By C. Harek. Delaware Valley College.
In addition buy chloramphenicol 500 mg mastercard antibiotic vs antibacterial, there is nothing against exercising in a variety of ways purchase chloramphenicol 250 mg with visa antibiotics hives, or rst with the ngers and if that is unsuccessful discount chloramphenicol 500 mg fast delivery bacteria 3d model, with articial aids or vice versa. The patient can do the exercises on her own, in the presence of her partner or together with her partner. She is asked to make time to do the exercises at least two or three times per week. However, a prerequisite is that when she decides to try the exercises, she is feeling relaxed, at peace with herself and is certainly not thinking I will just do them quickly to get them over with. Once she has managed to accept penetration of her nger or an articial aid, she can keep it in place for a period of time and experience what feelings arise on a conscious level and how the tissues feel. Careful movement of the pelvic oor muscles, ngers, or articial aid will increase the sensations. Then it is the end of the exercise for the moment and the ngers or articial aid are slowly withdrawn. Short exercise sessions prevent the patient from becoming obsessively preoccu- pied and also prevent tissue irritation. The use of a lubricant will facilitate the exercises and also prevent tissue damage. Quite apart from this, there is no change in the advice to continue love-making with the partner, albeit with a strict ban on coitus or attempts at coitus. Step 3 Once the patient is successfully able to insert one nger or an articial aid (i. If articial aids are being used and the patient has a male partner, then if she so desires, the procedure can be continued until she can successfully (i. If the patient has a female partner, then being able to insert a nger or dildo in a relaxed manner will sufce. Sometimes when a patient is using vaginal rods, she experi- ences the progression from one rod to another as being too big. In such cases it is useful to wrap the rod in more and more condoms during each exercise session, in order to make the transition more gradual. Step 4 During treatment, the partner can gradually become more involved in the exer- cises. Between steps, this usually requires a number of individual and/or relationship-oriented interventions. Step 5 It is the patient herself who indicates when she feels the time is right to exper- iment with her partner. She can choose a moment within or outside the context of love-making, or choose a moment in extension of an exercise session with ngers or articial aids. In order to prevent the male partner from insisting on penetration while the patient is not yet ready, it can be worthwhile only to tell her that the coitus ban has been lifted. The penis is inserted in exactly the same manner as that employed in the penetration exercises. Both partners should be warned that in the initial stages, love-making will seem rather technical or mechanical, but that gradually the technicalities will sink into the background. Cognitive Therapy The cognitive therapeutic approach is based on the notion that between stimulus and response, there are factors within the individual that determine the nature and intensity of the response. Interventions in this eld aim to change the behavior and feelings of the woman by teaching her to think and behave differently. Owing to the fact that vaginismus is often a conditioned response, the role of cognitive therapy is small. The active ingredient in cognitive therapy is there- fore to break the conditioned response, that is, just get on with things (exposure in vivo). Women with vaginismus will undoubtedly have irrational thoughts of too thick, does not t, and so on, especially when the complaints have been present for some time. Although such thoughts can be removed cognitively by means of good patient education, in principle, this will have little or no effect on the occurrence of the complaints. The most important aspect of cognitive therapy therefore is not so much removing the complaint, but instead motivating the patient, offering insight into the origination of the complaint, and further tackling the problem if it appears to contain a strong rational component. Vaginismus 289 sexual feelings and motives towards her partner, particularly the dicta- tion of her boundaries. In summary we can say that in the treatment of vaginismus, diverse interventions can play a role at any time in the treatment process. In relationship-oriented sexual counseling, attention can also be paid to: increasing mutual assertiveness; improving communicative expertise. Psychiatric comorbidity in heterosexual couples with sexual dysfunction assessed with the Composite International Diagnostic Interview. Difculties in the differential diagnosis of vaginismus, dyspareunia and mixed sexual pain disorder. Voluntary control over pelvic oor muscles in women with and without vaginistic reactions. The emotional motor system in relation to the supraspinal control of micturition and mating behavior. The relationship between involuntary pelvic oor muscle activity, muscle awareness and experienced threat in women with and without vaginismus. An investigation of pelvic oor muscle activity during exposure to emotion-inducing lm excerpts in women with and without vaginismus. Langdurige gedragstherapie in een geval van vaginisme [Longlasting behavioral therapy for vaginismus]. Sex problems in marriage, with particular reference to coital discomfort and the unconsummated marriage.
The value of Station purchase chloramphenicol 500mg online antibiotics for uti gonorrhea, two or more *All from industry having a physical centre is uncertain generic chloramphenicol 500mg on line infection after wisdom tooth extraction. This platform can impractical for them to be consolidated in be used both by one location cheap chloramphenicol 500 mg line antibiotics dizziness, and there would be concerns member and non- regarding anti-competitiveness and member countries to run management of intellectual property. Any revenues generated from the R&D could be divided as per the agreement between countries. InnovFin financing tools cover a wide range Investments would be of loans, guarantees and equity-type made mainly on funding. That is, this mechanism does not of supporting early-phase change the business model antibiotics will start-ups. Exit occurs by remain an unattractive business case and selling individual shares, future earnings should remain small to or by transferring entire moderate. Initially the fund would need public funding, but private capital could be invited to participate from an early stage. Later on, exits and gains from previous investments could possibly make the fund self-sustaining and profitable. An antibiotic- related incubator or accelerator can focus not only on antibiotics but also on diagnostics, preventive measures and all other supplementary and complementary technologies. The rationale is that the a transnational Strongly (7) Dont process of tendering to perform R&D is not organization, procures know (1) the business model of the pharmaceutical specified R&D activities industry (big or small). Industry wants to from a range of actors via *All from industry invest in areas matching its product open, competitive portfolio and risk profile, with the tenders. The R&D delivery opportunity to reap the rewards of these contract specifies the investments. Companies are not interested deadlines for the various in simply being paid on a fee-for- R&D stages and development basis where they do not own milestones covered by the intellectual property. However, even if the exclusivity trial data as the period extends the monopoly period where originating organization the innovator can charge high prices, it for a specified period of does little to improve the market time (from 5 to 8 years attractiveness. That is, newer antibiotics for new chemical entities will still need to be conserved, translating and up to 12 years for into minimal sales. Since able to change the market dynamics if the it is unethical to perform antibiotic achieves greater consumption, redundant clinical trials which may be undesirable. Market exclusivity gives a company exclusive marketing rights for a particular medicine for a set period of time. Monopoly Transferable exclusivity Not able (1) Although this mechanism would highly protections voucher: This would grant Weakly (2) incentivize antibacterial innovation, the a legal right to extend the Moderately (5) cost is estimated to be too high relative to monopoly time period Strongly (4) the gains. A company would pay for the (through exclusivities) of Dont know (2) exclusivity voucher only if it expected to any other patented drug, profit from it (i. Since in most European countries approval of a specified the government is the healthcare provider, antibiotic. The voucher this profit would be at the expense of the would be transferable or government, i. For example, if a government to pay an alternative reward, company developed like a Market Entry Reward. In non- Antibiotic A it could government-provided healthcare systems, receive an exclusivity this incentive has ethical ramifications since voucher that can prolong it would prolong high prices of important the monopoly period of medicines, which in some countries would its own Blockbuster have a disproportionate impact on the un- Oncology Drug or sell or underinsured. Since the voucher is designed as a one-time transaction, it would be difficult to rescind the voucher in cases where either the antibiotic was removed from the market, or sustainable use and equitability availability guidelines were disregarded. Prizes Lump sum diminishing Not able (1) Market Entry Rewards are meant to payments As with a Weakly (3) incentivize the commercialization of Market Entry Reward, Moderately (5) important new antibiotics with anticipated developers would receive Strongly (2) Dont low consumption. This variation increases a series of annual know (3) the price towards generic transition to delinked payments at the encourage generic manufacturers. Yet time of marketing generic manufacturers will be incentivized approval for a new to over-sell the antibiotic, which is antibiotic meeting a undesirable from a sustainable use specific target product perspective. Over time, the per unit price cap would be increased and the annual delinked payment decreased. Therefore, there will be an incentive for generic manufacturers to enter the market. This mechanism is too right to have a regulatory unpredictable and probably too small to agency evaluate the stimulate antibacterial innovation. Prizes Traditional prizes: Not able (1) Prizes have successfully stimulated Monetary prizes can take Weakly (2) innovation in other industries, and the a number of different Moderately (8) Longitude Prize has done this for antibiotic- forms, with variations on Strongly (3) Dont related diagnostics. A Market Entry Reward when the payment is know (0) is a type of prize, and the experts agreed received, how many that it is better to focus on this particular payments are received, prize form. It was anticipated that if the Market Entry Reward was perceived as attractive, this would facilitate greater interest from larger companies to purchase assets from smaller ones (which is, in essence, a Milestone Prize). However, milestone payments may provide useful supplementary financing for grant funders. Regulatory Regulatory Not able (1) Although regulatory harmonization is an mechanisms harmonization: Weakly (9) important initiative to more rapidly launch Regulatory harmonization Moderately (3) products across many markets, this does occurs when countries Strongly (0) Dont not solve the inherent problem with agree to standardize their know (0) antibiotics, i. This allows a company to seek regulatory approval in many countries more expediently. In countries with strong government or a stewardship and low resistance patterns, private/international sales may be very limited, leading to organization to purchase potentially higher prices than seen in other a specified quantity of a therapeutic areas. Alternatively, larger drug or a vaccine that quantities can be produced and stored, but meets certain criteria pre- this leads to waste, including costs for specified by the responsible destruction.
The excre- tion of amphetamine depends on urine pH acid urine increases its clearance order 500mg chloramphenicol with mastercard antibiotics for dogs simplicef. Ecstasy abuse Denition Clinical features Ecstasy is a semi-synthetic derivative of amphetamine Physical effects of an amphetamine-intoxicated state in- with hallucinogenic properties buy 500 mg chloramphenicol free shipping virus removal free download. A history should be taken of re- usually comes in tablets or capsules cheap 500mg chloramphenicol with visa infection nail bed, which may have centandpreviousrecreationaldruguse,includingmeth- logos or pictures on them. Occasionally it is and social history should be taken, as well as a medical found in a powder form that is smoked or snorted. Incidence/prevalence Complications Ecstasy use continues to rise, doubling in the last 5 Medical complications include seizures, coma, tach- years. Acute ecstasy, with rates approaching 30% in university stu- hepatic failure has been reported. There have been over 200 deaths from the drug in tions include paranoia, eating disorders, hallucinations 15 years. Clinical features r Effects begin within an hour and usually last 46 Management hours, but may persist for 48 hours with very high In more than mild toxicity, patients should have cardiac doses. Increasedthirstcanbemarked,suchthatex- 5 Metabolic acidosis should be corrected with sodium cessive water intake occurs, leading to hyponatraemia. Mood effects are 6 Narrow complex tachycardias are treated with intra- of euphoria, and ecstasy is unique in its ability to make venous -blockers. A psychiatric and social his- Overview of acute poisoning tory should be taken, as well as a medical history and examination. Denition Acute poisoning may result from accidental self- ingestion, deliberate self-harm or medical error. Neuropsychiatric complications include memory and concentration loss, insomnia, hallucinations and ash- Age backs. Aetiology Many different substances are involved in poisoning, es- Management pecially in children (see Table 15. In severe toxicity, initial management includes ensuring aclear airway, and ventilation if needed. Clinical features 1 All patients should have cardiac, pulse, blood pressure Acutepoisoningshouldbeconsideredinanypatientpre- and temperature monitoring. A full physical examination glyceryl trinitrate, but in refractory hypertension con- should be made. Principles of management: Other neurological features include altered behaviour, r Reduction of absorption by emptying the stomach seizures, hallucinations, motor disturbances. However, r Cardiovascular system: Altered heart rate, arrhyth- lavage or induced emesis is contraindicated following mias, blood pressure instability. The patient must have an intact cough reex dice, vomiting and diarrhoea, alcohol may be smelt or a cuffed endotracheal tube to protect the airway. Alternatively activated charcoal is useful for certain r Eyes: Miosis (constriction of the pupil is seen with drugs, ideally within 4 hours of ingestion dependent opiates and organophosphates) or mydriasis (dilation on the drug. Following an accidental These will depend on the presentation and the availabil- overdose social circumstances need to be considered ity of a reliable history. Patients presenting fol- mayhavetobeinvestigatedandmanagedasanacutecon- lowing deliberate ingestion require a psychiatric eval- fusional state or coma. Appropriate investigations may uation prior to discharge in order to assess their risk include of further self-harm and to identify and manage any r plasma paracetamol and salicylate levels. Accidental or deliberate overdose of paracetamol, caus- r blood gases to detect respiratory failure or metabolic ing liver damage. Complications Incidence These depend on cause and clinical state but may include Currently the commonest drug used for deliberate over- hypothermia, rhabdomyolysis and convulsions. In signicant over- dose a prothrombin time, liver and renal function tests and a lactate should be checked and repeated at 24 hours. P-450 Mixed function oxidase Prothrombin time measured 24 hours post ingestion is the best marker for liver damage. Toxic Intermediates Glutathione Hepatocyte Management macromolecules r Activated charcoal is given if the patient presents within 1 hour of ingestion and >12 g (6 g in the high risk treatment group) or 150 mg/kg have been in- gested, whichever is the smaller. It is maxi- mally effective before 8 hoursfollowing ingestion but Aetiology may be of value up to and beyond 24 hours. In older appropriate to start N-acetylcysteine prior to blood patients it is usually a form of deliberate self-harm; levels are known if very high doses have been taken or however, it may be accidental due to combination drug if presentation is delayed. Prognosis Normally toxic metabolites are inactivated by conjuga- If acute hepatic failure occurs, mortality is <50% with tion with glutathione. Liver failure leads Salicylate poisoning to encephalopathy, haemorrhage, hypoglycaemia, cere- bral oedema and death. Right subcostal pain and tenderness may then develop, Deliberate self-harm with aspirin is also unusual. Other features in- Pathophysiology clude hypotension, arrhythmias, excitement, delirium Salicylates have a direct effect on the central respi- and coma. This hyperventilation leads to respiratory hyperpyrexia, vasodilation and tachycardia. In severe alkalosis, which is compensated for by renal excretion overdose disorders of consciousness occur progressing of bicarbonate and potassium. Thecombinationofthemetabolicandrenaleffects Cerebral oedema and pulmonary oedema, which may be result in a metabolic acidosis. Investigations Blood glucose, blood gases, U&Es, prothrombin time Clinical features and bicarbonate levels should be measured.
Even when these explicit sexual stimuli are negatively evaluated purchase chloramphenicol 500 mg without prescription antibiotic cement spacer, or induce little or no feel- ings of sexual arousal generic 500mg chloramphenicol antibiotics that cover mrsa, genital responses are elicited purchase chloramphenicol 250 mg antibiotics for sinus infection penicillin. Genital arousal intensity was found to covary consistently with stimulus explicitness, dened as the extent to which sexual organs and sexual behaviors are exposed (66). Such a highly automatized mechanism is adaptive from a strictly evolution- ary perspective. If genital responding to sexual stimuli did not occur, our species would not survive. For women, an increase in vasocongestion produces vaginal lubrication, which obviously facilitates sexual interaction. One might be tempted to assume that, for adaptive reasons, the explicit visual sexual stimuli used in our studies represent a class of unlearned stimuli, to which we are innately prepared to respond. These stimuli seem to override the effects of various attempts at voluntary control (71). Emotional stimuli can evoke emotional responses without the involvement of conscious cognitive processes (72). For instance, subliminal presentation of slides with phobic objects results in fear responses in phobic subjects (73). Before stimuli are consciously recognized and processed, they are evaluated, for instance as being good or bad, attractive or dangereous. According to Ohman (74), the evolutionary relevance of stimuli is the most important prerequi- site for such a quick, preattentive analysis. Perhaps sexual stimuli fall within this category and can they be unconsciously evaluated and processed. A number of experiments in which sexual stimuli were presented subliminally to male subjects showed that this is indeed possible [see Ref. Preattentive pro- cessing of sexual stimuli occurs in women as well, but appears to be dependent upon the type of prime. Explicit sexual primes do not lead to priming-effects, but romantic sexual primes do (75). This seems to contradict Ohmans notion that evolutionary relevant primes can be unconsciously processed. Likely, preattentive processing is not entirely governed by evolution, but partly the result of overlearning or conditioning. A prerequisite of automatic processing seems to be that sexual meaning resulting from visual sexual stimuli is easily accessible in memory. In this model, sexual arousal is assumed to begin with the activation of sexual meanings that are stored in explicit memory. Sexual stimuli may elicit different memory traces depending upon the subjects prior experience. It directs attention to the stimulus and ensures that attention remains focused on the sexual meaning of the stimulus. This harmonic cooperation between the automatic pathway and attentional processes eventually results in genital responses and sexual feelings. The sexual meanings activate genital response, but the balancing of sexual and non- sexual meanings determine to what extent sexual feelings are experienced. The fact that disagreement between genital and subjective sexual arousal occurs more often in women might suggest that for women sexual stimuli have, more often than for men, sexual but also nonsexual or even negative mean- ings. There is some evidence that sexual stimuli generate negative sexual mean- ings in women more often than in men (78,79). Sexual stimuli evoke mostly positive sexual emotions in men, but a host of other nonsexual meanings, both positive and negative, in women. Sexual Feelings Emotions are not determined by distinctive stimuli, but by the meaning the stimu- lus has aquired over time. While there are biologically relevant stimuli that are innately pleasurable or aversive, most stimuli will acquire meaning through classical conditioning. As a consequence, meanings of stimuli depend on the individuals past experience, and may differ from one individual to another. Stimuli may have conveyed several meanings, and mean- ings relevant for different emotions may be present at the same time. Moreover, the value of a stimulus may differ over time since it will be inuenced by the current internal state of the organism. Thus, the rewarding value of a stimulus is dependent on the current internal state, and on prior experience with that stimulus. There is an increasing notion that emotional responses are automatic and precede feelings (80,81). Damasio stresses that all living organisms are born with devices designed to solve automatically, without proper reasoning required, the basic problems of life. The simpler reactions are incorporated as components of the more elaborated and complex ones. Emotion is high in the organization, with more complexity of appraisal and response. According to Damasio, an emotion is a complex collection of chemical and neural responses forming a distinctive pattern. When the brain detects an emotionally competent stimulus, the emotional responses are produced automatically.
Patients will also demonstrate signs and symptoms of a hyperdynamic circulation cheap 500 mg chloramphenicol with visa virus in us, such as systemic hypotension purchase chloramphenicol 500 mg with mastercard infection breastfeeding, resting tachycardia and warm periphery buy chloramphenicol 500mg on-line bacteria ua rare, as well as evidence of portal hypertension such as distended abdominal wall veins radiating from the umbilicus. Other complications of cirrhosis such as jaundice and muscle wasting, which can be quite profound, may also be present. Exactly 10 mL of ascitic fluid should be directly inoculated into blood culture bottles at the bedside. Indications for diagnostic paracentesis New Onset Ascites Hospital Admission of the Cirrhotic Patient Development of: o peritoneal signs/symptoms eg. Causes of Ascites Cirrhosis from any etiology (75%) Malignancies (15%) o Carcinoma of stomach o Carcinoma of colon o Pancreatic carcinoma o Hepatoma with or without cirrhosis o Metastatic intra-abdominal malignancies o Hodgkins and non-Hodgkins lymphoma o Ovarian carcinoma and Meigs Syndrome Heart failure (3%) Tuberculosis (2%) Pancreatitis (1%) Others (5%) o Acute Budd-Chiari syndrome o Nephrotic syndrome o Myxoedema o Ovarian hyperstimulation (result of in vitro fertilization) The appropriate frequency of a given cause of ascites is given in brackets. A high protein content may be associated with congestive heart failure, or Budd-Chiari syndrome (occlusion of the hepatic vein), and may also be seen in pancreatic ascites. In particular, abdominal ultrasound can detect even a few mLs of ascitic fluid and is highly sensitive (>95%) and specific (>90%). Abdominal ultrasound may also be used to establish the optimal site in which to perform the paracentesis, and will show the size of the liver and spleen. Treating the underlying etiology of cirrhosis has the potential to reverse the associated hepatic decompensation, thus the management of cirrhotic ascites begins with the treatment of the etiologic factors, if possible, such as abstinence from alcohol. Patients with decompensated cirrhosis from hepatitis B should be treated with antiviral therapy. Although bed rest will result in redistribution of body fluid, salt and fluid restriction is required to mobilise the ascites. The patient is usually prescribed a low salt diet containing 44-66 mmol sodium per day, which is even lower than that contained in a no- added salt diet. Professional dietary advice is necessary, and patients require specific instructions regarding where to purchase low salt food. Salt substitutes are contraindicated, as they often contain potassium chloride, and therefore predispose the patients who are taking potassium- sparing diuretics to the development of hyperkalemia. Patients should be carefully monitored with daily weights and with frequent 24-hour urinary sodium excretion measurements. The rate at which ascitic patients gain or lose weight can be used to assess compliance with the low salt diet, and the efficacy of diuretic treatment (Table 4). The urinary creatinine is measured simultaneously with as the urinary sodium to assess completeness of the urine collection. Random urine sodium assessments are unreliable, as urine sodium excretion varies over the + + course of the day. However, a urine Na /K ratio of >1 predicts with 95% accuaracy a urinary + Na excretion of >78 mmol/day. Predicting weight change in patients compliant with low salt (44 mmol Na/day) Diet Scenario I o Urinary sodium excretion is 100 mmol/day o Na intake = 44 mmol/day o Na output = 100 mmol/day o Na balance = (44-100)mmol/day = -56 mmol o Ascitic [Na] = 130 mmol/L o Therefore fluid loss = -56 mmol / 130 mmol/L = -0. Spironolactone, a distal diuretic with anti-aldosterone activity, is the preferred first line diuretic. Furthermore, any sodium reabsorption that is blocked by loop diuretics at the Loop of Henle will be reabsorbed when the sodium is delivered to the distal tubule. Combination diuretic therapy, with both a distal potassium sparing and a loop diuretic, acting on two different sites of the nephron, is now the standard of care. The combination approach has been proven to be more effective than sequential use of different classes of diuretics in the elimination of ascites. Spironolactone has a slow onset and offset of action because its half-life in cirrhotic patients can be as long as 35 hours. Therefore, frequent dose adjustments are unnecessary, and patients should still be monitored even after spironolactone is discontinued. One of the unacceptable side effects of spironolactone is painful gynecomastia in men. Amiloride, another potassium-sparing diuretic, is a less potent but certainly acceptable alternative to spirolactone. Either potassium-sparing diuretic is usually combined with furosemide, starting at 40 mg/day. Shaffer 523 * Monitor: daily weights weekly postural symptoms/signs twice weekly electrolytes, renal function symptoms/signs of encephalopathy Increase diuretics if: weight loss < 1. Electrolyte abnormalities and renal dysfunction are common in cirrhotic patients on diuretics, and should be monitored regularly. Initial outpatient management may be attempted if the volume of ascites is small, and when the ascites occurs in the absence of complications such as concomitant gastrointestinal hemorrhage, encephalopathy, infection or renal failure. Hypokalemia and hypochloremic alkalosis can precipitate hepatic encephalopathy, and should be avoided by the use of juicial changes in the dose of diuretics. Patients with peripheral edema can have their fluid mobilized more rapidly, as the edema fluid can easily be absorbed to replenish the intravascular volume. The dose of diuretic should be reduced if there are symptoms of encephalopathy, a serum sodium 125mmol/L, or a serum creatinine of 130mmol/L. Initially, daily weights and at least twice weekly electrolytes and renal function should be monitored. Urine sodium excretion must be greater than the oral sodium intake in order for the patient to lose weight. This is because the amount of ascitic fluid that can be mobilized each day is 700 mL. Refractory ascites is defined as ascites unresponsive to 400 mg of spironolactone or 30 mg of amiloride plus up to 160 mg of furosemide daily for two weeks, in a patient who has been compliant with sodium restriction. Non-compliance with sodium restriction is a major and often overlooked cause of so-called refractory ascites.
Younger if genetic risk If > 70 years chloramphenicol 500 mg visa antibiotics yellow urine, more likely to be indolent and hormone responsive cheap chloramphenicol 250 mg with amex infection yellow pus. Risk disappears within 5 years of stopping Radiation generic chloramphenicol 500mg with mastercard antimicrobial qualities, environmental hazards Not risk factors: Smoking Small (now disproven? Epithelial hyperplasia (1 2 times risk) Atypical hyperplasia proliferation and atypia of ductal or lobular epithelium. Easier to detect in an older woman (fat and intra-lobular fibrosis) All breast cancers are different. Can become infiltrative and then metastasise Intraductal carcinoma (20 30%): Comedocarcinoma: solid intraductal proliferation, central necrosis, microcalcifications on mammogram Classified by nuclear grade (low, intermediate and high) and the presence or absence of necrosis. Bisphosphonates slow osteolysis Risk factors for recurrence in breast cancer ( consider adjuvant chemo): Axillary node status (strongest predictor) Tumour size (> 1 cm) Histological tumour type and grade Adjuvant Chemotherapy: Reproductive and Obstetrics 381 Approx 25 30% risk of recurrence, 15 20% risk of death. However, lots of unnecessary interventions, and for a majority (>70%) whose cancer is diagnosed, the outcome is unchanged (but will live with 2 years extra knowledge of condition) Is there an appropriate infrastructure to provide screening and follow-up? There have been pilot studies Is it cost effective: Needs at least 70% screening coverage to be cost effective. Always attend for results Vaginal Discharge Cervical secretions in women not on the pill, and which change during the cycle, are part of normal discharge. Some inflammatory cells are normal in the latter half of a cycle Desquamating vaginal cells with healthy lactobacilli are major part of normal discharge pH < 4. Replacement of lactobacilli with small coccobacilli (Gardnerella) or motile curved rods (Mobilunus). Urine test is adequate for males and females Test high risk patients only for cure If reinfection, then? May require laproscopy Treatment: Antibiotics must cover anaerobes, chlamydia and gonorrhoea. Characteristic spreading edge, itchy Folliculitis: small pustule around a hair follicle Scabies: red, itchy nodules may not resolve despite treatment. Maori males 2 times more likely to be readmitted By specific diagnoses: Maori drug and alcohol first admission rates rising relative to non-Maori Maori admission rates for schizophrenia are similar to pakeha, readmission rates are higher Maori more likely to be referred to mental health services by welfare or law agencies than by a doctor (opposite for Pakeha) Maori more likely to be compulsorily admitted Issues: Maori view of mental health and illness vs. Western psychiatric paradigm Specifically Maori services Maori workforce development Issues in treating a Maori patient: Uncertain identity and alienation from society distrust of practitioner Must use interventions that enhance a Maori sense of well-being. Therapeutic alliance is with whole family, not just patient th th 410 4 and 5 Year Notes Complexity of problems lots of agencies involved in care (eg illness, substance use, poverty) Mental Health System Influences over the last 20 years: Individualised care Community based delivery: psych hospitals were very expensive and only cared for small proportion of people with mental illness Consumer empowerment and patient rights General management (during 80s non-clinical people involved in management) Purchaser-provider split Competition Public reactivity Thinking about disability as well as illness Aetiology of Psychiatric Disorders Predisposing factors: Determine a persons vulnerability to psychological distress. Eg early obsessional traits may obsessive-compulsive disorders Precipitating Factors: Factors that occur shortly before the onset of the disorders and are likely to have caused it. The patient may adjust the history according to the interviewers hypothesis and values. May help to draw up a family tree Get idea of family atmosphere during childhood: personalities of parents and relationships have lasting influence on subsequent relationships. Did you ever have any unpleasant experiences did anyone ever harm you, hit you, interfere with you sexually? Not a summary of problems but the crucial factors, based on a theoretical knowledge of the aetiology of psychiatric illness. Wont affect life insurance risk if insurance covers a mortgage or loan, or policy was taken out more than one year before. Suicide risk has no additional effect on premiums over and above the presence of depression Dont give prescriptions with repeats get them to come back for each script. Should include contact with other people and things the patient enjoys Ensure family member/responsible friend is available Encourage use of informal supports: whom can they talk to. If rules are broken (eg threats, etc) terminate the interview Interviewing tips: Is it wise to interview them at all? Basis in medical model Axis 2: personality disorder or traits and mental retardation. A short-term maladaptive reaction to a stressor (ie impairs social/occupational function or causes distress). Difficult to determine in dual diagnosis (substance related + non- substance related). Yerkes Dobson Curve (1908): moderate levels of anxiety can improve performance, but performance improvement plateaus and then falls with anxiety. May have limited symptom attacks Found across anxiety disorders and in non-anxious population Panic Disorder: Recurrent and unexpected panic attacks. Situationally-bound panic attacks are characteristic of social or specific phobias, although situationally-predisposed panic attacks are frequent in Panic Disorder Catastrophic misinterpretation of bodily sensations/mental events (eg has palpitations and thinks theyre having a heart attack). Fear visible anxiety symptoms Probability and cost of negative evaluation is over-estimated Early onset Leads to avoidance of social gatherings, public travel, etc Epidemiology: 6 month prevalence is 2 per 100, more females, onset in teens through to 35 social isolation Aetiology:? Aim is to elucidate these Identify and alter core conflicts Drug Treatment Benzodiazepines: may be useful for the short term or acute treatment of acute stress reactions. These prevent noticeable symptoms (eg blushing or shaking), which are typically interpreted catastrophically by individuals. Treating withdrawal: change to diazepam (greater dose flexibility), reduce dose by 10% every 2 4 weeks. Eg how do you feel about yourself, have you blamed yourself for things, do you feel guilty? Key difference between grief and depression is whether they themselves feel worthless or not Also review risk factors: Prior history of major depressive episode or suicide attempt. Previous episode 50% lifetime risk of recurrence Family history of mood disorder or suicide attempts. Its usually multifactorial regardless of cause may well need a multi-factorial approach to management Subgroups Subgroup Essential Features Implications Psychotic Depression Hallucinations and/or delusions More likely to become bipolar than non-psychotic types (esp under 25s).