This patient has experienced cardiogenic shock arteria hepatica diovan 80mg generic, as evidenced by his hypotension (systolic blood pressure <90 mm Hg) after a myocardial infarction hypertension 160100 diovan 40 mg lowest price. This has led to decreased renal perfusion blood pressure khan academy purchase diovan 160mg with amex, which has arrhythmia 29 years old purchase 40 mg diovan otc, in turn blood pressure high bottom number order diovan 160 mg without a prescription, led to prerenal failure white coat hypertension xanax purchase diovan 40 mg without a prescription. When the glomerular filtration rate drops, there is an increase in sodium and water reabsorption in the proximal tubule. This leads to an increase in tubular urea concentration, which favors increased reabsorption of urea. It would present with pain on urination and is unlikely in the setting of cardiogenic shock. Signs and symptoms include rash, fever, eosinophilia, eosinophiluria, and elevated IgE levels. Urine output is controlled mainly by two factors: the hydration state of the body and the level of kidney function. Therefore, low urine output is seen only in the setting of dehydration or kidney dysfunction. Stress by itself will not cause low urine output unless it is coupled with dehydration or an acute renal disease process. Acute poststreptococcal glomerulonephritis is an autoimmune disease most frequently seen in children. Under light microscopy, the glomeruli appear enlarged and hypercellular, with neutrophils and subepithelial immune complex depositions described as "lumpy-bumpy. This condition normally presents a few weeks after a streptococcal infection with peripheral and periorbital edema, dark urine, and proteinuria. These symptoms are caused by circulating antistreptococcal antibody-antigen complexes that deposit in the glomerular basement membrane, leading to complement activation and glomerular damage. Linear subendothelial patterns are seen in vasculitides such as Goodpasture syndrome. The patient described in this vignette has hepatorenal syndrome, which is a progressive functional renal failure caused by a reduction in the glomerular filtration rate due to declining hepatic function. It is characterized by splanchnic vasodilation and concomitant vasoconstriction in the renal vascular beds due to the production of mediators and to the activation of the reninangiotensin system. The combination of these two factors causes a prerenal type azotemia that develops, most commonly, without severe oliguria. One of the features of hepatorenal syndrome is that kidney anatomy is completely unaffected, and thus visualization of the kidneys by most modalities would reveal normal size and shape. Enlarged cystic kidneys can be a feature of polycystic kidney disease, but usually do not present with prerenal azotemia. Enlarged kidneys with hydronephrosis can be caused by obstruction from stones in the renal calyx or ureters. However, the other clinical findings in this patient implicate a hepatorenal (prerenal) cause of renal failure. Horseshoe kidney is a pediatric abnormality that is generally asymptomatic if not associated with other abnormalities. Horseshoe kidneys are caused by the embryonic blastemas (embryonic kidneys) partially fusing at their inferior poles and becoming trapped against the inferior mesenteric artery during their migration. A flea-bitten appearance in kidneys is usually seen in patients with malignant hypertension. The antibodies can also deposit in the alveolar basement membranes, resulting in hemoptysis. Because this condition may rapidly lead to a compromised airway or declining kidney function, immediate airway protection, plasmapheresis (to remove the autoantibodies from circulation), and treatment with corticosteroids and cyclophosphamide is indicated. Poststreptococcal glomerulonephritis typically affects 2-14 year olds who have recently suffered from either impetigo or pharyngitis caused by particular M types of streptococci (nephritogenic strains). Poststreptococcal glomerulonephritis is an immune-mediated disease that develops twosix weeks after skin infection and one-three weeks after streptococcal pharyngitis. Patients with this syndrome usually present in childhood with a combination of ocular defects, deafness, and hematuria. Berger disease, otherwise known as IgA nephropathy, is the most common cause of glomerulonephritis worldwide. It is caused by the deposition of IgA antibodies in the mesangium of the kidney and is often triggered by a recent upper respiratory infection. Classically patients with Berger disease present with new onset frank hematuria, usually within days of an upper respiratory tract infection. Although the hematuria may persist for several days, renal function usually remains normal, and the long-term prognosis is relatively favorable. The pathophysiology of this lesion is uncertain, although most agree there is a circulating cytokine that alters capillary charge and podocyte integrity. The patient most likely has hypertension as a result of the unilateral stenosis of a renal artery. Renal artery stenosis is usually caused by atherosclerosis or fibromuscular dysplasia, and the affected kidney usually becomes atrophic. The decreased perfusion of the kidney causes juxtaglomerular cells to release renin, which cleaves angiotensinogen into angiotensin I. Cushing syndrome, which can be of pituitary or adrenal origin, is marked by the excessive production of cortisol, which can cause hypertension. The only diuretics acting along the thick ascending limb of the nephron are loop agents (eg, furosemide, torsemide, ethacrynic acid). It is worth noting that ethacrynic acid is unique because it is not a sulfonamide and therefore can be used in individuals with an allergy to sulfa drugs. Acetazolamide, which acts in the proximal convoluted tubule, blocks resorption of sodium bicarbonate. Hydrochlorothiazide inhibits sodium chloride resorption in the early distal tubule. Osmotic agents act in three places along the nephron: the proximal convoluted tubule, the thin descending limb, and the collecting tubule. Triamterene, a potassium-sparing diuretic, blocks sodium channels in the cortical collecting tubule. A 29-year-old woman presents to the gynecologist complaining of a "fishy"-smelling vaginal odor noticeable during intercourse. Pelvic examination reveals a homogenous gray-white discharge, and a saline wet mount of vaginal epithelial cells is obtained (see image). Her medical history is significant for hyperlipidemia treated with simvastatin, and her only surgery was an appendectomy at age 21. Her family history is significant for an aunt who had breast cancer diagnosed at age 36, and a cousin with breast cancer diagnosed at age 29. On social history, she reports being happily married, never having had any children, drinking one-two glasses of wine every evening, and smoking about five cigarettes a week. The patient is concerned, and asks about the chances the mass could represent breast cancer. She has a history of multiple sexual partners but has been married and faithful to her husband for the last three years. Which of the following best characterizes the organism most likely predisposed this woman to her current clinical picture A 29-year-old woman in her third trimester of pregnancy is brought by her husband to the emergency department with contractions. The husband informs the nurse that "her physician said something about being at risk for seizures. Which of the following is associated with the drug this patient most likely received A 29-year-old African-American woman with menometrorrhagia undergoes ultrasound of the pelvis, which reveals uterine masses. An endocrine research laboratory is investigating the regulation of the hypothalamicpituitary axis through pharmacologic means in the brains of chimpanzees. They find that administering extremely high doses of chlorpromazine causes parkinsonism, amenorrhea, lack of positive reward trainability, and decreased cognitive ability test scores in female chimpanzees. These findings allow them to identify specific neural tracts in the brain that are interrupted by chlorpromazine. Interruption of what neural tract is responsible for the amenorrhea observed in the studied chimpanzees A 24-year-old man presents for his annual physical and is noted to have a nontender right testicular nodule. An 8-year-old boy presents to the clinic with a complaint of a runny nose and difficulty breathing. His mother says the boy has had recurrent respiratory infections, often with a productive cough. Chest auscultation reveals crackles and wheezing, but the physician is unable to auscultate a normal S1 and S2 heart sound. Radiographic examination reveals pulmonary hyperinflation, bronchiectasis, and a complete left/right reversal of his circulatory system. The woman speaks to her mother, who tells her that she should take her temperature to determine when she ovulates. The action of which of the following hormones is responsible for this change in body temperature Severing which of the following structures during surgery would most severely disrupt blood flow to the ipsilateral ovary A 68-year-old retired furniture mover comes to the doctor for the first time in years because of constant backaches that radiate down his legs. He smokes two packs of cigarettes per day and drinks at least three beers per day, and has done so for the past 15 years. The baby cries immediately and has Apgar scores of 9 at both one and five minutes. While examining the baby, the pediatrician present at delivery notes that the baby has ambiguous genitalia and labial fusion. A 50-year-old postmenopausal G5P5 woman sees her gynecologist for a yearly well-woman check-up. The patient mentions that her grandmother died of endometrial cancer, and claims that she will stop drinking and smoking if it will save her from the agony her grandmother experienced. Which of the following interventions would have best decreased the risk for developing endometrial cancer in this patient She assures the physician that she is taking good care of the baby, but has recently asked her mother to come stay with her for assistance. A review of her medical record reveals that she had an uncomplicated spontaneous vaginal delivery of a healthy baby boy weighing 7 lb 7 oz (3. A 28-year-old woman presents to her physician with concerns that she is unable to produce breast milk, despite having given birth approximately one month ago. On further questioning she indicates she has been exceptionally thirsty lately, and describes feelings of fatigue and cold intolerance. Laboratory tests reveal a serum sodium level of 150 mEq/L and urinalysis reveals a urine osmolality of 220 mOsmol/kg. A 63-year-old man with a history of a myocardial infarction, chronic stable angina, hypertension, and diabetes presents to his physician with a complaint of erectile dysfunction. His physician informs him that it is unsafe for him to take medication for erectile dysfunction. What is the mechanism of the medication that is contraindicated in this situation A biotechnology firm is developing a new small protein drug designed to prevent the spread of a sexually transmitted infection. A 30-year-old woman finds a lump in her right breast during a monthly self-examination. Diagnostic mammography reveals a 2-cm mass with uneven borders and spiculated calcifications; this finding is suspicious for malignancy. The pathology report further states that the malignant tissue is positive for human epidermal growth factor 2/neu receptor, but negative for estrogen and progesterone receptors. Bleeding has been sufficient to soak through four to five pads within the past few hours. She does admit to using cocaine three times within the past month, most recently last night. A 14-year-old boy is brought to the clinic by his parents who are concerned because he has not yet begun puberty. Laboratory results indicate hypogonadism secondary to failure of the hypothalamic-pituitary-gonadal axis. A 33-year-old G1P0 woman with no previous prenatal care visits a gynecologist for a prenatal triple screen. Vasectomies can be done in an outpatient setting through a small incision in the scrotum. A vasectomy involves bilateral excision of a segment of the ductus deferens between the exit from the epididymis and the entrance to the pelvis. After the ductus deferens is cut, spermatozoa can no longer travel into the urethra and the sperm degenerate in the epididymis and ductus deferens. When excising the ductus deferens segments, the surgeon takes care not to injure which anatomic structure that crosses directly posterior to the ductus as it courses from scrotum to urethra A 70-year-old woman presents to her primary care physician for a check-up after undergoing repair of a broken hip due to a minor fall. A 23-year-old athletically built woman comes to the physician complaining of multiple red, ring-like lesions on her body. A careful history and physical reveals the woman has tinea corporis acquired while working on poorly cleaned yoga mats at a local gym.
Syndromes
The surgeon will remove the part of your esophagus where your cancer is located, and any other related lymph nodes in the area.
Come and go, and do not last for more than a few days
Upper GI series
Viral infections, including viral encephalitis, measles, rubella, chickenpox, herpes zoster, mumps, and mononucleosis
Cranial nerve palsies
Infection in the bone
Lung conditions in which the lung tissues become swollen and scarred (interstitial lung disease)
Rest as much as possible for at least a week.
Stomach pain (possible bleeding in stomach and intestines)
Irritability
Using openflap surgical debridement hypertension 38 weeks pregnant diovan 160 mg without a prescription, root surface conditioning (tetracycline solution) blood pressure erectile dysfunction diovan 80mg cheap, and an allogenic bone graft reconstituted with sterile saline and tetracycline powder arrhythmia jet purchase diovan 80 mg line, the surgeons reduced the probing pocket depth from 9 to 12 mm down to 1 to 3 mm (3 mm of recession was noted) pre hypertension nursing diagnosis cheap 80mg diovan otc, and significant bone fill of the defect (about 80%) was reported (Figure 46-1) hypertension treatment algorithm generic diovan 160 mg mastercard. This case illustrates the potential for healing of severe defects in patients with localized aggressive periodontitis hypertension 1 buy diovan 80mg mastercard, especially when local factors are controlled and sound surgical principles are followed. The authors cited several factors that likely contributed to the success of this case, including a probable transition of disease activity from aggressive to chronic, tooth stabilization before surgery, sound surgical management of hard and soft tissues, and good postoperative care. Depending on the anatomy of the defect and teeth involved, the potential for bone fill and periodontal regeneration may be poor. This is especially true if the bone loss is horizontal and if it has progressed to involve furcations. The usual criteria of case selection and sound principles of surgical management for regenerative therapy apply equally to cases of aggressive periodontitis. Good clinical judgment must be used to determine whether a particular tooth should be treated with the goal of regeneration. Recent advances in regenerative therapy have advocated the use of an enamel matrix protein (Emdogain) to aid in the regeneration of cementum and new attachment in periodontal defects. A systematic review of the literature concluded that treatment with an enamel matrix protein can improve probing attachment level (mean difference, 1. One recent case report described use of the protein in a 15-year-old patient with localized aggressive periodontitis. A recent clinical and radiographic study with a split-mouth design included four patients with aggressive periodontitis and four patients with chronic periodontitis. The authors concluded that enamel matrix proteins offered no advantage over surgical debridement alone in these patients. At this time, it is unknown whether the use of enamel matrix proteins offers significant advantages for the patient with aggressive periodontitis. AntimicrobialTherapy the presence of periodontal pathogens, specifically Actinobacillus actinomycetemcomitans, has been implicated as the reason that aggressive periodontitis does not respond to conventional therapy alone. These pathogens are known to remain in the tissues after therapy to reinfect the pocket. Indeed, several authors have reported success in the treatment of aggressive periodontitis using antibiotics as adjuncts to standard therapy. B, Facial view of the circumferential osseous defect around the lower right lateral incisor during open flap surgery. There is complete loss of buccal, lingual, mesial, and distal bone around the lateral incisor, with minimal bone support limited to the apical few millimeters. Bone fill around all surfaces demonstrates remarkable potential for regeneration of a large osseous defect in young patient with localized aggressive periodontitis. Patients with deeper, progressive pockets seem to benefit the most from systemic administration of adjunctive antibiotics. Because of limitations in comparing data from different studies, however, definitive recommendations were not possible. Figure462 Radiographs depicting progression of the osseous lesion in patient with localized aggressive periodontitis (formerly "localized juvenile periodontitis"). Measurements of vertical defects were made at intervals of up to 18 months after the initiation of therapy. Bone loss had stopped, and one third of the defects demonstrated an increase in bone level, whereas in the control group, bone loss continued. Liljenberg and Lindhe36 treated patients with localized aggressive periodontitis with systemic administration of tetracycline (250 mg four times daily for 2 weeks), modified Widman flaps, and periodic recall visits (one visit every month for 6 months, then one visit every 3 months). The lesions healed more rapidly and more completely than similar lesions in control patients. These investigators reevaluated their results after 5 years and found that the treatment group continued to demonstrate resolution of gingival inflammation, gain of clinical attachment, and refill of bone in angular defects. Treatment consisted of oral hygiene instruction, scaling and root planing concurrently with 1 g of tetracycline per day for 2 weeks, and modified Widman flaps. In these cases the combination of metronidazole and amoxicillin may be advantageous. If surgery is indicated, systemic tetracycline should be prescribed and the patient instructed to begin taking the antibiotic approximately 1 hour before surgery. Chlorhexidine rinses should be prescribed and continued for several weeks to enhance plaque control and facilitate healing. Good clinical and microbiologic responses have been reported with several individual antibiotics and antibiotic combinations (Table 46-1). The optimal antibiotic or combination for any particular infection probably depends on the case. MicrobialTesting Some investigators and clinicians advocate microbial testing as a necessary means of identifying the specific periodontal pathogens responsible for disease and to select an appropriate antibiotic based on sensitivity and resistance. There may be specific cases in which bacterial identification and antibiotic-sensitivity testing is invaluable. For example, in localized aggressive periodontitis cases, tetracycline-resistant Actinobacillus species have been suspected. If antibiotic susceptibility tests determine that tetracycline-resistant species exist in the lesion, the clinician may be advised to consider another antibiotic or an antibiotic combination, such as amoxicillin and metronidazole. One study evaluated and compared the results of microbial testing offered by two independent laboratories. The results obtained for the paired samples from different laboratories were quite variable. The reported presence of bacterial species varied from one laboratory to another, as did their antimicrobial recommendations. Interestingly, the combination of amoxicillin and metronidazole yielded the highest level of agreement (80%) between the laboratories for paired samples. The high level of agreement in the recommended use of amoxicillin and metronidazole is likely attributed to the effectiveness of this combination as well as a clinical predisposition to favor a known regimen. These findings suggest that the usefulness of microbial testing may be limited and led the authors to conclude that the empiric use an antibiotics, such as a combination of amoxicillin and metronidazole, may be more clinically sound and cost-effective than bacterial identification and antibiotic-sensitivity testing. An accurate identification of periodontal pathogens and their antibiotic sensitivities is more important when the disease is not responding to the given antibiotics and periodontal therapy. LocalDelivery the use of local delivery to administer antibiotics offers a novel approach to the management of periodontal "localized" infections. The primary advantage of local therapy is that smaller total dosages of topical agents can be delivered inside the pocket, avoiding the side effects of systemic antibacterial agents while increasing the exposure of the target microorganisms to higher concentrations, and therefore more therapeutic levels, of the medication. Local delivery agents have been formulated in many different forms, including solutions, gels, fibers, and chips18,19,29 (see Chapter 52). FullMouthDisinfection Another approach to antimicrobial therapy in the control of infection associated with periodontitis is the concept of full-mouth disinfection. In addition to scaling and root planing, the tongue is brushed with a chlorhexidine gel (1%) for 1 minute, the mouth is rinsed with a chlorhexidine solution (0. In a clinical and microbiologic study, 10 patients with advanced chronic periodontitis were randomly assigned to test or control groups. Test patients were treated as just described while control patients received scaling and root planing by quadrant at 2-week intervals along with oral hygiene instructions. At 1 and 2 months after treatment, the test group showed significantly higher reduction in probing pocket depth, especially for pockets that were initially deep (7-8 mm). Patients in the test group also had significantly lower pathogenic microorganisms after treatment compared with controls. Several follow-up studies by the same center demonstrated similar results for up to 6 months after therapy. The authors concluded that the beneficial effects of one-stage full-mouth disinfection probably result from the full-mouth debridement within 24 hours rather than the adjunctive chlorhexidine treatment. A few reports have included patients with aggressive (early-onset) periodontitis in their evaluation of the one stage full-mouth disinfection protocol. They also found significant reductions in periodontal pathogens up to 8 months after therapy. Porphyromonas gingivalis and Tannerella forsythia (formerly Bacteroides forsythus) were reduced to levels below detection. HostModulation Currently, the influence of the host immune response in the pathogenesis of periodontitis is well known. Variations in host response between individuals are greatly responsible for observed differences in disease severity. A better understanding of and appreciation for the role of the host immune response in disease pathogenesis have created the opportunity for new, innovative approaches to treatment. A novel approach in the treatment of aggressive periodontitis and difficult-to-control forms of periodontal disease is the administration of agents that modulate the host response. Several agents have been used or evaluated to modify the host response to disease (see Chapter 53). Other agents, such as flurbiprofen, indomethacin, and naproxen, may reduce inflammatory mediator production. TreatmentPlanningandRestorativeConsiderations Successful management of patients with aggressive periodontitis must include tooth replacement as part of the treatment plan. In some advanced cases of aggressive periodontitis, the overall treatment success for the patient may be enhanced if severely compromised teeth are extracted. The outcome of treatment for these teeth is limited, and more importantly, the retention of severely diseased teeth over time may result in additional bone loss and teeth that are further compromised. The risk of further bone loss is even a greater concern now with the current success and predictability of dental implants and the desire to preserve bone for implant placement. Any additional alveolar bone loss in an area that has already undergone severe bone loss may further compromise residual anatomy and impair the opportunity for tooth replacement with a dental implant. This is especially true for certain areas with poor bone quality or limited bone volume, such as the posterior maxilla. Fortunately, healing of extraction sites is typically uneventful in patients with aggressive periodontitis, and bone augmentation of defect sites is predictable. In the patient with aggressive periodontitis, the approach to restorative treatment should be made based on a single premise: extract severely compromised teeth early, and plan treatment to accommodate future tooth loss. The teeth with the best prognosis should be identified and considered when planning the restorative treatment. The lower cuspids and first premolars are generally more resistant to loss, probably because of the favorable anatomy (single roots, no furcations) and easier access for patient oral hygiene. As a rule, an extensive fixed prosthesis should be avoided, and removable partial dentures should be planned in such a way as to allow for the addition of teeth. The desire to replace missing teeth in a permanent manner without preparation of adjacent teeth for a fixed partial denture motivated clinicians to attempt transplantation of teeth from one site to another. Transplantation of developing third molars to the sockets of hopeless first molars has been attempted with limited success. UseofDentalImplants Initially, the use of dental implants was suggested and implemented with much caution in patients with aggressive periodontitis because of an unfounded fear of bone loss. However, evidence to the contrary appears to support the use of dental implants in patients with aggressive periodontal disease. PeriodontalMaintenance When patients with aggressive periodontitis are transferred to maintenance care, their periodontal condition must be stable. Each maintenance visit should consist of a medical history review, an inquiry about any recent periodontal problems, a comprehensive periodontal and oral examination, thorough root debridement, and prophylaxis, followed by a review of oral hygiene instructions. If oral hygiene is poor, patients may benefit most from a review of oral hygiene instructions and visualization of plaque in their own mouth before debridement and prophylaxis. Frequent maintenance visits appear to be one of the most important factors in the control of disease and the success of treatment in patients with aggressive periodontitis. In a 5-year follow-up study of 13 patients with aggressive periodontitis, comprehensive mechanical, surgical, and antimicrobial therapy with supportive periodontal maintenance every 3 to 4 months, periodontal disease progression was arrested in 95% of the initially affected lesions. Acute episodes of gingival inflammation can be detected and managed earlier when the patient is on a frequent monitoring cycle. Monitoring as frequently as every 3 to 4 weeks may be necessary when the disease is thought to be active. If signs of disease activity and progression persist despite therapeutic efforts, frequent visits and good patient compliance, microbial testing may be indicated. The rate of disease progression may be faster in younger individuals, and therefore the clinician should monitor such patients more frequently. Finally, there is a constant need to reinforce patient education about disease etiology and preventive practices. These cases are difficult to manage because the etiology behind their lack of response to therapy is unknown. Initially, because contributing factors may have been overlooked, it is important to evaluate the adequacy of treatment attempts thoroughly and to consider other possible etiologies before concluding that a case truly is refractory. A patient with periodontitis that is refractory to treatment often does not have any distinguishing clinical characteristics on initial examination compared with cases of periodontitis that respond normally. Therefore the initial treatment would follow conventional therapeutic modalities for periodontitis. After treatment, if the patient has not responded as expected, the clinician should rule out the following conditions: 1. Most forms of periodontitis can be treated effectively with currently available modalities if they are performed properly. After treatment, if it is determined that the patient has not responded, the clinician must evaluate whether the therapy was adequately performed. Undetected or inaccessible subgingival calculus may be present in one or more areas. Thus, patient compliance and the adequacy of their daily plaque control should be assessed before concluding that a case of periodontitis is refractory to treatment. The presence of nonperiodontal infections in the area can perpetuate periodontal disease activity and prevent a normal healing response to conventional periodontal therapy. Endodontic infection of teeth in the area should be suspected and ruled out before a concluding that a case is refractory to treatment. The clinician should suspect an endodontic etiology especially in those patients with localized recurrent disease.
This may be because elderly patients are more likely to present with somatic complaints or experience delusions arteria umbilical percentil 95 order 160 mg diovan otc, and are less likely than younger patients to report a depressed mood blood pressure normal level purchase diovan 160 mg visa. Epidemiologic data indicate that depression affects 1% of elderly individuals in the general community fitbit prehypertension buy diovan 160mg on-line, 10% of those seeking primary care or in the hospital how is pulse pressure used as a diagnostic tool purchase diovan 80 mg line, and 40% of those who are permanently institutionalized hypertension recipes buy generic diovan 160 mg line. Fatigue and weight loss resulting from diabetes blood pressure unstable discount 160mg diovan free shipping, thyroid disease, malignancy, vitamin B12 deficiency, or anemia. Sleep disturbance with daytime fatigue and depressed mood as a result of pain, nocturia, and sleep apnea. Pharmacotherapy: General principles for pharmacotherapy in older patients are as follows: Medications are chosen largely on the basis of their side effect profiles. Side effects typically last < 4 weeks, but weight gain and sexual dysfunction may last longer. Psychotherapy: Cognitive-behavioral therapy, problem-solving therapy, and interpersonal psychotherapy are effective either alone or in combination with pharmacotherapy. Side effects of confusion and anterograde memory impairment may persist for up to six months. First-line therapy for patients who are severely depressed, for those who are at high risk for suicide, and in other situations when a rapid response is urgent. Also an option for patients who are not eligible for pharmacotherapy as a result of hepatic, renal, or cardiac disease. Fluoxetine is rarely used because of its long halflife and inhibition of cytochrome P-450. If it is discontinued abruptly, patients can experience withdrawal (flulike symptoms, dizziness, headache). May offer added benefit in patients with neuropathic pain, detrusor instability, or insomnia. Anticholinergic side effects (dry mouth, orthostasis, urinary retention) are common. Beneficial for depression with sleep abnormalities and in patients with unintentional weight loss owing to the side effect profile. Venlafaxine In addition to antidepressant effects, also used to treat anxiety and neuropathic pain. Psychostimulants (dextroamphetamine, methylphenidate) Sometimes used in patients with predominantly vegetative symptoms. Other clinical characteristics include the following: Dementia is characterized by an insidious, progressive course without waxing and waning. Insidious onset Progressive course No altered consciousness; no waxing and waning after history and observation Reduced coping skills Getting lost in familiar places Personality changes such as poor impulse control or behavioral disturbance Diminishment in simple problem-solving ability Trouble with complex tasks (balancing checkbook, making meals) Difficulty learning new things Language problems. Vascular (multi-infarct) dementia: May be due to multiple small strokes or cognitive impairment associated with a single stroke. Neurologic deficits on exam are correlated with previous stroke, with presentation varying according to the location of the brain injury. Frontal lobe dementia is characterized by early changes in personality and behavior with relative sparing of memory. Reversible dementia: It is important to note that these dementias are potentially reversible-i. Medication induced: Substances can include analgesics, anticholinergics, antipsychotics, and sedatives. Metabolic disorders: Includes thyroid disease, vitamin B12 deficiency, hyponatremia, hypercalcemia, and hepatic and renal insufficiency. Depression must be ruled out or aggressively treated prior to the diagnosis of new dementia. The Miller-Fisher test compares before-and-after gait following the removal of 30 cc of spinal fluid to predict the benefit of ventriculoperitoneal shunt. Creutzfeldt-Jakob disease: A rare, infectious, rapidly progressive dementia that is usually fatal within one year of onset. Diagnosis is based on clinical suspicion upon noticing rapid cognitive impairment accompanied by motor deficits and seizures. It is important to make the diagnosis early in the clinical course to assist in anticipating and adhering to recommendations. Neuroimaging is not routinely recommended but should be considered for young patients, those with rapid onset of symptoms, and those with focal neurologic signs. Benefits include improvement or stabilization on neuropsychiatric scales, but benefits appear to be modest at two years. These medications may also have some benefit in treating the behavioral symptoms of dementia. Vitamin E: Has shown mixed results with delayed institutionalization in one trial, but results were not robust. Although covered in detail in the Hospital Medicine chapter, it is mentioned here as a common mimicker of dementia. Annually, at least 35% of communitydwelling older adults experience an adverse drug event. Changes in physiologic function and pharmacokinetics in the older patient promote sensitivity to medications and hence the possibility of iatrogenic illness. Specific changes include the following: Medication distribution is altered by the following: cardiac output, tissue perfusion, and tissue volume. Water-soluble drugs become more concentrated, and fat-soluble drugs have longer half-lives (volume of distribution). Hepatic enzyme activity is, affecting the metabolism of drugs with high first-pass metabolism. Other common symptoms include nausea, anorexia, weight loss, parkinsonism, hypotension, and acute renal failure. Improve adherence by keeping the dosing schedule simple (once daily is best), the number of pills low, and medication changes infrequent. Generally accepted goals of end-of-life care include the following: To continue to treat potentially reversible disease. To help alleviate suffering, including physical, psychological, social, and spiritual distress. The following are required of training programs in the care of the terminally ill: Assume an obligation to provide appropriate and humane care to the terminally ill. In evaluating an older patient, seek out and consider the observations and opinions of family members and other concerned individuals, and bear in mind that the primary obligation is always to the patient. Understand the function and importance of a multidisciplinary approach toward caring for older persons, including appropriate respect for other health professionals and paraprofessionals and their roles in the provision of services. Understand that maintenance of function and quality of life are more often goals of care than are cures of disease. The ethical principle of double effect allows for treatments that may hasten death if the primary intention is to relieve suffering. Ethically, there is no difference between withdrawal of life-sustaining treatment. Physician-assisted suicide involves a physician giving a patient the information or means to end his or her own life. Medical Decision Making There are several ways patients can indicate their end-of-life wishes: Advance directives: Defined as oral or written statements made by patients when they are competent with the purpose of guiding their care should they become incompetent. The role of the surrogate is to offer "substituted judgment" such as that which would be offered if the patient could speak for him/herself. If a patient has not designated a health care agent, decisions default to the next of kin. Patients may be treated at home, in the hospital, or in an inpatient hospice care facility. However, some patients remain in hospice care much longer, as life expectancy is notoriously difficult to estimate. Help the patient set pain management goals (strike a balance between sedation or "double effect" and total pain relief). Always add a bowel regimen to prevent constipation in patients receiving continuous opiates. Nonpharmacologic measures include O2, fresh air, and the use of fans to keep air moving. In patients with excessive secretions, a scopolamine patch may alleviate dyspnea and "choking" sensations. Nausea and vomiting: If opiate related, consider a sustained-release formulation, a different agent at an equianalgesic dose, or the addition of a dopamine antagonist antiemetic. If due to vestibular disturbance, treat with anticholinergic or antihistaminic agents. Start stool softeners and bowel stimulants prophylactically, and add enemas and other treatments as needed. Consider the usual reversible causes of delirium (see the previous section in this chapter), and treat if indicated. Haloperidol or risperidone may be used if reversible causes are not identified and behavioral management is unsuccessful. It may be acceptable to do nothing if the delirium does not bother the patient and family. The use of opiates for end-oflife care is not associated with the development of addiction or abuse. For patients with irreversible conditions, tube feeding has not been shown to improve mortality and comfort but has been shown to lead to complications. Withdrawal of Support Requests for withdrawal of care must be respected when received from appropriately informed and competent patients or their surrogates. Psychological, Social, and Spiritual Issues Patients and families rank emotional support as one of the most important aspects of good end-of-life care. Clinicians can provide listening, assurance, and support as well as coordination with psychotherapy and group support. Victims tend to be women > 80 years of age who may be physically frail and/or confused. Characteristics of abusers include the following: Are often relatives or spouses of the victims. May also be manifest by emotional withdrawal, a sudden change in alertness, or the development of depression. Bedsores, unattended medical needs, dehydration, and poor hygiene may be signs of neglect. Institutional Self-neglect Maltreatment of an older adult living in a residential facility. Behavior of an older adult who lives alone that threatens his or her own health or safety. Improper or illegal use of the resources of an older person without his/her consent, benefiting a person other than the older adult. Neglect Failure to fulfill a caretaking obligation to provide goods or services. Abandonment Desertion of an elderly person by someone who has assumed responsibility for providing care to that person. Two key management issues should be addressed: First, does the patient accept or refuse intervention If the patient accepts intervention, management options are as follows: Implementing a safety plan for patients who are in immediate danger. Providing written information about emergency-assistance numbers and appropriate referrals. If the patient does not have the capacity to accept intervention, the physician should discuss with Adult Protective Services issues such as assistance with financial management, guardianship, and court proceedings. Reporting Requirements All states have laws about domestic or institutional abuse of the elderly, but these laws vary in the following ways: the age at which a victim is covered. The definition of elder abuse: Classification of the abuse as criminal or civil Types of abuse covered Reporting requirements Investigation procedures Remedies In many states, the suspicion of abuse constitutes grounds for reporting, and physicians making reports in good faith are immune from legal liability. The best first steps in evaluation are measurement of the absolute reticulocyte count (see Figure 9. The reticulocyte count can be used to categorize anemias as follows: Checking a reticulocyte count is a good way to begin to evaluate anemia, as it allows you to determine whether the anemia is hypoproliferative or hyperproliferative. The two most common causes are bleeding and hemolysis (covered in a subsequent section). Iron Deficiency Anemia Daily iron loss from exfoliation of the skin and mucosa averages 1 mg/day under normal conditions. Features associated with iron deficiency are as follows: Pica: Craving for nonfood substances, especially clay. Inadequate iron ingestion or poor iron absorption is rare; the latter is sometimes associated with celiac disease. Although normal values do not rule it out, values > 100 g/L make iron deficiency unlikely. The most common reason for treatment failure is noncompliance with or intolerance of iron (can cause constipation). Parenteral iron: Carries a risk of anaphylaxis; use only if the patient has a total inability to tolerate oral iron. Anemia Associated with Chronic Renal Failure Erythropoietin is produced by the kidneys, and patients with chronic kidney disease often produce inadequate amounts. If no other cause is identified and creatinine is 2, the anemia can be treated as anemia associated with chronic renal failure.
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A population-based approach to diabetes management in a primary care setting: Early results and lessons learned. System supports for chronic illness care and their relationship to clinical outcomes. Introduction Epilepsy is a common neurological disease affecting almost 50 million people worldwide (1,2) 5 million of whom have seizures more than once per month (3). The results of studies suggest that the annual incidence in developed countries is approximately 50 per 100 000 of the general population whereas in developing countries this figure is nearly doubled to 100 per 100 000 (1). In developing countries few patients with epilepsy receive adequate medical treatment, and an estimated 75 to 90% receive no treatment at all (4). Epilepsy is characterized by a tendency to recurrent seizures and it is defined by two or more unprovoked seizures (generally within 2 years). Seizures may vary from the briefest lapses or muscle jerks to severe and prolonged convulsions. They may also vary in frequency, from less than one a year to several per day (1). The risks of recurrent seizures include intractable epilepsy, cognitive impairment, physical injury, psychosocial problems and death (6). Much of the treatment of epilepsy is aimed at creating a balance between prevention of seizures and minimization of side-effects to a level that the patient can tolerate (6,9). About 25% of patients with epilepsy have intractable seizure disorders, of those between 12 and 25% are candidates for surgery (3). The direct costs attributable to epilepsy include physician visits, laboratory tests, emergency department visits, antiepileptic drugs and hospitalizations. Indirect costs include working days lost, lost income, decreased quality of life, the cost of failed therapy and side-effects of drugs (6). The direct costs of epilepsy are significantly lower for patients whose epilepsy is controlled than for those whose disease is not controlled (6). Recent studies in both developed and developing countries have shown that up to 70% of children and adults newly diagnosed with epilepsy can be successfully treated. In the case of treatment failure it is crucial to establish whether the failure is a result of inappropriate drug selection, inappropriate dosing, refractory disease or poor adherence to the therapeutic regimen (3,6). Good adherence to treatment and proper health education are fundamental to the successful management of epilepsy (10,11). Nonadherent patients experience an increase in the number and severity of seizures, which leads to more ambulance rides, emergency department visits and hospitalizations (12,19). Nonadherence therefore results directly in an increase in health care costs, and reduced quality of life (19). The aim of this chapter is to describe the prevalence of adherence (or nonadherence), to treatment for epilepsy, to identify the factors affecting adherence to anti-epilepsy treatment, and to discuss the interventions that have proven effective for improving adherence. Reviews and reports from international and national organizations were also included. Publications were considered for inclusion if they reported on one of the following: prevalence data on rates of adherence (or nonadherence), factors affecting adherence, interventions for improving adherence, and information on how poor adherence rates affect illness, costs and treatment effectiveness. Adherence to epilepsy therapy Adherence was not usually defined in the published studies, but referred to generally as patients following medical recommendations. Authors generally considered adherence in behavioural terms, whereby the patient had an active and informed role to play in a therapeutic situation (13,20). The types of nonadherence were described as follows: reduced or increased amount of single dose; decreased or increased number of daily doses; extra dosing; incorrect dosing intervals; being unaware of the need for life-long regular medication; taking duplicate medication; taking discontinued medication; discontinuing prescribed medication; regularly forgetting to take medication, and incorrect use of medication (18,20,22). The best indicator of adherence is believed to be serum levels of anticonvulsant drugs (18,27). Other methods of monitoring adherence, such as electronic measures are not discussed further here because of the lack of published studies in this area. In several studies, patients whose serum levels were outside the therapeutic range were classified as nonadherent (19,23,28). Although blood levels of anticonvulsant medications can be measured, it is difficult to translate them into comparable measures of adherence for patients on different medications and doses. Furthermore, sub-therapeutic levels of a drug in the serum can be due either to poor compliance or the need for a higher dosage (2). However, using the measurement of drug concentration in blood alone, except in cases of extremely low adherence and variability of drug intake, is not sufficient to detect incorrect drug intake. Therefore, the use of clinical markers and self-reported adherence should also be considered (11). Epidemiology of adherence Adherence can vary from an occasional missed dose to chronic defaulting on medication regimens (21). Factors affecting adherence and interventions used to improve it Nonadherence is a problem that has many determinants and the responsibility for adherence must be shared by health professionals, the health care system, the community and the patients. Also, the severity of seizures was not significantly associated with any adherence outcome. However, families reporting less parental education, illiteracy, lower income and high levels of stressful life events were more likely to adhere to treatment. Some interventions have been designed to improve adherence to anti-epilepsy medications. Education in the diagnosis and management of epilepsy was found to be effective in improving recruitment of patients into treatment programmes and in improving drug adherence, or markedly reducing nonadherence (5). Other helpful measures were: clear information about the treatment, including giving full instructions; discussing the pros and cons of treatment; reinforcing the value of treatment; explaining and repeating the rationale for the regimen; involving the patients in planning their regimens, and explaining the results of medical tests. It is important to note that patients from different cultures require different educational approaches to improve adherence (15). In developing countries it is necessary to maintain a regular, uninterrupted supply of medicines (33), to provide drugs at subsidized costs and to organize effective distribution systems (27). Conclusions Poor adherence to drug therapy is one of the primary causes of treatment failure. Forgetfulness of patients that may or may not be linked to memory difficulties, refusal to take medication and side-effects are the factors most commonly associated with decreased adherence. The impact of epilepsy and the side-effects of its treatment on cognition and of limited or compromised cognition on adherence deserve more attention. Communication with the patient about medication regimens and the value of treatment is extremely important. It can facilitate the identification of problems and barriers to adequate adherence, and help with treatment planning. Also a real partnership between the physician and the patient is needed to set and achieve goals related to treatment outcomes and adherence.
