Mark Corson

By S. Roland. Saint John Fisher College.

By contrast order tegopen 500gm with mastercard, follow-up studies in history and Obsessions + worry about attacks and avoidance flashbacks? Best estimates represent consensus view of experts on most probable estimate from identified range order 250gm tegopen amex. For panic disorder tegopen 500gm lowest price, frequent among those individuals with more severe anxiety prospective studies reveal high degrees of symptom chronicity symptoms. Childhood separation anxiety disorder often 2003) reveal a significant correlation between measures of anxi- resolves with entry into adolescence [I] (Copeland et al. Many patients with anxiety Retrospective longitudinal studies in obsessive-compulsive dis- disorders also simultaneously fulfil diagnostic criteria for another order suggest a very poor outcome, though prospective studies in disorder, this pattern typically being named ‘co-morbidity’. An early systematic review found that Recommendations: increased awareness of anxiety patients with comorbid conditions generally had worse outcomes disorders than those with anxiety disorder or depressive disorder alone [I] (Emmanuel et al. For example, a French primary care study of the prevalence, obsessive-compulsive disorder is present [S] recognition and treatment of social phobia found that detection ● Become familiar with the fluctuating nature of symp- rates were increased in the presence of comorbid depression toms in patients with anxiety disorders, and with the ten- (66%, compared with 53% in those without depression) [I] dency for symptoms to change in nature over time [S] (Weiller et al. However the presence of a seemingly more pressing comorbid condition can result in sub-optimal treatment for the anxiety disorder. Co-existing psychological symptoms and practice cluster randomised controlled trial of the impact of men- tal health guidelines, which found that only 54% of patients with co-morbid mental disorders a ‘common mental disorder’ (depression or anxiety) were offered Anxiety symptoms often co-exist with other psychological symp- active treatment, revealed that patients with anxiety or mixed toms, especially depressive symptoms, which are particularly anxiety-depression were significantly less likely to be offered 6 Journal of Psychopharmacology treatment than patients with depression alone [I] (Hyde et al. A Dutch patients with psychiatric comorbid conditions, and antidepres- study found a low (47%) rate of detection of anxiety and depres- sants significantly more frequently prescribed in patients with sion, recognition being more likely in anxiety disorders of shorter comorbid physical illness: in both forms of comorbidity, the pre- duration [I] (Ormel et al. Where anxiety 70%) of affected individuals were recognised as having clinically symptoms are present within the context of a depressive disorder, significant emotional problems, accurate diagnosis was less com- antidepressant drug treatment is often effective in reducing anxi- mon (34. Clinical practice has usually been to direct structured clinical interview did not have a recorded diagnosis treatment towards the depressive disorder in the first instance, (generalised anxiety disorder, 71. A United Kingdom general prac- will often improve the depression or depressive symptoms tice survey involving patients whose questionnaire scores indi- (National Institute for Health and Clinical Excellence, 2011). In a United symptoms are of more than mild intensity [S] Kingdom longitudinal study of the detection of depression and anxiety which found that many ‘cases’ were not detected at the initial appointment, the vast majority of undetected cases of depression or anxiety were recognised at follow-up [I] (Kessler 7. A Dutch primary care practice survey found that patients with an anxiety disorder were less likely to be diagnosed primary medical care settings than patients with a depressive episode, but the likelihood of Within the setting of primary medical care (general practice), diagnosis in both conditions increased with the number of con- most patients with anxiety or depression have relatively mild sultations, and the expression of more severe psychological and transient symptoms, which tend to resolve without the need symptoms [I] (Verhaak et al. However, many patients with anxi- Recommendations: increasing skills in detecting anxi- ety and depressive symptoms do not present to primary medical ety symptoms care services [I] (Andrews and Carter, 2001; Roness et al. Even when patients do consult their general practitioner, ● Remember that many patients are either reluctant to anxiety symptoms are usually not their presenting complaints. A cross- but not established at earlier appointments [A] sectional study of anxiety and depressive symptoms in Australian ● Routine screening of all patients for the presence of family practices found that unemployed patients, when com- anxiety symptoms is not recommended [A] pared to employed patients, were significantly more likely to report affective symptoms, to have greater symptom severity, to have previously undergone treatment and to be prescribed psy- 8. Screening for anxiety disorders in chotropic medication: but were no more likely to be referred to primary care settings mental health services than were employed patients [I] (Comino et al. In theory, patients and health professionals might benefit from Data from the United States indicate that black and Hispanic the use of screening tools for detecting anxiety disorders, which patients were less likely than white patients to receive care for can lead to discussion of psychological symptoms at both the depression and anxiety, or to receive antidepressant prescriptions index and subsequent appointments. However, use of screening questionnaires needs to This situation may not necessarily apply in all countries, as a be accompanied by other changes in practice structure, and it is Dutch general practice study of the quality of care for anxiety and uncertain whether routine screening and disclosure of ‘screened depression across ethnic minority groups found that all groups positive’ patients with anxiety disorders leads to improved clini- (with the exception of individuals originating from Surinam and cal outcomes. An educational intervention involving this design, the Antilles) were as likely to receive guideline-concordant medi- among United States primary care patients found no evidence for cal care [I] (Fassaert et al. The criteria for diagnosing psychiatric disorders are mainly from clinical observations in psychiatric outpatients and inpa- Recommendations: paying particular attention to tients and so may not be appropriate for routine use in screening certain patient groups for common mental disorders, among the more mildly ill patients in primary care. The use of question- pharmacological or psychological treatment [S] naires for detecting and following up patients with depressive symptoms has become part of routine primary care practice in the United Kingdom, suggesting that use of a similar question- 10. Increasing awareness of anxiety that are associated with stressful life events or troublesome situ- disorders in particular patient ations, which will often improve without needing specific treat- ment. However, the chronic nature and significant associated populations disability of anxiety disorders means that most patients who fulfil When compared with the general population, anxiety disorders the diagnostic criteria for an anxiety disorder – in terms of sever- are more common among patients with other mental disorders, ity, duration, distress and impairment – are likely to benefit from with chronic physical illness, and in certain demographic groups. The need for treatment is influenced by the intensity from certain ethnic populations, may be at greater risk of receiv- and duration of illness, the impact of symptoms on everyday life, ing sub-optimal care and treatment. A Dutch primary care the presence of co-existing depressive symptoms and comorbid 8 Journal of Psychopharmacology disorders, and the presence of concomitant medication; together with other features such as a good response to, or poor tolerabil- ● Record the diagnosis and review this at subsequent ity of, previous treatments. A United States longitu- dinal primary care study of the use of health services by patients with panic disorder found that 64% had undergone some form of 11. The quality of treatment in those who do receive it Many patients experience unwanted and distressing adverse may be enhanced through making an accurate diagnosis and by effects of psychotropic drug treatment, such as sexual dysfunc- regular monitoring of progress. Others fear developing a tion and an increased frequency of appointments would be more tolerance or becoming dependent on medication, and so are likely to facilitate adequate treatment than would physician edu- reluctant to start, let alone continue, pharmacological treatment. A study of adherence to evi- In addition, many patients and health professionals and some dence-based guidelines for depression and anxiety disorders commentators consider pharmacological intervention to be a within the setting of Dutch primary medical care found that only merely symptomatic and not a definitive treatment. For these rea- 27% of patients with anxiety disorders received guideline- sons, many of those who might benefit from treatment do not consistent care: symptom severity had no influence on adher- receive it, and many of those who do undergo treatment stop it ence, but documentation of a diagnosis by the general practitioner early because of the emergence of unwanted effects. This may be a factor in some settings, qualitative study of patients’ views on anxiety and depression though most studies find a low level of inappropriate prescribing found marked preferences regarding their perceived health and a high level of unmet need. Certain patient groups may dence of ‘overtreatment’ (including inappropriate counselling, be particularly reticent about starting or continuing psychotropic prescription of psychotropic medication, or specialist referral) in drug treatment. For example, in a United States study of beliefs 11% of individuals without a formal psychiatric diagnosis, but about psychotherapy and psychotropic drug treatment for an also found substantial rates of ‘under-treatment’ for individuals anxiety disorder which found few differences between diagnos- with the diagnoses of major depressive episode (49%) or gener- tic groups, coexisting depression was associated with more alised anxiety disorder (64%) [I] (Olsson et al. Another inves- of good response to, or poor tolerability of, previous tigation of perceived barriers to care suggested that difficulties in treatments [S] the continuing treatment of panic disorder were primarily admin- istrative, such as being uncertain where to seek help, worrying Baldwin et al. Pharmacological treatments in tine and venlafaxine have been associated with discontinuation symptoms after abrupt withdrawal [I(M)] (Baldwin et al. Antipsychotic drugs are often prescribed to patients with anxiety disorders, but the strongest evidence for benefit is restricted to acute treatment and prevention of relapse with quetiapine in gen- 12. The azapirone drug buspirone is efficacious in the acute erance and dependence can occur (especially in predisposed treatment of generalised anxiety disorder [I (M)] (Chessick et al. In generalised anxiety ● Remember that benzodiazepines can be effective in disorder, it is efficacious in relieving depressive symptoms of many patients with anxiety disorders [A], but recog- mild to moderate intensity [I (M)] (Stein et al.

Relative contribution of tech- netium-99m sestamibi scintigraphy effective 500 gm tegopen, intraoperative gamma probe detection tegopen 250gm sale, and the rapid parathyroid hormone assay to the surgical management of hyperparathyroidism order 250 gm tegopen free shipping. Thyroid carcinoma: biological implications of age, method of detection, and site and extent of recurrence. To discuss the anatomy and physiology of the swallowing structures and mechanism, including the physiologic lower esophageal sphincter. To discuss pertinent clinical history and physical examination findings as they relate to structural and functional pathology. To describe various therapeutic options for patients with neurologic, neoplastic, reflex- mediated, and dysmotility-mediated disorders. Cases Case 1 A 58-year-old man presents to your office complaining of difficulty in swallowing. Case 2 A 39-year-old woman presents to your office with burning chest pain, rapidly worsening over 3 years. Case 3 A 72-year-old woman presents to your office with difficulty in swal- lowing for decades. Swallowing Difficulty and Pain 201 Introduction The swallowing mechanism is a complex interaction of pharyngeal and esophageal structures designed for the seemingly simple purpose of propelling food to the stomach and of allowing the expulsion of excess gas or potentially toxic food out of the stomach. Initial evaluation of a patient complaining of difficulty (dysphagia) or pain (odynophagia) with swallowing involves a thorough, focused history and a physical examination. The advent of esophageal motility and pH studies has permitted correla- tion of physiologic data to the anatomic information obtained through radiographic and endoscopic studies. Others may only confuse the diagnosis, having no relationship to the patient’s complaints. In evaluating swallowing difficulty and pain, it is extremely important to relate symptoms to diagnosis, as inappropri- ate therapy actually may worsen the patient’s symptoms or initiate new complications. Anatomic Considerations The esophagus is a muscular tube extending from the cricoid to the stomach. It is composed of a mucosal layer, a submucosa, and a double outer muscular layer (Fig. No serosa is present on the esopha- gus, resulting in a structure that has less resistance to perforation, infiltration of malignant cells, and anastomotic breakdown follow- Ganglia of myentetric plexus [Auerbach] Ganglia of submucosal plexus (Meissner) Epithelium Submucosa Muscularis mucosa Lamina propria Muscularis externa Esophageal gland Longitudinal muscle layer Figure 12. Three layers compose the esophageal mucosa: a stratified, nonkeratinizing squamous epithelial lining; the lamina propria (a matrix of collagen and elastic fibers); and the muscularis mucosae. The squamous epithelium of the esophagus meets the junctional columnar epithelium of the gastric cardia in a sharp transition called the Z-line, typically located at or near the lower esophageal sphincter (Fig. Although the upper third of esophageal muscle is skeletal and the distal portion is smooth, the entire esophagus functions as one coordi- nated structure. Contraction of the longitudinal muscle fibers of the esophageal body produces esophageal shortening. The inner circular muscle is arranged in incomplete rings, producing a helical pattern that, on contraction, produces a corkscrew-type propulsion. Muscle layers are of uniform thickness until the distal 3 to 4cm, where the inner circular layer thickens and divides into incomplete horizontal muscu- lar bands on the lesser gastric curve and oblique fibers that become the gastric sling fibers on the greater curve. In an adult, the cricopharyngeal muscle is located approximately 15cm from the incisors, and the gastroesophageal junction is located approximately 45cm from the incisors. Because the lymphatic system is not segmental, lymph can travel a long distance in the plexus before traversing the muscle layer and entering regional lymph nodes. Swallowing Difficulty and Pain 203 upper esophagus can metastasize to superior gastric nodes, or a cancer of the lower esophagus can metastasize to superior mediastinal nodes. More commonly, the lymphatic drainage from the upper esophagus courses into the cervical and peritracheal lymph nodes, while that from the lower thoracic and abdominal esophagus drains into the retrocar- diac and celiac nodes. The sympathetic supply is through the cervical and thoracic sym- pathetic chains as well as through the splanchnic nerves derived from the celiac plexus and ganglia. Parasympathetic innervation of the pharynx and esophagus is primarily through the vagus nerve. At the diaphragmatic hiatus, these plexi fuse to form the anterior and posterior vagus nerves. A rich intrinsic nervous supply called the myenteric plexus exists between the longitudinal and circular muscle layers (Auerbach’s plexus) and in the submucosa (Meissner’s plexus). Physiology of Swallowing Passage of food from mouth to stomach requires a well-coordinated series of neurologic and muscular events. Failure of the pump, valves, or worm drive leads to abnormalities in swallowing such as difficulty in propelling food from mouth to stomach or regurgitation of food into the oral pharynx, nasopharynx, or esophagus. History and Physical Examination A precise medical history is essential to obtaining an accurate diag- nosis of swallowing difficulties. Does the patient suffer from difficulty in swallowing (dysphagia) alone, or is pain with swallowing (odynophagia) a primary or associated complaint? Sutyak primary complaint, elucidate its nature (squeezing, burning, pressure), aggravating factors (temperature and type of food, liquids and/or solids, medications, caffeine, alcohol, position, size or time of meals), relieving factors (medications, position, eructation, emesis), time course (lifelong, several years, slow progression, worsening, stable, episodic, constant), and associated factors (patient age, weight gain or loss, presence of a mass in the neck, preexisting disease processes, chronic cough, asthma, recurrent pneumonia, tobacco and alcohol use). When dysphagia is not associated with pain or with pain as a minor complaint, questioning should still follow the pattern above (nature, aggravating factors/relieving factors/time course/associated factors) and include questions focusing on disease progression (difficulty with solids at first, then difficulty with liquids, or difficulty with both solids and liquids). Appropriate identification and evaluation of esophageal abnor- malities rely on a thorough understanding of the patient’s symptoms and of how these symptoms relate to various disorders. A useful method is to determine how much the symp- toms have affected the patient’s lifestyle in terms of activity, types of food eaten, interruption of employment, and effects on family life. A precise relationship of symptoms to diagnosis is essential in order to avoid inappropriate and dangerous treatment. Although the majority of preliminary diagnostic information is obtained through a focused history, physical examination can add important clues to the diagnosis, particularly when malignancy is of concern. Signs of chronic or acute weight loss, lymphadenopathy, tobacco abuse, ethanol abuse, portal hypertension, and any abnormal neck or abdominal masses should be noted on physical examination. Further history and examination findings are covered under the spe- cific diagnoses that follow later in this chapter.

Clearly these two conditions require different treatment - for which will you prescribe Opium? In one the skin is dry and harsh tegopen 500 gm with visa, temperature high order 250 gm tegopen with mastercard, pulse frequent and hard purchase tegopen 250 gm on-line, secretions arrested. In the other the pulse is small and feeble, the face pallid, and the extremities cold. You find severe pain in a part, the patient wants relief, must have rest; did it ever suggest itself to you that it was worth while to take into consideration the condition of the part - whether it was one of activity or atony, or the general conditions as named above? In the ordinary use of narcotics these things are not considered, and hence the common use of these drugs is the worst form of empiricism. I have nothing to say about the uncertainty of their action, and the ill effects so frequently following their use. Every reader has had these experiences, and I have no doubt, would be only too glad to know how to get along without them, or learn to use them with greater certainty. I recognize the fact that there are two factors in this problem of unpleasantness - pain, sleeplessness. The one is the general condition of the body, embracing every function; the other is the condition of the brain and its sensitive nerves. Conversely, when we have either of these, we may expect relief just in proportion as we restore the body to its normal condition, and the brain to its normal condition. Thus, when my patient is suffering, or sleepless, I determine as near as may be, what derangement of function is the cause, and instead of prescribing narcotics, I adopt those means that restore the diseased function. If the condition is one of irritation and determination of blood to the brain, relief and sleep come from the use of the sedatives and Gelseminum. If the condition is one of atony, it comes from the use of stimulants, tonics, and food. Prescribing for the basic element of disease, is a very certain way of relieving pain and giving sleep. You will get those results from the simple administration of Bicarbonate of Soda, Muriatic Acid, Sulphuric Acid, Baptisia, Phytolacca, when these are specially indicated, as well as from the use of remedies that more especially influence the nervous system. Hoping that I have at least placed this subject in such light that our readers can think of it, and solve the problem for themselves, we will leave it for this time. I may remark, in conclusion, that I have not given a narcotic in eighteen months, and have not used the equivalent of a drachm of Morphia in five years. We all have our troublesome cases, in which the symptoms are not pronounced, and the diagnosis is obscure, and the treatment being guess-work, proves a failure. The best men may make mistakes in diagnosis, but it should be of rare occurrence, and never one that will lead to the improper administration of medicine. We are sent for to see a patient, and find him confined to room or bed, and complaining of inaction of the bowels. We see in constipation but a symptom and not one especially indicating the character of the disease. It might be acute enteritis, and then the dry skin, small, hard pulse, white narrow tongue, tenderness on deep pressure, would determine the character of the disease; and we would not give a cathartic under any circumstances. Again it might be hernia - some of the obscurer forms, or ileus - invagination, in either case, a cathartic would be the worst medicine we could give. In the above cases the constipation seems to be the direct symptom, if it is not the disease itself. So in many other cases, the symptoms that seem to point out the disease, are quite as likely to lead to wrong as right treatment. It won’t do, to depend upon the character of the pain always, to tell us the lesion or the proper remedy - and it don’t do to call it colic, and prescribe at random. As an example, I was called to see a case that had been under the care of a Homœopath, who prescribed for the character of the pain; but the woman had suffered intensely for hours, and was exhausted by the severity of the pain. The inhalation of Chloroform for ten minutes gave entire relief, and there was no return of pain - there was intestinal spasm. Another: I had prescribed for a case of abdominal pain, in the early part of my practice, the usual routine of aromatics, stimulants, chloroform by mouth, winding up with Compound Powder of Jalap, until the stomach refused to tolerate any more medicine - and all without relief. A Homœopathic practitioner was called, and prescribing Nux Vomica alone, had the patient comfortable in three or four hours. The peculiar yellowness around mouth, sense of fullness and oppression in right hypochondrium, and pain pointing at umbilicus, told the story clearly. I recollect a case of green apples in my boyhood, and the drenching with Composition and diluted No. So I have had cases which were speedily relieved by small doses of Sulphate of Magnesia, or Iodide of Potassium - lead colic. So we will find cases, requiring an absorbent like Charcoal, an Alkali, Ammonia, Chloroform, Aromatics, even Podophyllin. And again we reach the conclusion that the pain was not the disease, not even a reliable symptom. Thus, in almost every case we are obliged to look beneath the surface symptoms, and use our reasoning powers, comparing the evidences of disease, and thus determining the exact functional lesions. Unless, and here is an important proviso, we have studied this subject of basic symptoms; then in a number of cases, no matter what the disease, the remedy will be indicated by a characteristic symptom. In this I agree with some Homœopaths, as I agree that when a drug is thus clearly indicated, it will probably be the remedy for the totality of the disease. There is this difficulty here: in some cases there is no characteristic symptom, or if there is we have not learned to know it, or have not learned the remedy. But the cases given, though illustrating the necessity of care in diagnosis, and the danger of falling into error, do not otherwise bear upon our subject. These cases are not obscure if ordinary care is used, for the evidences of disease are unmistakable.