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By J. Lisk. Lafayette College.

Infusion ports were connected to external infusion pumps but suffered from an increased risk of infection and patient discomfort buy cheap levitra professional 20 mg erectile dysfunction caused by hemorrhoids. In one chamber levitra professional 20mg otc impotence underwear, a two- phase (gas and liquid) charging fluid (Freon) is permanently sealed be- tween the bellows and the outside wall of the cylinder. The other chamber is the drug reservoir, which is filled percutaneously via a self- sealing septum. As the reservoir is filled, the charging chamber is compressed and the charging fluid returns to a liquid state. As the fluid is warmed to body temperature, it converts to a vapor at a reasonably calculable rate, exert- ing pressure on the drug chamber. This pressure then forces the infusate through an outlet filter and a flow-restricting capillary tube assembly. The final result is a constant flow of medication if the surrounding tem- perature and pressure remain constant. These systems are reliable and simple; they are limited in their longevity only by the lifetime of the self- sealing septum, which must be punctured for refills. The systems are sub- ject to variable flow rates with altitude, as in mountain travel or on air- planes (increased flow), and most commonly elevated temperatures such as fever or a hot tub (increased flow). An inconvenience of these systems is the need to drain the reservoir and existing drug waste to add a more or less concentrated drug when the prescription is altered. The early efficacy and safety of intraspinally administered medica- tion was established by constant flow rate systems. Medtronic and Arrow Interna- tional in the United States, and Tricumed and Medtronic in Europe currently offer such systems. In 1988 the Medtronic Corporation introduced an externally pro- grammable, fully implantable pump in response to the demand for the ability to change a drug prescription without the need to physically re- FIGURE 15. This device was originally released for the treatment of cancer- related pain in the late 1980s and became commercially available for pain of all types in 1991, after 7 years of clinical trials. This device is an implantable, programmable, battery-powered pump that stores and delivers medication according to instructions delivered by an external programmer (Figure 15. Like constant flow rate pumps, the programmable pump is filled through a self-sealing septum into a drug reservoir. A bellows config- uration allows the drug reservoir to collapse as drug exists the cham- ber and to expand as the chamber fills. The programmable pump con- sists of a battery module, an electronic module for programming and pump control, and a peristaltic pump motor that pulls infusate from the reservoir by compressing internal tubing. The rate of drug deliv- ery is determined by the turning rate of the pump motor, which is con- trolled by the programming of the microprocessor in the electronic module. A telemetry unit allows communication with an external pro- gramming unit (Figure 15. Medication passes through the pump tubing by action of the peristaltic pump, exits the pump through the catheter port, and flows through an extension catheter to the intraspinal catheter and to the epidural or intrathecal space. The programming unit is essentially a laptop computer, printer, and a programming wand, as illustrated in Figure 15. The programming wand establishes a two-way radiofrequency link with the implanted pump. The programmer transmits interrogation and programming sig- nals to the pump and receives information from the pump. This capa- bility has established the implantable, programmable pump as the ideal approach for patients with chronic pain. A des- ignated implant coordinator does coordination of patient education and follows a patient through the implant routine. This person should be a healthcare professional skilled in monitoring all aspects of the tech- nique, including preoperative screening trials, surgical implantation and support, pump programming, pump refilling, long-term manage- ment of the patient, and recognition of potential adverse events. The management clinic should have the customary multidisciplinary access necessary to fulfill the requirements for patient selection, in- cluding psychological services.

The following specific action items emerged from the low back pain demonstration that are within MEDCOM’s authority and responsibility: • Maintain the proactive role of MEDCOM in managing a coordi- nated guideline implementation program across the system levitra professional 20mg low cost impotence of proofreading, in- cluding the responsiveness it has shown to MTFs as they have pursued local implementation activities discount 20mg levitra professional visa erectile dysfunction symptoms treatment. MEDCOM has eased the workload for MTFs by providing tools and technical guid- ance, thus enhancing the potential to achieve practice improve- ments. The analytic function should be equipped to provide training and support to MTFs for their local monitoring processes. Set objectives and define which aspects are mandated and which are left to MTF discretion. Maintain a bal- ance between flexibility for local MTF approaches and sufficient policy direction to be sure that AMEDD is moving toward greater consistency in practices. Although the low back pain documentation form was shown to improve provider efficiency, it became a point of con- tention that often distracted from the real task at hand. The number of new forms will multiply as more guidelines are intro- duced, which could be detrimental for the program if not pre- sented appropriately. Contract providers resisted participation for the low back pain guideline, and they were not actively involved in other demon- strations. These attitudes are due in part to financial incentives created by their contracts, where they are paid based on the number of visits they complete, and time spent on any other ac- tivities is unpaid time. Individual MTFs are not likely to volun- teer for the extra work involved in taking the lead in communi- cating with others without incentives and support from above. Examples of issues that occurred in the low back pain demonstration (as well as later in the asthma and diabetes guideline demonstrations) include how to handle patients presenting with multiple concerns or diagnoses, place- ment of documentation forms in the medical chart, procedures for use of diagnostic codes for visits, and reading levels for pa- tient education materials. Summary xxvii • Managing care according to the DoD/VA practice guidelines rep- resents a proactive primary care management approach for pa- tients with specific health conditions. Thus, consider replacing traditional utilization review functions with this more proactive approach to achieve appropriate and consistent practices. LESSONS FOR THE TREATMENT FACILITIES As we observed the experiences of the participating MTFs during the demonstration, several items surfaced that MTFs are likely to face regularly in implementation efforts: • Momentum (or lack of it) will strongly influence progress in achieving new practices. Therefore, teams should strive to capi- talize on the momentum generated by the start-up activities when the team is defining problems and preparing its action plan. Two essential elements are to quickly go into the field to test new ideas, and to frequently communicate what is being learned with those not on the team. Lead- ership must hold the teams accountable for following through on implementation actions, monitoring progress, and achieving their goals. It is worth tak- ing the time required to educate all potential participants about the goals and contents of a guideline and to build their under- standing and acceptance of the best practices being introduced. Even the best designed and executed action plan is unlikely to change the practices of all patients and providers. Ongoing monitoring will suggest new areas that need to be addressed, and continuing in- terventions will be needed to sustain and spread changes needed for full compliance with practice standards by all those involved. Ide- xxviii Evaluation of the Low Back Pain Practice Guideline Implementation ally, the implementation team should establish the capability to provide monitoring feedback to its MTF clinics within a month or two after beginning implementation of new clinical practices. As each MTF defines its action plan and schedule, it should anticipate and plan for military rotations, in- cluding effects on the clinic staff and on the members of the im- plementation team itself. Any surprise personnel movements that affect staffing can be accommodated by action plan updates and revisions. ACKNOWLEDGMENTS An extraordinary amount of dedication and hard work by numerous individuals contributed to the performance of the AMEDD demon- stration for implementing the DoD/VA low back pain guideline in the Great Plains Region. In particular, we wish to acknowledge the efforts of the guideline champions, facilitators, and action team members at the Army treatment facilities—William Beaumont AMC, Darnall ACH, Evans ACH, and Reynolds ACH—participating in the demon- stration. Because this was the first demonstration, these individuals were faced with delays and other challenges during the early months, as MEDCOM, RAND, and the MTFs themselves experienced a steep learning curve—the proverbial "learning by doing. We also acknowledge the commitment of the leadership team mem- bers at MEDCOM who have guided this project and have partici- pated as active partners in both the development and evaluation work on the low back pain demonstration. LTC Kathryn Dolter, who has primary responsibility for the MEDCOM guideline implementa- tion program, has shown unflagging commitment to learning from our demonstrations and making this important program come to life. Her willingness to lead and to listen to those in the field have been critical factors in the progress made to date. The personnel in the Patient Administration Systems and Biostatistical Activity (PASBA) also made a major contribution to the evaluation by generating the administrative data for the analysis of the effects of guideline implementation.

Cunningham offers some good suggestions in her article "How to Talk to Your Doctor" (Woman’s Day buy levitra professional 20 mg free shipping erectile dysfunction rap, August 4 buy discount levitra professional 20 mg on line erectile dysfunction treatment san diego, 1987). Some doctors ask the spouse to wait outside while the patient is in the consultation office. Cunningham suggests that a good response would be, "I’m really not up to par today, and I would like my spouse to stay. I think he can help me to understand and remember what you say better than if I were alone. Cunningham suggests that the way to avoid being cut off is to tell the doctor at the beginning of your visit that you have three (or some other definite number of ) symptoms to discuss with him or her. Then, if the doctor tries to cut your visit short, remind him or her that you still have other symptoms to discuss. If the diagnosis or the explanation is in medical jargon that you don’t understand, ask the doctor to explain it again in plain Eng- lish. Suppose you are still concerned about certain symptoms or side effects of medications, and the doctor says there is nothing to worry about. Also, ask your doctor to explain the nature and the purpose of any tests, treatments, or other proce- dures he or she orders for you. I can’t emphasize enough the importance of finding a doctor who will educate you about Parkinson’s, who will tell you where to find more information, and, above all, who will listen carefully to you. Because Parkinson’s symptoms, progression, and reactions to medication are so different for every individual, the doctor needs to listen to whatever you report and to observe you, in order to prescribe the medications and the dosages that are best for your individual case and to make suggestions about how you might change your daily habits. It would be helpful if, for several days each month, you kept a record of your symptoms each hour, over several pill cycles. Go over the records of these days with your doctor, letting him or her know the types of symptoms you expe- rience and at what point in the pill cycle you experience them. Distinguish between the symptoms of Parkinson’s disease and the symptoms caused by overmedication or intolerance to medication (see the next chapter for a discussion of both types of symptoms). Only when he or she is aware of the pattern of your symptoms will your doctor be able to prescribe the most effective medica- tions and the correct doses. After a change in drugs or dosage, you should be seen every two to three weeks for fine-tuning, until you have achieved 72 living well with parkinson’s the best balance of medication. If you experience bizarre or dis- turbing reactions, don’t wait for an upcoming appointment; call your doctor right away. I have heard the complaint from many patients: "My doctor treats me with ‘How are you? If you can’t get your doctor to instruct you and listen to you, look for another doctor. A few are so solicitous of their doctors’ feelings that they don’t report the re- sults when a treatment isn’t working. Parkinson’s patients may find it helpful to read the United Par- kinson Foundation’s pamphlet The Patient Experience, which focuses on the things that occur during a neurological examination. Call or write to the United Parkinson Foundation (see appendix A for the address and the telephone number). Doctors, of course, are not the only components of your Par- kinson’s medical team. Early in the course of your treatment, and from time to time after that, you should meet with physical and occupational therapists who will teach you important techniques for living with Parkinson’s. They will teach you, for example, to walk with your feet well apart—about 8 inches (20 cm) apart—to give you a wider base, which helps prevent falls. They will teach you how to get yourself going when you "freeze" and how to get out of bed without falling. They will help you learn the exercises you need to do in order to maintain your muscles, flexibility, and health. If you have any problems with speech, a speech therapist should be part of your team, helping you to overcome this imped- iment. The speech therapist will also teach you to doctors and other health professionals 73 swallow properly so that you don’t develop pneumonia that is caused by swallowing food into your lungs.

There is much more about managing the symptoms and lifestyle changes in the rest of this book purchase levitra professional 20 mg online erectile dysfunction drugs mechanism of action. Although there are significant geographical variations in the distribution of people with MS throughout the world purchase levitra professional 20mg free shipping erectile dysfunction queensland, a great deal of research has failed to uncover any tangible evidence that there are specific avoidable risk factors associated with the onset of the disease. Genetic versus environmental causes At present, the most likely cause appears to be a combination of genetic and environmental factors. Studies of identical twins, where one or both has MS, offer what might be called the ‘purest’ way in which to investigate this theory: it appears that genetic factors contribute between 30 and 35% and environmental factors about 65–70% of the total contribution to the cause. These two figures suggest that further research needs to be undertaken on both issues. There does not seem to be one simple gene linked to MS, but we do know, for example, that first- degree blood relatives of someone with MS, such as children and siblings (brothers and sisters), are at slightly enhanced risk of the disease. Amongst many other theories about the causes of MS, there has been a particular interest in the role of ‘heavy metals’. It is certainly true that an excess of some heavy metals in the body, such as lead, mercury and cadmium, may result in serious neurological damage. Lead in particular is a potential cause of neurological damage, although, with the reduction of lead in petrol, it is gradually being reduced in our environment, but at present there is no evidence that excess lead causes MS. Excess mercury can also produce neurological damage, and there has been much discussion about the possible problems with mercury-based dental fillings. However, a large proportion of the adult population will have had at least some mercury fillings in their lifetimes, and yet only a fraction of those people have MS. Dental amalgam does contain mercury which can erode over time and be absorbed into the bloodstream, but this is a very small contribution to the amount of mercury ingested by most people MULTIPLE SCLEROSIS EXPLAINED 9 (deep-sea fish is a much greater source). The exposure to dental amalgam is well within the safety limits currently recommended for mercury. Infections and other diseases Research has not shown MS to be caused by any particular bacterial or viral infection, but it is possible that the timing of a relapse may coincide with an infection. This could be due to a change in immune activity that allows the infection to gain hold: the bacterial infection can trigger an immune response, or both the relapse and the infection may occur in response to some unknown third factor. Candida At present there is a widespread interest, particularly amongst many involved in alternative or complementary medicine, in Candida albicans (thrush). Although candida can be associated with many symptoms, as well as having a low-level but debilitating effect on health, there is almost no formal evidence that it is associated with relapses of MS in itself. Candida infection may be a result rather than a cause of a weakened immune system, and it is also known to be more common as a side effect of some anti-inflammatory drugs used in MS. Of course, any infection with potentially problematic symptoms should be treated with antibiotics. Herpes Amongst viruses that have prompted scientific interest in relation to MS, the herpes virus HHV-6 is one of a number currently being researched. However, as with other viral candidates for a cause of MS, this line of enquiry is controversial and much debated. Lyme disease There is no evidence that this disease, which is spread by tics living on a range of animal species in the countryside, can cause MS, although its symptoms may mimic those of MS. Research studies have failed to demonstrate any link between injections (vaccinations or inoculations) and any subsequent worsening of the MS. There is no clear definitive link that been established between the prior effects of diseases and the onset of MS. Of course as MS progresses, it may itself give rise, in effect, to other conditions, through a weakened immune system or just by ageing, for example. There is no known link between cancer of any type and MS, but it is to be expected that some people with MS will develop cancer, but no more frequently than people who do not have MS. Autoimmune diseases There are strong similarities between some aspects of other autoimmune diseases, where the immune system is triggered into mistakenly attacking normal tissues in the body, and some aspects of MS. At present these conditions are still thought to be completely separate disease entities, although it is possible that there may be some very general biological processes underlying these conditions. Stress Fatigue, and possibly what we call ‘stress’, could have had some effect, not as a cause of MS, but perhaps as an exacerbating factor on some symptoms. However, although most people with MS probably feel that undue stress in their lives may bring on a relapse, scientifically this issue is still being argued over. Even so, many people have their own ideas about things that they feel are linked with their MS symptoms, and try to avoid them.

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