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  1. Board Review January 2008

  2. DSM-IV Criteria for Alcohol Abuse • A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: • Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school or home. • Recurrent alcohol use in situations in which it is physically hazardous. • Recurrent alcohol-related legal problems. • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the alcohol. • The symptoms have never met the criteria for alcohol dependence. Alcohol-Related Problems: Recognition and Intervention AFP. January 1999.

  3. DSM-IV Criteria For Alcohol Dependence • A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: • Tolerance, as defined by either of the following: • A need for markedly increased amounts of alcohol to achieve intoxication or the desired effect • Markedly diminished effect with continued use of the same amount of alcohol

  4. DSM-IV, Continued 2. Withdrawal, as manifested by either of the following: • The characteristic withdrawal syndrome several hours to a few days following cessation (two or more of the following): • autonomic hyperactivity (e.g., sweating or pulse > 100) • increased hand tremor • Insomnia • nausea or vomiting • transient visual, tactile or auditory hallucinations or illusions • psychomotor agitation, anxiety or grand mal seizures • Alcohol or other substances are taken to relieve or avoid withdrawal symptoms

  5. DSM-IV, Continued • Alcohol is taken in larger amounts or over a longer period than was intended • There is a persistent desire or unsuccessful efforts to cut down or control drinking • A great deal of time is spent to obtain alcohol, drink alcohol, or recover from its effects • Important social, occupational or recreational activities are given up or reduced because of drinking alcohol • Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol Specify if: With physiological dependence: evidence of tolerance or withdrawal (i.e., either item 1 or item 2 is present) Without physiological dependence: no evidence of tolerance or withdrawal (i.e., neither item 1 nor item 2 is present)

  6. Assessment of Risk for Alcohol-Related Problems Severity of problem Criteria________________ At Risk Men: >14 drinks per week, >4 drinks per occasion Women: >7 drinks per week, >3 drinks per occasion, or CAGE score of 1 or higher for past year, or Personal or family history of alcohol problems Current problem CAGE score of 1 or 2 for past year, or Alcohol-related medical problems, or Alcohol-related family, legal or employment problems Alcohol dependent CAGE score of 3 or 4 for past year, or Compulsion to drink, or Impaired control over drinking, or Relief drinking, or Withdrawal symptoms, or Increased tolerance Alcohol-Related Problems: Recognition and Intervention AFP. January 1999.

  7. Combination of negative D-dimer and low or intermediate Wells score indicates no further testing

  8. SIMERVILLE J, WILLIAM C, PAHIRA J. Urinalysis: A Comprehensive Review. AFP. March 2005

  9. Urine Nitrite Test • Causes of false positive nitrite on Urinalysis • Vaginal contaminant • Phenazopyridine • Dipstick exposed to air • Close test strip containers immediately • Strip exposed to air for 1 week: 33% false positive • Strip exposed to air for 2 weeks: 75% false positive • Causes of false negative nitrite on Urinalysis • Increased Urine Specific Gravity • Increased Urobilinogen • Bacteria lacking nitrate reductase enzyme • Urine pH <6.0 • Vitamin C supplementation • Low nitrate diet

  10. Brundage S. Fitzpatrick A. Hepatitis A. AFP. June 2006

  11. Brundage S. Fitzpatrick A. Hepatitis A. AFP. June 2006

  12. NOT Currently Taking Controllers Level of severity is determined by both impairment a & risk. Assess impairment by caregivers recall of previous 2-4 weeks.

  13. Assessing Control & Adjusting Therapy Children 0-4 Years of Age

  14. Severe Moderate Mild Sx: < 2/week Nighttime: 0 Daily 3-4x/mo Continuous > 1x/week 1-2x/mo

  15. NOT Currently Taking Controllers

  16. Assessing Control & Adjusting Therapy Children 5-11Years of Age

  17. Severe Moderate Mild Sx: < 2 week Night: < 2x/mo Daily > 1x/week Continuous Nightly 3-4x/mo EPR-3 (8/28/07): p296-304, 306

  18. NOT Currently Taking Controllers

  19. Assessing Control & Adjusting Therapy In Youths > 12 Years & Adults

  20. Severe Moderate Mild Sx: < 2 week Night: <2x/mo Daily >1/week Continuous Nightly 3-4x/mo EPR-3 (8/28/07): p326-343

  21. Vranken M. Prevention and Treatment of Sexually Transmitted Diseases: An Update. AFP. Dec 2007.

  22. Vranken M. Prevention and Treatment of Sexually Transmitted Diseases: An Update. AFP. Dec 2007.

  23. Antibody-mediated decrease in nicotinic acetylcholine receptors in the postsynaptic neuromuscular junction. Defective neuromuscular transmission and subsequent muscle weakness and fatigue. Myasthenia gravis

  24. MG Symptoms • The hallmark of MG is fluctuating weakness worsened with exercise and improved with rest • Generalized weakness involving proximal muscles, diaphragm, neck extensors in 85% • Weakness confined to eyelids and extraocular muscles in about 15% of patients • Bulbar symptoms of ptosis, diplopia, dysarthria, dysphagia common • Normal reflexes, sensation, and coordination Ferris Clinical Advisor 2008

  25. EPIDEMIOLOGY & DEMOGRAPHICS • INCIDENCE (IN U.S.): 2 to 5 cases/yr/1,000,000 persons • PEAK INCIDENCE: Female: second-third decade; male: sixth-seventh decade • PREVALENCE (IN U.S.): 1/20,000 persons • PREDOMINANT SEX: Female > male (3:2) in adults; female = male in elderly • GENETICS: Increased frequency of HLA-B8, DR3 Ferris Clinical Advisor 2008

  26. Clinical Presentations Michelle J. Mulligan, Michael J. Cousins In Atlas of Anesthesia: Preoperative Preparation and Intraoperative

  27. Osserman Classification in Myasthenia Gravis 0 Asymptomatic 1 Ocular signs and symptoms 2 Mild generalized weakness 3 Moderate generalized weakness, bulbar dysfunction, or both 4 Severe generalized weakness, respiratory dysfunction, or both Information from Calhoun RF, Ritter JH, Guthrie TJ, Pestronk A, Meyers BF, Patterson GA, et al. Results of transcervical thymectomy for myasthenia gravis in 100 consecutive patients. Ann Surg 1999; 230:555-61.

  28. MG WORKUP • Tensilon test: useful in MG patients with ocular symptoms. • Repetitive nerve stimulation (RNS): successive stimulation shows decrement of muscle action potential in clinically weak muscle, may be negative in up to 50%. • Single-fiber electromyography (SFEMG): highly sensitive, abnormal in up to 95% of myasthenics. • Serum AChR antibodies found in up to 80% of patients. • A subset of patients with seronegative MG may have muscle-specific tyrosine kinase (MuSK) antibodies. Ferris Clinical Advisor 2008

  29. Medical Management • Symptomatic treatment with Acetylcholinesterase inhibitors: • Pyridostigmine 30 to 60 mg PO q4-6h initially; onset of effects is 30 min, duration 4 hr • Immunosuppressive treatment with corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine for chronic disease-modifying therapy • Plasmapheresis and intravenous immunoglobulin are possible short-term options for immunotherapy • Mechanical ventilation is lifesaving in setting of a myasthenic crisis. Ferris Clinical Advisor 2008

  30. SURGICAL Rx • In thymomatous MG, thymectomy is indicated in all patients. • For non-thymomatous autoimmune MG: thymectomy is an option in patients less than 40 yr of age. Ferris Clinical Advisor 2008

  31. Treatment of Myasthenia Gravis Michael R. Swenson In Atlas of Clinical Neurology: Clinical Neurology. Edited by Roger N. Rosenberg. Current Medicine, Inc. 2000.

  32. AFP. 2001 Sep 15;64(6):934, 937-8.