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However generic 50 mg endep fast delivery, these vaccines still with addiction involving cocaine who received are undergoing clinical trials to test for safety daily doses of modafinil for eight weeks and efficacy generic endep 75 mg with mastercard. While they may be helpful in submitted nearly twice as many clean urine reducing the rewarding effects of nicotine in samples than placebo patients during the course those who already are addicted buy discount endep 50 mg on line, they do not of the study and were more than twice as likely to achieve at least three weeks of prolonged 167 † abstinence. Another study found modafinil to Who did not have co-occurring addiction involving be effective in reducing cocaine use and cocaine alcohol. The nicotine patch A cocaine vaccine also has been developed and is available both over-the-counter and by 187 was found in a preliminary study to reduce prescription. Side effects of Maintenance Medications/Medication nicotine gum and lozenges include sore throat, 190 Assisted Therapies. These medications may absorbed through the lining of the mouth and 191 function by reducing cravings or withdrawal through the back of the throat. Two meta- symptoms and/or by reducing the rewards analyses found that inhaler use can nearly associated with the addictive substance. The primary side effect is local 193 manifestations of addiction and in disease irritation. Meta- when used as directed, provides lower doses of analyses indicate that patients almost double 182 nicotine at a slower rate than smoking, their chances of achieving and maintaining 183 thereby easing nicotine withdrawal symptoms. The primary side 196 managing nicotine-related cravings when used in effect of the medication is local irritation. An eight-week course of may be higher than intended for those who do not use them as directed or who use them while † The review included only those studies that had 185 continuing to smoke. Most of the studies included in the analysis sprays deposit nicotine in the bloodstream drew participants from self-selecting populations of smokers and, in general, the studies’ participants through the lining of the mouth or nose, whereas received counseling regardless of whether they were randomly assigned to receive medication or placebos. A meta-analysis of 24 studies found that the use Methadone can be taken orally and has a long 209 of nicotine patches for six to 14 weeks can half-life with a slow onset of action. It abstinence for at least six months compared to allows individuals with addiction involving 201 210 placebos. The patch also appears to be starting methadone, when switching from effective regardless of additional psychosocial another narcotic/opioid medication to 203 211 interventions. Methadone rather an aid to smoking cessation to be used in also may accumulate in the body to a toxic level conjunction with other evidence-based acute if it is taken too often, or in larger than 216 care and chronic disease management recommended quantities. Methadone used as replacement therapy for patients with prescribed for addiction involving opioids can * addiction involving opioids. Methadone reduces cravings and withdrawal symptoms by † Because methadone does not require intravenous injection, methadone users are less likely to engage in * Methadone can be used in the stabilization, acute needle sharing and because they do not need the same treatment and disease management/maintenance amount of money to obtain heroin, they are less phases of treatment for patients with addiction likely to engage in prostitution compared to their involving opioids. Buprenorphine is used in the Buprenorphine provides moderate relief from treatment of addiction involving opioids and, opioid withdrawal and has less risk of misuse 227 when used as directed, functions both by and overdose than methadone. Another reducing craving for addictive opioids and by advantage to buprenorphine is that it can be 219 easing withdrawal symptoms. At low doses, dosed less frequently than every day and still buprenorphine enables patients with addiction have a beneficial effect, which could help to 228 involving opioids to discontinue their use of the enhance medication adherence. Promising drugs without experiencing withdrawal results are emerging from preliminary research 220 symptoms. Despite these There are two forms of the medication: advantages, buprenorphine has similar side buprenorphine alone (brand name Subutex) and effects to methadone and other opioids including 230 a buprenorphine/naloxone combination therapy nausea, vomiting and constipation. The naloxone for addiction involving opioids have found that component of Suboxone serves to reduce the regardless of the dose, buprenorphine is better 232 rewarding effects of opioids and helps to prevent than placebos for ensuring patient retention, the misuse of the medication which can occur if and that higher doses increase the likelihood of Suboxone is crushed and then injected or snorted retention and abstinence relative to lower 223 233 to achieve a high. A randomized, controlled trial found that patients receiving buprenorphine were Buprenorphine must be administered under the significantly likelier to have negative urinalyses 224 supervision of a trained physician. It can be than placebo patients and to report decreased 234 prescribed by physicians who are certified in cravings for opioid drugs. Association or any other organization that the Secretary of Health determines is appropriate. These therapies enhance patients’ in the idea that individuals with addiction often skills in coping with life challenges, navigating feel ambivalent about their substance use and the 244 high-risk situations, avoiding substance use need to change their behaviors. Some therapies focus on enhancing ambivalence and strengthen their commitment to 245 patients’ motivations to change their substance- engage in behavior change. All three groups showed Motivational techniques capitalize on patients’ significant and comparable declines in alcohol use up readiness to stop using addictive substances and to three years later. In § More than 450 individuals with addiction were acute care, motivational therapies are employed randomly assigned to receive three sessions either of early in the treatment process. Since lack of social and family support often is a barrier to treatment enrollment, the support of family members is important in helping Combination therapy is successful for multiple individuals with addiction enter and complete reasons. Studies have found family and modality tends to enhance compliance with the 276 couples therapy to be effective for adolescents other. For example, medication may help and adults, men and women and racial/ethnic patients better tolerate withdrawal symptoms minorities as well as for individuals for whom that otherwise might have discouraged their the primary substances of addiction are alcohol, participation in psychosocial therapy and 270 psychosocial therapy might encourage patients marijuana, opioids or cocaine. Medications used in more effective than individual-based programs conjunction with psychosocial interventions and tends to have higher retention rates than have been found to increase patients’ likelihood 271 of remaining in treatment and maintaining other evidence-based interventions. Smokers of 6–14 cigarettes per day urine tests submitted by patients with addiction probably are moderately dependent and will 290 involving opioids. Smokers of 15 or more cigarettes per day probably are compliance with their treatment regimen. Another study § doses of modafinil versus a placebo provided found that six months after treatment significantly more clean urine tests (42. One study found that significantly more of their time in treatment abstinent methadone maintenance patients with addiction from alcohol than any of the other study groups.

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It is important to try to determine the cause of ascites in order to look for reversible causes and for serious causes purchase endep 50mg without prescription, such as malignancy endep 10mg on line, and to guide therapy cheap 10mg endep visa. Ascitic fluid is obtained by paracentesis and examined for protein, albumin, cell count with differential, and culture. The treatment of ascites usually consists of dietary sodium restriction cou- pled with diuretics. Loop diuretics are often combined with spironolactone to provide effective diuresis and to maintain normal potassium levels. Spontaneous bacterial peritonitis is a relatively common complication of ascites, thought to be caused by translocation of gut flora into the peritoneal fluid. Symptoms include fever and abdominal pain, but often there is paucity of signs and symptoms. However, fluid cultures, when posi- tive, usually reveal a single organism, most often gram-negative enteric flora but occasionally enterococci or pneumococci. This is in contrast to secondary peri- tonitis, for example, as a consequence of intestinal perforation, which usually is polymicrobial. Empiric therapy includes coverage for gram-positive cocci and gram-negative rods, such as intravenous ampicillin and gentamicin, or a third-generation cephalosporin or a quinolone antibiotic. Comprehension Questions For the following questions choose the one cause (A-G) that is probably responsible for the patient’s presentation: A. Idiopathic or autoimmune hepatitis is a less-well-understood cause of hepatitis that seems to be caused by autoimmune cell- mediated damage to hepatocytes. Diabetes mellitus, cirrhosis of the liver, hypogonadotrophic hypogonadism, arthropa- thy, and cardiomyopathy are among the more common end-stage developments. Skin deposition of iron leads to “bronzing” of the skin, which could be mistaken for a tan. Diagnosis is made early in the course of disease by demonstrating elevated iron stores but can be made through liver biopsy with iron stains. Sclerosing cholangitis is an autoimmune destruction of both the intrahepatic and extrahepatic bile ducts and often is associated with inflammatory bowel disease, most commonly ulcerative colitis. Patients present with jaundice or symptoms of biliary obstruction; cholangiography reveals the characteristic beading of the bile ducts. Primary biliary cirrhosis is thought to be an autoimmune disease leading to destruction of small- to medium-size bile ducts. Most patients are women between the ages of 35 and 60 years, who usually present with symptoms of pruritus and fatigue. An alkaline phos- phatase level elevated two to five times above the baseline in an oth- erwise asymptomatic patient should raise suspicion for the disease. The inability to excrete excess copper leads to deposition of the mineral in the liver, brain, and other organs. Patients can present with ful- minant hepatitis, acute nonfulminant hepatitis, or cirrhosis, or with bizarre behavioral changes as a result of neurologic damage. Kayser- Fleischer rings develop when copper is released from the liver and deposits in Descemet membrane of the cornea. Clinical Pearls ➤ The most common causes of cirrhosis are alcohol use, hepatitis B and C, and autoimmune disorders. Most patients are asymptomatic until they develop complications of chronic liver disease. This page intentionally left blank Case 14 A 42-year-old Hispanic woman presents to the emergency department complaining of 24 hours of severe, steady epigastric abdominal pain, radiating to her back, with several episodes of nausea and vomiting. She has experienced similar painful episodes in the past, usually in the evening following heavy meals, but the episodes always resolved spon- taneously within an hour or two. She is married, has three children, and does not drink alco- hol or smoke cigarettes. On examination, she is afebrile, tachycardic with a heart rate of 104 bpm, blood pressure 115/74 mm Hg, and shallow respirations of 22 breaths per minute. She is moving uncomfortably on the stretcher, her skin is warm and diaphoretic, and she has scleral icterus. Her abdomen is soft, mildly distended with marked right upper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, and no masses or organomegaly appreciated. Her leukocyte count is 16,500/mm3 with 82% polymorphonuclear cells and 16% lymphocytes. A plain film of the abdomen shows a nonspecific gas pattern and no pneumoperitoneum. She also has hyperbiliru- binemia and an elevated alkaline phosphatase level, suggesting obstruction of the common bile duct caused by a gallstone, which is the likely cause of her pancreatitis. Considerations This 42-year-old woman complained of episodes of mild right upper quadrant abdominal pain with heavy meals in the past. However, this episode is dif- ferent in severity and location of pain (now radiating straight to her back and accompanied by nausea and vomiting). The elevated amylase level confirms the clinical impression of acute pancreatitis. The next most common cause is biliary tract disease, usually due to passage of a gallstone into the common bile duct. Hypertriglyceridemia is another common cause and occurs when serum triglyceride levels are more than 1000 mg/dL, as is seen in patients with familial dyslipidemias or diabetes (etiologies are given in Table 14–2). When patients appear to have “idiopathic” pancreatitis, that is, no gallstones are seen on ultrasonography and no other pre- disposing factor can be found, biliary tract disease is still the most likely cause— either biliary sludge (microlithiasis) or sphincter of Oddi dysfunction. The pain often is relieved by sitting up and bending forward, and is exacerbated by food.

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Richardson purchase 50mg endep with amex, former friends and former students generously cre- director of the Institute cheap endep 10 mg on line, was instrumental in ated a Visiting Professorship in his memory cheap endep 10 mg without prescription, assuring this memorial. A graduate of be selected from scholars distinguished in the Johns Hopkins School of Medicine and clinical or scientifc aspects of child develop- former member of the Pathology house staff, ment or the related medical sciences. Shelley served on the Pathology faculty selection of the lecturers will be left to a com- from 1960 to 1970. Shel- mittee representing the Department of Pedi- ley’s commitment and contributions to teach- atrics, Physiology, Neurology, and the Behav- ing and residency training, the Visiting Pro- ioral Sciences. In 1927 he joined the Department donated funds to the Johns Hopkins Universi- of Physiological Chemistry and formally ty to endow a lectureship to be known as the retired from his productive career in 1961. His pioneering work related to the structure of According to the terms of this endowment, enzymes, metallo-enzyme function and the the income from the fund is to be used to application of mechanistic organic chemistry defray the expenses of one or more annual to explain enzymatic processes. Among ship: During the 1930’s the Harriet Lane the goals of the professorship is to increase Board of Managers set aside funds toward communication between basic and clinical a tribute to Dr. Dandy was a Hopkins neuro- fessor of Pediatrics at the Johns Hopkins Uni- surgeon, whose outstanding research and versity. He is widely credited with establish- neurosurgical abilities were summarized by ing academic pediatrics as it is known today, his colleague Warfeld Longcope, Profes- and with creating the frst successful full-time sor of Medicine, who wrote that Dandy “-had university clinical department in this country. He commanded cal investigator, for example, concerning aci- respect and admiration from everyone who dosis and diarrhea, and calcium metabolism came in contact with him, and for those of in tetany and in rickets. The Visiting Professor us who saw him often, these were combined is to be selected from leading pediatric clini- with great affection. Kroc Lec- demic Affairs Committee of the Department tureship: In 1985 The Kroc Foundation of Pediatrics. Kunkel Lectureship: The The funds are intended for the advancement family, friends and former students of Henry of multiple sclerosis and other neurological G. Kunkel have endowed a lectureship in disease research at Johns Hopkins Univer- immunology commemorating this outstand- sity. Kunkel, a graduate of the Johns Hopkins informally with colleagues and to present a University School of Medicine, was Profes- lecture. The selection of the lecturer is made sor and Senior Physician at the Rockefeller by a committee chaired by the Director of the University. Eastman, one demonstration that myeloma proteins closely of the most infuential and important American resemble normal immunoglobulins laid the obstetricians, served for more than 20 years foundation upon which the present knowl- as Obstetrician-in-Chief at The Johns Hop- edge of immunoglobulin structure and led to kins Hospital and Director of the Department the recognition of IgM and IgA as separate of Obstetrics in The Johns Hopkins University antibody classes. Eastman was respon- work in systemic lupus erythematosus and sible in large part for the scientifc develop- rheumatoid arthritis contributed in a semi- ment of obstetrics and his numerous publi- nal manner to knowledge of the underlying cations probably represent the frst efforts to pathogenesis of these autoimmune diseases. Myron Belfer in honor of his par- obstetrics and gynecology through the Nich- ents, Ira and Jean Belfer. He had been responsible their youngest son, Peter, who was a patient for the teaching of all the residents that had at Hopkins from the age of 6 months until his passed through the Department of Derma- death from heart disease in 1991 at the age tology Residency Program at that time. Since that time, the Belfer family and Zeligman was highly respected in the private their friends have displayed unfagging inter- practice of Dermatology and one who gave est and continued generosity in the support freely of his time to promote the clinical train- of Belfer Laboratories. The Lectureship is sup- Lecture in Lung Health and Disease: This ported by revenues generated by donations lecture was established within the Division of from former residents and friends. Mountcastle Lectureship: Johns Hopkins School of Medicine following Upon the retirement of Vernon Mountcastle the death of Dr. The lectureship her commitment to excellence, the humanis- honors the major contributions of Dr. Mount- tic missions of the clinicians, and the contri- castle to neuroscience and to Johns Hopkins bution of women to medicine. Lehninger Goldwin Smith Professor of Chemistry Emeritus established a lectureship in his memory in the Department of Chemistry and Chemical Biology feld of biochemistry. He was then appointed Univer- Lecture I sity Professor of Medical Science, a position L. He Johns Hopkins University School of Medicine served in this position until his death in 1986. Capitalizing on Tumor Genotyping: Toward the This Lectureship was inaugurated in 1990. Irrespec- graduate students registered in the School of tive of the actual scheduling of the medical Medicine is $41,200. These tuitions cover all and graduate portions of their education stu- normal charges. Living expens- remaining years will be assessed annually es, health insurance, a $200 imaging fee for at the M. Alterna- matriculation fee are in addition to the tuition tive schedules for payments at the M. Tuition is prorated to Special schedules for payment of fees can be period of enrollment. There is a $25 annual fee for Student in Students will not be admitted to the regu- Residence status. Offce of the Registrar of the School of Medi- Candidates cine and arranged for payment of their fees for the frst half of the academic year. Regis- Tuition for each 12 month period (September- tration is not required for the second half but August) of enrollment will be at the rate estab- arrangements must be made for the payment lished by the University for Ph. The late charge will clinical electives will be assessed a $1,000 be 1-1/2% per month of the unpaid balance, and will be added to each unpaid account on tuition fee and $300 registration fee for each the frst of each month. The reg- parking fees, the 1-1/2% late charge will be istration fee for research electives is $300 per assessed thirty days after billing and on the quarter or fraction thereof.

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Lenze ea (2003) found little effect of co-morbid anxiety on outcome of late- life depression treated with interpersonal psychotherapy purchase endep 75mg visa. Depression in the workplace 1367 Risk of hyponatraemia and small increase in risk of falls generic endep 50 mg on-line. Recurrent brief depression This is a relatively new innovation that is said to be common and have a relapsing course order 25mg endep otc. One in twelve people may be affected and the risk of deliberate self-harm may be 13% over ten years. Diagnostic criteria include 3 episodes over 3 months, depressive episode lasting less than 2 weeks, and no association with the menstrual cycle. The usual treatments for depression may be given a trial, although it may be relatively unresponsive to antidepressants (Baldwin, 2003) because episodes may be too short. Also of significance are the adequacy and appropriateness of treatment received, and the duration of the illness episode prior to starting therapy. Other conditions In 1882, the French psychiatrist Jules Cotard (1840-89), described patients with what he called délire de négation, the term Cotard’s syndrome being first used by J Seglas in 1897. Associated features include le délire d’énormité or delusion of enormous body size or a delusion that urinating will flood the world, and delusion of immortality. Cotard’s syndrome may be associated with valaciclovir (Halldén ea, 2007) or may complicate Parkinson’s disease. Lycanthropy is the belief that one is transformed into an animal, classically a wolf or werewolf. This non- specific presentation can be associated with ‘hysteria’, bipolar affective disorder, psychotic depression, schizophrenia, or organic brain disorders. Essentially, the criteria are (a) one or more episodes of depressive symptoms that fulfil the duration criterion for major depression but there are fewer symptoms and less impairment, and (b) the following diagnoses are outruled: adjustment disorder with 1370 depressed mood , depressive disorder not otherwise specified, major depressive episode, dysthymia, cyclothymic disorder, periods of normal sadness, uncomplicated bereavement, mood disorder induced by substance/general medical condition, a history of major depressive /mania/mixed episode(s), and depressive symptoms that occur exclusively during schizophrenia or schizophreniform/schizoaffective/delusional/not otherwise specified psychotic disorders. Mania may be precipitated by sleep deprivation in people who are euthymic, depressed, or who have no history of prior mania. The risk of such a switch occurring in predominantly unipolar depressives has been put at <1%. According to Vieta,(2004) quetiapine (for mania) may not be associated with treatment-emergent depression. Current or past substance use in depressed bipolar patients was not associated with longer time to recovery but may have increased risk for switching directly into mania/hypomania/mixed states in an American study. First onset mania in 1377 later life may be associated with increased vascular risk factors and relatively high current serum cholesterol levels. Women are more likely to experience depressive episodes than mania (men experience both phases with equal frequency) and rapid cycling is more common in females. Mania may be induced in vulnerable people by lack of sleep, crossing many time zones during travel, and shift work. Less common are chronic depression, chronic mania (said by some to be rare today but one report of hospitalised cases of mania 1380 found that 13% were chronic), and so-called rapid cyclers. Cycling Rapid cycling, which is more common in females, is present when there are at least 4 episodes/year 1381 Ultra-rapid cycling is when attacks occur every so many weeks to several days Ultra-ultra-rapid (ultradian cycling) is when attacks are of less than 24 hours duration (or several episodes daily) Continuous cycling when there is no sustained period of stable mood. Bipolar I disorder prospective study (Solomon ea, 2009) N = 219; median follow-up = 20 years; 1208 mood episodes Major depressive episodes = 30. Nwulia ea (2008) found the best predictors of rapid cycling in familial cases of bipolar disorder to be earlier onset of symptoms (18 v 21 years), comorbid anxiety (47% v 26%), and antidepressant-induced mood switching. Persistence of depressive symptoms increased significantly in the 2 youngest groups. Earlier ages at onset were associated higher depressive morbidity throughout 20 years of follow-up but did not predict changes in symptom persistence. The proportion of weeks spent in episodes of either pole (depression or mania) correlated across follow-up period in all age groups, although correlations were stronger for depressive symptoms and shorter intervals. Bipolar spectrum disorders are associated with an increased premature mortality rate due to general medical illnesses, a consequence perhaps of unhealthy lifestyle, medication, biology, and disparities in health care. Adolescent-onset is associated with substance abuse, anxiety, and an episodic course. Both groups, in contrast to adult cases, have elation, mixed episodes, longer episodes, and poor inter-episode recovery. Forty ea (2008) compared major depression and bipolar disorder patients and found psychosis, diurnal mood varian, hypersomnia during depression, and more frequent short episodes of depression to predict bipolarity. Depression and cancer If a person becomes depressed in middle age, especially if it is for the first time and if no precipitant can be found, should be rigorously investigated to exclude physical disease. Affective disorders may be an early precursor of clinical cancer, especially with cancer of the pancreas (more than with gastric cancer). Other criticisms include the inclusion of mildly depressed outpatients, the difficulties of establishing an adequate placebo group, low numbers in light therapy studies, lack of comparison with established treatments, uncontrolled studies, apparent seasonality (non-seasonal episodes on follow-up), and the finding of peaks in all seasons, including spring-summer depression. Classically the patient becomes depressed in autumn or winter and the condition remits by the following spring or summer over at least two years (reversed in the Southern Hemisphere). Schlager ea (1993) found that healthy women, but not men, had more symptoms (anxiety, somatisation, depression) in the two weeks before testing in winter than at other times. According to one relatively small 420 study, recent negative life events and poor social support may increase seasonality in mood disorder. It may also simply be an exaggeration of normal familial seasonal changes in mood. Demography and severity indicators did not distinguish seasonal from non-seasonal cases. However, nocturnal plasma melatonin and mean 24-hour concentration has also been reported as being reduced in depression (Rabe-Jablonska and Syzmanska [2001] found mean melatonin concentration in depression to be higher than normal at some points during the night). As well as this, amplitudes of melatonin circadian rhythm may be smaller than usual whilst people remain depressed. Patients with two long alleles may have milder symptoms than if they had at least one short allele.

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