Specific Clinical Considerations Research Articles

Endoscopic Techniques for Obtaining Enteral Access

In the absence of contraindications, enteral feeding is recommended for patients who are expected to be intolerant of oral feedings beyond 7 days. Enteral access can be accomplished by a variety of means, including surgical, endoscopic, or radiographic methods. This review focuses on endoscopy-guided options for enteral access. These methods include gastric feeding, which can be accomplished by orogastric, nasogastric, or percutaneous endoscopic gastrostomy tube placement, and postpyloric feeding, accessed through oral or nasal jejunal tubes, percutaneous gastrostomy with a jejunal extension, or direct percutaneous jejunostomy. The indications, techniques, complications, and comparative data of these placement options are outlined, and special clinical considerations (including establishing access in patients with dementia or cirrhosis and those on anticoagulation) are discussed. This review contains 5 figures, 1 table, and 33 references. Key words: direct percutaneous jejunostomy, endoscopy, enteral access in cirrhosis, enteral access in dementia, enteral feeding, enteric access, nasogastric feeding tubes, percutaneous endoscopic gastrojejunostomy tubes, percutaneous endoscopic gastrostomy tubes

Effects of Age and Sex on Weight-Loss Dynamics in Obese Patients Undergoing Very Low Calorie Treatment

Background and Significance: Although known to effectively provoke large scaled weight-loss, less is known regarding age- and sex-related influences on treatment outcomes of bariatric patients treated with a very-low calorie diet (VLCD) program. Purpose: This study retrospectively examined body composition and metabolic changes induced by a 12-wk proprietary VLCD treatment in obese patients while assessing age and sex differences. Methods: Male (n=16) and female (n=16) patients underwent 12 weeks of VLCD under standard medical care. Results: Older patients exhibited a greater relative loss of FFM compared to younger patients (p=0.004). Older patients also lost a greater proportion of total weight-loss as FFM (p=0.003) and lower proportion as FM (p=0.003) compared to the young group. This age-specific difference in weight-loss composition was driven by the older males. Conclusion: The results demonstrate the need for special clinical considerations for VLCD treated patients, such as older adults and perhaps older males specifically, who demonstrate a reduced quality of weight-loss compared to their younger counterpart.

Endoscopic Techniques for Obtaining Enteral Access

In the absence of contraindications, enteral feeding is recommended for patients who are expected to be intolerant of oral feedings beyond 7 days. Enteral access can be accomplished by a variety of means, including surgical, endoscopic, or radiographic methods. This review focuses on endoscopy-guided options for enteral access. These methods include gastric feeding, which can be accomplished by orogastric, nasogastric, or percutaneous endoscopic gastrostomy tube placement, and postpyloric feeding, accessed through oral or nasal jejunal tubes, percutaneous gastrostomy with a jejunal extension, or direct percutaneous jejunostomy. The indications, techniques, complications, and comparative data of these placement options are outlined, and special clinical considerations (including establishing access in patients with dementia or cirrhosis and those on anticoagulation) are discussed. This review contains 5 figures, 1 table, and 33 references. Key words: direct percutaneous jejunostomy, endoscopy, enteral access in cirrhosis, enteral access in dementia, enteral feeding, enteric access, nasogastric feeding tubes, percutaneous endoscopic gastrojejunostomy tubes, percutaneous endoscopic gastrostomy tubes

Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections

Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders. Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injections. A collaboration was undertaken between the U.S. Food and Drug Administration Safe Use Initiative, an expert multidisciplinary working group, and 13 specialty stakeholder societies. The goal of this collaboration was to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections and produce consensus procedural clinical considerations aimed at enhancing the safety of these injections. U.S. Food and Drug Administration Safe Use Initiative representatives helped convene and facilitate meetings without actively participating in the deliberations or decision-making process. Seventeen clinical considerations aimed at improving safety were produced by the stakeholder societies. Specific clinical considerations for performing transforaminal and interlaminar injections, including the use of nonparticulate steroid, anatomic considerations, and use of radiographic guidance are given along with the existing scientific evidence for each clinical consideration. Adherence to specific recommended practices when performing epidural corticosteroid injections should lead to a reduction in the incidence of neurologic injuries.

Familial polythelia associated with dental anomalies: a case report

Polythelia has been defined as the presence of supernumerary nipples without accessory glandular tissue. Usually, these growths follow imaginary mammary lines running from the armpits to the groin.Although the presence of dental anomalies may occasion only a simple cosmetic problem with specific clinical considerations, the association with family polythelia has been scarcely reported.This paper reports on a case of polythelia that is associated with dental anomalies in an Argentine family and discusses suggestions for a thorough dental history and medical consultation to prevent possible pathological conditions or potential malignant transformation of mammary tissues.

Empowering the disempowered: harm reduction with racial/ethnic minority clients

Harm-reduction principles, such as empowerment of clients and goals for moderation, align well with the cultural worldviews of many clients of color. Empirically supported harm-reduction strategies often work well with ethnic minority clients. However, clients of color require special clinical considerations. A case study illustrates the use of the community participatory model, which combines harm reduction, cultural sensitivity, and community support. Treatment services can be provided under one roof to eliminate barriers to seeking and receiving services. Harm-reduction therapists can carefully assess and diagnose clients of color to minimize the potential shortcomings and cultural biases in assessment tools. Therapy will include the family and incorporate traditional practices as desired by clients. Use of these methods will empower and support clients of color as they seek their treatment goals.

Cochlear Implant Outcomes for Children With Auditory Neuropathy Spectrum Disorder

AbstractCochlear implantation is currently the intervention option of choice for many children with auditory neuropathy spectrum disorder (ANSD) who are unable to obtain benefit from conventional amplification. The aim of this study was to review the speech perception and language outcomes for children with ANSD who had received a cochlear implant and highlight specific clinical considerations for working with this population of children with hearing impairment who are being considered for implantation. Finds for the group of 17 children with ANSD using cochlear implants were compared to previously reported outcomes for children with sensori-neural (SN) type hearing loss using cochlear implants.Two children, identified with cochlear nerve deficiency pre-operatively, received no useful auditory percepts from their cochlear implant and discontinued device use. The remaining children demonstrated speech perception and language outcomes comparable to those observed for SN hearing loss peers using cochlear implants.This paper highlights a number of considerations for clinicians to be aware of and the importance of careful counseling pre-operatively regarding the potential for less-than-optimal outcomes, particularly for those children identified with cochlear nerve deficiency.

Kite in Flight

Adolescent girls are subjected to strong sociocultural forces as they shape and discover their sense of identity. We propose the therapeutic concerns of young women may be relieved by increased empowerment achieved through identity development and the strengthening of interpersonal boundaries. Feminist family therapy and Bowen family systems theory are integrated to offer a clinical approach toward greater empowerment through increased differentiation in the context of dating relationships. This approach applies a developmental perspective to the unique challenges faced by young women in Western society. The metaphor of a “Kite in Flight” is offered to help therapists conceptualize the elements of the model and goals for treatment. Case examples and interventions are provided, as well as the model application for Specific clinical considerations. doi:10.1300/J086vl9n04_01

The unique management of refractory advanced systolic heart failure

Advanced systolic heart failure refractory to ambulatory pharmacotherapy continues to be a clinical dilemma with increasing incidence and prevalence. By establishing the presence of signs and symptoms, clinicians could better evaluate hemodynamic perturbations, therefore targeting them through the use of intravenous diuretics, intravenous vasodilators, and intravenous inotropic therapy. This review focuses on the unique features that characterize advanced heart failure, and discusses the special clinical considerations in managing this morbid entity. (Heart Lung ® 1997;26:280-8)

Clinical considerations in the treatment of dens invaginatus

Abstract Dens invaginatus is a developmental malformation of teeth which results from abnormal morphodiflerentiation. Such a condition is often associated with pulpal and periapical pathosis, which require treatment. Due to their abnormal anatomical configurations, invaginated teeth present technical difficulties in their clinical management. The treatment modalities available to the clinician include: endodontic therapy, endodontic surgery, combined treatment, or extraction. The treatment of choice should be selected according to specific clinical considerations. This article discusses these clinical considerations and establishes criteria for case selection and treatment planning.

Orthodontic tooth movement response in Ehlers-Danlos syndrome: report of case

The clinical manifestations of Ehlers-Danlos syndrome have been discussed. These include oral symptoms and problems with the integument, joints, and vasculature. An outline of the variations in the types of Ehlers-Danlos syndrome was given. The expected tissue response to tooth movement was discussed. Finally, a report of the orthodontic treatment of a patient with Ehlers-Danlos syndrome with its special clinical considerations was provided.

Some considerations before using the aerial ambulance

The use of aerial ambulances for moving patients to hospitals requires some special clinical considerations. Various altitudes produce clinical problems. The Federal Aviation Agency has requirements for equipment. Factors to be considered in selecting the mode of transporting an emergency patient include patient's condition, weather, and landing location at destination. There are limitations as well as the advantages in using aerial ambulances.