By K. Kadok. Rice University.

However surgery carries the risk of haem- rioration generic super avana 160mg free shipping, with marked postural instability cheap super avana 160 mg on-line, frequent orrhage or infarction in 4%, with a 1% mortality. In later disease, be- r High frequency deep brain stimulation suppresses havioural changes such as emotional lability and per- neuronal activity. Bilateral subthalamic nucleus stim- sonality changes, disordered sleep and cognitive loss ulation or globus pallidus stimulation is most useful are features, which may lead to the initial diagnosis of in those with difficulty with the on-off phenomenon, dementia. Pathophysiology Cerebrovascular parkinsonism is likely to be due to pro- Prognosis gressive loss of dopaminergic neurons due to small vessel The course of Parkinson’s disease is very variable. Drugs which interfere with the dopamine path- averagesurvival is ∼10 years from onset of symptoms. Chapter 7: Parkinson’s disease and other movement disorders 321 Clinical features Incidence Features that suggest other causes of parkinsonism 1in20,000 include: r Symmetry of signs (Parkinson’s disease is usually Age asymmetrical). Normally, the number of repeats is less than 35, but once Benign essential tremor this increases to over 36, the gene product called hunt- Definition ingtin causes the disease. It tends protein causes the neuropathological effects, but it is to present in the teens or in the elderly and affects males thought that the mutant protein may cause biochem- and females equally. Thisresults Treatment is often unnecessary, small doses of a β adren- in a loss of inhibition of the dopaminergic pathway, ergic blocker such as propranolol or primidone often re- i. Clinical features The disease usually manifests as progressive cognitive impairment and increasing movement disorder. Chorea Huntington’s disease consists of jerky, quasi-purposeful and sometimes ex- Definition plosive movements, following each other but flitting Genetically inherited progressive chorea and dementia. When seen in middle age 322 Chapter 7: Nervous system Huntington’s disease should be suspected. The disease shows strong geographical variation, with whites having twice the risk of non-whites and those in higher latitudes (i. Investigations r It is thought that there is an abnormal immune re- Genetic analysis is becoming available for pre- sponse, possibly triggered by an unknown viral anti- symptomatictestingbutthisraisesanethicaldilemma,as gen. However, it is important, as many r Genetic predisposition to the disease – monozygotic young adults wish to know their status before embarking twins have a 20–40% concordance, whereas siblings upon having a family. Patients and their families should be offered ge- netic testing and counselling where appropriate. Pathophysiology Discrete areas of demyelination called ‘plaques’ ranging Prognosis in size from a few millimetres to a few centimetres. They There is a relentless progression of dementia and chorea are often perivenous and common sites in the brain in- with death usually occurring within 20 years from the clude the optic nerve, around the lateral ventricles and onset of symptoms. The cervical spinal cord is also commonly affected, but any part of the central white matter may be involved. Multiple sclerosis Initial oedema around the soft patches of white matter leads to symptoms that partially resolve as the oedema Definition subsides. An immune-mediated disease characterised by discrete The areas of demyelination are disseminated in time areas of demyelination in the brain and spinal cord. Old lesions are firm, grey-pink ‘burnt-out ing: plaques’ that have very few inflammatory cells and are r Optic neuritis – usually unilateral visual loss which dominated by astrocytes. There may be hemiparesis, paraparesis osensory and auditory evoked responses may demon- or monoparesis. Bladder symptoms, muscle spasms, pain ning like pains going down into the spine or limbs and other problems are treated appropriately. Internuclear improvement, but do not appear to reduce the resid- ophthalmoplegia is a horizontal gaze palsy resulting ual neurological deficit. They are therefore usually re- from a lesion affecting the medial longitudinal fas- served for disabling visual or motor disease. The diagnosis may be made clinically if there are Prognosis two or more attacks separated in time with, clinical ev- The prognosis of multiple sclerosis is very variable, the idence of lesions in different areas. Following a single relapsing-remitting pattern having a better prognosis attack or clinical evidence of only one lesion area the thantheprogressiveforms. Deatheventuallyoccursafter diagnosis may still be made if there is radiological evi- late-stage disease (optic atrophy, spastic quadriparesis, denceoftwoormorelesionsintimeorspace(McDonald brain-stem and cerebellar disease) typically from com- Criteria). Aetiology r Normal pressure hydrocephalus presents with one or Hydrocephalus can be divided into obstructive/non- more of dementia, ataxia and urinary incontinence.

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In some instances super avana 160 mg low price, a molecularly informed disease classification offers improved options for disease prevention or management even when different disease sub-types are treated identically (see Box 3 super avana 160 mg for sale. A Knowledge Network that integrates data from multiple levels of disease determinants will also facilitate the development of new therapies by identifying new therapeutic targets and may suggest off-label use of existing drugs. In other cases, the identification of links between environmental factors or lifestyle choices and disease incidence may make it possible to reduce disease incidence by lifestyle interventions. Importantly, as discussed below, the Committee believes the Knowledge Network and its underlying Information Commons would enable the discovery of improved treatments by providing a powerful new research resource that would bring together researchers with diverse skills and integrate knowledge about disease processes in an unprecedented way. Indeed, it is quite possible that the transition to a modernized “discovery model” in which disease data generated during the course of normal healthcare and analyzed by a diverse set of researchers would ultimately prove to be a Knowledge Network of Disease’s greatest legacy for biomedical research. Consequently, patients and physicians must currently make decisions about whether to undertake more intensive cancer surveillance (for example, by breast magnetic resonance imaging or vaginal ultrasound) without being able clearly to assess the risks and benefits of such increased screening and the anxiety and potential morbidity that arises from inevitable false positives. Furthermore, some patients elect to undergo prophylactic mastectomies or oophorectomies without definitive information about the extent to which these drastic procedures actually would reduce their cancer risk. Studies attempting to quantify these risks have largely focused on particular ethnic groups in which a limited set of mutations occur at high enough frequencies to allow reliable conclusions from analyses carried out on a practical scale. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 42 individual patients, health-care providers, and payers, by making it possible to avoid unnecessary screening and treatment while reducing cancer incidence and promoting early detection. Molecular similarities amongst seemingly unrelated diseases would also be of direct relevance to drug discovery as it would lead to targeted investigation of disease-relevant pathways that are shared between molecularly related diseases. In addition, ongoing access to molecular profiles and health histories of large numbers of patients taking already-approved drugs would undoubtedly lead to improved drug safety by allowing identification of individuals at higher-than-normal risk of adverse drug reactions. Indeed, our limited understanding of—and lack of a robust system for studying—rare adverse reactions is a major barrier to the introduction of new drugs in our increasingly risk-aversive and litigious society. Major disparities in the health profiles of different “racial”, ethnic, and socio-economic groups within our diverse society have proven discouragingly refractory to amelioration. As discussed above, it is quite likely that key contributors to these disparities can be most effectively addressed through public-health measures and other public policies that have little to do with the molecular basis of disease, at least as we presently understand it. However, the Committee regards the Information Commons and Knowledge Network of Disease, as potentially powerful tools for understanding and addressing health disparities because they would be informed by data on the environmental and social factors that influence the health of individual patients,. For the first time, these resources would bring together, in the same place, molecular profiles, health histories, and data on the many determinants of health and disease, thereby optimizing the ability to decipher the mechanisms through which exogenous factors give rise to endogenous, biological inputs, directly affecting health. Researchers and policy makers would then be better able to sort out the full diversity of possible reasons for observed individual and group differences in health and to devise effective strategies to prevent and combat them. A Hierarchy of Large Datasets Would Be the Foundation of the Knowledge Network of Disease and Its Practical Applications The establishment of a Knowledge Network, and its research and clinical applications, would depend on the availability of a hierarchy of large, well-integrated datasets describing what we know about human disease. These datasets would establish the foundation for the New Taxonomy and many other basic and applied activities throughout the health-care system. The Information Commons would contain the raw information about individual patients from which meaningful links and relationships could be derived. Recognizing that the Knowledge Network would need to be informed by vast amounts of information external to the network itself, the Committee envisions the need for substantial research in medical informatics directed at all steps of the creation and curation of the network, and, equally importantly, its use by individuals with diverse backgrounds and goals. The creation of the Knowledge Network and its underlying Information Commons would enable the continuous compilation and analysis of molecular, environmental, behavioral, social, and clinical data in a dynamic, shared platform. Such an information platform would need to be accessible by users across the entire spectrum of research and clinical care, including payers. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 43 community and extracted directly from the medical records of participating patients. The roles of the different datasets in this information resource are schematized in Figure 3-1. Figure 3-1: Building a Biomedical Knowledge Network for Basic Discovery and Medicine. At the center of a comprehensive biomedical information network is an Information Commons which contains current disease information linked to individual patients and is continuously updated by a wide set of new data emerging though observational studies during the course of normal health care. The data in the Information Commons and Knowledge Network serve three purposes: 1) they provide the basis to generate a dynamic, adaptive system which informs taxonomic classification of disease; 2) they provide the foundation for novel clinical approaches (diagnostics, treatments strategies) and 3) they provide a resource for basic discovery.

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However proven super avana 160 mg, outside of the im m ediate im pact sm oking m ay have on a young person in term s of the sm ell of tobacco and the cost order super avana 160mg amex, there are short-term adverse health effects: y Increased risk of dependence – those who start smoking regularly when young tend to carry on smoking throughout their adult life, most … adults who smoke began during adolescence. Outside of these short-term health risks, adolescent tobacco use is “… often the first drug used by young people who use alcohol, marijuana and other drugs. Because your lungs You get bad breath grow at a slower rate and are three times and don’t work as more likely to be well, less oxygen gets out of breath than to your muscles. Your hands smell Your heart has to of stale cigarette work harder, it will smoke and your beat two to three fingers and nails times faster than can become stained someone who yellow. Throat Cancer, Stomach Cancer, Heart Disease and Bronchitis Long Terms Risks The increased risk of lung cancer is the risk predominantly associated with smoking. However, long-term exposure to nicotine increases the risk of: y Heart disease y Heart attack y Blood clots y Strokes y Bad circulation y Ulcers y Lung infection y Bronchitis y Emphysema y Cancers of the mouth and throat29 30 Drug Facts Equally, smoking impacts on both male and female fertility – decreased fertility is associated with women who smoke and wish to start a family and the risk of impotence is 50% higher in male smokers than in non-smokers. There is evidence of an increased risk of a prem ature birth, stillbirth and early death of the newborn baby where the m other sm okes m ore than five cigarettes a day and infants born to m others who sm oked throughout pregnancy also have a lower birth weight. For children, this increases the risks of asthm a and other respiratory illnesses and ‘glue’ or m iddle ear disease. Legal Status Health Act 2001 prohibits the sale of tobacco to young people under the age of eighteen years. Harm Reduction Approaches There are no ‘safe or safer’ tobacco products and given the adverse health effects of any tobacco product non-smoking is the only safer option. However, this over familiarity with alcohol poses in itself an enormous challenge for the promotion of healthier life-styles. Given the prevalence of alcohol use in Ireland, “83% of men and 74% of women reported alcohol consumption in the last month (and) … 40% of school-going young people reported never having had an alcoholic drink Alcoholic drinks can be divided into six different categories: beers, cider, table wines, fortified wines, distilled spirits and liqueurs. Ethanol is produced as a result of the ferm entation by yeasts of sugars from fruits, vegetables or grain34 and it is the difference in production m ethods and ingredients which brings about the different tastes and strengths. For exam ple, beer is produced by the ferm entation of brewer’s wort, with hops added for flavour. This results in an alcoholic drink which is approxim ately five parts ethanol to 100 parts water; as opposed to whiskey which is produced by the distillation of ferm ented barley, rye or corn m ash, which can contain as m uch as 50% ethanol. The following table35 presents the six different categories of drink, the types within each category, their alcohol content and exam ples of “standard drink” equivalents for each type. A standard drink equals 10gm s of pure alcohol and is the m easure sim ilar to “units” which is now used in the Royal College of Psychiatrists’ guidelines to sensible drinking. The upper recom m ended lim it per week is 21 standard drinks for adult m ales and 14 standard drinks for adult fem ales. Stage of Intoxication Impact 1st Stage: Happy Talkative, sociable, relaxed, less inhibited and worried, some loss of judgement 2nd Stage Excited Emotional, erratic behaviour, impaired thinking, slower reactions slower, poor judgement, loss of control over actions, driving impaired 3rd Stage Confused Staggering, disoriented, moody, exaggerated emotional reactions (fear, anger), slurred speech, double vision 4th Stage In a Stupor Unable to stand or walk, vomiting, approaching paralysis, barely conscious, apathetic and inert 5th Stage In a Coma Completely unconscious, few or no reflexes, may end in death from respiratory paralysis The effects described above are variable and dependant on a number of different factors. Factors Impacting on the Mood Altering Effects of Alcohol Type of drink y alcohol content y carbonated or effervescent alcoholic drinks are absorbed faster How quickly it is drunk y it takes approximately an hour for the alcohol in a standard drink to be broken down by the liver. If alcohol is consumed at a faster rate than it can be broken down, alcohol remains in the bloodstream and blood alcohol concentration rises When food was last eaten y approximately 90% of the alcohol drunk is absorbed by the small intestine and the amount and type of food in the stomach will impact on the rate of absorption. If alcohol is drunk quickly, this leads to a greater concentration of alcohol in the bloodstream the surroundings y the environment in which the alcohol is consumed can contribute to the effects and of the drinker y amount of alcohol drunk in terms of the social norms and controls at play in any given situation. This is the only way to sober up; approaches such as drinking black coffee, getting fresh air, taking cold showers or getting sick (in the mistaken belief that it will clear the stomach of alcohol) have no effect on a drinker’s blood alcohol level. Short Term Risks Childhood and adolescence are periods of growth and development and, as with all drugs, this makes young people particularly vulnerable to adverse short-term effects arising from alcohol use. The combination of physical immaturity and the ongoing development and refinement of values and attitudes, choice and decision making skills, personal and social skills. Other sedative drugs would include: y Solvents y Allergy medicines y Cough and cold medicines y Benzodiazepines and tranquillisers y Heroin and methadone41 Long Terms Risks As referred to earlier, 21 standard drinks and 14 standard drinks spread over the course of a week are the recommended limits for men and women respectively. For women, up to 35 standard drinks would indicate an increasing risk, with more than 35 standard drinks being considered harmful alcohol use. The equivalent figures for men are up to 50 standard drinks increasing risk and more than 50 drinks leading to harmful alcohol use. There is a wide range of long term risks associated with heavy and prolonged use of alcohol. This is an overview of som e of the provisions, and should not be taken as a definitive statem ent. The Intoxicating Liquor Acts of 1988, 2000 and 2003 are the m ain pieces of legislation and provide for the following: Under 18s: y It is an offence for a person under 18 to purchase alcohol.

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Refection for educators Warde and colleagues discount 160mg super avana mastercard, reported increased marital and parental Get to know the spouses and signifcant others in the lives satisfaction have been closely associated with a decrease in of the residents in your program early on in residency confict between professional and familial roles cheap super avana 160mg amex. Educate residents’ spouses about the physician the confict between the demands training and home-life, and health resources available to their families (e. These individuals are often the frst to in both parental and marital satisfaction. Adequate vacation time, fexible Case resolution work hours and equitable part-time work are conditions of The program director organizes a day-long retreat for the employment that are conducive not only to improved family residents and their signifcant others. The program director life and mental well-being but also to greater job satisfaction brings in a well-known speaker to discuss issues surround- and productivity. Physicians are most satisfed as parents when ing physician health, including work-lifebalance, ways to they have a supportive spouse and when the work–home con- maintain healthy intimate relationships, and recognizing ficts of both partners are minimal. The resident body fnds the expe- medical practice can also affect physicians’ relationships with rience very useful and decide to make this an annual event their children. For instance, Armstrong’s group, found that to help prevent family stress related to residency training physicians who worked for a salary were more fulflled in their and to help recognize the roles that each of their families parental role than physicians who worked on fee-for-service play in their own residency program. Finally, the employment status of one’s spouse seems to play a role in parental satisfaction. It is also im- medical families, and portant to value the work and other pursuits of one’s partner, • explore challenges specifc to those relationships. Case As seductive as the practise of medicine can be, Michael Myers A resident requests a meeting with their supervisor over reminds us to “say yes to the relationship and practise say- coffee. The resident becomes distraught while disclosing ing no to other offers” (Myers 2001). Spend a minimum of that she miscarried her frst pregnancy three weeks ago twenty minutes alone with your spouse each day and plan a and that her partner, a more senior resident, is preoccu- date together every week. The resident acknowledges that her partner has tried Monica Hill and Nancy Love quote the novelist Henry James to be supportive, but feels that “he just doesn’t get it. Unbalanced criticism, defensiveness, Successful marriages and similar partnerships are built on ridicule, a posture of superiority, and “shutting off ” are poi- knowledge, friendship, fondness and admiration (Gottman sonous to this process (Hill and Love 2008). For physicians as for anyone else, this means having population, domestic violence and abuse occurs in medical time together to develop the essential advantage of such rela- families too. It includes affection, expressiveness, sexuality, cohesion, compatibility, autonomy Dual-physician relationships and confict resolution (Myers 2001). Confict between work and familial roles is inevitable at times, whether one or both partners are physicians. Classically, role Work and family life strain has been more frequently noted among female physi- The issue of deferring intimacy in favour of medical work has cians, but in reality male physicians experience it as well. Half been described in the literature on medical marriages (Myers of married women physicians are married to other physicians 2001 and Gabbard 1989). Dual-physician relationships bring sional advancement over the nurturing of intimate relation- certain challenges, such as complicated schedules and career ships, working long hours at the expense of their home lives. Careers postpone their investment in the “emotional bank account” of can be shaped, reshaped and salvaged more easily than rela- their families or in some cases, avoid admitting that they in fact tionships and families. Paradoxically, however, “the marital interests can be satisfying, which can lead to greater mutual relationship is the main source of coping with the stress of understanding, support and shared parenting (Schrager et al medical practice” (Gabbard 1989). It would seem, however, whether by preference, mutual decision or default, that women physicians continue to take Physicians who enjoy successful intimate partnerships learn more responsibility on the home front than their male counter- early that certain attributes that serve them well at work are parts. For example, while physicians of female physicians being the primary or sole income earner are accustomed to their role as experts and expect to be in in their households. In contrast to Protecting and nurturing our intimate relationships may require most physicians’ experience of medical education, marriage is a re-examination of our professional responsibilities and work non-competitive. As you develop your resident group or consider Relationships, however, do require work in realtime, a sense of your eventual practice setting, keep these questions in mind: humour, and a degree of luck. John Gottman, a respected re- • Does your group discuss shock-absorber systems for searcher in marriage and relationships, stresses the importance parental leaves and urgent family issues? She had speculated that a child would keep geographical triangle: home, school and workplace. Keeping her relationship together, given her partner’s attraction to logistics as simple as possible will beneft your marriage and “more medicine” and achievement.

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