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mcatmemoranda · 9 hours
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Typically, fontanelles close by the time your baby is 18 months old. The posterior fontanelle usually closes first — within 2 months of birth. The anterior fontanelle closes between 7 and 18 months.
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mcatmemoranda · 1 day
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Calcium and iron impair absorption of levothyroxine.
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mcatmemoranda · 1 day
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mcatmemoranda · 1 day
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Order serum bile acids. If they're 3x upper limit of normal, you diagnose it. Tx is ursodeoxycholic acid.
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mcatmemoranda · 1 day
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mcatmemoranda · 3 days
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We have Dynamed access with our Tufts logins. Dynamic (unlike UpToDate) has level of evidence associated with everything.
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mcatmemoranda · 4 days
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Orthostatic hypotension:
Systolic BP decreases by 20 mmHg or diastolic BP decreases by 10 mmHg within 3 minutes of standing from supine position. This is from a question I just answered. I thought having symptoms was also part of the diagnosis.
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mcatmemoranda · 4 days
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I'm reviewing questions and I answered this question about Down syndrome.
Children with Down syndrome can have iron insufficiency that can lead to long-term neurologic effects. Macrocytosis, which is present in up to a third of patients with Down syndrome, can mask the diagnosis of iron deficiency anemia. Therefore, a CBC with differential and serum iron & total iron binding capacity testing are recommended annually. In addition, it is recommended that a TSH level be checked annually, as the risk of hypothyroidism increases with age and by late childhood the incidence of thyroid abnormalities is fifty percent. Children with Down syndrome are also at increased risk for celiac disease.
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mcatmemoranda · 4 days
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mcatmemoranda · 7 days
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How long until the birth control implant begins to work?
If you get the implant during the first 5 days of your period, you’re protected from pregnancy right away.  If you get the implant at any other time in your cycle, use another form of birth control (i.e. condoms) during the first week. After that first week, the implant starts working and you’re protected from pregnancy for 3 years.
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mcatmemoranda · 7 days
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Taking trazodone can cause a urine drug screen to pop positive for fentanyl. I didn't know that. Had a pt whose UDS was positive for fentanyl. Send out was negative. He takes trazodone.
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mcatmemoranda · 10 days
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This is very helpful. I will use this to help my pt get off clonazepam. The pt takes clonazepam 1 mg tid. So we are going to use schedule 6 to taper off.
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mcatmemoranda · 10 days
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I'm reading about how to withdraw from benzos. So basically, you can decrease by 5% q1-2 weeks. This chart is helpful for seeing how strong the benzodiazepines are: https://deprescribe.web.unc.edu/wp-content/uploads/sites/20194/2020/04/Benzo-Equivalency-Table_UNC.pdf
My pt takes clonazepam 1 mg tid. 0.5 mg clonazepam is equivalent to 10 mg of diazepam. So my pt takes the equivalent of 60 mg diazepam a day. This is from the benzo.org.uk website:
Be confident - you can do it. If in doubt, try a very small reduction in dosage for a few days (for example, try reducing your daily dosage by about one tenth or one eighth; you may be able to achieve this by halving or quartering one of your tablets). You will probably find that you notice no difference. If still in doubt, aim at first for dosage reduction rather than complete withdrawal. You will probably wish to continue once you have started.
Be patient. There is no need to hurry withdrawal. Your body (and brain) may need time to readjust after years of being on benzodiazepines. Many people have taken a year or more to complete the withdrawal. So don't rush, and, above all, do not try to stop suddenly.
Choose your own way - don't expect a "quick fix". It may be possible to enter a hospital or special centre for "detoxification". Such an approach usually involves a fairly rapid withdrawal, is medically "safe" and may provide psychological support. Such centres may be suitable for a small minority of people with difficult psychological problems. However, they often remove the control of withdrawal from the patient and setbacks on returning home are common, largely because there has been no time to build up alternative living skills. Slow withdrawal in your own environment allows time for physical and psychological adjustments, permits you to continue with your normal life, to tailor your withdrawal to your own lifestyle, and to build up alternative strategies for living without benzodiazepines.
THE WITHDRAWAL
(1) Dosage tapering. There is absolutely no doubt that anyone withdrawing from long-term benzodiazepines must reduce the dosage slowly. Abrupt or over-rapid withdrawal, especially from high dosage, can give rise to severe symptoms (convulsions, psychotic reactions, acute anxiety states) and may increase the risk of protracted withdrawal symptoms (see Chapter III). Slow withdrawal means tapering dosage gradually, usually over a period of some months. The aim is to obtain a smooth, steady and slow decline in blood and tissue concentrations of benzodiazepines so that the natural systems in the brain can recover their normal state. As explained in Chapter I, long-term benzodiazepines take over many of the functions of the body's natural tranquilliser system, mediated by the neurotransmitter GABA. As a result, GABA receptors in the brain reduce in numbers and GABA function decreases. Sudden withdrawal from benzodiazepines leaves the brain in a state of GABA-underactivity, resulting in hyperexcitability of the nervous system. This hyperexcitability is the root cause of most of the withdrawal symptoms discussed in the next chapter. However, a sufficiently slow, and smooth, departure of benzodiazepines from the body permits the natural systems to regain control of the functions which have been damped down by their presence. There is scientific evidence that reinstatement of brain function takes a long time. Recovery after long-term benzodiazepine use is not unlike the gradual recuperation of the body after a major surgical operation. Healing, of body or mind, is a slow process.
The precise rate of withdrawal is an individual matter. It depends on many factors including the dose and type of benzodiazepine used, duration of use, personality, lifestyle, previous experience, specific vulnerabilities, and the (perhaps genetically determined) speed of your recovery systems. Usually the best judge is you, yourself; you must be in control and must proceed at the pace that is comfortable for you. You may need to resist attempts from outsiders (clinics, doctors) to persuade you into a rapid withdrawal. The classic six weeks withdrawal period adopted by many clinics and doctors is much too fast for many long-term users. Actually, the rate of withdrawal, as long as it is slow enough, is not critical. Whether it takes 6 months, 12 months or 18 months is of little significance if you have taken benzodiazepines for a matter of years.
It is sometimes claimed that very slow withdrawal from benzodiazepines "merely prolongs the agony" and it is better to get it over with as quickly as possible. However, the experience of most patients is that slow withdrawal is greatly preferable, especially when the subject dictates the pace. Indeed, many patients find that there is little or no "agony" involved. Nevertheless there is no magic rate of withdrawal and each person must find the pace that suits him best. People who have been on low doses of benzodiazepine for a relatively short time (less than a year) can usually withdraw fairly rapidly. Those who have been on high doses of potent benzodiazepines such as Xanax and Klonopin are likely to need more time.
Examples of slow withdrawal schedules are given at the end of this chapter. As a very rough guide, a person taking 40mg diazepam a day (or its equivalent) might be able to reduce the daily dosage by 2mg every 1-2 weeks until a dose of 20mg diazepam a day is reached. This would take 10-20 weeks. From 20mg diazepam a day, reductions of 1 mg in daily dosage every week or two might be preferable. This would take a further 20-40 weeks, so the total withdrawal might last 30-60 weeks. Yet some people might prefer to reduce faster and some might go even slower. (See next section for further details).
However, it is important in withdrawal always to go forwards. If you reach a difficult point, you can stop there for a few weeks if necessary, but you should try to avoid going backwards and increasing your dosage again. Some doctors advocate the use of "escape pills" (an extra dose of benzodiazepines) in particularly stressful situations. This is probably not a good idea as it interrupts the smooth decline in benzodiazepine concentrations and also disrupts the process of learning to cope without drugs which is an essential part of the adaptation to withdrawal. If the withdrawal is slow enough, "escape pills" should not be necessary.
(2) Switching to a long-acting benzodiazepine. With relatively short-acting benzodiazepines such as alprazolam (Xanax) and lorazepam (Ativan) (Table 1, Chapter I), it is not possible to achieve a smooth decline in blood and tissue concentrations. These drugs are eliminated fairly rapidly with the result that concentrations fluctuate with peaks and troughs between each dose. It is necessary to take the tablets several times a day and many people experience a "mini-withdrawal", sometimes a craving, between each dose.
For people withdrawing from these potent, short-acting drugs it is advisable to switch to a long-acting, slowly metabolised benzodiazepine such as diazepam. Diazepam (Valium) is one of the most slowly eliminated benzodiazepines. It has a half-life of up to 200 hours, which means that the blood level for each dose falls by only half in about 8.3 days. The only other benzodiazepines with similar half-lives are chlordiazepoxide (Librium), flunitrazepam (Rohypnol) and flurazepam (Dalmane), all of which are converted to a diazepam metabolite in the body. The slow elimination of diazepam allows a smooth, gradual fall in blood level, allowing the body to adjust slowly to a decreasing concentration of the benzodiazepines. The switch-over process needs to be carried out gradually, usually in stepwise fashion, substituting one dose at a time. There are several factors to consider. One is the difference in potency between different benzodiazepines. Many people have suffered because they have been switched suddenly to a different, less potent drug in inadequate dosage because the doctor has not adequately considered this factor. Equivalent potencies of benzodiazepines are shown in Table 1 (Chapter I), but these are only approximate and differ between individuals.
A second factor to bear in mind is that the various benzodiazepines, though broadly similar, have slightly different profiles of action. For example, lorazepam (Ativan) seems to have less hypnotic activity than diazepam (probably because it is shorter acting). Thus if someone on, say, 2mg Ativan three times a day is directly switched to 60mg diazepam (the equivalent dose for anxiety) he is liable to become extremely sleepy, but if he is switched suddenly onto a much smaller dose of diazepam, he will probably get withdrawal symptoms. Making the changeover one dose (or part of dose) at a time avoids this difficulty and also helps to find the equivalent dosage for that individual. It is also helpful to make the first substitution in the night-time dose, and the substitution may not always need to be complete. For example, if the evening dose was 2mg Ativan, this could in some cases be changed to 1 mg Ativan plus 8mg diazepam. A full substitution for the dropped 1 mg of Ativan would have been 10mg diazepam. However, the patient may actually sleep well on this combination and he will have already made a dosage reduction - a first step in withdrawal. (Examples of step-wise substitutions are given in the schedules at the end of this chapter.)
A third important practical factor is the available dosage formulations of the various benzodiazepines. In withdrawal you need a long-acting drug which can be reduced in very small steps. Diazepam (Valium) is the only benzodiazepine that is ideal for this purpose since it comes in 2mg tablets, which are scored down the middle and easily halved into 1 mg doses. By contrast, the smallest available tablet of lorazepam (Ativan) is 0.5mg (equivalent to 5mg diazepam) [in the UK the lowest available dosage form for lorazepam is 1mg]; the smallest tablet of alprazolam (Xanax) is 0.25mg (also equivalent to 5mg diazepam). Even by halving these tablets the smallest reduction one could easily make is the equivalent of 2.5mg diazepam. (Some patients become very adept at shaving small portions off their tablets). Because of limited dose formulations, it may be necessary to switch to diazepam even if you are on a fairly long-acting benzodiazepine of relatively low potency (e.g. flurazepam [Dalmane]). Liquid preparations of some benzodiazepines are available and if desired slow reduction from these can be accomplished by decreasing the volume of each dose, using a graduated syringe.
Some doctors in the US switch patients onto clonazepam (Klonopin, [Rivotril in Canada]), believing that it will be easier to withdraw from than say alprazolam (Xanax) or lorazepam (Ativan) because it is more slowly eliminated. However, Klonopin is far from ideal for this purpose. It is an extremely potent drug, is eliminated much faster than diazepam (See Table 1, Chapter I), and the smallest available tablet in the US is 0.5mg (equivalent to 10mg diazepam) and 0.25mg in Canada (equivalent to 5mg Valium). It is difficult with this drug to achieve a smooth, slow fall in blood concentration, and there is some evidence that withdrawal is particularly difficult from high potency benzodiazepines, including Klonopin. Some people, however, appear to have particular difficulty in switching from Klonopin to diazepam. In such cases it is possible to have special capsules made up containing small doses, e.g. an eighth or a sixteenth of a milligram or less, which can be used to make gradual dosage reductions straight from Klonopin. These capsules require a doctor's prescription and can be made up by hospital pharmacists and some chemists in the UK, and by compounding pharmacists in North America. A similar technique can be used for those on other benzodiazepines who find it hard to substitute diazepam. To locate a compounding pharmacist in the USA or Canada this web site may be useful: www.iacprx.org. Care must be taken to ensure that the compounding pharmacist can guarantee the same formula on each prescription renewal. It should be noted, however, that this approach to benzodiazepine withdrawal can be troublesome and is not recommended for general use.
(3) Designing and following the withdrawal schedule. Some examples of withdrawal schedules are given on later pages. Most of them are actual schedules which have been used and found to work by real people who withdrew successfully. But each schedule must be tailored to individual needs; no two schedules are necessarily the same. Below is a summary of points to consider when drawing up your own schedule.
Design the schedule around your own symptoms. For example, if insomnia is a major problem, take most of your dosage at bedtime; if getting out of the house in the morning is a difficulty, take some of the dose first thing (but not a large enough dose to make you sleepy or incompetent at driving!).
When switching over to diazepam, substitute one dose at a time, usually starting with the evening or night-time dose, then replace the other doses, one by one, at intervals of a few days or a week. Unless you are starting from very large doses, there is no need to aim for a reduction at this stage; simply aim for an approximately equivalent dosage. When you have done this, you can start reducing the diazepam slowly.
Diazepam is very slowly eliminated and needs only, at most, twice daily administration to achieve smooth blood concentrations. If you are taking benzodiazepines three or four times a day it is advisable to space out your dosage to twice daily once you are on diazepam. The less often you take tablets the less your day will revolve around your medication.
The larger the dose you are taking initially, the greater the size of each dose reduction can be. You could aim at reducing dosage by up to one tenth at each decrement. For example, if you are taking 40mg diazepam equivalent you could reduce at first by 2-4mg every week or two. When you are down to 20mg, reductions could be 1-2mg weekly or fortnightly. When you are down to 10mg, 1mg reductions are probably indicated. From 5mg diazepam some people prefer to reduce by 0.5mg every week or two.
There is no need to draw up your withdrawal schedule right up to the end. It is usually sensible to plan the first few weeks and then review and if necessary amend your schedule according to your progress. Prepare your doctor to be flexible and to be ready for your schedule to be adjusted to a slower (or faster) pace at any time.
As far as possible, never go backwards. You can stand still at a certain stage in your schedule and have a vacation from further withdrawal for a few weeks if circumstances change (if for instance there is a family crisis), but try to avoid ever increasing the dosage again. You don't want to back over ground you have already covered.
Avoid taking extra tablets in times of stress. Learn to gain control over your symptoms. This will give you extra confidence that you can cope without benzodiazepines (see Chapter III, Withdrawal Symptoms).
Avoid compensating for benzodiazepines by increasing your intake of alcohol, cannabis or non-prescription drugs. Occasionally your doctor may suggest other drugs for particular symptoms (see Chapter III, Withdrawal Symptoms), but do not take the sleeping tablets zolpidem (Ambien), zopiclone (Zimovane, Imovane) or zaleplon (Sonata) as they have the same actions as benzodiazepines.
Getting off the last tablet: Stopping the last few milligrams is often viewed as particularly difficult. This is mainly due to fear of how you will cope without any drug at all. In fact, the final parting is surprisingly easy. People are usually delighted by the new sense of freedom gained. In any case the 1mg or 0.5mg diazepam per day which you are taking at the end of your schedule is having little effect apart from keeping the dependence going. Do not be tempted to spin out the withdrawal to a ridiculously slow rate towards the end (such as 0.25mg each month). Take the plunge when you reach 0.5mg daily; full recovery cannot begin until you have got off your tablets completely. Some people after completing withdrawal like to carry around a few tablets with them for security "just in case", but find that they rarely if ever use them.
Do not become obsessed with your withdrawal schedule. Let it just become a normal way of life for the next few months. Okay, you are withdrawing from your benzodiazepines; so are many others. It's no big deal.
If for any reason you do not (or did not) succeed at your first attempt at benzodiazepine withdrawal, you can always try again. They say that most smokers make 7 or 8 attempts before they finally give up cigarettes. The good news is that most long-term benzodiazepine users are successful after the first attempt. Those who need a second try have usually been withdrawn too quickly the first time. A slow and steady benzodiazepine withdrawal, with you in control, is nearly always successful.
(4) Withdrawal in older people. Older people can withdraw from benzodiazepines as successfully as younger people, even if they have taken the drugs for years. A recent trial with an elderly population of 273 general practice patients on long-term (mean 15 years) benzodiazepines showed that voluntary dosage reduction and total withdrawal of benzodiazepines was accompanied by better sleep, improvement in psychological and physical health and fewer visits to doctors. These findings have been repeated in several other studies of elderly patients taking benzodiazepines long-term.
There are particularly compelling reasons why older people should withdraw from benzodiazepines since, as age advances, they become more prone to falls and fractures, confusion, memory loss and psychiatric problems (see Chapter 1).
Methods of benzodiazepine withdrawal in older people are similar to those recommended above for younger adults. A slow tapering regimen, in my experience, is easily tolerated, even by people in their 80s who have taken benzodiazepines for 20 or more years. The schedule may include the use of liquid preparations if available and judicious stepwise substitution with diazepam (Valium) if necessary. There is, of course, a great deal of variation in the age at which individuals become "older" - perhaps 65-70 years would fit the definition in most cases.
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mcatmemoranda · 12 days
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The new child developmental specialist at my clinic recommended Poop Guru for kids who don't poop well.
Basically, you keep titrating up the MiraLax until the kid is having at least a bowel movement a day and don't stop even when you get to that point; continue MiraLax for months before stopping it.
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mcatmemoranda · 12 days
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Pretty sure I made a post before about how opioids can cause sexual dysfunction. Had a pt the other day who is on methadone for hx of heroin use who complained about ED symptoms. Pretty sure it's the methadone that's doing that.
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mcatmemoranda · 12 days
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It annoys me when people don't understand the difference between sex and gender. It's pretty straightforward.
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mcatmemoranda · 16 days
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