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Lung Function In Health And Disease: Basic Concepts of Respiratory Physiology and Pathophysiology

All rights reserved. Am J Manag Care. Insomnia, whether short-term or chronic, is a common condition. It has a negative impact on vulnerable patient groups, including active military personnel and veterans, patients with coexisting psychiatric and medical disorders, those in life transitions such as menopause, and elderly persons. Although cognitive behavioral therapy for insomnia CBTI is first-line treatment for insomnia, its high cost and a lack of trained providers has prevented widespread uptake.

The first part of this article reviews the epidemiology and pathophysiology of insomnia with a focus on vulnerable patient groups.

The second part explores the rapidly evolving landscape of nondrug therapy for insomnia. Insomnia, the most common sleep disorder, is a substantial burden for the US healthcare system and vulnerable patient groups.

In , the third edition of the International Classification of Sleep Disorders ICSD-3 , the most widely used classification system for sleep disorders, revised how insomnia is defined.

The previous subclassification of chronic insomnia as primary or comorbid was eliminated because it did not improve diagnostic accuracy or differentiate treatment options. The underlying rationale for removal was that calling insomnia comorbid may misleadingly imply that it is a secondary concern that will resolve with adequate treatment of the comorbid condition.

To the contrary, the maladaptive cognitions and behaviors that perpetuate insomnia must be addressed regardless of coexisting medical or psychiatric disorders.

Diagnostic criteria for insomnia include difficulty getting to sleep or staying asleep and results in daytime dysfunction in a patient who has an adequate opportunity to sleep. Insomnia is often precipitated by a significant life stressor eg, acute pain, traumatic event.

It may end when the stressor resolves or the patient learns to cope, or it may evolve into chronic insomnia. Chronic insomnia is a clinical diagnosis that relies heavily on patient history about sleep, medical and psychiatric conditions, and substance use. Descriptors that measure and characterize sleep disturbances are shown in Table 1.

Insomnia can occur as a primary sleep disorder, a symptom of another sleep disorder eg, obstructive sleep apnea [OSA], restless legs syndrome [RLS] , periodic leg movements during sleep [PLMS] , or a comorbid sleep disorder. The sleep history may suggest the presence of another sleep disorder. Concerns about OSA should be heightened in patients with obesity or a thick neck.

Insomnia is a complex interaction of psychological cognitive arousal and altered circadian and homeostatic mechanisms. Decreased function of the sleep-wake switch may also contribute to insomnia. During sleep, there is a slow transition through stages of non—rapid-eye movement non-REM sleep to cycles of rapid-eye movement REM sleep.

Multiple brain centers work in concert to promote sleep or wakefulness. The sleep-wake cycle is a complex process in which wakefulness and sleep are switched on and off by reciprocal systems in a feedback loop.

This system projects widely into the cerebral cortex. This model of the sleep-wake cycle is often called the flip-flop switch because it permits one to either be awake or asleep, but not both, at the same time.

Via the switching mechanism, the active state suppresses the other state until circadian rhythms induce a switch to the reciprocal state. The cerebral cortex and the limbic system further modify wakefulness. Sleep-promoting centers in the anterior hypothalamus project into the brainstem and posterior arousal centers and function with the lateral hypothalamus as a sleep-wake switch.

Circadian factors promote wakefulness on a roughly hour biological clock, whereas homeostatic factors respond to accumulated wakefulness with the drive for sleep. During wakefulness, the ARAS inhibits the VLPR via activation of cholinergic neurons, monoaminergic cell bundles, and orexin nuclei in the lateral hypothalamus.

The orexin system promotes wakefulness and alertness and works to balance sleep and wakefulness. Orexin system activation maintains the fully awake state for longer periods of time; conversely, deactivation of the orexin system allows for consolidated sleep during the night. Orexinergic signaling by 2 distinct forms, orexin A and orexin B, maintains wakefulness via continuous depolarization in wake-promoting brain nuclei.

Sleep is cued by a homeostatic sleep drive inhibition of orexins. The 3P behavioral model of insomnia helps to explain how acute insomnia becomes chronic and lays the groundwork for assessing insomnia in individual patients. Predisposing factors, which are generally not modifiable, include genetics and personality traits eg, being a worrier; family history of poor sleep that lead to physiologic and cognitive hyperarousal. As shown in Table 2 , precipitating factors that trigger insomnia are typically stressful life events.

Patients usually identify problems related to health, family, work, or school as precipitating factors for insomnia.

Less quantifiable perpetuators include dysfunctional beliefs, expectations, and attributions about sleep as well as an intense desire to solve the sleep problem. The burden of insomnia in the United States was extensively characterized in by the American Insomnia Survey, a nationwide survey of more than 10, members in a national health plan.

The prevalence of insomnia based on other diagnostic criteria in place at the time was The incidence of insomnia appears to be increasing in the United States. Insufficient sleep has been linked to poor outcomes across many disease states, including cardiovascular and cerebrovascular disease, cancer, hypertension, and diabetes. Insomnia has bidirectional effects with coexisting medical and mental disorders, especially depression.

Active military personnel and veterans are extremely vulnerable to insomnia. Most veterans report sleep disturbances and about half meet the diagnosis of insomnia.

In a retrospective cohort study of more than 1. Medical conditions linked to more than a 2-fold risk of OSA included hypertension, gastroesophageal reflux, diabetes, PTSD, and being overweight or obese. Almost 2. The relationship between sleep quality and global functioning was also bidirectional, with greater sleep disturbance predicting greater functional impairment months later and vice versa.

This raises the possibility that early detection and management of sleep disturbances may both identify patients with a poor prognosis and improve recovery from TBI.

A key concern for clinicians is that insomnia strongly predicts the occurrence of depression. The risk of developing an anxiety disorder was also increased OR, 6. Alcohol use and insomnia have a complex relationship. Further, cannabis withdrawal can cause severe insomnia characterized by trouble falling asleep and staying asleep, as well as vivid dreams, all of which make it difficult to quit.

Vasomotor symptoms are an important precipitating factor for chronic insomnia in peri- and postmenopausal women. Insomnia was associated with depressive symptoms OR, 8. Biological factors related to aging that are thought to predispose elderly persons to insomnia include circadian rhythm changes that lead to less deep sleep, more sleep fragmentation, and early morning awakening.

Since the mids when sleep hygiene education was conceived, nondrug therapy has evolved to target both physiologic and cognitive hyperarousal factors that contribute to insomnia. Teaching patients about behavioral and environmental factors that improve sleep see Table 3 10,16,80,81 can improve sleep over baseline. Practice guidelines recommend against sleep hygiene education SHE as a stand-alone intervention because it is less effective than CBTI or mindfulness training 16 ; however, sleep hygiene education is still commonly used in primary care.

Study results show children and adolescents are particularly sensitive to insomnia worsened by light from electronics, with almost twice the magnitude of melatonin suppression compared with adults. The goal of behavioral treatment is to break the maladaptive connection between going to sleep and hyperarousal using 2 retraining strategies: 1 sleep restriction and 2 stimulus control.

Stimulus control aims to break the association between being in bed and negative aspects of insomnia, such as wakefulness, frustration, and worry.

The underlying rationale is that eliminating these activities allows the bed to be re-associated with sleep rather than arousal. Both strategies may increase daytime sleepiness in the short term. Sleep specialists recommend against sleep restriction in patients with coexisting conditions that sleep deprivation can exacerbate, such as untreated sleep apnea or seizure disorders. This streamlined 4-session approach, which focuses on stimulus control and sleep restriction, can be delivered by healthcare providers without specialized training.

The goal of cognitive therapy for insomnia is to identify and challenge myths and negative beliefs about sleep that perpetuate insomnia, and then replace them with rational thoughts and facts. Based on robust evidence from many clinical trials, practice guidelines recommend cognitive behavioral therapy for insomnia CBTI as first-line treatment of chronic insomnia. In comparative studies, the efficacy of CBTI was comparable with benzodiazepines or benzodiazepine receptor agonists during acute use; however, sedative hypnotics did not have continued benefit after discontinuation.

An important CBTI side benefit is improvement in symptoms of coexisting psychiatric conditions, particularly depression. Despite guideline recommendations and robust evidence of benefit, few patients receive CBTI.

The key access barrier is the lack of trained clinicians. Over the last decade, CST eg, Fitbit has become ubiquitous. There are more than 10, behavioral health apps, most of which focus on relaxation, mindfulness, and meditation. As part of a wider initiative to provide digital therapeutics as a health plan benefit, CVS Health is encouraging employers to offer Sleepio as an employee benefit. Improvements in functional health and psychological well-being were more modest, with respective adjusted differences of 1.

Somryst is a software application that provides CBTI and sleep restriction in 6 sessions. Clinicians should not assume all dCBTI programs are equal. Programs with a longer duration and more personal clinical support may have greater benefit.

Insomnia is a heterogenous and almost ubiquitous disorder with unique predisposing and precipitating factors in vulnerable patient groups. Successful management requires that managed care clinicians understand the factors that drive insomnia in these groups.

CBTI effectively treats chronic insomnia in most patients with coexisting medical and psychiatric conditions, in the elderly population, and in those in life transitions, such as menopause. A decade ago, understanding the subtleties of CBTI was a moot point because access barriers, primarily high cost and a lack of trained providers, prevented widespread adoption.

Today, managed care clinicians face a vastly different challenge—the relatively unexplored landscape of digital therapeutics. However, dCBTI is here to stay, and it is a scalable option that is being launched in managed care. Now, the issues are which dCBTI product to provide, how to deliver it, how to manage nonresponders and adherence issues, and overall, what role dCBTI will play in the step-care of chronic insomnia.

Author affiliation: Julie A. Funding source: This activity is supported by an educational grant from Eisai. Author disclosure: Dr Dopheide has no relevant financial relationships with commercial interests to disclose. Authorship information: Substantial contributions to the intellectual content including acquisition of data, analysis and interpretation of data, drafting of the manuscript, and critical revision of the manuscript for intellectual content.

Medical writing and editorial support provided by: Jill E. Winkelman JW. Clinical practice. N Engl J Med. Sleep Med Rev.

Multiple Organ Failure: Pathophysiology and Basic Concepts of Therapy

Richard J. Mahler, Michael L. SIXTEEN million individuals in the United States with type 2 diabetes mellitus and an additional 30—40 million with impaired glucose tolerance result in health care costs exceeding billion dollars annually 1. Treatment is predominantly directed at microvascular and macrovascular complications 2. In type 1 diabetes mellitus the relationship between glycemic control and microvascular complications has been well established 3. The relationship between tight glycemic control and microvascular disease in type 2 diabetes mellitus appears to be established in the recently completed United Kingdom prospective diabetes study 4 , 5. Despite the morbidity and mortality associated with retinopathy, nephropathy, and neuropathy, cardiovascular disease remains the leading cause of death in type 2 diabetes mellitus 6 , 7.

pdf pathophysiology and basic concepts of therapy

Pathophysiology / Concept Mapping


It is a multifactorial disease, including genetic and environmental factors. Environmental trigger is represented by gluten while the genetic predisposition has been identified in the major histocompatibility complex region. The reason of its under-recognition is mainly referable to the fact that about half of affected people do not have the classic gastrointestinal symptoms, but they present nonspecific manifestations of nutritional deficiency or have no symptoms at all. Here we review the most recent data concerning epidemiology, pathogenesis, clinical presentation, available diagnostic tests and therapeutic management of celiac disease. Core tip: Celiac disease is a chronic inflammatory disorder of the small intestine, produced by the ingestion of dietary gluten products in susceptible people. Thanks to advanced understanding of its pathogenesis, numerous therapeutic strategies have been devised for the treatment of celiac disease. But there is need of further basic research studies and randomized clinical trials to introduce them into usual management of this disease.

It seems that you're in Germany. We have a dedicated site for Germany. This book represents a comprehensive, clinically oriented text covering all aspects of male osteoporosis, from the basic concepts of bone physiology and regulation of bone remodeling in men, the causes and pathophysiological mechanisms responsible for the most frequent causes of osteoporosis, to diagnostic and screening protocols, as well as prevention and treatment approaches. It offers a broad overview of male osteoporosis by specialists involved in research and clinical practice and discusses the practical issues encountered. Filling a gap in the literature, this volume is a valuable resource for general practitioners, clinical endocrinologists, geriatricians and experts in osteoporosis.

All rights reserved. Am J Manag Care. Insomnia, whether short-term or chronic, is a common condition. It has a negative impact on vulnerable patient groups, including active military personnel and veterans, patients with coexisting psychiatric and medical disorders, those in life transitions such as menopause, and elderly persons. Although cognitive behavioral therapy for insomnia CBTI is first-line treatment for insomnia, its high cost and a lack of trained providers has prevented widespread uptake.

University of Cincinnati Ohio. This article is only available in the PDF format.

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Male Osteoporosis

Он превозносил достоинства Цифровой крепости по электронной почте, которую направлял на свой собственный адрес. Он писал письма, отправлял их анонимному провайдеру, а несколько часов спустя этот провайдер присылал эти письма ему самому. Теперь, подумала Сьюзан, все встало на свои места. Танкадо хотел, чтобы Стратмор отследил и прочитал его электронную почту. Он создал для себя воображаемый страховой полис, не доверив свой ключ ни единой душе.

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