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  • Vice Chair for Clinical Operations and Financial Affairs
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Median responses for both were in the middle of the scale primary hiv infection timeline purchase valtrex 500mg online, suggesting uncertainty in these areas hiv infection zero viral load cheap valtrex 500 mg on-line. Views about the benets of patients having a treatment reaction such as getting worse before getting better hiv infection by needle stick generic 1000 mg valtrex mastercard, or the exacerbation of presenting 229 5 hiv infection rates scotland generic valtrex 1000mg with visa. All the items associated with risk of vertebro basilar stroke were endorsed as important in the assessment of risk of treatment reactions when treating the cervical spine except gender. Despite this, they rated as important all the major risk factors associated with vertebro basilar stroke and emphasised undiagnosed pathology and structural decits as the most important factors in referral. Practitioners were not invited to describe their full triage and case history processes and therefore we do not have information about other known screening tests such as those for cranio-vertebral instability. The utility of such screening pre manipulation has not been established and they are rarely used by other musculoskeletal practitioners such as physiotherapists. The authors of the study conclude that patients present to chiropractors with symptoms associated with vertebro arterial dissection and subsequently develop ischemic stroke. Risk factors with some supporting evidence such as vessel size abnormality of the carotid artery are not assessable in osteopathic clinical settings. Clinicians should be alert to cervical vascular pathology, especially in the context of acute trauma and be aware of neck pain and headache as precursors to posterior circulation ischemia. History and examination should include awareness of vascular risk factors and ability to perform cranial nerve and simple eye examinations. It is therefore not surprising that the osteopaths in this study expressed uncertainty about predicting such events, while endorsing the comprehensive list of risk factors they were presented with in our survey. Some risk factors that are necessary or sucient to produce stroke are beyond the scope of clinical detection in osteopathic settings. Until screening procedures are established that are accurate and practical in the context of osteopathic practice, the detection of such rare events remains problematic for practitioners. Clinical education and professional development should focus on the history and clinical examination of patients rather than the use of clinical screening tests. Awareness of the func tion and anatomy of the cervical vascular system and clinical presentation of cervical vascular pathology is recommended to aid in the identication of patients at risk of stroke at presentation for treatment. A small proportion of osteopaths reported not gaining consent for examination (11. Practitioners perceived giving information and receiving consent more than appeared to be perceived by patients. Patients and practitioners considered infor mation giving and consent less of a priority where they have an existing relationship with their osteopath and have experience of osteopathic treatment. Most patients thought it important for osteopaths to ask their permission prior to examination and treatment, however a proportion of patients thought that osteopaths asking permission before examination (30%) and treatment (28. Again these ndings related to the patients’ prior experience of osteopathic care; new patients thought that osteopaths gaining permission for examination and treatment was more important than patients who were in ongoing treatment or were presenting with a new episode to an osteopath they were familiar with. Interview data from patients and practitioners suggested that a range of activities were included in consent processes including the use of written information, discussion at initial and ongoing appointments, and observation of patient behaviour. The salience of information about risks, benets and alter native treatments and the importance of the consent process was mediated by the experience of care, a positive therapeutic relationship, and the choice to attend for treatment. There was some sharing by practitioners and patients of the concept of consent being implied by choice to attend and compliance with requests by the osteopath. Some patients described a need for particular information concerning the intimacy of examination, the extent of undressing required and the need for chaperones between female patients and male osteopaths. Patients valued information about the process of care and saw its provision as relationship building and important in helping them set expec tations and to understand their condition and responses to treatment. Risk of treatment was predominantly construed of by patients in terms of a lack of benet from osteopathy rather than in terms of hazard and harms. Whilst practitioners valued giving information as part of building their therapeutic relationship with patients, some saw giving information about serious risks as an obstacle to this process and considered that information about serious adverse events caused stress in patients and promoted fear. Some of the practitioners interviewed elected not to disclose risks of serious adverse events to their patients. Patients however, did appear to value information about risk, but assumed that there was no or low risk when they had not been given information, or assumed that the osteopath would inform them if there were risk involved with treatment. Approximately a third of osteopaths replying to the survey felt that they had not received adequate guidance about consent. At interview, practitioners’ attitudes to consent as articulated in the 2005 Code of Practice34 included practical concerns about having received insucient guidance to adhere eectively to the Code and uncertainty about the nature of information that should be given to patients. In summary, we found that most information and consent-related processes occurred where patients were new to the osteopath they were consulting and that new patients rated informa tion as more important than those who were familiar with osteopathy. Osteopaths perceived consent giving taking place more than patients and a small minority of osteopaths reported not engaging in consent-related activity. The focus of information giving was around the nature of osteopathy and its potential benets, as opposed to risk and alternative and no treatment op tions. Osteopaths found it most challenging talking to new patients about unpleasant reactions associated with treating the neck. A signicant number of patients did not recall receiving information about risk and alternative or no treatment options. The importance of the consent process appears to be mediated by experience of care, a positive therapeutic relationship and the choice to attend for treatment. Risk often appears to be understood by patients as lack of benet rather in terms of hazards and harms. In contrast, a qualitative study of Canadian physiotherapists, reported that a blanket written consent to treatment, in line with local regulatory guidance, was obtained from all patients on their rst visit. There was also evidence from our interviews that some practitioners and patients thought that repeating information was unnecessary. Osteopaths in our study reported diculties and omissions discussing risks and major adverse consequences of treatment. As in our results, patient anxiety was cited as an important reason for this, together with the remote likelihood and lack of evidence of serious adverse events post treatment. Similarly, Canadian physiotherapists regarded the client to be responsible for opting out of treatment and where this did not occur this was seen as imply ing consent. Although not voiced by participants, an alternative interpretation is that in a commercial private setting there is a conict of interest for practitioners to suggest equivalent options for treatment from other providers. Practitioners focussed on consent being more informed by benecence (providing benet to others87, producing good outcomes88) than on principles of autonomy (self determination, right to decide what is done87,88). Doyal 90 dis cussing consent in medical contexts, acknowledges that some patients may not wish to receive a range of information, but nevertheless argues that patients still need to be given information to make reasoned choices. Refusal of information can only be valid when the implications of re fusal are understood, including what it will mean in terms of the management of an individual’s condition. There is also evidence that patient recall of risk can be poor, even when risk has been explic itly explained. It is probable that some osteopaths are not explicitly discussing risk in a way that patients understand. Our nding that patients focus on risk as a lack of ben et, rather than thinking of risk in terms of hazards and potential harms from treatment, may explain an element of the low rates of risk information reported to be received by patients in our study. This nding appears to be in accord with osteopathic patients’ expectations, where the most important patient expectations focussed on eective treatment. The transmitting and exchange of information between patient and practitioner is a key component of gaining and receiving consent and is explicit in professional codes of practice and standards of prociency34,35,93,94. Whilst the ethical duty to respect autonomy is clear, the impact of partial or absent consent procedures and information exchange on patients, partic ularly in the context of low risk interventions, is not clear. Across healthcare, partnership models have replaced paternalistic decision making and are associated with improved patient outcomes and satisfaction. In summary, as in our study, there is some evidence from other health professions that levels and recording of consent vary amongst practitioners. Most information given to patients concerns the nature of treatment and the benets of treatment. New patients are given more information than returning or ongoing patients and information and consent are perceived as more important by new patients. Patients receiving treatment may not understand or recall risk information and this type of information along with information about alternative or no treatment, is not consistently oered to patients. Risk of having no benet from treatment is part of the way that patients think about risk, but there is some evidence that patients expect information about risk in terms of hazards and harms. Chiropractors have similar concerns to the osteopaths in our study about giving information about serious adverse events and that there is a need for more information about the nature of risk associated with treatment.

The proposed amendment shall be adopted upon receiving at 22 least two-thirds of the votes entitled to first symptoms hiv infection include order valtrex 500mg without a prescription be cast by the total number of delegates accredited for voting hiv infection rates gay discount valtrex 500 mg free shipping. As 13 technology advances and the breadth of medical practice in this area expand hiv infection in older adults discount valtrex 1000 mg on line, there is an increasing call 14 to antiviral supplements for hpv buy generic valtrex 1000mg on-line regulate patient care delivered through technological resources. Advocates for telemedicine argue 15 that it provides improved access to medical care and services to patients in rural or distant areas. They 16 also emphasize that it allows for easier access to care for immobile patients and those with limited 17 mobility. Cost-effectiveness, through reduced travel times, is also noted as a cause for increased patient 18 demand for health care services through telemedicine. The primary issues involving telemedicine are: (1) licensure of out-of-state practitioners 21 who use technology to treat patients in a state where they are not licensed to practice; (2) technological 22 problems and barriers; (3) reimbursement issues regarding payment for services rendered; and (4) 23 quality of care. This change allows rural critical access hospitals to obtain consultations from a 2 subspecialty provider or facility without undertaking the administrative burden of credentialing each 3 provider individually. Care deemed to be below the acceptable quality standard can be addressed either via the 6 disciplinary action of a state medical board or via civil legal action (medical malpractice claims). Additionally, standard of care must be established and may vary 9 between face-to-face encounters and telemedicine encounters; although, many providers argue against 10 this variation. In cases of medical malpractice, where a physician licensed to practice in two or more 14 states practices medicine over state lines through electronic means, and an adverse event occurs. There is no 24 standard for telemedicine education and no certification in the provision of telemedicine. Therefore, 25 the burden of oversight currently falls on the state medical boards. State licensure requirements also diverge with significant 27 differences in testing, postgraduate education and continuing medical education requirements. Finally, uniformity fails to exist in what constitutes a visit (establishment of 30 the “physician-patient relationship”), with some states requiring a face-to-face visit before a 31 telemedicine relationship can be established. Due to these differences, some advocates have promoted 32 the concept of national licensure. They believe that a national license for the practice of medicine would 33 eliminate barriers that prevent widespread use of telemedicine. Concerns 36 have been expressed about who would assume responsibility for disciplinary action against providers if 37 a national medical license was initiated. Currently, protection of the residents of the state is a top 38 function and core value of the state licensing boards. New Mexico, a state where 91% of the counties qualify as medically 2 underserved, views telemedicine as a lifesaving mechanism to provide primary patient care and specialty 3 consultation services. Senator Udall has announced plans to allow physicians to provide 5 care using telemedicine and in some instances, travel more freely across state lines to more remote rural 6 areas by establishing a national licensure system. Reference Committee Explanatory Statement: the committee does not believe that it is appropriate to sunset policy No. The committee respectfully disagrees with the explanatory statement accompanying resolution no. The morbidity and mortality rates have declined 9 with the advent of early diagnosis and medication usage. While 13 this may have been helpful with a disease that had poor outcomes and a high mortality 14 rate, in 2016 the use of mandatory consent forms are now overbearing, time consuming, 15 and cost prohibitive. H-626 is unnecessary due to the fact that the subject matter and statements contain within the proposal have already been addressed in policy no. Reference Committee Explanatory Statement: the committee respectfully refers resolution no. Direct Primary Care: An Innovative Alternative to Conventional Health Insurance, the Heritage Foundation, 2014. Explanatory Statement: “Conversion Therapy” continues to be practiced in Ohio by non-licensed religious lay people, clergy, and licensed counselors, social workers, marriage and family therapists, psychologists, psychiatrists, and other physicians. American Psychological Association, Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Just the facts about sexual orientation & youth: a primer for principals, educators, & school personnel: efforts to change sexual orientation through therapy. Prohibit certain health care professionals from engaging in sexual orientation change efforts when treating minor patients (S. Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians. Reference Committee Explanatory Statement: the Committee agrees with the explanatory statement provided by the Board of Trustees. It is recognized that there have been issues with the distribution of b/c/c materials. To provide for further input from stakeholders, the committee respectfully refers resolution no. H-633 to the Department of Professional Affairs for review and further comment on how the development of programs by the American Osteopathic Association and/or state osteopathic associations would supplement and/or fill a void in existing training and education on sexual harassment and/or misconduct within the workplace. Budgeet Overvieww A brieef overview oof our fiscal sstatus and thee proposed bbudget followws. Information Technology Provide technology support as needed for Webinars, voice and video conferencing and to support public policy initiatives. Member Services Evaluate research opportunities to tie with new Membership member model offerings. Member Services Customer Service Center gain training on key public policy issues to help with grassroots initiatives when they arise. Membership Complete work on Membership Alignment Membership Recommendations through Committeeincluding fees, models of membership, communications enhancements, market targets. Public Policy Identify member options on public policy as part of membership alignment options. Information Technology Member Services Promote member opportunities, as defined through task Membership force to support international activities Evaluate membership options to market broader in international environments for members. Existing campaign assets will be refreshed with new headlines, copy and a few new faces. Increased outreach to prospective exhibitors and sponsors will be more focused and aligned. Education the Education Bureaus and Councils continue to work on program accreditation and training approval. Efforts to improve efficiency and cost-effectiveness of meeting time are also planned for all. A total of $300,000 has Page 3 been requested from reserves to reimburse the cost of reviewers and provide resources for in-person consultations, if necessary. International Affairs Focus remains on practice rights expansion and sustainability of mission initiatives. Page 5 B udgeted R evenues as a P ercentage ofTotalB udgeted R evenues R esearch Publications PostdoctoralA ccred. M embersh ipDues C O C A C onvention C ertified Boards F Y 2017 C ertification F Y 2018 A llO th er 0% 10% 20% 30% 40% 50% B udgeted Expense C ategories as a P ercentage ofTotalExpense B udget Salaries Benefits A llO th er Cert. The increased cost prohibits access to epinephrine for many of those who have the greatest need, children and the elderly. I would like to thank the following members of the Reference Committee for their collaboration and hard work. Barnes’ Myofascial Release Approach is considered to be the ultimate Tmind/body therapy that is safe, gentle and consistently effective in producing results that last. Fascia is a tough connective learn myofascial tissue which spreads throughout release for: the body in a three-dimensional web from head to foot without • Back Pain interruption. Trauma, posture or infammation can create a • Cervical Pain binding down of fascia resulting in excessive pressure on nerves, • Headaches muscles, blood vessels, osseous • Chronic Pain structures and/or organs. The viscoelastic quality of the fascial system causes it to resist a suddenly applied force. Barnes’ Myofascial Release Approach consists of the gentle application of sustained pressure into the fascial restrictions. This essential “time element” has to do • Sports Injuries with the viscous fow and the piezoelectric phenomenon: a low load (gentle pressure) applied slowly will allow a viscoelastic medium • Rehabilitation (fascia) to elongate. The seminars listed in this • Restricted Motion brochure all build upon one another providing a logical, step-by-step, comprehensive Approach • Chronic Fatigue for the treatment of pain, headaches and Syndrome dysfunction.

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Hepatitis B virus transmissions associated with a portable dental clinic stages of hiv infection diagram cheap valtrex 500 mg online, West Virginia global hiv/aids infection rates generic 500 mg valtrex mastercard, 2009 hiv infection rates new york city purchase 1000mg valtrex with visa. Dental Healthcare-Associated Transmission of Hepatitis C: Final Report of Public Health Investigation and Response antivirus windows server 2008 order cheap valtrex on line, 2013. The infection prevention coordinator with training in infection prevention— the infection should ensure that equipment and supplies. Policies and procedures communication with all staf members to address should be tailored to the dental setting and reassessed specifc issues or concerns related to infection on a regular basis. Provide supplies necessary for the facility and based on evidence-based adherence to Standard Precautions guidelines, regulations, or standards. Education during orientation to the setting, when new tasks on the basic principles and practices for preventing or procedures are introduced and at a minimum, the spread of infections should be provided to all annually. Referral arrangements are in place to immunizations, evaluation, and follow qualifed health care professionals. Evaluation ofers Routinely documenting adverse outcomes an opportunity to improve the efectiveness of. If defciencies or problems in the Monitoring health care associated implementation of infection prevention procedures infections in patients. Standard Precautions include— of infection prevention is used when patients have 1. Sharps safety (engineering and work practice to carry out all of the Transmission-Based Precautions controls). Education and training are systems for early detection and management of 6 potentially infectious patients at initial points of until the patient is no longer infectious or referral to a entry to the dental setting. To the extent possible, dental setting with appropriate infection prevention this includes rescheduling non-urgent dental care precautions when urgent dental treatment is needed. Hand Hygiene Hand hygiene is the most important measure to should be used when hands are visibly soiled. Education and training programs should surgical hand scrub before putting on sterile surgeon’s thoroughly address indications and techniques for gloves. For all types of hand hygiene products, follow hand hygiene practices before performing routine the product manufacturer’s label for instructions. Complete guidance on how and when hand hygiene For routine dental examinations and nonsurgical should be performed, including recommendations procedures, use water and plain soap (hand washing) regarding surgical hand antisepsis and artifcial nails or antimicrobial soap (hand antisepsis) specifc for can be found in the Guideline for Hand Hygiene in health care settings or use an alcohol-based hand rub. Use soap and water when hands are visibly other objects likely to be contaminated soiled. Examples include biopsy, periodontal surgery, apical surgery, implant surgery, and surgical extractions of teeth. Training should also stress preventing for Isolation Precautions (available at. The strategies target etiquette measures were added to Standard primarily patients and individuals accompanying Precautions in 2007. Provide resources for performing hand respiratory secretions in patients and hygiene in or near waiting areas. Ofer masks to coughing patients and and symptoms of a respiratory infection, other symptomatic persons when beginning at point of entry to the facility they enter the dental setting. Post signs at entrances with with symptoms of respiratory infections instructions to patients with symptoms to sit as far away from others as of respiratory infection to possible. Cover their mouths / noses wish to place these patients in a when coughing or sneezing. Perform hand hygiene after respiratory secretions to prevent the spread hands have been in contact of respiratory pathogens when examining with respiratory secretions. Most exposures in dentistry are hygienists, dental assistants) in identifying, evaluating preventable; therefore, each dental practice should and selecting devices with engineered safety features have policies and procedures available addressing at least annually and as they become available. Other work 9 practice controls include not bending or breaking and local regulated medical waste rules. Use either a one-handed scoop technique scalers, burs, lab knives, and wires) that or a mechanical device designed for are contaminated with patient blood holding the needle cap when recapping and saliva as potentially infective and needles. Place used disposable syringes and both hands or any other technique needles, scalpel blades, and other sharp that involves directing the point of a items in appropriate puncture-resistant needle toward any part of the body. Safe Injection Practices Safe injection practices are intended to prevent dental cartridge syringe is cleaned and heat sterilized transmission of infectious diseases between one between patients. Additional materials, including a list of frequently Safe injection practices were covered in the asked questions from providers and a patient Special Considerations section (Aseptic Technique notifcation toolkit, are also available. However, because of reports of is a public health efort to eliminate unsafe medical transmission of infectious diseases by inappropriate injections. To learn considers safe injection practices to be a formal more about safe injection practices and access training element of Standard Precautions. Complete guidance videos and resources, please visit on safe injection practices can be found in the 2007. If multidose vials will be used for more than one patient (this includes more than one patient, they should be manufactured preflled syringes and restricted to a centralized medication other devices such as insulin pens). Do not use single-dose (single-use) and discard within 28 days, unless medication vials, ampules, and bags the manufacturer specifes a shorter or bottles of intravenous solution or longer date for that opened vial. Ensure that the dental cartridge syringe is appropriately cleaned and heat sterilized before use on another patient. Each dental practice Note: Dental handpieces and associated should have policies and procedures in place for attachments, including low-speed motors and containing, transporting, and handling instruments reusable prophylaxis angles, should always be and equipment that may be contaminated with heat sterilized between patients and not high blood or body fuids. Although these for reprocessing reusable dental instruments and devices are considered semicritical, studies have equipment should be readily available— ideally in or shown that their internal surfaces can become near the reprocessing area. Use heat sterilized, the next patient may be exposed single-use devices for one patient only and dispose of to potentially infectious materials. Because these items vary by manufacturer and Critical items, such as surgical instruments their ability to be sterilized or high-level disinfected and periodontal scalers, are those used to also vary, refer to manufacturer instructions for penetrate soft tissue or bone. These items condensers, reusable dental impression trays) pose the least risk of transmission of infection. Protecting these surfaces with disposable Because the majority of semicritical items in barriers might be a preferred alternative. If other contamination are not removed, these materials none are available, it should, at a minimum, can shield microorganisms and potentially compromise 12 the disinfection or sterilization process. Automated timely information about the sterilization cycle than a cleaning equipment. A chemical indicator should be used inside disinfector) should be used to remove debris to every package to verify that the sterilizing agent. If the internal chemical indicator is should be inspected, wrapped, packaged, or placed not visible from the outside of the package, an external into container systems before heat sterilization. External indicators can Packages should be labeled to show the sterilizer used, be inspected immediately when removing packages the cycle or load number, the date of sterilization, and, from the sterilizer. Chemical help in retrieving processed items in the event of an indicators also help to diferentiate between processed instrument processing / sterilization failure. Multiparameter internal the sterilization process because they assess the chemical indicators are designed to react to sterilization process directly by killing known highly 2 parameters. A spore test should be used at least weekly and can provide a more reliable indication to monitor sterilizers. Maintaining Mechanical and chemical indicators do not accurate records ensures cycle parameters have been guarantee sterilization; however, they help detect met and establishes accountability. Wrapped Since these parameters can be observed during the packages of sterilized instruments should be sterilization cycle, this might be the frst indication of a inspected before opening and use to ensure the problem. The change color when exposed to high temperatures contents of any compromised packs should be or combinations of time and temperature. Chemical Recommendations for the cleaning, disinfection, monitoring results are obtained immediately following and sterilization of dental equipment can be found the sterilization cycle and therefore can provide more in the Guidelines for Infection Control in Dental 13 Health-Care Settings — 2003 (available at: Have manufacturer instructions instructions to ensure the efectiveness for reprocessing reusable dental of the sterilization process. Maintain instruments / equipment readily available, sterilization records in accordance ideally in or near the reprocessing area.

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Pain fare (an increase in pain in the treatment area during or shortly after radiation) occurs in some people hiv infection rates china valtrex 1000 mg with mastercard. Please let any member of your treatment team know if you have any problems with your pain control symptoms of hiv infection in toddlers buy 1000mg valtrex otc. You will begin to antiviral therapy journal best order valtrex notice hair loss 1-2 weeks after your radiation treatment is over hiv infection rate with condom purchase valtrex pills in toronto. Sometimes patients are prescribed an anti-nausea (anti-emetic) medication to be taken before each radiation treatment. If you develop more than two or three loose watery bowel movements per day, tell your health care provider. Most side effects of your treatment are short-lived and can be managed by medication(s) given to you by your doctor. You may have radiotherapy more than once in the same spot to help reduce your pain. Your doctor will discuss whether repeat radiotherapy is possible and what other treatment options you have (for example, further medications, surgery or chemotherapy). It can be used for certain patients with bone metastases in the spine as a way to provide more radiation to the specifc area while sparing normal tissues from high doses of radiation. Special imaging is used each day on the radiation machine to make sure the tumour is targeted accurately. More detailed instructions will be provided by the physician or nurse involved with the procedure. The pain may get slightly worse before getting better (pain fare), and you may need some pain medications. If radiated near the head region, then you may get some pain when swallowing or discomfort in the throat or cough. If radiated in the lower back, you may get some nausea or stomach upset or loose bowels. Surgery may be possible to fx broken bones or strengthen weakened bones to prevent this. Image shows hip fracture Image shows hip stabilized with metal rods by surgery 3030 Percutaneous Vertebroplasty: What is Percutaneous Vertebroplasty used for When standing upright, the spinal column supports the weight of the body, which means that the vertebrae have a lot of pressure on them. If a vertebra is weakened for some reason, the weight Cracks of the body can cause it to crack. There is no cutting, the patient is not asleep but sedated, and it does not usually require an overnight hospital stay. People who have 3131 vertebroplasty generally come to the hospital in the morning and leave for home in the afternoon. More detailed instructions will be provided by the doctor or nurse involved with the procedure. The next page will illustrate how a small balloon is introduced into the gap in the bone by a needle. The Infatable Bone Tamp (needle with balloon) is inserted into the fractured vertebral body the balloon is infated, restoring vertebral body height, and making a hole in the vertebral body 3333 the hole is flled with bone cement. Since every patient’s condition is unique, the side effects will be different for each patient. Cementoplasty: Cementoplasty is the stabilization of a bone anywhere else in the body by cement injection. This procedure can often lead to signifcant pain relief and improved mobility of the treated area within 24 hours. The goals of these therapies are to control tumour growth, reduce pain, and reduce the risks of bone fractures. Your doctor will describe the best treatment options for your situation and what possible side effects you might expect. They are medications that may help strengthen the bone, reduce pain, and reduce the possibility of the bone breaking. Bisphosphonates are used for certain stages of breast, multiple myeloma, lung and prostate cancers. Some examples of commonly used bisphosphonates used in the treatment of bone metastases are: Pamidronate (Aredia, Pamidronate Injection) and zoledronic acid (Zometa). Clodronate (Bonefos, Ostac, Clasteon) is a less commonly used bisphosphonate that is taken by mouth. Bisphosphonates including zoledronic acid, pamidronate, ibandronate, and clodronate reduce bone thinning in patients with bone metastases, delay the onset and reduce the risk of bone complications in multiple tumour types by 31% to 58%. They might include an upset stomach in the case of clodronate, and short-lived fu-like symptoms in the case of pamidronate and zoledronic acid. Bisphosphonates are given as often as needed and as long 3636 as your doctor thinks is best for you. You might be given instructions to take calcium and vitamin D supplements during treatment with bisphosphonates. Report any of these signs to your doctor or nurse: • Feeling sick to your stomach • Pain or swelling in the vein in your arm • Muscle stiffness • Confusion • Thirst • Change in how your foods taste • Pain when swallowing • Jaw pain 4. It is often recommended to see a dentist before starting bisphosphonates to make sure your jaw is healthy How long do I have to take Bisphosphonates Your doctor may prescribe bisphosphonates when metastases are frst found in your body or when your bone metastases cause pain. You may take them for several months or as long as your doctor thinks is best for you. Please see the pain section (page 41) for guidance on how to take your pain medications to give you the best pain relief possible. Other Therapies: Apart from the listed therapies and physiotherapy, occupational therapy and psychotherapy, there are complementary and alternative therapies that may be available to you through the community. Please be sure to check with your physician or nurse before beginning any of these therapies. Other forms of support are art and music therapy, support groups, relaxation therapy, spiritual therapy and exercise programs. Please refer to the He a l t H Ca r e the a m and re s o u r C e sections of the book for more details and contact information. New Advances: Please note, not all of these treatment options may be available at each cancer centre. The treatment of cancer that has spread to the spine (or "vertebrae") is often a multidisciplinary one. However, radiation or chemotherapy may additionally reduce the tumour size in the bone. Bisphosphonate therapy (similar to the drugs used in the treatment of osteoporosis or brittle bone) has also been of tremendous value in reducing bony pain. Patients who have not previously been considered for surgery may now have that option. Additionally, we are now able to apply a much higher dose of radiation safely using "radiosurgery" in some situations. This allows us to target the radiation to the disease and to spare as much healthy, critical parts of the body as possible, such as the spinal cord. Your cancer health care team will discuss with you which is the best available treatment option. In this section, we will describe the information about pain that is specifc to bone metastases, different pain management options, myths about medications, how to use a pain diary, and some tips on how to handle some side effects of medications. Pain from Bone Metastases Bone metastases can cause pain that may become worse with certain movements. Patients with bone pain often describe it as a "dull aching" pain at rest and a “sharp” pain with movement. Bone pain tends to be located right over the area of the bone that is involved or may be referred to nearby parts of the body. Some facts about you and your pain: • Your pain is unique to you • Your pain is whatever you say it is • Your pain can be managed • Managing your pain will improve your quality of life What different pain management options are there Examples include opioids, anti-infammatories, and medications for nerve type pain.

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