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Androgen ablation is achieved by a variety of strategies discount modafinil 100 mg amex. Castration or diminishing testosterone production can be achieved surgically with orchiectomy or chemically with luteinizing hormone–releas- ing hormone agonists discount modafinil 100mg line. Chemotherapy has a clear role in patients with hormone-refracto- ry prostate cancer. Docetaxel plus prednisone is now the standard chemotherapy for men with metastatic prostate cancer. A 65-year-old man attended a community-based health fair, where it was discovered that his PSA level was elevated; he was referred to your clinic. The patient states that he has always been healthy and that he has not seen a physician for years. On review of systems, he does note some frequency, hesitancy, and urgency of urination, which he has been experiencing for the past few years. DRE reveals a smooth, sym- metrically enlarged prostate gland and brown guaiac-negative stool. Which of the following is NOT associated with elevated PSA levels? Prostatitis 12 ONCOLOGY 23 Key Concept/Objective: To know those conditions associated with elevated PSA levels Screening for prostate cancer by use of PSA has led to an increase in the number of cases of prostate cancer diagnosed in recent years and has enhanced the ability to detect organ- confined prostate cancer. However, some prostate cancers do not produce sufficient amounts of PSA to result in elevations in PSA serum levels, and there are several other con- ditions that can lead to elevations in PSA levels. These conditions include BPH, prostatitis, seminal ejaculation, and genitourinary instrumentation. Uncomplicated urethritis cannot lead to an elevation in PSA level. A 58-year-old patient of yours is diagnosed with prostate cancer after PSA levels were found to be ele- vated.

The patient had locked himself in his home and is now accusing his family of being “out to get him order 100 mg modafinil mastercard. The emer- gency department physician consults psychiatry for evaluation of mania with psychotic features and inpatient management buy 100mg modafinil free shipping. Results of laboratory testing on admission are all within normal limits. Valproic acid appears most effective for classic bipolar disorder B. Carbamazepine is an approved treatment of acute mania C. Olanzapine has been shown to be an effective treatment of acute mania D. Evidence from clinical trials documents the efficacy of topiramate in acute mania Key Concept/Objective: To be familiar with different drugs available for the treatment of bipo- lar disorder and mania Lithium is most effective in classic bipolar disorder, which consists of discrete episodes of mania and depression with symptom-free periods between episodes. Valproic acid/divalproex sodium appears to be more effec- tive for manias that are dysphoric or mixed and for patients who experience four or more episodes a year. Carbamazepine is not approved in the United States for the treat- ment of mania and may be associated with a number of pharmacokinetic drug-drug interactions because of its induction of microsomal P-450 enzymes. Olanzapine, an atypical antipsychotic agent, has been shown to be effective for the treatment of acute mania. Other atypical antipsychotics, including risperidone, quetiapine, ziprasidone, and aripiprazole, may be efficacious as well. Early evidence suggested that topiramate may be an effective mood stabilizer, but three randomized controlled clinical trials in acute mania failed to demonstrate any efficacy. A 67-year-old man, 3 months after a myocardial infarction (MI), reports problems with severe insomnia. He cannot fall asleep easily and wakes up at about 4:30 A. He has had increased fatigue since his MI, is more forgetful, and has problems with concentration. His other medical problems include reflux esophagitis, benign prostatic hyperplasia (BPH), and a history of stroke with a related seizure disorder.

Hemolytic-uremic syndrome (HUS) is characterized by platelet aggregation and the presence of large von Willebrand multimers D modafinil 100mg without a prescription. The clinical presentation of antiphospholipid syndrome (APS) gen- erally comprises a single thrombotic event in the arterial system Key Concept/Objective: To understand the pathogenesis and clinical presentations of the vari- ous thrombotic microangiopathies The classic TMAs include TTP and HUS order 200mg modafinil with amex. The critical role of ADAMTS-13 (a disintegrin and metalloprotease with thrombospondin type 1 motif) in the pathogenesis of TTP has emerged in the past 10 years. ADAMTS-13, which is found on the surface of endothelial cells, normally cleaves large multimers of the von Willebrand antigen as they are secret- ed by the cell. These large multimers bind more efficiently than the cleaved von Willebrand antigen to platelets (at the Iba component of platelet glycoprotein Ib/IX/V vWA receptor). Plasma ADAMTS activity must be severely depressed for TTP to develop. The level of ADAMTS-13 plasma activity is modestly depressed in patients with liver dis- ease, disseminated cancer, chronic metabolic and inflammatory conditions, and preg- nancy, as well as in newborns. When plasma activity of ADAMTS-13 falls to less than 5% of normal, these large von Willebrand antigens predominate, bind to platelets, and cause aggregation and thrombi in small vessels. Although TTP is often defined by the classic pentad of findings, a presumptive diagnosis can often be based on a triad of lab- oratory observations: thrombocytopenia, schistocytes, and elevated serum lactate dehy- drogenase (from shredded erythrocytes). Conditions other than TMA may also be diffi- cult to distinguish from TTP. HUS is defined as a TMA that occurs after exposure to Escherichia coli 0157:H7 or other enteropathogenic serotypes of E. Systemically, Shiga tox- ins produced by the bacteria play two key roles in the development of thrombi com- posed of platelets and von Willebrand antigen. First, they impair the secretion of ADAMTS-13 through an unspecified mechanism, resulting in large von Willebrand multimers.