Sinequan

Christopher Strother, MD

• Department of Emergency Medicine
• Mount Sinai School of Medicine
• New York, New York

Also called parturition chloasma child care chloasma /klflfl zmfl/ noun the presence of child care / tflaflld kefl/ noun the care of brown spots on the skin from various causes young children and study of their special needs chlorchild health clinic chlor/klfl r/ prefix same as chloro(used bechild health clinic /tflaflld helfl klflnflk/ fore vowels) noun a special clinic for checking the health chlorambucil chlorambucil /klfl r mbjflsfll/ noun a drug and development of small children under which is toxic to cells anxiety symptoms head pressure buy sinequan visa, used in cancer treatschool age anxiety facts order sinequan 25 mg without prescription. It stimulates the gall bladder anxiety wrap purchase sinequan without prescription, treatment of diabetes making it contract and release bile anxiety symptoms numbness buy line sinequan. The disease is often fatal and vaccichondromalacia nation is only effective for a relatively short pechondromalacia /kflndrflflmfl leflflfl/ noun riod acute anxiety 5 letters buy discount sinequan 75mg online. High pain levels of cholesterol in the blood are found in chorea chorea /kfl ri fl/ noun a sudden severe diabetes anxiety 1-10 rating scale buy 25mg sinequan overnight delivery. Cholesterol is formed by the body, twitching, usually of the face and shoulders, and high blood cholesterol levels are associwhich is a symptom of disease of the nervous ated with diets rich in animal fat, such as butter and fat meat. Excess cholesterol can be system chorion deposited in the walls of arteries, causing chorion / kfl rifln/ noun a membrane coveratherosclerosis. Now called chronic obstructive chromic acid chromic acid / krflflmflk sfld/ noun an unpulmonary disease stable acid existing only in solution or in the chronic obstructive pulmonary disease chronic obstructive pulmonary disease form of a salt, sometimes used in the removal / krflnflk flb str"ktflv p"lmfln(fl)ri dfl zi z/ of warts noun any of a group of progressive respiratory chromicised catgut chromicised catgut /krflflmflsaflzd disorders where someone experiences loss of k t&"t/ noun catgut which is hardened with lung function and shows little or no response chromium to make it slower to dissolve in the to steroid or bronchodilator drug treatments, body. Rub your hands to get the circumany tiny hair-like processes which line cells lation going. The capillaries exchange -cillin /sfllfln/ suffix used in the names of penicillin drugs amoxycillin the oxygen for waste matter such as carbon cimetidine dioxide which is taken back to the lungs to be cimetidine /sfl metfldi n/ noun a drug which expelled. At the same time the blood obtains reduces the production of stomach acid, used more oxygen in the lungs to be taken to the in peptic ulcer treatment tissues. The circulation pattern is as follows: cimex blood returns through the veins to the right cimex / saflmeks/ noun a bedbug or related atrium of the heart. It can also ing progressively more difficult and finally imbe caused by heart disease (cardiac cirrhopossible. Compare agoraphobia cirrhotic claustrophobic cirrhotic /sfl rfltflk/ adjective referring to circlaustrophobic / klfl strfl fflflbflk/ adjective rhosis the patient had a cirrhotic liver. It is used in the treatment of ovarian claw foot / klfl fflt/ noun a deformed foot and testicular cancer. Both can be successfully cormed(fl)s(fl)n/ noun the study and treatment of rected by surgery. Also called coagulation time aorta congenital narrowing of the aorta, which cloud cloud /klafld/ noun the disturbed sediment in results in high blood pressure in the upper part a liquid of the body and low blood pressure in the lowcloudy er part cloudy / klafldi/ adjective referring to liquid coarse tremor which is not transparent but which has an coarse tremor /kfl s tremfl/ noun severe opaque substance in it trembling coat 78 coat coat /kflflt/ noun a layer of material covering information 2. Also coeliac disease coeliac disease /si li k dfl zi z/ noun called coccygodynia same as gluten-induced enteropathy coccygeal vertebrae coeliac ganglion coccygeal vertebrae /kflk sfld ifll v! Also called enteralgia, tormicognitive therapy / kfl&nfltflv flerflpi/ noun a treatment of psychiatric disorders such as na 2. A snow good collateral blood supply makes occlusion of a cold compress single branch of the coeliac axis safe. The cles of one substance dispersed in another subcommonest form is the inability to tell the difstance 2. A coma is often fatal, but a patient may facility continue to live in a coma for a long time, even Committee on Safety of Medicines several months, before dying or regaining Committee on Safety of Medicines /kfl consciousness. Also called come round carotid come round /k"m raflnd/ verb to regain common cold consciousness. It inand abdomen, which unite to form the inferior volves the removal of facial features, which vena cava are later rebuilt. Also called stance which forms part of blood plasma and is community mental health nurse. Also called istence through the fertilisation of an ovum open fracture Our son was conceived during our holiday in compress Italy. In some cases they can be separated by ing development of the fetus and present at surgery, but this is not possible if they share a birth. Constiing someone the hospital is anxious to trace pation may be caused by worry or by a diet anyone who may have come into contact with which does not contain enough roughage or the patient. He has a weak constitution and is often tafltfls/ noun inflammation of the skin caused ill. The whole group of tourists fell ill smaller the contraction of dental services 2. Opposite ipsilateral field contrast medium continuous ambulatory peritoneal dialysis contrast medium / kflntrfl st mi diflm/ continuous ambulatory peritoneal dialnoun a radio-opaque dye, or sometimes gas, ysis /kfln tflnjufls mbjfllflt(fl)ri perfltfl put into an organ or part of the body so that it ni fll dafl lflsfls/ noun a method of dialysis of will show clearly in an X-ray photograph In people while they are walking about. The administratju bju l/ noun a coiled part of a nephron tors are in control of the admissions policy. Also caused by brain disease such as meningitis called controlled substance but can also often be found at the beginning of controlled respiration a disease such as pneumonia which is controlled respiration /kfln trflflld respfl marked by a sudden rise in body temperature. Among primary corneal bank / kfl nifll b flk/ noun a place where eyes of dead donors can be kept ready health care services, 1. Also called corneal transplant, coronary ligament / kflrfln(fl)ri lfl&flmflnt/ keratoplasty 2. Also called water-hammer deprivation, deaths from unnatural causes, pulse during the post-operative recovery period and corrosive corrosive /kfl rflflsflv/ adjective destroying when the doctor feels unable to give a reliable tissue i noun a substance which destroys tiscause of death. The corpus luteum the doctor gave her a cortisone injection in secretes the hormone progesterone to prepare the ankle. She became worried when the costocosto/kflstflfl/ prefix referring to the ribs girl started coughing up blood. Also called bulboure(ophthalmic, maxillary and mandibular), abduthral glands [Described 1700. It was used as a constituent of the first craniometry / kreflni flmfltri/ noun the procvaccines for smallpox. The rhoea, in order to prevent gonococcal conjuncopposite situation where the patient gets bettivitis [Described 1860. Its symptoms substance in which a culture of microorganare fever, diarrhoea and stomach cramps. Also called curettement cubitus / kju bfltfls/ noun same as ulna curette cuboid curette /kjflfl ret/ noun a surgical instrument cuboid / kju bflfld/, cuboid bone / kju bflfld like a long thin spoon, used for scraping the inbflfln/ noun one of the tarsal bones in the foot. Sympcytocyto/safltflfl/ prefix cell toms include loss of weight, abnormal faeces cytochemistry and bronchitis. If diagnosed early, cystic fibrocytochemistry / safltflfl kemflstri/ noun the sis can be controlled with vitamins, physiostudy of the chemical activity of cells therapy and pancreatic enzymes. It can branch of genetics which studies the function cause stones to form in the urinary system of of cells, especially chromosomes, in heredity people who have a rare inherited metabolic cytokine cytokine / safltflflkafln/ noun a protein secretdisorder. Also called protanopia [Dedescribed this condition in soldiers in the Ameriscribed 1794. Founder of the dacryodacryo/d kriflfl/ prefix tears atomic theory, he himself was colour-blind. Also called day darkening case surgery darkening / dfl knflfl/ noun the act of becomdazed ing darker in colour Darkening of the tissue dazed /deflzd/ adjective confused in the mind takes place after bruising. It ensures that all information is deadly nightshade deadly nightshade / dedli nafltflefld/ noun stored securely and allows people to have acsame as belladonna cess to their entries. Very loud noise with a value of over decortication /di kfl tfl keflfl(fl)n/ noun the 120dB. Also called chiasm deep 102 deep defibrillation deep /di p/ adjective located, coming from or defibrillation /di fflbrfl leflfl(fl)n/ noun a proreaching relatively far inside the body. Oppocedure to correct an irregular heartbeat by apsite superficial plying a large electrical impulse to the chest deep cervical vein wall, especially in potentially life-threatening deep cervical vein /di p s! Also called cardioversion defibrillator vertebral vein defibrillator /di fflbrfllefltfl/ noun an apparadeep dermal burn tus used to apply an electric impulse to the deep dermal burn /di p d! Also defibrination /di faflbrfl neflfl(fl)n/ noun the called full thickness burn removal of fibrin from a blood sample to predeep facial vein vent clotting deep facial vein /di p feflfl(fl)l vefln/ noun a deficiency small vein which drains from the pterygoid deficiency /dfl fflfl(fl)nsi/ noun a lack of process behind the cheek into the facial vein something necessary deeply deficiency disease deeply / di pli/ adverb so as to take in a large deficiency disease /dfl fflfl(fl)nsi dfl zi z/ amount of air He was breathing deeply. The condition may affect anyone who is breaking the hymen of a virgin, usually at the inactive for long periods. If someone deltoid muscle is attached drinks during the day less liquid than is delusion passed out of the body in urine and sweat, he delusion /dfl lu (fl)n/ noun a false belief or she begins to dehydrate. A person can become delirious because ffl kfl st/ noun a forecast of the numbers of of shock, fear, drugs or fever. It includes haldemyelinating lucinations about insects, trembling and exdemyelinating /di maflfllflnefltflfl/ adjective citement. Denis Browne splint dentoid Denis Browne splint /denfls brafln dentoid / dentflfld/ adjective shaped like a splflnt/ noun a metal splint used to correct a tooth club foot [Described 1934. Also dental cyst dental cyst / dent(fl)l sflst/ noun a cyst near called venous blood. Also called corisomeone feels the world around him or her is um dermonot real dermo/d! A detached retina can a blunt instrument, usually an allergic reacsometimes be attached to the choroid again using lasers. Also called dermatographia detect dermoid detect /dfl tekt/ verb to sense or to notice, dermoid / d! Compare ascending aorta enzymes to remove protein stains can cause descending colon dermatitis. A swelling develdetach /dfl t tfl/ verb to separate one thing from another an operation to detach the oped under the armpit. The sore throat decusps of the mitral valve veloped into an attack of meningitis. Blood and urine tests deviance / di viflns/ noun sexual behaviour show high levels of sugar. Full form Dual Enerby diabetes gy X-Ray Absorptiometry diabetogenic dextrodiabetogenic /daflflbetfl d enflk/ adjective dextro/dekstrflfl/ prefix referring to the which causes diabetes right, or the right side of the body diabetologist dextrocardia diabetologist /daflflbe tfllfld flst/ noun a dextrocardia /dekstrflfl kfl difl/ noun a doctor specialising in the treatment of diabetes congenital condition in which the apex of the mellitus heart is towards the right of the body instead of diaclasia diaclasia /daflfl kleflzifl/ noun a fracture the left. They diagnostic 108 diaphragmatic pleurisy found it difficult to make a diagnosis. The the capillaries into tissues in the development period of diastole (usually 95 mmHg) lasts of inflammation about 0. Two large electrodes will in breathing, expands and contracts with the give a warming effect over a large area (medwalls of the chest. The average rate of respiical diathermy); if one of the electrodes is ration is about 16 times a minute. In the long term it is potento reduce weight by reducing the amount of tially addictive. Compare monophysician] chromatism, trichromatism diet sheet diclofenac sodium diet sheet / daflflt fli t/ noun a list of suggesdiclofenac sodium /daflklflflfen k tions for quantities and types of food given to sflfldiflm/ noun an anti-inflammatory drug someone to follow used to treat rheumatic disease differential dicrotic pulse differential / dflffl renflfll/ adjective referring dicrotic pulse /dafl krfltflk p"ls/, dicrotic to a difference wave /dafl krfltflk weflv/ noun a pulse which differential blood count occurs twice with each heartbeat differential blood count /dflfflrenflfll dicrotism bl"d kaflnt/, differential white cell count / dicrotism / daflkrfltflz(fl)m/ noun a condition dflfflrenflfll waflt sel kaflnt/ noun a test that in which the pulse occurs twice with each shows the amounts of different types of white heartbeat blood cell in a blood sample die differential diagnosis die /dafl/ verb to stop living His father died differential diagnosis /dflffl renfl(fl)l last year. There ponents which are absorbed into the body are two types of fibre in food: insoluble fibre, digestible. Fibre is thought to be necesdigestion /dafl d estflfln/ noun the process sary to help digestion and avoid developing by which food is broken down in the alimentaconstipation, obesity and appendicitis. Also called alimentary sysdilute /dafl lu t/ adjective with water added i tem verb to add water to a liquid to make it less digestive tract concentrated Dilute the disinfectant in four digestive tract /dafl d estflv tr kt/ noun same as alimentary canal parts of water. The Schick test bad light or to drugs is used to test if a person is immune or susdilatation and curettage ceptible to diphtheria. In countries where indilatation and curettage /dafllefl teflfl(fl)n fants are immunised the disease is rare. Abbr D & C -dipine dilate -dipine /dflpfln/ suffix used in the names of caldilate /dafl leflt, dfl leflt/ verb to become wider cium channel blockers nifedipine or larger, or make something become wider or dipldipl/dflpl/ prefix same as diplo(used before larger the veins in the left leg have become vowels) dilated. The drug is used to dilate the pupil diplacusis diplacusis /dflplfl kju sfls/ noun a disorder of the eye. Compare hemiplegia dilator pupillae muscle /dafl lefltfl pju pflli diplegic m"s(fl)l/ noun a muscle in the iris which pulls diplegic /dafl pli d flk/ adjective referring to the iris back and so makes the pupil expand diplegia 111 disinfection diplodiplo/dflplflfl/ prefix double wound discharged a thin stream of pus. In humans number of patients with a particular type of the diploid number of chromosomes is 46. If the skin on the lips is discoloured it may tions showing how to use something and how indicate that the person has swallowed a poimuch of it to use son. Diseases with dising from a physical or mental condition which tinct characteristics have individual names.

Sleep problems can cover a spectrum of difficulty around sleep anxiety 7 year old daughter purchase sinequan 10mg mastercard, such as trouble falling asleep anxiety symptoms vs pregnancy symptoms buy discount sinequan 75 mg online, trouble staying asleep anxiety breathing techniques order sinequan cheap online, or restless sleep anxiety depression purchase sinequan 10mg without prescription. The association with anxiety symptoms is not the same for all types of sleep problems [34] anxiety jaw clenching generic sinequan 75 mg free shipping. By investigating sleep problems separately anxiety rash safe 25 mg sinequan, stronger associations with anxiety symptoms may appear for some types of sleep problems. Hence, specifying the association between anxiety symptoms and different types of sleep problems can allow us to also be more specific in directing prevention and intervention efforts to specific sleep problems. Continuity of anxiety symptoms across adolescence and into adulthood Due to the low levels of anxiety symptoms in our population sample, although initially intended, I found out that I was not able to investigate the continuity of different anxiety symptom subtypes across adolescence and into adulthood. I was, however, able to investigate continuity of problems across adolescence in a broader sense: in chapter 2, I found that a very broad range of internalizing and externalizing symptoms early in adolescence predicted the onset of panic attacks during adolescence. While we know that anxiety symptoms predict later onset of anxiety disorders, we have very limited insight into the pathways of anxiety symptoms across adolescence that lead to elevated anxiety symptoms or anxiety disorders. Due to the high co-morbidity of different anxiety subtypes, it is plausible that across adolescence, the focus of the content of anxiety symptoms can shift from one subtype to another. For example, a child showing separation anxiety symptoms at age 11 may shift in presentation of symptoms to generalized anxiety symptoms by age 15. Studying these pathways in a population with more anxiety symptom endorsement, such as an at-risk population, can be promising as it would still allow the focus on General discussion | 97 anxiety symptoms (rather than focusing merely on diagnosis), while providing data with more variation in anxiety symptom severity across the anxiety subtypes. Hence, this thesis contributes to multiple domains associated with anxiety symptoms, rather than just one. The first general conclusion from this thesis is that even mild anxiety symptoms are associated with other health predictors and outcomes. This finding supports the notion that it is important to study anxiety in a dimensional way and to include symptoms of anxiety when assessing possible predictors and outcomes of anxiety. The second general conclusion is that we oversimplify reality if we disregard the possibility of dynamic relations of predictors and outcomes with anxiety symptoms over adolescence. Stable prediction of mood and anxiety disorders based on behavioral and emotional problems in childhood: A 14-year follow-up during childhood, adolescence, and young adulthood. Journal of the American Academy of Child and Adolescent Psychiatry, 1993;32(4):826-29. Longitudinal Invariance and Construct Validity of the Abbreviated Late-Life Function and Disability Instrument in Healthy Older Adults. Early and late perceived pubertal timing as risk factors for anxiety disorders in adult women. Journal of the American Academy of Child and Adolescent Psychiatry, 1997;36(2):255-62. Journal of the American Academy of Child and Adolescent Psychiatry, 2011;50(5):499-507. Journal of the American Academy of Child and Adolescent Psychiatry, 2008;47(2):148-55. Summary| 101 Summary Anxiety symptoms predict the onset of anxiety disorder and depression, and have been associated with lower levels of well-being even before they reach disorder status. Adolescence is a primary period of interest when it comes to anxiety research, since anxiety disorders most commonly have their onset at an early age, and they are the most frequent mental health problem in children and adolescents. The aim of this thesis is to further our knowledge of the development of anxiety symptoms from late childhood into young adulthood. The incidence of panic attacks increases dramatically during adolescence, yet little is known about risk factors for the development of panic attacks. Chapter 2 describes the relation between Internalizing and Externalizing Problems in childhood (10-12 years) and the onset of panic attacks in adolescence. In multivariate analyses, only Social Problems had a unique association with onset of panic attacks. Longitudinal measurement invariance was evaluated with a hierarchical set of psychometric tests: (1) invariance of the factor structure (configural invariance); (2) invariance of the factor loadings (metric invariance); and (3) invariance of the thresholds (strong invariance). When testing for strong invariance by restricting the thresholds across time, the model fit decreased; however, model fit for the strong invariant models still ranged from adequate to excellent. The relation between pubertal timing and anxiety symptoms is the topic of chapter 4. Pubertal timing refers to the timing of pubertal development in relation to peers, i. In this paper we explicitly took into account that pubertal timing can change over adolescence, since the pace of pubertal 102 | Summary development varies between adolescents and is not stable. In boys, the relation between pubertal timing and anxiety symptoms was age-dependent: at age 10-11, being ahead of peers in pubertal development was associated with more anxiety symptoms, while from age 14 onwards, being ahead was associated with fewer anxiety symptoms than in peers. In conclusion, pubertal timing is not stable across adolescence, and the association between pubertal timing and anxiety symptoms is dynamic and age dependent. Chapter 5 shows that sleep problems and anxiety symptoms hold a direct bidirectional longitudinal association in early adolescence (10-15 years), over and above the indirect association of anxiety symptoms and sleep problems. Later in adolescence, anxiety symptoms still predicted sleep problems, but sleep problems no longer significantly predicted anxiety symptoms. The indirect associations were all significant and the strengths of the associations were all stronger than those of the direct associations. Findings in chapter 6 show that the association between anxiety symptoms at age 10-12 and sleep problems at age 12-15 was moderated by parasympathetic reactivity. In chapter 7, the main findings, strengths and limitations of the research reported in this thesis are discussed. Two main conclusions of this thesis are (1) that even mild anxiety symptoms are associated with other health predictors and outcomes and (2) that we oversimplify reality if we disregard the possibility of dynamic relations of predictors and outcomes with anxiety symptoms during adolescence. Dutch summary | 105 Samenvatting (Dutch summary) Angstsymptomen kunnen voorspellend zijn voor de ontwikkeling van een angststoornis of depressie. Echter, al voordat er sprake is van een angststoornis, gaan angstsymptomen vaak samen met een verminderd welbevinden. Angststoornissen beginnen vaak op jonge leeftijd en zijn de meest voorkomende psychische klachten bij kinderen en adolescenten. Veelvoorkomende angstsymptomen bij kinderen zijn separatieangst, schoolangst en specifieke fobieen. In de adolescentie komen hier andere soorten van angst bij zoals paniek, sociale angst en gegeneraliseerde angst. Vooral deze angstsoorten zijn sterk voorspellend voor angstsymptomen en -stoornissen bij (jonge) volwassenen. Het doel van dit proefschrift is het vergroten van de bestaande kennis over de ontwikkeling van angstsymptomen in de late kindertijd en gedurende de adolescentie. Tijdens de adolescentie neemt de incidentie van paniekaanvallen fors toe; tegelijkertijd is er weinig bekend over de risicofactoren voor het ontwikkelen hiervan. In hoofdstuk 2 onderzocht ik of emotionele en gedragsproblemen op leeftijd 10-12 jaar voorspellend zijn voor het ontstaan van paniekaanvallen in de adolescentie. Bijna 20% van de jongeren rapporteerden minimaal een paniekaanval in de adolescentie (19. Voor longitudinale analyses van scores voor angstsymptomen is het belangrijk dat het meetinstrument leeftijd-invariant is, dat wil zeggen dat de vragenlijst hetzelfde meet bij iedere meting. Longitudinale meetinvariantie is beoordeeld aan de hand van een drietal hierarchische psychometrische tests: (1) invariantie van de factorstructuur (configural invariance), (2) invariantie van de factorladingen (metric invariance) en (3) invariantie van de drempelwaardes (strong invariance). Ook bij het testen voor invariantie van de drempelwaardes (strong invariance) bleef de modelfit adequaat tot excellent. Hoofdstuk 4 beschrijft de relatie tussen timing van puberteitsontwikkeling en angstsymptomen. Timing van puberteitsontwikkeling verwijst naar de timing waarin de puberteitsontwikkeling plaatsvindt in vergelijking met leeftijdsgenoten. Adolescenten kunnen voorlopen op leeftijdsgenoten in hun puberteitsontwikkeling (vroege timing), gelijk opgaan met leeftijdsgenoten of minder snel zijn in puberteitsontwikkeling dan leeftijdgenoten (late timing). In dit paper is expliciet rekening gehouden met veranderingen in timing van puberteitsontwikkeling, door meerdere metingen van puberteitsontwikkeling mee the nemen. Dit is belangrijk want het tempo van puberteitsontwikkeling varieert tussen jongeren en is niet stabiel over adolescentie. Bij jongens was een duidelijk verband zichtbaar tussen timing van puberteitsontwikkeling en angstsymptomen. Jongens die voorliepen in de puberteisontwikkeling op leeftijd 10-11 jaar rapporteerden meer angstsymptomen dan de overige jongens. Vanaf 14 jaar veranderde dit verband en was voorlopen juist geassocieerd met minder angstsymptomen. Bij meisjes was er geen verband tussen timing van puberteitsontwikkeling en rapportage van angstsymptomen. Hoofdstuk 5 en 6 bespreken de resultaten van onderzoek naar de relatie tussen slaapproblemen en angstsymptomen. Uit hoofdstuk 5 blijkt dat de longitudinale relatie tussen slaapproblemen en angstsymptomen bidirectioneel is in de vroege adolescentie (10 to 15 jaar). In de latere adolescentie (12-18 jaar) was er een verband tussen angstsymptomen en latere slaapproblemen, maar geen verband tussen slaapproblemen en latere angstsymptomen. Angstsymptomen voorspellen slaapproblemen bij sommige adolescenten, maar niet bij alle. Hoofdstuk 7 geeft een discussie van de bevindingen in dit proefschrift, inclusief de sterke punten en de beperkingen. De belangrijkste conclusies uit het onderzoek beschreven in dit proefschrift zijn (1) dat zelfs milde angstsymptomen al geassocieerd worden met predictoren en met andere gevolgen voor het welbevinden (paniekaanvallen en slaapproblemen) en (2) dat we de werkelijkheid simplificeren wanneer we de mogelijkheid van dynamische relaties tussen voorspellers en uitkomstmaten enerzijds en angstsymptomen in de adolescentie anderzijds veronachtzamen. Who) Acknowledgments | 111 Acknowledgements A journey of a thousand miles begins with a single step. Little did I know that this journey of a thousand miles would not just be a figurative one, but would literally encompass traveling 3887 miles to find a new home with the person I love. While this is great wisdom for life in general, it applies less to the life of a graduate student. I certainly did not take the most straightforward road to that goal, but I never lost sight of it. Frank and Floor: You were willing to take a chance when I proposed the idea of letting me do my research and writing from America. I am very happy that it did and I want to thank you both very much for this opportunity! Through your spot-on input and feedback I learned a great deal, not just about scientific writing and text structuring, but also about statistics and research procedures. Tom Olino, your spontaneous willingness to get involved in my dissertation project was beyond anything I could have ever hoped for. Thank you so very much for sharing your psychological and statistical knowledge with me, for your guidance, your patience, kindness and always open door. But mostly, thank you for your kind and motivating words when I needed them the most. I am especially grateful that so many of you stuck with us for so long and shared your life with us for all these years from the time you were children to the young adults you are today. I would like to extend a sincere thank you to the members of my small committee, Prof. Thank you for welcoming me and trusting me to revamp the stress-experiment for our cohort. My dear Accare research and PhD candidate colleagues, Esther, Julie, Vera, Mark-Peter, Sanne, Yvonne, I have great memories of ice skating outings, sushi nights and random chocolate cakes appearing in the kitchen (with Julie as the usual suspect). Esther, I have particularly good memories of visiting you after leaving Groningen. Sylvana, we hit it off during my first visit to Rotterdam, and not just because you also see that working with data trumps writing about data. Drauf abgebilded war ein fliegender Vogel im Sonnenuntergang, und ein Text den ich damals nicht lesen konnte. Das Poster habe ich nach Jahren wiedergefunden, drauf stand: There are two great things you can give your children: one is roots, the other is wings. You celebrated my achievements and helped me get up when I found myself at the bottom of a flight of stairs with an ego bruise or two. Chris Curriculum Vitae | 115 Curriculum Vitae Christina Maria Mathyssek was born on September 27th, 1981 in Starnberg (Germany).

Functions of Vitam in A Vision It provides the molecular basis for visual excitation in rods and cones anxiety quizlet buy sinequan 10mg visa. Secondary Vitamin D is essential for the metabolism of calcium X-N Night blindness and phosphorus and for the formation of bone anxiety symptoms lasting all day buy sinequan 25 mg line. It X-F Xerophthalmic fundus enhances the absorption of above minerals from the gut anxiety symptoms joins bones cheap 25mg sinequan with mastercard, X-S Corneal scars their mobilisation from bone and re-absorption of phosphorus and calcium from the kidneys anxiety breathing buy cheapest sinequan. Vitamin D and D are identical in potency and generally 2 3 In contrast to jaundice anxiety meditation order 10 mg sinequan mastercard, the sclerae are not involved referred as vitamins D anxiety symptoms or something else buy cheap sinequan. Vitam in A Toxicity Hypervitaminosis A is due to excessive intake of fish Causes of Vitam in D Deficiency liver, polar bear liver or therapeutic over dose. Benign intracranial hypertension, pruritus, weight Delayed milestones except speech, irritability, and loss and hepatosplenomegaly. Decreased density and increased trabeculaenamel with grooving, and pitting with high risk of tions of shafts with subperiosteal osteoid formation caries. Aluminium bone disease Deficiency result in decreased proprioceptive and Parenteral alimentation vibratory sensation due to posterior column degeneration, areflexia, gaze paraesis, and gait disturbance. M anagem ent It produces haemolytic anaemia and retrolental fibroplasia in premature infants. Otherwise Vitamin K1 is present in green leafy vegetables and treatment of osteomalacia is similar to rickets. It is a coagulant vitamin required for synthesis of Hypervitam inosis D unusual amino acid gamma carboxyglutamic acid (Gla) which is essential for the production of four coagulation It causes hypercalcaemia. Daily requirement: 80 microgram/day Clinical Features Sources: Leafy vegetables and liver Constipation, nausea, vomiting, drowsiness and renal Deficiency: damage. Nutrition 63 Vitam in K Excess Neurological M anifestations It blocks the effects of oral anticoagulants. In the absence of vitamin B, cells cannot metabolise glucose Investigations 1 aerobically. Low blood thiamine level, raised pyruvate and lactate Brain is totally dependent on glucose for energy and levels. Low blood or erythrocyte transketolase activity, so nervous system is affected early in thiamine which increases by more than 15% after administration deficiency. It is essential for the metabolism of carbohydrates and in its absence pyruvic and lactic acids accumulate, which produces vasoM anagem ent dilatation and increase in cardiac output. Dramatic improvement in 48 hours in cardiac type of Daily requirement: beriberi and the recovery is slow in neurological beriberi. Dietary sources: Benfothiamine(S-Benzoil thiamine-0-monophosphate): It Milk, cheese, butter, liver, kidney, meat, whole cereals, is a fat-soluble derivative of thiamine. It is particularly useful in diabetic Causes of deficiency: neuropathy and retinopathy. Clinical manifestations: Clinical Features Sore throat, glossitis, angular stomatitis, cheilosis, seborrhoeic dermatitis, normochromic anaemia. It causes either cardiac involvement (Wet beriberi) or nervous system involvement (Dry beriberi). Dietary sources: Dietary sources: Whole cereals, pulses, nuts, meat, fish, liver, kidney yeast Whole grain cereals, vegetables, yeast, meat, liver. Clinical Features Pellagra Glossitis, angular stomatitis, cheilosis, and neuropathy. In certain genetic disorders, pyridoxine metabolism Chronic wasting disease with signs of dementia, is abnormal, and in those infants pyridoxine deficiency diarrhoea and dermatitis. Biotin 100 microgram/day Nutrition 65 Vitam in B and Folate such as osteoid, dentine, collagen, and intercellular 12 cement substance of capillaries. Vitamin C is concentrated in adrenal cortex (160 mg/ degeneration of the spinal cord, optic atrophy and 100 gm tissue) and in the lens of the eyes. Women planning pregnancy and throughout Requirem ent pregnancy should consume diet rich in folate. Clinical Features the D-ascorbic acid and other analogoues have no anti-scorbutic activity. It is the main electrolyte in extracellular fluid (Plasma and interstitial fluid). Potassium Hyperkalaem ia Potassium is mainly present in the intracellular When the serum level exceeds 5. Acidosis shifts Causes potassium out of cells and alkalosis shifts potassium into the cell. It serves as intraphosphataemia does not produce any adverse cellular messenger of different hormones. Eighty per cent of calcium taken is lost in stool and some amount is also lost in the urine, and that is the Dietary Sources cause for negative balance when the calcium is Green leafy vegetables, fruits, onions, cereals, pulses, consumed in small quantum. The metabolism of calcium jaggery, grapes, dates, animal foods like meat, liver, fish, is intimately related to vitamin D, parathyroid hormone kidney, egg yolk. Nutrition 69 Iron Deficiency Iron deficiency causes microcytic hypochromic anaemia. Sea-fish and tea when taken frequently can form in beta cells of pancreas contains zinc but not when contribute as much as 3 mg/day. Plasma Prevention of Caries zinc is lowered in acute myocardial infarction, infections, When fluorine level is low, addition of traces of and malignancies. M agnesium Chronic zinc deficiency leads to dwarfism and hypogonadism and ophthalmoplegia. Secondary zinc Total body magnesium is 20 gm and 75% of it is deficiency is seen in alcoholism and poorly controlled complexed with calcium in bone. It is an activator of many enzymes and deficiency causes neuromuscular irritability, tremors and carpoChrom ium pedal spasm. Chronic diarrhoea, chronic alcoholism and Total body content of chromium is 6 mg and this level cirrhosis cause deficiency. Tobacco contains large amount of chromium and Total body content is 15 mg and maximum quantum is the carcinogenic effect of tobacco is linked to chromium. Selenium Source By its intracellular antioxidant effect, it protects tissues Nuts and tea-leaves. Selenium excess causes alopecia, abnormal nails, emotional lability, and lassitude and garlic odour to Copper breathe. It is present in Type of diet Disorders many enzymes including cytochrome oxidase and ceruloplasmin. Low simple sugar Post-gastrectomy state, lactose intolerance Low energy Obesity, hypertension Daily Requirem ent High energy Undernourished Small feedings Gastroesophageal reflux 2 to 3 mg/day Low fat Steatorrhoea, gastroesophageal reflux, acute hepatic, gallbladder or pancreatic Source disorders, colon, prostate and breast cancers Dairy products, cereals, meat, and nuts. Copper Low fat and Hyperlipidaemia and coronary heart containing ceruloplasmin helps in iron transport and in Low cholesterol disease the formation of haemoglobin. Waist circumference Waist circumference alone is enough to assess the As per the state of nutrition, the individuals can be prognosis in obesity. Skin-fold thickness: Aetiology It can be estimated by using special pair of calipers 1. Excess energy intake over the triceps, biceps, subscapular and suprailiac With excess feeding, excess calories are stored in region. Height in inches = weight in kg Little is used for energy expenditure and is mostly Height in cm 100 = desired body weight in kg. More than 20 genes and 12 chromosomes have been Apple-shaped obesity is nothing but abdominal implicated in obesity. It acts at the level of hypothalamus to internal organs, omentum, and in the intramuscular suppress appetite.

Patients with supraventricular arrhythmias in hypersinus rhythm if atrial fibrillation is of longstanding thyroidism should be made euthyroid before elective duration or the echocardiographically determined cardioversion anxiety while sleeping order 10 mg sinequan with visa. Atrial flutter is one of the easiest rhythms to convert diac surgery (as they cannot maintain sinus rhythm) anxiety symptoms unwanted thoughts generic 25mg sinequan amex. The donor heart is removed anxiety disorder 100 symptoms purchase sinequan master card, except for posterior wall Sodium bicarbonate in a dose of 0 anxiety symptoms cures best sinequan 25 mg. Angina is rare anxiety levels generic sinequan 75 mg mastercard, as the relaxation time by echo may also provide an early clue transplanted heart is devoid of autonomic innervation anxiety symptoms for 2 weeks 10 mg sinequan for sale. Immunosuppressive therapy is given with cyclosContraindications to Cardiac Transplantation porine, azathioprine and prednisolone. From the apices of the upper anteriorly and between the 4th and 5th thoracic spines lobe the inner margins of the lungs and their covering posteriorly. The ribs are counted downwards from the of the lungs continue down the sternum as far as the second rib. It marks the boundary between the Middle Lateral (4) Lingular Superior (4) Medial (5) Inferior (5) upper and middle lobes. Lower Apical (6) Lower Apical (6) Medial basal (7) Anterior basal (7) Bronchopulmonary Segments Anterior basal (8) Lateral basal (8) Lateral basal (9) Posterior basal (9) Each main bronchus divides into three lobar bronchi. Posterior basal (10) On the right side, one each to the upper lobe, middle lobe and lower lobe. On the left side, one each to upper lobe, lingular lobe and remainder of the lower lobe. Then Pleural Border these divide into segmental bronchi to individual At the apices and along the inner margins of the lungs, segments. It is a mixture of tracheobronchial secretion, cellular Upper lobes of the lung are accessible from the front, debris, micro-organisms and saliva. The character of lower lobes from the back and all the three lobes in the sputum is determined by its amount, colour, chronolaxilla. Amount Mechanism of Cough Bronchorrhoea: When the quantity of sputum producIt is brought about by contraction of respiratory muscles tion is > 100 ml/day, it is termed as bronchorrhoea. Dry cough: Pleural disorders, interstitial lung disease, Copious sputum production upon changes in posture mediastinal lesions is seen in bronchiectasis and lung abscess. Short cough: It is seen in upper respiratory tract Large amount of colourless sputum is present in alveolar cell infections (common cold) carcinoma. Brassy cough: Cough with metallic sound produced by compression of the trachea by intrathoracic space Chronology occupying lesions Chronic bronchitis: Sputum production is more in the 5. Bovine cough: Cough with loss of its explosive nature, early morning for many years. Prolonged and paroxysmal cough: It is present in chronic Bronchial asthma: Sputum production is more either in bronchitis and whooping cough the morning or at night. Barking cough: It is found in epiglottal involvement production signifies severe infection. Green or yellow coloured thick sputum indicates intrathoracic pressure, which reduces venous return to bacterial infections. The green colour to sputum is the heart, thereby diminishing cardiac output, resulting imparted by the enzyme myeloperoxidase (verdoin cerebral hypoperfusion and syncope. It is seen in bronchoMassive > 500 ml blood loss per day (or) rate of alveolar carcinoma. It may be pink, as occurs in blood loss > 150 ml/hr (or) 100 ml blood pulmonary oedema. Mucoid: It is clear, greyish white or black in colour and If there is > 500 ml blood loss per day, aggressive frothy. It may be seen in conditions like chronic bronintervention (rigid bronchoscopy or surgery) is advochitis and chronic asthma. If the blood loss is submassive, after subsidence of haemoptysis, fibreoptic bronchoscopy is indicated. Mucopurulent or purulent: Yellowish or greenish brown in colour, seen in bacterial infection. Differences between Haemoptysis and Haematemesis Odour of Sputum Haemoptysis Haematemesis Offensive and foetid: a. Malaena absent Malaena present It is defined as expectoration of blood, or bloody sputum. Previous history of Previous history of Types of Haemoptysis respiratory disease peptic ulcer disease Frank haemoptysis: It is the expectoration of blood only. Diagnosed by bronchoscopy Diagnosed by gastroscopy Massive and fatal blood loss may occur. Spurious haemoptysis: Haemoptysis present secondary Cardiovascular Disorders to upper respiratory tract infection, above the level of larynx. Endemic haemoptysis: Present in infection with Paragonimus westermani (lung fluke). J receptors, situated at the alveolo-capillary junction, are responsible for rapid shallow breathing and they 1. Metastatic lesions of the lung except in secondaries are stimulated by pulmonary congestion, oedema due to choriocarcinoma and renal cell carcinoma. The chemoreceptors in the carotid arteries, aorta and reticular substance of medulla which respond to Dyspnoea oxygen lack, carbon dioxide excess and decrease in It is defined as the undue awareness of respiratory effort pH or of the need to increase the effort. Receptors in the respiratory muscle which are immediate cause of appreciation of dyspnoea. In chronic lung disorder, unless bilateral Chest Pain extensive involvement is present, cyanosis may be absent) Pleural Pain 5. Anaemia may occur when there is It is caused by stretching of the inflamed parietal pleura. Excessive sputum production and protein loss catchy pain occurring with deep inspiration or coughing c. Loss of appetite leading to malnutrition and relieved by shallow breathing or lying on the 6. Pancoast Syndrome Pancoast syndrome is caused by either a superior sulcus Clubbing (Fig. It is a selective bulbous enlargement of the distal portion of the digit due to increased subungual soft tissue. The components of this syndrome are: the normal angle between the nail and the nail-bed a. Upper Retrosternal Pain It is a momentary pain which increases in intensity on coughing and subsides when the cough becomes productive. Mid or Lower Retrosternal Pain It is constrictive in character and may be present in: 1. Hypoxia: Persistent hypoxia causes opening of deep A-V fistulae of the terminal phalanx 5. Platelet derived growth factor: this factor which is released secondary to infection anywhere in the body, also causes vasodilatation and this is the latest and most acceptable theory for clubbing. Grade I Obliteration of the angle between the nail and the nail-bed and positive fluctuation test Unidigital clubbing: It is seen in: (Fig. Longstanding pulmonary tuberculosis Colour blindness Ethambutol (Red-green colour f. Scalene Lymph Node It is a group of nodes in a pad of fat on the surface of scalenus anterior muscle just in front of its insertion Cardiovascular Causes into the scalene tubercle of the lst rib. Large and fixed in secondary involvement from a primary lung malignancy Gastrointestinal Causes 2. Hard and craggy, matted, with or without sinus formation in healed and calcified tuberculous a. Whole of right lung and left lower lobe to right supraclavicular lymph node It may be seen in: c. Genito-urinary system and gastrointestinal the chemical system malignancies also involve the left c. Leukaemia due to tissue infiltration supraclavicular lymph node due to retrograde d. Scrofuloderma (caused by atypical mycobacteria, In superior vena caval syndrome look for presence of M. External markers of cor pulmonale vein, collateral venous circulation on the anterior sur1. Raised jugular venous pressure face of chest wall is less prominent as the intercostal 2. Inspection of Lower Respiratory Tract Non-malignant Causes All the findings in the clinical examination should be compared on both sides in the following areas: 1. The pretracheal fascia encloses the clavicular head of sternomastoids on both sides. When the trachea is shifted to one side, the pretracheal fascia covering the sternomastoid on that side relaxes, making the clavicular head more prominent on the side of tracheal deviation. Barrel chest: the anteroposterior to transverse Symmetry of Chest diameter ratio is 1 : 1. Seen in physiological states Normal chest is symmetrical and elliptical in cross like infancy and old age and in pathological states section. Hollowness or fullness in the supraclavicular and It is the exaggeration of the normal hollowness over infraclavicular fossae the lower end of the sternum. If the convexity of the spine and the lung lesion are on the same side, it is most likely that the scoliosis is congenital. If the convexity of the spine is on one side and the lung lesion is on the opposite side, it indicates an acquired scoliosis. Empyema necessitans in which there is an intercostal swelling close to the sternum. Scorbutic rosary: It is the sharp angulation, with or without beading or rosary formation, of the ribs, arising as a result of backward displacement or pushing in of the sternum. It reduces the ventilatory capacity of the Rate lung and increases the work of breathing. Tachypnoea: It is an increase in respiratory rate more Movement of the Chest than 20 per minute. Conditions causing tachypnoea It is described in terms of rate, rhythm, equality and are: type of breathing. Biots breathing: It is characterised by apnoea between several shallow or few deep inspirations. Apneustic breathing: It is characterised by pause at full inspiration, alternating with a pause in expiInspiration: It is an active process brought about by the ration, lasting for 2 to 3 seconds. It occurs in pontine contraction of the external intercostal muscles and the lesions diaphragm (Fig. Cogwheel breathing: It is an interrupted type of Expiration: It is a passive process and it depends upon breathing pattern, seen in nervous individuals elastic recoil of the lungs. Pursed lip breathing: this form of breathing is seen in Accessory muscles of inspiration (Fig. Abnormal Breathing Patterns Palpation Abnormal breathing patterns may be regular or irregular (Fig. The position of the trachea is confirmed by slightly flexing the neck so that the chin remains in the midline.

Trivedi & Pitchumoni classified risk drugs on the basis of the search of the reported cases in the National Library of Medicine/Pubmed from 1966 to 2004 anxiety 6 months postpartum generic sinequan 10 mg without a prescription. The authors classified reported medications into four classes based on the published weight of evidence for each agent and the pattern of clinical presentation anxiety symptoms postpartum cheap sinequan online american express. Class I included medications in which at least one case was proven by a re-challenge with the drug anxiety meditation order sinequan 25 mg free shipping. At least some of them also deserve more detailed mention anxiety symptoms 9dp5dt cost of sinequan, which can be found in following sections symptoms of anxiety buy cheap sinequan. It is a pro-drug metabolized into the active 6-mercaptopurine anxiety symptoms joins bones purchase sinequan with a mastercard, itself a purine synthesis inhibitor. The mechanism of action remains unknown, but is limited to the intestine as the agent is not absorbed systemically in significant amounts. Mesalazine belongs to drugs with the best documented association (Class I) with druginduced acute pancreatitis. Acute pancreatitis induced by mesalazine usually occurs during the first days or weeks of treatment; however, an occurrence following prolonged use has 24 Acute Pancreatitis also been sporadically reported. No dose dependence has been observed and the symptoms usually disappear within 10 days after drug withdrawal. Drugs commonly associated with drug-induced pancreatitis (* class effect probable) Acute Pancreatitis Induced by Drugs 25 4. Although usually mild, valproate-induced pancreatitis may have a severe course with associated complications such as necrosis or even death. The nature of an agent used as an anesthetic results in an immediate onset of drug-induced pancreatitis following a single use. At least 20 cases of propofol-associated acute pancreatitis have been reported in the literature with subsequent discussions on the possible role of drug formulation in the oil-in-water emulsion. In contrast to their wide use, the occurrence of acute pancreatitis caused by these agents is rare. The risk of acute pancreatitis in patients using cardiovascular drugs has been extensively studied in the European study on drug-induced acute pancreatitis. The risk increased with higher daily doses and was highest in the first six months of therapy (Eland et al. Histamine H2 receptor antagonists cimetidine and ranitidine have been reported to cause drug-induced pancreatitis in several case reports without an evidence of rechallenge or a consistent latency. Some experimental findings also indicate the possible causative relationship, whilst others deny it. On the other hand, a previous, much larger and better designed study brought no evidence for this suspicion (Eland et al. This phenomenon was probably even more pronounced in a newer group of agents with similar effects, dipeptidyl peptidase-4 inhibitors. A considerable effort has been made to refute this connection, which is, of course, in the interest of the manufacturers. Here is yet another example of a negative result in a pharmacoepidemiological study. Again, the probable reason lies in an extremely small proportion of drug-induced cases in total numbers of acute pancreatitis, which of course cannot influence the overall risk in high-risk populations. Available clinical case reports or series are usually too outdated to rely on the information contained (Bartholomew, 1970), but experimental studies on the effects of scorpion toxin are very interesting. Concurrent stimulation of pancreatic secretion and contraction of the sphincter of Oddi have been demonstrated in the late 1970s. Rare reports on pancreatitis caused by adder bite (venom containing neurotoxic phospholipase A2) or even blue-ringed octopus bite (venom containing tetrodotoxin) have been published. Aside from alcohol, another addictive substance often mentioned in association with acute pancreatitis is marijuana, abused by smoking. A smaller series of marijuana-induced pancreatitis cases was reported by Wargo et al. Interestingly, stimulation of cannabinoid receptors was found to be a protective mechanism during experimental pancreatitis. This is yet another example of ambivalent behavior of some xenobiotics towards the pancreatic tissue. Diagnostics, disease course and management Among the reasons why the real incidence of drug-induced acute pancreatitis is still not known, the difficulties in diagnosis are probably most important. Milder cases of pancreatic injury are often missed because serum amylase and lipase estimations are not part of the metabolic profile obtained during a routine health checkup and abdominal pain is often attributed to underlying diseases. The first criterion seems to be easy to achieve until we remember that monotherapy in our patients becomes more and more scarce. Use of the classification systems mentioned above may be very useful for that purpose. Excluding all other causes of the disease is also not so straightforward in many cases of acute pancreatitis. The validity of diagnosis may depend on the equipment available and even more on the experience of the medical staff. Discontinuation of oral therapy is a natural part of any management of acute pancreatitis. In patients treated by multiple pharmacotherapy, it is impossible to decide which medication withdrawal led to a resolution of the symptoms and laboratory findings. In these cases, acute pancreatitis is usually diagnosed within several days from drug administration. Due to the character of the disease and ethical considerations, deliberate, repeated administration of suspect drug to induce a new episode of acute pancreatitis is not possible. An exception is the use of essential drugs in cases where the benefits outweigh the risks. A simplified algorithm for diagnosing drug-induced pancreatitis is given in Figure 1. The suspected drug etiology should be considered after the exclusion of more common causes of illness. A detailed medication history documentation is obvious as well as the determination of suspicious substances. There is no evidence for preferring one of these systems, so it is possible to use both, mainly if there is a difference between them in classifying a specific suspicious agent. Using these classification systems may improve the quality of information for further patient treatment and further processing of the event for scientific or pharmacovigilance purposes. Level of Characteristics probability Certain A clinical event, including a laboratory test abnormality, that occurs in a plausible time relation to drug administration, and which cannot be explained by concurrent disease or other drugs or chemicals the response to withdrawal of the drug (dechallenge) should be clinically plausible the event must be definitive pharmacologically or phenomenologically using a satisfactory rechallenge procedure if necessary Probable A clinical event, including a laboratory test abnormality, with a reasonable time relation to administration of the drug, unlikely to be attributed to concurrent disease or other drugs or chemicals, and which follows a clinically reasonable response on withdrawal (dechallenge) Rechallenge information is not required to fulfill this definition Possible A clinical event, including a laboratory test abnormality, with a reasonable time relation to administration of the drug, but which could also be explained by concurrent disease or other drugs or chemicals Information on drug withdrawal may be lacking or unclear Unlikely A clinical event, including a laboratory test abnormality, with a temporal relation to administration of the drug, which makes a causal relation improbable, and in which other drugs, chemicals, or underlying disease provide plausible explanations Conditional / A clinical event, including a laboratory test abnormality, reported as an unclassified adverse reaction, about which more data are essential for a proper assessment or the additional data are being examined Unassessable / A report suggesting an adverse reaction that cannot be judged, because unclassifiable information is insufficient or contradictory and cannot be supplemented or verified Table 3. Of course, severe cases tend to be more often 30 Acute Pancreatitis reported both in the literature and in spontaneous pharmacovigilance reports. In the disease management, there are no specific issues concerning drug-induced pancreatitis, with an exception of an immediate withdrawal of the suspected drug. A difficult question is how to reintroduce medication if the causative agent is not unambiguously identified. We recommend not introducing all withdrawn drugs at the same time to distinguish the cause of a possible flare-up. The most suspected drugs should be substituted by their analogs with a different chemical structure. Secondary prevention consists of avoiding the drug which caused the episode of acute pancreatitis. Rechallenge of such an agent is justified only if its benefits outweigh the risks, as discussed above. Future research Given how inadequate the current state of knowledge on drug-induced pancreatic injury is, the area for further research in this field is remarkably wide. The majority of the knowledge on the topic has been obtained from case reports or their series. These will remain a major source of information, so it is necessary to improve their informative value substantially. Provide the age and sex of the patient, along with the indication for treatment with a drug; provide the dose and frequency of medication; b. Document a definite case of pancreatitis based on current diagnostic guidelines; c. Provide information on the time course between initiation of drug and onset of pancreatitis; d. Exclude the most common causes of pancreatitis; document a positive response to withdrawal of medication;. Higher level of knowledge may be obtained by performing multicenter studies targeted at the etiology of non-alcoholic, non-biliary pancreatitis. Several thousands of acute pancreatitis cases must be involved in these studies to reveal the actual occurrence of druginduced pancreatitis. Any new pharmacoepidemiological study on this topic would be useful, but to improve the validity of its outcomes, substantially better input data are required. For this purpose, it would be optimal that each single case of acute pancreatitis included in such a study be documented according to the above principles. An obvious field for this research is the issue of diseases with a high Acute Pancreatitis Induced by Drugs 31 incidence of this disorder. Another issue is the experimental pharmacological research of mechanisms by which xenobiotics can damage the pancreatic tissue as well as the common mechanisms of immune-mediated tissue injury caused by drugs. Any substantial progress in this research can contribute to a progress in two scientific challenges: recognizing the nature of more frequent causes of acute pancreatitis and also recognizing the cause and pathogenesis of idiosyncratic adverse drug reaction. Epidemiological studies show a very wide range of its incidence, but at least the absolute number of its cases is undoubtedly increasing. We are able to identify the drugs with the greatest risk and populations at risk, but the absolute risk for medication users is still very low. A better understanding of drugmediated pancreatic injury can also help to understand the etiology of more common types of acute pancreatitis. Research in drug-induced acute pancreatitis is both a challenge and an opportunity to improve the collaboration of gastroenterology and clinical pharmacology. Introduction Evidence accumulated for the past two decades leads to the conclusion that obesity enhances the development of acute pancreatitis and worsens its clinical course. We will try to give an answer to this issue by presenting the scientific data accumulated thus far. The advantage of this method is its application simplicity, namely the lack of complicated procedures needed to determine it as well as the fact that it has been globally accepted. Other methods used to determine obesity measure the amount of subcutaneous fat tissue. These methods are based on the fact that the amount of subcutaneous fat tissue correlates well with the amount of excess fat tissue. The methods include the measurement of skin fold thickness, waist diameter and waist-to-hip ratio. The limiting factor for these methods is the presence of edema in the investigated areas (liver cirrhosis, heart and kidney diseases). It is used to measure body composition based on the difference in the absorption of X-rays in different types of tissues (bone, fat, muscle, water). After two decades of tedious work in finding the best method for estimating the amount of body fat in acute pancreatitis, scientists offer no clear answers. The following sections offer a detailed insight into the best methods for estimating the amount of body fat in acute pancreatitis. Therefore, it is hard to determine whether or not obesity has a direct impact on the onset of acute pancreatitis. Analyses show that there is no difference in the weight distribution of patients suffering acute pancreatitis and the general population. The reason for this lies in the fact that while patients with biliary pancreatitis tend to be overweight (as obesity is a risk factor for biliary stones), patients suffering alcoholic pancreatitis tend to be lean or even malnourished. Since obesity is linked to acute pancreatitis, there have been many speculations about the pathogenetic links between the two. Adipokines once included only biologically-active substances secreted by the adipocytes, but today they refer to all biologically-active substances produced by the adipose tissue. The principal anti-inflammatory substance secreted by the adipocytes is adiponectin. It is a 30-kDa protein with plasma levels ranging from 5 to 30 mg/L in lean subjects. Adiponectin has many potentially beneficial effects in acute pancreatitis (Zyromski et al, 2008): it enhances insulin-sensitivity (Yamauchi et al, 2002), modulates endothelial adhesion Obesity and Acute Pancreatitis 37 molecules (Ouchi et al, 1999), alters macrophage and lymphocyte action (Ouchi et al, 2001; Wolf et al, 2004) and modulates the balance of cytokines in favor of anti-inflammatory cytokines (Ouchi et al, 2000; Huang et al, 2008; Masaki et al, 2004) Leptin, a pro-inflammatory adipokine synthesized in the adipocytes, is on the opposite side of the spectrum. Leptin acts pro-inflammatory by regulating cytokine production in favor of pro-inflammatory cytokines (Fantuzzi & Faggioni, 2000; Santosa et al, 2007) and by enhancing leukocyte activity (Loffreda et al, 1998; Lord et al, 1998). Studies have shown that excess adipose tissue generates more leptin and resistin, and less adiponectin. This, in turn, leads to the prevalence of pro-inflammatory over antiinflammatory cytokines, resulting in a state of constant inflammation of the adipose tissue. Normal fat tissue contains a balance of the so-called M1 or pro-inflammatory macrophages and the so-called M2 or anti-inflammatory macrophages.

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