By Y. Jorn. Marymount College.
Patients with clinical evidence of radiculopathy including atrophy of the muscles of the upper extremity should be referred to a neurosurgeon purchase propecia visa hair loss cure yet. Conservative treatment of cervical pain and radiculopathy includes one or more of the following: a buy propecia 5 mg with amex hair loss cure etf. Cyclobenzaprine (Flexeril): 5–10 mg tid or other muscle relaxants: 29 purchase on line propecia hair loss 18 months postpartum, 53, 69 (Appendix 2A). Gabapentin Neurontin): 300–1,200 mg tid or other medications for neuropathic pain: 11, 90, 111, 260 (Appendix 2A). Cervical traction, over the door beginning with 7 lb for ½ hr twice a day and gradually increasing 1 lb a week to 15 lb 1–2 hrs twice a day. Facet or nerve root injections with 2–4 cc of 1% lidocaine (Xylocaine) and 20–40 mg of methylprednisolone acetate (Depo-Medrol). Except in cases of acute neck pain or radiculopathy use narcotic analgesics only as last resort and then only until more definitive treatment can be instituted. Patients with no clinical evidence of radiculopathy or a neurogenic bladder may be treated conservatively. Patients with evidence of a neurogenic bladder or cauda equina syndrome should be referred to a neurosurgeon without delay. Patients with clinical evidence of radiculopathy and weakness or 919 atrophy of one or both lower extremities need neurosurgical or orthopedic Consult. Patients with clinical evidence of radiculopathy without muscle atrophy of the lower extremities may be treated conservatively, but should be given the option of an orthopedic or neurosurgical consult. Cyclobenzaprine (Flexeril): 5–10 mg tid or another muscle relaxant: 29, 53, 69 (Appendix 2A). Gabapentin (Neurontin) or other medications for neuropathic pain: 11, 90, 111, 260 (Appendix 2A). Firm mattress or bed board (3×5 plywood) inserted between mattress and box springs. Exercise to strengthen the anterior spinal muscles including pelvic tilts and sit-ups. If the clinician is unable to demonstrate these to the patients, consult a physiotherapist. Facet or trigger point injections with 2–3 cc of 1% lidocaine (Xylocaine) with or without 20–40 mg of methylprednisolone acetate (Depo-Medrol). Except in acute low back pain and radiculopathy, narcotic analgesic should be used as last resort and then only until more definitive treatment can be initiated. Valacyclovir (Valtrex): 2 g bid for 1 day for oral herpes or 1 g bid × 10 days for genital herpes. May use prednisone 60 mg daily for severe neuralgia, but must not use for extended period of time (more than 1 week) and cover with antiviral therapy during each use. Bacitracin + neomycin + polymyxin B, and hydrocortisone (Cortisporin) ophthalmic ointment: apply qid to eyelids. Look for the cause and treat: hypothyroidism, diabetes mellitus, nephrosis, biliary cirrhosis, etc. If patient is overweight, the first thing to do is prescribe a reducing diet and an exercise program. If weight is normal, prescribe a low cholesterol diet preferably with the help of a dietician. Reduce the fats to 30% or less of total calories and saturated fats to less than 10% of total calories. Cut fat off meat, restrict pork, gravy, and greasy foods and increase intake of fruits and vegetables. If above are unsuccessful, try a statin, such as atorvastatin (Lipitor): 10–80 mg daily. Cholestyramine (Questran) may be given 4–24 g within 30 minutes of a meal: Other bile acid sequestrants are: a. A fibrate such as gemfibrozil (Lopid) 600 mg bid or Fenofibrate (TriCor) 160 mg daily may be tried next. If patient is obese, place on a weight reducing diet with plenty of fresh fruits and vegetables and salt restriction (which is an appetite suppressant). Add spironolactone (Aldactone): 50–100 mg daily or potassium chloride supplement if potassium drops on above diuretics. When blood pressure is still resistant to control with the above, add a β-blocker such as atenolol (Tenormin) 25–50 mg bid or metoprolol (Lopressor) 25–100 mg bid. Finally, a vasodilator such as hydralazine (Apresoline): 25–75 mg qid may be added. If the above drugs are unsuccessful in lowering the blood pressure, a thorough re-evaluation for renal and adrenal causes of hypertension should be done and a nephrologist consulted. Monitor patients regularly for renal, ocular, and cardiac complications of hypertension. Treat mild elevations in obese patients with weight reduction, avoidance of free sugar, and regular exercise. Avoid or give lower doses of drugs that increase triglycerides such as β-blockers, diuretics, and corticosteroids. If there is combined elevation of triglycerides and cholesterol, atorvastatin (Lipitor): 10–40 mg daily or rosuvastatin (Crestor): 10–40 mg daily may be effective. If only the triglycerides are elevated, gemfibrozil (Lopid) 600 mg bid or fenofibrate (TriCor) 160 mg daily may be effective. Patients with triglycerides over 500 mg/dL should be treated aggressively to avoid pancreatitis. If patient is conscious, give orange juice with added sugar or 50% glucose solution by mouth. Monitor blood sugar for several hours especially in patients on oral hypoglycemic. Faced with mild hypokalemia in a patient on diuretics in the clinic setting simply prescribe slow K 10 mEq bid p. Switch to or add a potassium sparing diuretic such as hydrochlorothiazide/triamterene (Dyazide) or hydrochlorothiazide/spironolactone (Aldactazide): 25/25 or 50/50, 1 tab bid–tid. Hydrocortisone 20 mg daily or bid may be tried but be sure adrenal insufficiency is ruled out. Children and obese patients may need up to 4 μg/kg/day while the elderly require less than average doses. Occasionally, patients may do better with desiccated thyroid 60– 120 mg daily instead of levothyroxine. The substitution of triiodothyronine (Cytomel) up to 125 μg daily for 50 μg of levothyroxine has helped some patients with this disease.
By contrast purchase genuine propecia line hair loss in men kilts, reporting the number of times that something happened or the number of times that someone engaged in a particular behavior are examples of quantitative variables buy 1 mg propecia with mastercard hair loss in men vintage. These variables are considered quantitative because they provide information regarding the amount of something order propecia overnight delivery hair loss protocol scam. It is important to note that a single variable may fit into several of the categories of variables. For example, the variable “height” is both continuous (if measured along a continuum) and quantitative (because we are getting information regarding the amount of height). The variable “eye color” is both categorical (because there is a limited number of discrete categories of eye color) and qualitative (because eye color varies in kind, not amount). For example, in a study of the relationship between smoking and lung cancer, ‘suffering from lung cancer’ (with the values yes, no) would be the dependent variable and ‘smoking’ (varying from not smoking to smoking more than three packets a day) the independent variable. Whether a variable is dependent or independent is determined by the statement of the problem and the objectives of the study. It is therefore important when designing an analytical study to clearly state which variable is dependent and which is independent one. A variable that is associated with the problem and with a possible cause of the problem is a potential confounding variable. A confounding variable may either strengthen or weaken the apparent relationship between the problem and a possible cause. These background variables are often related to a number of independent variables; so that they influence the problem indirectly (hence they are called background variables). To obtain the defaulter rate we need a clear definition of what we mean by defaulting (how many times treatment was missed? Factors Responsible for the Outcome are Rephrased as Variables In the example 1: We can notice that most of what we called ‘factors’ are in fact variables which have negative values. However, in reality not everyone with good knowledge of leprosy treatment is a regular attender and not everyone with poor knowledge absconds from treatment. We can find-out by a study to determine to what extent these contributing factors play a role. Therefore we have to formulate them in a neutral way, so that they can take on positive as well as negative values. The table below presents examples of negatively phrased ‘factors’ and how they can be rephrased as neutral ‘variables’. If 10 questions were asked, you might decide that the knowledge of those with: 0 to 3 correct answers is poor, 4 to 6 correct answers is reasonable, and 7 to 10 correct answers is good. Defining variables and indicators of variables: To ensure that everyone understands exactly what has been measured and also to ensure consistency in the measurement, it is necessary to clearly define the variables and indicators of variables. For example, to define the indicator ‘waiting time’ it is necessary to decide what will be considered the starting point of the ‘waiting period’, e. Examples of common variables with different possible choices for indicators are given below in Table 9. For example, policy makers in India would Variables 117 like to eliminate leprosy. They have noticed that fewer women report for leprosy treatment than men and would like to know whether stigma keeps women from reporting for treatment and/or whether the services have to be more sensitive to the needs of women for privacy at diagnosis. Goffman (1963) defined stigma as an undesirable differentness that disqualifies a person from full social acceptance. However, we cannot fill in more precisely in what way men and women are discriminated against, as that has still to be studied. Some indicators for stigma could be the divorce rate of male and female patients, or the degree of isolation of the patient by the healthy spouse or by the community, but how the severity of this isolation should be measured is still unknown. Possibilities include, for example, whether patients and spouses still share a house, share food, share one bed? Do community members still accept leprosy patients as village leaders, do they welcome patients to attend village meetings, and, if so, do they still drink tea or eat together, and do they ask patients to bring their own cups? One could state that in exploratory, qualitative studies, such as stigma, to understand better how patients suffer from stigma and how they cope with it, we can also discover contributing factors to stigma: in some societies women are more vulnerable to stigma than men; adolescents are more vulnerable than adults who have settled economically and socially; patients with deformities are always more vulnerable to stigma than those without visible signs. With better understanding of the problem of stigma, we can opera- tionalize the definition of the strength of stigma on a scale. This will enable us to measure through a quantitative study the degree of stigma male and female patients suffer from, and the most important contributing factors to stigma. Using too small a sample may result in a difference not being detected or not being detectable. In most cases where the sample size is too small, no information is gained from the experiment at all, which implies that the effort, money and subjects (or material) involved are totally wasted. The patients/animals are subjected to unnecessary hardship; hence inappropriate sample size is definitely unethical. One question statisticians are frequently asked is: “How large a sample must I take”? Decisions concerning the sample size for any experiment are based on the combination of statistics and common sense. In practice, the sample size is usually fixed by the number of subjects available, or the cost or time limits. However, even in the case where the sample size is determined by practical considerations, the sample size calculations are useful. Sample size can indicate whether the experiment or survey is likely to be worthwhile, they will allow to determine what size differences is likely to be detected with the proposed experiment or survey. Adequacy of the sample size will depend on the following factors: • Degree of difference: This is the difference between two groups, e. In terms of %, it is 100 × (1– b) When b is selected, Power of Test is automatically fixed. Beta Power 10% 90% 20% 80% • Variation of results: Standard Deviations of control mean and the test mean. Z value (Standard Normal Distribution): z (1– α)/2, z(1–α), and z(1–b) represent the number of standard deviations away from the mean. Methods: There are various methods to determine the sample size like: • Arbitrary numbers ( not recommended), • From previous studies ( may be/ may not be correct), • Nomograms and tables can be used but may not be flexible and accurate, • Formulas but they vary with study design and analysis • Computer programs which are easy to use and usually based on formulae. Calculate sample size if: True rate (p) = 20%, Absolute precision (d) = 5 percentage points (15% to 25%), Confidence level = (1–α)/2 = 95% i. Previous studies tell us that there is 80% immunization coverage in a village Relative Precision (e): Relative difference between sample coverage and true population coverage (we decide that we want this to be +/ –10% of the anticipated population proportion of 80%) Confidence level = 0. Determination of Sample Size 121 Example 4: Calculate the sample size to estimate the proportion of pregnant women who seek prenatal care within the first trimester of pregnancy at a health center • Percentage of women seeking such care (P) = 25% (as per the previous study) • Relative precision (e) = 5% (of 25%), Confidence level = 95% (z = 1. Death due to diarrhea P = 2% [Q = 98%] • What is the limit of accuracy (L) required? How many children should be included in a new survey designated to test for a decrease in the prevalence of dental caries, if it is desired to be 90% sure of detecting a rate of 20% at 5% level of significance? How many patients are to be studied to test an alternative hypothesis that is not 70% at 5% level of significance? An investigator wants to have 90% power of detecting a difference between the success rate of 10 percentage point more in either direction.
Nodules: Erythema nodosum buy 5mg propecia amex hair loss cure in hindi, erythema induratum purchase cheap propecia on-line hair loss 5 years, and Weber– Christian disease fall into this category discount propecia 5mg mastercard hair loss in men gymnastics. Trunk: Pityriasis rosea, drug eruptions, herpes zoster, dermatitis herpetiformis, chickenpox, seborrheic dermatitis, and tinea versicolor occur typically on the trunk. Extremities: Smallpox and Rocky Mountain spotted fever often begin on the extremities and work centripetally. Palms of the hands: Four conditions typically occur here: Rocky Mountain spotted fever, penicillin allergy, syphilis, and erythema multiforme. Contact dermatitis, keratoderma, climacterium, warts, keratoderma palmaris, dyshidrosis, and psoriasis may also occur here. Hand, foot, and mouth disease is associated with a vesicular rash of the hands, feet, and mouth and is caused by a coxsackie virus. Feet: Tinea pedis, warts, purpuras, psoriasis, keratoderma plantaris, syphilis, penicillin allergy, Rocky Mountain spotted fever, acrodynia, varicose ulcers, diabetic ulcers, and ischemic ulcers may occur here more often than elsewhere. Face: Acne vulgaris and rosacea, impetigo, seborrheic dermatitis, milia, lupus erythematosus, lupus vulgaris, basal cell and squamous cell carcinomas, eczema, contact dermatitis, and erythema multiforme have a predilection for the face. Groins and thighs: Scabies, pediculosis, intertrigo, tinea cruris, moniliasis, and Weber–Christian disease occur here. Extensor surfaces of elbow and knees: Psoriasis and epidermolysis bullosa should be considered. Approach to the Diagnosis The association of other symptoms and signs is extremely helpful in differential diagnosis. For example, a rash with bloody diarrhea might suggest Crohn disease or ulcerative colitis. A dermatologist should be consulted if there is any question about malignancy, if the condition persists, or if the symptoms are systemic. It is foolish to persist in treatment without a definitive diagnosis for more than 2 or 3 weeks when one may be dealing with something serious. Anticentromere antibody (scleroderma) Case Presentation #76 A 26-year-old white man presents with an erythematous macular rash on his trunk and proximal extremities for the past week. However, he recalls a large oval red patch that appeared in the epigastrium a few days before the generalized rash. V—Vascular lesions suggest livedo reticularis, acrocyanosis, gangrene of Raynaud syndrome, necrotic areas of periarteritis nodosa, and petechiae from emboli. I—Inflammatory lesions include boils, carbuncles, folliculitis, hidradenitis suppurativa, abscesses, and erysipelas. Dermatophytosis, chancre, chancroid, and yaws, pinta, and tularemia are important. Scabies, insect bites, anthrax, tuberculosis, or actinomycotic sinus fall into this category. The bull’s-eye lesion of a brown recluse spider bite deserves special mention here. N—Neoplasms of the skin include fibromas, melanomas, lipomas, basal cell and squamous cell carcinomas, and metastatic carcinoma. C—Congenital lesions include epidermolysis bullosa, eczema, neurofibromatosis, and lipomas. A—Allergic and autoimmune diseases suggest pyoderma gangrenosum (ulcerative colitis), necrotic lesions of periarteritis nodosa, and subcutaneous fat necrosis of Weber–Christian disease. E—Endocrine diseases immediately recall pretibial myxedema, necrobiosis lipoidica diabeticorum, diabetic ulcers, the flushed face of Cushing syndrome, and carcinoid. Approach to the Diagnosis The approach to the diagnosis is similar to that of the general rash (see page 362). V—Vascular conditions prompt the recall of hemorrhoids, but one cannot forget mesenteric infarctions. I—Inflammation suggests perirectal abscess, anal fissure or ulcer, amebic colitis, or condyloma latum and acuminatum. C—Congenital and acquired anomalies suggest fistula-in-ano, bleeding Meckel diverticulum, and bleeding colonic diverticula, among other congenital conditions. E—Endocrine disorders do not suggest anything other than the Zollinger–Ellison syndrome, which, because it causes ulceration of the jejunum, may be associated with maroon stools. In disorders of the upper colon and small intestines, the blood is older and thus a maroon color is likely. In addition, the blood is mixed with the stool and may indeed be so well mixed that it will not be discovered without a test for occult blood. Approach to the Diagnosis Armed with a more comprehensive list of causes of rectal bleeding, the clinician is ready to eliminate some of them as he or she asks appropriate questions during the history and performs the examination with all the 717 causes in mind. The diagnosis may be pinned down by the presence or absence of other symptoms and signs. The principal diagnostic procedures are stool cultures, stool examination for ova and parasites, coagulation studies, proctoscopy, barium enema, and colonoscopy. Rectal examination failed to reveal the cause of her rectal bleeding, but the stool was positive for occult blood. M—Malformation that creates a nonbloody rectal discharge is loss of sphincter control, often due to rectal surgery or a deep midline episiotomy, but perhaps even more frequently due to neurologic disturbances such as spinal cord injury or stroke (really fecal incontinence). A pilonidal sinus, although not specifically related to the rectum, may suggest that the patient has a rectal discharge. I—Inflammation, in addition to those disorders already mentioned, recalls an anal fissure or ulcer that not only causes purulent material to weep on its own but also often permits fecal material to leak onto the underclothes of the patient. The fistulous tracts from regional ileitis and lymphogranuloma venereum must be considered here. Condyloma latum and acuminatum, although not causing a discharge themselves, may prevent complete closure of the anal canal and permit fecal material to leak. N—Neoplasms of the rectum and anus and even thrombosed hemorrhoids can behave in a similar manner. T—Trauma is mentioned merely to remind one again of episiotomies and rectal surgery that may create poor control and allow chronic escape of feces, especially the liquid form. Visualization of the lesion with the anoscope or sigmoidoscope is usually necessary. Other conditions to be remembered include Blumer shelf of metastatic carcinoma from many sites into the pouch of Douglas, prostatic hypertrophy, and carcinomas. I—Intoxication signifies a fecal impaction, particularly from a hunk of barium after a barium enema. C—Congenital and acquired anomalies should remind one of diverticula that may become abscessed and create a mass in the cul-de-sac. A—Autoimmune conditions include regional ileitis, which may lodge in the cul-de-sac and create a fistula with the rectum. E—Endocrine causes recall the various ovarian tumors and ruptured ectopic pregnancy that will produce a mass in the cul-de-sac. There are, therefore, numerous disorders to keep in mind when examining the rectum.