Rotator Cuff Tendinopathy-RCT-is a common cuase of painful restriction of the shoulder at all ages and affects about 1 in 50 adults and is particularly common in athletes who throw repetitively, swimmer and laborers who work with their arms over their heads.
o third most common musculoskeletal disorder after back and neck pain
o increases in incidence in those 60 years and over.
o 8-15% of athletic injuries involve the shoulder, and shoulder instability is very common in young athletes, nto so much in older ones
o It follows trauma in 30% of cases and is bilateral in only 5%
o Prevalence of shoudler diseases reported to range from 7-36% in general population, and shoulder complaints account for 1.2% of all GP encounters in Australia
It is ultimately the repeated impingement of the coroacromial arch onto the supraspinatus tendon that has been implicated as the likley mechanism of tendon injury, as the supraspinatus complex occupies a narrow space with light contact between supraspinatus and the coroacromial arch during normal abduction.
Tendinopathy is infact a more technically correct term for shoulder injuries, not tendonitis, as, although true inflammatory tendinopathies exist, most patients that present to a GP have had prolonged symptoms. Thus by the time they do present, acute inflammation would probably have subsided and been supplanted by degeneration of the normally highly arranged collagen structure of the tendon. There are three classifications of tendinipathy:
1) acute tendonitis alone
2) chronic tendinosus + acute tendonitis
3) chronic tendinosus alone
Thursday, August 30, 2007
Mangaement of Cataracts
Initial Mx:
• Glasses, strong bifocals, magnification, stronger lighting and other visual aids
Surgery:
• When cataracts begin to affect everyday life, most effective Rx is surgery, no medical Rx (usually when acuity is b/w 6/6 and 6/18)
• Cataract surgery proves effective in 95% of cases, with improvement in vision and no complications
• Day surgery/outpatient procedure: takes less than an hour
• If both eyes affected, surgery performed on one eye at a time, with 1-2 month gap b/w to let initial eye heal
• Can choose to postpone surgery if vision/lifestyle not affected significantly, but younger or diabetic patients have greater need for surgery-progress faster
Preparation:
o Ophthalmologist measure eye with ultrasound to determine power of lens to insert
o Local anaesthetic used, general used only if patient very distressed/anxious
Technique:
Basically crystalline lens with cataract removed during surgery, capsule remains, new artificial intraocular lens inserted
o 2 types:
Extra-Capsular Cataract Extraction (ECCE)-lens removed but majority of lens capsule remains to support the artificial lens.
-Can be via phacoemulsification, where a small incision is made-3mm long- where cornea meets conjunctiva, horizontal incision. Small needle like probe inserted via incision, and ultrasound waves emitted into eye via probe break up lens+cataract, and bits are suctioned out via probe
-If cataract is advanced stage, ultrasound waves may not be able to break it up, so larger incision required-10mm-where cornea meets sclera. Ophthalmologist opens lens capsule through incision, removes nucleus of lens in 1 piece followed by softer lens cortex, capsule remains in place
Intra-Capsular Cataract Extraction (ICCE)¬-lens and capsule removed b/c cataract has progressed into capsule (rarely performed)
o After cataract removed, a plastic intraocular lens-silicone/acrylic-folded when outside the eye is inserted through the incision
o Once in the eye, IOL unfolds and is position inside lens capsule, it’s 6mm in diameter
o Most IOLs are monofocal, multifocal lenses are being developed but problems exist with intermediate focus and glare with multifocals.
Recovery:
o Incision heals fast, b/c very small and made horizontally. No stitches.
o Swelling and redness should go down within few days- week and vision should improve almost immediately
o If larger incision may take up to 8 weeks to heal completely
o Can’t drive home, and ophthalmologist may restrict movement e.g. bending/lifting for a few days
o Need follow up next day, one week and one month after surgery
o Doctor may prescribe medication to prevent infection and to control eye pressure
o Contact Doctor if experience: Vision loss, pain despite use of over-the-counter drugs, increase in inflammation/redness, nausea/vomiting/excessive coughing, light flashes or spots in front of eyes
o Most people require glasses after surgery b/c artificial lens usually monofocal and astigmatism may arise from surgery (Px has difficulty focussing b/c cornea is not curved evenly in all directions, less common with smaller incisions)
o 2nd Cataract: about 25% of patients develop a second cataract where back of lens capsule-left in during surgery-becomes opaque b/c of build-up of cells. Also called Posterior Capsule Opacification (PCO)
-PCO can develop months/years after procedure
-Rx is YAG (yttrium-aluminium-garnet) laser capsulotomy where laser is used to make a small opening in capsule to let light shine through
-short procedure, less than 5 mins, but Px has to remain for about 1 hr to monitor eye pressure. Can cause glaucoma, or increase welling of macula and retinal detachment
PS. I've sent two pics of anatomy of eye+catract surgery to emails
• Glasses, strong bifocals, magnification, stronger lighting and other visual aids
Surgery:
• When cataracts begin to affect everyday life, most effective Rx is surgery, no medical Rx (usually when acuity is b/w 6/6 and 6/18)
• Cataract surgery proves effective in 95% of cases, with improvement in vision and no complications
• Day surgery/outpatient procedure: takes less than an hour
• If both eyes affected, surgery performed on one eye at a time, with 1-2 month gap b/w to let initial eye heal
• Can choose to postpone surgery if vision/lifestyle not affected significantly, but younger or diabetic patients have greater need for surgery-progress faster
Preparation:
o Ophthalmologist measure eye with ultrasound to determine power of lens to insert
o Local anaesthetic used, general used only if patient very distressed/anxious
Technique:
Basically crystalline lens with cataract removed during surgery, capsule remains, new artificial intraocular lens inserted
o 2 types:
Extra-Capsular Cataract Extraction (ECCE)-lens removed but majority of lens capsule remains to support the artificial lens.
-Can be via phacoemulsification, where a small incision is made-3mm long- where cornea meets conjunctiva, horizontal incision. Small needle like probe inserted via incision, and ultrasound waves emitted into eye via probe break up lens+cataract, and bits are suctioned out via probe
-If cataract is advanced stage, ultrasound waves may not be able to break it up, so larger incision required-10mm-where cornea meets sclera. Ophthalmologist opens lens capsule through incision, removes nucleus of lens in 1 piece followed by softer lens cortex, capsule remains in place
Intra-Capsular Cataract Extraction (ICCE)¬-lens and capsule removed b/c cataract has progressed into capsule (rarely performed)
o After cataract removed, a plastic intraocular lens-silicone/acrylic-folded when outside the eye is inserted through the incision
o Once in the eye, IOL unfolds and is position inside lens capsule, it’s 6mm in diameter
o Most IOLs are monofocal, multifocal lenses are being developed but problems exist with intermediate focus and glare with multifocals.
Recovery:
o Incision heals fast, b/c very small and made horizontally. No stitches.
o Swelling and redness should go down within few days- week and vision should improve almost immediately
o If larger incision may take up to 8 weeks to heal completely
o Can’t drive home, and ophthalmologist may restrict movement e.g. bending/lifting for a few days
o Need follow up next day, one week and one month after surgery
o Doctor may prescribe medication to prevent infection and to control eye pressure
o Contact Doctor if experience: Vision loss, pain despite use of over-the-counter drugs, increase in inflammation/redness, nausea/vomiting/excessive coughing, light flashes or spots in front of eyes
o Most people require glasses after surgery b/c artificial lens usually monofocal and astigmatism may arise from surgery (Px has difficulty focussing b/c cornea is not curved evenly in all directions, less common with smaller incisions)
o 2nd Cataract: about 25% of patients develop a second cataract where back of lens capsule-left in during surgery-becomes opaque b/c of build-up of cells. Also called Posterior Capsule Opacification (PCO)
-PCO can develop months/years after procedure
-Rx is YAG (yttrium-aluminium-garnet) laser capsulotomy where laser is used to make a small opening in capsule to let light shine through
-short procedure, less than 5 mins, but Px has to remain for about 1 hr to monitor eye pressure. Can cause glaucoma, or increase welling of macula and retinal detachment
PS. I've sent two pics of anatomy of eye+catract surgery to emails
Advertising in the Health-Care Sector
Advertising in the Healthcare Sector
Legislation regarding advertising in the health-care sector falls under the federal statutory Trades Practices Act 1974 and the Medical Practices Act 1994, and the regulatory body that enforces the act is the Australian Competition and Consumer Commission (ACCC).
The acts are designed to protect consumers and the community from false and misleading advertising.
The Medical Practice Act 1994 outlines the responsibilities of the Medical Practitioners Board of Victoria in relation to regulation of advertising by medical practitioners. It states that a person must not advertise a medical practice or medical services in a manner which:
➢ is or is intended to be false, misleading or deceptive
➢ offers a discount, gift or other inducement to attract patients to a medical practitioner unless the advertisement also sets out the terms and conditions of that offer
➢ refers to uses or quotes from testimonials or purported testimonials
➢ creates an unreasonable expectation of beneficial treatment.
There are risks that advertising which is false, misleading or deceptive can lead to the provision of unnecessary medical services, or create unrealistic expectations about the benefits of such services, with adverse consequences for consumers.
The TPA prohibits conduct that is unconscionable, misleading or deceptive, or is likely to mislead or deceive.
Forms of promotion that are subject to legislative regulation include:
➢ print and electronic advertisements;
➢ outdoor advertisements;
➢ patient information brochures;
➢ direct mail outs
➢ representations made on the Internet.
➢ oral statements made to patients by health care professionals and their employees
In addition, Health Complaints Offices exist in some states, and medical and other health practitioner registration associations also assist in providing guidance on appropriate advertising for health professionals. For example, the Australian Medical Association's Position Statement on Advertising and Endorsement states that information about medical services should:
➢ be demonstrably true in all respects;
➢ not be misleading, vulgar or sensational;
➢ seek to maintain the decorum and dignity of the profession;
➢ not contain any testimonial or endorsement of clinical skills;
➢ not claim that one doctor is superior to others, nor contain endorsements for any particular doctor;
➢ avoid aggressive forms of competitive persuasion.
In accordance with these general guidelines, the AMA Position Statement states that the chief purpose of any advertisement should be to present information that is reasonably needed by any patient to make an informed decision about the appropriateness and availability of the medical services offered.
Differences between receiving private and public cataract surgery:
Public hospital:
o No direct cost to patient
o No choice of treating doctor, and often no consistent doctor during course of treatment
o Waiting time for elective procedures.
Private hospital:
o Cost of insurance and out of pocket expenses
o Choice of specialist and continuity of care
o Minimal waiting time.
Legislation regarding advertising in the health-care sector falls under the federal statutory Trades Practices Act 1974 and the Medical Practices Act 1994, and the regulatory body that enforces the act is the Australian Competition and Consumer Commission (ACCC).
The acts are designed to protect consumers and the community from false and misleading advertising.
The Medical Practice Act 1994 outlines the responsibilities of the Medical Practitioners Board of Victoria in relation to regulation of advertising by medical practitioners. It states that a person must not advertise a medical practice or medical services in a manner which:
➢ is or is intended to be false, misleading or deceptive
➢ offers a discount, gift or other inducement to attract patients to a medical practitioner unless the advertisement also sets out the terms and conditions of that offer
➢ refers to uses or quotes from testimonials or purported testimonials
➢ creates an unreasonable expectation of beneficial treatment.
There are risks that advertising which is false, misleading or deceptive can lead to the provision of unnecessary medical services, or create unrealistic expectations about the benefits of such services, with adverse consequences for consumers.
The TPA prohibits conduct that is unconscionable, misleading or deceptive, or is likely to mislead or deceive.
Forms of promotion that are subject to legislative regulation include:
➢ print and electronic advertisements;
➢ outdoor advertisements;
➢ patient information brochures;
➢ direct mail outs
➢ representations made on the Internet.
➢ oral statements made to patients by health care professionals and their employees
In addition, Health Complaints Offices exist in some states, and medical and other health practitioner registration associations also assist in providing guidance on appropriate advertising for health professionals. For example, the Australian Medical Association's Position Statement on Advertising and Endorsement states that information about medical services should:
➢ be demonstrably true in all respects;
➢ not be misleading, vulgar or sensational;
➢ seek to maintain the decorum and dignity of the profession;
➢ not contain any testimonial or endorsement of clinical skills;
➢ not claim that one doctor is superior to others, nor contain endorsements for any particular doctor;
➢ avoid aggressive forms of competitive persuasion.
In accordance with these general guidelines, the AMA Position Statement states that the chief purpose of any advertisement should be to present information that is reasonably needed by any patient to make an informed decision about the appropriateness and availability of the medical services offered.
Differences between receiving private and public cataract surgery:
Public hospital:
o No direct cost to patient
o No choice of treating doctor, and often no consistent doctor during course of treatment
o Waiting time for elective procedures.
Private hospital:
o Cost of insurance and out of pocket expenses
o Choice of specialist and continuity of care
o Minimal waiting time.
PCL Week 7 - Doctors and Drivers
When a patient’s health affects their ability to drive, a doctor must consider their duty to their patient’s privacy, but also to the public’s safety. For many aging citizens, particularly in rural or remote areas, their ability to drive is more than just an issue of convenience, but also represents a level of independence. Many people may have had their licence for up to fifty years and so are naturally reluctant to give up what they have managed to obtain and maintain for such significant proportion of their lives. It is for this reason that they often require support and encouragement to make lifestyle changes in anticipation of not being able to drive.
Visual standards:
• Visual acuity - The person’s visual acuity in the better eye or with both eyes together must not be worse than 6/12. However, a conditional licence may be granted taking into account the opinion of the treating doctor, and the nature of the driving task, and is subject to periodic review. Cataracts often cause a loss of contrast sensitivity and greater sensitivity to glare, so patients may have more difficulty seeing when driving than is indicated by their visual acuity.
• Visual fields - The criteria for an unconditional licence are that binocular visual field has a horizontal extent of at least 120 degrees, within 10 degrees above and below the horizontal midline and that the person is free from any significant visual field loss that is likely to impede driving performance.
• Diabetes - A person with diabetes controlled by diet alone may drive without licence restriction and without notification to the Driver Licensing Authority. They should be reviewed periodically.
Reporting process:
The laws require drivers to report VicRoads if they have any permanent or long-term illness that is likely to affect their ability to drive safely. As the relationship between patient and health professional is confidential, the doctor will not normally communicate directly with VicRoads. They will however provide the patient with advice about their ability to drive safely as well as a letter, or report, to take with them (except in South Australia and the Northern Territory, where reports are directly made to the relevant licensing authorities).
Penalties may be imposed on a driver that fails to report an impairment, and may be liable at common law if they continue to drive knowing that they have a condition that is likely to adversely affect safe driving.
Doctors also have an obligation to public safety, so if they believe a patient is not heeding advice to cease driving, they may report directly to VicRoads. The Victorian Road Safety Act (1986) provides statutory immunity to doctors who, in good faith, report that a patient has a medical condition which renders them unfit to hold a driver’s licence.
Visual standards:
• Visual acuity - The person’s visual acuity in the better eye or with both eyes together must not be worse than 6/12. However, a conditional licence may be granted taking into account the opinion of the treating doctor, and the nature of the driving task, and is subject to periodic review. Cataracts often cause a loss of contrast sensitivity and greater sensitivity to glare, so patients may have more difficulty seeing when driving than is indicated by their visual acuity.
• Visual fields - The criteria for an unconditional licence are that binocular visual field has a horizontal extent of at least 120 degrees, within 10 degrees above and below the horizontal midline and that the person is free from any significant visual field loss that is likely to impede driving performance.
• Diabetes - A person with diabetes controlled by diet alone may drive without licence restriction and without notification to the Driver Licensing Authority. They should be reviewed periodically.
Reporting process:
The laws require drivers to report VicRoads if they have any permanent or long-term illness that is likely to affect their ability to drive safely. As the relationship between patient and health professional is confidential, the doctor will not normally communicate directly with VicRoads. They will however provide the patient with advice about their ability to drive safely as well as a letter, or report, to take with them (except in South Australia and the Northern Territory, where reports are directly made to the relevant licensing authorities).
Penalties may be imposed on a driver that fails to report an impairment, and may be liable at common law if they continue to drive knowing that they have a condition that is likely to adversely affect safe driving.
Doctors also have an obligation to public safety, so if they believe a patient is not heeding advice to cease driving, they may report directly to VicRoads. The Victorian Road Safety Act (1986) provides statutory immunity to doctors who, in good faith, report that a patient has a medical condition which renders them unfit to hold a driver’s licence.
Week 7 - Aboriginal Health Issues
* Aboriginal people have higher rates of ill health than any other group in Australia
* The Victorian Koori people account for only 0.5% of the population (the lowest number of indigenous people) but report the highest rates of acute illness, chronic illness, and cigarette smoking in Australia
* Main health issues confronting Koori people include smoking, diet, diseases like cardiovascular disease, diabetes and high blood pressure, stress, drugs, alcohol and poor children's health
For these health issues, there's a range of causes:
* genetic susceptibility
- it has been suggested that Aboriginal people have a "thrify genotype", which helped to support their traditional hunter-gatherer lifestyle. This means that their bodies are genetically programmed for glucose intolerance and high blood cholesterol levels - protecting against starvation. As traditional diets were rich in nutrients and low in fat, this did not create an issue until the high-fat, high-sugar western diet was introduced. This in addition to poor access to healthy foods for Aboriginal populations causes higher incidences of obesity, diabetes and cardiovascular disease.
- As a result of this genetic susceptibility and also poor access to healthy food, around 6 out of 10 Aboriginal and Torres Strait Islander people are either overweight or obese. This multiplies the chances of developing Type II diabetes by 10.
* Lack of physical exercise
* Low birth weight
- An aboriginal woman is twice as likely to have a low birth weight baby than a non-aboriginal woman. some studies indicate that low birth weight is associated with an increased risk of developing Type II diabetes.
* Poor standard of living/Low socioeconomic status
- Research shows that a person who has a limited income, low level of education and few employment prospects is more likely to engage in behaviours that increase the odds of disease.
- Aboriginal and Torres Strait Islander people are among the most economically disadvantaged of all Australians
* Reduced Access to Medical Care
- Culturally sensitive medical care is limited, especially for Aboriginal Australians who live in remote or rural areas.
FOR MORE INFO, LOOK AT THESE FACT SHEETS:1. http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Aboriginal_health_issues_diabetes?OpenDocument
2.
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Aboriginal_health_issues?open
* The Victorian Koori people account for only 0.5% of the population (the lowest number of indigenous people) but report the highest rates of acute illness, chronic illness, and cigarette smoking in Australia
* Main health issues confronting Koori people include smoking, diet, diseases like cardiovascular disease, diabetes and high blood pressure, stress, drugs, alcohol and poor children's health
For these health issues, there's a range of causes:
* genetic susceptibility
- it has been suggested that Aboriginal people have a "thrify genotype", which helped to support their traditional hunter-gatherer lifestyle. This means that their bodies are genetically programmed for glucose intolerance and high blood cholesterol levels - protecting against starvation. As traditional diets were rich in nutrients and low in fat, this did not create an issue until the high-fat, high-sugar western diet was introduced. This in addition to poor access to healthy foods for Aboriginal populations causes higher incidences of obesity, diabetes and cardiovascular disease.
- As a result of this genetic susceptibility and also poor access to healthy food, around 6 out of 10 Aboriginal and Torres Strait Islander people are either overweight or obese. This multiplies the chances of developing Type II diabetes by 10.
* Lack of physical exercise
* Low birth weight
- An aboriginal woman is twice as likely to have a low birth weight baby than a non-aboriginal woman. some studies indicate that low birth weight is associated with an increased risk of developing Type II diabetes.
* Poor standard of living/Low socioeconomic status
- Research shows that a person who has a limited income, low level of education and few employment prospects is more likely to engage in behaviours that increase the odds of disease.
- Aboriginal and Torres Strait Islander people are among the most economically disadvantaged of all Australians
* Reduced Access to Medical Care
- Culturally sensitive medical care is limited, especially for Aboriginal Australians who live in remote or rural areas.
FOR MORE INFO, LOOK AT THESE FACT SHEETS:1. http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Aboriginal_health_issues_diabetes?OpenDocument
2.
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Aboriginal_health_issues?open
Monday, August 27, 2007
practice exam answers from holly
1. C
2. B
3. FFTF
4. TTTT
5. TFFF
6. C
7. D
8. E
9. D
10. E
11. D
12. B
13. B
14. FFTF
15. FTFF
16. FTFT
17. TTTT
18. TTTF
19. FTFT
20. FFFT
21. FTTF
22. TTTT
23. FTTF
24. TTTF
25. TFTF
26. TFTF
27. TTTF
28. D
29. FTFT
30. E
31. C
32. TTFT
good luck for wednesday!!!!!!!!!!!!!
2. B
3. FFTF
4. TTTT
5. TFFF
6. C
7. D
8. E
9. D
10. E
11. D
12. B
13. B
14. FFTF
15. FTFF
16. FTFT
17. TTTT
18. TTTF
19. FTFT
20. FFFT
21. FTTF
22. TTTT
23. FTTF
24. TTTF
25. TFTF
26. TFTF
27. TTTF
28. D
29. FTFT
30. E
31. C
32. TTFT
good luck for wednesday!!!!!!!!!!!!!
Thursday, August 23, 2007
Management of Shingles
• The main challenge in the management of shingles is the rapid treatment of the pain involved.
• Early and adequate antiviral treatment will help to reduce the severity and duration of the pain involved.
• The use of antiviral agents is to stop virus replication as quickly as possible and minimize nerve damage
o There are three antiviral compounds which have been assessed for their ability to speed the resolution of shingles
Aciclovir
• Total Pain duration is greatly reduced
• 800 mg 5 times per day for 7 days
Famciclovir
• 500 mg 3 times per day for 7 days
Valaciclovir
• Speeds pain resolution significantly faster than acyclovir
• 1 g 3 times per day for 7 days
o Must be administered within 72 hours of rash onset
• These antiviral agents are appropriate for all patients presenting with shingles within 72 hours of rash onset
• Valaciclovir is probably the most effective agent available as it is the fastest at resolving the pain associated with shingles.
• Famciclovir and valaciclovir offer more convenient dosing than acyclovir.
• Complications can be reduced to 20% or less by early treatment, as well as reducing duration of lesion formation and time to healing
• Early and adequate antiviral treatment will help to reduce the severity and duration of the pain involved.
• The use of antiviral agents is to stop virus replication as quickly as possible and minimize nerve damage
o There are three antiviral compounds which have been assessed for their ability to speed the resolution of shingles
Aciclovir
• Total Pain duration is greatly reduced
• 800 mg 5 times per day for 7 days
Famciclovir
• 500 mg 3 times per day for 7 days
Valaciclovir
• Speeds pain resolution significantly faster than acyclovir
• 1 g 3 times per day for 7 days
o Must be administered within 72 hours of rash onset
• These antiviral agents are appropriate for all patients presenting with shingles within 72 hours of rash onset
• Valaciclovir is probably the most effective agent available as it is the fastest at resolving the pain associated with shingles.
• Famciclovir and valaciclovir offer more convenient dosing than acyclovir.
• Complications can be reduced to 20% or less by early treatment, as well as reducing duration of lesion formation and time to healing
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