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By: K. Cruz, M.B.A., M.B.B.S., M.H.S.

Associate Professor, New York University School of Medicine

At least five of the following must be present: (1) procrastinates and postpones completing routine tasks that need to menstrual relief cheap sarafem online amex be done menstrual gas pains buy 10 mg sarafem with amex, especially those that others seek to menopause years after hysterectomy discount 10mg sarafem amex have completed; (2) protests, without justification, that others make unreasonable demands of him or her; (3) becomes sulky, irritable, or argumentative when asked to do something he or she does not want to do; (4) unreasonably criticizes or scorns people in positions of authority; (5) works deliberately slowly or does a bad job on tasks that he or she really does not want to do; (6) obstructs the efforts of others by failing to do his or her share of the work; (7) avoids obligations by claiming to have forgotten. These syndromes have also been referred to as culture-bound or culture-reactive, and as ethnic or exotic psychoses. Some are rare and some may be comparatively common; many are acute and transient, which makes their systematic study particularly difficult. The status of these disorders is controversial: many researchers argue that they differ only in degree from disorders already included in existing psychiatric classifications, such as anxiety disorders and reactions to stress, and that they are therefore best regarded as local variations of disorders that have long been recognized. Their exclusive occurrence in specific population or cultural areas has also been questioned. There is a clear need for research that will help to establish reliable clinical descriptions of these disorders and clarify their distribution, frequency, and course. No attempt has been made to list detailed diagnostic criteria for these disorders: it is hoped that this will become possible when more reliable clinical, anthropological, epidemiological, and biological information is available. In certain instances, when available descriptions suggest that there is considerable variation in the clinical states covered by the term, more than one code has been given. Amok (Indonesia; Malaysia) An indiscriminate, seemingly unprovoked episode of homicidal or highly destructive behaviour, followed by amnesia or fatigue. Most events occur without warning, although some are precipitated by a period of intense anxiety or hostility. Some studies suggest that cases may derive traditional values placed on extreme aggression and suicidal attacks in warfare. Precursors are said to include excess coitus, urinary disorders, imbalances in body humours, and diet. Koro, jinjin bemar, suk yeong (various spellings) (south-east Asia, China, India) Acute panic or anxiety reaction involving fear of genital retraction. In severe cases, men become convinced that the penis will suddenly withdraw into the abdomen; women sense that their breast, labia, or vulva will retract. Studies cite factors such as illness, exposure to cold, or excess coitus as precursors, but interpersonal conflict and sociocultural demands reportedly exert greater influence on the condition. Responses vary, but include grasping of the genitals by the victim or a family member, application of splints or devices to prevent retraction, herbal remedies, massage, or fellatio. Latah (Indonesia; Malaysia) Highly exaggerated responses to a fright or trauma, followed by involuntary echolalia, echopraxia, or trance-like states. Studies variously interpret cases as a neurophysiological response, a hyper-suggestible state, or a mechanism for expressing low self-image. On-lookers usually find such imitative episodes amusing, while victims feel humiliated. Nerfiza, nerves, nevra, nervios (Egypt; northern Europe; Greece; Mexico, Central and South America) Common, often chronic, episodes of extreme sorrow or anxiety, inducing a complex of somatic complaints such as head and muscle pain, diminished reactivity, nausea, appetite loss, insomnia, fatigue, and agitation. Research links the condition to stress, anger, emotional distress, and low selfesteem. Cases are traditionally treated with herbal teas, "nerve pills", rest, isolation, and family support. Culturally interpreted symptoms or culture-bound syndromes: a cross-cultural review of nerves. Pa-leng, frigophobia (Taiwan (Province of China); south-east Asia) Anxiety state characterized by obsessive fear of cold and winds, believed to produce fatigue, impotence, or death. Fears are reinforced by cultural views of the condition as a legitimate humoral disorder. Overview of mental disorders in Chinese cultures: review of epidemiological and clinical studies. Pibloktoq, Arctic hysteria (Inuits living within the Arctic Circle) Prodromal fatigue, depression, or confusion, followed by a "seizure" of disruptive behaviour, including stripping or tearing off clothes, frenzied running, rolling in snow, glossolalia or echolalia, echopraxia, property destruction, and coprophagia. Most episodes last only minutes and are followed by loss of consciousness, amnesia, and complete remission. Injury is rare and, while some studies have related cause to hypocalcaemic tetany, most researchers link incidents to interpersonal anxieties and cultural stressors.

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Inspired oxygen should be Cardiovascular Disorders 493 limited to women's health lansing mi buy sarafem no prescription a fractional concentration of inspired oxygen (FiO2) of 0 menstruation hormone levels sarafem 20mg with visa. Following anatomic definition of left ventricular size menopause vs pregnancy purchase sarafem cheap, mitral valve, and aortic arch anatomy by echocardiography, cardiac catheterization or surgery should be performed as soon as possible to perform aortic valvotomy. With either type of therapy, patient outcome will depend largely on (i) the degree of relief of the obstruction, (ii) the degree of aortic regurgitation, (iii) associated cardiac lesions (especially left ventricular size), and (iv) the severity of end-organ dysfunction secondary to the initial presentation. All patients with aortic stenosis will require lifelong follow-up, as stenosis frequently recurs. Additional cardiac abnormalities are common, including Coarctation of the Aorta 93% 80 50 45% 75% 60 30 m = 10 m = 24 70 8 50 40 Figure 41. Coarctation of the aorta in a critically ill neonate with a nearly closed ductus arteriosus. Typical anatomic and hemodynamic findings include (i) "juxtaductal" site of the coarctation; (ii) a bicommissural aortic valve (seen in 80% of patients with coarctation); (iii) narrow pulse pressure in the descending aorta and lower body; (iv) a bidirectional shunt at the ductus arteriosus. The low measured gradient (despite severe anatomic obstruction) across the aortic arch is due to low cardiac output. In addition, hypoplasia or obstruction of other left-sided structures including the mitral valve, the left ventricle, and the aortic valve are not uncommon and must be evaluated during the initial echocardiographic evaluation. Following ductal closure in the newborn with a critical coarctation, the left ventricle must suddenly generate adequate pressure and volume to pump the entire cardiac output past a significant point of obstruction. This sudden pressure load may be poorly tolerated by the neonatal myocardium, and the neonate may become rapidly and critically ill because of lower body hypoperfusion. In infants with symptomatic coarctation, surgical repair is performed as soon as the infant has been resuscitated and medically stabilized. In infants with symptomatic coarctation and a large, coexisting ventricular septal defect, consideration should be given to repair both defects in the initial procedure through a median sternotomy. Balloon dilation of native coarctation is not routinely done at our institution because of the high incidence of restenosis and aneurysm formation, especially given the safe and effective surgical alternative. There are three anatomic subtypes of interrupted aortic arch based on the location of the interruption: distal to the left subclavian artery (type A), between the left subclavian artery and the left carotid artery (type B), and between the innominate artery and the left carotid artery (type C). More than 99% of these patients have a ventricular septal defect; abnormalities of the aortic valve and narrowed subaortic regions are associated anomalies. All other resuscitative measures will be ineffective if blood flow to the lower body is not restored. Oxygen saturations should be measured in the upper body; pulse oximetry readings in the lower body are reflective of the pulmonary artery oxygen saturation, and are typically lower than that distributed to the central nervous system and coronary arteries. High concentrations of inspired oxygen may result in low pulmonary vascular resistance, a large left-to-right shunt, and a "runoff " during diastole from the lower body into the pulmonary circulation. Inspired oxygen levels should therefore be minimized, aiming for normal (95%) oxygen saturations in the upper body. Surgical reconstruction should be performed as soon as metabolic acidosis (if present) has resolved, end-organ dysfunction has improved, and the patient Cardiovascular Disorders 495 Interrupted Aortic Arch 95% 75 45 70% 88% 95% 75 30 m = 12 55% m = 10 95% 75 10 82% 75 10 88% 60 40 Figure 41. Typical anatomic and hemodynamic findings include (i) atresia of a segment of the aortic arch between the left subclavian artery and the left common carotid (the most common type of interrupted aortic arch-break "type B"); (ii) a posterior malalignment of the conal septum resulting in a large ventricular septal defect and a narrow subaortic area; (iii) a bicuspid aortic valve occurs in 60% of patients; (iv) systemic pressure in the right ventricle and pulmonary artery (due to the large, nonrestrictive ventricular septal defect); (v) increased oxygen saturation in the pulmonary artery due to left-to-right shunting at the ventricular level; (vi) "differential cyanosis" with a lower oxygen saturation in the descending aorta due to a right-to-left shunt at the patent ductus. The repair typically entails a corrective approach through a median sternotomy, with arch reconstruction (usually an end-to-end anastomosis) and closure of the ventricular septal defect. Arch reconstruction and a pulmonary artery band (through a lateral thoracotomy) are generally not recommended, typically reserved for patients with multiple ventricular septal defects. A: Hypoplastic left heart syndrome in a 24-hour-old patient with falling pulmonary vascular resistance and a nonrestrictive ductus arteriosus. Typical anatomic and hemodynamic findings include (i) atresia or hypoplasia of the left ventricle, mitral, and aortic valves; (ii) a diminutive ascending aorta and transverse aortic arch, usually with an associated coarctation; (iii) coronary blood flow is usually retrograde from the ductus arteriosus through the tiny ascending aorta; (iv) systemic arterial oxygen saturation (in FiO2 of 0. B: Acute circulatory collapse following constriction of the ductus arteriosus in hypoplastic left heart syndrome. These neonates are typically in shock with poor perfusion, tachycardia, acidosis, and respiratory distress. Note (i) the low cardiac output (as evidenced by the low mixed venous oxygen saturation in the superior vena cava of 55%); (ii) narrow pulse pressure; (iii) elevated atrial and ventricular end-diastolic pressure-elevated left atrial pressure may cause pulmonary edema (note left atrial saturation of 93%); (iv) significantly increased pulmonary blood flow, as reflected in an arterial oxygen saturation (in FiO2 of 0. As systemic blood flow decreases, stroke volume and Cardiovascular Disorders 497 heart rate increase as a mechanism to preserve systemic cardiac output.


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Phases of fluid and electrolyte homeostasis in the extremely low birth weight infant menopause vs pregnancy symptoms generic sarafem 20 mg with mastercard. Water balance in very low-birth-weight infants: relationship to menstruation heavy bleeding discount sarafem american express water and sodium intake and effect on outcome pregnancy vitamins purchase sarafem without prescription. The definition of hypoglycemia as well as its clinical significance and management remain controversial. Blood glucose levels in the first hours of life are typically lower than normal values of older children or adults. In healthy babies, the blood glucose level can often be maintained in the appropriate range by initiating feeding soon after birth. Most cases of neonatal hypoglycemia are transient, respond readily to treatment, and are associated with an excellent prognosis. Persistent hypoglycemia is more likely to be associated with abnormal endocrine conditions, including hyperinsulinemia, as well as possible neurologic sequelae, but it is not possible to validly quantify the effects of neonatal hypoglycemia on subsequent neurodevelopment. Almost all fetal glucose derives from the maternal circulation by the process of transplacental-facilitated diffusion that maintains fetal glucose levels at approximately two-thirds of maternal levels. The severing of the umbilical cord at birth abruptly interrupts the source of glucose, and to maintain adequate glucose levels, the newborn must rapidly respond by glycogenolysis of hepatic stores, inducing gluconeogenesis, and utilizing exogenous nutrients from feeding. During this normal transition, newborn glucose levels fall to a low point in the first 1 to 2 hours of life, and then increase and stabilize at mean levels of 65 to 70 mg/dL by the age of 3 to 4 hours. The continued lack of a rational evidence-based definition of neonatal hypoglycemia has hampered the discussion of its incidence, effects, and treatment goals. Previous epidemiologic definitions that resulted in the acceptance of repeated glucose levels in the range of 20 to 30 mg/dL are no longer considered valid. One of the goals of current management is to anticipate and attempt to prevent symptomatic hypoglycemia rather than react to it. In 2000, Cornblath recommended the use of an "operational threshold" for blood sugar management in newborn infants. The operational threshold is an indication for action and is not diagnostic of disease or abnormality. Healthy full-term infant a) 24 hours of age-30 to 35 mg/dL may be acceptable at one time, but threshold is raised to 45 mg/dL if it persists after feeding or if it recurs in first 24 hours. Close surveillance is required and intervention is needed if plasma glucose remains below this level, does not increase after feeding, or if abnormal clinical signs are seen. Within the first hours of life, normal asymptomatic babies may have a transient glucose level in the 30s (mg/dL) that will increase either spontaneously or in response to feeding. A glucose level less than 40 mg/dL at any time in any newborn requires a prompt follow-up glucose measurement to document normal values. On the basis of developmental, neuroanatomic, metabolic, and clinical studies, our goal is to maintain the glucose value above 45 mg/dL in the first day, and more than 50 mg/dL thereafter. A report from the Eunice Kennedy Shriver National Institute of Child Health and Human Development workshop on neonatal hypoglycemia in 2009 identified the following knowledge gaps: 1. The complex nature and maturational features of global and regional brain energy use remain to be studied in human neonates. There is no evidence-based study to identify any specific plasma glucose concentration (or range of glucose values) to define pathologic "hypoglycemia. There is great inconsistency in the sources and sampling methods of blood (capillary, venous, arterial) and the methods used for subsequent analysis, including processing techniques, thus affecting "normal" values on the basis of existing literature. There are no noninvasive methods for measuring concentrations of glucose and other energy substrates (intermittently or continuously); the existing minimally invasive methods need further refinement for their utility. Hyperinsulinemic hypoglycemia is recognized as a major cause of persistent recurrent hypoglycemia in newborns, and it may be associated with an increased risk of brain injury since it not only decreases serum glucose levels but also prevents the brain from utilizing secondary fuel sources by suppressing fatty acid release and ketone body synthesis. Some cases of hyperinsulinemic hypoglycemia are transient and resolve over the course of several days, while others require more aggressive and prolonged treatment. Historically, the most common example of hyperinsulinism is the infant of diabetic mothers (see Chap. Developmental syndromes such as Beckwith-Wiedemann syndrome (macrosomia, mild microcephaly, omphalocele, macroglossia, hypoglycemia, and visceromegaly) iii. Malpositioned umbilical artery catheter used to infuse glucose in high concentration into the celiac and superior mesenteric arteries T11 to 12, stimulating insulin release from the pancreas vii. Abrupt cessation of high glucose infusion Fluid Electrolytes Nutrition, Gastrointestinal, and Renal Issues 287 viii. Insulin-producing tumors (nesidioblastosis, islet cell adenoma, or islet cell dysmaturity) 2.