Presentation on theme: " All Recommendations are level ‘C’: “Expert opinion” When preparing to give bad news, assess patient’s level of understanding about disease and future."— Presentation transcript:
All Recommendations are level ‘C’: “Expert opinion” When preparing to give bad news, assess patient’s level of understanding about disease and future expectations When preparing to give bad news, assess how much info the pt wants to know.
PCP should remain involved with the pt during all stages of cancer Initiate discussions ref availability of svcs like palliative care early. As dz progresses, transition from curative to palliative care
Avoid phrases & words that can be misconstrued & lead to misconceptions such as abandonment & failure Assess and be sensitive to pt’s cultural & individual preferences
Prioritize Practice & Prepare Assess Patient Understanding Determine Patient Preferences Present Info Provide Emotional Support Discuss Future Options Offer Additional Spt Consider individual Preferences
Breaking bad news Communicating Prognosis Discuss Disease transitions Coordinate Care Provide Support
Physician Frankness Family Involvement Decision-Making Advance Care planning Social, educational and family factors Religious & spiritual factors
Algorithm for what to do w.r.t. pt preference on knowing about prognosis Commonly Misconstrued Physician phrases
What is the difference between a hunter & a fisherman? A hunter lies in wait. A fisherman waits & lies.
Glucosamine Sulfate may be used for reducing SX and possibly slowing Dz progression in DJD of knee: ‘B’ Not Glucosamine hydrochloride Patients may need additional SX relief from analgesics 1500 mg Qday or 500 TID Cost: $9-35 per month
Chondroitin may provide modest benefit in some patients; but has no advantage over glucosamine: ‘B’ Research is not of high quality REC: Try Glucosamine first May Interact with Warfarin Cost : $10-25 per month
S-adenosylmethionine may reduce DJD pain, but is a less appropriate option for most patients : ‘B’ Probably takes several weeks to be effective Reports of hypomania with it; SSRIs Unstable shelf life Cost: $ per month
May Work BUT Research is inadequate to support any recommendation for usage
Devil’s Claw : May work; BUT need more study on safety Turmeric : Anecdote only Ginger : Maybe; BUT not enough evidence to make recommendation
The great tragedy of Canada is that They could have had › French cuisine › British Culture & › American technology Instead they have › British cuisine › American culture & › French technology
Interpersonal or CBT should be offered to pts with bulimia nervosa (BN) & binge- eating disorder (BED): ‘A’ A self-help program may be considered the 1 st step in RX BN & BED : ‘B’
Most Pts with anorexia nervosa (AN) should be treated as outpatients in a tertiary care setting by a multidisciplinary team : ‘C’ Antidepressant trial may be offered as primary RX or in combo with psychotherapy in Pts with BN
Diagnostic criteria Level of Care guidelines, outpt vs inpt Medical Complications of Eating Disorders Components of Guided Self-Help Practical Questions & Statements during interview
While heading into the jungle, she thought that she would impress her boyfriend with her knowledge, so she turned to the safari guide and said, “I know that carrying a torch will keep lions away.” The guide replied, “That depends on how fast you carry the torch.”
Paired, sit in tonsillar sinus Limited anteriorly by palatoglossal arch, posteriorly by palatopharyngeal arch, laterally by superior pharyngeal constrictor Enclosed in a fibrous capsule Blood supply from tonsillar and ascending palatine branches of facial artery, ascending pharyngeal artery, dorsal lingual branch of the lingual artery and the palatine branch of maxillary artery
Part of secondary immune system No afferent lymphatics Exposed to ingested or inspired antigens passed through the epithelial layer Immunologic structure is divided into 4 compartments: reticular crypt epithelium, extra follicular area, mantle zone of the lymphoid follicle, and the germinal center of the lymphoid follicle
Group A beta-hemolytic is most recognized pathogen Associated with a risk of rheumatic fever and glomerulonephritis Many other organisms are involved
Thought to be extension of tonsillitis to involve surrounding tissue with abscess formation Recently described to be an infection of small salivary glands in the supratonsillar fossa called Weber’s glands Would explain superior pole involvement and the usual absence of tonsillar erythema/exudates
Airway Obstruction Aspiration Pneumonitis or Abscess Death from carotid erosion Beep tissue extension Poststreptococcal sequelae
Aerobic › Grp A Strep › Staph A › H. InFLU Anaerobic › Fusobacterium › Peptostreptococcus › Pigmented Prevotella
Most Outpt If aspirate, watch for 3-4 hrs to ensure PO ABX & analgesics F/U 24 hrs ABX x 10 days
Steroid MAY help speed recovery If not competent/confident, refer to ENT
42 yo nonhealing ulcer x 6 weeks Painless, 2 CM, superficial, Firm base, Indurated edges No buboes What is it? Why?
Evidence favors Late cord clamping (> 2 minutes):anemia risk & iron stores; no clinical adverse problems Less Anticoagulation Needed after DVT or PE : 3 months as good as 6 months with less hemmorhage. Caveats Q Day ICS (with salmeterol) OK for step- down RX in pts with mild, persistent Asthma
Pulmonary Rehab works in COPD : › Endurance and weight training › Inspiratory muscle trng: NO › CPT : NO › Nutritional supplements: NO › Longer & higher intensity are better Premature Rupture of Membranes: › What to do at what EGA › Nothing new?
Ngo-Metzger Q. et al. End-of-Life Care: Guidelines for Patient- Centered Communication. AFP. January 15, Vol 77. No 2. Gregory P. et al. Dietary Supplements for Osteoarthritis. AFP. January 15, Vol 77. No 2. Galiato N. Peritonsillar Abscess. AFP. January 15, Vol 77. No 2.