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Vice Chair, Southern California College of Osteopathic Medicine
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There are no data at present to substantiate the suggestion that lens material per se is toxic, so the term “phacotoxic uveitis” should be avoided. The classic case occurs when the lens develops a hypermature cataract and the lens capsule leaks lens material into the posterior and anterior chambers. This material elicits an inflammatory reaction characterized by accumulation of 337 plasma cells, mononuclear phagocytes, and a few polymorphonuclear cells. Typical anterior uveitis symptoms of pain, photophobia, and blurred vision are common. Lens-induced uveitis may also occur following lens trauma or cataract surgery with retained lens material. Concurrent treatment with corticosteroids, cycloplegic/mydriatic agents, and intraocular pressure–lowering medications is often necessary. The cause is unknown in most cases, although syphilis, tuberculosis, and sarcoidosis should be ruled out with appropriate laboratory and ancillary testing. Multiple sclerosis should also be considered, particularly when supportive signs or symptoms are present. Intermediate uveitis is seen mainly among young adults, affects men and women equally, and is bilateral in up to 80% of cases. Pain, redness, and photophobia are unusual but can accompany a severe first attack. Adequate examination of the ciliary body, pars plana, and peripheral retina requires use of an indirect ophthalmoscope and scleral depression, which often reveals vitreous condensations in the form of snowballs and snowbanking. Anterior chamber inflammation is invariably mild, and posterior synechiae are uncommon. Posterior subcapsular cataract and cystoid macular edema are the most common causes of decreased vision. Corticosteroids are used mainly to treat cystoid macular edema or retinal neovascularization. Topical corticosteroids should be tried for 3–4 weeks to identify patients predisposed to development of corticosteroid-induced ocular hypertension. If no improvement is noted and ocular hypertension does not develop, a posterior sub-Tenon or intraocular injection of triamcinolone acetonide, 40 mg/mL, may be effective. Causes of Posterior Uveitis Infectious disorders Viruses Cytomegalovirus, herpes simplex virus, varicella-zoster virus, rubella virus, rubeola virus Bacteria Agents of tuberculosis, brucellosis, sporadic and endemic syphilis; Borrelia (Lyme disease); and various hematogenously spread gram-positive and gram-negative pathogens Fungi Candida, Histoplasma, Cryptococcus, Aspergillus Parasites Toxoplasma, Toxocara, Cysticercus, Onchocerca Noninfectious disorders Autoimmune disorders Behçet disease Vogt-Koyanagi-Harada disease Systemic lupus erythematosus Granulomatosis with polyangiitis Sympathetic ophthalmia Retinal vasculitis Malignancies Intraocular lymphoma Malignant melanoma 339 Leukemia Metastatic lesions Unknown etiology Sarcoidosis Serpiginous choroiditis Birdshot chorioretinopathy Acute multifocal placoid pigment epitheliopathy Multiple evanescent white dot syndrome the retina, choroid, and optic nerve are affected by a variety of infectious and noninfectious disorders, the more common of which are listed in Table 7–4. Most cases of posterior uveitis are associated with some form of systemic disease. The cause can often be established on the basis of (1) the morphology of the lesions, (2) the mode of onset and course of the disease, or (3) the association with systemic symptoms or signs. Other considerations are the age of the patient and whether involvement is unilateral or bilateral.
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You will also need to motivation, specialization, routine, relaxation, learn what the client hopes to fun, diet, and modification. The client’s goals, motivation, time schedule, and existing habits and preferences will serve as the foundation of the program and will greatly affect its soundness and effectiveness. Goals As discussed in Chapter 3, a good fitness program is best begun by writing down what the client hopes to obtain from the program. These goals should be written as objective, measurable goals, rather than subjective goals (see Figure 8-3). For exam ple, if a client is now at 20% body fat and would like to get down to 18% body fat, objectively evaluating the progress toward that goal by using skin calipers to measure the amount of body fat can greatly assist the client. This is because be measurable; if he wants a flat stomach, “tired and weak” is the way the client feels, a target waist size should be set. The goal records discussed in Chapter 3 are a great way to track a client’s goals and will assist in planning the conditioning program. Setting and achieving short-term and long-term goals is a good form of fitness management. For example, in a weight loss program, the long-term goal might be to lose a total of 20 pounds. Make sure that the goals are realistic and reachable, and that the goal setting does not take the fun out of the client’s exercise program. Goals can and should be used to motivate the client throughout the course of the fitness program. If the client begins to lag a little in the pursuit of a goal, reminders of the end result help renew the incentive for continued effort. Although an individual’s personal goals are probably the best source of motivation, the value of external motivation in the form of encour agement cannot be overstated. Praise for a job well done, congratulations for meeting a short-term goal, and enthusi asm for even the smallest victory will do wonders for your clients’ self-esteem and help spur them on to even greater achievements. The client’s goals should also be used to apply the specificity principle dis cussed in Chapter 7. For instance, if the client is an administrative assistant who wants to ski, then the exercises should focus on strengthening the muscles of the lower extremities and enhancing cardiovascular fitness. If the client is an athlete who wants to increase the height of her high jump, then the exercises should be geared to condition the body in order to meet that goal. Use the sport specialization chart shown in Figure 8-4 as a guide in determining which areas of the body to focus on to boost an athlete’s performance.
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It is prudent for adult and Wound Infection pediatric implant recipients to receive the available pneumococcal vaccine; moreover, children should be A postoperative wound infection can usually be adequately vaccinated against Haemophilus. Wound or skin breakdown can occur with an acute infection or may be Subjective Measurements related to excessive pressure of the magnet over the implant. It is important for patients to monitor the condi Cochlear implantation, not long ago viewed as experi tion of the skin between the magnet and the implant mental, is now a proven treatment for sensorineural device; the magnet strength can be adjusted to account for hearing loss in properly selected patients. Factors generally associated with efits that have been described include the treatment of better outcomes in cochlear implantation (listed tinnitus, the improvement of preimplantation depres in random order). Shorter duration of deafness Rarely in medicine is there a procedure that has such Better preoperative word or sentence recognition (or both) a profoundly positive impact on the quality of life. Yet, it is essen Better preoperative residual hearing tial to stress that the outcomes seen with cochlear Optimized implant technology and processing strategy implantation vary widely both within given patient pop Cause of deafness (eg, meningitis associated with poor out ulations and among differing groups. Multiple factors comes) have been shown to have a bearing on the degree of ben Intact, nonossified cochlea efit obtained from implantation (Table 70–2). Although Additional Factors in Children these factors are helpful in anticipating performance Younger age at implantation levels, additional unaccounted-for dynamics, which are Motivated family assistance difficult to gauge and recognize, do exist and account for Oral preoperative education about 50% of the variance in performance. Oral education rehabilitation program as opposed to total communication Objective Measurements A. As ened adults following implantation include an evalua previously alluded to, evidence seems to indicate that tion of both open-set sentence and word recognition these children do better if implantation is undertaken scores. Various reports have documented open-set sen before age 8 with the best outcomes usually obtained in tence recognition scores of 60–70% and word recogni children less than 3–4 years old. Note that patient variability, evolving inclusion criteria, and ever-changing techno Chmiel R, Sutton L, Jenkins H. Quality of life in children with cochlear logic innovations render the objective analysis between implants. Rehabilitation factors contributing to implant benefit in that has been frequently attained) for implant recipients children. Early identification and cochlear implantation: critical factors for spoken language development. Speech perception results in children using the Clar under age 3; also, development with an oral-auditory com ion multistrategy cochlear implant. Ann Otol Rhi with cochlear implants seen in both young and older adults nol Laryngol. With advances in the knowledge of wound healing, as well as the development of better materials and tech B. Nevertheless, Iatrogenic causes of poor scar formation include exces no technique has been devised to allow total and per sive soft tissue trauma while handling the skin, failure manent removal or effacement of scars. Patients should to reapproximate and evert the wound edges properly, be counseled to understand that the goal of scar revi and closure under excessive tension. Failure to evert the sion is to replace one scar for another to improve the wound edges at the time of closure leads to formation appearance and the acceptability of the scar. Lack of deep support of the wound the wound healing process is divided into three can lead to excessive tension on wound edges, resulting stages.
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In such cases, toxic contamination of the organs is attacked by Hepar compositum (liver), Cor compositum (heart), Solidago compositum S (kidneys), Discus compositum ampoules (disorders originating in the vertebral column), etc. Always indicated is the injection, interchanged, of such Composita preparations as are expected to bring about the participation of the corresponding organ or tissue functions. The dosage is adjusted according to the disease, the clinical picture and the stage of the illness: in acute disorders 1 ampoule daily, otherwise 1 ampoule i. Pharmacological and clinical notes Plantago major (plantain) Enuresis nocturna, cystalgia. Atropa belladonna (deadly nightshade) Localized reaction phases, cerebral sensitivity, incontinentia urinae, cystitis, vesical tenesmus. The consequences of mental emotions are functional disturbances; the co-ordination is influenced. For restless children, in addition to Ignatia-Homaccord, Valerianaheel and Viburcol, possibly also Nervoheel. The dosage is adjusted according to the disease, the symptoms and the stage of the illness: 10 drops 3-4 times daily; for acute disorders, massive initial-dose therapy: 10 drops every 10-15 minutes. For enuresis also formation of a wheal in admixture with Equisetum-Injeel forte and Agaricus-Injeel, and in addition Vesica urinaria suis-Injeel once weekly i. Pharmacological and clinical notes Podophyllum peltatum (may-apple) Pancreopathy with spurting, painless diarrhoea, cholecystopathy, colitis, haemorrhoids. Acidum muriaticum (hydrochloric acid) Chronic gastro-enteritis, dyspepsia, haemorrhoids, very sensitive to contact Ignatia (St. Mercurius sublimatus corrosivus (mercury (Il) chloride) Suppurations, abscesses, dysentery, colitis, rectal tenesmus. Based on the individual homoeopathic constituents of Podophyllum compositum, therapeutical possibilities result not only for the treatment of haemorrhoidal disorders and simple catarrhal colitis as well as colitis mucosa et ulcerosa, but also for the preliminary and after-treatment of neoplasia (pre and post-operative, as well as before and after radiation therapy), especially when mucous and sanguineous evacuations occur (acute and chronic colitis). Especially indicated is Podophyllum compositum for pains in the right hypogastrium, which radiate into the right thigh. Alternating remedies such as Veratrum-Homaccord (colitis), Diarrheel S (gastro enteritis), Nux vomica-Homaccord (rectal tenesmus, constipation with ineffectual straining), Mercurius-Heel S (dysenteriform diarrhoea), etc. Since spondylolisthesis can cause or stimulate comparable disorders, in painful conditions also the intervertebral origin should always be taken into consideration. The dosage is adjusted according to the disease, the symptoms and the stage of the illness: for preliminary and after-treatment of neoplasia (pre or post-operative), as well as before and after radiation therapy, 10 drops 3 times hourly and then only 3 times daily; in acute disorders, massive initial-dose therapy: 10 drops every 15 minutes. Indications: Stimulation of the defence system in disturbance of the renal function and excretion, albuminuria, irritation in the urinary system, cystopyelitis, cystitis, hydronephrosis, nephrolithiasis (as additional remedy in bacteriuria), particularly in micturition disorders (1st stage of prostatic adenoma). Dosage: In general, 10 drops 3 times daily; in acute disorders, initially 10 drops hourly.
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