The role of melatonin in pediatric headaches

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Evidence Based Medicine Series: The role of melatonin in pediatric headaches Sarah Lallaman 3 rd Year Pediatric Resident

Patient Presentation ,[object Object],[object Object],[object Object],[object Object]

Patient management ,[object Object],[object Object],[object Object],[object Object]

Patient Follow-up ,[object Object],[object Object],[object Object],[object Object],[object Object]

Background Information: The pineal gland ,[object Object],[object Object]

Background Information: Melatonin ,[object Object],[object Object],[object Object]

Background Information: Melatonin ,[object Object],[object Object]

Properties of melatonin ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Clinical Question: ,[object Object],[object Object],[object Object],[object Object],[object Object]

Literature Search: Pub Med ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Other literature searches ,[object Object],[object Object],[object Object],[object Object]

Selected Article ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Reviewing the article: The Patients ,[object Object],[object Object],[object Object],[object Object],[object Object]

Reviewing the article: The Headaches ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Reviewing the article: Exclusions for the study ,[object Object],[object Object],[object Object],[object Object],[object Object]

Reviewing the article: The study design ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Reviewing the article: The data ,[object Object],[object Object],[object Object],[object Object]

Reviewing the article: The data Mean (SD) P<0.001 9.7 (14.5) 9.9 (14.4) 10.4 (14.3) 13.5 (15.9) Duration of attacks (h) P<0.001 5.7 (6.7) 6.9 (7.1) 8.7 (7.5) 12.3 (8.9) Frequency of attacks / month Friedman test 3 month follow-up 2 month follow-up 1 month follow-up Baseline

Reviewing the article: The nitty-gritty about the stats ,[object Object],[object Object]

Reviewing the article: The weaknesses of the stats ,[object Object],[object Object],[object Object]

Reviewing the article: Is this evidence valid? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Reviewing the article: The weaknesses ,[object Object],[object Object],[object Object],[object Object]

Reviewing the article: Is this information important? ,[object Object],[object Object]

Application of the evidence: Risks for the therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Applying the evidence: Availability, cost and ease ,[object Object],[object Object],[object Object],[object Object]

How this applies to my patient ,[object Object],[object Object],[object Object]

Knowing what I know now... ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Where to go from here? ,[object Object],[object Object],[object Object],[object Object]

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对于早上抄作业的事，此时谁都不提。子允想过谢张腾一声，但不知怎么开口。因听到王峰说的幕后情况，香港六合彩对张腾有点同情，为自己感到有些不安，仿佛胁迫张腾服从的人里面也有自己一个。现在香港六合彩不说一句话，有心照不宣的意思在里头。子允见张腾没有刻薄自己的意思，这才重新想起周晨晨。进教室的时候，香港六合彩就看过香港六合彩。香港六合彩今天穿着白色的高领毛衣，粉嫩的脸庞被毛领子衬得像刚刚剥去壳的清水煮鸭蛋。想到香港六合彩昨晚跟自己打过那样的电话，子允的心中自有说不出的亲切和满足，香港六合彩不由想起《香港六合彩的睫毛》里的歌词，方文山真恶心，这么可爱的女孩谁会咬？谁咬，我咬谁！想着，香港六合彩竟痴痴笑起来。这时，香港六合彩有一种强大感，还有一种强烈保护香港六合彩的感觉。男生在女生面前的想法很难用香港六合彩平时的智商解释。子允想不到，现在来上学还带有周晨晨这个美妙内容，想一想都美滋滋的。第一节课如约而至，只有这个时候那些等着开抄的人才如此期待上课。只有上课了，才不会有老班的突然袭击，才能放心大胆地抄个精细，抄出风格。课代表已经习惯这种程序，反正等不到下课本子也会收齐，下课就可以送给老师。现在的学生做什么事都讲求个性，抄作业也不例外，模板用楷书，香港六合彩就用草书；模板有过程，香港六合彩就直接写答案。说起来是个性，其实是保护自己的方法，只有与别人不同，老师才不会怀疑。第一节课是物理课，老师是个好脾气的女老师，总笑眯眯与同学们举行授课前的见面仪式，从不马虎。好，同学们，今天香港六合彩接着昨天的课……在这个文科班里，理科的地位可想而知，理科老师采取的应付态度也可想而知，如果是脾气好的老师，教学效果更可想而知。正因为熟悉这位老师脾性，又知道老师的眯眯眼近视，那些要抄作业的同学更是抄风猛烈。当然抄作业的也不是无所顾忌，香港六合彩得了便宜还不忘卖乖，抄累了抬头听一会课，听到老师问对不对、是不是的这种低级问题时就大声喝应一下，老师以为自己受欢迎，笑眯眯的眼睛里根本找不到眸子的踪迹。子允不用抄作业，喊得更投入更卖力。香港六合彩喜欢课堂热闹的气氛，并不是爱闹，也不会乱闹，只是性格所致，更是今天的情绪所致。《Y滋味》心旷神怡周晨晨今天的心情也很好，第一节课的气氛给老师和同学们这么一烘托，更觉得心旷神怡。香港六合彩也几次偷看子允，都没跟子允的目光碰上。香港六合彩很想碰上的却又怕碰上，像香港六合彩很想找香港六合彩却又不好意思多加主动。有子允昨晚的表现，香港六合彩满意了，如果把香港六合彩现在矛盾的心态放在天平上

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Treating Insomnia in Depression: Insomnia Related Factors Predict Long-Term Depression Trajectories Bei Bei Monash University and Royal Women’s Hospital, University of Melbourne Lauren D. Asarnow Stanford University Andrew Krystal University of California, San Francisco Jack D. Edinger National Jewish Health, Denver, Colorado, and Duke University Medical Center Daniel J. Buysse University of Pittsburgh Rachel Manber Stanford University Objective: Insomnia and major depressive disorders (MDD) often co-occur, and such comorbidity has been associated with poorer outcomes for both conditions. However, individual differences in depressive symptom trajectories during and after treatment are poorly understood in comorbid insomnia and depression. This study explored the heterogeneity in long-term depression change trajectories, and examined their correlates, particularly insomnia-related characteristics. Method: Participants were 148 adults (age M � SD � 46.6 � 12.6, 73.0% female) with insomnia and MDD who received antidepressant pharmacotherapy, and were randomized to 7-session Cognitive Behavioral Therapy for Insomnia or control conditions over 16 weeks with 2-year follow-ups. Depression and insomnia severity were assessed at baseline, biweekly during treatment, and every 4 months thereafter. Sleep effort and beliefs about sleep were also assessed. Results: Growth mixture modeling revealed three trajectories: (a) Partial-Responders (68.9%) had moderate symptom reduction during early treatment (p value � .001) and maintained mild depression during follow-ups. (b) Initial-Responders (17.6%) had marked symptom reduction during treatment (p values � .001) and low depression severity at posttreatment, but increased severity over follow-up (p value � .001). (c) Optimal-Responders (13.5%) achieved most gains during early treatment (p value � .001), continued to improve (p value � .01) and maintained minimal depression during follow-ups. The classes did not differ significantly on baseline measures or treatment received, but differed on insomnia-related measures after treatment began (p values � .05): Optimal- Responders consistently endorsed the lowest insomnia severity, sleep effort, and unhelpful beliefs about sleep. Conclusions: Three depression symptom trajectories were observed among patients with comorbid insomnia and MDD. These trajectories were associated with insomnia-related constructs after commenc- ing treatment. Early changes in insomnia characteristics may predict long-term depression outcomes. What is the public health significance of this article? This study identified three distinct depression trajectories in patients with comorbid major depression and insomnia disorders during treatment and 2-year follow-up. Those with the largest and most sustained improvements in depression consistently scored the lowest on postbaseline insomnia and insomnia-related cognitions. Early changes in insomnia symptoms and insomnia-related character ...

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For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs. Case: An elderly widow who just lost her spouse. Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications: • Metformin 500mg BID • Januvia 100mg daily • Losartan 100mg daily • HCTZ 25mg daily • Sertraline 100mg daily Current weight: 88 kg Current height: 64 inches Temp: 98.6 degrees F BP: 132/86 By Day 3 of Week 7 Post a response to each of the following: • List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions. • Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why. • Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used. • List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. • List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. • For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities? • Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. Respond to the these discussions. All questions need to be addressed. Discussion 1 En Three questions to ask the patient and a rationale for asking these questions. How may I be of assistance today? This question creates a rapport between you and the patients, and it makes her know that the doctor is ready to listen and help her. What are you doing to cope with grief after losing your husband? This question will help the care ...

For this Discussion, review the case Learning Resources and the

DustiBuckner14

For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs. Case: An elderly widow who just lost her spouse. Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications: • Metformin 500mg BID • Januvia 100mg daily • Losartan 100mg daily • HCTZ 25mg daily • Sertraline 100mg daily Current weight: 88 kg Current height: 64 inches Temp: 98.6 degrees F BP: 132/86 By Day 3 of Week 7 Post a response to each of the following: • List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions. • Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why. • Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used. • List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. • List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. • For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities? • Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. Respond to the these discussions. All questions need to be addressed. Discussion 2 Me Treatment of a Patient with Insomnia The case presented this week, is that of a 75-year-old widow who just lost her spouse 10-months ago. Th patient presents with chief complaints of insomnia. Past medical history of DM, HTN, and MDD is reported. Since the passing of her husband, she states her depression has gotten worse .

For this Discussion, review the case Learning Resources and the .docx

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TO REPLY 1 COMMENT TO EACH POST WITH CITATION AND TWO REFERENCE EACH COMMENT APA ABOVE 2013. POST 1 Three Questions for the Patient After reviewing the material presented in this case study, there are some concerning questions regarding this patient’s psychiatric history. Additional questions would include: After each discontinuation of medication after an episode of depression, was this decision the choice of a physician or self -initiated? This question would provide knowledge of the patient’s medication compliance. For example, does the patient stop taking prescribed medication on symptoms are alleviated? What were the circumstances prior to each depressive episode? his question would enlighten the practitioner on triggers and factors that personally affect the patient before a depressive episode occurs. There appears to be history of alcohol abuse and depression in your family, has anyone in your family received treatment? This question would provide a view into the patient’s understanding of psychiatric treatment. Since the patient does not believe in psychotherapy due to religious reason, the patient may not know what treatments were, are or will be available to him. Feedback from People in Patient’s Life The patient has been married for 33 years. Assuming his spouse is around before, during and after an episode, she may provide information the patient failed to share or may not have been honest about. The first person to be questioned would be the patient’s wife. Some of the questions for the patient’s wife would include onset of symptoms. What occurs before each episode of depression? Is there conflict between you and your spouse? Are there any stressors, such as financial plaguing your spouse and you? The patient also has three children. All three of his children suffer from some form of depression. Questioning the patient’s children may provide a historical history of the patient. For example, the children may have noticed symptoms leading to the patient’s depression years ago. Questions for the children may include did your parent’s argue often while you were growing up? Did your father ever lose interest in your childhood years? Did you feel love or rejection while growing up from your father? What were your father’s behaviors? Did you ever notice any alcohol or drug abuse while growing up? Physical and Diagnostic Exams for Patient Unfortunately, there is not a certain test for depression. The primary goal of physical exam and diagnostic testing would to rule out other conditions causing similar symptoms. A physical exam should be preformed assessing respiratory and cardiovascular system. Vital signs should be taken as well. Certain labs should be assessed in the patient. The practitioner should check the patient’s thyroid levels. Thyroid hormones have been linked to depression (Stahl, 2008). Depression can be caused by an underactive or overactive thyroid. Another lab test to consider would be dexamethasone ...

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Dr Uju Ugochukwu Consultant Adult Psychiatrist Youth Mental Health Service/Early Intervention in Psychosis Great Yarmouth and Waveney (Norfolk and Suffolk NHS Trust) This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014. The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.

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Please I need a response to this case study. 1 page zero plagiarism three references The Case: The sleepy woman with anxiety This week’s discussion presents a case study involving a 44-year old woman with a chief complaint of anxiety beginning at age 15 years old. She has a long history of mental illness and continued therapies. The purpose of this discussion is to analyze her case history to determine medication and treatment effectiveness. Client Questions Question 1. Are you having feelings of harming yourself or harming someone else? Rationale: This is a possibly uncomfortable yet important set of questions to ask each client. Primary care providers may be in a unique position to prevent suicide due to their frequent interactions with suicidal patients. Reviews suggest that among patients who committed suicide, 80 percent had contact with primary care clinicians within one year of their death, whereas only 25 to 30 percent of decedents had contact with psychiatric clinicians within the year of their death (Stene-Lars & Reneflot, 2017). Question 2. What was happening in your life as a teenager when the anxiety started and you began to self-medicate? Rationale: Per our report, this patient began suffering signs and symptoms of anxiety at 15-years old. Asking these types of questions we may gain insight into an underlying cause or triggering event. Anxiety disorders are the most common psychiatric disorders with onset in childhood, with prevalence estimates ranging from 10 to 30 percent. Nearly 37 percent of behaviorally inhibited preschool-age children had social anxiety disorder at age 15, compared with 15 percent of non- behaviorally inhibited children . Children with anxiety disorders are more likely to have persistent anxiety disorders into adulthood. (Rapee, 2014). Question 3. What was happening in your life a year ago when these symptoms returned and became debilitating? Let’s discuss what the triggering events may have been. Rationale: Self-discovery of triggering events may help the client to come to terms with the determinants of her anxiety and depression. Studies have shown that specific types of stressors were found to differentially predict increases in specific facets of anxiety sensitivity; health-related stressors predicted increases in disease-related concerns and fear of mental incapacitation, whereas stressors related to family discord predicted increases in fear of feeling unsteady, fear of mental incapacitation, and fear of having publicly observable symptoms of anxiety (McLaughlin & Hatzenbuehler, 2009). Support System The support system as reported by our client is her husband. She states he is supportive and has little to no contact with the family of origin. She has a few friends and a few outside interests. As PMHNP, discussing relationships with the client is one avenue to gain insight into anxiety patterns and coping mechanisms as seen by outside support. With the client’s permissio.

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Running Head: Case study 1 Case study 5 Case Study Walden University Name NURS – 6630N March 9, 2019 Case Study Optimizing the dosing of medicines for neonates and children remains a challenge. The importance of pharmacokinetic (PK) and pharmacodynamics (PD) research is recognized both in medicines regulation and pediatric clinical pharmacology, yet there remain barriers to undertaking high-quality PK and PD studies. While these studies are essential in understanding the dose–concentration–effect relationship and should underpin dosing recommendations, this review examines how challenges affecting the design and conduct of pediatric pharmacological studies can be overcome using targeted pharmacometric strategies. Model-based approaches confer benefits at all stages of the drug life-cycle, from identifying the first dose to be used in children, to clinical trial design, and optimizing the dosing regimens of older, off-patent medications. To benefit patients, strategies to ensure that new PK, PD and trial data are incorporated into evidence-based dosing recommendations are needed. The client selected is an African American child having depression with normal development milestone. Other aspects reveal that the child has high ratings in depression scale. The criterion is used to diagnose the child. Decision point one In this case, we had to prescribe the first choice of drug to get an effective effect. Some Selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice to use in children with depressive disorder. The best medicine is Zoloft having sertraline. Now we decided the starting dose and that was 25mg to be administered orally. According to Vitiello (2012), if the medicine does not work in starting dose, we need to increase the dose. The child had been prescribed Zoloft and he came back with no change in his mental health. Decision point two If the drug is not working in a low dose, we need to increase the dose. Decision point two involved increasing the dose from 25mg to 50mg.The purpose of increasing the dose was to lower the depressive symptoms. Being within the range, we expected minimal desired effects (Stahl, 2013). Giving a single dose is more likely to give persistent desired effects in client. The patient experienced 50 percent decrease in symptoms. Hence Zoloft was successful in managing the patient’s depression. You must be cautious about the side effects of sertraline. One of the major is suicidal thoughts. Decision point three Decision point three is to decide if the dose will be maintained or increased to get rid of symptoms completely. The best decision is to maintain the dose because if the patient has shown 50 percent improvement then he will show more with the passage of time. His dose had been maintained now he further experienced decrease in symptoms. The best treatment is the complete remission as it is the main aim in contemporary psychopharmacology (Stahl, 2013). Then I recommended.

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