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Cuff sheet v7

Information for Patients ROTATOR CUFF TEARS
This booklet has been prepared to help you better understand your shoulder problem and the surgery that may be required. It will also help explain what will happen after the surgery has been performed. Although this booklet aims to be relatively comprehensive, you will probably still have some questions and I would of course be happy to answer these at any time.
Dr. Terry Hammond.
THE SHOULDER & SPORTS MEDICINE CENTRE
Pindara Place, 13 Carrara Street, Benowa. Qld. 4217
Telephone (07) 5597 6024 Facsimile (07) 5597 0644
Mobile 0434 474155 Email mail@kneesports.com.au
The shoulder is a ball and socket joint and is illustrated in Figure 1. The ball consists of the head of the humerus which is the top of the upper arm bone.
The socket consists of the glenoid which is attachedto the scapula (shoulder blade). Surrounding theshoulder are a number of muscles which help youmove your arm. The deepest layer consists of threemain muscles known collectively as the rotator cuff.
These are illustrated in Figure 2. The rotator cuff serves a number of purposes, but one of its mainaims is to help you lift (elevate) your arm.
The rotator cuff is made of three main muscles - The supraspinatus, the subscapularis and the infraspinatus.
The infraspinatus lies behind the shoulder and is not illustrated in this picture.
Figure 2. The muscles of the shoulder If the rubbing of the rotator cuff underneath theacromion continues, a small hole may be torn in the rotator cuff. An example of such a tear is shown infigure 3. This very often leads to significant painwhich does not resolve. If this tear is small then thearm may still have full function. If the tear becomeslarge then you may lose power in your arm, andeventually may not be able to lift the arm at all. Inrare cases this may also eventually lead to arthritiswithin the shoulder joint. In the early stages a rotatorcuff tear can be repaired with surgery. However, ifit becomes too large, it may be impossible to repair.
Figure 1. The bones of the shoulder Surgery in these cases can be beneficial but youmay still be left with some pain and loss of functionin the shoulder.
As you can see in Figure 2, the rotator cuff is situatedunderneath a bone of the shoulder known as theacromion. The space for the rotator cuff is very tightand in many patients the cuff may rub on the undersurface of theacromion. This can lead to inflammationwhich is painful, particularly with use of the arm orat night in bed. This condition is known asimpingement syndrome. Although this can sometimessettle with rest, physiotherapy or an injection, surgicaltreatment may be required particularly if your pain Figure 3. Rotator cuff tear. The tear shown is severe or ongoing.
involves the suprasinatus muscle. The tear can often extend to include the other muscles In the early stages of the disease, with impingement If the rotator cuff tear is massive, then it syndrome but no rotator cuff tear, the treatment provides us with a great deal of surgical is relatively straight forward. The operation difficulty. Sometimes there is no chance of performed is called a subacromial decompression repairing the cuff by any means. In this case (also known as an acromioplasty) and it involves a subacromial decompression is performed the removal of a small piece of bone (known and no other procedure attempted.
as a spur) from the under-surface of the acromion.
This increases the space available for the rotator cuf f and therefore the amount of rubbing on the under-surface of the acromion is reduced. The allows the inflammation and pain to settle. This procedure is done through keyhole (arthroscopic) surgery. A number of small holes (about 1 cm long) are made around the shoulder and a camera and surgical instruments are introduced into the joint. A shaver is used to remove the bone from the under-surface of the acromion. This operation is illustrated in Figure 4,5& 6.The scars usually heal to become nearly invisible.
Figure 5. View of the shaver removing the spur from the under-surface of the acromion Figure 4. Side-on view of the shoulder.
Figure 6. View after completion of the The spur at the front of the acromion is shown by the arrow.
Note there is now greater space for the rotator cuff.
If the rotator cuff is torn, then more extensive surger y is required. Stitches are used to repair tears in the tendon and to reattach the tendon to bone . An example of a rotator cuff repair is shown in figure 7. A number of small metal anchors may also be used to help with reattachment of the rotator cuff.
The type of surgery performed depends on the exact nature of the tear with the aim being to get as strong a repair as possible. In order to get a solid repair it is usually best to make a small incision – about 5 cms long – over Figure 7. An example of a the outside of the shoulder. However certain rotator cuff repair.
types of tears are best repaired arthroscopically Stiches are used to secure the cuff without the need for open surgery.
back down onto the bone.
Another potential source of pain in the shoulderis the acromioclavicular joint (the ‘ACJ'). This isthe joint between the outer end of the clavicle and the acromion and is illustrated in figure 8.
This joint is prone to arthritis not only in theelderly patients but also in the young. The bestway to treat this condition is to remove the outerone centimetre (half an inch) of the clavicle. Thisprevents the two bones rubbing on each otherand removes the source of pain. This operationis usually done arthroscopically and is shown infigure 9. After the surgery the coracoclavicularligaments remain intact and hold the clavicle inits normal position. This means there is no lossof function or strength in the shoulder – in facteven professional athletes can return to their sportwithout any difficulty.
Figure 8. The acromioclavicular joint.
Figure 9. The complete acromioclavicular joint excision.
Note that the coracoclavicular ligaments hold the remaining clavicle in place.
This allows full function of the shoulder RISKS OF SURGERY
MAJOR COMPLICATIONS: Although impingement and rotator cuff surgery is Thankfully, major complications following shoulder very successful, it may not be possible to eliminate surgery are very rare. Some of these complications all your pain. In the majority of cases any residual can include damage to major arteries and nerves, pain is mild and certainly less than before your sudden death from anaesthesia, heart attack or stroke, surgery. However, in some cases, the amount of deep vein thrombosis and pulmonary embolus.
pain relief obtained may be less than expected. This Obviously, it is possible that these complications can is particularly true if you have arthritis within the lead to either loss of your limb or your life, but this is shoulder joint, or a rotator cuff tear that is so large an extremely uncommon occurrence. If you have any it is not repairable.
particular concerns, myself or my anaesthetist would be happy to discuss this with you at length.
RE-TEAR OF THE ROTATOR CUFF:Most tears of the rotator cuff occur because the The list of complications is not fully comprehensive but tendon is at least partly worn out. This means that it does outline what are considered to be the major even after a successful repair, the rotator cuff may risks of surgery and those which have the most serious tear again. Even if this happens your shoulder is usually much better than before surgery. This is because the subacromial decompression which is Please feel free to discuss this with me at any time – performed with the repair usually gives significant you should not proceed with surgery until you are pain relief even if the rotator cuff tears again.
satisfied that any issues regarding the risks of surgery have been adequately discussed.
STIFFNESS:Your shoulder will be quite stiff following the surgery.
This will gradually improve but may take a few months until it is completely better. Occasionally THE DAY OF YOUR SURGERY
this stiffness can be quite severe and last for many months. This is called a "frozen shoulder" and can You will usually be admitted on the morning of your be associated with an increased level of pain. In surgery to either Pindara Main Hospital (Allchurch almost all cases it resolves completely and does not Ave) or the Day Procedure Centre (Pindara Place, affect the outcome, but it can certainly make your ground floor). You will often be admitted some hours recovery longer than we would desire.
before your surgery. This time can be quite boring so it is a good idea to bring a book or magazine CHANGE IN APPEARANCE OF YOUR UPPER ARM: Part of your biceps muscle runs through the shoulder The nursing staff, my anaesthetist and I will see you joint. This part can be torn and damaged and must before your surgery and go through a series of be released at the time of surgery in order to treat questions confirming your name, date of birth, what your pain. If this is required you may notice a slight surgery you are having and what side we are operating change in the appearance of your upper arm along on. In most cases you will have a general anaesthetic with some temporary aching. This does not generally and be asleep during the whole procedure. You will affect the function of your arm.
then spend some time in the recovery unit before either being allowed home or staying overnight. You will have strong painkillers and therefore you will be reasonable comfortable immediately after your surgery.
Infection in the shoulder joint is rare following surgery, but if it does occur you will usually require another You should tell your friends or relatives that this whole stay in hospital & possibly further surgery.
process is quite lengthy and will take some hours. I will see you immediately after your surgery but often There are a number of minor complications that can it is difficult to remember what I say due to the occur following surgery. These usually settle anaesthetic drugs. I will therefore see you in the ward completely and do not affect the outcome. These or contact you in the days following your surgery to complications can include bruising, swelling, tingling give you information about your operation. Patients of your fingers, nausea, vomiting, sore throat and admitted to Pindara Main Hospital will often stay bruising around the intravenous drip site.
overnight but those in the Day Procedure Centre will be allowed home on the day of surgery.
AFTER YOUR SURGERY
You should leave your dressing intact until I see you ADVICE FOR PATIENTS WHO HAVE HAD A in my rooms. There may be some fluid or blood SUBACROMIAL DECOMPRESSION WITH A
underneath them but this is quite normal. If there is ROTATOR CUFF REPAIR.
any sign of infection i.e. redness or a pusy discharge you will need to contact myself, my rooms or the WHEN SHOULD I WEAR MY SLING? Emergency department of Pindara Hospital.
You should wear your sling while in bed or up You should avoid getting your incisions wet for a total walking around. If you are sitting down you may of two weeks after your surgery. You may shower but remove your sling but be careful not to lift your arm.
try to avoid wetting the dressings. When showering You should discard your sling completely after six you can take your arm out of the sling and straighten your elbow out to allow your arm to hang straight down; you can then lean forward a little to wash your WHEN CAN I USE MY HAND? armpit.Your must not swim in the ocean, swimming pool or a spa for at least 2 weeks after your surgery.
You may use your hand at the level of your waist The following sections offer specific advice depending for activities such as writing, typing, eating and on whether or not you required a repair of your rotator going to the toilet. However, try to restrict these cuff tendon.
activities as much as possible – if you do too much the shoulder can become very painful.
ADVICE FOR PATIENTS WHO HAVE HAD A SUBACROMIAL DECOMPRESSION WITHOUT A
You cannot lift your arm for six weeks – this is ROTATOR CUFF REPAIR.
because doing so can tear out your stitches.
WHEN SHOULD I WEAR MY SLING? SHOULD I DO ANY EXERCISES OR HAVE ANY You should wear your sling for comfort but you can remove it anytime you wish. You can use your arm In the first six weeks formal physiotherapy is not and shoulder for anything you want. There are no required. You will be given separate instructions restrictions on what you can do but of course you regarding exercises during that period. It is important should let your pain level guide you on how much to only do exercises that do not cause pain in the activity you can manage. Try to restrict your activities shoulder ñ it is far better to do too little than too as much as possible - if you do too much the shoulder much. After your shoulder is beginning to feel can become painful.
normal you may visit your physiotherapist to begin a course of long-term rehabilitation.
SHOULD I DO ANY EXERCISES OR PHYSIOTHERAPY? WHEN CAN I DRIVE? No formal physiotherapy is required for at least the first six weeks. You should take your arm out of the Legally you cannot drive while wearing a sling sling and exercise your hand, wrist and elbow. Bend therefore you cannot drive for at least 6 weeks.
and straighten your elbow and then turn your wrist around in a circle. Make a fist and then straighten your fingers. Do these exercises at least three times As your arm will be in a sling for six weeks, you WHEN CAN I DRIVE? will usually need at least two months off work. You cannot do heavy work for at least three months.
You may drive when you feel safe and comfortable (usually after about two weeks). Legally you cannot WHEN CAN I PLAY SPORT? drive while wearing a sling.
Your must not play sport for at least four months after your surgery.
You can go back to work at any time but you will WHAT SHOULD I DO AFTER SIX WEEKS? usually need at least two weeks off due to discomfort from the surgery. Heavy manual labourers may need After six weeks you should discard your sling.
more time off.
The rotator cuff repair will now be strong enough for you to lift up your arm as high as you want.
WHEN CAN I PLAY SPORT? You can then resume gentle day-to-day activities, such as driving, washing your hair and lifting up You can play sport when your pain has settled.
PAIN RELIEF GUIDELINES
When your surgery is arranged we may give you prescriptions for pain killing medications. Most people prefer to get these tablets before their Take 100mgs twice daily. Take this regularly even surgery so they are easily available if they are if your pain is not severe but this can be stopped required. Alternatively, you can wait until after in 5 days if your pain settles. DO NOT TAKE if your surgery and only get those medications you you have ischemic heart disease i.e. a history of require. If you haven't been given prescriptions a heart attack or angina or if you have had a before your surgery, the hospital will give you cardiac stent.
tablets when you are discharged.Some patients should avoid certain medications – please read the information below to see if there are any you should not take.
Take 150mgs three times a day if you are less than 60 years old or 100mgs three times a day Please note that the description of the medications if you are over 60 years old. DO NOT TAKE if below use the generic (‘official') name for the you have had seizures or epilepsy. Occassionally drug. The drug you get from the chemist often tramadol can make you feel strange' or jittery'.
has the brand written in large letters on the box If so stop taking it.
but the generic name is usually written as well – often in smaller writing. Please note carefully the dose of the drug; this may vary depending on your age.
This is NOT TO BE TAKEN REGULARLY. It is a strong pain killer for use if the other medications Shoulder surgery can be very painful and it is are not completely controlling your pain. Take it therefore vital that you take enough medication if and when you need it – often this may be at to control your pain. The most common reasons for significant pain after surgery are using your Take up to 10-20mgs every four hours as needed arm too much and under-dosing your medication.
if you are less than 60 years old and 5-10mgs I strongly recommend that you keep an accurate every four hours as needed if you are over 60 record of the exact time you take each medication.
years old. If the medication makes you nauseated, This allows you to know exactly when the next stop taking it or decrease the dose.
dose may be taken.
Although you should take enough pain-killers to control your pain, you do not necessarily need This is NOT TO BE TAKEN REGULARLY. It is a to take all the medication. Start with the strong pain killer for use if the other medications Paracetamol and add the Celebrex if needed. If are not completely controlling your pain. You your pain is still not controlled add the Tramadol.
should not take this if you are over 60 years of Only take the Oxycontin or Oxycodone for severe age. However, if you are younger than 60 you pain – this may helpful at night to help you sleep.
can take 20-40mgs twice a day. If the medication makes you nauseated, stop taking it or decrease As your pain settles, decrease the number of tablets you take. Stop the Oxycontin and Oxycodone first, then the Tramadol. When your pain is improved further, stop the Celebrex and finally cease the Paracetamol.
The following guidelines provide further information regarding your medications.
Take this regularly even if your pain is not severe.
Take 1gm (usually two 500mgs tablets) four times a day if you are under 60 years old or take 1gm every six hours if you are over 60 years old.
RECOVERY FROM SURGERY
I will generally see you in my rooms 1-2 weeks three months before you are really pleased you after your surgery. We will remove your dressings had the surgery. During that time, there may be and check your wounds. I will ensure that your periods when the shoulder is quite uncomfortable; recovery is going as planned and I can answer any you may think it is improving only to find it seems further questions that you may have at that stage.
to get worse again. There may also be unusualsensations in the shoulder i.e. clicking, grinding When you have recovered from your surgery and or catching. All these findings are very common are using your arm relatively normally, it is often and generally do not indicate any problem. These helpful to return to your physiotherapist. At that symptoms will gradually improve with time.
stage they can begin a long-term rehabilitationprogramme that can reduce the chances of However, the full recovery often takes a year or developing fur ther shoulder problems.
more. This long recovery period can be veryfrustrating but luckily shoulder surgery is associated It is important to realise that shoulder surgery has with very good results. Well over 90% of patients a very long recovery period. It often takes at least will achieve an excellent result.
INSTRUCTIONS FOR YOUR PHYSIOTHERAPIST
(The following information is provided for your SUBACROMIAL DECOMPRESSION WITH ROTATOR
physiotherapist. You can show them this page and it will assist them with the post operative During the first six weeks I like my patients to haveonly pendulum exercises of the shoulder. In addition SUBACROMIAL DECOMPRESSION WITHOUT
they should have hand, wrist and elbow mobilization.
ROTATOR CUFF REPAIR They must not have active elevation of their armduring that time. They can use the hand actively at If patients have had a subacromial decompression waist level for activities such as writing, typing, only, they may have full active and passive use of eating and going to the toilet. However if the shoulder their arm without restriction from the day of surgery.
becomes painful even these activities should be However, it is very important to limit their activities decreased as much as possible.
as much as possible in the first few weeks. This isbecause too much activity can produce significant Six weeks from the surgery patients can discard pain in the shoulder. When they have made a their sling and begin using their arm for day-to- good recovery and can start to use their arm day activities. They can have full active use of their relatively normally, they can progress to more shoulder and can begin a rehabilitation program intensive rehabilitation. This can include core including core strengthening and scapular strengthening, scapular stabilizing and rotator cuff stabilizing exercises. They should not commence rotator cuff strengthening until four months fromthe date of surgery.
Obviously, if these exercises make the shoulder toopainful, they should be stopped and started again Other advice such when to wear their sling, when the discomfort has settled.
showering, driving, etc is outlined in the section inthe booklet entitled "After Your Surgery".
Please contact me in my rooms or on my mobilephone if you have any questions.

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14_nexium_ing:maquetaci—n 1.qxd

CUSTOMER SOLUTIONS NEXIUM CUSTOMER SOLUTIONS "El Centro Virtual de Experiencias de Internacionalización" (The On-line Centre for International Business Cases) is the result of the collaboration of the Spanish Institute for Foreign Trade ICEX and AEEDE, the Spanish Association of Business Schools , which includes eleven leading Business Schools. The aim of this project is to promote the internationalisation of Spanish SMEs,

mentalhealth.wa.gov.au

MENTAL HEALTH LAW CENTRE (WA) Inc. ABN 40 306 626 287 Our Ref: SB NCW 572 6 March 2012 Mental Health Commission GPO Box X2299, Perth Business Centre WA 6847 DRAFT MENTAL HEALTH BILL 16 DECEMBER 2011 Mental Health Law Centre (WA) Inc. SUBMISSION PHYSICAL AND DENTAL HEALTH OF INVOLUNTARY PATIENTS AND PRISONERS We take this opportunity to make a submission on the Draft Mental Health Bill released for public comment on 16 December 2012. General Position The Bill authorises a single "authorised mental health practitioner" (not necessarily a doctor and perhaps simply an enrol ed mental health nurse with two days training in making referrals) to assess/ examine, refer, detain and transport a person against their wil and without their consent, to a psychiatrist (sometimes thousands of kilometres away from the patient's home) for an examination to decide whether or not that person requires detention (involuntary admission to an authorised psychiatric hospital or hostel) and/or involuntary treatment; and authorises the examining psychiatrist (who may or may not have trained in Australia) to make an involuntary detention and/or treatment order sometimes on the basis of a hurried five minute examination. Mistakes and oversights happen in a busy, under-resourced system whose priority and objective is treating a person's mental illness. Physical and dental il health may be the underlying cause of mental il -health – such as urinary tract infection in elderly people causing psychosis, may impede recovery from mental illness and may be low on the agenda of mental health