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The change the antihypertensive medication to the beta-1 patient expressed doubt, insecurity, and frustration selective blocking agent, atenolol. Which of the fol- with the current regimen because of the necessity to lowing is the wisest method for making the change? Which of (D) Patients with pneumonia the following is the specifically indicated drug for this (E) Patients with urinary tract infections emergency? Each of the following (A) Bradycardia side effects is known to be caused by prolonged applica- (B) Gastritis tion of this preparation, except for which one? Which of the following drugs in (C) Simvastatin combination with warfarin acts to decrease warfarin (D) Atorvastatin blood levels? The foregoing is emphasized so besides those mentioned (captopril, barbiturates, met- more in diabetics, the very group for whom it is prescribed. Ethinyl estradiol is not metabolized angiotensin-converting enzyme receptor blocking agents in the 2D6 system. These drugs may cause fetal injury or metabolism, and the other drugs presented in the vignette death. Beta-blockers may exacerbate rebound hyperten- sion following discontinuance of clonidine. Acetazolamide increases renal excre- beta-blocking agent is present when discontinuance of tion, thus reducing the chance of lithium toxicity. All clonidine is contemplated, then the beta-blocker should other diuretics, that is, thiazides and loop diuretics like be stopped 2 days before the clonidine. If the beta-blocker furosemide, as well as any clinical dehydration states and is to replace clonidine, then it should wait for 2 days after conditions that result in dehydration including diarrhea discontinuance of clonidine before being started. Carbamazepine enhances the longed usage of glucocorticoids is perhaps not appreci- risk of neurotoxicity of lithium. Metronidazole may pro- ated; it is less well known than side effects such as voke lithium toxicity due to reduced renal clearance as do precipitation of diabetes, elevation of blood pressure, urea, xanthines, and alkalinizing agents. Lithium toxicity Cushing syndrome, aggravation of certain viral infections encompasses a large spectrum of physiological systems (varicella, herpes zoster keratitis), and osteoporosis. Thioridazine has been reported to tor blocker and is specific for overdose of this family of worsen the tremor of Parkinson disease when given along drugs. Hydrochloro- barbital, one of the most ancient sedatives, would, of thiazide/triampterene (Dyazide, Maxzide) has been course, aggravate the sedative effects of the benzodiaz- shown to increase the blood level of amantadine when the epine. Amitriptyline metic medication, is not employed in sedative overdose (Elavil), trihexyphenidyl (Artane), and benztropine management. However, dextroamphetamine inhibits gas- (Cogentin) each potentiates the anticholinergic effects of trointestinal absorption of the sedative phenobarbital. Lactic acidosis, albeit of tolterodine, an anticholinergic antispasmodic and as rare, has been reported with the usage of metformin in the such would be expected, even normally to result in a high presence of renal failure. This would be state that metformin should not be prescribed if the serum compounded and enhanced by any drug that increases its Drug Interactions, Caveats, and Primary Care 329 blood level. Beta-adrenergic blocking agents do distracters is actually a condition that would be amelio- not appear on the lengthy list of medications that increase rated by the anticholinergic effects of the medications the blood levels of atorvastatin. Rifampin is among the few drugs tensive crisis, behavioral emergencies, hyperthermia, and that interact with warfarin to decrease its blood level, risk- other problems, these two medications should not be ing hypercoagulability, and compromise of the therapeu- given together and should not overlap in time. Also, foods that contain significant Warfarin Levels or Risk of Hemorrhage amounts of tyramines such as cheeses must be avoided. In field stud- Barbiturates Amiodarone dextrophenydate ies, elderly individuals were 1. The Capecitabine Cefmetazole deaths were most often due to cardiovascular and cerebro- Mercaptopurine Cefoperazone vascular events as well as infection. Therefore, if the drug Phenytoin (chronic) Cefotetan is used in elderly people, those conditions as underlying Rifampin Chloramphenicol or symptomatic should be ruled out before deciding in Carbamazepine Fluconazole favor of starting the medication. None of the other condi- Fluvoxamine Itraconazole tions appears as definite or relative contraindications. Clarithromycin in conjunction with Phenytoin (acute) pimozide (and with astemizole, cisapride, and terfena- Salicylates (specifically enhance dine) may result in life-threatening ventricular dysrhyth- bleeding chances) mias, including ventricular tachycardia, ventricular Sulfamethoxazole fibrillation, and torsade de pointes. This is assumed to be Ticlopidine related to inhibition of metabolism of these drugs by Voriconazole clarithromycin. Systemic effects passed through References breast milk have not been shown with topical applications of glucocorticoids on nursing mothers. The Washington Manual effects mentioned, well known in association with oral or of Medical Therapeutics, 31st ed. Philadelphia : Williams & injected glucocorticoids, are possible as a result of the Wilkins ; 2004. Symptoms can be simple and focal, such as regional pain, or general and non-specific, often in the context of a generalized process such as fever or fatigue. The following are important points in assessing the time, type, and nature of presentation: • Why someone has presented at a particular time. First, the assessment of symptoms in adults and second, the patterns of disease presentation in children and adolescents. Therefore, pain is not merely an unpleasant sensation to many; it is, in effect, an ‘emotional change’. Localization of pain Adults usually localize pain accurately, although there are some situations worth noting in rheumatic disease where pain can be poorly localized (Table 1. Therefore, it is important to confirm the precise location of the pain on physical examination. Certain pain descriptors in adults are associated with non-organic pain syndromes (Table 1. Such descriptions may associate with illness behaviour in the consultation or during the examination. Pain from trauma/damage to tissues (‘mechanical’) in adults In general, mechanical disorders are worsened by activity and relieved by rest. This does not mean pain is not present at rest; in severe mechanical/degenerative disorders, pain disturbs sleep. Inflammatory musculoskeletal pain in adults Inflammatory lesions causing pain typically do so with or after immobility, such as when getting out of bed or after a long car journey. Interpretation should take into account the context in which the examination is done and the effects of suggestibility. This assumption has its own limitations, however, especially since passive movements of the joint will still cause some movement of the soft tissues. Myofascial pain is said to occur when there is activation of a trigger point that elicits pain in a zone stereotypical for the individual muscle. It is not clear whether trigger points are the same as the tender points characteristic of fibromyalgia. Do not dismiss the report of focal pain (or think of it as referred only) if there is no tenderness at the site on static examination. However, the technique is reliable only if localization of the injected anaesthetic can be guaranteed. Few, if any, rigorously controlled trials have shown it to give specific results for any condition. Typically, patterns of pain referral extend distally so problems at one joint can cause symptoms in the area of the adjacent distal joint. It may be a manifestation of inflammation or reduced movement due to mechanical pathology including swelling, or be used by an individual to describe reduced movement due to pain • Stiffness is often worse after a period of rest. Short periods (<30 min) of stiffness that persist after mobilizing is not a meaningful observation. Stiffness lasting >30 min and often several hours after mobilizing is a typical symptom of inflammatory arthritis. Individuals typically click or crack their joints to stretch the tissues and gain relief. Regard ‘swelling’ as a sign on examination unless the description of it as a symptom is convincing and the story has been elicited very carefully. Clunks, snaps, and clicks • ‘Clicks’ are often the focus of symptom reports and can cause some anxiety. However, ‘clicks’ from many different structures are not specific for ‘pathology’. Constitutional symptoms Fatigue, fevers, sweats, and excessive sweating sometimes occur with many different rheumatological diseases. Rashes There are many rheumatological conditions that are manifest in part by rashes. The association may be temporally related or separate in time so a broad view of the history of the rash needs to be taken. An atlas of typical psoriasis appearances is a very useful tool in the rheumatology clinic. Look for operation movements scars and Wrist extension and flexion ‘With the elbows in the palpation same position place the hands back to back with the fingers pointing down’ Elbows: look for nodules, rash ‘Bend your elbows bringing your hands up to your shoulders’ Shoulders: ‘Raise arms sideways, up Abduction to 180° to point at the ceiling’ Rotation ‘Touch the small of your back’ Hips, knees, Hips: lift leg (bended knee) and position upper leg vertical. With the patient standing upright, make a horizontal mark across the sacral dimples and a second mark over the spine 10 cm above. Pain assessment in children and adolescents Introduction More apparent in children, than at other ages, is that the level of distress from pain does not correlate well with the severity of the underlying or causative pathology. Pain assessment in specific scenarios The non- or minimally verbal child In the very young, or those with cognitive or emotional impairment, the history of pain and its impact is sought from the parent or carer and correlated with an astute clinical examination that looks for distress. Both can be carefully corroborated during examination feeling for, but not trying to overcome, any resistance to joint movement and monitoring facial expressions. The toddler and school-aged child • Children from <3 years old can volunteer helpful information and attempts to engage them in friendly discussion will provide reassurance before examination. Use of a picture or cuddly toy may help to localize the site of pain and the use of the Faces Pain Scale is a standard tool to indicate pain intensity, see: http://www. Swelling may arise from subcutaneous tissues, tendons, or joints, and may include oedema, lymphoedema, cellulitis, and haematoma. Teenagers • By speaking directly to the young person, a more accurate clinical picture will be acquired than from speaking to parents alone. Early morning wakening with pain may be associated with inflammatory or malignant conditions, whereas difficulty with sleep initiation or maintenance may be associated with chronic pain. Most cases of acute limp, however, have a preceding illness and are diagnosed as irritable hip or transient tenosynovitis. Subacute or long-standing limp or concerns about gait may present to rheumatologists. Age-specific assessment Toddlers and pre-school children • Review the child with reference to normal development and spend time observing the gait, first noting normal variants (see pp. Fatigue • It is unclear from what age children report negative experiences of generalized exhaustion, which as in adults may accompany any illness, but it may be reported by parents as a presenting symptom. In this way, a full screening joint examination can be played out as a game without touching the patient initially, thereby building rapport and patient confidence. Temporomandibular joint movement should allow three fingers of the patient’s hand to be held vertically in their open mouth. Chronic severe pain, lasting >3 months and affecting quality of life, is common too, with a prevalence of up to 16% in secondary school-aged girls. In this respect, pain is not a sensitive marker of disease yet it is still important to provide reassurance to avoid symptom amplification and prolonged disability. Although not the convention in paediatrics, we have taken a threshold of 3 joints to define multi-articular involvement: • mono/oligoarticular arthritis in children (1–2 joints). Early metastasization is associated with increased mortality necessitating early recognition. Key features which should trigger referral for further assessment in children and adolescents • Limp (see also ‘Assessment of the limping child’ pp. For example, these features might lead to disclosure of: • septic arthritis or osteomyelitis (high fever, hot and tender joint, or limb pain). These changes should not be dismissed as behavioural or anxiety induced (whether parent or child) without plans for a timely review of resolution or progression. The onset of muscular dystrophies, congenital and metabolic myopathies, and neuropathies are often insidious in onset. Muscle weakness, muscle fatigue, numbness, and delayed development predominate but may be associated with widespread or focal pain that is the presenting feature. There can be complete school absence and grossly abnormal sleep routines attributed to pain. Care must be taken when using the term ‘hypermobility’ as it can be perceived as disabling with a poor outcome. The cause of pain is often complex, but with effective communication and a range of integrated strategies that includes a focus on self-management and resilience, the outcome will be excellent with full participation in a normal quality of life. Functional weakness, not attributable to fear of movement from pain, may be indicated by walking on tiptoes and difficulties climbing stairs, and putting on T-shirts or jumpers. The 3 ‘Ss’: Stiffness, Swelling, and a positive Squeeze test (pain elicited by squeezing the knuckles). Assessment of children and adolescents Normal variants Effective reassurance that a child has a normal variant avoids unnecessary referral, investigation, and intervention. Causes toeing/out- include metatarsus adductus, toeing femoral anteversion, and tibial torsion.

Lawrence Appel blood glucose test micronase 2.5 mg purchase visa, frst author: A clinical trial of the efects of dietary paterns on blood pressure managing diabetes zorgtraject effective micronase 2.5 mg. Hennekens type 1 diabetes symptoms yahoo 5 mg micronase order visa, principal investigator of the Physicians’ Health Study Research Group and Chairman of the Steering Commitee: Final report on the aspirin component of the ongoing Physicians’ Health Study diabetes prevention 5 tips for taking control 5 mg micronase buy fast delivery. Ridker diabetes definition ada 2013 5 mg micronase fast delivery, frst author: A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. Chlebowski, member of the Women’s Health Initiative Steering Commitee: Risks and benefts of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. Denise Alberle, of the National Lung Screening Trial Research Team: Reduced lung-cancer mortality with low-dose computed tomographic screening. Patricia Cleary, principal investigator of the Diabetes Control and Complications Trial Research Group: T e efect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. Ridker, principal investigator, trial chair, and frst author: Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. Terje Pedersen, 4S Study investigator: Randomised trial of cholesterol lowering in 4,444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Hébert, frst author: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Laurent Brochard, frst author: Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. Emanuel Rivers, frst author: Early goal-directed therapy in the treatment of severe sepsis and septic shock. John Kress, frst author: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. Andres Esteban, frst author: A comparison of four methods of weaning patients from mechanical ventilation. Morin, frst author: Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. Joan Teno, frst author: Does feeding tube insertion and its timing improve survival? Temel, frst author: Early palliative care for patients with metastatic non-small-cell lung cancer. Richard Saitz, frst author: Individualized treatment for alcohol withdrawal: a randomized double-blind controlled trial. T e lifestyle intervention was particularly efective, with one case of diabetes prevented per seven persons treated for three years. Year Study Began: 1996 Year Study Published: 2002 Study Location: 27 clinical centers in the United States. Participants at Risk for Diabetes Type 2 Randomized Placebo Metformin Lifestyle Modi cations Figure 1. Study Interventions: Participants in the placebo group received standard lifestyle recommendations. Participants in the metformin group received stan- dard lifestyle recommendations along with metformin 850 mg twice daily. Participants in the lifestyle group were given an intensive lifestyle modifcation program taught by case managers on a one-to-one basis with the goal of achiev- ing and maintaining a 7% or greater reduction in body weight, improvements in dietary intake, and physical activity of at least 150 minutes per week. T e lifestyle modifcation program was taught during 16 sessions over a 24-week period, and reinforced with individual (usually monthly) and group sessions afer that. Endpoint: Primary outcome: Diabetes, as defned by either a fasting glucose ≥126 mg/dL or a glucose ≥200 2 hours afer a 75-g oral glucose load on two separate occasions. Preventing Diabetes 5 • Participants in the lifestyle group reported signifcantly more physical activity than those in the metformin and placebo groups, and at the fnal study visit 58% reported at least 150 minutes per week of physical activity. Summary of Key Findings Placebo Metformin Lifestyle Modifcations estimated Cumulative 28. Criticisms and Limitations: e participants assigned to the lifestyle group achieved an impressive reduction in weight as well as impressive improvements in dietary and exercise paterns. In addition, the trial did not assess whether either the lifestyle intervention or metformin led to a reduction in hard clinical endpoints, such as diabetes-related microvascular disease. Other Relevant Studies and Information: • Several other studies have demonstrated that lifestyle interventions can delay the development of diabetes in at-risk patients. Lifestyle modifca- tions are, therefore, the preferred method for preventing or delaying the onset of diabetes. As this woman’s doctor, you recommend that she begin a weight-loss and exercise program to reduce her risk for developing diabetes. Suggested Answer: T e Diabetes Prevention Program unequivocally demonstrated that lifestyle modifcations— more so than medications— can reduce the risk of develop- ing diabetes. T us, you can tell your patient that there is good evidence from a well-designed study that lifestyle changes can work. Since this woman is busy and may not have the time to participate in an intensive program, as the study participants in the Diabetes Prevention Program did, you might give her some simple recommendations she can fol- low on her own, for example, walking for 30 minutes a day. You might also give her manageable goals, for example, a 5- to 10-pound weight loss at her next visit with you in 3 months. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. T e long-term efect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. Lifestyle modifcation and prevention of type 2 diabetes in over- weight Japanese with impaired fasting glucose levels: a randomized controlled trial. Incidence of type 2 diabetes in the randomized multiple risk factor intervention trial. Year Study Began: 1994 Year Study Published: 1997 Study Location: Multiple sites in the United States. Who Was Studied: Adults ≥22 years of age with a diastolic blood pressure between 80 and 95 mm Hg and a systolic blood pressure ≤160 mm Hg who were not taking any antihypertensive medications. Also excluded were patients taking medica- tions afecting blood pressure, those with heavy alcohol use, and those unwill- ing or unable to discontinue supplements or antacids containing magnesium or calcium. Participants were instructed to avoid nonstudy food and to limit caf- feinated beverages to fewer than three per day and alcoholic beverages to fewer than two per day. T e total calories per day were adjusted for the participants to maintain a stable weight. Dietary Approaches to Stop Hypertension 11 Endpoints: Primary outcome: Change in diastolic blood pressure. It is likely that dietary compliance would be lower outside of an experimental seting, and thus the efects of these dietary changes would likely be considerably lower. He is in good health and reports that he jogs for 30 minutes three to four times per week. He lives alone and reports that he eats fast food multiple times per week and prefers meat and potatoes when he cooks for himself. He does not add salt to his food, but he reports eating prepackaged soups and potato chips that he knows are high in sodium. His vital signs in the clinic today are notable for a blood pressure of 144/94 and a heart rate of 72. Dietary Approaches to Stop Hypertension 13 Based on the results of this trial, how would you manage this patient’s blood pressure? Although a second measure- ment would be necessary to make the diagnosis of hypertension, his blood pressure was already in the prehypertensive range prior to today’s visit, and it is likely that he would beneft from lifestyle changes aimed at lowering his blood pressure. You might also refer him to a nutrition- ist or health educator to provide detailed teaching on these dietary changes. T e patient should also be instructed to monitor his blood pressure regu- larly (perhaps he could track his blood pressure at home with a cuf). If his blood pressure remains in the hypertensive range despite lifestyle modifca- tions, pharmacologic therapy may ultimately be needed. T e Women’s Health Study was open to apparently healthy female health professionals throughout the United States who were mailed invitations to participate. Who Was Studied: e Physicians’ Health Study included apparently healthy male physicians 40–84, while the Women’s Health Study included apparently healthy female health professionals ≥45. Who Was Excluded: Patients were excluded from both trials if they had exist- ing cardiovascular disease, cancer, other chronic medical problems, or if they were currently taking aspirin or nonsteroidal anti-infammatory agents. Both trials included a run-in period to identify patients unlikely to be compliant with the study protocol, and these patients were excluded before randomization. How Many Patients: e Physicians’ Health Study included 22,071 men, while the Women’s Health Study included 39,876 women. Study Intervention: In the Physicians’ Health Study, patients in the aspirin group received aspirin 325 mg on alternate days while in the Women’s Health Study patients in the aspirin group received aspirin 100 mg on alternate days. In both trials, patients in the control group received a placebo pill on alternate days. Aspirin for the Primary Prevention of Cardiovascular Disease 17 Follow-Up: Approximately 5 years for the Physicians’ Health Study and approximately 10 years for the Women’s Health Study. Endpoints: Myocardial infarction, stroke, cardiovascular mortality, and hem- orrhagic side efects. Summary of the Physicians’ Health Study’s Key Findings Outcome Aspirin Group Placebo Group P Value Myocardial Infarction 1. Summary of the Women’s Health Study’s Key Findings Outcome Aspirin Group Placebo Group P Value Cardiovascular eventsa 2. Criticisms and Limitations: In the Physicians’ Health Study, aspirin 325 mg was given on alternate days while in the Women’s Health Study aspirin 100 mg was given on alternate days. In addition, patients found to be noncompliant during a run-in period were excluded. Other Relevant Studies and Information: • Other trials of aspirin for cardiovascular disease prevention have also suggested that aspirin reduces the risk of cardiovascular events while increasing bleeding risk. Summary and Implications: In apparently healthy men and women, aspirin leads to a small reduction in the risk of cardiovascular disease while increas- ing bleeding risk. In men, aspirin may preferentially prevent myocardial infarc- tions, while in women aspirin may preferentially prevent strokes, though this Aspirin for the Primary Prevention of Cardiovascular Disease 19 conclusion is uncertain. Aspirin can be considered for primary cardiovascular prevention in both men and women with cardiovascular risk factors when the risk of gastrointestinal hemorrhage is low. Suggested Answer: T e Women’s Health Study demonstrated that, in female health profession- als ≥45, daily aspirin leads to a small but detectable reduction in the risk of cardiovascular disease while increasing bleeding risk. T e patient in this vignete has risk factors for cardiovascular disease and therefore might be a candidate for aspirin. However, she has numerous risk factors for gastrointestinal bleeding, making aspirin therapy risky. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. Aspirin in the primary and sec- ondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. T e use of aspirin for primary prevention of colorectal cancer: a sys- tematic review prepared for the U. Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specifc meta-analysis of randomized controlled trials. Sex-related diferences in response to aspirin in cardiovascu- lar disease: an untested hypothesis. Year Study Began: 1993 Year Study Published: 2002 Study Location: 40 clinical centers throughout the United States. Who Was Excluded: Patients with a prior hysterectomy, those with another serious medical condition associated with a life expectancy of less than 3 years, or those with a history of cancer. Postmenopausal Women with a Uterus Randomized Combined Estrogen and Placebo Progestin Therapy Figure 4. Study Intervention: Patients in the combined hormone therapy group received one tablet of conjugated equine estrogen 0. Other major outcomes: Stroke, pulmonary embolism, hip fracture, death, and a global index summarizing the risks and benefts of combined hormone therapy. Summary of Key Findings Outcome Combined Hormone Placebo Statistically T erapy Groupa Groupa Signifcant? Criticisms and Limitations: e trial only tested one dose and one formula- tion of combined hormone therapy. It is possible that the risks and benefts are diferent when lower doses or diferent formulations of estrogens and proges- tins are used. T is study suggested an increased rate of stroke among users of estrogen therapy, but the rates of heart atacks and breast cancer were similar in the estrogen and placebo groups. Since the absolute risks are small, combined hormone therapy remains an option for the man- agement of postmenopausal symptoms; however, combined hormone therapy should only be used when other therapies have failed. T e symptoms have not responded to relaxation techniques, and she asks about the possibility of starting hormone therapy to control the symptoms. Based on the results of the Women’s Health Initiative study, what can you tell her about the risks of hormone therapy? Suggested Answer: T e Women’s Health Initiative suggested that long-term (greater than 5 years) combined estrogen and progestin therapy is associated with increased rates of myocardial infarction, stroke, venous thromboembolism, and breast cancer, and a reduced rate of hip fractures. However, given that the absolute increase in disease rates is small, short-term (ideally 2 to 3 years) hormone therapy is Postmenopausal Hormone T erapy 25 an acceptable treatment for bothersome menopausal symptoms that do not respond to other therapies. Some experts believe that hormone preparations with lower doses may be safer although there are no data to sup- port these claims. Finally, recent data suggest that combined hormone therapy may be safer when initiated in younger women shortly afer menopause. Risks and benefts of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. Menopausal hormone therapy for the primary prevention of chronic conditions: a systematic review to update the U. Combined hormone therapy to prevent disease and prolong life in postmenopausal women. Brief report: Coronary heart disease events associated with hor- mone therapy in younger and older women: a meta-analysis.


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Personality is more constant diabetic diet no nos order micronase australia, whereas mood disorders tend to be episodic test your diabetes buy generic micronase 5 mg line, with acute periods and remissions diabetes medicine over the counter order micronase with visa. In the former blood glucose during exercise cheap 2.5 mg micronase visa, a clinician is struck by ingrained and repetitive personality themes that inten- sify under stress diabete mellitus symptoms discount 2.5 mg micronase amex. Whereas antide- pressant medications may help alleviate suffering in some patients with mood disor- ders per se, they tend to be ineffective in ameliorating the self-punitiveness or rejection sensitivity of many people with depressive personality styles. Blatt and his colleagues (Blatt, 2008; Blatt & Bers, 1993) distinguished between two kinds of depressive affect: “introjective” (called “melancholic” by early psycho- analysts), characterized by self-criticism, self-punitiveness, and guilt; and “anaclitic,” characterized by sensitivity to loss and rejection, and feelings of emptiness, inade- quacy, and shame. Introjectively depressive individuals berate themselves for real or imagined short- comings, and they respond to setbacks with the conviction that they are somehow to blame (a tendency that cognitive therapists have described in terms of “attributional style”; e. This readiness to blame themselves may be a residue of the familiar tendency of children in difficult family situations to deny that their caregivers are negligent, abusive, or fragile (ideas that are too frightening), but instead to ascribe their suffering to their own badness—something they can try to control. Thus introjectively inclined depressive people work hard to be “good,” but rarely succeed to their satisfaction. Anaclitically depressive individuals are notable for their distress and disorganiza- tion in the face of loss and separation. Their psychologies are organized around themes of relationship, affection, trust, intimacy, and warmth, or the lack thereof. They feel empty, lonely, incomplete, helpless, and weak rather than perfectionistic or excessively self-critical. They often complain of existential despair and the feeling that life is hol- low and meaningless. Shedler (2015) and Westen and colleagues (2012) empirically identified a depressive personality syndrome in which both introjective and anaclitic features may be salient. Countertransference to patients with depressive personalities, especially those at higher (e. Therapy sessions often feel cooperative and collaborative; patient and therapist often develop warm feelings toward one another; and clinicians often report feeling good about themselves and the work. The clinical challenge is recognizing that the positive feelings may stem from the very patterns the patient must change if the treatment is to have lasting benefit. More specifically, the therapist may feel good because the patient is recreating a pattern of subordinating his or her needs to those of others (in this case, those of the therapist), accepting responsibility and blame for the inevitable disappointments and frustrations that arise in the course of treatment, or defending against awareness of dissatisfaction or anger in the therapy relationship. In treating a patient with a depressive personality, it is vital for the clinician to recognize and welcome the patient’s negative feelings, especially hostility and criti- cism. Where self-critical and self-punitive (introjective) themes are salient, patients benefit from insight into the ways in which they defend against angry and critical feel- ings toward others and direct them against themselves. Where preoccupations with Personality Syndromes—P Axis 31 rejection and loss (anaclitic themes) are salient, patients benefit from the experience of having their perceived inadequacies and “badness” accepted within a relational con- text. Where preoccupation with loss predominates, patients may need their clinicians’ help to mourn what has been lost, before they are able to invest emotionally in what life can offer in the present. Patients with depressive personalities thus benefit from both the interpretive and relational aspects of psychotherapy. Hypomanic Defenses against Depressive Affect The clinical literature also describes a phenomenon that has traditionally been termed “hypomanic personality,” in which driven, obligatory optimism and energy defend against underlying depressive themes. The term “hypomanic” easily gives rise to con- fusion because the same term has been used to refer to different things: a defensive style (in the psychoanalytic literature) and one pole of bipolar mood disorder (in the psychiatric literature more generally). The hypomanic personality, as traditionally conceived, is characterized by mild mood inflation, high energy, conspicuous absence of guilt, inflated self-esteem, vulner- ability to substance abuse, and interpersonal wit and charm in the context of rather superficial relationships (Akhtar, 1992). The fact that these qualities are the polar opposites of those of depressive individuals has led some to propose that such a clini- cal presentation necessarily reflects a bipolar diathesis, but we suggest that careful assessment may point to a bipolar etiology for some patients, and to a personality style for others. Where the behavior reflects a defensive style and not a subclinical bipolar mood disorder, interpretation leading to insight into its defensive function (e. If instead it is an expression of a bipolar mood disorder, such interventions will accomplish little. Therapists initially tend to find patients with hypomanic personalities captivat- ing, but they may soon feel confused, overstimulated, irritatingly “entertained,” and distanced. Individuals with hypomanic personalities tend to be resistant to exploratory psychotherapy. In fact, they are hard to keep in treatment because of their tendency to bolt from relationships that elicit their feelings of dependency. They become uncon- sciously terrified of being abandoned and may seek to master that fear by abandoning the other. Depend- ing on other psychological factors and circumstances, hypomanic defenses can be extremely “costly” or highly adaptive (or both). Many therapists, after diagnosing a hypomanic personality style in a patient, call to the patient’s attention the lifetime pattern of abrupt flight from relationships that usually pervades the person’s history. They then try to preempt a similar flight from therapy by negotiating an agreement that the person will keep coming for a given num- ber of sessions after any abrupt, unilateral decision by the patient to stop treatment. Therapy tends to be both slow and fraught with outbreaks of intense negative affect and worrisome enactments. Differentiating Depressive from Masochistic Personality Dynamics The psychoanalytic literature is rich in accounts of patients who behave in ways that seem strikingly antithetical to their own well-being and who appear unconsciously drawn to pain and suffering (“masochism”). However, masochistic and depressive dynamics are different phenomena and often require different treatment approaches. The term has been used to refer to a range of phenomena that have different psychological origins and serve different psychological functions, with the common denominator of an apparent (unconscious) investment in suffering. A comprehensive discussion of masochism is beyond the scope of this chapter; here we simply note some variants that have been described in the clini- cal literature, and provide citations for readers who wish to explore the topic in more depth. On the basis of their frequent involvements (with intimates and with clinicians) in alternating dominance–submission or abuser–abused interactions, some writers (e. Others have connected them with other types of personality dynamics: nar- cissistic (e. Below, we briefly describe a version of masochistic dynamics associated with dependent personality themes, another associated with narcissistic themes, and still another associated with a more paranoid orientation. The more anaclitic version of masochistic dynamics, which overlaps with depen- dent personality, applies to patients who subordinate their needs to those of others and appear to view suffering as a precondition for maintaining an attachment relationship. The attachment relationship may be experienced as desperately needed; fear of losing the attachment overrides the patient’s concerns for his or her own safety and welfare. Beneath overt submissiveness, there is often an undercurrent of disavowed aggression, which the patient expresses in passive–aggressive ways that tend to trigger or provoke mistreatment from others (for empirical evidence, see the description of “dependent– victimized personality” offered by Westen et al. At the more disturbed levels of personality organization, the patient may rely on projective identification to defend against awareness of his or her own sadism, while simultaneously inducing the other person to enact it. The more introjective version of masochistic dynamics applies to patients who equate self-renunciation and suffering with virtue. In other words, the person’s self- esteem is tied to self-deprivation or suffering: The more self-deprivation, the greater the person’s sense of importance and virtue. This pattern includes patients who self- righteously seek to demonstrate that their suffering makes them morally superior to others (Reich’s [1933/1972] “masochistic character” or Reik’s [1941] “moral masoch- ist”). Such “moral masochism” is not uncommon in people drawn to the so-called help- ing professions, who attend to others’ needs while neglecting their own. Disavowed sadism may be revealed through intolerance (or outright aggression) toward others who do not share their moral values. Another variant applies to patients who appear to hold the (unconscious) con- viction that the world owes them compensation in proportion to their suffering (the “aggrieved pattern” of Millon & Grossman, 2007). To the extent that suffering secures imagined compensation and reward, such patients may be deeply invested in defeat- ing their clinicians’ efforts to help (cf. The attitude that contemporary therapists tend to call “victim entitlement” Personality Syndromes—P Axis 33 (“I’ve had a terrible life, so the world owes me”) often evokes irritated, judgmental, and even sadistic countertransferences. Clinicians can be helpful to the extent that they keep a focus on these patients’ need to grieve for past misfortunes and their capac- ity to take responsibility for current choices, irrespective of their difficult histories. In the context of a solid alliance, a clinician can help a patient recognize the negative con- sequences of efforts to convince the world that they have been wronged and to extract compensation in proportion to their grievances. The more paranoid version of masochistic dynamics involves the conviction that something terrible is bound to happen. For example, some patients who experienced a childhood caregiver as envious and retaliatory may become paralyzed with anxiety, expecting to be attacked for any personal success. Unconsciously, they may seek to “get it over with” by provoking the attack they anticipate as inevitable. This pattern is identifiable by the relief that follows the self-destructive enactment. The pattern needs to be identified and worked through patiently in treatment, as such a patient can only slowly tolerate the anxiety behind the urge toward self-destructive action. Patients with depressive personality dynamics generally benefit from their clini- cians’ sympathetic care and concern. In contrast, it is generally unwise to be too explic- itly sympathetic or generous when dealing with masochistic dynamics. Explicit com- passion and generosity may reinforce a patient’s unconscious conviction that suffering is the best or only route to connection, or may provoke self-destructive enactments in a patient who experiences guilt for accepting care that feels undeserved. Instead, tact- ful confrontation about the patient’s own contributions to his or her difficulties can stimulate curiosity about the meaning of self-defeating patterns. Finally, patients with masochistic personality dynamics may hold the unconscious conviction that their clinicians are interested in them only because they are suffering; such belief s can pose a powerful barrier to getting well. A clinician can help a patient become aware of such unconscious expectations, as well as help the patient recognize and feel that the clinician’s (and others’) interest and attention are not contingent on his or her suffering. Central tension/preoccupation: Self-criticism and self-punitiveness, or preoccu- pation with relatedness and loss (or both). Characteristic pathogenic belief about self: “There is something essentially bad or inadequate about me,” “Someone or something necessary for well-being has been irretrievably lost. Because individuals with severely dependent psychologies may find themselves unable to leave relationships that are exploitive or even abusive, such phenomena have sometimes been called “self-defeating” or “masochistic” (see the previous discussion of masochistic dynamics). The categories of “inadequate” and “infantile” personality in earlier taxonomies connote roughly the same construct as our use of the term “dependent personality. Psychological symptoms may appear when something goes wrong in a primary attachment relationship. At the neurotic level, people with dependent personality may seek treatment in midlife or later, after a bereavement or divorce, or after retirement confronts them with the absence of a context in which rules and expectations are clear. At the borderline and psychotic levels, dependent patients may become dysregulated when expected to depend on their own resources and may use costly defenses, such as somatization and acting out, in desperate bids to elicit care. Organizing their lives with a view to maintaining nurturing relationships in which they are submissive, they may feel contented when they have successfully developed such a relationship and acutely dis- tressed when they have not. Emotional preoccupations include performance anxiety and fears of criticism and abandonment (Bornstein, 1993). People with dependent per- sonalities tend to feel weak and powerless, to be passive and nonassertive, and to be easily influenced by others. They tend to idealize their therapists, ask for advice, and seek reassurances that they are “good patients. Some insist, even after being informed about professional boundaries, on offering favors and bringing gifts. Bornstein (1993, 2005) has conducted the only comprehensive empirical exami- nation of pathological dependency known to us. His findings suggest that it may arise from any or all of the following: overprotective and/or authoritarian parenting, gender role socialization, and cultural attitudes about achievement versus relatedness. Par- ticipants in his studies demonstrated “relationship-facilitating self-presentation strate- gies” such as ingratiation, supplication, exemplification, self-promotion, and intimi- dation. Although popular prejudice assumes that female patients are more likely than males to be excessively dependent, Bornstein notes that women may simply be more willing to acknowledge dependent longings. Contemporary feminist psychoanalysts (see, among others, Benjamin, 1988, 1995; Chodorow, 1994, 1999; Dimen, 2003; Dimen & Goldner, 2002, 2012) have criticized Freudian theories about female sexuality for normalizing the devaluation of femininity and the normal relational orientation of women. They argue that this masculinist bias has fueled cultural prejudice toward women and gender stereotypes. In addition to being sensitive to this issue, clinicians should recognize that different Personality Syndromes—P Axis 35 cultures have different conceptions of how much dependency is “too much. Clinicians’ countertransference with excessively dependent patients, especially those who are notably self-defeating, is typically benign at first, then increasingly characterized by irritation and a sense of burden. A patient with a dependent person- ality may devise unconscious tests (Bugas & Silberschatz, 2000; Weiss, 1993) to see whether the clinician supports the patient’s nascent strivings toward autonomy, or basks in the patient’s invitation to take on the role of expert and advisor. It is impor- tant that the clinician resist seduction into the role of expert authority, encourage the patient toward autonomous functioning, and contain the patient’s anxieties that arise in the process. Although clinicians treating patients with dependent personalities may be tempted to collude in avoiding negative affect, if they make room for the patients’ anger and other more aggressive feelings, they may facilitate the patients’ ultimate sense of personal agency and pride in accomplishment. An important variant of dependent psychology is a passive–aggressive pattern, in which the patient’s relationships are characterized by hostile dependency. Passive– aggressive individuals define themselves in relation to others, but with a negative valence (e. Because they locate themselves psy- chologically in opposition to others, it is hard for them to conceive of and to pur- sue their own autonomous goals. Like paranoid patients, they may attack to preempt expected attacks by others, but do so indirectly. Their indirect, underlying aggres- sion often triggers mistreatment from others, perpetuating a vicious cycle: Underlying anger and resentment lead to passive–aggressive behavior, triggering aggression and mistreatment from others, which in turn fuel more anger and resentment. This self- perpetuating pattern reinforces the core conviction that anger must not be experienced or expressed directly. It is therapeutically challenging to connect with a person who responds passive– aggressively to efforts to connect. The clinician needs a sense of humor as a counter- poise to the feelings of impatience and exasperation that the patient is likely to evoke.

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This baffle is created at the time of the atrial switch to allow pulmonary venous blood to enter the right atrium and then fill the systemic right ven- tricle diabetes medication order micronase 5 mg visa. Less commonly diabetes type 2 swollen feet micronase 2.5 mg purchase, the association with other structural abnormalities may conceal the clinical fndings and make Coronary anomalies are classifed according to their origin managing diabetes 2 with diet buy micronase 5 mg without prescription, the diagnosis even more difcult diabetes mellitus type 2 nice guidelines buy micronase 2.5 mg on line. For fur- ischemia leads to early progressive lef heart failure and ther details on coronary anomalies pertaining to adults see cardiac death diabetes mellitus rash buy micronase 5 mg cheap. The lef coronary arteries, the high risk interarterial course may other 80–85 % patients do not have adequate collateral be easily diferentiated from the diferent benign courses. The course of the anomalous coronary artery is inferior to the pulmonary valve annulus through the septum. Although the patient presented with atypical chest pain, this anomaly is considered benign and unrelated to his symptoms A ⊡ Fig. This is a potentially malignant anomaly (arrow ) with increased incidence of sudden death in those without surgical correction (Panel A). Surgical unroofing of the proximal course of the left coronary artery was performed and eliminated the patient’s exertional chest pain. The left main coronary artery originated from the pulmonary artery and was surgically transferred to the aortic root during infancy to restore normal anatomy. It should be kept in mind that scanning should be (a diseased aortic valve is replaced with the person’s own started when the contrast agent is in the ascending aorta pulmonary valve, a pulmonary allograf (valve taken from a (as usual) as there is retrograde flling of the lef coronary cadaver) replaces the patient’s own pulmonary valve), and in artery by the right coronary artery (Fig. Classically, 5 days of fever plus four of fve diagnostic criteria must be met to establish the diagnosis. Kawasaki disease is predominantly a disease of young children, with 80 % of patients being younger than 5 years of age. Kawasaki disease can cause vasculitis in the coronary arteries and subsequent coronary artery aneurysms. Virtually all deaths in patients with Kawasaki disease result from its cardiac sequelae. Mortality peaks 15–45 days afer the onset of fever; at this stage, patients have coronary vasculitis with a con- B B comitant marked elevation of the platelet count and a hypercoagulable state. The three-dimen- in individuals who develop coronary stenoses follow- sional reconstruction (Panel A) and maximum intensity projection ing a childhood history of coronary artery aneurysms. Many cases of fatal and nonfatal myocardial infarction in The patient is now managed medically by an adult cardiologist young adults have been attributed to “missed” Kawasaki disease in childhood. Evaluation of the coronary arteries should include quantitative assessment of internal vessel diameters relative to the patient’s body surface area. The Japanese Ministry of are nearly equal or as fusiform if symmetric dilata- Health criteria classify coronary arteries as abnormal tion with gradual proximal and distal tapering is seen. The patient showed only limited breath-hold capabilities, lead- ing to artifacts on the reconstructed images. Note the narrow lumen (arrow) of the intramural segment during systole and diastole (PanelsAandB ). Sebening, Heidelberg) used now that the Z-score standard deviations are the myocardium, beneath a muscular bridge. As the heart con- graphically, but the technique is not sensitive enough tracts to pump blood, the muscle exerts pressure across to exclude coronary stenosis. Mild forms of myocar- up afer childhood Kawasaki disease, while severe cal- dial bridging (less than 20 % diameter stenosis) are ofen cifcations may still impair estimates of the degree of undetectable, as the blood usually fows through the cor- coronary stenosis. Visualization of the coronary arteries during diastole and systole is mandatory to determine the percentage of diameter ste- 23. The efect of myocardial bridging is very myocardial bridge is a congenital condition in which a controversial and many think it is a normal variant that 23 segment of coronary artery runs intramurally, through does not require intervention. For leaks, the regurgitant fraction can be calculated from a function scan based on the stroke volume diferences between the right and lef ventricle. Approximately 1 year after her last signs of congenital cardiovascular abnormalities. Radiographics valve replacement, she was found to have an increasing mitral gra- 27:1323–1334 dient. Radiographics 17:939–959 shows a large paravalvular leak of the lateral mitral valve annulus. Am J Cardiol esophageal echocardiography, and increased flow wrongly sug- 107:1541–1546 gested mitral stenosis with an increased gradient. Safety and efcacy of pressure-limited power injection of iodin- Ann Torac Surg 77:2250–2258 ated contrast medium through central lines in children. Pediatr term outcome afer balloon angioplasty of coarctation of the aorta Radiol 39:950–954 in adolescents and adults: is aneurysm formation an issue? Three-dimensional reconstructions of the left (Panel D) and right (Panel E) coronary artery are also unremarkable and demonstrate a codominant coronary distribution in this patient, which is found in 7–20 % of all individuals. This distribution type is also seen on the corresponding conventional coronary angiograms of the left (Panel F) and right coronary artery (Panel G). The plaque causes positive remodeling of the outer vessel wall (see inset in Panel A ; arrowheads demarcate the boundaries of this plaque). The so-called remodeling index is defined as the ratio of the vessel area at the plaque site (including plaque and lumen area) to the mean of the vessel area at the reference site proximal and distal to the plaque. This plaque (arrow) caused a 35 % diameter stenosis, as measured with quantitative analysis of coronary angiography (Panel B). These findings were suggestive of a significant stenosis in the right coronary artery. There was good correlation with the findings on subsequently performed conventional coronary angiography (arrow in Panel E). During the same invasive angiographic examination, this lesion was treated by stent placement with no residual stenosis (arrow in Panel F ) 420 Chapter 24 ● Typical Clinical Examples 24 A C ⊡ Fig. However, there are also severely calcified plaques that do not result in significant diameter reductions. Panel F is a curved multiplanar reformation along the vessel path, and Panel G is a maximum-intensity projection. Conventional coronary angiography confirms the presence of the occlusion but fails to exactly determine the length of the occlusion (arrows in Panels D , E, and H), 423 24 24. Conventional coronary angiography nicely shows the occlusion (arrows in Panel E) and demonstrates right-to-left collaterals, with filling of the middle and distal left circumflex coronary segments (Panel F). Despite the purely noncalcified occlusion, percutaneous revascu- larization failed, most likely because of the location at a branching obtuse marginal artery. The corresponding cross-sections are pro- vided in Panels B – F using standard coronary artery settings (top row) and bone-window-like settings (bottom row). Interestingly, despite the diffuse changes, there is only one significant luminal narrowing (90 % diameter stenosis) of the coronary artery (arrowhead in Panel E), which is caused by a noncalcified plaque (plus in Panel E) and calcified plaque (asterisk in Panel E). Note that the residual lumen at the site of this plaque is better appreciated using the standard coronary artery window-level settings (arrowhead in the upper row in Panel E). In contrast, the stenosis diameter at the sites of highly calcified coronary artery plaques (asterisks in the bottom row in Panels C and D) is more easily evaluated using bone-window settings (arrowheadsin thebottom rowinPanels CandD). The proximal vessel segments (B in Panel G) and distal vessel segments (F in Panel G) appear very similar on conventional coronary angiography (Panel G ). Coronary bypass surgery was not considered as an option in this patient because there was good left- to-right collateralization of the occlusion (asterisks in Panel B), and the patient had only mild symptoms. There is good correlation with the corresponding invasive angiogram projections (Panels B, D, and F). On the basis of these findings, percutaneous coro- nary intervention was performed (Panel G). C intravascular ultrasound catheter 430 Chapter 24 ● Typical Clinical Examples 24 A C E 431 24 24. There is an excellent correlation with conventional coronary angiography, and the length (1. Percutaneous coronary intervention was performed during the same angiographic session, and good revascularization was achieved (compare Panel D with Panel C). Example of patent coronary arterial bypass grafts in a 68-year-old male patient with typical angina pectoris who underwent bypass grafting 7 years earlier. Note the metallic surgical clips along the arterial bypass grafts (arrowheads in Panels C and E) and the distal anastomoses (asterisk in Panels C and E ). Deviating from the standard procedure of contrast injection into the right arm veins and using left-sided injection instead might have been preferable in this patient. The distal anastomosis of this graft was normal (asterisk in Panel F), but there was a significant stenosis of the D1 (arrow in Panel F), which was also seen on conventional coronary angiography. During the same angiographic session, percutaneous coronary stenting of the stenosis of the distal anastomosis was performed (Panel J). Ostial occlusion of the venous bypass graft (arrow) that supplies the left circumflex coronary artery (Panel A). This finding was confirmed by conventional coronary angiography (lateral projection, arrow in Panel B). Subsequently performed conventional angiography confirmed this finding (arrow in Panel B), and during the same angiographic session, percutaneous interven- tion with a 4. In this patient, a sternal wire (arrowhead) is located left anterior descending coronary artery (curved multiplanar refor- near a venous bypass graft (V). Also, the distance from the sternum to mation) in a 64-year-old male patient with nonanginal chest pain. Interestingly, stents as large as this one are implanted in only about a fifth of all cases, and the vast majority of patients receive coronary stents of 2. Note the irregular vessel wall immediately distal from the stent that did not result in signifi- cant stenosis 441 24 24. There is good agreement in this large-diameter stent with conventional coronary angiography (Panel B ) A ⊡ Fig. Even stent kernel reconstructions (inset in Panel A, arrowhead , curved multiplanar reformation) did not allow reliable exclusion of significant in-stent restenosis in this case. There was also a large calcified plaque in the left main coronary artery that did not cause significant luminal narrowing (arrowhead in Panel A). In contrast, quantitative analysis of conventional coronary angiography demonstrated that there was no occlusion, but 90 % in-stent restenosis had occurred (arrows in Panel B). Because of the location of the stent at the branchings of the first (9) and second (10) diagonal branches, a complex situation involving a trifurcation stenosis was present (arrows in Panels C and D). Percutaneous coronary intervention was performed during the same angiographic session (Panel C). D1 first diagonal branch (segment 9), D2 second diagonal branch (segment 10) 445 24 24. The effec- tive dose of the diagnostic part of conventional coronary angiography was about 18 mSv. Conventional coronary angiogra- phy (Panel C ) confirmed these stenoses (arrows and arrowhead). The in-stent restenosis was treated during the same angiographic session by angioplasty (Panel D). Curved multi- planar reformation based on standard reconstruction kernel for coronary arteries did not allow reliable assessment of the stent lumen (Panel A). Also, the calcified plaque (arrowhead in Panels A and B) was easier to assess using a stent kernel, and significant luminal diameter reduction resulting from this plaque was excluded (Panel B). However, a 90 % diameter stenosis (arrow) of the first diagonal branch (D1), caused by a noncalcified plaque (Panel C ), was confirmed on conventional angiography (arrowinPanel D). Conventional coronary angiography confirmed the patency of the stent (arrow in Panel C), but the distal stenosis was considered on quantitative analysis to represent a 40 % diameter reduction (arrowhead in Panels C and D). Significant in-stent restenosis was excluded using stent kernel curved multiplanar reformations (not shown). Conventional angiography also demonstrated the 30 % prestent stenosis (arrow in Panel B). Results are shown on large fields of view with soft tissue (Panel A) and lung window-level settings (Panel B). Note that the effusions cause (nonobstructive) atelectasis in both lower lobes (arrowheads ) 450 Chapter 24 ● Typical Clinical Examples 24 A C ⊡ Fig. Results are shown on large fields of view with soft tissue (Panel A) and lung window-level settings (Panel B) and remained unchanged on follow-up (Images courtesy of S. The appearance is characteristic of calcified granuloma and is most likely due to prior infection (e. The calcified granuloma in the left lower lobe is most likely a remnant of prior tuberculosis. There is also an effusion in the left oblique fissure (arrowhead in Panels A and B) Guideline-based 6-month follow-up (According to MacMahon et al. Differential diagnoses for such nodules include benign infectious lesions, atypical adenomatous hyperplasia, metastases, and lung cancer. There were no significant coronary stenoses, and the nodule with a thin- walled cavity was found on the large fields of view only and was suspected to be due to tuberculosis. Note that because a medium-size scan field of view (320 mm) was chosen for acquisition (to allow using a small focus spot), the reconstruction field of view cannot be larger than 320 mm, and thus the carci- noma is only partially visible 455 24 24. Prior images of the lungs (6 months earlier) showed no lung nodules (Panels D – F) raising the suspicion of metastases. Because of suspected gastric carcinoma, gastroscopy including biopsy was performed, showing an ulcerating carcinoma (uT4a N3a M1, asterisks in Panels H and I). The patient underwent palliative chemotherapy with cisplatin, capecitabin, and trastuzumab. Both the small cardiac field of view (Panel A) and the large lung field of view (Panel B) show the bronchiectasis (arrow ) A ⊡ Fig. Pulmonary nodules (arrow) and pleural-based opacities were also visible (arrowhead in Panel B ). Common differential diagnoses of mediastinal lymph nodes include lymph node metastases, lymphoma, sarcoidosis, amyloidosis, and silicosis 457 24 24.

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Transthoracic echocardiography is a reliable and versatile tool for the assessment of cardiac structure, function, and hemodynamics. Compared with other cardiovascular imaging modalities, it is relatively inexpensive, does not expose the patient to radiation, is noninvasive, displays live real-time images, and is widely available. Sound waves consist of mechanical vibrations that produce alternating compressions and rarefactions of the medium through which they travel. Ultrasound consists of sound waves in the frequency range that is higher than what is audible to humans (>20,000 Hz). All waves can be described by their frequency (f), wavelength (λ), velocity of propagation (v), and amplitude. Frequency is defined by the number of cycles occurring per second (cycles/second or Hz) and wavelength is measured in meters. Velocity, frequency, and wavelength are described by the following relationship: Velocity = frequency × wavelength or v = f × λ The typical adult echocardiographic examination uses a transducer with ultrasound frequency between 2. This has important implications because image resolution cannot be >1 to 2 wavelengths (e. In addition, the depth of penetration of the ultrasound wave is directly related to the wavelength, with shorter wavelengths penetrating a shorter distance. Therefore, higher frequency transducers result in the use of shorter wavelengths that improve image resolution but at the cost of reduced depth penetration. A piezoelectric substance has the property of changing its size and shape when an electric current is applied to it. An alternating electrical current will result in rapid expansions and compressions of the material and thus produce an ultrasound wave. The piezoelectric crystal also deforms in shape when an ultrasound wave strikes the material, resulting in the production of an electric current. The transducer, and the piezoelectric crystal, thus oscillates between a short burst of transmitting ultrasound waves, with a brief period of no ultrasound transmission when it awaits reception of the reflected signals. Tissue harmonic imaging has become the standard imaging technique in many laboratories. It utilizes the principle that as ultrasound waves propagate through tissue, the waveform becomes altered by the tissue, with the generation of new waveforms of higher frequency but which are multiples of the baseline fundamental frequency. Setting the transducer to receive only harmonic sound waves that are multiples of the fundamental frequency improves image quality significantly. This image quality improvement is based on the fact that weak signals, which tend to be artifacts, create almost no harmonics. In addition, shallow structures, such as the chest wall, generate weak harmonic signals, whereas at depths of 4 to 8 cm, where the heart is located, maximal harmonic frequencies develop. These phenomena result in fewer near-field artifacts and better endocardial definition. One limitation of harmonic imaging is that valve leaflets appear thicker—an artifact generated during image processing that appears to be related to the rapid motion of the leaflets. The steps involved in creating a final ultrasound image are transmission and reception of waves, conversion to electrical signals, filtering, and extensive computer processing. Patient and probe positioning, electrocardiographic lead placement, and transducer selection are the first steps to beginning the echocardiographic examination. For the parasternal and apical positions, the patient should be in the left lateral decubitus position, with the left arm extended behind the head, because this brings the heart into contact with the chest wall. The subcostal and suprasternal views require the patient to be in the supine position. It is important that irregular beats be identified and excluded from the analysis. In general, any Doppler index requires the average of at least three measurements. For patients with very high heart rates, or with a noisy electrocardiographic signal, the digital clips can be set to record for a predefined period of time (usually 2 seconds). Transducer frequency is important, because at higher frequencies, spatial resolution improves but at the expense of reduced depth penetration. Therefore, for optimal 2D resolution, select the highest frequency transducer that will provide adequate far-field penetration. Prior to 2D imaging, the echocardiogram was obtained when the transducer sent an ultrasound wave along a single line and then displayed the amplitude of reflected signal as well as the depth of that signal on an oscilloscope. When these line-of-sight ultrasound images were plotted with respect to time, “motion” mode, or M-mode, was produced. Despite the increasing emphasis on 2D imaging, the M-mode display remains a complementary element of the transthoracic examination. Its high sampling rate of up to 2,000 frames/s, compared with 30 frames/s for 2D echocardiography, provides excellent temporal resolution, and thus it is very useful in the timing of subtle cardiac events that can be missed by the naked eye in 2D imaging. Rapidly moving structures such as the aortic valve, mitral valve, and endocardium have characteristic movements in M-mode. M-mode also has a great spatial resolution along the single line and can be used for precise size measurements such as ventricular dimensions in systole and diastole. The M-mode image is displayed like a graph, with time on the x-axis and distance from the transducer on the y-axis, with the structures closest to the transducer at the top of the image. In order to align the line of sight accurately, 2D imaging should be used to position the M-mode cursor through the structures of interest. A 2D echocardiographic image is essentially the scan line from M-mode that, instead of having a fixed line of sight, is swept back and forth across an arc. After complex manipulation of the data received by the transducer from the multiple scan lines, a 2D tomographic image is generated for display. Depending on the depth of the image, a finite amount of time is needed for each scan line to be sent and received by the transducer. As opposed to M-mode that has only one scan line and can provide up to 2,000 frames/s, 2D echocardiographic imaging can utilize 128 scan lines but at the expense of a lower rate of 30 frames/s. Faster frame rates can be obtained by electronic manipulation using parallel processing on current ultrasound machines. This reduction in temporal resolution reinforces the need for M-mode to complement 2D imaging in echocardiography, especially for rapidly moving structures and in precise timing of events. The introduction of Doppler technique to echocardiography not only added new imaging capabilities but also transformed echocardiography into a modality that could provide hemodynamic assessment of the heart. Echocardiography has now become the preferred method, and in some cases the gold standard, over cardiac catheterization for certain hemodynamic assessments. The Doppler principle states that sound frequency increases as the source moves toward the observer and decreases as the source moves away. The change in frequency between the transmitted sound and the reflected sound is termed the Doppler shift. This phenomenon is appreciated daily when an ambulance’s siren becomes higher pitched, because of the increase in wave frequency, as it approaches the observer and then lower pitched once it has passed. This Doppler frequency shift directly relates to the velocity of the red blood cell by the following Doppler equation: where v = velocity, fR = frequency received, fT = frequency transmitted, c = speed of sound in blood (1,540 m/s), and θ = angle between moving object and ultrasound beam. The cos θ in the Doppler equation makes the calculation of velocity depend on the angle between the beam and the moving structure (red blood cell). Echocardiography machines do not typically incorporate the angle for calculating the resultant velocity, and thus the goal is to have the angle between the ultrasound beam and the blood flow jet of interest to be as close to zero as possible (cos 0 = 1). When this is not possible, the angle should be <20°, so that the true flow velocity is underestimated by <6% (cos 20 = 0. Adhering to this requirement sometimes mandates off-axis or unusual 2D images to align the Doppler ultrasound signal with desired target. By convention, the horizontal axis reflects the time and is placed in the middle of the screen with upward deflections representing frequency shifts toward the transducer and downward deflections for frequency shifts away from the transducer. The vertical axis represents the blood flow velocity (or frequency shifts), with the density of pixels on a gray scale reflecting the amplitude of the signal. The final result is that at each time point, the spectral analysis shows blood flow direction, velocity/frequency shift, and signal amplitude. The maximal velocity that can be measured is limited by the time required to transmit and receive the ultrasound wave. If a velocity greater than the Nyquist limit is measured, the signal appears as a wrap around the baseline, known as signal aliasing. Hence, the peak velocity is limited by the depth of the area of interest and also by the transducer frequency (inverse relationship according to the Doppler equation; see previous text). It is, therefore, used primarily to measure low-velocity flow (<2 m/s) at specific sites in the heart. It measures Doppler shift along the entire beam, rather than at a specific location. A full-color flow map is generated by combining multiple scan lines along the areas of interest. To accurately estimate the velocity along a given scan line, the instrument compares the Doppler shift changes from several successive pulses (typically eight), and this is known as the burst length. Where Doppler shifts are detected, color pixels are displayed at that location, with the different colors representing the different degrees of Doppler shift based on a predetermined color spectrum. Tradition has set blood velocity toward the transducer as shades of red and blood flow away as shades of blue (Blue Away). When the flow velocity is higher than the Nyquist limit (indicated on the color map), color aliasing occurs (depicted as color reversal, red to blue or blue to red transition). Decreasing the filters (which normally eliminates low-velocity signals) and the Doppler transmit gain (which excludes the low-amplitude blood signals) results in the Doppler focusing primarily on myocardial motion. With worsening diastolic function, E′ velocity decreases and is directly proportional to the rate of relaxation. This technique, whereby color flow Doppler is imposed on an M-mode image, permits excellent spatiotemporal distribution of velocity (color) data, although it is limited to the defined scan line. It is a valuable adjunct in the timing of cardiac events, which may not be readily appreciated by 2D and color flow imaging alone. The slope of the early filling wave (velocity of propagation, Vp) is primarily dependent on the rate of relaxation and is reduced with delayed relaxation. It is useful for differentiating a normal mitral inflow pattern (normal Vp) from a pseudonormal filling pattern (where impaired relaxation results in delayed flow propagation into the left ventricle, slower Vp) (Fig. In diastole, the myocardial velocity is directed away from the transducer first with early diastolic filling (E′) and then with atrial contraction (A′). Most echocardiography laboratories have similar protocols for acquisition of a complete echocardiogram. Each echocardiographic view is labeled first by the transducer position (parasternal, apical, subcostal, and suprasternal) followed by the tomographic view of the heart (long axis, short axis, four chamber, and two chamber). To acquire these different views, the transducer is placed on different parts of the body and adjusted with rotation and angulation to optimize the final image. A2C • Rotate transducer approximately 60°–90° anticlockwise • Tilt posteriorly and rotate clockwise to open out descending aorta 5. The parasternal position is typically obtained by placing the transducer at the left of the sternal border in the third or fourth intercostal space. The optimal position for the patient is usually the left lateral decubitus position, but a hybrid between the steep left lateral and supine position may be required to optimize the view. This position allows imaging of the long axis as well as the short axis of the heart. The ultrasound beam is lined up between the patient’s right shoulder and the left flank. Optimize patient position (left lateral with left hand above head) and environment (darkened room) 2. Consider contrast to improve endocardial delineation for technically difficult studies 4. When parasternal and apical images are limited (body habitus, surgical drains, dressings, etc. Adjust transducer frequency to maximum that permits adequate far-field penetration/depth 12. Set time gain compensation in the midrange with lower gain in the near field and higher settings attenuation of the beam with increasing distance from transducer 13. Use the least amount of depth that adequately shows the entire area of interest 14. Adjust the transmit gain/output to optimize image brightness/quality—too low, everything appe “white-out. Typically, as compress is increased, the transmit gain should be decreased to ma scale 16. Adjust the focus (focal zone) to include the area of interest, because the beam is narrowest (impro area, especially when imaging near-field structures (e. While the transducer is in the parasternal position, rotating the transducer clockwise by approximately 90° displays the heart in the short axis. The ultrasound beam in this case is roughly from the left shoulder to the right flank. Using different degrees of transducer tilting, and occasionally moving up or down an intercostal space, results in four traditional views of the heart.

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