Celecoxib

By P. Akascha. Lincoln Memorial University.

An increase in the incidence of slipped capital ing ability [3 cheap celecoxib 200mg line degenerative arthritis diet, 28] femoral epiphysis has also been reported in the spring and – According to duration of symptoms summer months from April to August discount 100mg celecoxib with amex arthritis fingers diet, while a more Acute Duration of symptoms <2 weeks recent study has observed a concentration of cases in the Fall. Its occurrence is also related to race: Slipped Chronic Duration of symptoms >2 weeks capital femoral epiphysis occurs more frequently in the Acute on Duration of symptoms >2 weeks, but with sudden black population than in whites [2, 31]. Our own study chronic deterioration of symptoms, inability to walk ( Chapter 1. Classification Slipped capital femoral epiphysis can be classified accord- those who are very keen on sports, the perichondrial ring ing to the duration of symptoms). The hormonal tion [3, 30] makes a distinction based on walking ability weakening of the epiphyseal plate is a physiological condi- (⊡ Table 3. Overweight, however, plays a major role in the etiology Etiology of slipped capital femoral epiphysis. In a recent study pa- Experimental investigations with animals have shown tients with this disease had significantly higher body mass that the mechanical strength of the epiphyseal plates is index than the control group. Testosterones promote growth, while cents with slipped capital femoral epiphysis and found estrogens tend to accelerate the maturation process. Tes- that these were normal in all cases, but that over half tosterones and estrogens occur in boys and girls at the of the children with this condition were clearly over- same time, but in differing concentrations. If the Because of its anatomical situation, the proximal hormone status is disrupted, however, a slipped capital femoral epiphyseal plate is subjected to very high shear femoral epiphysis can also occur in children of normal forces. This particularly applies in cases of hypothyroid- by the perichondrial ring of fibrous ligaments. This zone ism, growth hormone deficiency, panhypopituitarism and is thicker in small children than in adolescents during hypogonadism. If this zone is chronically hypopituitarism, causing the pubertal growth spurt to overloaded, as is often the case with obese adolescents or take place at an abnormally late stage, hence the possibil- 217 3 3. Adolescents with adiposogenital dystro- ence is also reflected by the fact, that in central Europe the phy (Fröhlich syndrome) are at particular risk. If bone age is considered, Pathophysiology there is a relatively short period of 4 years during which The slippage process is usually described as follows: The slipped capital femoral epiphysis can occur. A recent study found that 90% of cases occurred femoral neck rather than the head that actually slips. The in the accelerating phase of the pubertal growth spurt femoral head remains centered in the acetabulum, while ( Chapter 2. Two-thirds occur even the femur slips in a lateral and ventral direction. A recent study than a pure translation, this movement involves rotation on a population of very young patients (below age 10, n= about an eccentric axis. Finally, genetic components may in a medial and ventral direction, or of the femoral head also play a role, as has been demonstrated in a recent in a lateral and dorsal direction [46, 49]. Up to a certain extent, the slippage of the femoral head in a medial dor- sal direction is a physiological process. In children with coxa valga or an anteverted hip, this process takes place during growth and leads to physiological derotation. As well as weight, sporting activity also places a particular stress on the hip. A comparative investigation with two groups of adolescents showed that a tilt deformity oc- curred much more frequently in adolescents who actively participated in sports than in those who were less active a (⊡ Fig. Diagnosis A slipped capital femoral epiphysis is usually diagnosed on the basis of the pain reported by the patient. The pain is often stated to be in the thigh, or even in the knee, rather than the hip. The hip must therefore always be examined in ado- b lescents who complain of pain in the knee or thigh area. AP (a) and axial (b) x-rays of the hips with epiphyseal separation in an 18-year old patient with hypothyroidism and whose hip or restriction of hip movement, an x-ray must epiphyseal plates are still open always be recorded. Measurement of the tilt deformity: A perpendicular line dividing the femoral neck should pass roughly through the center of the widest part of the head.

If the serum glucose is greater than 250 mg/dL or the urine is positive for ketones buy celecoxib 100mg line arthritis pain management specialist, the exercise session REFERENCES should be postponed buy discount celecoxib 200 mg online rheumatoid arthritis presentation. Balady GJ, Ades PA, Comoss P, et al: Core components of car- After exercise, patients should monitor serum glucose diac rehabilitation/secondary prevention programs: A state- levels and be alert for signs and symptoms of either ment for healthcare professionals from the American Heart hypoglycemia or hyperglycemia. Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Evidence-based nutrition principles and recommendations for the CORONARY ARTERY DISEASE treatment and prevention of diabetes and related complica- tions. Philadelphia, reduced in patients suffering a myocardial infarction Lippincott, Williams & Wilkins, 2000, pp 165–199. Promoting and prescribing exercise for the guidelines regarding staffing, supervision, and progres- elderly. Physical activity PREGNANCY and health: A report of the surgeon general. Atlanta, GA, US Department of Health and Human Services, Centers for Physical activity is safe for pregnant patients and should Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. Healthy People mulate 30–60 min of moderate physical activity at least 2010: Understanding and Improving Health. Washington, DC, three times per week (American College of Obstetricians US Department of Health and Human Services, Government and Gynecologists, 1994). Behavioral counseling in pri- As pregnancy progresses, a pregnant woman’s center mary care to promote physical activity: Recommendations and of gravity changes, and she should be counseled to rationale. The Surgeon General’s Call to Action Centripetal obesity in which the waist-to-hip ratio is to Prevent and Decrease Overweight and Obesity. Rockville, high indicates a subset of individuals at much higher MD, US Department of Health and Human Services, Public risk of cardiovascular diseases (Perry et al, 1998). Health Service; Washington, DC, Office of the Surgeon In spite of the health risks of obesity, a number of over- General, 2001. In some sports, including football, weight primary care physicians in the era of managed care. A ‘‘stages of change’’ power lifting, excessive weight has generally been approach to helping patients change behavior. These may include diets with excessive high fat and high glycemic foods. Michael Shea, MD Highly competitive athletes may need to consume Rebecca Spaulding, MD 1500 to 2000 access calories per day to account for David Stewart, MD the calorie expenditure of intense training. Dietary calorie consumption appears to be a learned behavior and appetite often does not decline with a reduction in activity levels (King, Tremblay, and Blundell, 1997). INTRODUCTION Injured athletes and athletes who retire from a sport have a tendency to continue to ingest excessive calo- Medical problems are common in athletes and lead to ries. This may lead to weight gain during injury approximately 70% of the visits that athletes make to recovery, the off-season, or after retirement in those doctors. A combination of a reduced calorie weight and as many as 15% having true obesity (NIH). Cancers occurring more Epidemiologists have pointed out that we have seen a commonly in these individuals include endometrial, dramatic gain in weight of Americans in the last two breast, prostate, and colon cancers. HYPERTENSION Formal cardiac rehabilitation programs help coronary artery disease patients get started on a therapeutic Blood pressure above the 95th percentile for age- exercise regimen. Speculation centers as to whether this Blood pressure is a product of cardiac output multi- may be one of the mechanisms by which exercise plied by peripheral resistance. Peripheral resistance lowers the risk of cardiovascular disease (Zebrack must fall dramatically or else blood pressure rises and Anderson, 2002). CARDIOVASCULAR BENEFITS The effect of exercise on hypertension has been stud- ied extensively. A Meta-analysis of 54 clinical trials of Cardiovascular disease is high in diabetics. Maintaining aerobic exercise showed reductions of systolic and a good fitness level lowers the risk of cardiac death and diastolic blood pressure in both hypertensive and nor- is associated with longevity (Blair et al, 1989).

A sudden increase in focal back pain with associ- Tunnel the extension catheter from the pump pocket ated tenderness to the incision in the patient’s back with a malleable Progressive lower-extremity numbness and/or tunneling device (such as a cardiac pacemaker or weakness shunt tool or the system included with the program- Loss of bowel and/or bladder control signaled by mable pump) cheap 200mg celecoxib with amex arthritis shoes. To avoid report radiating electric shock-like or burning sensa- a possible drug overdose caused by release of a large tions celecoxib 100mg free shipping arthritis treatment glucosamine and chondroitin sulfate. For a catheter without a side port, eval- consider placement at a different level. Depending on pump type, program a bolus dose or wait an appropriate time SPINAL CORD INJURY before scanning the catheter. Neurologic signs may not be The development of reinforced catheters has reduced noticeable, however, until the drug is infused. CEREBROSPINAL FLUID LEAKAGE Placing catheters in the subarachnoid space can lead PUMP COMPLICATIONS to cerebrospinal fluid leaks because the opening cre- ated by the needle in the dura mater is larger than the Overpressurization from overfilling (constant-flow- catheter. Often, however, the dura mater is elastic rate pump) can impede the delivery of predictable enough to seal this opening. If this causes problems for the patient, refill can be scheduled sooner. If the rotor additional intrathecal drugs has not turned 90°, the pump must be replaced. Failure of the telemetry or electric module renders THE FUTURE OF the pump nonprogrammable. Pump replacement INTRATHECAL THERAPY depends on the need to change the programming. This may require pump Development of alternate drug delivery systems, such revision and anchoring. Patients are generally aware as injecting sustained-release formulations of local that a pump has flipped. Intrathecal steroids to reduce pain after lumbar disc surgery: Because injecting a dose into the side port also A double-blind, placebo-controlled prospective study. Comparative therapeu- intrathecal space, carefully note the concentration tic evaluation of intrathecal versus epidural methylpred- and volume of drug in the catheter before using a nisolone for long-term analgesia in patients with intractable side port for bolus dosing or troubleshooting. Intrathecal and To treat overdose: epidural somatostatin for patients with cancer: Analgesic Immediately remove cerebrospinal fluid and effects and postmorten neuropathologic investigations of replace it with preservative-free saline. Intraspinal morphine for chronic pain: A retrospective multicenter study. Dose changes in Use naloxone to treat respiratory depression, and long-term and median-term intrathecal morphine therapy of monitor for hypertension. An Approach to Psychological Assessment of Acute pain Postoperative Upper extremity Chronic Pain Patients. Intrathecal infusion therapies for intractable Renal pain: Patient management guidelines. Inflammatory Percutaneous transhepatic biliary procedures masses associated with intrathecal drug infusion: A review of Trauma Thoracic contusion preclinical evidence and human data. Management Chest drainage after of intrathecal catheter-tip inflammatory masses: A consensus pneumothorax statement. Relief of intractable Postherpetic neuralgia Chest, abdomen cancer pain by human chromaffin cell transplants: Complex regional pain syndrome Upper extremity Chronic pancreatitis Abdomen Experience at two medical centers. Cancer pain Esophageal Thorax Lung Thorax Pancreatic Abdomen Breast Thorax 20 INTERPLEURAL ANALGESIA Michael D. McBeth, MD Pleural effusion (congestive heart failure, malignant) and hemothorax can also create difficulty in evaluat- INDICATIONS ing the placement of the catheter in the subpleural space, as well as affect the diffusion properties of the Placement of an interpleural catheter should be con- local anesthetic. The serratus ante- increase the incidence of significant morbidity or rior and serratus posterior muscles lie laterally and decrease the effectiveness of the procedure. The latissimus dorsi Systemic anticoagulation and low platelet disorders muscle lies inferiorly. The level of catheter placement can increase the incidence of hemothorax and frank (T8) is approximately at the inferior border of the hemorrhage. This is the 100 V ACUTE PAIN MANAGEMENT FIGURE 20–1 Insertion of a Tuohy needle into the sub- pleural space providing sepa- ration between the lung’s parietal pleura. A Tuohy needle is then advanced perpen- the vein superior and the intercostal nerve inferior.

These agents should only be continued after surgery if evidence of sepsis is confirmed discount celecoxib 100mg online arthritis knee exercises elderly. Bacterial surveillance through routine surface wound and sputum cultures is strongly advised discount 100 mg celecoxib fast delivery arthritis in bottom of back. When patients become septic, cultures are helpful to direct antimicrobial therapy. Knowledge of local bacterial flora and local sensitivities patterns helps to rationalize antibiotic use, but they do not provide definitive data for the diagnosis of sepsis. Quantitative wound biopsies are a better determinant of significant pathogens than qualitative surface swabs. If bacterial counts are 105 (103 in Streptococcus isolates), wound infection should be suspected. Burn wound sepsis can however, only be determined by results of histopathological examination. Diagnosis of sepsis in burn patients can be difficult to differentiate from the usual hyperdynamic, hyperthermic, hypermetabolic postburn state. Fever spikes are not always related to underlying infection, and blood cultures are commonly negative. Close monitoring and daily physical examination of burn patients are crucial for the prompt diagnosis of septic complications. In general, the most clinical subjective sign of infection is a sudden unexpected change in the patient’s progress. An increase in metabolic rate, feeding intolerance, change in mental orientation or gas exchange, increasing pain scores, or change in biochemistry will signal impending infec- tions. The patient should be inspected thoroughly, all wounds exposed, and cultures and other relevant examinations performed. Local evidence of invasive wound infection includes the following: Black or brown patches of wound discoloration Rapid eschar separation Conversion of wounds to full thickness Spreading periwound erythema Punctuate hemorrhagic subeschar lesions Violaceous or black lesions in nonburned tissue (ecthyma gangrenosum) TABLE 8 Definition of SIRS Two or more of the following conditions must be present: Body temperature 38 °C or 36 °C Heart rate 90 beats/min Respiratory rate 20/min or PaCO2 32 mmHg Leukocyte count 12,000/ l, 4000/ l, or 10% immature forms 50 Barret The diagnosis of sepsis is made when at least five of the clinical criteria below are met, in addition to the documentation of a septic source such as: burn wound biopsy with 105 organisms/g tissue and/or histological evi- dence of viable tissue invasion, positive blood culture, urinary tract infection with 105 organisms/ml urine, pulmonary infection with positive bacteria and white cells on a class III or better sputum specimen Clinical criteria for diagnosis of sepsis include the presence of at least five of the following: 1. Hyperglycemia Other parameters often seen associated with sepsis are enteral feeding intolerance, hypernatremia, and coagulopathy. Cardinal signs of gram positive and gram- negative sepsis are summarized in Table 9. In the absence of a confirmed organism or site, antibiotic selection should be based on routine surveillance cultures. Empirical antibiotic choice should also be based on sensitivities of the burn facility’s endogenous organisms. Routine perioperative antibiotics should also take ward-endogenous organisms into ac- count. Systemic empirical antibiotics should be continued until micro-organisms are identified; use of agents is changed based on microbiology results. Treatment is continued for at least 72 h after evidence of sepsis has resolved. If the wounds appear clean and there is no suspicion of burn wound sepsis, other sources such as the lungs, urinary tract, and catheter should be suspected. Pneumonia or bronchopneumonia is the most frequent site of infection in burn patients after burn wounds. Pneumonia The diagnosis of pneumonia in severely burned patients is exceedingly problem- atic. Many of the usual signs and symptoms of pneumonia are unreliable in burn patients. Fever, leukocytosis, tachypnea, and tachycardia may all be present in the absence of infection. A class III sputum sample should be obtained in order to make a General Treatment 51 TABLE 9 Cardinal signs of gram-positive and gram-negative burn wound sepsis Grain-positive sepsis 1. Burn wound biopsy with 105 organisms/ g tissue and/ or histological evidence of viable tissue invasion 2. Burn wound biopsy with 105 organisms/ g tissue and/ or histological evidence of viable tissue invasion 2. If not controlled, patient become hypothermic (34–35°C) plus leukopenia 6.