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Codm an order 60mg cymbalta anxiety statistics, a surgeon at Massachusetts General Hospital purchase cheap cymbalta online anxiety symptoms of, sought to orient assessment o f the quality of medical care from structural or input evaluation—who did it—to process 6 The Impact of Medicine 7 and end-result evaluation—how and why order genuine cymbalta on-line anxiety symptoms getting worse. T he results revealed shock­ ingly low quality of care; only 89 of the 692 hospitals could meet the standards established for the study discount cymbalta express anxiety xanax dosage. Limited circu­ lation of the results aroused so much controversy that Cod- man could not at first get his findings published and then could not find sponsors for further research. He argued that patients should be required to pay only for good results, and that people should be aware of the results of their care. This is a slight variation on the practice in Babylon o f severing the physician’s hand if he failed to cure. He published annual reports that docum ented the results of his care and his methods o f accounting for the results. Cod­ m an concluded that 183 (or 54 percent) were managed without undue complications. For the rem aining 154 cases that were not satisfactorily managed in his judgm ent, 204 separate judgm ents were m ade to determ ine why problems arose. In most cases (roughly 76 percent), the problems were found to be due to errors in physician care, including surgi­ cal misjudgment, use of faulty equipm ent, or misdiagnosis. Second, and m ore puzzling than the failure of the medical care enterprise to examine its results, is the paucity of re­ search on the impact of care on the health of populations. Controlled clinical trials have been used to measure the impact of medical cures for individual patients. But, histori­ cally, with the surrender of medicine to the scientific m ethod, “population” medicine was relegated to the schools of public health, while medicine went to work on the indi­ vidual. Consequently, we know something about medicine’s impact on individual patients but very little about the impact of medical care on populations. T hird, there is even less research on the relative impact of 8 The Impact of Medicine personal medical care services and other socioenvironmental factors such as education, housing, air, water, seat belts, and Muzak. In other words, other than some anecdotal and impressionistic evidence, we have virtually no inform ation on the relative weight to assign to the various factors that bear on health, including medical care. First, evidence about the outcomes of medical care, when it is presum ed to be efficacious, is examined. T hen the obverse is examined—when the outcomes are adverse as a result of iatrogenesis, or disease “caused” by the medical care system itself. Next, the placebo effect is assessed, followed by a discussion of the im portance o f caring. The balance of the chapter examines the slender research on the impact of medical care on the health of populations and concludes with a review o f the even m ore sparse work on the relative impact o f medical care and other factors on health. To grapple with this subject, the following definitions de­ veloped by the W orld Health Organization can be used. T here is also evidence that it is poor in a surprisingly high num ber of instances. The Impact of Medical Care on Patients 9 T he Center for the Study of Responsive Law incorporated much of the research that has been done in its publication, One Life— One Physician. Lewis reviewed the records of the Kansas Blue Cross Association over a one- year period (only two hospitals in the state failed to partici­ pate in the review). He tabulated the num ber o f elective operations for removal of tonsils, hem orrhoids, and varicose veins, and the operations for hernia repair, in all the hospi­ tals in each of the state’s 11 regions. Variations for the average rate o f these four elective surgical procedures ranged from a low of 75 operations per 10,000 persons in one region to a high of 240 operations per 10,000 persons in another. Striking variations were also found between regions within each elective surgical category. T he high and low regional incidences (rounded off) per 10,000 persons were: for tonsillectomy, 153 and 432; for hem orrhoidectom y, 11 and 35; for varicose veins, 3 and 7; and for hernia repair, 18 and 43. T here is little doubt, however, that part of the variation is due to the relationship between the medical care provided and the num ber and type o f providers providing it. In the United States, there are twice as many surgeons in proportion to population as in England and Wales. If the results of the H alothane study are accurate, many patients are rolling dice with their lives when they seek care. In general, the research shows that the quality of medical care varies greatly; many instances of poor care can be found. T he data are also remarkable in light of the presuppositions most consumers hold about the quality and reliability o f medical care. Most of the studies in the report judge the quality of care by examining the “processes” of care rather than “outcomes” of care. In other words, the “m anner” in which care was provided is the focus of most o f the studies, rather than the actual “outcomes” o f care. Initially, only 94 of the 141 patients com pleted the battery of studies based on diagnostic X-rays; 77 (or 55 percent) re­ ceived an adequate work-up based on the intern’s diagnostic impression; but only 37 o f 98 patients, having received diagnostic X-ray examinations, were inform ed whether the findings were normal or abnormal; and only 14 of the 38 patients with abnorm al X-ray results (or 37 percent) ap­ peared to have received adequate therapy for the conditions indicated. Thus, the study resulted in effective medical care for only 38 patients (or 27 percent). N either effective nor ineffective care was given to 19 patients, or the rem aining 13 percent. T he study was not conducted in a small rural hospital, nor in the inadequate and shabby facilities often found in m ajor public hospitals. It was conducted in the Baltimore City The Impact of Medical Care on Patients 11 Hospital emergency room, where it was assumed that the competence and efficiency of the house staff would be optimal. Although few doubts were expressed by his superiors about his m ethodol­ ogy, the uncritical assum ption was that the findings of the study were characteristic of City Hospital, a less prestigious institution than Johns Hopkins. T he challenge proved too much for Brook; his next target was the em ergency room at Johns Hopkins. Using essentially the same methodology, Brook’s work revealed that only 28 percent o f 166 patients with gastrointestinal symptoms were given acceptable care, 2 percent less than in the City Hospital. And, although he has refrained from generalizing about his re­ sults, that is, from drawing inferences about medical care in general from treatm ent of the “tracer” condition, generaliza­ tion seems w arranted. Less 12 1‘he Impact of Medicine understandable is medicine’s persistent refusal to examine what it does for the patient in relation to the result to the patient. T here are a num ber of reasons why this occurs, but a principal one is that the physicians need to keep busy. Tonsillectomy is the most common surgi­ cal procedure perform ed in W estern civilization. Nevertheless, recent data reflect that, in most communities, approxim ately 20 to 30 percent have their tonsils rem oved. Nonetheless, because of the volume of cases, tonsillectomies account for 100 to 300 deaths annually in the United States. Finally, there is some evidence that removal of the tonsils results in the loss to the patient o f an invaluable “im munity” mechanism, possibly linked to increased risk o f H odgkin’s disease and bulbar poliomyelitis. T he young tonsillectomy candidate, perhaps five or six years of age, is made captive in a hospital, separated from his or The Impact of Medical Care on Patients 13 her parents, and surrounded by mysterious figures in white coats. T he emotional harm is dem onstrable, and the pallia­ tive ice cream at the end of surgery hardly compensates. The psychiatric literature contains evidence that childhood tonsillectomy often has profound irreversible and lifelong repercussions.

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Not in every country a psychiatric assessment is required: in the Netherlands purchase line cymbalta anxiety 34 weeks pregnant, for instance cymbalta 60mg for sale anxiety disorder 3000, psychological counseling will suffice in several cases; • Hormone therapy and real life experience buy cymbalta 30mg without prescription anxiety symptoms duration. During this phase purchase cymbalta 60 mg anxiety problems, cross-sex hormones are administered and the patient gets ac- quainted with the new gender role, with the assistance of social workers; • Sex reassignment surgery; • Follow-up. Italy is considered one of the leading countries in Europe in the field 6 of sex reassignment surgery, with approximately a dozen hospitals providing this kind of treatment. Our search for dedicated websites yielded very limited results: only three public clinics (Bari, Bologna and Rome) offer some kind of information to potential patients, while the others can only be contacted by phone or e-mail. But again, the consultation of the websites led to rather similar findings as for Italy: only four of them include detailed information, while six hospitals just mention geschlechtsan- gleichende Operationen or similar terms among their treatments; in the remaining three cases, no mention at all can be found. In Italy and Germany, therefore, this field of medical intervention still appears to be covered by taboos or at least affected by lack of communication. In the Netherlands there are only two public clinics and infor- mation centers: this is in line with the growing tendency to concentrate highly specialized medical assistance in few centers of excellence. Gender Dysphoria 173 • informatie over de behandelrichtlijnen en behandelmethoden van het Kennis-en Zorgcentrum voor Genderdysforie8 The site presents ten patient brochures, varying in length from 10 to 20 pages, some of which with a glossary, and there is also a com- pletely electronic brochure. They are government-funded and their aim is to gather and disseminate information and knowledge in different social and economic sectors, such as health, education, environment. These first findings can already give a hint about cultural differ- ences in the perception of transsexualism and other forms of gender variance in the three countries involved, and also about different per- spectives on communication. So, in spite of the limited number of websites, it was decided to go on with the analysis of the texts in order to collect some preliminary data, to be verified in the future by contacting the hospitals and examining other text types. In this first phase, the analysis was focused on the collected texts, and did not cover other aspects, such as layout, images, audiovisual material etc. They focus mainly on the trans- mission of factual information without showing awareness of the dif- ferent cultural and technical background of the potential readers; much less attention is paid to interpersonal interaction. The German and Dutch texts, on the contrary, are more geared towards their potential readers and are probably the result of an intra-linguistic translation and/or adaptation of more complex texts. In the Italian texts, many descriptions show a high density of terms, typical of a communication between experts and not suitable for informing potential patients. The following excerpts, where we have underlined the more technical terms, exemplify this point: (3) Il lembo, di forma rettangolare, viene successivamente tubulizzato per forma- re il neo-fallo e trapiantarlo in regione pubica dove viene inserito sopra un piccolo lembo cutaneo di forma triangolare creato sul pube per allargare la base di impianto. Come il lembo prelevato dall’avambraccio, anche questo viene trasferito con tecnica microchirurgica eseguendo microanastomosi arte- riose, venose e nervose. As discourse specialist Ren- kema puts it, “a text can fail on the comprehensibility dimension when a writer puts too little effort into adjusting to the reader’s knowledge level” (2004: 183). For other concepts as well, the Italian texts use abbreviations, acronyms and English loan words without providing the full forms or an Italian equivalent. In the German and Dutch texts, on the contrary, many instances of de-terminologisation can be found, that is “the process of recon- textualisation and reformulation of specialized terms aiming at making the concepts they designate relevant to and understandable by a lay audience” (Montalt/Shuttleworth 2012: 16). Traditional terminology of Greek and Latin origin is not completely avoided, as it can be even useful for educational purposes, which are an important feature of patient brochures (Montalt-Resurrecció/González Davies 2007: 31), but it is often accompanied by detailed and understandable explana- tions. In the following examples in German, terms of Latin and Greek origin are preceded by paraphrases (5), and the reader is also provided with an explanation of the adjective frei in its technical meaning (6): 176 Mariella Magris / Dolores Ross (5) Dieser Eingriff dauert etwa sieben bis neun Stunden und beinhaltet: • die Entfernung der Brüste (Mastektomie) • die Entfernung der Gebärmutter (Hysterektomie) • die Entfernung der Eierstöcke und Eileiter (Ovarektomie, Adnektomie) • die Entfernung der Scheide (Kolpektomie) (Klinik Sanssouci Potsdam) (6) Operationsschritt zur Penoidkonstruktion: • Aus freiem Unterarmlappen oder • aus freiem Unterschenkellappen mit Anteilen des Wadenbeins zur Versteifung mit eigenem Gewebe (Fibula-Knochen ) Frei bedeutet, dass das Gewebe vom Unterarm oder vom Unterschenkel bei der Operation unter dem Operationsmikroskop an die Blutgefäße in der Leiste angeschlossen werden muss. But the lexis of the Germanic languages has been enriched with extensive loanwords from Latin, with an admixture from Greek, either directly transmitted or through the influence of French and English (Hawkins 1990: 75, Finegan 1990: 81, Kooij 1990: 140), thus creating a fairly remarkable split in the vocabulary of these languages between popular and learned words. Compared to Italian, the two Germanic languages clearly exploit their double-layered terminology: in German, for instance, almost every term of Latin or Greek origin has a synonym of vernacular origin (Puato 2011: 119), which is often built by substituting the erudite roots, prefixes and/or suffixes with their ‘inherited’ counterparts. In communicating with patients, the use of these ‘doublets’ can enhance comprehension and have an educational effect: “Die Arterien (Schlagadern) und Venen (Bluta- dern) […]”, “Faszien (Bindegewebshüllen)”, “Urethra (Harnröhre)” are just a few examples from the analyzed websites. The following sentence, for instance, avoids Urethra altogether and uses only Harnröhre: “Häufig kann das Prob- Gender Dysphoria 177 lem mit einem durch die Harnröhre geführten endoskopischen Eingriff beseitigt werden”. The following excerpt from a patient brochure on laparoscopic surgery contains very short sentences with simple syntax, word repetitions and explanations of terms in plain lan- guage. See for instance the explanation of the term hormones in this excerpt: (8) Behandeling met geslachtshormonen Hormonen zijn stoffen die op een bepaalde plaats in het lichaam worden gemaakt (de hormoonklier), aan het bloed worden afgegeven en elders in het lichaam hun effect uitoefenen. Zij worden zo genoemd, omdat zij in de geslachtsorganen worden gemaakt en verantwoordelijk zijn voor de ontwikkeling van het lichaam in mannelijke of vrouwelijke richting. Through one of these small incisions a laparoscope is introduced into the abdomen: this is a long, thin tube enabling the doctor to look into the abdomen. Hormones are substances produced in a particular place in the body (hormone gland), they are released into the blood and have an effect elsewhere in the 178 Mariella Magris / Dolores Ross There are only one Italian and one German website providing glossaries of key terms. These glossaries, however, do not cover all specialized terms contained in the texts, they force the reader to interrupt the reading process and definitely do not represent a reader- friendly alternative to lexical clarity of texts. We think that greater attention should be paid to terminological issues, as the terminology of this specific domain includes many neologisms and – as already seen – controversial terms. We have the impression that the authors of the site have made special efforts to guarantee proper communication, as this subject touches on quite delicate questions. The Italian texts are quite impersonal: they never directly address potential readers and refer to them in the third person as persona, soggetto and the like. In Germany and the Netherlands, no court judgment is needed: in Germany two psychological assessments are required, while in the Netherlands the decision is taken by the gender team, which includes physicians from different specialities as well as a psychiatrist. The absence of similar passages in the Dutch and German texts, therefore, might be due not only to differences in communicative style, but also (and perhaps more prominently) to the legal context of the surgical intervention. The next Italian example, on the contrary, is not related to any national specificity, as it points to the side effects, stressing that they can be minor, but also very serious and even life-threatening. Of course, it is fundamental to inform the reader about risks and compli- cations, but not necessarily in such a way as to discourage potential patients. While in German Sie cor- responds to the standard form used in web communication, in Dutch u might seem a formal choice, as in most contexts the second person singular pronoun jij/je is used, but it may have been chosen to express respect towards people with this condition. Uw lichame- lijke geslacht kan in een driejarig traject (achttien maanden preoperatief en achttien maanden postoperatief) worden aangepast aan uw genderidentiteit. In the Dutch excerpt in (14), the authors show a deep understanding of the many individual experiences of being transsexual and of the difficulty of coping with it. Enerzijds zien we dat patiënten vaak jarenlang vermijdingsgedrag hebben laten zien en niet in staat zijn om diepgaande contacten te onderhouden met andere mensen. Your biological sex can be adapted to your gender identity in a 3-year process (with an eighteen-month preoperative and an eighteen-month postoperative phase). On the other hand, we see patients who sometimes try so hard to come to terms with their biological sex, that they show features Gender Dysphoria 181 Another common trait of German and Dutch texts is that they appear to be much more reassuring than the Italian ones. In German, em- phasis is often placed on the possibility of achieving good, sometimes even excellent, results, thanks to well-tested surgical techniques: (15) Mann-zu-Frau-Operationen sind inzwischen zu standardisierten Eingriffen herangereift, die bei sorgfältiger Indikationsstellung und guter Vorbereitung in mehr als 80 Prozent der Fälle nach ein oder zwei Operationen zu guten funk- tionellen und kosmetischen Ergebnissen führen. Dies erfordert viel Erfahrung eines auf Transsexualität hoch spezialisierten Ärzteteams, welches in der Klinik Sanssouci Potsdam fester Bestandteil der transsexuellen Chirurgie ist. As already said, the Italian selected websites are run by public centers, and the same goes for the two Dutch clinics, whereas the German corpus includes some private clinics as well. Moreover, in Italy the sex reassignment surgery is covered by the National Health System (provided that there is a court judgment allowing it), whereas in Germany and the Netherlands it is refunded by health insurance companies. In these two countries, therefore, there could be the need to ‘promote’ this kind of surgical intervention and also the clinics performing it, and this could have influenced the wording of the texts.

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Approxi- patients in whom azathioprine therapy failed sub- mately 75% were administered oral corticosteroids sequently responded to cyclosporine A (CsA) and at the start of the study buy cymbalta cheap online anxiety for dogs. These studies376−378 suggest that inhaled cor- patients with chronic sarcoidosis with azathioprine ticosteroids have minimal value as the primary plus prednisolone order cymbalta 30mg with mastercard anxiety symptoms 101. Extensive ate cheap cymbalta 40mg with visa anxiety 38 weeks pregnant, azathioprine purchase cymbalta with paypal anxiety symptoms losing weight, cyclosporine, chlorambucil, clinical experience with azathioprine in organ cyclophosphamide, and leflunomide) have been transplant recipients and other immune disorders used, with anecdotal successes, in patients in suggests that serious late sequela associated with whom treatment is failing or who are experiencing chronic azathioprine use are uncommon. However, ran- Methotrexate: Methotrexate, a folic acid antago- domized trials evaluating these agents are lacking, nist with both immunosuppressive and anti- and the best agent has not been determined. In uncontrolled studies387,88 by investigators Azathioprine: azathioprine (2 to 3 mg/kg/d), from the University of Cincinnati who evaluated alone or combined with corticosteroids, has been 230 patients, favorable responses to methotrexate associated with anecdotal successes in sarcoidosis, were cited in 52 to 66% of patients. Further, studies directly comparing Although these studies are not definitive, azathioprine with alternative agents for sarcoidosis methotrexate has a role as a steroid-sparing agent are lacking. Because of potential toxicities, patients in whom corticosteroid therapy is failing methotrexate should be restricted to patients responded to azathioprine. In another retrospective requiring unacceptably high doses of corticoste- study,381 8 of 14 patients with neurosarcoidosis roids ( 20 mg/d prednisolone or equivalent) or responded to azathioprine. In a study395 from the National Insti- which may occur in up to 2% of patients with long- tutes of Health, eight patients with symptomatic term use ( 2 years). A subsequent Contraindications to methotrexate include study381 by these investigators cited favorable ethanol abuse, concomitant liver disease, history responses in 11 of 14 patients with neurosarcoid- of hepatitis, patients unable to adhere to dosing osis treated with CsA. Adverse effects (particularly renal enzymes, thrombocytopenia, or leukopenia war- insufficiency and infections) and relapses were rant discontinuation of therapy or reduction of the greater in the patients receiving combined ther- dose. I prefer the myriad complications associated with its azathioprine for patients with chronic, progressive use and the lack of demonstrated efficacy, cyclo- sarcoidosis requiring long-term treatment ( 1 sporine has at best a marginal role as salvage year). Anecdotal responses have been noted with the antimalarials for cutaneous,404 osse- Published data regarding alkylating agents (eg, ous,374 and neurologic405 sarcoidosis and sarcoid- cyclophosphamide, chlorambucil) for the treat- induced hypercalcemia. Given the potential serious ocular Nonsteroidal antiinflammatory agents (eg, toxicity associated with chloroquine, hydroxychlo- indomethacin and phenylbutazone) have been roquine, which is less toxic, is preferred. The dose used to treat the acute articular manifestations of of hydroxychloroquine is 200 mg once or twice sarcoidosis, but have no role in treating more daily for a 6-month trial. Slit-lamp Antimalarial Drugs: Antimalarial drugs (eg, examinations should be done by an ophthalmolo- chloroquine and hydroxychloroquine) have immu- gist every 9 months to rule out ocular toxicity. The nomodulating properties and are efficacious in combination of hydroxychloroquine with cortico- treating rheumatoid arthritis, systemic lupus ery- steroids or immunosuppressive agents may thematosus, and diverse immune-mediated dis- enhance immunomodulatory effects compared eases. High-reso- tive interstitial pneumonia and respiratory bron- lution computed tomography in idiopathic pul- chiolitis-associated interstitial lung disease. Mortality esophageal reflux in patients with idiopathic pul- from pulmonary fibrosis increased in the United monary fibrosis referred for lung transplantation. Prev- Occupational and environmental risk factors alence of gastroesophageal reflux in end-stage for idiopathic pulmonary fibrosis: a multicenter lung disease candidates for lung transplant. Association between ischaemic heart dis- fibrosis requiring mechanical ventilation for acute ease and interstitial lung disease: a case-control respiratory failure. Role of diabe- features and outcome of patients with acute tes mellitus and gastro-oesophageal reflux in exacerbation of idiopathic pulmonary fibrosis the aetiology of idiopathic pulmonary fibrosis. Mediastinal lymphadenopathy in cryp- nary fibrosis and lung cancer: risk and benefit togenic fibrosing alveolitis: the effect of steroid analysis of pulmonary resection. Diffuse lung interstitial pneumonias: prevalence of mediasti- diseases: a comprehensive clinical-radiological nal lymph node enlargement in 206 patients. A randomized pulmonary fibrosis: histopathologic study on placebo-controlled trial of bosentan in patients lung explant specimens and correlations with with idiopathic pulmonary fibrosis. Diffuse interstitial pneumonitis: clinicopatho- Brain natriuretic peptide and exercise capacity in logic correlations in 20 patients treated with pred- lung fibrosis and pulmonary hypertension. Pul- patterns: survival comparison with usual inter- monary hypertension in patients with idiopathic stitial pneumonia and desquamative interstitial pulmonary fibrosis. A pla- bined corticosteroid and cyclophosphamide cebo-controlled trial of interferon gamma-1b therapy does not alter survival in idiopathic pul- in patients with idiopathic pulmonary fibrosis. Randomised and clinical effects of high-dose N-acetylcyste- controlled trial comparing prednisolone alone ine in fibrosing alveolitis: adjunctive therapy to with cyclophosphamide and low dose prednis- maintenance immunosuppression. Immunosuppres- ment of idiopathic pulmonary fibrosis with a new sive and cytotoxic pharmacotherapy for pulmo- antifibrotic agent, pirfenidone: results of a pro- nary disorders. Nonspecific recipient age and procedure type on survival after interstitial pneumonia in collagen vascular dis- lung transplantation for pulmonary fibrosis. Sarcoidosis Vasc Diffuse Lung registry of the International Society for Heat and Dis 2003; 20:235–241 Lung Transplantation: twenty-first official adult 301. Sarcoid- to tumor necrosis factor-alpha, in patients with osis, race, and short-term outcomes following moderate-to-severe heart failure: results of the lung transplantation. The primary tive pulmonary disease, which occurs in up to systemic vasculitides are a heterogeneous group of two thirds of these patients, is thought to result syndromes of unknown etiology that share a clini- from a combination of smoking and an unknown cal response to immunosuppressive therapy. Granulomatosus inflammation of the ves- Pulmonary complications are the result of sel wall is found in 60% of temporal artery biopsy a unique arteriopathy predominantly of the specimens. The clini- Progressive defects in the outer media of the cal illness appears gradually with the development arteries and ingrowth of granulation tissue-like of nonspecific systemic symptoms such as low- capillaries associated with thickened intima and grade fever, malaise, and weight loss. Severe disease is either life threatening quently, antiviral therapy plays a prominent role or threatening an organ with irreversible loss of in the management of such cases in addition to function. In contrast, most symptoms leading to the vasculitides are most likely to cause respiratory classification as limited disease are the result of manifestations. Other histopathologic find- few or no immune deposits, affecting small vessels ings, including bronchiolitis obliterans organizing (ie, capillaries, venules, or arterioles). Necrotizing pneumonia, bronchocentric inflammation, and a arteritis involving small and medium-sized arteries marked number of eosinophil infiltrates, are atypi- may be present. Particularly, subacute bacterial endocarditis male/female ratio is about equal, and 90% of may represent a diagnostic dilemma because it patients are white. However, Fauci,40a the consensus now is to limit the dura- its use is preferred over oral cyclophosphamide in tion of cyclophosphamide therapy to the first 3 to patients with questionable compliance, in young 6 months. In the National infliximab therapy was associated with a high Institutes of Health report on 158 patients, perma- frequency of infections with bad outcomes. Only 11% of the enrolled patients did not 692 Pulmonary Vasculitis and Alveolar Hemorrhage Syndromes (Specks) exhibit a single point on the vascular damage index eosinophilic pneumonia. In contrast, peripheral nerve and consisted of regional wall motion abnormali- involvement, typically in the form of mononeuritis ties in 17 patients (65%), left ventricular systolic multiplex, is more frequent. Other findings included valvu- necrotizing vasculitis, eosinophilic tissue infiltra- litis, left ventricular aneurysm, and a large intra- tion, and extravascular granulomas. Available case studies a number of years, and the manifestations may and limited population-based incidence estimates remit and recur during this time period. Accordingly, cyclophosphamide should be added Secondary thrombosis with major venous occlusion to glucocorticoids for remission induction in all can occur.

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The likelihood of obtaining a radiographically: Langerhans cell histiocytosis diagnostic biopsy is related to the number of results from dilated bronchioles order cymbalta online pills anxiety symptoms in teens, paracicatricial specimens obtained cheap cymbalta 60 mg on line anxiety krizz kaliko lyrics, and the best results require a airspace enlargement (so-called scar emphy- minimum of 4 specimens in patients with stage 2 sema) cymbalta 60mg amex anxiety 5 steps, and necrosis in the center of the lesions discount cymbalta 20mg without a prescription anxiety frequent urination. Microscopic find- lymphangitic nonnecrotizing granulomatous ings include non-necrotizing granulomatous inflammation associated with broad foci of inflammation (although the granulomas often parenchymal necrosis and vasculitis. Differential Diagnosis of Diffuse Lung Disease With Small Granulomas* Hypersensitivity Pneumonitis Sarcoidosis Hot Tub Lung Interstitial pneumonia − − Chronic bronchiolitis − − − Granulomas Well formed − Single giant cells − − − Necrosis − Organizing pneumonia − − − Cultures − − Mycobacterium avium intracellulare * rare; occasional; prominent feature. Associations and Causes of Chronic Eosinophilic lung; (2) hemorrhage with or without capillari- Pneumonia Pathology tis (vasculitis involving capillaries recognized by presence of neutrophils in alveolar walls); Allergic bronchopulmonary fungal disease Simple pulmonary eosinophilia (3) bronchocentric; (4) organizing pneumonia- Systemic infection (parasites, fungi) like; and (5) eosinophilic pneumonia-like. Churg Strauss syndrome Positive p-antineutrophil cytoplasmic antibody Hodgkin lymphoma titers generally representing autoantibodies Inflammatory bowel disease directed against myeloperoxidase are less spe- Lung cancer cific but have been reported to be positive in *From Uchiyama H, Suda T, Nakamura Y, et al. Asbestos bodies are iron-encrusted fibers (one Classic pathology includes the following: type of ferruginous body, which is a more generic • Necrotizing granulomatous inflammation with term) that typically are beaded and dumbbell shaped geographic borders (appears more like paren- with a thin translucent core. There are no generally chymal necrosis than a true granuloma since accepted criteria defining how many asbestos bodies the foci usually lack significant numbers of epi- must be identified in any given case for a diagnosis thelioid histiocytes); of asbestosis, but the presence of even a single Centrally in foci of necrosis there is amor- asbestos body in a routine tissue section usually phous eosinophilic to basophilic debris with signifies “above-background” asbestos exposure. Pulmonary Complications of Asbestos Exposure* Palisading granulomas are tiny granulomas composed of a single layer of palisading epi- Pleural disease thelioid histiocytes that either radiate around Effusion a central point or surround a central eosino- Fibrosis philic structure resembling a collagen bun- Plaques dle. As the palisaded granulomas enlarge, Pseudoneoplasms (rounded atelectasis) Parenchymal lung disease they become more microabscess-like; Asbestosis • Necrotizing segmental (involving portion of Asbestos airways disease the wall) vasculitis of arteries and veins; and Neoplasms • Randomly dispersed, darkly staining multinu- Malignant mesothelioma cleated giant cells common variants. Simple (nodular) silicosis Silicotic nodules 1 cm Upper lung zones Pulmonary Infections Complicated silicosis Conglomerate nodules 1 cm See Tables 9−12 for a listing of pulmonary infec- Upper and middle lung zones tions. Microscopic findings include: The grading scheme is strictly pathologic and • Discrete foci of concentric layers of hyalinized does not rely on clinical parameters (eg, for the collagen; diagnosis of obliterative bronchiolitis syndrome): Abundant dust-filled histiocytes; and • Grade 0, negative for rejection: normal pulmo- Birefringent particles (usually); often a mix of nary parenchyma without evidence of mono- silica and silicates); nuclear infiltration or alveolar hemorrhage; When necrosis is present, complication by • Grade 1, minimal acute rejection: infrequent tuberculosis should be considered. Alveolar pneumocyte damage usually is asso- Small cell carcinoma typically is peribronchial; ciated with necrosis, airspace hemorrhage, endobronchial lesions are uncommon. Anti- ically, small cell carcinomas are round-to-fusiform body-mediated rejection and pulmonary hem- nuclei, nuclear molding, faint or absent nucleoli, orrhage, capillaritis, and complement deposi- and have scant cytoplasm. Immunohisto- with extensive necrosis, large nuclei with promi- chemistry is thyroid transcription factor 1–, cyto- nent nucleoli, and no evidence of squamous or keratin 5/6, and p63. Acute rejection (perivascular, interstitial and alveolar synaptophysin: 10 to 20% , cytokeratin 7 and inflammation) cytokeratin 20±, and thyroid transcription factor 1. Airway inflammation In bronchioloalveolar carcinoma there are nod- Grade 0 – None ules or areas of consolidation, more commonly Grade 1R – Low grade Grade 2R – High grade peripheral. Chronic vascular rejection – accelerated graft vascular sclerosis well differentiated, uniform, and grows along intact Antibody-mediated rejection alveolar walls, and there is no invasion into underly- ing stroma. Neuroendocrine Cell Hyperplasia References Neuroendocrine cell hyperplasia43 is defined [Note to participants regarding references: there are as increased neuroendocrine cells within bron- some primary sources quoted, but the textbooks chiolar epithelium. American Thoracic Society/European Respira- tory Society International Multidisciplinary Con- Microscopic findings include organoid, pali- sensus Classification of the Idiopathic Interstitial sading, trabecular patterns; large, polygonal nuclei Pneumonias. Respiratory bron- pulmonary fibrosis: relationship between histo- chiolitis-associated interstitial lung disease and its pathologic features and mortality. Profusion phoid interstitial pneumonia: clinicopathologi- of fibroblast foci in patients with idiopathic pulmo- cal and immunopathological findings in 18 cases. Idio- pulmonary disease caused by nonturberculous pathic nonspecific interstitial pneumonia: report of mycobacteria in immunocompetent people (hot an American Thoracic Society project. When patients with a supplied by the bronchial circulation that is situated pleural effusion are symptomatic, dyspnea and a greater distance from mesothelial surface. An may be caused by a large or massive pleural effu- ultrafiltrate of parietal pleural capillaries increases sion in a patient with normal lungs, a moderate interstitial pressure and promotes movement of effusion in patients with some underlying lung fluid into pleural space between the mesothelial cell disease, and a small-moderate effusion in patients junctions. Dyspnea is perceived by the patient with a Virtually all patients with a newly discovered large-to-massive pleural effusion because of its pleural effusion should have a thoracentesis per- effect on the previously mentioned structures with formed to obtain a diagnosis to guide manage- input from neurogenic receptors in the lung and ment. Pleuritic chest pain has been aforementioned examples; however, if the clinical described as having a “stitch in the side” or a “stab- bing” or “shooting” pain that may be exacerbated by deep inspiration, cough, or sneezing. However, the number or squamous epithelial cells on cytology and specific definitive diagnoses will vary with Fungal effusion Positive potassium hydroxide stain the population being studied. In a prospective or culture study of 129 patients with pleural effusion, tho- Chylothorax Triglyceride 110 mg/dL (high racentesis provided a definitive diagnosis in only likelihood); presence of chylomi- crons definitive 18% of patients and a presumptive diagnosis in Hemothorax Hematocrit (pleural fluid/blood 55% of patients. Interleukin-5 appears to be an impor- Some diagnoses can be established at the bed- tant chemotactic factor attracting bone marrow- side by visual inspection of the fluid (Table 3). In example, if pus is aspirated from the pleural space, patients who require thoracotomy for spontaneous the diagnosis of empyema is established and, if pneumothorax, eosinophilic pleuritis is commonly the pus has a putrid odor, anaerobic organisms encountered within hours of the pneumothorax. A coccidioidomycosis Drug-induced Dantrolene, bromocriptine, transudate, which is caused by imbalances in nitrofurantoin, valproic acid, hydrostatic and oncotic pressures, is associated and others 11 with a normal pleura. A metaanalysis of 1,444 patients11 determined that all effusion, they provide information helpful in man- agement strategies; and (3) in malignant effusions, of the following tests have statistically similar it provides information relating to extent of pleural involvement with tumor, ease of diagnosis, prog- nosis, and management. A Bayesian approach with application of Constrictive Bilateral effusions due to likelihood ratios to pretest estimates of the prob- pericarditis pulmonary and systemic ability of an exudative effusion improves diagnos- hypertension Trapped lung A result of remote pleural tic accuracy. However, an elevated brain natriuretic diomegaly in a patient with bilateral effusions peptide and compatible echocardiogram demon- should raise the possibility of another cause of the strating a low left ventricular ejection fraction or diastolic dysfunction supports the diagnosis. The chest radiograph usually dem- Noonan syndrome onstrates a small-to-moderate right effusion 70% Lymphangiectasia of the time; an isolated left pleural effusion and Movement of fluid from abdomen to pleural space Acute pancreatitis bilateral effusions have each been reported in approximately 15% of patients. Approximately unilateral or bilateral effusions with minimal evi- 25% of patients have a refractory hepatic hydro- dence of volume loss with a normal heart size and thorax. The diag- diaphragmatic defects and perform talc poudrage nosis is presumptive based on the patient’s presen- has been used but is associated with a high rate of tation. Furthermore, chest tube drainage in these individuals is contraindicated because it promotes Nephrotic Syndrome infection, depletes protein and lymphocytes, and increases the risk of renal failure and often creates Effusions develop in 20 to 25% of patients with a prolonged fluid leak after removal of the chest nephrotic syndrome. Liver transplantation is the best treatment for effusions is associated with the degree of hypoal- decompensated hepatic cirrhosis and, therefore, buminemia. Pulmonary embo- embolism without an infarction, an endobronchial lism should always be considered in patients with obstruction from lung cancer, acute pancreatitis, nephrotic syndrome who develop pleuritic chest splenic infarction, and subphrenic or hepatic pain when the pleural effusion is significantly larger abscess and the absence of a sympathetic effusion. Finding a Trapped lung, the end stage of an infectious or transudate by these criteria in effusions of vascu- inflammatory pleural effusion, presents as a per- lar origin almost always indicates a normal sistent transudative effusion months to years after protein reflection coefficient but also increased the acute pleural process. It is a relatively uncom- filtration and increased lymphatic bulk flow mon cause of a pleural effusion, representing 5% conditions, narrowing the differential diagnosis of effusions in the Medical University of South considerably. These patients Patients with trapped lung may present with typically have a pleural elastance of 15 cm of H2O an asymptomatic pleural effusion seen on a rou- per liter of fluid removed. Failure of the lung to tine chest radiograph or with dyspnea on exertion expand on chest radiograph after removal of all months to years after the acute pleural injury. The The chest radiograph typically shows a small- pathogenesis of these effusions is decreased to-moderate unilateral effusion without signifi- oncotic pressure that generally requires a serum cant mediastinal shift. It is highly unlikely a with a low nucleated cell count, typically 500/ L, patient with hypoalbuminemia presents with an and a mononuclear predominance characterized isolated pleural effusion without concomitant by a lymphocytosis 50% of the total nucleated anasarca. We still believe effusions and is generally not dyspneic at rest or that the fluid should be considered a transudate with minimal activity; however, those patients with and that the pleural protein concentration depends significant underlying pulmonary disease or heart on the plasma protein concentration, the protein disease may be breathless on exertion. The chest reflection coefficient, solvent filtration into the radiograph typically shows small-to-moderate 520 Pleural Disease (Sahn) bilateral effusions with a normal heart size.

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This tissue will often be quite tender buy cymbalta 20mg free shipping anxiety cures, and the There is still the possibility of sensing the firm tone order generic cymbalta online anxiety over the counter, patient is probably not accustomed to deep pressure rounded shape and fibrous texture of the muscle even on the abdomen generic cymbalta 60 mg amex anxiety symptoms dizziness. Simply maintaining steady pressure buy cymbalta uk anxiety symptoms 8dp5dt, though direct contact with the muscle has been or decreasing pressure slightly before slowly definitely lost. Visualization of the muscle is of enormous increasing it again, will help the patient to relax into value during this part of the exercise. This procedure continues with the examiner slowly and The examiner slowly increases pressure until a firm incrementally decreasing pressure, holding onto the tissue is reached. This is the anterior surface of the mind’s visual picture of the muscle, and working to psoas muscle and will most likely be very tender. This is done until Maintaining this deep pressure, the examiner moves the the examiner can no longer sense any trace of the fingertips across the fibers of the psoas, slowly, to get a muscle’s firmness or texture. This fibrous investigate this transition place – where the muscle is texture, along with the firmness of the muscle, absolutely no longer palpable. Having the The examiner should then very slowly decrease pressure patient briefly flex the hip will increase the tone of the until the hands are simply resting on the patient’s psoas, confirming that this is what is being palpated. The examiner should create a visual picture of the Thank your palpation partner and switch roles. The way the tissues respond when the barrier is released can also offer information. Both are capable of being employed in therapeutic How we make sense of what we feel when palpating settings to treat localized dysfunction (such as myo- has been researched, as have issues of sensitivity fascial trigger points – see Chapter 7) as well as and interpretation. Some of these were discussed in in more general, whole-person applications (see Box 6. Note: It is worth keeping in mind that palpation and assessment, when performed improperly (heavy handedly, clumsily, too rapidly, too persistently, etc. A small spring-loaded, rubber-tipped, pressure thresh- Such action would not be in line with the tenets of old meter (algometer) can be used to measure the naturopathy – first do no harm. When treatment has been successful, the pres- a short space of time, definite changes occur that may sure threshold over the trigger point should increase distort the findings – for example, in the firing markedly (Fig. Here the hand is stationary and (the cream is to ensure that no dragging occurs on only the thumb moves. Reproduced with permission from Chaitow (2003b) from Chaitow (2003b) Continued 136 Naturopathic Physical Medicine Box 6. Reproduced with permission • If trigger points are located, their target (referral) area from Chaitow (2003b) should also be noted (trigger point assessment is described below). Reproduced with permission from Chaitow (2003b) A B 138 Naturopathic Physical Medicine cephalad than the right. The pelvis will roll passively easier to the right than to the left because the lumbar spine is side-flexed left and rotated right. The left infraclavicular parasternal area is more prominent anteriorly, because the thoracic inlet is side-flexed right and rotated right. Tissue preference is the sense that the palpating hands derive from the tissues being moved, as to the preferred direction(s) of movement (for example, at its simplest, ‘this area turns more easily to the right than the left – and therefore has a “preference” to turn right’). Reproduced series of ‘questions’ posed by the practitioner, to with permission from Fernández-de-las-Peñas et al. Journal of tissues being moved: ‘Are you more comfortable Bodywork and Movement Therapies 2006;10:3–9 moving in this direction, or that? However, as valuable as an algometer may be in Positions of ease, comfort and tissue preference are research settings, its use is not really practical in every- directly opposite to directions that engage barriers, or day clinical work. Newer electronic versions that fit move towards bind or restriction onto a thumb-tip (linked to a computer screen) have The methods for assessing tissue preferences in this made their use both practical and desirable (Fryer context are described in Box 6. Differential assessment, based on Assessment of the common findings of supine and standing compensatory pattern (Zink & Lawson Zink tests (Liem 2004) 1979) If the rotational preferences alternate when supine, and display a greater tendency to not alternate (i. The left iliac crest will appear higher or more in the upper body, cranium or jaw. Is rotation more free left or used to take the neck into maximal unstressed right? The therapist stands below placed so that they lie, palms upward, beneath the waist level facing cephalad and places the hands on scapulae. The therapist’s forearms and elbows should the anterior pelvic structures, using the contact as a be in touch with the table surface. Leverage can be ‘steering wheel’ to evaluate tissue preference as the introduced by one arm at a time as the therapist’s pelvis is rotated around its central axis, seeking weight is introduced toward the floor, through one information as to its ‘tightness/looseness’ preferences. This allows a safe and relatively Alternation with previously assessed preferences stress-free assessment to be made of the freedom should be observed if a healthy adaptive process is with which one side, and then the other, moves, occurring. Is behind, places the hands on the pelvic crest, rotating rotation more free left or right? Is rotation more free left or with the therapist behind, with hands placed to cover right? The hands Well compensated Poorly compensated assess the area being palpated for its ‘tightness/ looseness’ preferences as a slight degree of rotation left and then right is introduced at the level of the cervicothoracic junction. The therapist stands at waist level facing cephalad and places the hands over the lower thoracic structures, fingers along lower rib (7–10) shafts laterally. Treating the structure being palpated as a cylinder, the hands test the preference for the lower thorax to rotate around its central axis, testing one way and then the other. Alternation in these should be observed if a healthy adaptive process is occurring. Tissue ‘preferences’ fingers along lower rib shafts laterally, the preference in different areas identify adaptation patterns in clinically useful for the lower thorax to rotate around its central axis is ways: ideal = minimal adaptive load transferred to other regions; tested one way and then the other. Is rotation more compensated (A) = patterns alternate in direction from area free left or right? Therapeutic objectives which encourage better should be observed if a healthy adaptive process is compensation are optimal. Chaitow (2003a) 140 Naturopathic Physical Medicine Questions the therapist should ask A reasonable knowledge of basic anatomic and him/herself following this assessment physiological features and characteristics will there- fore be assumed. Was there an ‘alternating’ pattern to the tissue preferences, and was this the same when the patient Thermal assessment was supine and when standing? Alternatively, was there a tendency for the tissue Various forms of thermal assessment are used clini- preference to be in the same direction in all, or most cally to identify trigger point activity and other forms of, the four areas assessed? What therapeutic methods would help the body are present in the majority, the sites are not necessarily to produce a more balanced degree of tissue where the trigger points are located. The elastic has reached breaking point, may commonly represent trigger point sites, some metaphorically speaking. Therapeutic focus should triggers may exist in ‘normal’ temperature regions, shift from specific to constitutional interventions – for and that hot-spots may exist for reasons other than the example, whole body massage rather than high veloc- presence of trigger points. Simons attributes this anomaly to the dif- From a naturopathic perspective this offers an ferent effects trigger points can have on the autonomic important insight and should help to prevent applica- nervous system. Much of the remainder of this chapter will be devoted Is manual thermal scanning accurate? Palpation and assessment methods for any structure Even passing the hand a quarter of an inch above the require an appreciation of its unique properties, so skin provides information on the surface temperature.

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