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By X. Lee. Carson-Newman College. 2019.

V—Vascular lesions include embolic glomerulonephritis and dissecting aneurysm; transfusion reactions are considered as well as intravascular hemolysis of any cause purchase red viagra 200mg with visa. I—Inflammatory lesions include pyelonephritis generic red viagra 200 mg on-line, necrotizing papillitis, and renal tuberculosis. N—Neoplasms of the kidney rarely cause anuria because only one kidney is affected at a time. Lupus erythematosus, polyarteritis nodosa, acute glomerulonephritis, amyloidosis, Wegener granulomatosis, and scleroderma are included here. T—Trauma includes contusions and lacerations of the kidney for completeness; however, lower nephron nephrosis from crush injury or burns is not unusual. E—Endocrine disorders include diabetic glomerulosclerosis, necrotizing papillitis from diabetes, and nephrocalcinosis from hyperparathyroidism and related disorders. M—Malformations may cause anuria; they include congenital bands, aberrant vessels over the ureters, horseshoe kidney, and ureteroceles. N—Neoplasms include carcinomas of the bladder obstructing both ureters, prostatic hypertrophy, and carcinomas of the uterus or cervix involving both ureters. N also signifies neurologic disorders such as polio, multiple sclerosis, and acute trauma to the spinal cord that may cause anuria. T—Trauma signifies surgical ligation of the ureters, ruptured bladder, and instrumentation of the urinary tract. Approach to the Diagnosis The clinical picture will be helpful in determining the cause of anuria. In cases of prerenal azotemia, there will be decreased skin turgor and orthostatic hypotension if the cause is volume depletion. Patients with postrenal azotemia may have an enlarged prostate, a distended bladder, and other signs of obstructive uropathy. Patients with renal azotemia may have bilateral flank masses (polycystic kidney), hypertension, peripheral emboli (embolic glomerulonephritis), or a rash (collagen disease, interstitial nephritis). The bladder is catheterized for residual urine; if this is significant, postrenal azotemia is likely and an urologist is consulted. He or she will most likely do a cystoscopy and retrograde pyelography after the patient’s condition is stabilized. Ultrasonography can be used to determine if there is significant residual urine also. The laboratory studies will determine whether there is prerenal or renal azotemia. If the sodium concentration in the spot urine is <10 mEq/L, prerenal azotemia is likely. If volume depletion is the cause, intravenous saline and plasma volume expanders are given while carefully monitoring the urine output. If this is ineffective, furosemide and a mannitol drip can be utilized to reestablish urine output. If these measures are ineffective, the patient obviously has a renal cause for his or her anuria, and an urologist should be consulted. If intravascular hemolysis is suspected, a serum haptoglobin test should be ordered. If dissecting aneurysm or bilateral renal artery stenosis is suspected, aortography and angiography would be done. Aphasia must be distinguished from dysarthria, which could also be due to involvement of the brain stem or cerebellum. Patients with dysarthria have no difficulty recognizing or interpreting words or phrases, but speech is garbled and difficult to understand by the clinician. D—Degenerative disorders include Alzheimer disease, Pick disease, Huntington chorea, and dementia with Lewy bodies. I—Intoxication should suggest the possibility of alcohol or drug intoxication and Korsakoff psychosis. C—Congenital disorders include cerebral palsy, the leukodystrophies, and congenital abnormalities of the brain such as hydrocephalus and microcephaly. Cerebral aneurysm and atrioventricular (A-V) anomalies might also be brought to mind in this category. A—Autoimmune disorders include multiple sclerosis, lupus erythematosus, thrombotic thrombocytopenic purpura, and other collagen disorders. T—Trauma should bring to mind epidural, subdural, and intracerebral hematomas related to trauma. E—Endocrine disorders are not particularly suggestive of cerebral pathology, but an amniotic fluid embolism may rarely be responsible for aphasia, apraxia, or agnosia.

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An empirical study dimensionality of the Brief Self-Control Scale: An of the psychodynamics of borderline impulsivity: evaluation of unidimensional and multidimen- A preliminary report discount red viagra 200 mg free shipping. The multi-factor structure of the Brief Self- ment cheap 200 mg red viagra, less pathology, better grades, and interper- Control Scale: Discriminant validity of restraint sonal success. Impulsivity in an epidemiological The relationship between impulse-control disor- catchment area sample of the general population: A ders and obsessive–compulsive disorder: A current confirmatory factor analysis of the Barratt Impul- understanding and future research directions. The Barratt Impulsive- factor model and impulsivity: Using a structural ness Scale–11: Reassessment of its structure in a model of personality to understand impulsivity. Psychological Assessment, 25, Personality and Individual Differences, 30, 669– 631–642. Protecting the self: Defense mech- tic and statistical manual of mental disorders (4th anisms in action. Profile of Mental Functioning—M Axis 129 Further reliability, convergent and discriminant functioning. The Defense Mechanism Rating pleted psychoanalyses: The Penn Psychoanalytic Scales manual (5th ed. American Journal of Psy- ing in psychotherapy, using the Defense Mecha- chiatry, 158, 467–473. Assessing evidence-based psychodynamic psychotherapy defense styles: Factor structure and psychometric (pp. International Journal of Psychology mechanisms during long-term dynamic psycho- and Psychological Therapy, 8, 171–181. European Journal of Psychologi- resilience: Have we underestimated the human cal Assessment, 28, 139–146. Jour- chological Trauma: Theory, Research, Practice, nal of Research in Personality, 39, 395–422. Ordinary magic: Resilience pro- opment of a new resilience scale: The Connor– cesses in development. Psychotherapy and Psychosomatics, Effects of treatment on posttraumatic stress disor- 76, 141–153. Journal of Personality and resiliency: Relations to observed parenting and Social Psychology, 92, 1087–1101. Manual for the matic growth: Conceptual foundations and empiri- Ways of Coping Scale. Journal resiliency from late adolescence to young adult- of Personality Assessment, 94, 638–646. Journal of Personality Assessment, 92, Ego-control and ego-resiliency: Generalization of 1–10. International Journal Item selection and cross-validation of the factor of Psycho-Analysis, 54, 35–46. Psychoana- the relationship among early maladaptive schemas, lytic Study of the Child, 59, 167–187. Relationships among psycho- ogy and Psychotherapy: Theory, Research, and logical mindedness, alexithymia and outcome in Practice, 87, 167–177. Comprehensive On the nature of the observing function of the Psychiatry, 31, 426–431. Affect regulation, mentalization, and the Psychological mindedness in relation to personal- development of the self. Journal of Clinical Psychology, 66, reflective function: Their role in self-organization. Self-narratives and dysregulated logical Mindedness Scale: Factor structure, con- affective states: The neuropsychological links vergent validity and gender in a non-psychiatric between self-narratives, attachment, affect, and sample. Measuring psychological Psychological-mindedness and the alexithymia mindedness: Validity, reliability, and relationship construct. British Journal of Psychiatry, 154, with psychopathology of an Italian version of the 731–732. International Journal of Psychoanalysis, 85, 879– Psychoanalytic Psychology, 31, 489–501. Journal of Personality conceptualization of the superego and the develop- Disorders, 23, 384–398. Without conscience: The disturb- of the Levenson Self-Report Psychopathy Scale: Is ing world of the psychopaths among us. Superego: An attachment perspec- traits, and prosocial moral reasoning: A multicul- tive. Purpose in life as psychopathology: Analysis of spontaneous descrip- a predictor of mortality across adulthood.

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Comparison of the efcacy and tolerability of zonisamide and con- trolled release carbamazepine in the newly diagnosed partial epilepsy: a phase 3 purchase 200mg red viagra mastercard, randomized generic 200 mg red viagra free shipping, double-blind, non-inferiority trial. Efcacy, tolerability, and safety of rapidly initiation of topiramate versus phenytoin in patients with new-onset epilepsy: a randomized double-blind clinical trial. Efcacy and safety of pregabalin versus lamotrigine in patients with newly diagnosed partial seizures: a phase 3, double-blind, randomized, parallel- group trial. Who Was Excluded: Patients were excluded if they (1) were aged <4 years, (2) had acute symptomatic seizures (such as febrile seizures), and (3) had a his- tory of progressive neurologic disease. Study Design Drug Randomized Patients Allocated (N = 716) lamotrigine 239 Topiramate 239 Valproate 238 Study Intervention: Afer the initial choice of drug was randomized, clinicians decided subsequent changes in dose or preparation, to most accurately mirror everyday practice. Endpoints: Primary outcomes: Time to treatment failure (stopping the ran- domized drug because of inadequate seizure control, intolerable side efects, or both); the addition of other antiepileptic drugs; and time to 1-year remission of seizures. Secondary outcomes: Time from randomization to a frst seizure; time to achieve a two-year remission; frequency of clinically important adverse events; and side efects. Valproate for Generalized and Unclassifable Epilepsy 35 • For adequate seizure control: lamotrigine was found to have almost twice the failure rate of valproate. Topiramate also appeared to have a higher failure rate than valproate, though the result was not statistically signifcant. T e pooled population of patients in the sections of this study had a variety of diferent types of epilepsy, and it is difcult to know how each seizure type responded to the study medications. T e drug was unfortunately not addressed in this study, despite its popular use, as it was introduced to the market afer the study’s inception. Finally, there were more men than women in this study, likely infuenced by the fact that valproate has known teratogenic efects and clinicians were reluctant to randomize women of child-bearing age to possible treatment with valproate. Valproate is now considered frst- line therapy for patients with generalized-onset or unclassifable epilepsy. Signifcant factors for 12-month remission included sex, treatment history, age, and total number of seizures prior to randomization. He had been started on valproate, though he is interested in “newer” anti-epileptic drugs— specifcally, lamotrigine and topiramate. Suggested Answer: Valproate is superior to both topiramate and lamotrigine for seizure control— especially in patients with idiopathic generalized epilepsy. T e patient should continue on his current anti-epileptic therapy if he tolerates the medication well. Time to 12-month remission and treatment failure for generalized and unclassifed epilepsy. Who Was Studied: Patients aged 18–65 years at the time of a migraine headache, as defned by the International Headache Society’s Headache Classifcation Commitee. All patients had a history of migraines for at least 1 year, and a maximum of 6 atacks per month. Those who had taken prophylactic migraine medications within 2 weeks, ergot-containing preparations within 24 hours, or simple analge- sic or nonsteroidal anti-inflammatory drugs within 6 hours were excluded as well. Patients with migraine headache Randomized Injection 1 Placebo Sumatriptan 6 mg Sumatriptan 8 mg If headache at 60 If headache at 60 If headache at 60 minutes then minutes then minutes then injection 2 injection 2 injection 2 Placebo Placebo Sumatriptan 6 mg Placebo Figure 6. Study Intervention: Patients with acute migraine headache were ran- domized to receive subcutaneous sumatriptan 6 mg, 8 mg, or placebo. At 60 minutes if they still had a headache, subjects in the sumatriptan 8 mg and initial placebo groups all received a placebo injection. If patients ini- tially received sumatriptan 6 mg and still had a headache at 60 minutes, they were randomized to either a second injection of sumatriptan 6 mg or to placebo. Sumatriptan for Acute Migraine 43 Follow- Up: 30, 60, and 120 minutes, then 2–5 days. Endpoints: Primary outcome: relief of headache from “severe or moder- ate” to “mild or none,” 30, 60, and 120 minutes after the first injection. Secondary outcomes: pain freedom, need for usual rescue medications at 120 minutes; relief of nausea, vomiting, photophobia, phonophobia; func- tional disability; recurrence of headache within 24 hours after treatment; adverse events. T e response rates of the three sumatriptan regimens did not difer signifcantly from each other, but all three were signifcantly beter than the response rate in patients treated with placebo only (P < 0. Response Rates 120 Minutes after the First Injection Placebo + 6 mg 6 mg Sumatriptan 8 mg Placebo Sumatriptan + 6 mg Sumatriptan + Placebo Sumatriptan + Placebo Total number 92 110 106 49 of patients Number with 28 (30%) 83 (75%) 86 (81%) 40 (82%) improvement (%) Criticisms and Limitations: Many groups of patients were excluded from this study, including those recently on preventive therapies for migraine headaches. Other Relevant Studies: • An additional randomized study of 136 patients with migraine found that 6 mg of subcutaneous sumatriptan was efective in treating acute migraine in the eD compared with placebo. In patients with headache recurrence within 24 hours, oral sumatriptan (100 mg) was efective as abortive therapy for the recurrence. T ese patients had initially been successfully treated with 6 mg subcutaneous sumatriptan for a migraine atack.

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