By B. Peratur. Pacific Northwest College of Art. 2019.

Te most efective single antibiotics were Gentamicin buy silvitra 120mg cheap, Tobramycin silvitra 120mg free shipping, and Ofoxacin which were bactericidal against 100% (60/60) isolates cheap silvitra 120 mg. Te study results revealed higher contamination rate on bone allografs and recommend the implementation of good tissue banking practices during tissue procurement order 120mg silvitra visa, processing, and storage in order to minimize the chances of contamination. Introduction the safety of allogeneic tissue grafs, complete eradication of microorganisms is essential. Human bone is the second most transplanted tissue afer Te risk of infectious disease transmission emphasizes bloodwhichhastheuniqueabilitytohealitselfperfectly. But the alteration in the biomechanical procedure annually take place worldwide in order to revise properties of particular tissues made it obvious that all forms skeletal defects by replacement or augmentation [1]. In addition,bonegrafsarealsousedtorepairthedefectsin of sterilization technique are not applicable [10]. Antibiotics bone caused by birth defects, maxillofacial defects, traumatic has for long time been used to control infectious diseases. Torough donor bacterial prevalence and emergence of infectious diseases due screening for the presence of transmissible diseases, bacterial to their resistance to the common antibiotics. Bacteria can testing, and aseptic processing practices can substantially defend themselves from the action of antibiotics by producing reduce the risk but do not completely eliminate all the various metabolites which either degrade antibiotics or help possible microbial contaminants from allograf [8]. Total 60 bacterial isolates were selected for antibiotic susceptibility test by 2. Tissue samples were collected Kirby-Bauer disc difusion method described by Bauer et al. Ten Shikdar Medical college Hospital, and Al-Markajul Hospital ∘ the plates were incubated for 24 hours at 37 C. Te ages of donors were ranged from 40 to 75 years and all the donors were prescreened for the presence of transmissible diseases 3. In the tissue banking laboratory the bones were diferent batches of processing is presented in Figure 1. For the isolation, tissue samples were weighed by digital balance and taken into a sterile 3. Characterization beaker containing 150 mL sterile normal saline and/or sterile of the bacterial isolates was performed based on their colony distilled water. Ten the −4 most frequently isolated group was Gram positive bacilli as sample was serially diluted up to 10. All the plates were incubated of microbial contaminants are presented in Figure 2. Cultural Characterization and Biochemical Studies of to identify the selected bacterial isolates up to genus level Microbial Contaminants. Based on the physiobiochemical characteristics, from the selective and diferential media, were character- Twenty-one Gram positive cocci (B1, B5, B7, B14, B17, B19, ized on the basis of their morphology (size, shape, and B31, B32, B33, B34, B35, B39, B41, B42, B44, B45, B48, B50, arrangement) by following Gram staining procedure. B28, B29, B49, B53, and B55) were identifed as Streptococcus According to Bargey’s Manual of Determinative Bacteriology spp. On the other hand, sixteen isolates of Gram positive rods [11], several biochemical tests were performed to identify (B2,B8,B16,B20,B25,B24,B30,B36,B38,B40,B43,B46,B51, the biochemical characteristics of the bacterial isolates. Among the tests were Oxidase test, Catalase test, Indole production test, eleven Gram negative rods, eight of the bacterial isolates were Methyl Red test, Voges-Proskauer test, Urease test, Citrate Pseudomonas spp. BioMed Research International 3 Table 1: Summary of the biochemical tests of bacterial isolates. Disc difusion method was used to frequently 50 observe the antibiotic efects among the strains. Apart from 20 this, other drugs showed diferent level of resistance such 10 as Oxacillin (80%), Polymyxin (70%), Cefpodoxime (60%), 0 Imipenem (45%), Meropenem (40%), and Erythromycin Gram (+)ve Gram (−)ve Gram (+)ve Gram (−)ve (30%). Individual resistance and sensitivity pattern of the cocci cocci rod rod bacterialisolatesispresentedbelow(Figure 3). Cultures facts: which antibiotics are the commonly prescribed by the were also positive for Streptococcus spp. Besides bacterial contaminations, envi- 40 20 ronmental exposure, underlying diseases, and host defense 0 mechanism can also contribute to the graf contamination in ratio between 2 and 5% [20]. We think that disease transmission can occur mainly in two ways: either through an infected donor or during tissue procurement, processing, even at the time of surgery in the Single antibiotic operatingtheatre,asithasalreadybeenreportedwithsurgical needles and suckers [21]. Bacterial transmission might be Figure 3: Percentages of antimicrobial resistance on bacterial occurring from infected donor to recipient (tuberculosis and isolates. Te perioperative administration of systemic the organisms into low and high pathogenicity in which antibiotics is the choice to limit the infection which can they considered organisms of low pathogenicity to be skin occur afer graf implant. Tis method is highly efective commensals and microorganisms of high pathogenicity were against bacteria while the efectiveness is depending on the thought to be originated from endogenous sources in the constituents of antibiotics [24]. One of the feared compli- donor, which more likely to cause infection in the recipient. To prevent the endovascular with Streptococcus pyogenes afer reconstructive knee surgery. Verhaegen, “Antimicrobial susceptibility of coagulase- Bone allografs were found to be contaminated and about negative staphylococci on tissue allografs and isolates from 80% of the contaminants were Gram positive. Verhaegen, “Antimicrobial susceptibility of coagulase- negative staphylococci on tissue allografs and isolates from oftherequirementsforthedegreeofMasterofScience orthopedic patients,” Journal of Orthopaedic Research,vol. Asaduzzaman, who analysis of incidence and predisposing factors,” Journal of Bone hassupervisedthewholeresearchwork. Roberts, “Overview of safety issues concerning the preparation and processing of sof-tissue allografs,” Arthroscopy,vol. Asaduzzaman, replacements due to infection,” Te Journal of Bone and Joint “Radiation response of bacteria associated with human cancel- Surgery A,vol. Galante, “Efcacy of autograf and freeze-dried allograf to Journal of Bone and Joint Surgery B, vol. Tsiridis, “Bone sub- through tissue transplantation,” in Advances in Tissue Banking, stitutes: an update,” Injury,vol. Stachowicz, “Sterilization of tissue allo- infection in dogs,” Vascular and Endovascular Surgery,vol. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Antibi- been utilized for treating bacterial and fungal infections −1 otics for susceptibility testing were prepared at 10 mg mL [8]. In some cases, the plant is also used to treat malaria, in sterile distilled water. In continuation to our earlier fndings, we have now embarked to further investigate the efects of the 2. Te Standards Institute 2007 [15] with recommendations adapted solvent system used for elution was n-hexane (He) with from several other studies [16–18].

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Other Psychosocial therapies: Although behavior therapy is most commonly employed purchase silvitra 120mg on line, accounts of successful treatment of selective mutism with use of play therapy buy silvitra 120mg mastercard, family therapy buy silvitra 120 mg without a prescription, psychodynamic therapy order silvitra 120 mg online, and group therapy are also available (Watson et. It is common for children with selective mutism to have some degree of speech or language difficulties which exacerbate speech- related anxiety. In such cases speech therapy should be considered as an adjunct to other interventions. A double-blind, placebo controlled trial of fluoxetine in children with selective mutism indicated significant benefit (Black & Uhde, 1995). As of now, behavior therapy when available and practical should be considered the initial intervention strategy. Journal of the American Academy of Child & Adolescent Psychiatry:Vol 44(3) March 2005 pp 258-264. Melissa; Manassis, K (2001); Familial Predictions of Treatment outcome in Childhood Anxiety Disorders. Journal of the American Academy of Child & Adolescent Psychiatry:Vol 40(10) pp 1182-1189. Mullin B, Farrell C, Wagner K, Emslie G (2002): Carpenter D Impact of comorbidity on treatment response to paroxetine in pediatric obsessive compulsive disorder. Is the use of exclusion criteria empirically supported in randomized clinical trials. A meta-analysis of pharmacotherapy trials in pediatric obsessive compulsive disorder. L (1988):Development of social anxiety scale for children revised : Factor structure and concurrent validity. L (1993): Anxiety scale for children revised : Factor structure and concurrent validity. Journal of the American Academiy of Child and Adolescent Psychiatry, 35,1502-1510. Toni C, Mucci M, Millepiedi S, Mata B, Perugi G (2001), Paroxetine in child and adolescent outpatients with panic disorder. Abali O, Kaynak N (2003): Citalopram treatment of children and adolescents with obsessive compulsive disorder: A preliminary report Psychiatry Clin Neuroscl. J Am Acad Child Adoles Psychiatry 42:331-339 96- Muris P, Schmidt H, Merckelbach H (1999): The structure of specific phobia symptoms among children and adolescents. Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry:Vol 37(10S) Supplement Oct. Walkup J (2001): Fluvoxamine for children and adolescents with obsessive compulsive disorder: A randomized, controlled multicenter trial. J Child Psychol Psychiatry 41:713-726 (239) 133- Target M, Fonagy P (1994) : Efficacy of psychoanalysis for children with emotional disorders. Methods: These guidelines were developed by Canadian experts in anxiety and related disorders through a consensus process. Treatment strategies were rated on strength of evidence, and a clinical recommendation for each intervention was made, based on global impression of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines. Results: These guidelines are presented in 10 sections, including an introduction, principles of diagnosis and management, six sections (Sections 3 through 8) on the specific anxiety-related disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder), and two additional sections on special populations (children/adolescents, pregnant/lactating women, and the elderly) and clinical issues in patients with comorbid conditions. Conclusions: Anxiety and related disorders are very common in clinical practice, and frequently comorbid with other psychiatric and medical conditions. Optimal management requires a good understanding of the efficacy and side effect profiles of pharmacological and psychological treatments. This guideline docu- Anxiety and related disorders are among the most com- ment is not focused on any individual type of clinician mon of mental disorders. Lifetime prevalence of anxiety but rather on assessing the data and making recommen- disorders is reportedly as high as 31%; higher than the dations. Subsequent “user friendly” tools and other lifetime prevalence of mood disorders and substance use initiatives are planned. Unfortunately, anxiety disorders The guidelines include panic disorder, agoraphobia, are under-diagnosed [6] and under-treated [5,7,8]. Also included are brief discussions of clinically pists, and nurses with the diagnosis and treatment of relevant issues in the management of anxiety and related anxiety and related disorders by providing practical, disorders in children and adolescents, women who are pregnant or lactating, and elderly patients, and patients with comorbid conditions. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. Treatment strategies were rated on subsequently, draft guidelines were prepared by the sub- strength of evidence for the intervention (Table 1). A clini- panels which were then circulated to the entire group cal recommendation for each intervention was then made, for consensus ratification during 2013. Preliminary based on global impression of efficacy in clinical trials, recommendations were also presented to the Canadian effectiveness in clinical practice, and side effects, using a psychiatric community for input in September 2012 at modified version of the periodic health examination guide- the Canadian Psychiatric Association annual conference. These guidelines are presented in 10 sections, the first The guidelines were initiated prior to the introduction of which is this introduction. Sec- The panel of Canadian experts in anxiety and related tion 9 discusses issues that may warrant special attention disorders responsible for the development of these pertaining to anxiety and related disorders in children guidelines via consensus process included 10 psychia- and adolescents, pregnant or lactating women, and the trists and seven psychologists who were organized into elderly. The last section of these guidelines addresses subpanels based on their expertise in particular anxiety clinical issues that may arise when treating patients with or related disorders as well as in treating specific patient anxiety and related disorders who are also diagnosed populations. Anxiety and related disorders are among the most com- Level 1 and Level 2 evidence refer to treatment studies in which randomized comparisons are available. Recommendations involving epidemiological or risk mon mental disorders, with lifetime prevalence rates as factors primarily arise from observational studies, hence the highest level of high as 31% [1-5] and 12-month prevalence rates of evidence for these is usually Level 3. Recommendations, such as principles of care, reflect consensus opinion based on evidence from various data sources, about 18% [3,4]. Asking patients if they are feeling nervous, anxious or Anxiety and related disorders are associated with an on edge, or whether they have uncontrollable worry, can increased risk of developing a comorbid major depres- be useful to detect anxiety in patients in whom the clini- sive disorder [10-12]. They are identification of anxiety-related symptoms; items scored associated with substantial functional impairment, which as mild or greater may warrant further assessment [26]. In addition, explored in more detail by including questions about studies have demonstrated quality of life impairments in the onset of the anxiety symptoms, associations with life patients with various anxiety and related disorders events or trauma, the nature of the anxiety (i. Anxiety has a considerable economic impact on avoidance, or obsession), and the impact they have had society as well, being associated with greater use of health on the patient’s current functioning. Suicide risk Conduct differential diagnosis In large surveys, anxiety and related disorders were The differential diagnosis of anxiety and related disor- independently associated with a significant 1. These data causes of the symptoms, including direct effects of a sub- indicate that patients with an anxiety disorder warrant stance (e. However, since comorbid conditions are common, the presence of some of these other conditions may not pre- Initial assessment of patients with anxiety clude the diagnosis of an anxiety or related disorder. The management of patients presenting with anxiety Certain risk factors have been associated with anxiety symptoms should initially follow the flow of the five and related disorders and should increase the clinician’s main components outlined in Table 3. A family [33] or Screen for anxiety and related symptoms personal history of mood or anxiety disorders [34,35] is Anxiety and related disorders are generally characterized an important predictor of anxiety symptoms. In addi- by the features of excessive anxiety, fear, worry, and avoid- tion, family history is associated with a more recurrent ance.

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A post hoc analysis of the tions) can be substantially impaired [I] (Aderka et al purchase silvitra 120mg amex. There are strong order silvitra 120mg line, domised placebo-controlled relapse-prevention studies in and possibly two-way cheap 120mg silvitra mastercard, associations between social anxiety dis- patients who have responded to previous acute treatment reveal a order and dependence on alcohol and cannabis [I] (Buckner significant advantage for staying on active medication (clonaze- et al buy cheap silvitra 120mg online. The potential efficacy of tricyclic antidepressants is findings of small randomised placebo-controlled studies suggest unknown. A double-blind randomised con- trolled studies of acute treatment and most reveal no significant trolled dosage escalation trial found no advantage for increas- differences in overall efficacy or tolerability between active com- ing to a higher daily dosage (120 mg) of duloxetine, when pounds. The 12-month prevalence of post-traumatic ment [A] stress disorder is estimated to be 1. Suicidal ● Advise the patient that treatment periods of up to 12 thoughts are common but the increased risk of completed suicide weeks may be needed to assess efficacy [A] is probably due to the presence of comorbid depression [I (M)] Longer-term treatment (Krysinska and Lester, 2010). Post-traumatic stress disorder is associated with increased use of health services, but is often not ● Use an approach that is known to be efficacious in pre- recognised in primary or secondary care [I] (Liebschutz et al. Diagnosis can be established through eliciting the history ● Continue drug treatment for at least six months in of exposure to trauma (actual or threatened death, serious injury, patients who have responded to treatment [A] or threats to the physical integrity of the self or others); with a ● Consider cognitive therapy with exposure as this may response of intense fear, helplessness or horror; and the presence reduce relapse rates better than drug treatment [A] of ‘re-experiencing symptoms’ (such as intrusive recollections, ● Consider cognitive therapy after response to drug treat- flashbacks or dreams); avoidance symptoms (such as efforts to ment, in patients with a high risk of relapse [D] avoid activities or thoughts associated with the trauma); and ● Monitor effectiveness and acceptability regularly over hyper-arousal symptoms (including disturbed sleep, hypervigi- the course of treatment [S] lance and an exaggerated startle response). Prevention of post-traumatic disorder ● Routinely combining drug and psychological approaches is not recommended for initial treatment in the absence after experiencing trauma of consistent evidence for enhanced efficacy over There is some scope for preventing the emergence of psychologi- each treatment when given alone [A] cal post-traumatic symptoms in people subject to major trauma. Comparative efficacy of 2009); but approaches with limited efficacy include single-ses- sion ‘debriefing’ [I (M)] (Van Emmerik et al. Acute treatment of post-traumatic efficacious and superior to ‘stress management’ [I (M)] (Bisson disorder and Andrew, 2007), and appear to have similar overall efficacy [I The findings of randomised placebo-controlled treatment studies (M)] (Seidler and Wagner, 2006). A systematic review of four studies of the combi- have not been found efficacious in placebo-controlled trials nation of pharmacological with psychological treatments could include citalopram, alprazolam, and the anticonvulsants tiagabine find insufficient evidence to draw conclusions about the relative and divalproex. However when 37 randomised placebo-con- efficacy of combination treatment compared to monotherapy [I trolled trials are subject to meta-analysis (restricted to compari- (M)] (Hetrick et al. Further management after non- response to initial treatment ● Continue drug treatment for at least 12 months in patients who have responded to treatment [A] Many patients with post-traumatic stress disorder do not respond ● Monitor effectiveness and acceptability regularly over to initial pharmacological or psychological treatment. Management of obsessive- ● Become familiar with the symptoms and signs of post- compulsive disorder traumatic stress disorder [S] ● Ask about the presence of coexisting depressive 21. Recognition and diagnosis symptoms [A] Obsessive-compulsive disorder has an estimated 12-month prev- Prevention of post-traumatic symptoms alence of 0. The female preponderance, early age of onset and the emergence of post-traumatic symptoms, and provid- typical presence of coexisting obsessions and compulsions are ing there are no contra-indications, consider preventive common features across societies, but the content of obsessions treatment with propranolol or sertraline [A] or trauma- varies between cultures [I (M)] (Fontenelle et al. Acute treatment of obsessive- psychological approaches is not established [S] compulsive disorder ● Advise the patient that treatment periods of up to 12 weeks may be needed to assess efficacy [A]. The evi- are efficacious in treating children and adolescents with obsessive- dence for enhanced efficacy of exposure therapy with clomi- compulsive disorder [I (M)] (Watson and Rees, 2008). A series of small some evidence for greater efficacy (though poorer tolerability) randomised placebo-controlled studies suggest that administra- with higher daily dosages [I (M)] (Bloch et al. A placebo-controlled study found that intravenous clomipramine infusion was efficacious after non-response to oral clomipramine, but the necessary arrangements limit its useful- 21. The findings of acute treatment studies indicate that the proportion The findings of some, but not all, randomised double-blind of responding patients increases steadily over time. Management of other anxiety ● Ask about obsessive-compulsive symptoms when disorders patients present with depression [S] ● Ask about the presence of coexisting depressive symp- 22. A recent meta-analysis cautiously concluded that the balance of The findings of randomised placebo-controlled trials of pharmaco- benefit and risk in the treatment of depressed children and adoles- logical treatment in children with separation anxiety disorder pro- cents may be most favourable with fluoxetine [I (M)] (Hetrick vide no convincing evidence of benefit for any medication, et al. However careful monitoring is advisable, due to possible diagnostic uncertainty, the presence of Recommendations: treatment of children and co-morbid depression, problems associated with estimating the adolescents optimal dosage, and the difficulties young people might have in describing untoward effects of psychotropic drug treatment. It ● Reserve pharmacological treatments for children and may be preferable to reserve pharmacological treatments for teenagers who have not responded to psychological patients who do not respond to evidence-based psychological interventions, and in whom the anticipated benefits are approaches. Special considerations in elderly, so lower doses may be required than in younger patients. Other type 1A controlled studies of the potential benefits and risks of psycho- antiarrhythmics (quinidine, moricizine) carry an increased risk of tropic drug treatment in younger people, and little is known about mortality in patients with ventricular arrhythmias and ischaemic the value of long-term treatment [I (M)] (Ipser et al. Psychological treatments also have evi- be avoided in patients with known cardiac risk factors including dence of efficacy [I (M)] (Gillies et al. Despite widespread belief that ● Remember that anxiety disorders are common among antidepressant drugs can lower the seizure threshold, systematic women who wish to become pregnant [S] review of data from placebo-controlled trials with psychotropic ● Keep familiar with the changing evidence base about drugs, submitted to the United States Federal Drug Administration, the potential hazards of treatment of pregnant and indicates that that the frequency of seizures is significantly lower breast-feeding women with psychotropic drugs [S] with most antidepressants than with placebo [I (M)] (Alper et al. Referral to secondary and tertiary care ety disorders in the aftermath of stroke [I (M)] (Campbell Burton mental health services et al. Despite the availability of many evidence-based pharmacologi- cal and psychological treatments, a substantial proportion of patients will not respond fully to initial treatments, provided in Recommendations: treatment in elderly and physically primary medical care. The criteria for referral to secondary care ill patients mental health services should be sufficiently flexible to ensure ● Remember that anxiety symptoms and disorders are that patients with disabling and treatment-resistant anxiety disor- common in elderly and physically ill patients, and that ders can have equitable access to mental health specialists. Pregnant and breastfeeding women patients with complex, severe, enduring and treatment-resistant Anxiety disorders are not uncommon during pregnancy and in anxiety disorders do not respond to the range of treatment options the post-partum period [I (M)] (Ross and McLean, 2006). Secretarial risk of spontaneous abortions, stillbirths, preterm deliveries, res- assistance for writing the consensus statement was provided by Magda piratory distress, endocrine and metabolic disturbance, with Nowak (University of Southampton) some evidence of a discontinuation syndrome and of an increased The consensus group comprised Christer Allgulander, Ian Anderson, risk of cardiac defects; antipsychotics are associated with Spilios Argyropoulos, David Baldwin, Borwin Bandelow, Alan Bateson, increased gestational weight and diabetes and with increased David Christmas, Val Curran, Simon Davies, Hans den Boer, Lynne Drummond, Rob Durham, Nicol Ferrier, Naomi Fineberg, Matt Garner, risk of preterm birth [I (M)] (Oyebode et al. However the Andrew Jones, Malcolm Lader, Alan Lenox-Smith, Glyn Lewis, Andrea overall evidence on the balance of risks and benefits of psycho- Malizia, Keith Matthews, Paul McCrone, Stuart Montgomery, Marcus tropic drug treatment during pregnancy evolves over time and it Munafò, David Nabarro, David Nutt, Catherine O’Neill, Jan Scott, David is wise to seek advice from respected information sources. Med J Aust 175: All participants were asked to provide information about potential con- S48–S51. Hum Psychopharmacol out concomitant depression: A 2-year prospective follow-up study. Int Clin Psychopharmacol 27: psychopharmacological clinical trials: An analysis of food and drug 197–207. J Clin Psychophar- dose, placebo-controlled study of paroxetine in the treatment of macol 29: 378–382. As pharmacological treatment of anxiety, obsessivecompulsive and effective as face-to-face therapies? Br J Gen Pract 51: the pharmacological treatment of schizophrenia: Recommendations 838–845. J Consult Clin Psychol 63: dictors of social phobia course in a longitudinal study of primary- 408–418. A pooled analysis of four placebo-con- der, social phobia, and panic disorder: A 12-year prospective study. Psy- of serotonin reuptake inhibitors in treatment-resistant obsessive- chopharmacology (Berl) 149: 194–196. Depress Anxiety with epilepsy: Systematic review and suggestions for clinical man- 29: 1072–1082. Br J Gen Pract Bisson J and Andrew M (2007) Psychological treatment of post-trau- 61: 489–490. Neuropsychiatr Dis Treat for mental health treatment and barriers to care among patients with 8: 203–215. A systematic review and meta-analysis of comparative Castle D (2008) Anxiety and substance use: Layers of complexity.

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Attacks are often so painful that opioids purchase silvitra 120 mg fast delivery, even in large doses cheap silvitra 120 mg without a prescription, do not provide relief silvitra 120mg visa. As the disease progresses purchase 120mg silvitra visa, recurring attacks of pain are more severe, more frequent, and of longer duration. Malabsorption occurs late in the disease, when as little as 10% of pancreatic function remains. It provides detail about the anatomy of the pancreas and the pancreatic and biliary ducts. It is also helpful in obtaining tissue for analysis and differentiating pancreatitis from other conditions, such as carcinoma. Medical Management The management of chronic pancreatitis depends on its probable cause in each patient. Treatment is directed toward preventing and managing acute attacks, relieving pain and discomfort, and managing exocrine and endocrine insufficiency of pancreatitis. Nonsurgical Management Nonsurgical approaches may be indicated for the patient who refuses surgery, who is a poor surgical risk, or whose disease and symptoms do not warrant surgical intervention. Endoscopy to remove pancreatic duct stones and stent strictures may be effective in selected patients to manage pain and relieve obstruction. Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. Surgical Management Surgery is generally carried out to relieve abdominal pain and discomfort, restore drainage of pancreatic secretions, and reduce the frequency of acute attacks of pancreatitis. The surgery performed depends on the anatomic and functional abnormalities of the pancreas, including the location of disease within the pancreas, diabetes, exocrine insufficiency, biliary stenosis, and pseudocysts of the pancreas. A Whipple resection (pancreaticoduodenectomy) has been carried out to relieve the pain of chronic pancreatitis. Pancreatic Cysts As a result of the local necrosis that occurs at the time of acute pancreatitis, collections of fluid may form in the vicinity of the pancreas. Less common cysts occur as a result of congenital anomalies or are secondary to chronic pancreatitis or trauma to the pancreas. Because of their location behind the posterior peritoneum, when they enlarge they impinge on and displace the stomach or the colon, which are adjacent. Eventually, through pressure or secondary infection, they produce symptoms and require drainage Cancer of the Pancreas The incidence of pancreatic cancer has decreased slightly over the past 25 years in non-Caucasian men. It is the fifth leading cause of cancer deaths in the United States and occurs most frequently in the fifth to seventh decades of life. Cigarette smoking, exposure to industrial chemicals or toxins in the environment, and a diet high in fat, meat, or both are associated with pancreatic cancer, although their role is not completely clear. The risk for pancreatic cancer increases as the extent of cigarette smoking increases. Diabetes mellitus, chronic pancreatitis, and hereditary pancreatitis are also associated Cancer may arise in any portion of the pancreas (in the head, the body, or the tail); clinical manifestations vary depending on the location of the lesion and whether functioning, insulinsecreting pancreatic islet cells are involved. Approximately 75% of pancreatic cancers originate in the head of the pancreas and give rise to a distinctive clinical picture. Functioning islet cell tumors, 88 whether benign (adenoma) or malignant (carcinoma), are responsible for the syndrome of hyperinsulinism. Clinical Manifestations Pain, jaundice, or both are present in more than 90% of patients and, along with weight loss, are considered classic signs of pancreatic carcinoma. Other signs include rapid, profound, andprogressive weight loss as well as vague upper or midabdominal pain or discomfort that is unrelated to any gastrointestinal function and is often difficult to describe. Meals often aggravate epigastric pain, which usually occurs before the appearance of jaundice and pruritus. Assessment and Diagnostic Findings Magnetic resonance imaging and computed tomography are used to identify the presence of pancreatic tumors. Gastrointestinal x-ray findings may demonstrate deformities in adjacent viscera caused by the impinging pancreatic mass. Percutaneous fine-needle aspiration biopsy of the pancreas is used to diagnose pancreatic tumors and confirm the diagnosis Percutaneous transhepatic cholangiography is another procedure that may be performed to identify obstructions of the biliary tract by a pancreatic tumor. Intraoperative ultrasonography has been used to determine if there is metastatic disease to other organs. Medical Management If the tumor is resectable and localized (typically tumors in the head of the pancreas), the surgical procedure to remove it is usually extensiveHowever, definitive surgical treatment (ie, total excision of the lesion) is often not possible because of the extensive growth when the tumor is finally diagnosed and because of the probable widespread metastases (especially to the liver, lungs, and bones). Nursing Management Pain management and attention to nutritional requirements are important nursing measures to improve the level of comfort. Skin care and nursing measures are directed toward relief of pain and discomfort associated with jaundice, anorexia, and profound weight loss. Pain associated with pancreatic cancer may be severe and may require liberal use of opioids; Promoting Home and Community-Based Care specific patient and family teaching indicated varies with the stage of disease and the treatment choices made by the patient. If the patient elects to receive chemotherapy, the nurse focuses teaching on prevention of side effects and complications of the agents used. If surgery is performed to relieve obstruction and establish biliary drainage, teaching addresses management of the drainage system and monitoring for complications. Continuing Care A referral for home care is indicated to help the patient and family deal with the physical problems and discomforts associated with pancreatic cancer and the psychological impact of the disease. The home care nurse assesses the patient‘s physical status, fluid and nutritional status, and skin integrity and the adequacy of pain management. Tumors Of The Headof The Pancreas Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region of the pancreas obstruct the common bile duct where the duct passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The tumors producing the obstruction may arise from the pancreas, the common bile duct, or the ampulla of Vater. Clinical Manifestations The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result from obstruction by the tumor to entry of bile in the gastrointestinal tract. Medical Management Before extensive surgery can be performed, a fairly long period of preparation is often necessary because the patient‘s nutritional and physical condition is often quite compromised. Preoperative preparation includes adequate hydration, correction of prothrombin deficiency with vitamin K, and treatment of anemia to minimize postoperative complications. Total pancreatectomy (removal of the pancreas) may be performed if there is no evidence of direct extension of the tumor to adjacent tissues or regional lymph nodes. A pancreaticoduodenectomy (Whipple‘s procedure or resection) is used for potentially resectable cancer of the head of the pancreas79 This procedure involves removal of the gallbladder, distal portion of the stomach, duodenum, head of the pancreas, and common bile duct and anastomosis of the remaining pancreas and stomach to the jejunum The result is removal of the tumor, allowing flow of bile into the jejunum. When the tumor cannot be excised, the jaundice may be relieved by diverting the bile flow into the jejunum by anastomosing the jejunum to the gallbladder, a procedure known as cholecystojejunostomy. It is important to give careful attention to changes in vital signs, arterial blood gases and pressures, pulse oximetry, laboratory values,and urine output. The nurse must also consider the patient‘s compromised nutritional status and risk for bleeding.

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