DOCSLIB.ORG

Geriatric Rheumatology: a Comprehensive Approach Encourages You to Think from the Older Patient’S Perspective

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Geriatric Rheumatology: a Comprehensive Approach Encourages You to Think from the Older Patient’S Perspective Geriatric Rheumatology wwwwwwwwwwwwwwwwwwwwww Yuri Nakasato • Raymond L. Yung Editors Geriatric Rheumatology A Comprehensive Approach Editors Yuri Nakasato Raymond L. Yung Sanford Health Systems Department of Internal Medicine Fargo, ND, USA University of Michigan [email protected] Ann Arbor, Michigan, USA [email protected] ISBN 978-1-4419-5791-7 e-ISBN 978-1-4419-5792-4 DOI 10.1007/978-1-4419-5792-4 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011928680 © Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Preface It is our pleasure to introduce an exciting new textbook that provides a much-needed and different perspective on rheumatology. Our outstanding contributors have put in a lot of effort and thought delving into the aging process per se, the older population, and how they affect the future of rheumatology. Let face it, our patient population is aging. Although patients over 65 years of age still compose around 15% of the total population, they are consuming about 50% of rheumatology resources. Innovative ways of doing research, patient care, education, and policy need to be addressed in order to improve quality of care, patient satisfaction, and the safety of our older population. Multi-disciplinary teams have always been the hallmark of geriatrics but they are cost- prohibitive in times of healthcare system reforms and social changes. As the age of retirement increases, it is crucial to keep the older patient with rheumatic conditions functional or – even better – active in the work force. We invite you to continue thinking in new terms and adapt to their needs, considering new models that are economically sustainable. Patients with rheumatic diseases are getting older and attaining closer-to-normal popula- tion life expectancies. On the other hand, patients without rheumatic diseases are living longer too, thanks to improved therapies and advances in public health. This allows the development of a variety of elderly onset rheumatic diseases with often atypical presentations. Furthermore, immunosenescence complicates the geriatric rheumatology panorama with a combination of suppressed immune responses, low-grade chronic inflammatory reactions (also calledinflamm- aging), and clinically non-significant autoantibodies that raise questions and puzzle even the more reputable experts. Moreover, uncontrolled inflammatory autoimmune conditions accele- rate atherosclerosis and may give the false impression of an equally accelerated intrinsic aging, since morbidity and aging both decrease the physiological reserves. Older patients present to rheumatologists with a milieu of baseline co-morbidities. This fact has highlighted the need to group rheumatologic with non-rheumatologic diseases such as diabetes, hypertension, atrial fibrillation, and cardiovascular diseases in the future. For exam- ple, it is starkly different to treat a patient with polymyalgia rheumatica and uncontrolled diabetes than a patient without diabetes. Until older rheumatic disease patients with multiple co-morbid conditions are included in clinical trials, it will be impossible to have high quality evidence-based treatment guidelines for the older arthritis patients. Different specialists have created a pharmacological vicious cycle by prescribing increas- ingly more medications; once the number of medications reaches the double digits, sophisti- cated drug inventory management techniques may be required. Older patients are known to have voluntary or involuntary compliance problems; drug cost, dementia, and visual problems are the main issues. Medications are justified but at times, they are not withdrawn promptly when the acute problem subsides, creating a list of necessary and unnecessary medications. As a consequence, the cycle is closed by a new round of problems attributed to medications, such as peptic ulcer disease (due to nonsteroidal anti-inflammatory agents [NSAIDs]), gas- trointestinal bleeding (due to medications interacting with Coumadin), falls with fractures v vi Preface (due to narcotics or psychotropic medications), infections (due to immunosuppressive therapy), or heart diseases (related to NSAIDs or anti-TNF [tumor necrosis factor] agents). The cache of biological therapies available to rheumatologists is ever expanding. Simultaneously, they are creating reactivation of old diseases (such as fungal invasive infec- tions and tuberculosis or herpes zoster), malignancies such as lymphoma, or new autoimmune diseases (drug-induced lupus). Surveillance, vaccination, and early diagnosis are becoming the rule rather than the exception. The question rheumatologists constantly face is whether to be aggressive or more conservative when treating the older patient. The focus of elder care is on cure (if possible), improvement in quality of life, rehabilitation, and palliative care. Some older patients and their families are coming to the clinic with new expectations of cure as they are better-informed, but they may also be confused due to the overwhelming amount of unfiltered internet information. Ultrasound technology controlled by rheumatologists is already at full swing in Europe, and it is becoming the new joint-stethoscope for rheumatologists around the world. Providers are enhancing their physical examination skills and becoming more precise and efficient doing procedures. Older patients with dementia, or those unable to talk due to hospitalization or delirium, can be examined by use of ultrasound for synovitis or fluid in unexpected areas for diagnostic arthrocentesis to allow prompt therapy and prevent unnecessary treatments. The health-care landscape is rapidly changing and the average age of rheumatologists is also rising. Much of rheumatology practice takes place in the outpatient setting. Instead of see- ing the patient in the hospital for a secondary consultation, patients may be discharged home with the expectation that they will be seen promptly in the rheumatology clinic. While Internal Medicine is undergoing a hospitalist movement, primary care overall is shifting to advanced practice providers, increasing demand for rheumatology consultations. The older patient is trapped in the midst of all these changes; our book Geriatric Rheumatology: A Comprehensive Approach encourages you to think from the older patient’s perspective. Fargo, ND Yuri Nakasato Ann Arbor, MI Raymond L. Yung Contents Part I Aging and Comorbidity in Rheumatology 1 The Immune System in Aging ................................................................................. 3 Anjali Desai and Raymond L. Yung 2 Bone Aging ................................................................................................................ 11 Arthur N. Lau and Jonathan D. Adachi 3 Atherosclerosis in the Rheumatic Diseases: Compounding the Age Risk .......... 17 Naoto Yokogawa and Joan M. Von Feldt 4 Neuropsychiatric Manifestations of Rheumatic Diseases in the Elderly ............ 27 Jamal A. Mikdashi 5 Tuberculosis and Rheumatoid Arthritis in the Elderly ........................................ 35 Eduardo M. Acevedo-Vásquez, Darío Ponce de León, and Rocío V. Gamboa-Cárdenas 6 Widespread Pain in Older Adults ........................................................................... 45 Cheryl D. Bernstein, Jordan F. Karp, and Debra K. Weiner Part II Multidisciplinary Approach to Geriatric Rheumatology 7 Pharmacotherapy Considerations Unique to the Older Patient .......................... 59 Keith A. Swanson and Mark A. Stratton 8 Rheumatic Disease in the Nursing Home Patient ................................................. 73 Joanne Sandberg-Cook 9 Post-acute Care for Rheumatologists ..................................................................... 79 Deborah W. Robin 10 The Gerontorheumatology Outpatient Service: Toward an International Classification of Function-Based Health Care Provision for the Elderly with Musculoskeletal Conditions ............................................................................ 85 Wim Van Lankveld, Josien Goossens, and Marcel Franssen 11 Health Policy, Public Health, and Arthritis Among Older Adults ...................... 93 Kristina A. Theis, Debra R. Lubar, and Teresa J. Brady 12 Physical Therapy Management of Select Rheumatic Conditions in Older Adults ........................................................................................................
Load more

Recommended publications
  • ADESIONE ALLE TERAPIE a LUNGO TERMINE Problemi E Possibili Soluzioni
    ADESIONE ALLE TERAPIE A LUNGO TERMINE problemi e possibili soluzioni Published by the World Health Organization in 2003 under the title Adherence to long term therapies: Evidence for action © World Health Organization 2003 The Director-General of the World Health Organization has granted translation rights for an edition in Italian to Critical Medicine Publishing s.r.l., which is solely responsible for the italian edition. Edizione italiana a cura di E. Grossi Tutti i diritti riservati. Nessuna parte di questa pubblicazione può essere riprodotta o trasmessa in alcuna forma o con alcun mezzo, compresa la registrazione o le fotocopie, senza il permesso scritto dell’editore. © 2006 - Critical Medicine Publishing Editore 00143 Roma - Via G. Squarcina, 3 - Tel. 06.51951.1 www.cmpedizioni.it Realizzazione grafica e stampa: Istituto Arti Grafiche Mengarelli - Roma ISBN 88-88415-25-4 Questa pubblicazione, realizzata con la collaborazione di Bracco S.p.A. è offerta in omaggio ai sigg. Medici Indice Sezione I Disegnare lo scenario 19 Capitolo I Definire il concetto di adesione ai trattamenti 21 Capitolo II Le dimensioni del problema della scarsa adesione ai trattamenti 27 Capitolo III Come può la scarsa adesione ai trattamenti interessare politici e manager della sanità? 31 SEZIONE II Migliorare l’adesione ai trattamenti: una guida per i paesi 37 Capitolo IV Le lezioni apprese 39 Capitolo V Verso la soluzione 51 Capitolo VI Come può il miglioramento dell’adesione ai trattamenti tradursi in benefici economici e per la salute? 71 SEZIONE III Review
    [Show full text]
  • Absolute Risk, 252 Acetabular Dysplasia, 38, 211, 213 Acetabular Protrusion, 38 Achondroplasia, 195, 197, 199–200, 205 Genetic
    Cambridge University Press 978-0-521-86137-3 - Palaeopathology Tony Waldron Index More information Index absolute risk, 252 angular kyphosis acetabular dysplasia, 38, 211, 213 in Scheuermann’s disease, 45 acetabular protrusion, 38 in tuberculosis, 93–4 achondroplasia, 195, 197, 199–200, 205 ankylosing spondylitis, 57–60, 65 genetic defect in, 199 ankylosis in, 58 skeletal changes in, 200 bamboo spine in, 59 acoustic neuroma, 229–31 erosions in, 59 acromegaly, 78, 207–8 first description, 57 and DISH, 208 HLA B27 58 and, skeletal changes in, 208 operational definition of, 59 acromelia, 198 prevalence of, 58 aDNA sacroiliitis and, 59 in leprosy, 101 skip lesions in, 59 in syphilis, 108 ankylosis, 51 in tuberculosis, 92, 95–6 following fracture, 146 Albers-Schonberg˝ disease, see in ankylosing spondylitis, 58 osteopetrosis in brucellosis, 96 Alstrom syndrome, 78 in DISH, 73 alveolar margin, see periodontal disease in erosive osteoarthritis, 55 amputation, 158–61 in rheumatoid arthritis, 51 indications for, 160–1 in septic arthritis, 89 ancient DNA, see aDNA in tuberculosis, 93–4 anaemia, 136–7 annulus fibrosus, 42–3, 45 cribra obitalia and, 136–7 ante-mortem tooth loss, 238–9 aneurysms, 224–7 and periodontal disease, 238–9 aortic, 224–5 and scurvy, 132 and syphilis, 224 causes of, 238 of vertebral artery, 225–6 anterior longitudinal ligament popliteal, 226 in ankylosing spondylitis, 59 aneurysmal bone cyst, 177 in DISH, 73 angiosarcoma, 182 anti-CCP antibodies, 49, 53 © Cambridge University Press www.cambridge.org Cambridge University Press
    [Show full text]
  • Provocative Discography 4 5 Irina Melnik , Richard Derby , and Ray M
    Provocative Discography 4 5 Irina Melnik , Richard Derby , and Ray M. Baker Key Points • Technical challenges, potential complications, and • Discography is an invasive diagnostic procedure interpretation mistakes can be avoided with proper not intended to be an initial screening examination selection of patients, including favorable psycho- due to associated potential risk to a patient. logical pro fi ling, use of sterile technique, intravenous • It is a con fi rmatory test, which can reveal the true and intradiscal antibiotics, judicious use of sedation, source of pain and thus leads to precise and effec- and good technical training of a practitioner. tive treatment as well as might help patients to avoid • Emerging alternative approaches including anes- unnecessary surgical interventions. thetic discography and functional discography are • The value of the test is not only in providing morpho- gaining attention, as well as noninvasive MRI spec- logic characteristics of the disc structure and degrees troscopy and other imaging tests, as an attempt to of internal annular disc disrupture but also in providing provide similar clinical information without putting unique clinical information by potentially evoking patients at a potential short- or long-term risk. patients typical/concordant pain and con fi rming a speci fi c level of the painful disc. • As a provocative test, discography is liable to false- positive results, which can be potentially avoided Introduction by adherence to strict operational standards and interpretation criteria, including pain ³ 7/10, pres- Discography was introduced in the 1940s to diagnose her- sure <50 psi a.o. , concordant pain, ³ grade 3 annu- niation and internal annular disruption of the lumbar and lar tear, volume £ 3.5 mL, and the presence of a subsequently cervical and thoracic intervertebral discs [ 1, 2 ] .
    [Show full text]
  • Q2 2020 Trend Highlights
    2020 Mid-Year THETHE STSTAATETE OFOF THETHE HOTHOT 100 100 TOPTOP 1010 SELECT HIGHLIGHTS Compositional and Industry Trends for the Billboard Hot 100 Top 10 The State of the Hot 100 Top 10 takes an in-depth look at Q1 and Q2 2020's compositional and industry-related trends for the Billboard Hot 100 Top 10. What follows are a few select highlights from the report. SONGS..............................................................................................................................................................PAGE 2 PERFORMING ARTISTS.........................................................................................................................PAGE 3 SONGWRITERS...........................................................................................................................................PAGE 6 PRODUCERS.................................................................................................................................................PAGE 10 RECORD LABELS.......................................................................................................................................PAGE 13 #1 SPOTLIGHT..............................................................................................................................................PAGE 16 2019 VS. 2020 COMPOSITIONAL TRENDS.............................................................................PAGE 20 Data is for songs that charted in the Billboard Hot 100 Top 10 and excludes holiday songs. Data related to compositional characteristics
    [Show full text]
  • Imaging in Gout and Other Crystal-Related Arthropathies 625
    ImaginginGoutand Other Crystal-Related Arthropathies a, b Patrick Omoumi, MD, MSc, PhD *, Pascal Zufferey, MD , c b Jacques Malghem, MD , Alexander So, FRCP, PhD KEYWORDS Gout Crystal arthropathy Calcification Imaging Radiography Ultrasound Dual-energy CT MRI KEY POINTS Crystal deposits in and around the joints are common and most often encountered as inci- dental imaging findings in asymptomatic patients. In the chronic setting, imaging features of crystal arthropathies are usually characteristic and allow the differentiation of the type of crystal arthropathy, whereas in the acute phase and in early stages, imaging signs are often nonspecific, and the final diagnosis still relies on the analysis of synovial fluid. Radiography remains the primary imaging tool in the workup of these conditions; ultra- sound has been playing an increasing role for superficially located crystal-induced ar- thropathies, and computerized tomography (CT) is a nice complement to radiography for deeper sites. When performed in the acute stage, MRI may show severe inflammatory changes that could be misleading; correlation to radiographs or CT should help to distinguish crystal arthropathies from infectious or tumoral conditions. Dual-energy CT is a promising tool for the characterization of crystal arthropathies, partic- ularly gout as it permits a quantitative assessment of deposits, and may help in the follow-up of patients. INTRODUCTION The deposition of microcrystals within and around the joint is a common phenomenon. Intra-articular microcrystals
    [Show full text]
  • Psoriasis, Psoriatic Arthritis and Secondary Gout – 3 Case Reports
    https://doi.org/10.5272/jimab.2018242.1972 Journal of IMAB Journal of IMAB - Annual Proceeding (Scientific Papers). 2018 Apr-Jun;24(2) ISSN: 1312-773X https://www.journal-imab-bg.org Case report PSORIASIS, PSORIATIC ARTHRITIS AND SECONDARY GOUT – 3 CASE REPORTS Mina I. Ivanova, Rositsa Karalilova, Zguro Batalov. Departement of Rheumatology, Faculty of Medicine, UMHAT Kaspela, Medical University - Plovdiv, Bulgaria. ABSTRACT: cells in the skin (Langerhans cells) migrate to the regional Background: One of the most common complica- lymph nodes, where interacts with T-lymphocytes. This tions in psoriasis is the development of secondary gout that provokes the immune response leading to the activation often remains undiagnosed for many years. In some cases, of T cells and release of cytokines. The local effects of the clinical symptoms of gout precede the manifestation cytokines lead to a cell-mediated immune response. In pso- of cutaneous psoriasis, leading to progression of the dis- riasis skin lesions are results of hyperplasia of the epider- ease and early onset of complications. According to the mis, which leads to enhanced cell reproduction, world data, there is a strong correlation between psoriasis hyperproliferation and at the same time shortening vulgaris and psoriatic arthritis on the one hand and gout keratinocytes’ life. This leads to increased production of on the other ranging from 3 to 40%. In Bulgaria, there are uric acid, as it enhances the exchange of nucleic acids. no studies observing the frequency of secondary gout in Psoriatic arthritis (PsA) occurs in 0.05 to 0.25% from psoriatic patients. the general population.
    [Show full text]
  • Human Rights Constitutionalism in Japan and Asia
    Page 1 Human Rights Constitutionalism in Japan and Asia The Writings of Lawrence W. Beer Lawrence Ward Beer was born in Portland, Oregon on May 11, 1932. In 1966 he received the Ph.D. degree from the University of Washington, Seattle. In over fifty years of studying the constitutional law and politics of Japan and other Asian countries, he has written and lectured extensively on human rights law (e.g., Freedom of Expression in Japan, 1984). He taught at the University of Colorado, Boulder, 1966–1982, and was F.M. Kirby Professor of Civil Rights, Lafayette College, 1982–1997. Lawrence W. Beer has chaired the Committee on Asian Law of the Association for Asian Studies and the World Association of Law Professors of the World Peace through Law Center. He received the Distinguished Asianist Award of the Mid-Atlantic Association for Asian Studies in 2003. In retirement, he lives with his wife Keiko in Boulder, Colorado, USA. Less noticed in the West than wars, terrorism and economic trends has been the historic develop- ment since World War II of constitutional government and law in Asia. Lawrence W. Beer has been a close observer of Asian linkages among law, politics, culture, and national security issues for over fifty years. His perspectives have been refined during long residence in Asia, especially Japan, by substantial friendly interactions with Asian legal scholars, judges and attorneys involved in the world of human rights constitutional law. This volume, which will be widely welcomed by students and researchers, brings together a selection of Lawrence W. Beer’s many works previously published in diverse venues, but no longer easily accessible.
    [Show full text]
  • Chiropractic and Spinal Research
    TABLE OF CONTENTS Dedication ......................................................................................................7 Introduction ...................................................................................................9 Is Chiropractic A Treatment For Disease? ................................................ 11 Chiropractic And Musculoskeletal Conditions.........................................12 Cost-Benefit of Chiropractic ......................................................................13 Acknowledgement .......................................................................................14 Spinal Care and its Effects on Human Physiology in Sickness and in Health...........................................................................................................17 Allergies, Sinus Trouble ..............................................................................18 Anorexia Nervosa ........................................................................................19 Arnold-Chiari Malformation .....................................................................20 Arthritis/Reversal of Arthritis ...................................................................20 Asthma .........................................................................................................23 Attention Deficit Disorder and Hyperactivity ..........................................29 Autism, Behavioral And Learning Disorders ...........................................34 Bed-Wetting .................................................................................................38
    [Show full text]
  • Treatment for Acute Pain: an Evidence Map Technical Brief Number 33
    Technical Brief Number 33 R Treatment for Acute Pain: An Evidence Map Technical Brief Number 33 Treatment for Acute Pain: An Evidence Map Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No. 290-2015-0000-81 Prepared by: Minnesota Evidence-based Practice Center Minneapolis, MN Investigators: Michelle Brasure, Ph.D., M.S.P.H., M.L.I.S. Victoria A. Nelson, M.Sc. Shellina Scheiner, PharmD, B.C.G.P. Mary L. Forte, Ph.D., D.C. Mary Butler, Ph.D., M.B.A. Sanket Nagarkar, D.D.S., M.P.H. Jayati Saha, Ph.D. Timothy J. Wilt, M.D., M.P.H. AHRQ Publication No. 19(20)-EHC022-EF October 2019 Key Messages Purpose of review The purpose of this evidence map is to provide a high-level overview of the current guidelines and systematic reviews on pharmacologic and nonpharmacologic treatments for acute pain. We map the evidence for several acute pain conditions including postoperative pain, dental pain, neck pain, back pain, renal colic, acute migraine, and sickle cell crisis. Improved understanding of the interventions studied for each of these acute pain conditions will provide insight on which topics are ready for comprehensive comparative effectiveness review. Key messages • Few systematic reviews provide a comprehensive rigorous assessment of all potential interventions, including nondrug interventions, to treat pain attributable to each acute pain condition. Acute pain conditions that may need a comprehensive systematic review or overview of systematic reviews include postoperative postdischarge pain, acute back pain, acute neck pain, renal colic, and acute migraine.
    [Show full text]
  • Crystal Deposition in Joints: Prevalence and Relevance for Arthritis
    Editorial Crystal Deposition in Joints: Prevalence and Relevance for Arthritis Within the present world of arthritis research and practice, surfaces as one manifestation of systemic urate metabolism investigators of crystal-associated arthritis appear to be a disorders13. While MSU crystals deposit on cartilage sur- small, aging, and dwindling endangered species whose faces, these crystals can accumulate and erode into carti- interests are seen to be peripheral to those of most rheuma- lage. In contrast, CPPD crystal deposition is restricted to tologists. This contrasts dramatically with the high preva- hyaline and fibrocartilages and reflects a metabolic disorder lence of these diseases1,2. Both gout [urate crystal within cartilage itself14. While CPPD crystals have been (monosodium urate, MSU) arthropathy] and pseudogout said to form principally in cartilage mid-zone, this study [calcium pyrophosphate dihydrate (CPPD) crystal arthropa- and our own unpublished observations show that CPPD thy] are common and distinct forms of arthritis that were crystals can form in hyaline cartilage superficial zones, distinguished and characterized clinically decades ago3-7. It within the cartilage surface and sometimes without deeper is easy to speculate on the reasons for the current clinical underlying deposits. MSU and CPPD crystal deposits on lack of interest. These include: specific therapy for gout, cartilage surfaces cannot be distinguished from each other absence of specific therapy for pseudogout, and blurring of by the naked eye. However, these crystals can be identified the clinical distinction between these diseases and by experienced observers using compensated polarized osteoarthritis (OA). It is an important but separate issue that light microscopy or by more elaborate methods such as OA itself, as a clinical disease descriptor, encompasses a Fourier transform infra-red spectroscopy or powder x-ray or wide range of diseases, distinguished only sometimes as pri- electron diffraction.
    [Show full text]
  • Arthritis and Other Rheumatic Disorders ICD-9-CM to ICD-10-CM Estimated Crosswalk
    AORC ICD-9-CM to ICD-10-CM Conversion Codes Arthritis and Other Rheumatic Disorders ICD-9-CM to ICD-10-CM Estimated Crosswalk ICD-9-CM ICD-10-CM Osteoarthritis and allied disorders 715 Osteoarthrosis generalized, site unspecified M15.0 Primary generalized (osteo)arthritis M15.9 Polyosteoarthritis, unspecified 715.04 Osteoarthrosis, generalized, hand M15.1 Heberden's nodes (with arthropathy) M15.2 Bouchard's nodes (with arthropathy) 715.09 Osteoarthrosis, generalized, multiple sites M15.0 Primary generalized (osteo)arthritis 715.1 Osteoarthrosis, localized, primary, site unspecified M19.91 Primary osteoarthritis, unspecified site 715.11 Osteoarthrosis, localized, primary, shoulder region M19.019 Primary osteoarthritis, unspecified shoulder 715.12 Osteoarthrosis, localized, primary, upper arm M19.029 Primary osteoarthritis, unspecified elbow 715.13 Osteoarthrosis, localized, primary, forearm M19.039 Primary osteoarthritis, unspecified wrist 715.14 Osteoarthrosis, localized, primary, hand M19.049 Primary osteoarthritis, unspecified hand 715.15 Osteoarthrosis, localized, primary, pelvic region and thigh M16.10 Unilateral primary osteoarthritis, unspecified hip 715.16 Osteoarthrosis, localized, primary, lower leg M17.10 Unilateral primary osteoarthritis, unspecified knee 715.17 Osteoarthrosis, localized, primary, ankle and foot M19.079 Primary osteoarthritis, unspecified ankle and foot 715.18 Osteoarthrosis, localized, primary, other specified sites M19.91 Primary osteoarthritis, unspecified site 715.2 Osteoarthrosis, localized, secondary,
    [Show full text]
  • Communal Pastoral Counselling: Culturally Gifted Care-Giving in Times of Family Pain—A Vhavenda Perspective
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Unisa Institutional Repository COMMUNAL PASTORAL COUNSELLING: CULTURALLY GIFTED CARE-GIVING IN TIMES OF FAMILY PAIN—A VHAVENDA PERSPECTIVE BY DEMBE REUBEN PHASWANA Submitted in accordance with the requirements for the degree of DOCTOR OF THEOLOGY in the subject PRACTICAL THEOLOGY at the UNIVERSITY OF SOUTH AFRICA PROMOTER: DR. M E HESTENES NOVEMBER 2008 ……………… a DECLARATION I Dembe Reuben Phaswana, student number: 0421 588 – 5 declare that COMMUNAL PASTORAL COUNSELLING: CULTURALLY GIFTED CARE-GIVING IN TIMES OF FAMILY PAIN—A VHAVENDA PERSPECTIVE is my own work and that all other sources that I have used or quoted have been indicated and acknowledged by means of complete references. __________________________ _____________________ DR PHASWANA _____________ DATE ______________ b ACKNOWLEDGEMENTS This thesis is the illustration of communal endeavour. Without the communal involvement I wouldn’t have started and submitted this thesis. I thank God All Mighty, the Father of our Lord Jesus Christ. He is big, and I am small. It reminds me of a trip of an elephant and mouse crossing the bridge. After crossing the bridge the mouse commented, “Did you hear how we shake that bridge?” The elephant agreed that they did shake the bridge, while the real shaking was done by the elephant. In this project God is the one that did the real shaking. “Soli Deo Gloria!” My thanks go to my promoter Dr. M.E. Hestenes. He gave me encouragement from the first day. As I keep on writing and rewriting he was reading and rereading with encouraging comments.
    [Show full text]