By: Tina Lee Cheng, M.D., M.P.H.
They were developed to buy female cialis 20mg low cost menopause play assist health care professionals in the management and care for patients with overweight and obesity buy 20mg female cialis overnight delivery menopause age. The content herein is based on medical literature and the clinical experiences of obesity medicine specialists female cialis 10 mg fast delivery menopause 34 symptoms. In areas regarding inconclusive or insufficient scientific evidence, the authors used their professional judgment. The Obesity Algorithm is a working document that represents the state of obesity medicine at the time of publication. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. Permissions the Obesity Medicine Association owns the copyright to the Obesity Algorithm but invites you to use the slide set. Access to the Obesity Algorithm content and/or permission for extensive quoting or reproducing excerpts and for the reproduction and use of copyrighted text, images, or entire slides will not be granted until the requestor has signed the copyright consent and permission agreement available at This 2016-2017 version of the Obesity Algorithm incorporates worldwide input, as well as interim scientific and clinical trial data. Purpose To provide clinicians with an overview of principles important to the care of patients with increased and/or dysfunctional body fat, based upon scientific evidence, supported by medical literature, and derived from the clinical experiences of members of the Obesity Medicine Association. Intent of Use the Obesity Algorithm is intended to be a “living document” updated once a year (as needed). It is intended to be an educational tool used to translate the current medical science and the experiences of obesity specialists to better facilitate and improve the clinical care and management of patients with overweight and obesity. This algorithm is not intended to be interpreted as “rules” and/or directives regarding the medical care of an individual patient. While the hope is many clinicians may find this algorithm helpful, the final decision regarding the optimal care of the patient with overweight and obesity is dependent upon the individual clinical presentation and the judgment of the clinician who is tasked with directing a treatment plan that is in the best interest of the patient. The Obesity Algorithm is listed by the American Board of Obesity Medicine as a suggested resource and study-aid for the obesity medicine certification exam. Obesity Algorithm Obesity as a Disease Data Collection Evaluation and Assessment Management Decisions Motivational Interviewing Nutritional Physical Behavior Pharmaco Bariatric 10 Intervention Activity Therapy therapy Procedures Reference/s:  Obesity Defined as a Disease 11 obesitymedicine. Reference/s:  Obesity Is a Disease When • the patient has excessive body fat, as assessed by reliable measures • Excessive body fat is caused by genetic or developmental errors, infections, hypothalamic injury, adverse reactions to medications, nutritional imbalance, and/or unfavorable environmental factors • Multiple pathogenic adipocyte and/or adipose tissue endocrine and immune dysfunctions contribute to metabolic disease (adiposopathy or “sick fat” disease) • Multiple pathogenic physical forces from excessive body fat cause stress damage to other body tissues (fat mass disease) the adverse health consequences of increased body fat are not simply “co-morbidities” or “associated risk factors” 13 Obesity Algorithm. Reference/s:  Obesity Terminology “People-first” language recognizes the potential hazards of referring to or labeling individuals by their disease. Thus, “patient who is overweight or has obesity” or “patient with overweight or obesity” are preferred over “obese patient. Reference/s: [2,3] Obesity Health Care Office Environment Clinicians and staff should be trained to avoid hurtful comments, jokes, or being otherwise disrespectful, as patients with obesity may be ashamed or embarrassed about their weight. Positive Office Space Appropriate Medical Devices • Sturdy‚ armless chairs and high‚ firm sofas in • Large adult blood pressure cuffs or thigh cuffs on waiting rooms patients with an upper-arm circumference greater • Sturdy‚ wide exam tables that avoid or prevent than 34 cm tipping • Extra-long needles to draw blood • Sturdy stool or step with handles to help patients • Large vaginal specula climb onto the exam table • Weight scales with the capacity to measure • Tables/chairs/toilet seats should sustain higher patients who weigh more than 400 pounds body weights • Extra-large patient gowns • Split toilet seat; provide a specimen collector with a handle • Reading materials in the waiting room that focus on healthy habits‚ rather than physical looks or being “thin” 15 Obesity Algorithm. Obesity as a Multifactorial Disease Genetics/ Epigenetics Environment Neurobehavioral (Social/Culture) Medical Immune Endocrine 17 Obesity Algorithm. Reference/s:  Multifactorial Inheritance Factors Contributing to Obesity Mother Father Familial/cultural/ Genetic Epigenetic societal inheritance inheritance inheritance Obesity and its complications 18 Obesity Algorithm. Reference/s:  Genetics: Melanocortin 4 Receptor Deficiency Clinical Presentation Genetic Abnormality • Autosomal dominant or recessive • Obesity, especially in families • Most common known genetic defect • Hyperphagia and obesity early in predisposing to obesity childhood • Polymorphism of gene localized to • Insulin resistance chromosome 18q22 • Increase in bone mineral density (“big boned”) • Accelerated linear growth • Reduced sympathetic nervous activity 19 Obesity Algorithm. Reference/s: [6,7] Genetics: Prader–Willi Syndrome Clinical Presentation Genetic Abnormality • Obesity, often hyperphagic • Not inherited • Short stature • Most cases involve loss of function of a portion of • Weak muscle tone chromosome 15 • Poor growth • Often reported as the most common human • Small hands/feet genetic "obesity syndrome" • Delayed development • Underdeveloped genitals (often with infertility) • Behavioral/emotional challenges • Mild to moderate intellectual impairment • Insatiable appetite • Narrow forehead • Almond-shaped eyes • Triangular mouth • Often with fair skin and light-colored hair 20 Obesity Algorithm. Reference/s:  Genetics: Bardet–Biedl Syndrome Clinical Presentation Genetic Abnormality • Obesity • Autosomal recessive • Metabolic abnormalities. Reference/s:  Obesity: Extragenetic Etiology/Causes Extragenetic • Environment (family, home, geographic location) • Culture • Lack of optimal nutrition and physical activity • Disrupted sleep. Reference/s:  Obesity: Epigenetic Etiology/Causes Epigenetics: Alterations in gene expression without alteration in the genetic code Pre-pregnancy • Pre-conception paternal or maternal overweight/obesity may influence epigenetic signaling during subsequent pregnancy: Increased risk of overweight/obesity in offspring Increased risk of other diseases. Reference/s: [10,11,12] Overall Management Goals Adult patient with overweight or obesity Improve body Improve patient Improve quality weight and health of life composition 30 Obesity Algorithm. Reference/s: [13-15] Percent Body Fat: American Council on Exercise Classification American Council on Exercise Classification: Percent body fat* Essential Fat Athletes Fitness Acceptable Obesity Women: 10-13% Women: 14-20% Women: 21-24% Women: 25-31% Women: 32% Men: 2-5% Men: 6-13% Men: 14-17% Men: 18-24% Men: 25% *Based on “expert opinion;” cut-off points not scientifically validated 33 Obesity Algorithm. Reference/s: [19-22] Obesity: Summary Diagnostic Metrics and Diagnostic Codes Body Mass Index Overweight and E66. Reference/s: [13-15] Percent Body Fat Advantages • More specific assessment of body fat • May be a reasonable longitudinal measure, especially in patients who may not be losing weight, but engaged in resistance exercise training, and thus may be losing body fat, and increasing muscle Disadvantages • Some measurement techniques are not always accurate, nor easily reproducible.
Slower growing gliomas are categorized as low grade (grades 1 and 2) order female cialis 20 mg fast delivery menstruation yom kippur, and faster growing gliomas are categorized as high grade (grades 3 and 4) purchase 20 mg female cialis fast delivery minstrel krampus full episode. The ventricular system contains the cerebrospinal fuid that bathes and cushions the brain and spinal cord cheap 10 mg female cialis visa menstruation yom kippur. Oligodendrogliomas can be fast or slow growing, and most commonly arise in the cerebral (upper) brain hemispheres. Medulloblastoma is a tumor that occurs in the cerebellum (lower part of the brain that controls balance and other motor functions). Germ cell tumors most commonly occur in the reproductive organs (testicles or ovaries). However, these tumors can also occur in other places within the body, including: · Abdomen · Pelvis · Central chest area (mediastinum) · Brain · Lower back/tailbone area (sacrococcygeal) Germ cell tumors can be malignant (fast-growing and have a tendency to spread) or benign (slow-growing and do not spread). Malignant germ cell tumors include several types, such as immature teratoma, yolk sac tumor, embryonal carcinoma, germinoma/dysgerminoma/seminoma, and choriocarcinoma. These tumors can damage the testicle or ovary and can spread to other parts of the body, such as the lung, liver, lymph nodes, and central nervous system. Some malignant germ cell tumors begin in the central nervous system, usually near the center of the brain. A teratoma is a tumor that may contain several different types of tissue, such as hair, muscle, and bone. Although usually not as diffcult to treat as malignant tumors, benign germ cell tumors can cause problems because of their size or location. Kidney cancer arises when a mistake or mutation occurs during the formation of a young kidney cell. The change in the kidney cell causes the cell to grow out of control and become a cancerous tumor. The most common types of kidney cancer in childhood are: · Wilms tumor (nephroblastoma) Wilms tumor is the most common type of kidney cancer in children. Usually, Wilms tumor occurs in one kidney (unilateral), but sometimes it can occur in both kidneys (bilateral). Wilms tumors can sometimes spread to other parts of the body, such as the lymph nodes in the abdomen, lung, and liver. Renal cell carcinoma can sometimes spread to other parts of the body, such as the lymph nodes in the abdomen, the lungs, and the brain. The liver is important in removing toxins from the blood, producing blood clotting proteins, and helping the body to digest food and use medicines. Liver cancers occur when a liver cell develops a series of mutations or mistakes that allows it to grow without the usual controls and to form cancerous tumors. The two most common types of liver cancers in children are: · Hepatoblastoma, which occurs most frequently in infants or very young children. Melanoma begins with a series of mistakes or mutations in the melanocytes, the cells that give color to the skin, hair and eyes. The change in the melanocytes allows these cells to become cancerous and grow out of control. Melanoma is not the most common type of skin cancer, but it is the most serious one. The sympathetic nervous system is a nerve network that carries messages throughout the body. Sympathetic nerves are responsible for actions of the body that are not under voluntary control, such as increasing heart rate, blushing, and dilating the pupils of the eye. Neuroblastoma begins when a change or mutation occurs in a young cell of the sympathetic nervous system, known as a neuroblast. Neuroblastoma can begin anywhere in the body, but is most commonly found in the adrenal gland, located on top of the kidney. Other common locations for neuroblastoma include the neck, chest, abdomen, and pelvis, near the spine. Neuroblastoma can spread to other areas of the body, including the bone marrow, bones, and lymph nodes. Retinoblastoma begins when a change or mutation occurs in a young cell of the retina called a retinoblast. Retinoblastoma is usually seen in infants and children younger than 6 years of age.
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Cranial nerves involved primarily include optic (optic atrophy and blindness are the most common neurologic manifestation) safe 10 mg female cialis breast cancer north face, facial discount 20mg female cialis menstrual cycle day 7, and vestibulo-acoustic (with deaf ness) buy female cialis 10mg fast delivery women's health center methuen ma, trigeminal nerve may also be involved. There may also be extensive intracranial calcifications, 91 hydrocephalus, intracranial hemorrhage and seizures. Co r t ica l s p r e a d in g d e p r e ss io n Posterior ischem ic optic neuropathy. Usually in th e settin g of sh ock Bila t e r a l vit r e o u s h e m o r r h a ge. Som e auth ors reser ve th e term exoph th alm os for cases due to endocrinopathies and use proptosis (of the eye) for other causes, but these term s are widely used interchangeably. Anterior displacement of 18 mm (Hertal exophthalmom etry can be used to measure clinically – requires intact lateral orbital bone). In a p e d ia t r ic practice the 3 most common etiologies in decreasing order of frequency: familial (parents have big heads), benign subdural fluid collections of infancy (p. Seen e sp ecially in n e u rofibrom atosis an d con ge n it al hyp e rm elan osis (It o’s syndrome). Treatment is required in 30%due to rapid enlargement or growth beyond first m onth. May also be seen in the rare diencephalic syndrom e, see tum or of anterior hypothalam us (p. Objective tinnitus is almost always due to vascular turbulence (from increased flow or partial obstruction). Enlargement of anterior tympanic segment of seventh nerve canal glomus tympanicum tumor (p. Th e t r a ct u su a lly e x t e n d s d ow n in t o t h e sp in a l co rd as far as the C2 vertebral level (although it may occasionally extend down to C4) Ebooksmedicine. Neurologic Dis of history, physical examination, and electrocar turbances in Paget Disease of Bone: Response to diography. Pro sp e ct ive e va lu a t ion o f p a t ie n t s w it h syn co p e: 1988; 68:80–84 a population-based study. Parosmia and hyposmia induced by sol Ve n t r i c u l a r Ch a m b e r: The c h n i q u e s a n d St r a t e g i e s. In the T-spine, may occur as ossified plaques or in a cylindrical for m su rrou n d in g t h e sp in al cord. Thoracic spinal cord herniates through an anterior dural defect frequently producing a Brown-Sequard syndrome or spastic paraparesis Neoplastic: 1. Most often in the territory of the anterior spinal artery, sparing posterior columns. Most commonly T4 le ve l (watershed zone) a) atherosclerosis of radicular artery in elderly patient with hypotension is now the major cause of this rare condition b) clamping aorta during surgery. Especially when angiogrammed in presence ofhypotension,where cardiac output is shunted away from viscera and into spinal radicular arteries. Begins with symmetrical paresthesias in feet or hands (posterior colum n involvem ent) > leg sti ness, weakness, and proprioceptive deficits with unsteadiness that is worse in the dark > spasticity > paraplegia > bowel and bladder dysfunc tion. Dementia (confusion, memory impairment, irritability) occurs in advanced cases due to cerebral white matter changes. Visual disturbances with or without optic atrophy may be due to optic nerve demyelination 3. The nerve passes out of the pelvis through the greater sciatic foramen along the back of the thigh. In the lower third of the thigh it divides into the tibial and common peroneal nerves. Th e d i erential diagnosis is similar to that for myelopathy (see above) but also includes: 1. In the lumbar region may occur as columnar, cylindri 26 cal, or irregularly shaped m asses. Lu m b o s a c r a l d e r m a t o m e s a r e i n v o l v e d i n 10– 15%of zoster cases. Rarely extends to the pos terior thigh or as far distally as the knee 31 b) myositis ossificans of the biceps femoris muscle 6.
Final drying of semicritical endoscopes shall be facilitated by flushing all channels with filtered air buy female cialis 20mg amex women's health clinic newcastle, followed by 70% isopropyl alcohol buy cheap female cialis 10mg on line breast cancer 4th stage treatment, followed by forced air purging of the channels order 10 mg female cialis overnight delivery women's health center queens. Semicritical endoscopes shall be stored hanging vertically in a dedicated, closed, ventilated cabinet outside of the decontamination area and procedure room. Healthcare settings shall have policies in place providing a permanent record of endoscope use and reprocessing, as well as a system to track endoscopes and clients/patients/residents that includes recording the endoscope number in the client/patient/resident record. Unacceptable Methods of Disinfection/Sterilization the following methods of disinfection/sterilization are not recommended. Boiling water is inadequate for the destruction of bacterial spores and some viruses. It is not 23 an acceptable method of disinfection/sterilization for medical equipment/devices. Glass bead sterilizers are difficult to monitor for effectiveness, have inconsistent heating resulting in cold spots, and often have trapped air which affects the sterilization process. Glass bead sterilization is not an acceptable method of 23, 47 sterilization for medical equipment/devices. Chemiclaves are occasionally used in 48 dentistry, although steam sterilization is preferred due to the lack of penetration achieved in a chemiclave and 49 an overall failure rate of almost 5%. If used, a chemiclave must be monitored with mechanical, chemical and biological monitors as is any other sterilizer. Because of the environmental risks associated with formaldehyde, this method of 50 sterilization is no longer considered to be acceptable. If used, the process must be closely monitored, local regulations for hazardous waste disposal must be followed and air sampling for toxic vapours may be indicated. Home microwaves have been shown to inactivate bacteria, viruses, mycobacteria and some spores, however there may not be even 29 distribution of microwave energy over the entire device. More research and testing are required to validate the use of microwave ovens for sterilization. The use of microwave ovens for sterilization of medical 23, 29 equipment/devices is not currently acceptable. A written procedure must be established for the recall and reprocessing of improperly reprocessed medical 1, 2 equipment/devices. All equipment/devices in each processed load must be recorded to enable tracking in the event of a recall. Facilities should consider implementing commercial instrument tracking systems to facilitate identification of patients in the event of a recall. Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings | May 2013 49 Health care settings shall have a process for receiving and disseminating medical device alerts and recalls 14 originating from manufacturers or government agencies. Reusable medical devices that have been recalled due to a reprocessing failure shall be reprocessed prior to use. If a failed chemical indicator is found, the contents of the package shall be reprocessed before use. A procedure shall be established for the recall of improperly reprocessed medical equipment/devices. Health care settings shall have a process for receiving and disseminating medical device alerts and recalls originating from manufacturers or government agencies. Single-Use Medical Equipment/Devices Health care settings must not internally reprocess single use medical equipment/devices. Critical and semi critical medical equipment/devices labelled as single-use must not be reprocessed and re-used unless the 51, 52 reprocessing is done by a licensed reprocessor. Health care settings that wish to have their single-use medical equipment/devices reprocessed by a licensed reprocessor should ensure that the reprocessor’s facilities and procedures have been certified by a regulatory authority or an accredited quality system auditor to ensure the cleanliness, sterility, safety and functionality of 53 rd the reprocessed equipment/devices. If a facility enters into a contract with a 3 party reprocessor, the liability for adverse outcomes in the event of improper sterilization, or changes to equipment functionality, must be clear to both parties. In order to have single-use critical or semicritical medical equipment/devices reprocessed by one of these facilities, there must be processes for: tracking and labelling equipment/devices recalling improperly reprocessed medical equipment/devices assuring proof of sterility or high-level disinfection testing for pyrogens maintenance of equipment/device functionality and integrity quality assurance and quality control reporting adverse events provision of good manufacturing procedures. Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings | May 2013 50 Single-use medical equipment/devices are usually labelled by the manufacturer with a symbol: Whereas reusable medical equipment/devices are sold with instructions for proper cleaning and sterilization, no such instructions exist for single-use medical equipment/devices. Furthermore, manufacturers often have not provided data to determine whether the equipment/device can be thoroughly cleaned, whether the materials can withstand heat or chemical sterilization, or whether delicate mechanical and electrical components will 51 continue to function after one or more reprocessing cycles. In circumstances where the manufacturer does not approve of reuse, the facility may bear the brunt of legal responsibility in establishing when and under what conditions reuse of medical equipment/devices presents no increased risk to clients/patients/residents and that a reasonable standard of care was adhered to in the reuse of the equipment/device.