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By F. Abe. Jewish Theological Seminary. 2019.

Introduction All individuals with diabetes should be regularly screened for the pres- ence of diabetes distress mildronate 250mg free shipping medicine wheel images, as well as symptoms of common psychiatric disorders discount mildronate 250 mg visa treatment notes. Research has shown an increasingly clear relationship between Compared to those with diabetes only discount mildronate generic medications herpes, individuals with diabetes and mental diabetes and a variety of mental health issues discount mildronate 500 mg online medicine 54 357. This term is used to describe the therapy and collaborative case management should be incorporated into despondency and emotional turmoil specically related to living primary care. Fear of hypoglycemia is another throughout the course of the illness so that appropriate interventions can common diabetes-specic concern. As a result, many people expe- rience distress, decreased mood and disabling levels of anxiety. Diabetes Psychological Effects of Diabetes in Adults is often associated with a signicant emotional burden, distress over the self-care regimen and stress in relationships (with family and friends, as well as health-care providers). Diabetes is a demanding chronic disease for both individuals and It is important to recognize your emotions and talk to your friends, family their families (5). It is associated with a number of challenges, includ- and members of your diabetes health-care team about how you are feeling. In addition, a range of psychiatric disorders can arise that contributes to greater complexity in both assessment and treat- ment. For instance, distinguishing between diabetes distress, major Conict of interest statements can be found on page S137. Although these constructs have some shared symp- of various symptoms) and methods to arrive at psychiatric diagnoses tomatology, diabetes distress has been most shown to have the stron- (e. Furthermore, indi- Psychiatric Conditions in Adults viduals with higher levels of diabetes distress were found to have a 1. Bio- Psychological insulin resistance refers to a strong negative chemical changes due to psychiatric disorders themselves also may response to the recommendation from health-care providers that play a role (38). Symptoms of mental health disorders and their a person may benet from adding insulin to his or her diabetes impact on lifestyle are also likely to be contributing factors (39). This can be a common reaction, particularly for individu- als with type 2 diabetes who may have previously been success- fully managed with noninsulin antihyperglycemic agents. Individuals Major Depressive Disorder may hold maladaptive beliefs that requiring insulin is a sign of per- sonal failure in their self-management, or that their illness has The prevalence of clinically relevant depressive symptoms among become much more serious. Further, many people report fear and people with diabetes is approximately 30% (4042). Clinically identied diabetes was associated with a dou- experiences, especially serious or nocturnal episodes, can be trau- bling of the prescriptions for antidepressants, but undiagnosed matic for both individuals and their family members. A common diabetes was not, consistent with the hypothesis that the relation- strategy to minimize fears of hypoglycemia is compensatory hyper- ship between diabetes and depression may be attributable to factors glycemia, where individuals either preventatively maintain a higher related to diabetes management (46). The prognosis for comorbid depression and dia- illary blood glucose concentrations (1922). Episodes of severe hypo- ment to the illness, participation in the treatment regimen and psy- glycemia have been correlated with the severity of depressive symp- chosocial diculties at both a personal and an interpersonal level toms (51,52). Stress, decient social supports and negative attitudes underdiagnosed in people with diabetes (53). Studies examining differential rates for the prevalence of Diabetes management strategies ideally incorporate a means of depression in type 1 vs. The interplay between diabetes, major depressive disorder and other psychiatric conditions. Risk factors for developing depression in individuals with dia- betes are as follows (5761): Bipolar Disorder Female sex Adolescents/young adults and older adults One study demonstrated that over half of people with bipolar Poverty disorder were found to have impaired glucose metabolism, which Few social supports was found to worsen key aspects of the course of the mood disor- Stressful life events der (80). People with bipolar disorder have been found to have Longer duration of diabetes prevalence rates estimated to be double that of the general popu- Presence of long-term complications. Insulin resistance is associated with a less favourable course of bipolar Intensive lifestyle intervention for people with type 2 diabetes illness, more cycling between mood states, and a poorer response with overweight or obesity reduced the risk of depressive symp- to lithium (85). Risk factors (with possible mechanisms) for developing diabe- tes in people with depression are as follows: Schizophrenia Spectrum Disorders Physical inactivity (63) and overweight/obesity, which leads to Schizophrenia and other psychotic disorders may contribute an insulin resistance independent risk factor for diabetes. People diagnosed with psy- Psychological stress leading to chronic hypothalamic-pituitary- chotic disorders were reported to have had insulin resistance/ adrenal dysregulation and hyperactivity stimulating cortisol glucose intolerance prior to the advent of antipsychotic medication, release, also leading to insulin resistance (6469) although this matter is still open to debate (8688). Personality traits or disorders that put people in constant con- Furthermore, substance abuse and psychosis among individuals with ict with others or engender hostility have been found to increase type 1 and type 2 diabetes increases the risk of all-cause mortal- the risk of developing type 2 diabetes (92). The risks A history of signicant adversity/trauma, particularly early in life, increase signicantly during adolescence (113,114). Conversely, as glycemic control worsens, the prob- to cause a 40% increased risk of developing type 2 diabetes; those ability of mental health problems increases (122). Adolescents with with sub-syndromal traumatic stress symptoms had a 20% increased type 1 diabetes have been shown to have generally comparable rates risk (96). The presence of psychological symptoms and diabetes prob- lems in children and adolescents with type 1 diabetes are often Anxiety strongly affected by caregiver/family distress. It has been demon- strated that while parental psychological issues are often related Anxiety is commonly comorbid with depressive symptoms (97). Anxiety disorders were found reduced positive effects and motivation in older teens (128). Long-term anxiety has been asso- Feeding and Eating Disorders in Pediatric Diabetes ciated with an increased risk of developing type 2 diabetes (100). Ten per cent of adolescent females with type 1 diabetes met the Diagnostic and Statistical Manual of Mental Disorders (5th Edition) Feeding and Eating Disorders criteria for eating disorders (30), compared to 4% of their age- matched peers without diabetes (128). Eating disorders are also asso- Anorexia nervosa, bulimia nervosa and binge-eating disorder have ciated with poorer metabolic control, earlier onset and more rapid been found to be more common in individuals with diabetes (both progression of microvascular complications (103). Eating dis- young adult females with type 1 diabetes who are unable to achieve orders are common and persistent, particularly in females with and maintain glycemic targets, particularly if insulin omission is sus- type 1 diabetes (102,103). Depressive symptoms are eating disorders may require different management strategies to highly comorbid with eating disorders, affecting up to 50% of indi- optimize glycemic control and prevent microvascular complica- viduals (105).

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It is however essential to identify any cardiac order mildronate 250 mg on-line medicine zoloft, should convert back to regular subcutaneous insulin respiratory 250mg mildronate fast delivery medicine nobel prize 2015, metabolic or endocrine disease buy mildronate once a day treatment receding gums, which may therapy generic mildronate 500mg without a prescription treatment 4 hiv. Any anaemia, uid and nutrition may cause signicant injury if extravasation electrolyte imbalance or cardiac failure should be cor- occurs. Other complications of parenteral nutrition rected prior to surgery wherever possible. Specic guidelines regarding the use of perioperative an- tibiotic prophylaxis vary between hospitals but these are Postoperative complications generally used if there is a signicant risk of surgical site infection. Prophylaxis for immunod- sions, wound dehiscence) and complications secondary ecient patients requires expert microbiological advice. It requires aggressive management and may necessitate return Nutritional support in surgical patients to theatre. Reactive haemorrhage occurs from small Signicantnutritionaldeciencyimpairshealing,lowers vessels, which only begin to bleed as the blood pres- resistance to infection and prolongs the recovery period. Blood replacement may be Malnutrition may be present preoperatively particularly required and in severe cases the patient may need to in the elderly and patients with malignancy. Enteral nutrition is the treatment of choice in all pa- r Alow-grade pyrexia is normal in the immediate post- tients with a normal, functioning gastrointestinal tract. Liquid feeds either as a supplement or replacement pletion, renal failure, poor cardiac output or urinary may be taken orally, via a nasogastric tube or via a gas- obstruction. Liquid feeds may be whole protein, oligopep- isation (or ushing of the catheter if already in situ) tide or amino acid based. These also provide glucose, and a clinical assessment of cardiovascular status in- essential fats, electrolytes and minerals. Mixed Early postoperative complications occur in the subse- preparations of amino acid, glucose and lipid are used quent days. Parenteralnutritionishypertonic,irritantandthrom- High-risk patients should receive prophylaxis (see bogenic. Intestinal stulae may be managed con- including cannulae) and Streptococci or mixed organ- servatively with skin protection, replacement of uid isms. The organisms responsible for organ or space and electrolytes and parenteral nutrition. If such con- infections are dependent on the site and the nature servative therapy fails the stula may be closed surgi- of the surgical condition, e. The risk of surgical perioperative atelectasis unless a respiratory infection site infection is dependent on the procedure performed. Prophylaxis and treatment Contaminated wounds such as in emergency treatment involves adequate analgesia, physiotherapy and hu- for bowel perforation carry a very high risk of infection. Respiratoryfailure Patients at particular risk include the elderly, mal- may occur secondary to airway obstruction. Laryn- nourished, immunodecient and those with diabetes geal spasm/oedema may occur in epiglottitis or fol- mellitus. Respiratory support may be may be of value to draw round the area of erythema to necessary. Deeper r Acute renal failure may result from inadequate infections and collections may present as pyrexia with perfusion, drugs, or pre-existing renal or liver disease. Specic presentations depend on the Once hypovolaemia has been corrected any remaining site, e. Treatmentinvolvesdebridement,treat- is preceded by a high volume serous discharge from the ment of any infection, application of zinc paste and in wound site and necessitates surgical repair. Late postoperative complications, which may occur Investigations weeksoryearsaftersurgery,includeadhesions,strictures Pyrexial patients require investigations. Injury or abnormal func- or isotope bone scanning to identify the source of infec- tion within the nervous system causes neuropathic pain. Itmaybe triggered by non-painful stimuli such as light touch, so- Management calledallodynia. Examplesofcausesincludepostherpetic r Prophylaxisagainstinfectionincludesmeticuloussur- neuralgia, peripheral neuropathy, e. Neuropathic pain is often dif- Severely contaminated wounds may be closed by de- culttotreat,partlybecauseofitschronicbutepisodicna- layed primary suture. The principal reason for treating pain is to relieve suf- r Supercial surgical site infections may respond to an- fering. It improves patients ability to sleep and their tibiotics (penicillin and ucloxacillin, depending on overall emotional health. Deeper surgical site infections may re- can also have other benets: postoperatively it can im- quire the removal of one or more skin sutures to al- prove respiratory function, increase the ability to cough low drainage of infected material. Abscesses generally and clear secretions, improve mobility and hence reduce require drainage either by surgery or radiologically the risk of complications such as pneumonia and deep guided aspiration alongside the use of appropriate an- vein thromboses. Assessing pain Pain control To diagnose and then treat pain rst requires asking the Many medical and surgical patients experience pain. Often, if pain is treated aggres- Surgery causes tissue damage leading to the release of sively and early, it is easier to control than when the pa- localchemicalmediatorsthatstimulatepainbres. In Pain may be induced by movement, which is sometimes some cases where verbal communication is not possible unavoidable, e. In contrast, immobility can cause pain due to resenting degrees of pain is useful. Depressionandfearoftenworsentheperception and these may require separate treatment plans.

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It may precipitate heart failure and deathsomeauthoritiesbelievethattransfusionmust never be given to patients with pernicious anaemia generic mildronate 500 mg on line treatment whooping cough. In the tropics it is often seen in association with multiple deciencies and with gut infection and infestation buy 500mg mildronate with visa treatment writing. If sufciently severe quality 500 mg mildronate treatment brachioradial pruritus, vitamin B12 and folate Haemolysis results in increased red cell formation order generic mildronate on-line cancer treatment 60 minutes, deciencies produce depression of all the marrow which requires folate more than B12. Phenytoin therapy interferes isusuallysomehaemolysiswitharaisedunconjugated with folate metabolism. Haematology 327 Hereditary haemolytic anaemias Haemolytic anaemia These are caused by defects in the red cell membrane or specic red cell enzyme deciencies. Haemolysis Hereditary spherocytosis is characterised by jaundice with a raised unconjugat- ed serum bilirubin, increased urobilinogen in urine An autosomal dominant disorder that causes in- and stools, increased haptoglobins and reticulocyto- creased osmotic fragility and produces spherocytes sis. There is no bile pigment in intermittent jaundice, which may be confused with the urine (the jaundice is acholuric). Gall- appearanceofchromium-taggedredcellsgivesamore stones, leg ulcers, splenomegaly and haemolytic or accurate measure of the rate of haemolysis. Spleno- aplastic crises during intercurrent infections may megalyandpigmentstonesmayoccur. During adult life the b- the X chromosome (affected males always show clin- globin variants combine with a-globin chains to form ical manifestations but females will have variable adult haemoglobin (HbA). Sickle-cell anaemia is usually drug-induced (sulphonamides, primaquine) caused by a point mutation, which involves substi- or occur during acute infections. Other features are tution of T for A in the second nucleotide of the sixth neonatal jaundice and favism. Sickle-cell haemoglobin (HbS) possesses two a- This is an acquired clonal disorder of haematopoiesis and two abnormal b-chains. Thisaccountsfortheincreasedsensitivityof red cells to complement, which forms the basis of Sickle-cell disease is found in Africa, the Middle East, Hams acid lysis test. Sickle-cell trait occurs in who develop paroxysmal haemolysis (with anaemia, heterozygotes (HbAHbS) whose haemoglobin con- macrocytosis, reticulocytosis, haemoglobinuria and tains characteristically 60% HbA and 40% HbS. Pa- haemosiderinuria) and life-threatening venous tients with the trait are usually symptom-free except thromboses. Normal adult haemoglobin is made up of two poly- This leads to the sickling phenomenon and to abnor- peptide chains, the alpha- and beta-chains, which are mal sequestration with thrombosis in small arterioles. Repeated renal infarction causes Haematology 329 tubular damage and failure to concentrate urine, Marrow disorders compounding sickle-cell crises. Median be given and penicillin prescribed to reduce mortality survival in both essential thrombocythaemia and from pneumococcus. Hydroxyurea can help by in- polycythaemia vera exceeds 15 years and the 10-year creasing HbF production. Bone marrow transplanta- risk of developing either myelobrosis or acute mye- tion is curative but limited by availability of well loid leukemia is relatively low. Polycythaemia vera presents in late middle age (5060 years), most commonly as a chance haem- Thalassaemia atological nding. Itisdiagnosedbyndingaraised A diagnosis of polycythaemia vera can also be HbA level generally (47%). HbF levels may also be made if there is a raised haemoglobin and two minor 2 slightly raised (13%). Secondary causes to be excluded include hypox- aemia and renal disease (ultrasound for polycystic b-Thalassaemia major disease and hypernephroma). Cerebellar haemangio- (homozygote) blastoma and hepatoma are associated but very rare. Treatment is with repeated venesection, low-dose Patientsarerelativelynormalatbirth(littlebeta-chain aspirin to reduce the incidence of intravascular coag- anyway) but develop severe anaemia later with failure ulation and hydroxyurea in high risk patients who are to thrive and are prone to infection. Treatment consists of transfusion to maintain the Diagnosis depends on nding all four major criteria: haemoglobin at 10g/dl, but this, combined with in- creased iron absorption, results in iron overload. Des- 1 a platelet count > 450109l1and ferrioxamine is given to reduce haemosiderosis with 2 megakaryocyte proliferation with no or little gran- folic acid replacement, and splenectomy may be in- ulocyte or erythroid proliferation and dicated if hypersplenism supervenes. Thrombocytosis (increased platelets) Primary myelobrosis typically presents with the. After haemorrhage, surgery or trauma nding of huge and increasing splenomegaly, and. Splenectomy or splenic atrophy evidence of bone marrow failure: anaemia, infection,. Hydroxyurea, thalidomide and the thalidomide analogue lenalidomide have been used in therapy. Allogeneic hematopoietic stem cell transplantation is Treatment potentially curative. Blood transfusion is necessary and has to be repeated reg- Myelodysplastic syndromes ularly. Chemotherapy, lenalidomide and allogenic bone marrow transplantation have all been used in Myelodysplastic syndromes are a heterogeneous therapy. Transformation to acute myeloid leukaemia occurs in approximately Anaemia (requiring the transfusion of about 1 unit 30% of cases. Survival following diagnosis varies from blood/week), infection, haemorrhage and blast a few months to > 10 years.

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With clinically-evident disease buy mildronate 500 mg amex medicine jar, short stature cheap 250mg mildronate free shipping symptoms 0f kidney stones, delay of puberty generic mildronate 500mg overnight delivery medicine identifier, pallor and anemia associated with iron and/or folic acid deficiency may develop buy mildronate 250 mg free shipping medicine disposal. Irritability and behavioral disorders, including depression and poor school performance may occur. Rickets was reported in earlier historical experiences, but is not so evident now. The initial detection of celiac disease in older children and adolescents is less common. However, in children on a gluten free diet for previously diagnosed celiac disease, symptoms First Principles of Gastroenterology and Hepatology A. Shaffer 238 may re-develop in this age group, as compliance to a gluten-free diet in older children and adolescents may be less. Some children also have less typical presentations suggesting other disorders including: recurrent and episodic abdominal pain, often with hyperamylasemia (i. Adult celiac disease There are now recognized to be severe types of celiac disease occurring within a spectrum (Table 4). In classical celiac disease, diarrhea, weight loss and significant malabsorption of a range of macronutrients and micronutrients may occur. Indeed, the extent and severity of these histological changes, the so-called proximal-to-distal gradient, correlate best with clinical features. With clinically significant malabsorption, for example, histological changes may be severe and extend well beyond the proximal jejunum. This may simply reflect exposure in the most proximal small bowel to normally higher concentrations of ingested gluten peptides, since studies have shown that the distal small bowel is in fact very sensitive to gluten peptides if they are infused through long intestinal tubes. After removal of dietary gluten, clinical improvement occurs with resolution of diarrhea and weight gain. This is usually accompanied by at least partial resolution of abnormal histological changes, first from the most distal portions of the small bowel, and later from more proximal small bowel (i. Latent celiac disease is a form of sprue in which the person has at one point in time both normal serology and intestinal morphology, but at a later time the intestinal biopsy becomes abnormal. These persons are often suspected from conditions associated with celiac disease (Table 5). In these, only limited histological changes are detected in the most proximal small bowel and only isolated nutrients absorbed primarily at this site may become deficient (eg. More than enough normal small intestine is present more distally to permit absorption of other nutrients so that diarrhea and weight loss are not seen. In this entity, the small intestine appears to be histologically normal, and serology for celiac disease is initially normal. In a small group of such individuals, intravenous immunoglobulin was therapeutically effective (Souayah et al. Refractory Celiac Disease In some persons with well-defined and treated celiac disease, diarrhea or malabsorption may recur and appear to be refractory to continued dietary gluten withdrawal. Often, these recurrent clinical features are associated with the return of severe histological changes which are typically seen in untreated celiac disease. In most, poor compliance with a strict gluten-free diet is evident as the cause of the recurrence of symptoms and histological signs. Sometimes, the actual source of gluten is ubiquitous, such as pill capsules or communion wafers. In these, treatment of the specific infection or the deficient nutrient may be sufficient for the patient to improve. For example, pancreatic exocrine insufficiency with pancreatic calcification may occur, particularly in celiac patients with long-standing malnutrition. On occasion, re-evaluation of the original diagnosis is needed to ensure that a different diagnosis was not initially missed. An unusual and rare disorder, collagenous sprue, sometimes may occur in celiac disease. In most persons with collagenous sprue severe panmalabsorption with diarrhea, weight loss and marked nutritional and electrolyte disturbance may develop. In a small number of persons with refractory celiac disease, no specific cause can be identified. Some have a rare syndrome with small bowel histologic changes of variable severity, splenic hypofunction and cavitation of mesenteric lymph nodes. Intestinal T-cell lymphoma are tumors which differ in their association with enteropathy, intraepithelial or nonepithelial origin, primary or secondary inducement, and T-cell or natural killer-like T-cell immunophenotypic (Muram-Zborovski et al. Unclassified Sprue or Sprue-like Intestinal Disease Occasionally, some adults may have diarrhea and weight loss. Severe intestinal mucosal biopsy changes are present, similar to those in untreated celiac disease, but these fail to respond to a gluten-free diet. Some could have a clinically-resistant form of celiac disease, whereas others may eventually prove to have a difficult-to-diagnose lymphoma. Most remain severely symptomatic with malabsorption and profound wasting despite a gluten-free diet. In some, an abnormal subset of intra-epithelial lymphocytes may be detected with morphologically normal, but phenotypically abnormal lymphocytes (based on immunochemical staining). Most of these persons unfortunately die with uncontrolled malabsorption despite steroid therapy and parenteral nutrition. This suggests that immunohistochemical changes represent a marker of poor prognosis. Malignant Complications Some of the malignant complications are listed in Table 6.

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