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The presence of one of the first impairment screens vitamin b12 1500mg generic, both performance-based and self- three or two of the latter three conditions should trigger reported measuring tools are used to determine hearing a dental referral. Of these, the whispered voice test Functional Status has been shown to have acceptable sensitivity and speci- ficity to be useful as a screen. A passing score is the ability to correctly monitor the course of treatment, or for prognostic pur- repeat at least 50% of the whispered words. Patients fail the screen if they Examinations of function may be divided into three are unable to hear at least two of the four tones. Com- levels: basic activities of daily living (BADL),50 instru- pared to pure tone audiometry, the audioscope has a mental activities of daily living (IADL),51 and advanced sensitivity of 94% and a specificity of 72% for detecting activities of daily living (AADL). Its positive predictive value in the functions that are necessary, but not sufficient, for main- elderly is 60%. Katz described basic The Hearing Handicap Inventory for the Elderly— functional tasks: feeding, maintaining continence, trans- Screening version is a self-reported questionnaire ferring, toileting, dressing, and bathing. Individuals with designed to evaluate the effects of hearing loss on the multiple dysfunctions at this level will require significant social and emotional well-being of elderly patients. National Health and Nutrition Examination Survey, also IADL are more complicated levels of activity that are accurately predicts hearing loss. People with several defi- oped using data from a relatively young population, aged ciencies in these areas usually require an assisted living 50 to 74, its value in those who are older remains uncer- situation, extensive community services, or some in-home tain. These are tasks such as working, attending reli- Dental Health gious services, volunteering, and maintaining hobbies. Dental disease, similar to visual or hearing impairment, These pursuits, because they are the most complex and requires a specialist for management. Nevertheless require the highest levels of multiple abilities to com- primary care providers should recognize dental problems plete, are likely to be the most sensitive to changes in and the resulting functional impact so that they can make health status. Two of the assessment instruments Self-reported measures of functional status can be available are the Geriatric Oral Health Assessment Index administered by questionnaire or by interview.

In summary order 1500mg vitamin b12, MRI probably permits better local staging than older tech- niques in certain subgroups of patients but with considerably less than 100% accuracy; the inability to detect microscopic invasion remains an important limitation, as does the inability to detect disease in nonenlarged lymph nodes with standard techniques. These facts have led to only cau- Chapter 7 Imaging in the Evaluation of Patients with Prostate Cancer 129 tious and scattered acceptance of the technique. Currently, it is probably wise to restrict its use to a subgroup of patients—those whose physical examination, PSA, Gleason score, results of standard workup for metasta- tic disease, and personal preferences leave them on the cusp of choosing surgery or local radiotherapy. When interpreting examinations in these patients, it should be remembered that diagnosis or exclusion of micro- scopic invasion cannot be performed with accuracy, but that visualization of gross tumor extension beyond the capsule or into the seminal vesicle is a relatively specific sign of invasive disease. Magnetic Resonance Spectroscopic Imaging In addition to high spatial resolution imaging by proton MRI, technology for spatially resolved spectroscopy of the prostate has been under devel- opment for some years. Proton spectroscopic data can be acquired from a three-dimensional array of voxels. These voxels are about two orders of magnitude larger than the voxels used for proton imaging, but can be superimposed on proton MRI maps to permit reasonably accurate spatial identification of the intraprostatic region supplying specific spectra. Spectral analysis relies on the fact that normal prostate tissue and the tissue of benign prostatic hypertrophy secrete relatively large amounts of citrate; prostate adenocarcinoma elaborates much less citrate, but produces a relatively elevated amount of choline; the ratios between the spectral peaks for these molecules are used to distinguish voxels containing neo- plasm from those that do not (123,124). Currently, the potential uses for magnetic resonance spectroscopic imaging (MRSI) of the prostate might be original diagnosis, biopsy guid- ance, local staging, and evaluation of recurrent following local therapy. With regard to diagnosis, several studies have shown that MRSI analy- sis of small groups of patients containing those without tumor and those with tumor can identify and localize tumors with reasonable, if less than perfect, sensitivity and specificity (125–128). But no sufficiently large or sufficiently well-controlled investigation has addressed whether MRSI is effective in screening for disease in a large sample reflecting either the pop- ulation at large or those at increased risk because of an elevated PSA. And given that many prostate tumors are considerably smaller than the MRSI voxels, it is unlikely that sensitivity can ever be very high until consider- able improvements in spatial resolution can be made.

A potential solution to some of these obstacles manner vitamin b12 750mg visa, discussions can occur at convenient times, even is use of home health agencies, which can provide a wide though team members may be in geographically dis- range of services to those who are homebound. However, in inpatient settings, where establishing a network of health professionals in the discharge planning is an exceptionally important role for community is essential in developing CGA programs in the team, most meetings still occur face to face. Reuben Outcomes of Traditional CGA geriatric evaluation and management assumes primary care of older persons who are at high risk for high health In virtually all studies of CGA, the process itself has care utilization for an average of 6 months and then resulted in improved detection and documentation of returns patients to the care of their primary care physi- geriatric problems. When evaluated in a randomized clinical trial, this lems has not always led to improved outcomes. A 1993 approach prevented functional decline and reduced the meta-analysis of five models of CGA (geriatric evalua- 13 likelihood of depression at a modest cost. A model of tion and management units, inpatient geriatrics consulta- geriatric preventive services for unselected community- tion services, home assessment services, home assessment dwelling older persons utilized a geriatric nurse practi- services for patients who had recently been discharged, tioner to provide periodic in-home assessments that were and outpatient assessment services) summarized the evi- 14 2 subsequently discussed with a multidisciplinary team. The prin- This intervention delayed functional decline and reduced cipal findings of the meta-analysis indicated that the nursing home placement in a randomized clinical trial. In hospital or rehabilitation unit model of CGA had the a replication study, however, the benefit was confined to strongest and most consistent benefits on mortality, living persons who were at low risk for nursing home admis- at home, and functional status. Finally, a model that combines CGA with an grams, all of which were implemented and tested in adherence intervention has been developed and tested. This program provided single outpatient comprehensive None of the other models demonstrated consistent geriatric assessment for community-dwelling older benefits across studies, outcomes, and time points. The team consisted ported these findings including negative randomized clin- 3 of a geriatrician, nurse practitioner, social worker, and ical trials of inpatient geriatric assessment consulation, physical therapist (when needed). The assessment was in-home assessment by a geriatric nurse practitioner then linked to an adherence intervention that was for patients who had recently been discharged from the 4 5 designed to empower the patient to take action and to hospital, and outpatient geriatric consultation. In a randomized clinical trial, this most robust traditional CGA model, the geriatric evalu- strategy was associated with less functional decline, less ation and management unit, may no longer confer the 16 fatigue, and better social functioning and was cost- same benefits in the current environment.