By O. Jesper. Texas A&M University, Galveston.

While many of the short-term studies showed a more dramatic effect on weight reduction with reduced fat intake deltasone 10mg generic allergy medicine 751, the long-term studies showed weight loss as well best 5mg deltasone allergy testing vaughan. However, a number of short- term studies suggest mechanisms whereby high fat intake could promote weight gain in the long-term. In addition, short- and long-term interven- tion studies provide evidence that reduced fat intake is accompanied by reduced energy intake and therefore moderate weight reduction or pre- vention of weight gain. For these reasons, it may be concluded that higher fat intakes are accompanied with increased energy intake and therefore increased risk for weight gain in populations that are already disposed to overweight and obesity, such as that of North America. However, this conclusion must be drawn with caution when it is applied to societies in which dietary and exercise habits differ markedly from societies in rural Asia and Africa. For this reason, the effects of low fat diets must be viewed in the context of current societal habits in the United States and Canada and of changing habits in developing countries. It has been postulated that a high fat intake predisposes to a pro- thrombotic state, which contributes to venous thrombosis, coronary thrombosis, or thrombotic strokes (Barinagarrementeria et al. When fat is con- sumed in typical foods it contains a mixture of saturated, polyunsaturated, and monounsaturated fatty acids. Even when the content of saturated fatty acids in consumed fats is relatively low, the intakes of these fatty acids can be high with high fat intakes. For example, if all of the dietary fats con- sumed were low in saturated fatty acids (e. Consumption of a variety of dietary fats would likely result in an even higher percentage of saturated fatty acids. Thus, in practical terms, it would be difficult to avoid high intakes of saturated fatty acids for most persons if total fat intakes exceeded 35 per- cent of total energy. This fact is revealed by attempts to create a variety of heart-healthy menus (National Cholesterol Education Program, 2001). A prothrombotic state is charac- terized by elevations of plasminogen activator inhibitor and high fibrinogen concentrations, whereas a proinflammatory state is indicated by high c-reactive protein concentrations and other inflammatory markers. An excess of intra-abdominal fat has been identified as being highly associated with the lipid risk factors of the metabolic syndrome (Després, 1993), although total abdominal fat appears to be even more highly predictive of the insulin resistance component of the syndrome (Abate et al. Thus, both obesity and weight gain are undisputed as major risk factors for the development of type 2 diabetes (defined as fasting plasma glucose ≥ 7 mmol/L) (American Diabetes Association, 2001). The contribution of diet per se to the development of type 2 diabetes is less clear. An important question is whether humans are similarly susceptible to this phenomenon independent of the effects of total fat intake on body fat content. Thus, if higher intakes of total fat lead to obesity, this in and of itself will reduce insulin sensitivity and predispose to the metabolic syndrome and type 2 diabetes. Recent studies have demonstrated that reduced fat intake and weight loss result in improved glucose tolerance and reduced risk of type 2 diabetes (Swinburn et al. In several population studies, investigators have attempted to determine the contribution of total fat intake to either insulin sensitivity or diabetes. These analyses are difficult to interpret because of the multiplicity of potential confounding variables. Nevertheless, several studies have reported an association between higher fat intakes and insulin resistance as indicated by high fasting insulin concentration, impaired glucose tolerance, or impaired insulin sensitivity (Lovejoy and DiGirolamo, 1992; Marshall et al. In the Insulin Resistance Atherosclerosis Study, total fat intake univariately correlated with less insulin sensitivity (Mayer-Davis et al. Lovejoy and DiGirolamo (1992) likewise found intercorrelations among insulin resis- tance, total fat intake, and obesity. In contrast, Larsson and coworkers (1999) found no evidence of independent effects of diet on insulin secre- tory or sensitivity among 74 postmenopausal women.

For example in a study where the outcomes are reported in binary terms such as life or death order deltasone 5mg line allergy treatment for infants, or heart attack or no heart attack buy 5mg deltasone with amex allergy medicine makes me irritable, a physician can describe the results numerically as a relative risk reduction, an absolute risk reduction, a number needed to treat to benefit, length of survival or disease-free interval. When describing outcomes, results have the potential to sound quite different Communicating evidence to patients 205 to a patient. The following example describes the same outcome in different ways: r Relative risk reduction: This medication reduces heart attacks by 34% when compared to placebo. This also means that for every 71 patients treated, 70 get no additional benefit from taking the medication. When treatment benefits are described in relative terms such as a relative risk reduction, patients are more likely to think that the treatment is helpful. The description of outcomes in absolute terms such as absolute risk reduction, leads patients to perceive less benefit from the medications. This occurs because the relative changes sound bigger than absolute changes and are, therefore, more attractive. A patient’s ability to understand study results for diagnostic tests may be ham- pered by using percentages instead of frequencies to describe those outcomes. Gigerenzer has demonstrated that for most people, describing results as 2% instead of 1 in 50 will more likely be confusing (see the Bibliography). Using these “natural frequencies” to describe statistical results can make it much easier to understand fairly complex statistics. When describing a diagnostic test using nat- ural frequencies, give the sensitivity and specificity as the number who have dis- ease and will be detected (True Positive Rate) and the number who don’t have the disease and will be detected as having it (False Positive Rate). Then you can give the numbers who have the disease and a positive or negative test as a propor- tion of those with a positive or negative test. The concept of natural frequencies has been described in much more detail by Gerd Gigerenzer in his book about describing risk. Patients’ interpretations of study results are frequently affected by how the results of the study are presented, or framed. For example, if a study evaluated an outcome such as life or death, this can be presented in either a positive way by saying that 4 out of 5 patients lived or a negative way, that 1 out of 5 patients died. The use of positive or negative terms to describe study outcomes does influence a patient’s decision and is described as framing bias. They were asked to imagine they had lung cancer and to choose between surgery and radiation therapy. When the same results were presented first in terms of death and then in terms of life, about one quarter of the study subjects changed their mind about their preference. To avoid confusion associated with use of either percentages or framing biases, using comparisons can be helpful. For example, if a patient is considering whether to proceed with a mammogram, using a statement such as “The effect of yearly screening is about the same as driving 300 fewer miles per year” is helpful, if known. This puts the risk into per- spective with a common daily risk of living and helps the patient put it into per- spective. We will discuss this further when talking about quantifying patient val- ues in Chapter 30. Recommendations about providing the evidence The most important recommendation is to avoid overwhelming the patient with too much information. The key to avoiding this pitfall is to repeatedly check with the patient before and during delivery of the information to find out how much she understands.

Chapter 9: Hair and nail disorders 397 Anagen buy 5mg deltasone with amex allergy medicine for pregnancy, Growth phase lasts two to three years generic 10 mg deltasone visa allergy medicine lower immune system. Catagen, Release of hair shaft involutional phase lasts two to three weeks Telogen, resting phase, lasts three to four months Figure 9. Topical minoxidil produces some response in up Idiopathic Possible steroidogenic abnormality to 30% of cases. Finasteride is also used in androgenic Iatrogenic Danzol, some oral contraceptive pills alopecia in males. Pituitary Hyperprolacinaemia r Telogen effluvium occurs when the normally asyn- Adrenal Congenital adrenal hyperplasia, Cushing’s chronous cycles in follicles synchronises after child- syndrome Ovarian Polycystic ovaries, hyperthecosis, some tumours birth, surgery or severe illness. Hir- develop well-demarcated circular patches of hair loss, sutism is caused by increased androgen production or, which may coalesce causing alopecia totalis. Pathog- more rarely, increased sensitivity of hair follicles to an- nomonic is the presence of exclamation mark hairs, drogens (see Table 9. Women with a normal menstrual cycle are unlikely to Hirsutism have an endocrine cause. Other features may include Definition acne, seborrhoea, androgenic alopecia, deepening of the Hirsutism is the androgen-dependent growth of hair in voice and clitoromegaly. The abdomen should be exam- awoman, which is in the same distribution as in males. Increased incidence Systemic illness Hypothyroidism, anorexia nervosa, of impetigo is seen in conditions damaging the integrity malnutrition, porphyria cutanea of skin such as eczema, and its spread is facilitated by tarda overcrowding and poor hygiene. Paraneoplastic syndrome Clinical features Impetigo appears as erythematous erosions with a char- Investigations acteristic golden brown crusting. There may be associ- Dependent on the level of virilisation and menstrual ated localised lymphadenopathy. Bullous impetigo de- anomaliesfound;hormoneprofileandabdominalimag- scribes punched-out blistering lesions with crusting due ing may be required. Management Management r Any underlying cause for excess androgen production Swabs should be taken. Of- r Physical methods of hair removal include shaving, ten the condition requires treatment with oral penicillin chemical depilatories, bleaching, electrolysis and laser (Streptococcus) and flucloxacillin (Staphylococcus). Cellulitis Hypertrichosis Definition Definition Cellulitis is an acute diffuse spreading infection of the Hypertrichosis is excessive hair in a non-androgenic dis- skin extending into the soft tissues. Clinical features Aetiology/pathophysiology Patients present with fine terminal hair diffusely on the The main causative organisms are β-haemolytic Strep- face, limbs and trunk. The mechanisms of infection are not clearly understood but may involve bacterial exotox- Infections of the skin and ins and cytokine release. There is warmth Impetigo andtendernesstotouch,oftenwithlocallymphadenopa- Definition thy. If untreated, there is spreading of the erythema, Impetigo is a contagious superficial skin infection oc- abscess formation and secondary septicaemia. Chapter 9: Infections of the skin and soft tissue 399 Complications Investigations Abscess formation, septicaemia, toxic shock-like syn- r Imaging may allow detection of gas in muscle too deep drome. Management Management Prevention of clostridial infections involves adequate Initial management with penicillin (Streptococcus) and wound care at the time of original trauma including ex- flucloxacillin(Staphylococcus);erythromycinisusefulfor cision and debridement of necrotic tissue. In vanced or if it fails to respond to oral therapy, parenteral established cases penicillin is the drug of choice.

It also means that it will cost someone a lot of money to care for persons with the disease order 5mg deltasone mastercard allergy nj. The hope is to reduce this cost both in human suffer- ing and in dollars by treating at an earlier stage of disease and preventing com- plications or early death buy 40mg deltasone visa allergy symptoms to juniper. This depends on well-designed studies of harm or risk to tell which diseases are likely to be encountered in a significant portion of the population in order to decide that screening for them is needed. For example, it would be unreasonable to screen the population of all 20-year- old women for breast cancer with yearly mammography. The risk of disease is Screening tests 313 so low in this population that even a miniscule risk of increased cancer asso- ciated with the radiation from the examination may cause more cancers than the test would detect. Similarly, the prevalence of cancer in this population is so low that the likelihood a positive test would be cancer is very low and there will be many more false positives than true positives. The screening test must be a good one and must accurately detect disease in the population of people who are in the presymptomatic phase of disease. It should also reliably exclude disease in the population without disease or have high specificity. Of the two, we want the sensitivity to be perfect or almost perfect so that we can identify all patients with the disease. We’d like the specificity to be extremely high so that only a few peo- ple without disease are mislabeled leading to a high positive predictive value. This usually means that a reasonable confirmatory test must be available that will more accurately discriminate between those people with a positive screen- ing test who do and don’t have the disease. It should be relatively comfortable, not very painful, should not cause serious side effects, and also be reasonably priced. A screening test may be unacceptable if it produces too many false positives since those people will be falsely labeled as having the disease, a circumstance which could lead to psychological trauma, anxiety, insurance or employment discrimination, or social conflicts. Several studies have found significant increases in anxiety that interferes with life activities in persons who were falsely labeled as having disease on a screening test. This is an especially serious issue with genetic tests in which a positive test does not mean the disease will express itself, but only that a person has the gene for the disease. For screening tests, most people will tolerate only a low level of discomfort either from the test procedure itself or from the paperwork involved in getting the test done. People would much rather have their blood pressure taken to screen for hypertension than have a colonoscopy to look for early signs of colon cancer. Finally, people are more willing to have a test performed to detect disease when they are symptomatic than when they are well. If the test is too complex such as screening colonoscopy for colon cancer, most people would not be willing to have it done. A test that is very uncomfortable such as a digital rectal exam for prostate or rectal cancer, may be refused by a large proportion of patients. Both examples also require more complex logistics such as individual examin- ing rooms and sedation for the colonoscopy than a screening test such as blood pressure measurement. Screening tests must also be well advertised so that peo- ple will know why and how to have the test done. Pitfalls in the screening process Simply diagnosing the disease at an earlier stage is not helpful unless the progno- sis is better if treatment is begun at that earlier stage of the illness. The treatment must be acceptable and more effective before people will be willing to accept treatment at an asymptomatic stage of illness. Why should someone take a drug for hypertension if they have no signs or symptoms of the disease when that drug can cause significant side effects and must be taken for a lifetime? During the 1960s and 1970s, some lung cancers were detected at an earlier stage by routine screening chest x-rays. However, immediate treatment of these cancers did not result in increased survival and caused increased patient suffer- ing due to serious side effects of the surgery and chemotherapeutic drugs.

With the input of a new editor and publisher buy deltasone 40 mg without prescription allergy testing edinburgh, we were able to significantly expand and update the content and substantially improve the layout deltasone 10 mg online allergy treatment tablets, while maintaining the same conciseness and practicality found in previous editions. Under each topic, the sections on differential diagnoses, investigations, and treatments are designed for the rapid retrieval of high yield clinical information and can be particularly useful when one is all alone assessing apatient at3 o’clock inthe morning. Other sections containmanyclinicalpearls thatareintended to help one to excel in patient care. We also included many comparison tables aimed at highlighting the distinguishing features between various clinical entities and numerous mnemonics (marked by w). For this new edition, we are very fortunate to have recruited a new associate editor, Dr. Alexander Leung, who brings with him a wealth of knowledge and outstanding commitment to medical education. We are most grateful to our section editors and contributors for their meticulous review of each subspecialty, providing expert input on the most up to date information. We would also like to take this opportunity to thank Jean Claude Quintal as a resident reviewer and the Canadian Federation of Medical Students for its support of the previous edition. Finally, we would like to thank all previous and current users of this manual for their support and feedback. We are pleased that Springer has taken this title under its direction and has helped to improve its quality in preparation for international release. We would particularly like to thank Laura Walsh, senior editor, and Stacy Lazar, editorial assistant, from Springer for their expert guidance and support throughout this mammoth project from design to production. Anderson Cancer Center, for believing in this work and making this collaboration possible. While every effort has been made to ensure the accuracy of information in this manual, the author, editors, and publisher are not responsible for omissions, errors, or any consequences that result from application of the information contained herein. Verification of the information in this manual remains the professional responsibility of the practitioner. Readers are strongly urged to consult other appro priate clinical resources prior to applying information in this manual for direct patient care. This is ix x Preface particularly important since patterns of practice and clinical evidence evolve constantly. We welcome any constructive feedback to help make this manual a more accurate, practical, comprehensive, and user friendly resource. Consider leuko sodes of fever, dyspnea, and productive cough triene antagonists or inhaled glucocorticoids if (brownish sputum). Other considerations include the distance between the top of thyroid cartilage need for non invasive mechanical ventilation and and suprasternal notch atend ofexpiration. Constrictive bronchiolitis (late, fibrotic, con Related Topics centric) is not responsive to glucocorticoids Cryptogenic Organizing Pneumonia (p. Not enough evidence to suggest smoking, cancer (high suspicion of occult malig any of the rules as superior. Clinical gestalt of nancy in patients who develop pulmonary embo experienced physician similar to use of rules. Unfractionated be very helpful as it provides clues to other potential heparin may be used concurrently diagnoses/pathologies as well. Treat by lung re expansion, peritoneal fluid into pleura because of negative sometimes requiring thoracotomy with decortication intrathoracic pressures and diaphragmatic defects. If high probability, sensory loss, decreased radial and brachial pulses, thoracotomy with resection or video assisted thora pallor of limb with elevation, upper limb atrophy, coscopy (for patients who cannot tolerate thoracot drooping shoulders, supraclavicular and infraclavi omy medically and physiologically) cular lymphadenopathy.

However buy 5 mg deltasone with amex allergy medicine poison ivy, the fellow also realizes that they may not participation in change and a vertical axis that measures ac- appreciate all the issues involved and that personal feelings ceptance of change cheap deltasone 5 mg overnight delivery allergy forecast berkeley. In the frst the mentor, only to discover that he is fully supportive of zone of change, people have a high acceptance of change and the change in leadership, as he is dealing with a terminal a high degree of participation in the change process: these are illness. In the second zone, people have a high acceptance tion during their mentorship meeting early in the coming of change but low participation in the process: these are the week. In the third zone, people have a low acceptance of change and low participation in the change process: these Strategy 3: Seek supports. In the fourth zone, people have a low tivated we are trying to protect ourselves from harm. These acceptance of change but a high rate of participation: these are defences can be positive and constructive, but they can also the pirates. A well-managed change process is mindful of all cause us to deny the legitimacy of alternative perspectives, to four roles, and a well-led process sails the ship through rough misconstrue the truth, and to dismiss our own errors and vul- seas and reaches the destination unharmed (fgure 4). Seeking the perspectives of others can provide a helpful corrective to one-sided perceptions. Friends and family members know us well and can often help us confront issues we might otherwise avoid. Colleagues can also serve in this role, particularly with respect to professional issues and situations. When the skills not particularly healthy, working with a professional (a waves of change are high it can be diffcult to remember that life coach, mentor or therapist) can be of value. When we are feeling consumed by change, it is The fellow meets with the other fellows in the department critical to force ourselves to shift perspectives. Physical activity, and discovers that everyone is dealing with the news in a mindful practices, healthy distraction, time with loved ones and similar fashion. They openly discuss their concerns about good friends, and engagement in hobbies and activities take on job security, workplace culture, and the way in which more importance. These activities remove us from the stress information was either withheld or presented late in the of change and also help us put our worries in perspective. More importantly, they talk about the posi- tive possibilities that the announced changes might bring. The fellow begins to spend more time at the gym, as One of the fellows notes that enhanced academic activity working out helps clear their head and brings them new might facilitate the development of new resources for insights. Suddenly, they see how placing that model in an academic setting could create new and Figure 4: Coping with change grid - seafaring metaphor innovative opportunities. The fellow also begins to spend more time with their hockey team and enjoys the break that this activity gives from the work-related worries. It can be helpful to consider where we would like to be at the end of that phase and to do what we can to progress toward that goal. If we allow ourselves to keep moving forward, and allow ourselves to be fexible and to let some things go, we are likely to end up in a better place than the one we left behind. Case resolution The fellow meets with the new chair and shares their personal career goals and aspirations. Together, they real- ize that a new opportunity in quality management exists that would allow the fellow to contribute to the academic mission of the department while focusing primarily on clinical practice. Several years later, the fellow is deeply satisfed with their clinical practice and overall position Strategy 4: Be fexible and anticipate the unexpected. When a hurricane hits landfall, the most vulnerable objects are those that are rigid. Without fexibility, structures cannot cope with stress and tend to snap or bend hopelessly out of Key references shape. In practical terms, this means ensuring that we take time to carefully refect on aspects of change, thinking Flach F.

Overall generic deltasone 20 mg free shipping allergy to cats, it is the reader’s job to determine if bias exists generic deltasone 40 mg with amex allergy symptoms green mucus, and if so to what extent and in what direction that bias is likely to change the study results. Instruments and how they are chosen Common instruments include objective instruments like the thermometer or sphygmomanometer (blood-pressure cuff and manometer) and subjective instruments such as questionnaires or pain scales. By their nature, objective measurements made by physical instruments such as automated blood-cell counters tend to be very precise. However, these instruments may also be affected by random variation of biological systems in the body. An example of this is hemodynamic pressure measurements such as arterial or venous pres- sure, oxygen saturation, and airway pressures taken by transducers. The actual measurement may be very precise, but there can be lots of random variation around the true measurement result. Subjective instruments include questions that must be answered either yes or no or with an ordinal scale (0, 1, 2, 3, 4, or 5) or by placing an x on a pre-measured line. Measures of pain or anxiety are Instruments and measurements: precision and validity 71 common examples and these are commonly known to be unreliable, inaccurate, and often imprecise. Overall, measurements, the data that instruments give us, are the final goals of research. They are the result of applying an instrument to the process of sys- tematically collecting data. Common instruments used in medicine measure the temperature, blood pressure, number of yes or no answers, or level of pain. The quality of the measurements is only as good as the quality of the instrument used to make them. The researcher must select instruments that will measure the phenomena of inter- est. If the researcher wishes to measure blood pressure accurately and precisely, a standard blood-pressure cuff would be a reasonable tool. The researcher could also measure blood pressure using an intra-arterial catheter attached to a pres- sure transducer. This will give a more precise result, but the additional precision may not help in the ultimate care of the patient. If survival is the desired out- come, a simple record of the presence or absence of death is the best measure. For measuring the cause of death, the death certificate can also be the instru- ment of choice but has been shown to be inaccurate. When subjective outcomes like pain, anxiety, quality of life, or patient satis- faction are measured, the selection of an instrument becomes more difficult. Some patients will react more strongly and show more emotion than others in response to the same levels of pain. There are standardized pain scores available that have been validated in research trials. A 10-cm line is placed on the paper with one end labeled “no pain at all,” and the other end “worst pain ever. If this exercise is repeated and the patient reports the same level of pain, then the scale is validated.