Vol 84. No.4. pp 347-468Niyomi De Silva

October 20th, 2011

Geriatric Assistive Devices Treatment Options for Localized

Prostate Cancer Exercise-induced Bronchoconstriction

Increase patient’s base of support improve balance redistribute weight from lower limbs -

alleviates joint pain increase activity and independence Delays functional decline Decreases burden of care

Attentional, neuromotor, musculoskeletal demands

Associated with falls and injury Act of lifting and advancing device Device interferes with limbs Stress on upper extremity joints Poor education

Standard Cane

Offset cane

Quadripod cane

Axillary crutch

Forearm crutch

Standard walker

Front wheeled walker

Four-wheeled walker

Correct height and fit• Canes and walkers• Axillary crutches• Forearm crutches

Proper use• Cane• walker

Second most common cause of cancer-related death in US

Incidence and mortality 2-3 x higher in black men

PSA screening – 90% with localized disease

Treatment associated with urinary, sexual and bowel dysfunction

Only increases survival by 1.2 months

94% patients choose treatment

Transrectal ultrasonography-guided prostate biopsy for PSA • >4ng/mL• 2.5-4.0ng/mL if has risk factors• PSA higher than age-adjusted range• <8% free PSA (vs. total PSA)• Increase in PSA >0.35ng/mL in 1 year

(baseline <4)• Increase in PSA >0.75ng/mL in 1 year

(baseline 4-10)

Surgery External beam radiation therapy Brachytherapy Other options

• Hormones• Cryotherapy• High frequency ultrasound

Depends on • treatment modality• specialist’s experience• criteria used to assess frequency, severity

and duration of symptoms Urinary leakage/no urinary control Erectile dysfunction

Transient reversible bronchoconstriction occurin g during or after strenuous exercise

Occurs in people without underlying asthma

Common in persons who participate in endurance sports and sports requiring high minute ventilation

10-90% of patients previously diagnosd with asthma have EIB

Prevalence = 11-50%• 90% in athletes with asthma

Rapid breathing of cold dry air over prolonged period

airway vasodilates water loss and engorgement of airwaysbronchoconstriction• Release of proinflammatory mediators

Wheezing Shortness of breath Dyspnea Cough Chest tightness during or after exercise Usually occur during strenuous activity

• Peak 5-10 mins after onset of exercise Physical Exam – usually unremarkable

Direct• Methacholine challenge

Indirect • Eucapnic voluntary hyperpnea• Field-based exercise challenge• Hypertonic saline test• Laboratory based exercise challenge

Non-pharmacologic treatment• Avoiding known triggers• Sports with low minute ventilation• Pre-exercise warm up

Short acting beta agonist Long acting beta2 agonist Mast cell stabilizers

Geriatric Assistive DevicesA front-wheeled walker has which one

of the following advantages over other walkers? (check one)

A. It is lifted with each step. B. It is the most stable type of walker. C. It has a small turning arc. D. It helps maintain a normal gait pattern.

Geriatric Assistive DevicesCorrect use of a cane involves which one of

the following? (check one)A. With the patient standing upright with arms relaxed at his or her sides, the handle should be at the level of the patient’s elbow crease. B. A cane should be held contralateral to a weak or painful lower extremity. C. A cane should be advanced alternating with movement of the affected leg. D. Patients should advance the unimpaired extremity first when going down stairs.

Geriatric Assistive DevicesWhich of the following caveats should be

considered when recommending assistive devices? (check all that apply)A. They may cause osteoarthritis and other musculoskeletal conditions. B. They can be destabilizing. C. They have been associated with worsening osteoporosis. D. They may worsen cardiorespiratory function.

Treatment Options for Localized Prostate Cancer

A 74-year-old man in the bottom quartile of health has stage T2a prostate cancer with a Gleason score of 6. His prostate-specific antigen (PSA) level is 9 ng per mL (9 mcg per L). Which one of the following treatment options would best align with the recommendations of the National Comprehensive Cancer Network? (check one)A. Active surveillance. B. Surgery. C. External beam radiation therapy. D. Brachytherapy.

Treatment Options for Localized Prostate Cancer

Which of the following is part of the Canadian protocol for active surveillance of prostate cancer? (check all that apply)

A. PSA testing and digital rectal examination every three months for two years. B. 10 to 12 core biopsies one year after diagnosis, then every three years until 80 years of age. C. Intervention if the PSA doubles in less than three years. D. Intervention for progression to a Gleason score of 7 (4+3) or higher.

Exercise-Induced Bronchoconstriction: Diagnosis and ManagementA 21-year-old college basketball player presents with symptoms suggestive of exercise-induced bronchoconstriction (EIB). After performing a workup, you confirm a diagnosis of EIB and discuss treatment options with her. She is concerned about choosing a treatment prohibited by the National Collegiate Athletic Association (NCAA). Which one of the following drug classes requires proof of prescription under NCAA regulations? (check one)A. Mast cell stabilizers. B. Inhaled corticosteroids. C. Leukotriene receptor antagonists. D. Inhaled beta2 agonists.

cise-Induced Bronchoconstriction: Diagnosis and Management

A 35-year-old man presents for follow-up of EIB that was diagnosed two months ago. His first choice of treatment was to try nonpharmacologic techniques that included a pre-exercise warm-up and a heat exchange mask. However, these changes have not relieved his symptoms. Which one of the following treatment options is the most appropriate next step for this patient? (check one)

A. A mast cell stabilizer to be used 20 minutes before exercise. B. A short-acting beta2 agonist to be used 15 minutes before exercise. C. A leukotriene receptor antagonist to be taken two hours before exercise. D. A low-dose inhaled corticosteroid.

Exercise-Induced Bronchoconstriction: Diagnosis and ManagementA 24-year-old woman presents with a six-month history of coughing, wheezing, and increased fatigue. She notes that the symptoms are worse on the days she exercises vigorously. Which of the following should be considered in the differential diagnosis? (check all that apply)A. Hypertrophic cardiomyopathy. B. Vocal cord dysfunction. C. EIB. D. Pulmonary disease.