Annals of internal medicine
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Anorectal disorders include a diverse group of pathologic processes that are frequently encountered in general medical practice but are poorly understood. The optimal management of anal pain, itching, bleeding, and incontinence is based on sound anatomic and pathophysiologic principles. Advances have been made in understanding the pathogenesis and management of four anorectal disorders frequently encountered by internists: hemorrhoids, fissures, pruritus, and incontinence.
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Nonobstetric disease requiring surgery may complicate pregnancy and jeopardize maternal and fetal well-being. Surgery may be safely done if the physician is aware of anatomic and physiologic alterations during gestation that necessitate an altered approach to diagnosis and management. Fetal exposure to all diagnostic and therapeutic agents should be minimized, particularly during organogenesis. ⋯ Furthermore, the broad range of available antibiotic, analgesic, and anesthetic agents provide the physician with options for treatment that have an acceptable degree of risk to fetal health. Anesthesia and surgery are tolerated considerably better by the fetus than is maternal hypotension, hypoxia, or sepsis. When an operative procedure is urgently or emergently indicated, pregnancy should not delay timely intervention.
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In several bacterial diseases, the clinical, laboratory, and histologic findings result from the elaboration by the organism of a toxic product that binds to and may enter the host cell to alter its metabolism. In some cases, the intracellular mediators of toxin action are the cyclic nucleotides, cyclic adenosine 5'-monophosphate (cAMP) and cyclic guanosine 5'-monophosphate (cGMP), the ubiquitous second messengers through which numerous hormones, neurotransmitters, and drugs exert their effects. Certain toxins act by enhancing the activity of cellular enzymes that synthesize cAMP or cGMP; and others, by themselves catalyzing cAMP synthesis after entering the cell. Studies of the mechanism of action of these toxins have helped in deciphering the enzymatic components within animal cells that are responsible for cyclic nucleotide synthesis, degradation, and function as well as in understanding the pathogenesis of the diseases in which they are involved.
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In hospitalized patients, the commonest causes of acute insomnia are the effects of illness, environmental sleep disruption, medication, anxiety, and depression. Treatment should correct underlying medical disorders; reduce environmental sleep disruptions; and lower anxiety with psychological interventions, sedative or hypnotic medication, and relaxation training. Special clinical problems include chronic pain, delirium, and insomnia in the elderly.
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Patient-controlled analgesia is a relatively new and investigational technique that permits patients to treat pain by directly activating doses of intravenous narcotics. The technique was developed in response to the undertreatment of pain in hospitalized patients. ⋯ The technique is also an ideal investigative instrument for studying equianalgesic states. Several foreign-made devices are now being used under investigational sanctions in this country, and it is anticipated that several American manufacturers will be seeking regulatory approval to market the devices.