It causes obstruction and Unknown 10mg provera with amex menopause pain, but associated with gallstones and chronic hence dilatation of the proximal ducts generic provera 5mg online breast cancer yoga pants. Histologically 90% of tumours are adeno- carcinomas and 10% are squamous carcinomas purchase provera 10mg with visa breast cancer zipper hoodies. Clinical features The usual presentation is progressive obstructive jaun- Clinical features dice. Other symptoms include vague epigastric or right Patients may have a history of gallstone disease. A mass is often palpable in the right upper empyema presenting with biliary colic and a non-tender quadrant. Direct invasion of local structures, especially the liver, is almost invari- Macroscopy/microscopy ableatpresentation. Spreadviathelymphaticsandblood The carcinoma commonly appears as a sclerotic stricture occurs early. The islets of Langerhans are islands of endocrine cells scattered throughout the pancreas. They are clustered Investigations around a capillary network into which they secrete their r Ultrasound may show dilated intrahepatic ducts and hormones. Management Acute pancreatitis Curative treatment is only attempted if the tumour is localised and the patient is t for radical resection. Denition r Carcinoma of the common bile duct is treated by the Acute inammation of the pancreas with variable in- Whipple s operation (see page 221). Incidence The remaining biliary tree is anastomosed to a Roux Almost 5 25 per 100,000 per year and rising. Palliative treatments include insertion of a stent or anas- Age tomosis of a Roux loop of jejunum to a biliary duct in More common >40 years. The prognosis is better for patients with carcinoma of Aetiology the common bile duct who are suitable for a Whipple s Biliary tract disease (80%), especially cholelithiasis, gall- operation. Alcoholism is the second most common cause (20% in the United Disorders of the pancreas Kingdom). Causes are as follows: r Obstruction: Gallstones, biliary sludge, carcinoma of the pancreas. Introduction to the pancreas r Drugs/toxins: Alcohol, azathioprine, steroids, diuret- The pancreas has two important functions: the produc- ics. Translocation of gut pancreatitis bacteria can result in local infection and septicaemia. Within 48 hours of admission Shock may result from the release of bradykinin and Age >55 years prostaglandins, or secondary to sepsis. Haemorrhage may cause Grey Turner s sign, which is bruising around the left loin and/or Cullen s sign, bruising around the umbilicus. The pancreas appears oedematous with grey-white Other investigations are required to assess the sever- necrotic patches. Bacterial infection leads to inamma- ity and to monitor for complications: full blood count, tion and pus formation. Healing results in brosis with clotting screen, urea and electrolytes, liver function tests, calcication. Complications In the most severe cases there is systemic organ failure: Management r Cardiovascularsystem:Shock(hypotension,tachycar- The early management depends on the severity of the dia, arrhythmias). Patients require careful uid balance zymes walled off by compressed tissue), pancreatic using central venous pressure monitoring and uri- abscesses (which may contain gas indicating infection nary catheterisation to allow accurate urine output withgas-formingbacteria)andduodenalobstruction. Prophylactic Investigations broad-spectrumantibioticsaregiventoreducetherisk When supportive clinical features are present the diag- of infective complications. Ascites and persistent obstructive jaundice with conservative management require laparoscopic may occur. Prognosis Investigations Pancreatitis is a serious condition: overall mortality is Serum amylase uctuates, but may be moderately raised 10%. Endoscopic retrograde cholangiopancreatography mayshowscarringoftheductalsystemandevenstonesin the pancreatic duct. Magnetic resonance cholangiopan- Chronic pancreatitis creatography is increasingly being used. Denition Chronic pancreatitis is an inammatory condition that Management results in irreversible morphological change and impair- Precipitating factors especially alcohol need to be re- ment of exocrine and endocrine function. Adequate analgesia is required, thoracoscopic splanchnicectomymayberequiredinrefractorypainnot Age associated with main pancreatic duct dilatation. Surgical M > F techniques include sphincteromy or sphincteroplasty, partial pancreatectomy or opening the pancreatic duct Aetiology/pathophysiology along its length and anastomosing it with the duodenum Two patterns of chronic pancreatitis are seen, a chronic or jejunum. Total pancreatectomy can be carried out, relapsing course with recurring acute pancreatitis and with replacement oral pancreatic enzymes and insulin. Risk factors includealcoholabuse,hereditarypancreatitis,ductalob- Tumours of the pancreas struction (e. Hy- percalcaemia, hyperlipidaemia and congenital pancre- Denition atic malformations are recognised associations. Clinical features Incidence Patients may present with an acute episode of pancre- 10 per 100,000 per annum and rising. Late com- plications include impaired glucose tolerance, diabetes Age mellitus and malabsorption (steatorrhoea) associated Mainly >60 years. Aetiology There appears to be some familial clustering and hence Investigations it is suggested that genetic susceptibility may play an There are no useful tumour markers or pancreatic func- important role. Specic inherited risks include famil- tion tests for diagnosis, which must be histological. Mosttumoursdevelop intheheadofthepancreasandthesetendtopresentearly ducts and may also be used for intervention. Clinical features Pancreatic cancer is associated with several clinical syn- Management dromes: Surgical resection offers the only chance of cure, but only r One third of patients present with painless obstructive about 10 15% of patients are suitable for radical surgery jaundice, i. Chronic epigastric pain radiating to the back similar to chronic pancre- denectomy with block resection of the head of pan- atitis develops in most patients at some stage. There is signicant orrhoea is common and failure to absorb the fat- perioperative morbidity and mortality. Stents of the bile duct and/or duodenum tend to become blocked and Macroscopy/microscopy have to be replaced.

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Mental health issues ranging from mild distress to severe and Take seriously a colleague who shows signs of disabling psychiatric syndromes are among the leading causes depression buy provera 2.5 mg online menopause depression. For example discount provera 5mg visa breast cancer 000 negative ductal, the point Suicide is a real problem buy cheap provera 2.5 mg on line menstrual 10 days late, and doctors who have prevalence of major depressive disorder in the general popula- suicidal ideation need care urgently. Studies suggest that rates Education and behavioural adjustments are of mood and anxiety disorders are slightly lower among work- necessary to improve the ability to cope with the ing physicians, but research also shows that serious emotional stresses of a medical career and to enhance distress is not rare in the physician population. Serious, recurrent mental health problems can the challenging decisions they must make every day, long change one s professional life and affect work performance and irregular work hours, and constantly witnessing sickness and patient safety. By extension, physicians who do reach out for nizes a mental health assessment by a psychologist. However, resident discloses a longstanding history of anxiety that corridor consultations and collegial interventions, even with has typically been ignored or minimized. The resident the best intentions, can result in inaccurate diagnoses and sub- realizes that they are vulnerable to panic and anxiety when optimal treatment. It is essential that appropriate boundaries sleep-deprived, not eating well, socially isolated or under between the physician provider and the physician patient be signifcant academic pressure. Slowly, the symptoms wane and the Approximately 70 to 90 per cent of suicides are associated with resident enjoys much better health, self-awareness and mental illness. It is important not to downgrade the clini- depressed and burnt out residents: prospective cohort study. Arlington: Improving personal resiliency can help physicians cope with American Psychiatric Publishing. Suicide rates among regularly and taking time for friends and family are essential. Early detection, education and treatment of mental health dis- orders are crucial in this safety sensitive profession. Appropriate follow-up and monitoring of these conditions, particularly those that recur, is essential for physicians with mental illness not only as individuals but also as professionals who wish to safely and competently practise their chosen vocation. Physicians probably experience substance use disorders at much the same rate as the general population. Although they don t have risks associated with low socio-economic status, there are Case other risks especially associated with being a physician. It has A resident is completing a fellowship and is in their fnal been postulated that many physicians have personality traits year. The resident has struggled academically during the that contribute both to their professional success and to their fellowship because of marital problems, fnancial diffcul- personal vulnerability. Over the past year, the cated in the extreme to the well-being of their patients, even at resident has noticed that they have taken to drinking daily the expense of their own basic health needs. In the past two months, this alcohol use has perfectionistic and obsessive personality traits. They are often increased and the resident has begun to keep a fask in rigidly self-controlled. One of the resident s close colleagues coping strategies, some fnd ease and comfort in the use of begins to suspect alcohol abuse when she notices the resi- drugs or alcohol. Access to drugs and the pharmacological optimism that comes with expert experience in prescribing for patients opens the Introduction door to drug self-administration. Anesthesiologists who inject Medical students, residents and physicians are as human as themselves with potent opioids such as fentanyl, which are their patients. They experience substance use disorders just particularly prone to cause dependency, are a special case that as others do. An important Physicians who are experiencing substance abuse problems sel- facet of addressing the issue is learning how to recognize dom receive assistance early in the course of their illness. They substance use problems in medical colleagues, intervening deny the magnitude of the problem, just as others in their on their behalf, and directing them to the excellent treatment discomfort and uncertainty about how to help deny what resources that do exist. They fear that reaching out for help might follow-up and monitoring is more constructive than a punitive, result in a report to their training program or to regulatory or disciplinary approach. They are needlessly trapped in their fear and Substance use disorders in physicians shame. Meanwhile, the bystanders who do nothing become Neither epidemic nor inconsequential, the prevalence of seri- part of the problem. This means that, over Recognition the course of a lifetime in practice, nearly one doctor in 10 will There is rarely a single observation that will clearly identify a experience a problem with drug or alcohol abuse or depen- substance-abusing colleague, at least not early in the progres- dence that will have a signifcant and potentially serious impact sion of their illness. Physicians are skilled at presenting an upon their lives and the lives of others around them. Alcohol appearance of calm and self-control even when they are suffer- is the most common drug of choice for doctors, followed by ing. Sensitive to the shame and stigma that are often attached opioids and other substances. But some mary disorder that, without treatment, can be progressive and clues can be readily apparent to a caring colleague, especially even fatal. It is if they are familiar with the doctor s baseline behaviour and characterized by a pattern of maladaptive use of substance(s) personality (see textbox). The desire to return to training or physicians work can in itself motivate a physician to seek the necessary mood swings and/or irritability, treatment. Successfully treated alcohol on the breath at work, physicians not only remain abstinent, but learn about living in nodding off at work, a more balanced way. It falls to each physician to protect the well-being of their col- leagues, to be watchful for signs of drug and alcohol problems, Intervention and to be prepared to respond. Waiting until a physician with a substance use problem asks for help, if that time ever comes, can have tragic results. We must pay attention to signs of distress in our colleagues, respecting Case resolution our own visceral empathy and formulating an intervention plan The resident s colleague alerts the chief resident and as soon as possible. At the least, one or two friendly colleagues program director of her concerns discreetly. They can mediately meet with the resident and request that they make time to talk, offer helpful suggestions and resources, and proceed to the emergency room for an assessment. They can do this without needing to know resident complies, and it becomes clear that the resident with certainty just what the problem might be. The physician health program is notifed, and arrangements are made for an urgent assessment. The If this intervention is rejected or proves to be unhelpful, the resident is placed on medical leave.

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Only 50% of those affected eventually recover after terminating exposure to plicatic acid provera 10mg mastercard women's health issues election 2012. Other examples of occupational asthma occur among snow crab processing workers and individuals who use solder 10 mg provera fast delivery women's health center of edmonton. In the latter case cheap provera 2.5 mg mastercard womens health jackson ms, colophony, a component of flux, is the asthmagenic material (275). Asthma exacerbated by direct irritation of the bronchi is common in clinical practice. Odors from perfumes and colognes, vapors from petroleum products and organic solvents, and fumes from tobacco and cooking oils cause coughing and wheezing in many patients. Metabisulfites, sulfiting agents used as preservatives agents used as preservatives and clearing agents, may act as a nonspecific irritant ( 276). The fumes are created when polyvinyl chloride is cut with a hot wire in the process of wrapping cuts of meat. Multiple epidemiologic studies have demonstrated a correlation between levels of common outdoor air pollutants and hospital admissions or emergency room visits ( 277,278). However, these epidemiologic studies are limited by confounding factors, including air temperature and levels of other outdoor aeroallergens. For this reason, experiments also have been performed under controlled conditions involving short exposures to individual pollutants. Ozone is generated by the action of ultraviolet light on precursor pollutants from such sources as automobiles and power plants. A few studies have suggested that ozone increases allergen responsiveness associated with both asthma and allergic rhinitis. Nitrogen oxides from car emissions also may play a role, although the evidence in controlled exposures is less convincing than for ozone ( 281). One study attempted to sensitize atopic individuals to keyhole limpet hemocyanin, a protein isolated from a marine mollusk, with no known cross-reactive antibodies in humans. Sulfur dioxide is a product of soft coal burned for industrial use and is the substance most closely correlated with respiratory and conjunctival symptoms. Incompletely oxidized hydrocarbons from factories and vehicular exhaust make up the particulate matter visible in any highly populated or industrial area. Carbon monoxide impairs oxygen transport, but its concentration in ambient polluted air is probably important only for patients with marginal respiratory reserve. Most formaldehyde symptoms occur in mobile homes, where large amounts of particle board have been used in a relatively small enclosed space. Concentrations of 1 to 3 ppm or higher may cause mucous membrane symptoms in some individuals; atopic persons may react at lower concentrations. Experimentally, formaldehyde can be rendered immunogenic by the formation of formaldehyde protein complexes. However, it has not been proven that these complexes cause IgE- or IgG-mediated disease, nor has it been proven that inhalation of formaldehyde leads to the formation of formaldehyde protein complexes (284). The term sick building syndrome refers to outbreaks of acute illness among workers in a particular building or area of building. Most buildings in which this has been reported have been energy efficient, with little direct outside air exchange. The symptoms most commonly involve the conjunctivae and respiratory tract, with additional nonspecific complaints such as headache, fatigue, and inability to concentrate. Except for unusual instances of contamination with microorganisms (such as Legionella) or of hypersensitivity pneumonitis, the outbreaks have not resulted in serious morbidity or permanent disability. The cause in more than half of the instances studied has been inadequate ventilation, and symptoms abated when corrective measures were taken. A study in Montreal revealed that workers with Alternaria exposure and sensitivity were more likely to have respiratory symptoms. Exposure was correlated with less efficient filtration systems and could represent a significant avoidable exposure for some individuals ( 285). Specific contamination from inside the building has been observed in 17% of sick buildings. Contaminants have included methyl alcohol, butyl methacrylate, ammonia, and acetic acid from various office machines; chlordane (an insecticide); diethyl ethanolamine from boilers; rug shampoos; tobacco smoke; and combustion gases from cafeterias and laboratories. Alkanes, terpenes, benzenes, and chlorinated hydrocarbons also have been identified in investigations of indoor air. In some instances, indoor contamination may occur from outside of the building: for example, the intake of automobile exhaust from an adjacent parking garage. Formaldehyde is released as a gas ( off-gassing ) from a variety of sources such as foam insulation, new furniture, and carbonless carbon paper. The role of tobacco alone in the sick building syndrome is not clear when adequate ventilation is present, however. Finally, the role of psychogenic suggestion in the sick building syndrome should be considered. Such instances have been reported, based on a variety of inconsistencies in the affected population and the lack of objective findings in both the patients and the building. Immunochemical quantitation of airborne short ragweed, Alternaria, antigen E, and Alt-I allergens: a two-year prospective study. Concentrations of major grass group 5 allergens in pollen grains and atmospheric particles: implications for hay fever and allergic asthma sufferers sensitized to grass pollen allergens. Effect of thunderstorms and airborne grass pollen on the incidence of acute asthma in England, 1990 94 [see comments]. Protease-dependent activation of epithelial cells by fungal allergens leads to morphologic changes and cytokine production. Airborne concentrations and particle size distribution of allergen derived from domestic cats ( Felis domesticus). Measurements using cascade impactor, liquid impinger, and a two-site monoclonal antibody assay for Fel d I. Airborne ragweed allergens: association with various particle sizes and short ragweed plant parts. Airborne allergens associated with asthma: particle sizes carrying dust mite and rat allergens measured with a cascade impactor.

Ackerknecht cheap provera 2.5 mg with mastercard menopause questions and answers, "Primitive Medicine and Culture Patterns provera 10 mg discount women's health clinic hamilton," Bulletin of the History of Medicine 12 (November 1942): 545-74 generic provera 5mg otc menstruation black blood. Sigerist states: "Culture, whether or not primitive, always has a certain configuration. It is one expression of it, and cannot be fully understood if it is studied separately. Evans-Pritchard, Witchcraft, Oracles and Magic Among the Azande (New York: Oxford Univ. I argue here that health and my ability to remain responsible for my behavior in suffering are correlated. Dunn, "Traditional Asian Medicine and Cosmopolitan Medicine as Adaptative Systems," mimeographed, Univ. He claims that 95% of the ethnographic (and also anthropological) literature on health-enhancing behavior and on the beliefs underlying it deals with curing and not with the maintenance and expansion of health. For literature on medical culture seen with the blinkers of the behavioral technician: Marion Pearsall, Medical Behavioral Science: A Selected Bibliography of Cultural Anthropology, Social Psychology and Sociology in Medicine (Lexington: Univ. Elfriede Grabner, Volksmedizin: Probleme und Forschungsgeschichte (Darmstadt: Wissenschaftliche Buchgesellschaft, 1974), provides an anthologv of critical studies on the history of ethnomedicine. Muhlmann, "Das Problem der Umwelt beim Menschen," Zeitschrift fr Morphologia und Anthropologia 44 (1952): 153-81. Arnold Gehlen, Die Stele im technischen Zeitalter, Sozialpsychologische Probleme in der industriellen Gesellschaft (Hamburg: Rowohlt, 1957). Ackerknecht, "Natural Diseases and Rational Treatment in Primitive Medicine," Bulletin of the History of Medicine 19 (May 1946): 467-97, is a dated but still excellent review of the literature on the functions of medical cultures. Ackerknecht provides convergent evidence that medicine plays a social role and has a holistic and Unitarian character in primitive cultures that modern medicine cannot provide. Fred Binder, Die Brotnahrung: Auswahl-Bib-liographie zu ihrer Geschichte und Bedeutung, Donau Schriftreihe no. Lucia, Wine and the Digestive System: A Select and Annotated Bibliography (San Francisco: Fortune House, 1970). Michler, "Das Problem der westgriechischen Heilkunde," Sudhoffs A rchiv 46 (1962): 141 ff. Heyer- Grote, Atemschulung als Element der Psychotherapie (Darmstadt: Wissen- schaftliche Buchgesellschaft, 1970). Kilton Steward, "Dream Theory in Malaya," Complex: The Magazine of Psychoanalysis and Related Matters 6 (1951): 21-33. Writing towards the end of the 15th century Ibn Khaldun observed the conflict between the craft of medicine required by sedentary culture and its luxury and Bedouin medicine, which was based mainly upon tradition and individual experience. Carlyle suggests that both ideas first took recognizable form in the toast of the victorious Alexander to the homo-ousia (like-naturedness) of men. Combined with the idea of progress, the Utopia of healthy mankind came to prevail over the ideal of concrete and specific patterns of functioning characteristic for each tribe or polis. Sidney Pollard, The Idea of Progress: History and Society (New York: Basic Books, 1968), deals with the ideology of human progress in relation to concrete history and the politico-economic aspects complementing philosophy. Ashburn, The Ranks of Death: A Medical History of the Conquest of America (New York: Coward-McCann, 1947). No comprehensive study of the imperialism of European medical ideology in Latin America is available. For a first orientation, see Gonzalo Aguirre Beltran, Medicina y magia: El proceso de aculturacin en la estructura colonial (Mexico: Institute Nacional Indigenista, 1963). Wilhelm Scherer, Der Ausdruck des Schmerzes and der Freude in der mittelhochdeutschen Dichtung der Bltezeit (Strassburg, 1908). Ernst Hannes Brauer, Studien zur Darstellung des Schmerzes in der antiken bildenden Kunst Griechenlands and Italiens, inaugural dissertation, Univ. People differ in the intensity with which they modulate experience; some reduce and others increase what is perceived, including pain. Jarvik, "Relationship Between Superficial and Deep Somatic Threshold of Pain, with a Note on Handedness," American Journal of Psychology 77 (1964): 589-99. Contains much information on the impact of culture on the level of fear and the relationship between fear and the pain experience. Beecher, Measurement of Subjective Responses: Quantitative Effects of Drugs (New York: Oxford Univ. Opiates exert their principal action, not on the pain impulse, which is transmitted through the nervous system, but on the psychological overlay of pain. Severe postsurgical pain can be relieved in about 35% of patients by giving them a sugar or saline tablet instead of an analgesic. Since only 75% are relieved under such circumstances with large doses of morphine, the placebo effect might account for 50% of drug effectiveness. Scott, "The Effect of Early Experience on the Response to Pain," Journal of Comparative and Physiological Psychology 50 (April 1957): 155-61. On the importance and practical utility of religion and superstition in early modern England in the relief of suffering. Jahrhundert in ihren Vorraussetzungen und Folgen," Medizinhistorisches Journal 6 (1971): 707-61. Ferdinand Sauerbruch and Hans Wenke, Wesen und Bedeutung des Schmerzes (Berlin: Junker & Dnnhaupt, 1936). An invaluable guide to the history of physiology since the 16th century, which comes as close as possible to a history of the medical perception of pain. Rothschuh, Vm Boerhaave bis Berger: Die Entwicklung der kontinentalen Psychologie im 18. Jahrhundert mil besonderer Beruecksichtigung der Neurophysiologie (Stuttgart: Fischer, 1964). Frenzen, Klagebilder und Klagegebrden in der deutschen Dichtung des hfischen Mittelalters, dissertation, Univ. Hartman, The Structure of Value: Foundation of Scientific Axiology (Carbondale: Southern Illinois Univ. The pain about which a history ought to be written is the personalized experience of intrinsic pain: the inclusion in the experience of pain of the social situation in which pain occurs.

J. Peer. Tuskegee University.