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By S. Koraz. Baldwin-Wallace College.

Some physicians are willing to spend large amounts of time on the phone with patients buy prednisolone 10mg amex, whereas others rarely speak to patients outside of the exam room purchase prednisolone 5 mg free shipping, opting instead to have most calls from patients returned by an office staff member. Whatever the protocol of the office, the physician is responsible for care delivered, regardless of whether it is delivered directly or through a member of the staff. In addition, the ability of a specific patient or caregiver to use telephone- based communication should be considered, as should the appropriate- ness of using the telephone to communicate sensitive clinical information. Telephone: Patient Expectation The growing frustration among patients regarding an inability to speak to their doctor on the phone only partially results from increased demands on the physician’s time and a lack of reimbursement for tele- phone-based care. A substantial portion of this frustration stems from inadequate expectation management. It is guaranteed that patients or caregivers will want to telephone their doctor at some point, likely when a need arises and stress levels may be high. It is also guaranteed that doctors who spend entire days on the phone providing unreimbursed care to patients will quickly find their practices in financial trouble. The gap between patient expectation and practical limitations must be filled with disclosure and expectation management, preferably done ahead of the telephone ring, and in writing. Physicians are well advised to develop written protocols associated with the appropriate use of the telephone in their practice. These pro- tocols should be used to set patient expectations and to set office procedures that should be followed by all—physician and office staff alike. The procedures should be reviewed annually, and patients should be reminded of these protocols on a regular basis. The physician should consider posting protocols in areas where office staff has frequent access, as well as in employee handbooks. It is also advisable for the physician to be notified when and if a patient or caregiver has shown anger or frustration related to telephone-based communication. These concerns should be addressed by the physician and the practical and clinical issues associated with the office protocol should be reviewed directly with the patient. Telephone: Standards of Care The standards of care as they relate to telephone-based patient– physician communication do not vary significantly with specialty and 78 Fotsch practice setting. In all cases, the physician is held responsible for the adequacy and reasonableness of the communication. Most impor- tantly, the physician must decide whether a face-to-face evaluation is necessary. The patient may be satisfied with a telephone consultation at the time, but if the outcome is adverse, the physician will need to be able to justify telephone-based care and not having insisted on a more direct intervention. Telephone: Security and Privacy Physicians are responsible for the appropriate security and privacy of their patients’ records and information. Because the telephone has been in practical use by patients and physicians for decades, there are stan- dard security and privacy technologies in place that provide safeguards. However, these safeguards are easily undermined by poor or unused protocols for the office. Physicians or staff can defeat standard safe- guards, for example, by speaking on the phone with patients in a manner that allows unauthorized third parties to overhear the conversation. This potential for security breach, although rather obvious and theoretically simple to avoid, can become a practical challenge in the environment of a busy office setting. Well-defined procedures for telephone-based communication, including specific provisions to ensure patient privacy, will diminish potential risk. The expansion of telephone-based communication to cell phones further expands the potential for security and privacy breach. The best approaches to diminishing these risks are to either avoid the use of cell phones for communication of patient information, or to consult the cell phone vendor about possible security breaches on the cell network. The potential risk from the use of cell phones can then be weighed against the practical need to use these networks. It is important to remember that the security concerns extend to the use of cell phones by patients as well as providers. If appropriate, expectation setting should be done with patients relating to the use of cell phones, and appropriate dis- claimers should be made. Telephone: Practical/Technical/Financial Considerations The practical and technical issues related to telephone-based care pale in comparison to the financial considerations.

For example purchase 20mg prednisolone overnight delivery, testos- Biological effect terone buy prednisolone 10 mg amex, the male sex steroid, promotes normal sperm forma- tion in the testes, stimulates growth of the accessory sex Simple and complex feedback loops in the glands, such as the prostate and seminal vesicles, and pro- FIGURE 31. B, A complex, multilevel feedback loop: the hy- istics, such as beard growth and deepening of the voice. Solid lines indicate stim- Multiplicity of regulation is also common in the en- ulatory effects; dashed lines indicate inhibitory, negative-feed- docrine system. For example, liver glycogen metabolism may be regulated hormone-effector pairs relative to normal feedback rela- or influenced by several different hormones, including in- tionships. For example, in the case of anterior pituitary hor- sulin, glucagon, epinephrine, thyroid hormones, and adre- mones, measuring both the trophic hormone and the target nal glucocorticoids. Furthermore, most dynamic tests of en- docrine function performed clinically are based on our The secretion of any particular hormone is either stimu- knowledge of these feedback relationships. Dynamic tests lated or inhibited by a defined set of chemical substances in 570 PART IX ENDOCRINE PHYSIOLOGY CLINICAL FOCUS BOX 31. In one test, a ter 32, the hormone plays a role in regulating bone growth bolus of arginine, which is known to stimulate growth hor- and energy metabolism in skeletal muscle and adipose tis- mone secretion, is given and a blood sample is taken a sue. A deficiency in growth hormone production during short time later for the measurement of growth hormone adolescence results in dwarfism and overproduction re- concentrations. Measurements of circulating growth poglycemia is a known stimulus for growth hormone se- hormone levels are, therefore, desirable in children whose cretion. Mild hypoglycemia is induced by an injection of in- growth rate is not appropriate for their age. Like many other peptide hormones, growth hormone Regardless of which test is used, by perturbing the system secretion occurs in a pulsatile fashion. The most consistent in a well-prescribed fashion, the endocrinologist is able to pulse occurs just after the onset of deep sleep and lasts for gain important information about growth hormone secre- about 1 hour. There are usually 4 to 6 irregularly timed tion that would not be possible if a random blood sample pulses throughout the remainder of the day. In addition to these in the synthesis of these hormones are discussed in detail in specific secretagogues, many hormones are secreted in a later chapters. For example, they may be pulsatile, episodic spikes in secretion lasting just a few minutes, or they may follow a Many Hormones Are Polypeptides daily, monthly, or seasonal change in overall pattern. Pul- Hormones in the polypeptide group are quite diverse in satile secretion may occur in addition to other longer se- size and complexity. A dynamic test of en- proximately 34 kDa, and is a glycoprotein comprised of docrine function in which hormone secretion is specifically 16% carbohydrate by weight. Hormones can be grouped into these families as a result of considerable homology with regard to amino acid THE NATURE OF HORMONES sequence and structure. Presumably, the similarity of struc- Hormones can be categorized by a number of criteria. Grouping them by chemical structure is convenient, since in many cases, hormones with similar structures also use TABLE 31. In addition, hormones with similar chemical structures are Insulin Family usually produced by tissues with similar embryonic ori- Insulin gins. Hormones can generally be classed as one of three Insulin-like growth factor I chemical types. Insulin-like growth factor II Relaxin Glycoprotein Family The Simplest Hormones, in Terms of Structure, Luteinizing hormone (LH) Consist of One or Two Modified Amino Acids Follicle-stimulating hormone (FSH) Thyroid-stimulating hormone (TSH) Hormones derived from one or two amino acids are small Human chorionic gonadotropin (hCG) in size and often hydrophilic. These hormones are formed Growth Hormone Family by conversion from a commonly occurring amino acid; ep- Growth hormone (GH) inephrine and thyroxine, for example, are derived from ty- Prolactin (PRL) rosine. Each of these hormones is synthesized by a particu- Human placental lactogen (hPL) lar sequence of enzymes that are primarily localized in the Secretin Family endocrine gland involved in its production. The synthesis Secretin Vasoactive intestinal peptide (VIP) of amino acid-derived hormones can, therefore, be influ- Glucagon enced in a relatively specific fashion by a variety of envi- Gastric inhibitory peptide (GIP) ronmental or pharmacological agents. The steps involved CHAPTER 31 Endocrine Control Mechanisms 571 ture in these families resulted from the evolution of a single Androgens, such as testosterone, are primarily produced ancestral hormone into each of the separate and distinct in the testes, but physiologically significant amounts can be hormones. In many cases, there is also considerable homol- synthesized by the adrenal cortex as well.

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In cases where juries hold defendants liable for actual negligence buy prednisolone 10mg cheap, damage calculations are often uninformed and unguided generic 10 mg prednisolone with visa, even when judges confront posttrial motions for remittitur. The fact that caps on damages have thus far proved the only way to stabilize malpractice insurance premiums makes matters worse. Statutes may place an absolute cap on total damages (as in Colorado); limit only damages for noneconomic injury such as physical or emotional pain and suffering (as in Ohio); or limit punitive damages (as in North Carolina). As of 2002, 21 states had placed caps ranging from $200,000 to $1 million on noneconomic damages. Noneconomic damage caps have been estimated to reduce the mean payout per claim by up to 40%; the effect on insurance premiums is smaller (9). In particular, flat caps on noneco- nomic or total damages may be unfair to young or severely injured plaintiffs but fail to constrain overly generous compensation for minor injuries because this compensation remains below the cap (25). The case of neonatal injury described in the preceding section illus- trates three additional limitations of a cap on noneconomic damages as a solution to the current malpractice crisis. First, economic damages can still be extremely high when prolonged medical care is required, and the money to pay them has to come from somewhere. Second, calculating those economic damages requires juries to evaluate com- plex and contentious expert testimony involving medical economics as well as clinical prognosis. Third, pain and suffering awards are increasing partly because long-term survival after serious injury has become more common. The implicit message in limiting damages for future suffering in these cases is that the patient should feel lucky to be alive. This approach is typical of “wrongful birth” claims, where physicians who do not cause but fail to diagnose congenital disease may be liable for the costs of caring for the child but not for its pain or suffering. A similar compromise also may be socially defensible in certain malpractice cases to preserve access to medical care that pro- longs life; however, its fairness should be debated openly. This example highlights the absence of a rational connection between what society invests in health care and what society expects to receive when health care goes awry. In part, this is an inevitable result of fund- ing the costs of malpractice through third-party liability insurance rather than first-party health and disability insurance. Insured health care pro- viders prefer that their carriers pay claims only as a last resort, and patient claimants see no direct link between the generosity of settle- 260 Sage ments and the cost of health care. The influence of medical cost-contain- ment on the malpractice system is similarly unplanned. Tort reformers cite a 10-fold increase in average annual liability premiums per long- term care bed over the past decade as evidence of a litigation explosion. Rising liability costs for today’s skilled nursing facilities are more accurately explained by two health policy developments. First, changes in Medicare reimbursement for acute care hospitals channeled younger but sicker patients requiring real medical treatment into what previously had been merely residential and custodial institutions. Second, public policy decisions at the state and federal level conferred enforceable legal rights on long-term care patients similar to those already in place for hospital patients. Finally, the adversarial system that governs malpractice disputes often precludes giving plaintiffs satisfaction in forms other than money. In some instances, patients and their families are more inter- ested in having health care providers acknowledge their mistakes and take steps to assure that similar tragedies never happen again (26–28). However, money tends to be the only medium of exchange that mal- practice lawyers on either side understand, both for themselves and for their clients. Unlike mediation and other more open-ended approaches to dispute resolution, litigation offers few opportunities for interest- based, as opposed to positional, bargaining (29,30). Liability Insurance POOLING AMONG SPECIALTIES A malpractice crisis is like an earthquake: it strikes unevenly. Even under the most extreme market conditions, only some physicians find liability insurance unavailable or unaffordable. Liability insurance typi- cally is priced according to the frequency and severity of paid claims associated with a physician’s specialty and with the community in which he or she practices (i.

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Other Metabolic Bone Disorders Introduction a A number of congenital and familial disorders can be as- sociated with increased bone density (osteosclerosis) and b abnormal bone modeling best 10mg prednisolone. These include osteopetrosis order prednisolone 10 mg amex, pyknodysostosis, metaphyseal dysplasia (Pyle’s disease), craniometaphyseal dysplasia, frontometaphyseal dyspla- Fig. Bone sia, osteodysplasty (Melnick-Needles syndrome), pro- densitometry: dual gressive diaphysial dysplasia (Camurati-Engelmann dis- energy X-ray ab- ease), hereditary multiple diaphysial sclerosis (Ribbing’s sorptiometry (DXA). The only condition to be considered in this chapter reference range for is osteopetrosis. Osteoclasts in affected bone are usually devoid of the ruffled borders by which osteoclasts adhere to the bone surface and through which their resorptive activity is expressed. In the presence of doses: 1-6 Sv) and is most often performed by radiogra- continued bone formation, there is generalised osteoscle- phers. The equipment would therefore be appropriately rosis and abnormalities of metaphyseal modeling (Fig. There have been reports of reversal of the osteoscle- spine is currently the “gold standard” for the diagnosis rosis following successful bone-marrow transplantation. Images must be scrutinized for in 1904, and is sometimes referred to as marble bone dis- abnormalities that can result in errors in DXA measure- ease, osteosclerosis fragilis generalisata, or osteopetrosis ments (osteophytes in lumbar spine) and for identifying generalisata. There are two main clinical forms: vertebral fractures and other pathologies on DXA im- 1. The latter is now feasible through improve- ifestations and an autosomal recessive transmission ment in spatial resolution of DXA images (0. Benign osteopetrosis with late manifestations inherit- faster fan beam scanning and, on some scanners, a “C”, ed by autosomal dominant transmission arm so that repositioning in the lateral position is not re- There is also a more rare autosomal recessive (inter- quired; computer-assisted diagnosis is also possible [85, mediate) form that presents during childhood, with the 86]. Bone densitometry is relevant to research and phar- signs and symptoms of the lethal form, but the outcome maceutical trials, and thus provides scientific opportuni- on life expectancy is not known. There are some limi- ly described as osteopetrosis with renal tubular acidosis tations of DXA (size dependency) that do not apply to and cerebral calcification is now recognized as an inborn QCT, which can be applied to axial and peripheral sites. The size dependency of DXA is a particular limitation of Neuronal storage disease with malignant osteopetrosis its use in growing children, in whom QCT has advan- has been described, as has the rare lethal, transient infan- tages. There is increasing interest in examining how tile, and post-infectious form of the disorder. MR imag- ing may assist in monitoring those with severe disease who undergo marrow transplantation, since success will be indicated by expansion of the marrow cavity. There is an intermediate recessive form of the disease which is milder than that seen in infants and distinct from the less severe autosomal dominant disease. Affected in- dividuals suffer pathological fracture and anemia and are of short stature, with hepatomegaly. The radiographic features include diffuse osteosclerosis with involvement of the skull base and facial bones, abnormal bone mod- eling and a “bone within a bone” appearance. Benign, Autosomal Dominant Type This type of osteopetrosis (Albers-Schonberg disease) is often asymptomatic, and the diagnosis may come to light either incidentally or through the occurrence of a patho- logical fracture. Other presentations include anemia and facial palsy or deafness from cranial nerve compression. Problems may occur after tooth extraction, and there is an b increased incidence of osteomyelitis, particularly of the mandible. Radiographic features are similar to those of the autosomal recessive form of the disease, but less se- vere. The bones are diffusely sclerotic, with thickened cortices and defective modeling. There may be alternat- ing sclerotic and radiolucent bands at the ends of diaphy- ses, a “bone within a bone” appearance, and the vertebral Fig. In type 1, fractures are unusual, show very dense bones, with loss of the in contrast to type II in which fractures are common. Affected children have episodes of fever, In affected individuals, there is obliteration of the marrow bone pain, and progressive enlargement of the skull, with cavity leading to anemia, thrombocytopenia, and recur- bowing of the long bones and associated pathological rent infection. Radiographically, the features resem- hydrocephalus, and cranial nerve involvement resulting ble Paget’s disease of bone, and it is sometimes referred in blindness and deafness. Radiographically, all the bones to as “juvenile” Paget’s disease, osteitis deformans in are dense, with lack of corticomedullary differentiation. There is an increased Modeling of affected bones is abnormal, with expansion rate of bone turnover, with woven bone failing to mature of the metaphyseal region and undertubulation of bone.

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