing the Risk for Overdose. We are pleased to have with us today Dr. Len Paulozzi from the Centers for Disease Control and Prevention and Dr. David Tauben from the University of Washington's School of Medicine, here with us today to review the epidemiology of methadone overdoses in the United States and discuss guidelines for appropriate opioid prescribing.\nYou may participate in today's presentation by audio only, via Webinar, or you may download the slides if you are unable to access the Webinar. The Power Point slide set in the Webinar link can be found on our COCA Web page at emergency.cdc.gov/coca. Click on Coca calls, the Webinar link and slide set can be found under the call-in number and call pass code.\nAt the conclusion of today's session, the participant will be able to discuss the role of methadone in fatal drug overdoses in the U.S., compare and contrast methadone prescribing to other opioid analgesics, and state circumstances under which use of methadone might be appropriate.\nIn compliance with continuing education requirements, all presenters must disclose any financial or other association with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product or products under investigational use.\nCDC, our planners, and the presenters for this presentation do not have financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or products under investigational use. There was no commercial support for this activity.\nAt the end of the presentation you will have the opportunity to ask the presenters questions on the phone. Dialing star 1 will put you into the queue for questions. You may submit questions through the Webinar system at any time during the presentation by selecting the Q&A tab at the top of the Webinar screen and typing in your question.\nOur first presenter is Dr. Len Paulozzi. He's a Medical (Epidemiology) in the Division of Unintentional Injury Prevention in CDC's National Center for Injury Prevention and Control. His area of concentration is drug overdoses, especially those due to prescription drugs. He has been concentrating on the drug overdose problem since 2005. Dr. Paulozzi has authored and co-authored more than 80 publications during his 28 years in public health. He has testified at Senate and House briefings related to prescription drug use and his work is frequently cited in both the popular press and scientific literature.\nOur second presenter is Dr. David Tauben. He has 30 years of internal medicine, community, primary, and consulting care experience in Seattle, Washington. He joined the University of Washington's faculty as a full time clinician and educator in 2009. He is Board Certified in both internal medicine and pain medicine. He is the Director of Medical Student Education in Pain Medicine at the UW, jointly appointed in the Department of Medicine and Anesthesia and Pain Medicine. A faculty member at the University of Washington's Center for Pain Relief, his group was recipient of the American Pain Society's 2010 Center for Excellence Award. He is currently implementing a four year integrated medical student curriculum in pain medicine and a primary care pain consultation tele-medicine project across Washington State, Wyoming, Alaska, Montana, and Idaho.\nAgain, the Power Point slide set and Webinar link are available from our COCA Web page at emergency.cdc.gov/coca. At this time, please welcome our first presenter, Dr. Paulozzi.\nThank you. And welcome to this COCA seminar. The material I'm going to talk about today is largely derived from an MMWR article that was published recently, actually on July 6, 2012.\nAnd you can see some of the references that I'm talking about cited there. I have some additional information here that is not presented in that MMWR article. Just by way of background, I'd like to describe the drug poisoning problem for you in the United States.\nThis figure shows rates per 100,000 for leading causes of injury death in the United States, motor vehicle traffic, the white line has come down in recent years. And in 2008, drug poisoning and poisoning in general passed motor vehicle traffic mortality. In 2009, drug poisoning shown in orange on this figure exceeded the number of deaths for motor vehicle traffic in the United States for the first time in U.S. history. If you look at the more recent trends in drug poisoning and\nbreak them down by specific type of major drug type involved, you get the results shown in this figure. Between 1999 and 2009, what has happened has been a dramatic increase in overdose deaths involving opioid analgesics or opioid pain relievers. Cocaine shown in white, mortality peaked in 2006 and is coming down. Heroin mortality has remained below the other two categories.\nA few years ago, the number of deaths involving opioid analgesics in total exceeded the sum of deaths involving cocaine or heroin. As of 2009, there were approximately 15,500 overdose deaths of all intents, that is included unintentional suicides and so on that involved opioid\nanalgesics. And if you break down the trend line for opioid analgesics into component parts, you can see the following categories shown now on Slide number 9. The top line is a category of opioids derived from opium that are semi-synthetic, hydrocodone, oxycodone, morphine, and codeine. The green line is methadone. The bottom line is synthetic opioid analgesics such as fentanyl and meperidine. And what's happened during this time period has been an increase in all three categories. But methadone mortality rose faster than the other categories. It peaked in about 2007 with roughly 5000 deaths involving methadone in the causation.The other categories have gone up since that time. Methadone mortality rates are still just about 5000 as of 2009.\nNext Slide, number 10, in this slide I take the methadone mortality rates, methadone related overdose deaths shown in the red dotted line in the middle, and compare it with methadone use for pain in the United States as measured in kilograms per 100,000 people. And this data comes from the Drug Enforcement Administration. It does not include methadone used in opioid treatment programs.\nThe bottom dotted line is the rate of methadone prescribing for pain per 100 persons in the United States. So as you saw earlier, the mortality rated peaked in 2007. Paralleling that, the use of methadone for pain also peaked in 2007. However, the prescribing rate stayed relatively stable after 2007. So what's happening is that there are fewer milligrams of methadone per methadone prescription after 2007. This may be a result of black box or boxed warning that FDA applied to methadone late in 2006 and/or DEA's restriction on the use of the 40 milligram formulation on methadone to opioid treatment programs and hospitals. So it was no longer available for prescribing in the outpatient setting for pain.\nSlide number 11, we can only learn a limited amount from death certificate data so we have to supplement that with studies done in individual states that have state medical examiner system. A number of individuals have studied this problem over the past 10 years and six studies are shown on Slide number 11. Basically, what it indicates is that, in the second to last column, there's 25% or fewer of people who die of methadone overdoses had been enrolled, or were enrolled in their state opioid treatment programs at the time of their death. And we also know, in fact, that most of the overdose deaths, in where it has been studied, involved the pill form of methadone rather than methadone liquid. So this leads to the conclusion on the part of everyone who's looked at this issue that these methadone overdoses are primarily from methadone being used for pain. The last column shows the percent of people who had a prescription for methadone, in something like the state prescription drug monitoring program. And as you can see, a minority in all the study had prescriptions, indicating that a lot of methadone is being diverted from being used for pain and is being used without a prescription by people who ultimately overdose on it.\nSlide 12, this is data from just 13 states rather than from the whole country. It is from 2009 and it comes courtesy of the Substance Abuse and Mental Health Services Administration's Drug Abuse Warning Network Medical Examiner component, otherwise known as DAWN. And it shows for these 13 states on this slide, the numbers of deaths that are related to the major types of opioid analgesics. And this is a kind of breakdown that you can't do with death certificate data.In the figure on the left you can see that methadone, shown in the hatched pattern, the number of methadone deaths in these states in this one year was comparable to number from oxycodone. If you look at the right figure, the bars in red indicate however, that when you're looking at deaths that only involved a single drug of any kind, methadone stood out from the other opioid analgesics with 298 deaths in these states in this one year where methadone was the only drug involved.\nIf you take the same data, same source, and convert it to rates, the pattern is revealing. These are rates calculated by using kilograms of morphine equivalents of opioid analgesics as the denominator. So in the left figure, for all drug related deaths, you see the rate of death for every ten kilograms MME. In this figure, as in the previous figure, methadone is shown in the hatched line, and its rate exceeded that of any of the other opioid analgesics. And not unexpectedly, in the figure on the right for single drug deaths, the rate for methadone was greater than any other opioids. These differences were all statistically significant. These differences will also continue to be statistically significant even if one subtracted 25% of the methadone deaths to allow for some of the deaths potentially being related to methadone use in opioid treatment programs. So there's a large difference there between methadone and other opioid analgesics.\nSlide 13, this is data that comes from SDI Vector One, a national survey of prescribers, the analysis originally done by Laura Governale of the FDA and presented in 2010. It shows the distribution or percent the methadone prescriptions for pain by prescriber specialty. Forty-three percent of these prescriptions were made by primary care physicians, 9% by mid-level practitioners and the others by a variety of specialties. So the majority of the prescriptions as of 2009 were being written in the primary care setting. And in the same survey, same analysis, you can examine the percent of diagnosis that were associated, different types of diagnosis associated with methadone use, in this office-based physician survey.\nForty-six percent of the prescriptions were associated with muscular-skeletal disease problems, in particular back pain, 17% were associated with headaches, 11% with cancer, 5% was trauma, 4% was a category known only as general symptoms, 4% for drug abuse and dependence, and 13% for all others. When you look at the distribution of methadone for pain by state, using the DEA data, there are wide variations across the country.\nThis map on Slide 16 shows the percentage of opioids that were accounted for by methadone. The darker the color, the darker blue, the higher the percentage. And the darkest blue ranges from 11.5% to 18.5% of the Morphine Milligram Equivalent that were distributed in that state, in the United States in 2010. So there's a several fold difference from states using little methadone and states using a substantial amount. Potentially related to this is the map shown in Slide 17 which indicates that methadone is the preferred long-acting opioid analgesics on the Medicaid formulary of some 31 states in the United States. And this data comes from 2012 so it was just ascertained within the last couple of months, again wide-spread use of methadone as a preferred long acting opioid analgesic by Medicaid programs.\nSlide 18 turns to what can we do about preventing this problem? For states, they can develop and promote the use of safe prescribing guidelines for methadone. They can support their prescription drug monitoring programs and staff there, to identify patients who are using methadone or other prescription pain killers for non-medical purposes. And obviously a lot of drug is being diverted to the individuals who died of overdoses. And of course they can continue to support the use of methadone as a treatment for opioid dependence in opioid treatment programs.\nSlide 19, health insurers have an important role to play. They can evaluate methadone's place on preferred drug lists. This can be both private and public insurers, such as Medicaid programs. They can consider strategies to insure that pain treatment with any dose higher than 30 milligrams of methadone a day, that's the recommended maximum daily starting dose from the FDA, consider strategies to insure that any dose higher than that is appropriate. And health care providers, last but not least, health care providers need to follow guidelines for prescribing methadone and other prescription painkillers correctly. They can choose not to prescribe methadone if they don't have training and experience with its use.\nMethadone is really not a drug for amateurs. And they can educate patients on how to safely use, store and dispose of methadone. Thank you for your attention. I'm going to pass the microphone to Dr. David Tauben.\nThank you, Len. That was informative and leaves us with my first slide, which is Slide 22. What's a prescriber to do with this kind of data? It sounds pretty terrifying, particularly for the primary care folks who do not have the experience and advanced training necessary. So my hope is, in the next 20 minutes or so, to give a very quick run through of some general principles and as my early introduction described, I am involved in academic work in the University Washington in the division of pain medicine. I am, by original training a primary care provider and spent 27 years in the trenches working with this problem of chronic pain and recognizing that there is indeed a value for methadone. So my objective - by the way, no disclosures of any interests and I'm happy to state that we are a part of the National Institutes of Health Pain Consortium Center Excellence and Pain Education. And we thank NIH for that support.\nSo the objectives are going to be, as implied by Dr. Paulozzi, that well my understanding, the indications for the use of methadone, be knowledgeable about its risks, follow safe methadone dosing practice and know why and how to apply the guidelines for opioid management and monitoring, particularly in the setting of methadone which we see does present unique hazards and as well stated is not for amateurs.\nOn the other hand, this is not intended to discourage primary care prescribers of all specialties to becoming a bit, become a bit more expert so that they can indeed use this very helpful drug.\nSo my Slide 25, for those following on PDFs, is a brief description of the basic clinical pharmacology. It's an excellent pain drug because it is a potent Mu-agonist, meaning it binds directly to the Mu-opioid receptor and has potent analgesic effects. Its challenge, however, is involved in the variability of absorption, which you can see is broad, oral a very wide range, 3-fold range of expected absorption orally. And the peak plasma levels are also up to a 2-fold range. And even more importantly there is up to a 30-fold inter-patient variability in both steady-state concentrations and in expected peak concentrations. We also can expect that age and illness of our patient increases toxicities, and I'll spend some time with those particular subsets in a few moments. That there are frequent drug-to-drug interactions which add to the complexity of prescribing this pharmacologically complex drug, that the drug is metabolized 100% through the liver and its phetachrome metabolic pathways and there being no active hepatic metabolites, it is very important to be able to use methadone properly in patients with liver disease. And it may give us a bit of a free pass, a bit, on our patients who may have renal disease as there's no active metabolites, and we're just discussing basically first-pass clearance of the effect of methadone in patients with renal insufficiency.\nSome special features that make methadone a particularly helpful drug and also a bit more challenging to prescribe are listed here on Slide 26. It is an NMDA antagonist which has unique properties in that it is thought to play a role in its potential for reducing the development of tolerance for opioids. It also has some non-opioid analgesic effects working on the NMDA receptor. It also, interestingly, has some 5-HT and norepinephrine reuptake in addition making it a bit like an SNRI or a tricyclic anti-depressant category drug, and therefore it may add some particular benefit for the management of neuropathic and central centralization pain disorders. Challenging, however, of the special features is its accumulation with repeat dosing. And that we can see that the initial half-life, though prolonged is far different than the half-life after an extended period of time, going for maybe a 1/2 day to a 1-1/2 or 2 full days to 2 days to 3 days to achieve steady state. It is also highly lipophilic and highly protein-bound, perhaps accounting for its increasing potency as the dose rises. And we'll spend a bit of time going over that. And it's also a factor in that it inhibits its own cytochrome metabolism by revving up those cytochromes. It increases and also inhibits its own metabolism producing the challenging algorithm I've laid out for you on the right, that in under 20 milligram methadone dose it's about a 4-fold multiplier of morphine.\nAnd as we go up it becomes 8-fold then 10-fold, and then 12-fold, which to many of us primary care providers is quite a surprise, since this is not part of the common education that any of us receive. So that when we're giving 60 or 80 or 100 milligrams of methadone we're equivalent to a morphine equivalent dose of up to 1000 milligrams of morphine, which when we make those conversions is, for us at least, should be a sobering event. What are the indications? Pain treatment, absolutely, and this talk is certainly not to discourage its appropriate use for pain treatment. It has the advantages listed. And likely for Medicaid the advantage, and hence its recommendation for states that are struggling with this very expensive population in this setting of difficult economic times, it's a very inexpensive drug. For addiction treatment, as most of you probably know, it is not indicated by any provider that does not have special DEA licensing and treatment support. As a once daily liquid it eases administration. And there is no doubt that it reduces mortality among heroin users so therefore it plays a very important role.\nOn Slide 28, in comparing here the differences and pointing out the similarities of methadone versus other opioids, again, to just reiterate, it is marked as different from other opioids inter-patient pharmacologic variability. It has an accumulative dosing potency. And as Dr. Paulozzi indicated, is a higher incidence of overdose and mortality. It's called by some a last resort opioid, which in my mind means it's when the practitioner has determined that this patient is committed to chronic life-long opioid therapy to manage pain and should not be initiated for certainly an opioid naive patient, but also not early in the course of determining whether an individual is going to require a long-term opioid management.\nIt's similarities as all other opioids, monitoring is important. It shares the same side effects of sedation, respiratory suppression, the same anticholinergic side effects of all other opioids and the same cardiac risks, in terms of QT prolongation. That is an area of some experimental work right now, identifying which are the worst agents, and we'll spend a little time talking about methadone unique cardiac research.\nBut as a broad class all opioids will share a cardiac potential. And of course, addition and diversion risks still remain for methadone.\nSo quick morbidity and mortality, this does not challenge the MMWR of course, but there is a 4-point concern as a provider that we need to be aware, for both pain treatment and methadone maintenance treatment, that adverse events typically occur early during the prescription initiation sequence and that speaks in large part, to poor prescriber knowledge at initiation of dosing. We also know, like other opioids that co-prescription with sedatives adds a very significant risk and calling up benzodiazepines in particular, and alcohol of course, but carisoprodol, another drug which has very high sedative issues and will lead to significant respiratory suppression. Respiratory disease of a variety types also increases risk, COPD and restrictive lung disease and sleep apnea, and as I mentioned earlier that QTc prolongation and potential arrhythmia at higher doses, particularly when they're used with other drugs that prolong the QT interval.\nAs Dr. Paulozzi mentioned, in 2006 there was an FDA advisory that likely deflected the trend, and I have just highlighted this for your review, that it is complex, that pain relief lasts four to eight hours, much different than its half-life, and that it may build up in the body to a toxic level if the amount taken is too high, and in particular, in the last phrase, if it is taken with other medications or supplements. So, a source of concern for all prescribers and that reference is available for your full review.\nSo what about QTc prolongation? Well we know QTc prolongation is a risk in just older age, and woman in particular, with co-occurring cardiac disease. And notice these are diseases not of a little bit of occasional arrhythmia or a little bit of angina, or a little bit of heart failure, but we're talking about more advanced diseases. So it appropriate to use in patients who have mild to moderate cardiac disease, electrolyte and magnesium disturbances and concomitant use with other QTc prolonging drugs. And as you can see, the list is substantial. It includes a variety of cardiac drugs. It includes all categories of anti- depressant drugs and it includes a broad range of antibiotics that are commonly used in practice, as well as drugs that work on the dopamine access for both nausea and psychiatric conditions. The QT prolongation concern for those of us doing the prescribing are milliseconds greater than 500 is worth considering discontinuation of the drug, based on this risk.\nWhat's also challenging is that we really can't tell from Slide 32 how high a risk of QT prolongation, in terms of matched methadone serum levels, this is the combined (levo) and (dexter) isomer concentration of methadone. And we can see that's it basically a shotgun blast for the different dose ranges, making it very difficult to predict at what dose we may begin to experience, or our patients should experience, and that we need to increase our surveillance of doses. Torsade de Pointes as you can see depicted here on Slide 33, is a rhythm we hope never to see. And what's interesting on review of the case series and reports available, and Bob Cruciani has done an excellent job and really supplies the literature with a great deal of excellent research, identifies that the dose range of methadone in most of these studies is quite high. Sixty-five milligrams again does not seem like a high dose but when convert it into Morphine equivalents it's up to 780 milligrams of morphine, and the doses were up over 12,000 MED. And most doses were above 250 milligrams of methadone in these case reports, again supporting that we're worried about this, or certainly need to be worried about this at the higher dose ranges.\nDrug-drug interactions complex and for the sake of time and people's ability to maintain cognitive attention, I'm certainly not going to read these drugs but this is available for quick reference in terms of what agents you need to be concerned about. For 3A4 inhibitors, that means they will reduce the metabolism of methadone and therefore raise its levels. And these would be, these are considered the moderate risk agents and I want to call attention to the listeners of a variety of antibiotics, many of which we use quite regularly. Certainly the quinilones and the macrolides used regularly and tetracyline, metronidazole, pentamidine, protease inhibitors and the like, all have a potential to raise effective methadone levels, hence need to be monitored carefully. And again, this is a caution about dose because when you're up on the precipice on the mountain top it doesn't take much more to push one up over the top into toxicity. Hence lower doses are clearly the safe way to go. Other commonly used drugs are associated with 3A4 inhibition, listed trazadone widely used anti-nausea drugs are widely used. Hence we need to be attentive to the drug profile that our patient is receiving as prescriptions for other indications.\nSlide 35 identifies a number of less potent cytochrome 3A4 inhibitors. They may raise methadone level and we again need to pay some attention and you can see a whole range of the drugs we use as antidepressants and the typical antipsychotics. Notably also, grapefruit and grapefruit juice is a factor and even some naturopathic agents may play a role in raising methadone levels. Again it's not quite clear and just caution is raised in this group.\nInterestingly, in Slide 36 we can see when we give our patients rifampin they report less adequate methadone effect, is indeed because these induce the metabolism methadone through induction of 3A4 and there will often be a need to dose increase your patient in order to maintain analgesia. And this is relevant often in the chronic pain population, certainly for carbamazepine and in the epileptic population of neurologists for diphenylhydantoin. And when patients who for instance have spinal surgery and end up with complicated wound infections may require rifampin and again concern may be raised by the patient that they are receiving inadequate analgesia and they do have a reason to report that. There's a listing here that I've provided of other drugs that have been reportedly associated with Torsade de Pointes. There's no specific interaction with methadone other than that these also may raise the rate and these again for your reference should be used with caution.\nAnd again we can see the macrolide antibiotics and again the - several of the not so commonly used antipsychotics, but those drugs also have been associated with Torsade de Pointes. So what are the general side effects and concerns that we may have to confront when prescribing methadone? I mentioned earlier that it generates anticholinergia, which is seen with all opioids to varying degrees. Patients will typically gain weight, they will typically sweat, there will be expectation of somewhat reduced motor coordination, and arguably and dose related and based on tolerance, a variety of potential of cognitive impairments. This again would be referent to all opiates as well.\nWe also know for all opiates they reduce sex hormone release, so we can expect men to reduce testosterone and women to have menstrual disorders related to this effect. And often in clinical practice, certainly I do, I measure testosterone levels in men to identify adverse risks related to libido, sense of well-being, and in fact pain may even be elevated with reduction in sex hormone.\nFor pregnancy, methadone at this point is recommended to not change and as I've put in yellow for an opiate addicted pregnant woman, methadone maintenance is the standard of care. So dose reducing an individual off methadone at the time of a pregnancy generates a risk of premature labor or miscarriage, greater than the risks associated with managing however gruesome it is and unfortunate it is in neonatal abstinence syndrome. And again, those of us prescribing during the third trimester there's an increased volume of distribution and hence it's common to require increased dose during that stage of pregnancy.\nSo for methadone dosing, once again go low and go slow, that's the mantra of many of the treatments we use in pain particularly those that are psychoactive. Dr. Paulozzi mentioned the dose recommendations FDA up to 30 milligrams maximum and we'll talk a bit about why in a few moments. But a starting dose, and this would be again though it can be used for an opiate naive patient, it is not recommended for the reasons that should be obvious by now, it is a tricky drug and that once you're committing your patient to methadone most pain experts would recommend that this is the time when you're going to commit for lifelong opiate substitution. And therefore they will be on another drug. I will frequently titrate in methadone at the 2.5 milligram, it's available, it’s a 5 milligram tablet at half of the 5 milligram tablet BID initially as I begin to rapidly remove the other opioid during a transition from another opioid.\nAgain the increased frequency of dosing should be at a prolonged interval at every five to ten days and many practitioners, myself included, will recommend weekly visits during an upward methadone dose titration so you can give your patients just the right amount so there's no temptation for them to take more than recommended because they will not be receiving adequate analgesic response until they get to a steady state level which as we saw can take up to that five to ten day interval.\nAgain in opiate naive patients I would not recommend it. There is certainly a risk of an accidental overdose when a patient's not tolerated. And per the FDA advisory, I've extracted this quote, "The use of methadone is indicated when pain is not improved with other non-narcotic pain relievers." And I will also add in my own personal recommendation that this would not be a first line opioid to choose when selecting an opioid for management of chronic pain. When there's age or disease related metabolic adjustments, one must always go slow and then the issues of drug-drug interactions need to be paid careful attention to in dosing as I indicated in the earlier slide.\nAt Slide 40 now, the Veterans Administration, Department of Defense really in my view have one of the finest and most detailed clinical practice guidelines. I've referenced it to you for there, one can Google that and get to their site pretty readily. The dose increments again are supported by what I just described of 2.5 milligrams. And their recommendations are up to every 8 hours and the increases are done every five to seven days and if there is no problem with daytime sedation. Note again the broad interval of time before dose increasing per their recommendations. And again stating as I mentioned in my opening that the half-life of the drug is longer than the duration of the analgesia, hence the common question is why don't we just dose this long acting drug once a day or twice a day, is that the clinicians experience with this drug for analgesic response appears to be more effective at Q8 or Q6. That in other words, three or four time a day dosing.\nIn the state of Washington, if you recall from Dr. Paulozzi's slides, we are up there with the high dosage, we're up there with the high opiate deaths, and I believe Washington State was one of the first that had opiate overdose deaths exceed motor vehicle accidents. And there's been a big effort in this state to improve provider education and increase the safety of the use of opioids. This is an (Excel) version. You can go to the agency medical directors group and get access to a web based version that you could use on any hand held device. The state of Washington identifies a threshold dosing of 120 milligrams before specialty consultation is expected.\nAnd this again speaks to Dr. Paulozzi's earlier comment that 30 milligrams is considered a high end dose for methadone and if the conversion is four, 30 times 4 is 120, so we're all talking the same numbers in my mind supporting the fact that this is a very robust recommendation. I filled in some numbers on this calculator to again reinforce that at 80 milligrams of methadone for instance, if you can follow that chart that I've outlined on the slide, you can see you're up to by using that conversion at nearly 1000 milligrams of morphine. So the calculation certainly does play a significant role in our ability to manage. And here's a blow up of the rationale for those dose issues because you can see at 40 milligrams a day you are up to 320 milligrams of morphine equivalent dose. Again, considered by many to be a dose that may - the risks may exceed benefits.\nSo for converting patients from methadone, onto methadone excuse me, from morphine, and this again is outlined in detail in the VA/DoD guidelines. Calculating the equianalgesic dose, you would go to, at most 50% to 67%, many of us would pick even a lower number, as low as 10% of the calculated equianalgesic dose due to the variability of patient response, that the dose calculation varies with the total dose as I indicated the dose has an accumulative potency. And again the dose is proportionately dependent on the morphine equivalent dose of the previous opioid. So it's a bit complicated but using a morphine equivalent calculation going to, my recommendation, no more than 50% and I would typically choose between 10% and 50% of the morphine going into the methadone dose choice.\nSo in a nutshell, above 200 milligrams, it would be 5 milligrams q8. And again in an opiate tolerant patient, in the higher dose of morphine range of 200 to 500, again picking 5% to 10% of the oral morphine equivalent dose, divide that by 8 and so that gets us again within the numbers that were described earlier. And I would urge that if your morphine equivalent, if your patient's morphine equivalent dose is above 500 milligrams per day, that's probably the time you're going to want to get some help to make these conversions because it is again not for amateurs.\nSo a summary here now, I brought together a number of studies incorporating the DA guidelines and some publications that are cited elsewhere that a rotation again is at the 10% to 15% of the morphine equivalent dose. And an important note is that if the previous dosage of opioids are ineffective, this may overestimate the chosen methadone dose that the analgesic effects can take days to stabilize, that the conversion ratios again are not bi-directional. These equivalent doses are very rough numbers without a lot of clear science to allow us to have a high degree of confidence that they're accurate and I round them to the nearest 10 or even, in some cases, the nearest 50 when we're dealing with methadone. And that the formula based on the morphine equivalent dose should be the dose taken at the time of the switch. And again for about the fifth or sixth time, repetition never hurts you, that the potency rises as its dose is increased.\nIn terms of risk monitoring, Slide 44, it's the same as other long-acting opioids. Opioids are all high risk drugs and Dr. Mark Sullivan here in Seattle has recently published a very interesting review and we're experiencing it in our clinical practice here at the University of Washington, what he describes as, oops, I have misspelled it, it should the principle, P-L-E, of adverse selection in that the highest doses of opioids of all categories are being given to our highest risk patients. And those high risk patients are high risk in terms of co-occurring substance use disorder and co-occurring psychiatric illness. And if you subset out these patient, those are the patients that are getting the highest risk drugs, receiving one of our highest risk agents. Chronic opioid therapy risk is also best evaluated prior to the initiation of the chronic opioid therapy and you can select which tool you'll use.\nAt the University of Washington we're currently using the opioid risk tool but the SOAPP-R or the DIRE score, some measure of risk before you embark on a long-term opiate plan for your patient is very important, so you can evaluate whether the benefits of opiate therapy are going to be supported by the risks associated with patients in particular who are at high risk for other issues.\nNext Slide 45 is the screen shot of Lynn Webster's Opioid Risk Tool. It is in the public domain. I got this off the internet a few years back. It's simply 10 questions and off this you can get scoring which is in yellow, low, moderate or high. And that in my practice has been a good launch point for a conversation with a patient that this may just be too high a risk drug. And the analogy I would make to clinical practice is, I'm not sure I'd given an NSAID to a patient with hypertension and congestive heart failure. And my conversation with the patient would be that you represent, due to your other conditions, in this case risks, represent too high a risk patient to be using this high-risk drug. It's a very useful strategy and then again in Washington State our guideline recommendations identify urine drug toxicology for adherence monitoring to be based on the risk category. So as you can see on the left, the risk category - low risk, moderate risk, high risk and the urine drug testing frequency that's recommended.\nSo if you're a 65 year old patient who's taking a low-dose opioid to manage osteoarthritis with low risk of abuse or mental health disorders and a high degree of adherence is someone for whom up to one year is adequate on urine drug toxicology monitoring. And that those patients who are at high risk and certainly with any of the behaviors listed are recommended to have very frequent urine toxicology monitoring. And frankly again, a high risk drug with marginal benefits because opioids in long-term use may not be more effective than 30% reduction on average of pain intensity, may be more risk than the benefit they can support.\nUrine test monitoring on 47 again is a little different for methadone than the other opioids. The point-of- care testing are generally reliable, however, in a number of studies we have between 20% and some studies up to 40% false positive results on the point-of-care urine monitoring based on the antibody to a variety of metabolites and the cross-reactivity of that antibody. And hence it is an issue for interpreting what's going on in a patient in who you have a surprise result. And you can see false positives are seen in a response to a number of fairly common drugs. Diphenhydramine, your patient may be taking over the counter in a sleep aid or for their allergies, verapamil, and your patients who are receiving psychiatric care might indeed be on quetiapine as well. So you may have false positive methadone on point-of-care.\nSo the confirmation testing by liquid chromatography or gas chromatography when the results are unexpected and the patient does not admit to those drugs. It's a very expensive test. It'll be about $400 versus about $20 for the point-of-care and therefore getting a confirmation on every patient, and when the patient says, well I really did use that drug, it does not appear necessary to spend that additional resource dollars on confirmation when you're simply confirming what the patient's already admitted. You can request reflex confirmation when you inform your laboratory of what you're expecting and this can be done reflexively. And there are a number of adulterants available on line and our sophisticated patients certainly know how to find what these drugs are that can interfere with the assay. Adherence monitoring, I want to just begin to close my conversation here with that there are available solutions. Dr. Paulozzi mentioned the prescription monitoring programs and we thank the states for support.\nWashington State as you can see in the top left corner does have a PMP on board. There's, essentially all 50 states and territories are currently ready to operationalize the ability to capture all prescribed, even cash purchased. It will not, however, capture illegal distribution of this drug so we're not off the hook by just inquiring prescription monitoring programs. Many states also are initiating emergency department information exchange. There's dated support of substantial savings to patients when systems introduce emergency room to emergency room to provider conversations that may allow the provider in whichever setting to identify no controlled substances. And the case manager can then move the patient through a system of informing the primary care team of what's going on.\nAnd here's the reveal of the rest that didn't appear in the slide. So there's a registration process and then a message to the primary care office that something's awry in the patient's behavior to emergency department. A number of co-occurring conditions that we need to be aware of and a number of screening tools are listed. The UW has an accessible pain tool kit which I'm happy to share with listeners to gain access to all these measures that are described, for sleep apnea, for depression and anxiety, and post- traumatic stress, for drug-drug interactions by reconciling or sharing an electronic medical record system.\nAnd then the question of cardiac monitoring remains a question and Dr. Cruciani and others still say, to EKG or not to EKG, it is still a question whether we do that on all patients. In my experience, we do not do that here at the University of Washington unless there is a concern about pre-existing or other drugs that are on board. So tapering methadone is a bit challenging. Our efforts have been to traditionally reduce by 10% per week using clonidine. It's listed in a number of guidelines as you can see. This is often challenging for patients and in the bottom bullet, dropping down and stabilizing at a lower dose may be necessary and even reducing the previous rate is outlined.\nI'm not going to spend a lot of time here and there may be some questions on how we can best taper, but even though it is a long half-life, patients do not do well typically with opioid dose tapering, particularly as you can see on one of my closing, near closing Slides, 51. That if the patient has a substance disorder as a significant concern, there is a very high incidence of relapse onto opioids and therefore referral to a methadone maintenance or other opiate substitution program may be best advised. And after a long epoch of high-dose use, patients will frequently destabilize even without an established substance use disorder, based on what we're describing here in Seattle as an opioid, a persistent dependency syndrome where patients begin to act like addicts even if they don't meet substance use disorder criteria. Their schedule may need to be protracted with frequent plateaus based on clinical response and in all circumstances a behavioral health support is necessary.\nSo in conclusion, methadone is an effective analgesic and should be prescribed for carefully selected patients. This is a very important cost benefit and in an era when we're very cost conscious about how we're going to be able to afford a shrinking budget for managing complex patients. Its analgesic interval is shorter than its half-life. It has huge inter-patient variability. Its dosing is complex with an accumulative potency. There are a number of drug-drug interactions and metabolic interactions which must be attended to and relevant to many primary care practices. But when used carefully, and hopefully this brief overview, will bring you up, not quite to expert standard, but you'll be a bit less than an amateur now at the end of this conclusion since methadone is an effective and safe medication.\nThank you for your attention and I believe now we're going to be ready to take some questions.\nLoretta Jackson Brown:\nYes, thank you, Dr. Paulozzi and Dr. Tauben for providing our COCA audience with such a wealth of knowledge. We will now open up the lines for the question and answer session and as always, you can also type your questions through the W ebinar system by clicking on the Q&A tab at the top of your screen. Operator.\nThank you. It's star 1 to ask questions on the phone. Please unmute your phone and record your name. Star 2 to withdraw your request. Once again star 1 at this time. One moment please for the first question.\nLoretta Jackson Brown:\nkay, and while we're waiting for the first question from the phone, we do have a question through our Webinar system. And the question is, "Is methadone a preferred lone acting medication for a chronic narcotic? Why? And if not, which medication is preferred and why?"\nOkay, let me take that because in my conversation I just concluded I would not consider it the preferred long-acting methadone, excuse me, long-acting opioid in chronic pain based on the complexity that we see and the associated documented epidemiological consequences of the widespread use for pain.\nHowever, it is a very reasonable choice for chronic opiate therapy in many patients who have not benefited from other opioids or who have other peculiarities of their case, for instance, cost, they can't afford these other drugs, or it's unique NMDA antagonism and other potential enhancements of analgesic response, but I do not use this as a first choice drug and it's certainly not a drug for the opiate naive.\nLoretta Jackson Brown:\nOkay, thank you, Dr. Tauben. Operator do we have a question on the phone?\nOperator: We have one question on the phone. (Sandra) your line is open.\nCalling from California. I really appreciate this lecture. At our institution we're having an increased use of methadone, in particular IV methadone. I was just wondering, I have a couple questions but first, I was wondering if you're familiar with any increase that QT prolongation with the use of IV methadone in respect to this preservative causing the increase in QT prolongation?\nHaving just reviewed that (Sandra), it's a good question. IV methadone is a very reasonable alternative to other IV agents. And again it's in an in-patient setting presumably and therefore the monitoring and concerns about other drug-drug interactions will be front and center. It's conversion to IV morphine is about one to one in terms of its use in that setting. There is reports of QT prolongation in the large studies that have been published. It's described as one of the causes for QT prolongation but it does not stand out as one of the unique factors that's associated with QT prolongation. It's only identified in a handful of studies that report this problem and I do not know anything about the preservatives that might be associated with that and my expert guess on this in clinical judgment would be, it's not the preservative it's the dose and the accumulative toxicity in the setting of other drugs. Often in an in-patient setting, patients are receiving sedative agents and possibly drugs used for psychiatric treatments and these do have significant drug-drug interactions. And as a general rule, I would never prescribe a benzodiazepine of any form unless there's a strong and absolute requirement for that in the patient receiving IV methadone, again, based on its risks with respiratory suppression.\nI really appreciate that. My second question is, we have a large number of our anesthesiologists who are, I'm calling from an in-patient setting, who are using IV methadone in acute pain treatment, particularly peri-operative in the ORs, they're giving them IV methadone doses and then in the (PACU) when they come out for 24 hours they're using IV methadone. And then just basically for 24 to 48 hours and then just stopping them, and after that they're not continuing on it. Have you seen or experienced or have any experience with IV methadone (for a QT)?\nAgain in the setting of a hospital-based practice that would be reasonable and every hospital will have its own culture and formulary requirements. It's a very effective analgesic. It has a nice durability of half-life and in the acute setting for a couple of doses to stabilize a patient seems reasonable. And there's also a prolonged duration of time before the drug clears, so there may be some carry over into the next couple of days of the hospitalization reducing (PCA) requirements. That is a downside because other drugs may be added and other opiate management may make it more complicated but I don't think there's a special red flag that goes up in response to their use and it would reflect the same practice approach using other opioids.\nAnd then I'm so sorry, I have one last question. This is particularly to monitoring and we are having some problems at our hospital in terms of putting into policy and procedure how to monitor especially for the cardiac side effects of methadone. And from your lecture I hear it's kind of inconclusive how everyone is doing it and I guess at your University in Washington you guys are really not doing EKG monitoring on the patients. Even on high dose patients you guys still don't require EKG monitoring?\nNo, no, that's not correct. That's a good question. There's no clear cutoff for when - or top end which time one would start monitoring. Certainly if you're going above the 30 milligram methadone dose you're putting your patient at risk simply for a lot of other reasons and an electrocardiogram would be very appropriate if a patient's on other QT prolonging drugs and, as you can see from the earlier slides, there are a number of them, I would recommend getting an EKG. The question that's begged is, for every patient that you're going to initiate methadone on, must one get a pre-treatment EKG? That's clear. The data is not at all certain as to when to proceed but I would recommend doses above 30 milligram would be a very reasonable time to introduce EKG monitoring for the QTc prolongation. And again, methadone is not unique in this category. All the opiates seem to have - they're not all documented yet but many of them do have QT prolongation and it may be a class effect rather than just related to methadone. And the issue is methadone has been dosed at such high levels historically that it appears to be predominantly a dose-related phenomena.\nI really appreciate your time and your lecture was very well put together and very informative. Thank you.\nLoretta Jackson Brown:\nOperator, are there any more questions over the phone?\nOur next question comes from (Sally). Your line is open.\nOkay hi, I have a question. If a patient is stable on methadone and the doctor wants to convert to morphine, what is the best way to do it? Do we (BC) it, cold turkey, or do we taper the methadone off and then start morphine slowly up and, you know, the ratio between the two are variable so I don't know what the best ratio some source has two to one, three to one, eight to one, it depends. So what is the best way to taper them, to switch them?\nOkay, I'm going to go backwards on that. I'm not sure why anyone would go from methadone onto morphine. So generally speaking, if one's going to do a rotation it would be a rotation on to methadone. If the patient's having an intolerance to methadone and one needs to come off, it is a, as you identify a tricky conversion and one can use the morphine equivalent calculator to identify sort of an approximate morphine equivalent dose. And then any conversion I would certainly use the 10% of what that morphine equivalent dose is before one even begins to substitute in morphine. The other issue is that the methadone will be biologically active due to its prolonged half-life for seven or even ten days. And therefore the up-titration of the morphine, for instance, would need to be staged in slowly. So it is not a typically recommended approach and many of our community providers in Washington State are frightened by methadone because of the scary data that we see. And the question is I've got a patient doing really well on 20 or 30 milligrams of methadone. I've got to get off methadone or morphine. And we say why? The patient's doing well, they're stable. Doing this conversion exposes them to increased risk. It's not clear to me why anyone would want to go that route. I'm concerned about the amount of time we may have on the further conversation. And let me propose, Sally, that if we want to go through some of these numbers more precisely, I'd be happy to do that through a separate conversation that won't consume the group time currently.\nLoretta Jackson Brown:\nRight. And if you have additional questions and we run out of time you can please email your questions to [email protected] and we will get that question to our presenters today. I have a question here perhaps for Dr. Paulozzi. This one is, "Are we in an era of excess narcotic prescribing and if so, why?"\nWell I think the pendulum has swung towards much more liberal use of opioid analgesics for pain in the United States from the situation that we were in let's say around 1990. Through 2010, rates of the use in the United States have continued to go up and of course we're seeing the consequences of increasing use in multiple outcomes, not just drug overdoses. So I think that there's certainly some indications that in some places, with some patients, under some conditions we are using too much opioid analgesic, that we might have done better with other modalities of treatment of pain and spending more time thinking about non-pharmacologic approaches to managing pain. The other question is why? Well, it's the availability of new products, changes in attitudes of health care providers, increasing rates of non-medical use of the drugs driving further prescribing. It's kind of a snowball effect over the last ten years of misuse leading to additional prescribing and more ambient levels of drugs in society, the more is available for diversion and people taking from friends and relatives left over drugs in the home. So it's a complex situation that many social and clinical factors have combined to create the highest use of opioid analgesics of any country in the world.\nLoretta Jackson Brown:\nThank you. And Dr. Tauben, I'm going to combine two questions from the Webinar system. And one has to do with positive urine drug screening for marijuana in patients who are also taking methadone for chronic non-cancer pain and how do you look at those drug screens as well as methadone being used safely in patients with cirrhosis.\nOkay, well let me, that's good that's, let me do the second question first. The answer is it's a risky proposition based on the principle hepatic metabolism. So that would not be a recommended choice of opioid. One would pick one that has a more balanced excretion and pattern that would include urine excretion, I'd pick long-acting morphine for instance which isn't costly. But I would not use methadone in a patient with cirrhosis. The earlier question is a lot harder. It almost requires a Doctor of Jurisprudence, not a Doctor of Medicine to answer, and perhaps at a national level. But the DEA restrictions on prescribing opioids in the setting of the known illicit drug use does come into effect. So if in your state medical cannabis, or marijuana, is not allowed, the use and finding of marijuana in a urine test would indicate clear illicit use and therefore there is some risk by the provider to provide any opioid. In Washington State it's more confusing. Washington is a state that has permitted with, under our administrative code, a legal use of cannabis for certain set conditions. And in this setting we consider cannabis, if it meets criteria, a legal drug. And therefore, one is not encroaching DEA restrictions on its use. And so I would number one, in conclusion state it is really a state by state decision. And again it's a provider by provider decision. And in our clinic for instance, several of our providers consider use of medical cannabis a contraindication for any opioid. And other providers who I admire and respect, and I would include myself in this group, I will prescribe an opioid in the setting of medical cannabis but I will make certain I understand why the patient is using cannabis, for what purpose. Are they relieving anxiety and distress? And perhaps to be better means that are non-pharmacological and other strategies other than the reliance on medication that they've chosen that may have other psycho-active effects. So it's a very complicated question and it requires number one, an analysis of your state policy and then your own clinic operational policy as to its co-prescribing.\nLoretta Jackson Brown:\nThank you. Operator, do we have another question from the phone?\nDr. (Lyon), your line is open.\nThank you, great presentation, really enjoying it. You had responded a little bit earlier to a question regarding the use of benzodiazepines and concurrent IV methadone use. I wanted to go back to just PO benzodiazepine and PO methadone use. Would you feel that they are also contraindicated there?\nActually it's a great question and I would say it is a relative contraindication, a relatively strong contraindication. But there are certainly circumstances in which benzodiazepine's oral and oral opioid including methadone are indicated. It needs to be with great degree of caution. And I'll quote one of the medical students who works with me, he says, "Well you keep telling me, Dr. Tauben, that we're not supposed to give opiates with benzos and why are all of our patients coming into this clinic on opiates and benzos?" And therein lies the rub, that it is very difficult for most providers to manage anxiety. And since anxiety is such a co-occurring disorder with chronic pain, it is a difficult challenge. And this is where non-pharmacological strategies are extremely valuable, getting your behavioral health team on board, learning how to manage anxiety with other strategies. And I would typically recommend in this circumstance a formal psychiatric consultation to see if there is another strategy that might be effective to control the patient's anxiety which would be driving typically the requirement for benzodiazepines. But it is a yellow, orange, red flag alert. Doesn't mean we don't do it in clinical medicine. But it would be an exception rather than any common practice approach.\nThank you. I have a follow up for that. I am at the VA. There are a significant number of patients with Post Traumatic Stress Disorder and chronic pain who are on benzos and methadone or other opiates. And it becomes a very, often confusing situation as to how to treat these comorbidities, especially with such a potentially dangerous combination.\nI agree. And the veterans have a unique challenge in this. We see a lot of PTSD in a variety of other civilian situations. So we're confronting this both at the Seattle VA and here at UW. And our approach has been generous use of prazosin as an urgent blocking aide. And we titrate up until nightmares are limited and the patient reports adequate sleep. We dose patients up over 20 to 40 milligrams of prazosin for PTSD management. And typically in that setting we are able to if not eliminate benzodiazepines completely, can lead to a substantial dose reduction in the benzodiazepine. So that has been one effective strategy. Administration of other psycho-active drugs that are less sedating in the antidepressant category, recognizing that QTc becomes an issue here. Also, it becomes part of the therapy, but most importantly cognitive behavioral therapy, relaxation, mindfulness, and other strategies other than benzodiazepines are our target.\nBy no means, Dr. (Lyon), am I implying that this is easy or that we're going to succeed in all cases, but it is really worth careful attention to this factor. And we spend a lot of time focused on getting the patients off the benzodiazepines. And many times that we will not do anything about the high dose opioids and focus first on getting the Benzodiazepines stabilized onto, not the short acting but the long acting agents at the lowest possible dose before we even begin to tackle the other projects. But prazosin has been a very effective drug for this and I don't know if this is (listed) approved indication or not and, I will state that to be certain to check to see if this is a recommended or just a clinical practice that's commonly used approach in use of this drug.\nVery good. Thank you.\nLoretta Jackson Brown:\nThank you. Dr. Paulozzi, can you comment on MMWR article in February that discussed utility and results in reducing overdose from increased access to (narcan)?\nSure, yes. There was a national survey of naloxone programs that provided naloxone to people for community use to, for treatment of acute heroin and opioid analgesic overdoses. And a number of programs such as Project Lazarus in North Carolina and physicians at Fort Bragg have started implementing co-prescribing of naloxone with opioid analgesics so that the individual and more importantly their family have access to and training in use of naloxone in case of an overdose. I think that this is a promising strategy that is growing across the United States. There are issues in terms of the availability of a nasal spray formulation of naloxone, which appears to be the easiest one to use. And there are general issues as to which patients is it appropriate to co-prescribe naloxone with. The suggestions in the data of course is that the drug at higher risk include drugs like methadone. And patients that are at high risk are those are taking high daily doses any opioid analgesic. And so those would be the highest risk groups. But, the approach is under investigation, people are studying it. We know that it's being done, naloxone use is being reported in a number of overdoses. And we hope to get additional information that would allow and evidence-based recommendation as to when co-prescribing or distribution of naloxone would be appropriate.\nLoretta Jackson Brown:\nOkay, thank you. Operator, we have time for one more question over the phone.\nAnd showing no questions on the phone lines.\nLoretta Jackson Brown:\nOkay, well thank you. So on behalf of COCA I would like thank everyone for joining us today, with a special thank you to our presenters, Dr. Paulozzi and Dr. Tauben.\nIf you have additional questions for today's presenters, please email us at [email protected]. Put August 1, COCA call, in the subject line of your email and we will ensure that your question is forwarded to the presenter for a response. Again that email address is [email protected].\nThe recording of this call and the call transcript will be posted to the COCA web site at emergency.cdc.gov/coca within the next few days.\nFree continuing education credits are available for this call. Those who participated in today's COCA conference call and Webinar and who would like to receive continuing education credit should complete the online evaluation by August 31, 2012 using course code EC1648.\nFor those who will complete the online evaluation between September 1, 2012 and July 31, 2013, please use course code WD1648. All continuing education credits and contact hours for COCA conference calls are issued online through PCE online, the CDC continuing training education online system at www2a.cdc.gov/tceonline\nTo receive information on upcoming COCA calls and to subscribe to COCA you can send an email to [email protected] and write subscribe in the subject line.\nCDC launched a Facebook page for health partners. Like our page at facebook.com/cdcpartnersoutreach to receive COCA updates.\nThank you again for being a part of today's COCA's Webinar. Have a great day.\nThank you. This does conclude the conference. You may disconnect at this time.\n- Page last reviewed: August 1, 2012\n- Page last updated: August 1, 2012\n- Content source:\n- Maintained By: |
When you pick up your cat from a place like Caring Hands Animal Hospital after their spaying or neutering operation, you may be surprised at how calm and groggy they are. For a few weeks, they're going to need attention and care. Keep these post-operation suggestions in mind.\nKeep Them Warm\nIn the hours after the operation, your cat could shiver from time to time. The anesthesia used could be the reason why, as it affects their body temperature. Do your best to set your cat up with a blanket, one of your t-shirts or cuddle them a bit to keep them warm.\nThere is another reason for shivering that you need to know about, however. They could be experiencing pain as the anesthesia wears off. It's critical to ensure you're giving the pain medicine the vet has recommended; if shivering continues well into the next day, call them for further guidance.\nDon't Let Them Out\nOne of the reasons you might have scheduled the operation for your cat in the first place is that they go outdoors and you want to avoid pregnancy. However, in the days following their operation, they shouldn't return to their regular routine. It's important that they heal and don't tear open their incision wound. In addition, if your female cat had their surgery done during a period when they were "in heat", attracting males will still be a lingering affect and that will be an annoyance to deal with while recovering from surgery.\nBe Especially Mindful of Other Pets and Children\nEveryone might be interested in your cat after their surgery, but they may be uncomfortable and attempt to scratch or even bite even more than usual. Monitor small children and your other pets to keep them safe and to ensure your cat gets enough space.\nWatch for Infection\nLike any wound, your cat's incision area needs to be watched for bacterial infection. This is vital when looking after an animal, because they can't tell you if they're feeling worse than before. The area should never become dark red or feel hot when you touch it. Sometimes, if you see pink or clear liquid seeping from their wounds, you might worry. This is normal, though; worry should only set in when seepage is green, yellow or foul-smelling.\nYour cat should return to their normal ways in a matter of weeks. If you're concerned or need questions answered, contact your vet right away. |
A study conducted to analyze the competence of medical staff in the operating room, has revealed that nurses exhibit the highest level of teamwork and increased awareness regarding operating room safety. Surprisingly, doctors were found to rate the lowest with respect to teamwork.\nThe survey, called the Safety Attitudes Questionnaire (SAQ), was adapted from an airline industry questionnaire and applied to the health care environment. The SAQ, developed by a Johns Hopkins-led team, contains 65 questions in six areas relating to safety, including teamwork climate, safety climate, job satisfaction, perceptions of management, stress recognition and working conditions. Results appear in the May issues of the Annals of Surgery and the Journal of the American College of Surgeons.\nOnly 65 percent of OR personnel thought surgeons exhibited a high or very high level of teamwork. In contrast, 83.5 percent of those surveyed believed general surgical nurses exhibit a high or very high level of teamwork and 85 percent rated certified registered nurse anesthetists (CRNAs) as showing a high or very high level of teamwork. Anesthesiologist rated third at 79 percent.\nMakary says other questions, like ones that directly ask OR teams members if they would feel comfortable being operated on in their own hospitals, send a clear message regarding patient safety concerns in the OR.\n'The bottom line is, you wouldn't want to fly with a pilot or copilot who wasn't happy with his working environment and the same applies to the OR,' he says.\nThe SAQ was adapted from the Flight Management Attitudes Questionnaire (FMAQ) and its predecessor, the Cockpit Management Attitudes Questionnaire (CMAQ), both of which were developed to address accidents in the airline industry. The theory behind all these surveys is that improving work-area issues improves safety, according to co-researcher J. Bryan Sexton, Ph.D., an assistant professor of anesthesia and critical care medicine at Hopkins. The survey is not limited to the OR. Variations of the SAQ have been used to analyze work environments throughout the hospital, he says.\n'We found that using frontline caregiver assessments of patient safety can give you a valid and reliable consensus on how things are going in a particular patient care area, and that this is related to important outcomes like hospital acquired infections, length of stay and nurse turnover,' says Sexton.\nReports by the Institute of Medicine regarding safety in the OR, rising malpractice costs and the demonstrated vulnerability and devastation hospitals face after public exposure of deaths due to OR errors have all drawn attention to the importance of developing sound hospital systems to reduce OR errors. As a result, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will require all hospitals to measure their culture beginning in 2007.\nWrong-site/wrong-procedure surgeries, retained sponges, unchecked blood transfusions, mismatched organ transplants and overlooked allergies are examples of potentially catastrophic events that, in certain circumstances, can be prevented by improved communication and safer hospital systems.\nThe team fine-tuned the SAQ by reviewing the literature on patient safety, by asking OR health care providers to review the survey, and by conducting focus groups.\nThese SAQ questions were presented to all OR caregivers in a Catholic health system comprising 60 hospitals in 16 states during July and August 2004. Results were gathered from 222 surgeons, 1,058 OR nurses, 564 surgical technicians, 170 anesthesiologists and 121 CRNAs. On each question on teamwork, participants were asked to rate themselves and their peer groups on a scale of 1 (very low) to 5 (very high). The overall response rate was 77.1 percent.\n'The results have already led to improvements in the OR,' says Makary. 'Before every operation, we now require a presurgery checklist similar to what pilots do before take-off. This not only minimizes errors but also improves teamwork.' Makary says 700 hospitals are already using the survey, and he expects to see more adapting it in the near future. |
Is it really all in the eyes? Believe it or not, studies show that the eyes are good reflectors of one’s vitality and age. In determining fatigue, studies reveal that participants look primarily at the eyes and then the nose of a person, followed by the forehead and the eyebrows. It is for this reason that cosmetic eyelid surgery – also known as blepharoplasty – is considered as one of the popular cosmetic procedures done in the US.\nDo note that cosmetic eyelid surgery also poses risks. A few of these include burning of the eyes, itching, sensitivity to light, dry eyes, double and blurred vision which could last for a few days. Though eye drops which lubricates the eyes help to relieve a few complications, swelling also occurs as well as scarring.\nThere may be instances where patients will find it difficult to close the eyes especially during sleep. Though this is extremely rare, there are cases wherein such a complication could become permanent. Another complication which could occur is termed as ectropion – a rare condition wherein the lower eye lids seem to be pulled down. The eyes may similarly appear asymmetrical.\nAs is common with other surgical procedures, cosmetic eyelid surgery is also susceptible to infection as well as negative reaction to anesthesia. In order to avoid this situation, one must select the proper plastic surgeon as well properly follow post-operative and pre-operative instructions.\nPrior to going through cosmetic eyelid surgery, it is best to first discuss your questions and concerns with a competent plastic surgeon who is board-certified as well as an opthalmologist. Some surgeons will also show patients pictures of other cosmetic eyelid surgery patients who possess similar eyelids. You can use the pictures to create your own unique surgical plan in order to get an idea of what you need to expect from the blepharoplasty.\nA few of the questions you need to ask your cosmetic surgeon is his or her credentials, the training he has undergone, how many times he has performed a blepharoplasty, the specific anesthesia to be administered, where the procedure will be performed, the limitations and recovery period as well as the risks and all complications which could possibly occur.\nThe cost of a droopy eyelid surgery varies so it is complicated to offer a price range. Take note that one eye could have a cost that is different from the other eye. The best way to know a cosmetic eyelid surgery’s cost is to have a surgeon examine your case as well as discuss your specific surgical plan and expectations. The cost of cosmetic eyelid surgery includes facility fees, anesthesia cost and fees for the surgeon. You can similarly ask your surgeon if you have questions with regards to filing for insurance as blepharoplasty may not be covered. |
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