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Although rates of depression do not appear to effects of depressive symptoms and physical inactivity on increase with age 50 mg nitrofurantoin, depression often goes undertreated in the 10-year cardiovascular mortality in a cohort of elderly older adults [2] cheap nitrofurantoin 50mg on line. The highest risk for cardiovascu- Adjusted Life Years calculated for all ages, including both lar mortality was attributable to the combined effect of de- sexes [3]. A meta-analysis of 11 prospective co- adjusted annual rate of cardiovascular events was 10% hort studies of initially healthy individuals indicated that among the 199 participants with depressive symptoms and depression conferred a relative risk of 2. Participants with depressive symptoms had a 50% 80 The Open Complementary Medicine Journal, 2009, Volume 1 Knapen et al. In the depressed group, physical inactivity was associ- rather preventative than curative [20]. Without a doubt, exercise really is medicine and it could potentially be preventable with behaviour modifica- can be seen as the much needed vaccine to prevent chronic tion. Especially exercise targets many of the mechanisms linking depression with the increased risk of cardiovascular disease (inactivity-related diseases) and premature death events, including autonomic nervous system activity, hypo- [21]. On the other hand, physical inactivity is one of the most important public health problems of the 21st century [22]. The epidemiological study, investigated health outcomes associ- pooled relative risk was 1. The most recent meta-analysis of Cosgrove, Sargeant, Griffin confirmed the the Cooper Clinic, Dallas. The study estimated the attribut- causal role of depression or depressive symptoms in devel- able fraction of risk factors for death in a large population of 12. The pooled adjusted relative risk were adjusted for age and each other risk factor. Twenty showed that low cardiorespiratory fitness accounts for about five percent of cases of diabetes could be attributed to de- 16% of all deaths in both women and men, and this was sub- pression in people with both conditions. Several pathophysi- ological mechanisms could explain the increased risk of type stantially more than that of obesity, diabetes, smoking and 2 diabetes in depressed individuals, including the increased high cholesterol. The results showed a strong inverse gradient for car- for combined aerobic and resistance training compared with diovascular disease death across fitness categories within aerobic or resistance training alone [16]. The researcher group emphasized that obese men who were moderately/highly fit had less than half Depression as a Risk Factor for Osteoporosis the risk of dying than normal-weight men who were unfit There is emerging evidence that depression is a risk fac- [15]. A pro- Physical (in)Activity and its Relation to Depression spective study compared mineral bone density in 89 premenopausal women with depression and 44 healthy con- Goodwin investigated the relationship between lack of trol women [17]. Low bone mass density was more prevalent physical activity and depression using data from the National in premenopausal women with depression. The bone mass Co-morbidity Survey (n = 8098), a nationally representative density deficits were of clinical significance and comparable sample of adults ages 1554 in the United States [24]. The potential mechanism by which osteoporosis devel- with a significantly decreased prevalence of current major ops in depressed individuals are multifactorial. Individuals who reported regular physical exer- and immune alternations secondary to both depression and cise were less likely to meet in the previous year criteria for osteoporosis play a pathogenic role in bone metabolism. Regular exercise, especially resistance training, con- activity also showed a doseresponse relation with current tributes to the development of bone mass. Exercise and Depression The Open Complementary Medicine Journal, 2009, Volume 1 81 Some prospective longitudinal studies suggest that physi- training reduced depression scores by approximately one- cal activity is associated with a reduced risk of developing half a standard deviation as compared to the non-exercise depression. Paffenbarger, Lee, diagnosed with major depression, Craft and Landers reported Leung found that physical activity negatively correlated with an effect size of 0. Limiting the associated with the risk of developing elevated depressive analyses to randomized controlled trials (n = 14), Lawlor and symptoms. After adjustment for potential confounders, the Hopkins reported an effects size of 1. The most recent meta-analysis of Cox included randomized controlled trials of exercise and Regular physical exercise is significantly less common in follow-up with clinically depressed samples of older adults women than in men and significantly less among those older conducted between 2000-2006. The data suggested that there was a clear were found for type of exercise, aerobic, resistance or com- dose-response relationship between increasing physical ac- bined training [35]. Lee and Rus- A fundamental issue concerns the minimal effective dos- sell reported on the longitudinal effects of physical activity age of exercise needed to improve depression. Patients in depression compared to those who exercised with low completed measures of depression, physical activity, exer- intensity and a weekly energy expenditure of 7 cise as coping strategy for depression, and other demo- kcal/kg/week. The latter regimen had results comparable to a graphic and psychosocial constructs at baseline, and after 1- placebo condition with stretching and flexibility exercise. In addition, physical activity counteracted the percent of participants in the public health recommendations effects of medical conditions and negative life events on group had a therapeutic response to treatment, defined as a depression. The rates of response There is growing evidence that exercise may be an effec- and remission were comparable to the rates reported in trials tive therapy for mild to moderate depression and a valuable of cognitive behavioural therapy, antidepressant medication, complementary therapy to the traditional treatments for se- and other exercise studies. Meta-analytic studies provide one means of summarizing the primary research and identifying variables Several physiological as well as psychological mecha- that may moderate the effects of exercise on depression.

In a research conducted by towards antibiotics is at least in part cheap 50 mg nitrofurantoin with mastercard, induced by - Novoslavskij et al cheap 50mg nitrofurantoin fast delivery, all tested Y. There is strains exhibited resistance to ampicillin and an alarming growing prevalence of Y. But, the Meat and meat products as the main sources of food- afore mentioned application has led to increased borne infectious diseases are crucial parts of the bacterial resistance to many antibiotics [27, 28]. The most frequently found species in dairy clindamycin, but were sensitive to chloramphenicol products were Y. All* clindamycin tobramycin and imipenem Turkey 2015 [29] *All: All strains of Yersinia enterocolitica Antimicrobial resistance of Y. However, In a study that evaluated resistance pattern in sea- these isolates were resistant towards cephalothin food-borne Y. In a study, A small number of 57 O serogroups are regarded as Lucero-Estrada C et al found all the Y. Today, clinically important bacteria are characterized not only by single drug resistance but also by multiple antibiotic resistancethe legacy of past decades of antimicrobial use and misuse. Drug resistance presents an ever- increasing global public health threat that involves all major microbial pathogens and antimicrobial drugs. In this review, we focus on the underlying principles and ecological factors that affect drug resistance in bacteria. Notable global examples include hospital and genes emerged in military hospitals in the 1930s4. Similarly, Acinetobacter baumanii and Pseudomonas aeruginosa3,1618 (Box 2, Mycobacterium tuberculosis with resistance to streptomycin emerged World Health Organization website). Fueled by increasing antimicrobial use, the frequency of individuals in hospitals in the United States and elsewhere for more resistance escalated in many different bacteria,especially in developing than a decade24,25. At present, the newly developed drugs daptomycin, countries where antimicrobials were readily available without pre- linezolid and the streptogramin combination, dalfopristin/quino- scription. Center for Adaptation Genetics and Drug Resistance, Departments of Molecular Biology and Microbiology and of Medicine, Tufts University School of Medicine, aeruginosa and A. Correspondence should be addressed to one, antibiotics, which seriously challenges the treatment of immuno- S. Resistant (and presumably the costs) as compared with drug-susceptible strains can be traced from the community to the hospital and vice infections88. A cost comparison of treating methicillin-resistant versa, indicating that drug resistance is no longer localized. Drug resistance emerges only when the two It noted that the antimicrobial resistance selected in one year will components come together in an environment or host, which can lead persist, and subsequent years will bear the burden of the resistance to a clinical problem. If community infections are considered, the costs are involved in essential physiological or metabolic functions of the bacte- even greater, particularly for combination therapies of multiple 1 rial cell (Table 1). Enterobacter and Klebsiella,destroy even the latest generations of peni- But how do bacteria acquire resistance? Ofparticular note is the increase in mobilethe genes for resistance traits can be transferred among strains bearing metallo--lactamases that inactivate carbapenems bacteria of different taxonomic and ecological groups by means of drugs that are often the last resort in serious infections of Gram-neg- mobile genetic elements such as bacteriophages, plasmids, naked ative bacteria31,32. And, like the antibiotics themselves, resistance recently recommended fluoroquinolones. This process was responsible for the initial emer- Resistance in pneumococci continues to be an ever-increasing gence of penicillin and tetracycline resistance in N. The global threat that curtails treatment of pneumonias and ear infections, organism later acquired transposons bearing genes with high-level particularly in children. One study has predicted that multidrug resistancewill over- mutations in the target enzymes (topoisomerases) and an increase ride single-drug resistance in the present decade37. This phenomenon was found to occur after the prolonged use of tetracycline for urinary tract infections53 and for Mechanism of action Antibiotic families 54 acne. Competitive inhibition of folic Sulfonamides; trimethoprim acid synthesis This phenomenon reflects the linkage of different resistance genes on the same transposon or plasmid. Bacteria that are already resistant to one growth- inhibitory agent seem to be favored in recruiting additional resistance Chromosomal mutants of S. Asmall increase in the minimum inhibitory concentration to an antimicrobial should alert clinical Loss of resistance is slow microbiologists in hospitals and communities to an incipient prob- Resistant bacteria may rapidly appear in the host or environment after lem of resistance. Although still classified as susceptible, a strain antibiotic use, but they are slow to be lost, even in the absence of the with decreased susceptibility to a drug heralds the eventual emer- selecting antibiotic. This phenomenon reflects the minimal survival gence of higher-level resistance and should galvanize efforts towards cost to the emerging resistant strains. In addition, as discussed above, altering the use of that antimicrobial in that environment. Some transposons contain integronsmore complex transposons that contain a site for integrating different antibiotic resistance genes and other gene cassettes in tandem for expression from a single promoter91.

Also secondary to hypophysectomy purchase nitrofurantoin 50 mg amex, post-radiation or infarction Craniopharyngiomas: suprasellar tumours that may extend into the sellae buy nitrofurantoin 50 mg mastercard. Water deprivation test if diabetes insipidous is suspected Treatment: surgery (trans-sphenoidal or transfrontal). Not gynaecomastia (usually only in testosterone or oestrogen) Investigations: basal prolactin between 10. Take after sleep or exercise Other Endocrine Problems Hirsutism: Male pattern of hair in a female. Refer for androgen secreting adrenal and ovarian tumours Galactorrhoea: may come with thyroid failure (primary or secondary), with a raised prolactin (prolactinoma, pituitary stalk section and especially drugs) and occasionally with acromegaly Gynaecomastia. May result from liver disease (metabolism of oestrogen) or testicular tumours (oestrogens) or with hyperthyroidism. Psychological causes are common (eg if clear stressor, or if morning erections still occur). Relative water retention is a common factor Condition and treatment can be hazardous. If correct too fast then pontine demyelination Treatment must be slow and monitored closely. Treatment can range from water restriction or diuresis to sodium restriction or normal saline. Need to know underlying cause Dont use hypotonic fluids post-op unless Na is high. Eg dextrose saline glucose absorbed very quickly post surgery hypotonic Symptoms The big boogie is underlying cerebral oedema. Hyperglycaemia shift of water out of muscle cells: Na 1 mmol/L for every 4 mmol/L in glucose If osmolarity is normal then pseudo-hyponatraemia (eg hyperlipidaemia, hyperprotinaemia). Detect and treat hypoxia Adverse neurological consequences of rapid correction: myelin breakdown in the pons, patchy symmetrical lesions elsewhere in the brain. If diuresis continues, give nasal desmopresson and continue measuring th th 110 4 and 5 Year Notes Potassium Normal value of K: 3. Compensates rapidly Renal: Alter bicarbonate reabsorption Titratable acid excretion: organic buffers in tubules acidifies urine. May be useful for an anaesthetist (eg simple and acute disturbances) Endocrine and Electrolytes 115 Neuro-sensory th References: Neurology, a 4 year Student Teaching Resource by Drs David Abernethy and Stuart Mossman, Wellington School of Medicine See also Dementia and Delirium, page 439 Neurology. Most serious association: frontal lobe tumour, presents with personality change, self-neglect, dementia 2: Ophthalmic nerve: lesions common and serious. Test each eye separately Visual fields: confrontational testing: first just hold hands in each visual field and ask what they see. Then wiggle one finger, then the other, then both, in all visual fields (or count fingers) Red pinhead test: test for colour sensitivity more sensitive than acuity (good for vague hemianopia). Blind spot = scotoma Hemianopia: Pituitary lesion bitemporal hemianopia (nasal retina affected). Upper temporal field in one eye is typically affected first Parietal lesion visual inattention 3, 4, 6: Seeing double. Often elderly have trouble looking up anyway Cover test: look at target, cover one eye, does other eye move? Use stick man drawn on tongue depressor Problems locating target (overshoot and come back) ? Test corneal reflex (early sign of lesion) patient looks up, use cotton wool on cornea (more sensitive than sclera) th Motor 5 : jaw opening in midline (tests pterygoids). Dont normally test taste 8: whispered voice at arms length, with patients eyes close. Observe sternomastoid and trapezius at rest for wasting, fasciculation, or dystonia. Always test neck extension if diffuse muscle weakness if abnormal indicates lesion above C1/C2 12: Hypoglossal nerve. Rapid passive movement maximal tone to start with, decreases suddenly as muscle is lengthened. Due to reflex contraction to muscle stretch Clonus: maintaining stretch (eg of ankle plantar flexors) further repetitive beating Power: compare between sides Test in position where patient has mechanical advantage: you shouldnt be able to win then if its normal Grade as follows: 0: no contraction 1: a flicker/trace of contraction 2: active movement with gravity eliminated 3: active movement against gravity but not against resistance 4: active movement against gravity and resistance, but reduced power (covers wide range can classify as mild, moderate or severe weakness) 5: normal power Motor exam of the arms: Observe arms at rest, then outstretched with eyes closed (check for drift non-specific test). Look st for wasting of 1 dorsal interosseus and abductor pollicis brevis Assess tone at elbow (flexion/extension and supination) and wrist (flexion/extension) with slow and rapid movements Arms (start at top and work down) Shoulder abduction (deltoid, C5, axillary nerve). Extended cocked wrist push it down Finger extension (extensor digitorum, C7). Look for atrophy of thenar eminence Motor Exam of the legs: Observation of legs: while standing, walking, lying down.

Thoughts Physical symptoms Behaviour Look at your thoughts generic nitrofurantoin 50 mg otc, physical symptoms and behaviour nitrofurantoin 50mg with mastercard. Linking thoughts, physical symptoms and behaviour. For example rather than say I feel depressed, identify what it is about being depressed that is a problem to you. These are examples of the common problems people say they have: It takes me 2 hours to get off to sleep at night. Using the above questions and the information you have on your thoughts, physical symptoms and behaviour define your problems and write them in the box on the next page. Helpful hints Keep a diary monitoring your feelings, thoughts and behaviour for 1 week to see if it helps you to identify the problem. After you have written your problem, use the scale below to rate each problem in the box titled Time 1. After you have worked on your problem for a few weeks rate the problem again at time 2 using the scale below to see what progress you have made. In a few months rate your problem again at time 3 to ensure that you have maintained your progress. This problem upsets me and or interferes with my life 0----------------2-------------------4------------------6-----------------8 not at slightly sometimes much all the all time Problem 1. Time 1 Time 2 Time 3 Problem 2. Time 1 Time 2 Time 3 9 Now you have defined your problems, you can decide what you want out of your programme. Goals will help you to: keep focussed on the problem; be clear about what you want to achieve; and get feedback on your progress. You may want to feel better or to feel less anxious but ask yourself what feeling better means you will be able to do. Examples of goals might be: to go and play badminton once a week and enjoy it; to get to sleep in 30 minutes on 6 occasions weekly; and to be able to concentrate and enjoy reading a book regularly. Working with too many goals can be confusing so we would suggest that you work with between 1 and 3 goals. After you have worked on your problem re rate the goal at time 2 to see what progress you have made. In a few months re rate the goals to ensure that you are maintaining your progress. My progress towards achieving each goal regularly without difficulty is: 0----------------2-------------------4------------------6-----------------8 complete 75% 50% 25% 0% success success success success success Goal 1. Time 1 Time 2 Time 3 Goal 2. Time 1 Time 2 Time 3 Goal 3. The strategies aim to change thoughts, physical symptoms or behaviour, and because they each affect one another, a change in one area will lead to changes in the other areas. All the strategies have been studied in research trials and have been shown to help people with anxiety and depression. It is suggested that you read through the following interventions and choose the one that you think is best for you. If you are depressed and finding it difficult to motivate yourself it is often helpful to begin with behavioural activation and then using cognitive restructuring. If you have a specific fear or phobia exposure will probably be the best way of overcoming your problem. If you were suffering from more general anxiety and stress we would suggest that you use problem solving and some relaxation techniques. This will lead to more helpful thoughts such as I have achieved something today and found it pleasurable. Changing your thoughts and behaviour will also lead to positive changes in your physical symptoms. This is to make sure that you can do what you set out to do and that you do not become physically exhausted. Ask yourself if it was because something happened that was outside your control or if it was because you set yourself an unrealistic schedule. Many studies have shown behavioural activation to be helpful when it is used with other treatments such as cognitive therapy. However there is also evidence that this treatment alone is successful in reducing mild and moderate depression.