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By: Lee A Fleisher, MD, FACC
- Robert Dunning Dripps Professor and Chair of Anesthesiology and Critical Care Medicine, Professor of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
https://www.med.upenn.edu/apps/faculty/index.php/g319/p3006612
Identifying menstrual cycle irregularities is important because they are associated with several poor health outcomes pulse pressure sepsis order toprol xl 100 mg. Women who have varying cycle lengths have decreased fecundity arrhythmia omega 3 buy discount toprol xl 100mg on line, and women who have cycle lengths shorter or longer than 72 28?31 days have decreased fecundity hypertension thyroid toprol xl 100mg generic. Special attention must be 74 given to precocious or delayed puberty, as they are linked to endocrine abnormalities. The Committee on Adolescent Health Care of the the importance of monitoring American College of Obstetricians and begins in puberty and adolescence. The opinion recognizes the menstrual cycle can signal other medical 76 problems and suggests that charting of menses may be appropriate. Identifying menstrual abnormalities in adolescence can allow for early diagnosis and treatment of underlying health 77 problems. The conditions that alter ovulation during adolescence will only worsen if a correct 78 diagnosis is not done. Monitoring menstrual cycle irregularities can be a diagnostic tool in determining underlying 79 health problems. They may be due to ovulatory dysfunctions, in particular endocrinal 80 disorders ; gynecological problems; or iatrogenic causes, such as contraceptive use and 69 Gerrie-Cor M. Various dysfunctions are detailed below with descriptions of possible accompanying menstrual irregularities. This gives a picture of how monitoring the menstrual cycle can play an important role in the diagnosis of an underlying health problem. Endocrine dysfunctions There are several types of endocrine dysfunctions that can affect the ovulatory cycle and fertility, including hypothalamic, There are several types of endocrine pituitary (hypophyseal), thyroid, 81 dysfunctions that can affect the ovulatory adrenal, and ovarian disturbances. None of the endocrine dysfunctions has cycle and fertility, including hypothalamic, a specific pattern of ovarian activity, and pituitary (hypophyseal), thyroid, adrenal, thus diagnosis must follow and ovarian disturbances. Hypothalamic disorders Hypothalamic disorders may result in hypoestrogenic cycles, cycles that are dry due to the lack 83 of estrogen and are marked by anovulation and amenorrhea (absence of menstruation). This change arises in several circumstances: functional hypothalamic amenorrhea, evidenced by the absence of menstruation for more than six months not due to anatomical abnormalities, results from excessive exercise, nutritional deficits/weight loss, or stress; physiological hypothalamic amenorrhea occurs postpartum and with breastfeeding; pharmacologic anovulation results 85 from opiates; and amenorrhea may result from psychiatric disorders, such as anorexia. Hypothalamic amenorrhea can also result from organic defects of the hypothalamic pituitary 81 See generally Vigil et al. Improvement in functional hypothalamic amenorrhea can result from weight gain, 87 reducing exercise, and psychological counseling. Pituitary adenomas (tumors) Prolactinomas, the most common pituitary tumor, can cause hyperprolactinemia, which is the 88 result of increased prolactin secretion in the blood. Symptoms of hyperprolactinemia include menstrual irregularities, galactorrhea (spontaneous milk flow from breast), infertile cycles, 89 decreased libido, and dyspareunia (painful sexual intercourse). Women with hyperprolactinemia who continue to have cycles often have short luteal phases, which is 90 associated with infertility. Treatment goals are normalizing prolactin levels; reducing, if 91 present, the tumor; and restoring menstrual cycles and fertility. Earlier detection and treatment of thyroid dysfunction can lead to fewer menstrual irregularities, and not all women with thyroid 94 dysfunction have irregular cycles. Severe hypothyroidism is associated with ovulatory 98 dysfunction as well, given that the thyroid hormones interact with the reproductive system. The adrenal glands synthesize sex 102 steroids, and excess production of adrenal sex steroids, especially androgens, leads to gonadal dysfunction, precocious puberty, delay of menarche, menstrual disorders, anovulation, 103 and infertility. Meyer-Bahlburg, What Causes Low Rates of Child-Bearing in Congenital Adrenal Hyperplasia? Premature ovarian failure can result in premature menopause, which due to early deficiency of estrogen increases the risk of stroke and cardiovascular 124 disease, independent of cardiovascular risk factors, and leads to decreased bone mineral 125 density and increased risk of osteoporosis. Estrogen replacement therapy, which is indicated 126 for these women, mitigates some of these complications. Gynecological disorders Gynecological disorders, including anatomical abnormalities, neoplasia, and inflammatory 127 diseases, can also account for menstrual disorders and mucus pattern changes.
Adults can help higher than other adolescents blood pressure chart low generic toprol xl 25 mg overnight delivery, with girls being more facilitate moral development in adolescents by modeling likely to blood pressure 10070 toprol xl 100 mg for sale experience these problems than boys (Svetaz prehypertension icd 9 code order toprol xl 25 mg mastercard, altruistic and caring behavior toward others and by Ireland, & Blum, 2000). Furthermore, youth with helping youth take the perspective of others in learning disabilities are significantly more likely than conversations. For example, an adult might ask the adolescents in the general population to report having adolescent, How would you feel if you were They are at especially high risk for involving fairness and morality are identified and these negative outcomes if they are experiencing discussed sensitively and in a positive atmosphere where emotional distress. For adolescents with learning adolescents are encouraged to express themselves, ask disabilities, feeling connected to family and school and questions, clarify their values, and evaluate their having a religious identity are all factors found to be reasoning (Eisenberg, Carlo, Murphy, & Van Court, associated with lower risk for negative outcomes such as 1995; Santilli & Hudson, 1992). This atmosphere should emotional distress, suicide attempts, and involvement in reinforce the concept that racism, sexism, homophobia, violence. Thus, families, schools, and other institutions 13 ageism, and biases against persons with disabilities are have important roles to play in protecting these youth inherently destructive to both the individual and society. Volunteering in the community is an important positive Because of the higher risk that adolescents with learning avenue for youth that can help promote their moral disabilities have for serious problems, professionals development. In addition to helping foster a sense of should monitor adolescents? social and emotional purpose and meaning and enhancing moral functioning, paying particular attention to signs of development, volunteering is associated with a number anxiety and depression. For example, one anxiety or depression who have not been identified as national study of girls from 25 schools found that those having a learning disability or emotional disorder who volunteered in their communities were significantly should also be evaluated to rule out the presence of less likely to become pregnant or to fail academically these problems. Professionals can help adolescents understand the value of volunteering and direct them toward valuable volunteer experiences. Learning Disabilities Learning disabilities refer to disorders that affect the ability to interpret what one sees and hears or to link information from different parts of the brain (Neuwirth, 1993). Individuals with learning disabilities may have problems with reading, spoken language, writing, memorizing, arithmetic, or reasoning. Without careful assessment, some adolescents with learning disabilities may be seen as having behavior problems, and the cognitive problems underlying their behavioral problems 14 strongly influence, either positively or negatively, global A dolescent self-esteem. This is particularly true in early adolescence Em otional when physical appearance tops the list of factors that D evelopm ent determine global self-esteem, especially for girls (Harter, 1990a). Comments by others, particularly parents and Emotional development during adolescence involves peers, reflect appraisals of the individual that some establishing a realistic and coherent sense of identity in adolescents may incorporate as part of their identity and the context of relating to others and learning to cope feelings about themselves (Robinson, 1995). Identity refers to more than just how adolescents see the process by which an adolescent begins to achieve a themselves right now; it also includes what has been realistic sense of identity also involves experimenting termed the possible self? what individuals might with different ways of appearing, sounding, and become and who they would like to become (Markus & behaving. So, just as one adolescent will traditionally been thought of as the central task of explore more in one domain. Adolescence is the parents or adolescents can assure them that most first time, however, when individuals have the cognitive experimentation is a positive sign that adolescents feel capacity to consciously sort through who they are and secure enough to explore the unknown. First is self-concept: the Although it may seem a simple strategy, professionals set of beliefs one has about oneself. Self-esteem develops uniquely for each develop their new abstract reasoning skills and moral adolescent, and there are many different trajectories of reasoning abilities. Thus, self-esteem, whether high or low, may remain relatively stable during adolescence or may steadily improve or worsen. Many of the factors already described in Developing Adolescents influence identity development and self-esteem during adolescence. For example, adolescents? developing cognitive skills enable them to make abstract generalizations about the self (Keating, 1990). The physical changes they are experiencing can 16 A helpful guide for parents about com m unicating with teens is Helping Your Children Navigate Their Teenage Years: A Guide for Parents, which can be found at Engage adolescents with nonthreatening characteristics have been identified by different questions. Choosing only one or two questions at researchers as being associated with low self-esteem in a given time, ask adolescents questions that help adolescents (Jaffe, 1998): them to define their identities. This enables the adolescent to realize that point of view you value his or her opinions, and thus to trust. Conforming to what others want and assuming a you more (Forgatch & Patterson, 1989). Ask questions that require more than a yes or no response; this helps Because consistently low self-esteem has been found to the adolescent think through ideas and options be associated with negative outcomes, such as (Hill & O?Brien, 1999). Try professionals identify youth who exhibit these to rephrase your questions to get at what the characteristics and help them get the extra help adolescent was thinking rather than the reason for 16 they need.
This research provides an initial understanding of the importance of some of the psychological mechanisms operating in an objectifying sociocultural context and their influence on the distress experienced by people who are visibly different blood pressure vs heart rate generic 25 mg toprol xl mastercard. These mechanisms seem important to arrhythmia joint pain generic toprol xl 25 mg with visa study given the increasing significance of appearance and appearance-related distress in Western societies peak pulse pressure qrs complex 25mg toprol xl. This 82 comprehensive approach ensured a sample size was aimed for that would provide sufficient power for multiple regression analyses to detect significant relationships. The large sample size achieved also enabled the researcher to assess the relevance of the findings to the wider adult acne population. For example, some items on their body surveillance measure seem to reflect similar yet different constructs. Additionally, their use of a double negative when asking I never worry that something is wrong with me when I am not exercising as much as I should? on their body shame scale (McKinley & Hyde, 1996) may be confusing for participants. Indeed, despite briefly consulting with adults with acne and researchers in the field on the measures? items, more extensive consultation is needed to help refine and develop the measures. Additionally, more rigorous statistical examination is required to establish the new measures? psychometric properties. Initially, this led the researcher to question whether these findings were representative of the wider adult acne population, however it was concluded that skewness in these variables is likely to be expected in this population given acne is a chronic and stigmatised condition. For this reason, and because the large sample size enabled the central limit theorem to be drawn on to assume the sampling distribution was normal, the researcher decided against correcting this skewness and other non-normal data distributions by transforming or bootstrapping the data. Nevertheless, to be confident the findings were not influenced by the non-normal distributions non parametric analyses were used when their parametric equivalents relied on the sampling distributions being normal. However, the online methods used coupled with the non-random sampling strategy adopted may have influenced the findings generalisability to the wider adult acne population. The sample may therefore have consisted of those most concerned about acne, most socially withdrawn and those who seek support from others. This may help explain why few males participated in the study, which negated the ability to analyse the findings by gender. Additionally, the generalisability of the appearance-distress hierarchical multiple regression model may have been impacted by non-normally distributed residuals. Although when reviewing the histogram and normality plots the residuals appeared normally distributed, a Shapiro-Wilk test indicated they were not. However, in large samples statistical tests can deem even small deviations from normality to be significant and therefore in this case the Shapiro-Wilk statistic was interpreted with caution. Nevertheless, the normality of residuals for this model is questionable and generalising the appearance-distress findings to the wider population should be done tentatively. As such, it would have been preferable to include a control group to compare the findings of those who have acne and those who do not. Although this study explored the influence of acne medication and specific co-morbid health conditions on the relationships between variables it did not examine the role of other potentially confounding variables. One study identified examined the influence of personality, social and socioeconomic factors in understanding distress in people living with skin disease (Magin, Pond, Smith, Watson, & Goode, 2008). Specifically, it is recommended the replication study employs a random probability stratified sampling strategy to ensure the sample include sufficient numbers for sub-group analyses. To further address bias it is suggested that participants be recruited at their treatment source. Furthermore, it is recommended a demographically-matched control group be included and information about potentially confounding variables be captured to enable more robust interpretation of findings. This would require the development of appropriate methods to assess sexual objectification experiences in people living with acne. Additionally, it is acknowledged that this study did not consider the role of stigma associated with skin disease. Finally, it is recommended that a dermatological quality of life measure be used as an additional criterion variable given their previous use in understanding distress in adult acne. These analyses are required to examine the proposed indirect relationships between both sexual objectification experiences and surveillance and the criterion variables. The analyses would also examine the proposed direct relationships between sexual objectification experiences and surveillance, surveillance and shame/appearance anxiety, and shame/appearance anxiety and the criterion variables. It is proposed that future studies further consider the influence of age and gender and it is recommended that moderational analyses be conducted to determine whether any of the above relationships are moderated by these demographic factors.
As discussed blood pressure lowering herbs buy discount toprol xl 25mg online, such hospitals would disproportionately serve fetuses or neonates with congenital anomalies heart attack band 50mg toprol xl with visa, thus introducing bias in the calculation of their birth prevalence blood pressure 150100 generic toprol xl 100 mg otc. Catchment area for a hospital-based surveillance programme R = fetus or neonate with a congenital anomaly whose mother is a resident; included if the fetus or neonate is identifed at a participating hospital. The magnitude of bias may change over time, with fuctuations in referral patterns and the proportion of births occurring outside the hospital setting. This could lead to changes in rates that have nothing to do with the underlying prevalence, but are the result of referral patterns. Also, the bias will depend on how many hospitals or facilities are included all, half or only a small percentage. Estimates of birth outcomes with congenital anomalies in hospital-based surveillance programmes represent only those births at reporting hospitals in which data are collected. The prevalence estimates could, therefore, be biased, particularly if the hospital births are a minority of all births, if they receive a high proportion of difcult or complicated pregnancies, and/or if they are not representative of the population of interest. However, if nearly all hospitals in a country participate in the surveillance programme and nearly all births occur in hospitals, the surveillance programme may approximate a population-based surveillance programme. Because congenital anomalies are relatively rare events, sentinel surveillance programmes may not be very efective for capturing congenital anomalies. Although population-based and hospital-based surveillance programmes have clear diferences, there are some characteristics that are common to both. Case ascertainment Once the type of population coverage has been decided, the next step is to determine how cases will be ascertained. Case ascertainment Active case ascertainment With active case ascertainment, the surveillance personnel typically are hired and trained to conduct data abstraction (abstractors). Abstractors regularly visit, or have electronic access to, participating institutions. Therefore, visiting all areas of the hospital where a potential fetus or neonate with a congenital anomaly can be identifed could be important. It is noted that for this process to work well, medical records need to contain relevant information in a format that can be identifed and abstracted easily by the abstractors, who usually have limited medical background. Although this type of case ascertainment requires considerable resources and personnel, active case ascertainment tends to improve case detection and case reporting, and improves data quality because more extensive clinical details are collected. To improve case ascertainment, the surveillance programme can link administrative databases. The identifed cases will require verifcation by personnel going to the maternity hospitals and reviewing the medical records. Passive case ascertainment With passive case ascertainment, hospital personnel who identify a fetus or neonate with a congenital anomaly or anomalies report this information directly to the surveillance registry. With passive case ascertainment, the information that is reported to the surveillance registry is typically not verified by direct abstraction of the medical record. This type of case ascertainment is less expensive because fewer resources and personnel are required. However, the burden of reporting falls on hospitals or clinics, which may require time and efort of hospital staf who are already busy. This could result in a less than optimal reporting rate, less complete documentation or less timely reporting, or a combination thereof. It also usually yields less complete detail on each case and underestimates the number of congenital anomalies that occur. In addition, because reported information is not validated, it could also overestimate certain congenital anomalies. Hybrid case ascertainment Hybrid case ascertainment refers to a combination of passive case ascertainment of most types of congenital anomalies, with active case ascertainment of specifc congenital anomalies, or for a percentage of all reported congenital anomalies as a quality control tool. For example, a surveillance programme can conduct active ascertainment of neural tube defects to gather more detailed case information in a more timely manner, but carry out passive ascertainment of all other congenital anomalies under surveillance. Similarly, a programme can use passive reporting with active follow-up verifcation of certain congenital anomalies. Regardless of the method selected for case ascertainment (active or passive), each participating hospital can identify a champion? who is committed to the programme. This could help to ensure more complete participation of the diferent hospital units and services participating in the surveillance programme. Also, the role of this leader could 19 be to train other personnel (such as doctors, nurses and technicians) on how to identify cases, record the information and oversee the information fow, so as to maintain an ongoing and active quality control on the quantity and completeness of information. Case fnding Congenital anomalies surveillance programmes can decide the sources from which cases will be identifed (see Fig.
Home of the Lithium Information Center and the Stanley Center PhD blood pressure medication kidney cancer buy toprol xl 25mg with amex, and Xavier Francisco Amador fetal arrhythmia 32 weeks toprol xl 50mg on line, PhD blood pressure when to go to er buy 50 mg toprol xl. Patty Systematic Treatment Enhancement Program for Bipolar Duke and Gloria Hockman. If you are interested in participating, visit: On the Edge of Darkness: Conversations About Conquering You can download an Adobe Acrobat file of this study and polos and Janice Papolos. Moodstabilizer+ Moodstabilizer+ P-value antidepressant(n=179) placebo (n=187) Durablerecovery* 23. Abstract Objective?The risk-benefit profile of antidepressant medications in bipolar disorder is controversial. When conclusive evidence is lacking, expert consensus can guide treatment decisions. Method?An expert task force iteratively developed consensus through serial consensus-based revisions using the Delphi method. Subsequent surveys included new or reworded items and items that needed to be rerated. Results?There is striking incongruity between the wide use of and the weak evidence base for the efficacy and safety of antidepressant drugs in bipolar disorder. Few well-designed, long-term trials of prophylactic benefits have been conducted, and there is insufficient evidence for treatment benefits with antidepressants combined with mood stabilizers. A major concern is the risk for mood switch to hypomania, mania, and mixed states. Integrating the evidence and the experience of the task force members, a consensus was reached on 12 statements on the use of antidepressants in bipolar disorder. Conclusions?Because of limited data, the task force could not make broad statements endorsing antidepressant use but acknowledged that individual bipolar patients may benefit from antidepressants. Regarding safety, serotonin reuptake inhibitors and bupropion may have lower rates of manic switch than tricyclic and tetracyclic antidepressants and norepinephrine-serotonin reuptake inhibitors. Hence, in bipolar I patients antidepressants should be prescribed only as an adjunct to mood-stabilizing medications. The efficacy and safety of antidepressant drug treatment in bipolar disorder is the subject of long-standing debate based on a scientific literature that is limited and inconsistent (1?6). The sparseness of high-quality clinical research hampers the formulation of sound clinical recommendations on the use of antidepressants in the treatment of bipolar disorder (7?12). We propose that a consensus formed by the experience and judgment of clinical and academic bipolar disorder experts, guided by the available research findings, may help in Address correspondence to Dr. Page 2 developing at least tentative treatment recommendations as additional research is awaited. Vieta to assemble a task force of international experts to review the evidence base for benefits and risks of antidepressant treatment in bipolar disorder and to formulate clinical recommendations based on the consensus development process. These procedures focused on the discussion and integration of findings from peer-reviewed published research findings on the topic, including reviews and meta analyses, as well as clinical trial reports. The aims of the task force were to conduct a thorough and balanced review of research findings and to integrate them into an expert consensus, based on clinical experience and judgment, as well as research evidence, and to provide a synthesis of current knowledge supporting clinical recommendations for this important and timely topic. The final section of this report, which summarizes consensus statements, was achieved through a face-to-face meeting, personal and group e-mail correspondence, and serial iterative revisions of the report, in order to provide a final guide on the use of antidepressants in bipolar disorder. Funding for this international project was provided solely by the Spanish government. We address here only antidepressant medications, not the treatment of bipolar depression in general. Hence, we did not include alternative or experimental agents such as sulfoadenosine-L-methionine; Hypericum perforatum (St. Systematic Review Methods Each report considered was rated for methodological quality according to the Jadad scale (13) as poor (scores of 0?2) or acceptable-good (scores of 3?5; see the data supplement that accompanies the online edition of this article).
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References:
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