By Y. Marcus. Bank Street College of Education.
It usually is expressed as a percent age and normally is 1%; correct ed ret iculocyt e count account s for an emia best buy for aldactone. The normal daily intake of elemental iron is approxi- mately 15 mg buy aldactone 25 mg fast delivery, of which only 1 to 2 mg is absorbed discount aldactone 25mg with visa. The daily iron losses are about the same generic aldactone 100 mg on line, but menstruation adds approximately 30 mg of iron lost each month. In women, men st r ual loss may be the main mechanism, but other sites must be considered. Supplemen- tal iron is especially necessary during pregnancy because of iron transfer from the mother to the developing fetus. Iron deficiency may also be a result of increased iron requirement s, diminished iron absorpt ion, or bot h. Iron deficiency can develop during the first 2 years of life if dietary iron is inadequate for the demands of rapid growth. Adolescent girls may become iron deficient from inadequate diet plus the added loss from menstruation. The growth spurt in adolescent boys may also pro- duce a significant increase in demand for iron. Other possible causes of anemia are decreased iron absorption after gastrectomy or malabsorption syndromes, such as celiac disease, but su ch m ech an ism s are less com m on t h an blood loss. Hemo- globin an d ser u m ir on levels m ay r em ain n or m al in the in it ial st ages, bu the serum ferritin level (iron stores) will start to fall. As t he iron deficiency becomes more severe, microcytosis and hypochromia will develop. Later in the disease process, iron defi- cien cy will affect ot h er t issu es, r esu lt ing in a var iet y of sympt oms an d sign s. Anemia is most often diagnosed on a rout ine laboratory test, and pat ient s are often asymptomat ic. More severe anemia may produce symptoms such as fatigue, short ness of breat h, dizziness, headache, palpit at ions, and impaired concent rat ion. Glossitis, ch eilosis, or koilonych ia may develop, an d in r are cases, dysph agia asso- ciat ed wit h a post cr icoid esophageal web (Plummer-Vinson syndrome) may occur. When the anemia develops over a long period, the typical symptoms of fatigue and short ness of breat h may not be evident. The lack of symptoms reflects the very slow development of iron deficiency and the abilit y of the body to adapt to lower iron reserves and anemia. A detailed history, physical examination, and further laboratory data may be necessary to achieve a final diagnosis. The reticulocyte count is another important parameter to help in the differen- tial diagnosis of anemia. T herefore, a corrected ret iculocyt e percent age is calcu- lat ed by mult iplying the report ed ret iculocyt e count by the pat ient ’s h emat ocrit divided by 45 (normal hematocrit). The absolute reticulocyte count is normally 50,000 to 70,000 3 reticulocytes/ mm. If the reticulocyte count is low, causes of hypoproliferative bone marrow disorders should be suspected. A high reticulocyte count may reflect acute blood losses, hemolysis, or a r espon se t o t h er apy for an emia. Iron studies are very helpful to confirm a diagnosis of iron deficiency anemia and to help in the differential diagnosis with other types of anemia, such as anemia of chronic disease and sideroblastic anemia (Table 54– 3). Ser um ferritin values are increased with chronic inflammatory disease, malign an cy, or liver injur y; t h erefore, ser um fer- ritin concentration may be above normal when iron deficiency exists with chronic diseases, such as rheumatoid arthritis, H odgkin disease, or hepatitis, among many other disorders. Chronic inflammatory diseases typically cause elevation in serum ferri- tin concentration. W hen chronic disease and iron deficiency anemia coexist, serum ferrit in con cent rat ion may be n ormal. The iron studies in sideroblastic anemia include increases in serum iron and serum ferritin concentration and saturation of transferrin. Although the treatment of iron deficiency is straightforward, finding the under- lying etiology is paramount. Treatment of iron deficiency anemia consists of iron replacement therapy, typically with oral ferrous sulfate 325 mg two or three times daily, which provides 150 to 200 mg elemental iron. O t h er iron pr epar at ion s su ch as ferrous fumarate or ferrous gluconate can also be used, and are equally effect ive. Correction of anemia usually occurs within 6 weeks, but t h er apy sh ou ld cont inu e for at least 6 mont hs to replenish the iron stores. Failure of iron deficiency anemia to improve wit h oral iron supplement at ion suggest s nonadherence to t her- apy, possible coexist ing disease interfering wit h marrow response (eg, coexist ing folat e or B deficiency), or malabsorption of iron (celiac sprue, atrophic gastritis). Caut ion must be t aken wit h parent eral high-molecular weight iron dext ran because anaphylaxis m ay occu r, b u t n ewer p ar en t er al ir on com - pounds are now available with lower rates of adverse events. It should be emphasized that after diagnosis of iron deficiency is established, the cau se of the ir on loss sh ou ld be id ent ified. Sh e asks wh y sh e could h ave iron deficiency wh en sh e is no longer menst ruat ing. The reticulo- cyt e count would be elevat ed wit h acut e blood loss, but the pat ient h as not experienced t h is. Iron deficiency occurs in pregnancy as a result of the expanded blood vol- ume and active transport of iron to the fetus. Chronic disease generally leads to a normocytic anemia with elevated ferritin level (acute-phase reactant); although a microcytic anemia can also be seen, a normocytic anemia is more common. Therefore, a negative fecal occult blood test in the presence of iron deficiency anemia should not discourage you fro m p u rsu in g a t h o ro u g h g a st ro in t e st in a l wo rku p. He became diaphoretic and began to experience chest pain, similar to that of his recent myocardial infarction. Co ro n a r y a n g io g ra p h y p e r fo rm e d prior to discharge revealed no significant coronary artery stenosis. His blood pressure is 124/92 mm Hg while lying down but drops to 95/70 mm Hg upon standing. He appears pale and uncomfort- able, and he is covered with a fine layer of sweat. His neck veins are flat, his chest is cle a r t o a u scu lt a t io n, a n d h is h e a rt rh yt h m is t a ch yca rd ic b u t re g u la r, wit h a so ft systolic murmur at the right sternal border and an S gallop. His a b d o m e n is so ft wit h a ct ive b o we l so u n d s a n d m ild epigastric tenderness, but there is no guarding or rebound tenderness, and no masses or organomegaly are appreciated. Rectal examination shows black, sticky stool, which is strongly positive for occult blood. H e is t ach ycar dic an d h as or t h ost at ic h yp o- tension, likely indicating significant hypovolemia as a result of blood loss. Rather than being a primary problem wit h his coronary art eries, such as t hrombosis or vasospasm, the cardiac ischemia is likely secondary to his acute blood loss and consequent tachycardia and loss of hemoglobin and its oxygen-carrying capacity. For a slowly developing, chronic anemia in pat ient s wit h good car diopu lmon ar y r eser ve, sympt om s m ay n ot be n ot ed u nt il the h em oglobin level falls ver y low, for example, t o 3 or 4 g/ dL. For pat ient s wit h serious underlying car diopulmonar y disease wh o depend on adequat e oxygen-carr ying capacit y, smaller declines in hemoglobin level can be devast at ing. Such is t he case wit h t he man in this clinical scenario, who is suffering a cardiac complication as a conse- quence of his anemia, in this case, unstable angina. Unstable angina is characterized by ischemic chest pain at rest, of new onset, or occurring at a lower level of activity. H e had been t reated wit h medical management, including dual antiplatelet therapy with aspirin and clopidogrel. In this case, it is more likely that his angina is secondary to the acute drop in hemoglobin rather than new car diac disease. In this case of secondary angina, the anemia must be corrected, which requires an underst anding of t ransfusion medicine. Anemia is generally considered to be a hemoglobin level less than 12 g/ dL in women or less than 13 g/ dL in men. Although lower values often can be tolerated or underlying et iologies treated, blood transfu- sions have been bot h necessary and lifesaving at t imes. Indicat ions for use of each of t hese blood comp on ent s are d escr ibed below. Many believe that a hemoglobin level of 7 g/ dL is adequate in the absence of a clear ly d efin ed in cr eased n eed, su ch as car d iac isch em ia, for wh ich a h emat ocr it level of at least 30% may be desired.
Female breast cancer incidence (total number of cases in a p op u lat ion ) h as in cr eased discount aldactone 100 mg mastercard, but the case fat alit y h as d ecr eased purchase aldactone 25 mg online. Thyroid cancer incidence and prevalence (total number of cases) have been st eadily increasing; however aldactone 100 mg with amex, t he case fat alit y has not increased cheap 100mg aldactone otc. O ne of t he cr it icisms of can cer screen in g pr ogr ams is that screen in g migh t ident ify can cer s ear lier but d oes n ot h ave any r eal impact on su r vival, an d the on ly reason that the screened patients live longer is because their cancers are foun d earlier ( lead t ime bias); lead-t ime bias ch anges sur vival but is n ot the only reason that screening mammography has improved breast cancer sur vival. Mammograph ic screening programs are associat ed wit h lead-t ime bias, but it has been shown that screening also has real impact on improv- ing survival (see Cases 11, 37, 44, and 41). The randomized cont rolled clinical t rial t hat compared t he out come of patients with asymptomatic or minimally symptomatic inguinal hernias wh o undergo immediat e repairs versus delayed repairs wh en sympt oms worsen, sh owed that t h ere were no benefit s t o early h ernia repair in men wh o were asympt omat ic/ minimally sympt omat ic. Based on t h ese obser- vat io n s, it wo u ld seem lo gical that scr een in g fo r h er n ias in asym p t o m at ic men does not make sense. The randomized controlled trials comparing laparoscopic to open inguinal hernia repairs did not demonstrate outcome advant ages of laparoscopic repairs. Laparoscopic and open repairs are sim- ply choices that surgeons and patients have in the management of this dis- ease process. D iabet es and old age are nonmodifiable risk fact ors associat ed wit h recurrences in incisional hernia repairs, and obesit y is a modifiable risk factor but one that is difficult to modify. Inguinal hernia is the most com m on t yp e of h er n ia en cou n t er ed in m en an d wom en ; fem or al h er n ias occur more commonly in women than men. Prioritization of management of this hypotensive trauma patient with multisystems injuries is important. This should be followed by decompression of the righ t pleural space wit h a ch est t ube. Next, the management should be directed at addressing and identifying the sources of bleeding. O pen fracture of t he femur can be limbt hreat ening, but limb-t h reat - ening injuries should never be priorit ized ah ead of life-t h reat ening injuries (see Case 6 and 7). W ith these findings, cont inu ed n on op er at ive m an agement is n ot appr opr iat e (see C ase 18). Radio-iodine scans still play a role in the management of patients with hyperthyroidism that is suspected to be the result of a hyperfunctioning adenoma (Plummer disease) or a diffuse hyperfunct ioning t hyroid gland (Graves disease). Because hyperfunctioning thyroid lesions are rarely malignant, the scan is useful for verification and allows for planning of t reat ment wit h medicat ions, radio-ablat ion, or surgery (see Case 44). See also Indirect inguinal hernia, 361 Biliar y at r esia Induction immunosuppression, 663 Isolated gastric varices, 230 Induction therapy, 666 Ivor-Lewis esophagectomy, 196t In ants, abdominal mass in, 625t In ected pancreatic pseudocysts, 414 K In ections. It is due to alteration of normal ratio of active androgen to oestrogen in plasma or breast (normal ratio of testosterone:oestrogen in breast is 100:1 and in blood is 300:1). Imbalance occurs either due to less testosterone production or action or increased oestrogen synthesis or both. Puberty (50% cases), may be unilateral due to transient increase in oestradiol level. Senile (40% or more) due to increased oestrogen from conversion of androgen to oestrogen (also decline of Leydig cell in testis). Chronic liver disease (common in alcoholic liver disease), hepatocellular carcinoma (hcg secreting). At puberty, affected individuals do not develop secondary sex characteristics, such as the growth of facial hair and deepening of the voice in males. Affected females usually do not begin menstruating at puberty and have little or no breast development. Reduction of circulating androgens, causes are—Klinefelter’s syndrome, primary and secondary hypogonadism, testicular failure. A: Excess oestrogen due to altered metabolism by liver and spironolactone therapy for ascites. Look carefully the following points (look and feel): • Swelling (multiple, nodular, variable in size and shape). Presentation of a Case: • There are multiple nodular, tender lesions of variable size and shape, some are red and some are pigmented in the anterior surface of right or left or both shins. A: It is characterized by non-suppurative, painful, palpable, erythematous nodular lesion in the skin due to delayed hypersensitivity reaction in dermis and subcutaneous fat. Usually, it is associated with fever and arthralgia, common in shin below the knee. Nodules may be 2 to 6 cm in diameter, occur in crops over 2 weeks, then resolve slowly over months, leaving bruise stain in the skin. Microscopy: Panniculitis (infammatory reaction in fat), infltration of lymphocytes, histiocytes, multinucleated giant cells and eosinophils, immune-complex deposition in dermal vessels. Erythema induratum (Bazin’s disease): Erythema induratum of Bazin type is a nodular vasculitis, related to tuberculous origin. It is one of the sequelae of immunologic reactions against antigenic components of M. More common in women, 20 to 30 years, in lower extremities, usually in calf muscle, also in shins. Confuses with chilblain, erythema nodosum, erythema nodosum leprosum, pancreatic panniculitis, lupus panniculitis. Differences between erythema nodosum and erythema induratum: Points Erythema Nodosum Erythema Induratum 1. Presentation of Case 1 (Face): • There are multiple nodules of variable size and shape involving right or left or both ear lobules, also face and nose. Depressed nasal bridge Nodules Hypopigmented patch in Hypopigmented patch and chest nodule on the back Q: What are the possibilities? Presentation of Case 2 (Hypopigmented Patch): • There are multiple hypopigmented patches of variable size and shape in the trunk, upper abdomen and back with loss or impairment of sensation over the lesion. Presentation of Case 3 (Multiple Nodules): • There are multiple nodules on the dorsum of the hand, forearm or leg and foot, which are of variable size and shape. Thickened great auricular Nodule in dorsum of hand Erythema nodosum Nodule in ear lobule nerve and facial lesion and foot leprosum Q: What are the differential diagnoses of hypopigmented lesion? A: It is a chronic granulomatous disabling disease, caused by Mycobacterium leprae. A: As follows: • Dapsone—Haemolytic anaemia, agranulocytosis, exfoliative dermatitis, hepatitis, hypoprotein- aemia, psychosis. A: It is defned as ‘episodes of infammation in the pre-existing lesion of leprosy’. Lepra reaction may be insidious or rapid, destroying the affected tissue within hours. In severe case—prednisolone 40 to 60 mg daily; reduce the dose to 5 mg/day each month, tapered over 3 to 6 months. It is characterized by fever, arthralgia and crops of small pink painful nodules on the face and limbs. Other features are neuritis, orchitis, myositis, nephritis, epistaxis, pleurisy, bone pain, arthritis, lymphadenitis and hepatomegaly. When symptoms improve, reduce the dose slowly over weeks or months, maintenance dose is 50 to 100 mg daily. Visible tortuous and dilated veins in chest wall and abdomen (see the fow, which is downwards). Engorged veins in chest Puffy face with Engorged veins in Engorged & non pulsatile congested eyes abdomen neck veins Presentation of a Case: • The face is puffy, plethoric and cyanosed. A: Mention the causes according to the age: • In the elderly or middle aged—Bronchial carcinoma and lymphoma. May be syncope, dizziness or blackout, stupor, seizure (due to increased intracranial pressure). Symptoms are aggravated on lying down or bending forward (indicates mediastinal involvement). Other features are due to involvement of neighbouring structures, such as— • Stridor (tracheal compression). Chest X-ray (which shows mass lesion, bilateral hilar lymphaedenopathy, mediastinal widening). A: Treatment should be given according to the cause: • In bronchial carcinoma—Radiotherapy in non small cell carcinoma and chemotherapy for small cell carcinoma. Presentation of a Case (Leg or Abdomen): • Veins in the legs are engorged, fow is upwards.
T h e t r an sfu sio n of b lo o d p r o d u ct s im p r oves h em o r r h agic sh o ck b u t is n o t indicat ed in dist ribut ive sh ock C buy 100mg aldactone with mastercard. Both types of shock produce low urine output buy discount aldactone on-line, but only hemorrhagic shock causes prerenal azot emia D purchase aldactone from india. A 33-year-old man with gunshot wound to the abdomen with extensive amount of free fluid in t he abdomen on ult rasound D order aldactone overnight delivery. A 38-year-old man who developed shortness of breath and hypotension aft er placement of a left subclavian vein cat het er. A 18-year-old man with splenic laceration and pelvic fracture following a motorcycle crash 3. The patient was taken to the operating room for an emergency exploratory laparotomy. O b ser ve the patient an d r ep eat the ser u m lact at e valu e in 4 h o u r s C. This is a young man who is hypotensive following an operation for st rangulat ed small bowel obst ruct ion. Given the scenario of hav- ing st rangulat ed small bowel obst ruct ion t hat required a bowel resect ion, it is likely that h e is hypovolemic secondar y t o the t h ird-space fluid losses associ- ated wit h his bowel obst ruct ion and his recent laparotomy. Furosemide is not indicated unless there is clear evidence that his intravascular volume is normal or elevated. Based on the information provided, there is strong concern for possible myocardial injury and cardiogenic shock. This patient h as p ost op er at ive r espir at or y d ist r ess, cou gh, fever, leu kocyt o- sis, and physical examinat ion findings suggest ive of left sided pneumonia. T h e u se of n or epin eph r in e is in dicat ed for the r esu scit at ion of sept ic sh ock patients if the patients do not respond favorably based on physiologic param- et ers and laborat ory paramet ers. Given t he dist ribut ive nature of sept ic shock, an alpha agonist such as norepinephrine is the pharmacologic agent of choice. Dobutamine is an inotropic agent that produces increased cardiac contractility and some peripheral vasodilat at ion to decrease t he afterload to the left heart. Dobut amine is an ideal pharmacologic support when there is intrinsic cardiac dysfunction leading to shock. Dobutamine use in the patient with septic shock will not likely improve t issue perfusion. The transfusion of blood products will help address the hypovolemia associ- ated with hemorrhagic shock; in addit ion, blood product s will improve t he oxy- gen carrying capacity in this setting. W ith distributive shock, the capacitance of the vascular system is increased, leading to a relatively hypovolemic state. Vol- ume repletion with crystalloids or colloids will help improve the vital signs and tissue perfusion. Some forms of distributive shock such as neurogenic shock will be associated with normal or low heart rate, but these findings are not present in all forms of distributive shock such as anaphylactic shock. The 30-year-old man with sepsis from perforated appendicitis will have increased cardiac output because he has increased heart rat e and normal int ra- vascu lar vo lu m e. T h e patient d escr ib ed in ch o ice “B” h as car d io gen ic sh o ck an d decreased contractility and reduced cardiac output. The patient described in “C” has hemorrhagic shock, and with decreased intravascular volume, the car- diac output is reduced. The patient described in “D” has tension pneumotho- rax that caused poor right heart filling and reduced cardiac output. The patient described in “E” has hemorrhagic shock due to decreased intravascular volume and wit h it decreased cardiac output. Based on the history given, this patient has anaphylactic shock, which is a distributive shock. Based on the scenario, the patient had ext ensive blood loss and was likely in shock in t he O R; however, following t he cont r ol of bleedin g, it app ear s that h is vit al sign s an d ser u m lact at e levels h ave improved. For these types of patients, antibiotics alone will not be sufficient for source control. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. D uration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Sin ce h is o p e ra t io n, the p a t ie n t h a s h a d in t e rm it t e n t fe ve rs t o 3 9. He h a s o n ly t o le ra t e d m in im a l o ra l fo o d in t a ke s in ce s u rg e r y s e co n d a r y t o abdominal bloating and distension. His indwelling urinary catheter was removed on p ostop e rative day 2, and he d enies any urinary symp toms. The p ulmonary exami- nation reveals normal breath sounds in both lung fields, and his heart rate is re g ular with out m urm urs. His ab d om e n is d iste n d e d an d te n d e r th roug h out, and the surgical skin incision is open without any evidence of infection. His cur- re nt m e d ication s in clud e m ain te n an ce intrave n ous fluid s, m orp h in e sulfate, and intravenous cefoxitin and metronidazole. H is ph ysical exam in at ion d oes n ot r eveal r espir at or y, urinary, or superficial surgical site infection. Most likely diagnosis: Deep surgical space infection or intra-abdominal infect ion. Need for an operation: Although his clinical course and current condition are con cer n in g, h e d oes n ot h ave a clear in d icat ion for r e-explor at ion of the abd o- men at this time. Operative intervention and percutaneous drainage are two import ant met hods t o achieve source cont rol in a pat ient wit h deep surgical space infect ion, if confirmed. Recognize the sources of fever in postoperative patients and become familiar with diagnostic and treatment strategies for these patients. Learn the principles of diagnosis and treatment of intra-abdominal infections in t he postoperat ive pat ient. Co n s i d e r a t i o n s When a patient fails to improve and exhibits persistent fever following definitive surgical t reat ment for an int ra-abdominal infect ious process, we must first ent er- tain the possibility that there are still untreated intra-abdominal infections. We must also consider other potential nosocomial infectious causes, as well as non- infect ious causes for h is fever. Given t he picture of persist ent ileus and fevers, t he possibility of intra-abdominal (deep surgical space) infection should be at the top of our differential diagnosis. W ith his current picture, it is not unreasonable to init iat e broad-spect rum ant imicrobial t herapy t arget ing G I t ract microbial flora. W hen identified, some intra-abdominal abscesses can be accessed and drained by percutaneous approaches (Figure 4– 1). Persistent secondary peritonitis can be the result of inappropriate or inad- equat e ant imicrobial t h erapy, wh ich can be addressed wit h addit ional ant imicrobial therapy or modification of antimicrobial regimen. Dive rt icu la r a b sce ss n o t e d b y a rro w (A) an d the n e vacu at e d b y co m p u t e r t o m o g rap h y– guided percutaneous drainage (B). They are treated primarily by wound explorat ion and drainage; systemic ant ibiot ics may be added when t here is ext en- sive surrounding cellulit is (> 2 cm from the incision margin) or if t he pat ient is immunocompromised. D eep surgical site infect ions may be a clinical manifestation of a deep surgical space infection. This type of infect ion in the sett ing of post abdominal surgery can include seconda r y per it on it is, tertiary peritonitis, an d deep surgical space abscess. Recurrence or persistence of this process can be due to insufficient ant imicrobial t herapy or insufficient cont rol of cont aminat ion process (inadequate source cont rol). Very often in these cases, low virulence or opportunist ic pathogens such as Staphylococ- cus epidermis, Enterococcus faecalis, or Candida sp ecies are id en t ified. T h e t r eat m en t for this con dit ion is somewh at un clear because most cases are relat ed t o poor h ost immune responses. T h e response produces loculat ed, infect ed inflam- matory fluid that cannot be eliminated by the host trans-lymphatic clearance pro- cess. W h en the abscesses are sizeable, su r gical or p er cut an eou s dr ain age are n eed ed to resolve this process. In t h ese sit u at ion s, the t h er apy sh ou ld be in it ially br oad an d t ar get Gram-positive and Gram-negative bacteria.
In addition cheap 100mg aldactone with mastercard, they can cause hypertensive crisis if the patient takes certain drugs or consumes foods rich in tyramine buy aldactone on line. Of the available benzodiazepines order aldactone overnight, the agents used most often are alprazolam [Xanax purchase aldactone with a visa, Niravam], clonazepam [Klonopin, Rivotril ], and lorazepam [Ativan]. An obsession is defined as a recurrent, persistent thought, impulse, or mental image that is unwanted and distressing and comes involuntarily to mind despite attempts to ignore or suppress it. A compulsion is a ritualized behavior or mental act that the patient is driven to perform in response to his or her obsessions. If performing the compulsion is suppressed or postponed, the patient experiences increased anxiety. Common compulsions include hand washing, mental counting, arranging objects symmetrically, and hoarding. Patients usually understand that their compulsive behavior is excessive and senseless, but nonetheless are unable to stop. In the technique employed, patients are exposed to sources of their fears, while being encouraged to refrain from acting out their compulsive rituals. When no dire consequences come to pass, despite the absence of “protective” rituals, patients are able to gradually give up their compulsive behavior. However, the remaining two—citalopram [Celexa] and escitalopram [Lexapro, Cipralex ]—are also effective. They all are equally effective, although individual patients may respond better to one than to another. With all six, beneficial effects develop slowly, taking several months to become maximal. Therapy of an initial episode should continue for at least 1 year, after which discontinuation can be tried. If relapse continues to occur after three or four attempts at withdrawal, lifelong treatment may be indicated. Social Anxiety Disorder Characteristics Social anxiety disorder is characterized by an intense, irrational fear of situations in which one might be scrutinized by others, or might do something that is embarrassing or humiliating. Social anxiety disorder has two principal forms: generalized and performance only. In the generalized form, the person fears nearly all social and performance situations. In the performance-only form, fear is limited to speaking or performing in public. In younger people, it can delay social development, inhibit participation in social activities, impair acquisition of friends, and make dating difficult or even impossible. Social anxiety disorder is one of the most common psychiatric disorders, and the most common anxiety disorder. In the United States 13% to 14% of the population is affected at some time in their lives. The disorder typically begins during the teenage years and, left untreated, is likely to continue lifelong. Treatment Social anxiety disorder can be treated with psychotherapy, drug therapy, or both. Studies indicate that psychotherapy—both cognitive and behavioral—can be as effective as drugs. However, a combination of psychotherapy plus drugs is likely to be more effective than either modality alone. These drugs are especially well suited for patients who fear multiple situations and are obliged to face those situations on a regular basis. Initial effects take about 4 weeks to develop; optimal effects are seen in 8 to 12 weeks. Accordingly, these drugs are well suited for people whose fear is limited to performance situations, and who must face those situations only occasionally. The usual dosage is 1 to 3 mg/day for clonazepam, and 1 to 6 mg/day for alprazolam. Propranolol [Inderal] and other beta blockers can benefit patients with performance anxiety. When taken 1 to 2 hours before a scheduled performance, beta blockers can reduce symptoms caused by autonomic hyperactivity (e. Among these are physical or sexual assault, rape, torture, combat, industrial explosions, serious accidents, natural disasters, being taken hostage, displacement as a refugee, and terrorist attacks, such as the ones that took place against the World Trade Center and the Pentagon on September 11, 2001. Two basic types of psychotherapy are recommended: trauma-focused therapy and stress inoculation training. Trauma-focused therapy uses a variety of cognitive behavioral techniques, including a very effective one known as exposure therapy, in which patients repeatedly reimagine traumatic events as a way to make those events lose their power. Stress inoculation training helps patients identify cues that can trigger fear and anxiety and then teaches them techniques to cope with those disturbing reactions. Current evidence does not support the use of monotherapy with bupropion, buspirone, trazodone, or a benzodiazepine. C H A P T E R 2 9 Central Nervous System Stimulants and Attention-Deficit/Hyperactivity Disorder Laura D. Our principal focus is on amphetamines, methylphenidate [Ritalin, others], and methylxanthines (e. Amphetamines The amphetamine family consists of amphetamine, dextroamphetamine, methamphetamine, and lisdexamfetamine. Lisdexamfetamine Lisdexamfetamine [Vyvanse] is a prodrug composed of dextroamphetamine covalently linked to L-lysine. After oral dosing, the drug undergoes rapid hydrolysis by enzymes in the intestine and liver to yield lysine and free dextroamphetamine, the active form of the drug. If lisdexamfetamine is inhaled or injected, hydrolysis will not take place and hence the drug is not effective by these routes. Methamphetamine Methamphetamine is simply dextroamphetamine with an additional methyl group. At usual doses, they increase wakefulness and alertness, reduce fatigue, elevate mood, and augment self-confidence and initiative. Amphetamines can stimulate respiration and suppress appetite and perception of pain. By a mechanism that is not understood, amphetamines can enhance the analgesic effects of morphine and other opioids. Norepinephrine acts in the heart to increase heart rate, atrioventricular conduction, and force of contraction. With regular amphetamine use, tolerance develops to elevation of mood, suppression of appetite, and stimulation of the heart and blood vessels. In highly tolerant users, doses up to 1000 mg given intravenously every few hours may be required to maintain euphoric effects. If amphetamines are abruptly withdrawn from a dependent person, an abstinence syndrome will ensue. Symptoms include exhaustion, depression, prolonged sleep, excessive eating, and a craving for more amphetamine. Because amphetamines can produce euphoria (extreme mood elevation), they have a high potential for abuse. Whenever amphetamines are used therapeutically, their potential for abuse must be weighed against their potential benefits. At recommended doses, stimulants produce a small increase in heart rate and blood pressure. However, for patients with preexisting cardiovascular disease, stimulants may cause dysrhythmias, anginal pain, or hypertension. Any patient who develops cardiovascular symptoms while using a stimulant should be evaluated immediately. Sudden death in children on these medications is very rare, and evidence is conflicting regarding risk for sudden death. However, given that millions of children have used the drug, the death rate is no greater than would be expected for a group this size, whether or not Adderall was being used. First, there are conflicting data showing that stimulants increase the risk for sudden death, even in children with heart disease.