By S. Marlo. University of Hawai`i.

Computed tomography revealed that the changes were all due to degenerative disease buy 100 mg extra super levitra fast delivery erectile dysfunction treatment psychological causes, however order 100 mg extra super levitra fast delivery erectile dysfunction 3 seconds, corroborating the predictive value of the PSA and Gleason data, and illustrating the value of these numbers in analyzing images (Fig. His Gleason score is 9 and his PSA is 21, which suggest that he is likely to have disseminated disease, and would probably have recurrent disease after prostatectomy. He continued to request radical surgery, stating that he had heard that surgery was his only chance for cure. Magnetic reso- nance imaging revealed gross tumor invasion of the seminal vesicles (the low-intensity regions replacing the bright lumina of the seminal vesicles), which both increased the likelihood of disseminated disease to the level at which surgery was felt to be inappropriate, precluded effective treat- ment by brachytherapy, and provided guidance for designing conformal external-beam radiotherapy (Fig. Imaging Protocols Based on the Evidence Transrectal Ultrasound Diagnostic images of the prostate should be recorded in planes both sagit- tal and transverse to the apex-to-base axis of the gland. Transverse images should be obtained at approximately 5-mm intervals; for large glands it may be necessary to angle the probe left and right to image the two sides of the gland independently. With the probe imaging in the sagittal plane, the midsagittal view should be accompanied by views produced with the probe angled to each side. Active foci originally interpreted as metastases despite the unlikelihood given the Gleason and PSA. Chapter 7 Imaging in the Evaluation of Patients with Prostate Cancer 135 Figure 7. A 59 year old man with recently diagnosed prostate cancer, Gleason score 9, and PSA 21. T2–weighted MRI reveals low-intensity tumor invad- ing the seminal vesicle lumen, primarily on the right (arrows). Although color Doppler and contrast-enhanced imaging have been described, they are not universally applied. Computed Tomography Evaluation of prostate cancer patients by CT involves a limited focus, which is to determine whether metastases are seen in lymph nodes or bones. Most patients have simultaneous skeletal scintigraphy, so that lim- iting the range of CT to the abdomen and pelvis—or even to the pelvis alone—is not likely to reduce sensitivity significantly. Since node size is critical, a slice thickness that does not cause partial- volume averaging of structures as small as 1cm in diameter is crucial; slices no thicker than 5mm are ideal. Magnetic Resonance Imaging Staging prostate cancer by MRI involves evaluation of the extent of any local extracapsular extent of tumor and detection of lymphatic disease that may have enlarged pelvic lymph nodes. The standard examination is limited to the prostate and periprostatic regions and pelvis; abdominal imaging is usually not routine. A series of T1-weighted spin-echo transverse images is performed, no thicker than 5mm with the gap no greater than 1mm. The TR should be several hundred milliseconds and the TE should be as short as the scanner permits. Newhouse Focused imaging of the prostate should be performed with an intrarectal coil, coupled with a body coil or wraparound pelvic coil. Imaging includes transverse T1-weighted spin-echo and T2-weighted fast spin-echo images of the prostate and seminal vesicles with T2-weighted sagittal and coronal series. The refer- ence axis for these images may be either the long axis of the entire body or the long axis of the prostate gland. Radionuclide Bone Scan The protocol for scanning patients with prostate cancer is no different from that appropriate for scanning adults for other malignancies that metasta- size to the skeleton; 20mCi of technetium 99m (Tc-99m) ethylene hydrox- ydiphosphonate (HDP) or Tc-99m methylene diphosphonate (MDP) are administered with scanning 2/1 to 3 hours after injection. The patient 2 should drink sufficient fluid that he can void immediately before scanning, since the isotope accumulates in the bladder and may obscure pelvic metastases. If planar scanning is performed, both anterior and posterior views should be obtained. If single photon emission computed tomography (SPECT) scanning is per- formed, a dual- or triple-head camera can be used; a 128 ¥ 128 matrix with 30 seconds per frame and 360-degree acquisition should provide good images. Positron Emission Tomography Scan Although compounds currently under investigation may prove to be more effective than 18F-FDG, this isotope continues to be the most frequently employed one for oncologic imaging; 10mCi is an appropriate dose. Patients should fast for 4 to 6 hours prior to the procedure so that blood glucose does not exceed 160mg/dL; the level should be checked before administering the isotope intravenously. Sixty minutes should elapse before beginning the scan, during which time the patient must continue to fast. Future Research • Can any imaging technique—especially metabolism-dependent modal- ities like magnetic resonance spectroscopy (MRS) and PET—be used to determine which cases of prostate cancer safely may be managed by watchful waiting? Chapter 7 Imaging in the Evaluation of Patients with Prostate Cancer 137 References 1. Vijverberg PL, Giessen MC, Kurth KH, Dabhoiwala NF, de Reijke TM, van den Tweel JG. Does neuroimaging increase the diagnostic accuracy of Alzheimer disease in the clinical setting? Can neuroimaging identify individuals at elevated risk for Alzheimer disease and predict its future development? Can neuroimaging measure disease progression and therapeutic efficacy in Alzheimer disease? Key Points By differentiating potentially treatable causes, structural imaging with either computed tomography (CT) or magnetic resonance imaging (MRI) influences patient management during the initial evaluation of dementia (strong evidence).

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New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures discount extra super levitra 100 mg line erectile dysfunction pills images. Initial outcome and effi- cacy of "kyphoplasty" in the treatment of painful osteoporotic vertebral compression fractures generic extra super levitra 100 mg fast delivery erectile dysfunction treatment pumps. Early clinical and radiographic results of kyphoplasty for the treatment of osteopenic vertebral compres- sion fractures. Retrospective analysis of the outcomes of balloon kyphoplasty to treat vertebral body compression fracture (VCF) refractory to medical management. Zoarski Prior to the development of imaged-guided percutaneous spine biopsy techniques, an open biopsy procedure was required for definitive di- agnosis. First, under direct visualization multiple, and larger, tissue samples can be obtained and made available for frozen histopathological analysis. Sec- ond, the open biopsy can be performed as part of a surgical decom- pression and/or stabilization procedure of the spine. Siffert and Arkin utilized a posterolateral approach for spine biopsy using radio- graphic guidance. The percutaneous image-guided procedure is faster and more cost-effective and has an overall lower risk of complications. The decision to perform a spine biopsy procedure is made after close communication between the ra- diologist and the referring clinician. Both individuals must be convinced that the benefit to be gained from the biopsy results firmly outweighs the risks of the procedure. To this end, as a prerequisite, there must be a thorough medical history and physical examination combined with a complete review of all prior imaging and laboratory examinations. This consultation will avoid unnecessary spine biopsies (when they are not indicated or when a more accessible bone biopsy site, such as the iliac bone, is available), ensure patient safety, and identify the optimal loca- tion and level for performing the biopsy procedure. Spine biopsy is often performed to evaluate destructive or space- occupying lesions within the spinal axis (Table 5. Abnormal foci of marrow replacement within the vertebral column that are detected 69 70 Chapter 5 Image-Guided Percutaneous Spine Biopsy TABLE 5. Suspected secondary spine tumor, with a history of two or more preex- isting primary tumors 3. Suspected inflammatory condition that involves the spine with noninvasive imaging modalities, such as computed tomography (CT) or magnetic resonance imaging (MRI), are also often referred for spine biopsy. In every instance, the decision to proceed with a biopsy procedure is based upon a thorough analysis of risks and benefits. The overall benefit of the information gained by the procedure should al- ways favor its performance. The results of the biopsy will affect the subsequent clinical management of the patient and influence treatment decisions in such areas as surgery, chemotherapy, radiation therapy, and antibiotic therapy. Yet even this condition, when properly anticipated and man- aged, can be corrected long enough to permit a surgeon to perform the procedure. When a vascular tumor such as a renal metastasis is sus- pected, a catheter angiogram should be considered in the diagnostic workup. These vascular lesions, however, can be carefully sampled with smaller gauge core needle biopsy systems and with fine-needle aspiration techniques (Figure 5. Informed consent must be obtained prior to the procedure after the patient has received an explanation of the benefits and risks of image- guided percutaneous spine biopsy. The procedure offers the benefit of supplying diagnostic information that will guide subsequent treatment decisions. The general risks of percutaneous spine biopsy include bleeding at or deep to the puncture site manifested as active hemorrhage or hematoma formation (Table 5. Infection is another potential com- plication associated with spine biopsy, hence the requirement for strict aseptic technique when the procedure is performed. The spread of dis- ease by the biopsy procedure, an extremely rare complication that has been described,7 is related to tumor implantation or spread of infec- tion along the biopsy tract. Site-specific biopsy complications that have been reported are related to the spine level (cervical, thoracic, or lumbar spine) that was sampled and the prox- imity to critical structures. Pneumothorax can occur not only during thoracic spine biopsy but also during the attempted biopsy of thora- columbar or cervicothoracic lesions. Neural injury, particularly to the spinal cord, is a devastating complication that has been reported. Nev- ertheless, the incidence of reported complications in percutaneous skeletal biopsy is low, estimated at less than 0. Axial CT image shows a lytic lesion (arrows) that is centered pri- marily within the posterior elements of the thoracic vertebra. Since the patient had a history of kidney resection, this lesion was sampled by fine-needle as- piration with a 22-gauge spinal needle. Patient Preparation Percutaneous spine biopsy can be performed either on an inpatient or outpatient basis. The patient must not eat or drink for a minimum of 8 hours prior to the procedure.

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THIRD LINE OF ARGUMENT: DEWEY’S BROAD VIEW OF MEANS AND ENDS DELIBERATION The work of John Dewey already provides many insights into alternate relations of means and ends order extra super levitra 100 mg without prescription impotence use it or lose it. His portrayal cheap extra super levitra 100mg mastercard erectile dysfunction treatment news, in contrast to economic rationality, better accommo- dates the realities of clinical care. His concept of means and ends allows a broader representation of and response to people’s troubles. I will draw heavily on his work in trying to construct a comprehensive theory which does justice to the complexity of real care and thus promotes effective function, while denying that "effective" and "efficient" are the same thing. A small group of pragmatically oriented medical ethicists including Micah Hester, John Moreno and Griffin Trotter have described the applicability of Dewey’s idea of intelligent inquiry to the assessment and resolution of clinical problems. Certain general themes of his work on which his more focused discussion of means and ends depends are set forth in this chapter. His contention that values arise in nature, not from divine edict or as a consequence of reason turned in on itself. His refusal to organize values in a hierarchy which privileges any one of them as foundational. His idea that values interact despite and because of being qualitatively different, and therefore involve mutual support. His contention that rationality is much more than deduction, calculation and the application of rules. The specifics of a Deweyan theory of means and ends, as best I can synthesize it from his various works, occupy Chapter Four. Dewey delineates a view of the situations which become problematic and require inquiry and the application of intel- ligence/judgment, as opposed to those more generic and less problematic encounters adequately handled through habit (or recipe). He then points out that resolution of a genuinely problematic situation involves creating unity and determinacy out of true indeterminancy. It follows that actual engagement in the process of inquiry and action is often necessary before a satisfactory outcome can be known. Therefore, values are partly created and are at least reinterpreted through engagement, not BROAD CONSIDERATIONS IN THE RELATION 5 simply given at the outset. The operational ends-in-view which are part of a developing plan, drawing us on in the process of diagnosis and treatment, are actually in part means, are malleable and are often to be distinguished from final ends or outcomes. Some final ends cannot be aimed at directly, and are achieved only as byproducts of other activity. He indicates that the value of an endeavor is spread out over its course and not only realized at the end. In assessing the prospects of any action or in evaluating it in retrospect, Dewey would have us look impartially at all of the consequences, not arbitrarily considering only specified ones. Among the consequences of action frequently ignored are effects on the character and relationships of the agents themselves. These "feedback" effects on character are salient to debates about abortion, euthanasia, assisted suicide, surrogate motherhood and live donor organ transplants today. And they are particularly important to the alteration of character which may occur during medical education and training. However, after reviewing Dewey’s work, although it has been my primary inspi- ration, I have found gaps and deficiencies. Some of these result from the fact that no complete or final theory of means and ends reasoning was ever articulated by him systematically in one place. Chapter Four ends with a presentation of problems in Dewey’s theory and areas needing further work. He defines "objective" in a new and complex way, but then seems to trade off the traditional connotations of the word. The great insight of Dewey, I claim, is that he showed not only the indispensability of judgment, but how better to employ it. In the end, Dewey lays out the range of deliberation we need without giving us a blueprint for reaching accord. Given the nature of causal reasoning in medicine outlined in Chapter One, and the non- classical, imaginative character of categories conceptualizing illness presented in Chapter Two, the arena for means and ends reasoning in medicine is best dealt with in the manner largely put forth by Dewey. FOURTH LINE OF ARGUMENT: THE LIMITATIONS OF EXPECTED UTILITY THEORY AND OTHER VARIANTS OF FORMAL MEANS/ENDS REASONING Chapter Five presents the axioms of expected utility and criticizes both their assump- tions and the claims made for their usefulness in fields like medical decision making. Tied as it is to utilitarianism, rational choice theory and the many variations, subtleties and elaborations of it, has tended to dominate thinking about means and ends in this last century. But this theory or group of theories in application suffers from three major problems. First, there is an ambiguity about whether the theory 6 OVERVIEW is a description of how people (and possibly other organisms) act or a prescription for how they should act in pursuing ends. Secondly, there are presumptions about the nature of ends, particularly "utility," "self-interest," and "winning" which need to be questioned more sharply. Thirdly, the theory fails to capture usefully many of the messy considerations involved in approaching real life problems like those in health care. While proponents of rational choice theory seem to believe that with refinements this sort of reasoning can best do justice to all of our practical needs, others believe that even a maximally refined rational choice theory is incapable in principle of addressing many moral and practical problems.

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While the object of going to medical school is ultimately to train as a doctor proven extra super levitra 100mg erectile dysfunction treatment injection therapy, most students take full advantage of the chance to pursue their hobbies or try new ones purchase extra super levitra 100 mg otc impotence ring, meet new friends, do new things, and generally do all the "growing up and finding yourself" things that students are supposed to do. Each year a few potentially good doctors forget the real reason for their being at medical school, fail their exams, and have to leave their friends and all that social life behind, not to mention having to find a new career. It is an unpleasant feeling seeing a good friend and colleague being asked to leave, so a great effort is made to encourage students to find the right balance so that medical schools train doctors who are both skilled at their job and also interesting and talented in other things; something they will cherish in later life. REMEMBER • Being a medical student, like any university student, is a complete change from being at school—you will have endless opportunities available to you but you will need to realise them for yourself. Medical school: the later years As the medical student progresses through into their third year and beyond,increasing amounts of time are spent in the various clinical teaching settings and less in the classroom. The white coat is donned,and the shiny new stethoscope is placed ostentatiously in the pocket,usually alongside numerous pocket-sized textbooks,pens,notepads,and sweet wrappers. Most students by now have some experience of listening and talking to patients and of the hospital wards. The sight of the ill patient in a bed does not come as the awful surprise it did to generations of medical students who spent their first two years cocooned in the medical school. The style of teaching changes emphasis, becoming more of an apprenticeship but retaining the academic backup of lectures, seminars, and particularly tutorials. More of the course is taught by clinical staff: consultants, general practitioners, and junior doctors, often in small groups at the bedside, on dedicated teaching rounds or in tutorials, in the operating theatre, in the outpatient clinic, or general practice surgery. Teaching also takes place at clinical meetings or Grand Rounds and the firm’s regular radiology meeting (when the week’s x ray pictures and scans are reviewed and discussed with a radiologist) and histopathology meeting (when the results of tissue biopsies and postmortem examinations are discussed). Some students find the change in the style of teaching frustrating as much time seems to be wasted hanging around waiting for teaching that never seems to happen. The registrar or consultant who is due to be teaching is often delayed in theatre with a difficult case or still has a queue of patients waiting in the outpatient clinic. Many of these doctors are fitting in their teaching commitments around an already punishing clinical workload, and so often a combination of better organisation by the schools and some initiative in self directed learning from the students is all that is needed to extract the value from such a valuable educational source. It may well be that with so much to learn, insufficient attention is given to the formation of attitudes. It is said that medical students have more appropriate attitudes to both patients and to others with whom they share care when they enter medical school than when they qualify as doctors. In the Bristol report, 72 MEDICAL SCHOOL: THE LATER YEARS Professor Sir Ian Kennedy expressed the view that "the education and training of all healthcare professionals should be imbued with the idea of partnership … (with) … the patient … whereby the patient and the professional meet as equals". As far as mutual respect in teamwork is concerned, opportunities for learning together (multdisciplinary learning), both in the undergraduate and postgraduate years, are not fully exploited. A patient who had complained about the attitude of his surgeon was interviewed by another surgeon as part of a formal investigation into the complaint. The patient was pleased to find that the investigating surgeon was a complete contrast— "conversational, sympathetic, and informative; wide ranging and encouraged questions (with) a very human approach which inspired trust. Arrogance is something that students need to lose early in their training, if they have the misfortune to be afflicted by it; patients can do without it. First patients Stepping tentatively on to the ward for the first time, resplendent in my new white coat, I felt that the long awaited moment had arrived. We had been told that this process, which has been handed down from doctor to medical student for countless generations, enables the doctor to make 95% of the 73 LEARNING MEDICINE diagnosis (75% from the history and a further 20% from the examination— the last 5% comes from further investigations). This is why clerking has and will continue to be such a powerful tool in the hands of the clinician, though not necessarily in the hands of a junior clinical student. This involves an overall framework of "presenting complaint", "history of presenting complaint", "past medical history", "family history", "drug history", "social history", and "any other information". Next comes the examination, something which opens up a veritable minefield for the inexperienced. When you perform a general examination every body system has to be inspected, palpated (lightly and deeply), percussed (examined by tapping with the fingers and listening to the pitch of the sound produced), and auscultated (listened to with a stethoscope). This is the theory but inevitably, either through incompetence or sheer bad luck, it is almost impossible to perform a perfect examination on every patient— either some of the pulses are not felt or the enlarged liver does not seem that enlarged; whatever the sign of disease that causes such frustration by escaping the student, you can guarantee that the senior house officer will come along and find it within seconds! The introduction to basic surgical techniques was one of the better activities organised for us during the junior clinical course. Armed with scalpels, sutures, forceps, and pigs trotters the surgeons demonstrated the basic principles of stitching wounds and then let us loose on our own practice limbs. This was an excellent afternoon for the students, not least because it gave us the opportunity to do something incredibly practical that most of us had never done before. The afternoon concluded with teaching us how to draw up and mix drugs with a syringe and how to inject them subcutaneously and intramuscularly (the intramuscular route was cleverly improvised with an orange). I felt ill equipped and slightly obtrusive as I clumsily searched, questioned, and of course palpated and percussed my patient. The sense of relief as I parted the curtains and left the cubicle, history complete, was overwhelming. First ward round—how I regretted not learning my anatomy better as in the words of our senior registrar I displayed "chasms of ignorance", only managing to redeem myself by the narrowest of margins.

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