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Michael Joseph Borowitz, M.D., Ph.D.

• Director, Division of Hematologic Pathology
• Professor of Pathology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0007310/michael-borowitz

The aim here was to assess operative complications and long term results of vaginal sacrospinous ligament fixation order 75mg pregabalin with visa, and risk factors associated 12 with recurrence order pregabalin 150 mg line, and to compare sacrospinous fixation with abdominal sacral colpopexy buy pregabalin 150mg fast delivery. A further aim was to compare outcomes of vaginal and transanal techniques for rectocele repair order 75mg pregabalin with amex. The patient was tied to a ladder-like frame, which was moved upward and downward for 3-5 minutes. The force of gravity and shaking motion were thought to restore the prolapsing organs to their normal position. He was also the first to suggest vaginal supporting of the prolapse by a half pomegranate soaked in wine, which actually provoked vaginal constriction as well as constituting a mechanical barrier (Loret de Mola and Carpenter 1996). Mechanical blocking of the vagina was the most widely accepted treatment for genital prolapse from the days of Hippocrates to the 1800s. Surgical procedure was accepted only when the uterus itself was gangrenous (Emge and Durfee 1966). Alsahavarius, in 1080, stated that if an organ was prolapsed and could not be reinserted it should be removed from below (Benrubi 1988). Terminology and suggested etiologic factors Benedetti was the first to use the word procidentia to describe complete uterovaginal prolapse in 1497 (Harris and Bent 1990). Van Roonhuyse of 14 Holland in the 1600s first described vaginal vault prolapse and suggested vaginal pessaries as treatment. In the seventeenth century the Swiss Johan Peyer described cystocele and the possibility that both the uterus and the bladder could prolapse (Emge and Durfee 1966). In the 1700s uterine prolapse was held to be a result of such factors as difficult and protracted labor and relaxation of both ligaments in the peritoneum. Manning introduced the theory that a rigid vagina was the most important factor in preventing uterine prolapse, and subsequently Hamilton suggested a rigid perineum to be the main support of pelvic organs (Emge and Durfee 1966). In the early 1800s the terminology and classification of genital prolapse evolved into that in current use. They included uterine prolapse of various degrees, relaxation of the anterior wall or cystocele, relaxation of the posterior vaginal wall or rectocele, enterocele and procidentia or total uterovaginal prolapse and vaginal vault prolapse (Emge and Durfee 1966, Harris and Bent 1990). In the nineteenth century many conservative methods were available for the treatment of genital prolapse, including different intravaginal pessaries. However, such treatments as cold water douches, hip baths and vaginal lavations and surf bathings were recommended, as well as uterine gymnastics and massage (Emge and Durfee 1966). Development of surgery Denudation of the vaginal mucosa was introduced in 1823 and was primarily used for uterine prolapse but subsequently also for cystocele. Toogood is credited with having performed the first vaginal hysterectomy for uterine prolapse in 1846, although there are reports of hysterectomies for prolapse from the 1600s and 1700s. Brown attempted repair of rectocele with a horseshoe-shaped incision in the posterior wall of the vagina. Tait, in 1887, used a mucosal flap-splitting operation for rectocele, which was later used for the anterior vaginal wall as well. However, surgery for rectocele was often confused with perineal repair (Emge and Durfee 1966). In 1888 Donald of Manchester introduced combined anterior and posterior vaginal wall repairs, perineorrhaphy and amputation of the cervix, which became the first widely used operation for genital prolapse (Loret de Mola and Carpenter 1996). He preferred (Donald 1902) plastic operations to hysterectomy and warned of the risk of vaginal vault prolapse after hysterectomy. The first attempts to fixate the vagina emphasized fixing the uterus in a position of anteversion, because retroversion was regarded as the first stage of the prolapse. Mayo (1915) described his classical technique of vaginal hysterectomy for uterine prolapse and later Heaney (1934) reported on 565 vaginal hysterectomies by a technique, which has persisted to the present. In addition to hysterectomy, both authors advocated concomitant pelvic floor repair. Zweifel is acknowledged to be the first to surgically correct vaginal prolapse by a sacrotuberal technique in 1892 (Morley and DeLancey 1988). Miller (1927) reported a transvaginal method of fixating the vagina and sacrouterine ligaments to the anterior sacrum. Subsequently Amreich (1951) described extraperitoneal posterior gluteal and later, in the 1950s, vaginal route for fixating the vagina to the sacrotuberous ligament, which is a precursor of sacrospinous ligament fixation. For correction of vaginal prolapse Ward (1938) recommended ox fascia to strengthen the round ligaments. Shaw (1948) introduced a technique with fascial support for posthysterectomy vaginal vault prolapse. Williams and Richardson (1952) introduced a transabdominal technique with ventral fixation of the vagina with transplantation of external oblique aponeurosis. Arthure and Savage (1957) described their hysteropexy and later Lane (1962) introduced a similar technique with interposing bridge between the vaginal vault and sacrum. The interposition operations did not gain popularity in this country and vaginal hysterectomy was infrequently performed after the 1910s. Vaginal anterior and posterior colporrhaphies with modifications were the most often performed operations in the 1920s and the 1930s, whereas abdominal ventrofixation of the uterus was popular in the first two decades of the 1900s. Elevated mortality led to abandonment of abdominal ventrofixation despite the fact that results of combined abdominal and vaginal approach were superior (Listo 1934). He reported poor results with pessary treatment of postmenopausal patients and recommended minor surgery under local anesthesia. The principle in this operation was to create a high perineum closing the vaginal orifice and preventing the prolapse from protruding. The Manchester-Fothergill operation for uterovaginal prolapse has been popular in Finland during recent decades. For vaginal vault prolapse abdominal operations such as Williams-Richardson (Leminen et al. Terminology of pelvic organ prolapse Prolapse (Latin prolapsus, a slipping forth) is a term referring to the falling or slipping out of place of a part or viscus. Cystocele is a herniation of the bladder base into the vagina, which in cases of urethral hypermobility may be referred to as cystourethrocele (DeLancey 1993, Kobashi and Leach 2000). Female rectocele is herniation of the anterior wall of the rectum outside its normal confines, causing protrusion of the posterior vaginal wall and/or the perineum (Kahn and Stanton 1998). Enterocele is a hernia of the peritoneal pouch of Douglas caudally between the vagina and rectum, usually containing small bowel or omentum (Raz et al. Uterine prolapse or descent is usually defined when the cervix protrudes outside the pelvis, generally concomitantly with cystocele and enterocele without rectocele. According to Nichols (1992) this is named uterovaginal or sliding prolapse, the other form being general prolapse with cervix outside the introitus with cysto and rectocele but no enterocele. The term procidentia refers to total uterine prolapse with the uterine fundus outside the introitus (Shull 1993). Vaginal vault prolapse is a similar condition in patients who have undergone hysterectomy (Nichols 1992). According to these recommendations prolapse should be discussed in terms of vaginal wall segments rather than the organs lying behind it because the only structure visible to the examiner is the vaginal surface. Thus, anterior vaginal wall prolapse refers 17 to cystocele or anterior enterocele, prolapse of the apical segment to uterine or vault prolapse, and posterior vaginal wall prolapse to rectocele or enterocele. Structural anatomy associated with surgery for vaginal vault prolapse, uterine procidentia and rectocele Each anatomic structure for the support of the pelvic floor provides a functional contribution (Strohbehn 1998). The pelvic floor anatomy can artificially be divided into passive and active structures. Passive structures include bony pelvis and connective tissues and active support structures muscles and nerves. All the pelvic soft tissues are anchored to the bony pelvis (Nichols 1991b, Strohbehn 1998). The connective tissue supports include organized aggregations of dense collagen called ligaments or tendons, and a less well defined aggregation of collagen, smooth muscle, elastin and fibrovascular bundles known as endopelvic fascia (Strohbehn 1998).

Diseases

• Anti-HLA hyperimmunization
• Blethen Wenick Hawkins syndrome
• Adrenal cancer
• Marcus Gunn phenomenon
• Ectodermal dysplasia, hydrotic
• Eosinophilic lymphogranuloma
• Cervicooculoacoustic syndrome
• Tricho onycho hypohidrotic dysplasia
• Hyper-reninism

He has a history of diabetes (E) Paradoxical embolism controlled by diet and of 25 pack-years of cigarette smoking discount pregabalin 75 mg without prescription. His father and maternal grandfather both died of heart dis 15 Two months later discount 150mg pregabalin fast delivery, the patient described in Question 14 expe ease before the age of 60 trusted 150 mg pregabalin. On the 5th hospital day purchase pregabalin pills in toronto, the patient riences several days of severe, sharp, retrosternal chest pain develops chest pain during periods of mild activity, which radiating to the neck and shoulders. Physical exami is treated with plasminogen activator and oxygen but expires sev nation shows diaphoresis and dyspnea. At autopsy, the heart is found to be enlarged but otherwise anatomically nor mal. His blood 114 Chapter 11 (A) Left anterior descending (B) Left circumfiex (C) Main right (D) Posterior descending (E) Sinoatrial nodal 20 A 69-year-old woman presents with crushing substernal chest pain and nausea. Cardiac catheterization reveals diffuse atherosclerosis of all major coronary arteries. The patient subsequently becomes acutely hypotensive and undergoes cardiac arrest. At what point in time following acute myocardial infarction did this pathologic condition most likely occurfi There is no evidence of coronary artery disease (C) 12 to 24 hours or valvular heart disease. Which of the following is the most likely cause of right (E) 6 months to 1 year ventricular hypertrophyfi Her past medical history is signifi cant for long-standing type 2 diabetes mellitus. Her relatives note that she had complained of chest heaviness and short ness of breath for the past 2 weeks. The patient suffered a mas (B) Essential hypertension sive anterior myocardial infarction 1 year earlier. Which of the following is the (D) Pulmonary stenosis most likely complication of this conditionfi He says (B) Carcinoid heart disease that he becomes short of breath at night unless he uses three pillows to prop himself up. Measurements of vital signs reveal (C) Cardiac metastases normal temperature, mild tachypnea, and a blood pressure of (D) Nonbacterial thrombotic endocarditis 180/100 mm Hg. Physical examination discloses obesity, bilateral (E) Subacute bacterial endocarditis 2+ pitting leg edema, hepatosplenomegaly, and rales at the bases of both lungs. An X-ray film of the chest shows mild enlarge 28 A 78-year-old man with a history of recurrent syncope under ment of the heart and a mild pleural effusion. A hard, markedly phy reveals left ventricular hypertrophy without valvular heart deformed valve is observed, but the patient expires during defects. Physical examination shows pallor, diaphoresis, and a murmur of aortic regurgita tion. There is a (E) Marantic endocarditis history of recurrent episodes of arthritis, skin rash, and glom erulonephritis. On physical examination, the patient is short of cause of heart murmur in this patientfi A prominent pansys (A) Libman-Sacks endocarditis tolic heart murmur and a prominent third heart sound are (B) Mitral valve prolapse heard on cardiac auscultation. An X-ray study of the chest (C) Myocardial infarct shows marked enlargement of the heart. The patient expires (D) Mitral valve prolapse despite intense supportive measures. At autopsy, microscopic (E) Rheumatic fever examination of the myocardium discloses aggregates of mono nuclear cells arranged around centrally located deposits of 27 A 50-year-old man with adenocarcinoma of the pancreas is eosinophilic collagen. The patient never (C) Subacute bacterial endocarditis regains consciousness and expires 2 days later. Which of the following is the (E) Viral myocarditis most likely underlying cause of stroke in this patientfi However, the patient suffers from recurrent pharyngitis and, a few years later, develops a heart murmur. Physical examination shows rales in the lungs, hepatosplenomegaly, and 2+ pitting edema of the legs. A chest 32 A 34-year-old intravenous drug abuser presents to the emer X-ray reveals only left atrial enlargement and pulmonary gency room with a 24-hour history of fever and shaking chills. The patient rapidly develops (A) Aortic insufficiency a headache and right-arm paralysis. Which of the (C) Mitral stenosis following is the most likely cause of stroke in this patientfi Which of the following is the most (E) Paradoxical embolus likely cause of death in this patient 2 years after transplanta tionfi The heart at autopsy (B) Aortic valve stenosis weighs 380 g (normal = 230 to 280 g in women). Physical examination shows facial red ness, as well as hepatomegaly and pitting edema of the lower legs. An echocardio (C) Dilated cardiomyopathy gram would be most expected to demonstrate which of the (D) Hypertrophic cardiomyopathy followingfi Physical examination shows evidence of congestive heart failure and echocardiography discloses a dilated left ven tricle and a left ventricular ejection fraction of 20%. Physical examination reveals peripheral edema, ascites, and (A) Acute bacterial endocarditis hepatomegaly. An echocardio (B) Acute myocardial infarction gram shows a remarkably enlarged right heart and no signs of (C) Endocardial fibroelastosis valvular heart disease. Endomyocardial biopsy discloses inter (D) Rheumatic heart disease stitial, pink amorphous deposits between cardiac myocytes. Physical examination shows clinical evidence of pul (C) Dilated cardiomyopathy monary edema, enlargement of the left atrium, and calcifica (D) Hypertrophic cardiomyopathy tion of the mitral valve. Before open heart surgery can be performed, the patient expires of an ischemic stroke. The heart at autopsy 40 A 50-year-old man underwent heart transplantation for low is shown in the image. Which of the following is the most output heart failure that was unresponsive to medical treat likely diagnosisfi It weighs 950g (normal up to 350g) and shows no evidence of coronary artery atherosclerosis. Histologically, the myocar dium demonstrates hypertrophic myocytes and foci of myo cardial fibrosis but no evidence of infiammation or myofiber disarray. She was seen for fiu-like symptoms (D) Metastatic melanoma and prominent muscle pain 3 weeks ago. Physical examina (E) Mural thrombus tion shows tachycardia and irregular heart beats. The patient 43 A 45-year-old male immigrant from Haiti presents with a subsequently dies of cardiorespiratory failure. Histopathology 3-week history of difficulty breathing, chest pain, and abdom of the heart muscle at autopsy is shown in the image. The patient was 118 Chapter 11 diagnosed with active pulmonary tuberculosis 2 years before. The patient eventually dies and the heart at (B) Mitral regurgitation autopsy is shown in the image. The patient develops mental status changes, suffers a massive stroke, and expires.

Hydrolytic enzymes generic 75 mg pregabalin visa, acting on phospholipids buy cheap pregabalin 150 mg line, meanwhile produce fatty acids like calcium palmitate and stearate purchase 150 mg pregabalin mastercard. Biofilm discount pregabalin 150mg on line, a glycoprotein produced by bacteria as their glycocalyx, then agglomerates this pigment material, leading to brown stones. Stagnation and recurrent infection predispose to chronic cholangitis and eventually in some, cholangiocarcinoma. Natural History of Gallstone Disease Gallstones grow at the rate of about 1-2 mm per year, over a five to 20-year period, before symptoms develop (often symptoms never develop). Gallstone disease is a common problem, affecting 10 to 15% of adults in developing countries, yet most (80%) never develop symptoms or complications. If problems do occur, the symptoms usually arise in the form of biliary pain (at a frequency of about 2% per year during the first five years, and then decreasing over time). Thus, biliary pain rather than a biliary complication represents the initial manifestation in most (90%) people with previously asymptomatic gallstones. As the rate of a biliary complication is very low (3% at 10 years), prophylactic cholecystectomy is not warranted in those with stones who lack symptoms. Obstruct the cystic duct, leading to cholecystitis: this begins as a chemical inflammation that later may become complicated by bacterial invasion; or 2. Pass out of the gallbladder into the common duct and either obstruct the bile ducts (producing biliary pain and cholestasis), often accompanied by bacterial infection in the bile ducts (cholangitis), or lodge in the common pancreatobiliary channel, temporarily blocking the pancreatic duct (or causing bile reflux into the pancreatic duct) and resulting in pancreatitis (Figure 2). Migration of the stone in the gallbladder to impact in the neck of the gallbladder or the bile duct can cause obstruction and result in complications. It is often suggested that chronic calculous cholecystitis may be associated with carcinoma of the gallbladder, but causality is unproven. Common duct obstruction leads to cholangitis, cholestatic jaundice and/or pancreatitis. Stricture formation and recurrent cholangitis on occasion can lead to secondary biliary cirrhosis. Clinical Features Biliary colic ensues when a stone obstructs the cystic duct, causing sudden distension of the gallbladder. Rather, the right upper quadrant or epigastric pain begins rather suddenly, quickly becomes intense, remains steady for 15 minutes to some six hours and then gradually disappears over 30 to 90 minutes, resolving spontaneously (though occasionally there remains a transient, vague ache for up to a few days). Its duration is seldom shorter than 15 minutes and is often sufficiently severe for many sufferers to seek medical attention and to require narcotics for relief. Mediated by splanchnic nerves, biliary colic may radiate like angina to the back, right scapula or shoulder tip, down the arm or into the neck, or even rarely biliary colic pain may be confined to the back. The patient is usually restless, and First Principles of Gastroenterology and Hepatology A. Fever and rigors are absent when they cystic duct is obstructed and there is no inflammation. Such presence of fever and rigors suggest that a stone has migrated and become lodged in the cystic duct, causing cholangitis, or that the gallbladder is acutely inflamed (acute cholelithiasis). Findings consist of mild-to-moderate right upper quadrant or epigastric tenderness. Once gallstones are complicated by an attack of biliary pain, a recurrent pattern is likely to ensue, days or weeks apart. Symptomatic gallstones have a more aggressive course than those that are asymptomatic. Although 30% of patients with one episode of biliary pain do not have further episodes, most experience a recurrent pattern that remains fairly constant. These episodes may be sporadic separated by pain-free periods lasting from days to years, during which the patient feels well and the liver biochemistry is normal. However, complications requiring surgery may arise at any time, with a frequency of 1 to 2% per year. Pain lasting more than six to 12 hours, especially if accompanied by persistent vomiting or fever, suggests another process such as cholecystitis or pancreatitis (Table 4). Diagnostic Imaging Detecting gallstones (as opposed to diagnosing clinically symptomatic gallstone disease) is by diagnostic imaging. Plain abdominal x-rays will only identify the 10-15% with high calcium content as radiopaque densities in the right upper quadrant. Ultrasonography is the most sensitive and specific method for detecting gallstones (appearing as echogenic objects that cast an acoustic shadow) or a thickened gallbladder wall (indicating inflammation). Also, if the gallbladder is fibrotic and shrunken, ultrasound may not visualize the gallbladder. Although most episodes of biliary colic resolve spontaneously, pain eventually recurs in 20-40% each year. Furthermore, complications such as cholecystitis, choledocholithiasis, cholangitis or gallstone pancreatitis emerge at a frequency of 1-2% per year, often necessitating emergency cholecystectomy. Because of recurrent attacks of pain and these increased risks, cholecystectomy is indicated once biliary colic develops. The risk of any emergency procedure is greater then elective surgery, so this is why elective cholecystectomy is recommended. In addition to the obvious cosmetic appeal, these smaller incisions result in less postoperative pain and shortened recovery time, allowing an early discharge from hospital (sometimes the same day as an outpatient) and return to work. The disadvantages include a somewhat higher complication rate, particularly from common duct injury and retained common duct stones, plus the potential for overuse. In 5% of cases the procedure must be converted to an open cholecystectomy because of technical problems. Laparoscopic cholecystectomy is now the standard for elective removal of the gallbladder in those with significant symptoms. Prophylactic cholecystectomy is not warranted in those with asymptomatic stones except for rare cases suspected of developing/ harboring carcinoma of the gallbladder. Chronic Calculous Cholecystitis Chronic inflammation of the gallbladder is the most common histological process, often manifest as mild fibrosis of the gallbladder wall with a round cell infiltration and an intact mucosa. Some degree of chronic inflammation inevitably accompanies gallstones, but the stones will have developed first. Even transient obstruction of the cystic duct can produce biliary colic and an element of inflammation that is chemical in origin. There is little correlation between the severity and frequency of such biliary episodes and the degree of inflammation or fibrosis. Chronic inflammation thus may follow the resolution of acute cholecystitis, evolve with recurrent episodes of biliary colic or develop insidiously. It is the presence of true biliary colic which drives the indication for cholecystectomy, not the possible presence of chronic cholecystitis. Clinical Features the clinical features are those of either biliary colic or a previous episode of acute cholecystitis that has resolved leaving the gallbladder chronically inflamed and scarred. The pain characteristically is a constant dull ache in the right upper quadrant or epigastrium, and sometimes also in the right shoulder or back. Flatulence, fatty food intolerance and dyspepsia occur, but are equally frequent in patients without gallstone disease. There may be local tenderness in the right upper quadrant of the abdomen but no peritoneal findings. If the gallbladder is fibrotic and shrunken, ultrasound visualization may be difficult. A nuclear medicine cholescintigraphy scan may be positive with the gallbladder failing to fill, but non-visualization is rather insensitive for chronic cholecystitis, because of frequent false positive and false negative tests. Management Once symptoms begin, they are most likely to recur, whereas asymptomatic stones, or stones associated with dyspepsia without biliary colic, are generally treated expectantly. Medical management depends upon gallstone size, gallbladder function and any co-morbid conditions. Cholecystectomy provides definitive treatment, removing the stones and the gallbladder, and eliminating recurrences of true biliary pain.

If an Urinary incontinence is ofen seen in elderly patients antimuscarinic is believed necessary in these patients purchase pregabalin online, with dementia buy pregabalin 150mg cheap. Using fi-blockers Estrogens concomitantly with antimuscarinics has become a sub Oral and topical estrogen therapy was thought to ject of interest safe pregabalin 150mg. The 2012 Beers Criteria recommend quency episodes and found signifcant median decreases against the use of oral or transdermal patch estrogen in women discount pregabalin online amex. The injections are 50% with duloxetine compared with placebo (Mariappan intradetrusor by cystoscopy. It was not known whether this beneft could be sus insert, in preapproval studies, the frequency of incon tained, but the available evidence suggested it was a good tinence episodes at week 12 was decreased by 19. One of the primary risks of using several trials, with some patients seeing beneft within 2 Onabotulinum toxin A is acute urinary retention. The typical dose is 40 mg twice daily, must be willing to undergo catheterization as part of this and the most common adverse efect reported in most therapy. Aminoglycosides cannot be used because Society Beers Criteria, duloxetine is listed with other of their interference with neuromuscular transmission, serotonin-norepinephrine reuptake inhibitors for use with which can potentiate the efects of Onabotulinum toxin caution in elderly patients because of the risk of syndrome A. Antiplatelet drugs also must be discontinued 3 days of inappropriate antidiuretic hormone or hyponatremia before injection. Duloxetine is not recommended when the treatments should not be repeated any sooner than 12 CrCl is less than 30 mL/minute. The injections do not even list fi-agonists as an option for treatment any are administered as described previously with cystoscopy. This is admin hypertension, arrhythmia, coronary artery disease, myo istered by giving 20 injections of 5 units each about 1 cm cardial infarction, hyperthyroidism, kidney failure, and apart in the detrusor muscle. The the efect wears of, but it must have been at least 12 weeks adverse efects of hypertension, headache, anxiety, and since the previous dose. T ose with cognitive weeks) afer injection with Onabotulinum toxin A or pla impairment may be a target patient population for this cebo. Providing prophylactic antibiotic therapy and Urinary incontinence has a large economic and func withholding antiplatelets is the same as previously rec tional impact and will become an even larger issue in the ommended for Onabotulinum toxin A. Pharmacists are in a prime position to help guide the choice of antimus Mirabegron carinic with respect to cost, adverse efect profle, patient Mirabegron, a new fi3-adrenergic receptor agonist, comorbidities, and administration. For patients seeing beneft, adjunc receptors, but overall, mirabegron has low intrinsic activ tive treatment can be recommended to help with adverse ity for fi1 or fi2-receptors. Practice Points According to the package insert, in preapproval tri als, mirabegron at 25 mg and 50 mg daily signifcantly ere is no single antimuscarinic agent with sig decreased the number of incontinence episodes in 24 nifcant data to show that it is the frst-line choice hours and the number of micturitions in 24 hours over for urinary incontinence. The most common as the medication to try frst line because no over adverse efect in initial trials was hypertension; healthy whelming evidence exists that it is tolerated any volunteers had a mean increase in blood pressure in of 3. Adverse event rates for the 25-mg daily dose were as have not been shown superior to other agents and follows: hypertension (11. Mirabegron increases the area under ever, these drugs must be used at the lowest dose the curve of digoxin by 27% when these are coadmin istered. The lowest dose of digoxin should be used, and possible and for the fewest daily doses. When used and caregivers must be counseled on watching concurrently, mirabegron increases warfarin concentra for worsening cognition. Urinary incontinence is tions as much as 9%, and warfarin dose adjustments may a leading cause of institutionalization, and use of be needed. These two factors must be weighed Patients with signifcant cardiovascular issues may not in each individual patient. Postmenopausal hor mones and incontinence: the Heart and Estrogen/Progestin The American Geriatrics Society 2012 Beers Criteria Update Replacement Study. American Geriatrics Society updated Beers PubMed Link Criteria for potentially inappropriate medication use in older adults. Agents for treatment of overactive bladder: PubMed Link a therapeutic class review. Efcacy and safety of sacral PubMed Link nerve stimulation for urinary urge incontinence: a systematic review. Ann Intern Med of urinary incontinence afer stroke: results from a prospec 2008;149:161-9. Consequences of stroke in impaired nursing home residents with urge urinary inconti community-dwelling elderly: the health and retirement study, nence. Efcacy and assessment and nonsurgical management of urinary inconti safety of transdermal oxybutynin in patients with urge and nence. Duloxetine ver nary incontinence in Medicare-managed benefciaries: results sus placebo for the treatment of North American women with from the 2004 Medicare Health Outcomes Survey. Duloxetine vs placebo in the treatment of stress urinary incontinence: a four conti nent randomized clinical trial. Continence pes sary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Benefts and harms of pharmacologic treatment for urinary incon tinence in women: a systematic review. Dual use of bladder anticho linergics and cholinesterase inhibitors: long term functional and cognitive outcomes. Decrease in uri nary incontinence management costs in women enrolled in a clinical trial of weight loss to treat urinary incontinence. The efect of behavioral therapy on urinary incontinence: a randomized controlled trial. Duloxetine versus placebo in the treatment of European and Canadian women with stress urinary incontinence. A 51-year-old man with type 2 diabetes your family medicine clinic, and the following drugs were mellitus who has urine dribbling and increased initiated: amlodipine 5 mg, calcium carbonate 500 mg/ frequency. A 45-year-old woman with burning on urination was hydrochlorothiazide 25 mg daily, which she has taken and increased frequency. Her medical history is signifcant for osteoporosis, diastolic heart failure, hypertension, type 2 Questions 5 and 6 pertain to the following case. Her medical history includes heart failure, deep venous thrombosis (three episodes), hyper 1. Which one of the following is the best intervention for tension, hyperlipidemia, and generalized anxiety disorder. Her siting blood pressure today is 132/80 mm Hg, and her heart rate is 76 beats/minute. Which one of the following option groups would be larly bothersome when she has been out searching for best to counsel T. There have been no ine 30 mg for depression, but her depression is not changes in her medications or medical history. An 83-year-old man with Alzheimer disease is being increased frequency and urgency with urination for the cared for at home. She denies pain with urination and does has noticed that it is increasingly difcult for him to not have a fever today. He has hypertension and constipation with two episodes of stopped telling her when he needs to use the rest bowel obstruction. Her home drugs include senno room, and she is unable to direct him to the restroom sides 8. Her urinalysis is positive begun to worsen during the past 6 months, and she is for bacteriuria.