Mark Corson

By L. Ingvar. The Art Institute of Southern California.

A long-acting benzodiaz- epine order 100mg geriforte with visa, such as diazepam or chlordiazepoxide cheap 100 mg geriforte free shipping, is preferable in treating symp- toms of withdrawal and preventing the major complications order geriforte 100mg visa. Flumazenil is a specific benzodiazepine antagonist used for the rever- sal of benzodiazepine-induced sedation and coma. When overdosage is sus- pected, it can be used in patients who would otherwise need intubation and ventilation (36), but care should be taken when mixed overdoses are sus- pected (37). Complications, such as convulsions, dysrhythmias, heart block, and cardiac arrest, suggest that its use in the prehospital environment should not be encouraged (38). Barbiturates Barbiturates are used in the treatment of epilepsy and for the induction of anesthesia. They became less commonly misused after the introduction of benzodiazepine drugs but may be used by polydrug users. Mild intoxication may result in slurred speech, oversedation, ataxia, and nystagmus, although severe intoxication may present with coma, absent reflexes, hypothermia, hypotension, and respiratory depression. Physical and psychological dependence occurs, and the withdrawal syndrome is similar to that of benzodiazepine withdrawal, with a greater risk of seizures. Benzodiazepines may be used to prevent the withdrawal syndrome associated with barbiturates (35). Adhesives, aerosols, anesthetics, dry cleaning agents, fuel gases, nail varnish, and paint stripper are among the substances inhaled (39), either directly from their containers, from a plastic bag placed over the nose and mouth, from impregnated rags, or sprayed directly into the mouth. Regular users may have nasal sores, known as “glue-sniffer’s rash” (perioral dermatitis), and have the odor of solvents on their breath. Acute effects begin within minutes (40) and may last 15–45 minutes; persistent abnormalities may occur in severe chronic abusers (Table 9) (41). Animal experi- ments confirm that myocardial sensitivity may continue for hours after the initial inhalant exposure (43). Tolerance may develop, and psychological dependence after long-term use and a withdrawal syndrome similar to delirium tremens has been described (44). There is a recovery period of 10–12 hours, where there may be periods of normal perception and cognition alter- nating with degrees of intoxication, which may affect fitness for interview. Acute effects include tachycardia, hypertension, pyrexia, dilated pupils with both anisocoria (unequal size) and hippus (spasmodic rhythmical dilation and constriction), dry mouth, sweating, flushing, tremor, and hyper-reflexia. Emotional lability, euphoria and anxiety, distortion of time, visual and audi- tory illusions (although true hallucinations can occur), and synesthesia, with a mixing of the sensory input—“seeing” sounds or “hearing” smells—may all occur (46). Both enjoyable and unpleasant effects, a “bad trip” may occur in a first- time user or with repeated use (47). Five major categories of psychiatric adverse effects have been described, which include anxiety and panic attacks, self-destructive behavior, hallucinations, acute psychosis, and major depres- sive reactions (48). Phencyclidine Phencyclidine, known as “angel dust,” is usually smoked, although it can be taken orally, intravenously, or by nasal inhalation. At low doses, euphoria, relaxation, and an altered body image may occur, but at higher doses, there may be agitation, bizarre behavior, and a paranoid psychosis (50). Physical effects include nystagmus (lateral and vertical), and with severe intoxication there is adrenergic stimulation with hypertension, tachy- cardia, flushing, hyperthermia, and cholinomimetic stimulation with sweat- ing, hypersalivation, miosis, dystonia, ataxia, and myoclonus eventually resulting in coma, respiratory arrest, and circulatory collapse (51). Chronic effects of phen- cyclidine abuse include memory impairment, personality changes, and depres- sion; however, there is probably no physical dependence. Adverse effects such as a polydipsia, hyponatremia, and catatonic stupor have been reported (53,54). Therefore, in view of the risk of hyponatremia, indi- viduals who take such drugs should avoid drinking fluid in excess of the body’s requirement. Regular users may habitually use chewing gum to overcome the effects on the jaw muscles. The clenching of teeth in the acidic environment caused by carbonated (fizzy) drinks will result in an increased likelihood of tooth wear on the back teeth (56). Other adverse effects have been described, including jaundice and hepatotoxicity (57); flashbacks and psychosis (58); pneumomedi- astinum (59); urinary retention (60); hyperthermia; coagulopathy (61); rhabdo- myolysis; and cardiovascular complications resulting in death (62–64). Evidence is emerging of possible long-term damage to the brain in the form of serotonin neural injury, which may result in depression, anxiety, and memory disorders (68). However, there are other factors, such as other concomitant drug use, that complicate the issue. Cocaine and Crack Cocaine occurs naturally in the leaves of the coca plant Erythroxylum coca, which grows predominantly in South America. Cocaine hydrochloride is a white powder that is usually snorted but can be taken orally. Crack is pre- pared by mixing cocaine hydrochloride with sodium bicarbonate and water and heating it. The onset-of-action and plasma half-life varies depending on the route of use, rapidly if taken intravenously or smoked compared with when it is snorted. Ingestion of stimulant drugs, such as cocaine or amphetamine, result in acti- vation of the sympathetic nervous system with resulting euphoria followed by irritability, depression, insomnia, and paranoia (Table 12). Tolerance occurs to the psychological effects but not to the effects on the heart. Deaths may occur, most commonly from cardiac dysrhythmias, myo- cardial infarction, agitated delirium, and stroke. Chronic effects include per- 300 Stark and Norfolk Table 12 Effects of Cocaine and Amphetamine Intoxication Initial low dose Euphoria, insomnia, dry mouth, hyperthermia, tachycardia, hypertension, increased respiration, sweating, dilated pupils With increasing dose Irritability, impulsivity, aggressiveness, agitated delirium, paranoia, delusions, seizures foration of the nasal septum and rhinorrhea, and long-term use may result in a range of psychiatric problems and vascular diseases (71). Cocaine produces a physical and psychological dependence, the severity of which will vary depending on the method of administration, being more severe if the drug is smoked or injected than if snorted. Dependence may result in a particular strong craving for the drug, followed by a withdrawal syndrome, or “crash,” with irritability, insomnia, depression, and anxiety on cessation. In conditions of police custody, the depression and inability to sleep may lead to acts of self-harm and suicide, and close supervision may be required, with con- sideration given to prescribing hypnotics and antidepressants. Amphetamine Amphetamine is usually found as a white powder, amphetamine sulphate, and can be taken nasally, orally, or intravenously.

Stratum lucidum (from the Latin word for “clear”) is found only in the thick skin on the palms of the hands and the soles of the feet buy geriforte 100 mg free shipping. This translucent layer of dead cells contains eleidin buy geriforte 100 mg visa, a protein that becomes keratin as the cells migrate into the stratum corneum geriforte 100mg, and it consists of cells that have lost their nuclei and cytoplasm. Chapter 7: It’s Skin Deep: The Integumentary System 115 Stratum granulosum is three to five layers of flattened cells containing kerato- hyalin, a substance that marks the beginning of keratin formation. No nourish- ment from blood vessels reaches this far into the epidermis, so cells are either dead or dying by the time they reach the stratum granulosum. The nuclei of cells found in this layer are degenerating; when the nuclei break down entirely, the cell can’t metabolize nutrients and dies. Stratum spinosum (also sometimes called the spinous layer) has ten layers con- taining prickle cells, named for the spine-like projections that connect them with other cells in the layer. Langerhans cells, believed to be involved in the body’s immune response, are prevalent in the upper portions of this layer and some- times the lower part of the stratum granulosum; they migrate from the skin to the lymph nodes in response to infection. Some mitosis (cell division) takes place in the stratum spinosum, but the cells lose the ability to divide as they mature. Stratum basale (or stratum germinativum) is also referred to as the germinal layer because this single layer of mostly columnar stem cells generates all the cells found in the other epidermal layers. It rests on the papillary (rough or bumpy) surface of the dermis, close to the blood supply needed for nourishment and oxygen. The mitosis that constantly occurs here replenishes the skin; it takes about two weeks for the cells that originate here to migrate up to the stratum corneum, and it’s another two weeks before they’re shed. About a quarter of this layer’s cells are melanocytes, cells that synthesize a pale yellow to black pigment called melanin that contributes to skin color and provides protection against ultraviolet radiation (the kind of radiation found in sunlight). The remaining cells in this layer become keratinocytes, the primary epithelial cell of the skin. Melanocytes secrete melanin directly into the keratinocytes in a process called cytocrine secretion. Merkel’s cells, a large oval cell believed to be involved in the sense of touch, occasionally appear amid the keratinocytes. In addition to melanin, the epidermis contains a yellowish pigment called carotene (the same one found in carrots and sweet potatoes). Found in the stratum corneum and the fatty layers beneath the skin, it produces the yellowish hue associated with Asian ancestry or increased carrot consumption. The pink to red color of Caucasian skin is caused by hemoglobin, the red pigment of the blood cells. Because Caucasian skin con- tains relatively less melanin, hemoglobin can be seen more easily through the epider- mis. Albinos, on the other hand, have no melanin in their skin at all, making them particularly sensitive to ultravi- olet radiation. Ridges and grooves form on the outer surface of the epidermis to increase the friction needed to grasp objects or move across slick surfaces. On hands and feet, these ridges form patterns of loops and whorls — fingerprints, palm prints, and footprints — that are unique to each person. You leave these imprints on smooth surfaces because of the oily secretions of the sweat glands on the skin’s surface. In addition to these finer patterns, the areas around joints develop patterns called flexion lines. Dermis: It’s more than skin deep Beneath the epidermis is a thicker, fibrous structure called the dermis, or corium. It consists of the following two layers, which blend together: The outer, soft papillary layer contains elastic and reticular (net-like) fibers that project into the epidermis to bring blood and nerve endings closer. Papillae (finger-like projections) containing loops of capillaries increase the surface area of the dermis and anchor the epidermis. It’s the dermal papillae that form the epidermal ridges referred to as fingerprints. The inner, thicker reticular layer (from the Latin word rete for “net”) is made up of dense, irregular connective tissue containing interlacing bundles of collagenous and elastic fibers that form the strong, resistant layer used to make leather and suede from animal hides. Within the reticular layer are sebaceous glands (oil glands), sweat glands, fat cells, and larger blood vessels. Cells in the dermis include fibroblasts (from which connective tissue develops), macrophages (which engulf waste and foreign microorganisms), and adipose tissue. Thickest on the palms of the hands and soles of the feet, the dermis is thinnest over the eyelids, penis, and scrotum. It’s thicker on the back (posterior) than on the stom- ach (anterior) and thicker on the sides (lateral) than toward the middle of the body (medial). The various skin “accessories” — blood vessels, nerves, glands, and hair follicles — are embedded here. A layer of dense, irregular connective tissue containing interlacing bundles of collagenous and elastic fibers is the a. Flattened and irregular cells with small, spine-like projections that connect them with other cells in the layer are referred to as a. Matrix Chapter 7: It’s Skin Deep: The Integumentary System 119 Touching a Nerve in the Integumentary System At least four kinds of receptors are involved in creating the sensation of touch. Free nerve endings: These afferent nerve endings are dendrites (branched exten- sions) of sensory neurons that act primarily as pain receptors, although some sense temperature, touch, and muscles (including the sensation of “stretch”). Found all over the body, free nerve endings are especially prevalent in epithelial and connective tissue. These small-diameter fibers have a swelling at the end that responds to touch and sometimes heat, cold, or pain. Some of the endings are disc-shaped structures called Merkel discs that function as light-touch recep- tors within the deep layers of the epidermis.

Allogeneic transplant may be considered of previously involved sites from nadir (balance between time to find allogeneic donor Nodal masses: appearance of a new lesion(s) and use of contaminated stem cells) geriforte 100 mg generic. All patients should meterofapreviouslyidentifiednode>1cminshort receive tumor lysis syndrome prophylaxis (hydra axis generic 100mg geriforte free shipping. Whole brain radia dominant masses; no increase in size of other tion represents an alternative buy generic geriforte 100mg on-line. Urinary amyloid precursor (light chains) aggregates that Bence Jones protein (urine protein electrophor deposit in tissues in antiparallel b pleated sheet esis) is required to detect paraproteinemia; non configuration. If good response, then proceed to high serum or urine, significant hypercalcemia, anemia, dose melphalan followed by autologous stem renal insufficiency, lytic bone lesions, extramedullary cell transplant. Radiation is usually treatment of disease, add bisphosphonate (alendronate, zole choice and may result in a cure. The chance of finding a sibling match is within 1 3 years post allogeneic transplant. Overall transplant related mortality is approxi for Caucasians and lower for other races. Symptoms include rash, hepatic dysfunction, mens include cyclophosphamide plus total body irra diarrhea, vomiting. Reduced otrexateandcyclosporineisusuallyusedforanyone intensity (also known as non myeloablative or ‘‘mini’’ other than identical twins. Treatments include cor transplant) regimens use a milder conditioning regi ticosteroids, cyclosporine, mycophenolate mofetil, men more tolerable for older patients (e. Can con clinical factors include women, Asian, never smokers, sider sequential chemo radiation but may have and adenocarcinoma. With all 4 factors, response rate reduced chance of cure 50% (compared to 10% normally). Palliative chemother apy (cisplatin pemetrexed Â4 (for non squamous Related Topics histologies), cisplatin gemcitabine Â4 (for squa Dyspnea (p. Hormonal and/or chemother women or premenopausal women after ovarian apy may also be considered ablation as suppress peripheral estrone production only) inhibit aromatase, an enzyme in skin, adi pose tissue, and breast that converts androstene Related Topics dione (from the adrenals) to estrone and estradiol. May sider aromatase inhibitors as first hormonal agent if be avoided if sentinel lymph node negative >10% risk of relapse in first 2 years (e. For postmenopausal tive (1 3 nodes) and Her2/neu negative women, aromatase inhibitor 1! Chemotherapy usually starts Premenopausal Postmenopausal 4 10 weeks after surgery. Use sin doxorubicin plus paclitaxel,capecitabine plusdocetaxel, gle agent only as no evidence for enhanced overall docetaxel plus gemcitabine, paclitaxel plus gemcita survival with doublets beyond first line bine, and weekly paclitaxel plus bevacizumab. Choice depends on ted with chemotherapy plus trastuzumab in the adju prior adjuvant chemotherapy, disease free interval, vant/neoadjuvant settings. Do not give concomi patient’s performance status, and willingness/ability to tantly with anthracyclines. Doublet regimens are associated give chemotherapy and then maintenance trastuzu with higher response rate and modest gains in overall mab until progression survival but more toxicities. T1=invades lamina propria or submucosa Definitive chemoradiation (5 fluorouracil plus T2=invades muscularis propria cisplatin, 5000 cGy) may be a reasonable alternative T3=invades adventitia tosurgery, particularly forolder individuals,medically T4=invades into adjacent structures (trachea, inoperable patients, and cervical esophageal carci mediastinum) noma (difficult resection). Con the first year, then every 6 months for a total of 5 sider supplemental feeding if significant weight years. The type and the Node +ve 59% 48% number of cycles of adjuvant chemotherapy are, how ever, not well established. Release of these vasoactive somatostatinoma), paragangliomas, pheochromocy agents leads to episodic symptoms. Gastric and bronchial carcinoids are asso indolent, may be multiple, not associated with ciated with atypical carcinoid syndromes (histamine). Derived from sube plaquelike,fibrousendocardialthickeninginvolvingthe pithelial endocrine cells. Tricuspid stenosis, pulmonary regurgitation, Usually right sided, often presents at late stage and pulmonary stenosis may also occur. Gastriccarcinoidcanrespondto to delay progression for midgut tumors, and perio a histamine blocker peratively to prevent carcinoid crisis. Corticos orradiofrequencyablation,andpost adjuvanttreat teroids maybe useful for prophylaxis. Chemoemboliza M1=distant metastasis tion may also represent an option for some patients. Early initiation of androgen deprivation and consider treatment with disease progression therapy may provide disease specific survival but not (i. With disease progression, con >2 scores positive, >50% involvement in core sider combined androgen blockade with anti sample). With further pro radical prostatectomy for low intermediate risk gression to castration resistant (formerly hormone group. Abiraterone is being investigated as a pro wise, treat as advanced disease mising agent. The bone density scan and be started on calcium and symptoms typically peak at 6 weeks and generally vitamin D supplements. For those who derived of omentum, and (6) total abdominal hysterectomy a complete response to carboplatin and paclitaxel, and bilateral salpingo oophorectomy. Response rate 20 30%, response G1=well differentiated ( 5% of solid growth duration 4 months. Multi factorial interven vomiting despite proper oral antiemetic use, consider tions required. Remember to stop all laxatives baseline; mild increase in ostomy output compared to baseline 2 Increase of 4 6 stools per day over baseline; moderate increase in ostomy output compared to baseline 3 Increase of!