O

Interleukin-2 (IL-2) therapy is approved by the FDA for the treatment of meta-static melanoma, and it is a reasonable option for patients with this stage of the disease. Combination chemotherapy or biochemotherapy increases toxicity significantly without offering overall survival benefit thus, they are not standards of care for stage IV melanoma. One of the most common sites of metastasis for melanoma is the brain and treatment options for brain metastasis include surgery, radiation, and...

Clinical Staging

Stage (anatomic extent of disease) is defined on the basis of the primary tumor size (Ti-4), presence and extent of lymph node involvement (Ni-3 or pNi-3 if pathologic examination of lymph nodes is conducted), and presence or absence of distant metastases (M0-1) (Table 89-3). For a more complete description of the staging system, the reader is referred to the guidelines. Although many possible combinations of T and N are possible within a given stage, simplistically, stage 0 represents...

Pharmacologic Therapy

Children with SCD should receive the required immunizations as recommended by the American Academy of Pediatrics and the Advisory Committee on Immunization Practices.10 Additionally, influenza vaccine should be administered yearly to SCD patients 6 months of age and older, including adult patients. Any SCD patient who is scheduled for splenectomy should receive the vaccine for meningococcal disease if over 2 years of age.11 Because patient with SCD have impaired splenic function they are less...

Oral Contraceptives Combination

Combination oral contraceptives contain a combination of a synthetic estrogen and one of several steroids with progestational activity. Most oral contraceptives contain one of two types of estrogen ethinyl estradiol, which is pharmacologically active, or mestranol, which is converted by the liver to ethinyl estradiol. Many different progestins are found in the various oral contraceptives. These include norethindrone, norethindrone acetate, ethynodiol diacetate, norgestrel, levonorgestrel,...

Patient Encounter Part 2 Medical History Physical Exam and Diagnostic Tests PMH Asthma controlled

FH Father living with diabetes mellitus, type 2 (controlled) and chronic obstructive pulmonary disease mother living with hypertension (controlled) SH Second year pharmacy student. Works as a pharmacy intern at a local hospital Allergies Penicillin (patient states she was admitted to a hospital at the age of 7 years with hives and throat swelling after receiving amoxicillin) Meds Albuterol (salbutamol) inhaler as needed ROS (+) dysuria, urinary frequency (-) fever, nausea, vomiting, flank pain...

Patient Encounter 1 CINV

MJ is a 42-year-old woman diagnosed with stage II hormone-receptor positive, HER2-negative breast cancer. She has been treated with lumpectomy and radiation therapy and presents to clinic for cycle 1 day 1 of adjuvant doxorubicin and cyclo-phosphamide (the AC regimen). She appears calm and optimistic about her prognosis with no more than expected mild anxiety about the side effects of chemotherapy. She reports drinking alcohol only on holidays but does report a history of motion sickness. All...

Nonpharmacologic Therapy

Nonpharmacologic treatment of GERD includes patient-specific lifestyle modifications, antireflux surgery, or endoscopic therapies. Although most patients do not respond to lifestyle changes alone, the importance of maintaining these lifestyle changes throughout the course of GERD therapy should be stressed to selected patients on a routine basis. The most common lifestyle changes that a patient should be educated about include (a) losing weight and (b) elevating the head of the bed if symptoms...

Pulmonary Function Tests

Postbronchodilator FEV1 1.70 L (13.3 increase) FEV1 after exercise 1.23 L (23.1 decrease) Given this additional information, what is your assessment of the patient's asthma severity Identify your treatment goals for this patient. What nonpharmacologic and pharmacologic alternatives are feasible for this patient Outline a treatment plan for this patient that includes nonpharmacologic therapy, pharmacologic therapy, and a monitoring plan. Justify your therapeutic selections. Children Up to 4...

Patient Encounter 2 Part 2 Medical History Physical Examination Diagnostic Tests and Creating a Care Plan

All developmental milestones within normal limits. Two episodes of AOM treated with no sequelae. Current on all immunizations ROS (+) nocturnal incontinence 5 nights week or more (-) vaginal itching, UTIs, urgency, frequency, dysuria, lower abdominal fullness VS BP_ _mm Hg, P_bpm, RR min, T 37.0 C (98.6 F) Resp Within normal limits CV Within normal limits Abd Soft, nontender, nondistended (+) bowel sounds bladder not palpable Neuro Within normal limits...

Treatment Goals of Therapy

The introduction of antibiotic therapy and vaccines has reduced dramatically the mortality associated with bacterial meningitis.19 Prior to these advances, bacterial meningitis was almost universally fatal, and those few patients who survived often suffered from debilitating residual neurologic deficits, such as permanent hearing loss. Although significant improvements have been made, the fatality rate of pneumococ-cal meningitis remains above 20 likely due to its occurrence in debilitated...

Patient Care and Monitoring

Assess the patient's signs, symptoms, and risk factors for meningitis. Do these offer any clues to the offending pathogen 2. Determine if the patient can undergo an immediate LP or if the LP should be delayed until a CNS mass lesion can be ruled out. If the LP is delayed, blood cultures should be drawn and appropriate empirical antimicrobial therapy initiated immediately. 3. Based on patient-specific data, local resistance patterns, and other relevant data, design an appropriate empirical...

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder that is often unrecognized, affecting 4 of middle-aged white men and 2 of middle-aged white women.15 In women, the frequency of OSA increases after menopause. OSA is as common or more common in African Americans and less common in Asian populations. The risk of OSA increases with age and obesity. Individuals with OSA experience repetitive upper airway collapse during sleep, which decreases or stops airflow, with subsequent arousal from sleep to...

Restless Legs Syndrome

RLS treatment involves suppression of abnormal sensations and leg movements and consolidation of sleep. Dopaminergic and sedative-hypnotic medications are prescribed commonly. In the last few years, dopamine agonists (DAs) have become the therapy of choice for the treatment of RLS, replacing levodopa carbidopa as first-line agents. The DAs offer many advantages over levodopa carbidopa, including longer half-lives to cover overnight symptoms, flexible dosing, and a reduced incidence of symptom...

Patient Encounter Part 3 Modifying Treatment Plan

CH returns to the clinic 3 months later. The physician previously diagnosed him with OSA and RLS. He received a prescription for CPAPs for OSA and ropinirole 0.5 mg at bedtime for RLS at his last visit. Via phone calls, his ropinirole dose has been increased to 3 mg at bedtime. He has received moderate relief of his RLS symptoms, but on occasion, he still awakens and cannot fall back asleep. His sleepiness and RLS symptoms are improved ESS 13 24. Based on the information presented, recommend...

Acromegaly Patient Care and Monitoring

Assess patient's clinical signs and symptoms to determine severity of acromegaly. 2. Review the biochemical disease markers to assess severity of acromegaly. 3. Review the available diagnostic data to determine pituitary tumor size and location. Determine if the patient has a coexisting prolactin secreting tumor. Determine if the tumor extends toward the optic chiasm or if it is continuous on the optic tracts. 4. Assess presence of acromegaly complications. Identify any significant...

Clinical presentation and diagnosis

Any interaction between a patient and a healthcare provider presents an opportunity to evaluate the patient's height and weight. From these parameters, the BMI should be determined as well as waist circumference and the presence of comorbidities or associated risks. BMI, waist circumference, comorbidities, and readiness to lose weight are used in the assessment of the overweight or obese patient. The BMI is calculated using the measured weight in kilograms divided by the height in meters...

General Approach to Treatment

Since the goals for obesity management in the adult population are multifactorial, it should be considered a chronic illness where treatment is maintained for life. Any implemented therapy promoting weight loss should focus on behavior modification directed toward both dietary restriction and increased activity in conjunction with the selective use of pharmacologic or surgical intervention. Before initiating therapy, secondary causes of obesity (e.g., hypothyroidism and Cushing syndrome) must...

Outcome evaluation

Successful management of overweight and obesity is determined by the ability the treatment plan has to (a) prevent weight gain, (b) reduce and maintain a lower body weight, and (c) decrease the risk of obesity-related comorbidities. Since weight is necessary to calculate the BMI, it, as well as waist circumference, should be determined. Obesity management may encompass more than weight loss or maintenance in the presence of other conditions other pertinent parameters should be assessed at...

Pathophysiology Ischemic Stroke

In ischemic stroke, there is an interruption of the blood supply to an area of the brain either due to thrombus formation or an embolism. Loss of cerebral blood flow results in tissue hypoperfusion, tissue hypoxia, and cell death. Tipid deposits in the vessel wall cause turbulent blood flow and lead to vessel injury, exposing vessel collagen to blood. This vessel injury initiates the platelet aggregation process due to the exposed subendothelium. Platelets release adenosine diphosphate (ADP),...

Treatment Of Acute Hemorrhagic Stroke Supportive Measures

Acute hemorrhagic stroke is considered to be an acute medical emergency. Initially, patients experiencing a hemorrhagic stroke should be transported to a neurointensive care unit. There is no proven treatment for ICH. Management is based on neurointensive care treatment and prevention of complications. Treatment should be provided to manage the needs of the critically ill patient including management of increased ICP, seizures, infections, and prevention of rebleeding and delayed cerebral...

Hemorrhagic Stroke

The pathophysiology of hemorrhagic stroke is not as well studied as that of ischemic stroke however, it is more complex than previously thought. Much of the process is related to the presence of blood in the brain tissue and or surrounding spaces resulting in compression. The hematoma that forms may continue to grow and enlarge after the initial bleed and early growth of the hematoma is associated with a poor outcome. Brain tissue swelling and injury is a result of inflammation caused by...

General Signs and Symptoms

Hypoperfusion of skeletal muscles leads to fatigue, weakness, and exercise intolerance. Decreased perfusion of the CNS is related to confusion, hallucinations, insomnia, and lethargy. Peripheral vasoconstriction due to SNS activity causes pallor, cool extremities, and cyanosis of the digits. Tachycardia is also common in these patients and may reflect increased SNS activity. Patients will often exhibit polyuria and nocturia. Polyuria is a result of increased release of natriuretic peptides...

Mghr on for 1214 hours off for 101 hours

Common adverse effects of nitrates include postural hypotension, flushing, and headache secondary to venodilation. Headache often resolves with continued therapy and may be treated with acetaminophen. Hypotension is generally of no serious consequence. However, in patients with hypertrophic obstructive cardiomyopathy or severe aortic valve stenosis, nitroglycerin may cause serious hypotension and syn- cope. Therefore, long-acting nitrates are relatively contraindicated in these conditions....

Upon completion of the chapter the reader will be able to

Identify the causes of constipation. 2. Compare the features of functional constipation with those of irritable bowel syndrome (IBS) with constipation (IBS-C). 3. Recommend general and dietary modifications and therapeutic interventions for the treatment of functional constipation. 4. Distinguish between acute and chronic diarrhea. 5. Compare and contrast diarrhea caused by different infectious agents. 6. Explain how medication use can lead to diarrhea. 7. Discuss nonpharmacologic strategies...

Epidemiology And Etiology

Constipation is a common complaint of patients seeking medical attention, and about one-third of patients with constipation seek medical treatment. Constipation occurs in approximately 20 of the population. Approximately 2.5 million physician visits and 90,000 hospitalizations per year in the United States are due to constipation.4'5 Many medications and some disease states are associated with constipation. Constipation is associated with high socioeconomic costs and has considerable...

Alosetron Lotronex11 5HT4 Raptor Agonist

0-t50 mg po daily 10-t 50 mg po daily Trig po then 2 mg po after each loose stool daily maximum 16 mg Withdrawn from general use available only under special circumstances. Bulk producers may improve stool passage in IBS-C but are unlikely to have a fa- vorable effect on pain or global IBS symptoms. Psyllium may increase flatulence, which may worsen discomfort in some patients. Methylcellulose products are less likely to increase gas production. Although fiber-based supplements are more likely...

Patient Encounter Part 2

CN begins to improve after 2 days of methylprednisolone 1 g IV daily. The treatment team wants to begin a disease-modifying treatment. Do you agree that she should be on a disease-modifying treatment Why If so, which treatment would you choose Recommend a dosing regimen. How should the patient be counseled on the chosen treatment MS patients usually have upper motor neuron spasticity this type of spasticity cannot be treated with muscle relaxants (i.e., carisoprodol). MS patients must be...

Autonomic and Other Problems

Drooling may be accompanied by speech problems and dysphagia. Anticholinergics, botulinum toxin injections, and sublingual atropine can decrease drooling. Speech therapists perform swallowing studies to assess the risk of aspiration, and nutritionists optimize diet. Patients at high risk of aspiration or poor nutrition may require placement of a percutaneous endoscopic gastrostomy tube. Nausea improves if patients take their PD medications with meals or pharmacologic therapy (domperidone in...

NSAIDs nonsteroidal antiinflammatory drugs SNRIs serotonlnnorepinephrine reuptake inhibitors SSRls selective serotonin

AX, a 27-year-old African American woman, presents to your clinic with GI complaints (e.g., constipation, bloating, and cramping) and fatigue. She is a single mother of three (ages 2, 3, and 6 years) and is a full-time college student. She states that she worries about everything her grades, finances, the 6-year-old riding the school bus, etc. She states that even if it's not important, I still worry. She has difficulty sleeping and says that she often feels like she might jump out of her skin....

Relative Contraindications

Smoking (less than 15 cigarettes per day) at any age History of migraine headache disorder Women stop their oral contraceptives owing to side effects such as headaches, nausea, vomiting, or weight gain that occur during oral contraceptive use. Package labeling reports a higher incidence of these side effects, although it cannot be determined if they occurred because of the pill or just happened when the women were on the pill.1 One double-blind trial compared women taking oral contraceptives...

Patient Encounter 2

A 36-year-old female who has been in good health presents to your clinic complaining of constipation and abdominal pain. She explains to you that she has been feeling stressed lately because her 40-year-old sister is undergoing chemotherapy for breast cancer and they just lost their mother to ovarian cancer a few years ago. Does she have a hereditary risk factor What screening tools could be used to monitor this patient Identify the treatment options for prevention of ovarian cancer available...

Clinical Presentation And Diagnosis Cancer

Palliative care is most commonly associated with patients who have cancer. Regardless of whether or not the cancer is curable, most patients have various degrees of physical, psychological, social, and spiritual symptoms which arise once a diagnosis is confirmed. The primary site of solid tumor and hematologic cancers associated with limited life include, but are not limited to, lung, bronchus, breast, colon, rectum, pancreas, prostate, ovaries, uterus, brain, esophagus, liver, kidneys,...

Nonsmall Cell Lung Cancer

The first step in treatment of NSCLC involves confirmation of the clinical stage and determination of resectability of the tumor. This decision should always be made by a thoracic surgeon who routinely performs lung cancer surgery. Treatment options depend on the advancement of disease (i.e., local, locally advanced, or metastatic), PS, and eligibility for resection. Local Disease (Stages 1A, 1B, and II A) Local disease encompasses stages IA through IIA and is associated with a favorable...

Colorectal Cancer Prevention

Strategies to prevent colorectal cancer can be done with pharmacologic or surgical interventions and involve either preventing the initial development of colorectal cancer (primary prevention) or preventing cancer in patients that demonstrate early signs of colorectal cancer (secondary prevention). The most widely studied agents for the chemoprevention of colorectal cancer are agents that inhibit COX-2 (aspirin, NSAIDs, and selective COX-2 inhibitors) and calcium supplementation.19 COX-2...

Extraintestinal Manifestations and Complications of IBD

Patients may manifest signs and symptoms of disease in areas outside the GI tract. These extraintestinal manifestations may occur in various body regions.5,13 Painful joint complications associated with IBD include sacroiliitis and ankylosing spondylitis. Ocular involvement with episcleritis, uveitis, or iritis may manifest as blurred vision, eye pain, and photophobia. Associated skin findings include pyoderma gan-grenosum (involving papules and vesicles that develop into painful ulcerations)...

Insulin

Insulin is one of a very few medications which is itself a whole protein, and can induce IgE sensitivity directly. This can result in anaphylaxis. Adverse reactions to insulin also include erythema, pruritis, and indurations, which are usually transient and may be injection site-related. For the sensitivity reactions, treatment options include dexa-methasone or desensitization. If the reaction is injection site-related, a change in delivery system (i.e., insulin pump or inhaled insulin) may be...

Other Contributing Processes and Factors

Many other processes are proposed to contribute to the development of hypertension, including obesity, physical inactivity, insulin resistance, potassium and magnesium depletion, chronic moderate alcohol consumption, and transient effects of cigarette smoking and caffeine intake.9 The assessment of global cardiovascular risk in all hypertensive patients should be part of the management plan while also pursuing target BPs through nonpharmacologic and pharmacologic means. Regardless of the...

Angiotensin Receptor Blockers

ARBs are another key class of agents whose role in managing patients with hypertension has been further defined by recently completed studies. ARBs are inhibitors of the angiotensin-1 (ATI) receptors (Fig. 5-3). ATI receptor stimulation evokes a pressor response via a host of accompanying effects on catecholamines, aldosterone, and thirst. Consequently, inhibition of ATI receptors directly prevents this pressor response and results in up-regulation of the RAAS. Up-regulation of the RAAS results...

Unique Oral Contraceptives

Along with varying doses of ethinyl estradiol and different progestins, there are also formulation modifications that may benefit various patient situations. In the United States, these formulations include products such as Loestrin-24 Fe, Seasonale, Seaso-nique, Ortho Tri-Cyclen, Estrostep Fe, Yasmin, Yaz, Mircette, Ovcon 35, and Lybrel. Each of these products may show benefit in certain women owing to their unique characteristics. Loestrin-24 Fe (norethindrone ethinyl estradiol) is an...

Abbreviatons Introduced in This Chapter

AML Acute myeloid leukemia ANC Absolute neutrophil count American Society of Clinical Oncology B ll sul fa n- ey cloph osph a m id e Chemotherapy-induced nausea and vomiting Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html.

ABlockers

Generally, ai-blockers are considered as inferior agents and should not be used as monotherapy. The ALLHAT trial had an ai-blocker arm that was discontinued early as terazosin was associated with an increase in cardiovascular events. aiBlockers may be considered as add-on therapy to other agents (i.e., 3rd or 4th line) when hypertension is not adequately controlled. In addition, they may have a specific role in the antihypertensive regimen for elderly males with prostatism however, their use is...

About The Editors

Chisholm-Burns, BPharm, PharmD, MPH, FCCP, FASHP, is professor and head of the Department of Pharmacy Practice and Science at The University of Arizona College of Pharmacy. She received her BS and PharmD degrees from The University of Georgia and completed a residency at Mercer University Southern School of Pharmacy and at Piedmont Hospital in Atlanta, Georgia. She is the founder and executive director of the Medication Access Program. She has also served in elected positions in...

Advantages

More hemodynamic stability (blood pressure) due to slow ultrafiltration rate 2. Increased clearance of larger solutes, which may explain good clinical status in spite of lower urea clearance 3. Better preservation of residual renal function 4. Convenient intraperitoneal route of administration of drugs such as antibiotics and insulin 5. Suitable for elderly and very young patients who may not tolerate hemo-dialysis well 6. Freedom from the machine gives the patient a sense of independence (for...

Airway Obstruction

Symptoms of airway obstruction include chest tightness, cough, and wheezing. Airway obstruction can be caused by multiple factors including airway smooth muscle constriction, airway edema, mucus hypersecretion, and airway remodeling. Airway smooth muscle tone is maintained by an interaction between sympathetic, parasym-pathetic, and nonadrenergic mechanisms. Acute bronchoconstriction usually results from mediators such as histamine, cysteinyl leukotrienes, prostaglandins, and tryptase released...

Allergen avoidance underlies all other treatments of AR

There are several limitations to implementing allergen avoidance Identification of allergens is necessary to successfully employ avoidance strategies Literature support for a clinically significant impact on symptoms from allergen avoidance, especially any single measure, is meager Quality of life may be negatively impacted by forced removal of a pet from the household Outdoor plant pollen and mold fungi parts Limit outdoor exposure, especially during high pollen conditions (warm sunny days...

Aloe vera

Lactose intolerance is responsible for many cases of acute diarrhea, especially in patients of African descent, Asians, and Native Americans. Possible food-related causes include fat substitutes, dairy products, and products containing nonabsorbable carbohydrates. The diarrhea of IBS is sudden and perhaps watery but likely loose, usually accompanied by urgency, bloating, and abdominal pain occurring upon arising in the morning or immediately following a meal. Inflammatory bowel disease is...

Amenorrhea in adolescents

Amenorrhea in the adolescent population is of great importance because this is the time in the female life cycle when peak bone mass is achieved. The cause of amenor-rhea and appropriate treatment must be identified promptly in this population because hypoestrogenism contributes negatively to bone development. Estrogen replacement, typically via an OC, is important. In addition, ensuring that the patient is receiving adequate amounts of calcium and vitamin D is imperative. Table 49-2...

Anovulatory bleeding in adolescents

Anovulatory cycles are not unusual in the perimenarchal reproductive years. Ovulation typically is established a year or more following menarche. When anovulatory bleeding occurs in this population, it may be excessive. If the bleeding is excessive, the patient should be evaluated for blood dyscrasias. The prevalence of blood dys-crasias, including von Willebrand's disease and prothrombin deficiency, and the prevalence of idiopathic thrombocytopenia purpura in this population ranges from 5 to...

AR[S Acutc rcspir310ry disticss syndrome MCT Mediumchain triglycerides

Self-assessment questions and answers are available at ht-tp www. mhpharmacotherapy. com pp.html. 1. Ros E, Navarro S, Bru C, et al. Occult microlithiasis in idiopathic acute pancreatitis Prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterology 1991 101 1701-1709. 2. Bradley EL, III. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch...

Aspirin

ASA reduces the risk of death or developing MI by about 50 (compared to no anti- platelet therapy) in patients with NSTE ACS. Therefore, ASA remains the cornerstone of early treatment for all ACS.43 Dosing of ASA for NSTE ACS is the same as that for STE ACS (Table 8-2). ASA is continued indefinitely. For patients with NSTE ACS, clopidogrel added to ASA and started on the first day of hospitalization as a 300 to 600 mg loading dose and followed the next day by 75 mg orally per day is recommended...

Bisphosphonates

Bisphosphonates are first-line therapy for osteoporosis due to established efficacy in preventing hip and vertebralfractures. They are also the most commonly prescribed therapy for osteoporosis. They decrease bone resorption by binding to the bone matrix and inhibiting osteoclast activity. They remain in the bone for a prolonged period and are released very slowly. These effects increase bone mineral density. Although sever- al bisphosphonates are currently available, only alendronate,...

Causes of Thyrotoxicosis Hyperthyroidism

Thyrotoxicosis is any syndrome caused by excess thyroid hormone. Hyperthyroidism is related to excess thyroid hormone secreted by the thyroid gland. Thyrotoxicosis can be related to the presence or absence of excess hormone production (hyperthyroid-ism). The common causes of thyrotoxicosis are shown in Table 44-6 ' disease is the most common cause of hyperthyroidism. Thyrotoxicosis in the elderly is more likely due to toxic thyroid nodules or multinodular goiter than to Graves' disease....

Cbnidine

Dexmedetomidine Digoxin Diltiazem D'pyridamole Disopyrarnide Donepezil Dronedarone Flecainide Acute treatment of the symptomatic patient consists primarily of administration of the anticholinergic drug atropine, which may be given in doses of 0.5 mg IV every 3 to 5 minutes. The maximum recommended total dose of atropine is 3 mg 14 however, this total dose should not be administered to patients with sinus bradycardia, but rather should be reserved for patients with cardiac arrest due to...

Cetuximab and Panitumumab

Cetuximab (Erbitux) and panitumumab (Vectibix) are monoclonal antibodies directed against the EGFR. Cetuximab is a chimeric antibody, whereas panitumumab is a fully human monoclonal antibody. The EGFR receptor is overexpressed in colorectal can- cers and leads to an increase in tumor proliferation and growth. ' ' Cetuximab received FDA approval for use in EGFR-expressing meta-static colorectal cancer in irinotecan relapsed or refractory patients. Cetuximab should be administered in combination...

Chemoprevention

Chemoprevention refers to the use of prophylactic medications to prevent the development of cancer. Many studies of potential chemopreventatives, including nonster- oidal anti-inflammatory drugs, retinoids, inhaled glucocorticoids, vitamin E, selenium, and green tea extracts, have been conducted, but none has been successful. Large randomized clinical trials have evaluated P-carotene and vitamin E as lung cancer che-mopreventative agents in high-risk patients (older smokers). Although vitamin E...

Clinical Assessment and Diagnosis

It is important for the clinician to identify the cause(s) of AHF in order to maximize treatment efficacy and reduce future disease exacerbations. Cardiovascular, metabolic, and lifestyle factors can all precipitate AHF. The most common precipitating factors for acute decompensation and how they contribute pathophysiologically are listed in Table 6-3. Routine laboratory testing of patients with AHF includes electrolytes and blood glucose, as well as serum creatinine and blood urea nitrogen to...

Clinical presentation and diagnosis Diagnosis

Osteoporosis has been defined by the WHO as a disease characterized by low bone density and weakening of bone tissue associated with an increase in fragility and vulnerability to fracture.1 Because bone strength cannot be measured directly, an assessment of bone mineral density is used, which represents 70 of bone strength. Low bone mineral density has been associated with an increased risk of fractures. X-rays are useful only in identifying patients suspected of sustaining a fracture and are...

Clinical Presentation and Diagnosis Pediatric Enuresis

Proper assessment of the child or adolescent with enuresis should explore every aspect of UI, especially the genitourinary and nervous systems. The minimum assessment should include34,35 Interview of child and parent(s), being sensitive to the emotional consequences of the enuresis Direct physical examination, looking for enlarged adenoids tonsils, bladder disten-tion, fecal impaction, abnormal genitalia, spinal cord anomalies, and abnormal neurologic signs (look for an organic cause amenable...

Clinical Presentation of MS1016

O MS symptoms are a function of the location of lesions within the CNS. Because myelin increases the speed of nerve impulse transmission, demyelination slows the speed of transmission. No impulses can be transmitted if the axon is transected. The primary symptoms of MS are caused by this delay or cessation of impulses. Secondary symptoms of MS result from the primary symptoms. Urinary Symptom . IjK Ora iriCrXfl Urinary retention Soawiciiy visual symptoms Optic neuritis Diplopia Rowel syrnplcmi...

Comorbidities Associated With RA

RA reduces a patient's average life expectancy by 5 to 10 years, but RA alone rarely 11 12 causes death. ' Instead, specific comorbidities contribute to premature death independent of safety issues surrounding the use of immunomodulating medications. O The comorbidities with the greatest impact on morbidity and mortality associated with RA are (a) cardiovascular disease (b) infections (c) malignancy and (d) osteoporosis.11' 2 Half of all deaths in RA patients are cardiovascular related.11...

Consolidation

After completion ofinduction and restoration ofnormal hematopoiesis, patients begin consolidation. The goal of consolidation is to administer dose-intensive chemotherapy in an effort to further reduce the burden of residual leukemic cells. It is in this and subsequent treatment phases that the presence of MRD is reduced by increasing the aggressiveness of the drug regimen. Several regimens use agents and schedules designed to minimize the development of drug cross-resistance. Studies have...

Courseprognosis

Symptoms of a major depressive episode usually develop over days to weeks, but mild depressive and anxiety symptoms may last for weeks to months prior to the onset of the full syndrome. Left untreated, major depressive episodes typically last 6 months or more, but a minority of patients experience chronic episodes that last at least 2 years. Approximately two-thirds of patients recover fully from major depressive episodes and return to normal mood and full functioning, whereas the other...

Diagnosis

Seven criteria must be met to diagnose RA appropriately 1 1. Morning joint stiffness lasting more than 1 hour before disappearing 2. Involvement of three or more joint areas 5. Presence of rheumatoid nodules A patient may be diagnosed with RA if four or more of these are present. Criteria 1 through 4 must be present for at least 6 weeks. Criteria 2 through 5 must be observed by a clinician. Table 57-2 Comparison of RA and Osteoarthritis FIGURE 57-1. Patterns of joint involvement in rheumatoid...

Diaper dermatitis epidemiology and etiology

Diaper dermatitis, or more commonly known as diaper rash, is a form of irritant contact dermatitis that affects the buttocks, upper thighs, lower abdomen and genitalia of an estimated 7 to 35 of all infants.35, Onset of occurrence is usually between 3 weeks and 2 years of age, with the most cases reported between 9 and 12 months of age. The rise in the number of adults who use diapers for incontinence also increases the risk of developing diaper dermatitis.

Differences in Vital Signs

Normal values for heart rate and respiratory rate vary based on their age. Normal values for blood pressure vary based on gender and age for all pediatric patients, and also height percentile for patients greater than 1 year of age. Normal values for blood pressure in pediatric patients can be found in various national guidelines and other pedi-atric diagnostic references. Heart rates are highest in neonates and infants, ranging from 95 to 180 beats per minute (bpm) and decrease with age,...

Differential Diagnosis

Major depressive episodes also occur in patients with bipolar disorder. Persons with bipolar disorder also experience manic, hypomanic, and or mixed episodes (see Chap. 39) during the course of their illness, whereas persons with MDD do not. The presence of a significant medical disorder can produce depressive symptoms via either psychological or physiological mechanisms. Examples include hypo- thyroidism, neoplasms, anemia, infections, electrolyte disturbances, cardiovascular diseases,...

DW 5 dextrose in water VF ventricular Fibrillation

Decision algorithm for resuscitation of VF or pulseless ventricular tachycardia. (CPR, cardiopulmonary resuscitation.) defibrillation attempt should be made after every dose of drug. bEpinephrine should continue to be administered every 3 to 5 minutes throughout the remainder of the resuscitation. Monitor the patient for return of pulse and blood pressure, and for termination of VF and restoration of normal sinus rhythm. After successful resuscitation, monitor the patient for...

Efficacy of Pharmacotherapy

Each antidepressant has a response rate of approximately 60 to 80 , and no antidepressant medication or class has been reliably shown to be more efficacious 7,21 than another. MAOIs may be the most effective therapy for atypical depression, but MAOI use continues to wane because of problematic adverse effects, dietary and drug restrictions, and possibility of fatal drug interactions. ' There is some evid ence that dual-action antidepressants, such as TCAs and SNRIs, may be more effective for...

Emerging and Life Habit Risk Factors

In addition to the five major risks, the ATP III guidelines recognize other factors that contribute to CHD risk. These are classified as life-habit risk factors and emerging risk factors. Life-habit risk factors, consisting of obesity, physical inactivity, and an atherogenic diet, require direct intervention. For example, emerging risk factors are lipopro-tein(a), homocysteine, prothrombotic proinflammatory factors, lipoprotein-associated phospholipase A2 (Lp-PLA2), and C-reactive protein...

Endocrine Factors

A number of endocrine factors have been linked to the incidence of breast cancer.5,6 Many of these relate to the total duration of menstrual life. Early menarche (prior to age 12) and late menopause (after age 55) increase a women's breast cancer risk. Similarly, investigators have reported that bilateral oophorectomy prior to age 35 reduces the relative risk of developing breast cancer. Nulliparity and a late age at first birth (greater than or equal to 30 years) have been reported to increase...

Energy Intake

Food intake is regulated by various receptor systems. Direct stimulation of Serotonin 1A subtype (5-HT1a) and noradrenergic a 2-receptors will increase food intake, whereas Serotonin 2C subtype (5-HT2c) and noradrenergic a 1-or ( 2-receptor activation decreases food intake. Stimulation of histamine receptor subtypes 1 and 3, and dopamine receptors 1 and 2 result in lower food consumption. Recently, the cannabin-oid receptor (CB1), which is a G-protein-coupled receptor in the endocannabinoid...

Enhancement of Lactation

Optimization of breast-feeding techniques is the first approach when decreased lactation is suspected. No drugs are currently approved by the FDA for lactation enhancement, but dopamine antagonists, metoclopramide and domperidone, are sometimes used for this purpose. The efficacy of metoclopramide is controversial. Maternal side effects include fatigue, irritability, abdominal pain, extrapyramidal symptoms, and depression (with long-term use). No side effects in the infant have been reported....

Enteral Versus Parenteral Feeding

With the advent of the technique of PN by a large central vein in the late 1960s, this modality of feeding quickly became popular. PN was used originally in patients with-inflammatory bowel disease (IBD) or congenital bowel abnormalities but was incorporated quickly into care of other types of patients such as the critically ill. The relative ease of PN administration, along with the perception that critically ill patients had prolonged high-energy expenditures, led to complications of...

Epidemiology and etiology Etiology and Mortality Rates

The etiology of bacterial pneumonia varies in accordance with the type of pneumonia. Table 71-1 lists the common pathogens associated with the various types or classifications of pneumonia. S. pneumoniae colonizes the nasopharyngeal flora in up to 50 of healthy adults and may colonize the lower airways in individuals with chronic bronchitis.67 It possesses many virulence factors enhancing its ability to cause infection in the respiratory tract. Therefore, it is not surprising that S. pneumoniae...

Epidemiology

Anovulatory bleeding is the most common form of noncyclic uterine bleeding.5 Patients often seek medical care to regulate their menstrual cycle or improve fertility. All women of reproductive age should have a pregnancy test when presenting with irregular menstrual bleeding. Anovulation may be secondary to physiologic or pathologic causes. It is common at menarche and in the perimenopausal period. During adolescence, ovulatory menstrual cycles may not be regular for a year or more after...

Etiology And Epidemiology

Practitioners must have a good understanding of cardiovascular physiology to diagnose, treat, and monitor circulatory problems in critically ill patients. The interrelationships between the major hemodynamic variables are depicted in Figure 13-1.1 These variables include arterial BP, cardiac output (CO), systemic vascular resistance (SVR), heart rate (HR), stroke volume (SV), left ventricular size, afterload, myocardial contractility, and preload. While an oversimplification, Figure 13-1 is...

Etiology and pathogenesis

HIV-1 is a retrovirus and member of the genus Lentivirus. These viruses have a characteristically prolonged latency period. There are two molecularly and serologically distinct but related types of HIV HIV-1 and HIV-2. HIV-2 is a less common cause of the epidemic and is found primarily in West Africa. HIV-1 is categorized by phylo-genetic lineages into three groups (M main , N new , and O outlier ). HIV-1 group M can be further categorized into nine subtypes A through D, F through H, and J and...

Fever

Fever is the most frequently reported adverse effect in children and adolescents. Fever associated with vaccination is defined as a temperature of greater than or equal to 38 C (100.4 F) measured at any site using a validated device. Fever is caused by a complex reaction induced by the production of cytokines that affect the hypothalamic neurons. This results in raising the hypothalamic set point. Temperature elevations above 40 C (104 F) can result in cellular and multi-organ dysfunction....

From

A great deal of research is occurring today to develop compounds that enhance the incretin effect, either by mimicking its action or by enabling incretin hormones to remain physiologically active for longer periods of time.15,17-19 As early as the late 1960s, Perley and others observed that insulin's response to oral glucose exceeded that of IV glucose administration.19 It was concluded that factors in the gut, or incretins, affected the release of insulin after a meal is consumed. When...

From Rf 2Z

Some regimens are designed for outpatient administration over much longer time periods and have been used, for example with allopurinol dermal reactions. Such late-onset morbiliform reactions, sometimes overlapping with erythema multiforme minor, are difficult to evaluate as it is often unclear to what extent the patients were at risk for recurrent reaction. Severe life-threatening reactions not mediated by IgE, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, are absolute...

G

For patients with mild symptoms, which the patient does not consider to be bothersome, watchful waiting is a reasonable approach to treatment. The patient is instructed to schedule return visits to the clinician every 3 to 6 months. At each visit, the patient's symptoms are reassessed using the AUA Symptom Scoring Index, and results are compared to baseline (Table 52-1). In addition, the patient is educated about avoiding factors that worsen obstructive and irritative voiding symptoms (Table...

General Approach to Therapy

Securing an adequate airway and ventilation is imperative in hypovolemic shock patients consistent with the airway, breathing, and circulation (ABCs) of life support. Any compromise in ventilation will only accentuate the tissue hypoxia occurring secondary to inadequate perfusion. Thus, tracheal intubation and mechanical ventilation may be needed (Fig. 13-4). IV access is also essential for administration of IV fluids and medications. IV access can be accomplished through the placement of...

Genetic Factors

Both personal and family histories influence a woman's risk of developing breast cancer. A past medical history for breast cancer is associated with about a fivefold increased risk of contralateral breast cancer. Cancer of the uterus and ovary also has been associated with an increased risk of the development of breast cancer. It has been recognized for some time that a family history of breast cancer is associated rather strongly with a woman's own risk for developing the disease. The...

GI Disease

Various GI disorders, including inflammatory bowel disease, celiac disease, and postgastrectomy states, are associated with osteoporosis due to impairment of calcium and vitamin D absorption, corticosteroid-induced bone changes, and chronic inflammatory states. The American Gastroenterological Association recommends bone mineral density measurement in high-risk patients and consideration of treatment for patients with a T-score below -2.5, history of vertebral compression fracture, or who are...

Gi tract structure and function Anatomy and Absorptive Function

With normal volitional feeding, food is ingested via the mouth. Here, the process of breaking down complex foodstuffs into simpler forms that can be absorbed by the small bowel begins. Solid food is chewed in the mouth, and enzymes begin digestion. The trigger for release of many enzymes is presence of food in specific regions of the GI tract. Food is swallowed and passes through the esophagus and the esophageal sphincter to the stomach, where additional digestive enzymes and acids further...

Gram Negative Bacillary Meningitis

Meningitis caused by enteric gram-negative bacilli is an important cause of morbidity and mortality in populations at risk, including those with diabetes, malignancy, cirrhosis, immunosuppression, advanced age, parameningeal infection, and or a defect allowing communication from skin to CNS (such as neurosurgery, congenital defects, or cranial trauma).10 The optimal treatment for gram-negative bacillary meningitis is not well defined. The introduction of extended-spectrum cephalosporins has...

Gut Immune Function

In addition to roles in digestion and absorption, the gut plays significant immune roles. The distal small bowel and colon host many bacteria and their endotoxins, and it is important that these organisms not gain access to the internal systems of the body. This function is known globally as the gut barrier function and can be divided into several components.6 Normal flora of the gut comprise one component. The normal flora, particularly some anaerobes, help to prevent overgrowth of potential...

Hemophilia A

Primary therapy is based on disease severity and type of hemorrhage.9 Most patients with mild to moderate disease and a minor bleeding episode can be treated with 1-desamino-8-d-arginine vasopressin (desmopressin acetate DDAVP ), a synthetic analog of the antidiuretic hormone, vasopressin. DDAVP causes release of von Wil-lebrand's factor (vWF) and factor VIII from endothelial storage sites. DDAVP increases plasma factor VIII levels by three-to five-fold within 30 minutes. The recommended dose...

Heparin

Full dose IV UFH has been commonly used in acute stroke therapy however, no adequately designed trials have been conducted to establish its efficacy and safety. Current acute ischemic stroke treatment guidelines do not recommend routine, urgent, full dose anticoagulation with UFH or LMWHs due to the lack of a proven benefit in improving neurologic function and the risk of intracranial bleeding. Full dose UFH may prevent early recurrent stroke in patients with large-vessel atherothrombos-is or...

Histocompatibility

Histocompatibility differences between the donor and the recipient necessitate immunosuppression after an allogeneic HSCT because considerable morbidity and mortality are associated with graft failure and GVHD. Rejection is least likely to occur with a syngeneic donor, meaning that the recipient and host are identical (monozygotic) twins. In patients without a syngeneic donor, initial HLA typing is conducted on family members because the likelihood of complete histocompatibility between...

Hormonal Feedback Regulatory Systems

The hypothalamus is responsible for the synthesis and release of hormones that regulate the pituitary gland. Stimulation or inhibition of the pituitary hormones elicits a specific cascade of responses in peripheral target glands. In response, these glands secrete hormones that exert a negative feedback on other hormones in the hypothalam-ic-pituitary axis (Fig. 46-1). This negative feedback serves to maintain body system homeostasis. High circulating hormone levels inhibit the release of...

Iro

Concentration, and a compensatory reduction in the PaCO2. The etiologies of metabolic acidosis are divided into those that lead to an increase in the anion gap and those associated with a normal anion gap and are listed in Table 28-4. Although there are numerous mnemonics to recall the differential diagnosis of the metabolic acidosis, two simple ones are shown in Table 28-3. High anion gap metabolic acidosis is most frequently caused by lactic acidosis, ketoacidosis, and or renal failure....

Motor fluctuations

Suboptimal or delayed peak response 1. Take Sinemet on an empty stomach 2. Decrease dietary protein and fat around the dose that is delayed 2. Use rapid-dissolving tablet (Parcopa), crush Sinemet, or make liquid Sinemet 3. Substitute standard Sinemet for some of the Sinemet CR 5. Withdraw drugs with anticholinergic properties 6. Add intermittent subcutaneous apomorphine B. Optimal peak but early wearing off 1. Decrease dose and increase frequency of standard Sinemet 2. Substitute Sinemet CR...

NR International Normalized Ratio

Most cases of VTE can be successfully treated with anticoagulation. In some cases, removal of the occluding thrombus by surgical intervention may be warranted. Surgical or mechanical thrombectomy can be considered in patients with massive iliofemoral DVT when there is a risk of limb gangrene due to venous occlusion. The procedure can be complicated by recurrence of thrombus formation. In patients who present with massive PE, pulmonary embolectomy can be performed in emergency cases when...

Idiopathic Unknown

A Atypicals (olanzapine and clozapine) other than risperidone may cause an early but transient elevation in prolactin. Adapted in part, with permission, from Sheehan AH, Yanovski JA, Calis KA. Pituitary gland disorders. In Dipiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy. A Pathophysiologic Approach. 7th ed. New York McGraw Hill, 2008 1291. In combination with clinical symptoms, at least three repeated measures of serum prolactin levels greater than 20 ng mL (20 mcg L) are needed to...

Dyskinesias

Evaluate the value of adjunctive PD medications 2. Decrease risk by lowering Sinemet dose when adding other PD medications 3. Adjust levodopa formulation, dose, or frequency 5. Add propranolol, fluoxetine, buspirone, or clozapine B. Off period dystonia in the early morning (e.g., foot cramping) 1. Add Sinemet CR or dopamine agonist at bedtime if having nighttime offs 2. Morning Sinemet dose should be immediate-release with or without CR 3. Selective denervation with botulinum toxin 4. Add...

Immunosuppressive Therapies Future Immunosuppressive Agents

The immunosuppressant armamentarium is expanding with novel small molecules (i.e., AEB, bortezimibe, and the Janus-Kinase 3 inhibitors) and biological agents (i.e., costimulatory pathway blockers) currently in clinical development. These newer agents appear promising and may represent the emergence of novel immunosuppressive agents that can deliver immunosuppression without the long-term toxicities. Some currently marketed immunosuppressants may also have beneficial effects in organ...

Inflammation and Peripheral Pain Sensation

Inflammation is a common pathway in soft-tissue injury of musculoskeletal disorders. Inflammatory processes lead to two outcomes swelling and pain. Inflammatory processes traditionally are considered to be a necessary part of the remodeling process because inflammatory cells remove damaged tissue. 9 0 However, inflammation also contributes to continued pain and swelling that limits range of motion. The initial injury exposes membrane phospholipids to phospholipase A2, leading to the formation...

Interferon

Interferon-a causes hypothyroidism in up to 39 of patients being treated for hepatitis C infection. Patients may develop a transient thyroiditis with hyperthyroidism prior to becoming hypothyroid. The hypothyroidism may be transient as well. Asians and patients with pre-existing anti-TPOAbs are more likely to develop interferon-induced hypothyroidism. The mechanism of interferon-induced hypothyroidism is not known. If LT4 replacement is initiated, it should be stopped after 6 months to...

Introduction

In 2007, the National Heart, Lung, and Blood Institute's (NHLBI) National Asthma Education and Prevention Program (NAEPP) updated its Guidelines for the Diagnosis and Management of Asthma.1 In this update, the Expert Panel Report-3 (EPR-3) defines asthma as a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hy-perresponsiveness and underlying inflammation.1 O Asthma is a complex disease that presents in a...