By J. Lares. Barton College. 2018.
However buy 10mg aciphex with mastercard, it is susceptible to motion artifact and requires extremely cooperative subjects cheap 20 mg aciphex fast delivery, and therefore is more successful in mildly injured than moderately or severely injured patients. There have only been a few small studies (insuf- ﬁcient evidence) attempting to correlate fMRI with outcomes (96,97). Measures of Atrophy Quantiﬁcation of the atrophy of various brain structures/regions (such as the corpus callosum, hippocampus, and ventricles) has also been studied with respect to predicting outcome, but it is time-consuming and often requires experienced raters and specialized software. Blatter and col- leagues (98) (moderate evidence) studied 123 patients with moderate to severe TBI compared to 198 healthy volunteers using MRI volumetric analysis of total brain volume, total ventricular volume, and subarachnoid cerebrospinal ﬂuid (CSF) volume. The TBI patients, particularly if studied later, had the greatest decrease in brain volume, suggesting that progres- sive brain atrophy in TBI patients occurs at a rate greater than with normal aging. However, because atrophy takes time to develop, it cannot be used acutely as an early predictor of outcome. Blatter and colleagues also showed that correlations with cognitive outcomes did not become signiﬁ- cant until after 70 days. One study of late CT scans (moderate evidence) of Vietnam War veterans with penetrating or closed head injuries found that total brain volume loss and enlargement of the third ventricle were signif- icantly related to cognitive abnormalities and return to work (99). Another study (moderate evidence) showed that frontotemporal atrophy on late MRI was predictive of 1-year outcome (measured by extended GOS or DOS) (6). In an MRI study (moderate evidence) of late MRI ﬁndings and neuropsychological outcome, hippocampal atrophy was correlated with verbal memory function, whereas temporal horn enlargement was corre- lated with intellectual outcome (100). Combinations of Clinical and Imaging Findings Numerous studies have attempted to analyze combinations of clinical and imaging ﬁndings to determine the best approach to predicting outcome. There is agree- ment that there is no one single variable that can predict outcome after TBI. In fact, there is often disagreement between studies regarding the predic- tive value of certain clinical variables, including GCS. Ideally, a combined clinical and imaging approach to outcome prediction would likely be most accurate. Ratanalert and colleagues (101) (moderate evidence) studied 300 patients and reported that logistic regression showed that age, status of basal cisterns on initial CT, GCS at 24 hours, and electrolyte derangement strongly correlated with 6-month GOS score. Ono and colleagues (64) (moderate evidence) retrospectively studied 272 patients who were ﬁrst divided into CT categories according to the TCDB classiﬁcation and found that within certain groups additional variables such as age and GCS score were helpful predictors of outcome. Schaan and colleagues (102) (moder- ate evidence) studied the utility of creating a single score based on a weighted scale of clinical variables and CT ﬁndings including pupillary reaction, hemiparesis, brainstem signs, contusion, SDH, EDH, and cerebral edema.
Within this broad conceptualization purchase aciphex 20 mg online, CGA and mutual respect among the different professions purchase 10mg aciphex overnight delivery. The has been implemented using many different models in team must also establish rules for process of care includ- various health care settings. Although such teams have been embraced in Most CGA programs have used some type of identiﬁca- principle by health care systems, in practice they often tion (targeting) of high risk parents as a criterion for run counter to the training of health professionals. The purpose of such selection ticular, physicians have had little training in working with is to match health care resources to patient need. For health care teams, and their basic training emphasizes a example, it would be wasteful to have multiple health medical model. Rather, the intensive (and expensive) members evaluate all patients; whereas extended team resources needed to conduct CGA should be reserved for members are enlisted to evaluate patients on an "as- those who are at high risk of incurring adverse outcomes. Most frequently, the core team consists of Such targeting criteria have included: a physician (usually a geriatrician), a nurse (nurse prac- titioner or nurse clinical specialist), and a social worker. Frequently, the constituency of the team failure) is determined more by the local availability of profes- • Expected high health care utilization sionals with interest in CGA than by programmatic Each of these criteria has been shown to be effective in needs. However, none of extended team is gradually yielding to a strategy that these criteria are effective in identifying patients who relies on ﬂexibility in team composition so that patients would beneﬁt from all geriatric assessment and manage- are assessed by only those providers who are likely to ment programs. In this model, the only consistent ria should be matched to the type of assessment and member of the team would be the primary care provider. For example, Brief screens, as described in Chapter 17, might identify a geriatric evaluation and case management program which providers need to conduct further assessment and might focus on persons at high risk of health care uti- therapy. Conversely, a preventive program might rely patient brieﬂy to determine whether a more in-depth solely on age (e. The overriding approach of this strategy is that each patient receives the only the amount of assessment that is necessary.