So, on to the causes of hyperbilirubinemia. I think the important thing is that you don’t really want to have a memorization of a long list. You need to think in pathophysiologic terms. One way to look at it is; increased production versus decreased clearance. Under increased production the biggest category, and probably the most common category of all, is intravascular hemolysis. I think the best way to think of all of these ways that red cells can hemolyze, is first of all you need to think of what can go wrong with a red cell, and then what are all of the components that a red cell has that may have problems. The first one obviously is autoimmune, which is often … well, not often but generally fetal/maternal incompatibility of blood type. Rh is historically the most dangerous and because of RhoGAM it is something we don’t see very much at all. ABO is now the most common problem, in terms of causing autoimmune hemolysis. Mother who is type O is the one who is most likely to have problems. You can also have minor antigens though. Antigens that at times can cause moderately high bilirubin levels. The second component of the red cell that you need to think about is the wall. The wall and structural problems, so you may see spherocytosis or elliptocytosis. Red cells also have enzymes so enzyme deficiencies can produce hyperbilirubinemia. Pyruvate kinase can present with a very impressive hyperbilirubinemia in the newborn period, as can G6PD. Hemoglobin, another component of the red cell and Hemoglobinopathies, can also present in the newborn period with jaundice.
Jaundice at wikipedia
A very important point here is that anything that affects the beta chain isn’t going to present in the newborn period, in the first few weeks of life certainly. So sickly-cell, which affects beta chain, isn’t going to show up in the first few weeks of life with jaundice. That is because there is plenty of fetal hemoglobin around and so these children really will not be symptomatic early on because of that fetal hemoglobin. Sepsis should be on your list as causing intravascular hemolysis. One thing I think that you need to know is that jaundice is not going to be a presenting sign of sepsis. You aren’t going to have this well-looking kid who turns yellow and sepsis is the cause of it. It’s more that septic kids can become jaundiced. I think keeping that in mind is important. Then finally, mechanical or red blood cell destruction in things like ADM is also possible but seems to be fairly rare.
Canadian pharmacy news
So on to other forms of increased production: extravascular hemolysis. So rather than having the blood cells breaking down inside the vessels we have breakdown of blood outside the vessels. Things like hematomas, cephalhematomas, can commonly cause increased bilirubins. Bruising doesn’t tend to be as much of a problem in full term babies. They seem to be able to handle that bilirubin a little bit better, but certainly premature babies, if they are fairly bruised, can get quite jaundiced just from the bruising. Hemorrhage also. If you bleed into any closed space that hemoglobin is going to be reabsorbed and converted into bilirubin, so you may see pulmonary bleeding, GI bleeding, and in the premature baby you can even see jaundice being fairly prominent if you have a large intraventricular hemorrhage. Excess RBC load – I guess this should be more in the intravascular hemolysis – but if you see hematocrits that are up in the mid 60’s and even in the lower 60’s, that load may contribute to hyperbilirubinemia. And sometimes what we will see is that you may have a couple of these things. Cephalhematomas are common. Polycythemia is pretty common. You put those two together and you are more likely to have pretty high levels of bilirubin.
Cheap generic medications
Jaundice in the newborn. Bilirubin is derived from hemoglobin. One gm of hemoglobin will produce 34 mg of bilirubin, so what you can see here is that you don’t need a heck of a lot of hemolysis going on to produce fair amounts of bilirubin. It enters the circulation in the unconjugated form and is bound by albumin. Then is transported to the liver where it is conjugated, excreted into the bile duct and then into the small intestine. One thing which is absolutely crucial for you to understand when thinking about jaundice in the newborn is the enterohepatic circulation where bilirubin is reabsorbed from the gut and the key thing is that it is reabsorbed in the unconjugated form. So that anything that produces a slowing of passage of stool through the GI tract will produce an unconjugated hyperbilirubinemia. When we talk about our differential diagnosis for unconjugated hyperbilirubinemia, a number of things that produce a slowing of passage of stool in the GI tract will be discussed.
Canadian levitra online
So why are bilirubin levels higher in newborns? A number of different reasons. Obviously there is large red blood cell load, not unusual to see hematocrits of 60 or 65. There is also a shorter red blood cell life span. There is a fair amount of hematopoietic tissue, which is being degraded. The liver is immature and especially in premature babies they are going to potentially have greater problems processing this bilirubin. Then there is also increased re-absorption via the enterohepatic circulation. Classically what we look at is unconjugated or indirect hyperbilirubinemia versus conjugated or direct. Conjugated hyperbilirubinemia is generally defined by conjugated bilirubin levels greater than 2, – this is key – and greater than 10% of the total serum bilirubin. Because what you may see, if you get very high levels of unconjugated bilirubin – say you are in the 20’s – you may see conjugated levels slightly above 2 and that doesn’t make it a conjugated hyperbilirubinemia if it’s not over 10% of the total serum bilirubin.
Canadian viagra pharmacy
So indirect hyperbilirubinemia: we’ll start with that. The most common cause of indirect hyperbilirubinemia is physiologic jaundice. The definition varies. It seems to be sliding upwards in recent years. It used to be classically thought of as full-term bilirubins less than or equal to 12 were thought of as physiologic. Premature babies, bilirubins less than or equal to 15, but I think what we see is that has crept up and especially in breast-fed babies. I think that a lot of people consider bilirubins up to 14 or 15 to be essentially physiologic hyperbilirubinemia.
Hangover Pills Info
Keys about non-physiologic jaundice: generally people say that if it appears in the first 24 hours, if jaundice appears in the first 24 hours it’s not physiologic. If the conjugated bilirubin is greater than 2. So if you have a conjugated hyperbilirubinemia, that’s never physiologic. Then some people also use bilirubin increases more than 5 mg/dl per day. Not sure I’d stick to … you know, if you have a level that’s going up 5.1 per day I’m not sure I’d be terribly panicked about that, especially in the first day or two of life. But those are the things which define non-physiologic hyperbilirubinemia.
16. Working with Depressed Patients
Breast cancer treatment information
1. Safety First- Risk of Suicide
2. The world really looks as bad as the patient says
3. Observers tend to become aware of depressed mood long after the patient (opposite of mood elevation)
3. Clinical Characteristics of Mania
1. Classic presentation of mania a state infectious euphoria
2. Frequently the “mood elevation” in mania is “dysphoric” in which irritability dwarfs, the euphoric or expansive quality of mood.
1. The jolly state is often transient or absent
Canadian pharmacy viagra
2. Conceptually- opposite of depression, but can overlap
1. Depression ratings are often higher during mania than during depression
3. Manifestations of early stages of mood elevation are often subtle, culture bound and may appear more isolated than the pervasive disturbance associated with depression
4. Risk of suicide increases during manic episodes
Horny Goat Weed
1. Thwarting a manic patient increases the potential for suicide and violence
2. The end of a manic episode is often extremely uncomfortable
1. Increased risk of substance abuse to sustain the high
2. Increased risk for suicide especially if mood state drops into depression
3. Patients are very poor reporters of mood elevation
1. Inter-rater reliability for mania is very high
2. inter-rater reliability for hypomania is very low
4. Not all manics are psychotic
5. Thought disorder is common in acute mania
1. 15-30% of acute manics exhibit Schneiderian first rank symptoms
2. About 50% show delusions, about 1/3 hallucinations
3. Variability extreme-clear to confused, with alternation
4. Differentiation from schizophreniform disorders may be impossible in acutely
6. Unipolar Mania
1. Rare, but no data indicate its a separate entity
2. Same risk of affective illness for first-degree relatives
3. Lower incidence of rapid cycling and suicide attempts
7. Mania can be a form of psychosis and may present with characteristic symptoms of thought disorder indistinguishable from schizophreniform disorder
8. Bipolar affective Disorder
1. Any history of Mania
2. Most have history of meeting criteria for Major depressive episodes
3. Always recurrent
9. Clinical Notes
1. Among bipolar patients, 10-20% present with a manic episode or history of such an episode
2. First onset of manic episode without prior depression is very rare after age 65
3. The hostility of manics is generally more dramatic than that of paranoid schizophrenia
4. Tearfulness, depressed mood, even suicidal ideation are not uncommon at the height of a manic episode or in the transition from mania to retarded depression
5. Time from 1st depressive episode to 1st manic episode is up to a decade or more; mode = 5-6 years. (Akiskal, APA III)
6. The differential diagnosis from schizophrenia
1. Long course with periods of normal or “supernormal” functioning favors BP disorder
2. Psychotic symptoms in affective disorder tend to occur at the height of mania and depth of depression
3. Poverty of speech content (vagueness, but not poverty of speech or laconic speech) and severe affective flattening tend to favor schizophrenia Dx
Ultram 100 mg online
4. Response to lithium or a TCA favors affective Dx
5. Positive DST and REM latency test, possibly blunted TRH test response can help identify affective disorder
6. Differential diagnosis form alcoholism
Comorbid alcohol abuse is common to many psychiatric illness, but sociopathy is the only diagnosis with a higher rate of comorbid alcoholism than bipolar illness. Alcohol abuse is considerably more likely to occur in association with mania than during depression.
The prognosis for alcoholism is better with comorbid bipolar illness than for alcoholism alone (Am J Psychi, 1995).
1. Diagnosis is bipolar illness if a single episode can be documented with
1. mania/hypomania independent of substance abuse or 2. with symptoms mood elevation clearly before substance abuse
2. Family hx is very useful
Canadian pharmacy
10. Course of Illness:
1. Prior to first major mood episode nonaffective diagnoses are common
1. Anxiety Disorders
2. Elimination Disorder
3. Sleep Disorders
4. Disruptive Behavior Disorders
5. Substance abuse
2. Chronic with periods of acute illness between which recovery to baseline function
3. Follow-up and Recovery
1. Over 30-40 year follow-up suggested 50% of BP patients achieved a full recovery
2. A small percentage suffer severe deterioration.
3. Harrow et al suggest <25% have excellent outcome
4. If recurrent, depressive episodes became more frequent, with shorter intervals between them, as patient gets older.
5. Progressive sensitization vs clustering
4. Manic Episodes are typically mixed with elements of both depression and mania
1. Coexisting or rapid alternation (bad prognosis)
1. Nearly 40% remain ill >1.5 yrs (Keller et al)
2. About 40% of manic episodes meet criteria for mixed state
2. DSM IV requires 1 week with symptoms meeting both As formalized in DSM IV, the criteria for mixed episodes provides a standard which enhances reliability of the diagnosis. It is unclear, however, if the stringent criteria requiring symptoms sufficient to meet both full depression and mania is clinically different than simply having the quality of dysphoric mood during mania. Several studies suggest prognosis is worse if manic episode is accompanied by 2 or more depressed symptoms or simply has includes the quality of dysphoric mood. There are no studies directly comparing the prognosis or treatment response of mixed episodes defined strictly versus loosely.
Female pink viagra
Many studies lump rapid cycling (especially of with short cycle length) with mixed episodes. This is reasonable since the reliability of diagnosing the onset and offset of short periods of dysphoria and mood elevation is probably quite low. If cycling length is on the order of 24 hrs it appears pointless to differentiate rapid cycling from mixed episodes. Such mixed episodes may represent an extreme form of rapid cycling
3. Mixed Episodes
1. Associated with secondary neuropsychiatric factors
1. Substance abuse
2. Subclinical drug toxicity
2. Higher prevalence among females
1. Winokur 1969, Murphy 1974, Krishnan 1983
3. Are mixed episodes the result of progressive worsening (kindling) ?
1. Typical of episodes of among Children and Adolescents
2. Mixed vs Pure
1. Over course of illness in 108 women (Dell’Osso 1990)
1. Median onset mania 30.6 yrs
2. Median onset mixed 39.2 yrs
2. Number of prior episodes not greater in Mixed (Prien 1988)
3. Greater number of prior hospitalizations for depression-(Post 1989) Family hx – (Dell’Osso 1990)
1. no difference – overall rate of affective illness
2. Rate of unipolar illness higher in relatives of Mixed
3. Rate of bipolar illness higher in relatives of Pure
11. Working with Bipolar patients
1. Understand that there is a person apart from the illness
2. Families/employers/friends tend to tolerate depression better than mania
3. Understand that mood is a filter coloring all experience
1. Consider the possibility of current pathological mood state
2. It is pointless to argue with a manic patient
1. A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.
Herbal xanax at Canada pharmacy
1. Note: The Major Depressive Episode must include
Criterion AI: depressed mood.
2. B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
3. C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.
4. D. The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.
5. Specify type:
1. Bipolar Type: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes)
2. Depressive Type: if the disturbance only includes Major Depressive Episodes
Prozac 10 mg
1. Evidence suggests its resemblance to Affective Disorders
1. No surprise since criteria require full affective syndrome
2. Can schizoaffective patients be distinguished from schizophrenics by high urinary phenylacetic acid levels (Sabelfi et al, 1989)?
15. III Clinical Notes
1. Clinical Characteristics of Depression
2. The principle problems
1. Distinguishing normal from pathological
2. Subtyping Depressive states
1. Reactive vs Endogenous
1. little empirical support for either concept
2. Psychotic vs Neurotic
1. Presence of psychotic features coded in DSM IV by fifth digit
3. Involutional Melancholia
1. Patients with involutional onset report more agitation, initial insomnia, somatization and hypochondriasis. (Brown 1984)
2. Genetically heterogeneous (Stenstedt 1959)
3. Same phenomenology seen at other times (Post 62, Angst 66, Weisman 79)
4. Unipolar vs Bipolar
1. Still considerable debate as to whether these are distinct. Goodwin and Jamison favor a continuum model
5. Primary vs Secondary
Buy human growth hormone
1. Attractive idea but this distinction is without grounding or definition
2. DSM IV skirts the issue by defining secondary as “due to” a medical condition or substance use without saying how it can be determined when depression is “due to” another condition
3. Causes of Secondary Depression
1. Medical Illnesses
1. Damage to Brain Tissue
1. Stroke, trauma, subcortical dementias,MS, HIV
2. Endocrine/Humoral
1. Cushings, Addisons, Hypo/hyperthyroid, paraneoplastic (pancreatic CA), hyperparathyroidism, hyperprolactinemia
3. Latrogenic
Reserpine, steroids, propranolol, thiazides, methyldopa, barbiturates, ACTH, contraceptives, L-dopa, amphetamine, benzodiazepines, metoclopramide, cimetidine, spironolactone
2. Other psychiatric Illness
1. Substance Abuse
2. Anxiety Disorder
3. Eating Disorders
4. Psychotic Disorders
6. Biological (Magic) Markers
1. Urinary MHPG
2. Dexamethasone
3. Decreased REM Latency
4. TRH Stimulation Test
5. CSF 5-HIAA
6. Response to Sleep Deprivation
7. Course Specifiers
1. Melancholic
2. Atypical
3. Postpartum onset
4. Rapid Cycling
5. Seasonal Pattern
12. Criteria for Mixed Episode*
A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a l-week period.
Canadian Generic viagra
B. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
C. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).
Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (eg, medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar i Disorder.
13. Simplified DSM IV Primary Mood Disorders
1. Unipolar
1. Major Depressive Disorder
1. Never manic or hypomanic
2. Single episode or recurrent MDE
2. Dysthymia
1. Period of chronic dysphoria or disinterest
1. Child or adolescent 1 year
2. Adult 2 years
2. During which
Cheap Canadian pharmacy
1. more than half the days dysphoria or disinterest is present and at least 2 associated symptoms of depression
2. Never meets criteria for Depression
3. Any euthymic period is less than 8 weeks
4. Never manic or hypomanic
3. NOS
2. Bipolar
1. Bipolar type I
1. one or more manic episodes
2. Bipolar type II
1. Hypomania but never mania
2. Must have at least one MDE
3. Cyclothymia
1. Period with frequent hypomanic symptoms 1. Child or adolescent I year 2. Adult 2 years
2. During which
1. more than half the days too low or too high
- 2. Never meets criteria for Depression
- 3. Never criteria for mania
- 4. Any euthymic period is less than 8 weeks
4. NOS
10. E. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).
C. The symptoms do not meet criteria for a Mixed Episode (see p. 335).
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
10. E. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).
1. Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (eg, medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.
2. This is a significant change from DSM III-R which stated
1. F. it cannot be established that an organic factor initiated and maintained the disturbance. NOTE: Somatic antidepressant treatment (eg, drugs, ECT) that apparently precipitates a mood disturbance should not be considered an etiologic organic factor.
11. Criteria for Hypomanic Episode*
1. A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
2. B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (eg, feels rested after only
3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (eg, the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
F. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication, or other treatment) or a general medical condition (eg, hyperthyroidism).
Viagra Oral Jelly
Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (eg, medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar !1 Disorder.
Recent Comments