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Chronic: Years later: heart failure; enlargement of the esophagus or colon Focused History: Do you recall an unusual, red, swollen insect bite or swelling around one eye Using Advanced Tools: Lab: Parasites in peripheral blood smears (thick and thin) can be found during febrile periods early in the course of infection. Prevention and Hygiene: Avoid insect bites and infested areas; wear protective clothing. Zoonotic Disease Considerations Principal Animal Hosts: Dogs, cats, rodents Clinical Disease in Animals: Intermittent fever, anemia, weight loss; may be asymptomatic Probable Mode of Transmission: Contaminated bite wounds or contact with fecal matter of Reduviidae family of insects (kissing bugs). Extrapulmonary disease occurs in approximately 15% of infected persons and can affect virtually any organ system (see Skin: Cutaneous Tuberculosis) and can disseminate throughout the body. Subjective: Symptoms Chronic productive cough (bloody), chest pain, fever, chills, night sweats, anorexia, weight loss, fatigue. Plan: Treatment Primary: Base the selection of antimycobacterial drugs on knowledge of local resistance patterns. Patient Education General: Comply with the medication regimen to avoid developing active disease, and then spreading it to others. Evacuation/Consultation Criteria: Evacuation not necessary unless clinically unstable or patient develops significant medication side effect. Consult with pulmonologist, infectious disease specialist or primary care physician prior to treatment and as necessary. Zoonotic Disease Considerations Agent: Mycobacterium bovis Principal Animal Hosts: Cattle Clinical Disease in Animals: Progressive emaciation, lethargy, weakness, anorexia, low-grade fever; chronic bronchopneumonia with moist cough, progressing to tachypnea and dyspnea. Probable Mode of Transmission: Ingestion, inhalation (occupational exposure to farmers) Known Distribution: Worldwide; rare in N. Pulmonary syndromes are usually chronic, often occurring in persons with other underlying pulmonary disease. Subjective: Symptoms Lymphadenitis (painless enlargement of the lymph nodes of the neck), usually unilaterally; skin and soft tissue infections edema, erythema; pulmonary infection chronic, productive cough with fever and weight loss; accompanied by malaise, night sweats and hemoptysis. Other Syndromes: Therapy based on site of disease, organism and susceptibility testing results. No Improvement/Deterioration: Reevaluation and repeat culture and susceptibility testing. Follow-up Actions Wound Care: Local care (clean, dry, protect, topical antibiotics) to prevent secondary bacterial infection. Consultation Criteria: Management of chronic pulmonary infection usually requires specialty consultation. Although the acid-fast bacilli can be detected in lesional or sputum smears or biopsy material, culture is required to confirm diagnosis. Cryptococcosis is found worldwide but symptoms are most common in the immunosuppressed and are not acutely life-threatening. Blastomycosis, coccidioidomycosis, histoplasmosis, and paracoccidioidomycosis are endemic fungal infec tions that should be included in a differential diagnosis so individuals with potential infections may be removed or referred to higher echelons of care.
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Lack of social support was also associated with longer duration and (chronic) physical illness had a predictive value on the duration of later depressive episodes. Determinants of duration in the early phase of the episode differed from determinants later on in the episode: in the first three months only illness-related factors predicted duration but if the episode persists personality characteristics, (chronic) physical illness and comorbid dysthymia became important. Chapter 7: Duration of depression and recovery and functional disability in the general population. Functioning in daily activities improved with longer duration of recovery but social functioning did not. Ilness-related factors were found as the strongest predictors of episode duration i. Furthermore, lack of social support and (chronic) physical illness were found to be associated with longer duration. Longer duration of depression was not found to be associated with increased functional disability. Depressed individuals with professional care utilisation were found to be more severely and longer depressed and more functionally impaired than those without care. The one-year outcome for those with professional care utilisation was worse compared to those without care. The rate of chronicity and the determinants of persistence of depression in the general population were very similar to clinical populations. Depressive patients with a high risk for chronicity should be referred for specialised mental health care or at least for consultation. For those with a medium risk for chronicity primary care treatment might be indicated with regular follow-up. A prognostic index should be devised for the assessment of the risk for chronicity in depressed individuals. Unipolaire depressie is wereldwijd een belangrijk volksgezondheidprobleem onder andere vanwege de hoge mate van voorkomen van terugval, recidieven en chroniciteit. Kennis over deze ongunstige belooppatronen is van belang om behandelingsstrategieen the ontwikkelen die het ongunstige beloop kunnen voorkomen. Wat is de duur van een depressieve episode in engere zin (verder genoemd depressieve episode) in de algemene bevolking en hoe vaak komt een chronisch beloop van een depressieve episode voor Wat zijn de gevolgen van een langere duur van een depressieve episode op het algemeen functioneren In dit proefschrift werden minder strikte definities voor chroniciteit gebruikt zoals een een-jaars definitie en een definitie van geen herstel gedurende twee jaar waarbij ook comorbide dysthymie werd meegerekend. Er werd een literatuuronderzoek verricht naar de determinanten van het beloop van unipolaire depressie met het focus op chronisch beloop.
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The use of different methods and diagnoses makes direct comparison of studies difficult. Parents, children and siblings are first-degree relatives of the proband, while uncles, aunts, nephews and nieces are second-degree relatives. Many of these studies have used age correction, blinding of interview ers and control groups. Genetics of bipolar affective disorder 247 As familial resemblance also may be due to shared cultural or environ mental factors the suggestion of a genetic component based on family studies is only tentative. Twin and adoption studies can help to separate the genetic and environmental effects and allow estimates of their relative contribution to be calculated. Results from twin studies are usually expressed as concordance rates which may either be calculated as pairwise concordance, which is the proportion of twin pairs in which both twins are ill, or preferably as the probandwise concordance rate, which is the number of concordant co-twins divided by the number of probands. Furthermore, concordance rates, and thus the influence of genes, increase with the severity of affective disorder. Family and twin studies point to a higher, or at least comparable, genetic influence in bipolar disorder compared to several common medical disor ders for which monogenic subgroups have been identified (Plomin et al. Adoption studies are potentially very useful for disentangling genetic and environmental components of a disease. Disadvantages of adoption studies include the facts that they are difficult to perform, that adoptees overall may have increased psychopathol 248 H. Ewald ogy and that the environment may differ between biological and adoptive parents. If polygenes and non-genetic factors are involved the disease is termed multifactorial. Statistical analysis of information from pedigrees, segregation analysis and prevalence analyses in different classes of relatives and comparisons between concordance rates in monozygotic and dizygotic twins have been used but no consistent results have emerged (Faraone et al. Linkage analyses of Danish families have found evidence in favour of susceptibility loci on chromosome regions 12q24, 16p13. Individual genes which influence disease susceptibility are probably neither Genetics of bipolar affective disorder 249 necessary nor sufficient for development of the disease as for monogenic disorders. For some of these characteristics evidence favouring the involvement of genes has been found. If knowledge exists on the biological background of the disease the corresponding genes may be directly investigated. Direct investigation of neurogenes makes most sense if they are located in a specific chromosome region which has been implicated by genetic mapping, by cytogenetic studies or co-occurrence with a monogenic disorder.
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Sexism, racism, poverty, homelessness, and hate speech can all be seen as forms of injustice and violence against the heart and soul of a people and a community. The real challenge is how to establish and maintain safety without invoking punitive, violent, and restrictive measures that add to the problem. What we have learned about the impact of traumatic experience directly leads to specific implications for any environment that is to be health promoting. Exposure to helplessness means that interventions designed to help people overcome traumatizing experiences must focus on mastery and empowerment while avoiding further experiences of helplessness. If they are to stop using these coping skills, then they must be offered better substitutes, most importantly, healthy and sustaining human relationships. Since we know that quality thinking under stress is almost impossible, then in formulating intervention strategies, every effort should be made to reduce stress whenever good decisions are sought. It also means that we need to look at the growing sources of social stress that are inflicted on individuals and families at home, in the workplace, and in the community and evaluate what kinds of buffers can be put into place that help attenuate the effects of these stressors. The memory problems that are a consequence of overwhelming stress imply that environments designed to intervene in the lives of suffering people must provide an abundance of opportunities for people to talk, and talk and talk about their experiences, their past lives, their conflicts, their feelings. If we fail to protect children from overwhelming stress, then we can count on creating life-long adjustment problems that take a toll on the individual, the family, and society as a whole. If we expect people to give up their self-destructive addiction to substances and damaging behavior, then we must be willing to substitute supportive human relationships. Physiological stability cannot be achieved as long as the person is on an emotional roller coaster of stimulus and response. People who have been traumatized need opportunities to learn how to create relationships that are not based on terror and the abuse of power, even though abusive power feels normal and right.
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