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By: Lars I. Eriksson, MD, PhD, FRCA

• Professor and Academic Chair, Department of Anaesthesiology and Intensive Care Medicine, Karolinska University Hospital, Solna, Stockholm, Sweden

Patients are often haunted by recurring dreams of their traumas and awaken in terror anxiety relief techniques buy phenergan 25 mg lowest price. This kind of progressive dream series shows the mind and brain slowly changing anxiety symptoms watery mouth purchase phenergan 25 mg overnight delivery, as the patient learns that he is safe now anxiety yelling 25mg phenergan with amex. What physical evidence exists that dreams show our brains in the process of plastic change anxiety symptoms for xanax buy phenergan 25mg with mastercard, altering hitherto buried, emotionally meaningful memories, as in Mr. The newest brain scans show that when we dream, that part of the brain that processes emotion, and our sexual, survival, and aggressive instincts, is quite active. At the same time the prefrontal cortex system, which is responsible for inhibiting our emotions and instincts, shows lower activity. With instincts turned up and inhibitions turned down, the dreaming brain can reveal impulses that are normally blocked from awareness. Scores of studies show that sleep helps us consolidate learning and memory and effects plastic change. A team led by Marcos Frank has also shown that sleep enhances neuroplasticity during the critical period when most plastic change takes place. Recall that Hubel and Wiesel blocked one eye of a kitten in the critical period and showed that the brain map for the blocked eye was taken over by the good eye - a case of use it or lose it. They found that the more sleep the kittens got, the greater the plastic change in their brain map. Each day, in analysis, Mr, L worked on his core conflicts, memories, and traumas, and at night there was dream evidence not only of his buried emotions but of his brain reinforcing the learning and unlearning he had done. L, at the outset of his analysis, had no conscious memories of the first four years of his life: most of his memories of the period were unconscious procedural memories - automatic sequences of emotional interactions - and the few explicit memories he had were so painful, they were repressed. In treatment he gained access to both procedural and explicit memories from his first four years. One possibility is that he repressed some of his adolescence; often when we repress one thing, such as a catastrophic early loss, we repress other events loosely associated with it, to block access to the original. It has recently been discovered that early childhood trauma causes massive plastic change in the hippocampus, shrinking it so that new, long-term explicit memories cannot form. These early stresses predispose these motherless animals to stress-related illness for the rest of their lives. When they undergo long separations, the gene to initiate production of glucocorticoids gets turned on and stays on for extended periods. Trauma in infancy appears to lead to a supersensitization - a plastic alteration - of the brain neurons that regulate glucocorticoids. Recent research in humans shows that adult survivors of childhood abuse also show signs of glucocorticoid supersensitivity lasting into adulthood. That the hippocampus shrinks is an important neuroplastic discovery and may help explain why Mr. Depression, high stress, and childhood trauma all release glucocorticoids and kill cells in the hippocampus, leading to memory loss. The hippocampus of depressed adults who suffered prepubertal childhood trauma is 18 percent smaller than that of depressed adults without childhood trauma - a downside of the plastic brain: we literally lose essential cortical real estate in response to illness. As people recover from depression, their memories return, and research suggests their hippocampi can grow back. In fact, the hippocampus is one of two areas where new neurons are created from our own stem cells as part of normal functioning. Antidepressant medications increase the number of stem cells that become new neurons in the hippocampus. Rats given Prozac for three weeks had a 70 percent increase in the number of cells in their hippocampi. It usually takes three to six weeks for antidepressants to work in humans - perhaps coincidentally, the same amount of time it takes for newly born neurons in the hippocampus to mature, extend their projections, and connect with other neurons. So we may, without knowing it, have been helping people get out of depression by using medications that foster brain plasticity. Since people who improve in psychotherapy also find that their memories improve, it may be that it also stimulates neuronal growth in their hippocampi. He also observed that a "depletion of the plasticity" tended to occur in many older people, leading them to become "unchangeable, fixed, and rigid.

These specialists have a good understanding of how changing the daily dosage or overall length of treatment optimizes these clinical benefits anxiety funny purchase phenergan 25mg amex. The difference in susceptibility to anxiety symptoms joints discount phenergan 25 mg overnight delivery radiation between normal cells and cancer cells is called the therapeutic index anxiety symptoms of phenergan 25mg amex. A skilled radiation oncologist manipulates each plan to anxiety or depression discount phenergan 25 mg amex take full advantage of this therapeutic parameter. If you choose to practice radiation oncology, get ready for all manner of button-pushing witticisms. But your more earnest colleagues will often ask you to describe, in the most fundamental terms, what it is that you actually do as this type of doctor. Radiation oncologists do not press buttons any more often than medical oncologists (chemotherapy physicians) stand over a Bunsen burner preparing a concoction of some chemotherapeutic brew. Those who actually deliver the radiation treatment- the therapists-hold their own special position in the care of cancer patients, which is quite separate from that of the physician. For a radiation oncologist, the care of a cancer patient begins with the referral for consultation. Radiation oncologists, therefore, take on the role of consultant, rather than primary, cancer care physician. You will receive patients from another member of the interdisciplinary cancer treatment team. Medical oncologists refer many of their patients with lung cancer or other malignancies to radiation oncologists for further management and specialized expertise. Radiation oncologists rarely receive patients directly from primary care physicians. This is mainly because a patient must first be diagnosed with cancer before they wind up with any oncologist. Sometimes the way to your clinic is even more serpentine, in part because radiation oncology simply remains a bit of a mystery even to other physicians. At the initial consultation, you will perform a history and physical examination that, in keeping with the academic nature of this specialty, is rather inclusive. Any patient under medical care needs observation for sequelae of disease and effects of medical intervention. Because patients receive treatment in clinic every day, the radiation oncologist often diagnoses many medical problems while the patient undergoes treatment. You must be well-versed in Enjoys an intellectual environrelevant surgical procedures, radiment with an emphasis on sciographic images, and pathologic variants entific literature. At consult, radiation oncolo Can cope with treating pagists have a considerable amount of intients who are terminally ill. All radiation oncologists must consider anatomic involvement as defined at surgery and then compare it with findings from diagnostic imaging. Further testing and clinical investigations are an important part of practicing radiation oncology. Radiation oncologists direct the overall plan for their patient by ordering whatever additional diagnostic studies are needed. Comprehensive skill at diagnostic techniques, therefore, serves you well in this specialty. Is that all tumor which needs to be treated, or perhaps there is associated consolidation, which could represent an area of lung that your treatment might spare? For the medical oncologist, this may be less of a consideration if it does not affect their treatment plan. Before initiating any radiation treatment, you may also suspect the presence of metastatic disease. Radiation oncologists need to understand the clinical behavior of the disease so that they can give the most appropriate treatment. Radiation oncologists also require a solid understanding of the histology and pathology of cancer. Endometrial cancer, for example, is one of the common malignancies these physicians treat. For this disease, knowing the pathologic difference between high-grade and low-grade tumors could determine whether a patient should receive any radiation therapy.

You could be operating every day anxiety disorder symptoms dsm 5 order 25mg phenergan with visa, or nearly every day anxiety symptoms 6 dpo discount phenergan 25mg on-line, and doing a wide variety of cases-cystectomy with a range of urinary diversions anxiety 9 year old boy discount 25 mg phenergan with visa, prostatectomy anxiety symptoms zollinger purchase 25mg phenergan mastercard, pelvic surgery for a mass that nobody else wants to tackle, repair of ureteric injuries from other surgeons, and revision of a urethral sling because a 60-yearold woman is still bothered by her stress urinary incontinence. Most urologists with academic careers spend a fair amount of time dedicated to clinical research. Some hold positions in which they mostly see patients in the clinic, operating occasionally, referring the big open cases to colleagues, and then spending the rest of their time in research endeavors. These academic urologists generally have established themselves as experts within their research field-for example, male sexual dysfunction-and nearly all the clinic patients they see are there precisely for that reason. Every once in awhile, these specialists may go to the operating room, for instance, to place a penile prosthesis. Some physicians may be partners only in economics and overhead but not in patient-care responsibilities. Some practices may be so tight knit that the entire group rounds together every morning at the hospital, seeing whatever inpatients they collectively have, treating all group patients as if they were their individual patient. A urologist desiring a part-time job in a group practice so that he or she can have time for family is not unheard of. Also, given the nature of the anatomy dealt with, most urologists are required to have a pretty good sense of humor. Given this environment, most women interested in a surgical career may have some hesitation about selecting urology. Certainly, if the doctor is uncomfortable, the patient will be uncomfortable, regardless of gender. The demand for women in the field has grown so much recently that women in urology training programs begin fielding job offers well before they are finished with their training. These are inevitably from group practices of urologists, all male, who have had women call asking if they can see a woman doctor. Of course, the struggle for the general practice woman in adult urology is to see male and female patients. Naturally, women sometimes need a major open surgery such as a nephrectomy or cystectomy, but for the most part, their complaints have to do with voiding dysfunction. Certainly, this is avoidable with awareness and careful planning with the partners. Women have some added disadvantages, which obviously have to do with our biologic role with birthing babies. While any employer is legally required to provide maternity leave, your co-workers are not guaranteed as a replacement while you are gone. This could potentially seed resentment if the delivery date is during a particularly stressful time for the department. The same numbers of patients keep coming in, and there may be fewer physicians to take care of them. Some department heads even find creative ways to support the remainder of the house staff if a female resident was not able to plan the pregnancy perfectly. Still, most female surgical residents do not attempt to have a baby while in residency training Another interesting phenomenon is the single female surgical resident. For unclear reasons, there are many super, bright, beautiful, dedicated women who are single. True, training in surgery is likely a bit threatening to the weaker members of the opposite sex. And true, professional women regardless of career in our culture are staying single longer and longer. They generally last 3 years: 2 years of research plus 1 year of clinical subspecialty training. Endourology includes advanced training in laparoscopic urologic surgery, percutaneous kidney surgery, and ureteroscopy. LaSource: American Urological Association paroscopy is still relatively new to the urology world, and not all training programs afford residents enough experience to then feel comfortable offering patients a fair choice between a laparoscopic and an open procedure.

Women who received exercise interventions were more likely to anxiety symptoms 37 discount phenergan 25mg free shipping have low gestational weight gain than control subjects anxiety symptoms 10 year old generic 25 mg phenergan overnight delivery. However anxiety symptoms light sensitivity buy phenergan 25mg overnight delivery, in that review anxiety 7 months pregnant order 25mg phenergan mastercard, women who participated in an exercise program during pregnancy were less likely to have hypertension during pregnancy. The more women exercised before and during their pregnancies, the less likely they were to develop preeclampsia. Reduce Back Pain A survey of 950 pregnant women (84% response rate) showed that low back pain is a common complaint in pregnancy, with 68. The investigators found a significant reduction in the first stage of labor among women who followed a prescribed exercise program compared with the control group. However, before exercise is prescribed, it is important that providers understand physiologic changes associated with pregnancy, and those associated with exercise in pregnancy. Cardiovascular and Pulmonary Adaptations There are many physiologic changes that occur during pregnancy. There are significant cardiovascular changes, including a significant increase in blood volume, heart rate, and cardiac output, and a decrease in systemic vascular resistance. In healthy pregnancies, blood pressure decreases, beginning in early pregnancy, with a nadir in mid-pregnancy. Heart rate and blood pressure typically normalize quickly in the postpartum period in the absence of superimposed complications. Glucose Metabolism Maternal physiologic changes in carbohydrate metabolism during pregnancy serve to ensure a constant supply of glucose to the fetus to sustain growth. Glucose crosses the placenta to the fetus by means of facilitated diffusion, a process by which the glucose is diffused across cell membranes by carrier proteins. Consequently in the fasting state maternal fasting glucose levels are decreased by 15% to 20% compared with those in nonpregnant women. There is also a diminished response to insulin caused by human placental lactogen and other hormones. Musculoskeletal Changes There are multiple physiologic changes in pregnancy that impact the musculoskeletal system. There is a variable increase in body mass, and the distribution of body mass changes with the growth of the uterus and fetus. These alterations are likely adaptive to compensate for the physiologic changes in the center of gravity and the increased lordosis of pregnancy. The goal of the guidelines is to define appropriate weight gain to promote normal infant birth weight, and to reduce postpartum weight retention. This review further identified that there was strong evidence that excess gestational weight gain was associated with increased infant birthweight, whereas insufficient weight gain was associated with lower infant birth weight. A recent study of healthy pregnant women assessed heart rate variability with exercise in pregnancy. The results showed that consistent maternal exercise throughout pregnancy was associated with lower maternal heart rate and increased heart rate variability, suggesting overall improved cardiac autonomic control. Results showed that pregnant women had more rapid and extreme drops in blood glucose with exercise compared with nonpregnant control subjects. In addition, pregnant women had more significantly decreased insulin levels after exercise. The fetal heart rate has been shown to increase as a result of maternal exercise, both during and soon after the exercise occurs. Assessments of fetal well-being were made before and after the treadmill exercise sessions. The results indicated that maternal treadmill exercise was well-tolerated by the fetuses in this study. Exercise is encouraged for pregnant women; however, physicians must evaluate each individual pregnant woman before prescribing her optimal exercise regimen. Women who are starting a new exercise program should increase their physical activity gradually over time. However, that limitation is no longer included in the updated guideline, published in 2015. These activities are recommended for healthy women who are cleared for exercise in pregnancy.

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References:

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