Orlistat
Chris Ghaemmaghami
- Associate Professor, Vice Chair of Academics, and Program Director,
- Department of Emergency Medicine, University of Virginia,
- Charlottesville, VA, USA
If vasculitis is suspected weight loss 80 20 rule cheap orlistat, then high-dose corticosteroids and cyclophosphamide are used similar to patients with severe weight loss 10 days order 60mg orlistat with visa, diffuse weight loss pills celebrity use discount 120 mg orlistat mastercard, or nonthrombotic manifestations weight loss pills under 30 dollars discount orlistat generic. Clinical experience suggests that cyclophosphamide is more effective than other immunosuppressive medications ultra 90 weight loss pills purchase cheap orlistat online. Plasmapheresis may be beneficial during the first week to allow time for the corticosteroids and cyclophosphamide to take effect weight loss motivation pictures cheap orlistat 120mg on-line. Whether chronic antiplatelet and statin therapies prevent thrombosis or atheroma formation in the damaged vessel is unknown, but they are often used. In patients with large or cardioembolic strokes, aspirin and prophylactic dose heparin are used for the first few days because therapeutic dose heparin may cause hemorrhage into the infarcted area. After estimating bleeding risk from long-term anticoagulation, the patient is switched to warfarin. In addition, any patient with recurrent strokes and a lupus anticoagulant treated with warfarin should also have chromogenic factor X levels followed and maintained at less than 20% of normal to ensure adequate anticoagulation. All patients should have their generalized lupus disease activity controlled with hydroxychloroquine with corticosteroids and immunosuppressive agents if necessary to help prevent further thrombotic events. Patients with status epilepticus or frequent seizures should also be treated with high-dose prednisone. Patients with seizures, cerebral infarctions, and moderate to high titers of 451 antiphospholipid antibodies should be started on anticoagulation therapy once seizures are controlled, although they are at increased risk for falls and cerebral trauma. In the absence of these clinical clues, doubling the dose of corticosteroids for 3 days while awaiting test results is one approach. If corticosteroids cannot be tapered, then psychotropic medications such as haloperidol or lithium can be used. Another difficult clinical situation is a patient presenting with acute transverse myelitis. In patients with probable vasculitis, cyclophosphamide should be instituted and prednisone continued. Consequently, the clinician must make every effort to limit the toxicities of therapy by controlling hypertension, treating hyperlipidemia and hyperglycemia, using osteoporosis prophylaxis, administering vaccinations, advising against smoking, treating hyperhomocysteinemia, and using medications for Pneumocystis jiroveci prophylaxis. When a patient exhibits one of these manifestations, the antiphospholipid antibody results may take a few days to return. If the antiphospholipid antibodies are positive, then the next decision is whether to continue with antiplatelet drugs or to treat with anticoagulants. Hydroxychloroquine, corticosteroids, and immunosuppressive agents are used to control lupus disease activity, which may contribute to the vasculopathy and risk of thrombosis. Patients with cranial or severe peripheral or autonomic neuropathy are initially treated with high-dose corticosteroids. Incidence and prevalence of major central nervous system involvement in systemic lupus erythematosus: a 3-year prospective study of 370 patients. The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Validity of the new American College of Rheumatology criteria for neuropsychiatric lupus syndromes: a population-based evaluation. Prospective analysis of neuropsychiatric events in an international disease inception cohort of patients with systemic lupus erythematosus. Short-term outcome of neuropsychiatric events in systemic lupus erythematosus upon enrollment into an international inception cohort study. Autoantibodies as biomarkers for the prediction of neuropsychiatric events in systemic lupus erythematosus. Patients with focal manifestations may stabilize but usually do not reverse their deficits during therapy. Several studies have shown that mild cognitive deficits detected by formal testing do not appear to progress or adversely affect the quality of life or work capacity over time in the majority of patients. Clinical and neuropathological findings in systemic lupus erythematosus: the role of vasculitis, heart emboli, and thrombotic thrombocytopenic purpura. Magnetic resonance imaging and brain histopathology in neuropsychiatric systemic lupus erythematosus. C5a alters blood-brain barrier integrity in a human in vitro model of systemic lupus erythematosus. Classification criteria for neuropsychiatric systemic lupus erythematosus: Do they need a discussion Development and validation of a new algorithm for attribution of neuropsychiatric events in systemic lupus erythematosus. Neuropsychiatric lupus erythematosus: a 10-year prospective study on the value of diagnostic tests. Validity of brief screening tools for cognitive impairment in rheumatoid arthritis and systemic lupus erythematosus. Cognitive dysfunction and antiphospholipid antibodies in systemic lupus erythematosus. Working memory and processing speed deficits in systemic lupus erythematosus as measured by the paced auditory serial addition test. Initial validation of the Pediatric Automated Neuropsychological Assessment Metrics for childhood-onset systemic lupus erythematosus. Assessment of cognitive function in systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis by computerized neuropsychological tests. Cognitive function in systemic lupus erythematosus: results of a 5-year prospective study. A prospective study of psychiatric disorder and cognitive function in systemic lupus erythematosus. Neuropsychological function in systemic lupus erythematosus: a five-year longitudinal study. A longitudinal study of anticardiolipin antibody levels and cognitive functioning in systemic lupus erythematosus. A prospective analysis of cognitive function and anticardiolipin antibodies in systemic lupus erythematosus. Neurotoxic lupus autoantibodies alter brain function through two distinct mechanisms. Anti-N-methyl-D-aspartate receptor antibodies, cognitive dysfunction, and depression in systemic lupus erythematosus. Validation of the Pediatric Automated Neuropsychological Assessment Metrics in childhood-onset systemic lupus erythematosus. A meta-analysis for headache in systemic lupus erythematosus: the evidence and the myth. The validity of the inclusion of "lupus headache" in the Systemic Lupus Erythematosus Disease Activity Index. Chronic or recurrent headache in patients with systemic lupus erythematosus: a case control study. Psychosis due to systemic lupus erythematosus: characteristics and long-term outcome of this rare manifestation of the disease. Neurolupus is associated with anti-ribosomal P protein antibodies: an inception cohort study. Accuracy of anti-ribosomal P protein antibody testing for the diagnosis of neuropsychiatric systemic lupus erythematosus: an international meta-analysis. Clinical and serological associations of ribosomal P autoantibodies in systemic lupus erythematosus: prospective evaluation in a large cohort of Italian patients. Mood Disorders in Systemic Lupus Erythematosus: Results From an International Inception Cohort Study. Neuropsychiatric manifestations and their clinical associations in southern Chinese patients with systemic lupus erythematosus. The prevalence of depression in rheumatoid arthritis: a systemic review and meta-analysis. Depression and cognitive impairment in newly diagnosed systemic lupus erythematosus. Endogenous typie-1 interferon activity is not associated with depression or fatigue in systemic lupus erythematosus. Psychological distress and changes in the activity of systemic lupus erythematosus. Psychiatric and psychosocial disorders in patients with systemic lupus erythematosus: a longitudinal study of active and inactive stages of the disease. Peripheral nervous system involvement in systemic lupus erythematosus: prevalence, clinical and immunological characteristics, treatment and outcome of a large cohort from a single centre. Frequency, etiology, and prevention of stroke in patients with systemic lupus erythematosus. Annual incidence and standardized incidence ratio of cerebrovascular accidents in patients with systemic lupus erythematosus. Baseline disease activity, hyperlipidemia, and hypertension are predictive factors for ischemic stroke and stroke severity in systemic lupus erythematosus. Valvular heart disease by transthoracic echocardiography is associated with focal brain injury and central neuropsychiatric systemic lupus erythematosus. Cyclophosphamide in combination with glucocorticoids for severe neuropsychiatric systemic lupus erythematosus: a retrospective, observational, two-centered study. Transverse myelopathy in systemic lupus erythematosus: an analysis of 14 cases and review of the literature. Neuromyelitis optica spectrum disorder in patients with connective tissue disease and myelitis. Clinical, radiologic, and immunologic characteristics of 50 patients from our clinics and the recent literature. Movement disorders in systemic lupus erythematosus and the antiphospholipid antibody syndrome. Seizure disorders in systemic lupus erythematosus results from an international, prospective, inception cohort study. Serum anti-beta2glycoprotein I antibodies from patients with antiphospholipid antibody syndrome bind central nervous system cells. Systemic lupus erythematosus with acute inflammatory demyelinating polyneuropathy: a case report and review of the literature. Chronic inflammatory demyelinating polyneuropathy in patients with systemic lupus erythematosus: prognosis and outcome. The association of systemic lupus erythematosus and myasthenia gravis: a series of 17 cases, with a special focus of hydroxychloroquine use and review of the literature. Late-onset systemic lupus erythematosus: clinical features, course, and prognosis. Posterior reversible encephalopathy syndrome: an emerging disease manifestation in systemic lupus erythematosus. Autoantibodies and neuropsychiatric events at the time of systemic lupus erythematosus diagnosis: results from an international inception cohort study. Risk of recurrent thromboembolic events in patients with focal cerebral ischemia and antiphospholipid antibodies. Antiribosomal-P autoantibodies from psychiatric lupus target a novel neuronal surface protein causing calcium influx and apoptosis. Anti-ribosomal p protein autoantibodies from patients with neuropsychiatric lupus impair memory in mice. Flow cytometric assessment of anti-neuronal antibodies in central nervous system involvement of systemic lupus erythematosus and other autoimmune diseases. A longitudinal study of autoantibodies against central nervous system tissue and gangliosides in connective tissue diseases. Cerebrospinal fluid antibodies to neuronal cells: association with neuropsychiatric manifestations of systemic lupus erythematosus. The pathogenesis of central nervous system manifestations of systemic lupus erythematosus. Intrathecal immunoglobulin production in patients with systemic lupus erythematosus with neuropsychiatric manifestations. A serial study of changes in intrathecal immunoglobulin synthesis in a patient with central nervous system systemic lupus erythematosus. Cytokines and chemokines in neuropsychiatric syndromes of systemic lupus erythematosus. Electroencephalography in the assessment of neuropsychiatric manifestations in antiphospholipid syndrome and systemic lupus erythematosus. Reliability and validity of the proposed American College of Rheumatology neuropsychological battery for systemic lupus erythematosus. Magnetic resonance imaging in the evaluation of central nervous system manifestations in systemic lupus erythematosus. Decreased regional cerebral metabolic rate for glucose in systemic lupus erythematosus patients with psychiatric symptoms. Recent advances and future perspective in neuroimaging in neuropsychiatric systemic lupus erythematosus. Systemic lupus erythematosus with and without neuropsychiatric manifestations: a neck and transcranial duplex sonography study. Microembolic signals in systemic lupus erythematosus and other cerebral small vessel diseases. Automated T2 quantitation in neuropsychiatric lupus erythematosus: a marker of active disease. Efficacy and safety of rituximab in the treatment of neuropsychiatric systemic lupus erythematosus during long-term follow-up. Therapeutic strategies in severe neuropsychiatric systemic lupus erythematosus: experience from a tertiary referral centre. Efficacy of plasma exchange and immunoadsorption in systemic lupus erythematosus and antiphospholipid syndrome: a systemic review. Corticosteroid-induced neuropsychiatric disorders: review and contrast with neuropsychiatric lupus.
Nutrition support for adults with specific diseases and conditions: Critical care weight loss blogs buy orlistat visa. Metastasis to a percutaneous gastrostomy site from head and neck cancer weight loss 900 calories a day buy orlistat us, radiobiologic considerations weight loss garcinia cambogia discount orlistat online master card. Percutaneous endoscopically guided gastrostomy in patients with head and neck cancer weight loss pills in stores discount orlistat 60 mg overnight delivery. Dysphagia after sequential chemoradiation therapy for advanced head and neck cancer weight loss pills 7253 order orlistat 60mg free shipping. Percutaneous endoscopic gastrostomy for postoperative rehabilitation after maxillofacial tumor surgery weight loss pills for women order cheapest orlistat. Gut mucosal nutritional support: Enteral nutrition as primary therapy after multiple system trauma. Visceral protein response to enteral versus parenteral nutrition and 268 Dysphagia assessment anD treatment planning: a team approach sepsis in patients with trauma. Effects of age and nutritional status on surgical outcomes in head and neck cancer. The National Dysphagia Diet: Implementation at a regional rehabilitation center and hospital system. Effect of route of feeding on the incidence of septic complications in critically ill patients. Metastatic spread to a percutaneous gastrostomy site from head and neck cancer: Case report and literature review. Percutaneous endoscopic, radiological and surgical gastrostomy tubes: A comparison study in head and neck cancer patients. The influence of supportive nutritional therapy via percutaneous endoscopically guided gastrostomy on the quality of life of cancer patients. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Audit of nutritional guidelines for head and neck cancer patients undergoing radiotherapy. The amount of thickener added will allow thickening from nectar-like to honeylike, or to an even stiffer spoon-thick consistency. It is important to compare the amount of product needed to achieve the desired consistency - some products have greater thickening power and, as a result, require less product. Manufacturers recommend different amounts of their product to obtain a nectar-like, honey-like, or spoon-thick consistency. The amount of product needed also may differ depending on the temperature, acidity (pH) and amount of sugars and other solids present in solution. Some of the newer gel-based thickeners have less alteration in taste and clarity of the liquid being thickened, which for some individuals, improves acceptability and effectiveness. Following is a list of some search term suggestions and, some websites, though by no means meant to imply endorsement or a complete list. Some products are intended (usually gels or powders) to be added to existing fluids at hand to thicken to desired viscosity. Other products can be purchased in a ready-to-consume container with a stated viscosity of nectar-like or honey-like. Currently, there is little standardization between company products as to what viscosity is obtained by following package directions using one of the powder or gel products added to foods at home. Hospital-based speech departments may be able to order through their Food Service, thereby accessing commercial vendors. Some suggested Web-based search terms: "Thickeners-dysphagia" and "therapeutic liquid thickeners. Product names include: Resource brand of thickened juices, milk, water; "ThickenUp" (modified corn starch), and "ThickenUpClear, (non-starch based thickening powder). The goal for every patient is a nutritional plan that optimizes recommendations from an experienced dysphagia clinician regarding what foods are most likely to be appropriate, given the details of impairment. Ideally, the nutrition plan should include foods that meet texture and viscosity restrictions, are nutritionally adequate and, to the extent possible, are acceptable to the patient. Trouble swallowing, which can cause coughing, choking, or longer time to finish a meal. Other Tips to include all of the food groups and increase calories: Grains (6 servings) Hot cereal (cream of wheat, oatmeal, grits) or cold cereal with butter, Half and Half, honey, and/or sugar Toast with butter, jelly, cream cheese, honey, or peanut butter Milk toast (soak toast in hot milk, and add sugar, cinnamon, melted butter) Pancakes or French toast with extra butter and syrup Mashed potatoes with extra butter, cream cheese, heavy cream, sour cream, or cheese Pasta with butter, oil, or cream sauce Rice with butter or oil Potato soup Bread pudding Canned fish (tuna, salmon),Vienna sausage, canned or soft meats in sauce Meat, tuna, or cheese casserole Stew, chili, lentil soup, split pea soup, or other soups with meat or beans Lentils, canned or refried beans with cheese Tofu or other soy products (add to soups, casseroles, sauces, etc) Eggs (such as soft-boiled, poached, or scrambled with cheese, bacon, or avocado) Fresh, canned, or cooked vegetables with melted cheese, butter, mayonnaise, or salad dressing Tomato or vegetable juice Homemade or canned vegetable soups Pureed yams, pureed winter squash 100% fruit juice or fruit nectar Fresh, canned, or stewed fruits (can add whipped cream) Pureed fruits (such as applesauce) Fruit smoothies Milk, Lactaid milk, flavored milk, soymilk (choose 2% or whole milk to increase calories) Hot chocolate made with milk Milk shakes or smoothies made with ice cream, frozen yogurt, or whole milk (can add peanut butter or flavored syrup) Yogurt, pudding, custard, ice cream Cream soups (such as chicken, mushroom, or asparagus) Cheeses (such as cream cheese, Laughing Cow cheese, soft cheeses like Brie, or melted cheese dishes) Cottage cheese (can add fruits, honey, or flavored syrup) Add avocado, butter, mayonnaise, sour cream, cheese, cream cheese, salad dressing, olive oil, canola oil, Half and Half, whipped cream, honey, sugar, flavored syrup, peanut butter Meat & Other Proteins (5-6 oz) Vegetables (2 cups) (2 cups) Fruits Milk & Dairy (2 cups or more) To increase calories: If you still are not able to eat enough. Add a nutrition supplement such as Carnation Instant Breakfast, Ensure, Ensure Plus, Boost, Slim Fast, or store brand equivalents. Increase calories in your Instant Breakfast drink by adding ice cream to make a milkshake. Store-bought nutrition supplements (Ensure Plus, Boost, Slim Fast) are useful if you do not tolerate milk (look for generic brands, which cost less). Choose higher calorie soups such as split pea, lentil, chili, clam chowder, or creamed soups made with milk. To add more protein to soups or other foods, mix in whey protein powder or powdered milk. If this is hard to chew, crush the multivitamin and eat with applesauce or pudding, or choose a liquid vitamin. Constipation can be caused by pain pills, not enough water or fiber, or less physical activity. Talk with your Doctor about medication for constipation, or talk with your Dietitian for ideas to prevent constipation. Children are constantly developing, and any clinical feeding assessment must take cognizance of this dynamic adapting system. Pediatric feeding difficulties lead to malnutrition, dehydration, failure to thrive, respiratory complications, as well as distress and reduced quality of life for child and family (Lefton-Greif & McGrath-Morrow, 2007; Loughlin, 1989). While a detailed case history, oral examination, and structured meal observation remains critical, the opinions of, and mealtime interactions with, parents also bear great significance. The following chapter will provide an overview of the components of a pediatric clinical feeding assessment covering neonates through to older childhood. For simplicity throughout the chapter, "child" will be used to describe the full spectrum of childhood from prematurity to adulthood rather than distinguishing between neonate, infant, toddler, and child. Regular interprofessional team ward rounds and meetings are essential for united, comprehensive assessment and management. It is important to observe the child in the most natural setting possible and, if different problems occur in different environments, more than one observation may be required - for example, a home visit and a school visit. Video recording of mealtime observations may be useful for further review and for monitoring change. There are many assessment tools/ parent questionnaires/observation checklists available to clinicians. Systematic reviews in this area have become extremely popular in recent years and critically appraise the currently available assessment tools (Calvo, Conway, Henriques, & Walsh, 2016; Heckathorn, Speyer, Taylor, & Cordier, 2016; Howe, Lin, Fu, Su, & Hsieh, 2008; Myer, Howell, Cohen, Willging, & Ishman, 2016; Poppert, Patton, Borner, Davis, & Gillette, 2015). Team members bring different expertise to the medical, motor, and behavioral management of the child (McComish et al. It is critical that the team communicates effectively to ensure family and health professionals have a clear shared goal. Instrumental assessments including endoscopic evaluation of swallowing, and/or a dynamic swallow study may complement the clinical feeding assessment (and will be discussed later). A comprehensive feeding assessment includes a medical history, feeding history, developmental history, oral sensorimotor assessment, caregiver interview, and meal observation. A thorough data collection should occur before evaluating the child - including a team discussion about the purpose/ goal of evaluation to ensure continuity of communication with family and an appropriately focused assessment. Medical History the pediatric swallowing team must evaluate the perinatal and neonatal history, medical diagnoses, previous hospitalizations, and any significant illnesses - focusing on organic precursors or causes of feeding problems. For example, respiratory problems may make it difficult for the child to breathe comfortably during feeding and lead to an increased risk of aspiration. Congenital cardiac problems often lead to increased calorie requirements for growth but fatigue makes feeding difficult, and gastroesophageal reflux from whatever cause may result in discomfort when feeding, as well as increase the risk of aspiration. Neurological problems, whatever the origin (congenital or acquired, central or peripheral nervous system or muscle diseases) may interfere with the development of normal oral-motor skills resulting in oral/pharyngeal/laryngeal/esophageal sensorimotor deficits, as well as impacting optimal positioning and self-feeding abilities. Structural abnormalities such as micrognathia, cleft palate, tongue tie, and laryngomalacia must be considered as well as dental problems in older children. Respiratory conditions and/or illnesses may be a contributor to the feeding difficulties, but may also indicate acute or chronic aspiration. These may be useful for the clinical team to ensure that all relevant information has been collated. A parent perspective of the medical history, sleep, nutrition, patterns of illness, weight maintenance, and feeding history is useful, as is a description of a typical mealtime and/or a typical day. Sensory craving should be explored, such as hot or cold temperature preferences, textural preferences. Nutritional History Nutritional Status Food diaries completed by the primary caregiver provide vital information regarding quantity as well as range of food eaten. For children with food refusal and/or selectivity concerns, a comprehensive food preference inventory may be required. It may be useful to probe into the feeding history of parents and siblings-not only family medical history, but also eating habits, food avoidance/selectivity or eating disorders. The most readily available screening tests are a complete blood count and a chemistry panel. A complete blood count may reveal concerns such as iron deficiency anemia or altered immune status. Anthropometric measures may include weight, height, triceps skinfold thickness and mid-arm circumference as a serial indicator of body fat and muscle mass (American Academy of Pediatrics, Committee on Nutrition, 1985). Prolonged inadequate caloric intake results in a child nutritionally failing to thrive. It is important to remember that the causes of failure to thrive may be organic (physical cause), nonorganic (psychosocial, including child abuse), or a combination of both. Intrauterine insults, such as fetal alcohol syndrome and intrauterine infections, may result in poor intrauterine and postnatal growth and health. Feeding History this information is usually elicited from the parent, nurse, caregiver, or teacher. It is useful to know when the feeding problem began, the medical and social circumstances that existed at the time, and the course of progression. Although a physiologically based feeding impairment is important to assess and treat, for many children the feeding difficulties may be behavioral, including food selectivity and food refusal. These problems can result in the same severity of medical consequences, including growth retardation, malnutrition, and social difficulties (Chatter, 2002). The interview with parents should cover food choices and mealtime behaviors as well as physiological signs and symptoms. Does the child have the physiological maturation for oral intake (heart range, respiration, digestion) (Porges, 1996) Behavior Behavior can impact feeding safety and pleasure but may also direct the clinical team to the root of a feeding difficulty. Irritability may also occur in response to gastroenterological issues such as reflux. Is this behavior in direct response to food presentation or to any other stimulus during the feeding Is the child performing tasks at the expected age, or is the child showing developmental delay Many children who are developmentally delayed exhibit some alteration in muscle tone, either hypertonia, hypotonia, or mixed tone. Hair that is brittle, pale blond, and sparsely distributed is seen with protein malnutrition. Examination of the eyes may reveal information regarding hydration status or infection. Malnutrition can affect the immune system and cause conjunctivitis (Kleiman & Warman, 1994). During the first three years of life, dramatic oromotor and developmental feeding changes have profound effects on the types of food, textures, and feeding methods the child can safely control. For example, preterm infants frequently demonstrate generalized hypotonia and immature development of their suck/swallow/ breathing, thus affecting their feeding efficiency. Clinicians may find primitive reflexes still present in an older child with neurological deficits, particularly cerebral palsy. Signs of Malnutrition There are a number of signs of malnutrition to look out for. Bruising may be due to vitamin K deficiency, but child abuse is also a well-recognized cause of failure to thrive. Deficiencies in essential fatty acids, zinc, or vitamins are known to cause skin rashes. When inadequate fluid intake accompanies poor caloric intake, the skin and mucous membranes will be dry. In rare situations, in particular in some developing countries, more severe signs of malnutrition may be apparent.
Gene expression profiling is increasingly used to support clinical decision-making weight loss pills in korea purchase orlistat online pills. The accuracy of this test has not been evaluated in patients with lupus or other autoimmune diseases weight loss tricks buy cheap orlistat 60mg line, but other studies suggest that expression profiles could be developed to differentiate between lupus flares and infections weight loss pills johnson city tn purchase orlistat 120mg mastercard. To accomplish this weight loss 58 buy orlistat 60mg free shipping, modular analysis analyzes activation of expression modules weight loss 101 proven orlistat 60 mg, or sets of genes that are consistently coregulated across diseases weight loss pills vitamin shoppe generic orlistat 120mg with amex. Hydroxychloroquine downregulates the processing of low-affinity antigens, such as selfpeptides, while preserving the processing of high-affinity antigens, such as foreign peptides derived from infectious agents. At present, clinicians must rely on constant vigilance, knowledge of identified risk factors, and judicious use of cytotoxic medications. In some cases, consultation with an infectious disease specialist may be warranted. In particular, autoimmune disease activity rarely causes fever in patients receiving immunosuppressive medications. Infectious manifestations may be difficult to distinguish from disease flares, although the biomarkers described in this chapter show promise in this regard. Several independent risk factors have been identified, and potential biomarkers are being developed to address this challenge. National lupus hospitalization trends reveal rising rates of herpes zoster and declines in pneumocystis pneumonia. Incidence and risk factors of infection in a single cohort of 110 adults with systemic lupus erythematosus. Serious infection rates among children with systemic lupus erythematosus enrolled in medicaid. Hospitalizations for coronary artery disease among patients with systemic lupus erythematosus. Prognostic factors in patients with systemic lupus erythematosus admitted to the intensive care unit. Risk of infection in hospitalised children with systemic lupus erythematosus: a 10-year follow-up. Low-dose pulse methylprednisolone for systemic lupus erythematosus flares is efficacious and has a decreased risk of infectious complications. Leukopenia, lymphopenia, and neutropenia in systemic lupus erythematosus: prevalence and clinical impact-A systematic literature review. Serious infections among adult Medicaid beneficiaries with systemic lupus erythematosus and lupus nephritis. Long-term survival of southern Chinese patients with systemic lupus erythematosus: a prospective study of all age-groups. Systemic lupus erythematosus: review of the literature and clinical analysis of 138 cases. Computer analysis of factors influencing frequency of infection in systemic lupus erythematosus. Survival up to 5 and 10 years of Mexican pediatric patients with systemic lupus erythematosus. Mortality and causes of death of 513 Danish patients with systemic lupus erythematosus. Risk factors and prognostic influence of infection in a single cohort of 87 adults with systemic lupus erythematosus. Causes of death in Korean patients with systemic lupus erythematosus: a single center retrospective study. Risk factors associated with the death of patients hospitalized for juvenile systemic lupus erythematosus. Serious infections in British patients with systemic lupus erythematosus: hospitalizations and mortality. The causes of death in Korean patients with systemic lupus erythematosus over 11 years. Mortality and causes of death among incident cases of systemic lupus erythematosus in Finland 2000-2008. Clinical presentations and outcomes of Filipino juvenile systemic lupus erythematosus. Prognosis for hospitalized patients with systemic lupus erythematosus in China: 5-year update of the JiangSu cohort. Mortality associated with systemic lupus erythematosus in France assessed by multiple-cause-ofdeath analysis. Spectrum of infections and outcome among hospitalized South Africans with systemic lupus erythematosus. A study of Thai patients with systemic lupus erythematosus in the medical intensive care unit: epidemiology and predictors of mortality. Childhood versus adult-onset systemic lupus erythematosus: long-term outcome and predictors of mortality. Infection in southern Chinese patients with systemic lupus erythematosus: spectrum, drug resistance, outcomes, and risk factors. Septic arthritis in patients with systemic lupus erythematosus: salmonella and nonsalmonella infections compared. Tuberculosis infection in patients with systemic lupus erythematosus: pulmonary and extra-pulmonary infection compared. Non-tuberculous mycobacterial infection in patients with systemic lupus erythematosus. Clinical features, prognostic and risk factors of central nervous system infections in patients with systemic lupus erythematosus. Incidence and prevention of herpes zoster reactivation in patients with autoimmune diseases. Low prevalence of Pneumocystis pneumonia in hospitalized patients with systemic lupus erythematosus: review of a clinical data warehouse. A rare opportunistic infection in a woman with systemic lupus erythematosus and multiple skin lesions. Strongyloides stercoralis hyperinfection in systemic lupus erythematosus and the antiphospholipid syndrome. Defective phagocytosis, decreased tumour necrosis factor-alpha production, and lymphocyte hyporesponsiveness predispose patients with systemic lupus erythematosus to infections. Fcgamma and complement receptors: expression, role and co-operation in mediating the oxidative burst and degranulation of neutrophils of Brazilian systemic lupus erythematosus patients. Effects of ultraviolet irradiation on natural killer cell function in systemic lupus erythematosus. Comparative Rates of Serious Infections Among Patients With Systemic Lupus Erythematosus Receiving Immunosuppressive Medications. Glucocorticoids severely impair differentiation and antigen presenting function of dendritic cells despite upregulation of Toll-like receptors. Risk factors and clinical features for tuberculosis among patients with systemic lupus erythematosus in Hong Kong. Herpes zoster in juvenile-onset systemic lupus erythematosus: incidence, clinical characteristics and risk factors. Herpes zoster infection in childhood-onset systemic lupus erythematosus patients: a large multicenter study. Cytomegalovirus infection causes morbidity and mortality in patients with autoimmune diseases, particularly systemic lupus: in a Chinese population in Taiwan. Cytomegalovirus in pediatric systemic lupus erythematosus: prevalence and clinical manifestations. Progressive multifocal leukoencephalopathy in patients with systemic lupus erythematosus: a systematic literature review. Progressive multifocal leukoencephalopathy and systemic lupus erythematosus: focus on etiology. Invasive fungal infection in systemic lupus erythematosus: an analysis of 15 cases and a literature review. Cryptococcal meningitis in systemic lupus erythematosus patients: pooled analysis and systematic review. Invasive fungal infections in Argentine patients with systemic lupus erythematosus. Invasive fungal infection in patients with systemic lupus erythematosus: experience from a single institute of Northern China. Major infections in a cohort of 120 patients with juvenile-onset systemic lupus erythematosus. Acute viral infections in patients with systemic lupus erythematosus: description of 23 cases and review of the literature. Infectious complications of immunosuppressive therapy in patients with rheumatic diseases. Disease control and safety of belimumab plus standard therapy over 7 years in patients with systemic lupus erythematosus. Use of rituximab in systemic lupus erythematosus: a single center experience over 14 years. Rates of, and risk factors for, severe infections in patients with systemic autoimmune diseases receiving biological agents off-label. Risk of serious infections during rituximab, abatacept and anakinra treatments for rheumatoid arthritis: meta-analyses of randomised placebo-controlled trials. Pneumocystis jirovecii pneumonia in two patients with systemic lupus erythematosus after rituximab therapy. Pneumocystis jiroveci pneumonia in patients with systemic lupus erythematosus after rituximab therapy. Anifrolumab, an antiinterferon-alpha receptor monoclonal antibody, in moderate-to-severe systemic lupus erythematosus. Sifalimumab, an antiinterferon-alpha monoclonal antibody, in moderate to severe systemic lupus erythematosus: a randomised, double-blind, placebo-controlled study. Mannose-binding lectin polymorphisms and susceptibility to infection in systemic lupus erythematosus. Association of mannosebinding lectin gene variation with disease severity and infections in a population-based cohort of systemic lupus erythematosus patients. Mannose-binding lectin and susceptibility to infection in Chinese patients with systemic lupus erythematosus. High-sensitivity C-reactive protein and erythrocyte sedimentation rate in systemic lupus erythematosus. Can procalcitonin be used to distinguish between disease flare and infection in patients with systemic lupus erythematosus: a systematic literature review. Detection of interferon alpha protein reveals differential levels and cellular sources in disease. Common Marker Genes Identified from Various Sample Types for Systemic Lupus Erythematosus. Could 25-oligoadenylate synthetase isoforms be biomarkers to differentiate between disease flare and infection in lupus patients A molecular host response assay to discriminate between sepsis and infection-negative systemic inflammation in critically ill patients: discovery and validation in independent cohorts. Molecular signatures in systemic lupus erythematosus: distinction between disease flare and infection. A modular analysis framework for blood genomics studies: application to systemic lupus erythematosus. Although the human eye measures less than 3 cm from cornea to retina, the eye contains a diverse array of structures, almost any of which can be the target of inflammation. The eyelid can be involved in cutaneous lupus, and ocular motility can be affected by cranial nerve abnormalities or by orbital myositis. Of the other ocular pathologic conditions, retinal vasculopathy in the form of cotton wool spots is the next most common and has ominous systemic implications. Central lesions, located near the macula, may result in symptoms of a well-circumscribed, small paracentral scotoma. Severe, occlusive retinal vasculopathy is far less common but is usually visually devastating, with one series reporting a final acuity of worse than 20/200. Fortunately, this subtype of retinal vasculopathy is rare with an incidence of less than 1% in the previously mentioned prospective series of 550 patients. One case report described a favorable visual outcome in a patient with lupus and severe occlusive retinal vasculitis. This patient failed corticosteroid therapy but appeared to respond to the combination of rituximab and pheresis. However, its use in macular edema secondary to macular ischemia from lupus and antiphospholipid antibody is anecdotal, with mixed results. One case study reported a rapid loss of vision and extension of ischemia after injection,12 whereas two other reported cases found some benefit. In a study of 60 patients with systemic lupus, 40% had drusen-like deposits in the retina. Patients with glomerulonephritis had drusen that were more numerous and larger than those who had normal renal function. The sectorial distribution of the hemorrhages distinguishes a branch retinal vein occlusion from a central vein occlusion. The blurred margins (black arrows) distinguish this abnormality from other causes of a prominent disc such as optic disc drusen. In a study of 40 children with lupus, Gawdat and colleagues16 found that 40% had an abnormal Schirmer test for tear production, and 7 of the 40 had retinal vascular abnormalities. In other patients, the presentation may be more insidious such as a painless loss of vision that may be gradual in its onset24 with an afferent pupillary defect and Choroidal Vascular Disease Retinal vessels are readily seen with an ophthalmoscope; therefore retinal vascular disease is relatively easy to assess.
Of the 413 respondents weight loss pills guidelines order 60mg orlistat with amex, 152 (37%) pharmacists provided smoking cessation services in their pharmacy weight loss supplements for men buy genuine orlistat online. Community pharmacists weight loss pills 935513 order orlistat 60mg otc, providing smoking cessation services weight loss programs that work orlistat 60 mg cheap, were more likely to have pharmacist assistants weight loss pills uk best buy genuine orlistat on-line, be a member of the Thai Pharmacy Network for Tobacco Control weight loss virtual model buy cheap orlistat on-line, and have more than 1 pharmacist on duty. Their most perceived barriers were being unable to follow-up and inadequate staff. In conclusion, only a minority of community pharmacists in Thailand are engaged in smoking cessation activities, even though some perceived barriers existed. Introduction Tobacco smoking is a preventable cause of death and causes more than six million deaths annually [1]. Smoking accounted for one in ten of all deaths in Thailand, and is related with increasing health expenditure [2]. Therefore, smoking cessation is one strategy to reduce the cause of preventable death from tobacco use. Pharmacy professionals are in an optimal position to aid smoking cessation, due to their roles in providing counselling and smoking aid products to support cessation. It has been well established that interventions for smoking cessation by pharmacists are cost-effective [7]. As community pharmacists are in locations where patients could easily access, evidence in many countries has shown the success of smoking cessation services provided by community pharmacists [8,9]. In Thailand, community pharmacies are in all provinces across the country and are primary places where people can go when they have a minor illness. Likewise, providing smoking cessation services in Thai community pharmacies is of interest to both professionals and patients. Research has confirmed that Thai community pharmacists engage in many smoking cessation services [8,10]. This study identified eight barriers in the provision of smoking cessation services, the most important three being: Lack of patient demand, lack of educational materials, and lack of smoking cessation products. Other studies in other countries, also identified barriers preventing community pharmacists from achieving the highest level of offering their practices of smoking cessation services. However, smoking cessation services are only available in some community pharmacies in Thailand. Thus, this study aimed to investigate activities and barriers related to smoking cessation services provided in community pharmacies in Thailand, as well as to compare these activities and barriers between those pharmacists providing and those not providing smoking cessation services. Participants and Procedures A cross-sectional survey was conducted among community pharmacies in Thailand, between 2013 and 2014. This study aimed to explore roles of community pharmacists in tobacco control, especially in providing smoking cessation services. Therefore, the questionnaires were sent to all community pharmacies, according to the list compiled from these organizations. Questionnaire Development and Data Collection the questionnaire used to collect information from participants was designed to be self-administered, and all responses were voluntary. The questionnaire was developed by the research team based on the objectives of the study and literature reviews. The content validity of the questionnaire was also reviewed by the research team and experts in tobacco control. The questionnaire was then tested with ten pharmacists, for the use of appropriate language, before sending the questionnaire to participants. The aim of this process was to ensure that the pharmacists properly understood each item in the questionnaire. The information on activities related to smoking cessation services in their community pharmacies, for those providing smoking cessation services, included number of people asking for help with smoking cessation, time spent with the smoking cessation services and services to aid smoking cessation. In addition, an open-ended question was asked about motivation of pharmacists to help smokers to quit, for those pharmacists offering smoking cessation services in their drugstores. The last part focused on perceived barriers by community pharmacists in providing smoking cessation services; this part was for all pharmacists to answer. Eleven Likert scale items (4-points: strongly agree, agree, disagree, and strongly disagree) inquired about perceived barriers for smoking cessation services. In all, 38 questions included a mix of multiple choice, open-ended, and Likert scale items. Pharmacists providing smoking cessation services were identified by the question "Do you provide a smoking cessation service in your pharmacy Questionnaires with cover letters explaining the purpose of the study and confidentiality were sent by post to 5450 community pharmacies, according to their addresses on the list. To increase the response rate, pharmacists were later contacted by telephone and given reminders. Ethics this study protocol was approved by the Ethics Review Committee, Faculty of Pharmacy, Chiang Mai University, Thailand, before commencing the study. All participants were informed about the study protocol through the subject information sheet, and that their completing the questionnaire was voluntary. Response Rate From the initial questionnaires sent to 5450 pharmacists, failure delivery notifications were received for 215 (3. Of the 435 returned questionnaires, duplicate submission to the same community pharmacies (10) and incomplete questionnaires unsuitable for the analysis (10) were removed. Hence, percentages presented are based on numbers of respondents answering each question. Characteristics of the Respondents Of the 413 community pharmacists, who answered the questionnaire, 152 (37%) reported having smoking cessation services provided in their community pharmacies. Most had graduated as a pharmacist before 1994, that is, graduated more than 20 years previously. Most pharmacists (97%) agreed that providing smoking cessation services was one role of community pharmacists. Total (n = 413) Pharmacists Providing Smoking Cessation Services (n = 152) p-Value 59 (38. Percentages presented are based on numbers of respondents answering each question. Pharmacy 2018, 6, 101 Smoking cessation products were available in 316 pharmacies (77%), and these products included nicotine gum, nicotine patch, bupropion, nortriptyline, varenicline, and herbal mixture for smoking cessation. Nicotine gum (73%) was the most dispensed pharmaceutical product to aid smoking cessation (Table 2). The most frequent activities pharmacists reported having performed for smoking cessation in their community pharmacies were providing materials to aid smokers to quit. Smoking Cessation Products Nicotine gu Bupropion Nicotine patch Herbal mixture for smoking cessation Nortriptyline Varenicline Others Pharmacists Providing Smoking Cessation Services (n = 152) 140 (92. Activities Providing materials for smoking cessation (n = 147) Brochures (n = 110 Video (n = 110) Poster (n = 110) Showing symbols in front of pharmacy (n = 147) A designated area for smoking cessation (n = 147) Engaging with the community (n = 147) n (%) 110 (74. Time spent in each cessation service was about 15 min per person for the first time, and 9 min for each follow-up visit (Table 4). The top two perceived barriers on providing smoking cessation services, were being unable to follow-up patients after providing the cessation services and inadequate staffing. These barriers did not significantly differ between those providing and those not providing cessation services. This study showed six significant different perceived barriers between the two groups, i. Interestingly, no payment for providing smoking cessation services was the lowest perceived barriers (23%), and did not significantly differ between the two groups. Number of smokers receiving smoking cessation services and time spent on smoking cessation services (n = 152). Unable to follow-up Inadequate staffing Lack of time Lack of population demand No smoking cessation products Lack of knowledge and skills Lack of self-confidence Lack of media/equipment No appropriate place No motivation No payment 346 (84. Smoking Cessation Services Provided by the Community Pharmacists this national survey across Thailand showed that approximately 37% of respondents provided smoking cessation services in their community pharmacies. In Thailand, community pharmacists are in an optimal position to provide smoking cessation services to patients, as pharmacists can be easily reached and asked for advice. However, not every community pharmacist can provide smoking cessation services, as smoking cessation requires not only knowledge and skills, but also time spent in assisting smokers to quit. This study showed that community pharmacists from all parts of Thailand engaged in providing smoking cessation services, mostly in Bangkok and northern Thailand. Community pharmacists at least had activities related to tobacco control or smoking cessation services provided to the public. These activities comprised (1) providing materials to aid smokers in quitting smoking. Some community pharmacists were encouraging community members to reduce or stop smoking through radio broadcasts or journals in the community. The results of this study showed that almost all pharmacists (97%) agreed that smoking cessation is an important role of community pharmacists. This finding is consistent with a related Thai study [10], suggesting that community pharmacists perceived they had important roles in helping smokers to quit smoking. Many smoking cessation aid products were available in community pharmacies: Nicotine gum, Nicotine patch, Bupropion, Nortriptyline, Varenicline, and Herbal formulas for smoking cessation. In Thailand, these products do not require a prescription, but need to be dispensed by a pharmacist. Nicotine gum was found to be incorrectly used by smokers as it is quite difficult to use, and a patient needs to know how to use it properly to get the most effectiveness from the product, to avoid adverse effects that may occur. For those 152 community pharmacists who provided smoking cessation services daily, the number of smokers who stopped smoking after receiving smoking cessation services ranged from 0 to 40 individuals, for each pharmacy. Six smokers, monthly, on average, could quit smoking, and 9 smokers, monthly, could reduce their smoking. It seemed that the number of smokers receiving smoking cessation services was quite low, and some pharmacists did not provide smoking cessation services at the time the study was conducted. This implied that pharmacists should encourage and motivate their customers to participate in smoking cessation services. In Thailand, levels of smoking cessation services provided by community pharmacists have been increasing in the past 10 to 15 years. Perceived Barriers of Smoking Cessation Services by Community Pharmacists Community pharmacists perceived some barriers preventing them from providing smoking cessation services. First, being unable to follow-up after providing the service was the most common issue considered to be a barrier, and did not differ between those pharmacists providing services and those not. Therefore, having professional communication with community pharmacists that involved follow-up was essential to help motivate smokers to stop smoking. This included training them to understand the purpose of follow-up and how to conduct it. Second, inadequate staffing was another perceived barrier, and did not differ between the two groups. Community pharmacies providing smoking cessation services had more than one pharmacist on duty and pharmacist assistants. Smoking cessation services require time spent with smokers to counsel them, especially for the first time, about 15 min and about 9 min for each follow-up visit. Normally in Thailand, only one pharmacist is on duty; therefore, providing smoking cessation services without other personnel was quite difficult. This was similar to other studies that reported a lack of staff as a barrier [8,10,15,20,25]. As smoking is unacceptable in Thai society, especially female smoking, where the provision of smoking cessation services is a role of pharmacists, identifying smoking status should be an initial step in pharmacy practice. Another perceived barrier to providing smoking cessation services was not having relevant medications, which was also identified in related studies [10,26]. However, this study found that Thai pharmacists perceived lack of smoking cessation medications as a weaker barrier, as per the findings of a related Thai study conducted in 2008 [10]. This was because medications for smoking cessation were only available in hospitals, at the time that the study was conducted. However, nicotine replacement products became available in community pharmacies starting July 2005. This study also identified the lack of materials for smoking services as a barrier to service provision, a result consistent with a related study conducted in Thailand by Thananithisak et al. Given that community pharmacists may be unaware of this fact, promotion and communication to pharmacists on this website should be increased. Interestingly, lack of time was more likely to be perceived as a barrier among those community pharmacists providing smoking cessation than those that did not. Further investigation should examine the reasons for providing smoking cessation services among pharmacists, even when they perceived time constrain was a barrier. Apart from perceived barriers reported by the pharmacists, motivation to provide smoking cessation services was investigated. This study found that the motivation of community pharmacists in providing smoking cessation services was mainly to enhance the pharmacy profession in helping patients, smokers, individuals, society, and the nation, to be free from the dangers of tobacco. It also expanded the roles of community pharmacies in tobacco control and smoking cessation. In addition, community pharmacists could create awareness of the dangers of smoking and be willing to communicate with patients and smokers to help them to quit smoking, and prevent diseases caused by smoking. This study showed that the motivation for providing public health services was related to the pharmacy profession and not a financial issue, particularly considering those working in independent pharmacies.
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