tag:blogger.com,1999:blog-47485611227105250702024-03-08T15:26:16.219-08:00healthcare, say what??Health care, Medical care.... truly, does anyone care?Unknownnoreply@blogger.comBlogger16125tag:blogger.com,1999:blog-4748561122710525070.post-6127756308672707812023-02-23T05:27:00.000-08:002023-02-23T05:27:42.705-08:00Lymphedema Treatment Act Passed<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjqyjrfLJx9LuVkFhInWmyrd7cJtF9CcXhUjqpI-NOVT6f4sHb9gVBlutvHouHrmraZTNersKUg4j1zn-Emeh2-n1e7CZS2_nKBvprU2AQK-4t-XC3sYKKtIGLpu4jBu_8eHymnqfh_qh__Zv48pmG0OhJMiMRylwYZM46jNpqN14wAV1gcnZVjae4/s768/We-Did-It-768x512.webp" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="512" data-original-width="768" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjqyjrfLJx9LuVkFhInWmyrd7cJtF9CcXhUjqpI-NOVT6f4sHb9gVBlutvHouHrmraZTNersKUg4j1zn-Emeh2-n1e7CZS2_nKBvprU2AQK-4t-XC3sYKKtIGLpu4jBu_8eHymnqfh_qh__Zv48pmG0OhJMiMRylwYZM46jNpqN14wAV1gcnZVjae4/s320/We-Did-It-768x512.webp" width="320" /></a></div><br /> <p></p><p>The educational process continues with this most unfortunate diagnosis that can be appropriately managed through proper and early intervention. <br /></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-49217891853259720072021-05-24T07:50:00.004-07:002021-05-24T07:53:31.637-07:00Lipedema— the push for medically necessary care <p><!--[if gte mso 9]><xml>
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</p><p class="MsoNormal" style="text-align: center;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 16.0pt; line-height: 115%;"></span></b></p>
<p class="MsoNormal">Lipedema is a misdiagnosed fatty disorder, commonly mis-characterized
as obesity (Herbst, 2012).<span style="mso-spacerun: yes;"> </span>It
predominately impacts women, roughly 10% of the female population (Kruppa et al,
2020). <span style="mso-spacerun: yes;"> </span>To date, a strong effort is being
proposed in the United States for creating an actual diagnosis code for
lipedema.</p>
<p class="MsoNormal">According to Herbst (2012), treatment for lipedema ranges
from conservative treatment with lymphatic drainage, aquatic therapy, whole
body vibration, compression strategies and some supplements, to an effective surgical
intervention known as liposuction.<span style="mso-spacerun: yes;">
</span>However, many insurers feel this surgical procedure is cosmetic and not considered
medically necessary, resulting in increased out of pocket costs or the
avoidance of timely restorative, medical care.</p>
<p class="MsoNormal">According to a review of several insurance policy handbooks,
to be considered as reconstructive and medically necessary, the procedure must
be proven to:</p>
<p class="MsoListParagraphCxSpFirst" style="margin-left: .35in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Improve or restore normal function, such as
activities of daily life, mobility and gait.</p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: .35in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-spacerun: yes;"> </span>Restore
the patient to a normal appearance.</p>
<p class="MsoListParagraphCxSpLast" style="margin-left: .35in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-spacerun: yes;"> </span>Improve
the quality of life (QOL) of the patient (ie. pain and fatigue).</p>
<p class="MsoNormal">Sadly, many liposuction recipients and surgeons are allowing the insurer's definition of this surgical procedure to be misconstrued as experimental or investigative and not being appropriately deemed
as a medically necessary intervention. <span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></p>
<p class="MsoNormal">Please stay vigilant and pursue the challenge of getting
these surgical interventions covered by your insurer by going through their
medical review process.<span style="mso-spacerun: yes;"> Ask the assistance of your medical team, this is not a tattoo or a haircut, it is a legitimate lipedema treatment for those having tried many years of conservative care. </span>Remember, lipedema is a progressive
disorder and may eventually lead to a comorbidity of lymphedema and/or obesity
(Herbst, 2012).<span style="mso-spacerun: yes;"> </span></p>
<p class="MsoNormal">You have the right to not suffer with pain of a “6” on a “10”
scale; you have a right to not feel heaviness in your limbs; you have a right
to not panic about cellulitis when bitten by a bug or scratched by your pet;
you have a right to feel comfortable in your clothing and so on….. while we do need more
good lipedema research (Peprah et al, 2019) we must continue to gather data in hopes of making these treatment choices irrefutable.<span style="mso-spacerun: yes;"> </span>Many medical
complications from lipedema can be mitigated if addressed early on.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal" style="text-align: center;">References:</p>
<p class="MsoNormal" style="line-height: normal;">Herbst KL. Rare adipose disorders
(RADs) masquerading as obesity. Acta Pharmacol Sin. 2012;33(2):155–72.</p>
<p class="MsoNormal" style="line-height: normal;">Kruppa P, Georgiou I, Biermann N,
Pranti L et al. Lipedema- pathogenesis, diagnosis, and treatment options. Dtsch
Arztebl Int. Jun 1, 2020; 117(22-23):396-403.</p>
<p class="MsoNormal" style="line-height: normal;">Peprah K, MacDougall D.
Liposuction for the Treatment of Lipedema: A Review of Clinical Effectiveness
and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and
Technologies in Health; 2019 Jun 7. PMID: 31479212.</p>
<p> </p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-28561407224123668152018-11-26T07:47:00.000-08:002018-11-26T07:47:40.486-08:00Spinal Cord Stroke--- Un-cloaking the fibrocartilaginous embolism It has been close to a year since my cousin passed away from complications involving a fibrocartilaginous embolism (FCE) in her upper cervical spine. Sadly, after 14 years of learning about an FCE, it is still listed as a rare disorder with most research being performed by Veternarians due to the high occurrence rate in dogs. Currently, there is still very little published about the impact of an FCE on human lives.<br />
<br />
Why are we not hearing about the impact of FCE on human lives? Well, one reason is it usually occurs in young people (under age 30). Best restorative prognosis is in the very early years of life, but there are too few documented occurrences in older patients to encourage further study. The second reason is the lack of immediate, effective treatment as it does not respond to "clot busters" or methylprednisone, making it one of those issues with little evidence based data and a small cohort. The third reason is its misdiagnosis as another nasty neurologic issue such as Transverse Myelitis (TM), Guillian Barre (GB) or Arterio-Venous Malformation (AVM). And finally, the fourth reason being the inaccurate characterization as "death by unknown cause", further minimizing the actual occurrence rate of an FCE.<br />
<br />
The sad, but typical scenario of an upper cervical FCE is the onset of severe headache/arm symptoms, eventual weakening and finally the shutting down of one's ability to breath or vocalize. Many of these patients simply pass away quietly; toxicology, cardiac and cerebral screens all appearing negative. Many of these cases continuing to fall into the category of "death by unknown cause". The challenge for the future is to help educate and expose the incidence of this nasty disorder, learning to question and identify it early so there can be a movement towards an effective and immediate treatment plan. This amount of suffering needs to come to an end soon..........and this diagnosis needs to be UN-cloaked.<br />
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-37280029192856897502018-03-25T06:10:00.000-07:002018-03-25T06:11:49.211-07:00Buying a gun with more ease than purchasing Sudafed<span style="color: purple;">I saw very interesting signs while attending the March for our Lives on 3/25/18. It was absolutely amazing listening to the young speakers, raw with emotion yet hopeful for the future. The most eye opening sign was the fact that a young person can purchase a gun with greater ease than purchasing Sudafed, a "behind the counter" product. Thinking it is time to change up some laws.........</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-14819272274853803802017-03-21T07:22:00.000-07:002017-03-21T07:22:04.909-07:00Cellulitis--Collaborative care is best practice<!--[if gte mso 9]><xml>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"> Skin infections encompass
many specialty groups, ranging from infectious disease and lymphology societies
to wound care specialists and emergency room clinicians, all uniquely aware of
the huge personal and financial cost incurred when infections are not handled
in a prompt and effective manner.<span style="mso-spacerun: yes;"> </span>The collaborative
management and treatment of cellulitis, an acute and rapidly progressing bacterial
skin infection, is critically important as 2.5% of the general population is
impacted by this disorder and its high level of recurrence when not addressed promptly
and effectively (Nguyen, Rowland & Mounsey, 2014).</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Cellulitis is a rapidly spreading
inflammatory skin infection that specifically affects subcutaneous tissues and
is characterized by erythema (redness), swelling and localized tenderness (Goodman &
Fuller, 2009).<span style="mso-spacerun: yes;"> </span>These authors further
defined a sub-category of cellulitis called <i>erysipelas</i>, a surface cellulitis
that primarily affects the skin and upper dermis, although it may involve
lymphatic vessels with an appearance of redness and sharply defined borders
with occasional red colored streaking. Cellulitis presents as warm and painful
to touch, reddened and edematous in appearance, but with smooth and ill-defined
borders except in severe cases where it may contain pustules or areas of
necrosis (Sambrano, Gordon, Mays, Lapolla & Scheinfeld, 2012). According to
Mortimer and Rockson (2014), cellulitis and erysipelas are among the most
common conditions seen in emergency departments.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Erysipelas, usually caused by group A
Streptococcus, results in the sudden onset of fever, pain and redness (Koster,
Kullberg & Van der Meer, 2007).<span style="mso-spacerun: yes;"> </span>The typical
scenario that creates a predisposition to infection is the interaction between high
bacteria colonization and circulation of the blood, compounded by increased vulnerability
in moist areas of the body and on the lower extremities (Erbil et al., 2014).<span style="mso-spacerun: yes;"> </span>The predisposition to cellulitis or erysipelas,
is increased by the presence of skin disruptions or lymphedema, an abnormal
accumulation of fluid in the interstitial space (Koster, Kullberg & Van der
Meer, 2007).<span style="mso-spacerun: yes;"> </span>This interstitial edema
occurs when the capillary filtration rate exceeds the capability of the lymphatic
drainage mechanism (Trayes, Studdiford, Pickle & Tully, 2013).<span style="mso-spacerun: yes;"> </span>The lymphatic system tends to be one of the
most poorly understood body systems, however it has been identified as having
three specific functions that include fluid balancing, fatty absorption and
host defense (Mortimer & Rockson, 2014).<span style="mso-spacerun: yes;">
</span>Their feeling is the lymphatic system maintains volume homeostasis and
creates an adaptive immunity through its immune surveillance of antigen and
immune cell transport, all important aspects in the maintenance of a healthy
body.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Cellulitis and erysipelas are definitely more
prevalent in patients with lymphedema and skin disruptions, but other risk
factors include diabetes mellitus, chronic venous insufficiency and skin ulcerations
(Perello-Alzamora, Santos-Duran, Sanchex-Barba, Canueto, Marcos & Unamumo,
2012).<span style="mso-spacerun: yes;"> </span>These authors feel that rendering
a diagnosis of cellulitis is often difficult to provide or problematic in differentiating
from other conditions such as an abscess, as gathering cultures for microbiologic
analysis or isolating a pathogen is not always accessible or available.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>When the diagnosis of erysipelas is
rendered, studies have found these bacteria respond well to narrow spectrum penicillins,
such as benylpenicillin (penicillin G), <span style="mso-spacerun: yes;"> </span>or
to macrolides such as erythromycin, for patients allergic to penicillin (Koster,
Kullberg & Van der Meer, 2007).<span style="mso-spacerun: yes;"> </span>According
to Ciccone (2013), penicillin G is classified as an anti-infective and falls within
the pharmacologic category of penicillins. The anti-infective mechanism is the occurrence
of cellular death through its binding action to specific enzymes within the
cell wall, making the cellular membrane unable to act as a selective barrier
and unable to handle the high internal osmotic pressure of the bacterial cell
(Ciccone, 2007, p. 504).<span style="mso-spacerun: yes;"> </span>This anti-infective
mechanism makes it very effective in treating most gram-positive organisms,
some gram-negative organisms and a few anaerobic bacteria and spirochetes (Ciccone,
2013). <span style="mso-spacerun: yes;"> </span>Ciccone (2013) further states
that Penicillin G, known as a natural occurring penicillin, is particularly
helpful with streptococci and staphylococci, as well as some
penicillin-susceptible strains of <i style="mso-bidi-font-style: normal;">N.
gonorrhoeae </i>as it gets widely distributed throughout the body, although
poorly distributed in the central nervous system (CNS).</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>A
common adverse drug reaction (ADR) for penicillin is the frequency of allergic
reactions that may include hives, skin rashes, itching and difficulty
breathing, although in some cases it may even progress to life-threatening
anaphylactic shock (Ciccone, 2007, p. 505).<span style="mso-spacerun: yes;">
</span>Other ADRs mentioned were the possibility of seizures, with some milder gastrointestinal
side effects like colitis, nausea, vomiting and diarrhea, as well as nephritis,
eosinophilia and leukopenia.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>In the presence of an allergic sensitivity
to penicillin, a macrolide antibiotic such as erythromycin is the alternative
of choice for treatment of erysipelas and cellulitis (Koster, Kullberg &
Van der Meer, 2007).<span style="mso-spacerun: yes;"> </span>The role of the macrolide
antibiotic is to corrupt the peptide bonding between adjacent amino acids thus
disrupting structural and functional features at specific areas of the
ribosomes, resulting in the inhibition of bacterial synthesis (Sothiselvam et
al., 2014).<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>As with penicillin, erythromycin is an
anti-infective that is very effective with gram-positive streptococci and
staphylococci, and gets widely distributed throughout the body, although poorly
perfused throughout the CNS (Ciccone, 2013).<span style="mso-spacerun: yes;">
</span>According to this author there are several strong ADRs that include
ventricular arrhythmias, QT prolongation characterized by palpitations,
seizures or syncope, as well as pseudomembranous colitis.<span style="mso-spacerun: yes;"> </span>Other side effects mentioned were
gastrointestinal issues like nausea, vomiting, cramping and diarrhea, as well
as rashes, drug induced hepatitis and on rare occasion, drug induced
pancreatitis.<span style="mso-spacerun: yes;"> </span>Both penicillin and
erythromycin cross the placenta and enters into the breast milk (Ciccone, 2013).</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>The <u>diagnosis of cellulitis tends to be
based mainly on clinical findings versus microbiologic </u>results from needle
aspirations due to an issue of unreliable accuracy with organism identification
that is common in healthy hosts (Sambrano, Gordon, Mays, Lapolla &
Scheinfeld, 2012).<span style="mso-spacerun: yes;"> </span>These authors found
the most common cause of cellulitis was S. <i style="mso-bidi-font-style: normal;">aureus</i>
and streptococci, treated initially with beta-lactam, administered
intravenously in severe cases. <span style="mso-spacerun: yes;"> </span>Ciccone
(2007) characterizes beta-lactam antibiotics as cephalosporin drugs that
utilize a penicillin-like anti-infective mechanism to adversely impact the
integrity of cellular membrane (p. 505).<span style="mso-spacerun: yes;">
</span>He states that cephalosporin is commonly used as an alternative for
patient’s having difficulty tolerating penicillins, although it should not be
used in those having allergic reactions to penicillin.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>The treatment of cellulitis varies in
response to the specific causative agent, as methicillin-resistant S. <i style="mso-bidi-font-style: normal;">aureus</i> <span style="mso-spacerun: yes;"> </span>(MRSA) will typically require interventions
with vancomycin, linezolid or daptomycin (Sambrano, Gordon, Mays, Lapolla &
Scheinfeld, 2012).<span style="mso-spacerun: yes;"> </span>These authors feel
that vancomycin should be used with MRSA cellulitis, especially in the presence
of a penicillin allergy, but promptly switched to linezolid, an oxazolidinone, if
there is a vancomycin-resistant infection. But they all believe that
cellulitis, especially those atypical in nature or in the presence of MRSA,
should be treated in an empirical manner utilizing patient history, anatomic
site and clinical presentation for the most appropriate antibiotic choice.</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Vancomycin,
an anti-infective, also has an action of binding to the cell wall, resulting in
cell </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">death (Ciccone,
2013).<span style="mso-spacerun: yes;"> </span>He highlighted the most severe
ADRs as being hypersensitivity and anaphylaxis, with lesser side effects being
ototoxicity, hypotension, nausea, rash, chills and neck or back pain.<span style="mso-spacerun: yes;"> </span>This author feels vancomycin is also widely
distributed throughout the body and crosses the placenta, but it also allows
some permeation into the cerebral spinal fluid (CSF). </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Linezolid, an oxazolidinone, has an anti-infective
action that inhibits bacterial protein synthesis at the ribosomal level
(Ciccone, 2013). <span style="mso-spacerun: yes;"> </span>This author feels it
serves as a very effective treatment against streptococci, as well as having a
bacteriostatic action against staphylococci.<span style="mso-spacerun: yes;">
</span>Side effects of linezolid include headache, insomnia, diarrhea, nausea,
lactic acidosis, thrombocytopenia, as well as optic and peripheral neuropathies
(Ciccone, 2013).</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Recurrent episodes of cellulitis or
erysipelas manifest in spite of antibiotic treatment, whether curative or
preventive in nature.<span style="mso-spacerun: yes;"> </span>An analysis by
Koster, Kullberg and Van der Meer (2007) reported patient noncompliance,
incorrect selection of antibiotics, insufficient dosages or antibiotic
concentrations, as well as the possibility of other causative agents as reason
for recurrence.<span style="mso-spacerun: yes;"> </span>According to Cox (2005),
40% of cellulitis cases currently have recurrences. However, in a study summary
by Nguyen, Rowland and Mounsey ( 2014), they found the prophylactic use of
lower dose penicillin effective in reducing recurrence of leg cellulitis, but
feel that more trials are needed to determine if this lower recurrence rate
persists upon its discontinuation.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>In a study by Morgan and McGuckin (2013),
they found that collaboration between dermatology and lymphedema services created
a multi-specialist approach that provided prompt and effective management of
cellulitis.<span style="mso-spacerun: yes;"> </span>The treatment plan they
identified began with intravenous antibiotics that progressed to oral
antibiotics for 14 days, or until the cellulitis resolved, topical steroids and
wound dressings/soaks, if needed, followed by compression. From there they
highlighted the progression to multilayer compression wrapping using short
stretch bandages, followed by thorough instruction in self-care strategies for
good nutrition, hydration, proper skin care and manual lymphatic drainage
techniques. The final phase of this treatment plan was the progression to
custom or over-the-counter compression garments and the incorporation of appropriate
self-care strategies. </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Physical therapists treating patients with
lymphedema must always be aware of the potential for cellulitis or erysipelas, carefully
monitoring the skin on a daily basis.<span style="mso-spacerun: yes;">
</span>Once cellulitis is diagnosed it is important to monitor the involved area
of redness, either by measurement or photography, observing the impact and
effectiveness of the empiric antibiotic. Those therapists specialized in
complex lymphedema management will work with bandaging, skin care, compression
garments, manual lymphatic drainage and exercises. However, caution must be
utilized during the performance of an active physical therapy (PT) program as
these antibiotics possess ADRs <span style="mso-spacerun: yes;"> </span>ranging
from</span> <span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">anaphylaxis
and seizures to<span style="mso-spacerun: yes;"> </span>pseudomembranous colitis
(Ciccone, 2013).<span style="mso-spacerun: yes;"> </span>Side effects may include
nausea, fatigue, hypotension and neuropathies to name just a few, but all
require astute clinical observation for safety while attending the PT
appointment (Ciccone, 2013). <span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>In conclusion, the benefits of the collaborative
management of cellulitis are clearly presented in many studies similar to
Morgan and McGuckin (2013), with the education of healthcare professionals
being an essential aspect to insuring early antibiotic intervention or early referral
to appropriate dermatology or lymphedema services. Early intervention provides
significant patient benefits by limiting tissue damage and medical complications,
as well as significant cost savings through shorter hospital stays and less
frequent recurrences.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span></span></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>References</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Ciccone, C. D. (2007). <i style="mso-bidi-font-style: normal;">Pharmacology in rehabilitation</i> (4th ed).
Philadelphia, PA: F. A. Davis </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Company.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Ciccone, C. D. (2013). <i style="mso-bidi-font-style: normal;">Drug guide for rehabilitation professionals</i>.
Philadelphia, PA: F. A. </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Davis Company.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Cox, N. H. (2006). Oedema
as a risk factor for multiple episodes of cellulitis/erysipelas of the </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>lower leg: a series with community
follow-up. <i style="mso-bidi-font-style: normal;">Br J Dermatol,</i> <i style="mso-bidi-font-style: normal;">155</i>(5), 947-50.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Erbil, B., Ersoy, G.,
Ozkutuk, A., Akarca, F. K., Korkmaz, T., Demir, O. F. & Kiyan, S. (2014). <span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>The effects of oral antibiotics on
infection prophylaxis in traumatic wounds. <i style="mso-bidi-font-style: normal;">Ulus
Travma <span style="mso-spacerun: yes;"> </span></i></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Acil Cerrahi Derg, 20</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">(4),
231-235.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Koster, J. B.,
Kullberg, B. J. & Van der Meer, J. W. M. (2007).<span style="mso-spacerun: yes;"> </span>Recurrent erysipelas despite <span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>antibiotic prophylaxis:<span style="mso-spacerun: yes;"> </span>An analysis from case studies.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">The
Netherlands Journal of <span style="mso-spacerun: yes;"> </span></i></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Medicine, 65</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">(3),
89-94<i style="mso-bidi-font-style: normal;">.</i></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Mortimer, P. S. &
Rockson, S. G. (2014). New developments in clinical aspects of lymphatic </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>disease. <i style="mso-bidi-font-style: normal;">The Journal of Clinical Investigation, 124</i>(3), 915-921.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Nguyen, L., Rowland, K.
& Mounsey, A. (2014). Low dose penicillin for recurrent cellulitis? </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">The
Journal of Family Practice, 63</i>(1), E10-E12. </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Perello-Alzamora, M.
R., Santos-Duran, J. C., Sanchex-Barba, M., Canueto, J., Marcos, M. & </span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Unamumo, P. ( 2012). Clinical and
epidemiological characteristics of adult patients </span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>hospitalized for erysipelas and
cellulitis. <i style="mso-bidi-font-style: normal;">Eur J Clin Microbiol Infect
Dis, 31</i>, 2147-2152.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>DOI 10.1007/s10096-012-1549-2</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;">Sambrano, V.,<span style="mso-spacerun: yes;"> </span>Gordon, R., Mays, R., Lapolla, W. &
Scheinfeld, N. ( 2012). Intravenous<span style="mso-spacerun: yes;">
</span></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 150%;"><span style="mso-spacerun: yes;"> </span>antibiotics used in dermatology. <i style="mso-bidi-font-style: normal;">Dermatologic Therapy, 25</i>, 70-81.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Sothiselvam, S., Liu,
B., Han, W., Ramu, H.,<span style="mso-spacerun: yes;"> </span>Klepacki, D., Atkinson,
G. C.,.…. <span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Mankin, A. S. (2014 ). Macrolide
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>translation arrest. <i style="mso-bidi-font-style: normal;">PNAS,</i> <i style="mso-bidi-font-style: normal;">11</i>(27), 9804-9808.<span style="mso-spacerun: yes;">
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Trayes, K. P.,. Studdiford,
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span>Management. <i style="mso-bidi-font-style: normal;">Am Fam Physician</i>, <i style="mso-bidi-font-style: normal;">88</i>(2), 102-110.</span></div>
Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-4748561122710525070.post-12329001892202726362016-01-31T05:36:00.000-08:002016-01-31T05:58:08.758-08:00USE OF MANUAL LYMPHATIC DRAINAGE THERAPY FOR THE RESOLUTION OF POST-INFLAMMATORY HYPERPIGMENTATION: A CASE REPORT<!--[if gte mso 9]><xml>
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<![endif]--><b style="mso-bidi-font-weight: normal;"><span style="font-family: "times new roman" , "serif"; font-size: 12.0pt; line-height: 115%;">Background:</span></b><span style="font-family: "times new roman" , "serif"; font-size: 12.0pt; line-height: 115%;"> Literature suggests that manual lymphatic
drainage therapy (MLDT) can positively impact general skin complexion.<span style="mso-spacerun: yes;"> </span>MLDT was selected as treatment for dark skin
discolorations caused by post inflammatory hyperpigmentation (PIH).<span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;">Purpose:</b>
The purpose of this study is to observe MLDT in reducing PIH. <b style="mso-bidi-font-weight: normal;">Methods: </b>MLDT was performed on two adult
women for more than 2 ½ months. Skin was observed each session with photographs
taken pre/post treatment.<span style="mso-spacerun: yes;"> </span>Patient 1 had
PIH related to leg flea bites and familial predisposition; Patient 2 had PIH
from cystic acne at inner thighs. Each received 60-65 minute MLDT sessions,
performed full body and locally on hyperpigmented areas.<span style="mso-spacerun: yes;"> </span>Instruction in diaphragmatic breathing began
day 1, with each educated about diet and water intake.<span style="mso-spacerun: yes;"> </span>The Dermatology Life Quality Index (DLQI) was
provided pre/post treatment. Frequency of treatment was individualized, patient
1 coming twice monthly for 4 months and patient 2 was weekly for 2 ½
months.<span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;">Outcomes:</b><span style="mso-spacerun: yes;"> </span>Patient 1 had
noticeable improvement in skin discoloration at 2 ½ months, with near complete
resolution at 4 months. Patient 2 had partial resolution of skin discoloration at
2 ½ months.<span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;">Discussion:</b><span style="mso-spacerun: yes;"> </span>Observable
improvement in skin discoloration was seen in both cases, but longer duration
treatment and habitual use of class 1 compression socks may explain the more
complete resolution of PIH in patient 1. The DLQI deemed unnecessary by one
patient, demonstrated improvement in the other, particularly in areas of
clothing choice and intimacy. <b style="mso-bidi-font-weight: normal;">Conclusion:</b>
These findings suggest that MLDT may be a feasible non-invasive alternative for
reducing PIH. </span><br />
<br />
<span style="font-size: small;"><br /></span>
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Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-32438748738841960322015-01-05T08:16:00.002-08:002015-01-05T08:25:50.433-08:00Management of Hashimoto Thyroiditis<!--[if gte mso 9]><xml>
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In 1912, Harkarum Hashimoto described a specific type of hypothyroidism called chronic lymphocytic thyroiditis, an autoimmune disorder impacting thyroid-specific antigens, now known as Hashimoto thyroiditis (HT) (Thompson, 2014, p. 152). This author found that 5% of the general population suffers with hypothyroidism, the most frequent cause being HT, and the greatest incidence seen with aging and predominantly in women (p. 152). Sahin et al. (2012) went further to suggest that HT is the most common cause of hypothyroidism in iodine-sufficient areas of the globe with numbers exceeding 10% of the population (p. 319).<br /><br /> According to Sweeney, Stewart and Gaitonde (2014), HT is fairly routine to diagnose, usually characterized by a painless goiter, elevated thyroid peroxidase (TPO) antibodies with presenting symptoms of low thyroid such as cold hands, weight gain and hair loss (p. 389). In some hypothyroid cases there is no goiter, considered a atrophic form, and may correlate with extensive fibrosis of the thyroid and increased susceptibility of overt hypothyroidism (p. 390). Occasionally other unusual diagnostic findings may present, such as suppression of the thyroid-stimulating hormone (TSH), a finding more commonly seen in hyperthyroidism (p. 389). An understanding of the management of hypothyroidism offers great insight into clinical presentations, enabling early detection and appropriate symptom monitoring in the rehabilitation setting for improved thyroid health.<br /><br /> The typical mechanism for hypothyroidism is still not fully understood, but appears to be the byproduct of the interplay between susceptibility genes and environmental factors that produce high levels of antithyroid peroxidase (anti-TPO) and antithyroglobulin (anti-Tg) antibodies (Thompson, 2014, p. 152). Although some studies show that 10-15% of HT patients may actually test antibody negative, demonstrating the need for greater clinical surveillance (Caleo et al. 2013). A clinical correlation between high rates of HT with family history, as well as, a personal history of type 1 diabetes mellitus, Addison disease, Turner syndrome or untreated hepatitis C seems to exist (Sweeney et al., 2014, p.391).According to Sweeney et al. (2014), initial clinical complaints present as fatigue, fullness in the neck, intolerance to cold, increases in body weight and diffuse muscle aches (p. 392). A careful examination should not only include serum TSH and TPO antibody levels, but also a thorough history and palpation of the thyroid (p 392). The palpation of the thyroid gland usually reveals a firm, bumpy surface with symmetrical gland enlargement (p.392). If pain is present in the thyroid region, then a diagnosis of subacute thyroiditis (SAT) may be rendered if associated with fever, elevated serum makers for acute inflammation such as C reactive protein (CRP) and decreased radioactive iodine uptake on thyroid scan (Ipekci, Ozturk and Cakir, 2011, p. 125). In some cases a fine needle aspiration may be indicated formulate a differential diagnosis between painful HT and SAT, as lymphocytic infiltration and fibrosis is seen in HT and granulomatous changes in SAT (p. 127). A thyroidectomy may be considered in cases of unrelenting HT pain, as the causal pain mechanism is still unknown (p. 127). Ipekci et al. (2011) further states the incidence for converting to a permanent form of hypothyroidism is quite high in HT but only 5% in SAT (p.127).<br /><br /> SAT is known as a transient thyrotoxic state that may be caused by an upper respiratory virus that disrupts thyroid follicles via an inflammatory reaction (Sweeney et al, 2014, p. 395). SAT tends to be self-limiting and the thyroid gland can spontaneously resume normal functioning within a few months of diagnosis (p. 395). First line treatment for SAT is aimed at the reduction of anterior neck and jaw pain through the use of high dose nonsteroidal anti-inflammatory or acetylsalicylic acid agents, with prednisone being a pharmacologic alternative (p. 395). Interestingly, in a study of twins living in separate geographic locations, diagnosed with SAT years apart, suggests the pathogenesis of SAT may be a genetic predisposition, specifically in those possessing the human leukocyte antigen (HLA)-B35 (Hamaguchi, Nishimura, Kaneko and Takamura, 2005, p. 562).<br /><br /> Sweeney et al. (2014) found patients with overt hypothyroidism showed elevated TSH and low free T4 levels, with typical treatment consisting of T4 or levothyroxine (Synthroid) to achieve a goal of TSH levels of 1 to 3 mlU per L (p.392). Thompson (2014) went further to state that laboratory findings for hypothyroidism may include decreased T4, possibly decreased T3 and the presence of antibodies for an array of thyroid antigens (p. 152). HT is considered an autoimmune disorder that is part of an organ-specific autoimmune subgroup, best known as autoimmune thyroid disease (AITD) (Nada and Hammouda, 2014, p. 575). Findings show that T lymphocytes and regulatory T cells get down regulated in AITD, compromising the body’s ability to control autoimmune processes (p. 579). Apoptosis or cellular death of thyroid cells was first observed in 1995, a probable result of the dysfunctional immune response (Asik et al., 2013, p. 54). Of significance, it is suspected that apoptosis could take many years to occur, suggesting that early diagnosis and appropriate treatment is a necessary step in preserving overall thyroid health (p. 54).<br /><br />Pharmacologic treatment of HT typically consists of a T4 hormone called levothyroxine (Synthroid), starting at a low initial dose of 1.6 mcg per kg daily, with incremental changes made every three months, as needed (Sweeney et al., 2014, p. 392). Levothyroxine’s action replaces endogenous thyroid hormones, causing an increased metabolic rate in body tissues (Ciccone, 2013, p. 618). It promotes gluconeogenesis, mobilizes glycogen stores, stimulates protein synthesis, promotes cellular growth and aids in brain and central nervous system (CNS) development (p. 618-619). However, excessive T4 dosing may result in iatrogenic hyperthyroidism and other side effects include insomnia, headache, cardiac arrhythmias, angina, abdominal cramping, vomiting, diarrhea, menstrual issues, sweating, weight loss and heat intolerance (p. 619).<br /><br />Levothyroxine has variable absorption in the gastrointestinal (GI) tract and is distributed to most tissues with the exception of the placenta and breast milk (Ciccone, 2013, p. 619). Levothyroxine is best taken on an empty stomach, 30 minutes to one hour before breakfast and four hours before or after taking an antacid to obtain the best absorption (NIH, 2013). Ciccone (2013) reports that levothyroxine gets metabolized into active T3 by the liver and other body tissues, with excretion occurring in the feces through the bile (p. 619). It is contraindicated in patients with a history of a recent myocardial infarction, hypersensitivity or hyperthyroidism, and should be used cautiously in the presence of severe renal or adrenal insufficiency and during use with infants or the geriatric population (p. 619).<br /><br />Drug to drug interactions that reduce effectiveness of levothyroxine include bile acid sequestrants used for high cholesterol or concurrent estrogen therapy (Ciccone, 2013, p. 619). It may minimize the anti-clotting efforts with warfarin, reduce effectiveness of insulin or other oral hypoglycemic agents but may potentiate cardiovascular effects when combined with adrenergic agents such as bronchodilators or vasopressors (p. 619). Drug to food interactions occur with items containing high levels of calcium, iron, magnesium or zinc as it may bind to levothyroxine thus limiting overall absorption (p. 619). Drug formulations for levothyroxine are available in tablet, soft gels and powder form for injections, with dosing routes being oral, intramuscular or through an intravenous application (p. 620).<br /><br />Thyroid (Armour thyroid) is a desiccated thyroid hormone preparation used for treatment of hypothyroidism through a T3/T4 combination therapy of levothyroxine and liothyronine (Cytomel) that compensates for hormone deficiencies and helps restore hormonal balance (Gaitonde, Rowley, and Sweeney, 2012, p. 249). Ciccone (2013) not only indicates its use in thyroid supplementation and treatment of euthyroid goiters, but also as suppression testing to differentiate mild hypothyroidism from thyroid gland autonomy (p. 1072). According to Vigneri et al. (1993), autonomous thyroid nodules may develop as a result of iodine deficiency, independent of TSH, with a clinical diagnosis determined by the presence of negative suppression of nodular iodine uptake and scan imaging upon T3 administration.<br /><br />The drug action of thyroid (Armour thyroid) increases the metabolic rate of body tissues, a similar mechanism to those mentioned for levothyroxine, although it also possesses T3 in addition to T4 activity (Ciccone, 2013, p. 1072). The adverse reactions, drug to drug and drug to food interactions are similar to those mentioned for levothyroxine, however, there is an additional contraindication listed with hypersensitivity to beef (p. 1073). These thyroid formulations are limited to oral tablet use, with each 1gr being equivalent to 100 mcg of T4 or 25 mcg of T3 ; T3 being well absorbed and T4 having variable absorption (p. 1073).<br /><br />In cases of persistent hypothyroidism, combination T3/T4 therapy with dessicated hormone preparations of Amour thyroid or levothyroxine (Synthroid) plus Liothyronine (Cytomel) may be the treatment of choice, although the use of dessicated preparations made from domesticated animals is not recommended by the American Association of Clinical Endocrinologists (Gaitonde et al., 2012, p. 249). According to Antonio Bianco, MD in an interview with Gustafson (2014), he suggested genetic testing of type 2 deiodinase polymorphism known as a disruption in the enzymatic conversion of T4 into T3 and necessary for the appropriate management of persistent hypothyroidism associated with unsuccessful T4 replacement therapy. Gaitonde et al. (2012) states although T3 is a biologically active form, its short half-life and dependency upon the peripheral conversion of T4 into T3 by deiodinase enzymes may result in impaired serum concentration levels, creating a hormone imbalance.<br /><br />Liothyronine (Cytomel) is a T3 supplement used for treatment of hypothyroidism and in suppression testing to differentiate hyperthyroid from thyroid gland autonomy, and as an intravenous formulation for treatment of myxedema coma (Ciccone, 2013, p. 624). As with the other thyroid hormones, it has an action that increases the metabolic rate of body tissues and aims to restore hormonal balance (p. 624). It is contraindicated in patients with a history of a recent myocardial infarction, hypersensitivity or hyperthyroidism, and should be used cautiously in the presence of severe renal and adrenal insufficiency or during use with infants or the geriatric population (p. 625). The pharmokinetics demonstrate good absorption that gets distributed to most body tissues, although it does not tend to cross the placenta and may sparingly enter into breast milk (p. 625). It is metabolized by the liver and other tissues, getting excreted in the feces through the bile (p. 625).<br /><br />Drug to drug interactions that reduce effectiveness of liothyronine include bile acid sequestrants used to control high cholesterol or concurrent estrogen therapy (Ciccone, 2013, p. 625). Liothyronine may limit the anti-clotting effect of warfarin, reduce effectiveness of insulin or other oral hypoglycemic agents, but may potentiate cardiovascular effects when combined with adrenergic agents such as bronchodilators or vasopressors (p. 625). Drug to food interactions were not common although care should be taken with iodine containing products such as seaweed.<br /><br />When reviewing studies on HT, Nada et al. (2014) found patients with HT had variability in presentation, either high or suppressed TSH along with positive tests for anti-TPO and anti-Tg (p.575). A study by Sahin et al. (2012) revealed TSH seemed closely associated with vitamin D levels with their findings showing TSH levels of 3.88 mlU/l when vitamin D levels were above 30ng/ml with 25(OH)D testing (p. 318). Their animal studies revealed that low dose vitamin D and cyclosporine A, a powerful immunosuppressant, correlated with a reduction in experimental autoimmune thyroiditis (p. 317). Their conclusion was that vitamin D deficiency may be involved in the primary pathogenesis of HT and not simply an adverse result of HT (p. 319).<br /><br />A review of studies concerning complications related to HT revealed evidence of Hashimoto’s encephalopathy first documented in 1966 following a patient presentation of aphasia, seizures, disorientation and hemiparesis (Yong, Soule and Hunt, 2014). They felt it was a rare diagnosis of exclusion, factoring in the seizures and neurologic symptoms, positive thyroid autoantibodies and responsiveness to steroids. Myeloneuropathy, a complication of HT, is also a rare diagnosis of exclusion, looking carefully at the autoimmune factors including anti-thyroid antibodies in order to not mistake it for a B12 deficiency (Kayal, Basumatary, Dutta, Mahanta, Islam and Mahanta, 2013, pp. 427-428). The myeloneuropahty presentation is characterized by scattered weakness and spasticity along with peripheral neuropathy, and it also is highly responsive to steroid therapy (p. 427).<br /><br />Studies revealing risks from HT included a report by Thompson (2014), stating HT has an increased risk for developing lymphoma, making careful monitoring of long term laboratory levels a necessity (p. 152). Dhanwal (2011) found that thyroid hormones play a role in balancing bone mineral and bone density, noting increased fracture risk in both clinical presentations with hypothyroidism or hyperthyroidism (p. S111). Hypothyroidism, to a lesser extent, did reveal some reduction in bone mineral density (BMD) in qualitative ultrasound studies, and showed poor bone quality that directly correlated with increased TSH (p. S111).<br /><br />Issues necessary to consider in physical therapy (PT) that are associated with hypothyroidism, specifically HT, include aiding in the diagnosis of an occult thyroid disorder or monitoring for medication trends or tolerances. Caution needs to be used during the performance of aerobics and conditioning exercises due to the increased risk of angina or cardiac arrhythmias. The incidence of increased sweating may heighten the risk of skin issues such as rashes, infections and blisters, making certain heat generating activities less tolerable. It is important to stay aware of the patient’s mental clarity, motor coordination, pain complaints and fatigue level as a way to assist in monitoring their medication response or effectiveness of their thyroid dose. Querying the patient about the timing of their thyroid medication and foods ingested may reveal absorption issues or possible interactions with concurrent drugs such as lithium or amiodarone.<br /><br />In conclusion, it is clear that HT has a multifactorial origin, with causation ranging from increased stress, infection and pregnancy to limited iodine absorption, genetic issues, radiation exposure and abnormal hormone levels (Sahin et al., 2012, p. 319). Time is crucial, as minimizing the duration of symptoms is necessary to limit the permanent, long term thyroid damage that may occur from persistent abnormal thyroid hormone levels that enables autoimmune thyroid destruction. The rehabilitation setting is a perfect venue for closely monitoring the physical, emotional and spiritual issues associated with disease states, with time provided for patient education regarding stress management and physical therapy treatment for the associated risks and comorbidities of HT.<br /><br />References<br /><br /><br />Asik, M., Sahin, M., Anaforoglu, I, Ankan S., Haydardedeoglu, F. I., Ertugrul T. D., & Tutuncu,<br /> N. B. (2013). The antibody response to endoplasmic reticulum stress in Hashimoto’s thyroiditis. Turk Jen, 17, 53-56. Doi: 10.4274/Tjem.2151<br /><br />
Caleo, A., Vigliar, E., Vitale, M., Di Crescenzo, V., Cinelli, M., Carlomagno, C.,…Zeppa, P. (2013). Cytological diagnosis of thyroid nodules in Hashimoto thyroiditis in elderly patients. BMC Surgery, 13(Suppl 2), S41. Retrieved from http://www.biomedcentral.com/1471-2482/13/S2/S41<br /><br />Ciccone, C. D. (2013). Drug guide for rehabilitation professionals. Philadelphia, PA: F. A. Davis Company.<br /><br />Dhanwal, D. K. (2011). Thyroid disorders and bone mineral metabolism. Indian J Endocrinol <br /> Metab, 15(Suppl2), S107-S112. Doi: 10.4103/2230-8210.83339 <br /><br />Gaitonde, D. Y., Rowley, K. D. & Sweeney, L. B. (2012). Hypothyroidism: An Update. Am <br /> Fam Physician, 86(3):244-251. Retrieved from http://www.aafp.org/afp/2012/0801/p244.html<br />
<br />Hamaguchi, E., Nishimura, Y., Kaneko, S.& Takamura, T. (2005). Subacute Thyroiditis<br /> Developed in Identical Twins Two Years Apart. Endocrine Journal, 52(5), 559–562.<br /> Retrieved from https://www.jstage.jst.go.jp/article/endocrj/52/5/52_5_559/_pdf<br /><br />Ipekci, S., Ozturk, K. & Cakir, M. (2011). A difficult decision—Hashimoto’s thyroiditis or<br /> subactue thyroiditis? Turk Jem, 15, 125-127. Retrieved from www.researchgate.net<br /><br />Kayal, A. K., Basumatary, L. J., Dutta, S., Mahanta, N., Islam, S. & Mahanta, A. (2013).<br /> Myeloneuropathy in a case of Hashimoto’s disease. Neurology India, 61(4), 426-428.<br /> DOI: 10.4103/0028-3886.117591<br /><br />National Institutes of Health (NIH) (2013). Levothyroxine. Medline Plus. Retrieved from<br /> http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682461.html<br /><br />Nada, A. & Hammoda, M. (2014). Immunoregulatory T cells, LFA-3 and HLA-DR in<br /> autoimmune thyroid diseases. Indian Journal of Endocrinology and Metabolism, 18(4),<br /> 574-581. Doi: 10.4103/2230-8210.137524<br />
<br />Sahin, M., Taslipinar, A., Keapcilar, L., Yilmaz, H., Akgul, E. O., Beyhan, Z.,….Delibasi, T.<br /> (2012). Low vitamin D3 levels in euthyroid Hashimoto thyroiditis. International Medical<br /> Journal, 19(4), 317-320. Retrieved from<br /> http://connection.ebscohost.com/c/articles/85041330/low-vitamin-d3-levels-euthyroid-hashimoto-thyroiditis<br /><br />Sweeney, L. B., Stewart, C. & Gaitonde, D. Y. (2014). Thyroiditis: An integrated approach. <br /> American Family Physician, 90(6), 389-396. Retrieved from http://www.aafp.org/afp/2014/0915/p389.html<br /><br />Thompson, L. D. R. (2014). Chronic lymphocytic thyroiditis (Hashimoto thyroiditis). Ear, Nose<br /> & Throat Journal, 93(4-5), 152-153. Retrieved from www.entjournal.com/article/chronic-lymphocytic-thyroiditis-hashimoto-thyroiditis<br /><br />Vigneri, R., Catalfamo, R., Freni, V., Giuffrida, D., Gullo, D., Ippolito, A.,… Regalbuto C.<br /> (1993). Physiopathology of the autonomous thyroid nodule. Minerva Endocrinol, 18(4), <br /> 143-145. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8190053<br /><br />Yong, K. W., Soule, S. & Hunt, P. (2014). Endocrine encephalopathy. NZMJ, 127(1394).<br /> Retrieved from http://journal.nzma.org.nz/journal/127-1394/6132/ Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-4748561122710525070.post-88031616728664247582015-01-05T07:51:00.002-08:002015-01-05T07:51:47.876-08:00The Impact of Bisphosphonates on Bone Health<!--[if gte mso 9]><xml>
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<span style="mso-spacerun: yes;"> </span><span style="font-family: Arial,Helvetica,sans-serif;">There are 44
million Americans living with osteoporosis or low bone density, with roughly
one in two women and one in four men over age fifty sustaining fractures as a
result of poor bone health (National Osteoporosis Foundation, n.d., p.6).<span style="mso-spacerun: yes;"> </span>Estimates suggest that 10 million people
already have osteoporosis and another 34 million are suspected to have undiagnosed
low bone density, further adding to the emotional and fiscal impact of bone
disease across the nation (p. 8).<span style="mso-spacerun: yes;">
</span>According to the National Osteoporosis Foundation (NOF), osteoporosis accounts
for more than 2 million fractures in 2005, a cost of $19 billion, with numbers forecast
to exceed 3 million fractures, at a cost of $25.3 billion by 2025 (p. 8).<span style="mso-spacerun: yes;"> </span>They estimate 300,000 hip fractures are
occurring yearly, with 25% of these injured patients over age fifty dying
within a year of fracture (p. 8).<span style="mso-spacerun: yes;">
</span>Reports also suggest that post-menopausal women are vulnerable to
osteoporosis and fractures, losing up to twenty percent of their bone mass within
five to seven years following cessation of menses (p. 4).</span></div>
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<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>Bisphosphonate
(BP) agents, previously known as disphosphonates, were first synthesized in the
late 1800’s, expanding research towards fluoride’s impact on tooth enamel and
calcium chelation of dental plaque in the mid 1960’s, finally culminating as
research on the treatment of bone diseases in the late 1960’s (Francis &
Valent, 2007, pp. 2-3).<span style="mso-spacerun: yes;"> </span>These authors found
that international sharing of physical-chemical research on bisphosphonates
(BPs) helped to reveal possibilities for reducing bone resorption by blocking
the dissolution of hydroxyapaptite crystals (p. 4).<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>Drake, Clarke and
Khosla (2008) found BP agents are structurally similar to the naturally
occurring inorganic pyrophosphate (PPi), both demonstrating efficacy in
regulating bone mineralization through its binding action on hydoxyapaptite
crystals (p. 1033).<span style="mso-spacerun: yes;"> </span>Besides BP’s
attraction to bone minerals, they also integrate themselves directly into
active areas of bone remodeling and employ bone-specific targeting with the
excess excreted through the renal system (p.1033).<span style="mso-spacerun: yes;"> </span>However, these authors state there’s limited
bioavailability of oral BP, with poor absorption by the gastrointestinal (GI)
tract and approximately fifty percent selectively absorbed by skeletal tissues
with overall absorption correlating with favorability of host conditions (p.
1035).<span style="mso-spacerun: yes;"> </span>According to Vigorita, Silver and
Eisemon (2012), possible adverse issues with BP’s bone mineral regulation has
prompted the Food and Drug Administration (FDA) to warn health professionals
about unusual femoral fractures reported with long term use (p. 861). </span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>Francis et al.
(2007, p. 5) found that etidronate (Didronel), an early first-generation drug
with an additional use as a hypocalemic, had its first human trial as a
germinal bisphosphonate in 1967 for treatment of heterotrophic calcifications
in chest musculature caused by myositis ossificans progressiva (MOP).<span style="mso-spacerun: yes;"> </span>The study found it blocked advancement of
calcifications and decreased inflammatory ectopic lesions following the third
oral treatment, with the disease being managed by occasional oral treatments
over her lifetime (p. 5).<span style="mso-spacerun: yes;"> </span>Ciccone (2013)
found that etidronate, known as a bone resorption inhibitor, decreases bone
resorption or bone turnover by blocking calcium hydroxyapatite crystals via a
binding mechanism with calcium phosphate (p. 406).<span style="mso-spacerun: yes;"> </span>He also reports this drug has usefulness in
combination with other agents for the management of hypercalcemia found with
malignancies (p. 406).<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>First generation
non-nitrogen-containing BPs like etidronate had been difficult to safely
administer for home use due to daily oral dosing and an upright posture for
thirty minutes, refraining from eating for two hours prior or thirty minutes
post meal to keep GI effects to a minimum (Drake et al, 2008, p. 1035).<span style="mso-spacerun: yes;"> </span>Other adverse reactions include impaired or a
metallic taste, rash, muscular aches, kidney toxicity and necrosis of the jaw,
with contraindications in the presence of severe renal impairment (creatinine
>5mg/dL) or hypercalcemia due to hyperparathyroid disease with caution
advised in pediatrics, pregnancy, lactating mothers, long bone fractures, low
vitamin D or creatinine levels of 2.5-4.9 mg/dL (Ciccone, 2013, pp. 406-407).
Decreased absorption occurs with concurrent use of buffering agents containing
aluminum, calcium, iron and magnesium, as well as, antacids and mineral
supplements, although calcitonin may potentiate its effect (p. 407). Similarly,
foods containing aluminum, calcium, iron and magnesium may impair drug
absorption (p. 407).</span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>Tiludronate
(Skelid), another non-nitrogen-containing BP drug, also structurally similar to
the PPi, gets integrated into molecules of new adenosine triphosphate (ATP),
creating an intracellular cytotoxicity and eventual osteoclast apoptosis (Drake
et al, 2008, p. 1034).<span style="mso-spacerun: yes;"> </span>According to
Ciccone (2013), tiludronate is taken orally for three months and used in the
management of Paget’s disease when the serum alkaline phosphatase > 2 times
upper normal level (p. 1079).<span style="mso-spacerun: yes;"> </span>The
adverse reactions include vertigo, anxiety, fatigue, bronchitis, chest pain,
dependent edema, GI issues, pathologic fractures, paresthesia and infection, as
well as, jaw necrosis, musculoskeletal pain, rash and spasms (p. 1079). Contraindications
include hypersensitivity, severe renal impairment, with caution
used in the presence of dental surgery, pediatrics, pregnancy and lactation (p.
180).<span style="mso-spacerun: yes;"> </span>Drug to drug interactions causing
decreased absorption are aspirin, antacids containing aluminum or magnesium and
calcium supplements, but this drug’s impact may be potentiated by indomethacin
(p. 1080).<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Drug to food interactions occur with all foods
and results in decreased drug absorption (p. 1080).</span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>The newer second-
and third-generation BPs, also considered bone resorption inhibitors, have
nitrogen-containing side chains that inhibit the enzyme farnesyl pyrophosphate
(FPP), in turn minimizing resorption through the disruption of a protein
signaling pathway necessary for osteoclast activity on the bone (Vigorita et
al, 2012, p. 864).<span style="mso-spacerun: yes;"> </span>According to Capsoni,
Longhi and Weinstein (2006), nitrogen-bisphosphonates (N-BPs), known as aminobisphosphonates,
are more potent and more selective than early BPs and include alendronate
(Fosamax), ibandronate (Boniva), pamidronate (Aredia), risedronate (Actonel)
and zoledronate (Reclast) (p. 219).<span style="mso-spacerun: yes;">
</span>Alendronate, ibandronate and risedronate are first line therapies for
the treatment and prevention of osteoporosis, while pamidronate and
zolendronate are important agents in minimizing bone complications and managing
severe hypercalcemia associated with multiple myeloma or bone metastases from
prostate or breast cancer (p. 219).<span style="mso-spacerun: yes;">
</span>Drake et al. (2009) found that BP’s long skeletal half-life, up to eight
years with pamidronate, warrants great caution during consideration for use in
adolescents, pre-pubescent girls and in fetal development (p. 1041).</span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>Ibandronate is
typically used for postmenopausal treatment or prevention of osteoporosis,
being orally administered once a month or through the quicker acting
intravenous (IV) method every three months (Ciccone, 2013, p. 531).<span style="mso-spacerun: yes;"> </span>According to Drake et al. (2008)
ibandronate’s efficacy is best for use with spinal fractures, while alendronate
and risedronate have more effectiveness in prevention and treatment of spinal
and hip fractures, loss of height and spinal deformities (p. 1036).<span style="mso-spacerun: yes;"> </span>According to Vitor, Nunes, Fonseca and
Freitas (2012), N-BPs were created to improve patient tolerance, enabling
longer intervals between doses and less adverse reactions (p. 342).<span style="mso-spacerun: yes;"> </span>Although these newer N-BPs have demonstrated
a short term record of less adverse GI issues, studies suggest that long term
use may still result in upper GI issues similar to those seen with the early,
non-nitrogen containing BPs ( p.342).<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>The typical side
effects for ibandronate and most BP’s includes mild GI issues and
musculoskeletal aches and pains (Ciccone, 2013, p.531).<span style="mso-spacerun: yes;"> </span>According to Capsoni et al. (2006), jaw
necrosis can also be an issue with long term BP use, characterized by bone
tissue not healing or slowly healing following mild dental trauma or tooth
procedures (p. 219).<span style="mso-spacerun: yes;"> </span>In a study of
infusion administered BP therapy for myeloma and breast cancer patients,
osteonecrosis of the jaw had a 10% incidence with zoledronate, 4% with
pamidronate, .7% with alendronate, but insignificant findings presented with
ibandronate and risendronate as too few cases were involved in the study (p.
220). However, these authors feel strongly that a direct correlation exists
between BP therapy and osteonecrosis of the mandible or maxilla (p. 221).<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>According to
Goossens, Spahr and Rubbia-Brandt (2013), they found only eight cases of
documented BP hepatotoxicity, with none involving ibandronate, until their case
report demonstrated an acute drug-induced cytolytic hepatitis related to
ibandronate treatment for osteoporosis (p. 1139-41).<span style="mso-spacerun: yes;"> </span>In light of risks associated with BP
therapies, a study by Ro and Cooper (2014) presented safety considerations
through proposed drug holidays or drug cessation based on factors relating to
the antiresorptive potency and binding affinity of each BP and associated side
chains (p. 48).<span style="mso-spacerun: yes;"> </span>Zoledronate with the
highest antiresorptive potency is followed by risdronate, ibandronate and
alendronate (p. 48).<span style="mso-spacerun: yes;"> </span>The highest binding
affinity occurred with Zoledronate, decreasing to alendronate, ibandronate and
risedronate, respectively (p. 49).<span style="mso-spacerun: yes;">
</span>Proposed interventional algorithms for determining appropriateness of
drug holidays are based on fracture risk, duration of BP treatment, type of BP
used and patient compliance as a means to provide an evidence based hiatus from
BP therapy for one to five years (p. 50).</span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>In a report by
Tandon, Sharma and Mahajan (2014), their analysis studied proposals for and
against drug holidays, finding that evidence provided only weak support for the
concept of drug holidays (p. 112).<span style="mso-spacerun: yes;"> </span>While
they applauded the theoretical value of an alternative option that would
decrease BP risks, the benefit of this discontinuation was not clearly
substantiated by clinical findings and warrants further research (p. 113).<span style="mso-spacerun: yes;"> </span>They did find recommendations from the
American Society for Bone and Mineral Research stating long term use of BPs, in
excess of five years, or drug holidays in excess of five years warranted an
annual assessment by clinicians, evaluating issues such as medical history and
bone density (p. 113). Vigorita et al. (2012) suggested that although
osteoporosis treatment may be effective, the long term impact of N-BP’s
anti-osteoclastic activity may actually be creating abnormal bone remodeling
and observable changes in osteoclast morphology, referred to as “giant
osteoclasts”, increasing a vulnerability for adverse skeletal issues or
fracture (p. 864).<span style="mso-spacerun: yes;"> </span>Drake et al. (2009)
went on further to suggest that prolonged BP therapy can actually create
“frozen bone” through the over-suppression of osteoclast activity, impairing
the body’s innate ability to repair fractures (p. 1042).</span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>Oral treatment
with N-BP’s may typically consist of once weekly dosing for aldendronate and risdronate
or monthly dosing for ibandronate or risedronate, but a varied schedule of<span style="mso-spacerun: yes;"> </span>IV or infusion administration for
ibandronate, pamidronate and zoledronic acid (Drake et al., 2009, p. 1035).<span style="mso-spacerun: yes;"> </span>According to Ciccone (2013), zoledronic acid
( Reclast)<span style="mso-spacerun: yes;"> </span>may be administered yearly, has
drug interactions with loop diuretics and aminoglycosides, and requires caution
with severe renal impairment and history of aspirin induced asthma (p.
1176).<span style="mso-spacerun: yes;"> </span>Some additional adverse effects
for this specific N-BP include agitation, anxiety, conjunctivitis, decreased
blood pressure, gastrointestinal issues, renal failure, rash, anemia and low
blood levels of calcium, magnesium, potassium and phosphorus (p. 1175).<span style="mso-spacerun: yes;"> </span>Additionally, it is believed that 10% to 30%
of patients receiving an initial N-BP infusion or IV will experience an acute
reaction of flu-like symptoms such as myalgia, low grade fever, headache and
body aches.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>It is clear that
BPs can be highly effective in the treatment of bone health, with inherited skeletal
disorders such as osteogenic imperfecta (OI) in children being effectively
treated with oral alendronate to decrease the incidence of fracture, thus
limiting medical costs and personal suffering (Drake et al., 2009, p.
1040).<span style="mso-spacerun: yes;"> </span>BPs can also assist in
glucocorticoid-inducedosteoporosis as seen in rheumatic conditions and can
reduce osteolytic bone pain, as well as, bone metastases in breast cancer
through IV administration of pamidronate, zoledronic acid or ibandronate (p.
1039).<span style="mso-spacerun: yes;"> </span>However, studies regarding BP
therapy for the prevention or treatment of osteoporosis suggest focusing use on
patients at high risk for osteoporotic fractures, carefully avoiding long term
BP prescriptions as a way to limit abnormal bone modelling and lower fracture
risk (Lee, Lee, Moon & Lee, 2014, p. 56).</span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>Physical
therapists must be cognizant of the prescribed BP, the drug or food
interactions and side effects associated with the specific bone resorption
inhibitor.<span style="mso-spacerun: yes;"> </span>Pain, flu-like symptoms and gastrointestinal
issues are noted side effects and must be recognized early.<span style="mso-spacerun: yes;"> </span>Careful program planning is necessary to
minimize fall risks and cardiopulmonary challenge, while increasing the regenerative
weight bearing forces on the spine and peripheral joints.<span style="mso-spacerun: yes;"> </span>Monitoring blood pressure, heart rate and
auscultation is appropriate, being provided as clinically indicated.</span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;"> </span>In closing, the
studies in this paper highlight the necessity for judicious use of all BP therapies
for bone health, utilizing strong clinical judgment, comprehensive patient
education and interventional algorithms to help determine the risk to benefit
analysis.<span style="mso-spacerun: yes;"> </span>Capsoni et al. (2006) state
long term BP use is risky and the casual consideration for systemic or local
predispositions, such as pending dental work, increases medical risks of
osteonecrosis of the jaw and causes unnecessary suffering (p. 220).<span style="mso-spacerun: yes;"> </span>Clearly, more research is needed to explore
the best treatment duration and appropriate selection of drug candidates for
the best outcomes with bone health.</span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div align="center" class="MsoNormal" style="line-height: normal; text-align: center;">
<span style="font-family: Arial,Helvetica,sans-serif;">References</span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Capsoni, F., Longhi, M. &
Weinstein¸R. (2006). Bisphosphonate-associated osteonecrosis of the jaw: The
rheumatologist’s role.<span style="mso-spacerun: yes;"> </span>Arthritis
Research & Therapy, 8(5), 219-224.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>doi:10.1186/ar2050<span style="mso-spacerun: yes;"> </span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Ciccone, C. D. (2013). Drug guide
for rehabilitation professionals. Philadelphia, PA: F. A. <span style="mso-spacerun: yes;"> </span>Davis Company.</span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Drake, M. T., Clarke, B. L. &
Khosla, S. (2008). Bisphosphonates: Mechanism of action and role in clinical
practice. Mayo Clin Proc, 83(9), 1032–1045. Retrieved from<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2667901/pdf/nihms100526.pdf</span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Francis, M. D. & Valent, D.
J. (2007). Historical perspectives on the clinical development of <span style="mso-spacerun: yes;"> </span>bisphosphonates in the treatment of
bone diseases. J Musculoskelet Neuronal Interact, 7(1), 2-8.<span style="mso-spacerun: yes;"> </span>Retrieved from<span style="mso-spacerun: yes;">
</span>http://www.ismni.org/jmni/pdf/27/03FRANCIS.pdf</span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Goossens, N., Spahr, L. &
Rubbia-Brandt, L. (2013). Severe immune-mediated drug-induced liver injury
linked to ibandronate: A care report. Journal of Hepatology, 59,
1139-1142.<span style="mso-spacerun: yes;"> </span>doi:http://dx.doi.org/10.1016/j.jhep.2013.06.003</span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Lee, J. H., Lee, Y.-H., Moon,
S.-H., &<span style="mso-spacerun: yes;"> </span>Lee, Y.-S. (2013). Influence
of insurance benefit criteria on the administration rate of osteoporosis drugs
in postmenopausal females. Clinics in Orthopedic Surgery, 6, 56-61.
http://dx.doi.org/10.4055/cios.2014.6.1.56<span style="mso-spacerun: yes;">
</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">National Osteoporosis Foundation
(n.d.).<span style="mso-spacerun: yes;"> </span>Strong voices for strong
bones.<span style="mso-spacerun: yes;"> </span>Advocacy Tool Kit, 1-49.<span style="mso-spacerun: yes;"> </span>Retrieved from<span style="mso-spacerun: yes;">
</span>http://nof.org/files/nof/public/content/file/63/upload/49.pdf<span style="mso-spacerun: yes;"> </span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Ro, C. & Cooper, O. (2013).
Bisphosphonate drug holiday: Choosing appropriate candidates. <span style="mso-spacerun: yes;"> </span>Curr Osteoporos Rep, 11(1), 45-51.<span style="mso-spacerun: yes;"> </span>doi:10.1007/s11914-012-0129-9</span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Tandon, V. R., Sharma, S. &
Mahajan, A. (2014). Bisphosphonate drug holidays: Can we recommend currently?
Journal of Mid-Life Health, 5(3), 111-114. <span style="mso-spacerun: yes;"> </span>doi: 10. 4103/0976-7800.141186 </span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Vigorita, V. J. V., Silver, J. S.
& Eisemon, E. O. E. (2012). Osteoclast abnormalities in fractured bone
during bisphosphonate treatment for osteoporosis: A case report. Skeletal
Radiol, 41,861-865. doi:10.1007/s00256-012-1407-4</span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;">Vitor, S. Nunes, A., Fonseca, C.
& Freitas, J. (2012). Ibandronate-associated ischemic colitis--case report.
ACTA REUMATOL PORT., 37,342-344.<span style="mso-spacerun: yes;">
</span>Retrieved from <span style="mso-spacerun: yes;"> </span>http://www.ncbi.nlm.nih.gov/pubmed/24126426</span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="mso-spacerun: yes;">
</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal" style="line-height: normal;">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><div class="MsoNormal">
<br /></div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-33636242132494552212014-11-02T14:47:00.002-08:002014-11-02T14:55:13.021-08:00curcumin may hold promise for its anti-inflammatory impact on Alzheimer's<!--[if gte mso 9]><xml>
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Sadly in September 2014, I lost my dad to Alzheimer
Disease (AD), a sneaky and devastating disease.<span style="mso-spacerun: yes;"> </span>My father was a rocket scientist
with Grumman, managing the lunar module team that got the astronauts back to
earth on Apollo 13.<span style="mso-spacerun: yes;"> </span>So watching this
brilliant man slowly slip away was very, very painful experience that endured for over an 8-10 year period.<span style="mso-spacerun: yes;"> </span>That said, it gave me 8 years to prepare for
his passing.</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>Growing up, I saw
my dad do everything that was possible to avoid getting dementia, having a very rich
holistic and active lifestyle, doing chelation therapy 20 years ago, reading lots,
using herbs and always seeking new challenges.<span style="mso-spacerun: yes;">
</span>But once he got atrial fibrillation and was placed on coumadin
(warfarin) and amiodarone to minimize the occurrence of stroke, I think his
fate was set. <span style="mso-spacerun: yes;"> </span>According to Ciccone
(2013), amiodarone is a class III antiarrhythmic with many side effects that are known to significantly impact the thyroid, neuropathy, confusion, disorientation
with the more severe adverse reactions being pulmonary fibrosis, abnormal liver
functions and pulmonary toxicity.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>And according to a study by the Intermountain Medical
Center (2014), the difficulty in managing blood levels of warfarin doses can lead to a higher
incidence of dementia. That said, my dad was always diligent with utilizing a
warfarin clinic, so I can only imagine what is happening out there with the
rest of the population that is not so attentive. </div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>I have personally
found that this disease is not only dreaded by the patient, but also by the
family.<span style="mso-spacerun: yes;"> </span>It was very, very painful
admitting my dad to the Veterans home when his “sun downing” made him a bit
difficult to handle during night time attempts at assisting him or changing the bedding.<span style="mso-spacerun: yes;"> </span>Amazingly, all through his
decline, he remained mild, polite and kind throughout the daytime, except during
those moments with night time “sun downing”, so with consideration for their
long term care insurance, the choice for<span style="mso-spacerun: yes;">
</span>the Veterans home was the best, safest choice although emotionally traumatic
for all of us.<span style="mso-spacerun: yes;"> </span>I think we all had more
difficulty with his nursing home admission than with his death, although both
felt pretty bad.</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>My wisdom for the treatment of Alzheimer's disease is to
include family or friends in the rehabilitation process, my dad always
did better in my presence, both as a PT and daughter, as I stimulated him and
worked with whatever I could.<span style="mso-spacerun: yes;"> </span>I worked to en-train my dad's nervous system as he was still somewhere in there.<span style="mso-spacerun: yes;"> Both</span> my family and his aide
learned about exercise and respiratory techniques, and they read up on activities and
music commonly used with dementia patients.<span style="mso-spacerun: yes;"> </span>Up
until his death, I was able to get him to smile, respond and even chatter.<span style="mso-spacerun: yes;"> </span>But as typically stated in the literature, infection is one of the
leading causes of death in Alzheimer’s, and in my dad’s case, a few frequent
bouts of aspiration pneumonia finally took its toll in spite of the special soft
diets, tooth care, suctioning, respiratory therapy and IV antibiotics.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>In retrospect,
and as a result of my research papers required for graduate school, I feel my dad had foci of
infections that did not respond to the chosen antibiotics, as his typical
pattern would be to do well for several weeks after its discontinuation and
then just vomit for “no apparent reason”.<span style="mso-spacerun: yes;">
</span>This last pneumonia event was 2 weeks after a previous bout, having had
a good week and a nice lunch, he simply vomited after saying goodbye to my
mom.<span style="mso-spacerun: yes;"> </span>He was immediately suctioned and had respiratory therapy within 45 minutes, but the infection never seemed to respond, and
he passed away several days later on his 82<sup>nd</sup> birthday and 60<sup>th</sup>
anniversary, having had all of us around him.<span style="mso-spacerun: yes;">
</span></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>As a holistic
therapist, I did use some turmeric (curcumin) with my dad, but his swallowing
difficulty (mild dysphagia) made that an arduous endeavor unless mixed into his
food, but that probably limited its bioavailability.<span style="mso-spacerun: yes;"> </span>According to Morales, Guzman-Martinez,
Cerda-Troncoso, Farias and Maccioni (2014), they found that curcumin may hold
promise for its anti-inflammatory impact on AD by disrupting the inflammatory
response and self-aggregation of the τ protein.<span style="mso-spacerun: yes;"> </span><br />
<span style="mso-spacerun: yes;"> What is the answer, do more aggressive antibiotics for repeated bouts of resistant pneumonia that can ravage a person's health or simply let this horrible mind sucking disease take them?</span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
References</div>
<div class="MsoNormal">
Ciccone, C. D. (2013). <i style="mso-bidi-font-style: normal;">Drug
guide for rehabilitation professionals.</i> Philadelphia, PA: F.A.<span style="mso-spacerun: yes;"> </span>Davis Company.</div>
<div class="MsoNormal">
<span class="MsoHyperlink"><span style="color: windowtext; text-decoration: none; text-underline: none;">Intermountain medical center (2014). <i style="mso-bidi-font-style: normal;">Patients with atrial fibrillation at higher
risk of developing dementia when meds are out of range</i>.<span style="mso-spacerun: yes;"> </span>Retrieved from <a href="http://www.sciencedaily.com/releases/2014/05/140509203841.htm">http://www.sciencedaily.com/releases/2014/05/140509203841.htm</a></span></span></div>
<div class="MsoNormal">
<span class="MsoHyperlink"><span style="color: windowtext; text-decoration: none; text-underline: none;">Morales, I., Guzman-Martinez, L.,
Cerda-Troncoso, C., Farias, G. A. & Maccioni, R. B. (2014). Neuroinflammation
in the pathogenesis of Alzheimer’s disease. A rational framework for the search
of novel therapeutic approaches.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">Front. Cell. Neurosci.</i><span style="mso-spacerun: yes;"> </span></span></span><a href="doi:%2010.3389/fncel.2014.00112">doi: 10.3389/fncel.2014.00112</a><span class="MsoHyperlink"><span style="color: windowtext; text-decoration: none; text-underline: none;"></span></span></div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-41558096239165794902014-11-02T12:59:00.002-08:002014-11-02T12:59:40.089-08:00Opiates in a nasal spray?<!--[if gte mso 9]><xml>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;"> </span>Has
anyone heard of nasal sprays for opiates?<span style="mso-spacerun: yes;">
</span>Maciejeweski (2012) found there were off-label uses of agonistic opioids
that included intra-articular and intranasal routes of administration as well
as peripheral nerve blocks.<span style="mso-spacerun: yes;"> </span>According
to Steenblik et al. (2012), <i>intranasal</i> (IN) applications of an opioid called sufentanil
has been effectively utilized in clinics at winter resorts, urgent care facilities
and emergency rooms for its rapid analgesic impact on acute injuries.<span style="mso-spacerun: yes;"> </span>They found that although most IN research was
performed in the pediatric population, IN was actively being utilized in adult
populations in spite of the higher volume of medication required to produce an effective
analgesia.<span style="mso-spacerun: yes;"> </span>Kendall, Maconochie, Wong
& Howard (2014) also found an atomized opioid called diamorphine that was quite
effective in the rapid relief of moderate to severe pain as in case of fracture
and burns.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;">
</span>Sufentanil (Sufenta) is a synthetic opioid that is similar in action to
fentanyl,</span> <span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">but is better suited for IN administration due to its
higher potency, lower cost and tendency to cause less adverse effects within a wide
dose range (Steenblik et al., 2012).<span style="mso-spacerun: yes;">
</span>Diamorphine is made from a semisynthetic derivative of morphine, is
highly lipid soluble and crosses the blood brain barrier better than morphine,
therefore producing a more rapid and intense central nervous system (CNS)
response that is desired for analgesia in acute injuries ( Kendall, Maconochie,
Wong & Howard, 2014). These authors also reported this medication has the
sedation and gastrointestinal issues of nausea or vomiting oftentimes seen with
other opioids, as well as a mild nasal irritation or burning sensation correlating
with the volume of spray.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;"> </span>Sufentanil’s
action occurs as it binds to opioid receptors of the CNS, thus diminishing the
response to pain and depressing the CNS (Ciccone, 2013).<span style="mso-spacerun: yes;"> </span>He went on further to state that sufentanil
is mostly metabolized in the liver, although some metabolism occurs in the
small intestine and it has an intravenous bioavailability of 100%.<span style="mso-spacerun: yes;"> </span>He also noted that the most dangerous side
effects were apnea and thoracic rigidity, cardiac arrest, laryngospasm and
anaphylaxis (p. 1022).<span style="mso-spacerun: yes;"> </span>The most fatal
drug to drug interaction is the combination with MAO inhibitors within a 2 week
time frame, and less severe reactions may occur in the presence of other CNS
depressants like alcohol, sedatives, antidepressants or other opioids. </span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;"> </span>According
to Kendall, Maconochie, Wong & Howard (2014), there are benefits to<span style="mso-spacerun: yes;"> opiate </span>nasal spray with its fast action
compared to oral medications, plus it is as effective as an intravenous
administration, but with quicker implementation in fast paced situations.<span style="mso-spacerun: yes;"> </span>These authors felt this nasal spray
demonstrated a good safety profile, but with that said, their study was limited
to the pediatric population, an unfortunate limitation in this study.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;"> </span></span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">References</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Ciccone, C. D. (2013). <i style="mso-bidi-font-style: normal;">Drug guide for rehabilitation professionals</i>. Philadelphia, PA: F.
A.<span style="mso-spacerun: yes;"> </span>Davis Company.</span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Kendall J., Maconochie, I., Wong, I. C. K. &
Howard, R. (2014).<span style="mso-spacerun: yes;"> </span>A novel multipatient
intranasal diamorphine spray for use in acute pain in children:
pharmacovigilance data from an observational study. <i style="mso-bidi-font-style: normal;">Emerg Med J, 0,</i>1-5.<span style="mso-spacerun: yes;">
</span>doi:10.1136/emermed-2013-203226</span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Maciejewski, D. (2012). Sufentanil in
anaesthersiology and intensive therapy.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">Anaesthesiology Intensive Therapy, 44,</i>
35-41.</span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Steenblik, J., Goodman, M., Davis, V., Gee, C.,
Hopkins, C., Stephen, R., & Madsen, T. (2012). Intranasal sufentanil for
the treatment of acute pain in a winter resort clinic. <i style="mso-bidi-font-style: normal;">American Journal Of Emergency Medicine, 30</i>(9), 1817-1821.
doi:10.1016/j.ajem.2012.02.019</span></div>
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-81348599814235209402014-11-02T12:30:00.001-08:002014-11-02T12:31:20.053-08:00NSAIDs--the good, bad and ulgy side of these medications<!--[if gte mso 9]><xml>
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</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>Aspirin
(acetylsalicylic acid) and ibuprofen are the more popular over-the-counter
(OTC) non-steroidal anti-inflammatory drugs (NSAIDs) seen in many outpatientclinics.<span style="mso-spacerun: yes;"> </span>Hauser (2010) reported that globally,
especially in the more developed countries, over 25% of geriatric patients suffering
from osteoarthritis (OA) will take NSAIDs to address pain (p. 305). <span style="mso-spacerun: yes;"> </span>According to Ciccone (2007, p. 199), aspirin
is classified as a salicylate, but is the most representative example of NSAIDs
due to its anti-inflammatory, moderate analgesic, antipyretic and
anticoagulation properties. <span style="mso-spacerun: yes;"> </span>He reports
the anti-inflammatory property of acetylsalicyclic acid results from the inhibited
synthesis of prostaglandins, an endogenous lipid-like substance that regulates
cellular function (p. 200).<span style="mso-spacerun: yes;"> </span>Hauser (2010)
agrees the mechanism of NSAIDs is caused by the inhibition of both cyclooxygenase-1
(COX 1) and cyclooxygenase-2 (COX 2) enzymes, with COX 2 being the newer and kinder
on the gastrointestinal tract, but both limiting the prostaglandin messenger
necessary for inflammation . He expressed strong concerns over the treatment of
osteoarthritis (OA) with NSAIDs and suggested focusing the medical intervention
on the articular cartilage breakdown or pain of OA versus swelling, favoring a
more conservative approach to NSAIDs with lower dosages and shorter durations (p.
311).</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>There are other pro-inflammatory
lipid-like substances that are similar to prostaglandins called leukotrienes
and thromboxanes, with all three being collectively known as eicosanoids (Ciccone,
2007, pp. 200-201).<span style="mso-spacerun: yes;"> </span>Eicosanoids are
powerful at regulating issues like inflammation, but their exact action on the
immune system is still not totally understood (Pratt & Brown, 2014, p.
3).<span style="mso-spacerun: yes;"> </span>However, it is known that in the
presence of dysfunctional regulation of inflammatory and anti-inflammatory
mediators or eicosanoids, this mechanism has a direct impact on the course of a
disease (Pratt & Brown, 2014, p. 5).<span style="mso-spacerun: yes;">
</span>Hauser (2010) found that prostaglandins stimulate the proliferation of
chondrocytes, a very beneficial aspect of cartilage healing, but also a
mechanism that gets blocked by NSAIDs.<span style="mso-spacerun: yes;"> </span>According
to Nasjletti (1998), the same is true for blood pressure regulation, where
eicosanoids mediate angiotensin-dependent hypertension through the balancing of
prohypertensive and antihypertensive functions that may be hindered by NSAIDs (p.194).</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Hauser (2010) feels strongly that the adverse
long term side effect of aspirin is the degradation of articular cartilage caused
by the degenerative impact on the cartilage matrix and possibly the reduced compensatory/protective
joint strategies caused by local analgesia (p. 316).<span style="mso-spacerun: yes;"> </span>He believes in situations of osteoarthritis,
oftentimes characterized as a condition of joint degeneration that is usually without
swelling or heat, the use of anti-inflammatory drugs like NSAIDs for<u> a
non-inflammatory condition</u> can be very problematic to the individual’s
cellular healing (p. 311).<span style="mso-spacerun: yes;"> </span>He found in
some cases where matrix alterations or internal changes to mechanical
properties of the cartilage had occurred, the result was consistent with an
increased incidence of bone cysts, nodules or spurs (p. 308).<span style="mso-spacerun: yes;"> </span>However, on a more positive note, Wang et al.
(2003) had an in vitro study showing aspirin’s promise of inhibiting growth of <i style="mso-bidi-font-style: normal;">H pylori</i>, as well as value in increasing
the organism’s susceptibility to antimicrobials, however suggesting further in
vivo research aimed at drug resistance and virulence was needed (p. 494).</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>Adverse drug
reactions (ADR) or side effects of acetylsalicylic acid commonly seen in my
clinic are tinnitus, gastric distress and easy bruising.<span style="mso-spacerun: yes;"> </span>Ciccone (2013) finds the most severe
reactions are gastric bleeding, anaphylaxis and laryngeal swelling, but to a
lesser degree a skin rash, anemia and abdominal pain (p. 80).<span style="mso-spacerun: yes;"> </span>Caution must be taken during physical therapy
to minimize bruising during manual therapy and therapeutic exercises, carefully
monitoring for rashes, blood pressure, shortness of breath, nausea or abdominal
pain as it may be related to an allergic reaction or bleeding associated with
acetylsalicylic acid (p.80).<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>The ugly side of
drug to drug interactions must now be written on the front of prescription labels,
mandated by the FDA, stating that any prescription and OTC drug containing
NSAIDs, blood thinners or steroids may cause bleeding or stomach ulcers with
this product (Hauser, 2010, p. 318).<span style="mso-spacerun: yes;">
</span>Ciccone (2013) further highlighted that ibuprofen may decrease the
antiplatelet effect, pencillins and oral hypoglycemics may be potentiated, sulfonamides
and methotrexate may be potentiated, ACE inhibitors may be limited and antacids
may limit the salicylate effect.<span style="mso-spacerun: yes;"> </span>This
drug is well absorbed in the small intestine and rapidly distributed
throughout, crossing the placenta and entering breast milk, so it should not be
used in children, new mothers or in pregnancy (p. 81).</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>The main food to
drug interaction occurs during the over-consumption of foods that increase the
acidity of urine as this may increase serum salicylate levels (Ciccone, 2013,
p. 81).<span style="mso-spacerun: yes;"> </span>Herbals that increase the risk
of bleeding are arnica, chamomile, clove, garlic, gingko, ginseng and ginger
(p. 81).<span style="mso-spacerun: yes;"> </span>Hauser (2010) also believes
limiting alcohol consumption is necessary to minimize the risk of bleeding and
ulcers (p.318).</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Finally, according to Scott, Khan, Roberts,
Cook and Duronio (2004), inflammation is a complex, integrated cellular phenomenon
that encompasses many mechanisms from cell death and cellular debridement to tissue
proliferation and cellular regeneration, so having assumptions that pain
directly correlates with inflammation is misguided and may even be harmful to
the healing process (p. 372-375).<span style="mso-spacerun: yes;"> </span>The use
of NSAIDs must be prescribed or taken with great caution and accuracy,
utilizing physical therapy modalities, complementary and alternative medicine,
exercise, proper body and joint mechanics, as well as good nutrition and
hydration to achieve the goal of pain relief and improved function.</div>
<div align="center" class="MsoNormal" style="text-align: center;">
References</div>
<div class="MsoNormal">
Ciccone, C. D. (2007). <i style="mso-bidi-font-style: normal;">Pharmacology
in rehabilitation</i> (4th ed). Philadelphia, PA: F. A. Davis </div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>Company.</div>
<div class="MsoNormal">
Ciccone, C. D. (2013). <i style="mso-bidi-font-style: normal;">Drug
guide for rehabilitation professionals</i>. Philadelphia, PA: F. A. </div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>Davis Company.</div>
<div class="MsoNormal">
Hauser, R. A. (2010). The acceleration of articular
cartilage degeneration in osteoarthritis by</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>nonsteroidal
anti-inflammatory drugs.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">Journal of Prolotherapy, 2</i>(1), 305-322.<span style="mso-spacerun: yes;"> </span>Retrieved from </div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span><span style="color: red;"><a href="http://www.journalofprolotherapy.com/pdfs/issue_05/issue_05_10_nsaids.pdf">http://www.journalofprolotherapy.com/pdfs/issue_05/issue_05_10_nsaids.pdf</a></span>
</div>
<div class="MsoNormal">
Nasjletti, A. (1998). <i style="mso-bidi-font-style: normal;">Hypertension,
31</i>, 194-200. <span style="mso-spacerun: yes;"> </span><a href="doi:%2010.1161/01.HYP.31.1.194">doi: 10.1161/01.HYP.31.1.194</a></div>
<div class="MsoNormal">
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Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-21100308657411943022010-10-31T11:28:00.000-07:002010-10-31T11:43:25.438-07:00Politicians, are you listening???Halloween isn't the only frightening day out there, so is Election Day! Red, Blue, Purple, Green.... are any of you Politico's listening to "we the people"?? You know, those of us who VOTE.......... and collectively choose whether or NOT to employ you?? We aren't the big lobbyist. We aren't the Unions. We aren't Corporate America. We are simply masses of people who are very UNHAPPY with many of you, most of the time. Please do NOT continue to ignore us, try to hear us. As a small business owner of a physical therapy clinic, you are fiscally burying us with proposed Medicare cuts, insurance mandates, high premiums, ruthless credit card lenders, fearful bankers, high taxes, and so on .........<br /><br />Please try to reach across the aisle and get something done; try to listen to the constituents; try to simply be moderate with special interests, Unions and Corporate America. Truly practice what you all preach and live a life consistent with your voting........ try to walk in our shoes...... they are a bit broken down and unpolished, but at this rate they will have to sustain us for at least another 2 years.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-42430603608957497742010-08-11T11:45:00.000-07:002010-08-11T11:59:56.148-07:00Medicare, NOT! Mediscrew, Yep......Okay folks, Medicare in 2011 is going to eat Seniors and Healthcare clinics alive. Sadly, if these cuts go into effect, most clinics will be forced to STOP taking as many Medicare patients. Doctors will simply drop out "at will", while therapists (PT, OT, SLP) will be forced to stop seeing Medicare patients until legislation changes so they too can drop out "at will".<br /><br />Congress, wake up and take a real hard look at the potential consequences of your actions. The punitive Medicare Cap will continue, but we don't have a figure yet. The Exceptions process for complicated patient diagnoses will stop, so once the Cap is reached you must either stop your care, pay out-of-pocket or convince your secondary insurer to pay. The physician's fee schedule will reimburse less. Paperwork requirements will increase due to the need for "data mining" in order to justify future reimbursement cuts. And the real "WINNER" here is the cascading reimbursement reductions that will virtually destroy healthcare as we know it...... essentially forcing 50% penalties on practitioners who dare spend more that 22 minutes performing any type of therapy on a patient. <br /><br />Write Congress and CMS/Medicare now........ before it is too late and discourage other insurers from following the Medicare path. Thanks.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-52703564725324735192010-07-24T07:35:00.000-07:002010-07-24T07:50:55.870-07:00Mentoring private practitioners--mission, passion or exploitation?Sadly I have been receiving input from physical therapists and other practitioners interested in attempting private practice saying that they are being told it would cost ~$500 per hour (minimum) to meet with a therapist to discuss private practice. Seriously, we don't have to give away all of our hard earned company or trade secrets, but shouldn't we mentor these folks a bit as part of our passion or mission for making this a sustainable profession?? Yes, I know there are folks who try to bleed us dry with information, but our professional responsibility is to guide them towards educational options regarding business coaching, professional seminars, accountant and lawyer selections, electronic records, etc. <br /><br />I would hate for us to be short sighted and fail to nurture newcomers to the healthcare field, and worse yet, hate to see a financial exploitation of newcomers be a means to our end.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-28879788497494223612010-01-09T06:24:00.000-08:002010-01-09T06:59:05.582-08:00Large Group health coverage through trade and professional associationsWe all should be able to have affordable "Group" health insurance coverage through our professional associations (AMA, APTA,ASHA, AOTA......) , Costco, Chamber of Commerce, trade associations, or through other well-formed groups and agencies. Don't settle for "insurance marts" that simply offer individual coverage or small group coverage; request to become part of a large GROUP. This way the group coverage is affordable, not as punitive and is portable. Allowing folks to pursue other career opportunities without having to be tethered to large employers. This paradigm shift will take time, but through writing, faxing, phoning, emailing and personal visits this insurance dilemma can begin to improve. Encourage your special interest group to do the RIGHT thing!!!Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-4748561122710525070.post-89347631203255944892009-12-12T10:25:00.000-08:002009-12-12T10:36:21.163-08:00have to curb fraud/abuse before expanding healthcareWhile many healthcare providers are fair minded, they are possibly committing fraud through inappropriate billing and up coding. Throwing more government or private dollars at a system riddled with fraud and abuse makes NO sense. We MUST educate providers and do drop-in clinic audits to insure proper coding and billing is being done. I am seeing that the insurance dollar and medicare dollar is shrinking, so office administrators are getting more and more creative with "up coding" or mis-coding the actual service being rendered. I challenge the professional organizations of medical providers and professional educational programs to truly educate students and practitioners about the appropriate way to bill and code. Ignorance is REALLY NO EXCUSE!Unknownnoreply@blogger.com0