The Medical clinics of North America
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In the setting of characteristic features of thyrotoxicosis, the timely diagnosis and aggressive management of thyroid storm should result in a successful outcome. However, severe storm may lead to irreversible cardiovascular collapse, especially in the older patient who may have atypical features of thyrotoxicosis. The fundamental approach is prompt and optimal treatment in the emergency department once the presenting clinical features suggest its presence. ⋯ The prevention of myxedema coma entails paying special attention to certain high-risk patient groups. These groups include older women with a history of Hashimoto's thyroiditis, or previous irradiation or thyroid surgery for hyperthyroidism. Inform such patients of the symptoms and signs of hypothyroidism, and perform annual thyroid function tests, such as a serum TSH, in order to provide early, adequate treatment once the test becomes positive.
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Suicide is a major public health problem among adolescents. Although the event is rare, and rates have stabilized and even shown slight reduction in recent years, suicide has nevertheless become the second leading cause of morbidity among youths aged 15 to 24, which is otherwise a robust and relatively disease-free population. ⋯ Current neurobiologic research holds promise for the use of biologic markers in the identification of high-risk adolescents, and pharmacologic research may yield further advances in the treatment of affectively disordered youths. At this point, the most promising approaches to treating adolescent suicide appear to be (1) treatment of disorders antecedent to suicide crises, such as depression, substance abuse, family conflict, and conduct disturbance, and (2) prevention efforts targeting known high-risk groups, such as affectively disordered young men with accompanying alcohol and drug involvement and other antisocial behavior.
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Epidemiologic studies of inflammatory bowel disease indicate that these disorders occur in susceptible individuals, possibly due to genetic abnormalities, resulting in disturbance of bowel wall function. Environmental factor(s) exerting a primary effect at an early age, in most patients, cause the disease to manifest usually in teenagers or young adults. Secondary environmental factors may alter disease expression, severity, or influence relapse. ⋯ Changing trends in disease incidence (seen in many countries) provide strong support for environmental factors as playing a major influence in disease expression. We now require further laboratory and epidemiologic studies in family members at risk of disease, in migrants who move from low incidence areas to high incidence areas, and in area where Crohn's disease particularly is starting to appear. The clinician can play an important role by performing careful observations in patients with a view to uncovering new clues to disease etiology.
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Pregnancy alters both the fibrinolytic system and coagulation cascade. In addition, pregnancy presents unique triggering mechanisms for DIC. ⋯ Inherited coagulation defects, while rarely resulting in bleeding diathesis in the pregnant patient, do require monitoring of maternal factor levels. Genetic counseling should be offered to all patients with inheritable coagulation disorders.
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Med. Clin. North Am. · Nov 1988
ReviewDiabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic coma.
Diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic coma are two of the most common acute complications of diabetes. The pathophysiologic changes that occur in both disease states represent an extreme example of the super-fasted state. The physiology of the fed and fasted state, evaluation, therapeutic issues, recommendations for therapy, immediate follow up care, and complications of therapy are reviewed for both syndromes.