The first of the shorter half-life benzodiazepine hypnotics to be introduced were temazepam and triazolam. Temazepam has a half-life of 5 hours and is commonly used in primary, secondary and tertiary settings for insomnia. A possible drawback of very short half-life hypnotics is rebound insomnia. This is a state of worsening sleep which commonly follows discontinuation of a regularly used hypnotic.
Second MBBS Revisited
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Much clinical practice and opinion suggests that benzodiazepine can be used as first-line treatment for acute anxiety episodes as long as CSM guidelines are adhered to. For more intractable conditions such as established social phobia, generalised anxiety disorder and panic disorder, they should probably be reserved for adjunctive or second-line agents.
Ultrastructural analysis shows that the nodules are composed mostly of closely packed bundles of fibrillary material of high electron density and cellular elements of various kinds, irregularly dispersed within the fibrillary mass. The basement membrane of the amnion epithelium is usually present under the nodules and sometimes appears multilaminated.6 This indicates that the process is largely superficial and the underlying stroma does not participate in the formation of the lesion. The microscopic and ultrastructural features lend credence to the belief that AN represents deposits of cellular elements from the fetal skin accumulating and organizing on the surface of the amniotic epithelium and undergoing secondary degenerative changes, with subsequent invasion of the squamous cell mass by connective tissue.
It is generally believed that AN is associated with conditions that lead to significant prolonged oligohydramnios. The association with marked oligohydramnios was first reported in 1912, when it was thought that perforation of the amnion by fetal hair had resulted in proliferation of the epithelium forming the nodules.13 It is found in placentas from fetuses with renal agenesis, following premature rupture of membranes, in the donor twin of the twin transfusion syndrome, in diamniotic acardiac twins, and in sirenomelia.10 Relationship between AN and oligohydramnios have been explained in 2 ways: (1) squames from the hyperconcentrated amniotic fluid might adhere to the surface of the amnion, producing secondary degeneration of the amniotic epithelium, and (2) fetal movement could erode the amniotic epithelium, leading to the incorporation of fetal squames and further proliferation of the exposed amniotic mesoderm.4 Available evidence suggests that reduced liquor in oligohydramnios allows the fetus to come into direct contact with the amnion, thereby leading to transfer of fetal squames to the amnion by a detritic mechanism.7
Although the typical model association of AN are anomalies of the fetal urinary system, our analysis has shown that AN secondary to prolonged premature rupture of membranes is almost as common as AN associated with congenital malformations and more common than AN secondary to genitourinary malformations alone. This, however, may be because prolonged premature rupture of membranes is a very common condition, much more common than fetal genitourinary malformations.
Doherty et al have described five levels of family-centred medical care.4 The first and minimal level is the consideration of the family in the diagnosis of genetically related diseases and medical legal situations. The second level is the involvement of the family in the disclosure of diagnosis and management of a patient's illness. The third level is the recognition of the impact of an illness on the family and family problem as a possible causal, precipitating or perpetuating factor of a person's illness. The fourth level involves the conduct of family interviews to assess the family structure, relations and dynamics in order to detect any family dysfunction, and to stimulate the family to find more effective ways of solving their problems. The fifth is the highest level in which specific family therapy is given to change dysfunctional family relationships.
Basic medical education teaches doctors at most up to the second level of family involvement, which is the level required by doctors in most medical disciplines but it is not adequate for family medicine. The family doctor must have the knowledge and skills to provide the third level of family-centred care in order to fulfil the roles of early diagnosis and whole-person care. Like physical diseases, family problems are more likely to have a better outcome if the family doctor can detect them early so that proper management can be given. The family doctor is also in the best position to anticipate and prevent possible family dysfunction in relation to a patient's illnesses, e.g. dementia, or at different stages of a person's life, e.g. newly married. 2ff7e9595c
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