By I. Fraser. Huston-Tillotson College. 2018.
A particularly puzzling nding is showing close adherence to formal denitions of the state of burnout the often-observed stronger connection between depression and job- can be considered a minimal precaution for avoiding spurious conclu- specic factors than between job-specic factors and burnout sions regarding the overlap of burnout with depression purchase fluticasone 100mcg fast delivery asthma symptoms from allergies. Such an observation tends to conrm of consensual diagnostic criteria for burnout has led to a multiplication that the traditional generic 250mcg fluticasone mastercard asthmatic bronchitis 3 times, scope-based distinction between burnout and de- of the operationalizations of the burnout construct purchase fluticasone 250mcg without prescription brittle asthma definition. Whether vulnerability factors for depression also predispose to question related to the conceptualization and measurement of burnout burnout remains largely unexplored. Investigating, for instance, the that may be critical to the issue of the burnoutdepression overlap. In the sion) constitute major limitations to current knowledge and prevent end, systematic clinical observation may be indispensable to clearly any denite conclusion regarding the burnoutdepression overlap. In- identify the singularity, if any, of the burnout phenomenon and de- stead of comparing burnout to rather unspecied sets of depressive cide whether a new nosological category is needed. Contributors Besides, when attempting to distinguish burnout from depression, The rst author conducted literature searches and wrote the initial draft of the man- attention should be paid to not generalizing ndings associated with uscript. All authorscontributedtoreviewseveralversionsofthemanuscriptandhaveap- the early stages of burnout to its late stages (Bianchi et al. In order to deal with the current lack of consen- sual diagnostic criteria for burnout, conservative cutoff scores should be Conict of interest used when interested in isolating cases of burnout. Studies (in chronological order) Approach Burnout measurement Depression measurement Country n 1. Studies (in chronological order) Follow-up Approach Burnout Depression Country n duration measurement measurement 1. Occu- pational burnout as a predictor of disability pension: A population-based cohort study. Job strain, burnout, and depressive symptoms: A prospec- tive study among dentists. Relationship between burn- out and depressive symptoms: A study using the person-centred approach. The relationship between job-related burnout and depressive disordersResults from the Finnish Health 2000 Study. Contribution of burnout to the association between job strain and depression: The Health 2000 Study. Interventions in relation to occupational burnout: The population-based health 2000 Fig. Occupational burnout and medically certied sickness absence: A population-based study of Finnish employees. Occupa- tional burnout and severe injuries: An eight-year prospective cohort study among Finnish forest industry workers. Occupational burnout and chronic work disability: An eight-year cohort study on pensioning among Finnish forest industry workers. Burnoutasapre- dictor of all-cause mortality among industrial employees: A 10-year prospective register-linkage study. Darwinian models of depression: A review of evolu- tionary accounts of mood and mood disorders. Joint effect of chronic medical illness and burnout on depressive symptoms among employed adults. Relative frequency of use (%) of dimensional, categorical, and mixed approaches the association between obesity and burnout among apparently healthy men and to burnout and depression. The convergent and discriminant validity of burn- of changes across time in burnout and its facets. Journal of Personality, 80(2), out measures in sport: A multi-trait/multi-method analysis. Burnout and psychiatric morbidity among medical stu- nia relationships: A prospective study of employed adults. Journal of Psychosomatic dents entering clinical training: A three year prospective questionnaire and Research, 65(1), 512. Predictorsofrst onsetandrecurrenceofmajor work-related depression among nurses in the Caribbean. International Journal of depression in young women during the 5 years following high school graduation. Theassociationbetweenburn- The relationships between work characteristics and mental health: Examining nor- out, and depressive symptoms in a Turkish military nurse sample. Bulletin of Clinical mal, reversed and reciprocal relationships in a 4-wave study. Using equity theory to examine the difference between burnout and depres- tus in Italian air trafccontrollers. The convergent validity of Distinguishing among antecedents, concomitants, and consequences. Present but having a children with cerebral palsy on quality of life, burn-out, depression and sick: A three-wave study on job demands, presenteeism and burnout. European Journal of Physical and Rehabilitation Development International, 14(1), 5068. The prevalence of burnout and depression and their association with 3(13), 217221. Canadian Journal of Behavioural Science, 26(2), function performance is reduced during occupational burnout but can recover to 210227. Annals of Internal tion: Cross-sectional study of obstetrics and gynecology residents. Associations between satisfaction with life, burnout-related emotional and physical Patient Education and Counseling, 93(1), 146152. Perceived control, depressive symptomatology, vantages and disadvantages of a unidimensional approach in burnout research. Depression, burnout, and percep- not identical twins: Is decline of superiority a distinguishing feature?
Studies examining differential rates for the prevalence of Diabetes management strategies ideally incorporate a means of depression in type 1 vs fluticasone 250 mcg with amex asthma attack 8 month old. The interplay between diabetes buy fluticasone 500mcg line asthma definition xu, major depressive disorder and other psychiatric conditions buy fluticasone 500mcg amex asthma symptoms for adults. Risk factors for developing depression in individuals with dia- betes are as follows (5761): Bipolar Disorder Female sex Adolescents/young adults and older adults One study demonstrated that over half of people with bipolar Poverty disorder were found to have impaired glucose metabolism, which Few social supports was found to worsen key aspects of the course of the mood disor- Stressful life events der (80). People with bipolar disorder have been found to have Longer duration of diabetes prevalence rates estimated to be double that of the general popu- Presence of long-term complications. Insulin resistance is associated with a less favourable course of bipolar Intensive lifestyle intervention for people with type 2 diabetes illness, more cycling between mood states, and a poorer response with overweight or obesity reduced the risk of depressive symp- to lithium (85). Risk factors (with possible mechanisms) for developing diabe- tes in people with depression are as follows: Schizophrenia Spectrum Disorders Physical inactivity (63) and overweight/obesity, which leads to Schizophrenia and other psychotic disorders may contribute an insulin resistance independent risk factor for diabetes. People diagnosed with psy- Psychological stress leading to chronic hypothalamic-pituitary- chotic disorders were reported to have had insulin resistance/ adrenal dysregulation and hyperactivity stimulating cortisol glucose intolerance prior to the advent of antipsychotic medication, release, also leading to insulin resistance (6469) although this matter is still open to debate (8688). Personality traits or disorders that put people in constant con- Furthermore, substance abuse and psychosis among individuals with ict with others or engender hostility have been found to increase type 1 and type 2 diabetes increases the risk of all-cause mortal- the risk of developing type 2 diabetes (92). The risks A history of signicant adversity/trauma, particularly early in life, increase signicantly during adolescence (113,114). Conversely, as glycemic control worsens, the prob- to cause a 40% increased risk of developing type 2 diabetes; those ability of mental health problems increases (122). Adolescents with with sub-syndromal traumatic stress symptoms had a 20% increased type 1 diabetes have been shown to have generally comparable rates risk (96). The presence of psychological symptoms and diabetes prob- lems in children and adolescents with type 1 diabetes are often Anxiety strongly affected by caregiver/family distress. It has been demon- strated that while parental psychological issues are often related Anxiety is commonly comorbid with depressive symptoms (97). Anxiety disorders were found reduced positive effects and motivation in older teens (128). Long-term anxiety has been asso- Feeding and Eating Disorders in Pediatric Diabetes ciated with an increased risk of developing type 2 diabetes (100). Ten per cent of adolescent females with type 1 diabetes met the Diagnostic and Statistical Manual of Mental Disorders (5th Edition) Feeding and Eating Disorders criteria for eating disorders (30), compared to 4% of their age- matched peers without diabetes (128). Eating disorders are also asso- Anorexia nervosa, bulimia nervosa and binge-eating disorder have ciated with poorer metabolic control, earlier onset and more rapid been found to be more common in individuals with diabetes (both progression of microvascular complications (103). Eating dis- young adult females with type 1 diabetes who are unable to achieve orders are common and persistent, particularly in females with and maintain glycemic targets, particularly if insulin omission is sus- type 1 diabetes (102,103). Depressive symptoms are eating disorders may require different management strategies to highly comorbid with eating disorders, affecting up to 50% of indi- optimize glycemic control and prevent microvascular complica- viduals (105). Type 1 diabetes in young adolescent women appears sumption of >25% of daily caloric intake after the evening meal and to be a risk factor for development of an eating disorder, both in waking at night to eat, on average, at least 3 times per week. Night terms of an increased prevalence of established eating disorder fea- eating syndrome has been noted to occur in individuals with type 2 tures as well as through deliberate insulin omission or underdosing diabetes and depressive symptoms. Other Considerations in Children and Adolescents Sleep-Wake Disorders The prevalence of anxiety disorders in children and adoles- cents with type 1 diabetes in 1 study was found to be 15. The presence of psychiatric disorders was related to elevated A1C levels and a lowered health-related quality of life score in the general pediat- Substance Use Disorders ric quality of life inventory. In the diabetes mellitus-specic pedi- atric quality of life inventory, children with psychiatric disorders The exact prevalence of substance use disorders among indi- revealed more symptoms of diabetes, treatment barriers and lower viduals with diabetes is not well established, and the presence of adherence than children without psychiatric disorders (132). Another study found that people with newly diagnosed type 2 dia- betes had a rate of past suicide attempts of almost 10%, which is twice the rate estimated in the general population. The rate of past Prevention and Intervention suicide attempts in currently depressed patients with diabetes was reported at over 20% (156). Children and adolescents with diabetes, along with their fami- lies, should be screened throughout their development for mental health disorders (134). Given the prevalence of mental health issues, Psychiatric Disorders and Adverse Outcomes screening in this area is just as important as screening for micro- vascular complications in children and adolescents with diabetes Two independent systematic reviews with meta-analyses showed (135). Older adults with diabetes and depres- ing overall well-being and perceived quality of life (137), along with sion may be at particular risk (109). Psychiatric disorders and the use of psychiatric with validated questionnaires or clinical interviews. The available medications are more common in children with obesity at diag- data does not currently support the superiority of any particular nosis of type 2 diabetes compared to the general pediatric popu- depression screening tool (160). Children and adolescents prescribed an atypical instruments have a sensitivity of between 80% and 90% and a antipsychotic have double the risk of developing diabetes (145). Scales that are in the public domain risk of developing diabetes may be higher in adolescents taking con- are available at www. Considerations for Older People with Diabetes Psychosocial (Non-Pharmacological) Treatments Type 2 diabetes does not appear to be more common in geri- atric psychiatric patients than similarly aged controls. The presence of depressive symptoms in elderly people with by a nurse working with the patients primary care provider type 2 diabetes is associated with increased mortality risk (154). Suicide Individuals with diabetes distress and/or psychiatric disorders benet from professional interventions, either some form of psycho- A review article found that people with both type 1 and type 2 therapy or prescription medication. Evidence from systematic diabetes had increased rates of suicidal ideation, suicide attempts reviews of randomized controlled trials supports cognitive behaviour D. Gains from treatment with psychotherapy are more likely to benet psychological symptoms and glycemic control in adults than will psychiatric medications (which usually reduce psychological symptoms only) (185). Furthermore, evidence suggests inter- ventions are best implemented in a collaborative fashion and when combined with self-management interventions (185). Lower diabetes regimen dis- tematic review estimated and compared the effects of antipsychotics, tress (produced by an intervention combining education, problem both novel and conventional, and noted variable effects on weight solving and support for accountability) led to improvements in medi- gain (206). The weight gain potential of clozapine and olanzapine cation adherence, physical activity and decreased A1C over 1 year has been established (207,208).
Prognosis Post exposure prophylaxis has reduced this transmis- Case fatality rate less than 1 per 1000 buy fluticasone 100 mcg otc asthma symptoms following a cold. Nosocomial infections may Geography occur due to needle stick injuries or contaminated in- More common in the developing world with highest lev- struments order fluticasone 250 mcg free shipping asthma symptoms for kids. The virus is not cytopathic buy fluticasone 500mcg with mastercard asthmatic bronchitis drugs, the liver damage is immune- r Vertical transmission is the most common route in mediated by the cytotoxic T lymphocytes response to high endemic areas. It occurs at or after birth and is viral antigen expressed on the surface of liver cells dur- mostcommoninbabiesofe-antigenpositivemothers. The complete virion or Dane particle is spheri- Hepatitis B is diagnosed and followed using serological cal, 42 nm in diameter (see Fig. It has also sAg made in yeast cells) is given to at risk individuals been noted that patients who present with jaundice including health-care workers and in areas of high during the acute infection rarely convert to a carrier prevalence. The likelihood of these conditions depends on also used as post-exposure prophylaxis for needlestick the age of the patient: injuries. Less than 10% of patients have an acute u-like illness with jaundice, the remainder are asymptomatic at the time of infection. Followinginfectionmostpatients developchronichepatitisC,whichpredisposestocirrho- Denition sis and hepatocellular carcinoma. Chronic hepatitis C is Hepatitis C is one of the hepatotrophic viruses, which oftenasymptomaticbutmaycausefatigue,myalgia,nau- predominantly causes a chronic hepatitis. Symptoms and signs of chronic liver disease occur years after initial Incidence/prevalence infection. Five per cent carrier rate in Far East; 12% in Mediter- Fatty change is seen in the hepatocytes, with little active ranean. Quantication of the viral load may be of ing to an increased risk of rapidly developing cirrhosis use in tailoring treatment. Com- bination therapy with pegylated interferon and rib- Management avirin is recommended for the treatment of people aged There is no vaccine for hepatitis D; however, vaccination 18yearsandoverwithmoderatetoseverechronichepati- against hepatitis B will prevent hepatitis D infection. In- tis C (histological evidence of signicant scarring and/or terferon can be used to treat patients with chronic signicant necrotic inammation). There is no Recovery from hepatitis B leads to clearance of hepatitis available vaccine. Any patient at risk of Geography hepatitis B is at risk of hepatitis D, particularly intra- Cause of water-borne epidemics in the Indian subconti- venous drug users. Hepatitis r WhenhepatitisBandDsimultaneouslyinfectthehost E, like hepatitis A, is transmitted via the faecaloral route aco-infectionoccurs. It causes a able severity, but is more likely to cause fulminant self-limiting acute hepatitis, with no chronic or carrier hepatic failure. Liver cell membranes may become immunogenic resulting in a lymphocyte-mediated cytotoxic response against Other liver diseases the liver cells. Alcohol-induced liver disease Clinical features Denition Differing patterns are seen: r Acute alcoholic hepatitis resembles acute viral hepati- Liver disease caused by alcohol range from a fatty liver to hepatitis and cirrhosis. Characteristically Mallorys bodies composed of cytoskeletal fragments Pathophysiology andubiquitin,aheatshockproteinthatlabelsproteins r Any alcohol ingestion causes changes in liver cells, as being damaged and targets them for breakdown. Alcoholic It appears as bright eosinophilic amorphous globules hepatitis refers to alcohol-induced liver injury visible within hepatocytes. This form of change is seen in those ingesting more than 80 g alcohol per day (6 units, 1 bottle of wine or 3 pints of beer). Steatosis r Cirrhosis: Repeated damage has led to brosis, with damage to the normal architecture upon which func- Steatohepatitis tion is dependent. Up to 10% of patients with cirrhosis, secondary to Cirrhosis alcohol use, develop hepatocellular carcinoma. Ultra- sound may show signicant cholestasis and be mistaken liver injury, occurring in patients with little or no his- for extra-hepatic obstructive jaundice. In late stages patients ranges from fat accumulation in hepatocytes (hepatic maybeconsideredforlivertransplantiftheyhaveproved steatosis) to hepatic steatosis with hepatic inamma- abstinence. The pathogenesis of nonalcoholic fatty liver disease is r Fatty liver is reversible, with complete recovery. However, if they abstain from drinking 90% acid entering the liver, decreased free fatty acid leav- have a full recovery. Insulin resistance appears to be important in the acute episode of hepatitis have the poorest prognosis development of hepatic steatosis and steatohepatitis. Hepatomegaly is a frequent nd- atotoxicity may be subdivided into predictable (dose- ing. Most cases are found on incidental abnormal liver dependent) and idiosyncratic, although more than one function tests. Patients who develop cirrhosis may be at increased risk for hepatocellular carcinoma. Ultrasound r Idiosyncratic hepatotoxins appear to cause a chronic scan may indicate fatty inltration. Management The pathophysiology of drug hepatotoxicity may also be r Obesity, hyperlipidemia and diabetes should be man- divided into the liver pathology caused (see Table 5. Denition r In the few patients who progress to end stage, liver Achronic hepatitis of unknown aetiology characterised failure transplantation may be required; however, re- by circulatingautoantibodiesandinammatorychanges currence in the transplanted liver has been reported. Patients may have an acute hepatitis or complica- drugs tions of cirrhosis such as portal hypertension (e.
In clinical practice buy fluticasone 250mcg free shipping asthma unspecified icd 10, this typically results in numerous physical investigations ranging from standard gynecological exami- nations and tests for infections fluticasone 500 mcg for sale asthma red zone symptoms, to invasive procedures such as colposcopy and laparoscopy buy 500mcg fluticasone with amex asthma symptoms clip art. If such investigations yield negative ndings, the default is to assume a psychogenic causation (it is all in your head) and refer the patient to a mental health professional. Depending on the orientation of the mental health professional, dyspareunia may be attributed to factors ranging from inadequate arousal to childhood sexual abuse. Because most women with dyspar- eunia present without an identiable physical explanation for their pain, rarely is there a primary focus on the pain or on direct pain control in the case of dyspar- eunia. For example, 85% of back pain patients present without identiable pathology (15), yet they are still provided with treatment alternatives, such as analgesic medication and/or physical therapy. As in the case of back pain, we recommend a similar multidimensional pain approach to the understanding and treatment of dyspareunia (16). Dyspareunia 253 Gate Control Theory of Pain, which states that the experience of pain includes sensory and emotional components and that psychological factors play a role in pain control (17). This theory has helped explain the powerful inuence of cog- nitive processes on pain perception via descending modulation from the brain, and scientists have since learned that the complex experience of pain cannot be simply equated with tissue damage (18). The italicized portion of this denition is reserved for pain patients without identiable physical pathology, as in most cases of dyspareunia and other chronic pain conditions. Within this framework, the study of underlying physiology is ascribed great importance, but is not sufcient in order to charac- terize the whole pain experience. In terms of pain history, many women link the pain onset to their rst intercourse experience, but it may actually have long preceded this. Similarly, women with vulvar vestibulitis have been found to describe their pain in a consistent manner (14). Some patients, however, may have limited knowledge of their pelvic/genital anatomy, in which case a diagram is often helpful. It is also important for the physician to try and locate the affected region by attempting to replicate the pain through pal- pation and/or pelvic examination. If upon examination, pain is experienced, the physician should then determine whether this is the same pain experienced during intercourse. This can be assessed by inquiring about pain location, quality, and intensity during both inter- course and examination. In the case that the gynecologist fails to replicate the pain, it is important to clarify to the patient that the gynecological examination is not the same scenario as the bedroom and that there are many factors that could produce variability in the pain experienced. A further assessment of these factors includes inquiring about activities that produce the pain (e. To this end, keeping a pain diary can be extremely informative for both the physician and the patient. Asking about past treatments, previous diagnoses, and remedies that helped/worsened the pain are also key in obtaining a complete picture of the problem. Vulvar Vestibulitis Syndrome Case Study Following numerous yeast infections after using a new oral contraceptive pill 2 years ago, Sandra, a 25-year old primary school teacher, started experiencing an intense burning pain at the entrance of her vagina during sexual intercourse. The pain started with initial penetration, lasted throughout intercourse, and was present for $30 min afterwards. Thinking that it was caused by yet another yeast infection, Sandra purchased her usual treatment from the pharmacy: over-the-counter antifungal vaginal suppositories. However, this only increased her pain to the point that, 6 months later, she had become apprehensive about sexual activity with her long-term partner. She also noticed a tensing up of her pelvic oor muscles while engaging in foreplay and a marked decrease in her sexual desire and arousal levels, which further contributed to her pain. She sought treatment from several medical professionals, underwent several painful examinations, and tried various topical creams and lubricants without any improvement in her pain or answers as to what her pain was. She began doubting her love for her partner, thinking that the pain was indicative of relationship problems. Finally, through one of her friends at work, Sandra obtained the phone number of a gynecologist who diagnosed her with vulvar vestibulitis syndrome and recommended physical therapy and pain relief therapy. Dyspareunia 255 Diagnosis Friedrich (6) proposed the following diagnostic criteria for vulvar vestibulitis: (1) severe pain upon vestibular touch or attempted vaginal entry, (2) tenderness to pressure localized within the vulvar vestibule, and (3) physical ndings limited to vestibular erythema of various degrees. Although the third criterion has not received much support in terms of its validity and reliability, the rst two have (14). Typically, vestibulitis patients present with provoked pain at the entrance of the vagina, their main complaint usually being painful intercourse. The cotton-swab test, a standard gynecological tool for diagnosing vestibulitis, consists of the application of a swab to various areas of the genital region. If the woman reports pain when pressure is applied to the vestibule during this test, then the diagnosis of vestibulitis is made. The cotton-swab test is usually performed in a clockwise manner around the vestibule; however, research has shown that pain ratings increase with each successive palpation. Therefore, we recommend a randomized order of cotton-swab application with adequate pauses after each palpation to avoid sensitization of the vulvar vestibule and unnecessary pain to the patient (16,20). Although the cotton-swab test for the diagnosis of vulvar vestibulitis syn- drome is considered the clinical method of choice since it is fast and easy to perform, it is not necessarily the standard tool for research purposes. First, the amount of pressure applied during the cotton-swab test is not standardized either between or within gynecologists (16,20,21). Indeed, it has been shown that different gynecologists apply different pressures and can elicit signicantly different pain ratings in the same women (16,20). The vulvalgesiometer replicates the quality of pain that women with vulvar vestibulitis report experiencing during intercourse, and is currently being used in numerous studies. The sensations started progressively, initially with short periods of discomfort, but gradually became more frequent and intense to the point that she always felt some degree of pain during a 24-h period. She, like Sandra, underwent many invasive examinations and received numerous treatments, none of which helped.