Augustus O. Grant MD, PhD

• Professor of Medicine, Cardiovascular Division, Duke University Medical Center, Durham

https://medicine.duke.edu/faculty/augustus-oliver-grant-mbbch-phd

Physicians should complete this card and instruct the patient to keep it in their possession at all times medicine urinary tract infection order 25/200 mg aggrenox caps with visa. The patients should refer to this card anytime they visit additional healthcare practitioners sewage treatment buy 25/200mg aggrenox caps free shipping, particularly for an additional diagnostic procedure medicine man movie buy genuine aggrenox caps on line. This temporary identification card should only be discarded when the permanent identification card is received treatment dynamics cheap aggrenox caps master card. Upon receipt of the completed Device Tracking Form medications definition purchase aggrenox caps 25/200mg on-line, Medtronic will mail the patient a Permanent Device Identification Card treatment variance discount aggrenox caps on line. If a patient does not receive their permanent device identification card, or requires changes to the card, call 1 800 551 5544. This booklet provides patients with basic information on lesions of the descending aorta and endovascular repair therapy. The exclusions and limitations set out above are not intended to , and should not be construed so as to , contravene mandatory provisions of applicable law. If any part or term of this disclaimer of warranty is held to be illegal, unenforceable, or in conflict with applicable law by a court of competent jurisdiction, the validity of the remaining portions of this disclaimer of warranty shall not be affected, and all rights and obligations shall be construed and enforced as if this disclaimer of warranty did not contain the particular part or term held to be invalid. Follow Up 27 Implanted Device Identification Card 27 Magnetic Resonance Imaging 27 Lifestyle Changes 28 Questions You May Want to Discuss with Your Doctor 28 Additional Information 29 *See pages 19 22 for important safety information. Your doctor has given you this booklet to help you further understand the endovascular repair device and procedure. Only a doctor can determine if a patient is a good candidate for endovascular repair. A glossary is provided in the next section to help you understand the medical terms used in this booklet. Aneurysm rupture: A tear in the blood vessel wall near or in the diseased part of the vessel. Congestive heartfailure: A condition in which the heart can no longer pump enough blood to other organs of the body. Endovascular repair: A procedure in which a tube shaped stent graft is placed inside the aorta, allowing blood to flow normally and excluding the injured or diseased portion of the aorta, without cutting open the chest or abdomen. Fluoroscopy: A real time X ray image that allow doctors to see inside the patient. Fusiform aneurysm: A type of thoracic aortic aneurysm that has a varying diameter and length and typically involves all sides of the diseased vessel. Isolated Lesions: Isolated lesions include but are not limited to blunt thoracic aortic injuries, intramural hematomas and pseudoaneurysms. Lesions: Lesions include but are not limited to isolated lesions, aneurysms, dissections and penetrating aortic ulcers. Malperfusion: A complication of aortic dissection where the vessel supplying blood to the organs in the body narrows down or is completely blocked. Open surgery/Open surgical repair: A procedure in which a doctor makes a large cut in the chest or abdomen to remove an aneurysm, dissection or injured section of aorta and then replaces it with a fabric graft. Penetrating ulcer: A weak area of the thoracic aorta that causes one side of the diseased vessel to bulge or expand but, unlike a saccular aneurysm, does not go completely through the first layer of the aorta. Pseudoaneurysm: Bulge in the aorta, formed usually at areas in the aorta that have been damaged by previous surgery or trauma. Pseudoaneurysms can enlarge over time and could lead to rupture if left untreated. Renal failure: A condition where the kidneys fail to adequately filter toxins and waste. Retrograde Type A Dissection: A rare complication after endovascular stent graft placement. It is defined as a dissection that advances in the reverse direction of blood flow towards the heart. Rupture: A tear in the blood vessel wall near or in the diseased part of the vessel. Saccular aneurysm: A type of thoracic aortic aneurysm that is spherical in shape and typically involves only one side of the diseased vessel. Spinal cord ischemia: A lack of blood flow to the vessels that carry blood to the spinal cord. Stent graft/Thoracic stent graft: A fabric tube supported by a metal frame that a doctor puts inside the injured or diseased portion of the aorta. Stroke: A loss of brain function due to the loss of blood supply to a part of the brain. Thoracic Aorta: the portion of the aorta that is within the chest and close to the heart. Thoracic Aortic Dissection: A condition in which a tear in the inner layer of the aorta allows blood to flow into the middle layer of the aortic wall, causing the layers to separate (dissect). Transfusion: Receiving blood into circulation from an external source, needed as a result of loss of blood. Ultrasound: An imaging technique that creates a picture through the use of high frequency sound waves. An aneurysm rupture needs immediate medical attention because it can lead to death. A fusiform aneurysm has a varying diameter and length and typically involves all sides of the diseased vessel. A saccular aneurysm is spherical in shape and typically involves only one side of the diseased vessel. You should talk to your doctor about what type of aneurysm you have and what that means for you. Blood flows through this tear into the middle layer of the wall of the aorta causing the inner and middle layers to separate (dissect). If the tear goes through the vessel wall (rupture), dissection can be life threatening due to the potential for bleeding inside the body. Even without a rupture, dissection may cause malperfusion of the organs of the body, resulting in organ failure. This injury can result in a complete tear in the wall of the aorta or a partial tear that weakens part of the aorta (Figure 4). Care of the patient will require immediate medical management and prompt diagnosis before a repair option is pursued by the doctor. If this course of treatment is chosen, a doctor will cut open your chest or abdomen (Figure 5), cut out the injured or diseased portion of the aorta and replace it with a fabric graft that is sutured into place. This treatment aims to replace the injured or diseased aorta and prevent a rupture. Figure 5 is an illustration of an open surgical procedure for thoracic aortic aneurysm repair. After this, you will likely spend several days in the intensive care unit and then several more days in the hospital. Depending on the other injuries you have, you may have to stay in the intensive care unit or hospital longer due to treatment of injuries to other parts of your body. The long term results of endovascular repair with a thoracic stent graft have not been established. A catheter holding a fabric and metal stent graft is inserted into the cut, guided to the diseased or injured location in your aorta and then released into the aorta. Figure 6 is an illustration of an endovascular repair procedure for thoracic aortic aneurysm. This procedure protects the diseased/injured area of the aorta and reduces the chance of rupture. In some patients, the iliac artery and femoral artery are too narrow for this catheter. In these cases, your doctor will sew a fabric tube to your iliac artery and then put the catheter into the vessel. This procedure can take from 1 to 6 hours, depending on the nature of the disease or injury. After this, you will likely spend some time in the intensive care unit and several more days in the hospital. Depending on your other injuries, you may have to stay in the intensive care unit or hospital longer due to treatment of injuries to other parts of your body. Your doctor will discuss the procedure with you and tell you what to expect based on your condition. It will help repair or protect your diseased/ injured aorta, restore appropriate blood flow and prevent rupture. If you have the appropriate anatomy, an endovascular repair procedure may be an option to treat your thoracic aortic aneurysm, dissection, blunt injury or other lesion. When Endovascular Repair Is Not An Option If you have a condition that can infect the stent graft or you are allergic to the stent graft materials, you should not have an endovascular repair because the graft could get infected or you could have an allergic reaction, both of which could be life threatening. In addition, Medtronic conducted smaller clinical studies with patients with blunt traumatic aortic injury and patients with thoracic aortic dissection. The health and medical history of the patients in the studies may or may not be similar to yours. You should talk to your doctor about how your situation may be different or similar. Many problems experienced after endovascular repair of a diseased or injured aorta do not have symptoms associated with them. Before deciding if the procedure is right for you, please review the possible complications with your doctor. Most complications associated with repair of lesions in the descending thoracic aorta occur within the first 30 days after treatment. If this happens, your doctor may recommend a second endovascular repair procedure to fix this. In the two Medtronic clinical studies of thoracic aortic aneurysm repair, about 5 to 10% of patients had a second endovascular repair procedure to treat this problem. If left untreated, aortic lesions can expand and rupture, resulting in bleeding inside the body, which is life threatening. Options for treatment of serious lesions of the aorta include endovascular repair or open surgical repair. The results in the table below suggest an improvement in specific outcomes with endovascular repair versus open surgery. Endovascular repair requires regular follow up visits and sometimes requires additional procedures to treat possible complications such as endoleak. These studies were smaller so there is not as much data available regarding the outcomes. During the procedure: Typically, the endovascular procedure takes 1 to 6 hours to complete. A catheter holding your thoracic stent graft is inserted into the cut and advanced through your femoral artery to reach the lesion in your aorta. Once the catheter is placed, the stent graft is released into your aorta (Figures 8 10). When your stent graft is released, it expands to its proper size to fit in your aorta, both above and below the diseased or injured area (Figures 11 13) Note: Additional stent grafts may be required to treat the diseased/injured aorta. The catheter is removed and the doctor will test to make sure your stent graft is working properly. After the procedure: After the endovascular repair, you will go to a recovery room where you will have to lay flat for up to six hours. You will likely need to stay in the hospital for several days depending on your condition. Again, the long term effects of thoracic stent grafts are not known and since most problems with endovascular repair also do not have symptoms, you will need to let your doctor check on your progress regularly. This card will tell you the size and number of your thoracic stent graft implants. Please consult your doctor to reschedule any follow up visits if you are traveling. If there is anything that we as a company can do to assist you, please feel free to contact us at: Medtronic, Inc. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. A 48 year old woman who reports mild fatigue but no dyspnea, chest pain, or palpita tion is found to have a diastolic cardiac murmur. Cardiac examination reveals decreased S1 and increased S2 intensity, with a grade 1/6 systolic murmur and a grade 3/6 diastolic murmur along the left sternal border. Doppler color flow echocardiography shows a bicuspid aortic valve with an eccentric jet of aortic regurgitation. The left ventricle is moderately en larged, with an end diastolic diameter of 66 mm (or 39 mm per square meter of body surface area) and an end systolic diameter of 46 mm (or 27 mm per square meter); the ejection fraction is 51 percent, and the ascending aorta is enlarged, at 48 mm. In Western coun es and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minn. Ad tries, rheumatic disease is now rare, and severe aortic regurgitation is most frequently dress reprint requests to Dr. Enriquez due to diseases that are congenital (in the bicuspid valve) or degenerative (such as an Sarano at the Mayo Clinic, 200 First St.

Attacks treatment 12mm kidney stone 25/200mg aggrenox caps, in a menstruating woman symptoms 7 dpo bfp aggrenox caps 25/200 mg visa, fullling cri Diagnostic criteria: teria for 1 medicine world nashua nh purchase aggrenox caps 25/200mg otc. Documented and prospectively recorded evidence over at least three consecutive cycles has conrmed that attacks occur exclusively on day 1 2 symptoms you have diabetes cost of aggrenox caps. The rst day of menstruation is day 1 and the pre the importance of distinguishing between A1 medicine 7 years nigeria cheap 25/200mg aggrenox caps visa. Documented prospectively recorded evidence treatment strep throat order aggrenox caps from india, kept for a minimum of three cycles, is necessary to Diagnostic criteria: conrm the diagnosis because many women over report an association between attacks and 1 A. For example, the endogenous Notes: menstrual cycle results from complex hormonal changes in the hypothalamic pituitary ovarian axis 1. Therefore research from either the normal menstrual cycle or from should separate these subpopulations. Management the withdrawal of exogenous progestogens, as in strategies may also dier for these distinct the use of combined oral contraceptives or cyclical subpopulations. The rst day of menstruation is day 1 and the pre attacks, at least in some women, result from oestrogen ceding day is day A1; there is no day 0. At least three of the following six characteristics: When pure menstrual migraine or menstrually related 1. At least two attacks fullling criteria B and C days per month which are not attributed to drug B. Not interrupted by pain free periods of >3 hours on Infantile attacks of hemiplegia involving each side alter ! Recurrent attacks of hemiplegia alternating between the two sides of the body and fullling criteria B Diagnostic criteria: and C B. At least one other paroxysmal phenomenon is asso aura or one of its subtypes ciated with the bouts of hemiplegia or occurs inde B. Evidence of mental and/or neurological decit(s) bral vasoconstriction syndrome, posterior reversible E. Recurrent episodes of irritability, fussing or crying Migraine associated vertigo/dizziness; migraine related from birth to 4 months of age, fullling criterion B vestibulopathy; migrainous vertigo. Vestibular symptoms of moderate or severe inten 3 4 Comments: sity, lasting between 5 minutes and 72 hours Infantile colic aects one baby in ve, but failure to D. At least 50% of episodes are associated with at least 5 thrive needs to be excluded. History and physical examinations do not suggest Vestibular migraine, include: another vestibular disorder or such a disorder has a) spontaneous vertigo: been considered but ruled out by appropriate inves (i) internal vertigo (a false sensation of self tigations or such a disorder is present as a comorbid motion); or independent condition, but episodes can be (ii) external vertigo (a false sensation that the clearly dierentiated. Migraine attacks may be visual surround is spinning or owing); induced by vestibular stimulation. Therefore, the b) positional vertigo, occurring after a change of dierential diagnosis should include other vestibu head position; lar disorders complicated by superimposed c) visually induced vertigo, triggered by a com migraine attacks. Vestibular symptoms are rated moderate when they as they also occur with various other vestibular disor interfere with but do not prevent daily activities ders, they are not included as diagnostic criteria. About brainstem aura 30% of patients have episodes lasting minutes, Both migraine aura and migraine with brainstem aura 30% have attacks for hours and another 30% (formerly: basilar type migraine) are terms dened by have attacks over several days. In these patients, episode duration is dened before headache starts, as required for 1. At the other end of the spectrum, there Vestibular migraine cannot be regarded as migraine are patients who may take 4 weeks to recover auras. However, the core episode Although vertigo is reported by more than 60% of rarely exceeds 72 hours. It is a transient and bilateral phenomenon that Migraine with brainstem aura are not synonymous, must be dierentiated from recruitment, which is although individual patients may meet the diagnostic often unilateral and persistent. Vestibular migraine: Diagnostic eral throbbing headache may occur during attacks but is criteria. Dizziness and migraine: A causal rela Fluctuating hearing loss, tinnitus and aural pressure may tionship In the rst year the following alternative criteria may be applied to after onset of symptoms, dierentiation between them A2. Headache has at least three of the following four (on behalf of the Committee for the Classification of Vestibular Disorders of the Barany Society). Classification of characteristics: vestibular symptoms: Towards an international classification 1. No nausea, vomiting, photophobia or phonophobia with motion from onset to termination taking just a few E. A trigeminal autonomic cephalalgia like disorder Backward moving pain starts in a frontal or periorbital occurring in children and adolescents with characteris area and tends to reach the occipital region. Will epicrania out the expected responses to indomethacin, oxygen or fugax go in the opposite direction Atypical migraine Longitudinal studies are required to understand progressing from nummular headache to epicrania fugax. Epicrania Brief paroxysmal head pain, with stabbing quality, Fugax with backward radiation. Headache attributed to trauma or hemicranium in a linear or zig zag trajectory, com injury to the head and/or neck mencing and terminating in the territories of dier A5. Comment: the current stipulation that headache must begin (or be reported to have begun) within 7 days of head injury Comments: (or awareness of the injury) is somewhat arbitrary. A structural lesion must be excluded by history, physi Some data suggest that headache may begin after a cal examination and, when appropriate, investigation. Future studies should continue to International Headache Society 2013 798 Cephalalgia 33(9) investigate the utility of diagnostic criteria for A5. Time of onset of headache is uncertain, and/or ciated with at least one of the following: headache is reported to have developed >7 days 1. Future studies should continue to inves tigate the utility of diagnostic criteria for A5. Any headache fullling criteria C and D moderate or severe traumatic injury to the head B. Traumatic injury to the head has occurred, fullling both of the following: Diagnostic criteria: 1. Traumatic injury to the head has occurred, asso c) post traumatic amnesia lasting >24 hours ciated with at least one of the following: d) altered level of awareness for >24 hours 1. Headache persists for >3 months after the head as intracranial haemorrhage and/or brain injury contusion. Any new headache fullling criterion C ability to sense or report headache following B. Any headache fullling criteria C and D radiosurgery, most studies do not provide detailed B. Traumatic injury to the head has occurred, fullling descriptions of its clinical characteristics, neither is both of the following: it usually clear whether headache occurring after 1. Carefully controlled injury, with one or more of the following symp prospective studies are necessary to determine toms and/or signs: whether A5. Time of onset of headache is uncertain, and/or Diagnostic criteria: headache is reported to have developed >7 days after all of the following: A. Headache has persisted for >3 months after eec or injury tive treatment or spontaneous remission of the vas D. Trauma or injury to the head and/or neck of a type intracranial disorder not described above has occurred A7. Comment: Clear descriptions of headache associated with electro convulsive therapy are sparse. Headache attributed to cranial or cervical vascular disorder or Diagnostic criteria: one of its subtypes or subforms, and fullling criter ion C A. Headache has persisted for >3 months after expo headache has been eectively treated or has sponta sure has ceased neously remitted D. Headache attributed to intracranial fungal or other parasitic infection, and fullling criterion C Bibliography B. Localized pain than brain abscess or subdural empyema, has been associated with seizures originating in the parietal lobe. Use of or exposure to the substance has ceased ing lesion International Headache Society 2013 802 Cephalalgia 33(9) 4. Evidence of causation demonstrated by at least two headache are toxoplasmosis and cryptococcal meningi of the following: tis. Headache is reported by more than half of people Evers S, Wibbeke B, Reichelt D, et al. The subject is travelling through space Valcour V, Chalermchai T, Sailasuta N, et al; on behalf of the C. Orthostatic (postural) hypotension has been anaemia, adrenocortical insuciency, mineralocorticoid demonstrated deciency, hyperaldosteronism, polycythaemia, hyper C. Evidence of causation demonstrated by two of the viscosity syndrome, thrombotic thrombocytopaenic pur following: pura, plasmapheresis, anticardiolipin antibody 1. Headache attrib homoeostasis uted to disorder of homoeostasis, and fullling criterion C A10. The disorder of homoeostasis causing the headache has been eectively treated or has spontaneously remitted Description: C. Headache has persisted for >3 months after eec Non specic headache caused by travel in space. The tive treatment or spontaneous remission of the dis majority of headache episodes are not associated with order of homoeostasis symptoms of space motion sickness. The prevalence of the following: and association of neck (coat hanger) pain and orthostatic 1. Symptoms associated with orthostatic hypotension in pure autonomic fail b) pain has signicantly improved in parallel ure and multiple system atrophy. It has been dicult consistently to demonstrate supposed trigger points, and response A. Any headache fullling criterion C c) pain is temporarily abolished by local anaes B. Clinical, nasal endoscopic and/or imaging evidence thesia of the relevant nerve root of a hypertrophic or inammatory process within 1 2. Often there are lancinations of pain in one in (with or without treatment) or worsening of of the areas subserved by the upper cervical roots on the nasal lesion one or both sides, generally in the occipital, retroauri 3. A source of myofascial pain in the muscles of the Note: neck, including reproduceable trigger points, has Examples are concha bullosa and nasal septal spur. Remission of headache is more suggestive of disorder a psychiatric cause when a major depressive disorder improves under treatment with other type of antide Introduction pressants shown to be less eective in headache Headaches are commonly associated with various psy treatment. Any headache fullling criterion C describe the association between comorbid headache B. Headache occurs exclusively in the context of actual probably reects common underlying risk factors or or threatened separation from home or from major aetiologies. Thus, either the headache onset occurs simultaneously with the psychiatric disorder or the headache clearly Comment: worsens after the psychiatric disorder becomes evident. Separation anxiety disorder is persistent, typically last Denite biomarkers and clinical proof of headache cau ing at least 6 months, although a shorter duration sation are dicult to obtain, and the diagnosis should may meet diagnostic criteria in cases of acute onset be based on high levels of clinical suspicion. The disorder causes clinically sig those cases where it occurs solely in the context of nicant distress and/or impairment in social, aca actual or threatened separation, without any better demic, occupational and/or other important areas of explanation. Headache occurs exclusively when the patient is sants, are eective against headache disorders even exposed or anticipating exposure to the phobic when depression is not present. This makes it dicult stimulus to determine whether remission of or improvement in a D. Behaviours asso ciated with this disorder include avoidance of activities or events with possible negative outcomes, marked A12. Headache occurs solely when the patient is exposed disorder or anticipating exposure to social situations D. The person fears that he or she will act in a way or show anxiety symptoms that will cause Note: him or her to be negatively evaluated. The fear or anxiety is out of proportion to the actual threat posed by the Comments: social situation. The disorder is persistent, typically Exposure to actual or threatened death, serious injury lasting 6 or more months. Any headache fullling criterion C cers repeatedly exposed to details of child abuse). After migraine or cluster headache, a low grade In migraine, for example, the most frequent are non pulsating headache without accompanying nausea, vomiting, photophobia and phonophobia; symptoms may persist, but this is not part of the osmophobia, diarrhoea and other symptoms occur attack and is not included in duration. Judgement is required to make the distinction (see Aura: Early symptoms of an attack of migraine with also Frequency of attacks). Through long usage Prodrome, Premonitory symptoms, Warning symp the term has acquired special meaning in the context toms and Neurological symptoms.

In the severe forms there unilateral medicine images cheap 25/200mg aggrenox caps overnight delivery, as for example in some cases of endometrio may be massive intraperitoneal hemorrhage; as in these sis symptoms zinc overdose buy generic aggrenox caps on line. Main Features these resemble primary dysmenorrhea medications narcolepsy cheap aggrenox caps 25/200 mg on-line, but the pain of Pathology ten lasts longer medicine zoloft aggrenox caps 25/200mg with mastercard. Possible causes include maturation of Main Causes the follicle or ovulation itself or contractions of the tubal the main causes of secondary dysmenorrhea are: endo wall in a case of hydrosalpinx medications emts can administer aggrenox caps 25/200mg with visa, or an increase in the basal metriosis treatment 4 toilet infection order aggrenox caps 25/200 mg fast delivery, adenomyosis, submucous fibroids, and vari tone of the myometrial contractions around the time of ous causes of obstructive dysmenorrhea, as described ovulation. In more severe forms with intraperitoneal bleeding, a laparotomy may be necessary. The most frequent symptom is pain, which may present Diagnostic Criteria and Differential Diagnosis as dysmenorrhea or as premenstrual pain with menstrual the essential feature is recurrence at the time of ovula exacerbation, or continuous pain with or without men tion. The menstrual pain may last the the periovulatory period by means of the basal body whole duration of the menstrual period and sometimes temperature, which will show a shift toward a premen even one day after its end. Severe cases with right sided location of endometriosis, refer to the section on Endometriosis may erroneously be taken for appendicitis. Main Features: hemorrhage, the time of occurrence will differentiate clinical diagnosis is difficult, so diagnosis has generally severe Mittelschmerz from ectopic pregnancy or rupture to await microscopic examination of a hysterectomy of a corpus luteum cyst, but blood transfusion and lapa specimen. The prevalence varies greatly, depending on rotomy will be indicated in both cases. The most common symp Reference toms are menorrhagia or metrorrhagia and dysmenor Renaer, M. Page 165 Associated Symptoms: adenomyosis frequently causes blood in the vagina will manifest itself by distention of infertility. Signs: the uterus is either symmetrically or the vagina with the hymen bulging at the introitus and asymmetrically enlarged and firm, and there are gener the posterior wall of the vagina bulging into the rectum. Usual Course: the uterine volume enlarges cause an asymmetrical enlargement of the uterus. The progressively over the years but rarely grows larger than distended blind half of a double vagina will bulge into a 14 week gestation. Pathology: Various con ing disappear at menopause but, owing to the severity of genital anomalies may cause secondary dysmenorrhea, symptoms, most patients have to undergo a hysterec. Pathol double uterus one half of which does not communicate ogy: adenomyosis is diagnosed only when endometrial with the vagina, or a uterus duplex bicollis, one half of glands are found at least one low power microscopic which opens into a blind half of a double vagina. The nests of quired forms may be due to adhesions in the cervical endometrial tissue are generally surrounded by a prolif canal after amputation of the cervix or conization or eration of fibrous tissue. In the lower part of the uterine cavity, for example, in an adenomyosis no nodules are found; the uterus varies in Asherman syndrome. An early unilateral dysmenorrhea, contrast medium may suggest adenomyosis if, in a pa combined with the presence of an asymmetrical mass in tient with dysmenorrhea and menorrhagia, the uterine the lower abdomen or in the vagina is suggestive of an cavity has an irregular shape and if small diverticula are asymmetric malfusion deformity. If dysmenorrhea or teria: if the uterine size is only slightly enlarged, hys cryptomenorrhea appear after an amputation of the cer terography may detect a submucous fibroid or a fibroid vix or an electrocoagulation or a conization of the cer polyp. A circular or polycyclic filling defect is then vix, or after a curettage performed for retained products found that generally deforms the uterine cavity, whereas of conception, the diagnosis is easy and the condition a mucous polyp does not. A laparotomy will rarely be required menorrhea is called obstructive when obstruction of the to divide the adhesions under visual control. In congenital forms the pain mostly the frequency of such dysmenorrhea has been exagger begins a few months after menarche, as it starts only ated. The diagnosis of dysmenorrhea of psychological when enough blood has been retained to distend the va origin should be accepted only where no organic cause gina or the uterus. When there is an atresia of the hymen, can be found and when psychopathologic evaluation there is dysmenorrhea with cryptomenorrhea as the men reveals neurotic behavior or other psychopathological strual blood is retained in the vagina. X4 With adenomyosis or fibrosis double uteri are frequently accompanied by absence or 765. X6b With acquired obstruction tend the vagina and the uterus and give rise to a retro 765. X9a Psychological, tension grade menstruation, which, after a few months, may 765. Social and Physical Disability Third degree dysmenorrhea is the cause of periodic ab Definition sence from work or school in many teenagers and young Dysmenorrhea, or painful menstruation, refers to epi women. Pathophysiology Primary dysmenorrhea is found at the end of an ovula System tory cycle; it has also been reported in women taking Female internal genital organs; either the uterus or both oral contraceptives. Several authors have found ele radiate towards the sacro gluteal zone in the lower back, vated prostaglandin concentrations in endometrium and i. It sometimes radiates into Although the exact mechanism of primary dysmenorrhea the anterior and superior aspect of one or both thighs. If the pain has a with an increased production (or perhaps increased re lower abdominal location, which is usually symmetrical, tention) of prostaglandins, which leads to increased, or and if no structural anomaly is found on clinical exami dysrhythmic, myometrial contractions, sensitization of nation, the dysmenorrhea is termed primary. Cases with nerve terminals to prostaglandins, and ischemia of the structural organic anomalies are classified as secondary uterine wall. Prevalence: between 5 and 10% of all girls in their late Treatment teens and early 20s suffer from severe, mostly primary, Mild and moderate cases are best treated by analgesics. In In severe cases the pain can be prevented by cyclic es one study, 72% of women aged 19 years had some dys troprogestogens, or the pain may, when it appears, be menorrhea. Pain Quality: the pain is generally colicky; in Differential Diagnosis about one fourth of all cases the pain is continuous. In From conditions causing secondary dysmenorrhea, tensity: the pain may be mild. Third degree or incapacitating dysmenorrhea has ity of the internal female genital organs. Du tions have shown that in about 10% of cases with a ration: in most cases the pain starts a few hours or half a negative clinical examination, laparoscopic visualization day before the beginning of the blood flow, and usually of the internal genitalia may detect endometriotic le lasts less than one day. Associated Features With third degree primary dysmenorrhea there may be Code nausea, vomiting and/or diarrhea. X7b Usual Course Reference Primary dysmenorrhea may disappear spontaneously Andersch, B. The Lower abdominal pain due to foci of ectopic endo ectopic tissue may grow on the surface of the perito metrium located outside the uterus (endometriosis ex neum or it may become buried in a fibrous capsule. The pain may start as secondary dysmenorrhea; it may later become premenstrual as well as menstrual, or Site may become continuous. The pain due to endometriotic the pain may be located in one or in both iliac fossae or foci is usually alleviated by pregnancy. Subocclusion or Prevalence: the frequency with which endometriosis is occlusion of the small or the large intestine is possible found depends on the circumstances in which it is but infrequent. It was found in 15 and 20% of two different se in an ovary may cause an acute abdominal emergency ries of laparoscopies, but, on the other hand, it was due to irritation of the peritoneum by the old blood flow found in 50% of a large series of laparotomies. The ectopic foci Pathogenesis are located either in the pouch of Douglas or on the ova Retrograde menstruation, i. This seems to be the rather seldom they infiltrate the bladder wall or the wall pathogenetic mechanism in most cases of endometriosis. Age of Onset: It used to be thought that However, it does not explain all the possible locations of endometriosis usually develops in the late twenties or in the foci. Tiny fragments of menstrual endometrium may the thirties, but since more laparoscopies have been per be carried away by lymphatics and, more rarely, by formed on younger patients it has been found rather fre veins of the endometrium. Symptoms: In Diagnostic Criteria some 30 to 40% of patients with endometriosis there are the history and the findings on clinical examination will no complaints except perhaps infertility. When any doubt re symptom of endometriosis is pain; it may manifest itself mains, a therapeutic trial with cyclic estroprogestogens as dysmenorrhea, as premenstrual pain with menstrual will alleviate the pain in 8 of 10 cases. Lesions located in the inspection of the pelvic cavity has been used rather fre pouch of Douglas may provoke firm adhesions between quently in recent years to verify the diagnosis and to the anterior wall of the rectum and the posterior vaginal evaluate the extent of the lesions. Acute pain episodes in wall; this location may cause pain on defecation during the right iliac fossa due to endometriosis may be mis menstruation. Recurrent episodes of lower ab fixed uterine retroversion due to endometriotic adhe dominal pain, tenderness, and a slight fever may sions frequently cause deep dyspareunia. Endometriotic erroneously be taken for recurrent pelvic inflammatory foci that penetrate into or through the bladder wall may disease. Treatment Treatment of endometriosis will be hormonal or surgical Signs or combined. It will vary depending on age of the pa On pelvic examination a fixed painful retroversion may tient, stage of the disease, and the main presenting prob be found, or tender, enlarged, adherent adnexa on one or lem pain or infertility or both. Small, tender nodular lesions, which are fre consists of cyclic estroprogestogens or in the continuous quently palpated either in a sacro uterine ligament or on daily administration of oral progestogens, for example, the posterior surface of the uterus, are almost pathogno Lynestrenol or norethisterone acetate. During recent years excellent results have been obtained by the con tinuous oral administration of Danazol, a strong antigo Page 168 nadotropin and mild androgenic drug. In these circumstances treatment with broad will, depending on the indication and the stage of the spectrum antibiotics and local heat is indicated. If the disease, consist of conservative surgery preferably by pain disappears, this confirms the diagnosis. If the pain microsurgical techniques, or semiradical or radical sur and the parametrial tenderness persist, another cause of gery, i. Definition Main Features Pain with low grade infection of parametrial tissues, Prevalence: genital tuberculosis has become quite un especially the posterior parametrium. Synonyms: pelvic common in most developed countries thanks to the lymphangitis, chronic parametrial cellulitis. It re mains a problem in many less developed countries System where pulmonary tuberculosis is still widely prevalent. Symptoms: the most frequent symptoms are sterility, pelvic pain, poor general condition, and menstrual dis Main Features turbances. Genital tuberculosis presents under two Site: Lower abdomen, sometimes the back also. In the silent lence: Because histological proof of the diagnosis is forms there are no particular symptoms; there is no pain usually missing, the prevalence is unknown, but the and no fever. It may be found soon general symptoms and signs of the tuberculous process, after a delivery, especially if the cervix has been torn meno or metrorrhagias, sometimes amenorrhea. In the active cases there is usually abdominal pain with or without low backache, and deep pyrexia, weight loss, and night sweats. The pain may occur during the premenstrual period and disappear dur Signs ing menstruation, or it may be continuous, with premen On pelvic examination a fixed retroversion with palpable strual exacerbation. Spontaneous pain and dysmenorrhea may be explained by a pyo or hy Signs drosalpinx or by a tuberculous pelvioperitonitis. A more or less severely torn cervix is found and either Dyspareunia may be due to a fixed retroversion or to an acute or a chronic cervicitis. Usual Course Pathology the tuberculous process may become latent or may heal Posterior parametritis on chronic cervicitis is believed to spontaneously. It may, on the other hand, evolve towards be due to extension of a cervical infection along the a pyosalpinx or an ovarian abscess or to a tuberculous lymphatics of the parametrium. Diagnostic Criteria Diagnostic Criteria and Treatment In advanced cases general symptoms and signs of the Diagnosis of cervicitis depends on finding agglutinated tuberculous process, abdominal pain or discomfort, signs leukocytes in the cervical mucus during the periovula of a pelvic infection, together with a positive tuberculin tory period. The presence of an infected cervical canal test and bacteriological evidence of tuberculosis consti and of a tender posterior parametrium and the absence of tute the basis of the diagnosis. Tubercle bacilli may be a history and of clinical findings suggestive of endome cultured either from menstrual blood or from an endo triosis make the diagnosis of posterior parametritis plau metrial biopsy, taken preferably in the premenstrual Page 169 phase. Silent cases are usually diagnosed by the presence metriosis or posterior parametritis on a chronic cer of tubercular lesions in an endometrial biopsy taken dur vicitis, and if the pain disappears after anterior reposition ing the evaluation of infertility cases. If a patient with a Treatment fixed retroversion complains of some symptoms, it is Treatment is essentially medical by means of a com usually impossible to prove which symptoms are due to bined drug regimen with Rifamycin, isoniazid, and the retroversion and which are not. It should last for a minimum of 18 months therefore be directed against the causal disorder, which to two years. Surgery will be resorted to only if pelvic may be either endometriosis or sequelae of acute pelvic masses persist or increase under medical treatment, if inflammatory disease or of a pelvioperitonitis, or a tu endometrial lesions persist, and if pain or other pelvic berculous salpingitis. If the patient complains of pain, reposition of the uterus will be tried and a pessary in Reference serted. If it does, operative correction of the retroversion may be under Definition taken. If the retroversion is fixed, treatment must be directed Main Features against the causal condition and a suspension operation Retroversion of the uterus is found in 15 to 20% of adult should be performed only when the retroversion itself is women, but only a small number of mobile retroversions probably the cause of the complaint, as in some cases of cause symptoms. In a few cases it may give rise to in dyspareunia, or when there are other reasons for surgical termittent pain with or without deep dyspareunia. The pain usually Code is worse during the premenstrual period and mostly dis 765. The symptoma examination the retroverted uterus is tender and fre tology of uterine retroversion and, in particular, pain in uterine quently slightly enlarged and softer than normal. Pathology It has repeatedly been observed that the size of a painful retroverted uterus diminishes and that it becomes firmer after anterior reposition. These circumstances seem to indicate that Lower abdominal pain due to an ovarian lesion. Main Features: lower abdominal pain due to recurrent painful functional cysts is sometimes, although rarely, Diagnostic Criteria seen in young women. If roversion is said to be fixed when adhesions bind the the result of this examination is compatible with a func uterine corpus down in the pouch of Douglas. A mobile tional cyst, it is recommended to treat it conservatively retroversion should be considered the cause of the pain by means of oral contraceptives. There is a good chance only if no other causes of pain are found, such as endo that the cyst and the pain will disappear, whereas surgi cal exploration with wedge resection of the ovary is Page 170 likely to be followed by a recurrence of the cyst and of gynecological pain; and (3) if the syndrome is not due to the painful episode. The lower abdomi adhesions, active rests of ovarian tissue may cause a nal pain may be felt either in the whole lower abdomen painful condition called the ovarian remnant syndrome. The low Diagnostic Criteria: an ovarian remnant will be sus back pain may be felt over the whole width of the sacro pected when the patient presents evidence of estrogen gluteal zone or over a part of this zone. The pain is usu secretion that persists after a short course of corticoids ally more severe for several days before menstruation, prescribed to suppress adrenal androstenedione secretion and its intensity decreases on the first or second day of and its peripheral conversion to estrone. When a chronic pelvic pain syndrome has lasted for several months and Code has not been cured by medical treatment, it is useful to 764.

Syndromes

• Children younger than 2 years
• Dizziness
• Pollen
• The bladder and front wall of the vagina are bulging into the vagina (cystocele).
• Stiff muscles in neck, face, or back
• Abnormal high muscle tone, abnormal muscle movements
• Heart failure
• Enlarged heart
• Blood test for anemia
• Difficulty breathing through the nose

In most cases the use of higher doses than those needed to treat depression were more likely to produce better therapeutic effect medicine lake montana buy discount aggrenox caps 25/200mg line. If one starts with a lower dose patients should be reassessed and the dose should be increased if the response is not satisfactory medications like abilify buy aggrenox caps 25/200mg online. The problem of adverse effects is extremely important because the negative influence on adherence to treatment medications prescribed for pain are termed purchase discount aggrenox caps online, and efficacy also red carpet treatment purchase aggrenox caps 25/200 mg line. Clomipramine usefulness is limited by side effects typical of tricyclic antidepressants symptoms checker order aggrenox caps 25/200 mg without a prescription. Depressive symptoms do not respond to antidepressants that have a strong activity on the serotonin system medicine vile purchase generic aggrenox caps on-line. The presence of a borderline type of personality disorder, schizotypal or avoided also have a negative predictive role. Also it was found that the severity, duration of disorder, gender, age and type of symptoms have no predictive value in this respect. Even if other compounds were tried to be used for this purpose buspirone (20 60 mg/day), lithium (300 600 mg/day), gabapentin (300 2400 mg/day), inositol (16 18 mg/day), L tryptophan (4 6 g/day), fenfluramine (20 60 mg/day), topiramate (250 Anxiety Disorders 29 mg/day) only small doses of risperidone (1 2 mg 2 times/day) and pindolol (2. Clonazepam that has serotonergic action too, has proved to be effective as monotherapy in a double blind study. However, there were presented cases in which clonazepam augmentation was beneficial in cases resistant to treatment. For this reason, clonazepam can be a useful option that can be taken into account in some cases requiring augmentation. Patients should be encouraged to continue treatment with the same dose with clinical response was obtained for periods of at least one year after they get this response. However, there are insufficient data to support the usefulness of the techniques of psychotherapy. They consider their symptoms as extreme shyness or as an unpleasant feature of their personality, so they have to be convinced that a long term treatment may be useful. Specific social phobias such as fear of speaking in public, respond quite well to blockers drug administration, although most data come from isolated cases. Among benzodiazepines, clonazepam alone is demonstrated efficacy in a double blind study. Clonazepam has the advantage of twice daily administration and a lower potential than other benzodiazepines to be misused. However, clonazepam as monotherapy because of adverse reactions is not considered first line treatment. Therapeutic effects appear quite quickly, with greater efficacy in less severe cases. It may be useful as an adjunctive therapy in patients with a high level of anxiety, but its use should be limited to initial clonazepam period of treatment. It was shown that patients who discontinue paroxetine or phenelzine have a significantly increased risk of relapse than those who continued treatment for longer periods. Most patients who responded to treatment achieved a reduction of anxiety and avoidance behavior, leading to improved social and occupational functioning. However, most patients do not obtain a complete and permanent disappearance of symptoms. Treatment should be started at doses used to treat depression such as paroxetine 20 mg/day, sertraline 50 mg/day. When this event does not get a response, is another option and then use of clonazepam, the gabapentin Anxiety Disorders 31 or venlafaxine. Having achieved a significant improvement of symptoms is recommended to continue treatment for at least a year. Interruption of treatment is achieved by gradually lowering the dose very slowly during several months (eg, lowering the dose by 20 30% every 6 8 weeks). In two recent meta effectiveness of pharmacotherapy and psychotherapy should be similar, with a slight superiority in the short term pharmacotherapy 8. In addition to the choice of therapeutic modalities, the physician should take into account other factors that may influence the disorder: the stigma, ambivalence regarding treatment, shame, social support, attitudes and behaviors of family antitherapeutics possibility of legal action or the victim. The effectiveness of these compounds has been demonstrated in double blind studies for sertraline, paroxetine and fluoxetine in open studies for escitalopram (10 20 mg/day), citalopram (20 60 mg/day), fluvoxamine (100 300 mg/day), nefazodone (200 600 mg/day), venlafaxine (150 225 mg/day) and mirtazapine (15 45 mg/day). Improvement of symptoms seen in 2 4 weeks, but may improve irritability and dysphoria as the first week. The doses used are higher than those commonly used, being 100 200 mg/day for sertraline and 30 50 mg/day for paroxetine (Ninan and Dunlop, 2006). Also, amitriptyline and imipramine (initial dose of 50 75 mg/day increased to 300 mg/ day) have proven their efficacy in the treatment of this disorder. It has been suggested that patients with comorbid mental illness and another might show a better response to antidepressant treatment than patients who do not have other comorbid mental disorder, since the differences between active drug and placebo would be higher if a comorbidities. This might explain the higher rate of response to placebo if no other comorbid condition. Nefazodone, amitriptyline, imipramine, lamotrigine are other options for these patients. Quetiapine (100 mg/day) is recommended in the treatment of refractory severe insomnia (Robert et al. Discontinuation of treatment, as with other anxiety disorders, it is recommended to achieve the slow decrease in dosage (eg 20 30% of the dose a few months). Currently there are no sufficient data on the maintenance of therapeutic effect compared with placebo or the long term development disorder after discontinuation of drug therapy. Among the most effective techniques are used exposure therapy and cognitive restructuring. Stresorul can be a traumatic experience involving a serious threat to the security or integrity of the subject or someone close (eg natural disasters, accidents, fights, criminal assault, rape, etc. An important role in the occurrence and severity of side play individual vulnerability and capacity to cope with events. Treatment of acute stress disorder include psychopharmacological and psychotherapeutic intervention, psychoeducation, and case management. Currently there are few studies on the psychopharmacological intervention in acute stress disorder. Benzodiazepines are useful in cases where immediate cause persists (diazepam: 5 10 mg / day or i. In patients who are contraindicated benzodiazepines can be used low doses of neuroleptic sedatives 8. Treatment Adjustment disorder requires a psycho therapeutic approach centered on stress, on its significance and how the patient perceives and controls the stress. Medications (anxiolytics) has an auxiliary role by reducing the severity of symptoms. Introduction the global burden of mental health problems including anxiety is enormous, neglected and under resourced, particularly in the developing nations [1 3]. People with untreated anxiety disorders are at dire risk of descending into other mental disorders since the anxiety symptoms interfere with social and occupational functioning and therefore lowers their self esteem. While studies on the effects of untreated mental illness on national economic development have not been conducted in developing countries, research in developed countries provides an important framework and data for understanding these costs in developing countries [4]. Overally, lack of treatment for mental disorders results in much infallible expenses, as a result of the higher indirect costs associated with greater morbidity to untreated disorders [5]. Most of these costs are quantifiable and occur outside the health sector; loss of employment and income generation, increased absenteeism from work or school, poor performance within the workplace or school work and premature retirement [5]. People with mental disorders have higher unemployment rates, less access to treatment and face more discrimination [6 8]. Anxiety is, "one of the main motivating factors in most of human behaviour" and is a normal reaction to threatening or unthreatening situations in the environment. These symptoms occur as a result of increased amount of adrenaline that is produced by the autonomic nervous system in response to a perceived threat from the environment. The increased level of adrenaline causes an increase in the heart respiration rate, elevation of the blood pressure and the contraction of blood vessels and intestines as blood is diverted to the heart, lungs and muscles. Although these reactions are appropriate when faced with incidents of threat or danger, the state of anxiety usually continue after the threat has been removed, or when there is no real threat existing. Anxiety disorders are therefore combinations of various physical and mental manifestations which are not attributable to real danger, but keep re occurring in attacks or as a persisting hyper aroused state. Classification of anxiety disorders A comprehensive review of available data worldwide has shown that 8 12% of children, youth and adults suffer from anxiety symptoms that are severe enough to interfere with daily life and functioning. Anxiety disorders in childhood and adolescents Recognizing anxiety symptoms in children is important because in most cases of anxiety disorders in youth and adults, the onset is usually during childhood [9]. Social anxiety for clinical pathology in this population of high students in a similar setting of 80% prevalence is not surprising since there are high levels of bullying in the same schools [12]. Panic disorder these are recurrent spontaneous episodes of panic associated with physiological and psychological symptoms. The physiological symptoms can be seen as emanating from circulatory, respiratory, gastro intestinal, and urinary systems. Symptoms from respiratory system include: chest pains, shortness of breath, choking, dizziness/giddiness, fear of dying or going crazy and lapse into unconsciousness. The respiratory symptoms are related physiologically to changes in blood gaseous imbalance with a result of low levels of carbon dioxide. Symptoms from circulatory system include: palpitation, sweating, trembling, elevated blood pressure and muscle tension. Gastro intestinal symptoms include nausea, butterfly feeling at the epigastria area and sometime diarrhoea and vomiting. While in the urinary system there is increased frequency of micturation, all these are in preparation for either fight or flight However, most instruments for measuring Anxiety Disorders in children do not screen for Panic Disorder Epidemiological Patterns of Anxiety Disorders in Kenya 37 In Kenyan setting, adolescents who have spontaneous panic attacks report greater severity of attacks, more depression and greater lifestyle changes as a result of the attacks 5. In adolescent it is miss diagnosed as a conversion disorder Often children are shy, negative, controlling or oppositional. Been seen more common in family settings where mothers are overprotective; child develops fear of the environment and therefore cannot manipulate it. Separation anxiety disorder the essential features of Separation Anxiety Disorder are excessive worry about separation from attachment figures. Fear of getting lost is common in separation Anxiety Disorder and fear of germs, illness and bee stings. Separation Anxiety Disorder seems to be a nonspecific precursor to a number of adult conditions including depression and anxiety disorders. Children with separation anxiety disorder must have symptoms for at least half the time and this may cause interference in function (school work) or social communication. Separation anxiety was associated with symptoms of depression, such as sadness, withdrawal, apathy, or difficulty in concentrating. Social phobia Persistent fear of social or performance situations when the person is exposed to unfamiliar people or scrutiny Social Phobia had all the features of panic disorder and was to be frequently co morbid with other anxiety disorders 9. Simple phobia and fears [12] Simple phobias are specific, isolated, persistent fear of circumscribed stimuli. Girls fear more than boys do the commonest fears expressed by Kenyan children in Nairobi (urban setting) are: Being confronted by bad news Not being able to breathe Being mugged Getting burned by fire Falling from a high place Burglar breaking into the house Death Getting poor grades being battered or watching a relative being battered (domestic violence) 10. However they commonly engaged in posttraumatic play or reenactment behaviour and had nightmares They also showed more distortion in their sense of time and a striking foreshortened view of the future. Epidemiological Patterns of Anxiety Disorders in Kenya 39 In children with ongoing trauma. Students indicated that being confronted with bad news was the commonest traumatic event they experienced (66. Further, traumatic grief in which one looses a loved one through circumstances that are objectively traumatic and in which the trauma symptoms interfere with the normal grieving process causes the person to develop other mental disorders. In Kenya many human atrocities have occurred that have left many people with traumatic grief which affect both children and adults [18 20]. Adolescent reactions include intense emotional distress and physiological reactions; more similar to adult reactions such as re experiencing the event through intrusive thoughts, memories and flashbacks. Assessment in children is particularly challenging because those less than 11 years old may not be able to conceptualize or verbalize their symptoms. These symptoms must be present for more than 1 month and cause clinically significant distress or impairment in functioning. Posttraumatic stress and grief were examined in middle school children 8 to 14 months after experiencing loss in the Embassy bombing, adding to the growing body of literature that documents posttraumatic stress and grief in children who experience traumatic loss within 40 Anxiety and Related Disorders and outside the immediate family [18 19]. The finding that posttraumatic stress related to other negative life events was associated with higher bomb related posttraumatic stress. Posttraumatic stress associated with prior negative experiences may increase the vulnerability of children exposed to later traumatic events. Neither the time elapsed between the bombings nor subsequent loss, or the child relationship to the deceased in losses unrelated to the bombing, were assessed and should be addressed in further research. Thus, both posttraumatic stress and grief should be examined in children following mass casualty terrorist events. Consistent with a view of traumatic grief as a convergence of conditions rather than a distinct entity, posttraumatic stress and grief should be measured instead of unique reactions associated with a specific construct of traumatic grief [18 20]. It was well known that this slum was acutely affected by violence during the month following the broadcast of the 2007 Kenya Presidential election results. The violence experienced in Nairobi following the 2007 elections was unique in that it involved clashes between neighbours of differing tribal heritage, excessive violence against girls/women, forced circumcisions on boys/men, and the concentration of violent activities (including murder) in certain urban slums. In addition to personal physical violence, many safe havens such as churches and schools and common areas such as kiosks and stores were burned or destroyed.

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