Depression

Recently, the National Guideline Clearinghouse compared smoking cessation recommendations from the Public Health Service, the University of Michigan Health System, the Singapore Ministry of Health, the New Zealand Guidelines Group, and the US Preventive Services Task Force. Highlights of guidelines from the US groups are presented here.

In patients with underlying disease, a preoperative evaluation and targeted perioperative management strategies can minimize surgical complications and maximize healing. This article focuses on how to identify surgery patients at risk for complications caused by diabetes, chronic obstructive pulmonary disease (COPD), and other medical conditions; I also describe strategies to minimize such risk.

Traumatic brain injury may occur without visible head injury; it manifests as confusion, focal neurologic abnormalities, an altered level of consciousness, or subtle changes on neuropsychological testing. The initial evaluation includes assessment of the patient's airway and respiratory, circulatory, and neurologic status.

Abstract: The coexistence of asthma and obstructive sleep apnea (OSA) in a given patient presents a number of diagnostic and treatment challenges. Although the relationship between these 2 diseases is complex, it is clear that risk factors such as obesity, rhinosinusitis, and gastroesophageal reflux disease (GERD) can complicate both asthma and OSA. In the evaluation of a patient with poorly controlled asthma, it is important to consider the possibility of OSA. The most obvious clues are daytime sleepiness and snoring, but the definitive diagnosis is made by polysomnography. Management of OSA may include weight loss and continuous positive airway pressure (CPAP). Surgical intervention, such as uvulopalatopharyngoplasty, may be an option for patients who cannot tolerate CPAP. Management may include specific therapies directed at GERD or upper airway disease as well as modification of the patient's asthma regimen. (J Respir Dis. 2005;26(10):423-435)

An 87-year-old woman who recently moved to an assisted living facility from her home is seen for evaluation of facial edema and erythema after a bee or wasp sting sustained 2 days earlier. Patient denies pain, pruritus, or visual changes. She took one dose of diphenhydramine shortly after the event and has noticed that the edema, which affected primarily the right side of the face, near the sting, has improved.

An 87-year-old woman who recently moved to an assisted living facility from her home is seen for evaluation of facial edema and erythema after a bee or wasp sting sustained 2 days earlier. Patient denies pain, pruritus, or visual changes.

A 63-year-old woman who was on long-term hemodialysis because of diabetic end-stage renal disease had a 7-month history of waxing and waning papules and plaques on the front of both legs. The asymptomatic multiple, discrete, slightly erythematous, round to oval lesions ranged from 5 mm to 3 × 4 cm. Several had heaped-up borders and contained central crust and keratotic debris; others were superficial ulcers with central eschars. The lesions improved only slightly following twice-daily application of a superpotent topical corticosteroid preparation.

A 5-month-old boy's head hit the floor after he tumbled from his mother's arms. No injury was noted by the parents, and the infant immediately began to cry. His mother brought him to the emergency department just to be sure he was not seriously injured.

A minimally responsive 26-year-old man was brought to the emergency department after being found in his home by a friend. A suicide note lay next to his body. The patient had a history of depression.

A 30-year-old woman had an extensive psychiatric history of anxiety and depression. She was concerned that the numerous lesions on her body might be signs of possible infection or infestation. The patient was undergoing treatment for multiple addictions to drugs, primarily methamphetamine (“crank”).

A 65-year-old woman with a long history of hypertension treated with metoprolol and felodipine complained of dizziness, headache, nausea, and vomiting of acute onset. Her blood pressure was 220/110 mm Hg. She was drowsy and unable to stand or walk.

During his last routine pediatric visit, a 4-month-old boy with a large head circumference (98th percentile for his age) was referred for radiographic evaluation. The infant had been delivered by cesarean birth because of cephalopelvic disproportion; his head size had gradually increased since birth. There was a family history of this condition.

During a routine ophthalmologic examination, a round depression in the temporal region of the optic disc was found in a 35-year-old woman. Her past ocular history was noncontributory.

An 85-year-old white woman was brought to the emergency department (ED) with acute, severe left posterolateral chest wall pain of several hours' duration. The nonradiating pain was accompanied by shortness of breath. She denied palpitations, diaphoresis, syncope, or dizziness.

A 42-year-old woman sought medical advice for a facial rash of 4 weeks' duration. She denied any drug allergies, changes in her routine, or use of new laundry products.

A 61-year-old man with a history of squamous cell carcinoma was concerned about a tender nodule on his ear. He complained of exquisite tenderness with pressure, such as when lying on the affected side at night.

A 30-year-old woman was brought to the hospital with syncope, bradycardia, and hypotension. For the past 6 years, she had vomited after eating meals and after occasional episodes of binge eating.

Urinary incontinence is common--especially among older adults--but underdiagnosed. Many persons with this disorder are reluctant to discuss it with their physicians; often, only direct questioning can uncover the problem.

Advances in the understanding of multiple sclerosis (MS) have translated into aggressive treatment regimens that enhance patients' quality of life. In this article, we discuss the therapeutic options, especially treatments that are directed toward the underlying immunologic mechanisms of the disease. Because of its direct effect on quality of life, aggressive management of symptoms is emphasized.

Studies have indicated that depression occurs more frequently in adults with asthma than in the general population; however, few studies have investigated the relationship between depression and asthma outcomes. A recent study by Eisner and associates revealed noteworthy findings: depressive symptoms appear to be associated with poorer outcomes, including increased risk of hospitalization for asthma.

An 82-year-old woman complains that for the past 6 months, she has "not felt like herself." Previously, she was very active and energetic; in fact, 9 months earlier, she had vacationed in Hawaii. It now takes all of her energy just to get out of bed.

Confounding Factors in Treatment-Resistant Depression (Part 1): The Role of Subtyping and Bipolarity Michael I. Casher, MD, Daniel Gih, MD, Joshua D. Bess, MD, and Prachi Agarwala, MD

Combination therapy with pegylated interferon alfa-2a or alfa-2b and ribavirin (RBV) results in a greater rate of sustained virologic response (SVR) than that seen with standard interferon alone. Patients infected with hepatitis C virus genotype 1 require higher doses of RBV and a longer duration of therapy than do patients infected with genotype 2 or 3. Closely monitor patients for neuropsychiatric effects, especially depression, and hematologic and other toxicities. Because of the teratogenicity of RBV, strict birth control must be used throughout the course of treatment and for 6 months afterwards. Patients who have not demonstrated a 100-fold reduction in viral load after 12 weeks of therapy are unlikely to achieve SVR; discontinuation of therapy may be considered.

A 69-year-old man seen because of a pruritic pretibial rash of 3 months' duration. Started as reddish brown papules that slowly enlarged and changed.

The parents of a 16-year-old girl report that during the past several months, she has exhibited behavioral changes, irritability, increased anger, depression, and anxiety. The girl had previously been healthy, and there has been no recent illness or trauma.

Abstract: The laryngeal mask airway (LMA) and intubating LMA are valuable alternatives in patients in whom intubation has failed and who need oxygenation and ventilation immediately. The dual-lumen, dual-cuffed airway tube is effective in a variety of settings and can tolerate ventilation at pressures as high as 50 cm H2O; it is contraindicated in awake patients who have intact airway reflexes, caustic ingestions, and upper airway obstruction from a foreign body or pathology. Surgical airways are lifesaving techniques when intubation is unsuccessful or impossible through the mouth or nose. It may be particularly appropriate in patients with laryngeal or facial trauma, upper airway obstruction, or oropharyngeal injury. When patients aged 12 years and older cannot be ventilated by mask or intubated with traditional methods, surgical or needle cricothyrotomy is the procedure of choice. (J Respir Dis. 2005;26(7):298-302)

Multiple sclerosis, the most common cause of disability among young adults, can take years to diagnose because symptoms may wax and wane over time, and patients may not initially seek evaluation.

ABSTRACT: The management of chronic daily headache is difficult and complex. Those affected have a sensitive nervous system, and their predisposition for a low tolerance to sensory stimuli appears to be inherited. Under appropriate conditions, the equilibrium or balance between bombardment from painful stimuli and the regulatory systems that inhibit those stimuli is disrupted, allowing painful stimuli to become manifest at a greater intensity than in the nonmigraineur. Successful management depends on close adherence to nonpharmacologic approaches and pharmacologic regimens that desensitize the system and restore equilibrium. Comorbid conditions must be identified and treated as well.

A 37-year-old man presents with a large, pruritic, hyperpigmented, lichenified plaque on the left side of his upper back. A 7-year-old boy is brought for evaluation of a noninflammatory, nonscarring 3.5-cm area of alopecia in the right occipital region, which has been present for 6 months.

Over the past 5 to 10 years, there has been an increasing incidence of synthetic club drug use that has quietly permeated the adolescent and young adult culture. This review of MDMA, also known as Ecstasy, ketamine, GHB, and methamphetamine, provides a basic introduction to help practitioners get up to speed.