Sulfasalazine

Mark Franklin, M.D.

• Department of Anesthesiology
• Northwestern University Medical School
• Chicago, IL

Therapeutic eclecticism: process of selecting concepts treatment for post shingles nerve pain purchase sulfasalazine 500mg on-line, methods pain treatment consultants of wny buy sulfasalazine with mastercard, and strategies from a variety of current theories that work 1 treatment for post shingles nerve pain purchase sulfasalazine online now. Lazarus early "technical eclecticism" has been modified into multimodal behavior therapy pain treatment center somerset ky buy sulfasalazine 500mg cheap, which is behavioral in basis but embraces cognitive and affective concepts also 2 pain treatment center northside hospital purchase sulfasalazine with visa. Openness and flexibility; but can encourage indiscriminate joint & pain treatment center order sulfasalazine toronto, haphazard, inconsistent use of therapeutic techniques and concepts B. Western psychology and mental health concepts characterized by assumption that they are universal, that human condition is governed by universal principles, and members of groups that dont fit those standards are deficient 1. Surgeon Generals Report on Mental Health: using European American standards to judge normality and abnormality is fraught with dangers, may result in denying appropriate treatment to minority groups, may oppress culturally different clients, it is important to recognize and respond to cultural concerns of other groups 2. Few studies exist on empirically supported treatments with minority populations B. Guidelines are suggested for working with particular groups, but they should not be adhered to rigidly. African Americans: bring up issue of racial differences between the client and the white therapist; to try to understand clients worldview; see clients suspiciousness/reluctance to self-disclose as a survival mechanism; assess clients positive assets; problem-solving approaches are useful for external problems. Asian Americans and Pacific Islanders: be aware of potential social stigma of seeing a therapist; psychological conflicts may be expressed via somatic complaints and/or other socially acceptable issues; reluctance to self-disclose/ express feelings may be due to cultural factors, not psychopathology; explain purpose, expectations, and process of therapy, and use action-oriented, problem-solving approach. Native Americans: patience is important; basic needs should be addressed first; clients communal environment is important; sensitivity to differences in communication styles, especially body language; consider consulting with indigenous healers. American Psychological Association endorses principle of properly trained psychologists prescribing medication 4. Primary prevention: reduce the number of new cases of disorders a) Head Start is one example b) Munoz and colleagues (1995) report communitywide effort to prevent depression c) Interventions to prevent juvenile delinquency 2. Secondary prevention: shorten duration of mental disorders, but problems exist a) traditional diagnostic methods are often unreliable, provide little insight into which treatment procedures to use; more specialized diagnostic techniques are needed b) once detected, it may be difficult to decide what therapy is most effective for the specific disorder and patient c) prompt treatment often unavailable 3. Describe and evaluate the use of antianxiety, antipsychotic, antidepressant, and antimanic medications. Discuss why traditional psychotherapy may not be effective with individuals from non-Western cultures and ethnic minority groups. Describe the goals and techniques of psychoanalysis and post-Freudian psychoanalytic therapy. Describe the therapies based on the humanistic/existential perspective, including person-centered therapy, existential analysis, and gestalt therapy. Describe the therapeutic techniques based on classical conditioning, including systematic desensitization, flooding and implosion, and aversive conditioning. Describe the therapeutic techniques based on operant conditioning, including token economies and punishment. Discuss the goal of health psychology and describe the techniques used to promote lifestyle changes, including biofeedback. Describe the common components and types of group therapy; evaluate the effectiveness of group therapy. Describe the functions of couples and family therapy, and the different emphases of the communications and systems approaches. Consider the issues raised with respect to culturally diverse populations and psychotherapy. Discuss the changes in mental health service delivery caused by managed health care. Draw on the board a threeor four-generational diagram of a hypothetical family in which one or two current family functions or traits (alcohol-abusing black sheep or workaholic, distant parent) can be traced from previous generations. The genogram also clarifies the sides of the family issue in most marriages and the tendency for traits or problems to skip generations because children use their parents as a negative reference. Many family theorists (for example, Jay Haley and Paul Watzlawick) suggest that two things occur when a symptom is described to a family: the family is challenged with an entirely original reappraisal of its experience, and it is influenced by the change agent. If the family accepts the therapists suggestion, the influence of this change agent is clear, and it can be used for future interventions. If the family resists the suggestion, the family shows itself its own power and moves toward health. You should accept concerns that acceptance of the paradoxical instruction (Go home and beat your children; its how you show your love) can be dangerous. However, an analogue study shows that although students find paradoxical interventions less acceptable than nonparadoxical ones, they do not negatively influence the perceptions of the therapists expertness or trustworthiness (Betts & Remer, 1993). The impact of paradoxical interventions on perceptions of the therapist and ratings of treatment acceptability. A series of articles in Psychological Bulletin illustrates the difficulties in performing therapyeffectiveness research. It also shows students how researchers from different viewpoints can interpret the same information differently. Bowers and Clum (1988) performed a meta-analysis on 69 studies comparing behavior therapy with placebo and nonspecific treatment conditions to assess the value of behavior therapy for a wide range of conditions. Several years later Brody, (1990) argued that the meta-analysis gave a misleading picture. Brody took the ten studies that involved neurotic conditions such as agoraphobia and anorexia and did a simple box-score to see if behavior therapy was more effective than placebo conditions. Brody concluded that there was no evidence for the superiority of behavior therapy. Therefore, the outcome studies and the meta-analysis on which they were based did not yield clinically significant information. The same data prove both that behavior therapy is superior and is not superior to placebo treatment conditions; the result depends on the method of analysis. Relative contribution of specific and nonspecific treatment effects: Meta-analysis of placebo-controlled behavior therapy research. The ethics of methodologically sound psychotherapy-effectiveness research is a good topic for discussion. Ask students to suggest an appropriate control group for a study of treated individuals. If they respond, people who do not receive treatment, point out the possibility that people who ask for help (and get it) may be different in some outcome-relevant way from people who do not ask for help. Further, how can we be sure that untreated people do not get some other form of help (for example, read a self-help book) that might be much like therapy These questions highlight the problem of random assignment, a key component of true experiments. A second kind of control group, the waiting-list control, includes random assignment but has its own problems. Ask students how they feel about the ethics of arbitrarily placing people in distress on a waiting list. The American Psychological Association site for ethical principles of psychologists. The common components of psychotherapy mentioned in the text are reasonable and accurate. Frank, in his classic book, Persuasion and Healing, argues that the social aspects of the therapeutic relationship overwhelm any technical or theoretical considerations. According to him, the three active ingredients in the change process are (1) a socially sanctioned healer whose powers and status are respected by the sufferer, (2) a sufferer who seeks relief from symptoms, and (3) a fairly structured set of contacts (with their own rituals) that convinces the sufferer to change his or her attitudes and behavior. Key to this last process is the sufferers need to have mysteries explained by the healer and to feel that there is hope for improvement by relying on the expert. Ask students whether the same analysis can be applied to faith-healing evangelists or voodoo doctors. Chapter 17: Therapeutic Interventions 287 Imagine out loud this therapy with your students: A charismatic person writes a book and appears on television talk shows arguing that depression and fatigue are the result of certain allergens and toxic chemicals seeping into peoples bloodstreams through their clothes. The offending chemicals, this person asserts, come from polyesters and other synthetic fabrics and from modern laundry detergents. The cure is for people to throw away all their garments except for 100 percent natural cottons and wools and to wash only with pure soap. Given the mystery of depression and fatigue, the desperation of some, the status afforded television appearances, and the effort involved in the treatment, it is fairly likely that such a therapy could catch on (and be successful) with some sufferers. The professionals most often involved have frequent contact with troubled individuals but are not specifically trained to interact with them. For example, school teachers, police officers, and emergency room nurses often come in contact with distressed individuals and need to know how to best interact with them and make referrals to professionals when necessary. Ask students to think of other professions that have this kind of frequent contact with distressed individuals. Some examples are funeral directors, clergymen, general practice physicians, bartenders, hairdressers, and divorce attorneys. It is a contracted arrangement in which the mental health professional listens to the consultees difficulties and provides advice. The consultee is seen as just as much a professional as the consultant: the consultant never tells the consultee how to do his/her job. The relationship involves only indirect coaching; the consultant has no specific supervisory role. Gerald Caplan (1970) laid out a scheme that indicates the range of mental health consultations that are possible. One week, a teacher might mention the problems she has had with a boy who is suspected of having attention deficit hyperactivity disorder. The consultant might provide tips on how to structure the environment to reduce the boys impact or how to set up a reward system so he stays on task longer. Another week, the focus might be on a student who is excluded from play activities because she is intensely shy. Consultees usually feel most comfortable asking for help when the focus is on cases, not on their own difficulties. However, Caplan notes that sometimes consultees reveal, indirectly and over time, that they have emotional blind spots that interfere with their ability to relate to clients. For instance, if one of the kindergarten teachers repeatedly described herself as losing her temper with children and storming out of the room, the focus of consultation might have to change to what Caplan calls consulteecentered consultation. Care must be taken not to imply that the consultee has a psychological problem because this form of consultation can come dangerously close to therapy. A third type, called administrative consultation, focuses on the administration of a program. For instance, if a teacher wanted to establish a parent-teacher coordination program so that homework was more frequently checked and turned in, the consultant could act as a sounding board for ideas on how to approach parents, teachers, and administrators to get support for the program. Like case-centered consultations, the consultant would provide information (in this case about organizational behavior and persuasion) that would augment the consultees professional knowledge. If your training has prepared you to do so, model the style of various therapy strategies by asking a student volunteer to either think up a fictitious problem or discuss an actual, but not very significant, personal concern (for instance, trouble getting to sleep at night). Ask the volunteer to leave the classroom while you inform the rest of the class that during the first four to five minutes of the interview you will play the role of a Rogerian therapist and then, without warning, you will change roles and play an operant-conditioning-oriented therapist. The object will be to see whether the student volunteer notices that any change occurred and whether one or the other pattern of therapist behavior was preferred. When the student volunteer returns, spend the first four to five minutes mirroring statements of the students feelings and thoughts (for example, Sounds like getting to sleep frustrates you). Then the questions should abruptly take a decidedly behavioral turn (for example, What exactly are the circumstances that precede sleepless nights After ten minutes of interviewing, ask the volunteer whether he or she noticed any shift in the therapists behavior. This exercise should keep student interest and illustrate the differences in therapeutic strategies as well as their impact on the client. This activity helps students see how the theoretical orientation of a psychologist guides the development of a treatment plan. The experience also gives you a chance to correct any misperceptions the students may have about the techniques used in the various treatment approaches. In order for the activity to be relevant to a range of therapeutic orientations, choose an adult, nonpsychotic condition such as an anxiety disorder, mood disorder, or form of substance abuse. Each group will be responsible for one therapeutic approach: drug treatment, psychoanalytic psychotherapy, behavior therapy (you can stipulate classical conditioning, operant conditioning, or modeling or allow them to use their own judgment), and cognitive behavioral (rational emotive or Becks cognitive) therapies. Have each group develop a treatment plan using the specific techniques of the therapeutic approach they were assigned. Also have the groups examine the potential barriers to successful treatment and their estimation that the client would be successfully treated. Ask each group to report to the whole class the results of their discussions and list their ideas on the board. At the end of the activity, encourage students to think about integrative treatments that might use the best of each approach. Underscore the fact that most therapists approach problems with this kind of eclecticism. One way to increase student involvement in the class and the material is to have them role-play different therapies. You will need at least four therapists, one each for psychoanalysis, behavior therapy, humanistic-existential therapy, and cognitive therapy. It is a good idea to supply the clients with guidelines on what their problems are.

Personnel with minor infections of the skin and minor viral infections of the upper respiratory tract may work so long as they are scrupulous in their practice of personal hygiene and Standard Precautions are followed laser pain treatment utah buy sulfasalazine 500mg mastercard. Those with ongoing respiratory symptoms should be considered for evaluation by occupational health to determine appropriateness of contact with patients pain treatment center at johns hopkins buy 500 mg sulfasalazine free shipping. Settings where there is a high risk of infection should be evaluated for environmental infection control knee pain treatment kansas city buy sulfasalazine 500mg without a prescription, such as air handling pain treatment for tennis elbow buy generic sulfasalazine line. This last classification should always be temporary pain management for my dog order sulfasalazine online from canada, corrective steps taken pain medication for dogs metacam 500mg sulfasalazine with mastercard, and the return to medium risk made within one year. Testing for evidence of hepatitis B infection should be routine for healthcare providers, especially those with occupational exposure potential. If the test is positive, it means that the person has been exposed to the 178 virus and may or may not have active hepatitis C. Additional testing will need to be done to determine if the person is a carrier, has chronic hepatitis, or is immune. This test can help determine if the person has been infected with the virus but cannot determine the stage of disease. The review panel should include experts who represent a balanced perspective and may include all of the following: 1. A health professional with expertise in the procedures performed by the healthcare worker. If the healthcare worker is institution-based, the panel could include the hospital epidemiologist or other infection control staff. Healthcare workers based outside the hospital/institutional setting should seek advice from appropriate state and local public health officials regarding the review process. Infected healthcare workers should notify prospective patients of their seropositive status before undertaking exposure-prone invasive procedures. The risk is not sufficient to justify the costs such mandatory testing programs would incur. Education, training, and appropriate confidentiality safeguards are the best means to insure healthcare worker compliance by healthcare workers with recommended prevention procedures. In 1996, the application of the concept was expanded and renamed Standard Precautions. Standard Precautions are intended to prevent the transmission of common infectious agents to healthcare personnel, patients and visitors in any healthcare setting. During care for any patient, one should assume that an infectious agent could be present in the patients blood or body fluids, including all secretions and excretions except tears and sweat. However, once contaminated, gloves can become a means for spreading infectious materials to you, other patients or environmental surfaces. Under Standard Precautions, gloves should be used when touching blood, body fluids, secretions, excretions, or contaminated items and for touching mucous membranes and nonintact skin. Since bleeding occurs only extremely rarely during needle insertion, gloves are not needed for acupuncture needle insertion. The same would be true with acupuncture procedures as long as contact with blood is not anticipated. However, some types of needling of the scalp or ears may increase the risk for bleeding. The individual employee performing acupuncture does not make the determination whether gloves are to be worn. It is critical that proper hand hygiene is practiced along with glove use to best protect healthcare personnel. They also keep hands that may be contaminated from healthcare practices from touching the eyes. Lab Coats: Lab coats are personal protective equipment and should be worn in the lab when working with chemicals and biologicals to protect the skin and clothing from splatter and spills. In order to prevent the spread of contaminants do not wear lab coats in public places, such as offices, lunch rooms, lounge areas, or elsewhere as they can transfer hazardous materials and contaminate these areas. Also, remove your gloves if they become torn and perform hand hygiene (wash hands) before putting on a new pair of gloves. You should also avoid spreading contamination by limiting surfaces and items touched with contaminated gloves. Note that in some states such as New York, it is recommended that someone with a needlestick injury be evaluated within the first 2 hours after such an incident. Failure of hand disinfection with frequent hand washing: a need for prolonged field studies. Physiologic and microbiologic changes in skin related to frequent skin related to frequent handwashing. Infection control as a major World Health Organization priority for developing countries. Prospective study of infection, colonization and carriage of methicillinresistant Staphylococcus aureus in an outbreak affecting 990 patients. The temperature effect of in vitro penetration of sodium lauryl sulfate and nickel chloride through human skin. Comparison of cloth, paper, and warm air drying in eliminating viruses and bacteria from washed hands. Changes in bacterial flora associated with skin damage on hands of health care personnel. The bacteriology of normal skin: a new quantitative test applied to a study of the bacterial flora and the disinfectant action of mechanical cleansing. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. An outbreak of coagulase-negative staphylococcal surgical-site infections following aortic valve replacement. In: Program and abstracts of the 41st Interscience Conference on Antimicrobial Agents and Chemotherapy. When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap and running water as soon as feasible. Routine Skin Preparation with 70% Isopropyl Alcohol Swab: Is it Necessary before an Injection Thyroid function in infants following cardiac surgery: comparative effects of iodinated and noniodinated topical antiseptics. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. The Risk of Occupational Human Immunodeficiency Virus Infection in Health Care Workers: Italian Multicenter Study. Guideline for Isolation Precautions: Precautions to Prevent Transmission of Infectious Agents in Guideline for Isolation Precautions 2007. Acupuncture schools and clinics offer training in the practical applications of these regulations for the acupuncture practitioner. The cleanliness of the general environment also has a direct impact on the practitioners ability to create a clean field. If a custodial contractor is responsible for clinic maintenance, the contractor must be instructed regarding maintenance and the presence of biohazardous materials. The clinic manager must provide written notification to cleaning contractors regarding the presence of contaminated sharps and the potential for bloodborne contamination. A sink with hot and cold running water must be located in or near the treatment rooms. Any paper or other disposable material used as a covering on a chair, seat, couch, or treatment table, and any towel, cloth, sheet, gown, or other article that contacts the patients skin should be clean, and should not previously have been used in connection with any other patient unless laundered before reuse. The treatment room table tops, shelves and other working surfaces should have a smooth, impervious surface, be in good repair, and be cleaned with a suitable disinfectant at least once a day and whenever visibly contaminated or whenever a patient may have contaminated the surface by coming in contact with the surface directly. Hepatitis B virus can survive on surfaces for at least one week at room temperature. Disinfectants do not kill all germs or spores, but they will reduce the danger of infection. These solutions lose strength over time and must be remade at specified intervals, as per the manufacturers label instructions for the types of surfaces being disinfected. Check with the manufacturer for dilution protocols and expiration times on commercial disinfectants. The label should state what the solution is, when it was mixed, and the concentration. Used disinfectants must be carefully discarded according to the manufacturers instructions. Classifications of Disinfectants Chemical germicides are classified by several different systems. It is important, therefore, to understand the manufacturers label to interpret the usefulness of a product for its stated purpose. These chemicals are quite toxic and are not used for office cleaning/disinfecting. Critical objects enter the vascular system or any sterile internal part of the body. Semi-critical items touch mucus membranes and non-intact skin, and non-critical items touch intact skin. Disinfectants may be classified as high-level disinfectants, intermediate-level disinfectants, and low-level disinfectants. Product labels often describe the level of germicidal action in terms of the infectious agents they challenge. Types of Disinfectants Chlorine and Chlorine Compounds the most prevalent chlorine products in the United States are aqueous solutions of 5. These products have a broad spectrum of antimicrobial activity, do not leave toxic residues, are unaffected by water hardness, are inexpensive and fast acting, and 190 have a low incidence of serious toxicity. Follow manufacturer directions for use on both smooth, impervious surfaces and porous surfaces or organic material. Practitioners need to follow label directions for the appropriate concentrations for non-critical and semi-critical reusable devices as well as for cleaning of common surfaces with hypochlorite solutions. Microbiocidal Activity Hypochlorite concentrations approved for use on non-critical items and common surfaces have a biocidal effect on mycoplasma and bacteria in seconds. Only when the solution is "activated" (made alkaline) by use of alkalinizing agents to pH 7. It has limitations in its mycobacteriocidal activity and coagulates blood and tissue to surfaces. Glutaraldehyde should not be used for cleaning noncritical surfaces because they are too toxic and expensive. The hydrogen peroxide sold over-the-counter in pharmacies is 3% and is often old, resulting in less effectiveness than that provided by a fresh 3% peroxide solution. Iodophors Iodine solutions or tinctures have been used by health professionals primarily as antiseptics on skin or tissue. Iodophors, on the other hand, have been used both as antiseptics and disinfectants. Hypochlorite solutions should be made fresh daily according to the use for which the solution is intended. The label must include what the solution is, when it was mixed, and its concentration. Ensure that, at a minimum, noncritical patient care surfaces are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily depending on the type of surface and the frequency of use). Before the late 1970s most medical devices (including acupuncture needles) were considered reusable. Reuse of single-use devices involves regulatory, ethical, medical, legal and economic issues. Pre-cleaning of Reusable Medical Equipment Cleaning is the removal of foreign material. Thorough cleaning is required before low-, intermediate-, or high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the 193 effectiveness of these processes. Also, if soiled materials dry onto the instruments, the disinfection or sterilization process is ineffective. Smooth surfaces can be disinfected through 2 steps: soap and water cleansing followed by wiping with a low or intermediate disinfecting agent. Cups or gua sha Intermediate Step 1 tools used over disinfecting Removal of all biological and foreign intact skin. SemiAll cups used Sterilize before Step 1 Critical for wet reuse; or highRemoval of all biological and foreign cupping; cups level material. Instruments used in performing invasive procedures should be appropriately sterilized prior to use. Equipment and devices that do not touch the patient or that only touch intact skin of the patient need only be cleaned with a low-level disinfectant or detergent. Equipment and devices such as cups and gua sha tools that have touched intact skin, but where that skin has been subjected to compression should be cleaned with at least intermediate level disinfectants. Contaminated equipment that is reusable should be cleaned of visible organic material by washing and scrubbing with soap and water, and then disinfected using an intermediate-level disinfecting solution (such as CaviCide, Sterilox, Spor-Klenz, DisCide, or Super Sani-Cloth). Whenever the tools will be placed over nonintact skin (such as in cupping after needling or wet cupping), they need to be treated as semi-critical reusable devices. The current controversy is about how often the skin barrier is compromised when using equipment such as cups and gua sha tools. However, the contact is not incidental but involves enough repeated or sustained pressure as to (intentionally) cause extravasation of blood and fluids that can seep or be let from the skin even if not immediately visible. Taking into consideration the potential risk to patients, it is the editors opinion that is prudent to consider high-level disinfection of all cups and gua sha instruments until additional studies are completed to demonstrate the degree to which cupping and gua sha compromise the skin barrier.

Describe how cognitive disorders are categorized by cause and the problems in diagnosing cognitive disorders treatment guidelines for shoulder pain 500 mg sulfasalazine with visa. Describe and differentiate dementia and delirium and discuss the possible causes of these disorders wnc pain treatment center arden nc generic 500 mg sulfasalazine visa. Describe the amnestic disorders and differentiate them from dementia and delirium treatment for severe shingles pain buy sulfasalazine without prescription. List and differentiate the types of brain traumas pain medication for a uti discount sulfasalazine 500mg with visa, their symptoms and aftereffects osteoarthritis pain treatment guidelines purchase sulfasalazine us. Describe the health conditions that accompany old age neck pain treatment youtube order 500mg sulfasalazine mastercard, including the nature and effects of, and risk factors for cerebrovascular accidents (strokes) and vascular dementia. Discuss the characteristics of Alzheimers disease, brain abnormalities, and what is known about its cause. Describe methods of treating cognitive disorders, including medication and cognitive and behavioral approaches. Discuss the need for environmental interventions and methods of supporting the caregivers of individuals with cognitive disorders. Discuss the class of disorders known as mental retardation, including different forms of retardation, how mental retardation is diagnosed, the four levels of retardation, and the predisposing factors associated with mental retardation. Explain the causes of mental retardation, including how environmental factors and nongenetic biogenic factors may be involved. Describe and discuss early intervention and employment programs and living arrangements for people with mental retardation. There are so many different cognitive disorders and the names of some are so unfamiliar to students that they will appreciate a handout that lists the categories of disorders, their names, and their major symptoms. Students will quickly recognize a major problem for diagnosticians: the similarity of symptoms despite widely different causes. The Handout for Classroom Topic 1 organizes the various brain disorders by type and symptoms. In most cases, stroke survivors leave the structured environment of the hospital and return home, often without much preparation given to the family. In Leeds, England, a transitional program is in place that seems to improve the psychological and physical adjustment of stroke survivors (Geddes & Chamberlain, 1989; Geddes et al. Substitute careers help the patient, and the rest of the family devises rehabilitation plans and provides information and assistance in the recovery process. Apparently, patients who learn to cope soon after the stroke develop greater motivation to continue their rehabilitation and have greater acceptance of their changed lifestyles. The Leeds Family Placement Scheme: An evaluation of its use as a rehabilitation resource. Provides an extensive list of national associations involved with stroke, paralysis, spinal cord injury, and other neurological conditions. Alzheimers disease is a cruel disorder because it robs people of their memory so that they know that it is being stolen. Both the individual with the disorder and the family member who is caregiver experience an extended grieving process for the person who used to be. Even if the individual fights hard to retain memories and tantalizingly, on good days, recovers functioning, there is the inevitability of loss long before death itself occurs. Below is a poem written by a professional writer, Cris Cassidy, who is watching her highly educated mother lose her battle with Alzheimers. It is taken from an Internet site (see On the Internet at the end of this chapter) where people can submit poetry concerned with neurological disorders. Expect a discussion of the quantity versus the quality of life and a return to issues of suicide or family-assisted suicide. Death Before Dying It isnt fair that a woman who spoke four languages and knew every word in Websters dictionary should be brought to this. Source: the Neurology Web Forum run by Massachusetts General Hospital, Department of Neurology Ms. Neuropsychological tests have had a great impact on the field of cognitive assessment. The following demonstrations can give students a window into the kinds of tasks that are used in such assessments without invalidating the tests. A subtest of the Halstead-Reitan that screens for aphasia can be simulated in the following way. Ask a student volunteer to come forward and, without looking, place a hand into the bag. Finally, place all three shapes in the bag and ask the volunteer to take the correct shape out of the bag when the word for it is written on the board or said aloud. This test examines the comprehension of written and spoken words as well as the association between touch and language. A second subtest, trail making, asks the test taker to link labeled circles in a certain sequence. In the first test, the volunteer must, as quickly as possible, draw lines linking the circles in the order labeled. In the second set, label some circles with the sequence 1, 2, 3, and so on, and the rest with A, B, C, and so on. Now instruct the volunteer to link the 1 to A, the A to 2, the 2 to B, and so on as quickly as possible. Finally, ask students to tap their desk surfaces with their dominant-hand index fingers as rapidly as possible and count the number of taps over ten seconds. Then ask them to tap with the index fingers of their nondominant hands for ten seconds. Explain that the test indicates not only the speed of responding, but also whether there is a difference between dominant and nondominant brain hemispheres. This subtest, more than others, can show how elderly, high-functioning individuals might perform poorly on neuropsychological tests. Recent research suggests that it may be possible to identify early in life those individuals who will develop Huntingtons disease in midlife. Given the fact that the disorder cannot be treated or cured, and that developing it represents a ten-year deterioration into psychosis and death, would people want to know their fate ahead of time What are the implications for genetic counseling if more commonly occurring degenerative and incurable cognitive disorders such as Alzheimers disease could be predicted To get students thinking about these issues, split the class into groups of four to five students each. Ask the students to discuss in the groups whether they themselves would want to know whether they would develop such a disorder. Ask them to discuss the advantages and disadvantages to the wider society of the ability to predict the development of incurable disorders. Finally, discuss the psychological counseling that might be necessary for both those who learn of their fate and their close family members. The odds are good that at least 10 percent of your students have a relative who suffers from dementia. Chapter 14: Cognitive Disorders 247 relatives dementia has had on them, their parents, or other caregivers. Students who have had contact with dementia can give others an appreciation of the specific forms the symptoms take, the degree to which symptoms come and go, and the physical and emotional toll on caregivers. This site defines and discusses dementia, delirium, and depression in elderly populations. Traditional-age college students (18 to 22) often have difficulty empathizing with the situations older people face. Although it is important to underscore the fact that most older people remain in good health and do not face cognitive deterioration or depression, the reality is that life is often more trying for older individuals. If one has impaired eyesight, hearing, and flexibility of movement, many activities become more difficult to perform. The following demonstration can increase students awareness of the impact of sensory and motor impairments on behavior, emotion, and thought. You will need the following equipment: several pairs of the inexpensive reading glasses available at pharmacies, a jar of Vaseline petroleum jelly, a box of absorbent cotton, a roll of transparent tape, at least four unsharpened pencils, and four rolls of elastic (Ace) bandages. Ask for at least two volunteers from the class to participate in an exercise to mimic some of the impairments experienced in older age. If the students wear glasses, ask if they are willing to have the lenses smeared with Vaseline, promising that they will be cleaned later. If they say no or do not wear glasses, supply them with reading glasses that you have already smeared with the jelly. This visual impairment will mimic that of cataracts, a common eye disorder of older people. Have the volunteers stuff their ears with absorbent cotton until quiet speech is muffled. Now put strips of tape on the second knuckle of each finger on their dominant hand and the thumb joint. This should give them some appreciation for joint stiffness experienced by those with arthritis, although we cannot convey the pain that is involved. To reduce mobility, you can put one pencil on each side of the knee joint when the leg is straight and wrap tightly with the Ace bandage. Have the volunteers talk with each other in quiet voices while the rest of the class engages in normal conversation. In about a minute the volunteers will appreciate how little of their conversation they can understand and how much they ordinarily use visual cues to assist in their interactions. Because of the smeared lenses, they have few visual cues and may experience some of the frustration that older people feel when, in loud restaurants or other social settings, they cannot maintain interactions with others. After this portion of the demonstration, give the volunteers some lined paper and pens. They will struggle to see the words on the page, will not be able to manipulate the pen well, and will gain some empathy for those who suffer from arthritis. Finally, have them walk around the room, out into the hallway, and, preferably up and down a flight of stairs. For this last one, make sure an able-bodied person is close by to protect the volunteers from falling. As the volunteers stumble or just feel unsure of themselves, they will begin to appreciate how disorienting, depressing, and isolating some of the physical disorders of the aged can be. Encourage the volunteers to voice their awareness, emotions, and thoughts to the rest of the class. Help them understand that cognitive disorders that occur on this background of sensory and motor impairment are more difficult to treat. You could also indicate on the board how a vicious cycle can evolve: Physical impairments increase the likelihood of depression and isolation, which increase the likelihood of cognitive disorders. Finally, encourage the rest of the class to try some of these activities on their own and report their experiences to the class. The fact that many cognitive disorders have similar symptoms and that these overlap with symptoms of noncognitive disorders presents problems for the diagnostician. Show students the thought processes that diagnosticians use to rule in or rule out various cognitive and affective disorders. Present this very sketchy portrait of a person who may have a cognitive disorder: Mrs. She is accompanied by her daughter, who is highly observant and an accurate reporter of Mrs. First, provide students with the handout so they can think through the potential cognitive and affective disorders that might be appropriate for Mrs. The object is to brainstorm for legitimate, likely cognitive and noncognitive disorders. These include Parkinsons disease, Alzheimers disease, multi-infarct dementia, stroke, depression, and possibly negative symptom schizophrenia. Next, ask students what information they need to make a firm, differentiating diagnosis. If they need assistance, suggest that interviews, psychological testing, and neurological assessments might help. When they have worked on the cognitive-noncognitive issue, ask them to refine their diagnoses to differentiate among the cognitive disorders. You can help by reminding them that some cognitive disorders involve dementia and that others involve delirium. When they have finished this portion of the activity, ask for the information they listed for each of the disorders you have listed on the board. Correct any mistaken impressions and add your own thoughts on how to perform a differential diagnosis. Remember to mention that this task is extremely complex and difficult and that misdiagnosis is all too common. As an example, ask how they would differentiate Alzheimers disease from vascular dementia. In some cases (such as Alzheimers disease versus multi-infarct dementia), there is little difference in treatment of the condition. In others (such as Alzheimers versus depression), differential diagnosis makes a huge difference in appropriate treatment. Screening for dementia can involve asking patients and their relatives for information on their recent cognitive, emotional, and behavioral functioning. A more standardized procedure is to ask questions from a mental status examination. It will give students an idea of how to define orientation and the kind of short-term memory that is impaired by dementia. Further, since no cutoff scores or norms are provided, there is no way to evaluate responses. Chapter 14: Cognitive Disorders 249 given in the form of probability that the patient is normal.

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Identifying unhelpful thoughts associated with anxiety is the first step in changing your thinking arizona pain treatment center reviews discount 500mg sulfasalazine mastercard. Overestimating the chance they will panic People with panic disorder often believe they are more likely to have a panic attack than they really are 2 treatment for lingering shingles pain purchase sulfasalazine in india. Exaggerating the feared consequences of panic People with panic disorder often believe the medical otc pain treatment for dogs buy genuine sulfasalazine on-line, psychological or social consequences of panic are more obvious pain medication for shingles pain sulfasalazine 500mg with amex, longer lasting or serious than they are 3 pain management senior dogs buy sulfasalazine on line amex. Underestimate their own ability to cope People with panic disorder often judge themselves as being unable to cope menstrual pain treatment natural purchase cheap sulfasalazine online. In most cases, they 31 actually are able to perform their activities on some level, its just that they feel very anxious while doing so. Misinterpreting normal and anxiety-related physical sensations People with panic disorder often mistake day-to-day physical sensations as dangerous. They also misinterpret the physical sensations of anxiety and panic as dangerous, rather than just unpleasant. Some people also start to misinterpret normal physical sensations, such as those that occur during exercise. Physical sensation Common misinterpretation Pounding heart Im having a heart attack Im going to drop dead Feeling short of breath Im going to stop breathing Im choking Feeling lightheaded Im going to pass out or collapse Im having a stroke Exercise: Look through the list of physical sensations commonly associated with panic attacks. Write down those physical sensations that occur during your panic attacks, and the beliefs you have about those sensations. Having done this, we will later find alternative, less threatening, thoughts to challenge your original beliefs. These situational fears may be explained by two basic groups of unhelpful thoughts: v If I have a panic attack, I wont be able to get out v If I have a panic attack, help wont be able to get to me Of course, some situations involve both types of thoughts. For example, a crowded underground train may be anxiety producing because it is difficult to get out, because it only stops at stations, and because it is difficult for help to get to the train. For example, an individual who is worried about panicking on a train may start to worry about being on buses and planes. This is understandable, because all three of the situations share some features: other people, limited opportunities to leave, and limited control over their direction. Cognitive restructuring should be used with the technique of graded exposure, to help you re-enter situations that you currently avoid because of anxiety. I can use my techniques to manage my anxiety People wont notice me, and even if they do, theyll just think Im a little tense. Breathing too hard will make the symptoms worse, which proves it is not a heart attack. It is therefore important to distinguish rational thinking from irrational positive, or wishful, thinking. It is sometimes difficult to tell the difference between irrational, wishful and rational thinking. One of the best ways to challenge unhelpful thinking is to write them down on paper, and replace the unhelpful beliefs with more realistic or rational alternatives. We will begin by starting with common examples of unhelpful thoughts that individuals with panic disorder report. It will take time and practice, but your skill at this will improve if you apply the technique consistently. Start with the following examples of thoughts reported by individuals with panic disorder. People would think I was strange If I feel dizzy the next time I drive I could have an accident and kill someone If Im left alone and panic, Ill really lose it and go crazy. What if all the doctors have been wrong and Ive really got something seriously wrong with me Exercise: Now think of a recent situation where you felt anxious or had a panic attack. Write down a description of the situation, and any anxiety-provoking thoughts you may have had. Then try to come up with some more realistic and helpful thoughts that could be applied to that situation, in order to reduce your anxiety. It may help to wait until the anxiety has dropped, then think about the situation and associated fears. I cant think of alternatives After many months to years of having anxiety-provoking thoughts, it may be difficult to think up less threatening alternatives. Look at all available evidence, especially evidence that contradicts your thoughts. Ask yourself why others around you do not fear the situation, and try to consider what they might be thinking about the situation. Im doing it and its not working Use all available techniques, including relaxation and slow breathing, to reduce your anxiety. Do not expect to be perfect at cognitive restructuring or expect the technique to work immediately. I still feel anxious Cognitive restructuring is designed to provide more realistic and appropriate responses to given situations, events or interactions. If the reality is that a particular situation is associated with some anxiety for most people, do not expect to use the technique to reduce all anxiety. I dont believe my new thoughts You may not have addressed all of your anxiety-provoking thoughts. Go back and look at your thoughts about the situation or physical sensations and try to identify any other related fears that need challenging. Also remember that at this stage you are not expected to completely believe your new, helpful thoughts. Part of therapy involves you testing out what you fear, using exposure techniques. You have now had practice identifying and challenging anxiety-provoking thoughts associated with panic. Using your knowledge about anxiety and panic, reminding yourself of the anxiety management techniques, and considering past evidence that the absolute worst outcome did not necessarily happen, are ways of answering back to your unhelpful, catastrophic thoughts. You can obtain further evidence against your unhelpful beliefs by actively testing out what you fear. Consider the following examples of anxiety-provoking thoughts: If I spend time on my own, I will panic and I couldnt cope with that. If my heart starts pounding and I exert myself, I could have a heart attack If I catch a crowded bus, Ill have a panic attack and Ill pass out. In addition to mentally questioning these unhelpful thoughts, further evidence can be obtained for yourself by actually doing what you fear, or provoking the very sensations you fear in a situation without safety objects or people. Not only will they help elicit the thoughts (what better time to identify thoughts than when you are afraid), you will be able to test them at the same time. For example, you could develop a graded exposure hierarchy aimed at challenging the idea that you cannot cope on your own. To do this, you might gradually spend more and more time alone, in different situations. Ultimately you could consider hyperventilating for a set time while alone to properly challenge the idea that you could not cope if you panicked on your own. To directly test out the belief that exerting yourself might cause a heart attack, you could regularly perform some strenuous activity or exercise which will provoke a rapid heart rate. Rather than stopping as soon as you notice the sensations, continue with the activity while thinking realistically about the sensations. To test out the belief that you will panic on a crowded bus and pass out, you could structure an exposure progran which involves you travelling alone on a bus at progressively more crowded times of the day or on busy routes. Travelling on a hot, humid day might be more difficult as it might be more likely you experience some physical sensations similar to those you experience when you panic. Ultimately you could hyperventilate on the bus, while standing up, to thoroughly test out your fears of fainting. It is important to be performing these experiments in the absence of safety behaviours, safety objects or safe places. This assists in proving to yourself that your beliefs may not be correct, that you can cope on your own, and that the physical sensations are not dangerous. Sometimes it is possible to think yourself into a fearful state without even being near situations you fear. Challenging irrational thoughts will eventually decrease the power the thoughts have over your feelings, particularly when you are using cognitive therapy in combination with graded exposure. As you begin to consistently replace the irrational thoughts with rational ones, your feelings will eventually become more appropriate to the situation you face. To give you some extra help there are four types of questions you can ask yourself which may make the unhelpful aspects of the thoughts more clear. Try to generate more helpful, realistic responses to the examples of irrational thoughts below. From your or other peoples experience, what is the evidence that what you believe is true Consider alternative explanations for an event or ways of thinking about the situation. Some examples of common thinking errors include: i) Thinking in all-or-nothing terms. This is black-and-white thinking in which things are seen as all good or all bad, safe or dangerous there is no middle ground. Example: No-one elses problem is as bad as mine, everyone else in the group is improving so much faster than me. Because there is one thing that you cannot or have not done you then label yourself a failure or worthless. Try to think of other times you have attempted or even been successful at something and think about the resources that you really do have. Things will certainly go wrong and there is danger in the world but are you overestimating these Example: If I go to the movies tonight it will be so crowded and Ill panic and pass out. Often we think that some event will be much more important than it turns out to be. Just because you acted a certain way in the past does not mean that you have to act that way forever. Predicting what you will do on the basis of past behaviour means that you will cut yourself off from the possibility of change. Coping Statements There are times when you may need some short cuts to coping with feelings. For example, if you feel butterflies in the stomach, instead of saying "Oh no, Im really getting anxious and upset" say "I know what these feelings mean. Develop some personal self-statements, such as "Take this step by step", "Dont jump to conclusions" or "This fear cant hurt me I can tolerate it". Dont say, "A baby should be able to do this", "Im hopeless" or "Ill never get the hang of this". As long as you say these sorts of things to yourself you make them come true (but only for as long as you say them, fortunately). Say things like "That was good" or "I felt I was having a bad day this morning, but I still managed to get on the crowded train. Introduction One of the elements central to panic is the fearful reaction to bodily sensations, such as a pounding heart, dizziness etc. We deal with this subject towards the end of the first part of the program because the techniques involved are not easy for all people to do and we want to be sure that you have some anxiety management techniques. As we noted on the first day, individuals differ in the particular sensations that frighten them the most. If you are not sure which symptoms are most relevant to your fear we can use a series of exercises that generate sensations similar to the sensations experienced during anxiety and panic. The aim is to practice the exercises regularly in order to reduce or eliminate your fear of the bodily sensations. In other words, you aim to become desensitized to internal bodily feelings in the same way you become desensitized to situations you fear through graded exposure. Fear reduction can only be accomplished by repeatedly confronting the things that frighten you, in this case, the bodily feelings associated with panic. Although you may not like the idea of deliberately bringing on the feelings that are similar to those you experience when you panic, dealing with these fears is very important. Many everyday experiences will cause you to feel sensations that are similar to panic sensations. For example, any individual who engages in a hard game of squash or goes for a jog, may experience breathlessness, sweating and lightheadedness. These are normal reactions to the stress of exercise and should not lead to fears of panic. In this part of the program we wish to dampen down, or even extinguish, your anxiety response to these harmless sensations. In addition, performance of the exercises will provide you with a chance to practice more purposely the strategies you have acquired up to this point, especially the rational thinking exercises. Their application during these repeated practices will enhance their effectiveness and their preparedness. The more you rehearse a particular strategy, the more powerful and natural it becomes. The goal is for you to identify any sensations that you feel as a result of each exercise. After performing the exercises set out below, write down all the physical sensations you experienced during or after the exercise, as well as any anxietyprovoking thoughts.

Treatments mented epidermis; here lymphocytes are rarely observed that resulted in the complete or almost complete repigadjacent to apoptotic melanocytes (satellitosis) pacific pain treatment center victoria purchase 500mg sulfasalazine with visa. Lymphomentation were psoralens and ultraviolet light [8] pain medication for dogs dosage buy cheap sulfasalazine 500mg, as cytes are thought to indicate an active disease state with the well as ammoidin and solar exposure [7] pain home treatment purchase sulfasalazine online pills, respectively wrist pain yoga treatment buy sulfasalazine with a visa. Dermal infiltrates another report [26] myofascial pain treatment center virginia generic sulfasalazine 500 mg on-line, L-phenylalanine (a tyrosine precurof inflammatory cells pain treatment in multiple sclerosis best order sulfasalazine, lymphocytes, plasma cells, and histiosor) for 6 months resulted in 75% clinical improvement cytes are minimal or inflammation can be completely abin four dogs. Vitamin and mineral supplementation and sent, then suggesting an inactive disease stage. In the latter diet change resulted in partial repigmentation in some situation, histology does not easily differentiate vitiligo from dogs but not others [9]. Adrenocorticotrophic hormone normal white spots, but this dilemma can be resolved injections over a 3-month period only resulted in a temwith the clinical history. In another dog, a change of environment tiple samples are ideally collected from the depigmented was suspected to lead to partial repigmentation of the margins of recently active lesions, especially if erythema nasal planum and gingiva over several months [9]. In the latter breed, a sponIn humans, due to the heterogeneity in the designs of taneous remission occurred 3 weeks after treatment with clinical trials and often-small numbers of participants, toceranib phosphate for mast cell tumour was stopped. Spontaneous repigmentation, chological impact on the quality of human life, as do albeit only partial, on the concave and convex surpsoriasis and atopic dermatitis [16]. This may explain faces of the pinnae, was reported in one case 40 why treatment of widespread, facial or recalcitrant vitimonths after initial onset [12]. In non-responding areas, especially those other report [31], partial repigmentation occurred after with high cosmetic impact, surgical grafting with the supplementation with high levels of chelated copper. A aim to replace the melanocytes with those from a norrelapse of depigmentation occurred approximately 5 mally pigmented autologous donor site is recommended months after the copper supplementation was reduced as the third-line therapy. Finally, in patients with extenand then a noticeable clinical improvement occurred sive and refractory vitiligo, depigmentation techniques when the daily intake of copper was re-increased. It is (hydroquinone monobenzyl ether or 4-methoxyphenol) plausible that the depigmentation in this horse was assois proposed as the fourth-level treatment. In humans, acrofacial vitiligo (lip-tip vitithe administration of high levels of thyroprotein-based ligo) is resistant to treatment [16], as does a appear the product might have caused a relative vitamin A deficanine disease homologue. However, to the authors such as tofacitinib, are currently under investigation as knowledge, there is no evidence that vitamin A defimonoor adjuvant therapy for this disease. Thereammoidin (xanthotoxin) with solar exposure [7], psorafore, the outcome of these nine horses of this report lens with ultraviolet light [8], systemic glucocorticoids should be interpreted cautiously. Therefore, any humans [17], as it results in better repigmentation rates, treatment for this disease should always be discussed between 40 and 100% [17]. Interestingly, the dogs that with the owners to avoid interventions of dubious effihad a complete [8] or an almost complete remission [7] cacy and those with possible adverse effects. Therefore, vitiligo could have a significant and negative impact for phototherapy treatment, either alone or in combination the owners of show animals. For areas that have both leukoderma and man with coexistent vitiligo and alopecia areata [42]. Should this clinical trial reangiectasias), the frequency of their application should port a noticeable degree of efficacy, it may be worthwhile be tapered to the lowest possible effective one. If topical therapy were to fail, oral suppledetermine if this condition is a variant of vitiligo, or a mentation with L-phenylalanine could be attempted for separate disease condition. Herein, we will religo is higher in those with family history of such disease view the available information published to date on the [19]. This could be followed by a genomic wide-associated study to Historical perspective assess if any variant of vitiligo in some breeds is associated More than a century ago, in 1906, a medical resident with a single trait. His paper focused mainly on poliosis tween viral antigens and proteins from pigmented cells (patches of white hair) and only briefly described uveitis. Twenty-three years later, another and chronic disease and these antibodies could be a proJapanese ophthalmologist, Yoshizo Koyanagi wrote a reduced in response to the retinal damage [55]. In addition view article that described in detail a disease including to this syndrome, antiretinal antibodies have been also severe uveitis, poliosis, alopecia and dysacusis [45]. Eleven dogs (8%) [64, 72, 75, 90] [73, 74]; it is more common in individuals with a pighad cutaneous lesions that preceded ophthalmic signs, mented skin [44]. The location of the first sign/lesions were syndrome has been reported in other breeds as well. The prodromal stage lasts from seen ocular signs were uveitis (27/68; 40%) and conjuncseveral days to a few weeks [44] and it is characterized tivitis or red eye (12/68; 18%); it is not known if the by flu-like symptoms such as headache, tinnitus, nausea, dogs with uveitis had concurrent conjunctivitis, and if neck pain and back pain [50]. The convalescent stage ensues several skin lesions reported have been a swelling of the nose weeks-to-months after the acute stage, and it consists of [75], pruritus [69], hyperkeratosis of footpads [81] and signs of depigmentation of the uveal tissue and/or inonychomadesis (loss of claws) [64]. Finally, in the chronic recurrent stage, a note that the dog reported by Tachikawa developed onymild panuveitis with recurrent episodes of anterior uvechomadesis 1 month after the initial onset of skin depigitis occurs and this stage is considered the consequence mentation, and ocular signs only developed 3 months of an inadequate or delayed treatment [50]. Interestingly, all dogs (10/ these three categories (Additional file 1: Table S1). In the which information on the location of the first sign/lesion oral cavity, the most commonly affected region was the pal(eye versus skin) was available, 114 (85%) developed ate (4/10; 40%) [67, 79, 87, 94]. Depigmenthe underlying cause of these signs was not determined tation of the eyelashes was reported in six dogs (14%) [47, and therefore, it is not known if they were part of the 62, 78, 90]. One dog was diagnosed with polymyositis 3 bilateral and symmetrical except for one dog [90] with years after the onset of uveitis and glaucoma [65]. Melanosomes (melanin granules) are spilled to the lus) are difficult to confirm or rule-out in dogs and/or dermis and are found in melanophages (pigmentary inthese might have resolved by the time of examination. Additionally, it is extremely sometimes nodular and periadnexal, but it can be sparse difficult to clinically differentiate meningismus from in advanced disease stages. An epidermal hyperplasia is overt meningitis or meningoenchephalomyelitis in aninormally seen and can be accompanied by erosions, ulmals [J. Skin biopsies are indispensible to conwhom subclinical involvement of the meninges, based firm the diagnosis and should be performed early in suson post-mortem findings, has been documented [84]. Whether or not an adjunctive immunosuppresvanced skin lesions such as painful erosions or ulcers. Macrophages inflammation and pain and to prevent the appearance of are cited as a prominent feature but might not always be synechiae (adhesions). The exocytosis of lymther as ophthalmic drops, intravitreal or subtenon injecphocytes into the lower epidermis leads to a blurring of tions [44]. There is partial-to-complete loss of melanocytes often used for the assessment on the effectiveness of a and, consequently, of epidermal pigmentation. Melanosomes are spilled into the dermis, where they appear as a fine granular, dust-like, appearance in macrophages (arrows). This requires the collaboration of veterintreatment regimen was not stated in one dog that had both ary ophthalmologists, dermatologists and neurologists. Likewise, diagnostic tests that are more 97] where information on the final treatment outcome and sensitive and can reliably detect tinnitus in dogs should time lapsed between the initial onset of signs and the initibe investigated. This observation implies that initiating treatment sponse would be of value, as it would allow for a within 1 month after the first clinical signs would result in standardization of the reporting of treatment outcomes a better outcome. Until the exact etiology is Guidelines for the management of vitiligo: the European dermatology forum consensus. Antibodies to surface antigens of Additional file 1: Table S1 Diagnostic criteria for Vogt-Koyanagi-Harada pigmented cells in animals with vitiligo. In: Griffin C, Kwochka K, MacDonald J, this article being a review of published information, data sharing is not editors. Vitiligo in two old English sheepdog littermates and in a dachshund with juvenile-onset diabetes mellitus. Advances in Veterinary Dermatology, the authors declare that they have no competing interests. Efficacy of L-phenylalanine in the treatment of Author details canine vitiligo: a preliminary report of 4 cases. Generalized vitiligo in a purebred Rottweiler: Medicine Institute, College of Veterinary Medicine, North Carolina State case report. Generalized vitiligo in a dog with primary Pathobiology, College of Veterinary Medicine, North Carolina State University, hypoadrenocorticism. Anti-retinal antibodies associated with Revised classification/nomenclature of vitiligo and related issues: the Vogt-Koyanagi-Harada-like syndrome in a dog. Skin depigmentation induced by sunitinib diffuse uveitis accompanied with dermal depigmentation in Akita dog. Low 25-hydroxyvitamin D levels are associated with Harada-like) syndrome with sloughing of the nails in a Siberian husky. Uveodermatological syndrome (Vogt-Koyanagicutaneous allergic reactions in dogs: a placebo-controlled pilot study. Vogt-Koyanagi-Harada disease: novel insights into poliosis following uveitis in a dog. Immunohistochemical studies of Vogt-Koyanagiassociated with poliosis and vitiligo in six dogs. Ocular histopathology of Vogt-Koyanagicomplex on melanocytes of Vogt-Koyanagi-Harada disease. Vogt-Koyanagi-Harada-syndrom bei einem T-cell line from a Vogt-Koyanagi-Harada disease patient. Yamaki K, Takiyama N, Itho N, Mizuki N, Seiya M, Sinsuke W, Hayakawa K, syndrome Vogt-Koyanagi-Harada chez un fox-terrier. Vogt-Koyanagi-Harada diease: review of a Husky atteint dun syndrome uveodermatologique. Retinopathies associated with antiretinal Uveodermatologic syndrome in an Akita dog. An immunohistochemical proteins are antigens specific to Vogt-Koyanagi-Harada disease. Uveodermatologic syndrome in a Siberian husky: clinical and histopathological findings. Novel of chronic canine uveodermatologic syndrome (Vogt-Koyanagi-Harada-like syndrome). Uveodermatologic syndrome concurrent with keratoconjunctivitis sicca in a miniature poodle dog. Uveodermatological syndrome (Vogt-KoyanagiHarada-like syndrome) with depigmentation in a Siberian husky. Prompt therapy reduces the duration of systemic corticosteroids in Vogt-Koyanagi-Harada disease. Correlation between peripapillary atrophy and corticosteroid therapy in patients with Vogt-Koyanagi-Harada disease. Physicians using this drug should be very familiar with this risk as well as with the mutagenic potential to both men and women and with possible hematologic toxicities. Each scored tablet contains 50 mg azathioprine and the inactive ingredients lactose, magnesium stearate, potato starch, povidone, and stearic acid. The structural formula of azathioprine is: It is an imidazolyl derivative of 6-mercaptopurine and many of its biological effects are similar to those of the parent compound. Azathioprine is insoluble in water, but may be dissolved with addition of one molar equivalent of alkali. Azathioprine is stable in solution at neutral or acid pH but hydrolysis to mercaptopurine occurs in excess sodium hydroxide (0. Conversion to mercaptopurine also occurs in the presence of sulfhydryl compounds such as cysteine, glutathione, and hydrogen sulfide. Maximum serum radioactivity occurs at 1 to 2 hours 35 after oral S-azathioprine and decays with a half-life of 5 hours. This is not an estimate of the half-life of 35 azathioprine itself, but is the decay rate for all S-containing metabolites of the drug. Because of extensive metabolism, only a fraction of the radioactivity is present as azathioprine. Usual doses produce blood levels of azathioprine, and of mercaptopurine derived from it, which are low (<1 mcg/mL). Blood levels are of little predictive value for therapy since the magnitude and duration of clinical effects correlate with thiopurine nucleotide levels in tissues rather than with plasma drug levels. Azathioprine and mercaptopurine are moderately bound to serum proteins (30%) and are partially dialyzable. Both compounds are rapidly eliminated from blood and are oxidized or methylated in erythrocytes and liver; no azathioprine or mercaptopurine is detectable in urine after 8 hours. Proportions of metabolites are different in individual patients, and this presumably accounts for variable magnitude and duration of drug effects. Renal clearance is probably not important in predicting biological effectiveness or toxicities, although dose reduction is practiced in patients with poor renal function. Homograft Survival: the use of azathioprine for inhibition of renal homograft rejection is well established, the mechanism(s) for this action are somewhat obscure. The drug suppresses hypersensitivities of the cell-mediated type and causes variable alterations in antibody production. This agent has little effect on established graft rejections or secondary responses. Alterations in specific immune responses or immunologic functions in transplant recipients are difficult to relate specifically to immunosuppression by azathioprine.