The Medical clinics of North America
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Med. Clin. North Am. · Sep 1993
ReviewBiliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis.
Acute cholecystitis, acute cholangitis, and acute pancreatitis represent the most common biliary tract emergencies. Most are due to gallstones in the gallbladder and bile ducts. ⋯ Although the role of either surgery or endoscopic treatment may be more clearly defined in some biliary tract emergencies, in other situations either modality may be appropriate or they may compliment each other. Most biliary emergencies should be managed by gastroenterologists, surgeons, and radiologists working together in a harmonious fashion.
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Since its revival in the United States in the 1970s, ambulatory surgery, that intermediate level of care between inpatient and outpatient surgery (with immediate discharge of the patient), has grown phenomenally. During the past decade, the growth has been the result of new surgical techniques, improved anesthetic agents and practices that make such procedures safer, improved and better managed ambulatory surgical facilities, and regulations by government and third-party payers. Consequently, increased utilization of expanded ambulatory surgery appears almost unlimited in the foreseeable future.
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The headache to worry about is one that is unique or different from headaches which the patient has suffered in the past. The association with the headache of meningismus or of focal neurologic symptoms of oculoparesis, other cranial nerve palsies, hemiparesis, or loss of consciousness are particularly worrisome, especially if onset is recent and acute. Headaches related to arteritis or vasculitis usually have a slower subacute course but may also produce focal neurologic deficits. For subjects over 50 years old, temporal arteritis is always a consideration and any new type of headache requires testing of the sedimentation rate to rule out this treatable but potentially devastating problem.
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Neuroleptic malignant syndrome is a rare but potentially fatal reaction associated with neuroleptic drugs. It occurs in about 0.2% of patients treated with neuroleptics. Risk factors include previous episodes, dehydration, agitation, and the rate and route of neuroleptic administration. ⋯ Neuroleptics may be safely reintroduced in the management of the majority of patients recovered from an NMS episode, although a significant risk of recurrence does exist, dependent in part on time elapsed since recovery and dose or potency of neuroleptics used. Data drawn from clinical observations and basic studies support the primary role of an acute reduction in brain dopamine activity in the development of NMS. Additional studies of facilitating cofactors may lead to innovative risk-reduction strategies and the development of safer neuroleptic drugs.
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Parkinson's disease is one of the most common neurologic disorders. Recent advances have shed new light on the nature of the disease process and have led to new strategies for management. This article reviews the biology of Parkinson's disease, the diagnostic approach to patients with parkinsonism, pharmacologic treatments, and practical strategies for managing common clinical problems.