Susan R. Winkler, PharmD, BCPS, FCCP
Investigations were conducted to see whether the number of confidantes had any impact on perceptions of symptoms or on treatment utilisation rheumatoid arthritis heart buy trental 400 mg low price. Attempts to create a composite measure also failed because the variable was highly skewed and non-predictive of either perceptions of symptom severity or of treatment utilisation arthritis diet the best foods to eat buy trental paypal. Coping questions were used based on Stone and Neales (1984) measure of Daily Coping arthritis in knee leg pain purchase trental 400mg without prescription. As discussed in Chapter 3 treating arthritis of the hands cheap 400mg trental free shipping, long checklists of coping are problematic because coping tends to be situation- and disposition-dependent and it is difficult to define a typology of coping that is appropriate or reliable. In order to resolve these issues and to ensure that the questionnaire was not overlong, a reduced version of the Daily Coping questions was used. Participants were asked what was the most bothersome event of the previous day, whether this was a problem that had happened before and how much control they had over it. The event was rated on a scale of 1 (minor annoyance) to 100 (very stressful event). The participant was then asked how they had handled the event, by selecting from one or more of eight descriptions as defined by Stone and Neale, which include distraction, situation redefinition, direct action, catharsis, acceptance, seeking social support, relaxation, and religion. Finally, participants were asked if this was typical or not typical of how they usually handled bothersome situations. The checklist of 8 items was also used in the context of menopause-related events in the diary phase of the study. Four scales were used which met reliability criteria; an invisible and unvalued belief (Cronbachs Alpha 0. It encompasses biomedical and non-biomedical treatment including complementary therapies, changes to diet and the use of herbal products and supplements. This was also split into two scales, biomedical treatment utilisation and non-biomedical treatment utilisation. Details of the construction and characteristics of the treatment utilisation scale are in Chapter 6: analytical strategy. Study 3: Qualitative study to explore how womens beliefs about menopause are located within their social context. However, this constraint was relaxed in two cases in order to better understand treatment-seeking behaviour. Diaries were used to record information because they have the advantage of reducing retrospective bias and facilitates the collection of reliable person-level information (Bolger et al. In addition, as Bolger and colleagues comment, capturing life as it is lived allows for the recognition of the importance of the context in which the processes unfold. However, the requirement to keep diaries for a long period can increase the burden on participants and reduce the level of compliance (Stone, Shiffman, Schwartz, Broderick, & Hufford, 2003). For each day, women were asked to rate the existence of menopause symptoms on a scale of 0 (none) to 4 (very severe). Women were also asked to record the frequency of hot flushes and night sweats on each day. Research has indicated that diaries that recorded the number and severity of hot flushes over a shorter period were an accurate reflection of experience. On this basis, a 7-day diary was considered to be as effective as a monthly diary. After completing the 7-day calendar, women answered questions about which of the symptoms recorded were most problematic, and to what extent these symptoms affected family life, work, and relationships. This was based on the Day Reconstruction Method (Schwartz, Kahneman, & Xu, 2009), which aims to improve accuracy and reduce recall bias by limiting reports to very recent activities. Thus, being asked to focus on very recent episodic events results in more accurate information. Participants recorded information about their activities on an hourly basis and were contacted as soon as possible (preferably the next day) to describe the events that had occurred. The 24-hour diary was in hourly segments and was divided into two sections: section 1 concerned what was being done at the time and section 2 concerned the recording of the menopause-related event. For each event the participant recorded how long it lasted, who they were with at the time, how they felt (mood) and what they did to minimise the experience. The main purpose of the diary was to act as a memory aid for use during the interview. The 24-hour diary reinstates the events of the previous day in working memory; retrieval from autobiographical memory is facilitated by recording the detailed sequence of episodes (Kahneman, Krueger, Schkade, Schwarz, & Stone, 2004). In keeping with the recommendation from Kahneman and colleagues, the 24-hour diary was confidential and respondents did not need to return it to the researcher. The subsequent interview used the diary as the basis for discussion in order to better understand how women described the experience of the menopause symptoms and how this affected their moods, and enabled the contextualising of the experience in terms of the situation and beliefs about treatment, and social constructions of the menopause. Semi- structured interview: For the interview, women were asked to describe their day, hour by hour, using the diary as a prompt and were asked to explain why they rated the episode at a particular level, with specific attention being paid to the situation and who they were with at the time. Women were also asked to describe the coping mechanisms used to minimise the experience. After completing the description of their day, women were asked about their reasons for seeking or not seeking treatment, and about their experience of getting treatments for menopause. Finally, women were shown four statements that represented the most prevalent social constructions of menopause as identified earlier and also tested out the emergent idea of menopause as contradictory and confusing (Table 5. Women were told that these were statements made by other women about menopause and they were encouraged to comment on the extent to which they agreed or disagreed with them. Hormone Replacement Therapy is good for treating hot flushes, preventing osteoporosis, delaying the signs of aging and improving your sex life Statement 2 Menopause is a confusing time. Women dont know what to believe because there are so many conflicting views and even doctors dont know everything so women should do whatever they think is right Statement 3 the menopause is natural and nothing out of the ordinary and doctors should not be giving women drugs for it. In fact, life is more interesting after the menopause and women have more confidence in themselves Statement 4 Older women are not respected or valued and at menopause they become invisible. The media are so obsessed by youth that it is difficult for older women to get noticed and menopause is a sign of getting old the interviews lasted between 45 and 90 minutes. Women were told that the diaries were confidential and were to be used as prompts for discussion. They did not have to return them to the researcher but could do so if they wished. A stamped addressed envelope was provided and 28 out of the 30 participants returned the completed diaries. The interview took place as soon as possible after the 24- hour diary was complete (preferably the next day) in order to improve recall. Wherever possible interviews were face-to-face but women who lived at some distance were interviewed by telephone. Thematic analysis of the qualitative data was used because it enables the researcher to move back and forth between the process of collecting the data and the analysis. Thematic analysis seeks to describe patterns across the data set and is particularly relevant to the study of meanings at menopause because it can examine events, meanings and experience within a broad context (Attride-Stirling, 2001; Braun & Clarke, 2006). The data collection continued until all possible codes had been identified and allowed for the development of themes during the process (see Chapter 6: analytical strategy). This approach has explanatory power when considered in combination with the quantitative data because it is systematic and can illuminate the beliefs and mechanisms associated with the transmission of these beliefs. A note on reflexivity and potential interviewer bias An often-expressed concern about qualitative (and perhaps also quantitative) analysis is that the researcher will influence both the collection of data as well as its interpretation due to the individuals position and perspective. This is more likely to be evident in interview situations where an intersubjective element is explicit and where the researchers behaviour may affect the participants responses (Finlay, 2002). It is, therefore, important to acknowledge the position of the researcher vis-a-vis the data being 64 collected and to encourage reflexivity. Reflexivity has been described as an attitude of attending systematically to the context of knowledge construction, especially to the effect of the researcher, at every step of the research process (Malterud, 2001). This requires thoughtful self-conscious awareness and the continual evaluation of personal subjective responses. I am within the age range of the women who participated in this study and as a woman who is postmenopause and has made use of Hormone Therapy I can claim some personal experience of the transition. This had some advantages during the interview process, especially when discussing sensitive issues such as changes to the body or reduction of libido. I felt that women were more likely to (a) talk to me rather than to a male or to a younger woman and (b) to be honest about their experiences and feelings because I am a woman of similar age and might be more likely to understand what is being said. This is almost certainly because a variety of neurological insults associated with learning seizure may still be very helpful rheumatoid arthritis blood test trental 400 mg on-line. The diagnostic individual seizures as well as for background predisposing factors arthritis diet drinks discount trental express. Again there are some traps: the psychiatric phenomenology and the neurophysiology of dissociative states are ongoing arthritis in fingers uk discount 400mg trental otc. This underlines the importance wherever possible of showing For practical purposes arthritis pain gloves generic 400mg trental otc, dissociation may be defined as a psychologically mediated alteration of awareness the video to an informant to establish that the seizure is representative of the patients habitual attacks. The highly stereotyped nature and very brief duration of the seizures are helpful features on the psychophysiological basis for dissociative states is not understood. Clearly these studies raise ethical concerns primary gain of hysterical symptoms). However, clinical experience suggests that a proportion of patients related to the use of placebo. Most recently, however, McGonigal and colleagues have combined simple who initially deny triggers for their attacks are eventually able to recognise highly specific and emotive suggestion with routine photic and hyperventilation stimuli, fully disclosing the aims of the procedure cues (for example related to traumatic past experiences). These authors estimate they were able to reduce the need for prolonged telemetry admission in 47% of patients. Adverse or traumatic experiences, particularly with epilepsy) and it is therefore critical that an informant who has witnessed the patients seizures in childhood, are a common underlying theme. Sexual, physical and emotional abuse are well replicated is available to confirm that the provoked seizure resembles their habitual seizures. Why some children exposed to grossly abnormal experiences develop Serum prolactin psychiatric disorder later in life but others do not, and what determines the form the illness takes, is not Serum prolactin rises after tonic-clonic epileptic seizures, peaking between 20 and 30 minutes understood. Further studies of coping styles, putative dissociative and somatising traits, and how these following the seizure41. The post-ictal prolactin level should be compared with a baseline measure taken are related to childhood traumatic experiences will help tease apart the undoubtedly complex individual/ at approximately the same time of day. A prolactin rise is less reliable following complex partial seizures, environmental interactions involved. It is important that patients are not left with the impression that investigations alone hold the key to diagnosis; a quest for Psychological Social further tests might otherwise ensue. Once the patient understands that epilepsy and other medical causes have been excluded they will often be extremely sensitive about being accused of putting on their attacks. Predisposing Perception of childhood experience as adverse Adverse (abusive) experiences the clinician should put aside any prejudices they may have in this respect, suspend disbelief if necessary, in childhood and reassure the patient that their attacks are real, disabling and involuntary. Somatising trait Poor family functioning Next, an intelligible explanation of what the patient does have is required. The concept of dissociation Dissociative trait can be explained as involuntary episodes of switching off or going into a trance. Mood disorder Patients often express a fear that they are mad and are reassured to hear how common the problem is Precipitating Perception of life events as negative/unexpected Adverse life events and that it is treatable. For example, one might explain: We dont fully understand what causes this disorder but two-thirds of people with it have suffered Maintaining Perception of symptoms as being outwith personal Angry/confused/anxious the sort of traumatic experiences you have described. We cant explain the link for certain, but it may control/due to disease reaction of carers be that when people are exposed to repeated frightening incidents as a child they learn to switch off. Agoraphobia: avoidant and safety behaviour Fear of responsibilities of being well/benefits Table 4. Angry/confused/anxious reaction to diagnosis of being ill There is no evidence at present for biological factors which are therefore not listed in the table. However, there may be genetic the discussion should cover: influences on relevant personality attributes, coping styles and traits. Finally, for some individuals at least, the benefits of the sick role may provide an 3. The early literature includes a number of compelling descriptions back later in life as these seizures. Treatment, which included psychodynamic and cognitive behavioural approaches (mostly in combination), was tailored to reflect A description of maintaining factors is especially useful when other aetiological factors are not apparent. In a larger, uncontrolled series, Mayor et al72 have recently Patients will often recognise that their confusion about the nature of the seizures, avoidance of situations in reported outcome in 66 patients who received brief inter-personal (dynamic) therapy augmented with which they fear having one, and the protective reactions of carers together create a vicious circle whereby cognitive behavioural techniques. Other fear of having attacks may eventually become the most important cause of them. A few patients clearly reports have described psychoeducational group therapy60 and eye movement desensitisation61. It may be of therapy based on psychodynamic, insight-oriented and group-based methods are undoubtedly widely helpful to explain that many patients are initially unable to identify triggers for their attacks but that these practised and believed to be effective but controlled studies of such interventions are needed. It may be useful to explain that we all think at many different with agoraphobic avoidant behaviour suggest that techniques developed in cognitive behavioural therapy levels at any one time and some of what we are thinking about is instantly forgotten. Controlled studies of longer-term outcome following treatment are required, as are comparisons important, however, to caution against abrupt withdrawal. A significant proportion (see below) of patients continues to have seizures despite intensive treatment. A pragmatic approach in such cases is to offer long term-follow up to provide support for the patient the second, Both and their family, social interventions to improve quality of life, and also to limit the cost and morbidity are extremely useful resources. Patients who have comorbid epilepsy often pose the most difficult management problems. Showing patients and carers videos of seizures captured Psychiatric treatment has been associated with a positive outcome in some studies, but not others. A poor in telemetry is useful but the semiology frequently changes and the issue often requires regular review. Being unemployed and in receipt of disability benefits has recently been reported to be a predictor of poor outcome76. Treatment Pharmacotherapy is clearly appropriate for the relatively small proportion of patients with significant References psychiatric comorbidity. Even in those patients without a comorbid psychiatric disorder that might be expected 1. The misdiagnosis of epilepsy and the management of refractory epilepsy 54 in a specialist clinic. However, a small randomised controlled trial of sertraline recently failed to show significant benefit71. For the majority of patients some form of psychological treatment is usually recommended79. Conversion disorder with pseudoseizures in adolescence: a stress reaction to unrecognized and untreated learning Edition). Psychosensorial and related phenomena in panic disorder and in temporal lobe epilepsy.
Doppler tissue color M-mode imaging M-mode echocardiography displays mo- may aid in the diagnosis of fetal arrhythmias tion of the cardiac tissue with respect to time rheumatoid arthritis reddit order trental 400 mg free shipping. The display shows ing tissue velocity imaging arthritis in dogs pain relief order trental with a visa, with creation of movement of both chamber walls with time rheumatoid arthritis medication uk purchase trental australia, a fetal kinetocardiogram additive arthritis definition cheap trental 400 mg on-line, as well as strain reecting atrial and ventricular systole. Many factors inuence the quality of Tissue velocity and strain rate imaging may the M-mode tracing. First, alignment with signicantly enhance current fetal echocar- both heart chambers can be challenging, and diographic diagnostic capabilities. Note 1:1 relationship of normal mitral inow (E- and A-waves above baseline) and normal aortic outow (below baseline). All of these indices in the atria, junctional tissue, or ventri- need to be reassessed for progression by serial cle. Pulsed spectral Doppler tracing from the umbilical vein in a fetus with hydrops fetalis. Diagnosis can be made tus has not been well established; however, with a combination of Doppler and M-mode the rate of extrasystoles in healthy premature echocardiography. With M-mode, simultane- infants is 20% to 30%, with a slightly lower ous atrial and ventricular recording is per- frequency in term infants. E- and A-wave components of mitral inow are above the baseline, whereas the aortic outow signal is below the baseline. Calipers measure from the beginning of the A-wave (line A) to the beginning of the aortic outow signal (line B). Premature ventricular contractions mias, the prognosis correlates with the asso- also occur in healthy fetuses, for whom the ciated condition. Premature aortic valve opening (large arrow) can be clearly seen to be followed by atrial wall contraction but with no variation in P-P interval (A-wave interval), giving a compensatory pause (small arrow, allowing diagnosis of ventricular premature beat). Fetal sinus tachycardia is due to an un- derlying fetal or maternal abnormality such as Sinus Tachycardia drug exposure, hyperthyroidism, myocarditis, infection, hypoxia, or other causes of fetal Fetal sinus rates rarely exceed 210 bpm, distress. In sinus tachycardia, fetal M-mode echocar- diography shows synchronous atrioventric- Supraventricular Tachycardia ular contractions. Detection is most ectopic atrial tachycardia, are difcult to dif- common after 15 weeks gestation, although ferentiate from sinus tachycardia using cur- earlier presentation has been reported. Arrowheads indicate atrial contractions, and large arrows indicate ventricular contractions. The calipers measure 243 ms between successive ventricular contractions, indicating a heart rate of approximately 250 bpm. In such patients, prognosis is generally excel- Although an abrupt onset and termination of lent, and no treatment is indicated. If tachy- the tachycardia, if observed during the fe- cardia is sustained at fast rates (>260 bpm), tal echocardiogram, would support the di- prenatal demise may be as high as 25%. Two of the earli- larly, Doppler ultrasound of ventricular inow est signs of fetal compromise are exaggerated and outow demonstrates sequential atrial umbilical venous or inferior vena cava ow re- and ventricular contractions. Maternal ecainide ventricular systolic function, atrioventricu- by mouth in cases where premature delivery lar valve regurgitation, and hydrops fetalis of the fetus is too high a risk may be help- (pericardial effusion, pleural effusion, ascites, ful. Sotalol appears include decreased fetal movement and abnor- to be effective for atrial utter, but probably mal umbilical artery pulsations. Success with the Fetal treatment options include early combination of digoxin with amiodarone or delivery, transplacental (maternal) pharma- the combination of digoxin with verapamil cotherapy, or direct fetal pharmacotherapy. As conversion using transesophageal pacing in in postnatal patients, ventricular response is fetal sheep. Labor induction is the treatment variable, but rates are greater than 200 bpm of choice for term and near-term pregnancies in a majority of untreated fetuses. Variations with sustained fetal tachycardia or evidence in atrioventricular conduction frequently lead of fetal compromise. Digoxin the diagnosis of prenatal atrial utter treatment is safe and often effective. The drug is conrmed by characteristic echocardio- can be administered to the mother in oral or graphic ndings. If conver- calculated after measurement of the time in- sion has not been achieved after two weeks terval between successive atrial contractions of therapy, a second antiarrhythmic agent (the mechanical P-P interval). Similarly, ven- may be added; ecainide, along with other tricular rate is calculated after measurement drug choices are reasonable (Table 1). Other of the time interval between successive ven- medications with reported efcacy include tricular contractions (the mechanical R-R in- procainamide, verapamil, quinidine, amio- terval). Arrowheads mark atrial utter waves (400 bpm), and large arrows mark less frequent ventricular contractions (200 bpm), demonstrating 2:1 conduction. As in usual fetal arrhythmias rely on postnatal test- older patients, it is likely that atrial dilatation ing with an inferred mechanism of the pre- due to a variety of causes will predispose to natal arrhythmia. Fast ventricular tachycardia, however, is poorly tolerated in Other Forms of Supraventricular the fetus, and the prognosis is extremely poor. Recently, Doppler tissue tachycardia, persistent junctional tachycar- imaging has been reported useful for detec- dia, and chaotic atrial tachycardia. When the fetus is in ventricular tachycardia (large arrows), the ventricular (V) rate exceeds the atrial (A) rate. When the fetus is in sinus rhythm (small arrows), the rates of the ventricular and atrial contractions are the same. Sinus pauses mia is indicated due to fetal compromise have been documented in the healthy fetus, or persistence of a fast ventricular rate, the and prenatal sinus arrhythmia is common. In addition, the use of normal E- and A-wave conguration and size transplacental and transcordal lidocaine has (Figure 2). Other As with sinus tachycardia, sinus brady- sources of fetal bradycardia include blocked cardia is a reaction to fetal stimuli, not a pri- premature atrial contractions (previously dis- mary cardiac arrhythmia. In addition, maternal medications, such block is approximately 1:20,000 live new- as beta-blockers, may cross the placenta and borns. In cases of severe hydrops is likely higher, given that some cases may re- fetalis, sinus bradycardia is an agonal rhythm. A presump- drome, rheumatoid arthritis, Raynauds syn- tive diagnosis can be made in cases of fetal drome, and mixed connective tissue disease, bradycardia with a strong family history of have been reported. Nearly all cases occur in the pres- rected at correction of the underlying cause of ence of circulating maternal Ro (Sjogrens fetal distress. M-mode and and disruption of the normal cardiac conduc- Doppler studies will show 1:1 atrioventricu- tion tissue. Severely affected fetuses will de- lar conduction and normal Doppler tracings velop signs of generalized cardiac myocardial (Figure 5). In some se- prolonged, and can be estimated using gated- vere cases, cardiac muscle and other fetal tis- Doppler ultrasound. In addition, evidence of associated structural congenital heart disease, hydrops fetalis, including pericardial effusion most commonly atrioventricular discordance and progressive slowing of the atrial rate, in- or endocardial cushion defects (especially in dicate impending fetal demise. Arrowheads mark atrial contractions above the baseline, and arrows mark aortic outow signal below the baseline. Doppler of healthy, showing no signs of distress, no treat- ventricular inow will show abnormal E- and ment is indicated. All affected fetuses reversal with corticosteroid therapy, one can show some degree of ventricular dilation. If the fetal ventricular survival and continuance of pregnancy un- rate is below 55 bpm, if the atrial rate is til term. One area of ongoing is indicated in anticipation of postpartum study that may yield signicant positive re- pacing. Minimally transplacental pharmacotherapy with digoxin, invasive fetoscopic techniques are now under furosemide, and beta-receptor agonists. All intense study, and may offer improvements for of these drugs are of limited efcacy, and fetal arrhythmia therapy in the future. Generic trental 400 mg with visa. BEING DIAGNOSED WITH RHEUMATOID ARTHRITIS|Episode 1. Diseases
|
