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Follow-up after curative resection: Yearly liver tests symptoms magnesium deficiency buy cheap oxytrol 2.5 mg, complete blood count symptoms rsv 5mg oxytrol free shipping, follow-up radiologic or colonoscopic evaluation at 1 year-if normal, repeat every 3 years, with routine screening interim (see below); if polyps detected, repeat 1 year after resection. Abdominoperineal resection with permanent colostomy is reserved for those with large lesions or whose disease recurs after chemoradiotherapy. Most are found incidentally but may cause pain; intratumoral hemorrhage may cause circulatory collapse. Focal nodular hyperplasia is also more common in women but seems not to be caused by birth control pills. Male:female = 4:1; tumor usually develops in cirrhotic liver in persons in fifth or sixth decade. High incidence in Asia and Africa is related to etiologic relationship between this cancer and hepatitis B and C infections. Aflatoxin exposure contributes to etiology and leaves a molecular signature, a mutation in codon 249 of the gene for p53. Physical Findings Jaundice, asthenia, itching, tremors, disorientation, hepatomegaly, splenomegaly, ascites, peripheral edema. The tumors are ductal adenocarcinomas and are not usually detected until the disease has spread. About 70% of tumors are in the pancreatic head, 20% in the body, and 10% in the tail. Mutations in K-ras have been found in 85% of tumors, and the p16 cyclin-dependent kinase inhibitor on chromosome 9 may also be implicated. Long-standing diabetes, chronic pancreatitis, and smoking increase the risk; coffee-drinking, alcoholism, and cholelithiasis do not. Pts present with pain and weight loss, the pain often relieved by bending forward. Gemcitabine plus erlotinib or capecitabine may palliate symptoms in pts with advanced disease. Carcinoid tumors of the small bowel and bronchus have a more malignant course than tumors of other sites. About 5% of pts with carcinoid tumors develop symptoms of the carcinoid syndrome, the classic triad being cutaneous flushing, diarrhea, and valvular heart disease. Octreotide scintigraphy identifies sites of primary and metastatic tumor in about two-thirds of cases. Prognosis ranges from 95% 5-year survival for localized disease to 20% 5-year survival for those with liver metastases. They are generally slow-growing and produce symptoms related to hormone production. Normal or elevated serum insulin levels in the presence of fasting hypoglycemia are diagnostic. The classic triad of somatostatinoma is diabetes mellitus, steatorrhea, and cholelithiasis. Provocative tests may facilitate diagnosis of functional endocrine tumors: tolbutamide enhances somatostatin secretion by somatostatinomas; pentagastrin enhances calcitonin secretion from medullary thyroid (C cell) tumors; secretin enhances gastrin secretion from gastrinomas. If imaging techniques fail to detect tumor masses, angiography or selective venous sampling for hormone determination may reveal the site of tumor. Exposure to polycyclic aromatic hydrocarbons increases the risk, especially in slow acetylators. Risk is increased in chimney sweeps, dry cleaners, and those involved in aluminum manufacturing. Schistosoma haematobium infection also increases risk, especially of squamous histology. Field effects are seen that place all sites lined by transitional epithelium at risk, including the renal pelvis, ureter, bladder, and proximal two-thirds of the urethra; 90% of tumors are in the bladder, 8% in the renal pelvis, and 2% in the ureter or urethra.
Impaired cognitive function should be borne in mind when treating elderly subjects with diabetes treatment internal hemorrhoids purchase 2.5 mg oxytrol amex, as it has implications for their safe treatment; it may cause difficulty with glycemic control because of erratic taking of diet and medication medicine woman dr quinn discount oxytrol american express, including hypoglycemia when the patient forgets earlier administration of hypoglycemic medication and takes more. Mental illness in elderly people with diabetes Cognitive impairment and dementia Diabetes and cognitive dysfunction are related and have evoked some interest over the last decade (Table 54. Impaired cognitive function has been demonstrated in elderly subjects with diabetes, but these studies were mostly not population-based, excluded subjects with dementia and generally used a large battery of tests to show the deficit [63]. These are easily learned, bedside screening tests of mental status which test several cognitive domains such as memory, orientation, calcula- Depression Depression in diabetes is a serious co-morbidity associated with poor outcome and high health care expenditure (see Chapter 55). The presence of a major depressive disorder significantly increases the risk of diabetes [72], this association being apparently independent of age, gender or coexistent chronic disease [73]. Moreover, depression was the single most important indicator of subsequent death in a group of people with diabetes admitted into hospital [74]. Failure to recognize depression can be serious, as this is a long-term life-threatening disabling illness that can significantly damage quality of life. It is also associated with 928 Diabetes in Old Age Chapter 54 worsening diabetic control [75] and decreased treatment compliance (see Chapter 55) [76]. The relationship between diabetes and depression is complex and may result from the presence of a chronic medical condition in a susceptible individual. There are also complex neuroendocrine and cytokine changes in both conditions that may provide an explanation to link these two conditions (see Chapter 55). This may delay or confuse the diagnosis, although the commonly used diagnostic assessment scales are unlikely to be invalidated. Enquiries about well-being, sleep, appetite and weight loss should be part of the routine history, with a more comprehensive psychiatric evaluation if appropriate. Depression in diabetes can be treated successfully with pharmacotherapy, and/or psychologic therapy, but blood glucose levels should be monitored closely especially with pharmacotherapy. Goals for treating patients with depression and diabetes are twofold: 1 Remission or improvement of depressive symptoms; and 2 Improvement of poor glycemic control if present [78]. It is estimated that as many as half of all repeat prescriptions for antipsychotics occur in people aged over 65 years [81]. A systematic review of 17 studies examined the relationship between treatment with several antipsychotic agents and the risk of developing diabetes; olanzapine had an increased odds ratio but the risk for risperidone was small [82]. Data are still relatively limited in the elderly but suggest that the relative risk is less than for younger people with schizophrenia. Nevertheless, it seems prudent to undertake regular monitoring of weight, glucose and lipid profile [83]. Disability Disability in elderly people with diabetes Chronic diabetic complications often cause considerable disability in older people. Moreover, one in three subjects with diabetes had been hospitalized in the previous 12 months (twice the rate of those without diabetes), and subjects with diabetes had significantly increased levels of both physical and cognitive disability. Mortality in elderly subjects with diabetes People with diabetes die prematurely, mostly from cardiovascular disease. Early reports suggested that excess rates among people with diabetes fell progressively with age, especially in those aged 65 years and over. A recent systematic review of the relationship between mortality and age has suggested a higher incidence of premature death in older subjects with diabetes [85]. Cardiovascular mortality is primarily responsible, accounting for 42% of the overall mortality in the Verona Study. Age remains the strongest predictor of mortality; the contributions of classic cardiovascular risk factors are uncertain in older subjects with diabetes. In the Verona Study, long-term metabolic control was a better predictor of outcome, and subjects with more variable glycemic control (measured by the coefficient of variation of fasting plasma glucose) had lower survival rates, especially in those aged over 75 years [88]. Methodologic variations have prevented a consensus from being reached across different diabetic populations. Unequivocal evidence of increased mortality would argue for a more sustained 929 Part 10 Diabetes in Special Groups commitment to diabetic health care provision; otherwise, future care strategies should focus on reducing morbidity and disability.
Spontaneous flexion of elbows with leg extension symptoms during pregnancy order 2.5 mg oxytrol with amex, termed decortication treatment yeast infection men order oxytrol with visa, accompanies severe damage to contralateral hemisphere above midbrain. Internal rotation of the arms with extension of elbows, wrists, and legs, termed decerebration, suggests damage to midbrain or diencephalon. Pupillary Signs In comatose pts, equal, round, reactive pupils exclude mid-brain damage as cause and suggest a metabolic abnormality. Pinpoint pupils occur in narcotic overdose (except meperidine, which can cause midsize pupils), pontine damage, hydrocephalus, or thalamic hemorrhage; the response to naloxone and presence of reflex eye movements (usually intact with drug overdose) can distinguish these. A unilateral, enlarged, often oval, poorly reactive pupil is caused by midbrain lesions or compression of third cranial nerve, as occurs in transtentorial herniation. Bilaterally dilated, unreactive pupils indicate severe bilateral midbrain damage, anticholinergic overdose, or ocular trauma. Conjugate eye deviation to one side indicates damage to the pons on the opposite side or a lesion in the frontal lobe on the same side ("The eyes look toward a hemispheral lesion and away from a brainstem lesion"). The eye with a dilated, unreactive pupil is often abducted at rest and cannot adduct fully due to third nerve dysfunction, as occurs with transtentorial herniation. Vertical separation of ocular axes (skew deviation) occurs in pontine or cerebellar lesions. Cheyne-Stokes (periodic) breathing occurs in bihemispheric dysfunction and is common in metabolic encephalopathies. Respiratory patterns composed of gasps or other irregular breathing patterns are indicative of lower brainstem damage; such pts usually require intubation and ventilatory assistance. The pt is unresponsive to all forms of stimulation (widespread cortical destruction), brainstem reflexes are absent (global brainstem damage), and there is complete apnea (destruction of the medulla). The absence of deep tendon reflexes is not required because the spinal cord may remain functional. Special care must be taken to exclude drug toxicity and hypothermia prior to making a diagnosis of brain death. Recently proposed new definitions classify all brain infarctions as strokes regardless of duration of symptoms. Stroke is the leading cause of neurologic disability in adults; 200,000 deaths annually in the United States. Much can be done to limit morbidity and mortality through prevention and acute intervention. Small, deep ischemic lesions are most often related to intrinsic small-vessel disease (lacunar strokes). Low-flow strokes are seen with severe proximal stenosis and inadequate collaterals challenged by systemic hypotensive episodes. Hemorrhages most frequently result from rupture of aneurysms or small vessels within brain tissue. Variability in stroke recovery is influenced by collateral vessels, blood pressure, and the specific site and mechanism of vessel occlusion; if blood flow is restored prior to significant cell death, the pt may experience only transient symptoms, i. Intracranial Hemorrhage Vomiting and drowsiness occur in some cases, and headache in about onehalf. Stroke needs to be distinguished from potential mimics, including seizure, migraine, tumor, and metabolic derangements. Osmotic therapy with mannitol may be necessary to control edema in large infarcts, but isotonic volume must be replaced to avoid hypovolemia. Other neuroprotective agents have shown no benefit in human trials despite promising animal data. Treatment for edema and mass effect with osmotic agents may be necessary; glucocorticoids not helpful.
Diabetes mellitus is more common in pts with a family history of diabetes medications 2 order oxytrol 5 mg with mastercard, and hypogonadism may be an isolated early manifestation treatment math definition order 2.5mg oxytrol amex. Diagnosis Serum Fe, percent transferrin saturation, and serum ferritin levels are increased. In an otherwise-healthy person, a fasting serum transferrin saturation >50% is abnormal and suggests homozygosity for hemochromatosis. In most untreated pts with hemochromatosis, the serum ferritin level is also greatly increased. If either the percent transferrin saturation or the serum ferritin level is abnormal, genetic testing for hemochromatosis should be performed. Liver biopsy may be required in affected individuals to evaluate possible cirrhosis and to quantify tissue iron. Death in untreated pts results from cardiac failure (30%), cirrhosis (25%), and hepatocellular carcinoma (30%); the latter may develop despite adequate Fe removal. Chelation therapy is indicated, however, when phlebotomy is inappropriate, such as with anemia or hypoproteinemia. Each of the nine disorders causes a unique pattern of overproduction, accumulation, and excretion of intermediates of heme synthesis. These disorders are classified as either hepatic or erythropoietic, depending on the primary site of overproduction and accumulation of the porphyrin precursor or porphyrin. The major manifestations of the hepatic porphyrias are neurologic (neuropathic abdominal pain, neuropathy, and mental disturbances), whereas the erythropoietic porphyrias characteristically cause cutaneous photosensitivity. Laboratory testing is required to confirm or exclude the various types of porphyria. However, a definite diagnosis requires demonstration of the specific enzyme deficiency or gene defect. Clinical and biochemical manifestations may be precipitated by barbiturates, anticonvulsants, estrogens, oral contraceptives, the luteal phase of the menstrual cycle, alcohol, or low-calorie diets. Narcotic analgesics may be required during acute attacks for abdominal pain, and phenothiazines are useful for nausea, vomiting, anxiety, and restlessness. Treatment between attacks involves adequate nutritional intake, avoidance of drugs known to exacerbate the disease, and prompt treatment of other intercurrent diseases or infections. It is due to partial deficiency (familial, sporadic, or acquired) of hepatic uroporphyrinogen decarboxylase. Photosensitivity causes facial pigmentation, increased fragility of skin, erythema, and vesicular and ulcerative lesions, typically involving face, forehead, and forearms. The skin manifestations differ from those of other porphyrias, in that vesicular lesions are uncommon. Redness, swelling, burning, and itching can develop within minutes of sun exposure and resemble angioedema. Chronic skin changes may include lichenification, leathery pseudovesicles, labial grooving, and nail changes. Protoporphyrin levels are increased in bone marrow, circulating erythrocytes, plasma, bile, and feces; protoporphyrin in erythrocytes is free rather than zinc-complexed as it is in other types of porphyria or hematologic disorders. Cholestyramine or activated charcoal may promote fecal excretion of protoporphyrin.
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