Depression in Young Adults
(Australia—Australian Family Physician, February 2000, p. 123.) The prevalence of depression among adults 18 to 24 years of age is estimated to be 15 to 40 percent. In this age group, nonclassic symptoms such as aggression or risk-taking/self-destructive behaviors may be as common as anhedonia, sleep disturbance, fatigue or concentration problems. Suicidal ideation is also common; successful suicide may be the first manifestation of depression. A broad treatment strategy that includes counseling and medication is indicated for young adults with depression. Several forms of psychologic treatment have been suggested, including psychotherapy, cognitive behavioral therapy and family therapy. While many cases of depression in young adults can be managed effectively in primary care, referral should be considered in patients with significant risk of self-harm; complex associated issues, such as a history of sexual abuse; or persistent or refractory illness.
Treatment of Pancreatic Cancer
(Great Britain—The Practitioner, April 2000, p. 336.) Adenocarcinoma of the pancreas is one of the most common causes of cancer mortality. Most cases occur in the head of the gland. While the disease is increasing in incidence, the mean five-year survival rates are 5 percent or less; most patients survive about 17 months following pancreatic resection. Risk factors for pancreatic cancer include cigarette smoking, diets high in fat and protein, and certain occupational exposures to chemicals. It is unclear if diabetes is a predisposing condition or an early symptom of pancreatic pathology. Patients with pancreatic cancer typically present with weight loss, pain of the upper abdomen or back, and obstructive jaundice. Pruritus, nausea and vomiting are the symptoms of pancreatic cancer that may be the most distressing to patients. Several abnormalities on physical examination and laboratory testing may contribute to the diagnostic evidence of pancreatic cancer, but the most useful initial investigation is abdominal ultrasonography. Computed tomography or laparoscopy is often chosen as the next stage of investigation, depending on the clinical situation. Specialized investigations such as endoscopic retrograde cholangiopancreatography may be indicated in selected patients. Surgical resection of the pancreas using Whipple's procedure remains the mainstay of therapy, but many cases of pancreatic cancer are inoperable. Chemotherapy and/or radiotherapy may be used as adjuncts to surgery or as part of a palliative approach to treatment.
Acute Appendicitis in Pregnancy
(Great Britain—The Practitioner, April 2000, p. 312.) Acute appendicitis is the most common nonobstetric cause of acute abdominal pain during pregnancy. However, the diagnosis of acute appendicitis can be challenging. Throughout pregnancy, the signs and symptoms of appendicitis may resemble obstetric complications or gynecologic conditions. The date of the patient's last menstrual period should be ascertained in all women of reproductive capability who have abdominal pain, because ectopic pregnancy is a serious consideration. Appendicitis should be considered in all pregnant women who present with fever, anorexia, and pain and tenderness of the abdomen. As the enlarging uterus displaces the appendix toward the right upper quadrant, symptoms may suggest large bowel or gall bladder pathology. Pregnant patients with appendicitis are at increased risk of perforation and peritonitis because the omentum is less able to contain infection. Early appendectomy has reduced the rate of maternal death to less than 0.5 percent and the rate of fetal loss to less than 10 percent.