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C O G N I T I V E T H E R A P Y O F S U B S T A N C E A B U S E -•̂ .̂ '̂ ySi:'yf̂ '̂ ''->->*' 'r. ^'i-'Mt .#''a^K"'-M>' • M ^ i € • ̂ ^. M'^::. A A R O N T . B E C K • ^ • r f - F R E D D . W R I G H T C O R Y F . N E W H A N B R U C E S . L I E S E C O G N I T I V E T H E R A P Y O F S U B S T A N C E A B U S E C o g... |
w l e d g m e n t s w w e would like to offer our thanks to our highly esteemed colleagues in the field of substance abuse treatment and research, Drs. Dan Baker, Lino Covi, Tom Horvath, Jerome Piatt, Hal Urschel, David Wilson, and Emmett Velten, for their extremely help ful insights and suggestions on earlier version... |
the social costs of illicit drug abuse, it is estimated that more than 2 5 % of property crimes and 1 5 % of violent crimes are related to illicit drug use by the criminal. Financial losses related to these crimes have been estimated at $1.7 billion per year. Homicides are also strongly linked to activities surrounding... |
In fact, an important component of cognitive therapy involves the case conceptualization (Persons, 1989), defined as the evaluation and integration of historical information, psychiatric diag nosis, cognitive profile, and other aspects of functioning (see Chap ter 5, this volume, for a detailed description of the cas... |
mous and other disease-model programs) view total abstinence as the only acceptable goal of treatment. Proponents of these models view addiction as an all-or-nothing phenomenon, with any use seen as pathological and abstinence considered a state of "recovering" (rather than "recovered"). Alternatively, proponents of co... |
barbiturates, benzodiaz epines, and alcohol may be preferred because of their relaxing effect and, perhaps, their presumed relief of inhibitions. Hallucinogens are attractive to some to relieve boredom and "expand consciousness." Most people addicted to cocaine have also abused other drugs and/or alcohol (N. S. Miller... |
a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behavior by modifying the faulty or erroneous thinking and maladap tive beliefs that underlie these reactions (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). The approach to a particular patient is derived from a thorough... |
patient will act on the craving (Carroll, Rounsaville, & Keller, 1991). Urges are governed by the anticipated consequences, for example, reward for doing something or pain for not doing it. The urge may be accompanied by a positive feeling when it is driven by a positive expectation or a negative feeling when it is dri... |
the patient's life ranging from low frustration tolerance to marital problems. "Will Power" In the context of drug using, "will power" refers to a deliberate conscious decision (plus sufficient drive and technical self- help know-how to enforce it) to halt or delay the implementation of Cognitive Model of Addiction 37 ... |
cognitive perspective, the way people interpret specific situations influences their feelings, motiva tions, and actions. Their interpretations, in turn, are shaped in many instances by the relevant beliefs that become activated in these situ ations. A social situation, for example, m a y activate an idiosyncratic be... |
drug dealer, or receiving a weekly pay check. Internal circumstances (or cues) include various emotional states such as depression, anxiety, or boredom, which can trigger drug- using beliefs and, consequently, craving for the drug. As shown in Figure 3.5, drug use may be regarded as represent ing the final common pat... |
con viction) the reasons for not using, drug users have difficulty in recall ing or attaching the same significance to these reasons once they are in the throes of a specific drug-using episode. Since all their atten tion is focused on the mechanics of obtaining the drug, the reasons for using at that time become ve... |
of Medicine, 1990b). From the very start, such patients will be sizing up their therapists to determine if they can be trusted and if they know what they are doing (Perez, 1992). A perceived negative experience with the therapist can lead such patients to choose never to return for further sessions. For those patients ... |
the patient's thoughts, followed by sincere involvement by way of questioning and direct, honest, humble feedback, will be a boon to the establishing of rapport. As patients attempt to engage in the process of treatment, thera pists can help facilitate the establishment of rapport by giving posi tive verbal reinforce... |
may be personally involved. This includes situations in which you intend to kill your self or someone else, or where you are causing harm to a child. Another such situation would be where you have the AIDS virus, but you're not telling your sexual partners or making any attempts to protect them from infection. Please ... |
their home tele phone numbers for use in emergency situations, we realize that some therapists may prefer instead to make use of an intermediary such as an answering service. In either case, we believe that it is necessary for patients to be able to make contact with their therapist after hours in the event of critica... |
the confrary. For example, one of our patients suffers from diabetes and frequently neglects his medical care as a sign of defiance, much in the same way that others might choose to go on a hunger strike. Ray and his therapist often engaged in power struggles over whether The Therapeutic Relationship 77 or not Ray shou... |
process that is associated with their emotional life. The patient's behaviors are the end products of the vulnerable situations, and the activation of beliefs, automatic thoughts, and emotions. C o m m o n dysfunctional behaviors include actively seeking drugs, using drugs, engaging in irresponsible activities (e.g., u... |
is the only way to cure the boredom." His circumstances and beliefs have led to the following behavioral patterns: brief periods of abstinence from drug and alcohol followed by solitary use of alcohol with Valium, which, in turn, leads to intermit tent use of crack cocaine, and then to daily use of crack cocaine. Mike... |
statement applies to himself or herself. Half of the questions indicate a sociotropic personality style, and the other half indicate an autonomous personality style. One example of a socio tropic item is, "I find it difficult to say no to people." There are five possible responses-this appUes to m e (1) 0%, (2) 25%, (... |
expect to make progress in future sessions. The therapist, recognizing that this feed back indicated that the patient held very negative views about therapy, suggested that this be discussed at some length in the current ses sion. To get a sense of the patient's world, it is helpful to review briefly the patient's li... |
anything, it can suppress your ability to feel well after you stop taking the medi cation. You see, if the medication runs out, and you've sup pressed your body's own natural abilities to kill pain, you're going to go into withdrawal and be in a lot of discomfort. Then, you won't be able to get a refill of the dentis... |
a t i n g P a t i e n t s i n the Cognitive Model A J. ̂ s the cognitive therapy of substance abuse is a collaborative enterprise between therapist and patient, it is essential that patients gain a conceptual grasp of the key components in the model, such as understanding the associations and causal relation ships bet... |
of money he was spending on cocaine. Furthermore, he was not as productive because he began to miss days at work after cocaine binges. Later, when he tried to stop and he began to experience strong urges and cravings, Mr. C's beliefs centered on the cravings themselves. Some of these were, "I can't stand the craving," ... |
The initial goal in therapy was to help the patient develop better ways of coping with his anxiety about some of the urges and cravings that were reappearing. Although this was the primaty focus of therapy, it became obvious after several sessions (when the patient was less anxious about relapse) that he was also exper... |
to be part of the crowd. People to talk to when I'm doing it. It seems like I have friends, but they are not friends, you know. TH: OK, so you have more friends, but they are not real friends. Maybe we can consider this as a disadvantage to using? What do you think? PT: Yeah. It seems like you have more, but you don't ... |
looking at the situation, and to begin to brainstorm solutions. The process of searching for an alternative in order to com bat the patient's hopelessness is illustrated by the following: TH: Let's discuss this problem of your girlfriend calling you when she is high. PT: No need to talk about that. there's nothing I c... |
so I can't possibly have a drinking problem." "My life's a mess anyway, so drags couldn't make it worse." "If I stop using, I'll get depressed." Individuals who abuse drugs are typically not attentive to their drag-related beliefs, often viewing their drug use as a function of extrinsic factors. For example, they attri... |
sad, 1. Write rational response 1. Re-rate belief 1. Actual event leading to preceded emotion(s) anxious/angry automatic thought(s) in automatic unpleasant emotion, or 2. Rate tielief in automatic etc. 2. Rate belief in rational thought(s) 2. Stream of thoughts, 0-100%. 2. Rate degree 0-100%. 0-100%. daydreams or recol... |
has been described by Moorey (1989), who suggests that drag abusers can learn to empa thize with important people in their lives by role-playing the part of a significant other who has been hurt by the patients' drag use. This exercise also serves to highlight the destruction that the drag abuse has wrought on the pat... |
patient to understand the various factors that contribute to craving, to reframe the experience, and to develop better ways to deal with this problem. Horvath (1988) has distinguished the phenomenon of cravings from urges, describing the former as the subjective sense (e.g., physi cal arousal, emotional arousal, "need... |
him from taking the first drink. Positive image replacement is a related technique to help cope with cravings and urges. For example, one patient experienced vety strong negative images about his current situation, that almost his entire family was Strang out on drags. His father was about to lose the house where the p... |
I'll be a nervous wreck all day. Evetyone will think I'm having a breakdown." "I'll never have a normal life again. I'm a slave to the drag. I simply have to have it to get through the day." "If I resist taking the drag now, I'll just need twice as much later to feel normal later. I might even overdose if that hap pen... |
will last. TH: So when you slip, even once, you see yourself as having a relapse. PT: Right. Beliefs 173 TH: And when you say "I don't suppose it will last" I get the impre sion that you don't feel fully capable of staying off drugs. PT: No, not really. Sometimes it seems pretty easy to stay clean and sometimes it's re... |
cocaine is really the only fun you can have with your friends? PT: Actually when you put it that way, and when we look at my life, 1 guess I got into it at a time when any escape would have looked good. At the beginning of this dialogue Bill was confident that noth ing was as rewarding as cocaine use. However, his the... |
She is calling m e all kinds of names: "lazy," "worthless," you know the list. Anyway, I feel this urge to ran, but I know there's nowhere to go. I want to hit her but of course I don't. I want to cty, but I wouldn't give her the satisfaction of seeing that she has hurt me. And finally I start thinking about going to M... |
led a drug-free lifestyle. Roland's drag use had led to numerous negative consequences in his life, yet his sense of helplessness in dealing with these mounting difficulties, coupled with his desire to "forget all his troubles" through the use of drags such as cocaine, perpetuated his drag-related lifestyle. These were... |
patient whose significant other is abusing drags, the belief that "if I stay off drugs I will have to give up the person I love and be all alone" may prime the patient to resume using drags. "Walter" had told his therapist many times that the love of his children was one of the only things he cared about in his life. T... |
a livelihood, (2) dealing with continuing cravings for cocaine (although they have diminished somewhat over time), and (3) rebuild ing his self-esteem, which deflated when he lost his high-profile lifestyle and had to look at himself without the masked feelings pro vided by cocaine. Another high socioeconomic status ... |
to remain drag free. Walter also experienced a significant degree of dysphoria in reaction to automatic thoughts about his legal statiis. In particular, he was frastrated and angered by the limitations set on his traveling by the terms of his parole. He believed that most of his problems had to do with his family membe... |
It was only after Ray began to experience significant physical malaise that he finally relented and contacted his doctor. Once there was open communication between patient, therapist, and physician, the next phase of treatment could begin. This entailed having Ray bring his insulin and needles to session, so that inten... |
crisis in a constractive manner. Yet another red flag for the therapist to notice and address is the patient's sounding or looking abnormally groggy, on the telephone or in person, especially during the middle of the day. One of our patients used the excuse that she had worked "the late shift" the day before a session ... |
patient's abstinence. For example, a patient who derived most of his self-worth from his job will prob ably react quite adversely to being laid off. He may then believe that he has nothing to lose (including his pride, which has already been damaged) by going out and getting "stoned." In this scenario, the patient mig... |
situation except [to engage in the illegal activities]." Violent Confrontation with the Therapist Another related crisis—that we have been fortunate enough rarely to have encountered at the Center for Cognitive Therapy—is one in which the patient threatens the therapist with bodily harm. If the threat is purely verbal,... |
Depression 229 which strategies to use initially, the therapist should consider t following questions: 1. Is the depression so painful that the emphasis should be on symptom relief rather than on an immediate confrontation of the using or drinking problem? 2. Is it likely that relieving some of the symptoms will reduce... |
pro cedure. Dealing with Suicidal Ideation The therapist needs to be alert to covert suicidal ten dencies and to deal with them frankly. A number of interventions are available (see Beck et al., 1979, Chapter 10). As in the preceding illustration, the therapist needs to address the underlying hopeless ness and negat... |
demonstrating to them that they are capable of utilizing their time constractively. Severely depressed patients may report a sense of "going through the motions" with the notion that there is little purpose in their activities. By planning the day with the 240 COGNITIVE THERAPY OF SUBSTANCE ABUSE therapist, they are of... |
exerts as powerful an influence on other people, particularly if the offended individual is in a position of strength. The patient assumes that punishment, whether in the form of a complaint, a reproach, or a tantrum, will help to shape the other person's future behavior properly. The implicit punishment will supposedl... |
patients per ceive themselves as the cause of the problem, they criticize themselves and feel even more helpless. Issue of Control The problem of control is particularly pertinent to the treatment of drug abusers since the therapy involves, in essence, the therapist's attempting to control patients' behavior. This pro... |
sarcastically and walked away in a huff. He was so upset that he felt incUned to go to the bar next door and have a few drinks. Much later he learned that one of his colleagues had picked up the package and delivered it to Bob's secretary. In the therapy session, Bob realized that he had "personalized" the problem—as t... |
booze." Such messages from his par ents taught Rick to have dichotomous beliefs about alcohol. For example, he believed, "If 1 am going to drink at all, 1 might as well get totally drunk." As a result of his extreme thoughts about alcohol, Rick had difficulty drinking in moderation. Rick's anxiety, loneliness, and iso... |
can at least calm myself to avoid having a panic attack." Rick's therapist also engaged him in assertiveness training in order to provide him with essential communication skills. SUMMARY Unnecessary or exaggerated anger takes its toll not only on other persons but also on the person who is angered. Sub stance abusers ... |
such that responsibilities toward others become ignored (symptom of narcissistic personality disorder), as well as numerous other behaviors. As we can see, the particular problems that accom pany the Axis I substance abuse disorder often look suspiciously like— and need to be distinguished from—full-blown Axis II diso... |
experience chronic cross-situational, exaggerated feelings of threat to their physical and psychological well-being, fall into this category. They maintain beliefs that make the use of drugs seem quite enticing, certainly more Personality Disorders 277 attractive than facing up to (and solving) real problems. Such bel ... |
will serve as the basis for necessary therapeutic confron tations. For example, a patient who missed an appointment with his thera pist gave the alibi that, since his driver's license had been revoked, he was dependent on others to drive him to his sessions. He claimed that his "driver" failed to show up; therefore t... |
thoughts that discour aged the patient from doing the assignment. Sometimes the responses are quite surprising, such as one patient who resisted reading a book that we had recommended, even to the point of purchasing it and then throwing it out when he got home. After much careful probing by the therapist, the patient... |
the antisocial drug-abusing patient, it is vitally impor tant to carefully nurture and make clinical use of the therapeutic relationship (see Beck et al., 1990; Layden et al., 1993; Young, 1990; Chapter 4, this volume, for more detailed explications). The all-or- none thinking style of the borderline patient often sho... |
have to believe that he was in an irreversible free fall. Instead, he could practice reciting some control beliefs that might help him to "pull out of the nose dive" (Shiffman, 1992) if confronted with similar situations in the future. Such control beliefs might be "If I stop now, I can show myself that I am stronger t... |
in spite of his cravings and urges. As Mike's case illus- frates, relapse prevention necessitates that patients learn to cope with both general life stressors (e.g., marital discord) and discomfort that specifically is related to temptation to use drugs (Wills & Shiffman, 1985). A long-term goal for Mike, essential to ... |
positive advantages from using that substance. In fact, such people typically minimize or ignore the disadvantages of their drug use, especially when in high-risk situations. The advantages-disadvantages analysis is a technique commonly used in cognitive therapy (see Chapter 9, this volume). This technique is particula... |
under pressure at work. 35. I a m thinking about having sex. 36. I a m angry at m y spouse/partner. 37. M y spouse/partner is bugging m e about m y using. 38. M y family is bugging m e about m y using. 39. I was just told I have a positive urine. 40. I didn't use, yet m y urine was positive. 41. I a m watching a dmg-re... |
DAILY RECORD OF CRAVINGS (DTR ADAPTED FOR USE SPECIFICALLY WITH CRAVINGS) Degree Thoughts of or craving Rational response Date Situation Feelings (0-100) and/or coping 6-12 Boss came down Felt stupid. Thought: 50 1 can try to work it hard on me. 1 need a smoke. out—waited it out for half an hour and craving went away. ... |
131-178). N e w York: Guilford. Alberti, R.E., & Emmons, L. (1974). Your perfect right (2nd ed.). San Luis Obispo, CA: Impact. Alterman, A.I., & Cacciola, J.S. (1991). The antisocial personality disorder diagnosis in substance abusers: Problems and issues. Journal of Nervous and Mental Disease, 179, 401-409. Alterman, ... |
to action: The role of the World Health Organization. In W.R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (pp. 51-57). N e w York: Plenum. Grossman, J., & Schottenfeld, R. (1992). Pregnancy and women's issues. In T.R. Kosten & H.D. Kleber (Eds.), Clinician's guide to cocaine addiction:... |
the Socratic method. In C Stout (Ed.), Annals of clinical research (pp. 1-7). Des Plaines, IL: Forest Insti fate. Peele, S. (1985). The meaning of addiction: Compulsive experience and its inter pretation. Lexington, MA: Lexington Books. Peele, S. (1989). Diseasing of America: Addiction treatment out of control Lex i... |
5 EUinwood, E.H., 6, 7, 25, 31, 37, 51, 197 Harrison, R., 95 Ellis, A., 28, 242, 244, 246 Harstone, E., 5 Emery, G., 27, 42, 327 Hatsukami, D., 27, 234 Emmons, L., 254, 264, 286 Havassy, B.E., 28, 57, 124, 167, 301 Epstein, N., 94, 95 Heath, A.W., 5 Erbaugh, J., 93 Heatherton, T.F., 38 Estroff, T.W., 7 Helzer, J.E., 25... |
see Structure prevalence, 5 Permissive (permission-giving) beliefs; see crimes, 5 Beliefs deaths, 5 Personality disorders, 10, 27, 29, 268-291 marijuana, 5-6 antisocial, 236, 268-269, 278-287 Subject Index 3 5 3 assessment, 271-276 Relapse Prediction Scale, 93, 95, 313- avoidant, 254, 270, 276 314 borderiine, 269-270, ... |
Handbook of Inpatient Endocrinology Rajesh K. Garg James V. Hennessey Alan Ona Malabanan Je rey R. Garber Editors 123 Handbook of Inpatient Endocrinology https://www.facebook.com/groups/2202763316616203 Rajesh K. Garg James V. Hennessey Alan Ona Malabanan Jeffrey R. Garber Editors Handbook of Inpatient Endocrinology Ed... |
Israel Deaconess Medical Cen- ter, Harvard Medical School, Division of Endocrinology, Diabe- tes and Metabolism, Boston, MA, USA Margo Hudson, MD Brigham and Women’s Hospital, Department of Endocrinology, Hypertension and Diabetes, Boston, MA, USA https://www.facebook.com/groups/2202763316616203 Contributors xv Gwendol... |
ples for ACTH and cortisol measurements should be obtained prior to the administration of steroids. The hypothalamic-pitu- itary-adrenal axis usually responds to critical illness with an increase in serum cortisol levels, and it is expected that a random cortisol level will similarly be elevated during the acute phase ... |
evaluation of pitu- itary function. On the other hand, some pituitary hormonal defi- ciencies may recover postoperatively, and such recovery can also be assessed as part of this evaluation. Studies have shown partial or complete recovery of pituitary function in up to 50% of patients. In most cases, patients will be tr... |
useful to measure gonadal and thyroid function in acutely ill patients. Similarly, the growth hor- mone axis is not assessed in hospitalized patients. Genetic Causes Mutations in several genes involved in pituitary development and differentiation, and hormone production and secretion are 2 Panhypopituitarism 21 associa... |
K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_3 28 A. Z. Feldman and P. Hartzband Assess Hormone Status Before Surgery if Possible – Ideally patient should be seen by endocrinology as outpatient prior to surgery. Intraoperative/Postoperative Steroids Patient with ... |
thyroid hormone preparations, antithyroid medication (methimazole or propylthiouracil [PTU]), exposure to iodinated contrast or iodine supplements, weight loss supplements, or other medications, including amiodarone, lithium, tyrosine kinase inhib- itors, and immune checkpoint inhibitors for cancer treatment. Performin... |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Respiratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Genitourinary . . . . . . . . . . . . . . . . . . ... |
type, dose, route, frequency of administration, and duration of therapy. An approach adopted by earlier studies is administration of an intravenous L-thyroxine 300–600 μg loading dose to replete the deficit in the total body thyroid hormone pool, followed by maintenance doses of 50–100 μg LT4 daily by intra- venous or ... |
levels can lead to abnor- mal values in a euthyroid patient. Several TSH isoforms can be expressed in humans that are not biologically active. Some labo- ratory assays may detect these isoforms leading to the reporting of abnormal TSH values that, however, do not correlate with hypothalamic- pituitary-thyroid dysfuncti... |
process Sarcoidosis 6 Abnormal Thyroid Stimulating Hormone Values That Are Not… 67 Table 6.2 (Continued) Histiocytosis X Iron overload (hemochromatosis, blood transfusions) Infectious diseases Tuberculosis Toxoplasmosis Fungal infections Table derived in part from Table 2 of Beck-Peccoz P, Rodari G, Giavoli C, Lania A.... |
have used to administer antithyroid medications. Studies range from healthy volunteers without thyroid dysfunction to case reports of critically ill patients with thyroid disease (Tables 7.1 and 7.2). These studies show that rectal administration of PTU and MMI in either enema or suppository is readily absorbed and wel... |
interfering with thyroxine absorption. Best Pract Res Clin Endocrinol Metab. 2009;23(6):781–92. Nabil N, Miner DJ, Amatruda JM. Methimazole: an alternative route of administration. J Clin Endocrinol Metab. 1982;54(1):180–1. Okamura Y, Shigemasa C, Tatsuhara T. Pharmacokinetics of methimazole in normal subjects and hype... |
(approximately the fraction of oral LT4 that is absorbed) of the oral dosing at 1.6 mcg/kg of body weight per day. The administration of intravenous liothyronine (T3) in addition to IV LT4 is optional. The rationale is that periph- eral T4 to T3 conversion is decreased in acutely ill patients, and IV T3 may accelerate ... |
scenario due to concern of exacer- bating thyrotoxicosis, for the reasons stated previously. As in the case of severe hypothyroidism, patients with severe hyperthyroidism remain high surgical risk despite optimal periop- erative management. A multidisciplinary approach with the sur- geon, anesthesiologist, and endocrin... |
Patients undergoing surgery for Graves’ disease should be treated with beta-blockers and rendered clinically and biochemi- cally euthyroid preoperatively with ATDs. Potassium iodide may be administered in the immediate preoperative period. If the patient needs urgent surgery, beta-blocker, ATDs, and potassium iodide sh... |
Medicine, Endocrinology and Metabolism, Boston, MA, USA e-mail: jpallott@bidmc.harvard.edu © Springer Nature Switzerland AG 2020 115 R. K. Garg et al. (eds.), Handbook of Inpatient Endocrinology, https://doi.org/10.1007/978-3-030-38976-5_10 116 A. E. Stephen and J. A. Pallotta Introduction Hypercalcemia is a common cli... |
127 After Emergent Treatment with Intravenous Calcium Gluconate, a Calcium Gluconate IV Drip Should Be Maintained (with EKG Monitoring) Titrating the Free Serum Calcium Estimate to the Lower Limit of Normal 128 Chronic Treatment of Hypocalcemia Includes Treating the Underlying Causes (Hypomagnesemia, Vitamin D Deficien... |
parathyroid hormone (PTH) levels in the setting of hypercalcemia without renal failure. PTH-dependent hypercalcemia in the setting of prolonged renal failure could indi- cate tertiary hyperparathyroidism. Calcium levels should be cor- rected for serum albumin. Occasionally the PTH levels will be within the normal range... |
g of elemental calcium is typically given orally in divided doses in the postoperative periods for several days to weeks depending on the serum calcium and PTH concentrations. Aggressive vitamin D repletion with high-dose ergocalciferol or cholecalciferol can be considered in patients with preoperative vitamin D defici... |
and when In oral forms, estrogen is associated with back to baseline increased DVT risk, which may be ambulatory status exacerbated by immobility. Discontinue in as an outpatient the setting of DVT, MI, stroke, or immobility 13 Management of Osteoporosis in the Inpatient Setting 151 Recurrent Fracture Trial, a randomiz... |
outpatient. 13 Management of Osteoporosis in the Inpatient Setting 157 Suggested Reading Bone HG, Wagman RB, Brandi ML, Brown JP, Chapurlat R, Cummings SR, C et al. 10 years of denosumab treatment in postmenopausal women with osteoporosis: results from the phase 3 randomised FREEDOM trial and open-label extension. Lanc... |
Diagnostic Categories of Hyponatermia Based on the Extracellular Volume 175 Hypervolemic Hyponatremia 177 Hypovolemic Hyponatremia 178 Euvolemic Hyponatremia 180 J. L. Seifter (*) Brigham and Women’s Hospital, Department of Medicine, Boston, MA, USA e-mail: jseifter@bwh.harvard.edu H.-Y. Chang National Cheng Kung Unive... |
• Low solute intake Fig. 15.2 Establish the type of hyponatremia by first measuring plasma osmolality, and obtain urine osmolality to assess ADH activity in the hypo- tonic hyponatremic patients. Note that a rapid decline in plasma sodium over 24–48 h is a medical emergency and requires acute intervention 174 J. L. Sei... |
into cells. By the time water was expanded enough to cause edema, life-threatening hyponatremia would develop. A second reason is that an acute water load expands the plasma volume enough to cause a mild, acute natriuresis. But distinctively the cause of edema in ECF expansion is raised intravascular volume and pressur... |
in outpatients. Am J Med. 1981;70(6):1163–8. Ayus JC, Caputo D, Bazerque F, Heguilen R, Gonzalez CD, Moritz ML. Treatment of hyponatremic encephalopathy with a 3% sodium chlo- ride protocol: a case series. Am J Kidney Dis. 2015;65(3):435–42. Chung HM, Kluge R, Schrier RW, Anderson RJ. Clinical assessment of extra- cell... |
expansion such as heart failure. Furosemide can be started at a dose of 40–80 mg IV twice a day, but higher doses may be needed in renal impairment. For patients who are not hypervolemic, loop diuretics can be given with an infusion of IV saline to maintain euvolemia and urine flow with distal sodium delivery. Oral loo... |
Morning cortisol levels less than 5 mcg/dL confirm the diagnosis of adrenal insufficiency, along with a concomitant ACTH level that is at least twofold greater than the upper range of normal (but usually several hundred or even greater than a thousand, pg/mL). Further, the deficiency of aldosterone may result in hypona... |
enables a good quality of life. with isotonic fluids should be If the cause of secondary adrenal insufficiency was initiated iatrogenic glucocorticoid administration, then the goal of therapy should be to gradually taper the glucocorticoid doses to permit normalization of the hypothalamic- pituitary- adrenal axis. The ... |
how- ever, the effects of acute illness on cortisol levels should also be considered when interpreting test results dCarbamazepine, fenofibrate (in some assays), licorice, and carbenoxolone Measure Plasma ACTH to Direct Further Investigations Once CS is confirmed, measure plasma ACTH to determine whether CS is ACTH-dep... |
structures. However, the open approach to adrenalectomy is associated with more pain and longer postoperative hospitaliza- tion than less invasive approaches, although this is a reasonable trade-off to allow more complete resection in cases of suspected malignancy. Ensure Completeness of Preoperative Endocrine Evaluati... |
alpha-1 receptors, and initiation of α-blockade can lead to severe orthostatic hypotension. A patient may need 2–3 L of fluid orally or intravenously with 5–10 g of salt to increase the intravascular volume, reverse catecholamine-induced blood volume contrac- 20 Pheochromocytoma and Paraganglioma 241 tion preoperativel... |
Diagnostic Considerations Primary aldosteronism (PA) is the most common cause of endo- crine hypertension. Patients with PA have higher cardiovascular morbidity and mortality compared with age- and sex-matched patients with essential hypertension and the same degree of blood pressure elevation. Case detection screening... |
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