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Assess whether the patient is a candidate for an anterior lamellar keratoplasty generic plendil 5 mg with mastercard, endothelial keratoplasty buy generic plendil line, or penetrating keratoplasty 3 discount plendil. Counsel individuals at greater risk for continued melting due to systemic disease buy 5mg plendil with visa, inform them of imperfect visual outcome even in ideal circumstances due to interface image degradation 9. Determine additional procedures that may need to be done at time of anterior lamellar keratoplasty such as: amniotic membrane overlay, tarsorrhaphy, punctal cautery, lid reconstruction, bandage contact lens application, etc. List the alternatives to this procedure (based on presence of corneal opacification and visual potential) A. Potential for better acuity due to lack of interface irregularity in cases where significant residual host stroma remains (baring of Descemet membrane was not possible during surgery) 2. Surface ablation for superficial opacities and irregular astigmatism is faster, easier and less traumatic 2. Corneal glue with bandage contact lens application for small perforations and Descemetoceles 2. Usually retrobulbar, may be topical if using femtosecond laser or microkeratome for anterior lamellar grafts 2. Donor prepared to similar thickness stabilized on artificial anterior chamber or sutured to gauze- wrapped sphere d. Smallest possible diameter trephine used to encompass area of thinning, and trephination taken to 80% depth or more, anterior tissue removed, and donor prepared and placed as described above d. Filter paper can be placed over the recipient bed and then cut to form and used as a template for preparation of the proper shape for the donor tissue. Microkeratome cuts pre-set depth and diameter of recipient and donor, utilizing artificial anterior chamber for preparation of the donor b. No sutures required if graft less than 200 microns thick (place bandage contact lens over graft) 4. Femtosecond laser cuts pre-set depth and diameter of recipient and donor utilizing artificial anterior chamber for preparation of the donor b. An air bubble in anterior chamber used to judge the depth of stromal dissection by using the reflection of the tip of the dissection instrument seen on the air bubble. Specialized stromal dissectors are used to create a total stromal pocket, limbus to limbus, just above Descemet membrane d. Intraocular pressure lowered as much as possible by air-fluid exchange through paracentesis e. Cohesive viscoelastic is injected into the pocket to detach Descemet membrane into anterior chamber f. Anterior tissue removed, leaving bare Descemet or Descemet and minimal posterior stromal fibers h. Descemet membrane detached from the stroma into the anterior chamber using forced injection of either air (Anwar Big Bubble technique) or fluid (hydrodissection technique of Sugita) using a 27 or 30-gauge needle with bevel down or a rounded cannula. Tip needs to be deeper than 80% depth, but does not need to be immediately above Descemet membrane to achieve detachment c. Limbal paracentesis made to reduce pressure and allow room for intrastromal air bubble or fluid to expand and further detach Descemet membrane d. Cohesive viscoelastic may be placed into space between detached Descemet membrane and overlying residual posterior stromal tissue after small entry into this space with sharp blade to pop big bubble f. Blunt spatula placed into space and blade used to cut down from surface to spatula or scissor used to divide posterior tissue into halves or quadrants g. Standard corneal scissors used to cut a trephination circle and excise residual stromal tissue, leaving 8. Used in cases where a big bubble cannot be attained or do not want to attempt due to scarring involving Descemet membrane (risk of perforation) b. Create deep dissection plane 50-80 microns above Descemet membrane and dissect across corneal surface by peeling back stroma and excising at base. Interface fluid ("double anterior chamber") due to break in Descemet membrane with separation of recipient Descemet membrane from overlying swollen graft a. Management: place large enough air bubble into anterior chamber to cover defect in Descemet membrane and position head to allow contact of air bubble with defect 2. Pupillary block from residual air bubble: remove air via paracentesis, or place inferior iridotomy to prevent pupillary block 3. Alternatively, graft could be removed, infection cleared, and then new graft placed after the eye no longer inflamed 6. Endophthalmitis: urgent, aggressive intervention with consultation with retina specialist for anterior chamber tap, vitreous biopsy and intravitreal antibiotics 7. Treat with aggressive lubrication with drops and ointment, punctal plugs, autologous serum and topical cyclosporine 8. High degrees of surgically induced regular or irregular astigmatism, hyperopia, or myopia a. Treat in same manner as penetrating keratoplasty with selective suture removal or adjustment, relaxing incisions, laser refractive surgery, etc. More commonly seen if topical steroids are discontinued prior to suture removal b. Frequency of postoperative visits related to Descemet membrane attachment, interface haze, surface topography and control of intraocular pressure and inflammation 1. Topical prednisolone acetate 1% 4 times a day initially, tapered over 3-6 months, and discontinued. Fluorometholone drops may be used once daily as long as sutures remain in certain cases to reduce risk of vascularization and immune reaction 2. Stress importance of compliance with medications and need for regular postoperative care to ensure visual rehabilitation B. Discuss symptoms of infection and need for immediate attention (redness, sensitivity to light, visual changes, pain) C. Discuss physical restrictions, importance of eye protection, and details for emergency care D. Patients can achieve good visual acuity although interface haze may occur between the recipient cornea and the donor tissue Additional Resources 1. Complex cascade of events initiated by recognition of foreign donor corneal antigens by the recipient 2. Cell surface markers - human leukocyte antigens present on donor corneal epithelial, stromal, and endothelial cells interact with recipient cytotoxic T cells resulting in local inflammation, cellular destruction and corneal graft rejection B. Predisposing factors (broken suture, focal corneal neovascularization, suture infiltrate, patient non-compliance) 3. Keratic precipitates - may aggregate to form endothelial rejection line (Khodadoust line) c. Describe patient management of endothelial rejection in terms of treatment and follow-up A. Periocular injections or oral corticosteroids may have a role in severe rejection episodes or in patients with poor compliance c. Central corneal pachymetry measurements allow detection of early immunologic reactions as well as gradual return to normal function after treating rejection episodes. Awareness of symptoms that may represent worsening of disease Additional Resources 1. Epithelial ingrowth following penetrating keratoplasty: a clinical, ultrasound biomicroscopic and histopathological correlation. Epithelial downgrowth following penetrating keratoplasty with a running adjustable suture. Cystic epithelial growth after penetrating keratoplasty: successful curative treatment by block excision. Patient-reported symptoms associated with graft reactions in high-risk patients in the collaborative corneal transplantation studies. The impact of corneal allograft rejection on the long-term outcome of corneal transplantation. Prepare the recipient bed by dissecting the conjunctiva, use minimal cautery (allows better vascularization, reduces inflammation) B. Carry a lamellar dissection from the underside of the conjunctiva to the limbus E. Consider the use of amniotic membrane as a substrate for the graft or as a bandage covering to promote healing, or both V. Suture more securely, assure glue adherence, have patient wear shield continuously to avoid rubbing graft off 3.

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Strengths Weaknesses Tools Did the review identify any tools that facilitate step-by-step practical application? Strengths Weaknesses Evidence What evidence was identified in the review and what is the quality of this evidence? Strengths Quality Weaknesses Quality Health & communicable What evaluation outcomes were used? Strengths European focus Targeting including hard-to-reach populations Weaknesses European focus Targeting including hard-to-reach populations The reference numbering system used in this table does not stem from the completed review plendil 2.5mg low cost, published in the technical report series as: [insert full reference of relevant review] cheap 10 mg plendil mastercard. Legend for matrix strengths and weaknesses table above Concept: Is there a commonly agreed conceptualisation for the main focus of the review? Models & theories: Are there any models discount plendil 5 mg online, theories or frameworks identified in the review? Comment if they are specific to the topic area or health communication communicable disease discount 10mg plendil overnight delivery. Tools: Does the review identify any tools that facilitate practical step-by-step application? Comment if they are specific to topic area or health communication/communicable diseases. Where possible, this should section should also include: Europe – is the identified application within Europe? Focus – are the applications focused on specific health topics, including communicable diseases/health communication? Targeting (hard-to-reach groups) – do the applications target hard-to-reach groups? Evidence: What evidence is identified in the review and what is the quality of this evidence? For example, these could be indirect indicators of success such as awareness /knowledge and ‘behavioural and other changes’, e. Evidence reviews A rapid evidence review of interventions for improving health literacy 10. Health literacy as a public health goal: a challenge for contemporary health and education and communication strategies into the 21st century. Complex interventions to improve the health of people with limited literacy: a systematic review. Interventions to improve health outcomes for patients with low literacy: a systematic reviewGeneIntern Med 2005; 20:185-92 18. Orthop Nurs 2008 Sep-Oct;27(5):302-17 A rapid evidence review of health advocacy for communicable diseases 20. Stop The Global Epidemic of Chronic Disease: A practical guide to successful advocacy. Public health campaigns to change industry practices that damage health: an analysis of 12 case studies. Advocacy, communication and social mobilisation for tuberculosis control: collection of country-level good practices [internet]. Evidence review: social marketing for the prevention and control of communicable disease 37. Developing a common language for using social marketing: an analysis of public health literature. The effectiveness of social marketing in reduction of teenage pregnancies: a review of studies in developed countries. Effectiveness of a hospital- wide programme to improve compliance with hand hygiene. Literature reviews A literature review on health information-seeking behaviour on the web: a health consumer and health professional perspective 50. Internet use and seeking health information online in Ireland: demographic characteristics and mental health characteristics of users and non-users. Group disparities and health information: a study of online access for the underserved. Effects of interactivity on the comprehension of and attitudes toward online health content. Journal of the American Society for Information Science and Thechnology 2007; 58(6):766-776 62. Using the internet for health-related activities: findings from a national probability sample. Reasons, assessments and actions taken: sex and age differences in uses of internet health information. Going online for health advice: changes in usage and trust practices over the last five years. Googling for a diagnosis – use of Google as a diagnostic aid: internet based study. The information-seeking behaviour of paediatricians accessing web-based resources. Internet-based information-seeking behaviour amongst doctors and nurses: a selective review of the literature. Assessment of internet use and effects among healthcare professionals: a cross sectional survey. Identifying strategies to improve access to credible and relevant information for public health professionals: a qualitative study. Patients using the internet to obtain health information: how this affects the patient-health professional relationship. Untangling the web – the impact of internet use on health care and the physician-patient relationship. Number of ‘cyberchondriacs’ – adults going online for health information – has plateaued or declined. Health Psychol 2006;25 (2):205-210 A literature review of trust and reputation management in communicable disease public health 89. Effective health risk ommunication about pandemic influenza for vulnerable populations. Public support for government actions during a flu pandemic: lessons learned from a statewide survey. Influenza pandemic: perception of risk and individual precautions in a general population. Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey. Public Health Response to Influenza A(H1N1) as an Opportunity to Build Public Trust. A case study in crisis management: how planning for the worst can help protect reputational integrity and restore operational effectiveness. Infectious diseases and governance of global risks through public communication and participation. A literature review on health communication campaign evaluation with regard to the prevention and control of communicable diseases in Europe 126. Evaluating large-scale health programmes at a district level in resource-limited countries. Interventions for improving coverage of child immunization in low-income and middle-income countries. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Guidance for Evaluating Mass Communication Health Initiatives: Summary of an Expert Panel Discussion (Sponsored by the Centers for Disease Control and Prevention). A 10-year retrospective of research in health mass media campaigns: where do we go from here? Do health promotion messages target cognitive and behavioural correlates of condom use? Kumaranayake L, Vickerman P, Walker D, Samoshkin S, Romantzov V, Emelyanova Z, et al. Effects of a multi-faceted programme to increase influenza vaccine uptake among health care workers in nursing homes: a cluster randomised controlled trial. Promoting uptake of influenza vaccination among health care workers: a randomized controlled trial. Stone S, Fuller C, Slade R, Savage J, Charlett A, Cookson B, Duckworth G, Murray M, Hayward A, Jeanes A, Roberts J, Theare L, McAteer J, Michie S.

The results of this study may contribute to positive social change by enhancing doctors’ understanding of thyroid disease in women and the influence of the doctor-patient relationship in determining positive treatment outcomes order 2.5mg plendil mastercard, thus equipping doctors with enriched knowledge for providing their female thyroid patients with the highest quality of care order 5mg plendil fast delivery. Women and Thyroid Disease: Treatment Experiences and the Doctor-Patient Relationship by Laura J buy cheap plendil 2.5mg. Ruth Crocker—Thank you so much for sharing your wisdom with me during this long journey buy cheap plendil 10mg on line. We will overcome the debilitating effects of thyroid disease and help to ensure better outcomes for individuals yet to be diagnosed. Across cultures, the prevalence of thyroid disease is much higher among women than among men (Canaris, Manowitz, Mayor, & Ridgway, 2000; Cassidy, Ahearn, & Carroll, 2002). In fact, women have an estimated 1 in 7 chance of developing thyroid disease (Godfrey, 2007). A number of factors make proper diagnosis and treatment of thyroid disease challenging. In addition, as thyroid dysfunction produces symptoms similar to those of other disorders (e. In the face of such challenges, a doctor-patient relationship based on mutual trust and collaboration helps to ensure positive treatment outcomes (Houle, Harwood, Watkins, & Baum, 2007; Munch, 2004). In addition, effective communication between doctors and patients is critical in both the diagnosis and management of thyroid disease (Shimabukuro, 2008; Simmons, 2010). However, the culture of the medical profession, diagnostic bias, and gender differences in communication may interfere with doctor-patient discourse (Cheney & Ashcraft, 2007; Hamberg, Risberg, & Johansson, 2004; Hoffmann & Tarzian, 2001; Kaiser, 2002; Munch, 2004). An exploration of women’s experiences in the treatment of thyroid disease, especially relative to these three points, may contribute to better understanding on the part of doctors and thus more effective doctor-patient communication and relationships. Despite the pervasiveness of thyroid disease in women and the importance of the doctor-patient relationship in positive treatment outcomes, there is a gap in the literature regarding the treatment experiences of women diagnosed with thyroid disease, particularly regarding the doctor-patient relationship. Therefore, the purpose of this phenomenological study was to explore female thyroid patients’ experiences of treatment and the doctor-patient relationship. The phenomenological research approach was used, as it is designed to examine the meaning of experiences about a particular phenomenon (e. The theoretical perspectives used to guide data interpretation included feminism and social 3 constructivism. More specifically, the following issues were addressed in regard to their relationship with women’s treatment experiences: (a) the culture of the medical profession (see Kaiser, 2002; Thomas, 2001), (b) diagnostic bias (see Hamberg et al. The following paragraphs provide a review of the literature relevant to the study, followed by the problem statement, the purpose and nature of the study, research questions, conceptual framework, definition of terms, assumptions and limitations, and the significance of the study. Background of the Study The incidence of thyroid disease is higher than previously thought (Canaris et al. Across cultures, the prevalence of thyroid disease is much higher in women than men (Canaris et al. Approximately 1 out of every 7 women develops thyroid disease, and its prevalence increases with age (about 20% in women over age 60; Godfrey, 2007). The two predominant conditions resulting from thyroid disease are hyperthyroidism and hypothyroidism, with Grave’s disease and Hashimoto’s disease, respectively, as the most common causes (Zeitlin et al. In the United States, the most common cause of hyperthyroidism is Grave’s disease, an autoimmune form of thyroid disease (Bunevicius & Prange, 2006). Individuals with hyperthyroidism experience heat intolerance, hot flashes, absent menses, insomnia, decreased libido (Godfrey, 2007), rapid heartbeat, sweating, and tremors (Aslan et al. In the United States, the most common cause of hypothyroidism is Hashimoto’s disease, an autoimmune form of thyroid disease (Erdal et al. Individuals with hypothyroidism experience fatigue (Bono, Fancellu, Blandini, Santoro, & Mauri, 2004), lethargy, apathy, difficulty concentrating (Aslan et al. In extreme cases, the individual may experience slowing of thought processes, progressive cognitive impairment, hallucinations, and delusions (Bono et al. Furthermore, abnormalities in thyroid function present with symptoms similar to those of other disorders and can be mistaken for other conditions (Canaris et al. For example, hyperthyroidism and hypothyroidism are frequently misdiagnosed as anxiety and depressive disorders, respectively (Aslan et al. Postpartum thyroiditis, which affects more than 8% of women, is sometimes mistaken for depression (Fassier et al. In older patients, symptoms of hyperthyroidism and hypothyroidism often lead to inaccurate diagnoses of menopause or dementia (Godfrey, 2007; Shimabukuro, 2008). Thus, it is vital that physicians conduct a thorough assessment of their patients, including an ongoing discussion of symptoms, to ensure proper diagnosis and treatment. Although antithyroid drugs have been used for over 60 years, remission rates are variable, and relapses are frequent. However, some experts recommend the addition of T3 (liothyronine; name brand Cytomel) due to its antidepressant effects (Dayan, 2001; Joffe, 2006). As previously mentioned, proper treatment of thyroid disease is dependent upon accurate diagnosis. Misdiagnosis of thyroid disease delays treatment and can result in progressive psychological and physiological problems (Heinrich & Grahm, 2003; McDermott & Ridgway, 2001) including psychosis (Gaitonde, Rowley, & Sweeney, 2012; Heinrich & Grahm, 2003) and potential heart failure (Hak et al. These risks highlight the importance of an effective doctor-patient relationship in ensuring proper diagnosis and positive treatment outcomes. The treatment experiences of women with thyroid disease might be best examined from social constructionist and feminist viewpoints, as both worldviews emphasize individuals’ experiences in social contexts (Docherty & McColl, 2003; Fernandes, Papaikonomou, & Nieuwoudt, 2006; Hearn, 2009). From a social constructionist viewpoint, patients’ interpretations of their illness experience are important in understanding and treating illness. The feminist viewpoint suggests that female patients’ interpretations of their experiences are influenced by social constructs (e. Because social constructs come from patients, physicians, and social institutions (Hearn, 2009), women’s experiences with thyroid disease diagnosis and management may be influenced by the culture of the medical profession, diagnostic bias, and gender differences in communication. Culture of the Medical Profession In the Western medical profession, health-care practitioners are taught via the medical model to base their diagnostic and treatment decisions on “objective evidence” of disease (e. Additionally, as argued by Annandale and Clark (2000), health has become “marketed as a result of lifestyle choice” (p. In other words, the patient is totally responsible for his or her condition; if a person is overweight, then he or she must lack self-control. According to Vanderford, Stein, Sheeler, and Skochelak (2001), the traditional medical culture has encouraged physicians to behave in a paternalistic or authoritative manner when faced with differing treatment expectations from their patients. Traditional doctor-patient relationships are characterized by authoritarian and paternalistic approaches in which the physician controls the interview, makes a diagnosis, and chooses the treatment plan without the patient’s input (Ehrenreich & English, 2005; Vanderford et al. Research indicates that these types of doctor- patient interactions are related to lowered patient satisfaction and negative treatment outcomes (Bradley, Sparks, & Nesdale, 2001; Chrisler & Parrett, 1995; Copeland, Hudson Scholle, & Binko, 2003; Krupat, 1999; Stokes, Dixon-Woods, & Williams, 2006). Research indicates that physicians are more likely to interpret men’s symptoms as biological and women’s symptoms as psychosocial—that is, that women’s symptoms are a result of a mental, rather than physical, illness (Chrisler, 2001; Hamberg et al. In their study on the treatment experiences of women with chronic pain, Werner and Malterud (2003) purported that the medical profession encourages a normative, gendered view of illness, which results in a perceived need for women to work harder in order to be perceived as credible patients. As a result, female patients can become wary of honestly communicating their symptoms and the psychosocial effects of those symptoms (Peters et al. Gender Differences in Communication It has been argued that gender differences in medical treatment can be partially explained by gender differences in communication. Whereas men tend to describe their symptoms in a frank and confident manner, women often give generalized descriptions of their symptoms (Hamberg et al. Although these generalizations do not apply to all men and women, variations in communication patterns across genders have the potential to 9 influence how physicians and patients interact (Hamberg et al. With regard to conversation during medical consultations, evidence suggests that there is a significant disparity between the communication styles preferred by patients and those preferred by physicians. Platt (2008) reported some of this evidence, noting that doctors commonly complain about verbose patients who tell long stories when doctors ask questions. Additionally, Platt noted that doctors use their authority to encourage patients to communicate in the doctors’ preferred styles. Doctor-patient relationships are affected by communication, and gender differences in communication styles could amplify these effects. In summary, an effective doctor-patient relationship helps to ensure proper diagnosis and positive treatment outcomes (Copeland et al. An ineffective doctor-patient relationship, on the other hand, has the potential to result in misdiagnosis, delayed or inappropriate medical treatment, and termination of the doctor-patient relationship (Chrisler & Parrett, 1995; Copeland et al. The nature of the doctor-patient relationship, and hence women’s treatment experiences related to thyroid disease, may be influenced by the culture of the medical profession, diagnostic bias, and gender differences in communication.

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