Benicar

Bruce Allen Leff, M.D.

Director, The Center for Transformative Geriatric Research
Professor of Medicine

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0006176/bruce-leff

Note the presence of a marked thickened nuchal translucency (asterisks) in A and fetal hydrops and cystic hygroma in B arteria vertebral generic benicar 20mg fast delivery. Maternal age is often not increased and the nasal bone is typically ossified (arrows) pulmonary hypertension 70 mmhg purchase 10 mg benicar amex. Fetus A and B has cystic hygromas (asterisks) blood pressure readings low buy generic benicar 40 mg online, whereas fetus C has lateral neck cysts (long arrows) 01 heart attackm4a order benicar from india. B: An axial plane of the chest in another fetus with monosomy X at 11 weeks of gestation blood pressure chart on age order benicar 10 mg on-line. The typical pattern of diandric triploidy includes the presence of a molar placenta (Fig arrhythmia natural treatment buy generic benicar. This discrepancy in dimensions between the head and abdomen is an almost pathognomonic sign of digynic triploidy. The presence of left ventricular outflow tract anomaly including aortic coarctation or hypoplastic left heart syndrome is a typical finding in fetuses with monosomy X. Note in both fetuses the marked difference in size between the abdominal (yellow arrows) and head (white arrows) dimensions. In addition, the crown-rump length is significantly short, reflecting the presence of early growth restriction. Note the marked difference in dimensions between the abdomen (yellow arrows) and the head (white arrows) in both fetuses. A high detection rate for triploidy is also achieved with first trimester screening for T21. In a study involving 198, 427 women with singleton pregnancies who underwent first trimester screening between 11+2 and 14+0 weeks of gestation, the overall detection rate of triploidy was 25/30 (83. In published studies, the 16, 17 detection rate for T21 is at 99% for a false-positive rate of 0. This expansion in first trimester ultrasound led to the detection of single or multiple fetal malformations, which in some cases suggested the possible presence of a genetic syndrome. We presented in Chapter 5 four possible pathways that result in the detection of fetal anomaly in the first trimester. In the absence of a prior family history of a genetic syndrome with fetal anomalies, the de novo diagnosis of a genetic syndrome in the first trimester is quite challenging. When presented with a constellation of sonographic abnormalities in the second or third trimester of pregnancy, an expert sonologist is commonly able to suggest the presence of a specific syndrome. This is a more challenging task in the first trimester however as the full display of all of the sonographic features of a genetic syndrome is rare in early gestation. Nevertheless, there are four ways that syndromic conditions are diagnosed in the first trimester: Figure 6. Chorionic villous sampling revealed a partial monosomy 9q and partial trisomy 2p as unbalanced translocation. The presence of an abnormal karyotype following an invasive diagnostic procedure such as trisomies, triploidy, monosomy X and large unbalanced translocations, deletions, and duplications. Monogenic diseases detected by selective molecular genetic examination of a special condition or with the use of next generation sequencing. The traditional karyotypic analysis will detect the presence of large balanced or unbalanced translocations (Fig. Small deletions, termed microdeletions, such as 22q11 (DiGeorge syndrome), are typically too small to be identified by this method (Fig. Monogenic Diseases and Other Syndromic Conditions Many fetal anomalies identified in the first trimester can also be caused by a monogenic inherent disease. In these cases, knowledge of typical sonographic features is needed in order to test for the specific gene(s) involved. Recently, there has been an increased use of selective panels for genetic diseases and in the future the use of next generation exon or genome sequencing will be more widely used. Until then, expert sonographers and sonologists should become familiar with fetal anomalies in the first trimester that are commonly associated with monogenic inheritance patterns. B: the corresponding axial plane of the head and C is the 3D ultrasound in surface mode. Prolonged culture of cells from chorionic villous sampling revealed deletion 4p (red arrow). Keep in mind that noninvasive prenatal testing in such a condition would have missed the diagnosis. The ability to suggest the presence of a possible association of a fetal anomaly with a monogenic type of inheritance vary based upon the expertise of the examiner and the types of fetal anomalies. The diagnosis of monogenic syndromes is difficult when anomalies are subtle and expressivity of sonographic markers is incomplete in the first trimester. In this setting, follow-up ultrasound examinations in the early second trimester are required. Often, genetic diseases are diagnosed in early gestation due to routine screening or in diagnostic testing in the presence of maternal or paternal carrier status, and before any sonographic markers are present. Examples of such conditions include cystic fibrosis, tuberous sclerosis, fragile X, thalassemia, sickle cell, storage diseases, and others. Detailed discussion of ultrasound features and genetic testing of all genetic syndromes is beyond 23 the scope of this book. Interested readers are referred to reference books and Internet sites such as Online Mendelian Inheritance in Man ( Chorionic villous sampling revealed a deletion of the small arm of chromosome 18 (red arrow). Nuchal fluid accumulation in trisomy-21 detected by vaginosonography in first trimester. Accuracy of first trimester combined test in screening for trisomies 21, 18 and 13. How effective is ultrasound-based screening for trisomy 18 without the addition of biochemistry at the time of late first trimester First-trimester screening for trisomies 18 and 13, triploidy and Turner syndrome by detailed early anomaly scan. What are the most common first-trimester ultrasound findings in cases of Turner syndrome Rare chromosome abnormalities, prevalence and prenatal diagnosis rates from population-based congenital anomaly registers in Europe. Pregnancies with twins and higher order multiples are at an increased risk for many maternal and fetal/child complications to include miscarriage, gestational diabetes, hypertensive disorders, preterm birth, fetal genetic and congenital malformation, fetal growth restriction, perinatal death, and 2, 3 cerebral palsy. Ultrasound is an integral part of the clinical care of multiple pregnancies, from the initial diagnosis to guiding the delivery of the neonates. In this chapter, we review the utility of ultrasound in the diagnosis and management of multiple pregnancies in the first trimester with a focus on twin pregnancies. Detailed evaluation of fetal congenital abnormalities is covered in subsequent chapters of this book. Criteria for first trimester assignment of gestational age on ultrasound are also similar in twins and singletons and are discussed in detail in Chapter 4 of this book. In twin pregnancies conceived by in vitro fertilization, the oocyte retrieval date or the embryonic age should date the 5 pregnancy. In early gestation, the growth rate of twins is no different than that of singletons. Dizygotic Twins Dizygotic twins, also called fraternal, occur when two eggs are fertilized with two separate sperms resulting in two fetuses that are distinct genetically but share the same uterus. Dizygotic twins are always dichorionic/diamniotic, as each fetus has its own set of placenta and membranes. Several factors affect the rate of dizygotic twinning including maternal age, race, increasing parity, geographic 7 area and presence of assisted reproduction. The rate of dizygotic twinning varies significantly around the world with high rates reported in parts of Nigeria and low rates reported in Southeast 7, 8 Asia and Latin America. Monozygotic Twins Monozygotic twins (also referred to as identical) occur when one egg is fertilized by one sperm followed by division of the embryo into two. Unlike dizygotic twins, the rate of monozygotic twins is fairly constant throughout the 9 world at 1/250 pregnancies excluding pregnancies of assisted reproduction. Monozygotic twins are associated with higher pregnancy complications and perinatal morbidity and mortality than dizygotic twins. Monozygotic twins can have various types of placentation based upon the timing of the division of the fertilized egg. Although conceptually monozygotic twins are identical, post 10, 11 fertilization genetic events result in genetic heterogeneity between the twin pairs. Furthermore, discordance in fetal malformations, which poses significant challenges in clinical management, is not uncommon in monozygotic twins. Zygosity and Chorionicity in Twins Zygosity refers to whether the twins are genetically identical or not, whereas chorionicity refers to the type of placentation in twins. Parents commonly ask at the time of the ultrasound examination whether their unborn twins are identical or not. It is important to note that the sonographic diagnosis of identical twins can only be made when the criteria for a monochorionic pregnancy (discussed later in this chapter) are met. When a dichorionic spontaneous twin pregnancy is diagnosed by ultrasound, the chance of identical twins in this setting is about 10%. From the point of view of pregnancy care chorionicity is therefore more important than zygosity. The diagnosis of dichorionic/diamniotic twin pregnancy can be made accurately when two separate and distinct chorionic sacs are seen in the endometrial cavity as early as the fifth week of gestation (Fig. Indeed, until about 8 weeks of gestation, the presence of two distinct gestational sacs on ultrasound with embryos/cardiac activities confirms a dichorionic/diamniotic twin gestation (Fig. Later on in early gestation, when two adjoining gestational sacs or fetuses are seen within the endometrial cavity, the characteristic of the dividing membrane(s), when present, is the most accurate way for determining chorionicity. Indeed, chorionicity should be ideally determined between 11+0 6 and 13+6 weeks of gestation if feasible. If the placenta appears to fill the junction of the dividing membrane(s) at its insertion into the placenta, resulting in a thick wedge-shaped configuration (lambda or twin-peak sign), this is diagnostic of dichorionic/diamniotic placentation (Figs. The thick separation of the chorionic sacs (arrows) suggests a dichorionic twin gestation. Note the thick dividing membrane with a twin-peak sign (asterisk) at the placental insertion of the membranes. In monochorionic pregnancies, the dividing membrane attach to the uterine wall in a thin T-shaped configuration without any placental tissue at its insertion site (Figs. The shape of the placental attachment of the dividing membranes (T-shaped) has a very high sensitivity and specificity for the diagnosis of monochorionicity between 11 and 14 weeks of gestation. Commonly, the presence of communicating fetal vessels on the surface of the twin placenta can be documented by ultrasound in color Doppler and this finding confirms the presence of monochorionic pregnancy (Fig. The demonstration of such vessels however has no clinical relevance to twin pregnancy management. Although in general the number of yolk sacs correlates with the number of amnions (Fig. For pregnancies beyond 8 weeks of gestation, the number of placental masses can be assessed as the presence of two distinct placental masses signifies a dichorionic gestation. The reliability of the number of placental masses is questionable, however, as 12 in about 3% of monochorionic twin pregnancies two placental masses can be seen on ultrasound. The thickness of the twin separating membrane can also be used for determining chorionicity, and similar to findings in the second trimester, this technique is not reliable to be solely used for chorionicity diagnosis. Occasionally the use of three-dimensional ultrasound can help in assessing membrane thickness in the first trimester of pregnancy (Fig. Discordance in fetal gender at 13 weeks of gestation and beyond implies the presence of dichorionic gestation. The separating membrane (asterisk) is thick with a twin-peak or lambda sign (l) at the placental insertion of the membranes. The dividing membrane (asterisk) is thin with a T-shape configuration at placental insertion (T). A thin separating membrane is visible with a T-shape configuration at placental insertion separating twin A from twin B. The use of color Doppler shows in this case an artery with a course from twin A to B (red arrow). Such connections are present in almost all monochorionic placentas and can occasionally be demonstrated on ultrasound by color Doppler as shown here. The presence of two yolk sacs at this gestation suggests monochorionic-diamniotic pregnancy but does not confirm it. The presence of a dividing membrane on follow-up ultrasound examinations with high-resolution transducers, confirmed this diagnosis. When no dividing membrane is noted on ultrasound, especially with high-frequency transvaginal or transabdominal transducer, the diagnosis of monoamniotic twins can be performed (Fig. Color and pulsed Doppler confirms the diagnosis of monoamniotic twins by demonstrating the presence of cord entanglement (Fig.

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However hypertension 1 benicar 20mg generic, we acknowledge that the position adopted by the law is compatible only with some views on the moral status of the embryo and fetus blood pressure bottom number 100 buy generic benicar 10mg on line. We also acknowledge that some consider the existence of the fetal anomaly ground to be discriminatory heart attack and water cheap benicar online visa, and this is the subject of current Parliamentary debate blood pressure chart dot purchase benicar in india. There were 3 low pressure pulse jet bag filter order benicar 20 mg without prescription, 213 abortions (2 per cent) carried out under the fetal anomaly ground arrhythmia ventricular tachycardia discount benicar 10 mg, of which 1, 179 (37 per cent) were for chromosomal anomalies. A total of 883 residents of Northern Ireland travelled to England or Wales to have a termination, 14 (1. The reasons for this are thought to include forms not being submitted to the Department of Health and the selection of another reason for abortion if it took place before 24 weeks. The guidance states that doctors will be better able to demonstrate that their opinions were formed in good faith if they have sought advice from appropriate specialists, such as those with knowledge of the management of the particular condition. It concludes that an assessment of the seriousness of a fetal anomaly should be considered on a case-by-case appraisal, taking into account all available clinical information. We recognise that what constitutes a significant medical condition or impairment is a judgment that depends on several factors, including the likely level of impairment, the available treatment options, and the views of and potential impact on the family and the individual themselves. However, it cannot always be known in advance whether a condition or impairment will have a significant impact or not, and this can only be established on a case-by-case basis taking into account those factors already described. The Equality Act 2010, which brought together a number of pieces of legislation relating to discrimination, protects disabled people against discrimination and created the Public Sector Equality Duty in England, Scotland and Wales. This includes the duty to make reasonable adjustments in order to ensure that, as far as is reasonable, a disabled worker has the same access to everything that is involved in doing and keeping a job as a non-disabled person. In Northern Ireland, the Disability Discrimination Act 1995 makes it unlawful to discriminate against disabled persons. In healthcare, choice and the power that individuals have to make free, informed decisions about the examinations, treatments and care they receive are widely considered to be important goods. This power is often referred to as patient autonomy, or reproductive autonomy in the context of prenatal testing. One prominent model of patient autonomy in bioethics construes patient choices as autonomous broadly when patients have sufficient relevant information, and their decisions are free from external 122 Disability Discrimination Act 1995, available at. This requires that patients have mental capacity and that they are able to understand, retain and weigh up information about healthcare options before choosing to undergo them. This notion is now widely seen as a basic tenet of healthcare ethics, and respect for patient autonomy is critical to the provision of quality healthcare. Lanarkshire Health Board ruling has been widely interpreted as marking out, in law, requirements for healthcare professionals to adopt an approach that is more in line with autonomy-centred models of healthcare when seeking consent from patients for treatments and tests (see Paragraph 1. For people to be able to exercise reproductive autonomy they must be in a position to make informed decisions and so must have access to accurate, balanced and non-directive information relevant to choices they make during their pregnancy about the prenatal options they are given. Women must be in a position to make decisions voluntarily about undergoing examinations, tests and treatments. Individuals have the freedom to make choices about how best to make use of their own resources to access goods and services available in the private sector, for health or other reasons. Appraising the likely results of different courses of action can sometimes be practically difficult and, where the likely impact of different possible outcomes is high, this may pose psychological strains on those presented with different options. Making prenatal tests available to women and couples does not mean that they have to accept them, but it does oblige women and couples to make decisions about whether to accept or decline the offer. In the case of reproductive choice, women might find it difficult to make decisions either about whether to undergo prenatal testing or about how to proceed if a fetal anomaly is detected. All such developments pose potential risks of physical, psychological and broader societal harms that are important to take into account when assessing the possible impacts of any new healthcare technology. Regulations prohibiting the sale of pharmaceutical drugs whose effects on human health are unknown, or food that does not meet health and safety standards are uncontroversial examples of the state constraining choices in order to minimise harm. Further, there are questions about instances of wrongdoing that may not involve direct harm; see for example: Stewart H (2010) the limits of the harm principle Criminal Law and Philosophy 4: 17-35. Nevertheless, the notion of harm reduction or avoidance has been influential in politics and policy and demonstrating evidence of harm, or risk of harm, is considered to be important in many areas of evidence based policy making. The state also has a duty to consider broader, societal harms, which we discuss in Paragraphs 1. This means that, where costs are neutral, governments should provide, within publicly funded healthcare services, treatments and tests that are safer, more efficacious and are associated with less discomfort or other negative side effects than alternative treatments and tests. Doctors, nurses and other healthcare professionals are required to provide tests and treatments that are safe. In part, these concerns relate to the harms to which inequality could give rise for particular groups, as existing problems may be exacerbated. In the context of a liberal state, some view inequalities as wrong in principle, in addition to having concerns about the harms to which those inequalities give rise. Many accept that the state has a role to play in addressing and minimising inequality and injustice, and has duties to promote equality and endeavour to ensure that all people are treated fairly and are not excluded from society. Even in societies where all people have the same legal rights, inequalities and injustices often persist. This can be because laws are routinely broken when, for example, people are discriminated against, or because law alone is not sufficient to alter entrenched societal or cultural conventions, nor to address the legacy of previous injustices. Societal inequalities persist at the levels of income, wealth, education, health, gender, age and elsewhere, even when people have equal legal rights. Equality in society might also be undermined when others exercise free choices, putting these values in tension with each other. See for example: Otsuka M (2003) Libertarianism without inequality (Oxford: Clarendon Press). Such policies might aim at minimising health inequalities through public health programmes, or by counteracting explicit and implicit biases that exist amongst educational institutions or employers. They might also involve addressing negative public attitudes towards certain groups and proactively promoting diversity and inclusion. All state spending carries opportunity costs and it is appropriate for governments to consider any given health intervention in the context of wider national policy and public spending. Disability is generated by the societal environment in which people with impairments live, which includes the prejudice, oppression or discrimination experienced by people with physical impairments. It looks at ways of removing barriers that restrict life choices for disabled people. The international classification of functioning, disability and health, available at. There is also debate about whether the availability of new screening technologies may exert pressure on women to make use of them during pregnancy, and the wider impact of other forms of reproductive technology on gender issues includes discussion of both negative and positive potential consequences for women. Healthcare professionals and those working in health management have parallel responsibilities to those held by the state to its citizens to treat each patient fairly, and to ensure that similarly situated patients are treated similarly. Research suggests that this will increase prenatal diagnoses, giving more women the opportunity to prepare for a disabled child or to have a termination, and will lower the number of invasive diagnostic tests, reducing procedure related miscarriages. If this leads to a significant reduction in the number of people born and living with these syndromes, it is possible that the quality of health and social care they receive and the importance attributed to research into these syndromes will be affected. Recognising that there may be wider consequences of prenatal screening, beyond those being aimed for, is important for the appraisal of the appropriateness of screening programmes. From some point in 2018, pregnant women who are found to have at least a 1 in 150 (0. This combination of accuracy and safety has the potential to reduce anxiety during pregnancy, such as among women who would not have a diagnostic invasive test. Failed or inconclusive tests may prolong the screening pathway for some women and may result in greater anxiety. As a result of accepting the offer of screening, those women who choose to do so can potentially access other healthcare services, such as specialist antenatal care or termination services. Only approximately three per cent of pregnant women who opt for screening will fall into this category. Introducing the Public Health Wales strategic plan for 2015-18, available at. A whole system strategic framework for public health 2013-2023, available at. There also must be evidence of benefit to those to whom it is offered and that providing the test would be a fair and proportionate use of public resources. This raises questions about whether such an increase in the use of state resources would be proportionate to the resulting promotion of choice and reduction in harm. The combined test takes place at between 10 and 14 weeks of pregnancy and the aim is for results to be returned within three working days. This delay of a week or longer will be significant to some women, particularly those considering a termination. Some research suggests that later terminations are associated with higher levels of stress for women than first trimester terminations, at least in the short term. It will be important that women are able to go straight to diagnostic testing after a high chance combined test result if they wish. However, concerns were raised by respondents to our survey and consultation about the quality of information and support currently provided to or accessed by women and couples undergoing prenatal screening. This will include the offer of a termination of pregnancy or continuing support through pregnancy. Screening providers must monitor and report on how they have delivered these specifications against set performance indicators. Women and their partners should be provided with information including: the implications of receiving a high or low chance result; information on the false positive rates of the screening test; the techniques involved and risks that may be associated with any diagnostic tests and also information about the conditions themselves. If a pregnant woman receives a high chance screening result, the guidance states that she should have rapid access to appropriate counselling by trained staff. The guidance recognises that women and their partners will need as much information as possible on the implications of the diagnosis.

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This requires effortful control of emotions and initially requires assistance from caregivers (Rothbart pulse pressure greater than 70 buy benicar 20mg overnight delivery, Posner blood pressure medications that start with l order benicar with mastercard, & Kieras arrhythmia epidemiology cheap benicar 10 mg, 2006) arteria in english buy 40mg benicar with visa. Young infants have very limited capacity to adjust their emotional states and depend on their caregivers to help soothe themselves blood pressure chart symptoms purchase benicar 20 mg fast delivery. By 4 to 6 months hypertension lowering foods discount benicar online, babies can begin to shift their attention away from upsetting stimuli (Rothbart et al, 2006). Older infants and toddlers can more effectively communicate their need for help and can crawl or walk toward or away from various situations (Cole, Armstrong, & Pemberton, 2010). Lewis and Brooks found that somewhere between 15 and 24 months most infants developed a sense of self-awareness. Once a child has achieved self-awareness, the child is moving toward understanding social emotions such as guilt, shame or Source embarrassment, as well as, sympathy or empathy. The formation of attachments in infancy has been the subject of considerable research as attachments have been viewed as foundations for future relationships. Additionally, attachments form the basis for confidence and curiosity as toddlers, and as important influences on self concept. Freud believed the infant will become attached to a person or object that provides this pleasure. Consequently, infants were believed to become attached to their mother because she was the one who satisfied their oral needs and provided pleasure. The infants were separated from their biological mothers, and two surrogate mothers were introduced to their cages. One, the wire mother, consisted of a round wooden head, a mesh of cold metal wires, and a bottle of milk from which the baby monkey could drink. The infant monkeys went to the wire mother for food, but they overwhelmingly preferred and spent significantly more time with the warm terry-cloth mother. The warm terry-cloth mother provided no food but did provide comfort (Harlow, 1958). From this base, they can gain the confidence they need to venture out and explore their worlds. He defined attachment as the affectional bond or tie that an infant forms with the mother (Bowlby, 1969). An infant must form this bond with a primary caregiver in order to have normal social and emotional development. In addition, Bowlby proposed that this attachment bond is very powerful and continues throughout life. He used the concept of secure base to define a healthy attachment between parent and child (Bowlby, 1982). A secure base is a parental presence that gives the child a sense of safety as the child explores the surroundings. Additionally, Bowlby observed that infants would go to extraordinary lengths to prevent separation from their parents, such as crying, refusing to be comforted, and waiting for the caregiver to return. He observed that these same expressions were common to many other mammals, and consequently argued that these negative responses to separation serve an evolutionary function. Because mammalian infants cannot feed or protect themselves, they are dependent upon the care and protection of adults for survival. Thus, those infants who were able to Source maintain proximity to an attachment figure were more likely to survive and reproduce. Mistrust As previously discussed in chapter 1, Erikson formulated an eight stage theory of psychosocial development. Erikson maintained that the first year to year and a half of life involves the establishment of a sense of trust (Erikson, 1982). Infants are dependent and must rely on others to meet their basic physical needs as well as their needs for stimulation and comfort. A caregiver who consistently meets these needs instills a sense of trust or the belief that the world is a trustworthy place. Consider the implications for establishing trust if a caregiver is unavailable or is upset and ill-prepared to care for a child. Or if a child is born prematurely, is unwanted, or has physical problems that make him or her less desirable to a parent. Under these circumstances, we cannot assume that the parent is going to provide the child with a feeling of trust. Mary Ainsworth and the Strange Situation Technique Developmental psychologist Mary Ainsworth, a student of John Bowlby, continued studying the development of attachment in infants. Then a strange adult enters the room and talks for a minute to the parent, after which the parent leaves the room. The stranger stays with the infant for a few minutes, and then the parent again enters, and the stranger leaves the room. The child will typically play with the toys and bring one to the caregiver to show and describe from time to time. The child may be upset when the caregiver departs but is also happy to see the caregiver return. When the caregiver leaves, the child is extremely distressed and is ambivalent when the caregiver returns. The child may rush to the caregiver, but then fails to be comforted when picked up. The child will not explore very much, regardless of who is there, and the stranger will not be treated much differently from the mother. The child may cry during the separation, but avoid the mother when she returns, or the child may approach the mother but then freeze or fall to the floor. It is estimated that about 65 percent of children in the United States are securely attached. Another 5 to 10 percent may be characterized as disorganized (Ainsworth, Blehar, Waters, & Wall, 1978). As a result, the rate of insecure-avoidant attachments is higher in Germany and insecure-resistant attachments are higher in Japan. These differences reflect cultural variation rather than true insecurity, however (van Ijzendoorn and Sagi, Source 1999). Overall, secure attachment is the most common type of attachment seen in every culture studied thus far (Thompson, 2006). Caregiver Interactions and the Formation of Attachment: Most developmental psychologists argue that a child becomes securely attached when there is consistent contact from one or more caregivers who meet the physical and emotional needs of the child in a responsive and appropriate manner. However, even in cultures where mothers do not talk, cuddle, and play with their infants, secure attachments can develop (LeVine et. Consequently, the infant is never sure that the world is a trustworthy place or that he or she can rely on others without some anxiety. A caregiver who is unavailable, perhaps because of marital tension, substance abuse, or preoccupation with work, may send a message to the infant he or she cannot rely on having needs met. An infant who receives only sporadic attention when experiencing discomfort may not learn how to calm down. The insecure avoidant style is marked by insecurity, but this style is also characterized by a tendency to avoid contact with the caregiver and with others. This child may have learned that needs typically go unmet and learns that the caregiver does not provide care and cannot be relied upon for comfort, even sporadically. The insecure disorganized/disoriented style represents the most insecure style of attachment and occurs when the child is given mixed, confused, and inappropriate responses from the caregiver. For example, a mother who suffers from schizophrenia may laugh when a child is hurting or cry when a child exhibits joy. The child does not learn how to interpret emotions or to connect with the unpredictable caregiver. Infants who, perhaps because of being in orphanages with inadequate care, have not had the opportunity to attach in infancy may still form initial secure attachments several years later. Source Social Deprivation: Severe deprivation of parental attachment can lead to serious problems. According to studies of children who have not been given warm, nurturing care, they may show developmental delays, failure to thrive, and attachment disorders (Bowlby, 1982). Non-organic failure to thrive is the diagnosis for an infant who does not grow, develop, or gain weight on schedule and there is no known medical explanation for this failure. Poverty, neglect, inconsistent parenting, and severe family dysfunction are correlated with non-organic failure to thrive. In addition, postpartum depression can cause even a well-intentioned mother to neglect her infant. Reactive Attachment Disorder: Children who experience social neglect or deprivation, repeatedly change primary caregivers that limit opportunities to form stable attachments or are reared in unusual settings (such as institutions) that limit opportunities to form stable attachments can certainly have difficulty forming attachments. According to the Diagnostic and Statistical th Manual of Mental Disorders, 5 edition (American Psychiatric Association, 2013), those children experiencing neglectful situations and also displaying markedly disturbed and developmentally inappropriate attachment behavior, such as being inhibited and withdrawn, minimal social and emotional responsiveness to others, and limited positive affect, may be diagnosed with reactive attachment disorder. This disorder often occurs with developmental delays, especially in cognitive and language areas. Fortunately, the majority of severely neglected children do not develop reactive attachment disorder, which occurs in less than 10% of such children. The quality of the caregiving environment after serious neglect affects the development of this disorder. Resiliency: Being able to overcome challenges and successfully adapt is resiliency. Resiliency can be attributed to certain personality factors, such as an easy-going temperament. Some children are warm, friendly, and responsive, whereas others tend to be more irritable, less manageable, and difficult to console, and these differences play a role in attachment (Gillath, Shaver, Baek, & Chun, 2008; Seifer, Schiller, Sameroff, Resnick, & Riordan, 1996). It seems safe to say that attachment, like 105 most other developmental processes, is affected by an interplay of genetic and socialization influences. A positive and strong support group can help a parent and child build a strong foundation by offering assistance and positive attitudes toward the newborn and parent. Shame and Doubt As the child begins to walk and talk, an interest in independence or autonomy replaces a concern for trust. Erikson (1982) believed that toddlers should be allowed to explore their environment as freely as safety allows and in so doing will develop a sense of independence that will later grow to self-esteem, initiative, and overall confidence. Parenting advice based on these ideas would be to keep toddlers safe but let them learn by doing. Children are evaluated in five key developmental domains, including cognition, language, social-emotional, motor, and adaptive behavior.

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Finasteride would also be expected to impair sex corticoid antagonist heart attack normal blood pressure purchase 40mg benicar visa, is also a weak antiandrogen blood pressure chart dr oz order benicar canada. Finasteride would also be expected to impair sex ual diferentiation in a male fetus arrhythmia overview buy 20mg benicar with mastercard, and it should not be almost as efective as cyproterone acetate when used at ual diferentiation in a male fetus blood pressure after exercise buy benicar 20mg cheap, and it should not be used in women who may become pregnant heart attack 90 year old proven benicar 10mg. Efornithine cream (Vaniqa) has been approved as be monitored intermittently for hyperkalemia or hypo Efornithine cream (Vaniqa) has been approved as a novel treatment for unwanted facial hair in women blood pressure medication you can take while pregnant buy benicar 20 mg on-line, tension, though these side effects are uncommon. It can Pregnancy should be avoided because of the risk of but long-term efcacy remains to be established. It can cause skin irritation under exaggerated conditions of feminization of a male fetus. Spironolactone can also cause skin irritation under exaggerated conditions of use. Ultimately, the choice of any specifc agent(s) must be tailored to the unique needs of the patient being tion with an oral contraceptive, which suppresses ovar be tailored to the unique needs of the patient being treated. As noted previously, pharmacologic treatments ian androgen production and helps prevent pregnancy. As noted previously, pharmacologic treatments for hirsutism should be used in conjunction with non Flutamide is a potent nonsteroidal antiandrogen that for hirsutism should be used in conjunction with non pharmacologic approaches. It is also helpful to review is efective in treating hirsutism, but concerns about pharmacologic approaches. It is also helpful to review the pattern of female hair distribution in the normal the induction of hepatocellular dysfunction have lim the pattern of female hair distribution in the normal population to dispel unrealistic expectations. Finasteride is a competitive inhibitor of population to dispel unrealistic expectations. Seiden ovarian CanCer and likewise have different phenotypes and clinical pre sentations largely dependent on the type and quantity of incidence and PatHology hormone production. Tumors arising in the germ cell are most similar in biology and behavior to testicular Ovarian cancer is the most lethal malignancy of gyne tumors in males (Chap. In 2010, 21, 880 cases of ovarian masses from metastatic mucin-secreting gastrointestinal cancer with 13, 850 deaths are expected in the United cancers are termed Krukenberg tumors. The ovary is a complex and dynamic organ and, between the ages of approximately 11 and 50 years, is responsible for follicle maturation associated with egg maturation, ovulation, and cyclical sex steroid hormone ovarian cancer of ePitHelial origin production. These complex and linked biologic func Epidemiology tions are coordinated through a variety of cells within the ovary, each of which possesses neoplastic potential. Epithelial both on the surface of the ovary and in subsurface loca tumors of the ovary have a peak incidence in women tions known as cortical inclusion cysts, believed to be in their sixties, although age at presentation can range entrapped epithelium from the healing associated with across the extremes of adult life, with cases being reported prior follicle rupture during ovulation. Known risk fac thelium in good health appears as a simple epithelium, tors that increase the chance of subsequent ovarian can but with neoplastic transformation, it undergoes meta cer include epidemiologic, environmental, and genetic plastic changes into what is termed mullerian epithelium. Protective factors include the use of oral in some cases different clinical presentations. These tumors are the most common ovarian neoplasm; they protective factors are thought to work through sup may be benign (50%), malignant (33%), or of borderline pression of ovulation and perhaps reduction of ovarian malignancy (16%). Age infuences risk of malignancy; infammation and damage associated with the repair of tumors in younger women are more likely benign. The the ovarian cortex associated with ovulation, and perhaps most common of the ovarian epithelial malignancies suppression of gonadotropins. Other protective factors, are serous tumors (50%); tumors of mucinous (25%), such as fallopian tube ligation, are thought to protect endometrioid (15%), clear cell (5%), and transitional cell the ovarian epithelium (or perhaps the distal fallopian histology or Brenner tumor (1%) represent smaller propor tube fmbriae) from carcinogens that migrate from the tions of epithelial ovarian tumors. Signs include the rapid copy of a mutant allele have a very high incidence of increase in abdominal girth due to the accumulation breast and ovarian cancer. Most of these women have of ascites that typically alerts the patient and her physi a family history that is notable for multiple cases of cian that the concurrent gastrointestinal symptoms are breast and/or ovarian cancer, although inheritance likely associated with serious pathology. Radiologic through male members of the family can camoufage evaluation typically demonstrates a complex adnexal this genotype through several generations. Hematogenous and lymphatic spread are seen but ovarian malignancies in their forties and ffties, with are not the typical presentation. Early prophylactic oophorectomy also protects these women from subse Screening quent breast cancer with a reduction of breast cancer Ovarian cancer is the ffth most lethal malignancy in risk of approximately 50%. Ovarian cancer may appear in tumors often produce proteins that can be measured women younger than 50 years of age in this syndrome. Nevertheless, the incidence of ovarian cancer in the middle-aged Presentation female population is low, with only approximately 1 in Neoplasms of the ovary tend to be painless unless they 2000 women between the ages of 50 and 60 carrying undergo torsion. Thus, effec to compression of local organs or are due to symptoms tive screening techniques must be sensitive but, more from metastatic disease. Women with tumors local importantly, highly specifc to minimize the number of ized to the ovary do have an increased incidence of false positives. Even a screening test with 98% specifc symptoms including pelvic discomfort, bloating, ity and 50% sensitivity would have a positive predictive and perhaps changes in typical urinary or bowel pat value of only about 1%. Unfortunately, these symptoms are frequently riers, ongoing studies are evaluating the utility of vari dismissed by either the woman or her health care ous screening strategies. It is believed that high-grade tumors metas cancer is currently not recommended outside of a clini tasize early in the neoplastic process. Three randomized studies have demonstrated improved survival with intraperitoneal In women presenting with a localized ovarian mass, therapy, but this approach is still not widely accepted due the principal diagnostic and therapeutic maneuver to technical challenges associated with this delivery route is to determine if the tumor is benign or malignant and increased toxicity. In women who present with bulky and, in the event that the tumor is malignant, whether disease, an alternative approach is to treat with platinum the tumor arises in the ovary or is a site of metastatic plus a taxane for several cycles (neoadjuvant therapy). Metastatic disease to the ovary can be seen Subsequent surgical procedures are more efective at from primary tumors of the colon, appendix, stom leaving the patient without gross residual tumor, and sur ach (Krukenberg tumors), and breast. Unfortunately, only half of the complete responders have already disseminated to the peritoneal cavity and/ remain in remission. Recurrent splenectomy, and in certain cases more extensive upper disease is efectively managed, but not cured, with a abdominal surgery. Eventually all of ian cancer to minimal visible disease is associated with an these women develop chemotherapy-refractory disease improved prognosis as compared to women left with vis at which point refractory ascites, poor bowel motility, ible disease. Patients without gross residual disease after and obstruction or pseudoobstruction due to a tumor resection have a median survival of 39 months, compared infltrated aperistaltic bowel are common. Once gery to relieve intestinal obstruction, localized radiation tumors have been surgically debulked, women receive therapy to relieve pressure or pain from masses, or pal therapy with a platinum agent typically with a taxane. Agents with >15% Debate continues as to whether this therapy should response rates include gemcitabine, topotecan, liposo be delivered intravenously or, alternatively, some of mal doxorubicin, and bevacizumab. Patients with tumors of low malignant potential are managed the mainstay of treatment for sex cord tumors is surgi by surgery; chemotherapy and radiation therapy do not cal resection. For the small subset of women who present with metastatic disease or develop evidence of tumor recurrence after primary resection, survival is ovarian Sex cord and still typically long, often in excess of a decade. Because StroMal tuMorS these tumors are slow growing and relatively refractory Epidemiology, presentation, and to chemotherapy, women with metastatic disease are predisposing syndromes often debulked as disease is usually peritoneal based Approximately 7% of ovarian neoplasms are stromal or (as with epithelial ovarian cancer). Defnitive data that sex cord tumors, with approximately 1800 cases expected surgical debulking of metastatic or recurrent disease each year in the United States. Ovarian stromal tumors prolongs survival are lacking, but ample data docu or sex cord tumors are most common in women in their ment women who have survived years or in some cases ffties or sixties, but tumors can present in the extremes decades after resection of recurrent disease. These tumors large peritoneal-based metastases also have a procliv arise from the mesenchymal components of the ovary, ity for hemorrhage, sometimes with catastrophic com including steroid-producing cells as well as fbroblasts. Chemotherapy is occasionally efective, and Essentially all of these tumors are of low malignant women tend to receive regimens designed to treat potential and present as unilateral solid masses. These proteins are detectable in serum toms due to hormonal production by these tumors. These totipotent cells contain associated secondary malignancies, such as endometrial the programming for differentiation to essentially all tis or breast cancer, may present as synchronous malignan sue types, and hence the germ cell tumors include a his cies. Alternatively, endometrial cancer may serve as the tologic menagerie of bizarre tumors, including benign presenting malignancy with evaluation subsequently iden teratomas and a variety of malignant tumors, such as tifying a unilateral solid ovarian neoplasm that proves to immature teratomas, dysgerminomas, yolk sac malig be an occult granulosa cell tumor. Malignant germ cell tumors include dys variety of inherited disorders that predispose them to germinomas, yolk sac tumors, and immature teratomas, as well as embryonal and choriocarcinomas. Fallopian tube malignancies typi Germ cell tumors can present at all ages, but the peak cally have the same histologic pattern as ovarian malig age of presentation tends to be in females in their late nancies, with the most common epithelial malignancy teens or early twenties. Previous teaching was that become large ovarian masses that eventually present as these malignancies were rare, but more careful histo palpable low abdominal or pelvic masses. Nearly 500, 000 pelvic and para-aortic nodes are common and may cases of cervical cancer are expected worldwide with afect treatment choices, these nodes should be care approximately 240, 000 deaths annually. Cancer inci fully inspected and, if enlarged, should be resected if dence is particularly high in women residing in Central possible. In the United States, 12, 200 women were with advanced-stage disease, cure is expected. Although types makes it imperative to determine economical, the tumor is highly radiation sensitive, radiation produces socially acceptable, and logistically feasible strategies to 220 deliver and distribute this vaccine to girls and perhaps in that it identifes many women with transient infec boys before their engagement in sexual activity. Invasive carcinomas often women clear the infection without specifc interven have symptoms or signs including postcoital spotting tion. Presentations that include pelvic or sacral pain E6 and E7 molecules that are particularly effective at suggest lateral extension of the tumor into pelvic nerve inhibiting the normal cell cycle checkpoint functions of plexus by either the primary tumor or a pelvic node and these regulatory proteins, leading to immortalization but are signs of advanced-stage disease. Over the gests either extensive nodal disease or direct extension course of as short as months but more typically years, of the primary tumor to the pelvic sidewall. TreaTmenT Cervical Cancer Risk factors include a high number of sexual part ners, age of frst intercourse, and history of venereal Scans are not part of the formal clinical staging of cer disease. Relative overexposure tain fertility, radical trachelectomy removes the cervix to this class of hormones is a risk factor for the subse with subsequent anastomosis of the upper vagina quent development of endometrioid tumors. Larger cervical tumors con progestins drive glandular maturation and are protec fined to the cervix can be treated with either surgical tive. Hence, women with high endogenous or pharma resection or radiation therapy in combination with cologic exposure to estrogens, especially if unopposed cisplatin-based chemotherapy with a high chance of by progesterone, are at high risk for endometrial cancer. Larger tumors that extend down the vagina or Obese women, women treated with unopposed estro into the paracervical soft tissues or the pelvic side gens, or women with estrogen-producing tumors (such walls are treated with combination chemotherapy as granulosa cell tumors of the ovary) are at higher risk and radiation therapy. In addition, treatment with metastatic disease is unsatisfactory due to the rela tamoxifen, which has antiestrogenic effects in breast tive resistance of these tumors to chemotherapy and tissue but estrogenic effects in uterine epithelium, is currently available biological agents. The molecular events that uTerine CanCer underlie less common endometrial cancers such as clear cell and papillary serous tumors of the uterine corpus ePideMiology are unknown. In 2010, it was diagnosed in 43, 470 these mutations typically have a family history of cancer women, and 7950 women died from the disease. Devel and are at markedly increased risk for colon cancer and opment of these tumors is a multistep process with modestly increased risk for ovarian cancer and a variety 222 of other tumors. Prognosis depends on stage, histologic are typically resistant to hormonal manipulation and grade, and depth of myometrial invasion. The role of chemo 10% of patients have tumors with areas of squamous cell therapy in the adjuvant setting is currently under inves differentiation. Chemotherapy for metastatic disease is deliv is called adenoacanthoma; when poorly differentiated, ered with palliative intent. PreSentationS GesTaTional the majority of women with tumors of the uterine cor TrophoblasTiC Tumors pus present with postmenopausal vaginal bleeding due to shedding of the malignant endometrial lining. Pre global conSiderationS menopausal women often will present with atypical Gestational trophoblastic diseases represent a bleeding between typical menstrual cycles. These signs spectrum of neoplasia from benign hydatidi typically bring a woman to the attention of a health care form mole to choriocarcinoma due to persistent professional, and hence the majority of women present trophoblastic disease associated most commonly with with early-stage disease in which the tumor is confned molar pregnancy but occasionally seen after normal ges to the uterine corpus. Epithelial tumors may spread to tic tumors are partial and complete molar pregnancies. Pulmonary metasta these represent approximately 1 in 1500 conceptions ses can appear later in the natural history of this disease in developed Western countries. Serous varies globally, with areas in Southeast Asia having a tumors tend to have patterns of spread much more rem much higher incidence of molar pregnancy. Regions iniscent of ovarian cancer, with many patients present with high molar pregnancy rates are often associated ing with omental disease and sometimes ascites. Nodal metastases are uncommon with sarcomas, which are more likely to present with either riSk factorS intraabdominal disease or pulmonary metastases. Trophoblastic tumors result from the outgrowth or per sistence of placental tissue. They arise most commonly in the uterus but can also arise in other sites such as the TreaTmenT Uterine Cancer fallopian tubes due to ectopic pregnancy. Risk factors include poorly defned dietary and environmental fac Most women with endometrial cancer have disease that tors as well as conceptions at the extremes of reproduc is localized to the uterus (75% are stage I, Table 14-1), tive age, with the incidence particularly high in females and defnitive treatment typically involves a hysterec conceiving younger than age 16 or older than age 50. In older women, the incidence of molar pregnancy the resection of lymph nodes does not improve out might be as high as one in three, likely due to increased come but does provide prognostic information. Tumor grade and depth of invasion are the moles, diploid tumors with all genetic material from two key prognostic variables in early-stage tumors, the paternal donor (known as parental disomy). Hydropic changes disease, prognosis can be estimated through a variety of are less dramatic, and fetal development can often occur scoring algorithms that identify those women at low, through late frst trimester or early second trimester at intermediate, and high risk for requiring multi-agent which point spontaneous abortion is common. The risk of persistent gestational trophoblas prior normal antecedent term pregnancy are considered tic disease after partial mole is approximately 5%.

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