@ therapeutics* WHAT YOUR. PRACTIG§ DESERVES 9 out of 10 users recommend e-Therapeutics' a JEAN GRAY, BSC, MD, FRCPC, EDITOR Therapeutic Choices Manse, Graphic Communications: artim Bafa‘ayo bolita ay ny ay memes mean ‘ern athe Conpenaan otrmarnicas oe Spector? ‘naw lomouve conc! ar slediorncat ca ibaa ie anda ed etna ow Table of Contents Reviewers cee va Procitioner Review Board >i Glossary of Abbreviated Terms o ‘Sceeary of Mroorganism Abbrevons ot Hom To Use Thompeutic Choise. Dee Deseipton and Uantatone of lfrmsion cow ychlare Disorders 2 Ansty Sone, RP Sima nee " 5 Atertin Deft Hyperacty Dentro a 4 Damen Kona Rochood end Tey hho “a '5Dapeson Sino H Kennedy, Sag. Park on Baa Ese, eee 00 {5 Bate Deore Sagar. Pak is 17 Pajcoate, Heanor ation a7 9 Ong Wire Serene, ome Kanne, 135 40. Siang Casaton Pater Say 1. 11 Eng Deore, Lot Brminghon 158 Neurologic Disorders 14 Acta Pi, Bono Bay 198 15. Nawropatic Pai, C Pater N Whtson 208 18 SatsPaey, tim Pre Prtps citi zs 17 Cente Spesty, Ven Dovonshio 28 18 muscle Crags, gna ovonstire 235 49) RestessLageSycome,Aae-Louise Lorena 239 20 Parson's Dear, OA. Games ar 21 Serres ane Eplopsy,R Mark Sater 258 Eye Disorders 22 Calarct Super Postoperatve Cae, Stan P. Geo 23 23 laos, Mark R Leth and Pao Rate. 288q t ‘able of Contos Agevehtod Macs Dogeton, Mcrae Ptr Endocrine and Metabolic Disorders cardiovaseu Disorders Prrer Preversan of Vascular eae, Tan Mysok Sypeterson Hom RE: Campa see Conary Syrenes, Mena Gators ‘ate cee Sote, Sle Pip nd Grd Guz Suprveira acy, Dad Brie ‘orca Tacyarmyomas, Pol Ooo. ‘YerausTomboentatem, Asani 6.6. Tie irrmiert later lard Ope Respiratory Disorders ra Rinne Poy Lyne ‘stain aris ad Chon, Mare Monigory (nip, Dvi Jobson. Gastrointestinal Disorders ial Hepat, Kavi M Patan and orn Hic ‘ontoseghagea! Rel Danae, Eon A Shaler Interna Bowe Olea, Bua G. Fegan 483 sy sot ore, 02 148 781 ‘Table of Contents Genitourinary Disorders 58 Lower Uiary Tact Sygtame an Bean Prete 59. Uinry cennancen Adin, Gomera 651 Conracepton, Gian Graves {52 yenerornea, lean Ga! 63 Endorse ion, {5 Ferma Sonal Dytinaon, Rotor Boson 08 tae Sout Oytnton, Rosemary Basan. Musculoskeletal Disorders r Frenyoa, Hove Si (6 CronieFatgue Sytem, Este Monn = 8 Pobmyaiga Rhaurates and GantCal Anat, hn Fea 70 Gout an Hyannis, Sune Kapur and Gunnar Kaas 71 Oster, Pau Danis and Anges by 72 Rheumat Atie, Van P Byte 73 Ostepoeas, Onvs A Haney 76. Sporsinites, saraeKesck : ‘Skin Disorders 79. Sunbury Gorter. 11 Prenie cers Sitar Tan 1 Ape Dermat, Mian Weitein : Pret, aura A Fon. 15 Saber and Peicon, Sande Kroes and No Blood Disorders 157 Conmon Anemia, SRatedge Hang on 60 75 Lavo o19 928 955, sr ‘004 1029 1097 1058 1069 077Vi Table of Content | Table of Contonts vil Fuld and Eloctrolyte Disorders | eve comin Adu, Poares Wor. 1590 {8 Datycston in Cen, Gary ovo, tat | 9 Persistent esate dome Wht 1508 59 Hypo, Pater MeLeod 3 | 20 Pa ce, on Eup we | 80 Edens, Tn Keough yan 147 ee 81 Hypucsooma, WaterWatal= oss vs 1860 1 Dosage Ausimen in Ran! ensimen, Jes 82 Potssim Detapences, on Ener. | ss WIZ carmect ace Catan Pe la... 1552 2 Aen ete ein Crisbood Joseph. Vayatimia!... 1188 | M_Phpmacoewnamie Consors Jefiey, Jason 1888 | 34. Srepococea Sar Trost, Dail Spee 95 | | 5S Sosan Fors ant Ean nds) 1208 96 Ace Sorts, Czy Marsal and Ware Puna wz | 90 Tunes, Vitoria J Conk ond Mark FexGorlé. + $264 {0 Baca Meine Ala Rocenthl and Undy Sensor. | $280 101 Ao Ostomyets, Sinan Dobson 1295 Srp nd Spe Soc Siren Cyl andiny 105 Herpes ecto Fred ol! : 1370 “io 88 Montane nn nn 1380 107 Opporuneo nscune'n HV postive Paes, Edad. cs 403 ta cons te Gace Pat, Colman Ret 1424 Cancer Chemotherapy Toxcty 111 chamoerapyndunedNaiean and Vor, ni ‘2 thers Pure ss ene myers Symptom Contro!, M3 Nauanain eis, MacLean. = rl 14 Gorspton, Hig Chean S12 0 115 Dares, turd Fs a Anne M. Boome: 902 116 Fevr Chien, dotoe Lang. 15, ‘17 Themorapuary Osetia Ada, Mao Sion. | 1520Reviewers ato hesty own Elesae Heath Jeter Blk, Mo, FRESE cna ote Fe resi Hoga ote Con, MD, FRCPC, FACE Pau Donic, Mae, Freee Mario de Lemes, BSe(Pharm), ‘Sein Pre Phar, oe {once Vircower 867 ‘are EvaneBSP MSc, FOSHP oye Urea Heol ‘Seecerlaah asen ‘rt Gin Phar, avd Getoam, Dee, FRCPC ony dnd, MO, £570, ‘irers Hosp f Eastern 2 ode, MD, MP, PRD ‘ha Shaws Evan Ba tga 2 Seren (riers ot abet Etat Pramacstgy & eu Scares Corte tee tet eno os seat tin weak Sarees Conse Aaa atta, BSP Fra ea tory ‘Sir era os onsen Entaon et persis Donon coi rtsy Hal Corb ar Moms, 05 recy feo ‘na Masicte, Pharm, MSc Sropmrmaion Cre ‘he Otowe Hoos twa, Ow any esnneand Scot murray, mo, FRCPC Sistem of Comotiay Batol very Unto of atten see Mo se, Fre, erty of Abrax Reviewers | amore xt say sine, B8cPom, ‘Alc tan Cora Wo, i} Authors Slee Duncan” Setanta roa —— aie Geert ap esi Girestyetimn caumea Putra Lo al fred ont erm 6, Camel Eee caer ei a tt tivo Caner eiowin AS Wome, Cpa A orm hesg 8 Host Hg Chan ; | Siete Pace ' |) cceatysatgsec Tory Cloke ! ease 8o Scovom conee sows ON ‘Sato Conte cores monsetan rest ofan Cau marion AB tore J Cook Unters of Saskatonowan Menrest Cones Hows! ‘Seataton, Sk He ney Sry ara ‘Ania Calinare Eamonn A ‘SO oanpn Heatare | Bahai voy aul Davis _ mo jf Meer Seehh aw i ety of name Antony W.Chow fm:Jean err DesGroses 2s Eaaecncayenoa Pt Dovoreaue fat ny Pett rato lrmatin Dovid Dupers eon Elbe 1 Heat Besta §Eletld ean Eer {Spoon eats Senos Urea fae croan Cee Jonathan AE. Fleming iy hee Pre Fort Gd er Rago cana cher ON sone See ‘stan P sorge arte amoral Host ‘Wits ea, Be ‘Setanta Heath Bord Ststaoon, Sk rites Hosp Wee Cree Sr ota eH Goa te Topkal ontario Sree Sone uny ‘Svea of entob Wines, Me alin ‘Genter Oeraloy Rear Davis A. Hantey| re tae, alga. AB ohn @ Hany Scecnreny Seraynn Hirsch Span Beet a sty Jota Hote ‘Ror Cas Hosp ian inne Meat ary Joubert ‘don Hoan Sooo Cane Angee aby reat ‘prone ot Gheostye Otome aired hee Sidney Keonegy ‘ity a avers oct Serer a Saxiv Authors atadur Spor Mesiine & ‘ro noe or Sick Chien Sha Ce spat ver) Joanne Wt Langley ‘eae ners tween Conve Masonneave Rosemont Hosp Timo Py ‘Gocen Elsah I Host tie NS ico care or roca Danse Notes Gera Hoop Sai aay ome 1 Andrew Motor MedtotrUnersty Peters MeLeod enol ena Hospital asec ion Stenyprook Women Cotege ‘Sens Hoop Sager ee =" “ye Makes BE cice ney Lindsay €. Neate Wane Dance Unvery Richard 1, Ove ‘ee wt erty Heth Netw Dehaale nvr eri ay Cvestyo in Coke strapon om PeysePnp Slane Ser Dehowle mrerety Depersont ot ptthsiaogy and Veen! Seleces| Dine ey {nto eal ey an sin Sate very Ghisane 0. Rondererxvi Authors fer Yor: Gores! Moet! (tendonon) Chon Nee. Oare Hosp a Rua Hao Lin someon Chere Hosp of Eso Uniweraty Cary tas ey Scr Wome’ Caen Caney Gone Hosa agen 08 ptt vat aw Somat Beno notte Guaers& womens eam (Gnomses) Sere rey of rth tc om Se Usa Caary Se ioceps Hosts step Tan Sans vat Senn ot Inteeoate, IN USA 1 Grant rompson Unset tone ‘Alorander 0.6. Ture fie ent se ata (Octet oc ash Cums Burma 8 Rl at wan Sse tee ‘erons 88 owpa eSek haen Aurore vil cre apo Sree ie of i Hn ete mes gh ‘cay te catsxvii Practiioner Review Board Practitioner Review Board ‘ormmanty Prorat ami Pracivoner ‘ ew banyan 8 ‘Antony Gagnon, Phar, CDE, CAE, FASCP i mtr Fay Hai ean ron nt, is, PE | ean mens ia Mra, ‘Sosy ‘Shannan Neubaver, 852, Prarad Margret Anne Woodside, BSc, MO fran ate Fay ne Glossary of Abbreviated Tamme XIX Glossary of Abbreviated Terms Sr Sidonerpanme AAP ‘American Academy of Pearse. Soil od aes feectamicimeing eye Nbneimere de ‘Stention det hypervisor ‘overs eter Sep ne ita bi nicer ‘Agony fr Hess Care oly an Research AIDS" gure mmmenodetcensy sire ‘Aims ‘Alton trointary Movant Sele AN” See mera eps ALP alse pose AMD Spelled cua degeneration ietetPO tn! prose ‘APACHE ‘RestePhysiolony and Chronic Heal Elation APSAC. Syl pstingen septic cmple SrrT Seated ta rbot ineXX Glossary of Abbreviated Terms ARDS ORY Ssor ast pg as jt receptor Hoke Seren doves Sens ery id Sioniepbine ee ‘Riera Urologist Asecinton ‘render the concentration cue ronctntvealae age ‘res Ah Sete than Came utio ‘eodiarnine Babyy Hosp Initiative two tines er semper deasty Sy mas ace ‘ont mete re hod presse bret cpoponte eng prostate es er mie Sty mre re ie sipgo-sophoreomy smu seek loo wes nos ies est roa) rey pps ‘Sinnneny nd aerate medicine ‘Set Semone monaposphte ‘Stnunanit acquire poems ‘Cogntne Hebi Analg System of Peychohegy ‘comple led cunt ‘gun below heapy ‘Sieh cmt Hoke ‘Coad Cove fo Eis ia Sport ‘Go's deane ‘Chonan Dnbeies Aiton: Con center for Diese Control (US) on iors Cann Food Guide to Helhy Fae ‘Sie in ine Glossary of ABbrevatd Terms >aXh ‘jcc prnosine monopbospats ‘Stren er cnene ‘Sop bea re ‘Sonaidcsion ‘Shenotherpy induced nase ‘rntne ne ‘Stine eleance ‘feet ‘Chote Noto tite forthe Bint ‘Sova eownelr membrane Steold orb hypesteaion enc obsmctive peony dase ‘Seoonyeemee? baer ‘Chinn Pamir Sy ‘Sacro F480 206 Diabetes Cea at Compson Ta eerie tetytaanide Aitroyactne: acomberacroe ait {tye eisreepanirnerne Aligaeeststerne ‘adeno Sr inert ‘trite eesti compton Srapinced nase everetio: dbes mets {deememodiningsntteumatie ag ‘eorytenele acdxxl Glossary of Abbreviated Tens re Dsaeav be pvr Bie EXC 5 ber Eerv eco. ree ect eD) TAE TAQ Fas FDA FATS Bo, Fan igi rsa exainatin Dingrotic and Stra! Moral of Men Disorders, ‘ch don im weer seen es ‘Sep venoms ‘Sal coe soy avarptiomery orone huarsioe ‘Seat cat ‘Shergenyconmeeption ‘Sacra ‘mela ld volume ‘Seeasiopam rere ie ‘ergy cinta pill ‘Retrcoeelne egy rete dain ‘sh estat ‘emer ‘Sexipepmtrtndenoscony ‘xem hemostatic hey eyae liked nmanosrbet 5y tect mt foal nestetice ‘rome aa teat See ‘ctopsanct yempins ‘Sulovopc top cholsngayocrentopraphy Spare enon me ‘Exropyma Sypiome Rating Seale ‘Shatnnagen ackeicha cll ‘Srronment oct sake force ios sical tose finctonl tsnmet questionnaire {eal yee Food Chel Cou {sia ombined peti oodand Dap Admmistaton (USA) fared expt volume {Ered expntry vue noe sera fara ypeeeiero ffecton of asped yee {meatal annus Fern Francs) fine neal pinion Des HMA aw He. (Gossary of ADbrevated Terms — xxl {ole tinasagtorone {reviioetyrece fee thyoune [ral ast ‘dco phoupat dey drogenne Frecld way tse Sate ‘Sramalceyt oon aimulatng itor festosepogel rua dsc fs tan pe Fanlocremacroniagecloy-sinlaig ats ‘ronlottpivesctig beemcse Eoonotpneesing hormone algae weer antagonist yaniv antec! ery Npattode cereal ea DNpalindepolmonry elena sepa hmm caronte gomeoropa hepa Cue Np ens pope oeterot TepntsD (det vias eeonous familial ypercelesterlemis tents ‘patnine purine ower ware eparinsndead thrombocytopenia Iman eckooye angen aah potency aewoleicxxv. Glocsary of Abbreviated Terns nro, He Hoo. ns spp Hse HS0, HN wert tirctc imo yptlanic pinta oran oman ppm eee quit of He Ihomone replace ey npn corvette Imes fi ‘noynime preea ‘rca pessire Ine contests ‘coma Sosy Hpopocins intetre f chee bert dae ‘eatin ‘eral acer onguaton ‘nena nos nad [iran Normalized Rast ocular rows ‘Bc tyme sty ies ere) iene i ula nua contacepive device ‘mine device Inte ste vig ezaton—emteyo taser arvensis fneveoos potas joule Glossary of Abbroviated Terms eraonconincvi seca Iegracting by aoa tearm ene fs tow ak al ures deta i decree lowest pricks laver esophageal shins Nips peters ene ry Icing oene (crower (emotectnnweth heen ‘bor pete lowe aco Inet spay tat infetin sedis tye ine abrasion {eeetene reper magi Isprsepicutromcal eve sbiton ‘eRe {ef vet ection ion cinta open tmconraocine rwbo e ‘tana oxide inhibi nem crs yolane mrad ni Ress ane ate endocrine neoplasia ‘eae eae {alg peemia ‘toca eon eins ‘Bnet es xmxvi Glossary of Abbreviated Terms Bisa Ms Ne Mist wn. PANY age sommes eae ‘een rent Sores tons ig sees ‘momoraiom gases ‘moral rate mano ae ‘naopttange (ea) Nitcots Ancrous ‘Neeiprecoiame Navn sesocton of Phsrmay Rely Autos ondnndrepyeie ‘ison Sed Advisory Comite engin ovr copa ease Fino tts of ea onmulende eve ames ioe tural pei tumescence ‘iste rpiacmet ey onteredal ieflemesiony dg {mT spent vation mesial ton eral ae det tiosteei ence dpe ‘Now Soo eat Association ‘Scart ‘hw. tmcied nausea and vomiting Sa cenaceptve ‘eanveompulive rer Sr soneneape pl ‘Sppontonl elt order npr ‘Hise wath efston (al retyeton slo: eulrespintory syne Sil eter ea Seven phere iene Propmecy-terncined asa tnd vomiting este ents mas Glossary of Adbreviated Terms xxvii cctamon comma irc Psthenthrpy nasa and Voting Pesce slo nie ection Panos fect ot Po mosasanin inition prstgln syrhcts iios Pr” PrwtlecinB FEN Posty mal ft ote ia Plo Fuels deve Bip Facmacuas roel pena Feu Femina Pap remem esphodonde PMMA Pelymctiyimcthayie PMN” fotymorbonelenye PMS Brower fndte 70. Smo FONY pena nates nd voting POTS Pastoral onbonatc lnc sme TD: Red pc dete tk rey PRCA real ai PRP piney Rayne phenomenon ln replacement id Tes penliesern Spel FSA) proc pecibe gen SC may ring ccngs tr rr FTCA cra rare coronary anglp Fin. frsayrod foment seni PTSD porrmmat ss indeXvi. Gtossary of Abbreviated Terms Pry proytiouact 7D Peels dics PUVA Foie bit Fics jen velar conmactons Pvp) Feber! vr dae PvE Bus vi ood Fx Past. Gaty anaes if ear Shs Sek tetime me ‘evn ARS Ter meron Feri Soi clasiteton Aly Iminate linc pe RAST Inlivalogaaren eng ‘meuren ous ulcers ‘Soto ‘Seommetded iy allowance sere movenen {ere an varia iar ewe for ‘er competion, elevation ‘Sri mio of menue oxides A ‘ig lower ude ‘ace st {commends int ike Ryan peomenon punto socal vie ‘Sembin ame pasingsn star (ales) abt ope ond ‘ett bt amie ‘ston allege soja Senna aleve dst ‘shamed henoreape Skee mate Simpson Anges Sale ‘Sonacrar cera pesos etm beri er ‘ene itn ovation; single dove see dtunction eling ea ach, reese us (ees infin) ‘Sactome of hapropne ntti orore een detn yao ‘Stevens Jobaseesyasoe Tinie (Glossary of Abrevated Terms XxIX. temic pa tomato Sg leprae Seam au sulfite {rtm and norepneine eupnkenhibiar ‘Socity of Obata and Gymecoopts of Cas se potion ctor ‘ony Rar phesomenon felniveserotoni uptake eiior ‘apes ied en noe Sua ani nfecton ST sepmeat clevaion ecard intron Spruit chara ‘encase, pine, comine mite teal toy suri ae ‘eal choles trjche stepresant tarde dykes ‘crane ria srv sin tise fc yshwy sbi tegen trl chemi atc, ‘cron bin \enretial microwave rote {rrr nese sition pret (Gururetbal roseon of fe ose ‘Sralneiones stable agi ‘ror etXXX. Gostary of Abbreviated Terms ve bea bet sieeve coi UUsedeoryebte aid ‘iene pei ‘Sper wetosestial stine ‘emi preci Unie Ses Pharmscoocin ony ction Sirol demos horace gery ‘tere! Diere Revere Labonte ecm con dees ‘aurea Belson eneow eal die To oe deny pein Yast maa obigae Vitae Over of Nes telat sur compounis ‘oval sea imation ests ‘etesiar tyra Sus trombocnation Sheree ‘ke blond et Wome en tative ‘Word Heth Organ eke ‘oon, stony and continence mse seu Abrvation cr ee eae caer ee ise iss tee i ‘Sen ae ie ae een, wher 1M cork ‘M pmconoe 1 gowortboee 1 gonorrwar sb eee N meningitis omer Pacer Pails Perma P mire 5S opi Glossary of Miccoganam Aébrevtons Glossary of Microorganism Abbreviations ult ame. Bacteridesfrhas ‘Rectomids gis Comprintetrieont (Clary peimiae ‘Choma acon Encroncen cals ‘tohrch ca Factors ncrphoram Freon an Gone rier osmophis ieee “Heteobacte pros ‘lesela permorie ectotacthes adopt {tc a Legon pnephla ‘teres manecrogenet Melts rr Mora rl ‘Meraetotacaote vcobacterum abot Nbeoptaoma pcumoniae esr gomrhone [ese gonorhonar wbypecis Neer foen oxixox Glossar of Mcoargnis Abbreviations er a ee feommrpkheyeet Spesmte Srepoece Ponenes Sean Semen a = ao a eae —— Peete a een fs == = ea — eae! pingee Eko ‘Plimpton fcc eee rent — aa oo fps ar Cpa Corea por — a im, = ees icc, | Eee, ioe mas fee ie tot, | Reals, coal ees ay aoe iy oun i eaered i Es Pa iris ce oe fe eee a sca a ae 4 eee Foreword xl Foreword Wola the th eto of Therapete Choe, Mh as appet ‘ine te fourth eon wa pulsed in 2003, Pheapee Chae tw aval lecronaya at of an smbitoae COMA progr of ‘carte pblshing ied e-Merpeutes. 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In tin te entities of Kite Alsop snore een Sy ra fora mnogers have been moa opeccatd MY pers le sovall ‘We comin inst on evidence ted aproach io mela An hope tat the edition of Therapie Cotes saves You wll. Pease tu kaw of movies changes you wou ef {cin Therap Chtos te tie ee prea orig beth ‘cents pint versoa ofthe content na foram a we hope mete alyoxxiv How To Use Thorapeute Choices How To Use Therapeutic Choices “The th edion of Therapeutic Choices ints 10 chars a3 Tenney ac cana rset eset herpetic ormaio, meetin cy eae sea bls The tae) of rs Jerse a ie ont ot exch te, Chapter ae erence ‘esac ie err tow the Sappesed Readings Seton Das thery is scans sing generic drug aes, Brand ame ROR choptr toned a eogrenen of tt ad ‘Sin any Cannan re sumer ae ated the abe cae, re eat nce and ar ine sn any oder ef reference, “Tne we cost ao speiferapyivaves a mae of elements ‘Riad he wana’, i markup andthe dispensing ‘Een Teng of dug hry an css elated co rg dann. SSSR ermine mt ot thorny nts Book me te angio Eine inOvewa abe ue of wrane The dr cote ables do 98 Fel a pening feo kup. Coss wn ae lative ante nated by he symbol at ot SeSown cesta. Formos coaitoseeultons were made Spi elorie lover posed patton dose fr neh Tout wee peed siete for mat bron eonons 30 Te cnr, mesma pod vay nd tegen ccs abi sui be cone estes of heap Chace retin ore ied neation on ede they shold coma opened txts pen esc dang arent in paints wth compro’ ‘Menon tales» mall con () appears afer the dg name ‘Tange abuser told be onset “te ne of rugs ding pregatey snd lettin she abject of ope Selden lade pamactcomni cnietons. Te pea ished ent long ech of hese ches Cover ispen ‘Foimemeontenne ar nce Append Description and Limitatons of Information 20K Description and Limitations of Information ‘hrapetc Ooices caste best valde viene oo {Saher over tl oan cannes Terpeott Cher thal be teu ate ety contin Inde fig review pn shold jor aco wilb Cone wmeoly ora tmaaans tl ett on Suplumag Alero oa cose het st onCHAPTER 1 a fel oy. Acute Agitation te : Kurt Stakun, MD, FRCPC and "yn. Jey PRs, MD, MS, FRCPC) 28) cate agation isa dangers contin, Sih valence of 10-20% ‘Seslted seu pens es cna tte wel-beag and ‘Mecvely asf. To ecacre le wnetyng cus gation tno be deeined sd ated were posse. ‘eco Agaenion, dcfosd wt “btaviou iting 0 seal seings. de caper wil oes one eereec To, ‘nkcton,seuvlope cnn eg. exima, sere rake or), Inuton dug dave (oe Chapter 9) adverse dg sects (Ge tue alley tats), codon does Blood gt ‘rglriescxdovacalepobcm and selec darn ‘Aplaite te ejay soit wit one, Psychic ‘Sts hat can char apaton nln yeh man depresion, ‘Seve snd penalty Sores Goals of Therapy Keep the work envionment af fr sta lnvestigations Obra history rom te patient and despot pati’ ‘chive lm ff ander cola eres In + Review motions and consonant media condone 1 Detrmine wether he agitation x sconpanig hy othe sant bch oufnns, ced concours cogtve pales gal sympeoms mh a fee Hopoe o pie2 Psychic Disorers «Mesa stats etait,» splat pyre examination and {vant abr nvesttions re esta te dng “Therapeutic Cholces (Figure 1) ‘Nonpharmacotogie Cnoices Seemann ranean a aot facu ne pesos Siivmanreteiereeteeeomiance SESE niekceresmestiecl ity le Renata hint eae te manatee memerrowiant cate Spent tee ict rts See masa vn tao elo ta Saas Pharmacologic Choices Deum lim i conden n which an cue on mpm it Dele al conten asocted vita mdr ne. ‘Toe nura pay Roce over he ome fe a. “eit eps to deine deme the medial ae of die {Pata 's ove ct ed sl ston Pt enecuny teat fe pate parmaclogey, Anipyetot a Siatine nse tn hese tne (Tle 1). Hatopt iol th tec teeedandtecve monte fo Scranton nos Fret esl and er names arctan ‘ec. Sia eplty mld doses ae pce ve ab ‘SSS vue pone ae generation peyote fsapine Thottongenertion appcn) aipssebotes sek wlaneapne. ‘perdonc and quetiapine tn ao been ed to Wet diam ‘WEST seer necks to mon epics tae orn see esha ntenent sofas ang deh incr ais ‘Sordi, cr ae inte ey fr managing st onsen ‘Ssh Sn ov aggeson shoul be dove only when he eves ‘iosy cate tes ‘Berutiarepnes sold be served frases where mons ae ‘nd aatcobot with ose Chops) Dementie cts wit vaius forms of mena equ exibition, ‘ics bdo can be diewpve to he ce evionment ond chapter 1 Acute Agtation otal dangerous. Fie, dune the asaece, een od ure of te behold nan cogs nce 1 ‘melcabom ae nce they shld be prsried fllowing he a Tow. a0 sow” pene mee ccna of thir more urbe eft pis, typ topes re bin nrg ned ovr Bat erate ‘Stpeystotce« Risperidone hr fen shown seve sis 2 ave ‘irre eet on he aptaton en ter beara yes (wat tava, earession an payers soca i Alzbeers rose: Rupee st dove of 61 sd my pe day font th ‘Sher dongs may off an tescy advantage bt dso ate ak of need see sncldng fl" Olammpln Sto 1 er Sy Fedncesagresiveces anya eaporie' Thre ite ven ca ‘het of quetapine the corr of aaton sm geen pens ‘wi deme, A een andomied ee ban, cme il ‘ttyl stpecheac i Ashemers dace pes showed ha tte chanc of tenet fs tenet gel othe cance bene ‘nsec ty he tae eters Ceding the poet nese ks ‘tetany sok, den) enh ned ley ard beet ‘ny piles fhe dection owe a anipnychse th cree 0 Into west f apeton or sepreson in patents wih exo nea be mae on an ida aes Hass nh career pee alopeidl sc ven adi again ptt wih denen Regt mo an sch Nat ‘te msteston tv alo been ud, cctadngéezodone, ‘holineserte nhs and bemdancpnes iis tao re ‘ited at tay’ bel ect fade cece ta Side ela ofl A eee sy sugeststhat chnneterne hire (Ge, donee may rece boar Sherbanee cated ih ‘Siticmers eae" Benodimopne an be eal and ete for ‘rating st nya spate Cae mst eke ase ths clr of ues beau fa earl ik oa ‘Sepaedcogiion. Lorsuspam sd easepam sre the enanazeines, ‘fice inthis sexing bec hey have maven ee tnenotsm minimally afete by apne Brain injury Many maications fom feet clases have Ben ed nth tng, ‘hough consve evidence acing. te roy to mnamns he tlie fc hes choosing sweatin hese patent A ‘Sree he an apa era ae ‘i Segue ban nan renrge anno Inesappored bythe bs eee. sas where proprensal fas tren nando eels nedig he dene ope, eh iss have bee ed Aseptic rags ch ar earbamaepin sh 34 Peyehinre Diaoréors irene en Thr ome mtn bien Srescetodineynes rel in traegra paens.Antpnetes TES RRE SSSI tatcagareme ett epi of teeter “Tarte ben sl otter oer medication ining cael Setpresansn ssetve serotonin reuptake Inhbor, ‘talons baspcon,nnaants so Bon ses aman eke cedex song capaho renee eit een ape ‘Mental tiness-aszocioted Agitation ‘Wath aeuey payers nv sortactng rena frmeltios Wiapteacs cer sone rn combat wi pases Fema here fecmmee treme alanaprs sald ACESS coupes tue oth ac ii a Sito comsintone apa dolor ui formulations of be Fearne eelcons wid me beens sa eee nim medians" Rlgperane SINR as pay doling mb prearaons, Olanzapine SSTIERMe es ly dasfing ae fom Several e-reraon ‘Sejushves hc ase sre oad formations, Fe a td uncon eager aise Intl atypical antipsychotics (speridone, olamcapine ot sane eaten cating cnt of ged Yana TE Fer esc almitsera ret anton Tice see, ater rae sac Saree tS aut aa mczken nh ote ns oF eee Chater ‘Staton! or CharcterotogtcAgiaton Aggression ‘esonion ai agaesion no tibet any Ft previous ‘SESE ALES ecurees i merge) ro ‘Rens resne a wets crv eating The fa imevenion are seni Th mos cosa SENSE CE ve rcemeratonanipyeonics ng 2 isfoataceine tie ay fa sami vinous etn "ei cece marsh tp mye Therapeutic Tips 7 rental le use lowe doses faye elder ptt 1 WoyiSven meanest over dei an any atenant gon ‘pects (pa to emang eed ch CChoptar 1: Acute Atation locks and calendars, ety mabilizato allowing sarey prevention ‘tate dation sfepbaesxting at opm foesonte Sndcommiiatin 85 moose iat smal gee hocimctey SRMARO “Waa SRE enti eres suse seen jo Sata wena ay eerie “aaa St ners mo | come ' mom enemy into sel = — sean OI sierra "nT etarese wnt eaten ts ‘ene aay buoSeoe wa oP sg| | = = SS SE ee eee le a BS me EEE cee we sreearas sna oot as ee i =a at = =40 Psychiat Disorders Suggested Readings Ne cumen therapies. Clin Pacary 2006:6Supp OF 13-2. NoTIL/BT Ric ain Stl Tecan ad mangement of be nc sds pen Sad 208,907,978 Necro Amenan pene Asoc. dvd Pry Hoobs Sup 20 CHAPTER 2 Anxiety Disorders RP Swlnson, MD, FRCPsych, FRCPC FPA Goals of Therapy {limite or ete aeaetytasd ety 1 treateomortdcondons Investigations 1+ Thorough soy with ateton ‘nate of smpton an set, _resence of omer mee or psychi conditions 1 Intense qution stein ctaiing nacre igo Table Cte) + Phase camisole dn orcad ant 6 ~ ERG, ver fection tt gummy raspetiase {Soreid inden serene TSH, EC aT dre ofr metre matings ication of Anaety Disorders!12 Payeniane Otsorders ‘Table 2: interview Questions to Establish Specific Anxiety ‘ape hl (a1 rooney se iegitrinnereneerrees, Eee cmesaaeeeee seen Saunas Nonpharmacologle Choices 1 Cee or oer sn esos be ede ae ono {leo ie huh! beminimal akon not ewe onl mses. 1 Resch an eedad ae of shooting benzodiazepines a mach ‘posi ely such ne thou a be continued forge to four ye ‘Stes roti, nluing relation taaog and tine management, ines bei enews * PyStSnC cml rcomancde rey at who doc not [ove i i oft separate aioe Chapter 2 Amity sors 13 Pharmacologic Choices (Table 3) Pyccetrmere ree cr race ieee Seyi iyi ) etalopra, {Scitiopram,Avoxctine, dvoxamine,peexctine ut sertraline [Sealer in edcing pot mais. Ventas, © ‘Sotonin secpneine opal (SARI asses emer ‘itary inrepated double ln, puedo conidia SSRIs a Sit hive tecome fat oe ages in seating pan dts with ribet gorapinia There ely dly in epee fe ‘Seetstmny b accompanied by ina! piston, Conbning the SSRI {rSNRE wh ti out flow doe tenosinepin psetsion ‘heap (yao lnge tn gt wens) can arene acres Ineleron sd prods more a reps wih apes ‘The trys nmidepressns(TCAS) imipramine, desipramice snd ‘prams nen ree ey ty nd SS itera ate wed pide Weaen chee. Mitaranine {nk (WAOs) phenle and tranpeyprming sso sts ‘emore iste “The dove equements sd eng of weiner ae he se or ir and vnlafarine® a fit-lne Gptons,Oteranspennts sexier fees cae rotaminemirazapine meclobemide™ a phemrang ‘Adin be apc aipseotesruperdane ant oinmrapine* ‘ve bon shown fe fest opment of anceps n FISD.Monateapy wit beep i a rsoomneded deo hie ‘fects os thiten a a bight of ustedes thaw esd by PIS. Th ee tt ropraml ch i. Bs eget ts hve ote conte Bese at Bangs Generatzed Anxiety Disorder Cain ley ari rset y ssn nd ‘contol wry elated to veya concer, achsfty ‘tty member onc do oc a heat ats th stale une) dourder equ esi epesed mo and ober lay symp. Ci the mun effete paychonei trates be ‘en taker Wor mor seas tbe eceve™ ‘Sits and SNRs have hesome estab frsttne dig sient for {eneraled one dapat Thee of exctalapeam.'® paroaring® Servatie se veniateine x apport nay ct ‘cane aside fits nd salty cone n teste, Imipramine ‘efetve apt in pnelze nty sorely trad fa ‘when nine cca nent fete, Bapropin a fr ce Lows betaodazepines (eg alprerlam,romazepe, dlazepam, lorazepam) carte wed far sev weeks ie ers ee, batatenton ms te pido ero penne nd neti mpm asprone, a ezine; bs low sane poli ands es tng than berasdanpe. ike adver iil ow thas lence ignog erm apne yo sos {ebimponan roto decom he Basalasepae sry, bea eve ign ros-olerance beeen bememepc ad atone, ‘enzdiepine wihdrwal spins cod te ecpated ‘Therapeutic Tips + Shor nerves fi, pectoris, elation tecniges, beac) maybe etc + Hoe ateremant eno efertve mage dosage ad er sage i sch ane se Mika + Tete second antidepres not etetve fn deste doug and tert adeqae prod of ine, meh oon ot ater i + Rest bezotaepnes to vey Soren ube (sn tig week) © ‘Sehwid SSRISMR ie ian inert ht og © rae Pema isi Ara 1. Management of Ansioty Disorders exes) eis) Ec | ci —_ a]crap 2 Ansty Disorders 19 18 Peyciane Disorders one i a ew Be Sao sa ns ‘emsomsms unseen tance ad's owners 4 cwvcowmn SAE aa SS us = ES GSES SRO meee MS ot Sot Se eee eee eat Et TRS mene val alte “UR Spas ae a cenit “ieee eee TRE aS eS asens ewe PT CHLjan 2 Sn = a i : = =e Ei ORES aE nay toe i a = Bes nem = i manos sine mines ase ee oe SEE EEE es om = | == Soot a ce me Ssainy adhe erence or feet ets ever cee Se eae EE A Sanaa “ i aioe oust SE we owen ames EEE eee EE AES ean om é opie eke one on pry SELChapter 2 Anesty Osordars 23 in il i it J 8 iil iijglll| gl ib {ah i Hl pile all | ta | | taal nl ii HE ie | file t En lt WHE i ne “hit iChopier 2 Aity Disorders 25 eet a ere ‘indo Bh Zar Holand & eral, Word Feemtion of Scie of ‘Bolo Peis (WPSID) pets othe pharmaco | trotment of was emeosivecompulie aptamer 1 ‘Svar Mvld/ Bit Peay 2002;40).17 99 Barow Dice dwt and in doorders the nanré and remen of "tc nl pan Sec New York GUY) Gator rey 203 omadion PoehiieAsocaton” Cail prasice giles Wansgement of snc diorers Con J Pcie) 2008S1(8 Sap Bests Seager ntode asay We mar le ne CHAPTER 3 al Attention-Deficit Hyperactivity Disorder Adil Virani, BSe(Pharm), Phare, ECSHP Aseno-dihyperacivy dd (ADHD), he a coramon byes fatima eaten hyper vty an symptores preset before the age of seven stl may pers! thouphout Se ie 8 The ae tee sbyper oF ADHD pedoan ‘Shee (10-20%) peony typeset Ms) ond ‘Stine instene an yperacve C0 80%) 6 Goats of Therapy + Improve behaioual aa adem eomanee Investigations. ‘The dngnosiof ADHD iss o ‘vier jpn nel Tae | paseo (wire apace ca cue a raion of ADHD spe ~ lyuct of sypemson nctoing om ‘ponies det dre ont ddr macy + arousing sae abe edo collect th above infra and ass popes se hr adcnclng lis gid i fin tne ox spp cn eh28 Peyhiate Disorders nitro ce ing. vn, tis + RR Sateen Sy faye Spray nna se gc eh and ced rere, gt nd wei psy if * Stan we the woe ed) Table 1:_DSMLV-TR Criteria for Diagnosing ADHD ° mst Ohepter 3: Atenion-Defct Hyperactiy Dsorter 29 ‘Therapeutic Choices (Figure 1) Evidence sige ts combi ‘sorhamacolge tras (eg. htevicr most 8 of phamsesogc and ois te Bet eae stiegy freien DNB SE ‘Ringe medications and aomeacne nc he on one emea {ere pom a ADHD Se Boa he ‘portant le improving sc cache ‘common bleu arn ADHD SSO Whe cnpaed estat ese ‘srophaacolog eons me ee fine ane ‘Stplons of ABD 1 Beheionst herpes desi Sed prema pst oes hd eng compan besowt cry a combined teswioura panne, ae xa tap lee wa if30 Peyenstic Oisorsers sy ir in ih en nen re meant + Hoc ieeaa miata ey siti terbeseett St ate ees Pharmacologic Cholees Prychostimulants _ na ree culabecnar neta toni dn cscs lt tae piemeensnne smamrnytanmeee Ee ee ionakanieaecaees Though neigh ssrnedlee bese Ri SR) an TecRtapheninesstine ese panes (Deven haven teogc aon of co op ho) am meine else ‘eeSicip cease ey en ue mre ha once sin. ‘Long stn! fraine tet a Concer, Biphentin rd ‘alot Xk we Tae) wea stents onpopiy he ‘Nove acng slants Tez omns hve raion of con (Sto a Adept mgr pices ice le ‘rath most st hot dtr ep nd ‘Screed at afrebownd pero Given searing ude, ‘rica Caan gains eee! ADHD reer Uneactng ager far tetine ween of ADMD. tettpenpogeer en eter at crescent Sao Sintec seeders ae ce SEAN. Th isome cence om dling as chen [Chaplr3: Alenton-Defck Hypersctity scree 34 sda ta ossfini(170-$28 maa) spain pce in ‘resin cre ympoa of ADHD. Atomoxetine ‘emu, oping mt eal Cae eee et hentia Sree ac erie, sSopeistarwmraanss Reger ne ier eps pre clon ei ee at aa ane ea teen ‘So hr sane “Antidepressants Inger meres oil ied ne ‘the magetent of ADIID i calle hence tye corse con thine ons er adjunctive iy Amon nny tenet pais vith comorbid Carns sh ay Semen vey, ea ore odes Bupropion, norepinphie sn dopamine opine iit, as eso found te socal eee for teanea of ADHD estas tlre and el 08 Sone vane agers oat ‘cto an norpinepvige rape nib) te hel ie ‘management of ADHD 0 Todt, atin tees fom ovoid nd wale recommen fs ae ear Mary conoid was have casos the fee of TCA ach a 20 mpiday oe qoipee > 1D ‘gig te ormeinch reir ft shoal be wed unre eat of Spochiaret + Atenas hen ar tt nea a 2 dae dou feapeati ange Ut" Pets wo alt ‘loner ven min response 6 th eae vel fo ene ita longer consider methionine wo muting» yeh + “Therein ood evidence to guide switching frm oe aniayehetc ‘erat ater Cossvermeeaion sates, ove tre Seti ue pera npn oe, Teedaton i ot spported by evidenr ad should be weeny ‘esse aie om clzaplae hve nt fen she eet om switching oy ler atpeyehatic median Staion Stable Phases ‘+ During th sabiivaton ecover) plas ates ae ere terete awd sheng m anipyeerte medcton vos are Inc ineleuble se effec or perastent esi poms Ga Atsacssg andor dsabig fo he pate. 1+ Nonceone tery seen o prevent elas ised schon aoe wa 1040 bere flop win Be fois who conte medion ae ve es oily {tape nye onger hes rose {pte tracery ay nat ea erring ern ‘al japon a fetal sai ~ nme manne raf sone ea ‘Georepised ntchale wha ahve som rise fineal ever ner weiner (woo fie Jet) ay be ‘Spied raring aon atl cons ‘Of uaa or agressive behaouc*2* For pants with two of ‘espe anenance phamacolerpy Soul coi Chapter 7: Psycnoses 105 teas ive year daring which in the pint soul ese the ee ‘any patents wl require antpsycha etc inky ~ imgoe te owen son af sya tat na se ‘etesimes shouldbe used i maennce eset ‘Conde ings inna spect for nl with oor esenat ibe [i cdconimuion of mation 3 be deren, gal rece ‘he dse by nr ore than 29 eo tee as a a iho te uct end yo SSR a a es Depresiv ympoms ae common in the roca ase pseing theme ainda ee pay ‘sonalpicpisde patents, Seresive spe aly tent sho ‘ith th postive oycote pions = SOAS may temve flecve than PGAS ia tstingSoreive ‘mpl inthe cute pase thre nme evince app he ‘Se an amidepesant nthe arte ase, _ Major dpresivecpder oscuro of naval dngosed ‘item on wi ior hte ero ~ pats wih fs pode psschoss havea greek {pemiom congue to bliptecpto pats, pretty ie {he cabileston pase poate pte a eee ‘Srp ond ince eft se man ong 8 Emrepsae of pence ean eit dre wean psn ging Depression Inveory have av heen valde mia _chlooptreni The Calgary Depron Scaler Schism {Sel ei men pate pad poe “Aatdepresin! medication may be ttl a he este for ‘preston nth sabato ele panes" Atop eehave ‘Seba few austen super fr COT igh ate of sarc sideendence Anders ef in {ndviuls wih scizopbren (came pevalanc o 47-800) Eerpated he genet poplton. Peta cance bs i ‘stele with neatly pore ote106 Payciaric Disordors invite parc ested sco) wo appt to ave aig aha i eet an as + Refer invieae with perenne abet amet eal [Pour tn can ove compres iepnted proseh=™ ‘Antipsychotics in Prognency ‘Steester but ike and tenet at be aretlly weghod for each bien Te tri own mei) apt woe ‘Scots hs ben noted fing reputa ohappe POAT ‘Sido Eects of Anipsyehotes Neuralepie Malnent Syndrome (MS) "Satpal casey and ha hh moral ee stacy mal i ee oom ence {nde ime. us oer eoorte whl anipeychotis acon eccor sony dome sanyo: Deletion 2 te Soovgnimmron tices « eer beim neee image er See ace eres sels San th sn he inti Seer Stats seen it severe st aceon te Seite ety te RePub get Peet Ee eerie, ceetaceege eta centre SSeSnooe CChactr 7: Psycheses 107 + Parkinsons ca te ascined wi dysphoria, dened ‘cheno and sowing of eget + Morita atecve ad oat eres) son seed ‘prshotc agin which co nn on ce dae ee ‘Stang neonate + Bale dtl consis ofp, vontay costo fice fnk exerts or eapiiny mars snd ca oe et a shatig: ~ te nein Spr yer with FAs ud the cunatv iki puss enfin tne ytGarceowe Thence ect les wih persone ancl Guess se pin ave sates of TD quale! plate, sad eee nay mprove cing 1D ~ fo pn fe kT wing en with ysnipchots mediation, ceca sing sont ‘Wel Ga, Oabetes and Dysipemis = Atingchticindced wept gins a sro ieee gen at fndivils wth achaopeea en ole cre re slay at ihr i of benty compared oh ene opt, For GAs, the ik of weight gin i reset wa pee soe ‘Te kof weight ain with SGA higher compuco Fos ltough his vais: Clorapine and olmtapne mt aeies och He ‘tet wept gi llowed by guspieaadthen hoe ‘Weight ain dos no cela wth dae in se of oe omer nee cin dn any on tig sept ‘diode ea caine frp om era longer Wee cea igacommon cose of sonnei aan lof ta scone craic apc weds "SSS aah + Dacula nnong S04 brea norms nde i aid wtp te ens pene, Ss as ‘esc ade Ta Cana, St 9GAV cary a sana a Foetal sion sbrmaiic| Hrpetindemi as teen aoe with chp and arene, tod tiers hve een ep ne ocagn ‘apeonc han tot bon sted ih donee108 Peyeriatic Diordors ‘Cardiovascute Side Eee: + oxic hypotension is the mex conan an ‘ravi se ec poriasly rpc “nite ora he let. f= mare common wth fw pteny Iisegenaton antipyehticy and ih empty or with ‘tetepine perdon onze Frolonotion ofthe GT, otra sociated wih the potently teal arn veri td ryt tad ‘each Chia 9 GT, ea of 450 mace rconcermng "OF, polngton oc wit bterrmarne, pnise rite aise) od ee atone te ‘gts, ln (an 1) i) Pty ‘lial sigtcant QT, proongtion infect wih caine {i100 V0 pansy loz is noone with an nscate sk of yan {Gepeilynbtnotiied theft month of heap pecans, ‘eed effi, crop eat alte, tocar feorto ad mia fsuctene. Hse and sya af any of thee pene a sien hy sel Endorinw ond Saal Se ects 5 es coon eof Fe omy ey ages meh ar haope) nd apron ply SB Sea nies npdpetaet soc {epi or Spine seman pao" rypemolatiemin on ces lilly sion effects tut in'women. galcobes aod gyncconmst nen sl sx ‘stunt a both mena rams seal dfn weve, {Sec aha sph open! of pcan ~ thet approach tthe management of lily signe ‘Misti deo hypepacionin nrc be se mips Chapter 7: Peycnones, 109 TWbie3Anipnychoticinducad Se Etec: Assere ent, jonoring and Management110 Peyetiare Obordrs Table 3 Antipsychotic Induced Side EMfecte: Assessment, ‘Monitoring and Management on SRO —- ae SEES Eee Re cee hare ‘hap 7: Peychoses 114 ‘Therapeutic Tips + itt eames beth elon ish ele ates aviatiyof commanity resources (ekg oth ener ‘Scoala gprs leas ecg nteeoms Softee en sbi ereapete ty ences + eg ch ee a ay force sop ray ans maga we ‘Se orantpyconcmescation i tte pone serene eae Sal opnis cma + Cond tains rd er reigns fire an ‘Supt poh carb ot, nel ot Gctiag, ape ements deed ce ag ‘Mines othe eA at som se ‘osname ios lin sees? + Toga conta freon flo apy te se thar srtutcpinn a eosCcnapte 7: Peychoros 145 a “sspmtnimene Grog secennes chy slmmantw se ey = oe a ae =e Ts = ih 114 Peyetiattc Dione118 Peyote Disoters Table: Fst. goneraton Antpsychotes uns ‘onapter 7 Peyneses 149 Suggested Readings naan Psciare Assciton Cline pac une. Teaent ‘hep tk of ciel mnagncr Lda Newcomer 3W, Haupt DW. The metsobe ects of andpsychotic Tmesieatinn Cond Pnchinry 2006 5(8)440 91 Remington 6: Raa pharmacy meaty pes, BJ Prete Spl 200.187 )1-8 Spine Si etoacer W Lieberman J. Paamcolgis ‘eset of chops’ fr Liberian J ary BM tio. Comprehensive cre sehzphreni thal nel ‘Managence Landen (OX) arin unt 201. p38. “hon chaser WW. Comparative eee oF penis in ‘be teament of sezoprel cal semen Shp Res aan 79 1883,120 Psyetiatic Okordors‘Camas 20087" [$202 lon Sk5S bn ee ‘Schizophr bse with groan aman Banden aa Diet mel reseres cast inthe cat of patents wi ‘shpat waters deprive “is Sete a on-scte bepalzsions adrenal ie figs Novel esate intade cal sowie an ey | [Syement saves, poce pu Cow week pty ininerin seman tat of homie were cea ome of employe spice ley heating revi Ak Preporon (1070) al wih ‘chuaphvcla ne oeapaoes® Iago owes ihn ve mr sen wel tamed bay aves Seca pct | se veal sci con of hepa | compo ete aatpnceice Nope sup | tteroncanpiance reaver anya ope aos a push phnmacocononn tas pte antjycteie ss end vce ea mpc ants wih one she alhegh se ey of ee inact bear sere byCHAPTER 8 Insomnia Jonathan AE. Fleming, MB, FRCPC tc asp donde rina oom chon pcos oul lesa he faces hi bape Secadary fon sei ‘oa the rng ides tls ape Goats of Therapy etl) er teal, pm anc) factor car asleep, + Reine date impairment (eg spon, ign, dcened erie) sosoeted wih sp ae tints with pier, chun soma meena Invetigations rm So nce a a yea wg ton la cance na Chapter @ Insomnia 125: ‘Therapeutic Cholces (Figure 1) Nonpharmacologie Choices. Tone pent in seep hygiene (able 2; monitor and ensourape ‘tren rougher este an follow-up pan sues ‘tony mere Suggest venation exes (vi x mi recoding for me oeca. np wm cng mplapes. “Conid see etic, ama coutl or ster behavioural Sepchn one or wit puns ee ‘io promce dlp and nore etl seep: ecaage patents Wit nro decree dayne Ys pros tn incre eee Pharmacologic Choices (Table 4) 1) af liyponc are well combined wth od Slsphypene(Tabio2) A cospekense evatston cocoa sete {ie laps of ea iene one preering eee slop ‘chat mg neal ep pes of ote han ight oes) sh Sel monn pes ego Sess heb 126 ejcnatic Disorders sgh cet an ihn, ly saihoran in en Tibi 2° Steep Hygiene Guidatines Benzodiazepines (802s) AIL B02 tae seis hyo ppt, bt fe sginty inpteny aed peanocotinece.Alinay cae contin snd maa SEES Ls ly nd eden For panany env pred over tor DZ When oman sundae prose ty poms ogacting BDZ (ch ss lonaespan gies sf hy rom seep and manage due macy Frappe tose one DZ rng the dy to mage ay and iret BB? 5 "hymen night nthe same pate Canada, oar BD2s ae ofl ect fr none uracspam, ‘itrazepa, temarepa an tetaralam Desa ote lane Iie, Rzepmo an napa carte with open Sxing {nd ar tect wih mere hangover eos haa har ning BOA tery hy me cori mp eng a Sete apn aspen ‘Temazepam is 304 all prose hype wil al. aici nvrihe dsp prod witout enunng hangover eet However fer pots lave provee aay te lr and cee ny be Chapter &: Insomnia 127 soit with file i his option Menus oss ebundinsorin {Ron more potest Za mck repre ‘Tzu bs fs ost ad short urton of sion making it nae {bie cman ii somite) ate ao Innintenace oma oa foe mig) Thao sine ‘hound sori i has unique vee vet profile (cn, plo, sols) ming emer nese Sls ‘Xsonet sexiest coe (net seven a) ecmmended oe Although te namber of smparave stain elt ral, ‘nanepam greece ar he BD that are ofl not for hen 90 ims betes bce cms of slow sor Extvercly, pens mb have no iy fling ale bot xpercne ‘punta soma ca le oxaepr wen eign be ‘Tere ae fw sng thee of wrazpam 99 ins ay cane signa bord ects tc or ay ad Benroaiarepine-Receptor Agonists Although 03 BDZ, he ycopyolnesopeone atte DZ ‘capo and sue cimiar hrs sn ee aces ‘oyhomeorsptoment st wi combine we of zp and ‘ial or hngover efit ta coulis ong rin, when wed ‘nce wae slcshol Compare wi BDEs wane ts opens’ [ppm efct my ede ye an eon nr maybe ee” Ettopitoe th ac (4) ore of tile ses lt [laccelgi ropes ti acne compourd Ba ore potent ‘orn tli be cement ecay ute and coe ‘ecomasn with pe demons cot teary oe 12 onto of {isons dcowtinstin Espen aot vale Canad. ‘The prrzloprinidine slp ws witheowe olny Som he naan martin 200 Inaiplon rs sor stn rane ‘Gatton to nope et he GABACA sepa. dont mt ‘lal x Conan prcsnnary nts Pa les pod coy ant sate Other Hypnotics ‘The txt and dragnet pole of hoe hydrate mse it ‘eg sf tna 802s, Tolerance os hype develops “inminatl inthe management of tenn due to ek asc ‘ft pele128 Payette Olorder “Tne Canin soppy of Ltrplophan ba not een asad with he Evento he cosiophimpalglagondore potetl a ‘Sentara es Jerbiton pence I ay beef when oe wishes 0 ‘Uso lata (tS me pray insomnia remains cuter SeSSUMEI NE Cashed deta aso release ooh Mittens nse of mde sd old pe, Kameleon ‘eon wih cron epee ena pve ss creel ond ighssests aoe MT an TE tis ‘Sirs ae fe US bat mtn Cane I aus aia Eo amet ns demote bypote rperis wil 10 ‘Treen mers oe mor erin. Human tis ‘eSSong Sane ec patent wel wierd, ot Foe er conplled tly ne roe to cose soles © ‘leg proetng gs ‘Therapeutic Tips sheng sta hypothe wet dose and ste for the sere ose tine Scene sen goals wt the pats mil 0 mine ‘Sym moe sep om a Theseges of dytineimiment cs the inerventon: he msciechage dye ncn. sor core of yea a ete rt latine mara ml ocho. nial erenton fe herp retin st “Sherpa (lle 3) fen elf n defining the iat Shia moons pees od ising thas + Wratnepoprne fos be eae sid effect anther miion [eaeitiaminn, sept) 6 noid sigs BDE (ce punishes bee ape ae he eanent of ce. ‘Stlemodcinon eth onprecton agent recommended, Schur ce te pti tow soresing soe «ar pans abou combined fects when pote ae wed wih (he ENS deren eat fast couneafa spate hasbeen td, pln to wil 2 Aifaticsn eae neem. Tv nis bfoe the pened ‘Mime heat sou shorten he se ine (ie ng ‘int medomica) by 30 mate. This moe deaee of ep, ‘Eplsatinil peenote pyle sepnes whic boa etc nyse Saptonsanted wih witha, Ti, ‘Senet sep pein shold be masined fr one mere ean sia fre cmeace fm hore ih sad Chapt 8: Insomnia. 129 2 rc insomnia maybe he prston of an ete ils, cma Sein ‘of ood soca he eae ews ane TIN ek Flgue 1: Monogerent of Primary nsomnlsChapter & insomnia 134 130 Peyciate Disorders| ere eee j === SS SEE = é open nme 132 Prychiavie Disorders134 Peychiane Osontore ‘Suggested Readings Dex RM. Dram ee of do mi ew Frc SSeS Site Mii Cn pracice Chine cota: 9 gl! Ned 20053838) 808-40 ‘omen Eh ep ny li bon Og CHAPTER 9 Drug Withdrawal Syndromes James R. Kennedy, MD. ERCPC ‘Treat dr wtaal mires egies atetoe ba he ioe ital moe od thas yh ‘ice suche nd ton rabbit Opi wheal ‘ous in aed ampentan syne ho sett meet ‘ere Sting win iene chtutel teow wath Re ‘bt inorant beng natty tne common, Nalco ‘te pts Wirhdawal syome diagnose ei! + Thedevclopment ofa ststinceseciie sine ue eseaon or 1 Clncaly signa tes or ogame of inns © teins ‘Table 1: Dlagnoste Criteria for Substance-speciic136 Peychiate Disrdare Goals of Therapy 1 Reteve symptoms 1 Amc poset nd west complications 1 Asses Yara wat comorbid a pay) 1 Fie senive peyehonca Nevin eaten 1 prevent epee Investigations ‘tthe soba (amou, eure duatien and comedies Salen adres payne 1+ Spee aspen: ols sch as he Chal nite Wilowa ‘Nsenment for Aleaol CTWA Ar or CIWA Bera oratory tess nd imaging oases comndiescompiions reveal story abd ysl (compte ool coa ener ‘netomat, mages, papers cet ay CT 9F ea trae etl in be wun or nergecy pte where ie) Imacenate ‘Therapeutic Choices (Figure 1) Nonpharmacotogie Choices + Nonlamenl approach to explain proces esse ant sport 1 rehome pop (opie beau ten, trv ener se npn eas, ‘ong and hy apie) Pharmacologic Choices 1 Mito signs anf peo {Taree mpm of witha and assed comptioons tulcomerian acl ma pre). + Subsite use dag with ene of sme of sina cls Sromtolerapont that es katy Be tus al th ingot [Alcohol Withdrawal Syndrome ‘Assessment (Table 1) “The severity ofthe label wide yame wd it complcations ‘ee dey bt consent wi be next ad drain Chapter 9: Drug Wiharmual Syatromes. 137. sf nto ae. Those complications cs eens, ow pr, nie undemin(. ‘eho halcouon, esses). Mi wil ptm cle ‘Teor, ral Ising 46°72 hota: Severe ‘Sempron anand Ahern tng po seu ie dys ‘cide inom eb, seers, haloes desis so Pesta The CIWA"Ar oa face semen ots Management (Table 3) Apresinatly woth of ptt with mid o-osere wih ‘plone can be rexel with upon aod meting tough operon ih pharmacterap int desere ih trae Buniog sme with aw ose short drain benzodiazepine therapy ay befell and so ow ke Sever lah withdrawal syndrome aaysrequtesphamslope tevin end oieines sul ecard the mae for erst ‘toa Laan an tly ronutmend dss of Deserts £E'Sb me Sasepa vin ft hour or= 200 gn ours) Siaioom os ctent GaA-scv So ie phenobarbital (80-1230 Imemen one 3090 mg) maybe eguted or seen eco ihr (sot es, and hse pts ege metering ace ae Sten emergent) on, nese cet otitis cr unt). Although cy emergency room physi ad an apy asaly Aatpertoo's 0 mn tessa ch! wih, ne goed ‘rset pet hes there af ptt sei sad Iapoten, tents ited obit frugal less may hav ocala ‘Ependnce, an npopiate propia an amen of sto ‘ezitie hey ove ry sel ep we Alster ‘Sonia eideee to sop he we wf pharmacies (oa ‘leon ith sig ACen even tee se is ‘Stimulant (Cocaine and Amphetamine) Withdrawal Syndrome. ‘Assessment (Table 1) ‘Symploms of ose wim ale nowy pychonal ale ‘Stuimciallynimporan symptoms and tne cop for be ak138 Peyciaine Disorders {sree depeston nd mic in sal eon of tet ‘hetonic oe manent ty atom, eigen snr ad {ven the wi ste ori y somes ond ‘Scat ape: Dereon aa abe sp dance thy ning owe caved ee Sol © xo ‘tira tus ry incude pov ees or mor sete ‘Ergon ayaa Cae ple Thom snctanpbetamie (eral met) pete pyc ny tera ome pecans uncon) et sera sek wy ‘Srnec mph Macon ‘steve sbsctendocang HiVand opaed nd Management rahaton of vey of pharmasothraysppcaces both fo ‘Teac a he wana nde nl for ose even Yel oases, eng ncletve Wate: Dopanine| ite cetomertcl no saat es: Besant oe Sateen hve il ra eevee nes! apse ‘evento, tet my have ar cena open ty Aarne eplcenetbrpy wi orcas apheam or ‘etyipenidate sso Senin le reve ery ‘Str may i er nls undergo ee dard ‘Sven Maing is dpe requer ahi espe: Renabitiaion Although bepeenorpine and methadone yf bent cas ‘hiked on sia pnd my enmity eect for eating ore rant dependence nese sat ic dpi ete cy agus behavioral ray tbe mont tect wton ioaddessing the jen comarbic Opioid withdrawal Syndrome ‘Assessment (Table 1) Symptons of oo witha ae not mei serous, with mule chs estes and ins pedonaing. Toes wie ‘yaa sual ts atone wee, bt ach anger in sith Fo methadone, with og eoting oon pring for cero Chapter @: Drug Wantrawal Sytiomes 139, Management (Tato 4) -Atatnacetsed west maybe dsl, tte mst ee ‘eatnent by farses to olen herp wth» ons ng ‘Sim ic wethadene the prt eg bprennepine ich ‘Rita tres Heh Catala Sect Actes Pear, Hstidone sad bepeeombis ome ned wh the witha Ripon 2 apy ae mr teste fen ower Betas of meadone ong hii of not 30 sy tk of ‘sn wh annem ee oooh ut gona with fg half (3 hoe) and peel oes fot Ente arcu nove = ‘Cloning an lp? agonist tht dereves he verona pat of ‘Seinen amb te te peace wns at ‘cle acer sd ries ess alex, ong “ponent, sed back apd agonist flees ihe ear totuppon npc absnctce Mower bot of hee apes re Ince dessin ang tem a sn te of epee ‘penne Genta ‘Rehabatiation “The ea longs res ar bind with epee they {Goatdone buprenorphine) coeine wih cogaite of Bene {Ermppcraneing and ap ruppors Wt metesone dconsnton (Sconalern th at tomer oor ih sl peing ewer mans Benzodiazepine Withdrawal Syndrome ‘Assessment (Table 1} Asworngbnaodzepine with syoe associ with hee Site 1 isingishing ecamene of ney, pane orinsomnia fom he onset «ssn rk of serra autioondehyperstivity 1 Sctng he at eaten fr he nein pyciticoitio, ‘The withieval yao hei within 1-2 dye af rt ‘Lecoustin an can be sve, with hypecemon, hyena and inentleia popsesnng oscars ere wa lng, Mose (Bein ert ney a neds, nie Sst may ery ie (ever > 100 me dae per dy) ey be esc with ‘doe yee ernment {lve wth srry of th eaeedasepine wba Syedrome: hay de ef ages wt abo aie, ong ron oT,140 Psyenatic Disord ns smi dnd, pes Management apiece wid aoa ae tesoenie ‘tai dns, combina with suppose sad even of ere Axi dns and prolonged ping theray forthe underying condition, form the oly effective wexmeet ‘Grids, pclnpedbenndazepme depen. Mow Cahn ‘gt ne anno nara for epee hry (Tle) Ina pring the diy de 50% i satng dose aly ‘iearovers 3-4 Wek pei the st Seg es tary meds ‘Staines porate wecks wih done chge todo ow ety nn carp en eee en ‘hold cite wih beneodaspne ag and may lee pees ‘sf aiaentcs, Puen can be anaged ins ene tain Progr Fe palin se with anced caterer ee, SENSE tai er petour ser) request spat Chapter Onag Wahdrewe! Synomea 144 “ptosis oo, low potency apse. asm ca be ‘Sie wih hee ages ih traradone 00 me bee {Bapiree cane eerie ston fe peal ane) a tow ‘pte reasons bt mot raat sey gue 1: Management of Dug withdea rameter) rc — ‘tle 2:_Dose Equivalents of Benzodiasepinee (Cieiminar | [isanetionl) | Benet | Se cate pak a cee (Cr a — ns | a Renabitiation “The et eaten! fr the uering ondton (enon sprained rey. pm dante dor Cope ‘eww teap® Phraactherapy shold Be Sc the ‘Specie uneryingcoiion stu aves wri for dependence;chapter 9 Drag Winarawal Syesrames 143, 142 Poycriatic Disonere TeneipuA oupory yo wauidbeven a/ojeSeuueug “SameChapter 9 Crug Windrawal Syacromes 145, a ve ae TemepaIM BO We WownBaueR BEOeoEUURIE > SaeL 144. peyeitie OsordrsCHAPTER 10 Smoking Cessation Peter Selby, MBBS, CCFP iF orci (0 090 mints fre epee anata tip icine vl Ot oycoacine Compan n sake Goals of Therapy! * Famistn fo otc ue and cede opcodes ~ tht of ting eva hems Investigations (Figure 1) "Given everyting going om in Your ight amos sel of 1010, ewe 0 the most enor ng to. etn am ‘tpn fer yout quiamoking sete Chapter 10: Smoking Cessation 147 “Gveeveing ig oii on on ase a ‘ouident do you fel you will be able to gut smoking ager ‘Therapeutic Choices (Figure 2, Tablo 2) Nonpharmacolagie Choices Most eokes yt ut on several casos though succes ates over Tice ypc of ewidece ponerse reraed cond a with ‘Sibentmonn rte fsls are sola ream Tovah ‘Sy promnen. eo gues forth teary of ype o 1 tine professional belp 1 ing meeation ogo mating ‘ze! Esti tinge tes iccace for 5 th minal Seager ame(< nan om rect ‘iinenc tsof apronimatly 29948 Stokers whoa {put shal be coun nt cae prior toe ut dt ‘Btowin te use ant nee reser ac nectnr opie ‘hogy alo ow and manag erty lp Fora hat ave ‘on tan ob tae lca foto eal 300) ‘SSanehing aswel a coast by tpn, emer mal Pharmacologic Choices “he addon of urmacterpy eee he ft oF git (ce Thies sol Ye oftcd Wal pcs soke 1 mere Svcs ya sepia Peter e ‘tc asf latin replacement therapy a bupropion ‘tnd cline 1510 Varin, am apa betarnicotini receptor148 Poychiatte Oierder ei ant ne ie tn vy xing pes, Ince as of suceesly gta over bari an eta IP tees (arene #5 nupeopon 3.5 an eae 7} However freee t sont ey} son fe ethene nae Hopped) wer mar vreihe 22% bupropion 10 pasha 82). Too 1: Estimated Abstinonce Rates with Pharmacotherapy T erin canbe ein rie ely nds ih inna ‘fr overs or dae denne men Sine tespie sr Sie nieve samc Chi my adie ‘Sone with ewan ype, Hwee postu bytes in be predic se dogma be apr pee awa Npetemon Chef mtoon shad pd pat resis an absence oct she non, Tee evidne th combination therapy ‘shar the meaine pte conned wih cite scare pnt eine inhi mtn par bopio ete in the Hore tha ‘menatieapy Homerton rs ming or and combation ery ig tony ee td iecommundicatdcomfaton wh ‘Thenicene orange anal pay an ingle a tle ‘ana Rinnah tnndcp agai proved Trot approved for shing cation Uo Sts an ro rab nC ‘Therapeutic Tips ‘mean for a ee fr wee nde Revo eons {Oh tem op skin Chapt 10: Smoking Cessation 149 te smotese sing the pth compa of wmanageble evings an Soe ete aid ns gm tale Weaken te important io monitor fr low mood and eneramnce of depression Insmokers be gu — Poti weight gaa long stoking cesaon soul eared eke qulting sod cal sve sos be ofr Yo ei he ‘Soke: nou ming weight hey it nd enree an ‘Sedans ot ihsupar rode whi th pent caves wen ‘quning smoke . rete therapeu eae in wich he att ca eet ck the tips lp fo set is son os ose182 Poyesiatic Disorders ailell i ih seit Soe teminmeren e eae eaeFy i i td lau iy [tbeytlist ld i neat ti y i i i l i hihi156 Poyetiame Otorders ‘Suggested Readings haaerany Tr iacco dependence as een ie ‘a coho! Rv 00625) 3871 Laxoge Reon Heston eames fr ntne pend, Boca Tite FL) CRCMavlor Pant 207 Metin Ayes Metab He aL Mama of king cet “efor oun and practioner aden (AY Aiton ‘rs awl 206 ‘Waal Bupropion Tor emoting cessation. Expert Opin Pharmcothr Sed eho wera, Daan & suction sore forest of ‘tedden one waco Aceh [Chapter 10: Smoking Gessaton 157a CHAPTER 11 Eating Disorders Laird Birovingham, MB, MIS, FRCPC carci dcr ls ah Goals of Therapy 5 Anca ah ate ic of tn sep Tet bing nd ureter Investigations A through Mtr with pci tation 1 ‘ciptting haits,ge an pare chair ection it ‘Ema an fone as mas Chapter 11: Eating Disorders 159 ~ pylon of malate codec walpaper, tance weit o Can cps of canon Gir try + Pa cnn pa ergy a ens ‘serosa ook ase fr postal hypension near, tango bash ibe cui wis RBC ad hse ng Sad fous ei + Frama ation tf Anorexia Nervosa ‘Therapeutic Choices (Figure 1) Nonpharmacologie Cholce 1 Consistent fr atl of tai nerserton a eaten info ps omg od. Sapporive mung ae eae + Exec shoul be lini, However, supervised sade cree pct yop) casts ty Warming, by amas warm oan or warming ves sy rece sieht screry sd neon he chances of lone160 Peyetitic Osorders Pharmacologic Choices (Table 1) Prokinove Agents Domperdane ed metclpramide rly po ee the ekg of ‘ng snses by Sted een mot re ely oe ‘feng Oe pote: tonal cape hs bn compared {5 pace mth pte grup, bu twas wha oe the mah eles oft anslaton Siocon ee of ety ed eh nes the nanan tet of etoclopaie need dompesdone nant alone eden of extapah eet ‘Ry ihe cing of floes mting eset ad opr ‘nencloyamid fect, the nos of erytramyea yp ‘The pnt fr hse drags cause OT polngton sou be ype. hyonteens. Other Therapies Zine locate sopleinition (100 daly oo oth incense ‘Geese! weigh gn renee of hese 2 urea Zine ‘Sussman aut 3 tent won en say bu ca De {Sten wah oo to rele ave oe ‘Olamapie decrees noes rnin renting proved ‘maton and my they promote eight galt even ncn ‘Sucun neva! A raed cond a soppors ese ‘ining demons ht he at af weet pin a ese a stents wh snes nro beyond the eth an oaxapne would ESS caunen's pemon wat nea Ta pra n ‘Shosunnowon safer rome thy weld not wae he wedionen “ip talm were ps. Doves of 2.51 5 ply have ee fete, ‘ah mason de of 20 mpl. Beene of extepremil sie ‘tes shoal ot be wed Tong ee less he ents weigh SEs ater mene ae Uo ee Too) anda catmun BME gin ood a rape ‘ncese mappa lah gi my car Coanapite econ. Dlabter df reser sentir acommenty sbcree dvenefet foasapne, bt not ths tet Eo To ete “Cyprohentadine 4 16 gat ne ay be wef pareuttyin ‘oni srrens avon. Itimay cases modes weight pm and feed asap Serzadaepnes (¢ ouarepam) cn be wed to et Svee amity ec esau dgeane ein wt conacapa 091009 iD and cule te upeati necesiay no oem an every ces Te ay spnychuicqutapine sel sed ‘a tenvdinepin to manne sey ‘ecve sn ave CChapiee 11: Eating Does 164 Seatve serotonin retake inhibitor (SSRI) aniepressnt held ‘Stsod only or corte cote pre ese ca Sots eae (eg, Oe es han 450 loco, oe Bains ‘Remora, Annecpecants ‘Give thiamin i os 100 my fr aye he being of Feeding peen te development of Werke onal ems (ocepsipsty) ‘Ondansetron esos esi in contingents Fv ‘Stoll wit eng deren ‘Therapeutic Tips + ypotyeznia a oc er cain Deca er ebengen ‘epee, Bled glo shuld be menue to hour er ea for She fen day ro edn i soasin oars + Gholi can eve soy apres oer “+ Noonan body ft ees fr psa etment be (feces force ° “Women wid anorexia aero cas Bese pain when + Teament es compon, A cael reeset ofthe tees pln tect Foy thy paral enor oe Errment af hicn an sosca 1+ Sled, wereing depron 0 an aily to gun weight treintetons fer relerl an xing Sander specnle Oupaton ‘Siew or patent eaing ore enter tay breed" Bulimia Nervosa ‘Therapeutic Choices (Figure 2) Nonpharmacologic Choices, ‘Cognitive behevicaral therapy and interno erp ae help In adesgcogmtive and croton cst acing nad ‘ing behave Follow popes 1+ Neca piensa ston and dae so at i prea. 1 Poyehredcationl group desing natronal and eye {sen on cabsnce ica rps “ Pharmacologle Choices (Table 2) Antidepressants “ein of pats aking a meprezat experince a 50% ‘econ abe den There xn olin been the presence ‘ecm depen an aelmle eof teatro, ‘Soe ithre ay vans ta oe enters see ft tan162 Paycriatic Dsoers \ Cheptee 11: Eating Disorders 163 sth However, eens of teiciy a poe emp, do ot rsrib meychc sadopessase MAD or pep wich has been lined of Sonne pe ‘Seder, Skt, venti {Spores bythe mon eens radone helps wih sn ace wah al Daina they erat east i oat prefab one yen gmptoms erst ater a al of comming ad sanders ext 8 ‘acinar ean ay be Ree ‘Therapeutic Tips + lefletve, comin siepesnt for 610 12 ont ndvids ‘pons to mein vate soa enc anes ny have 1 Trevino with ted or atdgrean athe a tie a 20 oven sdamtge dhs pte ont vee les Sco + Ofer ding pega cance nese ‘wi signiantifesues, awemporary worsening of hinge and parge | Te catches scien operate io Trent pyc cmb ie essay foc longterm care. teal gue 2: Management of ulimie Nervosa Epes beef . Tse.Chapter 11: Eating Donde 167 § os sot ee “corer “roma oes a oe a im é ‘eoAiON BRM pORn FBG "ZameL 3168 Pyrite Bsordors CHAPTER 12 Headache in Adults 2. Allan Purdy. MD, FRCPC Goals of Therapy Investigations (Figure 1) + Athragh isos an physical examination re mot porate ‘arn nga! Note rts of he headache! frejeneyluten af asec ring eves en drnt a cy a rs Mag eo" ‘ene Copesny vol etsy pes Sega ‘Riuspesed oe abet). ° Liner ocr frie: ei go abort es oa nivalis) ach for algnaoey finde| t 170 nowoioge Osortrs ‘oblo{+_ Red Flags for Serious Headache ‘Therapeutic Choices. seus ruta CNS css fr headaches al in hye Been Nonpharmacologic Choices +The management of henace ia mich at a inthe seme ‘csr canes eel he ron wih he patio ites and mos sopra terapet chice ~ conmorcnte it uit than hr ei headahe Sct they Save nape aprons ~ cine pein expectation lexan arapanent options Ade patios ‘icp, regular ea kof repr cee, ares of ens oF ‘ota kom dry ge pty So sep or et a ark, nh th “To infra pychalerap ny pyseian retro yea iE poet aby see ‘Ty bier, relation thon: coset kai hry, te, Src aes, vane 1+ Reser aati anor meld Rea or pain anagerene "ipl tov comple o equ mulicptnary apne Pharmacologic Choices (Table 2) dence tse iden for symplomaic and poplars Ive fee puis» eet ‘Chapter 12: Heaaecne Acute 174 Symptomatic Treatment Anageses ‘hapten, naproren, at ASA oe aetaminope with iho ‘tnt lace pin Mediation aver bench xy et ost ‘Stern of ngewe ie oogonia To va Imeicanoverne headache, ooo agen sou by Usd 1 thn 1 dps pr mnths ad combustion nage bel be ‘re es han 10 days pr ent Hall cna! pds ve md acne endche dares bets ofthe oat fo dpe ergot Donation rgetamine ton srtoni ec ad els wt formipine s choster nace bt a Hed by de ‘tog Egon i sett any formations 2 ‘Mmunseraton xt erates nay pce cha i _iyreergotamine mesa (DHE) hs sna scons oe wpe uta tects cently wih dopamine and acer receptors ‘reumling fo sre of te as eft ican Be tnd oat oe ESSRESSLRS ide in aye: DE peas 0 Tiptane rrintam, rtrptan,aatepta,sumatipan snd Zl, ‘Aiton serronn (Se) sate aad HO recy on een oc nd may pty Peed Teepe arund vene Band yuocorseiton The neve penta) pe parame ely tcl a eg too fest eficacicurpan for ssevre mga sack Wives etl at tte chatr heh. Nararpon hte tomes ost ost ith ‘nina! efiency tour bour st hades th "ent ani nen paces fie effect Narn ay he et or ‘Madly severe mri ants ad arias who ove ‘eval, vs pot vt a the sie posse ‘tics genoa lad osteo ht ‘Eitrence gt ane ely sl tidy best ‘owt pins Hower he nets in pate may ‘Sp, my patent perme specie Ferman cs esi, ‘spy leo ise lt)” tan re come172 Nourcigie Seeders ia tos with ci dry, sine hyper nd {ead tion nore ptm sl be ss on Cae cn tn many ace dares nig ‘ts mune, cate hence wt oe neopisns ih ede ‘Specter Cac mol ‘ctoned nas apy lr snc Pip od ‘nce heath Wao succes ion with te above treatment forsee ining eoctacm may be efeive: Meperiiee, minced on, ‘ui erp ose fit rat Inmet hc ‘oon weft oni pron herr ad eae dere mcg inbred {ion olint Seems fe metelopramid 1 mp or hd stipes 3 mn) al me ny Tegrramise i) dap heaache deere ne ain ning, alate tori of mesa sn pets” ‘Prophylactic Therapy (Table 3) Propo nt fhe migrine tack severe enh 0 nr hepato’ ayo oi the pat Se re limon snr sok per nth i ond ga Srp erp Preps her meant facto nacre agent. =cut ae ay tus CNS pene, meme son Fear they tay crow the Hoodman entree nee (siecle, mada od tell may have en CNG a eft. Caleum Channel Blockers “These dys ay werk by mndaing serrate fun rer [Ssclat in mira ad chstrhena Phyto Phan Selene acum en oker anda god enya, (chapter 12: Head in Actsts 473 Tyee Antgiee Amite nortrpstine and doxpin at seve for maine and ‘Rhein ism ser ‘elrivey safe madness" ‘Aniepeptic rugs ‘Valpoie ai po diatproessoiam ae eff emigre rophyisns td may wot yo fen mr ee [GAR respon ie peghoralapeionscune ate uel Toeate ve Bon pis Teratgeny etal ae ee cc “Topiramate canbe pl in the eneret of som pint in oe Ait 1b me or ocestnaly Nghe Randers al Sen rer {the Isobe pone ptets th fel Stones nd ca case Scacctetcn eto me peta tw Soe ‘Sutin ‘irate nell ete and has ese sis on econ | ‘Serotonin Antagonite Mathers poten prophylactic medication for iene it hse heats. fos prema seus one sie flat Sek ent aoe ining urton of tweter. Ano es Poet ha mtr, pen pene} sp ne ‘ated st mama ees rats 40 gaya shown ome ney nine prepa bt more re eel idm 30 mg TID ssl in the propa anagement of crnie ‘Sher Renta “The ele of btalinam fai she management of migraine i wader Ivestaton. CChronle Dally Headache and Medication-overuse Headache ‘eon beatae acu iyo alos ity fr 15 ys pee oath Simoes ooagr Te mos conmen cuss these esos oe ‘econ snc n-ne ‘ack heuer ec, Sonn te migaine chaser ge way {echrenc dal each wth ay er needy beeen Renee tha aenemtiesn peal ensue Fonte" Pope wa ‘Shroseesasype heahe ay have Ho isn of sin mgr174 Neursogis Borders ie ite diss gue aa exces cits above ing set cums, ASk aa ed ag ache te nm ray hve syntoms fSoesson or oe Posto cemartes Rebound Seach oa ese ih e ‘Scominution exe meds pseu sed cles General imple nag hol be ze sha 1S drape mth ‘ngrmsry hentcie dards saa mips most neste "hey wil ed te Sevtopmnet weber each ta onl duly beac. Prey, cron diy hadi derclopey ‘ter wef abortive wl propio meditons sul have Fest omc etd pion fie do pag a tori th eg gen) tings propa nono ‘has amiepeline or ather agers oad te eke 8. Dare ‘ehdawal pra io patents ih eonfomned mien se ‘orve a cha DU ra iptan fer tenn th ie hetaches tat emerge. Short-eom acon hsp my ‘eed eee Fak rien ang DHE) ie oppor Ef eyhologial comer cudng Seen, ae Rese ty ‘etmaaged an ate. Constr tos eu lney ps ‘mete lic former ang 0 end a erty Therapeutic Tips 1 Give shore sine, without exconingresommendel dover ‘oon a pnble + Ue snp malgeves tes han 5 dys pet nd ett, ‘poisons comnts fsa 1 a pe 1 clea or ay of nacho i etl i fllow-ap ast Arend of mediation: eines, done ad se es) sold olen “inh onset apn eat pa vy "eicaios or seerat monte a ee Sonia ese to res ongoing ond Die ciation: na ned w het, ning rent tenor of he ume clas, sok ions eastane ad explain emt pn fo pte in he fens tom ay fn ih heen nif ae chapter 12: Headers In ute 175 Tit [htc176 Ncursioge Dlcordrs ‘DpH Jo WHUTESH, apEUOYdKG 1) SUOREDPOR ZOE181 42: Headache in Adit ‘chapter 180 Neurologic Discrtas ses ba ean Bt erie siotves sammy es —€ ememes rote ttn ge ae ““Sigwetomonnss —wnuiisGraneioeaseacy ating stuonc ge Sag = oo or eo‘Chapter 12: Headache in Adu 183 | iis | ik i qCHAPTER 13 Headache in Children Sharon Whiting, MBBS, FRCPC ne Rtepbi amy atay of mie Goals of Therapy Investigations (Figure 1) + Teh A ke nos oc nt sol be ie ges sch a wee pnb, ges dri, Ieee cou lee wh stg) a see ‘motors sh de vomiy nd tors {peste nerlop spo uch ae snes, vis dsc, ‘Fenty whan peony change meskes totes peegsney sb, i ene se cd "ood presie val sins, palpation fas, cain of teh pa sf, cumitaton 0 op a igh weigh, ead tnfenee ore now eaninton nding ri sre, mac Chapter 13: Headache in Chisten 187 | Frequency of headaches, ri heave doesnot to kao pans + The tin se of any diagno ay ot indiued when Tension-type Headache ‘Therapeutic Choices Nonpharmacologic Choices 1 Bofestock Pharmacologic Cholcos + Amlrptin (Table 2) ett npn with component of Medication-overuse Headache Freameat ve ston seg wih of ange ds Coder on os popbylatengen (Tale 3)" Migraine ‘Therapeutic Choices Nonpharmacologle Cholces ter excision of leo oF ter ema + bia asf mig a of eo ch188. Nowrotoge Disorers + Encounge sepa thee o eu and met tly the ‘our ofthe het Pharmacologle Choices “These cane divided ino meen given st the ine ofthe headache {shpat} ames wo preven Hence popes) ‘Symptomatic Treatments (Table 1) ‘naigetes ‘eer nl slg, given ery inthe our of he nda 2 fanble are the mana of pramacnoge mangement fcidand ingraeAeetaminpher,fuprofn nd ASA ae eectve st ‘propia nes Te evauaton of be viene fr teen of lpn ores cmc ta bpten sed scemmapoen te Combination pods sch ax ASA. eaten buco {ey Florina pay scoot toes shoul he nal sgn Thess edstng dug ave abese pote and soul reser Cor resces(12 to ea) fr bet pen my Tk cre okt maces opin. beer being ising. ol oman analgesie ioe, sirromarn ere - Incog he beach" Caervomaine combed era yarse to fue leg) lan effctve ep cho erie got Derivatives zante cpus ve vey ied ein pds = Aura se weomnin and incon hrafre, waning indicts ‘haa te ime oe with ergot ar en abe 1s can exacerbate gastos vse 1 Exot are connate in complicated migraine syndromes ease ‘ofthe isk of cessing vaso ‘ra ycrocrgoamise sowed sigue ifeenc in bedache peat in stay comparing ith acct = eves tee aoc, erotica be ned combi th Siem ine meeney depart CChopter 13: Headache in Chitren 189 Taptans (Oe si gets sve in Canad almerptan, eta Se pclnay apres cen, gh evr ol ive donors an xcetow ty poem chen wpe 018 ‘ers. Cnr tps foros in decent wi dee severe harem ocr sulce Rol soak {yeas and older" Upleasane tase isa common side effet Prophylactic Agents (Table 2) ace prac onthe phamacologic treatment of hil ‘ans, te evdece fr eeay war exited fr sever. Ieicatons® Alduph mny re caret wean maybe et, {ir Resine oe ded hy lt aon ie harirne han bon show gcc eae heart fey ind seeiy in igen Alu ceidenes fis cacy aking latien peti) may ‘eel ons u pte! han methpcrde wih ose in ‘Fela head eens of potest longterm sees idence propane config, although i corny od sob cpt ae cu el cna ce ‘Hovay dens, dubs lias a bryan Spm ok ‘Tramon oe on ner soporte bt oman ae ie alr Despite kf rides of ea, yproeptading tn aisine ‘taster nd alum cnc stacog poperion widely ‘ho a roping oe lr che ed alco id by vane proper intense py gs. _Amrptine i son icy in al tis inci [NSAIDe radce each Feqency a severity ead presnaly ‘ugh roalanin bio Aogh evens ots hide king, mproten satu ca be ed alate prophase herpes ps) YVaiproi at hasten sed cio. However: tere ace ‘Duane fo sormcad Hest Pearl ond pen seo fooper ses ‘Therapeutic Tips + Thee are very fo comtld ts of pharmacologic management of Chitbocd mirsin: ene, nese cxperence peal ts oun fates migrate do tte day meeton ot end ae {eel anapein a Pome and a Schoo‘aid WF BEPGEH FO WouneN, FAM(Chapter 19: Headache in Charen 193, 192 Nowotgle Disorderscha: Hn cen 498 | i i I : i ee me ACME eet CE 2 TEEN EN co mowneomer eae Section sero wo no Seon ioc nes as oat aut s coat Sent RE lao ele A ‘Sas uni UF BepeeH Fo WeuReRAL ALeyo ny SEEN comet mee oer =e ong tag ws REE SROMRIATSS saneneee PSS tt i eer i aeeennes “eee | po 2S te Te SEE ae ee a a ee $ Fa we ELc Cro CHAPTER 14 Acute Pain Benoit Bailey, MD, MSc, FRCPC Goals of Therapy Investigations 1 laut th tl istry at perfor pyial extn Use lara invesewton a pyropit to determine he amet ‘Sac lignnslesn(usertestnet of pis) The ets tix ‘Sresncn shout be sondage, Theos analog {SSIS Cte unborn ine ancheed by" pl man ted {isthe aandedized cokar analog scale or the Wong Baker Faces Pain sopesivey ‘Therapeutic Cholees (Figure 1) Nonpharmacologle Choices. Patents resenting with acl pn sos be icky acai amsed Chapter Ate Pain 199 (4; mse ctr, py resign et lamocologie sent red Dnt wok nt fleece Pharmacologic Choices (Table 2) Oral Anaigesies sale Forse Song old rane wore ripped eatery Also asoited with single (of) dove of omeleive NSAtDe are tad le gael slr hse of ASA ‘rept feet fr hehe of he paler 10 sys) ‘Avoid NSAID patents with hanya pete ler eas, renal trom NSAIDe are more fie alent tan aldose of ASA oe teonminaphen ss Cen ean ss prt ato200 Nevrolegie Disorders ASA cane guen wit pie er ave ages et It shoul iS rent hen, pcan thse se tan oes wih thienpos or ke mp, eee of pnb scaton vin ‘yet Somes apes sna ASA sme paints. Tbeproten 20 mg i eosvaent 0 60 mg ASA or acetaminophen Ib tame snipes dove of £00 mgs spin ad loner {Ein npr sonar sgn of smn of ‘SetminonSoweadine "A 10 mi dose of poten sa fe 09 [Stn dos of setminopen sthovgh Gt Seeding hasten epted seu upon aprven 20 mp sua a oe 650 mg EASA 8 ‘eanon tae ASA" opeias inde ante ws vy or te teat of ment 1 seein. wens soe ps he prenera mtn prefered bcs ot ternary yl we os rote, Canon shld sivas wed when swing mens oped, Uta asorene, kes eRe acd onion (Chicos ma be th wnt omer een, edition, rsp {freon and ts forme ped ibe) aan, pendence Sih spor ‘Godene i equenty given conta with acannon or ASA fie mie et sonoma ene ls? Arproinarly te ofthe poner palates Ses hx sess ‘tn Crab 2 son i ee nen no ‘tht mht CYP2DS cam also deevease the malgesi effect of codeine. ee ofp ey ube money ‘Steeles pepactine.Homeversotaindelase reais ‘haiti ben rte wasime of sae pin. Beco of Toe ‘Mn eet compare acon: morph ca eae ave oie ee "Tramadel sigue aac esc elated to mori and ‘rato tia st tough pid and aonepad mecaeans Alea’ ‘Spence paladin on copy toy orc ar facie uremic wt sote alse och a ‘ampea so Tranmdt sneha etn eg | Chapin 14 Acute Pain 204 Parenteral Aneigosics Ineramcolnr te becuse pin fee an ore of acon i presbeble NsAioe gen Gab raat en Huceaueteatiee sameeren SRS ete natant oar coeieheenataeteanse ews the andro whic ter pis ae compared. ts ver maps fc lone Gro ace, ane etalon of y Tver and el dace can be steed non rca na FA Programme to delet a rest ato ag by comin nftcon oe ‘pet bab well salle ands for beskhrush am ‘void sing mepeiiae in pis wih ea fre Besa an active ‘aap ll ace cas sine ‘eine Camanche), Meee tout ‘ho'be avoid pens wither dese ud hoe who re ese fn hat enfcted ft mre thn ts here where merpsine Frater che a vm hopin meine Hs ee eoved fom he ‘mur bec oa oe conser ental a sythee opioid whch haa dution of acon of ony eed masse mang ton deal noes for it pesdars a iting its weines fr amg sate pin. Ths ean overcome by {rine fa by ion bt ts offers adantage over merine ‘ule much noe cry Penton abnot hrm fs tl dot not indice hist rene, lke erin ol eet iat etn cn adic a yt so ie Topical and Local Anesthesia Infirsv techniques wig Moan ate ot gue ve or {hat fr de! ian or gn serv ck. Coadmintaton of “Spimphrine slows an cree of doce deseo Sto) mp, less ‘cfm ene. os ry ys ek ‘cle cea) fag amide pe cal apres Tien, biasing ie supe an ese (ee procaine, ran, ‘enzocnne) ean be wed bea ne sben of erst202 Nowcioge Diora ‘iene pean O00 anda a Scarce ut of ces a eens A mn of foci ST cme esd wan 105 (LET as ne Tepes wets uch cosine anc EMEA Wenn acne, pga caine hens ease ie ca fet Tobe eMecve, a lrge spout show be applied Tor a east Aoecane vw MLA peeing incite ih Bit Gnas inst ee Eaves nth peel iol renter tthe fonda Whore sone popes neo ‘Syndr sb manera cage ed br {ime younger Inhalation Pain Management irene 2) one 3015 ne wd at ‘ntutbe Adc el om ta a Tan ra Sete ncn gay saa ee Binoy eae nomen, ek, Lcompeo sees towel ena an mir ch nem dn hemes ‘towne, nev eo cen ‘Therapeutic Tips + Choo the metenion and ute of seizing acading tthe ‘Scary ofthe pie dsl ome a drt of ston 1 Comision Fr poets, bat ise Soeldeot replace maleic + Forte eldety, chose Be right salon comeing pt ad ‘onl neti wel a consent ean 1 Alvays wat th apap enant of ine, according the net of ‘Som athe smaigee to perma posta sto ase nce “+ Monitor be ove of consis od rnance of adver effete er anil fe ange + Reuss th eed for alg estat sing pains, Chapter 14: Acute Pain 203, * fyuidthe us of opis an an aaa ase Aree whe of ‘Const seca a ain services 6 ede * Secrecy rte eee cee Tablet: Treatment of Opioidindvcad Respiratory Depression i seagate mv14: sos Pon 208. | i i ‘Sanol mami ‘teers wa eee nme meena —en ee ay Et “See “ES Se ES ee = a = ne aa nom CHLCcrmpter 14: Acute Pan 207 od a =o ‘ined ny Jo RES, OF FROBCUY _THREL208 Newesng Disorders ‘Suggested Readings ‘ede CB, Seth NE. Anais fr be west of pin in chien. Wns ited 2002247(8:1084105, cx mscas i Gude ange 2 gece, Us vitae do Coles Ntsc Qutb” Mere {GE da Mec ie Boe tnt” Dros or pl, hat Godt Md Cet ee aaa oossiystsk CHAPTER 15 Neuropathic Pain Peter N. Wasson, MD, FRCPC ‘cen, This chapter fine on peripheral neuropil bt te sabe Ppncper maybe spot cowl pm ep mae cere ‘Etowing sea coe iy or sreke hte “neurite fer fr neurosis pnb! pant prxyann, be laniating Goals of Therapy (hems ice ane amor) o etx teatment spi fox capa ‘Manet roms or mmurengrenae oe wei newopay) >y operate imaging (CT an i) or cecbomgournhy 1+ Retice pin fom severe or made a mil nd clei. Both ‘Conse gual dg witli coo of pi and {senate ei (pn sac poster etl * oetuoga ond psealnemree Investigations ~ hme of neopahy CaNe ‘crn hero ices ht mig md» trmeainis vscise mesclr sje210 Nowatoge Diordrs | snapng wah CT ar Manns a space oceupying leon spec ~ slaensi sympathtic ck icone eon pn ee Inmet hough heres 0 esse herpetic range, monitoring Scum evo tye anorenas (TCAD) and ae “rect may hl to aos adbornce na pad Sange Tiabie 1. Definitions Related to Neuropathic Pain ‘Therapeutic Choices (Figure 1) Pharmacologic Choices (Table 3) eset youre hte ve een ever aio the tape ‘Acute Nouralgia-Herpes Zoster (HZ)? ‘The villa vir, derma dria ot nla, s eacated simone a dened male ote Ne cer mor cammony pero se 0. Seat a bb “Shi dpcatheaia are sm felowed by veneulr rpton te aeced ‘Simmer danetomes aut Seo ees and sna a ‘Sour 158) Pata may recede thems bys nace re ‘eo pany cc wth oath (serie bp) making ges ‘Eeuit Mat se osu inte severe cao: Wien Heche {eben erat foreye completions een, ‘The tk of soni potholes with age and with {ery the pn. Ey este 1 may ee the pence ‘pole stray, Ams (vaiaeycorir ae mello) sewn ove stared within 78 hr fhe ose he as Fret the nt hs no appeared the ren appearance of see Stet pan ry eed tain ‘top snc tee pent ee and wel rtd Ge Capt 185 {er pein tration chapter 15: Neuropathic Pain 241 ‘Cancel with ining an atv agent itn aie {het Tur y tenes wh pl ner, ‘Move ods cyst te anaphase ‘vaccine a reveat eps 2st and posthepetic neuralgia is xpi (Orascom in lands and er avaunie now mh Ud Sater Recurrent Neuralgls—Trigeminal Neuralgia (TH) pare reer eee Sueeceeiesieaegeer cast Scuimenemaneacee atts Sines Marae ave Sieg eri cece supe ae emareeres Sa om eestor, Seis mn el aaa ca =m ‘Csi epeince sw hl ther parmscalagc approaches ae ‘sro cabanas, Thro if sme rete aed th ‘Shou hs Ald phempni rence tele with eta {Sinan rapa rac a et ‘Sea mat ery il ity of eae tt a Ingh cen mie mepereed ccc tae pote Ele mits! Scamprenin, Sve procedure hw ‘Pree tion balloon compression of th sean pngion, “nd react te pana fle MRI can el ety cance ‘emia dcmngresion by malig ot oer eases of ee ‘Serponon: Threat of erence ih ll sive merc ad 1 Tapren of neti rons nee ty Pan eel ‘agen wil posure chronic Neuragia ewe Root Compresion: Cervca and Lumbar Radeulopathy is mth ye ied gh he ai a Te ‘SSCs nie seus, NGalDe yr acaminopten oie ‘Sapte tie, hee slay ion pn eet eee a shen epea, propria reper of ono svldace of Tiers “This in oe sels wih conservative marazement. Comer ‘iat nena icc eamen far overt 2 wen nd if2AZ Novroioge Osordors wna th CT or MR shows a sarily weal von if “ht pt eenueuing and ican ot aco: Ste nd Sera eon ee presen Sips os popeanve nolo ei ‘soba wen rac wan sl eel ron ‘Sculy epost. Invent gm soe narra wins ‘Sescoaie ne re ois he rt pose man cary pea {Gernmt of pore algnney oether soto cs). Complex Repional Pala Synerome Type (CRPS I RES omy en a ees soi nyo ‘paisicywateine pany may cate nampa Ps and ‘seawscar2 ystepicanges. nay eu xs penettg of ‘hu jure ere be smeancr aces arte ov gece ‘Bros Charcests foe baring pai peas hepa {epapons pes flr a ew months one ys widen of te [Bulle Conl eyo nin, onyappemiace othe si ated orm and posesv oso fanaon Some wil popes ‘asope canes al eng, sobetneu ning wn pormes gies father los fantom witha Bez Tower ant carne ever pan "While CRPS Iwas ought be doo smpattc overt, fics now pas ordering rensatian 9 benetsc ‘Seep alton yaoi backs en prove teopray ee, ‘Sismacomy doe nt eermry role Penmaes! scion Blerlocs sag pumehiine ae petectve Phys ery vtec, Smpubectomies an open ype cs have ma ony sb eme-quarr eu fly roma ct Tet ‘Benepe for ste herp ste ay requ eWone pond tery Crane Perper! Neuropehe Pan! ‘Thictegon of neritic in coon icles parker srs bee a te sew, cntlia PS phantom Ist ce punts TE AS on ean eerie Pd inte i hes ap haste ample lupe {posal we seats ste ages. Noreptytine wd Sere dan tsi ue eon ‘ane bur (SMI iepreansssh oe donee (oe ‘Nala Cau) sn venti te eat Ses shown eleve ‘coat prin, bu eos ee etc fan TEAR A sol noener {hs out spay af ara sea mat pret te armen sie ‘Mc of xeon nd ey ou Ransome cooled Wasa Cchapte 15: Neuropatic Pain 213 if dbs newapty init le of pn ine pcs wih Ie pin ere and etc nies ad antipep dags, ‘old hry may te pee Psychologie depen, lance oe wie oposite ad ‘Suto epee Table ‘then request knowidge a pest uoreaten. Codeine ids combined wih aetaminopen i pos ace fo seve Pah Table 2 Guidelines for Opto in Chron Nonmalignant Pain Lidocaine 3 oil ge and tranetral puch hve an shown Feline PI the pth saab nthe ted Stes Br hot Yeti Coma Spontnenas ain eon ‘tough he evens fhe therapeu pons ny fom ‘eis ents with PN sod abe europa, hey en be ‘patents pantr ib pai oer coe riper214 Nourdogc Diorio nora in. Sera tesco a PHN another ps ‘encuopae pate nthe jr of sens ‘Therapeutic Tips + Wile pation equ ny hey hae aed nite ot htasuepne ser sen hae drape ave eee ben odin ‘Seetrtoo lw adn norton ser eo ofan ‘et appropiate tow, so, pres tev ee + evar he yatet versus the geal of therapy rection pin ftom moder or severe md athe pace of mine side elect ht + Ustapain waeumet ol ch te of 0-10 whee 06 pain td 1 he worst pin ogi, evaluate pn eet + Peri ae arti save moth pry ith TCAS ad soot fottener TCAs and api as eo cise + Uae eotledseene format feta sd pide Geetae + Tryalienet ds within cass 1CAS), gs of eres citer tlcomaton heey isa) for pes ie essere fe 1 Moraperind of inf oe to he mate ay be pose * ‘Sipe eS tn ptt sd 1 Wepios age egies ee Table 2) are portant and should worked hough withthe pte Aaa and eer approach f Slt wopovenwetments ‘scoala therapy 1 Repeated vis en provide nortan pycologia uppart and ope [ewer prenatal eno aprons weed «+ eho pathic pain ng managed opener practice, ‘es or amiss pain spe, whee vb lp ovide soppor oe er ines pene Miche apes an fer he hance ts navel heapy fete alent Chapter 18: Newrpathic Pan 215 igure 4: Pharmacologic Mar sment of Neuropathic Paine ot en]ak alfillltrophic Pain 219) 248 Neurtoge Disorders alae ino: nase nag uate taeeat TEARS Selita mes aoa SSUES ggtuorcs am sates ‘io area aiedonay ui posh sBrUG Eee220 Neurotoge Diserdrs aoa ial. [3s222 Newotoge Oisortars ‘chapter 15: Nowopatnc Pain 223 | | | pi | He | i i : t) |i | HOT : ii i iH : te RohCHAPTER 16 Bell’s Palsy Williom Pryse-Phillips, MD, FRCP, FRCPC Sis po eye ont pre tous incomplete paca eter popes 10% Goals of Therapy Investigations “The csc presen of Bes ly clades abrupt aoe of iat ‘resi fccting the per and ower csp a are a, ie t's Paley Cchaptae 16: Bats Paley 225 Compe amore (7) sen appropri aun eal + Maga snc nig MRD i nditin prne of ‘Therapeutic Choices (Figure 1) Pharmacologic Choices (Table 2) Eye Care sous ate with pts dops inet tae te epel lved at igh nd protect with lases dag the Analgesies , hcl ray yas foreseen of Balls pay a te eidence ister ontnapting sr -nb Monee ative aan tha lg aerial evidence fora ection ‘pun ith ery str eras dll experienc geese thse nen acct beter oneal ely {o ovep devaton, Theos te following for egies ‘Sito: predneone | my pe day fore ay, he per over Swerve ays See Figen Tbe). Inthe sof complete fi al conicosteo tenet showed ‘ust’ ep mtd inthe Aman Academy of Nerlogy (ets Bal pay Sol tn ince of compe i ‘pati, crteerois therapy isnot advisable ‘Aeylevrie seldom given wiht pean Te err ud in the {ego sis fone a Canal ange om 0 24g ove ‘Sh Buy. A Coane eiew conchae nt before defaive ‘omnia at ei l yv226 owoiogc Disordrs ‘andomized conte and in tay wih test 12 moms islow'p be AAN cova tha tbe beret of xy ot {intel ered’ Horeyr a Rumery Ine same er ‘ower infcnon ofthe VI canal pee), ajo esp nome rca Reports of decompressive suey In ao Ben scizs bt he ‘lly sf cna nak o llow ecammnenaton ‘Therapeutic Tips No teament eno or it wens ht so lenge tli 1 Use eisone eso x posible al ter nef Bes ply ts there n poten eoutation to rid ws such a= Units or pep ler seme + Thee tno ot evience fo ote fom predeisone ii ated ‘moe an nc ays the sel of spon 1+ Noveviene port heute of ayo alone 1 Tie sombinn f ayo and pedisone ot oven be ‘pcr pedisve soe ahh at eat ne rere Sy ‘hehe it ae Teta dvs of syeavr not emblhad ‘ube rao mats trappopite for ote oe Figure 1 Management of Ball's Pal Cchoptor 16: Bets Pay 227 Table 2:_Drugs Used forthe Treatment of Bes Palsy Suggested Reading singer. Hepes simplex vi an el pay. Ana nt ot ioSeazad meyers ood Foss fy Hartng HE. Pst fil pay ots, “Duptoes and cata! ar Nae! 191135 Sonne #, Altre Gr Fae Corot for Bells sy ‘Ge pay ake i =e ‘amsCHAPTER 17 Chronic Spasticity iginia Devonshire, MD, FRCPC sar ny ta a tt up sea (UMN) ‘Sevres hortsing of muscles which em ext join dstvetion) Sevres anand in teow omens pty ow weight ering los ty ental“ at ib a wel Tas pty shnd eye when Goals of Therapy Investigations «+ Noinvestgntons nel ise ag part ofa UMN complex alendy ‘Therapeutic Choices (Figure 1) Nonpharmacologie Choices ‘Sins pus i na feex nk posture an revert chapter 17; Chronic Spatoty 228 Ie spat compitis ad oe ral peroroe Sette doa ‘Enerane edn, hell in pining anton ad even Pharmacologic Choices (Table 1) satiety ‘moins tag et evs oa te sts Snowe tat tet beter ns of a org age ‘ies nena ong marys a) rugs haves cen! mode a con, -aclte the tail mediation fr pasty. mst be ‘ray ate ode placer dene 30! 0 many. ABR. ‘Toeonutn can see conus scares a aluceations Atuldhowsse con int ie is best sat ths ow doe of esi ny bom force ‘a of rxinet and very oro teenie saben ny cl here oan ny Cantino o, dronabinal ablne, ative) may emer Sttheropton fet maneing peti Seve was hve sown ned ‘ues Tuer sey compared wk ober medcaons fetes proedhwspscty contol og ol edition. Fecal eats ‘Mee nates of cota cn where curen rg bere a iS etilhey se pty ech. nse block serves going to specie pate mascle groups. ljecton: eax be comorbid ect tobe ened nae; adver cr an230 Newrtoge Dlsoriors Chapter 17: Chronic Spasticiy 234 inci pin, dss ndinfcton otalinum toxin inetons Flque ts ot Chronic {Coated oad my be teste tated than poo The on Siete choise aga tin sg ‘eos eced toe) tht mace Te ef tee moh — erosion sc Weve te men (ei a Trrathera dln of ection ly inet when wal a. esis ft onl payor teeta el in fs Heme eer ae ieee cna ices cet ma a ea Sepreeniom trae eterna Slpnve tices Te fect spate be profiuna alton = iCimoreflesine forlorn ane as thee es concesaon gant i i fio rar coast a ‘Therapeutic Tips + Th et tte pity, The ol ingore on (aaa) «+ Thatemeictons slowly anda marina ole dos bere seichingaine «Coser cater efor i nip fe een ‘Sieee {Fegan waa tern of coche ona = {tne Getto apd oe ae) See Muscle spams ocr rag then can neu sep. Dinh o omepa can be ey pi nec tse ncursesi i 232 Nourioge: Disorders234 Newologc Dordre Suggested Readings te Cpa DE. Peamacio of spicy ai aie Spain ne oh rece.Wl Psiia CHAPTER 18 Muscle Cramps Virginia Devonshire, MD, FRCPC trader Caen cp a aly tcan be asx lted wh set exacts role eee ins omings excess senting. “het rang), sans meal ‘ordering hrmon changes {resins ype, ‘rot Iver dasa heredity dane ad eaten onto (tote gant olage ge pots chancs), Goals of Therapy Prevent nd vleve caps Investigations ‘ume depen, ‘apes, calm oi, haa and CK" lai, eyclsporne,ifeipine, oie lowering agen, ‘stam donepeni phonies nso Consider pdesying patoloy f camp ocr nara muscle [oup rdring ates, oi they occa the cing of esis, Iocua aophy keaton oe tense ston: ough sone my all be beng, seer fsckulton saivong, snowy ne mtorr ao esp ‘onions aces ring 2 movement se), esess Therapeutic Choices Nonpharmacologie Choices, ates hod be essed fhe Henig nat of camps sdstands wo fom wall and en tte wal etching tbe Ailes ‘So. Fai inbalaner car ected sad eur tng oy trent is poten ays, Pharmacologie Choices ‘Therapeutic Tips 1+ Check pint’ mesicaion history ceil befor teaing camps. zt ely iene ate Bey aed severe ahd Reguintyreaeas se of ining cramps can esl spontaneity rater ho stn of her 1+ Cramps ary aed fel unless associated with ote earcog [Chapter 18: Muscle Cramps 237 “elo; Management of Nocturnal Leg Cramps238 Neurtoge Oterders Suggested Readings SiGe Sapect cee ias ar CHAPTER 19 Restless Legs Syndrome Anne-Louise Lafontaine, MD estes eps syne (RLS) i aeucogicswercharcerzd by es and take The prevalence of BLS i the genera population x TREE’ a “ceey-cmy “tering nagging “put * Quenascoaton nthe Symptom ae pty otal eleva by movement, sch as ps re ween inthe vein it ing they oF (Ext orci seo (PLS) {oreque wenmen! bt ot een eno ora daly ey ‘Dal frtne syns ta serge’ vd ees enough toregute dy trp Fans ih ey LS ar we nestor Gol of Terps) nt esponlng nme eet i wile ecctring pao pari heapy foe day Sep Goals of Therapy + Inoror the ynpoms of moter estestes and dicomfor 1 Redce the PLMS, if rptive iy orang Colneding wt he ee Sore weming of Of ‘Sevens‘tavshoncr renin sto andor oped of yom ae Iheeaper exec nd ak? Investigations 1 Hor rom patent so paring resaiing sep and FEMS 1 be, soarlye BUN, cenin, ning glcoe, sem on + Neve coin esa be pore i pier pty + Peiponngrptysboald be preformed i her i lines sion face apc econ See order ‘Therapeutic Chooes Nonphamacoiogl Coles * ocr at ee ont 1 Herta ig mene ee *Secameron amen Pharmacologic Choices reomeenee ig se Mn irs cia an retin ns Dep pean es els om pe mcr sre SRS Schaerer pss tpt ope ap ‘eae rene as ne wea? ipweene Nike ieee ep rh cane arent Eien ae jeoeaiete tierra etaet Tatas ne rene re ecrn cc immhartygeswoctengags ser SE eee per nee eect ripen Reet ieee Gheer oe ofan weet ari Lacie sega oars meee Seiiginniet, aheeedeesctioe | | | | Chapter 19: Reatees Logs Synstome 244 iteympoms aie air in he day Side fects f dopamine gos Incl nuts seat ghee Levadopaiarbidopa it Yon shoe a my ln Wa to etter the werner RUS Toe ain ton oF vodopalbopa rt tho Hal, whi cents the poten [rebound sapnenatn, While evodopcsop may Sropents fr ne Sesto merit RS pein pbs ‘SErtaonent of chic du LS. Gabapentin ony dean arativ te dopamine agonists inthe event of ‘Slcnbiyo gnenaton xe Goat of Tap. etiens of {Dihepnta a bea dees oop! and endomtedconled {Ei sam be cms the da cole the presence of {arcu pal RLS. Major se less nla downs tod sty gt eopectl nthe ec ‘Opis ave bon usd ne the earn descriptions ofthe weumen of ‘RES china fevers bon monet ins few cctlod ‘well ar opel wala? Opi yt elle by i oF ‘heratong salting properties er than ther eft o x inves ‘Because otal or spenete, ow pteny eps ch a Drepenypene so codeine ae reserved frre tly RLS, hare potent agent such uenyendone ormethadone fo lity ‘enzniazepne a been demons in int inst siginatty [prove set sesp ney and sje iep aul both S25 an PEM Tn mnt of hs clas digs the pet for dpendence:Benrosneins espn Ie [rime firma: RES o may RLS where hey en be acetic ng ale of dome a> ttl tenner sedation md anes, comin sh enero ages win seo tamed dra of aton try ‘Therapeutic Tips «Always cone onphamaccogl mange, 1 Ste witha singe doe ot dpamine agit 12 bos pie ‘ptm Tunas feces + Tete even of mptoms ean et ia he aya eons oe, {dopa govt canbe pescracdia he eat a ent + Rebmand cn beside by pescrbing dopamine agonist ther fan ierosone «Aspen as Bas repost es feuely with dopamine ‘Some tan wih evedoyhincan aloo be manoged Wy acrating distin tes schng between modieaton closes every Te ‘monic aresiss vecamnnmrtnwatoy sacra —AlCRt ae at ~ its ea nnn - . sariroun es wonetunsons Cruaamcbur aed om SEER sande -anenege mae eccraneaneat Settee ite244 Nexrolgic Disorders iE IEE SMR oo eae a ca oo rene 5 | nd uses mc sola mame aory mewn ei aes stereo ‘Soa eancrnpern s8_sudote nea cows comes "heaters tite soto ‘nee our a me i ey eK BTL246 Nourlegec Disorders Suggested Readings Come CL Rests ps yore: wennee with dopamine “eet, Newolny 2002388 Supp 1) 387392, AAG Ciel pacce Ro ee ome. raat Sie MH, rene BL, Alea RP tan grit for ‘Se tae ren seme hw Cn Pe CHAPTER 20 Parkinson’s Disease DA. Grimes, MD, FRCPC Paina’ duct PD) oni, progressive, eurdegeneaive theme whose canon fentsror are remedies a ily. ‘Cavony wei wots pce creme me ‘wry; however no temo date bee shows oc {elltyie Sse proces! Nttton roving te moet benet ore (deed eplensing dopamine tn bas Goals of Therapy 1 Improve funcining and quality of be 1 Mini sete and ong orm side ees of mediions 1 lami postiesaeo, despite he hone progresie matte oD Investigations +The cla dings of PD canbe made wih confidence ite cassie ‘Ene of sui orasyamere resting emo pus buyers eed ac rren erence, ‘oat notes emer «+ Ponul nea, tenons diction, dementia, imped eye oer pi roesson ed pos ems to dora Teo ar aot ses of early PD and rset guest a eet ‘ings 1 Peflo iging ate in young patent cr hse wih apical fees. Face Wins duet yung patent by eo {Sum ceuoptaomin samp exam aed 2 2h oie Torcopner Sines se Saad sand enraton may chotcs and ‘SnrlJopomine biokngstetctesep, metoprare and procera ‘Therapeutic Choices Nonpharmacologic Choices + Pet cation viabooks, websites a clan atin Fastin SS eae gh he Pei ey of om «Stew importance of saying sche and eving 8 epular exrcie Encourage anarens the paran rolr of ae eat ‘pote sch aspect nd copa apis.248. Nourioglc Disorders Pharmacologic Cholees (Figure 1) Levodope Levedopa conver dopamine within presynaptic dpaninege ‘ero atcgh vt san when hn Ssovre soy scored opin detente eerie, “Tere a en coce ht evga could be toxin lend damaged ‘aes psi he ipseer and ath th oe {Gok peered wis prea neat ce) ay (engy wer tos aly tan nang 025 ke jrsconiine bondi spresss he maton fe and Sete tae ra ay fopesngl an sgh Son Cotinergle Agonists ‘The tpl cote goss plecarpne an eatbacha esy {tbecelar outfow" These drags fe characte by oct ie eee, ‘tetadng mow ec ip ven), ccna pst (em a mn ete ‘Ss abdominal erp or arcs The oso Por med ‘chien nyo ns ‘Fired continedon Prepertons ‘There ae crenty fonr fed comin tpl laacon heres, ‘ah consinng ill ae Cad Dorzlmielten ‘menace! ntanoprentioll and ravoprostimoll? ‘teal move elev tha thelial eget a fey hve mae ‘cur bypstensve cece. Dorcas ta yet get {ck aco The combined agent are hugh fo have aang expe to aioe ers. (ral CaronleAnhyerac nhttors Acetate and tethacotamide ower 10 by devas he Practon of asus emer "Tse we aemaly renewed or Energon case of significant side eect Approxmtcy 50% of fe are unble to re hve gets io omy brane or CNS ‘iene, prea el ea’ Ora and tpl eaten ‘yrs basen show rosea apt al 0 “Therapeutic Tips + Tia gncoma mediation ar highly concent to allow Atego era peneton Sytem atumton ers oh ‘Ronmal meson, Ths canbe edcedoush dpi ssh he cra dine se fo Sveal ie flowing ates {fe ops rough etl lou for eto ive mie + Neepeesepticaanthisamie products (hich cary a cution ‘insu In lace pus dc to amicblieie sie eect) lots dg! ily oes olen tee,i cn 2 oon 2 | van sao saroneoomiee splemne teen noises “on rete wounczes ee ene ae me morte meee son SESETG meni REESE wena een on ssurarommeoapnas) ——waeion open et vo “cosmos seis “Veastomimenemmins ——yomice nmi et 00 pest rime SMES meso Sh po esas rene ees eee ee Plsescsiiemen — ——Chapter 23: Glaucoma 295 t a HH ' eel con Doon i all | : Hak TE lie HE i bode li file feat ft ae wood i: allt (ln fi Male OE aadre 8 Pema | CHAPTER 24 | | | TI acta coe nt neaese ‘Sueda ABor, MD, FRCSC “cpitaologt Goals of Therapy = Prenve eyesight sry fit tn teem Investigations (Figure 1) ort ‘une (Tabi I). The ene of or ae htt Cette aw oe ‘Table 11 tology of Red Eye | ea298 eyo Dusorders ‘able 2_Warning Signs for Ophthalmologist Referral ‘Therapeutic Choices (Figure 1) Nonpharmacologic Choices. Instruct patent Sop wearing conaet ess ui te poem is reslved Pharmacologic Choices ai denon ndings be’). One mer ines ee sewer eee er smo eee ees dea of alti Wal ‘sutton i ‘eserved fr ocesoul and srt we Overs nese ‘hound hyper ‘Therapeutic Tips: Mt ically afmininer ye dos se in seapy are hes osteofcnesmg aon or oxy. + Conicseade rattled combiasions may worsen ‘pet tngl ket and tou oe ee intra aon operon my cause aco we ict decongestants may pevoke angle le tlimcoa inthe presapsed ce Chop 5), Chapter 24: Rod Eye 299 1 Some patio ay tot preserves in iia as. nth Snes ai te Figae 1 Management o Red hepetebiei i matenoies —ipiniicass pmmaana = z : 6 ‘socminene pasos semester ae cece . |__ s B —eeoo anion cata mam gt pa en 8 enetocenmg ten EEL ie 1 romaine one saete mcm NGS ee os| 304 eye Disorders ‘sate serecvimsimens ———oassin2 srnmstgnonons anya ata van meaenro chemin sexe ut wiecosne “ovtmemrg natantChapter 24: Res Eye 307 306 yo Disorsers I308 Eye Dsorters Suggested Readings [Ateormal ee appearances ls Faith PT ei clinical proce, 2d canadian Ophisaimolgieal Sei Setdrevted ering Tiptlnwa cyte ca tnctscrModacin Mods, TOC “pe: New Yoo (NY): Metra Hil 2003. 88-128 Mics Hamer the en pri care rappin bed aprock ovine get | pcan guide to eye car. 2d ed. San Tratsco (CA): American | ‘Renkny of Opnoniogy; 2001 P 1- CHAPTER 25 Age-related Macular Degeneration Michael J, Potter, MD, FRCSC Agee acl degeneration (AMD) i asi hy o wer (Gltdanse) AMID. The Sy for characters by ren (ste Yetow spo he ese) yey te se Inte hey nr sc df ep whe 13 ercon Inthe sa hens incon who goof velop the wer om ot Spread yr MD snr cn Tecan uofetd eye ve five sea, Whether mio ede fom cing bance it) weg matt opt Goals of Therapy 1 Optimize fmstin and guy fH Investigations Thorough sory wih stenton ene fsa et) « ttamargbpi (Jitrton rch ha sight tine appeae coved orcs)310 Eye Disorders ~ Aas pd (vac t srewsthkeseyeconveye/Ansler¥ithin) ~ fundssopy inte fdas exam with imp biomioscny ‘otomes by apse prornce of enable an net AMD, + Phen npowaphy ale aly tents tnd interred by retinal pili ~ involves inravenes inet of Mores acu, flowed by Photog ofthe oer nd = Sonsdened the god anand fr vesipating AMD ie Some pains ave allege eatin to Meresein soti, (ich choca cae ey coos ad cota on, + Opie eoerenemopphy Ina nurs ~ sini th god stand for teanen decisions wing vascer ‘Snell gost acer shoe ‘Therapeutic Choices (Figure 1) Nonpharmacologic Choices. ‘The mors ef or selnniing by pets. A ce ue ‘Thess man be panned with ne aye closed thn roped with heather eye. Renan posse mst be od fore te pen ‘Satay foqures tee Aids sch agers, high-power ses nd rang chines an nae ily rept pan us oa pt ‘atonal nse forthe Blind (CNIB) are wily aval ia Card ‘hastens, potodyame therapy wt sertepertn tty be ‘erteorta tn perpen derivate tanh tated ‘ete cotaindianon ‘chapter 25: Age-olated Maculr Degeneration 311 PDT ashen shown sisi rece vison os compar 0 placebo Pico ae ecover ot vo, od ced fen Toe frer vison arb tain eran ble pang evle ‘Sah tr wos ptt: veal atom rn ay sey ost “Trotman dione eure the ntrpetatin of oracin esograns {ope wih cna evaluton by trial pecs. PDT involves inst of irvena vetepn fallred Py aorta ‘Gonthrma ur igh tase the CNY sion uh a ‘nspniting conc ns ong sang The 10 mint no {alowed «Swen wating pid Te iit 8 eh mpl Patents must in sem-daress re eaten and erin of 48 tour aera Shin plosmaive cues ine, a severe ‘Samay rer agit or bp ihe ike epost yrs 08 The body Tne warming bude ing Stns: halogen exaanon. Ths ed in emeryency wars sre hel ting ed ‘el pocedares Une! sarstens rovice protection fr this ‘uonbesay ecto, Inadsonot suttanous extravasation f veer cn cae pin nd pein patssshvay ofthe ering sino he Sg bt erin Severe bck pia ding veep infson occuring in 2.2% of ates, tar once enon tn nvover amet ope ‘hoomtnsing te tfson, Uncommonty as than 0) poses ey ‘tpenege terre decene mvs loving apy, sate ity ‘ober lar ah tee emprtt ont at he eliod o ‘eves door nin stoted wi vercprin tea oer {han nuteated pens Pauets re rn ee ce mons {orchoroidl neovascular leakage; teament mayne oe repeated st Acoune of photedaune herp can cot ver S100, Mos proini fest pas cover ome ofthese eaten ‘The du cee VEGI leven the eres space ich srs rth an nes eran of ow bred veel CNY ‘ice mca ema restr Moe sty312 eye Disorder ‘Bevaczumah sin widesrend use worden its ppoved in is orth weston of oan ence Iie fequnty asd abel mpi ml een cael oer pon my ‘Aid agent rami, eine om gen of vain ithe staphertinding sy fr VEGI Nis peat fen ‘eee iu ot en than ee nero second von ‘hand 40% showed inproveren at ea! Tere excelent fisaronn Canada ay be ranted Te 200 VEGF inhibitors are ie inte the vito avy ofthe ee (tien! jc eveyone Toto month The endo of tres hve yer de esse, br sk nectons er or ae oe ‘ioe Cpe eserene omy ses ee prem a ch ‘Site dtcmine weer furor tomes nee, Combination thay ncding POT sd VEG ibe smcinee ‘sed Sader se camenly udev to determine opal fesaent bnew ‘ta spam om the cin precede, whch occur a * ‘Trourny of 2 100 roceaes ree Severe sf on ‘heh copia Pa and edn of he yey ‘Spee. Bett near Minds ny ooo endo ‘Scored mot emegeney tht eis immediate extent. Uyeavopthanolon;anagemant ces pry fer cera fate feowed y inane! nein of non On sree ‘Shocenary sad oucones vary wet pening he darter ond ‘op oie ces Pane receing viel WG nes {reared io cabs oie teen tered I they devel ‘Simpl afendnphais. Many patents wil have md pun fom te dog injection procedure, wish does a recs inde rote aku seneotoge commen ely ‘kpendintondieineceton nde proving Provention ‘ismin 400 1. sne 80m ad epee ees [AND oct vison bm nau Ponts 6) 25% oer Seve eas inthe Age Relat tye Dace Stay {ARLDS), = age atc ‘al Copper wa ied to ete he od nein pase {aking Inge sunt ae A smercal pepetion of save CChepter 25: Agovoated Macular Degeneration 313 ‘iain and spleens is vale (Table), The nari at ‘engi of sath posits shouldbe erful heed mur ey siaucaats eee met Soke wth east fe en yer yao be adie oo ae Seaehariie internets Sr ae ty ta Sareeeeanater ymca fan Neca Savloaemt eens St Soe Sercteeerathe taco uate enone ena tea a fetes nee carnage eeeiaaee ciceecttant ne ccr n Gintama kedeaioay menace Spice arama (etn ec ete mt ees mince sie ryaroteee notre sacar Saori eee acceso Se Seer artes Seca eeree treatannare Scat Omega 3 and 6 fty aids yao pyre in male action. Therlem peveton of vin oa the sje cet investor‘Suggested Readings ‘Ase Reied Bye Deas Stay Resarch Group. A anomie, nmi oa a ih npn it degeneration and wen ne MRED epart s¥ teh Opal Soniitoryster ae tle NM Tresimet of Age-Related Maul Degenerate with ‘owt Therapy (TAP) Sey roy. Phteimamte tery ‘taut! shorn scovecartn age reed mca ‘kgensasn wih veep: two-year ent of? domized ‘ici TAP Repos 2 4c Ophniml 200111912) 98207 te Sore PT Agertae mci Seperate, fal J Mod dotesaa(t 85, icin Ket Torry SC et a Te eine od ogres ot sgevelel macepahy” the Denver Dam eye Epttimoloy 2003:109(0517079 ‘ertrrfin in Penge Therapy Stacy Groep. Nene “hoaps a ohowel hora necator ‘ol ning estar with Seat mith cla shoal ‘evan "Vereyoi in PotdyanieTheopy Rep 2 Jay Gplaima 3008 Soest ‘vein Rownle 290 so 001 Patan Tranent of Teele act deercation wih photoyase thcsy CAP) ‘ay ase pial eensporr Vetepr sm ote ‘hey et) sy ro pial ives ls or wing ‘Srear atc) napa py Sa tine 20225619818 316 Eye Disorders CChapler 25: Agetelotad Macutar Depenerstion 317 | | | eas | \Endocrine CHAPTER 26 Thyroid Disorders Heather Lochnan, MD, FRCPC ‘Mfced tan en The sypiome sociated wits yd dase te Goals of Therapy Hypothyroidism Hypshyretion sa iil syndrome ta sal res om (een of bye heme Tae Rare, it be due torsssance {gel bmone, A groiétineliing tsmone (SH) mea i ava seve mato of ipo br maybe ow or nora fete TSH 10 mI formally 3 tem depen oF ‘Sipe who areata pea antTPO} poste ce who Investigations. Thorough story wih stein = yim ae atigue, weak i, pire meme, ‘Cnn and cold loce = Aloe rtaraton pase of eens treme cas ay reset with eyed coms (ypoesion fms pote) Chapter 26: Tyrod Osordars 319 = fe eodetyrnine (FF) = tre tori eto prose (-TPO or antimirosom “able t:_Causes of Hypothyrotiom ‘Therapeutic Choices Pharmacologic Choices (Table 4) Levothyroxine (7) epkctncat atop evrge Fs pkey nds a 10116. (Weck an needed. Generally stakes sx weoks 0 attain 2 tew seady Toe edecigeaostmen Inthe ely orm patents th coor ‘apes Sot rs dve a tow ae 12S yaya tolerate a Liothyronine (Telodethyronine, 7) Thateging waa f The cobain of L*, aT ra el be replace sayy, oh set iss ‘own nt oo nei of coinatog bey tod hse cont of ng aiveweefrs nth y320 Endocrine and Metsbosc Disorders ‘Therapeutic Tips + Tec thy ining pin ince aig pepe «Namo dus cif with th sero ad aot oF, Cable) In pleco gue eco LT Sorin followed hy 100 ig daly These faints ae eenitanthy ‘ral wih crise cas hyrercnne 100 me QS. ‘Soporte py a pune raring rina a eed Hyperthyroidism Hyperthyroidism (hyo s eine the some of exesive ‘toroid bomose produ nd fer (Tobe) Sue [pehoim commen nd cat bea for fe ata ation Indubelncelnperyroien, TSH ssappesed wie ytd boone IEelere mma Teumen fides ae fa or ‘nish ater it fcr or stra sso ha mptms o terion Phyo tm i ie rene ei! emergency cance tyne yranscoce se wel Sher signe and sym can pei mary nue nig rnc incon, adn, gery eral oon eyo ros Investigations +A eri stn with eto 1: ‘eae md acy «+ Psa examin wih tet ria ches jel gar an opalnopethy sited ‘rt Graves" ease! eben: prea, ty it ocr dle + Labor tot ack nein nding: TSH Me = ey a ranstve fine wt (RAT) Soe: upto o TH cn i myo he dein (Cer dompetdoe: acoclpranise, pen) ‘chapter 26: Thyoks Doorers 321 ‘Gauss of Hyperthyriaism Therapeutic Choices Nonpharmacologic Cholces Conse tyo surgery in pts with hyo nods, lege wie, {ou osu in tn wih Grover dee Sergey part of {fe imangane’ of ft can ant scope pdm of hyrod one Mate heray i ese ete port srg fo ake ‘he peat extol possle Pharmacologic Choices (Table 5) ‘se radiative one (1 oat thyroid ‘Saves aces, tone evonoas snus and one meno 0 nc yc ma ee wit te ‘ih condcestrtde tn patens th sgaica phic Metin QM nd proprtoaach FED dee TierTy PIU ibe dng sfchoe fore Urner ot ypertyoiiam epatt women, Both gsm be opp boa eye pr 0322 Endocrine and Metabolic Disorders syd sam RA oe teatmer wih OL PTU my mae the yd roe essa 9 1 Sie ees bese nga elie eh, ‘rtulytn nae. hpattoncy an pba eae leche ncn he yp of nea ‘och as ropraoll an dsrense sce pens wists, neath fm Lago lation (3m odie pe drop) oc dium inde, oct yrlshomone poston Tone ane ted [theta managment of sere hypeirodo Cone cotenterid a adjurane hey in eaten resistant cee ‘Te marageret of droid storm insoles soppontive hry in eniucton nth aguesvetezment wits antyrid median, ‘Sticks and caicseon Use sstaonpen fo hyperrmit ulavoit ASA a ater NSAID! Pisaphae canbe Gre in ‘Therapeutic Tips Pte wilh Grave iene ay ave pong sappreion of {TS Spt nmaliatan ae deers lees of ye Borman. alow TH, yan vel 1+ Pons on ropytiurat ee metinazate can evi atta {eta ekhiyt cid by rp eset ie ‘emvarba of yt Ty Avo bet ‘hi pasnt shoul beaded contact pyian omei [Ssaprs of isin eee + orn patent who decline weatnen of he sks of watt Ayreon. wc nla myopathy, ae yess, ‘ean ad nears Thyroid Nodules and Goitre nivale may be a higher ik fr dcr of tyid {conan she seed wih TSH level Coven eared avec protic ping voting somprve mpm ‘Fest wee surge’ Tid pyenson eh LT help. oven rt row deanna a he and ‘hyd nodes are very somnnoe They ey be sie ictal yur Ct or MRI of te neck Solty scales ae concern, treo wig mse within modu ote ble be tocol ml os ey nae Tyrell oppress ey Ferns no fonger rote sed? Table ak ot fo thea cancer | | | Chapter 26: Thyoit Disorders 323 ‘able 3:_ Risk Factors for Thyroid Concer« ‘Therapeutic Choices (Figure 4) Nonpharmacologlc Choices Suro dtive trpy. Sul poly wil oti ‘cla malay nd vedute compress symptoms The rik ‘itt with gery ele yputhoni,bypopartorntao, ‘nd va coed ptal, Coie suey io oe Fa aes Pharmacologic Choices (Table 4) -adivacive dine thenpy ca be ed test liar giteore Iavnede, wit ccd kof porn Levothyroxine cen be considered o prevent rer growth of ni fide The goal it beep TSH teow 10mm, and above te iowet imi tbe noma gen setng th rao nc, ype ial enmey + Athyrod sean rely nde fhe TSH nc 1 Repeat e eete spton los (FNAB) anode owingchapter 26: Thyoid Disorders 327 | 326 endecne and Mata irre ae ex ae Stee ee me RE some geste = «ee vows SEE yt sox oa cote: mamta mo Seer oe ae weer = ee = od = Tuapeshquedi jo oust ov poe eBTIG FOFTbe S\_Druge Used inthe Management of Hyperthyroidism i Chapter 26: Thyoss Diordors 320 GH; Ghandi ae sos oto. “Eng od 201384():50 dete mages Soxth Dartouth (MAY Endo Eaton ‘dpe DS. Aird Drs na! Mad 205:3529 905.917, ha "Avulble om: pivw ronanagerry Accessed May 25, jon.CHAPTER 27 Diabetes Mellitus | | ‘sah Wen severe, ates arate, pda prose abl involving small blood vests mcromgiepathy), age bland vessels (apo) se danse sty sag ail Ares The ein weet creat evideme Bl even minor Segre of hou sion brannaiesnreae crore sat a pina blood pore ees have ma yerbeen ented, Classification to abso sulin deine. ts st often immune diated, bat ‘ler sri in Nov Amen, pe scum fr 3 Tak ‘nel diese. tos prodonina aia metry det wa inten eqn The cence nd prevalence OF pe ‘Widen aod asses (Geta ibe i deed x one or epiion of pucne Same cicrdeassteedag wcrinbjame maken oravginawced | {Sipdte tance: Drogen peru load ucsevelsand | (choot 27° Diabetes Matte 334 ine wi ecenic onl inp with diets ae pret Goals of Therapy ‘Con! symptoms topreoamin ‘Aetseveapisl contol of comedies ih as hypertension nt Satie Invostigations (Figure 1) ‘Diabetes mets nay eset ina vr of tings: =" yma inet dacovery hough scecing presence of dabei compton such t macroatel o ~ teu retabotc yng sch pega poy, weights The gnosis tase by ‘etal rad lama pate 1 moi the presen of ‘sig om ~ Saigon css (8G) 27.0 mit canrme by 3 Secon st doe om gue dy ting deb 90332 Endocrine and Mataboke Dixons = pln leone evel > 11.1 nal two Bou afer 5 ga Screening ‘Allindvidl shold be evtatt anal fr dab kA fing ‘sna cae fel said be ear vey ee yeas noes ‘te 0 years of oe. Conse ere a me aon eng invita ats ges ak Table 3). ting ta lec (FG) level ae et eve srening ess han ‘oso! pues eves hose ase by ol pues lta {casera of FPG the recommend serene beens ices ae ope nd er a i her ‘Table 2: Risk Factors for Diabetes Molltus? Type 1 and Type 2 Diabetes Mellitus ‘Therapeutic Choices “Terpy fr spe 2 aes told be aimed a cieving lye ‘age close fo ial as post sear pus Ai schleve tae lyominted bemoan (HbA) wan 12 mone [ioapbanesclopc ther st eal euglycemia tug teppei In pans with marked pegomin HAy 25% atte time a gnosis ag tarot ith oop algi tea. Nonpharmacologic Choices Nonpasacoogc therapy plays iva lin he eaten fb ‘Spe and type 2 abet, howe wid ype abet mit be oid ay mtn ine of ign slong with nagar 1 Education italia making the ain fallen ine Sabet sel are dary cm si nnn ht yc aes ane chaste 27° Olabotos Malis: 333 expen tnt tn on eee Spee rorneier a 2 SUE ansehen - eae a - epee heater iar are crate teint ce ects aes ones oomeeasroe Soho, a eer cae eager eect pelacchyeame Senemceeaeescee eae Se pm ee acter Se i ee, eure ee ie unneaesestaren ences fe Semenraemaneane, Belsnancaeieanienmnat somes cratenentareny Zoasaeneaenea, anroneiee sean cen acrennga tows tern oe er tea oy Sees eect ranter tater zpimoarrcn erent SEtESS teeters bxtigicin tate atryaat eee Sac een mn Eecreretincaatteeems ~ Siete pngemeg mtn tee sea arrandvepantstats ts334 Endocrine and Metaboe Disorders Chapt 27: Diabetes Mesto, 335 ! note fo hereon ery atatipeibsenic | tan oxine an es te sale essen lod poe ~ sssuring the accuracy of blood plucore messarements made by the || to 30 minutes before meats. Altematvely, a sey rapid acting inslin ren {augue ny be coca soured cy Wel ets, ‘tac sls adn eon ty comng ‘eset rane min mile so oii = ry aun acta te ig he sbi cetne ‘Reahinproves he tayo posal pe ves a my eo eat analy Sm he gun wd nro pean cal ry ~ fg idl, stein fig an vr 1-3 yeas ‘octal orgie Csi sie wa pc see ier SSA nt “ Z ta mre eos dave of one onl Sarasa 1 ~ Syeeamiaon nig lt donpy of wean ‘rnd oe pate Hl ‘ccna pmppty se ee gen pans | Tijd dante an een sopane a pe “able 3:_Inaln Regimens Type 1 Diabetes Mats | Rill wistgge ued pets entre yen f ay ta | Sto ~ Sm ica mization ad oes euncil = | Pharmacologic Choices al \ | pet Dobos | | Insulin may be administered by syringe, en oF contnoos subcetanecus ' |S isn (Sy id spd neta se = | | SeSttnractse soe fore winetine Wesrebeiie =. |) Ga lope tara asses proved ia Cade Eke bran = j scl pr ry ea, sn | longer peisd in Nor Amc. The lompartng te ages | Goi nn pe ea | ‘Sion emnede roc sci asia pepsin ex an Sa | for beter sont of FRG Isls wh ewer ypgceme pb Sayer Spec ctal aS k » 1 ape “he Daten Col nd Compan Tl (OCC showed hat Sime ae | Incsie wninent epimens cme Wn puss meee | ti conedonal ep em i ede fhe kof ln or “tec oucomagranti complains rope. epepahy, ‘esrpathy Folie ap da fom hel Semotstnte oor {ef af erie heaps on the Hak of acoscaa ve “Nesey diagsed plies and those woth poor glyce contre oF | ‘coven eens soa beefed te ote oa na | “tees mnagenen pine | | Most patent requ approsinatly 0.5 U of ini pe ofan {ody nae To svad ppv, tite ery wih wer doe Sud he done erring bo acoe erp. Rept Tome merstevig allows pet fo is be dose of nan covet ‘ioral ood lacse eel ont th de more acer foe P Ippoeicomi tbe mos conto sie fect fain ergy and sr ene ten scm Nhe ony way to compely wid ypeglyema thous monly lee cent ont Hppopyeemsn mat336 Endocrine and Motabale Disorders cement te est of ether a mised elo a9 us Ippotyceman mwa Teac pants eet or et and pigs sctriy when plmnng ali reste cpio ~ mid wypsyeemin inlets by aden spon: Seti, eto, ar, ge adn gent onto of ‘weames. rea cay be eid by the patent ha eure ‘Sisspur Asal gine wewecchs je wil maya ts ‘lo! ghcon pproninately 2 ot sere bypoglynmia eres artnet copia aor ‘Eaten Reuepcopent pons, onsen, are ‘Shana ed dlsrenttoncan pros see and coma and rete hatin fons pops teating the hypopeemie {se Ife patent soma, ral geste reparation Shon use” Unwetene uc, ita espa ake. tay be ell. acne an dextrose do et rou ition Fete asain in anconcius patents ago glucagon ior se emporsy Irene lod pane, lling fer te mike of wl {litohyaat, Gearon mr eeive a maleate pats ‘rinacsh inte bypogscom, arenes samira of Sis ots deses mater te oxen of cies + Lovano ere eee Ml etn, ch a iain aioe, rater a ee + more a ance deo the preacton of trina shod, rare wth ran ni Patent wo ave ‘tveloped smane medined etnce onal ails Soak ievithed ha an Reduce the done stanly the {Nimon ofthe such, Conrad rep sel, 30) Us ‘epee emer ates eg ge es Type 2 Diabetes Melts Figure 2) Prarmacloie ry foie 2 dikes indicted i ood ‘loco cota a scved wih 3 to § one uaing ‘eaponncolgi tap. Dog texte meaned ly (2 ‘toe dey) he presece a severe hyperyecs HBA, = 95) Skee smo “The ke of herpetic agent shold be ered ote pte ods, Ine dered teapot fet sd he rosa of cotniatene Pet tral sted enone lu. However the ha enon warants iors amenonble expe ecient mtr with ra maou th eset oy Bia Wi a CChaple 27: iabotas Mote 337 ‘ombinaton ofl agus anor insulin patients with HbA 2 9% ‘x resaaten combat tora wih Se anyon gts idm aieret case or mae ereommenét’s' Weegee ort ot sceved wih wenserpy wibin 31'S owt ie aon ‘ccd rl get roma ite hapa ah note dled. Ttbieod cae ot soled by» conbaton of ra ps sulin "apy ay bests ‘ra agent Table 7c be dived int ever! oad eter: ii Scretgcpoes(ifensasn ed mop) to ew decree ‘pms pcnspodcton he ina tom gs at crease tte sity iin heen rd ened rap tht deny oe prevent he gesion of commen eters ‘Gheaighe cose lor sso) ot Ce mera! pe ‘Shit estan Toe mean Gece bay atueved with neta, ‘ogre rage wnt talon a gener angel om otto 8 lnc aly Inco themean rere hy. hve with carb stg and rat ar been owe (= 14h ‘When sd ania nergy ieltizone, etfomin and stride sere serine wits rape alle rate dee conde FPG" matt of Snr al%eand eae fe years low ap fhe ADOPT wl p00 rs Coste th te primary auton, #0, 36% aed 205 of pate ‘ened wih vightrone, esl and youre, especie bad Hu evels Pv aert yas eam Patents pb the inte pei 8 yet had peasy een ene ‘eres ss and xcine FP bw 7 an TO mmo. [ADOPT Roultatone was scat wi he igher me of meght (no par) edema (119: frminwsocaa ‘Sith the highest owen mi of penton hers 3K) the mest mon of wich sas Sain (23 7) nd hare as marital, ‘wthie hgh ro poeem (38790). Among the te ‘Sewpic gsburde wae tecied with he lest ik of cerca ‘rete Te a of hea fe na alr tient ated ‘oxpiazoe (18) and meorin (33), bol was owes Se ‘eae with yur 0) ‘The ADOPT ri i not ade the mers of ay we of cambiation ‘heap, The eo ale as wn shore drain of omy {ssgelsed with evra nwer aoe an HOA level a higher ‘bay of eachng coud try a oat with monotherapy ‘ver age! lve “The ren fhe UK Prspectve Dakss Sty sung tht obese mets nh ood stg contl on morn they hv bee ‘utomes tan vero ith nln or slonpiea apes‘33B Endocrine and Melabote Oiordors nse fermi he itl dag choice fr obese patios unless ‘The non of meri gr rane the einen gates ot wel econ any ge conn Soe pans anatower ua requromene. The coburn 4 ‘Nitcldreion postin hase bcnaprovel by et Cnala Insut Secrgogues, Suonyrees Sunes atta neg, bare, crpropamide tn ibutamae simul ba ii serene an ce ‘matted men eToys he ed SSiy-puss iin capone: Sunplr con soreypeevezia ad Ben eprenpeeec ne eran poy elise oftvrp, Satin of act reo cima a ‘of siacnet te opr on pret bau ele. Sm gee ‘ety else, prose neuer nin et ha or ‘Inula eereagoque, Megitines Should be ken only with ea. Roepe Jered rete nnn ca!" FPG ally op her Sout ne ‘treglar se» ueginie een coat sete an ‘ome al eiteby lod lcs ve Bigvanider Mettormin dere hepatic gre prcton ad yer acne ‘hen lid ee Mame {men ed lone emi cs ot ose hypoges ta ts poemine he hypegheemte eects of alia an slays ‘Maton sate edn patent mph ri tne ses, ‘chr thoes witha tet pie en, congue ae rtypenemic st Thiaroliinedones (1205) osightazone and pogtzane are goin a alee PPARY recelore Sr enance oul sci an lower th lw ese ad ‘Sialsing insta eves Thaae dug ert eins hc cll anti oan and ower hep acon ious hey ay ece paras Init T2 ‘iy ter nee ef mr ped be we sata wih ‘et pa do nese abuts ft pest, ud leon et odin ee nt ir Tay oaper 2: Dibows Metis 349 “he cadovascular safer of oneiazone is nies seting. A nectar dn fo cise! ae comcadl tht patients ‘ened whos have a al bt gach Ieldence of myer fron (MD) compre with pce or ‘nr amgperpvceme eget Then noe ae eo eco incon rn say of anomie al dese examine he ‘Seaimncalarsatg of rogttasone open tht hae sro evince ‘Stanimscnnd nie of dnt fom erin or et aes “wc wik meni fo brs need ‘Ap-ghucsidase Inbotors cae sd mig (ai Cana nit mei ‘Theses techy edcing ppm huose eves They do ‘sien bel acace. Acetone dows Wot aoe ype area eres te isk otyoniyca when combined ‘Wiican nen anregogues, Bees edges sure npn by scare hyposycemiin tents ake aarbowe hod ‘een ga usc mer ham ure Intestinal pase iniitors ‘Orta ea itil pase nib wd intl a a a hey mmc cru ae evens cl Froporton ie degree of wiht lo rst shoul wt ewsed a Imomtherpy foe syer conte Instn Rogimens for Type 2 Diabetes Melts in patients with ype? abet, insta ay be sed singly orn oibinton wheats actin mle pl einen. creo tr ndeiyngrentaaoe to sul ay poten eure igh docs ota Tex re several commeniy ed nuit gine 1 Single bstime ton of sin aed fo an ong'ng oak Sctlpperyesnc rpmenStartwi dag of 01-02 tsk of ‘Moll MMT orlane stg annoy and ade the ds aces ‘Semin cuppa The done of a apn may edo be ose Gree smal achive Rete he don of -ulfnyreni mecesary "ip dove admnateed fe maine before fret te Fenty one pnd tie day due smncoed Brean ‘nel (ef aly 3070 ta the am and 3090 o 3070 te pom 1 ume) These eimone provide convenience athe expense of ‘eal Sn he buy fost frais ene The Sse a ‘Spear mate may heveto teased cee scene mes ‘seco. wat) mtd asl ain NH ce ong Inslogs) and20s of the dy denoted before mes vee340 Endocrine and Metabo Disnders "ies ty Repl o very rapid etn analogues. The do i ten melt scieve pyc ae Targets tor Controt Conta of od pace (abe dresses thei of angen Seapets pe ran ype? dere Blears ea ‘stn and aia The mai isk of ah com! Df od pose ess ‘Sthemrnsed ako joyce pede? Freq’ pesyeema ‘ay indo posh moons = Table 4: Recommended Targts for Blood Glucose Control sear protection i poy in pats wih nbs, Vascular ogc Comte wr ek« ono yemic cone aciev loo presi ae Caper 33) ad serum pats Cher) ensure swing ceo {Gre Chapa 10 an prose aplate erapy eed” “+ Amiplttet therpy recommended for racy nd secon frenenton of estas evens maul wl pe Ind pe ats Seer smalyce upper the io asp fr py iret i pint sonore “stesonenlasely nds popelation " + Cont of serum ipl recs tek of adiesclr evens ot sth an cuse of matty nd soy in ites, Preis ped 30 yer ary igh i onary ty 14090-mm ig The ret BP “14090 mn He forms patent npaiens wh dates melita cree isey ‘Sees: tapt BPs 1800 amg hecho ampere ‘ect port han alvin pat BP Soe Chaps 32 or ‘Srvntrecommentaties on the lle of atyperensive age Dyslipidemis Cotestea-owsig therapy wi MIG ConA reductase inhibitors (Gate duns he tive fa of rman ser event ‘SESHMe ble ) when corr wth pcb The pony ae ‘fthapy LDL-C wih be sei trget ber based on dal eter ec amen iat Stes ie Char) ‘sa conor, corenpudens recommend pie at ow rk should target (DLC SO emo thse eh k= 3.3 mol fete bik a 28 mmo Te we DL it ahi ‘hc ads cing > Mor aet arse achieve tage level of LDL-C om statin ‘tr, eee rant yee oan Bey Ingemar rovnton, Sx Chops forcurene commendation ot {hehe of nmin se Diabetes Motus “The net emotion with peo pe 2 ‘Btistos i= Man: for hse a whom ent Besa achieved” Shea cot of hog pcan rece te Poof merovasae382 Cardiovascular Disowort complications (inp) but evidence aking ih scemie ‘Solio qevertn of macrotsclr compton sous 2 ‘he Cuandan Dubs Aston Gudalbes prove igo So ‘Ss cide toyed cote thor Soe Chap 27 ‘Stent resmmcnstons oa be hace of sahypenyseme pet Anutromboties ‘The ol of aia heey in pen nevenin of vasa ese ‘Wcontotesi Amerada oe ve mor mary reventon ae gaat etn 13 patents or yea th [KSA proven one soit (SRR) tres 90 pa or Ave years reves oe ngotan vasa event (8s RR) Th ont set bya nce nthe anne of lee The ‘ake wat oa sigicaly eee by ASA 23+ Gunner ‘commend ASA 78-162 malay frp moderne "(Snes Sloyear CV mic Lote sending TS) ‘The dao which isrecommentioe hse wee ean fom ‘has eet ele predomi mex The Women's ess Sy {QE found tat ASA 100 vey ny ede th reboek ‘fake worn ap0d45 ys oly TR(AR OS NNT, ‘crate Sako fo sacar deh A sesment tc aayss ‘thane aie of ASA cold iene cifsence ‘Roweun men ad women However lar women nthe WHS (ose de a all cerca vs a ASA ao (At? 36, NNT 4) 93 eave edicn erak TAL NR 1b) bute redaction nh ik of eke Eigemlope ia om the us Healt Stay ao sgn» ponte agers ‘aa bent fom ASA" At sine smear common {Ser ASA that pis all pesos conot be mae Potent wh aia iat pe a ghee cardiebolie ok {Suds be coats or mararn hry 0 rents se o ‘Guise chem stack (TIN) CHADS, a scene! lt ‘hb te toate y the kf ke othe as ook Far inning congestive ear ale CC), hypoeasin CH. age syn (4), dale meta (1D) nd hay uaa oT (C55 ASA 325 ma diy onset o wart foro ents 0 complete erin of CHADS, provided in Chae ‘Smoking Cessation Oversigt th thle vaca iskindaed by ‘Swe nating can be creme y lg sd reves ae five ‘Ses of absinene " Siensf smoking eoton canbe ance by ‘eotin replacement therapy (NET) mpl, bupropion ‘nvareniine Beppe and NRT we wopy equate ater [Chapter 20: Primary Proventon of Vascular Disease 383 fhany and ctr arsine he obnaton of bapopon sod NRT imey provide higher aces rae Noapharacalogc interes in combination with parcels Thelen ae ect opting sce racy an ye "ipso pharacge heros lone See Chap 10 fo cura ‘etoaeendrsns onthe of mnparmacslgi nd peaesone epic Obesity ‘Curent drops approve for obey nce risa and ibutenmine {vmonsbant is ppeovel ae US an eae ere bt nt Cara) Enc dog prone» Ts weigh ns tht lanes ve wo ‘ets oso pte however th imputed weit [Geo te mga ou veel ot and ery len condones of tery general lade wig rep, error, ‘Tose rugeet mut acs on ity change Dro herp ‘hel be regard wa rape tial sn tonped if sgn eh ieee not nove air evra months So Chapter Stor cueat ‘scummendaton othe sce of monpharmacloge nd plore ‘Soups ‘Mutitional Supplements ‘salar i alhouph etary recommendations mest acting hee ‘oat nance te retro fda osing ome tty te Fund ty aha lint) hinder y poo stay Sein Reduction of ik by tami therapy (og le a an Ey ‘ro wir obi vasa seas aglaw be ‘etiam do mt mo iemennnin ay provenioa oom Hormone Therapy (41) Women ssl net be eeowagd tonne IT ithe oe reason ‘Sueulr pect, While ones! at ropgad arae ‘et redtonDoet of homone erpy im pomp wee, Experimental dw hve ret at ee, Therapeutic Tips View evry aint encounter san ppt t en fctos, Stous ak fer osifenton and eonarape pe progress + Comsidergorghemmclogc manaperent io te an nel component ‘frat retcton seeps Drprcan hve aovere ef Pas Stable oe prisey prevention vent yt expeened roms of + nna pata goat based on he ik faving an cv The ‘oopraveb anal Sere Bests of many rg herp for‘Chapter 3: Prmary Proventon of vascular Disease, 385 Disorders 3841386 Cavtionsseuar Disorgers Suggested Readings ‘Aeamson HI, Hackl V Anand St Canadian Cova ‘Stet Consensus Coneene: peripheral areal diseate—etecutive catnin Babes Aneto Cine race City Commie Cady Dates Asc 009 eal pace sles fete eves Sod manage of be a Econ Cony bute 20032 S32. Ae fom poe alpe2000 Ace Match 307 camantoyetenice Eattaton Roget. CHEP 2007 ‘mcommendrs Avuable romp hpernsioncache! chapter 0: Prmary Proventon of Vascusr Oseace. 387 ree eee teCHAPTER 31 Dyslipidemias Ghislaine O. Roederer, MD, PAD Goals of Therapy + Redice kof dora dens (CVD) an rena dee 1 rove! pret rom severe hyperthermia Invostigations 1 Medic story wit stenton ts CVD (paso ese) posbe ose af ondary dysipien(abW abd major ctovabaar tisk cto ae Figure) rg hw 8 mae 6 fal in ‘signi ‘Bo wei kit) rca comene (peal ite youn atin) undue Ciponia eal, renga) lip depts ethos, xe) Lanny et tp open ves! “Sanetpoprinenisoteksamicrons are presen ‘wreaablah bacline before inal Gignoss of» dyalipemi Te, hgh deny pein colonel (HDL-C, ‘nse cheers (LDL-C) ‘Seipidemiae cae re CChoptee 31: Oysipderine 389 Classification of Dyslipidemias nary en) eras nda rides: The WHO Phenotypes esther primary or secondary, can real ows ean ‘etme enon and genic ts Gs polygon sa herefore {Ecbypercgiomroonin, Sek possesses or secondary ‘Tetment ten becomes necetan, eg dabetedsipgenia Table | Common Causes of Secondary Hyperipideria Criteria for Intervention ‘loa carve ik sessment described a he ecommendaons [Dytipidemasoeodes elles sans ay, es pases wilt m0 Spee eae ee a iad oitonal CVs mare by a pact ty stor (sth 88 Sear for men and 63 yar fo wom th presence oft ea. ‘ono hypeneion a abdominal oes. None a ators Maabote tndrome x hanced by aoa bes, therogenic ‘pst gh ihn, spall LDL pte HD ‘Selene byperensin, nin resins tn preteen ‘womfonmsoy states (Tole 2)? Manngemen nudes ee It pet tad re op op‘Tabla 2: Clnialdentiieation of the Metabote Syndromes (Chapter 31: Oystpomas, 391 le 3:_ Dietary Interventions iat ensign iene ed eal aeplat patents ae ensieed very high: High rpcere eves 2.3113 ro) ‘eran aivonal CV nik her when uscd wth atherogenic ‘atpdeman femal somines perpen inn resins ‘betes, eal nice ery hgh glee eve (10 mal) ne 8 hc Yor ponent ‘Therapeutic Choices Nonpharmacologic Choices Dit et etn ood iid eee ad wept inde, Sais ateaye fe pt the eaten Forse prevent nd Fr onimary pve. scoot Sty tral (able is {ccmmencd belre otidring medio, drs ane, he {wo (ely the) pd ad ippectn menaremon Encourage othe sy changes futher modi ipo pole and ete the rh of CVD, weit spy iy sd “nol enrdon Soting cosa ao help se HDL-C Pharmacologle Cholces (Table 6) “Tbe summaries eee ofp oweeng drags Hippos. Rosine ‘Theil si segusting resin ehaetyramin nd cletipl ruc ‘uu COL and can sigh arrse HL tens, They veo {ny record Rena ae the nly pidomerng ages proprint ot {SET crn Zon) or mt cracaeg women ‘Table 4:_ Lipid lowering Agents—Effect on Lipoprotsing HMG CoA Reductase nhbitors (Stains) HMG CoA secant most potent LDL-lwarng ages, Inet wt be atheros preree Si rent [RCV mari CUD moray antl ea moth emery 2d ‘sonary preston have boon acted wi here Isting, ‘tn ery prevention depen othe iia oe ‘vases Pure 2, Fr patents a high ik of coronary ary ‘Steace stn shold be aiated te rcommmendd sang des: f 392 Cardovascua Disorders an sites wo reac pets Figue1). Howevr, dice tats have Arent depres ofp fowenng potential» Tae). evan ‘Finda othe reaction of stoke an her otek inns wrth type tte wiht eidene of hen ene ut wth oe nk ‘torn ao ovedme he ra of stoke accel waht nen ptormacokieis vivo properties ad tency. no doe dose ‘huvlcore cn be daw tang tomer the one may rel ‘Str Scr n DL an pel crowns i Sin and lets aor inning potent moos fects be ‘ioe to vid ou amples (abe) “oble 5; Patlent- and Statinseted Factors Tht May Inftuence myotori Erect: Fapmadtnyteme [Orenpee | Smarty ‘cotinkeActd (Niacin) ‘ext “oes aya night” dosage ofan exend-leeFmulaton ‘Slay Fut tases o vet ver a eto han ‘tie oaltons. More inal eperience wit hse orton Soe novernln rogue. ‘Clucosenolerance into sate ‘cotrndiatin tote ue icin. Anthypergyeame pesca preamnely aja oma geen ona creer 9 opti 288 rte eat an tr nlc Sete erates era Beem are water came ithe ue tometer eae Seeman eee Segeneooaniventnoaen sacar? sx Chotesterot Absorption Inibitors ae, an etna cholestrol ssoin inhi i tla Iwethesy rin combiwtn wi stmt Seer lems than ‘info en pon for ag inractons with etochroe MSO States and dosnt ale! he absorp of fstab vam Combination Therapy ‘Aen rom dierent clits cin be ome oes imal fey ‘eta aceite level of sf copay fale ru ls 0 ‘eho tcp However ieee combat erp (sch Tes stains) cory geese ra rg txt comer ‘eral fo sch pate a ‘Therapeutic Tips + pitti met anays bean asin ot ion + Fri rr eld poi dein chien nd rept Naini dy wows nage oi eth hs + Tyee gents within hse clas in ese of inlemnce or ‘note ee. + Longer incl an ory follow is seta to mantar lip lowering eny nd tty of her + Allow te mace fra bled an epresettiv pen ip prof fe amor mesial vem Ace trey sence eie {romaine tin herpy veges te ip protic. Donbling be dose of sin wl farther oe the LDLC kvl y ‘iy Pe | ip) Tapper fe to fower pt LDL-C levels 018 rol. (Tompson Sirona hear dese aed feu riak cre4 394 Cardiovascular Disonters | Figure 1: Management of Dystipidemist CChopler 31: Oystpcomiae, 395 Figure: Model for Estimating the 10-year Risk of Corona ry Diseaee| nt Without Diabetes Maite or Clinielly Evident CardiovarculerGizasean| mee aot aoe Raeme Geecs a = ee een ed ste ene mene ES a402 cardovateuor Dlsoers ‘Suggested Readings ‘Chapior 31: Dystnitomias 403 | Age gis Fh il eats CE Saat ances cnc Se ttt ree, Saaehsat cage nse! ena Sr See taro renee rc, ee bee eee tcc ade Se ewe a aca met sheer ea pideminony Country (Yea) [Prevalence ‘Cana 20069 | 23 milion a aged 4074 yeas ee Upatresmen bse on 203 idetions vor Diet Cot Anaiest Crate Camis RF Eatorace | Coa emis PEcpoe mind [Nora ‘on ‘Comments TLoneig lon-lensty Upopseia (LDL) ete cs wah ‘eft LB heal el nd opr ne se ‘Sst intoefcat pons tices ek Lpeloncing als ‘hose eee of Cech oro coma a ‘tor pricy ete stung of pay preven, Satpal Se SRR Sine ptt keasis tsa ow ecole oat Sedan pp rh on oe Seven tghrak pt bse ay haved ‘Shift tts 38m Mans ‘nory wl ute combination epimens,Howeve dts af king SIO pa aroucocr nace Seana eps Most avaiable cot fectienes ayes have ee bie From ey tervals nd Se refs sume sale themes oe cuca reabrnt ree, Newer ote pote sat temic oaheve re ip eves sme poten, allionsh an wel pay fr tose wth ca “Th ete retin Sty showed tha clever ofa mean "eduction e LDL of ml. rode nian fetes in ‘ey erin ook pater "Ro stay conlaed tint wert wih geen san (esa {mpi} would poee sun nie expectancy fr ge teen 3 to 9 yea a ht women mou be ca404 cansowascular Disorders Cheeta thsi 2 en Sa ate stinhienr he eieaa ct ects char tare eS fate lean hts ag sent hat Toot ae seers tpg ite ie pon ec a ed a epee aoe pe ie anger a Speer chad eames roy Seen nye ely SSeS ie Aig e sored or vol ot 2350 peje gained athe wih aver | CHAPTER 32 Hypertension ‘Norm RC. Camptell, MD, PRCPC Goals of Therapy moray + Tiget for blood pesre contol nto sins at ton Tae Investigations + His drtion of hypertension a level of ood pres and sy Soddon saa scenty of pene ~ ae opened en chain es, ~ des aay ease yeti (Tle 2) ~ family sory of ypernsion carole isk fits md remtieendomnir dese tua it, caret weight a “stipe = cerca atic a peripheral ascii stesso ge orn mage ~ fynptoms af secentnybypecaion which elu fr exam, pheachnar iperae pas yes sid chang dtc nd”406 cartiovascise Oiocters Totle 2: Droge and Other Exogenous Factors That Can Induce or aggravate Hypertension othe agnor ypenension i mate inthe case of Inpenetvecmeresces and urgency Th foes pets ‘espero tat compeomiig val ean net (Gocennopty aria, apy deren al ution), Speen anda majr essen, thee wa DBP oT ms ~ hypeseonay e ignd in of wnt ithe tod prewar > Is} or> 14090 mn Hg inthe reece a “iit, rel dens ates coors ds oF ‘rerovicar ds ~ edingwoiemay berined safer fw vise i sod pecs ‘memureent or wobuiery bod preare esses! wel = the diagnos may regu he vis ft ood prose SST ower ap va ay {Evid men tad thee wo get og snc, ‘Kuen he dts of mening ion reas ewer ‘aiming ecoect diagno un fr types enoathy tui and perl pues for asa seas nd enol erento chapter 92: Hypertension 407 bear sc and apex fro vetclrhypertony sma mas for pole key nd ore acura ~ ewrolo nam fer ecole dose + loa berating: ser posi, salu and centnine eels © fang glo, toalcoleser, HDLC, LDL-C, ieee = andi tend BCG eet tne soold have ional teting (Table 3) THe 3 ypetansve Pats Recuting Atos! [iboratory Test i | i u ‘Therapeutic Choices ‘Nonpharmacotogie Choices ‘Alvida should be aid aot a ey ie to preven or ‘Stowe yperenion snd crdvasce dees Cae408. Corcovascutr Diseers “Weil 4g or more veri (get by ae nde Thule 289 hn wast ceeueercnce Ure men ood 88 cin women + sty et high nc rte, vegetables soluble ea ow (SS prodce win satura an. + Repay morte ten etoepaary pyial ctiyfor 3620 mines om et ys Hw i nl consston (62 dinky, <9 dria eck fr ‘women an’ 1 Sneek or ne) 1 Some fe enivameet “able 4; Effect of Lifesyle Changes on Blood Pressure in ‘Adults win Hypertension Pharmacologie Choices! (Table 6) ete average SBP-DBR ie 140-15990-99 mm He, eave ‘commen a the pesos ether 1 ypenesne tet xsi dae ot 1 alte ndependon ik fins or advair dies, ‘ewe satin Spiers cong any ty of pete (Sktisescter eas tcl aber seen ae mater de ‘hom 35 yer, ema le than 0 ears Tl nos i have {ypeneion inthe abn of the asc lth yong SPDEP 40-1590 9 mm gan hei ‘Gor sx hae atin fi ctor he sort te ene nromoesapy areal cus tit ond Bene of eran Themen, Manor bod peur rd eh alos vegas of ‘th such ten chose Sep us hey CConier ASA inpatient over ae 50 one od presente. ‘ou iain ee sch ear ‘never te reduction earhovasala isk depends mare on the ‘heft redicton noe presse han on he pete ood Chapter 32: Hypertension 409 eure medication Pharmacol heap shoul aly estat ‘Sera ow soe othe nua Sog, Con onsen kt td ‘Seas une wen slong il hay Case 3). Dove eon ‘ie pel lo reser shld be ote Sey fr eg wen fo {ia tee wa adver ipetenion opt ogan arag igh ‘semi chs tony at ae er a laste eae therapy or cried hypmtemion. They are Inexpensive tat sion he ee) ‘Tharfre fw ne tarde eld dense nda cid {Engr Diacics have proven niypermmaveefiecrvenes niente ‘stad syste hyprenion. he lea lack pont htc can cus pole tht maybe ascii with averse ‘downs ouomee, Comiderabemtv flr agents ose ‘ho urngy prions eave ona fr cape FPolnsed syndrome, Conse ning embination pact Fina be ik of hypokalemia (beled ps = freuen it or, amr) Roser the me high Snore > 38 mpd ot hyenas) {orcas with esa pension vrsposie to edna ih ute rp racy rl part Come wg ap Ses tara oon ce who eta-biockers ‘Betcha fstn thpy i pent ho ae youage than 60 eros no ba table spa, het ie oF soy af ‘ocur infrron ters ne owen pens 0 Tove mine ences cari or eel ert ower tetas are ater angina I vecp laces (AB) cali chanel Mocks (CCB drt si erry {Sr pettary prevention of cariorselr event a pet ve te ‘eft e0 yas ain, they maybe fv a esting ‘Sruvasculor evens in people tho smoke” Angiotensin Converting Enzyme nhiiiors ‘Angiotensin converting enzyme (ACE init fringe for Frets ith wpoompised lypernto ud fopatent wth ete ‘ent myocar! nection, ba Sar choc ny ear ACE ‘Shorr onesinisedin women och batng psa *10 carsovescisr Disorers Angiotensin i Receptor Blockers [ARs fit-tine agente or pte with snompise hypertension Ando tens iabe’They ae good arms ACE UM en he tre apes ita but ote 'AR conan wane tc bing penal” tongs Clu Chana Boker | tenting yon Coben ea eine st celine stay Satay oman ny | ham and son me be wed. Ebel ptes wt folate ic paren di a eet repre > Other Antnyportensive Drugs esc ws three peti actos Tae) eorrcntons [rinlerancs of rap, ra eget fr nina aed suns lrcring in cobaten wih eee satya gs Combination Therapy Aout 0% of pation wil ecient than one athyperensive age ied esse ntsc oer han abe, ‘Svat dap Aay combination of «bat bicker ACE ttn ad [SUA hai tan soi anthgperensie feces to ru ‘Seinen. Those somata shold be avo en ee epee ‘Eh ample ofan ACE ver and tr ech rcmyocrat mrt Tale 3). Al posable cambio of [rine agents asain hae flower Had peewee fe nga whe ic een be ite pin f ACE mies mers, here sme ‘rene ths erbirten any be benetl in ee ih oa ‘Sutncson or Uaofa dete dosnt coment wi ther rapes. ‘Adherence ‘Ahrens shou fe act th it, Lack of arene tte ‘SS ssa of por bod pee conol t's end + Aiming nnabrene when qosond ina notre manner 1 ales ken aces appoinnen 1 Poo ood prove conta Lack ofsocondeypysilgi ec eg. decreed bart mon alr renew pects oa ine {Lack ofawarones of tal pilaking routine aed prescnpins Chapter 92: Hypertension 414 Noms canbe psn Roin cr sl ince he 1+ Ente atin ar weiner about ype anit rst, reerayvrely and wth poet neato ppts vase woretyperesic fe pie edcaton son) Toc family or soil spor nex ication sea snp enero ong-ctina oce iy dap nd ie tebe tateotin edge mcombussn when pnt Ente he pati con fod te peed ge [Adie the patent eli dy rie for pl-ahing, 6 Fine er sy eh on hing em ey ig = Deri the ee fy aouerence sd ior mie or 1 cease te eyency of oc ise + Adve oe of adrencenhansing motosion pens, 1 Consderaessing adherence with en tonic il rpms 1 Adve stoning adherence with lf coated makig on Stenr won he preston nese renewing ‘Consider repr elon cote with be pati fese ‘Resistant Hypertension Many ptt with hypertension eie mip igs or od press ‘st Inthoe with ein ypesenson, mest ora whi cot ‘tc secencary hypertension, eal afaton, nea ‘hes witha poor tapos oan acute combination of median Soret uly fo erga er dev do tonal esi muee yess Hypertensive Emergencios uncommon fr cleat ond prentae sone, widow ne ot rouse tat esa mage, a equ cmreney thera or Sitienn cmp ete cs ih i {he eee terme actin ge wth hr oe presse he Seren lg nig hones tc re ‘Therapeutic Tips + Presb a lower stating dose of antihyperesive dap in hey| misnspunteyzsrasman puutungs TAD ecto ‘Se Cchepler 32: Hypertension 443 Teer ‘he pron eet dering soray avery = 10% son Inthe vorrei ‘Therapeutic Tips. = When am ACE initio presetied ox patent with rma {hf moore eta psn denne wiht tinea canons ACE mie dg + Seria tea tow ons ad ete according 9 mgt, ‘tenga {0 -our tee pid each yt rad ‘hrm, Sehedle th tate eto fos one whe inal Symp re epee, uly ag Tete we of barter ese na ptt with eng era toe wth mgs ce ‘esting het rata bern 0 a bape ite (PM snd ‘Sheree he te ht doesnot exceed 100 to IO BPA The dae of {Eyaopyriies (eg anode, iene) sous Ye ese to “cee mason smptom eet with ver et “Inga wt fet veaiular ssid ection faton £2 fori stat bet hetero at ey fw doses ad ately {eg more neque tan ever 0 Mec). Ccnoplr 38: Stabe Angina 437 + Dour waht bts ke hepsi ptt who ie ‘inar cororySyirome. Tere sr ot ay fet ‘Avid verapamil nd ize in pens wih et wena soe ‘Sekincton an we with cevon patents with AV nl tae. ‘As pearl, whe ang calcium chanel Hacker te ‘eoimen a a pa ith essen ang ho ate o09 Ieee sea loaring diy cronyeine era or itazem combine win bt blocker ray ‘Cylooygemse2 (COX) bona al elton nse ‘stant droge (USAID) eres the rt aca cvens ‘ihc phyisne should mnie ti wen pains wih ana gute |: Medica! Management of Stable Angins Pectoris |(438 Carsovascuar Deorore pee ene Seas a SS TERRES omeaeits oe neem! oe ee SESS lS = eerie ween ES ETE “eas Tee Se mee TS a ‘emeueu40 = ay ed440 carsoveacisae Disorders Cchaplr 33: Stable Angina 41 Pome ged =e ex eo cate my gree uty may “SE —— as ro sein gmt “tant ca vont “Ships Sn pe Se eam camaChapter 22: Stable Angina 443. AA2 Coniowareuor izxtors esi eBay ages 205 SB RELCHAPTER 34 | Acute Coronary Syndromes Michelle Graham, MD, FRCPC ‘plan compu snc myocar So Yenc ‘yocudial nrction (whic ples eam! eben and wa Teter Kom seme wave mca sarton) a osbie | ‘Th tm cr se" (ACD) ef yl | | UNSTABLE ANGINA AND NON-ST SEGMENT | ELEVATION MYOCARDIAL INFARCTION (usremy Goal ot Toray Investigations Cae isi ith pci atemton pin uty, seve, Sct in, png ici) an of Mpemcsconary dn) snd fet of ogee + yea exmian, with tnt tte presence of hypertension ‘Sn, rine Ke (Keon deol pole ‘Sion atysimin yrow ese : ‘Scone th passe of epost wall ton sora Chapter 34: Acute Corny Syraromes 445, ‘Therapeutic Choices (Figure 1) {Slowed i youl by evacuation wa eratners Soronncy fneventon (FC, sip) or ops rary al haha potent ances ae ar igh ley ave Cr mor eng Pos ‘ne ery, age! change TIMI Rise Score» ecu ea emo pues Nonpharmacologle Cholces SERS sl one nny Sve ‘Segment hfe Gt valle) aio in al hgh pau Pharmacologic Choices (Table 2) st tts he Se ered Fy446 carsiovascuar Dlsntars Bota-blockers and Calcium Channel Blockers Sut bei blockers a 008 a oil in alpen without ‘onndienons ecie ureye dace, year, sconce thous he ek winning paceman. ‘Thrdse held be sed oa esting bea ate 0 30 60 bap ‘te (PM 1 anginal pas egg at presen, ee oes $enlly saat inravenusy tome ol dane aleans canel locker ca be ted ont ogoig noms lt sckemia in pans wo are receving maximum lrted oes of Wehcckar apd segue dene af mis In iin, ve apes ‘Tuadinpadets wh cect oleate bts ck tt thre wih Siena eran spn Avon mete poe “Angiotensin Converting Enzyme (ACE) Inhibitors AAC intr ease main pons with een poe ction he ential Foc Byte inl Beat are, tm ops nth carry tdi pain with hypersion sot contoled with sts Socks a Aniiplatelet and Anticoagulation Therapy : [ASA provi a mxiing Dene in pains wih sat coronary ‘Sens If pate wit surpeces UAINSTEM re et ea ‘eeeing ASA, shuld bette pomp tnd continue ang em. ienopyrnes Coat te prefered get in he ies eo mone ai ‘st of ion and beter safety profil compared o elope. the CURE Clot n Unmet tpi a povet Recent heme Evens) wi clopidogrel gis ASA) signe ead he ence ‘ot major aber cre ents ACS patie Compared With ASA ‘hme an rodnnd the nine feu seem ane! whch encanta Go ours Th be of shggr wacom {ino mens repartcarof TIM Rat Sere Tae mr benettr ‘reseed a 0 dys sal adtona Pets served over te Seinen eaten pre evrge gt oth) a CURE ‘hee was an xc ofboth major td mor lng nh last tou ihn sitet en towards a eres i ieee Side Didi nen wih meng pin de Bas Snvate clopdog ls clear tt byenary nt ned ppc rerscuzton.Clopogre shod blo ae. (Fle dap in tte chad for pas ren chapter 94: Acute Coronary Syndromes AAT! UstractionstedHepara (UFH) o Low Molecular Weigh eparins re pari is hey componente sscesfe manage’ of pats MEG! Sues ot aan wa eter UF er LAH he ole tre rate redoctos (soe 38 5%) me ae of death {eh inte ft monk UA hs tpn tons So poe ‘eaainy and tna vray meteor [Niwit fave the advantage fess of amornrten peel toast espone ol ck ned for monsstgCinl ias otopara ove UF, bt have vi ce LMWH (apart ‘edo 08 npn el sae LUNAISTEMI we dnt have spmcan real tention sie ‘cette lane 0 mL) fe hve wh etna reste ‘Stance © sb mimo, UF's prope Fenris nt te Soar eee Seishin Seen chinese? repent cies Terre en fe re Seiten ema strates, Sec wantenntcvoometictst gltbnld ad refine at te tne of sdmsson oe trmedaely eoe Tomine ete ae Sisters menace src etn es ely Siriaas eke SX let Therapeutic Tips: + The snd de of ASA i325 mp diy. This ds can be eee {obimp tna ptonrecen mg ter lois + Bisomtnae lpiogrel ve dys rior types rer to decene thera beeing ST SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI) {one specie cmd 9 bea medal emeeny ad ‘Sere rere rene omesment eset448. cardovesctar Disorders Goals of Therapy = Decrease morality wd complains 1 Recap eeny of he itt ened anny Investigations 1 Rap, urged hisory and physical examination, with parce ‘tenon te net spo, conaeaton oe of ‘Grombatyt agent al evsdencs fhe fetes (och, ‘ypoteaon congestive beat te) “ECO Sta thon eer ig so thes 24 hors then daly or ‘Tabyr neison,opent he BOG wth cch acuence of cet in 1 Bastin CK, CXC AE and opin CT) STAT, thn ery ight ous {betes tus, CRAB ad 6 ot cod be embed ser “+ CC rl at th rsene of seni setine erly, ‘resin, fg ip pri nd ver ton 5 Pale ces ay (CXR) STAT Eetocrdowranly lo aes LY ftn afer sable ad ‘cman Echoctsiopaply io wed emergent whee hte Sniicion fase metal cpton ee ‘Therapeutic Choices (Figure 2) Nonpharmecologic Choices. Pace latins ca beet wit supplemental xg ad coniasous ECS moog Being atonon ser inion poded thee mo vee of emctons Primary Percutaneous Coronary intervention (PCH rae coronary angigrphy ith PT an excellent atv 2 ‘rombsiyies appa high-volume card ctheetntion fies fist Peary PCs ened npn cama t ‘homboyne capy an hse wi earigete tc. Ie dtm, [Sree pens over te age of 5 bere of a igh rk of {nscunal herbage nt Rh ovr cry moray see i homoge nthe up Pharmacologle Choices (Table 2) Tarombotyie Terepy “Tebotie herapy adinitered eat in he cours of STEM ‘betty ests oy sd ry, arly te paint ‘en wthin hor of yap sam. The ene set bt st [Stn sympiom once 013 how porte pesos, a Chapter 34: Acute Coronary Sytromes 449) ‘he evdence ie mach lear fo pretension yond 12 ws. The grower abolte ote seen wee kof mary che ES i, previous Steptanaae se rfoednas ‘ve 75 gre ler patents spate Ph) teplae oe eoccapase ae general eee. ‘rons oe perio hain patent ested wa eecelre tt be sel wth auton epee with onl ‘artic estat Cer = 0 mL ese of eae ein ‘ah eatin par arson ne ct ‘eet fle hota of emt Bote-blockore ‘These pens ae recommend in ll STEMI paints without nants, sa repartee when shed Speen are prevent They she te nated eee homey ‘hii sacle Title doses ating beara oF 50 060 BPM CCalclam Channel Blockers Cale heel blacker: te recomend in tent ib STEM ‘they have een shown a ncteate mort wn oti Tey ty iets cone for bchems ror reel npn wh sea ‘bilan fc oker ae continued Mteogtycerin Cine ST tenn erp ns ene ees er he [ACE inittors “Thee recomended for ot in all ens pos STEM spits rd nytt in 2 us of ‘Beever unlote pten fs yptenve GOP oD mt). Doses. shoei irened every 24 hors od reser ttn oe ‘owl anda enc owe mere eupatents: Bed one ‘also he HOPE wi a remota conte a ACE nner [aici even non pate nth pesered LY cn An Sin omic str sabe tae STEMI pane wo ae ‘ee of ACE aan tinea or ce os450 carsovascuor Disorders Aldosterone Antagonists Long-tem ie fa lone ange (6, sionaactone, {perenne eos mori and moray ie STEM patents wih teraTeviane of tea tur LV eet ction «40a sl nthe sul of wo rbd ls Caan tte ed {epaeme wirea ulceny or re-eitinghypereloisbdo ‘he resting ACE nbs concomtany lopidogret 1 pains with STEMI wate wi bios lpg iaceses uncy of be eed eel a eee eon copes ‘orn ote rei of to randoraed wa and cou there ‘Seiden fr oune ue hse pons Complications of STEMI Recurrent or Ongoing ischemia ‘Opie a-sgia tay, an conse al pte with his problen ‘Gruen coca angopphy and pose ersclation Heart Faure “Treat eat ite maesively, In ation consi nglownghy and perenne pens wih dpsed Lf afer ML, Arttrytomies Aspe penatce vente conaston (PVC) do ac equite ‘ican. Symp coy ma tere hers ‘cracker Cant sens we omental. Pen ih etn ‘ecco etnias requ lvetiton fore ot ecren ‘em ny rie son etmpysoge aanea ‘ia vit casing chee ete Testa ets ‘ha rao contol venti aaiy wth ete Sacer Sr igoin i tse conexant beat Els) cone na Sovcogul tap with wart ‘hee mete pos evar seal rere fr sci {npn donee dentin hey (ICD) Pericarditis Pca vou, uly seis within 72 wr ‘empsmatie pees canbe tated by increasing the dose OF [ASA to 6g OD fran to wo Wena 1 AAs meen @ ‘Sots ose doug EAL US" mntmunion of anicogunerungesctny i pond ‘ters aly pot nfirton bu caution ged paca presen Chapter 3: Aeuta Coronary Syntromes, 451 weeks of mons owing MI Dress ome) deo he ik of ‘Fecal Bedig nd tnpomns>™ ‘Mechanical Complications “Tha we devting prions neue encouried Yas Roped papa lend severe mia regurgton),verrcalie ‘Soa dee, vole ee wal pecan reset is ae ‘Shu art rage hoch. Patents sol cst for ‘Seegeecyanslopmy sn mal nerveton, even en ‘rent he ory vn ceiied wih hacen ery gh, Special Consideration: Clopidogrel in PC Pevexn ithe! pero PI sti! te sit fa, Uitaiepeteneedanel de Rett whey ony Mire Slnaced a too peer rest Teeny tems a ore rangers et SSSETEi pte ay eee te ee Souci ance afk ne oon fr Siren ety a ceo ceo SOIT arian, eer tl te Cio em ce bcm mmo {SEainesgcy soul be pion un er te cour of cpg Sp aes be rene cine Copel EON cpr ey cotton cone! SOHIST Mag eke senor estoy =e. ‘Therapeutic Tips The gil for thoeolyewonment sa doorso-oeile tine of 1 The alr primary PC is dose ilaatin time of 90 mines orice ‘+ Ceti testin ro maximum pin ee 1 inputs wit right vent tres oid ne and cn fe idee rotopeso tet hypotension + Administer telockers ean al pater without contrindeaens, ‘egonns with sdmstton Ol soninstaon an follow [Rtas every Ihe eer 28 hous fer once sty bem lockers) {te ptent ha ech aque ba bck Stat ACE inhitorr ey. The cote of get ca pend on erste: ei fry rina er452 Cantovseeuar Disorders Chapter 94; Acute Coronary Syncromes, 453 stepetn toma tbe tet e, Figure Early Management of WAMSTEM + Soa tens ae ofr wo the mete pos MI pti to +i ae offen woo ar a ceded asin he mmite posh pv.Jovesciar Oleoders 2 Management of STEMI i i i all ala dhz ¢ = en eames seat elguae by ne own Seve naa io ~_ vane ecm me com ote vemos Gemseme gaa i = Seay es 2 CUMSSECCSE mero i SS ES ce ee ay » SSS Tien Stee ee sen gage SSS ecco meri ORES FUSES meer yt = — a os ee = Ss {=e Be =a a awa a STL 8{ | 458. cordovasuiar orders Chapter 94: Acute Coronary Syndromes, 459[Ghoptor 34: Acute Coronary 480 carsovaccuar Disorders482 cartiovarcular Oortors Suggested Read Bosra F Huriglo RA, Molitro Dt. Pblt yop Tila its eterna syaroer a meta al ‘Boo dome heal wae Eoncet0s9o305}4 9 ‘sua fy Ata EM, Boley IW etal ACCUARA pooling ‘pn ibe mame ot pets with sabe ogi wd {iki arty de manias Collegeof CatiooayAmerca Far Assoviaton Tsk Fore op Price Oieies (Commie ‘ihe Manage of Pasa WH Unsble Ang) Coeaion ome: 193 900 yin TI, Aina EM. Broks NH et 1999 uplate: ACCIAHA ulin forthe management of pet wh sete oct Itacine A apt ie Ameren Cale of Caniogy American Hae Assocation Ish Ferro Paco Cetin (Comte on ase of Ate vara inn) Cnt Chapter 34: Acute Coronary Syndromes, 463| lovascular Disord CHAPTER 35 Post-myocardial Infarction Iam L Wiians, MOCM, FREPC ins rseing wh moc inion (0 onl Rnd 3.) ry om 10% bec} ad ha ped ‘eeurent schema andthe isk of eythmia Table 1) OW pains chapter 35: Postanoconil efron 465 strict, ween hve been veep incline wl, {nvetgatio nd weatnent pts afer myo ifeton shld cen et ayo pon tree br Goats of Therapy Preven: Soh dl reen o ay recreates (ML eat ite es) «Rear roression feronary diene 1 Retr atin a nesnighl gait of ie fast mal i factors ha responsi SO of ik Investigations ‘hate wit or witout osolyeais presented igwe The hich Te tee tl the pct wil ese rm rts ng iain en ih nbn i onan ey 1 Predictor fervent net (one sc wth post Fyetenson, tigen, her Rip sae abe) stein + Proctor of ate recur ove (ont to sen on reise vera section acon = 30% er ag comers ele, ober vse466. Carsovseclar Disorders ‘An important steominant of prognosis eM i et venient “int etd ye le veel een Raton {Ge DE mre copay wee frm incl signe penn the ne sn 0s uly gest, resting achat, hj, ne be anh ck “recon ri. The ectemt the cet of ery ater ECG od th dere ene rete orb net 225 LVEF pet (cf rtrthe pas ey cae cae {orfurhervenigion Other, ea cee i eae fo ‘hocrtaogapy en prem omodied wean tx poo Sacre ‘re gustioosare acd n anes wet i ay cate {ote red wh vombolytes lo vn he raoeagy se Bee ‘spat darharge’ athe prognosis imped a tose th sdevocure sehen {A decison slgvt for he nique ston presented by po Ml Pete flowing pemary snponsy e asd Fig “uble 3: Evidence-bared Indications for Postintarction ____Goranary Anglography* ‘Set pati ny be invested or ayia (Hor most, vet ‘ck desea iss one ‘Therapeutic Choices ‘esol ifammationcobates the pabognei of lg pie ‘Than ogres wih atantary oo temo prope ow Congcetsve magento the pn pai sol ine trotnen! of hypereasion, dyin and Saker alia Skin ‘Smaton Sects the este of dst an enim by Se Pct wth Mis therat of rtson at det dees fom 16 ppt smeling Weigh ss and py Sait ae sso woporot Components of econdey prevention 0 Chapter 38: Post myocar Ircton 467 Nonpharmacologic Choices + Ect lent of adie cabin ae povde in Fins 3 1 Weight oss inetd the patent BML 25 ofthe Wat Stine St 1% deccmen by weg” Neon cuneling ‘ena oe pens atempns oe wept Reysa exit with an ivi preston dt ass fr 8, ‘She level of iets and bomen ope ener he ‘esol tmig ff 00) heabwoc en be ted by ene {Slot arte ea ey ee or ae ot “+ Revacaaiton acct cet pains (igi I and Figure), 1 An implanablecatoveerdeeate maybe indicted nsec. en Pharmacologic Choices Aor hs si pases, np aps, be blokes, ACE instars nd pid lowering traps indepen ede indence esa een ype 28 ies} nee “Tabled: Potential Cumulative impact of Four Treatments for Secondary Prevention of Cardiovascular Events468. cardiovascular Disosters Antplteet Agents 1118 Aspe agens ac fone in evening isc vets incaing ‘onal an des post pnt ASA we ep ‘SE ofeoice due tot even and nw cont an een ‘2 Gon herp i ll CAD pan wat conan, {cdg eee nae pow Maw Sone (0925 mg 8) ae ‘Soa ee lsmel ma) ‘Copiogrt recomended ipa wh hve contains ‘Sot lea ASA. Acute unl foe umes patients we eraely or wih rombotas re mproved by opiogr “oir ot! hry fr hoe undroing et Sepleymen ‘itn sc wis ASA lpia ae bon ete eon ‘emmy ann ao ni or ea sg ne wih sable sag ST-epnent elevation Ba vente with hora al arent deployment When a hing tere ‘ced according the approved fio ie ommenond theodore! be contr fer at en om year ar deployments Sten hese Seve ated in ore op of el seg i ‘Reonmended hat clopidogrel be continued inca Bota Blockerea122 es lskers ede croatian ncn ee, diners th probity of mg tom arr by apse Tate ‘sens of oration hee dup ar recommeded al Fase [ose nung ose wth non epmentlvaton NU (STEMI) Shia eciing erably hapa primary agp (ge 2) They sald be mtd wn af dae of Man eres ‘hathenpy sb be continedideely* Hen Stocker ahold Be Ersicoone pan wth np, hdl sda bat ighr spats with ceded LY function expecially when asst sic ie cane ee em pve ‘Stile tp cane Moor sre ens eablskers a rtd in the poet ME popstion©wth s tan ine dus outwei the ruk npn where 1 ‘htt eit, cre berate emanate (COPD), seo pc! scl eese 2 PR ner 0 se an ota oe ‘Se ire te Lomi sy ely Sintered mse patent wih ory of stn Te oppose ‘eof bau Sockere afer MI ilhauated a figues, Chapter 35: Post myocardial ifrcton 469 AGE iniotora228 ACE ais impove hea ile, reduc tity a may redace ‘dab ents amon pha pate wih LV dfn oe ‘By congeaen, Sint ACE aie nly aller at is recommended for putes with STEM withthe greatest Bente ‘tert mon he Maersk mabgroap with previ mys {ntti ha res seprened LVEF and aehycard” Among Patents nit evens of bereits cory chronic ‘reo an ACE ior obs the a of ML Angiotensin Receptor Blockers Angiotensin ceptor Wacker (ARB) ave iirc ACE ‘nh lngendomised il demonstrated equa fewecn {he ACE iat cape andthe ARB saan il se ‘a fae and LV Speoncton™ Tre wa adranings of ned they with captor and vate ARDery be ed sta of -XCE ssn patos who do oleae the ater de to caus ot ‘nected em fale oran IVE tone " HMG-CoA Reductase Inhibitors (Statins) ‘AE Lipomerog tear to acheven {male Jeese a LDL-C ‘ect abate ky 1 and ease ok by 20% wee Eve Sem The peop bonito atin they iy exe beso ‘ne lip wena Aaa lowing ty ee he Recommend tte for LDL-C hve become progresvey er the ay and etacy of oleae lowering ene bane eco ‘ablated "Among bight pe atanment osu LDL-C 22 ime posts opp bento’ tip tomceng tg nal be ‘orn form indiah with an LDL-C tl a ta ‘lest heen pee cote rat TCHDL-C) of ‘rete wty orexnmplesevasain 80 maid or eosvasain only, ‘Only 1% patents dcoatina heapy dao muse dssanfo,st ‘hee iso reas opm wth mote gress bea) ‘A sel mio of patents ayes ain! therapy with an {thats coksol abortion he cane oie ak ‘Stucatat uch as cholestyramine470. Cardiovasc Disorders Recommendations mh Canaan Carvel Society Geis ‘ecmegeted by carvan ik Tale 3) Strang Satin pie ‘Techrgeier an acu a improrer tat eary ani otcmes The ‘eo indepen ofthe ip love ate st wee “ubleS: Canadian Cardiovascular Society 2006 Guidlines for pidionerng Treatment mum | rat Anticoagulants a ‘ra acount ac recommende for post Mt patents wi peste Sepa an moma a re All poo MT pate sem to nef mode fm wai hspy with aPC duc live ASA lathe combine enti of ah ‘elton ase ARR oder may ‘ah ASA, speriorto ASA alot in remy composts evs Bt is hatte witrs igh ak feeding "Te incetcd ak of esting ndthe dds of suring the de 9 ainsi INK preset | ‘Haw Cong, warren be scrote pats at Teznnble a fora tioaove sede ‘Therapeutic Tips + eisai that a ee poorton of aes citing sinely ‘petro therapy wl ity ow aie of «Patents rcevng therapy ately adheres opie guidelines {osigicaty beter tn hose whose heap Seem alle, cpeily tore who ae oer, dome, overweight nape 35: Postyocarl nfrcion 474 Depeesion i baited with ncened morality pos, Main Fret of wane an ea ce coniion sro Ave eof nel meee ‘The tu sua atti can be guide by x bse eercse ‘ese darken nthe ly busted ptt ng = mosod ‘ubiliaton pote, Poor exereaeensraen proveras of ‘hain ences ECG abnor may pom ur esa {dor casino he at eevee Paes Sere ‘avo ih wl gone Sacersics canon pogo flav and eum wort or ee wes Give al tiene wire with isons wt rexpon ‘recone chest pa Provide enquvocl commendation oqutsmoking, Ease ‘Reve amine apices or Buproios tds Sno Hormone therapy itd fa pinay sonar proven of carovanaar vent pena NO Rowtios of aniniant vitamin (tin Emin Cs ‘noon ar prvenson eos event nt rece Seletive Cot Inbitor so me nnstive NSANDr such ‘lbpotea may seduce he prt eens of ASA, ating ih472 cardowsseuor Disorders Figure 1: Statilying Post Patients to Conservative or Chapter 36: Post myocardial ifatcton 473 lque 2: Managemont of Ml Patonts After Primary PCI | Figure 3: elements of Cardiac Rehabittationtim ptfemaon wre’ sentuaroe Se = = ona a a Won weisog aww pes eBRIG 9 SHEL‘Chapter 36: Post myocar! intrcton 477 476. Cardiowsecuar Disorders SSeS — ae . SEER aie Se cwewcormmting ang wees ae cerca Gries ohana wrisea on uipaen song —BeREL| i i § h ; in i i | i | wee See EE ~ ruene seg 8 U pes SBI -oenEL 478 contiovorctor Dlsnters480 Cardiovascular Disoters \ es ‘ener te Sogn “atl Drugs Used inthe Post Patent ccs oe Bae = Chapter 96: Postmyocarta Interction 484 Suggosted Readings Auman EM, Anbe DT Amstong PW etal. ACCIAMA midline fr themanagnen of fauons wk ST elevation poe con Crean 3004 09; 265293 ‘Bound Attn FM, Besley TW etal, ACC/AMA eieline te the manager fps wh usta ad ‘e'stsgmet lean mycarl incon 2002 Ceaon Bas ogtay 693300,482 Coctovascular Disorders ‘ CHAPTER 36 Heart Failure ‘Simon de Dens, B. Pharm, MSe and ‘Michel White, MD, FRCPC, FACC Heart ie QF seca with fv year mati of 550% ‘epedng on he erty noms! HE may ree tetpuaitons od snc ees quay of ean eerie Tecan! pied syapiome of che dye, fngue a Bie LY icharacertze by ipa eset (LY) fai a ‘éaced LV resce. Hb general categoria tbe ce HE ‘rh preserved satis atin (PSE Less common pes of HE THe ic hrs hy end ame GEE i Not cca sa eer ot np th ‘oie etment 2 vy dfn asthe sees of ans espe of HE it LVEF» aor Sth HE wih PSF ca ‘Seach nny codons (ypetsion, nei shes, ales ‘eis lingh haan! april ino ty or Goals of Therapy!2342 Tea fa fos 1 revet dicate progrnion Inport erie and uty of He Redace moti and morality ‘able 1: Laboratory investigations for Evaluation of Pationts ‘sith oer Pare484 condoveecuar Disorders Investigations (Figure 1) Ansory,pyscal examination nd sft abortion es shi he feo octal te tnpone Tale) Tesi and cnet modifable ik actors and oxacetating fctore ciate?) Detcmine vesicle and function wih rantorace ‘Sieceingay wtp ocnloy get ‘Shemales ander myer poles ‘Adon sou epee eset nds ey ‘Secslon of Fadi guste specie wonton hen spree ‘Toe New York Heat Aeon onion clasieatin coun ‘iodo downbeat with (Tae) | i | | | | CChepte 96: Hoar Fate: 485 able: Now York Heart Association (NYHA) Functional ‘Therapeutic Choices "Nonpharmacologie Choices'* + Cont HF ik cor hypereson,ebesiy daets ‘peavey dpc ocray ae data ahd ‘her ear ices. 1 Recommend moderate regular pyscal avy in stable patients 1 Recmen no nore han nose nebo! commun ea 5 Wo completely in leslie casonyopst, + Reta ete (2312 By owe + Rosie ii intake (= 1.52 Lay) in putin with uid exon dat [shot eayeomrbed wth ree oFm pct hp 1+ Anal itvoen vccvaton al pate ‘Peunococl vacation tal pent 1 ay weit =" pent whe gin 0 Shay on several omsecve dys 0? ga ye sul ae set am apy Device Thereoy ‘Given hi high cas he owing device shuld gency be reerved fetes bdo molest comories tat eet 2 ‘Spent ii sa wimpinbe carter deftriaers (ICD at esomnee for Hein (VE) or beady aes sin erica {team (pa sence of eves feo orca ‘Siny daece eth bet to modes symone VEE 230! An ICD ay aro be comer fr table pens ‘eu nonce NYHA he I-l HE don LVEF = 40% oF chemi iF and 2 matey of myocar NYHA css iV nd ay LVEF of 3 Saban iuctie VV Sorng a oaroplony 0+ Canta repnchronization herp (CRT) shoul be oid in Dents th VHA sie 1H dept opel metal ery ‘here nian hgh a ave an VEE 2S and QRS eal 1 Tet sonic apt devices LVADY should be uted a bide ‘erpiamaton. seo LVAD ara bgt recovery sectors 1+ Contmana pte siren preter (CPAPY al essed ‘pats wih catace apes Reperiution and Surgery 1 Rereularsaton, ether by pertains coronary evo ot ‘honey pt sane souls pete i lec pent ‘eo symotoate chess + Cana manapintatin soul be consid in pate ih sever ‘eracory HE despite epi hop, Wha would tees hve be expectancy Pharmacologic Choices ‘Systolic Heart File ‘ne absence of comnts, he ereson of hry for pte tHe mal pose wh an LE = (YHA clan 11) ogee "remeat wih the combution of mn anpotess convening eye (ACES entra better Figar 2) ars re ed ovo sgn sad symptoms of yperveemia ipo egitar t ‘Seo rks (AR) sdoteone aenonie ore comboton of [Sottero ae wed els idle” Caney soli pve othe se face fr wich may ‘oul moriy Sensi hae been eal a he enon ela ‘iii hale’) Drops wed ine remem fH are presen Table Target dons ae thse used i sie as Consider ata comorbid onions when contenpiting he ws of paler la of modo, api pet nd te tage dae ACE ahibtrs eommende i al pits cae they mprone ‘Sets md ee te ako hopin, cara infeton ‘hdc pres with sre HE Stat wit ow dose an ate (hedow t)'tcny seta he ge over maemo ese (helt net dove Cannot be sce vache doves ‘mor efave a or dees Meme mr reine, potion ‘Sablon pce bel ting an ACE mbt or ctesing te ‘Were eget and veep ater natn of an shoe at roses kof yperinems sreinse th then nhc, er craw eatoue 487 | ‘Beas leks pore spon and ace he rik of hawialtion ‘get atc wise HF = They ae receded ital pat wah as LVEP © 40% Oly beta cen ha he been soto ete morality shuld te ed eave, iseprtol sae ‘picts chs) Mora tert ‘i HF Dose tation should be perfoed at 2- teehee ‘onior too preure ai beat fc before niving xt ao ‘scompenaion wien ning or nceaing he done nfs het ck ‘ay pric auenon othe daly omit Weight Bete ocho ‘Boel not be sapped sbrpys Hele patrs wth rere HF NYHA ‘Ses HIV) wan apeiron a ean! iui ae recomended contol sig a ympias of congestion. ‘Thine artes cn ewe patients wh ia Tha tote, eters nly ern wera mets {Tecra pwr effeacy woes apt ih este ‘lente “sin higher doer of remade re era fete mt en dytantioa Te mest evans dose suid be 1S dapat natn oa rete and hen ated ‘erum ptasstum andl fenton re ble) afer eran te de. “hie ad op artes depict plssam sl magnesion. Senn on soel enn a 4p bene pele {scenes he a eee pel coin tay ‘i patente with etactry volume avr emir the additon nde thee ineriey fg ae nee) 04 non ‘here 2 Th stg shoul be wed ony by experienced tnene ‘rah owe montering of weigh real meton tam ose ‘rons of thei of severe and poeta faa dear ond ‘Skt itunes“! When prs ence ny. ets should Seer be taken he moring When yeserbed tice dal or more ‘Seat done tld be len beloe 400 pr, toavod de dong thee With se exception of spoolone se below, the ole of [persaemrsparing saree ironed opreventon fhe sd jpomagneremi pon ened wth Wer op atin? Angotenain Receptor Blockers ‘Asotin receptor lakers (AR ae a alernive to ACE ‘Shion patos with ACE ter need cough anges. Pate edn ad foto ap ae sent bcaae ARE iced ‘Shean een opored Siar o ACE noes RB ore488. cardiovascular Olsrders ‘sociated wth eal dysfunction nd hyperalenn: s, ARBS should tbe sbstied for ACE ii Speatialyfoe these severe ‘ent Conisertns fer ato, dongs tran and monn fr [Xk the same ae for ACE nino ‘Addon of ARB mayb considered in pte ih ‘Bers peopl yw ae NCE hon "Mocker in th veting,endevetan reduc ceo ‘oray sn oepztonsfor Hr Redacion nor et ct morality were obaned i valerian nance al imi ata Set that an ARB ay be a vanoble ton foam ACE nto eto reciving et acer! Clove mwiorng of ial se ‘Sein crinine en poms i eset when combing at ACE ‘ldnurane anagonnt nt recommended beste fe sacri ‘exuding the Done and sy of is combi Aldostorane Antagonists Agoterane staan auc he if morality and mb in pen wih sever HF (VHA clan 1 and VEE © 35%) an [Epon hl pases with on LEE 494 an eter sympa ‘hte itso: Te emt of these gent in pts wth able mid made yom unknown Alston tages ‘Should beuned patents ath bane psn = 3.0 OU, ‘nilmins nyt wit cine cere of 0-50 Limi, tact Shirontnctone ata dose a 13 mg dy a evry herd. Monitor Ing tat ne de pono and epee as esa i te ota evel a en uncon re sale! Monon shal then be tonne my for mom and hen vey 8 mon” peenane sa slesive aosteroneazagons that does wo prosice troecomast no! waite sn Cana) Digoxin igen topones yploms and eden he ik of tmp or bt doe rtrd monaity npn with moet severe Prose aymptoms (YHA cls IPTV) spt pina media Ahepy Hayao be soared fr conta of he veneulae at pase it stra brian tha cant be ona by ‘Saucer, ot in pats whe erg este btlockers? The ‘Songe mainline td on the pats age, wep al ‘Stn sd concmat rgy,bt wal ge rom 825 0138p aly. Lower does yt approptn nel patents. Given the maow therapeu inex af Sonn arcu atten sould be devoted to eating and evening pret dg nots gos sian an erring drug adorei, | Chapter 36: Heart Fate 489 sabe goin oy upeted. Sem concentrations may 0 Uetmoned ence ea ic chev flr nating digo tical iy tet sd thos Wit eal dyatenton re rh sera concorraton est sous ater seston ‘The combination of ore dinate po dace reece ‘mei and moray Black ponte NYU hc TF {lt reommened in ation star therapy Inst" Ue thscombiation mys cose lc pan nih [NYHA elif HE" and ter patie hn dont ote ACE Inbboreund ARB ‘So mo ale trp of a nen Ive not ton sows toredice morality nthe sbence of Mine Fendipine nd amlodipine ae ae tut do norte mortaliy ot ‘mov aps wah tlc Hany my beast set ‘ater with pom ang depts te ue ete echt (and Sc ens ypemsn dpe ase of ‘Avoid ye of diaz nd ver pats thsi HE bese “tte agate nope ees Arad mteiin sae oe Ino fc and ashy of fe sere, Aritarttniest ‘Cosieramlodarene mini sins hh in patents wt iat Iibalason, Amarone abo reduc he gue of wpe ICD (detarer Avo tar antares Atay ot ‘commended to pete! uo ain: Seah beau ey Jo nl ace ‘Heart Faitre with Preserved Systote Function ‘Troumet af HE with PSF as ben sie ited eet Cont ‘ak eters types dace ln, vetenay en pte ‘tithe artim, clue tes lar bee ae {Sas ing te Ua of ACE nhs or ARS sould be fete paral the wih CAD, pr i hopveson or ta ‘bsato igpe3)* Dass stool te edt opts volane ‘ous Ure ofrerapamilordilinem may be conse econ he ‘etic atein patents wih supersector angin, {owe who antler ete ocr’ any be prc490 Cerdovascube Disorders ‘fl in pains with ype cnsiomyenety: CBs yao be ‘Sion in ats wit ypererson® Decompensated Heart Fallire Fw lags ranried til ave en pcre in patients with (compere or acu HF Tora.cnows oop aarti a reomsnendd ‘pnts sip and symp fa eeton ep arom 53a rei ny toc oi re Cambios fs ation of oem ‘strlen, neti ot wean Cord) o tropes ‘Soul bere tapatm eho done rerped tn eee ‘tose Inaeenos vend ia op dre cn be wed Tata fe paents wa moet svere spn poner Sesto thse wth severe perenne begat ‘ane pen efor tnrsooss miopiycr. mie morta ‘Stonmensl when aumento "Grn ee should Be [Skcnia event pri an else uit we opie: ‘Soul in pes wa Beate bere ae ‘1 pti wath ead cup inne o butane soo ie sul od rete > 0 mr fg? snd Sabine foc psec 90 mang Te oe of saree npamine or morepiepiving sdb nad pact Sone nyptentens Doge of tes pete sed on ia Sa, ‘sl sue comers a he went ene ofthe et Te ‘Slsrpasc, irae ning of homey proce at) ead adiat oe doe ‘Therapeutic Tips = Ted of cin ACE iro ete ‘ier fna ge pa bed om the tal gn Hoe pest ‘Serer Mow cian ilu bh pet slaneoaty st 1 Maced saucy, nat messy to feach be age dose ‘tan apeat bef arg theater «+The cnn of ACE ttn and bet sks shold generale incremed satarcouay + Hypotcson worming ee! ution the itn rinsing tna NCE ai my acs et ae += TS niin cm wii non nate oaths essay oes sat pe Ei femelle comer sg fr at abe fr {uinan of Have tre incnded ie Canin pdt. Marty {hip se wee gna mee ‘edhe ae a! doe 3D Chapter 36: Hose Fature 491 sf es marten a spoon ecaermatecnaee iciah entice, sen agen mig pace tee Scere irae Ch ue a sramecmte sce teqeye ommey Sohigincecepeestatat an Secs sae492 cortiovaeeuar Disorders ‘lgue 1 Eveluation of Patients with Heat Failure Chapter 36: Hear Faure 493 1s Management of Systolic Heart allurehos 3: Hoo ote 495 | a496 Carsiovesciar Disorders Chapter 36: Hoar Fone 497 samp xaseatmee ang “SaSeanes Sou se ese ah ‘aoe een STanUw EIS ences ‘mown snl aman ety — eee en ond cross ed all alk si bas Wik th i i } BF hyCChepter 36: Heart Fotue 499 | 498. cerdovoscuter Disorders 1 Seis teats wae na, te sscocmeeme rm nsueincty _ venandmmes attwert won “ncaa slit i ane re ed ‘st TW RY AEE owen oth "goes SSS Sanremo sesamin ms reammens rile yore ona Someming eon or =e eeeaten netnetig eee ater RRS DEERE weacas nono SSA GT Se “EESES cane 22 SEES WSRE Tee om ‘wom — ———— ae = Reece tone cE senses oe pe wersorceonses ‘Seenthisy suutlon's stan ~ usu, ‘oreinraoae “hayes Yoo veh wonton ot wl meneame soca smoue 00520, en Tren ‘pesoneseg otha wa os502 coviovacular Disorders Suggested Readings Amol Lin, Demet Ce a. Cantando Society eanat one teconatneo em fae 290 ‘pons nd mage Cong Carl 206201), som i ey Sin i enti ban ‘eye peeing J Cand Fat boot es stat $8. NCEA‘ 205 lin pt fore poss nd "tong vc bet fsa 2 ep he ‘near Cog of Carnay/ Amaia He Assos Tsk ‘eon Pract Guts (Ring Commie Upate the 270% ‘line rhe Eahnon a Mangere fe ae. se rot’ at Bg M200 4820.20" ‘Shrodberg Kc Caled 3, Dagie Ht a. Guides forte daguais. “ree cron beat nie execute met ute Sayre tt Fae rhe Dagon nd Teement of Ceone ‘ten ae af Ebopen Secay of Coos Bur ew Pharmacoeconomic Consideration Chapor 36: Heart Foire 503 Heart Failure pidemiotens ‘Countey ear) [Frevalnee Cana 2000 2001) | 559 people peas al OFA alien ds Inoptal rte tee Melia et fy 7 ys504 Cardiovarcaae Dortors Chapter 96; Heart Faire 505 ‘County and Vara emai pieet Cone Une SOF | Dec cone a a ed Te ‘flim enon Us ase Comme ‘be substi Pteis who posse the medical cos of hea Gaile {0 burden fave wore heat status hoe with spree ‘ono ard Ths, ngring nt ar! cons. {svavigoiermentes ofthe cre lum (ma, sa sok lara yb pl aren tcc ha 8 hapten or eu fae and 90% dts ‘hE meam abe operon hopaie ore are 88-20, ‘tn yar snd the eas moray ae ab 18 The oar ponimasy ae ht of which ere ae ron {itn of tet fren Cada projected ores the Trpolatonagers Messrs at abe he Soe nd ede be ale [rhpaon ar Tay tobe hy eave rage fr tear lure reduces syaptons pve Fetes guny of eyrnesocrepogesn, prove Isopiznton nf potne ie The os enenare isc of ‘once persis iothe eof ACE bbb antes ecko + “Thre evidence of substance ss whee he Benes of hee {alu nape ent beng else fue cil paste $fneiererce inp of trenton cla ta Sn eal ‘enon print icreningatbrnce wh ene pine iSite tobe sosceffecv. For earls neeasing we of ACE ‘bts tes tlecher, ign andspsclcues by 1% oon be ‘tected io eee ate hori a het ie ad ave ‘Suh a$4 milion one year ease on Alber atu Toe would Drove tet dove foreach oan ian hull Be ae ovo to pectic apron digs blo athe dose ove ‘howto pence bowen cata ia Prognns ftw apy ‘rst o glare 9h pete lewd ts hapa ave ben ‘Sownt reduce adios an bona ens wits non Mos pharaacoecooomi tude ar coated a he sci fate han on bun peepee The elect of nal ‘eatin fer br fares pespenee been fhe aay ‘tgerere pods ever, becasue abe of gate seve opal uae het! ot or dal nyCHAPTER 37, Prevention of Ischemic Stroke Robert Cété, MD, FRCPC etteation of bigh isk invidnehaned on vs profle fststake se clnsfed cera nonmoutable eg. ape er, my ‘Ntog) or moda ypenension adel staking aes ‘elit ear Ses), riry prevention of Sco is vere la Eich tn Cap 30, cnr everson acme “The eccrece of fist ase asec tack (TA) orci fk ernest if eprecing ond ker eet The Sino 106 wil reset ita stake wis ee mows Adverse, Fe ee ciokerinchs asec yems dabs eli speck ‘Edler min ynpons snd dunno fp for 0 sae ‘Neorg bee per ak pens shou pomp ieee {dest pill iin wo mec of thei chem ever. Goals of Therapy + Prevent itling erg fit (ks) and cuent TA lvestigations ” fancaion ensieton wc ite ets Complete vali stsinton ning asain (rau, SSPE cen plo (el are, pore pe) + tab eet rn th Harms wr ean smo exlude bomoage proces an TA {3h eri sad tamer esate uation paeter, ed coe el Hpi and esse pele Chapt 87: Proventon of chemi Sroke 507 ~ frsta\"aoreepestteed Boo exe, Eom mmnciog Serbo, tng fe fypeconulcie is, spose Tobin, homoeywcts) sand be prec basting ECG (esd ml rian) ‘te gic ws (eg. Unshoate rtansesophagen! sso: ny eae oy fnyoung woke pen) ‘Shanreretong) MRLLMR angiography HRA) or angioanhy Therapeutic Choices (Figure 1) Nonpharmacologie Choices. + Stop smoking (ee Chapter 10, 1 Gonot esolr sk ators tough weight dace feedicavon (eve cael fe aed sn consonin) + Sar rebiltnve thorny (pene, eeepc Penpy) i nee, caret Entree <"epenin ete m= Bufo sneer Sac tmepme Stone spe SESLA asigh deyeohs Ste Sean ah eu ae SAE meee Reaper on cpetecciimiscrmainmtaone Sa, ‘tes (© 96)? In many eases, however, ose fllow-np with patent Sees ‘oa significant (70°) carotid stenosis documented by angiography,508 cardiovascular Osordors Pharmacologic Choices (Table 1) Ample gee ae the dap feos for atom prevention of ‘Meron evens terrier sense Wit secon embede fevonen ‘ol penamed tobe ofan opin face Cheer 3) however [XSXovotier anil mations ae pectene fer the pvemion of ‘strpen dip twig einen hn ety es take, especny those wh ate hype (E> 14090) orhave ‘eat ciestee LDUC> 26 mo Antipatetet Agents ‘Aceeateye Att (ASA) ‘Tamora vein Ise nese wth ow (Soe Sopendos) Soe ees Pate cept alow cod ae advange The ‘Reommendel decage forsee prevention SO 128 mgiay + ‘Sipending oe the ton surance sd be ial sano For “caplet ath concn coronary diese he osonsnended ‘imo dovage 75 my ‘he combed wih an fl anteoaguln, ASA 100 malay ovis So pect stool ven han sce oe Menopysines Copiogeel 75g daly somewtt ore fective tan ASA or te reef chen even tang sod, npn mph isk [Ficems vet, The tele deta in en te of ich ‘Stoke, Ml rvs de beteonclopiogel und ASA ma 0390 ‘errerentin oan 8.74 env ik reco in faour of cope Boat nha neni em arose ‘Bia loins ut oes ot ire hed of aero snd ‘Waumtend ene ay. ‘The combination of wee ASA a clog i at signify ‘else the rt ches eve mci sake. patos wih ‘Sect stoke TIA when compared wt cloplogel ar oi Jaen ahi fore when compere wi wove ASA, 5iine” fomever combination thrpy sence ered he ik ‘feign sh sae! andthe eof nner emerge a [Chapter 31: Proventon or tchemie Stoke. 509 ‘he say th enol pct wi istry f eke o TA. Tha ‘Soog ASA pla lopli more eave than ASA sone tet wh oct ortnuy roms the combination ad wot be ese ge sony revo ose en pont ‘Telopidng 250 ng twice daly opr to ASA fr prevention of ‘nearer pinto aad my be spy sper or Sekt rc an ai oon se ce otek rena ernie bt potty sro {nd ees neque moaonng (every vo wees fre it ee Ito) Pern enon apn ro recomend or ie ‘ete nese preenson Dipyidamotnsa ‘The combination of spyridamole SR plas lw dose ASA. (20025 mg) Brent aly react eave cease ty 23% Gly er ‘chon sates) nen compare witb ASA i pobre ‘Shen sympors Thi ding Wasco 2 ean anomie neo wi mubich te tidence of enh sek or afr ‘Stevia comtinons ered sgniscaty ier fc npn ‘nth cereal chemi eed with dipole ASA tan ASA sane Goss se oer emenn of 3.3 year) Ne rene of cade ‘ews eas port i te pyrite ASA group in ee sy. owever her dare of AA many Be deaae patents th onorlanteoonry sry dete Te aldton of me of ASA the ‘ipyamels ASA ctatemon spears tbe emmabils thee tea Andeoagutants Catan pre rn ate tin pies 2 ee ee a SS einai naeerinenentere Ther ease ESOS aee ar eee eels Sites acy es enc ever ‘Therapeutic Tips bt cates niobate eaten shoul be conned long tm, {heey ner ais it arrensio mvc ak 1+ The combintion of low-dore ASA and show ene dyin spe mor sve hat ASA sles i eh ‘tral ncheme event common practic fo wich tenent fo dpyridanol/ASA oF oping pen experience recent sche of cer510 cardiovascular Disorders Jha ile on leone ASA. 25 my ole tgh ‘ruosepotic sok ath ish oc boo aida nial ‘role Suck ation alte lined very cis asthe se for emorap complains cred ‘+ Combination ern (rt anton: a ow dose ASA) it ‘Sere t ntconpis sone patents wth rote hurt ‘aes bat iar arcadia of sor ewting epoden oc tes leant of ASA ipyidamot D0 mg) poe am ral ntconan may te we This oppo bs ot et val in + Inhalt pstmenopail women, th ite asi with ‘ombimatonetrogenprogetin thrapy (se rene fk Of ‘Soraya ns be cacera ances ok) ‘etal the Bee effecton colorectal canoe a ip fete + Inpsmenapasl omen wha have suffered een stake oe TTA, omen! they wh esvogen docs ot ate aproweveeeeo™ + Ther of oben soe tr icrened i users ofto-dse or vont Th tract hash of sok excep Posey the pss fe ts acy, Suepier Sold prosaby be aoe ‘ohaptr 37 Prevention of cremic Stoke. S11 Figue 1 Secondary Prevention of Cerebral schema orphanage cies ti in[Chapter 37: Proventon of tchomic Stoke 513, Some oe ANTE * vee EE my ener =a eee Ps oe oS, som att orcas “Cement ‘anc ote nas anery ete a ee | | i q {i I i y :514. cassovssetor Olsonters Suggested Readings ‘kes Gi, Areo0 PE, Eso ID ta Anthmbot nd ibremooit thou fren soe” the Seven ACCP 001960 Sapa 525, within Ta ColabrtionColsortive rete alse ands aio pile apy for revenue af ‘att ec inferin and ke igh sk sens BM nonsaagiayy Tae CGoitin Ada Alberts MU Pinay prevention of sbemic ‘rate Clon e159) 78393 Sac RL Aan Alber tulsa preven of stoke ote) S77-07 Chapter 37: Prevention of echams Stoke 515, Pharmacoeconomic Considerations: Prevention of Ischemic Stroke Cuda TOL penane wih webowio sake 3S | {Gactec 198.2002 | Wi nrg sake ‘Co of Me Data Region and Yeor of Comma [The spiilos of ik changing in Conds, Ovar a Foye ea im ace se eof chem sake honed by 32348 ‘ten and 380 women andthe ose iyo dee The fesSpmu re ange te owl ‘fate agente minagemen of factors may Beers ieee ihackr ke Aah nord deat inst survreg Taga ines ome yh cara se sun mesma tobe US S14D000 A Europea stay conch th! He estsf fst ond euro area ren rele ape £200 ver ant Teretre, renin ‘ Secleecrene uf to hve te pot pose on Se ‘Svings or th hehe ae sem ma ats516 corsiovarclee Diswdors Asparagine penning Res ake Whalen costae Aponte Arava © ASA aioe hydanluASAD we he Seog td lr ale ord esas {stray nnd sence mb cely mostned ese a eRe cae sling casos bod esas u CHAPTER 38 Acute Ischemic Stroke Stephen J. Philips, BSc, MBBS, FRCPC and Gord Gubitz,BSe, MD, FRCPC {Gisheme rake, ape raat 4956 ofa ken tact Ther io steps keratin of proven ae fy cerebral Theaen of sbnalooi temortage fe pnry weeping (ees gal on a he dng sus) Goals of Therapy cee Secor s nt Investigations. = sear emo angina, Ml, est Ee, i ition, ‘er, ly hry af vane dene hemos Gerd) other health rblens (ghia pete ley dame o te, Stord ta preinpse toes)‘518 ardovascuarDisotors ~ elim part wri ASA a er iit “Phy examination ols he eon tai gion ond "Donat etme he edema dango, vey and ‘Choe ad sa or coeds EHC INR, PTT, coe (el ut bypogieemi 4 tke (Gish eel een cst er con oe, bin — Pating toot, helen A cole! panel (sk tor ‘poston ~ BGG (fo ok ir ail Sian, Mad et venir Iypeeny Trier aa san gi fe al patients ole oot {nmvcrerlhenorage and aoe mis rch aor The {taney depends nt chmea! aoe Tee i) — get Het dy) vee iain pes etd “snonogmpiy, CT angopaphy or Mt ngoaranh fe equied Terps wi pond cru antary sek ho ae fired endure to determine the gree of cod eps Urge ee ts eke comme eq opts “cosriogpiy (eashracic - anssophagea ise to SShSviore cal mare cb pts wih recat ‘ino of i rere sy thse aot 50 yeas an ‘Sy pst wi ages! ry (nlc stokes elarsclr mee naies Sowing wo hege-veel aes, (vied tcp tsar hor inventions sw te unleaken nated orale out omit thembocnbole oes ‘nanea “able: indications for Immediate Brain Imaging ‘Therapeutic Cholees (Figure 4, Figure 2) |. Minimize Brain Damage [estore Perfusion ettepase shold be sintered (within thee Bours of stoke ria ee pyc Ce ate CChopter 28: Acute lecemic Stoke 519 Intnl amin of tromoyc agent if ed ‘Sets: Eigity tra ane imei fr herby tmny te eee x mnt om anomie tas become alae eam ets of ating ae “oble 2° Altepiago fn Acute lechemic Stroke: Eloi itera a Salvage tschemie Brain «+ Proviespplemestl onygin i plot sows eration {eve body sompentre i amend wath poor oxcome fe secs tic heb nana et of ‘take Symptomatic rent ofpyen on nvesigion ‘cus is commendat a + Hyperivcemia moc with por oucome ser eck, ‘etn at sn om canny enc boo 1+ Ther aren god dest ie tool pene esmea nthe eng ‘Tfacetesoke 20 Trceernal sly owes od pres ‘housing crc lo Bw In tetra secm ae{520 Cardiovascular Disorders “Te impact of tao presi oweing wih loses on ates Bisco are coping tal ENOS)™ Neurosurgical Intervention eCremecomy or ened santing's omnes peomed on ce ac nena crear tet when ent spices delay, Tore no cvence om coed Semi rasw sapert pencte,br cones on at Sir ime sc pric et = esrig aaa a oki om nid ACER afar fe sympomatie rod sean ae {esninmn tea yore mbm Sets tatnm nd cn epetl on ones ere on of Spon ei ped nal ne it tet ptess nn 0-8 cnn and fe 3 west fo ‘ens ah ens 70% “able 3: Attoplas in Acute lachemte Stoke: Monitoring? cane en {Prevent Complications ‘pet using cv and ent enbizaton are themisty of enon CChepter 38: Acute lechemic Stoke 524 ‘Aspiration Pneumonia and tanutrion™™ 1 Review th tonal stats (peat wei ‘Set ysonts mn were mutourbed ofr te Give otong moth ay ft floming ae pen edad {Svc ofeenansnon severe yar, wet vue weak cough, {mpd pls soar, nity to soap specs + Monroy of dyphapin wig sel beads swallowing ect The ert yada st Speccrangege plop + Avideasrscopie eamitton (noi barim seals) may ‘cteuad exe signa eprton whe thee a he edie rmination se signs fl 1 Tube esting maybe gure igifansprtion is demons ‘raupecog Init ees done vt orogens te ‘wallowing dow ot econ tt fing vin prearons fadscople mats (PEG) ny be necessary. The tals of he [FOOD wa mo sport a iy acy naan oF PEG eding in agi sake pao 1 Poonral tition frequen in exceptna ceumstnce. 1 Grew tere moda sit fr deni patent at lowe tsk of ‘Slaton ASdonl see ae oem naenry or es pale Venous Thromboembolism” + Evy mization eve oly up in hi) isrcommended (Le, Srinath rt dy sis hosp I sot adequate hyn ‘Gnd compression snckings ae smn if iyi Tey ee ese. ASA 75 325mg di) ees the isk f romboerlis. Svbccansos unfactonid beparin, tow melealar weight porns or heparin thio ep vein rose talpemonary enim sGersene mote bt trese the sk of fae not oan. Hepare So nol Screener ‘dents rans re cy mp aly nao, Fata, spor cing nd ASA Reduce the Risk of Stroke Recurrence “Antitrombotie Drug Treatment ‘nepal herp 2 hoi anpnlt agents 24 bors in pens who ave sive ‘Somers 1 Give ASA 325 mga so a intacraialbmorige ec by sa flenedby 48h 8-35 pny ae). Ade ‘sa mppentary evn angie fote toda pats ‘ShavCoted omen for paent wh can swallow No eine‘522, cartovsseulor Dlsordors supports th we of ASA. Sones preter tha 28 ml fo scondy keeeenion the Gt saaecew or ASA we one lad. For ptns we moe ing ASA rr ei se cnet ‘te snl stich a aplegrel 75 J ‘Chmbinalon of Aba ad santa reese dppinamale 25200 theme Sly cg enemas hve ee + Theconbiation of ASA and lpidogre it recommended er {amg ts seeoasry sake preven Anicoogalantwerany met ysteme oncogsion with unraconte eatin low Ileal weight ep, bepanocie especie hohner [ttt ecommenéad athe ting of eats Stee stoke “one ‘Shenae pn natal ion (AF) bees the #0 SNEED te mtr ane Spel rescten only ‘ten hanes comply feat by a ease roe ‘mcr nd exccranal Boss 4 ASA sav efoctive war for candy stake pean in Pea yn et Fores i AF. we wart at dos 0 mini he NR {true £01030, peed ere a enundestone {Ontong Fer pears eo cana he wai se ‘Shertconed ASA BO 525 me ai “Tete tne tintin atic therapy inl, For patients “Tint tke stat wet 00mm! temorase Tsbeon ice y Cr sem. Forpnets wih oy stokes delay ‘She nla roan done stars mes ortwo afte the sk as ‘EE Renwsapetantomnon of te nrc. Fr posta onion eset cd endarterectomy and Fak cor denon se per 'V. Restore Function af the individual 1 Outomes a pied by cae ota she wit provi by ‘Sodan erp team «St sailion a soa th ets medically sable {Fania cman upon apart fr sil eisai. Therapeutic Tips: a Theettetenssf tomboy therapy with asa xa tie pds pray ra eae A iro en presen so al wine at 80 mes oe ore. Tei fide rac, com with oem ‘ite cl serene CY sen, tao eto eonset ‘Chapter 38: Acto Ischemic Stoke 523 roses ar linear that espe sl at bing [ikon an ply a pesie pro spine dmtntotan er sti non wa op pt he Determining he ine feo ott re in ding we ‘heptvefcherig tlc tara esto he ing ‘tanacate wake Exige pers a nfs nk afin ‘choses wat noone aor TV a in, wt pm te pant dy one i te pon rte) Feo hace kere wala, When Exec bia if e patent netted) po or yd net hr enon ce ne ot for the patent ie refered o tiny cae Boat, ve he tod ‘wk (BC IN rn a comunity opi the eae Resto need cae srson apostle Sign f fron on Caan done within he ur of ok fmt rua: the CY sean opie! ing cried ‘Semenment wi else dows sey debe fre ns eaten {Secs he prog ta pans ad op ete he524 cardiovascular Disorders Figue 1: Diagnosis an Intl Management of Suspected Deut stroke528 carsiovasclar Disorders Chapter 38: Acto Ischemic Stoke 529 Pharmacosconomic Considerations: ‘Acute lachemie Stroke Meole Minmana, MS, PRD Enldenioigy H ‘Country Clee) Tacdeace ad Prevalenes O2) ‘Canad 2002)" | 000-500 expr ye 0000 iis ve with he eof | ‘Country and Year of Entwte Direct Conte | tater Conte {nai 99495). “ Connie a0) race | Nana {nario 1991-72» _| Stoke admion Commie 59163 orsewe se | Ral pared {nario 300 | amino Comment, ~ Tachi roe wigan dss n te ain pops, From sono perpen, te toe rem wey ne fererue 50 wl We dachargd ihe, 20 wil dc Sf ating he sree ng ct 10 ir tas a econo pac on th patent ea cae syste and out. Diet mel and net coste ssid with stoke te tho Sine Dee so lig 0.12 ann pene terwneWdecompienxijeard nan la yaien its ery Ec compen Met wicca: ets emmuaoe of ge ep a to VE punta Significance of VIVE seinteie stained or nonsatinel and wheter dv wed dommomate: Aoyotrc VE uly dae deg aie ‘sf siuctral eat diewe, epoca fh veratrine ympomatie VI (sa porsstatmes)may inden ak of ane Simona: Symmes nde patos, epoca, het Seve af spam Sr a ene te pea ee ‘ea sch pent vogue recrance: tnt pecs pece amie erp) Senet atonal adn th ceed yh het shined VE may kad cnc amet afr vara Son otking atom nisms ohn sind wire eos Sea ply corer dieare wih prvias Ml Sosaned VF ‘pled cadhoveterdeflier or antachjcane ae “Mos commonly tere «1D coneetve vented cole less sample # rues eaten only the eto! of egies suniond Vi orca ares igh ‘ot ypatesive hear dice. teal spicata see ‘NE gh sk of sodden cath or ores i sss)546. cardiovascular Disorders symptomatic an soci witht oat mode isk f ste death (Godan ee maga ot error atten the Sopot progr tor Pressed witha ctl nomal heart Maybe symp ‘uray tesa ven aes egies mo heey ‘Shree sod nownsond” onomorphic VT: Usely ips x soar atomic os nth tere ed eat pny anor ina sx. ees Westssgeen pornos oer. ° Potmarphte 7: Ural prensa long i of ams V1 CoaaeP tect hommes opoizton {ene poms VF win QT proknanions ‘VF may compass Ml Hewenr, he rogosis or recat wi’ UE ocarng ign thr pl sie Bee ens ike ineton of ete sever encompicated I'VE ine mot commem debng sae cry ney Sse (GAD) often sik poor Mi wither itu be em oi fox pti wih V ae atigh isk ofrecurence, These indie 2MGUiER mci tam en opens wh in VT Method be ene to revel eens = ‘Therapeutic Choices Immediate Therapy for Sustained VT or VF for sosinel monomorphic VT the pata is uns ( et erotik oes st ind Sea yaeoace pase hock of (30 rae Sholyeatese er isdn mein ss ban ‘Spectator em Bess x ptymapic Vora ain rye sock of 29 153807 ign egret eet pce Cth mie Sep GW al biases che Amturon: ooo entering VT a i SEPSIS dary br cesta tom noc by owe rene of VIVE) and poly elm shock ren VESTA? ‘RoW Se mp ener 0 mine wey 405 Bee winter nd to rover ft 24 how, The ‘Gc Eov randori o pie ning, but most expert the ‘ore donne gdh. ypesenin ayo expen be dost inoncro eryny (Chops 40: Venticuar Tachysythnias. S47 1010 15 gigi over 30%045 mina wil fen save ‘Vand vermin tachyeardie ypc ny ots eet oe ‘apd floras so lod po shld be cael sole fete pins VT anotied wiOF pcg sat [eset of myocua hema spo fm ened in os Dh ATS Megs is generally ale bt may trl tse hypetesion Beiablockers (e metoroolpropranale emo) vb Becher EE even VT oF VFin th eng oct myocar chemi cet MM rctecticalsomn’"» Braye cr yptenion may coer doce: 115 mg/g elloned by 13 mgm axon ‘ccna ave fein“ 20% fee of anand mentale VO) iFeomersion des pot oecur mtn 1 0 Sma esta we ebay nt be fete Ther nop evidence at hacen ‘oe in shock estat VE Coie ray eases scans Aiur high doves can one CNS adverse evens Chronic Therapy—Provention of VIIVF Recurrence (igure 1 Figure 2) ‘Terps coe fo fong som manage of wind VIVE {tee both rg hry te 1) and nog hey oop Sebel eBay gentle, cee ‘Sestuned manele VIVE i ikl to ean he ase of {cunt Oct dacimcrton of tay Cog, ease age sig cin of oper on ae oc a Emile pens wit LV anton ory ul ra ‘ited eth el therapy fr herent fteeneeseeanel Yespica FV ae pele ary Inco of eticary of dogs ia nvidia pets: the by of rug preven nditon a VT aug a slesophyiloi tty ov ison ol prod enn nyo tan ‘Tele indo uneven an aateconmencd ON ae wit hist of VF ocr ets a isk of ctrense of VEGrVT sce ther oginal atin my ave bun VF depecaig, {0 VE Ther ethene hat of patents wh reed sioagh macro fue drag eeney (tle Vier Ws PC oe Seeuned VT on Hermann) sr ls fen ese” Detablockers ile, bold ean al pte ‘win dua sed an wil eed in ny ee at‘548. Cartiouaecular Oioreers items ith CAD or severe LY dysfonton Tey ae pari ‘eh non wi kere ote oF ehera-eed VE ‘Amiodarone a setae ae fee nprevating VT o VE bt nos. (STEERS Show tye es eect an mpd ers i ‘scan death and seen ame ota aie SINGER Bend Vt on ve os csh No randomized ud) hs shows tats dyes ede moray, Hower, ‘ebuttet o soni can ne urd arama o HCD pan 6 ove! ICD shocks hice pal Crneunmm owe To etic ‘erin aie aa Sates ieieeaeeen Senet waa epee in SSS ecto Segsees somerset Snesnticentnemert ace gation Toctanbattewerecae Nonpharmacologie Cholees for VT i implanted crlioverer dil ID) ey elie srthing ec VF bt ruc complex even a ‘Boma cste The AVI ta oped 39% edaton [ete oy after me yearn HCD etd ait late to sie therapy (pote aadoe) Mpuded endovanda! abatin or surgery eps cl pat eee Sod tte snd complex ope epee lpm. ‘Remy Say eleine in cere pten supe Bo acy terion ms nalone prose 1 Conte tation sing iegaey enemy maybe epeialy GROSSE ee aang taker cies pies ih Sosa oral ene Inpatient wih LY snc, ic aly ‘MR or pasts wih anc wo hve ears VT Ferenes| ‘pn amy erg ep. ‘Chapt 40: Venticta Tachyatytamias 549 Fioue t Managoment of Nonsustained Verticuar fschyeardi{< 19 best) = |2S = ae i monument! ee i 2 == 2 alee Son ot } SOSETSS I a = yet onenva.s RRA pue eprESKy>eL FeO}AUEA 36 ious Blog} AL | ja VT) 18 bana), Vontrculer Fbration "or Resuscitteg Carding Ares Long-term Management of Sustained Vertical Tse Figure 2: 1550 Cardiovascular Disorwersrenin tne anne come acaneteraeaet Slime meena ee 4 _auecamapeirmm mun “mnmbee ment so up n —Metwoorsoy Saces ae554 Cardovaccler Diordore ‘Suggested Resdin 2s Ameren Heart Association uielies or crdoplnenary fessional emegeny vag erePar 8 Ela {feu nataed real ein Setcian caer ad pacing, Calin 00811304 Suppvtva5-46. Ave ait abmaonenscouen 124 pl 95 ins Di- Daan Gonzales ER tl, Treen of tachyarihytbmias. “ton Erg ed 200374 Sap) 91-109 Conny Sr iainom AF Cappo ket a. Meteanalyseof te Tete core eilor seca reves ae INUID, CASH and CIDS stoner oes 20002(29)2071% ‘scape thn asses ean Win Sec Zips DP et ‘SP ACE/ATLATESC 2000 pine for minageren of pats ‘etic atiag ae peveton tdci death, Fm Cll Crt 200530817348 odo Advanced cae spat nthe dag. Col Cin 2002200177987, Chopter 40: Venice Tecyatythmias 555 1m ReR Nin wocoaa weno oy oyeCHAPTER 41 Syncope Rater Sheldon MD, PAD Spoons elon seme meen ore em cts tic en a > SSNS SPE Chm ope tees ie ‘able 1 Common Causes of Syncope Chapter 41: Scope S87 Goals of Therapy “Angesively venlgte neat hip patos Invostigations examination’ Ral ete toh con eter, iar ioe ue 1) + Tr aboraory mssigaions othe india pten™ BCG (os pens lerpatets (> 5 ea) told hae abun ECE moniting ‘nk the sory sly pertnsie for vasvagal Scape ~ hocardogram or oer noninvasive meats of et vtraar ‘Sacton eros en dese peed ~ coon angiography as iced ‘fr pant with eta ea ewe fr lepton le conindcse, cot sinus masage sould be perorned {prens> 30 yems sata screen ocho ius hyposeay piilatenen me ur chies cmon! song reremoved, os paigns wil ave oe of evel size of ‘roware oleraces postural otha acetate (POTS) “i tora nrc yds ale init on1558. Cartovarcuar Disorders supine fr ive nna ten ero an for mints of sading Neral eu sonal ancone: men sina ae bot JSeujand Sood etre abut 1. cre etre chan: 230 BPM rie het PQEThv'RPAE wh soa ted resus of ald eboetase pons ean utnomi flr: poses lia oo press of 20 HS Sesame ig tte wate devetopoent oF presyteore: ‘Rin nce heart te ‘Therapeutic Choices “rete diet a the case of yncope, Tea ay eerie ‘Shosr. Refr pees with syncope sendy bradearai ooe ‘Ssmpie be ie) rs remem oe pat ith Se ae eel ee an cron |SRNGlewing sso tsaient of symuromes of hows Vasovagal Syncope . Nonpharmacologic Choices eure the patent ta spre not ie hesening a SSIES prtiem ata penis. Encorge [Round don sor insue of aba t3 dn ine aon of ‘Sonnets ssh or yprtesin cr a fe * = Tench ie pte toe physic coterie manoeare athe ‘Sehr eek eae unomman pes Sel be moe a feta velo lise Pharmacologic Choices (Table 2) rag ey maybe fective in ome, bough te eidence ie Poets ec evaun og domed in Ther ey ESSERE rp wi neue! sve spe sa be amiable remenirymptons Chapter 41: Syncope 559 unérocartisone us be wed if sien sl supplement ae inetve “The gn sd seton, whch may pcp heat fae, A sage ‘Bnd tal nhl na epi action as ot en ‘ted inact o upomoes ia ‘pb apn nce ts ey vig met i al nent incline tt showed icone ‘moe cfsve afer months tha lo ld pee ‘Supine bypenenion may comple ene ets her gti ve ont ‘Third on one sdeanely pomee,andontzd pace ok ‘Hal and two wasn ‘tnt ry ee pes Sthotyttcmeceenerare Seg intra a SLINGS Londen oa Orthostatic Hypotension ‘The go of herp it reive spor of cea hypopetsion itl cvtding wezmen side tice Orho ypecnaee aes ‘Sci with spite hypenenson, which compte er Nonpharmacologic Choices Iowa try se om comnts isn eo he ‘on oes o brs by 15 9 30cm (sof not wel ler. Iter pate avoid tener es och geing wp ss, ‘Sting rg sen wom cnviornct oot a heey Snr Pharmacologic Choices (Table 2) Soi nd wate ttn ay be boc natin with ost ‘ypeennonHlerecorvone cet lod ees wns {uel sph ecepor NSAIDs promos Rad seeaton sn io {tec case vsoonstiuon. Ty indomethacin 3 030 mg ee ‘er ly rogue doer fete gs esr nie that caer ot venoconiiton560 Cardiovascolar Deore: “The etyicinsterse aio pyedentimine, ive aloe Fn ‘rn i io seneanly poe sang via esi pve Dd presen hoe Peres psc contd oa Putra needed Wetee ‘Hagen san be ecommendee ‘Ocirete,s somata analog hat lols production of ut Sei moges mn ec spanned ow mat Be TEP otinanialipptencnn The content of octet doit fancy need ponent! lod resus Pd ee kere cnt of spn, to eae exe hn ie SEE sani domed croneve sty Oren ven SC neton ‘Yohimbine san lp, stagonin hat stimulates pate oat ‘Nivene esr yt tse ‘Nonslstive het lockers (eg. propranolol, made Hlock NSnEENy ons fesero snd faucets ten loo Freue up standing pases wth rosa hyptesion Postural Orthostatic Tachycardia Syndrome ot aedeagal, Inti inet Si fiefs oa sn ‘Therapeutic Tips Al poss rewingsypeope patents shld cir with ‘nun egos er the why af oymeope patents ve Te ‘Renmione ay wh tc care of socoe wih he hogy, The ‘CEnntow Con Scie rece ped gone ‘helices of syope pte dave" cept 41: Syncope 561 40 the Patient with SyneChapter 41: Syncope 563 vem SS SNC atta sperma rnin cmesmmioee} — Sag, as wr “Seieweeweang yemtiecy RE Seatten “Ss at Sey woe ET =e = — ‘eon 9BRROUNO 6 SHUIPLA jo WEUIRAAL 2 BUG1564 Cartovateuar Disorders Chapt 41: Syncope 565 Suggested Readings ‘ i | ent DO, Fay OF, Lave KO ta, Paraeaberay of mally | ‘nignole i, Ais Bent ea Outi on unagsneot \ ‘atmo al exe meee nde 2008. Enoatve Seta Bar ar) MOSSES ) Cont Bt Karr cca ae the nono neous sem Sattar eeecomee | * SRR Oe | i t | ‘Sins eaiaton sod mangement Pasay Ca lecrophyil "Si ese Soa mse tom te ibooasy9es, Sao Monlo CA. Kea A Manapenent of vega sybope 3004, Esporte Cardone Ther DEA O}S 2.ft CHAPTER 42 Venous Thromboembolism Alexander G.G. Turple, MD, FRCP(Lond), FRCP(Gis), ACP, FACC, FRCPC Treatment of Venous Thromboembolism Goals of Therapy Deep Vein Thrombosis (OV) Pulmonary Embotism (PE) Investigations + "DVT. B-mode compresionulkasound (ost practical an fo Elineay) seen choppy, pales ehysearny “= Patients ude the age 40 with ecurent VTE s fai history ‘uid be weaned for tmbopia ce Cea Rik Cogan Therapeutic Choices General Measures The mat of rons with DT a be ee ats “Enculnony incon ey be Wen at paint, Res ifsymplona wart faces pin and swelling. {vt in (duces eds ad pain. (Chapter 2: Venous Thromboembolism 567 aterm NSAIDs tei bu mayne eo Pumonary Embetlsm 1 Other easton means (depending oe patent ata) Pharmacologic Choices Sistas ow malecaar woh bapa LAIWH {pndanarng ornate peri UF we acmened diye EMME, endput o UFH i come fort nina ove ‘Seurence of VIE Cable aetnen ofa step ape ot Regn ol aaanday Props for Venous1568. Cardovaseter Orders Prophylaxis of Venous Thromboembolism Goals of Therapy = Prev decpventmboris (DVT and imonary ems (PE) | 1 Redce morality 1 ove pspeitestome 1 revet crn trombone pulmonary hypertension Cinial Risk Catogorios | ‘enous homboemboien (VTE) i cmman se af roti, | lio pt athe eng vate sng | ‘lero venus ton eongugty Tle 3, Comes ‘ferns ve dened ek sere tel on linea st od ‘Sh Spee recommen for tcrboss propayins coding | ‘Dv esp che sh | | | t chapter 42: Vonous Thromboentolam 569 Nonpharmacologic Choices Graduated conpresin siching an incident pmeanatc compression ‘Bees ede the tk uf VTE and te pari wea hea ‘Sings nbre thc tk of Seed cig egaher obese) aval eration by retina or pinay grophyas but ‘houlebecouisred inputs ni antag ve te of {EC aol conned Avaya remeber se ne ‘Nailed se prefered everbepemmanen nee Pharmacologic Choicests# (Table 6, Table 7) ‘Low Molecular Weight Hoparins Enoxapri,dlteparin tnaparin snd adroparn se aprowst {cat meni coco tay od weno of VTE (iabiea? tate ye ek ote me price eo UF al eit linia lf nga These propre ake wee’ ngs denne Nia ele are nike 1 UF teal ate VTE. LsWHs have become the ‘managment che for nil ern! of BVT er mn otis, ‘They See ean nthe neat of PE Unfractionated Heparin (UFH) ar teanen of VTE, UFH ian commonly aie by ie inison {nuance sed okng te ted pu rome ne (GPT) to 13 w25 tines coo be gat apt gs sos be ‘decmined yao stn’ ong nraty),ss ciene tse meron if rly gh one gen (general 1300950 Boon ents O12 An bl (000 t wie) sal fe ven ‘shh scene tinal eaten Monin or tsi ars ‘tee te ve se soul aim ran PF of 2402 eect A ‘racic! weights nomograms on develope er aduring Arar cables) " Tobie 3: Body Weight-based Dosing of Intravenous Heparin Inada1570 cardiovascular Disorders Chapter 42: Venous Thomboemtaiim S74 Tle 3 Body Waight-based Dosing of Intravenous Heparin Thole Clinically Signicant Wertarin Drug Ineadultan ra ction Wartrin Org Intoractionss srrient) EST nen ee ‘Specific Factor Xa inhibitors Fendaparinus oe fst of new ls of nitro ages he ere ctor tt. Ke apved forthe propyl of VTE EB b cuppa wo te etme DVT nd PE Fr ss presen TE wih inn of Heesing er ential pats mang his nt approved neon Cons - Wart ‘rn hray i mnie ing the INR i nen ina ‘sheik a3 energy int NR end eine sy ofen wetness generally mene yor eer dy forthe fs fou ay he every he dys 8 SS TR ov ro tes wehbe vet wou weak ne ‘sks Wit a imore vel of aecmauton (N13) Bes Book sae ceceras ses tone andd vewtnest NR IS). ‘seomnon cause of oor ncaa conti dive nerains Gabe Sot eA conte ein yng at {intn Seve hea cheat edu’ nas ih ware fame peti peg aed totes wor. Paes seu be ‘Shcoumgel em ig Soh roc obi Chinicaly Signiftant Warfarin Drug Interationse ‘toemminaeDnge Ena te(Chapter 42: venous Thrombosnbotam 573 Sen aone Ros ne,CChaple 42: Venous Trambosmboism 575 ‘574. cardiovarcular DisordersCHAPTER 43 Intermittent Claudication Richard L Ogilvie, MD, FRCPC, FACP Goals of Therapy 1 Investigations, ~ sstpcenia Vote bos wd tht) eacnncentel + Dane oan (611 on a ra a ec ion, dyslipidemia, dibetes melins, | ‘Sion, pen poser shea nor doris fs ani) | Ting Dpgldrvedarspygmemmosoetic tem ecie | Chapt 435 Intermittent Ctausiesion 579 ‘Therapeutic Choices (Figure 1) Nonpharmacologie Cholces Discectinaten af skin (aie a sive) (se Chater 10) 1 Tine cls ow develop over to 12 met) 1 Nondnit renent of steric Cage 2) pd dsr ce {hep ypenenion (8 Chat 19) and wane sod Regular dynam exerci 5 ines per mek for 8 wees aly) Eamon xe St a mn ss onto cee {amr seek over 419 36 mone ses ncn et * imfar ete on spent eget andl came may ee ‘ern pr. altuph mbit nd cost are ger pcs Stil shighc and lleauce moc ewe eter wa yen an aati ei rman Pharmacologic Cholees (Table 1) ‘penal Brgy fine cme Cordovescular Rick Reducton Paes with intemsitetclaition area inceae tk of St hyparesin (oe Cer 32), syapldcni e Chop 31 an Sine mel ee Chater 2 ‘ 3 ipratot 25% sd ave eal fete in how wih corouary ater cee (CAD) pig steal nee PAD)" Cpr ny {EVDY' buts usualy reserved for tose who caot tlerte ASA or Simi ae et who ASA Cine i A et ‘etcmtinatn aay oer io wg? on$580. carsovasclar Disorders ACK tnktrs lice the ik of ashe evens ean hat ‘Eon sr fs in pas who abot AD inthe HORE sy, Ramp ao teaet wig inet tance ver ‘mp es th PAD, ang too ask Bete acare ac the of Mla dt in patie with ‘thegsclr bt eo thse agent pats wih PVD nas tau thy shale el cutout ae wi sere PVD. Sh atari tse of pet io Lpitonering drs reste i ofcarioasaar hat patiens ‘ethers su ay prove symptoms ad crease wang ‘Seance in patent wih enoriget iudton Spectc Therapy for Intermittent Ciausication Fentniline a methylene deriva ates enteoete ‘stomata relues boo waco lt eee ad pla ‘Srescmabiy Renton proce mage tal ‘ca improvement in pon ean mato walking stance sod Same ‘madera casement ine red, ta 34 wee of thrpy flees bya ig weck due pid a exec ween Frees) com desea ite th eed ar peti etoile may be enti ajntiv hp for pie ers ‘hatte rd wont pate Asse apy fourm al toss inhibi place prepa by select iaibing ‘heterene Ean ari ht insove ne {faim waking dvance isn aval Canal Other Therapies ‘The rl of vsonsie eget biomes protaplandinansloyes™ Tako aera ane ray" hs a en deed oy Senate ‘cl is Low molecular weit pr, ol scoop amin Eandchelton durapy are not eect foc PAD. Chapter 43: termitent Clavdeaton 581 igure 1: Treatment of tntermitent Claudistion 9 ==" |%.| [som | [SREi i 582. cantovasc sens ats SNES reemerged aman stead Pome meus pornomelice ty mantiey1584 cartovarcular Dsntors CHAPTER 44 Raynaud’s Phenomenon André Rosin, MD, FRCPC Goals of Therapy + Dee emptne(ol-ned Mnchgo he fag) in pens 1 Heal less pen widhsecondary Raynaud's phenicaon Investigations (Figure 1) + Thorough isto dierent eran ‘primary Rayeaut' eneaen no moc ines or tauns) ~ fecondary Rayan’ phenomenon esa to oapatons! ‘oars trevor sranstWe toe mney CTD, cpa ‘eel yndrme pps or dvr) site dindced Rayna’ phenomenon (ce Tae 1) = tee! gn of TD (og. leroy a carpal noel yen ~ System sgn of CTD (eg elansectnts putmonary Hos), ‘acl dees sd pio{586 Cardiovascular Disoraes ld tic mop nde mpi ad te ‘ole, copilrescopy wil lp dag aly sleet inate tea cof Ra eon pec Songer eso dese re sumecee MAREN ANA taniclen aptiodi), ENA fexactale niche ‘robe ACA anicenromer ana) ea best ‘itor dest C1 ~ fe CS sun eee oti a er \fomunsope tee) ae es wt i mas of stead ‘Reyna pheramcnon ‘Therapeutic Choices (Figure 1) Nonpharmacologic Choices 1 Minimise coll expose 1 Avoid rserbing mediaons wih vatosonaicve pte (e. ‘Seve deatves belkin the scons bei cue patent witcornayaney Sse + Retr pe tcp i on pa Rayan endo eee. rt et want deltng te d st0 ‘taming Covi n tne bot appre and feta ‘+ Facrurape patient op ski nt aold sing aig toe {ier prea mers, dels cha a) 1 Acopeacie was ntete patent wi seondary ‘aynoas phonancnon ened ts naman, doe Bnd, ‘chon al Pharmacologic Choices (Table 2) iyo al chane Mocer (CC cece he ase ‘never aac we tae agent non wih pny ‘Su econ Raya’ pbesomenen Wife the bet ted ‘iv. eda caltan camel odertepaeioe XE ‘ean S10) 69 miter ere eal capone repay tiring ie wintetmorthe ieee eet woe sr aay ‘Shoe ctr ay be cose sho hey mets corre Teraymaodspoeamenoe. Higher does maybe wed pte ih te ams vierusty (Chapter 44: Reynause Phenomenon 587 cy pry weary Ray's pence ile ae Perper alpo-lskes eg. przota) a es este tan aim Etna tock, abou hi ar hea orcad aie iis opionPrasosn was mot cv tan ice in ples with ‘lerdron secondary Rayna’ poenmenen nt andi seabfllowees besos ined bynes oni Asics consering care iniiis pines Ison ‘osteopenia pening penealy ecve ‘Srkaynands oenomenon Inmet Sepa (Ge) yb wet ha my treument frees phenomenon nee he Hegoeney aed severity ef ticks ann sme ene ieee i of fier Being lp else Ol ea (svt ceptor nape) es the dracon symp ‘mei Nether drags omtmecalysatabe in Cana Besentan, a envi isbn apeoved fer planar Eypercsin hel gl ler an redone Roma: phtomenon Sete peat ih slr Phorhodieserse pe 5 nibs, which et proved for Raya penometn rece every of Rayenad plemnccon IS ny rales te hegccy an art of Rape sacle ‘end had acceptable erty In pues wih severe sesoodary ‘aye peproon tense rsedao Sy tt nce, ound place cond coor sy Gardena asa. ‘eciown ibs ttre sac af nie ay Se ce pues amen Surgical Choices ‘Exum empathectomy,pateley by horace in pine ‘cite cominy Rapa’ pcromenon wih ia ses + Disa ampaeoy maytemoreein,atough ence ‘Therapeutic Tips 1 Many negate sie of parole hep fo Raya Penamezon have never hen posh complain he Incpetaton ote area oma aia ot pet dak repo postive etter oes van of og5BB_Cartiovaretar Donters Chapter 44; Raynauts Phenomenon 589 hormsclogle memento Hayaand phoneme Figur ted {i casa exponen of ihn, + Sic pharmacstgc propa of Rayna’ phenomenon ‘sec nol 6: patents (asm Ses pra testes soapnnacalags apc od sere pits Oy sheer 3 ef atts th pty Roane cnn leon ‘eecay sonny Rays Pearce Ise unl ‘loeme eater tae plstreon at ees oles. + Thkig mediation dy rather han ede ing the winter wl rane wae ode eRe cg Redes ayy inci ieee) et + Lato colnded rt ata inmrson with oper ‘ncouemea of te op in Sigil pear or Sled Row os ttrelaly pres pte syns oy pn ug dhe ‘ean rope pts Rane pone Pare with rinry an secendery Pym’ phenornongeesly ‘pond aly well mediation: fe the Gequncyo aac ‘ate ian tensity and ion a sy eed ‘it fever + Newer saprven an ffl thai, oc stent and Dhospodlsterase pe inkbirs, seco cose oly r+ er sre meony Rags penne, ma | | rts ote ety al ae te i ‘tind signin eft Speci ensaion is "commends before prescribing ste hp I 1+ There anno evidenoe-tated or consensus-based guidlines fr the | Pique: Investigation and Management of Raynaud'sCChaptr 44: Raynauts Phenamenon 584 vce erm artes ort te 2 , See Se oe i ESS ees PRS oes j cree anrmaannaies i 2 ememeneet ESE weet OE ame 3 ES aay =a jo : onoaGia SBR © wR ween ABN HL 8CHAPTER 45 Allergic Rhinitis D. Wiltam Moote, MD, FRCPC Goals of Therapy ‘ine ofa. eg misnalreente shealo Investigations + Cini hsry Cable 1) wih pacar tension hurtin abd pater emptns atari perse) eral fay hs of allegy + Pyalexaton (aes "ew mac macon( cky, tomy) aig ovary keep ‘able 1: Differential agnosis of Rinks Cchopia 45: Alorge Rete 593 ‘Therapeutic Choices (Figure 1) Nonpharmacologle Choices 1 Avoid expose talon tn wish pte i. ~ Remi foie wipes ne Pharmacologic Choices (Table 2) Satine ne sprays, sae ove, cm sip love Soom by got ml heed eg, Sin Athogh eatin pd anchor side fet ae cones with Belmpled win eapst tate story vagne nd gel594. Respatory Disorders ‘nay be ete, The curently avaible second hi enero, ‘Scoedatngathtrame ate not oad al pakgasons 1 ied on ang ole shemales Alioagh ler ‘eons ow af eetoenss sh ove ac ere ‘eile: Nolan fetnen sheen ows up oe yeas OF ewe anhstaines, eisiae mor ily oes so eda, ‘Specialy a hier dose . Decongestants(Aipha-adrenergic Agonists) al decongestants pceudophedrine, phenylephrine tlie nse etstctn. Some ln de reer the st ees ‘cngrtots.Atd ol ccna hse eng woman ‘enters Use thm wheat in tts wh yperegion, ‘rr ican eapon ea evidence veo pal al acoso ‘eet ie to seen tayenny cut ne medicaments, ey shuld weed in aes cae nm ep ‘lene, ‘et ‘ ‘ Antihistamine-Decongestant Combinations -Aatiitanines a decongoathave complement eft. Pate ‘Sete gr may an combos nes come, igey trace ee pene ans wh fy ing Some sombeabons cepts nay spe “irs an epoca, wis seat En gc ae Intranasal Therapy Intranast otitis a he sey of henpy fr ete le gevere ia ympoms. Aquos pets genral have Strut iy poner: ment hen “bofincon sin soaker Newer peprns te slower hone” ‘ray whch may be tre by same Bude sve at Scam mri A tote id may eed econ a “epi concostrouts at ealyand are uit mele once hotbed Aten! sppresin her ashen soe at apeic dese St ned crc ge a ‘an fects cera doesn he ange of 10000 3008 oF {relometsnoe or equtlen mach ghee reed Feralersc ris: Naval sepa ptr’ hs at ocr conta ‘coals! boweve tpt oa he pay ae chapter 45: Alerge ris 695 msigie tegen eens Sirus eter oeanretcmenteominr ess Siete ‘efctne FR an foal tae Sy ect te med ines Sb ine aevaeeat Sieuucnitimnetenmananma Iara ipratropium, 00% slain, ees the ome of watery ual etary be ned when ones ee ny 7m {then hiereaiefacoyf pia trae octets ‘sonar hints eg. ser ace Leukotriene Receptor Antagonists ‘Montelakast haa moder ft nthe eaten of aegis hin at urate eset ade oe fat deoed.tiay bo ‘Spec hell in peas wal concomitant sms or sae pos. “Montltast approved te tenant of i ints when tee ‘Dect ae teste oe pooled Ophinalmic Preparations ‘ra seitain tsa weil for contests. Tope tints satses och leveeabating, sloped, ‘neds Kenton, rovide een mines Wit ton of et ‘Stet 13 hous Topic mart ell saints ach ermogene ‘dermoid, equre sever days for ese wl te ‘Sinner QLD italy: Repl woof pial vasocastctrs is “incourged teense f development of bound Yasoaon Once ‘rent evosaarine and cromyete shoul be etd hi ‘ton Oigptndin, eon er emestie eyarops ae more ae Immunotherapy Desenitsation or allay shot ar wate fo symptonss ‘tc by poten rt mie = emucerpy fia cay ‘then reise of gt mediated neat te specie stn ‘Beant canoe ect avd and when oqoeny od seve ‘Gaon tia snl weaned ay ‘Manegement of Allergic Rhinitis in Special Populations ‘Allergic Rhinitis During Pregnancy and Lactation Rinks common a pregntcy. rept meme also more ety {tcomplamn of congenton even inh acne flee a596 Respatoy Dioordore ‘te of pepe A wht mtn i ean tnistarines eros the placenta, Unfotnatly hee ae very few ‘incl ii ea usw Fm his {or vse of beclomethasone budesonide cromogtyene” and ‘Shep ae aang yeh ee ‘Thesattyofpeewoephestine during regan as ot ee bls icone be tng hw oho ps oF aiese “Altergie Rhinitis in Chitdren "oo comet hts rc aig eerie ‘len Teint of hs mp cen hmpee by he ‘ity of nities oy Kg st onan ane sufi, they maybe the weal eboice Second generation ‘binned sn str re ‘trotted wh sedan ad cumin ina speyr arenes ‘ermarsn fica. Croenoghet alot cetyl nd my ‘ete aaa! corsone tre ore eine Memeasene futasne ates recommensed tesa ay sid hg of fon agen ng. Hwee a Scented sed many chives peer anactsed property. Toad Spry ae not oct, ry pe oman badeonie ss ‘ed urbe) One dy doing of ines creetesd a The morning sot ede vk grow ropesson” Ay ki sc ih led une tee ‘ald eotcoiols for sho, thet ae ante taken ce mediaion woo te bw ere dove ‘Therapeutic Tips + Inganasalconiostoie ae he herpy of coke be oat stdfesvenee Aauisamines tet eet only fr te ‘ier sympon Opin coro alee intr ay fe 3 ‘Sninsen oma concorde at arnnsaaes + ral atcotrie wl shi na pope, bat nee ‘eat egies Ancona emt aly tprned. py ‘Seonsdeed the we of pel cocoate er sre sho he roaece ae futce not sonnet pore PRN dsp armada + St matics fhe manu dose a thn taper he inn ‘euler Chapt 45: llomle Rete $97 ations wih pecdiabe seasonal allege hitscan sta medion {char nsec oro bor te see eo perod ke toe repalarty an eh sao te ses ne utd i a ot chin with ne ay desing pve + othstaminer re ot conrad i tht ain mary five abo hese esos spon{600 respiratory Dicoore602 Respratery sorters ‘pein snug IG aCe604 respratery Disosers vee ls “ere cations ateeceiomy ete a8 oe BS sntnewine “Si ats ote SEE SI ee606 respiratory Disorders{608 Rospratory Disorders a3 2 [able S:_ Intranasal Drugs Used in Allergic Rint ow, ih ‘I t i ih Chapter 48: Alergic Rhiniis GOO |‘Chapter 48: Allergic Rhinitis 614 | = Ca612 Rosin aon crt: ities 613 | s Reading 1 | Bons). Van Canenberg F, Khalncy Meta Alli inti | slip op i ey Ci mie 201,108 | Dyke iS, FseanS, hover DP ea Diagoss and maangenent | ‘fain: compte eins of he i Tah Foe on Pre termtn Rs mn tei, Ni Rec | ‘OF Allen Asthma, nd tometogy on Alergy Ash ial | ‘Dai Ri etal, Clea outcomes ad vue et ‘Wein i acs 7 Ay Cle Inne 30081158 Fraysse Mulgan 8, Adverse fs of wiatns oi, dan oe “Eichmann 198178539 8. 2 ean cana Put tei MD: Ciel paces Alle eins. Eg 7 Soin Syaats ‘iad 208 888)99444oe CHAPTER 46 Viral Rhinitis Timothy P Lynch, MD, FRCPC Goals of Therapy Investigations ‘yet couple mechs" Ss oft Bt mr sive how henacbe sidesugh? ina nase of colt aad + ‘Therapeutic Choices (Figure 1) Dpopionofchuonis and nal congsstn sate used 70 {ese Symp aa tne patent uae nopharmaclog ad nad cain nuh inmsfe ar ws s Chapt 46: Vial Rhinitis 615 Pharmacologic Choices (Figure 1, Table 4, Table 2) econgestants(Alphe-adrenergic Agents) inertia Thien ashy png arflon icf ser O10) lef ong fase There Anichotinerole Agents Antistamines The aichoinerge ees some fes-genention aihitines sy ins nee on hn pet we Viuamin © Daly amin C(scaticacdspplenentation so eee nthe aren af ole Howes dl eect () oats The ingestion oigh doses (3 to 8p a he ont of cal yeep hs ‘ache show to edice either erton col symtoms oe ine lense aes may ee yep an ration of he inroved has ene when ey we san ‘ordered atough may hve ss ups ese aed ey ts Scmetbnodiewieake sobs artes en616 espratory Disoncers Notural Heath Products Eehinsene ‘A Cochrane review of 16 sien conse ht Echnacenpurpurce ‘rahly cae efttive i the feventon ma teste of accoon te clincaly signin eects on tevin Wea Me A Sd oe cn ln pr ‘ein placebo, ven treme diy ull eld sepa weve llc er Sean kof nnn ity of moms amone dy chitenif atone Nort American Ginseng Exact (able 3) ‘A rocet dy ofa soda Noi Ameen ong exact, ive dy sting November four moot Showed 9 sian Fedacton, corpse plas, nthe msm acer and aoe ‘Sid int abject: The bone wa demented ais oko [ottvo or mor eae pores ‘Appropriate Treatment for Specific Age Groups {ctaminaphen cc aprofen may ehepa fr fever or henacke ‘pnecal lilion, ASA thould nt be sed a cides thence nid of Reye's one sss hse Si nea vs nections, Brest er ote ted a ek ipo eco ce ‘roihes can dom hem ‘Thera en aw in scot aged hte hsb own tn 2 tothistanine-dcrapesit-aniv omaton ws aes Sn nistinite-expecorn combination i edgeng ol eee = ‘he ae no usd ha etn pel soa ecg Ashita decongestant combinations may eof tft sks of ‘remo shoul be cctalycomaercd a adolescent and ad, decongestane (opel o ont) a ‘vhs e-deongestn combination be bee Sows inpove ‘hore al spies © Or Incrnted umber of tdvere effacts» Pshenge we alee ee Ave seinen: Comet i to moderate dha een ‘las brat and easement falcon with eae sxe ‘sthma mandonCiwly low up ll cre deere oe ‘om he emergency Semen, ‘Therapeutic Tips + Usa loge an, ned eri ‘anism of sei mone a Syrpame have snd ete that anny bypaeacy icone PMDIS and DPis ae cvs anaes in aa svere thn ‘oie of delve device depends on fama wth we and ‘Stoic pes Revi inher ehmaue elt Wo eamre opti we of devies Prove writen istnetons tn cee sg of msn thn ugh whee shortness f breath that mfr wh se, cgh, ‘rez rset eth ater wih et ere ‘tet-agons fr etet dep pk ow ts, ‘Provide writen sro fr th fal oping tions take whe sign a worsening ata ae deteod646. Respiratory Disoters op a = a ares ee Se comm tual vue sea cod 4 {Chapter 48: Asthma in nants and Ciren. 647 Maintenance Therapy of Asthma in Chiléron£650. espcatoryDisorers654. Rospratory Disowors Suggested Readings Donel AT Kua Pedic tos: rnin and ene. “Gna Pro 2006251 Sopp 8335 i agers Metres bad time management anion ow) WC Decker 200 (tal lative for Ashe. Pocket guide for asthma Sei ai nice a2 TaiOp [Chapter 48: Asthma in Intorts end Chiron 655 ®656. Respratory Disorders CHAPTER 49 Chronic Obstructive Pulmonary Disease BR Andrew Sel MD, FRCPC Chr sarc palmar See hime se ichcacely tng cnet po ‘rato, and imereming Beuency ad seen of xceinone. The ‘Saal pions re shores of beth sch eon coals of Therapy? 1 reve ts poesin tnvostigations Fema ato cs st ecm Roce Cr erase = pe eto ematdie aac ca ta he, ~ Ghcgccy im via orien s e prcre We ctsa fing sip pete, pce end «cnet menoan el cor dpe nd nt ree cae Sea terete eet ame {to establish the dingnosis 2% Approximately 30% of patients(658. Respiton Disorsers soa tone COPD wine mises 1% ant 20 = CBC nme for anemia tha can woe rene. = chest ay tral out ng cancer brea tesco ais omer = ater lod ents FEV, «$0 pre or Sim sis respi ate or ight ar tae” phates vel if peat = 5 ears ld pects wih {COpib ornarn song tay hse of COPD! Tate 1: Mosifed Maca! Research Council Questionnaire forAsseosing the Severity of Breathowsnesae® ‘Therapeutic Choices "Nonpharmacologic Choices 1+ Recommend smoking esta son COPD progrsion. race See Com th et eae Minuireannteepomee ct tins ad hs fais ean pint outcomes and fs ning bye i en ad Encourage ysl activity to reve eres in moi and inseam Pars we lows yee ao nth iow ese es + Conroy rfl of ypc pnts 6 play ‘sunliaton propune jrovtleg rnin, nyse cod ‘Sceuptna ep, eee enn, aria ses ‘Shayeychonca and vse motion Along ed ‘ours pans Hect om pelmonary estonia ages of corneas aa (chapter 40: Chronic Obese Pulmonary Disease 659 Pharmacologle Choices (Figure 1, Table 3, Table 4, Table 5) ‘Asta inproveret in iow in COPD pats ith severe ohton ‘aye ogni coal bene aa apy Commence ‘exulr long seung broods 25 Naiman brenchodaion ‘may te oie with embiaton of loging Heras aporie tad Dever Systerns Inale roetaints ate delved i eet meted Inaler ip) uth het pacer ie dy poder er {Gein lr hgh cele woot oe {he bonreppatry ce andvo sol pbs cordate ‘ime inner stan nd nt Dry pws ences erence ‘bigs wth hand eh cotintn soe ith pMDI Apopts ‘roves opal dus delivery and shouldbe encovraaed se edulis, Society nts yn a Spa ee “he eae of dlery deve pMDI DF fr pies wh COPD pene onthe pen agen reterece,the pn ay ‘arly te te devis convene case of Se 0d aoa 2) Reser carte ec ema rr ay Bronhodists the mainstay of pamacatcry, decree itp, fprove FEV ede spt et yep, inprove aes ‘apy and uly of en stale COMD ad mace exacerbations ‘STCOrb noted once ube ned nese for ean Fyrpioms ce eu for sje prevention snr redo ‘nutan gine fvur he eglrneof sncbotne age the Funditon of COPD trot aap ‘Antenolnerste Agents “The haacingstcolnric pratroplom brome hs slower net of ton thon med ety ago bene rain toa (Gntos dy Te ecommendt de of 40, hoe ou tes pet ‘hy proce stn ina rotons ay Coble “Totropim bromides slong ating sneer ale a eth ‘Sir dey ps ae, Comer wtp ‘en Asal diy Teg dose gies axial smicholerpe sc660 espratory Disordore 2 i fi ns, opiatarn ernie etetara Sate, Shoe Pumeieees enna sien agit see er oven ri ‘yep pie 4h) tn rin Datars camer ep siesig sytem si desecm at Sen teedeenaitennar are cee pe nt Seon stinametkimone eso terest crt Scares tte et an Sinn Siriaas ti amen Sonera cae eyes oe in i ene Samaras a ‘Stuer gratrmgrovement hn anc net Sen one ‘edovbing te de of se enchoditar™ Topline ‘The se of or copy for estnet of COPD i contove hoje ie romeo ff bserved bey hat opin ‘ding of abled rons. Theol ay be we ‘jest othe roncodiners Bane of namo hein ‘nl compen parma, scares shal tauren ‘stl tow hempeat ge (585 pl Yo mine fdvere fice Theopylie hs pean rg miei, {eet may be doubled pte Spe sak By the ais of ‘slate ssh on oon carers, commonly bcd Sig ace exaerbaone of CORD. nated Cortcoutwoids "he ined conor (ICS) belomethaane, badesonde xd fateten efostiney reduce ee an seventy af ae caer [STCUPD in tens th sever atiow steraton who expense Frequent ctterbtons” Sai seg hat 1S ees he ee Steuart in avaneed sympa ieee and aie Chapter 4: Chron Obstructive Pulmonary Disses 664 Ensure optinal acho hrapy before cositering ICS tery o [roen chacehen CS ay been pnt pemting rt Sime win ection of COPD, ICS ivecommenied athe ch ‘anFE 50% peed nd vp exam ee ere pet ony ety hr sean ee ee Sy ‘Kite big on opal bronchi herpy Recently, a de yer monty sul deat o severe COPD fio show mort See fr te combton pot 2 otcaoncsaimctcrl versa, seugh dee ete of ‘racer Ao year Cdn sty ang aime enone ‘Steheson incurtatan ner hooves ofthc ‘Bimgeove lg actin and decree baspaltons onvgen Therapy ‘Oxygen hry roc thei of eh nse! pati th CORD sus we gies hyponemia Pa," SS por Sad." 88), Tong-erm oxen heap mn pot ie bys seen Improve uv er ec nt hen ogni ited For 2st sour pray sading moemaly Tepes sr ‘eae ith cominotsy amie onyn.& patient woes Pay Etat vsdene pene cog damage Ory ery ‘unl adninstered a ena faces or sal proses owe Stat i roduce a etn Pa, ewes 3 and SD tp Po ‘aes aro icrenel by fo? Lime ring eee dp Iypoentnio Pac, > 5 rm Hy preset te wiaton of on ‘ty waren hyperesrbi ypoia, to meron’ Si vaccines ecinestmly agate ery the fF cine reaueseaceato and duh pte nih COPD 6 Resommane Preosoceel vacant al pts with COPD wt ‘omndeasonePrermcace cca ieee paints = {Sens wit COPD ad hse < 6 yeas with FEY, = 40% peed ‘they we at ernest of tnpezaton ad moral fom evioni, onal een enol vee. Pgh feat a S10 yer ‘Acute Exacerbations of COPD cate exacerbation te he most eu case of matical, Fp sons an eth mong COPD patents They cont 0 ‘ict eof dase a ule sects equney of easing tochoaeyeesinea Tet apne wie ‘Combination shreactngbets-agnit od ratropion, pet om. ‘Spmizingthe bosch patents pumas xaos662. Rospaioy Disordore Sere fm mitts, Severe COPD ue un ina eet ‘nor fn ad shonin eng hepa say tl pte Tse ‘Sino fing ang seta ses A to mea eae o eal reds 25-20 nay or equa ufc Tei fe ny The orale fermi soa mnie herp) for pats wth COPD, Antibes (able 2, Table 8 “The most common infectious gets in xan: a Eng ‘he oramibits in mcte exacerbations of COPD bse on ie revlon of optansobalressane an de chgig pate ot Phage Aiea ais when exacrns af COPD te acon by wo eo he linger ig iteresel spn, Iceased Sut eres stu pene ’d in pan where acetate of COPD equrng ere mechan vention “To oman baci pathogens easing aie exacerbation of COPD Sc Sepicccwspreamoniay leophes ifs en orale ; ‘cote competes tent: Resp dee pu-egsivesaclaingPctdnncs aragonite i Cones ar cost rs abot whe Ss pic re of ii in sete tncotnon oT COPD teapot hoe conc re bse on ‘hence pevlece oases he Seng iter of plop Enptc cote of nebo sh ik nto asount inva ‘ulstfcason ad previous wef sate Coniders ange Iantiote cathe stm ntibosas hsten ased ithe ‘Ee tent: Rest pens et ond in ‘Cxyoen Toran Chapter 49: Chronic Obstructive Punonary Dzease 663 Tobie 2: Empire Antibiotic Therapy for Acute Exacerbation oreopos ‘Therapeutic Tips + rena smoking cession at each is {Petr some with nnshnaor aeesent in pats teh Patsmotens 238 © ptenker wit a 20pckent hs af smoking whether ot Sot the pase! complains oF syptons664 Respiratory Diseore ~ pats with cant rch espirstoysyptoms acing up an eles on ene patents with ay tery of COPD ~ patna sept spore repinay + Encourage physi activi wo ponent vicious ye of dereing sy enn pe + ae par and amy oe ae of waning sgn of « COPD ‘xara shave sn acon plan fra anes Review inhaler techgie at exch rcs ince wi yy ming ten sph + Cone cabing trop and LADA for usin ‘Sronheinon pater ith meats severe feet ‘Smo and excess norenc aad SABA PRR frie Syrplom et dw improve errs 1CSand LABA combination tre eve th ed aloe in lems af ress enarnce, symptom cont ad fang fncon Involve hbtine props ncn he Lun Asnlation New asin. lace mies P0-717 COPD ea capi 48: ChronieObseucve Pulmonary Disease 66S ‘que 1. Pharmacologic Management of COPD __ ‘Sepa aa nora ace sta ps er eg666. Respratery Disordersmonary Disease. 674 beret Pu 670 Respiatory Disorders ee ee “ees etn mma NS Maas ~“GRERSSE 1 eS moe ~ RRS eo tSh TEE eemne Senemug soe = aS Oa TMP FLonic Cbstucive Punenary Owsease 673 672 Rospistory674 ospratory Olsosers Suggested Readings [Annu A Clinical our of choc absusve pulmonary dene: ree Ope tas i Med CS Tens wth chon orc porary trate letespeic ‘Sicnaagene crv fr ed 2001639) 853, ‘lea! lsiatve for Chie Gusev Lang Dsces (OLD). ‘Global ste) forthe dogmas. management al prevention ‘fino osoucrve pinay eae 2008 aval om attr Ace Bee 13,2080 Srmonches to and drome’ Gorse & feng 2007009213230 citrine Fehoeossmctve pment dase BR Sun. sirs07; ‘rbintel DE, Aavon Bouts tS of te Ant Conpendio: (Cains tiara Solty rcomneratione ol mangenet of ‘Sane ostestivepumoary dee Con Rep) 200811 pp Bins “chapter 48: Crone Obstructive Putmonsry Davose 675, ake676 rosprotery Disorders Pharmacosconomie Considerations: Chronic Obstructive Pulmonary Disease Freie 31200 pe pai Shi per pa © ‘COPD bas npr Iwan dc to encamped ia (hldseae) is mal dest ae oes yr pts hy hr {C660 an asa Cons, th dst eose of COMD ve tet {sted ot aprosinaey $200 per atin neal ith et ‘Set team ron rf he soe of COPD Wty Chapter 49: Chronic Obetuctve Pummonary Okease 677 | teach evra numberof COPD cacao er ate pet ye ‘wiley decreas the overt det mec cots of COPD. TheCHAPTER 500 ¢ Croup David W. Johnson, MD “ePrints woe goa Goals of Therapy + Decrease the duriton ad seeriy of symptoms 1 Minit away of ti dae paren) Investigations + ison with paral ateaine spt epee cong hiro and eter opt 40°C) may precede Sntotaly wos aight and proves daring he ay, agemoted ‘yaa ae yin ‘hanetve smons enealy rove witha 48 hous: asl consge of den team tymptost oop oS dye" + fy eine rg en wl actos eps tips den: need bet il nein Cchaptr 50; Croup 679 ‘nerd nope (A) fs pc fl yt Seay croup street rw seer nto mi 2, ‘pouente (os) orsevere 3) “ole Alena agnones (Omer tan Cro fr ‘Therapeutic Choices (Figure 1) ss thm rp be manage i he oes tine we ‘peenen fer reine md norton + Resp len xn by enuring cm an eotsaing stmerpere ‘Thr wi nine oxygen demand and reeptory msc eve {Ener col, "caged entonment eared om tie pet ty poke antic ai aptation an shld Be ved Sigucant option “Dow-by"acnnreion of onygen hough 1+ Helion-on zon tres ton) may Bonet ren wth serene Smmpeoing vena and edcing eapnoy deat These680 Respiratory Disorders ‘einwfcient viene to anette ote hist. ‘Admiisren ola chide With soup as bs propos eee ofthe til eee dns gs (elie og) ‘utc elent sow ins mowed any Pharmacologie Choices (Table 2) Contcosteroids Comer ace he inn of therapy fr cv, reac of incr cen hw ceo, Spit ee fn he aon hand aces pinnate ate of tr ot bea cre practioner ‘Spe ep tn Bevan Dexamethasone 06 gig i fev when sve oly or Ferctraly = Whe oe Say sugges owe oss of oxamensne ‘Betas 01S mag ae eects” atneteaajls of cooled a ‘tts ihe done of coer ik cline pero ‘Sense reste roportion of pens snot kow heee ‘pl ows of cooterns provide retrbewfi a4 gle ‘ise Given tb sh dative of rp sympa ee my ovetea agi don of corscnted may be sie Inhaled badesnie i ffctve and ein to cat {nape 90 Routine ef nl dente ebay ow" Fanon wish sever coup oh ae hn espa ay ‘Sint tmutansur somite of ind con nd ‘Shalit eprpivine To cbinaion ay De more fete ton pein ne Corts should be avoided in chien with» brows Epinephrine (Adrenergle Agonist) as on irks te anon of mele pine in ‘Sietn wal severereap see ede the nie rang Seca siney Eptepbioe stn odes ear” ‘Tame iia 10 ane of nan tad ts for eh a ‘imisston hough psn rene with meen: may eu 0 ‘Strole sever they do nt olny develop worse symptoms he id ound he} et ere nd pe ‘Siw Sees hat ptt eed wth epoprine my bese ‘ringlets eno cae ere Lepiepine1100 i comparbly form angle ve dene ml of 22554 come eptephene $a ot epinepvie 1 00) acd al chien rep fe ‘fic reltne eof al oom opi dsie he dose ‘fag acl delved Yo We upper ary. ack-back adminiaton of epinephrine cn be wei cien With ‘hl wit sete cup tested wi hte nebulization of epinephrine ‘tuhinane hor wo developed vena achenda ann myocar ‘blrion* Repeat dsc a pnepivne sou eer be wed ons ‘hse earrepwory fre Icke nck epinephrine i conseed ‘roe he tag pyc should contacts pear en at ‘Soon as pile wearing fer heat ao anspor Analgesics -Aalgscs may povide sere dere of inressedcomfort by resin ‘ver nd pin ‘Anttussives and Decongestants No cxperiners sae ve ban pubis guding the pel [bet tase or Scompean incre wit erp The Anebiotice Antibes ovement eat fou bat ye wc ia ‘here arr of Sacer uperteton ever ii ve pry commends because te pet rap terran,684 Respracery Oisowors Suggested Readin ow JC The magn fp Br Med i 2026119820 Byam lyon DW Crepe pat Plt Ber Coe sim os chapter 50: Croup 685CHAPTER 51 Chronic Liver Diseases Mark G. Swain, MB, MSe, FRCPC TS tite Taian dene nceing spree Tiaeding meanete lent), hema ean oe Goals of Therapy Treotsomteatons of cane dente, in Ascites (Portal Hypertension) Investigations «ysl examination for etre of rosie ver disease [cas sigma pence eee a es ‘Simulation (tg dslcm sbdominl pretence, everson ato eo praise pn as (Guieruesa tse. se) ‘prosealbumin amylase, lactate dcbysrogensse. CSE ‘cle srum-scter albumin waet AAG! ‘Therapeutic Choices (Figure 1, Table 1) ia nu een: ts opronsactone @ specifi lactone ot rt af Foe aie ‘ike shes retary prnalacton dfs {econtinaton of erred nd melsane a prooce porous hues oung vole deleon an elcweyeeboomaticn CChaptor St: Chronic iver Diseases 687 Spontaneous Bacterial Peritonitis (SBP) Investigations 1 Hino of ever borin pais ln deterraion ‘Therapeutic Choices (Table 2) eae a PMN cell cou 0.25 «10 (250 ele), tat {ers dana cmmcns sess fa atm (hs os See cement Sch eae ttamiocetnie ace Hepatic Encephalopathy Sec Figee 2nd Tbe 3 Cholestatic Disease Goals of Therapy Investigations + Claalitiocimicaleidenc of cols (1 thane hoes {nd gm gta strc (OG) and erty sh Tor priary oy carat (PBC) poaive tno688. Gosvointestnal Dterdas sigh his abate rege if psn a poste incon abode sad chess chem rote = ferprmaryselrengcologit(PSC) dtl snares {acer beating ec) om edonoperororae ‘Selanglopacenjrapty (ERCP) angrier aging aren’ 1 Meni amin deine robin ove (ff amin K dein) © frm ala and 25(0} iti eels fem ini A adr crime levels ‘Therapeutic Choices (Figure 3, Table 4) Primary Bilary Clrhosis (PBC) and Primary Sclerosing ‘Cholangitis (PSC) ‘Unodeoneboie aed (UDCA) 131615 may ingyoses serum {nerves et ptent wl POCO nd PSE: Rappers to [clit sayin reventing dens progression n PSC atau pope UDCA (201 30 may) mayo ewe In PBC, ‘Nonbcd analyse ee ae suggested ht UDCA signet ‘ete py andr den aera mein Tesect on stnoms (oe tine ris) controversial ut ikely Inu ps chong ere wenn i pope. [nbs (area poesia mutant nl epooes, itravenes ile" pent mevoniarle o honpiatieg te Vitamin Dfiiencies ‘Vitamin A: Do K solemn ny erga delves {soy icin el Peter amin apts Management of Prurtus ‘uleoatoactosrarcane pris. sem. Choletyramine tiloont stow eof pent eemat becom os tong a prus ‘sca Amihtamine (e hosin) ne om roan ee Rta sede popes nny help. Fer pac who dn reed, Streamer nny hid Nano es inane Chapter St: Chronie Liver Daoasos 689 Autoimmune Chronic Active Hepatitis Investigations. 1 Naked i rum snasiitses wd ypernastbatincrin: tht oy (ANA) preset inst T>s pate pS ‘ema opi) Dingo oie by Be bigpy “Te lac pnt ina youn worn who pete wit citer an cae rir tes charac by eda. ttabs, ebro, ‘ecg pt ed wh ar cog spenones wi ‘Therapeutic Choices (Table 5) Seep ihre ai, Sees were Seg onion tance, irre ea ener coenwie Soaienns aiergucinerrmests iNeearalppictenta iatnencaasy ES ecores Gece ete Saal apiece ate ne Sete ito lr a tt Seehigere cnc sstmaeeae sekgt Alcoholic Liver Disease Investigations An AST! ALT rio 2: and GGT=2 » the upper ii aaa ‘only snge alcool tae ‘Therapeutic Choices (Table 5) Cchronte Alcohol related Liver Disease ‘Therein univer accepted metic hry encp anton fom alcool otc tenet wth pothole ha ‘Sensmlcd ut emus have no teen emg Alcoholic Hepatitis Corticotrids and penton pore sorter sia ie et nn severe py proven atc hepa Severe ashe ‘tps an be dametedy scaling he Madey daca Tinton sass 32 deste sere seal hepattis wth moray ‘at apronching 584" Coico ergy fr sve chai(690 Gestrntostna! Disorders ‘patti us ben cxmied a eros sao wit vrnle el ‘TiSeat he beets elects enone have been document in ‘Tigi ay evened by Haber ta Hemochromatosis Investigations 1 evr ero ei ( 200 pi. formals > 200 pf females) fasng paso sri stration de cr tom evel ‘cope a formes or> 0% for les {Conran overload 2 ver boyy of pstie CRI (ost ‘Simon genet “The le pot ea mie-agtl an who pees with Increment fia anmina pupa Sie Ti ico ody tran bees en ‘Therapeutic Choices (Table 6) Reduce dcary no inte Peat (00 mt of whole ood weekly (chess oer) wil tly nore Dodo ters Shenoy shy fs may take upto wo yu the att lew ra lebetomy dat te tna of on overdo omisneforalsem) ceaton wih deteruamine cated Wilson's Disease Investigations Heo resetns alae flan Repair ating ‘eptivand cons Thedaposia conned y her py wih [fat copper casomeriesr anor a peative eee ot. Gc (Sl rosie nn a 658 patente artery est amnarnsfee,jerucenoplasin a otal Scena cpperexreton (100 play) 1 Family tisory mor patet se dagnose bef age 30 ‘Therapeutic Choices (Table 7) ‘Copper chai ant (pentane tenting othe eet ofthis oe Woes abe ie Tremine a Sebeter mst sie og eS Aah ‘Pyridine 25 my sa be pm th penne court Spintec wen four bor wom epee exertion a ‘Som cine rch eee ni ene era ‘Sey Tren mye wad pve ear of piling laments option pts lr of pene Chopter 51: Chronic Liver Bisewses 691 salen. Foti ine alte nis pms Figuo 1: “Management of Ascites Sacondary fo Porat tensionu gl 3 I L IL Lichapter St: Chon Lver Olsases 695 “Specie yetety eo no asa soos eure = cor es “ ore ee a oo = — Tana RE ROSTER SAL herders (694 GostontstnatChapter 5t: Chon Liver Dassses 697 696 Gasroinestnal order ee ean ee ened es ven nee seg EES aa song misao HH pon ing FL eer = et3 B a i i z & ee ee ee ——— RAE se ee sens ee700 Gosucintestnal Disorders [chapter St: Chronic Ler Deoeses 704 ‘Suggested Readings: as 2 ‘Aan RC. Review aici te mon gros nd anaes of 7 teem. mo Fama Sea 05t =e = totnnscaintonm son i i é i 5 7 i i aCHAPTER 52 Viral Hepatitis Kevork M. Pelikan, MD and Geralynn Hirsch, RN-NP. MSN Herat A vis (WAV, epatieBvins (BY), Dea C wee {UiEvy hepa B ste (DN) (ote egazesSosing BN Inst) Sn pan ss (HEV) cane 95% of arte a tiie soso Arc Tate 1 eas lei This copter foes om the prevention of te viel pai ma Tic mangement of home tral hepa, which sy ed 6 the {isch fies sieht arinams aa ie aie Table + Summary of Viral Hepatitis Goals of Therapy Prevent sped of infection Couper 52: Val Hopattis 703 Specific + Seine spre of epi ad nti of Be : Teponee UR), defo ar undtale senan EN’ RNA Prevention of Viral Hepatitis, ibeAg for entry iat and et fom hepatocytes thus, vocation east Inv igh ik of cng pte A o B soa be ‘erga (Table 2) Mapa A img nd ep B [mmole provide mode shen pave ny aginst racine ato he ted gt x rege Te ueikproue Deable ody peu ne mor in 96 Sdnca ert done dn heater baer ‘Sutctag HAV before adegune un HAV antibody tes are achieved ave the highest espanse rate (9995). The response te fo “lin bro with hiro oe 7 ition prose nna cn pce704 castoinestnal Disorders Tob 2: Recommendations for Hepatitis A and 8 Vaceinationst Acute Viral Hepatitis, ‘Acute vl hpi a yt ra infeon tt, diz, ‘Sie rn st andes noo Ito tence st oor oe ports however mint {rpotn ceure feof patent (aghor rat women) > Fst rth pongd IN. uc and ence shoul refered Sma soa iver mention cere sce ase nets ay tea vr ioe sd dst Ccnaptor 52: Vial Hepatits 705 Invastigations (Figure 1) 1 Chock or ink strech a jst deg ie, dak send beavis, evel eyo yee expire. 1+ le ot drys put cing da cased by ‘etna betas, ssmne bea nd Wib's ‘ine opel im chiens Yong au), 1+ Heny tapas by the presence ef sercope makers 1 the prence fans o heat 8 core mid (gy Inde sce HV toagh en impose wo einw fareop of comic HB econ fr anaes oe, Ony me il + eat apts C can be tenia by 9 postive ICY RNA tt ‘Severo } weske aernecton. An HCY mbes my nt be ‘Sec fru to 20 wes ae xpos tthe oe + Motrin A SD ne tn to ‘Therapeutic Choices In ost cases speci tiv apy inet nt (igu 1 rove with epee porte care tnt pate wth ute epi or 8 recove cmp a do na expres coe Completions. Unfors. hot he ane hepa most puts what patie bear coic sai Nonpharmecologie Choices 1) Avo lebol fort asthe ont owl compete nexmaliton ster emymes and hepa ncn No dtr rerio te come. 1 No seta of pyc action eee Pharmacologic Choices Spall hepatotoxic drugs. Fo pases ith prongs INR adit ia 10 me since (vo en ua eee dre ‘lacie een) te patent Svclop ncptopn hy heling ‘Limit Iver fae, sat acts oes 0 fo the os wel movements pr fc an ci tal ery te ny ee epi Cs the acon of yoperon sa tsa, ‘uchonc feats © and abe Mow cue of se HCE Inkeon se mpmpenmetic ad ar rly igmovd wnder te ‘roumncer” deemed serosarveniom Known separ © Selleck expose) si cae lal Beats wt runic ‘Wore, yung sin anc atin are more ie tle the ‘rar ter pens i seeps CA singl epalve HCV706. Gestcintstina Disorders RNA tet et nent fi rl serine na in wi soc Ki de ei ep aoe HCY ‘Paneer ately Be wes SVR reso ‘se ben abned wih epee mona. Pale ced ire genotypes? Shout wena fr methane nected ‘iho onsypes sil bere or 34 weeks Chronic Viral Hepatitis ‘Vie hep scone whee present rsx ni longer. ‘Shpopess acto, dsompematon (iver far) and patra {Geom nce cane), HA and eV are the ot conan came. Chronic Hepatitis B MAY ifn bors coin es tan of ely nil ‘whoa inetd a bat 0 9% ose chide) “Knog toe i coi hops one percent wi serene Sune sach yer Goma MBSA postvete aaa HBS positive te Ge teeome me. Investigations 1 Perstenc of decal eves of HBsAg or more than sk monte lps hom epats B necton, 1 Sice HBV an HIV ate acqie bythe same nso route, nccts nin HBV shoe ete or coatectan, epee Sie considering mile aloes or BV 1 Chor oe HDV cones a patent wih erat ALT eves at {ow sem HBV DNA concematio eset in he who ry nnn neta ugh ject dre they re om ‘demic asf HV, susan Alin, Roma, Cea ‘Xl acre Mera andthe Aaron Check Hite an ane dsr aneminae (ALT, AST) “ats to cine the eptatne ste of HV. The rata ot Tita akcncs ugha repo (tet eb whan agen) + Mescnenen of HBV ONA vin in seam snot ott vale ate il whan ranean els ehh Heep tol ancfibe postive patents I reamed th HBV DNA {Evin onfoned ey tee tos obs ‘Live ogy srcommence especialy in howe der 40 yeu5 Chapter 82: val Hopatis 707 ‘Thorapeutic Choices (Table 5) Nonpharmacologic Choices. Avie sail ut mod alcool consuton (shan ine Forrest Pharmacologic Choices (Table 6) Peginterferon ate Preparer lia so tat ptt with hon heat B who Septet sneered ene ne {tle postive state hich asoced wih pratt of eam ‘weckly) and donee acy, paariron aa recommended [tnca of standard intercon a hich nus be aise tet ‘ice weekly forthe maragemen fen hepats 8 Most patent wih psi Doo-infoton repeater pete ft eats respon pool to pepineson sl ‘Mucleos(dide Analogues acter atalogue ffctinly bit replication of HBV in ptt tio ae Heap postive a HBeAg-mgnve sd should te wie only {Oats hve nga pt ponent ALT ad HV DNA. ‘Seva Inkbon of HBN replat with male analogs = ‘Sst et sigan vanes io ep nsoueraton ad ‘Sieaed eof nesconvesion Resistance to mules) males isa imporant see Ameng ‘BSc iat st ih ae eo {Smiudweressmn DV croeseuotoelbwatne a ‘Stan an anette get wih acti gat HBV). ‘Satan tat costorrentance lamivudine do not by henlves {eof vesstanc etc, however area pret er the ‘levlopmen af emecnirnstane std een oneness, ‘nniviercery ot rin FN Aden ha a ‘aint liane HV. Comenel bot adie se ‘te inrepoes tobe ht Lamivine ses BV exe shot {Sta 25% of patents afer ne ero reatment and wp tT ar fivesears of hry Lamivine inprves stores nates with ‘compere cnn and ay beard ops See Ee peuens on immanonprseve ay108. Gasiraotestnat Disorders sen denne an in ne to iter nent eases erent cena SRR ie ere Ein cea cenennt paca me pee yo Gee Ar tigate csi ened at ES Si Saath See Scere sete Bae ‘inven tat reir rors sung tha the rate of resstance any Suances a ea Fetes es me es cd aie tera ature ee Gabvesis Settee rs Chronic Hepatitis © ‘vert of see non wit HCY Become one he ati Fer cen Me tacql nt fey ei ru, tose snr nto dug ws) oo rane toto {Soh anne st meow mune Bk ts one [Moots cos hs emp ee 40 Sarr furan ns cons 0 gan nd cotton Suv oats ppc Invostigations fAMHHCY sea maker. ‘Sie noth epic te anne [retce of HCV ray be detected oly by HE RNA a). Tre BNA fy PER a cont he ingnoss {eve igo deri fms rae and ori ge resem ye eat pen Pr 1 Meare HCV INA vin ond (gun ing eset anand genotype Pie o CChopter 52: Vist epatis 708) ‘Therapeutic Choices Nonpharmacologic Choices + Advise anneal bode abl common es ‘ake wet, + Cami ance Soi in patents wth ron ite tnd we thw bacon our Pharmacologle Choices ‘The pharmacologic managment of patie with hon apatite Cs ‘ied ia Tale, Aner af he properties of amv as wd {err epi wed Te? SOR wml “nd beat enya ie reactonrn ver etd oun ed moti ond rable ‘Combination Poginterferon plus Ribaviin ‘The combiaton of einer al pls ivi te ecommendd sre or hoe ys Cad eon dcr Pepitrere af ants is neal es eerie tha nto ys ari ny eps hve “Kitavirin monatherapy ineffective, thus bain shld never be ‘Monier sone The duran o tenn an done of haa Spend ‘ava gente (ible Tate) Fasano key tone ‘iSVR artnet ponte or inane we ‘eke HCV RNA lovel sd hue witout anced Beatie os Fox pens inetd wih HCV gerorypes 20 te sana rion ‘oF wement a eal bean 24 week estar on 9 isin 20 onlay. For pec fied wih HEY denne the andar dan ef eames diol bce 48 weeks she dan ere oho e100 or 1290 gly Waly, HCV RNA soa be testa weok 4nd wesk 120 eran, Fates wi aap volo guns RVR), Seed ar negate FEV RNA (SOT by quaizne 9CR) a werk hoe sory hp cance of whleving at SVK ed the draton of arapy may be [Bhovined nue ete gen ye en hey on tn fo Seem pees oreescuer means, Roeser ee maton em SRI tes ioe ue nc sine iS 2 es es el ea, ‘Som Sc ot a ya crac CA rectoanal!TAO. Casrinortnn! Disorders IEHICY RNA is ete weak 4 teament shold Be coins ti Seat ath ten FCW NA remedy ge Tey, Matesemitiou = 2 drp HCV BNA slate a bseline ‘Sundae HCN RNA steak? we ery iy aches an ‘eosin | apts wih unectbe HCV RNA at wk 2 ‘toutlConpce sh necks combination hap. Comey pants ‘a= logy op Bt deste HCV RNA x week 12 sa te sip tecmse ofthe low bait of SUI THCY RNAi date at week comin or eke ane coneration (Cpralonsing tenet orp to 72 mec tnd eve) Frclmiay dna he shot Seer tcmes wipro eset a radi hare” rpondees AI patos wh complete eatin mit beaded otra 2 we he conpictn of ery fort quate HCV RNA tet eee ine have not eps or who have elas afer ves ment ‘a smd arf aone ot embintion wt ibvian y be Sivets vrolope pense wk 2, us outine shove, iret ‘Sp lo itt fa SVR an esi soa be oped Expect SVR los wih the eam eens fc eee |, Mitre town in Tables aoc sith gamut ec tan 1-3 {rec a nmon a ulema rele el ela SV rater ‘petal re more sie opment han es hey ‘hon managed a awa sar gene Table 3: Expected SVR Rates in Patonts with Chronic epatits ¢ Aner Treatment wih Bogitereron alfa Plus Ribavirin Sennett ‘Therapeutic Tips «+ Avo msonippresive drugs inching predsizoe. Fity perce! otha Baers experens# Aare upon wire Chapter 82: Virat Hepat. 744 cf immenosuppressive dag wth rie i sera ance Saf sex een with mip xl ars. The [SGHCY pce of Hens pate en 12% fn [rms hae oe Hk ast)» Presa “remeat of HBV and HCY in pation with decompensated ino pst-iver oplontion shold be handled alan atlas ot. In patiers wih diction problems, ety emmet of HCV aii ‘iyo se yan cine Coveecton with HCV aii HBV nHIV-gotv patient shold ‘chanel by infectowe ae spe tv efecive fr pointer induced epesn, Moto pons {i dpesion sad tet pret Hemolytic anemia ic a omsnn ad dosent of mea mee eo eons = ramen of aaah so tin es CaperChapter 52: val Hepats 743 so 4. Treatment of Acute Vial Mops TA2 Gaatoivostnal Disorderschapter 52: va Hepatitis 745 714 Gastomestnal Ooroore a eee aoe aren ‘Senin inane | nore me swcttgitam encom | amore | a oe] 2S moe ae Ti aweby Gummy @ aedOH puR W smNECEH FELTAG Gastrointestinal Disorders "ieacanecestecm Res etna aes eed Sits anagem SI “sunedew ein wi paen snug 1 8] “a aed 2] jo WHWOBEURA ORE,Cohaptr 52: Vil Hepatis 719 or db wan w pst 6G LOBEL"20 cestrotesina! Oerdes CHAPTER 53 Gastroesophageal Reflux Disease Eldon A. Shaffer, MD, DABIM, FACE, FRCPC Seana fede GERD) en tyro omely et yea fanned reo peptic ops. Fens, rier soph ster of GERD wth enrcope opal rdeos of phage! fama GERD i m0 ‘donememble exphageat are (Cea meal cophagur a eoeaceny Stent on any wean) terol omer rer danas NERD) ‘ronan negate far ease (MRD). Goals of Therapy + Reeve gto pacar Rea, a ingrove qui ie 1 rose heating of peas 5 Revenge te oon ei se ego Tobie 1: classiest of Symptom Seventy \722 Gasteintesinal Disedors Investigations ma, en nto a eget er pecactae are at Teese homer emaecahy Siaomaetaemenianmn eh, Deas Sea nce emma aerate ‘egress ser Soenmea! yopagin om ste, epi leeration jcc or onsen ayo) ~ redoing sociated coon: pregrany, bey, = Gt tesing anemia ~ exesopagea! poms spit, rpbarnge) ~ weigh ss 3% Aneto 2h pt mniring since in atts wit ‘Mops et nts fr hse who i standard medi heey {tu vcs nl endscpy), ands peopernive evaluson {crys wah END) bette anti serge 1 Helter position dos wot pla cosa eine futopenes OF GERD Tesi er It prot mat ences Prt despot eccvenes of Peay nods lrucno en symptom ‘Therapeutic Choices (Figure 1) ‘Nonpharmacologic Choices ‘Therese evidence o spot the efctvenes of ie changes ac mi ep lees However Tetry mottos (od chelate, alee aii cis jes, tse yes) Weigh lose if bose (BM>25 130 Ea) 1 Nosncks within dee hur ore baine [Chapter 5%: Gastoeophagea! Refi Disease 723 1 No png down ter meas 1 sate ag unr th ad fhe Bd on to 1S em lok 1 Sop anche ee Chapter 1) 1 avo ih tins Pharmacologic Choices (Table 2, Table 3 and Tablo 4) ‘When oe clint drags ht inp exhale al ower ‘opti interne (oc har! blockers hei ‘cj smepenan eetecke, incline ge). TeviaLte‘Mild GERD on peopl wit ld symtoms dome ssk mon ston a hat spun ele wh ante gamer earn “Sreegin Mrteceptor antagonists (HAs) The ter ae expensive dil gute det aed edad yp ot, Raat ‘Berapy bonmes nessa IF GERD see een, Moderateo-Severe GERD Aci or somrscption stent HRA aloe ae no tee The ‘it efotie sus entman approach treating cher oe copbagiae ‘naeorv ofc dase rece ea erent a prem ‘Pump nko (PP). The gal irae th raga pt the [ESTs whch ny ef w wll ost sym cae ‘Soptageal dame Heracepior Antagonists ining, adn, atin nd naan aly cine “ice day donate mpl ins nd esl tall mid ‘Sopapis oer 40% of ater Ther say pie exelent ‘Tefen ime byte ap deemed acy ak ‘Reins poperysppenrnel sel eel een ‘Thigelas of russe or sever: xeon et reserved [orGERD when-ymptons sre id ad neyo (2 nce pr wes. ‘Seapwn hrap bere Hc ae sted ae sree ‘leh ben aheved with Ps, on be susceatl wit ately ‘Sfecting got fife nd redues css” ‘hea ial thempy i enti mintenane wil be mecesary {Oiensymgons reer an mel be ened by worpharmcologie ‘mean Use the wet one pnb contol moms an prove Splesions. This woul efectve ld GERD. Proton Pump Inhibitors (PPIs) ‘tesopgis PIs heal rads of sopapsin tot pains op"2A custisntesinal Dserdor Recibeng mate, Mates toe aoc RAs my aut ter ahiving iS a rps begs th pt antecetoy spe ‘noe tape conera. The tens foe spree ‘Sth nny dressed nit eaktarnghsymptoe oc Wh thle tone they crest saa ging yrs ‘howgh Ps ea ends tey do nt revere eit sc ws rcs eptogseTucygin ict as poe, ba Sc tebound cers a aceimaton or ENRD, Pe are chy sper a HAs inking syrapioms (Chen tony ins conling Sgn ‘nsec potency somal ese hve no npr ce Hoicreacaaciedarete ttre Se tecentn ce emecrsteee Sasi forsvee tose espa Conse ect he a Seen er cece ita pee ah dnp irlecohrt estos so eaten elstacter ro’ etn es ot extra sil mp0 {GERD etn fr ptr ma ees 7 part eration bs nyse on GERD symp sain sight were gan thc eran use an prover a hose st nniprdamt ssa ‘oble2_Efieaey of rugs Used to Treat GERD impons _tnpagte rope 8 astosopogpl Ret ese 725 Prine Agonts ‘ies ces leant one sutton Sie coir ada Maintenance Theropy or erere OERD ‘Sipnguts "Pt unmai emi frre ctl a HAS wd tsi anaes ee ae nda rien a ey i cy a oa ‘xSch ne he pen cecowince he ug. PP Beyonce =, ‘homme tance een ig ‘eiatin ropa o reve sce of ou apap Sh pro apy ee een seo ow se hase Pi ee tet than std oes se These sic, swine rc, Ea aes pac na Management ofthe Refractory Patient Ps tough pote ninety get yaa provi syns ‘eb or ba esp ins tents. PP are ay reste 1 ncomet dagen eg exophogelhyperonitiy (seat Eypeigeny nein pepe cele 4+ eller ene fcephstiaal (i) fl, cosine ‘Sephon pila + dei pe ie Sig ine spor we = Sang FPL nth meas on ombiation wih RAs (OP ‘rovadsbiyiipkes wr seen of ie a ~ nei apd metabo va CVP2C¥ (es conten) ~ fei od hypenceren es comios) Adon invesgntons sich a ecopy wit opi 2 ‘porn rape ty se my be waa ‘heeaue of reiadoy expat726 Gastrointestinal Disorders Nesta cif catrough with gsc pH <4 and mpm cn Narita serps eee day Peay. Supplements, Sang Fa try may tmpraty improve sopoms, ba ‘See it te aking tek trap Bete than pace ‘SEER apo or patents etary toa PL us nt Comoe ‘Apalachee ahem tte espe tae Por sates ™ Auirate Surgery ire oopiva mec ery age tv ta etary Fe otto suger ose the ysl cau ene yes ples sinter In tt comple espets medi ‘aay othe feat te sural scce, Aen gery i [SEC sono nell sled cose. nets tae Stearn voy noone pe Soe cece ema oc eeoeet tng dese (p;sation pI) tous cone se show ie serene agialy Ses AST cd poems Ine tye ray eye st pee sty taparsegt sppronher and nara ori emia ‘tse separy NOTES) have ms Gee rial see “Therapeutic Tips: Foren with nd sync GERD, nongesxption HRA te xyes and gute moet nid rednton an pon onto 4 Pec per to RAs for edn of ear an Mel of ‘Syn npn wih meen onrte ERD. FRASIy be The recone fe of GERD tr xr high an ong em miennce hey inser Plc neon fp secre ly on fe. On eran sete heap ith Betsy bo oleate Sele! pens Chopter 53: Gastoosophayed! Remix Disease 727 igure 1: Managemant of GERD.cate "got etait, ‘seroma any woBeudosoonETD UI peen sBnaq wonduossig Fr OrReL730 Gastrointestinal Disorders732. Gasrointosinal Disorders chapter 59; Gastoosophagea!Refux Disease 733 SEER cate ptecnentat agains County Fema OD Jems Seat jpn wiv GERD Wow me fos 70% of population wit GERD symone nai ‘eat pion GERD a “County a Year of ‘emate ieee Coste __ | Init Cont USF ‘US $93 biton | US 3479 milion ‘erway ‘neal Teds and ec mala coos gesrosoagl eux Soe Taegan somes rete mo cst vt (GERD) ae sgn af GERD a ccm fs at 3 a er aoe tencon a As patents wih GERD SeSereant pent, hch seen depends * roe of ass vail fr the setent of GERD, Pion Amara iy ae more cstetee tas hai Fae eet rately ew econo ratios eect compas eer Pi.” Pate rely ae te ay pies od and rss are nal sae aye avy o geese Ps havea mrt tere dc dale eineCHAPTER 54 Peptic Ulcer Disease JAB Thomson, MD, PHD, FRCPC, FACG vrei anagem est ty Seen) «che 5). Goals of Therapy oS Feeve dagen a el he les: » Ree Saptcsioes «esting pester Investigations saebadamcn, ee hho bear ase oh nu ens oN, EN ese gecome ales i! fggantion (Se Caner S¥GERD) Crayne eng. HE cre ing tr SAIDIASA ws, tangled SI tone poms meine vio wih sy mr Brgy ewes +p a hte (URT) in lee idl is a nde erase Song a oe Seralony feria the ns aly H. par MBAS = [Chapter 54: Pepte Ucer Disease 735; spose Ses as gh mn Sirgen suse ewe rae pene len tina Gebel ts cine ae eet Saath pvaiee cee eee en a icin lee. actotnraaee ody Eis tt ee eins Smee ei: A ales ee Shen | 20 poss sch pt she psi Bot nothing Seiou ka kccn minal art Src raiee cine, Caprese tere The rapouti Clee (Figure Nonpharmacologic Choices. » ‘adatom fd or bron ule rg wet Coso fetes eae ites, Soe Cpr 10736. Gastrointestinal Disorders rama che C2 telnet Po . seer tren ti ane pte scan en cian cpm” weer erapy — teat witt a proton psp inhibitor (PPE) once a 7 Bar hore eakft oan Hy eoepne antagonist (HLA) ocean Sess iin Sarena ce es ethan Someone teeta seinp Brite. tn ne i wg eS alate tama ever SeensRctneteee memtarng a na Er acetic tent Spiga aeaeect eee toe rca eae ce pacar Sapte Comselha re beat nt arse, tenet tation ee iercseagecatinrs Sere ey ce erate byte aac Ss stow Rrstommesteruatee taser Eerie ewes Secrwaicessca Ware tangle = postive test result seated wid ripe therapy (Table 1) Tis rans Beier gration vio ny ey yn peo np wit sey SSCS Spied ty Bcd pte Canada an he et ee ASNIy pon eh ere pa veep omlcrpntswitan rt fection the Renan ama (Peso 15% spe relan) Modest Acid inition verte sot (OTC egy wih ane Hy Ras cone Ce ce sting media adie. The poe er EER inte opts ofp CChaplor 54: Pape Ucer Osease 737 resrgtion doses of H RAs say be wed fo yp ei at oe ch es ete fora or ss og ha Ps st be ‘Sed ay and fr kngt peas (to wen for donor vos ‘Se ec nt etn ates ‘he time) my develop qty, an th Re Rav have mle ep in ecient Sadat yore Extensive Aeld Inhibition re Salmaceectrecrtaresteertn Ba eimiaen, Sree eee me Sucheiachomceon Seles rence say ace ounce cane Seasons ‘Asa clas of medion, he five Pls vial in Ca are ey ‘ficctve Trav minor pharmacokinetic and partment Maintenance Therapy Coninnous we of id nition peely witha PPI. may be ened ‘elec yates wie DUCGU tacit with pot eo ‘Specialy when the le compte by tsodng frost ot ‘onthe patent ies om feguont erence aes isconzoversil wathr sm ler patentee of hie pot lnfeson may develop de noo reheat ae vu isermient o ontaes PPL Some high puree ‘ontnour wt of NSAIDs may nee toe mained ow Pe sdice ISenk oreeuren GUID ‘Eradication of H.pylort infection (Table 3) dono ppl infection more cst-eive tan mainteance roy wih ai owerng medications end rdaces the io deveping sti ence er mocost scale phon ts HAL) phen ‘renmeat egiment aoe bythe Caan Hlelcobvcter Stay ete itn cut (a os ts) of alent 8 Fs tine tens nts et eae imvoidn) we ily bx en ae) Dene Ste comidrd fle ean’ Rashdie ign Ci hh ‘tates recommend in ler wan Cana, Reese ‘he prevatne of meniccoe eso mn Cada at 0% and738. Gestointsinal Disorders Ghopter St: Pope Vee Disease 739 estan moni ies han 14 gees te mn of sevikofdeet ‘ces reg ream, reacted combat 2 Regs dereingan NSAID oe pn thon ae ast Tete arate erro “oule 1H. pylon Exatction Regimens ———_—_ SORERID reso aihertoercnphnon Ba nc {nt symp sched wat led op, ape cle | = a ives eigenen ck femaee a - eae ema ea _ cieaanari Canae eh aoe xe ‘AENSAIDsnid we hod tad he aro NSAIDs = = Aker Whenever psig be RSAID shold be sonped cn ‘Teg is abe tt etn po neon NSAID. Se Ee nie develop! of ep er an her eng Fo arn, Sheltie send fo loan west fam ob poste moee Soe tre sti fon ep here einen, pet crime ith Ee a no nt feo mek aber Bh. it at, on orsbonle pee. ae etn he ae of recon OY onan ating by UBT or elope opis to ron ration it ape tng th comple le eting esr) ey ers Inte cael pte WAS See ae Ee elcn to {Eee new comes or er NsAID-assoelated Ulcers Che rnin er CUR ety ASA SA Uni and ene pet or Ht we i cn or perinsn et ae eter ras of cosorsclr complains wih He Soeur ad changed hv a742. Gasvointosina Disorders ‘suggested Readings. en ihr aH olen nein SH Sh nls 0 ee At Canali cece ys comin ST Rn caf ase). Samet ways aL osetia seat de Mackall OB. esc ot tant caste Yon ORD RIDES [Setomaceert ot dspetc pti ton sson8) 3500. | SESS ig ea meme tema ete Chapter 54: Peptic Ueer Disease 743 Pharmacoeconomic Considerations: Peptic Ulcer Disease evle Mims. MS PAD Enidenioogy ney (Wee) | Prealase Une Se (9 | An cid 67000 Anas ve Pe inet Coser | nase Contr ‘Unie Sais 998)" US $3.1 mito [US $0.2 milan ‘uepatiet pyc ace vin cca ote mao GO) oF eet eile sori i pep sere (PUD) [TOD is asocted wah gnc lt wrk rosin 42% of feats wet beat of pysan vil sk dys ‘epreductve cure of PUBS Sere us hve sped hat ‘oni eo det cone tame ot Poa re Ninos as nea thet mal conto PUD Sesing fos Helicobacter yor an eatin wih aii is ‘Sete nese mp tesiente P, e e few dea compaatve als orhacmine (i) recep nage, RAs ang prtn pump tbs. A mete aati or ron rye inhbors to bee ietive thn pace for Sepep mpm Beene i RArcon beprcanes crac he cas tone ‘jth pene Inconat pcon pnp sso se pesersion oly ‘igs nd cata We covered by hid party pee,P cosoivin Oso CHAPTER 55 Upper Gastrointestinal Bleeding ‘ADR. Thomson, MD, PRD, FRCPC. FACG pe mint eg Ue crs el = rane Cacmon crate meade duodenal eer (OU ee ces pst or coped eonios and euphagea Fa ing ty sea toma ses iste ood TERVickcty estoy one comonomer of he SERS ton iy wes Goals of Therapy {ponent typonie led damage cher engans Investigations see Be cote Gumaon EA omega con hse sage of et ae eer nak (ems cohol use, ets Nea Gigs we ome a SoEaM lume of ed, bet maya be dangerous te ler sale ol comb sa 3 COPD or coos eT) Some Dene nas od er asp an ress ach Coal ie Ca re et ad eo more doped om te sve of Mitch Subieceenaton bene etl, rou SSS ete A dcp as oe (chaps 55: Upper Gastolnestina Bleeding 745, Rapid stint of od ls ane det the edie: S06 as of _ heb me tena Gyan Nt ‘Sian ne NO tae mp demesne Severe Beaey and pms toe eusebeing nthe ver Gla ne ~ tree of eh odin the NE abe pate, be ae ‘let te ahr adem ie es + An ceeatoga isc oer pies wh upc or fate wih UGID. The Pagar po nt stn ‘ay care hae eld for been cophagopadcorony FS we rae emo bay MT tal rans ‘ati Ul leigh eee EOD ae ey ‘inh iy casa eats peel seman Torte EOD cle lan tose mach wh merit. fom the nomach wich {nalty tomate adage usmle por Ecininel uber nanos wal eon wh cae ‘rally paths patent ay ee ae ‘Therapeutic Choices (Figure 1, Table 1) Nonpharmacologie Choices Joe ae 8 i tn sndTAG. Gastoinosinal Disorders Endoscople Treatment In enor eros vom en EG, sachs ker wth an aden ete et grate cei. ET at be wid ERT voles cee eal essginion jen of pene o e108 Sema a mecaest hmong ch, ops, 3) oro eng, con ey, eal any eee ete staph ban ty Sece ntate Scancige once ay ail wy a repel ob F41% 54 a 9% serra et Fee conon For ceding ste varcs, he ne asi Pharmacologic Choices Nonvaricea! UIE tray 1 Vat nae iy BOD itn 24 eee osm ‘ne ae of ‘elt hat a eth pon py ner Sees cter antago ent econ rete eects ni rece in sheteamttenta eRe = (GieSee Bris in sonra UG, bol hiss coeroversih Tntopeizae spd omepraae ee mot ecenively sad ‘rd i fr Cl tei ot ain Ca ere ee dye of ergy, ph onan Fo eal ae ato eopgie Woe EMT or Ps ret abl ian dove of ter PP} ‘atomepr note 4 er he eH Heer iy ho epodes eee esting an te tes ys” Trin pst por nei, et er wi PPL oe wees tf neared win prt we of ASA or NSAIDS, coe Fees ce tery er escheat eles (Chapter 55: Upper Gastrointest Bloding 747 ‘Bleeding Esophageal Verices Tor bleating essa varies, EMT (handing) ey be speed th pharcologie ct se ae oa ssi The ng acting sonmtstatineoalogue, etree, ces Fora resis and bldg nd gente ope {yar been tps Vapi dsc mlancie lod wean por ste, tance conten oie sat ‘ns The oto ea in aes it ecard ‘eight ade, Whe oteler bday Ect avai, vsopemiamay bel 1 nltogyerin ts Ie advan vsocnsfctve eect a speci, Prevention of Varco! Bieding te tsk (e.propranoat made ay be sd ‘ea dr eng ihren hopyans mtc nines dee re ak [berg etre tO teed pa iba cher ‘heray satay In patents it heh age) epg arcs, Soman ne esta ln on pat ‘Therapeutic Tips “+ Rapid agnosis of UGB wing EOD ie important oistiete ‘oferty Pach UG soe hemsramialy ile pie o BaD, + Blain scat ni pi or deal oer sol be ee 1+ The tin sald be tend or por and weed with pe tery fron wet lected A flowup tc eth et ak ‘siggy eae ins stig fo pve acne rests of750. castoinestnal Doras Suggested Readings ___ =o se ating, Can J Camoenem 20081800) 8059, sole Sh Sore he Cnn Rosie wre Fini Pane ie ARC of he wet gsi act: Upp a Cott hineage, BND ON SDSCNETNINIST. See eect be, Gsoctptapeat ancl bamarbgs N Engl “Fa D1 Ho CHAPTER 56 Inflammatory Bowel Disease Brian G. Feagan, MD, FRCPC anya of the gana Tt whe crave elise Investigations ~ hana, bdoninl pin etal ‘ot enone spams c's deat) the Rest subcepesiiy gene WenlGed far vows med! (de deve, tion esi nn Gea opednd mat spe) ‘ih bdominalendres, presence of ‘mer sa)752 Gasvoinestna! Disorders the conftns egond dierent dug Seay exe noone «le atomic alzaton iemeesnry for sleing ev DEY Snoring sey 7 rea flammation (WC, ip BER, Cece tes Some) Stee, fee xin ty Goals of Therapy ee Settee entail 1 Meee etn tater wt eee) 1 Ree soe enor heat, ih ait ih * Gleerative colts and eolosic Crohn's divease . «Sy cs nisi pone sritts, Ty uti ei gu en oa ree setae a Haaren ee marl coles a) ee = of inflamenatory bowel diwease includes aa Cs aden tees, FO of rims) ana ple ove eve. “Amingsateyates ‘ours conning Sinai aid (SA) a free ‘chaste et es catatonia, Mes Fest is deren albert, sin 0d Aso ‘Gen ASA primary nthe sen Tan corpus ati ffetve forthe ene of eve aa Naseer tisnance hs ony matt ney at, SS MES epoinaey be thoy fr ncn remit Cr ec) a generally ea pats sya ane veo vase an mt See ative rela eter weed we or Bath Chapter 86: Intammatory Bowel Desase 753 Inui in mann of iso is cng tri ‘Stuy: Athugh he compos we of and intrcane {nln cite erin vu so stats ry ce nar ee te {ems ae eps. However anys ee ee we mae dane he mary of se nes (08pm si ie sgytine macy hich shot cent a ASA puts, Soest Corticosteroids Pains witha moderately severe exacerbation of Cat's ee or “erative sola se reste say wih sel ree 40 thoy tthe ith severe dae tomnalaton sent wih ‘ero (eg rr myn) my tee sae Tne te pedo dee mpovcmen occ ‘Sra of therapy 12 Lowen fo Ci deans nels {orate cota? Lona of uae sl aires Patents unesponsve tose se puts a he nt Sac eect and ei none conan. Ceopores score ‘i ong hap. Speman els visa Bah, Skog cvaton cnet, nt inion ene th ‘Metosates be uel irene Une ghcocde ‘Sova mth stscloncrs fhe ool ad ‘Basdesnie aptly nnetatd inthe vr, esahing in wer syste Sway toed to yan py ‘tenon ea ht sil ciple Crm’ dist and to cs fecal stein alesse ater wiv active Cn dust (8 mG etn 303). Anim [nvaiage of buenonice ver prodnzone ia he mesons of Snare tear est enya re ‘teen cer renee a ave lowe inns oe ‘tc, bet se nore cosy Imewunosuppressive Agents Azathiprine, Gmercepopurine 6-MP) or methterat oe wd {nites wih etry Cro’ ate we cnet empemso ‘dice he dos of prednisone" Al manors deb Inport stn ete (eg, tone marow npycstun septs and Infection) Hyperenty posuronta a pmo are te ak Important advewe ec f eben Consrinstatin ol ed754 Gontintstina! Disorders recommended vith tense (Imi. Paneer in ‘same a of pants wen with azirine or MP" lopment of hangin ion of wate Development of enon a women come ere acabeles, sas mo reong ovine es 190. Sir rlauomip wih ebro ‘lologle Response Moditers Teta chine rina wtb dae ma amie sagan (Nay meen cite frm aes etal pew cv lob’ ese ety ee gereomcns and pena erie ie ‘pt ees saeco trary. nso rexctons y are (lace fing ibd) ce aor raisin cra eS" remus tr ele os eM ot er saa nd imphow ae pore ner. a schemas iamanaitceoae hinges dete osc ‘ome . _rt tn ot otemtneca sone are SSicnectee Semie ee em coctarome Ea a anne tan ange geri aea Eee epi eae aceasta aes etree rteesaten con sociemoiihaceaecnate ‘rents who develo dates ier etensive bowel resecie oe TESS esm ha bes (ecole. Opiate Analgesics (Opn decreas gansta iy, Cale we ay ead Sr cette, he nak habia Mz and some ‘Riva spore pons oR Atle tris or medi, te we Chepter 56: inflammatory Bowe Osease 755 Crohn's Disease ‘Therapeutic Choices (Figure 1) [Nonpharmacologic Choices + Erne i yoke vec ge 1+ Avie patents ot zr od groups The goa i ‘emu dene cal inake ea! lcs peter! mon muy he neeny sl pans sho ace Fate refacney wo mele inane Recreesersrgey ino nines ncoserstve uel manage eth een ‘th mime amount of bowel coe, + Pacino ad sil spp is mga pect fr inca ma Pharmacologic Choices (Table 1) See he previous goer dacusin of phaoassogc ces Teammate! dienes Contested emt tive fr the ids of remission 20% Fesonse at) Precnaene (40 tmp fo Tt ek) themest commen usd vg ‘Chroiclow-doecartioteri thray i eitive Sr the Itnenance of mmsion” However in ate with chilly ‘ie duese my roe consol ne redo (101013 topiny)wosapese er spe 4 Salaatcine (10 5 iy) nl sarily fective fo the ‘nis freon penny eens ee SASA refer for eaten ose den + The alee of ASA ass munennce henpy fer Cos dicate Scoala tse ico). + Pacts who recive pie antinetoies an mths soe ‘Seeftcivecorerpann a tee dg ay te testogeis gan, metboterae abst oni pine stole we oer cd ith cot ‘iain fs beeen peg wh ae [mince and erica ar mdr tae oa tm be ota In pepe ideted™ 4 Tati is etectve for paints who ae efron oat Ierepy= lau conned 4 pny they fe756. Gastioniestnt Disorders cy reife scectnemnsn ccna Scene ia upenrc pera he eof ia sia ee gee Serenata tape Sests nona smeesraoaman ‘Therapeutic Tips _ sa hyertnty ectin 10 ASA prpuaions a 2 SXSA des nt havea conicosteoitparng te {fale tended aes may occ pets who ave al ect tral een Tesora erties atlareeat Viera By icin Toon etn io invint nay eis etent mith Uncen: auhatins an crested Ns may exacete jor aso be aie Tess ctseneepy wenn force eanet corn 0 pbb Ulcerative Colitis, Therapeutic Choices (Figure 2) Nonpharmacologie Choices. eeNnmn weltolnced it wa supplements Tot pace MERI Ay cnoerny ns mney ofpatents wih severe ease Suge coletony) may be wd wo teat pent wh te actor See8 cay orb be cance changes 18 1+ Clone vitae prog input at ih 8 COS TSRy seer ena cremate dee, ong Sedation, SR en ising chtagiaa i ecommentd tng ven ‘ave te une cingnoss «Rito cole fe erat oii poi on 1 ont hear ae ea ral rere ara Soe eebtenoe = Symgtrs of pout ide ‘Src, rte on een Pharmacologic Gholees (Table 1) See the previous ge dacsin fpharcooge coisa ‘Aminoeyites ate by efetve x ecg nd sinning inc camel compre ih peck chapter 56: totar-matery Bowel Desase 7ST Smtr sth lea expensive prpraton sable an is wel, Toe by es pens Ang the meme © ASA products sheer {oe tin saan, thy dont poss perches, On, ia patents walb nae le mf. Cominos ocortiteroy,munevappresive agent ot nnimab revel fee tents mica dase who decine sry Use he awe ‘pote don of presse tocol dacte svi ‘The ene ofthe purine animetboles in env coli ee ‘well esata tam Crt’ ase Metotrenate notice [Bethe eeamen of ert cole” Highdow eyprine ny Se etecve mp th of pte with ene ese ee bf sca wih Boyar may es bf {opulent who rete sre an are toed of he pret for teu Recent muds he Conte he ny fei rhe Treaimet of tact elec cle. ‘Therapeutic Tips + ince con hen peeing mcs td mice ‘ior rps wave uence cee le penn se gs ny we a er ars be + Wea vidos gg ot te spanestion a igh ‘epics wien apy yee te ‘isk of colon cancer, 225 7 +a wi ee of wl ma ee + NSAIDs ny eaten or psp ep nd sb Ulcerative Proctitis ‘Therapeutic Choices (Figure 3) Pharmacologic Cholces (Table 1) Given hemi eset ofthe ienmation stun clo) he fos ont ery. SABA pars ont ena) {opi coeosterolds ose Ws aynce ea she meets svt fe er svi. Sopot ‘Rett nthe omingonsnecon om epe ere 1 remsion sot nce within Wf fr wack el 5:4 can be Aiea dt apg it tere ran av bento some ‘tard topical ASA incon dhrap Sue pate worse {Sihase menus a pedisone or are) concer PensChopler 56: Inflammatory Bowel Disease 759i n nal ui il Ht ‘Chapor 56; Intammstory Bowel Disease 763 I i deed = ena ng e Te emmayang rns 7 stove pect womens ee ed mei wena conn i = neice nimpacoay abet i m= arai i BE Ss i Secacese Senet a om i TEES SER eee EE a = = ee ai | 764 Gastoistosinal tee sntrase "Geet a ee =$ } 3 766. Gastoirosina! Disorders768. Gaevoinestnal Disorcers Pharmacoaconomic Considerations: Inflammatory Bowel Disease Me Mamann MSE PAD [Chaplar 56: Infommstor Bowe! Disease 76: Commentary Teens of tengo dacs, taint i more cxpenive ah {sina conte shen sonines wth meter seca ngennt of Cage any Saunton ftimathaepeversy como penny {oRanard tenes iow citer teatcn opin, Honeve dee Tefsormary et das BD) et cllevaly Eee tis (UC) a Cs dase (CD) Wages ot oa UC CO sean an ate more an double the dect Cou of east Fone tgm be Ue Ronn ot wages accord fe 120 {500 pe puem over eemorth Poe ‘toorg han 1 i comp Seer te ia Serpe Magali ce es ens Psi Rea li ok pean Epldemiobey Country Tncidnee and Prevalence ‘Cos (19871990) | Ueenive ais 15.6 ees per 100000 | pesonyea “Cont of Wis Dat eee ‘Country and Year of noon eeees Eimte iret Conte —_—_| tntieet Cost ‘Usiet snes Gamo [USS SOsbin | USS 12. 0blion CommentaryCHAPTER 57 Irritable Bowel Syndrome W. Grant Thompson, MD, FRCPC ‘acon ag sti oer a! SLM tee ae cg as sponte rr ta ems ‘an eee cman cnet tie floc eng tn eee ie mt ‘dy care Ce at dt tints, the few tt are tered sare neahars osetia Se enn cqcodnawen ones Bion Goals of Therapy + Alri ane weap wadiein a ee eel pany be ov US ater an ce! Howerce eel saeco eases Pn St font pesercnnty CT Teen tha te aon fas Cone to cosa physica, ove ry he waecesay na you pesoe with crue a pica Fee Pees slap ad fal story oka me rma bowel dose (DD) or eie dw abe 2,1 ‘SEMIIPEENIN geo Soyer. ane hs tk factor fr eases oF chapter 87° rable Bows! Syntne TTA Mt Ute Caglste uo revenues ht i Sots ee Cage and Chapter 115) “able 2._Alarm Symptoms That Cannot be Expllned by 18S ‘Therapeutic Choices (Table 3) Nonpharmacologie Chote + Feeney ie eben fo Meye aiatan Encourage compton ofa en det (Cana Food Gd to Avo fod ene cae, ols gs ‘otis a rs Gn peeves)772. Gastontostinal Osordors + Many ete propos by aerate practioner ote mia teteao oan fy Sos den boos ws Bese fo gat eymptoms that maybe cused by advene fs Beet east pede forte frei “+ oat, ona cent tary be, 1 Litsaleadheimen: sess managemen react vice, qt ime fir eatig and desecton a Treareomoridconions: depres. ane. pai, Me Poetic tents ny regi the involvement of eta rot atessont ant he bees apes with te ie Tear aiorng ry ip eatery cae, when ‘fcoptoloey x rte ptoptarnclog™ add 0 ny ‘Seopalive meal hey rps” STOR ond sete magenta tenes olin loan io pe oi improper and unecessary ey TBS pos ‘Beles mien or eypenieg or blader nese Pharmacologic Choices (Table 4) ervoth urpesesofwetment parent re oupes byte pedomiat vel fan conten geome pesotant {ating ewe onsen and ee «Whur nenparmacalogc mest tre the mast oleae ‘Sonam Tie) The Brel Sol Form cae Figur can be se to enti cents ester fo cnstipton odin Section of [sematerpy depends nly upon predomi oma. «Forget th paint hes (Set Stoo Ferm Sale re ES apNitamle rio may be secoomendd espera Pet El et a Sioa Form Seale type I: recommend two. Four blespoonful oF fae bono py day with plenty Bad For ots ith croc nomial ota pais tos ‘anSnang npn’ deipramne' ny be sand tape ete mowers anaes doses “s Teeapere aS HT pial agonist) apron waren with 1S REN on etna opt ramon, como TEE abtne seme dyn ofp hat sep edt ove sal et of CI symptoms oe pu Ca en ar 380) nade Uc ot AS Sattndtred cota ga tt ewe thse rs ine (Cpt be sia secant mae ily oar nchenic Ccnapter 57: table Bowel Sypdcome 773, ‘apy 23 hee ter dosing chp etd rte Fat rch of casemate eel y me tne rs aca ‘eho equi Htcan bound in women over 3s yar of pe wh Soke, ns who cant let eon, have uae Se Te ‘Sih, epenence mime beaches wih neuln Tintin wom wo ae testing anne Injectable Medrosyprogestrone Acetate (PA) 2a, gen by depot nection (Deo Proven) prance mena in {Se migrty of cnet re Wome cxprone sep tng ‘Suid efests eas owing, weg pn oie and med win ‘Dept Sia cn bs ud he psa ste ve aye pope) ‘Seng i weeks orc. cen ‘When depot P's coos, vlan and ep mensi erie yaa enue foro os Yar ae be at injection. Fate fea-oSenrea oe814 Sonat Heath ‘Atage coset staty omen (1898 yea fags) eda 428Ne pal Sone neal emsty (EMD) mses Depo Powe ‘han Amen Toe te of ss was baer fr women ho ae Ming Deg Pventefare age 31 ant tore wing iforloner ation TERE ccs he lone nuy oot be completly teers he lect sncace alow Ba, cape rants who hve ot Sect pak ove tne, ns be oie Ceo me ESR espns wae sown aml of denet wore (18 Pata ve te moa of MPA ees a sic is to sara inte ely veer Sal ued Pinson ht stogenepyiemematoe ote of one ‘Motecens is eon Spor PA ‘vautarine Syste US) Aeris of he rogentn-soang tantrine device Qi to Sete aion de ofrecer ist 2 ‘ed ofat ative years taste with ow yee el of TeSSere and sey effcscions 02 pegancy rate per year) [Ren tues meatal od Ise, fon pom alder, Iisa renee cnc atone mt Section [Risks associated with Hormonal Contraception ont ses ae equ omy cava ik er ses of otb Sttetonconbine onl conraepve(COCS) compared tv COCs (hts llr ogee Allcaovsclr kee sprech SMe cpeey coer tang COCe containing 90 ey ‘Shale Tate 3 Sing an yperenson aceze he ik of choc soe in EGER eESS Women wo tvenaloe wih nara a ot 8 ‘is ra of ache soe tan ween Who ave mine wit MBSLIS.SS/ tk or moke don ot ier beteeneecrton iat comand n COCs 2 Coarse cotacpt> ‘lel aren ser frm mais ih os eee ene smoke cipene or are hyperetse" ches ends er recite of ce Piano oN AN mcr er oe ate een a hes ‘Chapt 61: Coniracepon 815 “Tues vemos romboemboin (FTE cases wih ad [eto st aod ong ters COC t,t ea tanh to ld inrearea tk anacata wih pens" The ak oF VTE ase, ‘ihe esrogin dose bt he UTE ak sci CO {Sotnng 0 pe Een at of COCr oman 3. Sine Ee nhc nypercmpanie nt nc os aca Lien att, poten €or & Sete aged conn chm ‘si wos ony a ed wah re a {shes Woe nih Ft Laon wt we COCs ‘xpecnce a VTE Jo ner gh han oF COC a witht he ‘Rion trond dad ceting for eos domboptiss {fete a) angie an ety colons stich stecting cont re 9 og al ccs hate of VI reg ronmented = COks a ‘Scioto homens hstey of VE and ype In mary, he ik of cadhvacua diesen naneoking oan wore nthe ge of 38 5 sha ne eat [Rpt chews sn vor eo on {nlvsbalee COC sles ted hry Conte nals ‘ikon pee such phi, Smoking snd ‘pertentin: Nonsooscpine bene shoul abo be one ‘The rik of rent eancria COC urs comtoersia, Most ses fC ate and etn cancer nd ay overall oa te erase Sarat! Invwomerunderthe ae the kn 1000 CO Incest te sk 13-73 i O00, Ar women ae tek roses ‘Oncor for bean camer tee! having sty by the ee sin cena et ciel ih ean ‘he dtay in resnncy In women wih = porte Ely hry fest ‘Scion Sie wine nie Emergency Postcoltal Contraception (see Teble5) Levon Pan Be spr does of 27 mga 12 os Sone S ged nin bo of apse Menute evens 9%, ot eeted popes The ane etind {Gresopans Sct oEE 100 pg wih eengel 3p en {Cov Spur preven tof cepted epee Te sec (Sema bent rns a hy ‘ims can eter eto vey aerate rsh ‘the effectiveness declines with incrensing delay between unprotected L Me cymes Voor ee tied compe tad ads ond ekg owe tan leo Benin ter Tana beet sess ite wet are C5 Steeda MA ses eae 3 wes ar816 Sonus Heath ‘ade of acs ch mo ming oe re eer mh creme alone sn wih he Yuzpe met Beet Bente a ernment by 1 uy arenes he os "Te rogestinanly method Pian 8) ha goo say reed, Thee Pee Urb o Pe witun 4 ay tthe presen RESORTS inergenysortacpne ser To combed OC (Si eheeta cate cmt in aes wih eBay a sold not be sed i thse wih» sory of Siders Pan may be etd n pts wo have aa ata th eovogens a conned comecepves. ENSESEY Sareea ns no ie one eablisbed postmpantaton erate escitalinseion of copper TUD ea be onside pt see dye TacSiopttele eco, Prir oto, sport exci ra pez. Asana doors Ele ae of Bn om neta 400 Irn poco TUDs = Tah the techn of howe spss 0 harper ‘uy and mpbotaon ‘Contraception in Special Populations ‘raaetwaing and Contacep ot . care rmctatementcnen eyramateiremmie mates er espe Dcton pegetoc a Se Ee crete oer iris ee rma teenn ee ace fon ee ‘eestor een Sean Shoe aa oa ne slits opener Se tee i mn sere caeenmnetme my ewscutel we eco ee et ioxecticears ise aac i ads vega nus an rept noes op a cater mraastcne eames en nin gaat gba THe am be ete as chapter 61: Contscepton 817 ‘iv and Contraception Come a onsen of mal onda ihe most fective wy ‘oreace ri of sequin and ansman f TV Regards of ovulation dope, series canning anonyme ovide any pte ga HIV onmecpve meio ct Aibough ee coche ‘Sere fap netn rome HIVATOS wt oe {brand atow wonrmo io tnifeedprnrs ven kng People who engage mmx nercourse wl are who maybe [iia soe content and corey ue ae condoms iO ‘monje sparen 0 oer conrsopive tebe oed ‘chseces as proportions ween it IVIAIDS. Tho iron ‘tong eines of oociation enen ne Oso dept MPR ad NV teen’ sa ‘Therapeutic Tips + OCshelp opal eycls an derese mens flow. This may help (Gera sore ween wah her or arog pe, + Noncontcaptve heath benef buted 0 OC wt nls ‘tres the equeny of eedmetal ease i fendometions po benign test See: fea vara) ‘Slop regnatey,dumencricn, pec inflammatory dene oad ‘mene! gts + Hoon! coneaeption doe ot protect guint acuson of ‘Sully transi nfeton, Evie pets on eo Fier + Compared t cyto ut, continuous tf mosophace il rx In fwer bleding da, crease liteliond of sie eft soc recente ein dre ‘Wlower beeing dae ave may bene noe lego ‘heme Longer fy dss. however + lnnensmoling women with 0 cadiovasala rk fats, COCs ny te come or coneacopton cr seel of tunes were ‘slag bal meaopase ‘vances compart tenementchapter 6: 818 Sonal Heath tanning un wanes nwo mes Sos semeenmpmonwanetennmns TEESE rsmay ccicamtncnc cae tars enn en ne neseeraes ga eles nme sce Seat Seat UMD RAE cSt ea “RN TERE eet ee eS coment tne “ES ‘pow endabie5 wiowioWoN “EAL1820 Senusl Hoa halle! Hitt Wk824 sonusl Heaths EE ane QoS mnt ates mon 0B geomet sae ue tue 7 * SEES ncn enh potent pti a ‘par aponog onpdeoenuiog |evOWLOH FORE, 826 Sonus Heathit tlt ih AH 1828 Servo! HeathTeese tute uahotin wot nme Meno oa ‘ ame cae ot sa) sete ae cut Siteesnse foto reces donee “Sed god See a Se Ee ot Ee ee : pam ease na FOR832. Senun! Heath ‘suggested Readings = bg Feo oe a Cai eterna ie Arana’ Rowe a, Carian cnacesion cosets soe Css Con 908 2934787, 39-0, So es ae Te SOG cal ratios “ei iumterteaytm somente. Obst! Cynoee! Can Soataae)2-98 aca at Fay Ping Reqrdive Heals Ca, FFFRIC ate iy 2008 Contraceptive aes fr Mri Sees fy Pann ep Hea care ane 0) 181, ran th Steen RAC Tompson CR tal. Ppt bed ty Ta i sens irrgembtion oct wis aos ta hacepve Lancer 1997 890085) 938 Pea R NS Mages Ica The i of cope pregame er Sega US Colssonsive Reve of Seiizaion Wong ‘Group 9 bgt ed 1997.38611) 7527, CChapiar 61: Contraception 833 = GEES UGS one834 somal Heath Rese eaeRE Bae CHAPTER 62 Dysmenorrhea Glenn H. Gill MD, COFP, FRCSC semen ssn sho bem ne apo nc ee? ‘yeberrnth Goals of Therapy + Decree oish mem psin tha eres with every + Ruleou ogi ane pin tht may ete sre teas Investigations 1 A throu Mtn drei pinay i secondo Spano (ble 9 1 Inprimary dsrenrbe: ~ pain sts within eer our eos mension a te rae the star fees! ~ pain se ton res dys ~ ins bw cm nove soe ad ~ ster spon of psa eet my be sat, ‘en von, en ace gh phe + Physical eamiaton for rary dyanenante should ea ~ tonal absomialeaniation, Le, noel of hm otten aed thr shia aay ~ somal exe genta = never of vagina anomalies with tow xtucion son pi amit wih eva eal woe, ‘uspected: hen pe ison, lapaepy tera oF Iystembingogim (ISG) may be cae836. Sonuat Heath ne ea Seemenagee” | Seater nee “Therapeutic Choices (Figure 1) Nonpharmacotogle Cholces ae tt piony demenore fa common, stl Pa ‘Siegel phenomenon Fea yn eso 20 HE POT rma not es 1 ee arpa ter Sec ren ype so eo enn Pharmacologic Choleet INSAibs (Table 2) trary encased cca cis Sori 2 mary ne san (PC) poco yt emda send incense es ses i) nates se ee eet of ie De eet ASA har rime ft ae eine tt NSAID, nett AS npc happen be mi for ofcne of re needs mae wees siceseand oe vee pt nyse ts of a SAD ner we i te ing meat ote ost of NSAIDS Sl vodcotm 23 6? Ccnapier 62: Oysmenortea 837 ‘Combined Oral Contraceptives ‘Combine a eonrsetves (OCs iit wun, hic nits Satin seh ad ics nema od ov, ey meen etn re cp wages ee aera eae efetenan ota abe COCs COC ae abe Perce for howe wing contraption, Comics ao jt gens ay decent reoray of esta Pent ec er ps tm on Progestin-only Contraceptives ‘Levonorgestrel intestine ter (UNG TUS) stor men LeEeeee Groves dyameneiens°! The eae of low dose of Meeker Cetin overs pstod of fst ve oars a \eronpe ato tonne spe a iave” (es Cape) aes ac weumcm epsnnsn he anageest of PAM “pmmencrbe Mearenyprogeserone (MPA), vn by depot jon, supe steams? ies enamel aro tn pode memos Hn ey Conder dept MPA se atreatmet option ie se cece of pinay dyemnarbe a women wo ent era cee ie omen wy arove 3S years wn sok, Use Se nas ge 100 18 you dae 0 se of CE, ‘Seven dost ‘Therapeutic Tips. rr Tnepat ao hes ix mon fea NSAID or COC fap ae deme ccanenes either fh, he ‘maybe defo ure vesipton ‘Comimus we af COCs ir fen syeces ieyehe we als Tevemorgesel 1S sight ecive fo prima dsmenres ot Ep teenday teenie « rcannateany isn 2% of patent, These patent fen have atmo rere eer invetsoe, Dag eg gett aerenane pimary eon nconny «ns pal prema of ptt wom phamacatengy fal ta pain i ot Henly speci come, Coser serge uch me» Cl x sce poten) when ‘omacaterpy fal «Catt chanel leks, magni, loi, nanos ce Ate samt, seeps, typos Engel sening re rem ineS) i ss wmnaone nema Sane SS eee scope ted TTS TERE ete EIS ESOS SousSU RAEN SGNEN LCHAPTER 63 Endometriosis G. Barry Gilltand, MD, FRESC Endometfonis lagna by Sing sue th scope eembles ‘os sr ee cy cece pam iret wine ttc no ds Femity Stel Cascio’ (VARS) ere det celta Recarentpain fom eadontiss cus gue. ARE eaten “mone en (eta he ‘timated to be as ih a 4% a ten Yeas of allow-op? nomen yb ete wil rg gery oth nid ‘resent aterdngo sg duno itary event pli a, Goals of Therapy Investigations Diagnosis i ita eo variable rvetation Suce’oaia i abe covsio og, able bowel ymsroe, "story of pli pin (cca at it, Pecans comin rendement west, d¥smenehen Obes a inh iat 3: Sp apn ery Posi examination Chapter 62: Endomeviosls 843 Signifcamtlyskvsed (39 (Um) bat ot ats foe fotow-ap and may ac in ying infers women wise ‘etn mh cl ec ng {ivoetons? however, these Fetes se erect Sty of elaaound poor rte dt o a impatt MRI: st fer dein dep sapere eos ad for Endometriosis-associated Pain ‘Therapeutic Choices (Figure 1) ety Remmatced to be eterna he ahr wap occ, Nonpharmacologle Choices ‘Surgery (Table 1), Def ey of nda pin eis Sree econ or ato o comets. cndrs ‘palit o pon ype sy. The maj st {pene one memes fro hereto ace ee Fetoge eplcenen thempypoopcativcly reacted wi nina (1080 ro ese eee844 Sonus! Heat Conservative sree for coders it creed roe ‘Sar lenoxnocury cus Sity to 1084 of pases Srp Cicrened cvriy fin ar ablative sugary" ecarence tren fm foo aha ve yun Conair gery cn be prone ‘lapracony a opr ad ba proces ae aly ete octal vantages of apracopy ince he by to eat thedsase [Srcume ofdiaposs, bane removal ma ation of endometie ‘edncd mshi sr pital saya every nd pel ‘Eres nite co ponoperatve sthesn formation Later aon “nd apatepic trocar nerve sition (LUNA) eet rere hn et 9 of ed put compat 228 th coma res neasclomy, a conjunction with comer sure or ‘Senay be ec scons ine met ‘rosnssinave pean Reus of ang ths proce coms Sezer ne mcd Table 1! Surgical Managoment of Endometrosis-atsociated {oferty or Pate Chapter 63: Endometiosis BAS Pharmacologic Choices (able 2) [Nonsteroidal Antnflammatory Drugs (NSAIDs) ‘mene mnie se ten SSiercreteeergete nce Seeetedeatamatee Soveeers anon patiadeedee, Opioids pio anaes ar wad at el etet on tel mosiy my itp oi Attu ong ter ey Tend onion, ‘nay be appropri male pats with ntactechenc pian ‘otto of rg abe" Avo ts wit anes oy are ‘Ssoitd wit wound pon Fenland Waster ues ay be nol colce as more cane st rele ae manned Contraceptives ee ea re rae Save e mre, eae CS tmp ora ee on mt pres {omotope secretion thereby inducing» Mycogen pc omona neon = Medrosrpregestrone acetate (MPA), 10 ng very 6 12 necks hen byt ope injerten (Dupo rental edn ain Sindee smenartben "Do otc MPA yomge ween whe SiN fecome nt imme se spe earn se ‘Rniption of evlaton cay folowing cstion a apy. A ‘pet MPA may deerme tone minal dy ons Chae 1)" ‘ete ts fo de pets wha do nat wnt tscontre a wish {avid srry. Comino oa MPA, 20-0 mg ay rele STaumes pomplyaterdaceurecoe LSet 80) inure J) pres nv es aecing ‘agit me te ee cavity a ead rao 30 pay ener ‘tcp prog An efsnehomoal eon er eat st ‘piplomaendomeresis nto matte daze) ENG TUS tes ‘Seago cows and ett symp cone er pee Sear advarngs cle ower cov, oY ese el foe fi ete Breakthrough ling Canaan expec he int tee months: Arena ecu ap 35 opts on Yea. | | |£846 Sens! Hoatn Androgen Agonists ‘Sonoeonca ef home pli in’ Eadometomas ses: ha Ices open pony omen Fs mayo Ubecarlr sags ofthe dacaze> Hypownropenic side effects sch a ‘Seom and oe ae comer wit noo tar. sng Hormone Analogues Gonadotropinreleas (Gnttansiogues ‘Gonadotropin-slasing hormone anloges(GaRW- analogues) ‘Eh he byte pay godt treating he rte SFE ans ro qt for fla development an vesting a tntellybypcsnopene tt, which indies soph wo eareson Sent naman apn ot Us afarsin 200 namely ee daly, pocereia 36 nb ‘NScumnaesy mayor uprohe 75a erect omy ‘ieee to ahongs of one Git-oalogur ever ane Ne reat ing see oe imal spam wee eset ‘ing Coiaagwe her fee rsx ont Hypoestoxeme “tcf comes aise b a nomi ‘Sans vagal spy. Decree tone mineral diy oF ‘S35 sea nace af loge aa forte oem ‘Rocurece of anlonction syns common esc ane © ‘sve mont ale capcom o ep, “As back ormone ep, consisting of contusion (6, Ser eeSegne eeu eS ma als propesin er itd may irnovesbypestopeie spo nl cies I dy, wath my tow ge raion of ergy” ‘ites tery conn wih aS therapy. a eective ‘Gaited are od fore ote one with aback, ‘Bato cay or osc monn sl tek noes =n ‘Spa ie ft back ray as teen asd ‘oon an be wed in ptt who are GaRanaogne ‘router bunstinate oro sr as igh isk or ave ede of ‘near oe Caper 73). ‘Aromatase inhibitors frets with comets have a high eel fate P40 Capes te copie md scope endmernane Arms P30 ‘sens tnsnewel trot setae stop rue Fun sss ‘Sher tanh ovr ache he ave pon Aromat ios re CChople 63: Endometicsis 847 smc iter Galt ang rage oreice "promising new approach toe therapy for endometio "Se bt ‘min mvt = Antiprogestins Mileprtone (R48) sows promi in the sagen of pia [Mendomeron bu ger ono tcl tare sede ‘Sabian he role canopies nthe manapanent of endoneioia epaane nt sate Conn Endometriosis-associated Infertility Therapeutic Choices (Figure 1) Nonphamacologie Coleen Sanne ase) ‘con cman iy ape Sear Stat short plo pnd eh en a Temagami fn a om EIR seca oe nee eae Septeeee peraice ae ea Spe crak oer ‘epson geno ber ioe Sosinieeintemcna ease em ‘Assisted Reproductive Technologies “Te eae ofa vito frtnin- cote ante VET) aig foetus nocd inet bs been vain aed set cf mc ro prac rn hs a Therpy maybe cosidered in mide fons endomesrons raced | inet, Pharmacologic Choices (Table 2, Table 3) Ovuintion induction Comin om iy dy. nti na es ‘Slovan odtton wither eto mmacoe meminten Soe nt ‘Nose inns pero) rer at ele wih nung increase ‘rinmasienne renin Maman chorion Bonadeapin WC)848 Sonal Hosth sometines ed in doe of Sf 1 000s i miele © (A Cochrme sve cnsided ht sinister Gok analogues iictiec a mon posto IVE or taco spe {Secon (i) women wih euometre rel foto ‘Exotic tecnica! preguney= Use genagoopin ery, ‘Sih sn auyeoration commas ornare heraton ‘on arc fy eth es inion eee reanon ecu of sue et pons hey (ete te ‘Meroe tote 1 yea ec pasts may Bee ea an ‘Soaks ae at penn as cron ‘Overian Suppression Inara presets pregnancy ay esd ran opon th ‘rae Cociendo pn Recurrent Endometriosis : ‘Therapeutic Cholees (Figure 1) Nonpharmacologle Choices. ‘Surgery (Table 1) Conran surgery maybe considered fo rcurent dss, ifin ‘Sioa a a dec tn ney. Sean Prguany door bt nance average ne fo een tSmpons Hysrcony,it o wit ir nreomy. on a at fete pn ora mas A reronperive muy feet of ‘Notes deve ser, wih mee low apo es, rn sel ha pans hn comeraton recor spt snd M5 ee rer ey. TES ‘tt isc Gopretomy, 1H fad recent sy and 376 ‘ied rer ugery The major of patents eho had eal ‘efecto hed ubaqoety hen cegen elon ry with tetnivewe eet on enomerion Tere nivuage delaying the IMevthctin af ogo sopicement erapy ae spe Chapter 63: Endometiosla 849 Pharmacologic Choices (Table 2, Table 3) ‘Mid Disease Low-doe OC rece symptoms of mil nese (agg by ple ‘eobeparto igh ton dre Os ate wa od Idee OC may winchoet “ees ‘Advanced Disease Medioxyogeterene, dala & GAR analog rive he pain ‘ot mvaned nase (cgay on aes mas ed wes oe ‘heaton fe al-es) at ty o alec te dsne prces ‘Although hve drags my toc hee enone ee (Stitecteriy save ms fection a srbea ine othe ental one of ge. ‘edn or progesterone wen ere ha ben ‘mae secon bone lee with Gt asgi therapy Bae deat ‘roo boingevlated rth patent hs he’ aces oseaposs ‘Use Gn analogue exment, combined witha. bek beara ‘hop aa alraie to repesed Cat moat Gee ‘Alogi aon fs aphnphte pve tnt Sal pop of easmeions pan teated wi = Gn smi ‘Ructck terpy (dig HY to Gait augue) Soe toe the recence ter of endian. cay of amen tt ‘evo sd sive ypoetogeni ees deere atch ot ‘Therapeutic Tips ‘+ Endometriosis usb dingo by laproseopy = boy 1 Gans ev pin pon mil and toad be weve as «rug tne fendmetiss doer nt improv fein. {NSAIDs cin be sodas an acne! with coined rl eonaceptves, genio conc, Catt noes See + Caney no singe nuk mone tea he eon rected {oral women ened wis Galnaniopsc ‘+ Gaibanloges ate pot more eet tan COCs progesine in Inanoingentetins nected pu. + Hormonal wentnent may be se ror t surgery to ode he sue of ave pnts howeve the ty oer pons pee + Porsargey veil dane ested with rope, dase) {° Galtanioge in combines with spr aprteny,: Se venommeuitseanees tus mumunne sesame —amocens eng a : eincomamigaies teimncasattesten mate eS 3 comyoogmtece oman Ey te Oh | -aSSe ——_SEe SES ‘ealae-amon see wer mons aun aes setae miomeneshieness Ta eam ee Sa + sxopibandaian sitions Yourummamane tm fapedans riesgo ms =e Sia Za =e i i | iSE pm = ee ene = 8 _Aeenpuamevinueissieonmy avanarsusmominaone ‘SoSwgt wmewisnaes cube weaned ean wor mag Nomen ts Pee cmmelg | e a Red ener ams a com “Shoat ua" “etmemorsoiannaes etic i ua aa SSRN, ce nme ep SORE oun ianne ERE vtme wriin Te weve ommute x onive pacoires, pane aecie masse oer ~ SESS SS et i estes “Soe ie SE = = =e Sd eee _ ‘ : Simeone imemmnsinmen ies 3s te mapa sige spe SeLemououmuMisesaees — temotan, Boe Ss om rr en i asmcpransQlcemies SuimonanemOtarsae —fepaeeeL en oscomant iceman —eieamamdtes ene a — a 3 Tie PRON TINGBERG ToSee eeete|1856 Sonusl Heath ‘able 2) brags Used for Endometosis- associated nfertiy ‘chapter 88: Endomewosls 857CHAPTER 64 Menopause Amie J Callnore, MD, MSe, FRCS Seciovscenny tet ston pstcan yey ‘ation or hetoterpy este or resort o theories ine ‘ono spins, commonly how a at ates a night sweats ‘lupe The equocy of ho ashes paul eres ver sk ‘renee thai deo ow extoge eves Wane on corps of SSeS gm ae yr sna ped Unie ak Mood clang esha port nthe mop eso ad Goals of Therapy 1 Redic symploms asolated with ect extogen eves ahing ‘omer abit thes, ares ight rea) ogee "copy (rapnal eos, dypecmi) an! to eae hangs {cpio at sepesaes) ‘rok and venous rrmbouraion (VTE) Investigations 1+ Conf extn of van activity Fes) Ccnapir 64: Menopause 861 ‘amt nd cena ptalogy ~ Conaderyoungee women fe rarmeerapy iat herr or ‘rent saen song aly Sy + loveigte ty unexpected bleeding by meee 6 dome ‘pling lou adomer erin ‘Therapeutic Choices (Figure 1) Nonpharmacologic Choices + Lele notion nay psively mgt vasomotor symtoms ‘one mote eapomre and igh ot mass index (27 4) roc wih poner prevalence of mt fash” ~ srt improves Bushing in overweight pastmenopota Pcting paced spiation may ede quency of sng ‘oncing eros engrtie eng Wy a tin Pharmacologic Choices (Table 1, Table 2) ‘The tement of vasomotor symp, vagina aptoms an 00d Vasomotor Sympioms ‘eniaresing,Pching or ght owes a lad erpcm nigh, ‘Miguc end decreased pdoctig s work? trogen ini forthe sorte eli of vasomotor symptom a ‘Merc ome tne Bogonng with one of 03 me fens ‘oper ein) enone td then cee the dae afer862 Sesuat Heath sogen preputons my tendered oa, ander, ‘cil farenarlySropte olen such erased {ES ee hrc tite ra ‘Stinton ae theta comes of pee ee a ‘myc neon or ctr . Wists ines snares Ting or eauvalnt) and 012 eck low ame (compos {stopns 0.3 mg or aqtalen Laer dase of stops ne sect ‘tiered melee of trea Hedin bret eden mace anlar doves Egon lone a women witht a ers shoul ews contimusty ‘rng ie mono reac the ak of eactbaton mena Table ‘> Absolute Gontraindications to Estrogen and Progestin ‘meray Rp sounsttnatnny rea toyeseae menage Progestin ic inca in women using nsec estrogen who have on ‘actus The dove the eile fmg medranyprogeerone rca (MPA) far peal egumens 25 forces eats ‘Aisolucontnnctons io etogen on popes tea ar ied Consider orogens sich ax ala injectable MPA ad megertrol ‘Scene aera teatmens or bo ashes some women ‘Tio caaot or who dono want owe enrugea rp Do nt [Resmmend progesterone saben tc ot event rei ‘Sjgeal when we io cmblnton with eotogen therapy a yomen ‘rb nace cue noen wheter pogns ‘monoterpy insross the of beast cancer? Contmaous atop with tcl pogesin bps ace he Hk of ‘Sdn byperian or ercinoma i wren wih ser Incyte ‘Seimen,exbopen ate somtncsty and progestin take day TB tof elendar om A momen cn expects awl lcd Cchapir 64: Menopause 863 ‘when he progenin i stappe. Thizapmen is feed beste of ‘Benes etn Contmos combined haropy with sop nd progestin ken daly ‘eoata teak ahs mont Somamaiy ped pen Thebes {hero of teeing andthe rik of done arcane. Dag Arty se, anexpeed open rig lading ay our ‘Therein god evidence osgpe the Dest ay to dscotine ermone Aheupy.Ailwemen sbeld have an asa vi ote teary threat cre prvi Avo ie stop Scanian ay rally reducing te dove nd expr. Ithe pate fees ‘Yetta ith ter does, conta doe wl the oe Syploms abate Prevention of Cardovaecler ieeare and Oxteoporesis with Eseogen Use stop is ot nt forthe primary oscar penton ‘Sf catdiovsslar dene ad entero Two ore, niall ls fae shown tha ebrgenpogein reste inet friar end prevenson of creay rer Seare {CAD} Preenton of CAD i at achive by Smponng ea Stent ne ety cn ce my Sch onthypnecer se pu owen aps (oe Chr nd Gate Care viens indices tat he reveton of copa smd Be sees ea en pene Shaner “ese ‘Risks Associated with ExtrogenTherpy In the esrope pops Wore Heath Itt) at he hk fet cone ne and VTE: cutwegh he ene of ‘iced faces and colorectal cance equ ar five ye of {otinen VIP ik teat jer of we war 6d higher ih scoge-pogenun compared peso. AUugh te ik dace over time te overage yas temained agent elevated iia Ra 28h cr 36835) Tne cag wah teil ah erie end ancl oe ‘The ri of ree cancer with xtoge-pogestin we ior the Ince i with deed menopse the sonal ok ch ch ‘Moar ens of se The solute Wk oe hvda! war, bomen |1864 Sonus! Heat ‘ul 8 cmsexintomone usr cerpred wih 10 acho wer pet iBton wines ua art een nce tates howeret, ong mote ath trgerslon res oe Seiten andthe lesb am canes fo boron ray HT) orca 0 hempeite open A merteeien cowed edd Feeney and seve ot meno us ith paroetne, ‘enlnferne clone 2d gabypentn neh ompoaa ween ‘Thee ue my belied bye ce Vente, 78mg ad 13 tp occa ht ah scetby cmpared ts an plsebo [tfanenrprua wtnen sr 4 ook of tentnent™ Paonetoe ‘hold coe 12 mg eceael dy ot sh compost ere by [2s Compared 78am wih lab afer weno reset (Comer elaine a paroncine oe ley protons Catupenin 990 mg ny reac ef gee Sh seveity by 34% compara 37% Sen with pace ser 12 wens ‘tet onenenepasal nomen eapurencing = hot Base ‘dy A pe cle tal owed a retacton not ag scores ‘ih tonetine compared to 36% win pce mone wih esr ‘lolly acing anthgpenetne, a acoso rds coming ‘herbaria, fgoane and bono Beet Spaeabs) se mc one er dered anne myn al ES chou over damage" Vlada 80 1 dal se Sow 1 Saleem decreng bot antes" Progetrone cca anon etecommended cnet er ne reverential papas ‘ten ed a cembation wih estrogen hep in worsen Wit aac ‘Therein evidence oppor the wef cipuncre st Vaginal Symptoms strgen adn intragaally (reams, agin bles soe sein nga cose for esting te symgton fyi ‘opt ponntsoyatl wren and may eo ane ‘xperenng ony vial stom Vail stopens ae peered ‘neonate srogen fal, rade os they ‘cs ower sytem oi levee nd ntact Stila, sine eng od east ends ‘agin! moistries Repl) grow vain yes an dyer ‘shen cd contac Naga tries can teed need ace ‘me Chapter 64: Menopause, B65 Mood Changes ‘Wonca pomsin thu te meng! aston ny notice Shines nol eng ney and eta ck on ‘Supine y selene: Woke rate a ert of ‘Span ce ew prove nyo cerns Sens forse! eal and «ng Frmeopaealwaaion* ew tod ‘irda an amy mh SOR a meose boone ray fo the wo da tepond ones oe Therapeutic Tips + Consider te neds nd want of ach pent pie ecmmendng ‘Stoure of tery formeneaual spon Hash pst ha {ic heath istry al it poe ets te eave ent ‘Sew drve tom hormone thepy and tow ite mses Seons ‘eu ie and health Unewerigpecyaplo al pcs iyo met he nia eds af ma + Conse ify ces either lone or combination wth armone {serpy erases ts nadia ed ent ‘+ Prscbe vagina estogenpepurtion if menopasa symptoms ae ‘elo. ‘+ resi mone thay fr pins who ener menpanse pir ge, petra fare acid wha caryh {Be eden af aval dene and oseoyrins, Cons ‘steal ae eae 0, the age hen nt woman eachseas nS ate ee muon an ante ee Ee eee 3 = a3 "es Bay pe ure 1 Reece 3 eeesioes aS oe torent TREES weneny seve walh = =a “ale ete mo ou Bu 003 Pe a ce cot rd a SEE ot * serous rimeneiitat Senne Taeacuta wana gn na Teron ot wa Spe oo maton em sta ord pesca amc bia ne sn gti i il A a L lh sft th heiz ee M SS ER RETA ATTN TL g874 senuat Heanh CHAPTER 65 Female Sexual Dysfunction Rovemary Basson, MD, FRCP(UR) Interviewing for Female Sexual Dysfunction® eral poems in the patients own words Clay wth ct ‘Senaytehoiu pe sel acta priaey sty be ‘Sco fea tre ns wn ac ech are x te: How cana determine wha precipitated this eguest fr ely Asses each ore alone Tare atm of he tnt ener ‘Seater thay sea facie Sine ming opossums owe copel Who876 Sexust Heath aye) was this pron lose, sow tfton by ft ved ‘Semper ° Represent ts in ‘SST een a one and oot cso inp (SusSte o e problee t Women’s Sexual Desire/Interest Disorder ‘Abe dined flings of sexu interest odes, best ‘22a Shap noes dance eoonsive des setines ESET enters aoier Motos tnd ‘Sthuincemes) for atoning to Beste sexy ened ae ‘etcanent The oko iert comic tbe Dyer oat {Semin wigs sd relator cation Goals of Therapy 1 Leofy peed inerperoon end ei! tes 1 rode pent and pts with tooled and undertnding of xl eons ple ee 1) Aes prelate rss 1 emiy ced for pyhogil or ayehite constaton or Spee ies dat pen de orman espamdng Seva ‘fetal eta seultn ber enpersnong neat emo ich ‘Sane, git oc gst with aru Investigations Sena history indigent pst sen Sain of oth ‘etme oe Inuriowng for Fen Seal Dyaincie) Past ‘Eh! nction song seule issn sex fen® ‘Metical istry snldng meatonLble 1) and 008 Rettnsip dt, toh pt an preent, coins an mst Inn, stand eet sen, ir cnt, fy an re Feng erica forthe rete eee with women's + Labinvestignon only snc ty media hse. No cetaton Shit oll betwee mrogeneetzond eal non 1 Thi inure teomee swt St of onnatre made within cls [acted eel sae tay eee ‘ee tone) eons in he ae ranre™ Ccheptr 6S: Female Sexi Dystncion 877 Table 1: Drager Associated with Fomale Sexual Dysfunction Therapeutic Choices Nonpharmacologic Cholces 1 Coumel or eer he oop when hele enotons! timocy is wien npr sie Aes ak of stim iui ongeial ial or onpensate genial sa lds pycoloia fo ht re inbbiting the fecvees of xc stmoiaon Mjtrctonlnosec resort = yphori soul may inte evs abuse) © Corts! stots © low etaonpoor by ae ‘xpecition of pina pst isory af dyer ca tree ‘Site proces ssansimaty ven pains cme eat ~ fegatveoteome, eg purine’ sexe djtietin, In this [Runon, ares tbe prim robles Ad bls for ting the eflivens of simulation ‘epresion ~ medion Tale 1 file: eg sop ands it work, disturbed ngs © deteand sadrogen sty (Table 2) = inert mens eoe,¢g, hyperraucneia yori | |878 semua! Hosts G ‘Toble2:_Theortial Causes of Androgen Inautiieney® “The diagnosis of mdogen asin sed on ines tent seat Succ in epee fo fhe oon sted In tube ae ac tat to wgger ei nd becme mane ‘ante dae sea expen now ome ial ‘hatduneder Sop sniogen uns whem owe fe ot os thes Tbe? cats Pharmacologic Choices “Thee at approved phanacoogi ene for womens sexe desreiners doovetAlhoog physicians experienced women ‘Sta tinction are vetigaingtstoteroe ray wih el ishowcap for women with coos sets wih marked ection {andogen acy (Tele 3) gules fom the Amen Ensie ‘Sisley sccomment hte the eof estenne plc in wom ‘oe ther safc Bovomes valle ‘There are na are famulstions of dope or wore. esting ‘trope pstmcnopaurl women witha esac puch cong ‘Stoners S00 gh ee nested 85 Sac apy elt ‘esosteone eit he ape ht none fe oan shy ‘tomes, The dose delivered svat eh ramus nd re ‘erms af enoerne couse unwanted sopepisalopca estesterne fetes and so a ee Women’s Sexual Arousal Disorders Alas of jective mul equ ocas despite x arma ental ‘ctogete rons A wetorsswaenes of be engorgset of {he eel ein minal Her ujestie expeencs lrced ‘or conaitenty by concent gs eto than estback om he aocongeinggenaln 2 Combined geno siete several daorder ise of ‘emareil dimes feng of snl rows xual eevee ‘Suen pee oo oy ype txt tilt as well 1 compas of abet or imped geil sexu arose (la Selig hia) Boku rout oy ype ota ‘tos and ay eres of penta vasongstion ae ase + Sujet vernal arse! dre the tence of mately mimi ting fox wos tun exe sex i eae fom any peo een selon Vag aaton ot | ‘her sien a psa apna ll aetr’ Deme ack face i etl on ty Spe say NS sateen setng | ino. | i | ec 8: Forte Sao opticton 87 | | * Leinial valat etn vga tien om ay pe ‘Sal simaton and outed etl senenton fom eresing [ental Suge sonal xcement sl ose fo say ‘Senge sil bra "pei! dade” repre” Goals of Therapy | 1 Addiessany ack of equte aud ior ysl sea sia + 1 Ades peopl ctor impaving eet ore | ‘tacts sea ney, esos, eos ee res {+ Adis ope ets inpaing subjective woul eg tg, Sepronion, section (Tbe onope auimsy Table) Goges deflect unr mere dps metion i (abe stogennuticoey Cabe3) trveatigations ‘Soni Hstory: cent ap pat sexual fenton bth ports {imerewing fr Fema Srl Dyrtencon’) Metal story ceding sneition (abe and med 1 Reh dette, be past and preset owing en oneal ‘mms, reps sft cont, es and ss + Genta examination: aihugh ya exaination sally nema, ‘tepaned nk gna pons ay be he est of vulval {sop or ond such anon sclera + Lablevestigons oly inked by edie stay ‘Therapeutic Choices Nonpharmacologic Choices : 1 Prose nfrnston iter ak of imal outlet \ 1 Connalrfer when he couple's enim ininay i eset ‘eal the vine nade for sean sour 1+ Addeaspgclopal ets. ey nonsena dacsions, ing ‘ey ttsndardor ana capri eave tone, aegane1880 Sona! Heath eosin thems spores anger an therefore peed ‘Stat enaton sme ater of fing emotions inal Pharmacologic Choices ‘how in peed asco een bi et Toone aloes nicer ela weet at vaca apne msec nl rte re se eens Heng Ge Nomen Sel Dea acet Sete ltecoge choc [Astest nea ant Meg its ho den {see eon ven ask of et cnet of fo se ase eS pr pose Sixtheonm tine av one a abe phous ene Rope wel es ntl my np gee cg he ‘ine ihre ire consent these ee Capt 6), Sle tne! of OES avon women Siro seen or ac saree Dysparounia/Vaginismus Dope is pests oe ears pin wih eng of compete el ty or pea veal merase {ibe Sina nye poe singer nay bet dept he ‘omit cupeot watt dn, en pb vedae nd “Inpontcvepeince i, sng there and inottry ‘alt mae comet Goals of Therapy oN eage dency = nse peti scl tone ~ eto, ston agin, chronic etanmatry = pelle pola, endometrial esti, ‘eaamomioy towel dese ~ tare congenial sooromiies ean pum ~ feesive pene msl sig ont con (ragisos) chapter 65: Fomate Senuat Dysfunction 881 ~ yaar vestibalis(S: valvodyiaonging dere, Purine, ‘atom ound ctrl mena and vent me) may be eset 1 Address pcos Beton: "fear opin being darmged by someting ering he vga, ‘Sticuly with engine con = tmbialesce aba bing eta! With trou be pi may be Sse fom appre ihtening i evap ce) | lick of sean aoa peor ck of ices elas, (item an expansion of prone waging = saute of wonten wih VS show marked pjcologia nee ‘ieitd wit nence ear efbepaive oneon a saiety + Addis syoloia eto ipmered srl acnfence ad decreased dete 1 ‘eltsimeine ~ oii acta sul eBags neetve bees of {he fc on eptve oar = feting beg extrnely abana same, gui and er of emus erty opera who itera hs bever Bes pose . i = pare ay be confine, fe tative ad with ‘ron, cmpounna the wera ow seal lage Investigations + Desemine timing of pln. Pain may cece ith: ater cota, inn nity of pens ide finger (ompase ‘it vapaisms) al entry of pi compatible with vaginas, WS, rogenia ‘top, es of psf) ~ fillet and thas Compatible wth ck of ous VWS, ‘ve polo) = anle moverent (ica of WS, urogenital atopy nfeton) ~ pool ean, pre's clan ical of VS bat aso En py a pe = pain coninwes er oar after nercourse (ypc of WS, Endonetoss)| + Gymcaopie ad mete sory 1 pia xa king for: Aeon edema masses = solveratopy (nid wih estrogen een) itera sures (ssn with esvogen iene or ‘ids1882 Sexual Heath sign o utes of posterior fucete | sSheson een aia minors which prec pen eat ood ‘ere sual dv | = defi pont fwchte ogg spe porncpiay Shoo secherge agin ection oe possibly more eons ‘atvc polos) ~ Sate of tol nace Consistent wth VS) thd cate fp om eth ota maa {iba so eons cin onan. When seedy the ‘ram alberta be ari separating abi nd och (Cetinit’s Oxip fr VS) amb dey he Fal xamnaon ‘Sethi dey sbsequat is + tart ies nt by Hy ys "OH white (sy oer ines ation of ew sos ‘fn 1 vail seta on sono Imerescopy ad i fr bate vain, emis Michanenein ~ fing ghacoe a HIV stati chron canis preset by of any val rn with sora ppexance = NA andor cute for gooroces wd anya ‘Therapeutic Choices Benttis moe itely when pychosesl wn medial aproaches ce Nonpharmacologic Chotces 1 Advis couples 0 fu on nopenertve eran vo acl ‘Recourse bre cyl of pat 1 Refer fordottnewentmen if pave pabolgysupected [Chapor 65: Female Sowa Oysunction 883 + Rana yet i io «Sapa ce ert a en meta Seer ay ae «mete mtn mnt Pharmacologic Choices “Ter iene god evidence er the ett of dpncueogins ‘Teollowingosommendaton ie buco he oahors exper a Local erage canbe wed for alvin py (ae Caper). or VS, cose antpiete dos, topiramate or gbapentn. ‘rales ce Chap) Vena oreee anlaprtants ‘Shy ano bowed gia athe owe dee and een low ‘Ondo patient ae very mnepieo ieete Wat pist ‘en ncntimatin af alcatel sal aires ‘Tops andummstory medications for the slidyia of VVS ly ome wae. Ins tbs of wen sem romeplyeate 2 in aa ‘Siew may tee tects an pss ae an Byarocertiane (2 ‘Mteugh tse ac nn eae ls. Medication mw be pedo ‘Hea aly febly wit a needles syrne unde det vision ‘nga mor Pedctng wach nism tina fo ec cman ‘Reus uepoie Higher pone troupe sn le tte manne wth chund Sacemton apd nt econmeted ‘het any STi tt reed oe Chapter 108, Toc xtrogen ream can eed fr recat posterior fouchte {Sing “opal tetnterone Bley Apsara ely to the poster owehete and rv are mous ‘Vagina uri nd vagina ities ae el a (1 Cape ‘Therapeutic Tips + Information fen rape, especayfx changes ia el {inom and nots in bot men snd momen wih cyl eae Ad aging Women's dour morally eee with arn of” ‘Shine. The ned for ora it ach ena eto, ‘Salis whey ad inn, ‘ninco Je batty bcos ned md igee ‘Eee "onc not” "coma" or mtideaps nd ole wore + Losec desis comme sapinm of erin, Many(884 sexva! Hoot ese, Ropopion apie and oslo apear to bee ‘iay wo chu seal Syfection «+ Forthe woman comping of tw saul deseo rus cont [avees rayon cle (gue tt en tebreks Tito {heopenic sss ny el aeons ad Face wate ‘he comes ebenges need ese aon an ay fo ‘pase semi wonned + Mert women complaining flak frou! bve normal veal an ‘asnacongnton Fora scene apy oe ec) [Ts ad some! a te once! a psfbolopel face Sherr wth ars ober se + Whon te slog of desir an aoa des npr 1 ten Tom deep-seated ens acd aad aolesctee sor ere {tiny fare (mea maton psn reer tos pyc fe popes When th leva tors ar ack of well eral ‘mest emul meu! tran medal ee ol atactve csi tee comer erat vex terap Figue 1: Model of Female Sexual = 7s, Chapt 65: Female Sexual Dystuncton 885, ‘Suggested Readings Pawson R Clea race Sean dei nd onl disorder Seen N rg ied 300 9449700 “ance 20073610859) 40898, hacia tin Covsio Ae a. Sera futon nme ad roman with ndnrine rer ace S07 30861) 59781 [ReenPh Fowlr Ch, sa €P Saal aston ten and woven ih Tine $B ter. Hanahat of nical ea for motte profesional New York (NYY Bre Reed: 208.£886 Soxsoi Hosth CHAPTER 66 Male Sexual Dysfunction Rosemary Basson, FRCP (UK) Tha chapter rene erecledafnction a prema siin Erectile Dysfunction tmreesionsiccay Ge fr sasticory vex avy. Acoso stn cir eee enc Reals mvptonae crt) ary Goals of Therapy 1 Assess th safety of resuming nero a as afer Serious 1 esos sexual ntncy tallow seve arco Investigations (Figure 4) Sera story Table) with stint everblecunezof ED (Table 2) = Heattyngpeysbloil ies undying or contbutng ED, iy tadr he tay 0 ponent “revel forse, medion (Tble3, depression, doce ‘Suoerone, pets (abe 2) ~ free tice pee. smaing cl ore dene) kes nln peor ss own ike sessed with rexamption freer and ng, ‘pare o es cmon ok of eset ert be, Feito or aber py compromise888 Sexual Hoan “able 1! Questions to Clarify Sexual History and Curent Table 2 Chios to Potentially Reversible Erectile Dysfunction SSSseS Gooey Chapter 66: Male Sewal Dystunction 889 Penonal pseseal sir pefealy fom cack pater ‘navaily wh aeto pn gh ing el apgment of i ote of ~ ast sexual experiences both postive aod negative ~ thos experienc hat ay have need by 9 Be ima, foe emotions (special fe og em nein) ‘aroun (CV) ie tyne cree eal sce ey prem nl hogs, or Note: Nam CV exam dot nt ecde mae logy, ‘dbl cls ining corpora ever! snus can (CNS sigs tat may indicate never newoloe dase, ‘tulip sles eesti, Pinte’ dense peer crops spl cor jury oder elites ~ Ite in of hypotonia ie by tne. mot Stns teicur top, enig of be, gyre Iepeomeesty ~ seta exe 6 dere sigs of prostate patoiogy = ecm of andor rok Table acne with seat ‘Savi aig sess esting ofour metab equaeis (METS), {Sey teat rampart edie chet tha con oceet ‘veloped simiar genes or maangencnt of ED bar on ‘anes Table Management Recommendations Based on Graded (Cardiovascular (€V) Rik AssessmentLibrary invettions seated fee estoone of onal etree and Folate tbe pate elie ching amy Urs nsenal en, Li, FSH estoxetene ow ~ fhsing ood Bc Up profile, CBC ad Tver anton et a amr hn prt my dann ‘Therapeutic Choices Nonpharmacologie Choices, ‘Addrose Sexual Avoidance 1 Remind couples wh have del voi sxe iainacy ‘ene orton th nautical tc} ree fo he ft poor is to make tine to be together vay Eom ‘poms ances comet oppo iting ox Throughout the day alow each nd to one pa iw the ‘ther era pte eal proee — tires psn aan someqnce of aempting 0 be ‘etal getho france nr pepae. ntl SS, Chaplet 68: Mate Senue! Dystuncion 894 ‘Address Lack of Subjective Sexual Arousal ‘Ades its interpersonal pychologl sues ee {Sey contrite ED armed Re ete + Adds partner soe! ysfancionack of exioyment Vacuum Ereetion Devices (VEDS) Avene bed back ne te penis: The Bod hen dpe ty He {Score reaig fund wound ie of pe oma faane ‘ar patents that eights a the een band see ond the ‘Toad te semoned win 90 nates ate beng sped. Some ‘non cau tlethe dgrs of tighten ed Ay conn ha Propet papi (ef eahemi poerhemia ellis Ende cl Geos) ra nneconndinton tthe eo ‘VED. VED i cmumincate ia pater who aon wera orbave a Pharmacologic Choices (Table 6) Phosphodiestease Type 5 (PDES) Inhibitors ‘Sen, vardenat taal re he gs fi ebice or ED ico ht aly ely te rl sansa“ Say apd ley item’ PS inseam an esi a paily Srl" esate of ction eng wi talib, ctry 0 pesos ‘tin iene myo 4 a ny he omit of soto fey at 10 mites “iceman te ay or PS pec nb ia ‘Seouning for ocaonal vial te efec, Tada ha mre ay Ise Dea which ny deep asco with hdr The Sybod Headtohed te ofthe tre droge jt being Contino othe sof PES iar ince: coseunet we of ‘eter or onetve isn Noches symptomae hype (hese ‘emily Spree cop) pecs ppm ay conan ch ‘en asi lowering of tee pese woul be pool wetted Sicindng condo recing tore etiow md olome depletion ‘ite stations preduposngoparpum, cp leer Poymer, tyteons and hell daeoe