睿学教育Wisdome Education

Nrupen Bhavsar, PhD

• Assistant Professor in Medicine
• Associate of the Duke Initiative for Science & Society

https://medicine.duke.edu/faculty/nrupen-bhavsar-phd

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The mainstem bronchi branch into smaller bronchi symptoms of gastritis flare up ditropan 5 mg fast delivery, then Lung Circulation into bronchioles gastritis diet ketosis purchase ditropan 5 mg on-line. Bronchioles are approximately the size of a pencil lead and do not contain cartilage or mucus-secreting the pulmonary circulatory system transports O and CO gastritis poop 2.5 mg ditropan order mastercard. The walls of the bronchioles contain smooth mus- After oxygen enters the bloodstream across the alveolar– cle, which is controlled by the autonomic nervous system. Car- stimulation of sympathetic nerves causes relaxation or bon dioxide combines with hemoglobin in the cells for return dilation. The epithelial lining of the bronchioles becomes thinner with the lungs receive the total cardiac output of blood and progressive branchings until only one cell layer is apparent. The are supplied with blood from two sources, the pulmonary bronchioles give rise to the alveoli, which are grape-like clus- and bronchial circulations. The pulmonary circulation pro- ters of air sacs surrounded by capillaries. Type I oxygenated blood to the lungs and the pulmonary veins cells are flat, thin epithelial cells that fuse with capillaries to return oxygenated blood to the heart. The bronchial arter- form the alveolar–capillary membrane across which gas ex- ies arise from the thoracic aorta and supply the air passages change occurs. The bronchial circulation also ported to body cells; CO2 enters the alveoli to be exhaled warms and humidifies incoming air and can form new ves- from the lungs. Type II cells produce surfactant, a lipoprotein sels and develop collateral circulation when normal vessels substance that decreases the surface tension in the alveoli and are blocked (eg, in pulmonary embolism). The alveoli also contain macrophages that helps to keep lung tissue alive until circulation can be help to protect and defend the lungs. The lungs are encased in a membrane called the pleura, Capillaries in the lungs are lined by a single layer of ep- which is composed of two layers. Once thought to be a pas- adheres to the surface of the lung, is called the visceral sive conduit for blood, it is now known that the endothelium pleura. The outer layer, which lines the thoracic cavity, is performs several important functions. The potential space between the rier that prevents leakage of water and other substances into layers is called the pleural cavity. Second, it participates in the transport of respi- allows the layers to glide over each other and minimizes ratory gases, water, and solutes. The lungs expand and relax in response to changes in pres- Nitric oxide also regulates smooth muscle tone in the sure relationships (intrapulmonic and intrapleural pressures). Elastic tissue in the bronchioles and alveoli allows the lungs When pulmonary endothelium is injured (eg, by endotoxins to stretch or expand to accommodate incoming air. This abil- or drugs such as bleomycin, an anticancer drug), these func- ity is called compliance. The respiratory center is stimulated orders may be caused by agents that reach the system through primarily by increased CO2 in the fluids of the center. A lesser tract secretions, asthma, and other chronic obstructive pul- stimulus to the respiratory center is decreased oxygen in monary diseases). The cough reflex is especially important edema, acute respiratory distress syndrome) is associated because it helps protect the lungs from foreign particles, air with the release of histamine and other biologically active pollutants, bacteria, and other potentially harmful substances. These mediators often A cough occurs when nerve endings in the respiratory tract cause inflammation and constriction of the airways. Once injured, cellular functions are impaired (eg, decreased mu- Musculoskeletal System cociliary clearance). Common signs and symptoms of respira- tory disorders include cough, increased secretions, mucosal the musculoskeletal system participates in chest expansion congestion, and bronchospasm. Normally, the diaphragm and external inter- treatment may lead to cell necrosis or respiratory failure. The abdominal and internal intercostal muscles are the muscles of expiration. DRUG THERAPY In general, drug therapy is more effective in relieving respira- SUMMARY tory symptoms than in curing the underlying disorders that cause the symptoms.

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Thereafter gastritis symptoms shortness breath generic ditropan 2.5 mg free shipping, PT and INR are determined every 2 to Choices of anticoagulant and antiplatelet drugs depend on the 4 weeks for the duration of oral anticoagulant drug therapy curing gastritis with diet buy 5 mg ditropan with visa. Heparin is the anticoagulant of choice in acute venous often until a stable daily dose is again established diet to help gastritis order 2.5 mg ditropan mastercard. Warfarin is the anticoagulant of choice for long-term plastin and calcium to citrated plasma and measuring the time maintenance therapy (ie, several weeks or months) (in seconds) it takes for the blood to clot. Aspirin has long been the most widely used antiplatelet and the instrument used to measure PT. The INR system stan- drug for prevention of myocardial reinfarction and arte- dardizes the PT by comparing a particular thromboplastin with rial thrombosis in clients with TIAs and prosthetic heart a standard thromboplastin designated by the World Health valves. When anticoagulation is required during pregnancy, less risk of bleeding or thrombosis, and more consistent reports heparin is used because it does not cross the placenta. Various combinations of antithrombotic drugs are used Warfarin dosage may need to be reduced in clients with concomitantly or sequentially (eg, abciximab is used biliary tract disorders (eg, obstructive jaundice), liver disease with aspirin and heparin; thrombolytic drugs are usu- (eg, hepatitis, cirrhosis), malabsorption syndromes (eg, steat- ally followed with heparin and warfarin). These conditions in- crease anticoagulant drug effects by reducing absorption of vitamin K, decreasing hepatic synthesis of blood clotting fac- Regulation of Heparin tors, or increasing the breakdown of clotting factors. Despite and Warfarin Dosage these influencing factors, however, the primary determinant of dosage is the PT and INR. Heparin dosage is regulated by the activated partial throm- Warfarin interacts with many other drugs to cause increased, boplastin time (aPTT), which is sensitive to changes in blood decreased, or unpredictable anticoagulant effects (see Nursing clotting factors, except factor VII. Thus, warfarin dosage may need to be increased or values indicate normal blood coagulation; therapeutic values decreased when other drugs are given concomitantly. Most indicate low levels of clotting factors and delayed blood co- drugs can be given if warfarin dosage is titrated according to agulation. During heparin therapy, the aPTT should be main- the PT or INR and altered appropriately when an interacting tained at approximately 1. INR or PT measurements and vigi- 844 SECTION 9 DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM CLIENT TEACHING GUIDELINES Drugs to Prevent or Treat Blood Clots General Considerations ✔ With warfarin therapy, you need to avoid walking barefoot; ✔ Antiplatelet and anticoagulant drugs are given to people avoid contact sports; use an electric razor; avoid injec- who have had, or who are at risk of having, a heart attack, tions when possible; and carry an identification card, stroke, or other problems from blood clots. For home management of deep vein vegetables (eg, broccoli, brussels sprouts, cabbage, thrombosis, which usually occurs in the legs, you are cauliflower, chives, collard greens, kale, lettuce, mustard likely to be given heparin injections for a few days, fol- greens, peppers, spinach, turnips, and watercress), toma- lowed by warfarin for long-term therapy. These medica- toes, bananas, or fish; these foods contain vitamin K and tions help to prevent the blood clot from getting larger, may decrease anticoagulant effects. With Lovenox, you need an injection, usually ✔ To help prevent blood clots from forming and decreasing every 12 hours. You or someone close to you may be in- blood flow through your arteries, you need to reduce risk structed in injecting the medication, or a visiting nurse factors that contribute to cardiovascular disease. The results of this test determine your below 130 mg/dL; weight reduction if overweight; control daily dose of warfarin. Once the blood test and the war- of blood pressure if hypertensive; avoidance of smoking; farin dose stabilize, the blood tests are done less often stress reduction techniques; and regular exercise. If superficial bleeding oc- such as wearing tight clothing; crossing the legs at the curs, apply direct pressure to the site for 3 to 5 minutes knees; prolonged sitting or standing; and bed rest. Too little medication increases your is uncommon with the small doses used for antiplatelet risk of problems from blood clot formation; too much effects. Do not crush or chew coated tablets (long-acting medication can cause bleeding. The blood after morning and evening meals for better absorption tests can help your health care provider regulate drug and effectiveness. If ex- or treatments are begun; and keep all appointments for cessive bruising occurs at the injection site, rubbing an ice continuing care. Helen Innes is admitted to your medical unit for management of bacterial pneumonia. She has been on oral antibiotics for 7 days but her respiratory condition has not improved. In addition to her in- Thrombolytic Therapy travenous antibiotics, you administer her usual dose of Coumadin that she takes for a history of pulmonary emboli. Thrombolytic therapy should be performed only by ex- ment the medications given, you notice that her international nor- perienced personnel in an intensive care setting with malized ratio (INR) is 6. All of the available agents are effective with recom- Use in Older Adults mended uses. Thus, the choice of a thrombolytic agent depends mainly on risks of adverse effects and costs. Older adults often have atherosclerosis and thrombotic dis- All of the drugs may cause bleeding.

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First-generation drugs gastritis symptoms lower back pain ditropan 5 mg on line, mainly cefazolin gastritis healing symptoms purchase ditropan us, are used for procedures associated with gram-positive postoperative infections gastritis hypertrophic 5 mg ditropan order with visa, such as pros- Use of Penicillins in Specific Situations thetic implant surgery. Second-generation cephalosporins (mainly cefotetan and cefoxitin) are often used for abdominal Streptococcal Infections procedures, especially gynecologic and colorectal surgery, in Clinicians need to perform culture and susceptibility studies which enteric gram-negative postoperative infections may and know local patterns of streptococcal susceptibility or re- occur. Third-generation drugs should not be used for surgi- sistance before prescribing penicillins for streptococcal in- cal prophylaxis because they are less active against staphy- fections. When used, penicillins should be given for the full lococci than cefazolin, the gram-negative organisms they are prescribed course to prevent complications such as rheumatic most useful against are rarely encountered in elective surgery, fever, endocarditis, and glomerulonephritis. With Probenecid When used perioperatively, a cephalosporin should be Probenecid (Benemid) can be given concurrently with peni- given within 2 hours before the first skin incision is made so cillins to increase serum drug levels. Probenecid acts by the drug has time to reach therapeutic serum and tissue con- blocking renal excretion of the penicillins. A single dose is usually sufficient, although be useful when high serum levels are needed with oral peni- clients undergoing a surgical procedure exceeding 3 hours cillins or when a single large dose is given IM for prevention should receive additional doses at 3-hour intervals. With an Aminoglycoside A penicillin is often given concomitantly with an amino- Use in Children glycoside for serious infections, such as those caused by P. The drugs should not be admixed in a sy- Penicillins and cephalosporins are widely used to treat infec- ringe or an IV solution because the penicillin inactivates the tions in children and are generally safe. Hyperkalemia may occur with large IV doses of penicillin G potassium (1. Use in Older Adults Cephalosporins Beta-lactam antibacterials are relatively safe, although de- creased renal function, other disease processes, and concurrent • Reduce dosage because usual doses may produce high drug therapies increase the risks of adverse effects in older and prolonged serum drug levels. With penicillins, hyperkalemia may occur with large < 20 to 30 mL/minute), dosage of all cephalosporins ex- IV doses of penicillin G potassium and hypernatremia may cept cefoperazone should be reduced. Hypernatremia is less likely with excreted primarily through the bile and therefore does other antipseudomonal penicillins such as mezlocillin and not accumulate with renal failure. Cephalosporins may aggravate renal impairment, • Cefotaxime is converted to active metabolites that are especially when other nephrotoxic drugs are used concurrently. These metabolites Dosage of most cephalosporins must be reduced in the pres- accumulate and may cause toxicity in clients with renal ence of renal impairment, depending on creatinine clearance. With aztreonam, imipenem/cilastatin, and meropenem, dose and frequency of administration are determined by renal Aztreonam status as indicated by creatinine clearance. Dosage of many beta-lactams must be decreased according to creatinine clearance (CrCl) levels. References should be consulted to de- termine dosages recommended for various levels of creati- • Dosage of imipenem should be reduced in most clients nine clearance. Additional considerations are included in the with renal impairment and the drug is contraindicated in following sections. For clients already on hemodialysis, the drug Penicillins may cause seizures and should be used very cautiously, • Dosage of penicillin G, carbenicillin, mezlocillin, if at all. For clients tial amounts and produces subtherapeutic serum drug on hemodialysis, administer the daily dose after dialysis. Amoxicillin/clavulanate (Augmentin) should be often associated with high doses of parenteral peni- used with caution in clients with hepatic impairment. Hepatotoxicity is attributed to the clavulanate • Electrolyte imbalances, mainly hypernatremia and hyper- component and has also occurred with ticarcillin/clavulanate kalemia, may occur. CHAPTER 34 BETA-LACTAM ANTIBACTERIALS: PENICILLINS, CEPHALOSPORINS, AND OTHERS 523 Cefoperazone is excreted mainly in bile and its serum (eg, Unasyn) are most likely to be used. With cephalosporins, half-life increases in clients with hepatic impairment or bil- third-generation drugs are commonly used and usually given iary obstruction. Adverse effects include cholestasis, jaun- by intermittent IV infusions every 8 or 12 hours. Serum drug levels should be monitored if possible advantages of continuous infusion are being studied. Blood levels of cephalosporins and penicillins need to be Aztreonam, imipenem, meropenem, and ertapenem may maintained above the minimum inhibitory concentration for cause abnormalities in liver function test results (ie, elevated microorganisms causing the infection being treated. Thus, con- aspartate and alanine aminotransferase and alkaline phos- tinuous infusions may be of benefit with serious infections, es- phatase), but hepatitis and jaundice rarely occur.

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While input from each eye is delivered to the visual cortex as an independent message gastritis diet garlic best buy ditropan, the layers of visual cortex manifest binocular responses to varying degrees gastritis etiology 2.5 mg ditropan order with visa. Ocular dom- inance was readily mapped using the UEA by recording the responses from all elec- trodes in the array to sinusoidal grating stimulation delivered sequentially to each eye gastritis quick fix cheap ditropan online visa. If the di¤erences between contra- or ipsilateral firing rates during stimulation and the firing rates in the absence of stimulation were negative, this dif- ference was set to zero. Thus, if the multiunit activity is exclusively driven by the con- tralateral eye, the ocular dominance will be approximately þ1, and if it is driven exclusively by the ipsilateral eye, the ocular dominance will be approximately À1. Koulakov RF Type Histogram Ocular Dominance 60 20 40 10 20 0 0 No RF Off RF On RF Both On -1 0 1 and Off RF Ocular Dominance Orientation Histogram Area Histogram 8 40 4 20 0 0 0 30 60 90 120 150 Orientation Area in Degrees Squared Figure 3. Imaging 2-D Neural Activity Patterns 53 A Anterior B C 81 81 61 61 B 41 41 21 21 1 1 I 1 3 5 7 9 1 3 5 7 9 Figure 3. The numbers surrounding the map represent electrode coordinates and are separated by 400 mm. Multiunits driven equally by both eyes will have an ocular dominance factor of ap- proximately 0. An ocular dominance factor was calculated for the multiunits recorded on each electrode, and the resulting ocular dominance map is reproduced in gray scale in fig- ure 3. In this and all subsequent maps, the activity maps represent neural activity on each electrode as viewed looking down on the top of the array. The anterior and medial directions of the brain are indicated on the map of figure 3. This map preserves the discrete 400-mm sampling of the UEA, but the sharp boundaries between adjacent map regions make patterns present in the overall ocular dominance image di‰cult to appreciate. In order to compare this map with maps made using other spatially aver- aged imaging techniques (histological or optical techniques), we used electrophysio- logical imaging methods to develop an estimate of the ocular dominance in the region sampled by the array, as shown in figure 3. Orientation Sensitivity Maps Another general organizational feature of the primary visual cortex is that many of the cells in this area manifest orientation sensitivity (as shown in figure 3. Furthermore, the preferred orientation of these cells seems to vary in a 54 D. Koulakov A Contralateral Ipsilateral 90 81 81 45 61 61 0 41 41 -45 21 21 1 1 -90 1 3 5 7 9 1 3 5 7 9 Figure 3. The numbers surrounding the map represent electrode coordinates and are separated by 400 mm. The scale indicating the principal angle orientation of multiunits in maps is given on the right. We used the multiunit recordings obtained with the UEA in combination with electrophysiological analysis methods to create orientation sensitivity maps of the cat visual cortex. Sine wave patterns of various orientations were drifted across the stimulation monitor and the responses of all multiunits recorded. Since we were demonstrating orientation sen- sitivity, not directional selectivity, we combined the data for 30 and 210 degrees, 60 and 240 degrees, etc. Thus, the orientation angle was converted to the principal angle through a modulo 180 function. The maximum multiunit response from each elec- trode for the principal angle orientation was determined from the combined data. This di¤erence does not seem to be due to eye rotation caused by the paralytic agent because the two maps cannot be made identical by a simple redefinition of the stimulus bar angle by any given amount for one eye. Thus it appears that while a given unit generally is activated by bars of a particular orientation for monocular stimulation, the optimal orientation for stimu- lation via the other eye is often not the same orientation. This di¤erence in the con- tra- and ipsilateral orientation sensitivity of the visual cortex has been noted by others (Hubener et al. Imaging 2-D Neural Activity Patterns 55 Visuotopic Organization the visuotopic organization of the visual cortex has been studied by many investiga- tors (Hubel and Wiesel, 1962; Tusa et al. However, the UEA is particularly well suited to the task of studying the visuotopic organization of the cat primary visual cortex. Because recep- tive fields are measured simultaneously with this approach, any eye drift that occurs during the course of the measurement is a common-mode interferent, and the conse- quences of such eye drift are significantly reduced by di¤erential measurements of the receptive field properties (Warren et al. We have measured the visuotopic organization of area 17 by simultaneously recording the responses of all multiunits to our ternary checkerboard stimulus.

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A review of methods for spike sorting: the detection and classification of neural action potentials gastritis symptoms loose stools cheap ditropan 5 mg on line. Neuronal interactions improve cortical population coding of movement direction gastritis diet ������ purchase cheapest ditropan and ditropan. Relationship between stimu- lus amplitude gastritis healing order ditropan with visa, stimulus frequency and neural damage during electrical stimulation of sciatic nerve of cat. Dynamic and distributed proper- ties of many-neuron ensembles in the ventral posterior medial thalamus of awake rats. Analysis of retinal correspondence by studying re- ceptive fields of binocular single units in cat striate cortex. High-resolution spatiotemporal mapping of visual pathways using multi-electrode arrays. A method for pneumatically inserting an array of penetrating electrodes into cortical tissue. Chronic intracortical microstimulation (ICMS) of cat sensory cortex using the Utah Intracortical Electrode Array. On the separation of signals from neighboring cells in tetrode recordings. Feasibility of a visual prosthesis for the blind based on intracortical microstimulation of the visual cortex. Long-term optical imaging and spectroscopy reveal mechanisms underlying the intrinsic signal and stability of cortical maps in V1 of behaving monkeys. Synchronization of cortical activity and its putative role in information processing and learning. Reconstruction of natural scenes from ensemble responses in the lateral geniculate nucleus. Visual sensations produced by optic nerve stimulation using an implanted self-sizing spiral cu¤ electrode. Decoding visual information from a population of retinal ganglion cells. High-resolution two-dimensional spatial map- ping of cat striate cortex using a 100-microelectrode array. To date, the most successful case in which a nervous system-related structure has been replaced by hardware is the cochlear implant. It is likely that this technology is successful partly because the cochlear hair cell array is a discrete and relatively independent structure, and we have a good idea of what the cochlear hair cells are designed to do. Perhaps the biggest factor contributing to the success of the cochlear implant, however, is the fact that all of the neural structures in the auditory system remain intact, starting with the peripherally located ganglion cells, and the brain continues to do its job as usual. The replacement part would probably also need to be adaptable, changing its prop- erties in response to the overall state of the organism, the sensory or behavioral con- text, or other factors. The success of the coch- lear implant can probably be attributed to the exquisitely adaptable operation of this system, which can take the highly artificial, impoverished, and distorted input 70 Ellen Covey Figure 4. Crossed monau- ral pathways are shown in black; binaural pathways are indicated in gray. CN, cochlear nucleus; DNLL, dorsal nucleus of the lateral lemniscus; IC, inferior colliculus; SOC, superior olivary complex; INLL, inter- mediate nucleus of the lateral lemniscus; VNLLc, ventral nucleus of the lateral lemniscus, columnar divi- sion; VNLLm, ventral nucleus of the lateral lemniscus, multipolar cell division (from Covey, 2001). A great deal is known about the function of brain molecules, especially those involved in neuro- Brain Parts on Multiple Scales 71 transmission and neuromodulation. These classes of molecules include neurotrans- mitters, receptors, second messengers, ion channel subunits, etc. Although perhaps not directly relevant to the theme of this book, replacement of brain molecules through pharmacology, transplantation of cells, or gene therapy is clearly an area in which the strategy of replacement has met with considerable success and is likely to be a major area of research and development for therapeutic treatments in the future. Thus, replacement of a molecule is likely to a¤ect global aspects of brain function as well as specific ones. Here we will consider just two examples of molecules that are distributed rather ubiquitously within the central nervous system but that are es- sential for proper auditory system function on a cellular, circuit, and global level. Inhibitory Neurotransmitters, g-Aminobutyric Acid and Glycine Throughout the central auditory system, a large number of neurons synthesize and release g-aminobutyric acid (GABA). Below the level of the midbrain, there are not only many GABAergic neurons, but also many neurons that synthesize and release glycine.

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Thus gastritis cats buy ditropan with visa, them are likely to be encountered in any clinical practice all health care professionals usually involved in the care setting gastritis and gastroparesis diet buy 5 mg ditropan. Herbal medicines gastritis upper gi ditropan 2.5 mg buy fast delivery, also called botanicals, phyto- of a client with a particular medical diagnosis should be chemicals, and neutraceuticals, are derived from plants; represented. The labels contain essen- Do not take a laxative if you have stomach pain, nau- tial information about the name, ingredients, indications sea, or vomiting, to avoid worsening the problem. Such products can raise blood pres- ✔ Do not take OTC medications longer or in higher doses sure and decrease or cancel the blood pressure–lowering than recommended. This could lead to severe ✔ Note that all OTC medications are not safe for everyone. Many OTC medications warn against use with certain ill- ✔ Store OTC drugs in a cool, dry place, in their original con- nesses (eg, hypertension, thyroid disorders). Consult a tainers; check expiration dates periodically and discard those that have expired. Some specific precautions include the following: ✔ Measure liquid OTC medications with the measuring de- Avoid alcohol if taking antihistamines, cough or cold vice that comes with the product (some have a dropper or remedies containing dextromethorphan, or sleeping pills. If such a device is not available, use a measur- of them with alcohol may result in excessive, potentially ing spoon. Accurate measurement of sedative-type drug (eg, for nervousness or depression). Older people are more likely to Ask a health care provider before taking other products have adverse drug reactions and interactions because of containing aspirin if you are already taking a regular dose changes in heart, kidneys, and other organs that occur of aspirin to prevent blood clots, heart attack, or stroke. Most testimonials from family members, friends, or celebri- products have not been studied sufficiently to evaluate their ties. With the continued caution that relatively little re- safety or effectiveness; most available information involves liable information is known about these products, self-reports of a few people. Overall, the effects of these several resources are provided in this text, including: products on particular consumers, in combination with other • Table 4–1 describes some commonly used herbal and herbal and dietary supplements, and in combination with dietary supplements. In later chapters, when infor- pharmaceutical drugs, are essentially unknown. Two major concerns are that scientific support for their use are described in more use of supplements may keep the client from seeking treat- detail. For example, in Chapter 7, some products ment from a health care provider when indicated and that the reported to be useful in relieving pain, fever, inflam- products may interact with prescription drugs to decrease ther- mation, or migraine, are described. In this chapter, general in- need to have an adequate knowledge base and to incorporate formation is provided (see Client Teaching Guide- their knowledge in all steps of the nursing process (see below). In later chapters, guidelines may em- • Seek information from authoritative, objective sources phasize avoidance or caution in using supplements rather than product labels, advertisements, or personal (text continues on page 59) CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 55 TABLE 4–1 Herbal and Dietary Supplements Name Characteristics Uses Remarks Black cohosh • Thought to relieve menopausal • Most often used to relieve symp- • No apparent advantage over tradi- symptoms by suppressing the re- toms of menopause (eg, flushes, tional estrogen replacement ther- lease of luteinizing hormone (LH) vaginal dryness, irritability) apy (ERT) from the pituitary gland and dysmen- • May also relieve premenstrual syn- • May be useful when ERThis contra- orrhea by relaxing uterine muscle drome (PMS) and dysmenorrhea indicated for a client or the client • Well tolerated; may cause occa- refuses ERT sional stomach upset. In overdose • Recommended dose is 1 tab stan- may cause nausea, vomiting, dardized to contain 20 mg of herbal dizziness, visual disturbances, drug, twice daily and reduced pulse rate • Not recommended for use longer • Most clinical trials done with Reme- than 6 months because long-term femin, in small numbers of women; effects are unknown other trade names include Estroven • Apparently has no effect on and Femtrol endometrium, so progesterone not needed in women with an intact uterus Capsaicin • Derived from cayenne pepper • Capsaicin is a topical analgesic that Applied topically (see Chap. However, tion of use (eg, inhibits platelet more well-controlled studies are aggregation; may depress or stimu- needed before the herb can be late central nervous system [CNS], recommended for these uses. Siberian wort, phenelzine, selegiline, tranyl- ginseng should not be used longer cypromine); headache, mania, and than 3 weeks. These include antidepressants, adrenergics and others Saw palmetto • Action unknown; may have anti- Used mainly to relieve urinary symp- • Reportedly effective in doses of androgenic effects toms in men with benign prostatic 320 mg/day for 1–3 months • Generally well tolerated; adverse hyperplasia (BPH) • Men should have a prostate spe- effects usually minor but may cific antigen (PSA) test (a blood test include GI upset, headache. Also tive drugs and should not be used • Adverse effects with acute overdose has muscle relaxant effects regularly or chronic use include blurred • Many extract products contain vision, drowsiness, dizziness, ex- 40–60% alcohol and may not be citability, headache, hypersensitivity appropriate for all patients reactions, insomnia, nausea. Also, • Most studies flawed—experts do risk of liver damage from combina- not believe there is sufficient evi- tion products containing valerian dence to support the use of valer- and from overdoses averaging 2. As a result, ✔ When taking herbal or dietary supplements, follow the in- the types and amounts of ingredients may not be stan- structions on the product label. Inappropriate use or tak- dardized or even identified on the product label. In addition, components and active adverse effects or drug–supplement interactions.

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During the initial examination gastritis symptoms lump in throat cheap 5 mg ditropan free shipping, the child had a dull expression treating gastritis without drugs buy ditropan paypal, and there was lassitude of the spirit and a fat body gastritis diet ��� buy generic ditropan 5 mg online. The parents said that the child was also difficult to wake when Representative Case Histories 193 asleep. Therefore, the treatment princi- ples were to warm the kidneys and reduce urination, transform phlegm and open the orifices. For these purposes, the following Chinese medicinals were prescribed: Shi Chang Pu (Rhizoma Acori Tatarinowii), 12g, processed Nan Xing (Rhizoma Arisaematis), 9g, Yuan Zhi (Radix Polygalae), 3g, Ma Huang (Herba Ephedrae), 6g, Fu Zi (Radix Lateralis Praeparatus Aconiti Carmichaeli), 9g, Xi Xin (Herba Asari), 3g, Yi Zhi Ren ((Fructus Alpiniae Oxyphyllae), 6g, Sang Piao Xiao (Ootheca Mantidis), 10g, Rou Gui (Cortex Cinnamomi), 6g, Shen Qu (Massa Medica Fermentata), 6g, and Chuan Niu Xi (Radix Cyathulae), 9g. After taking four packets of this formula, the patient had enuresis one time. After continuing to take the medicine for four more packets, the enuresis had stopped and her essence spirit was slightly bet- ter, but the child had vexation and agitation at night. Thus, six grams of Huang Lian (Rhizoma Coptidis) were added to the above formula and this was continued for six more packets when all the symptoms were eliminated. After this, the patient took Shen Qi Wan (Kidney Qi Pills) for one half year to consolidate the treat- ment results. Case 13:13 the patient was a seven year-old boy who was first seen on February 16, 1965. He had enuresis four times per night and would not wake up from sleep when called. The enuresis was accompa- nied by occasional abdominal pain, an abstracted essence spirit and unsettled heart spirit, a moderate (or slightly slow), forceless pulse, and thin, white tongue fur. His TCM pattern was heart- kidney dual vacuity with non-interaction of fire and water, and lower origin not secure. The treatment principles were to supple- ment the kidneys, reduce the stream, and promote the free flow between the heart and kidneys. For this, the following formula was prescribed: Sang Piao Xiao (Ootheca Mantidis), 15g, Fu Pen Zi (Fructus Rubi), 12g, Bu Gu Zhi (Semen Psoraleae),10g, Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 10g, Tu Si Zi (Semen 194 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Cuscutae), 10g, Ze Xie (Rhizoma Alsimatis), 6g, Yuan Zhi (Radix Polygalae), 10g, Shi Chang Pu (Rhizoma Acori Tatarinowii), 10g, Gui Zhi (Ramulus Cinnamomi), 3g, Wu Yao (Radix Linderae), 5g, and Jin Gui Shen Qi Wan (Golden Cabinet Kidney Qi Pills), one pill taken two times per day. After six packets of the above prescrip- tion, the frequency of enuresis was less, the interval between episodes of enuresis was longer, and the accompanying symp- toms were improved. After 12 more packets with additions and subtractions, the enuresis had stopped and the other symptoms had all disappeared. The patient continued to use Jin Gui Shen Qi Wan, and five months after using this formula there had been no recurrence. Case 14:14 the patient was an eight year-old male who was initially seen on October 5, 1989. One month prior to the initial visit, a urine examination at the same hospital had been pos- itive for white blood cells. Therefore, the patient had taken some Western medicine and Chinese medicinals to clear heat and resolve toxins, disinhibit the urine and free the flow of strangury. After two weeks, there did not appear to be any improvement, and now the patient presented with torpid intake, yellow urine, and a floating, rapid pulse. This was due to lung channel depres- sive heat descending to distress the bladder. Therefore, the treat- ment principles were to clear heat and diffuse the lungs with: stir- fried Ma Huang (Herba Ephedrae), 5g, Xing Ren (Semen Armeniacae), 9g, Shi Gao (Gypsum Fibrosum), 15g, Huang Qin (Radix Scutellariae), 8g, Che Qian Cao (Herba Plantaginis), 10g, Gui Zhi (Ramulus Cinnamomi), 6g, and uncooked Gan Cao (Radix Glycyrrhizae), 7g. After taking seven packets of these medicinals, the case was cured and follow-up visits showed no recurrence. External treatments Case 15:15 This case involved an eight year-old boy who was first examined on November 8, 1993. This boy had had enuresis for more than five years, and the patient had already taken more than 10 pack- Representative Case Histories 195 ets of Chinese medicinals by mouth. After stopping these medici- nals, the child still had enuresis 1-2 times per night. The patient had a slightly pale tongue with thin, white fur, and his pulse was fine and deep. For this equal amounts of Ma Huang (Herba Ephedrae), Ba Ji Tian (Radix Morindae Officinalis), Liu Huang (Sulphur), and Fu Shen (Sclerotium Pararadicis Poriae Cocos) were ground into powder and stored in an air tight container.

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Recordings from single cutaneous thewithdrawalreflexesrelatedtothestimulatedskin afferents allowed a further characterisation of the field (cf gastritis diet nuts ditropan 2.5 mg with amex. Single shocks of weak intensity may have little effect gastritis diet ���������� order ditropan online now, particularly when Plantar responses applied to skin eosinophilic gastritis elimination diet cheap 2.5 mg ditropan with amex, and most authors use trains of stimuli applied to nerves. The trains must be short Plantar responses are evoked by firm stroking of the. At rest, the reflex ical extension) may be replaced by dorsiflexion to response is suppressed at repetition rates above 0. Methodology 393 (a) (b) (c) (d) (e) (f ) (g) (h) (l) (i ) (m) (j) (k) (n) p) q) Fig. A (dashed line) and A (thin dotted line) afferents in the sural nerve activate biceps (Bi) motoneurones (MN) through different chains of interneurones (IN). Modified from Hugon (1973)((b)–(f ), (n)–(q)), Willer (1977)((g), (h)), Willer, Roby & Le Bars (1984)((l), (m)), and Willer, Boureau & Albe-Fessard (1978)((i)–(k)), with permission. Noxious Abdominal reflexes are evoked by a rapid stroke with responses are often investigated in the tibialis ante- a blunt pin on the abdominal skin, again a stimu- rior to stimulation of the medial aspect of the sole lus that produces spatial and temporal summation of the foot at the apex of the plantar arch (Shahani of inputs. The latency of the response increases and &Young, 1971), or of the medial plantar nerve of the the amplitude decreases with repetition due to rapid foot (Meinck, Benecke & Conrad, 1983). Increases in stimulus strength also result in the appearance of a late response Withdrawal reflexes. Abdominal skin reflexes are considered Provided that the stimulus is painful, withdrawal trunk defence reflexes (Kugelberg & Hagbarth, 1958; reflexes can be recorded consistently at rest, partic- p. Trains of analysis of withdrawal reflexes in human subjects ten painful stimuli at 4–6 ×PT to the fingers will pro- began with Pedersen (1954). The reflex is mediated by small myelinated stimulation of tactile cutaneous (A ) afferents, A afferents (see p. Ifthestimulusintensityissufficiently strong,theRIIIreflexmaybeelicitedbyasingleshock the RII response elicited in the short head of the. Lower intensities are sufficient to evoke biceps femoris by stimulation of the sural nerve the nociceptive reflex when a train is delivered but they then also produce pain (Willer, Boureau & Albe- This is the most consistent cutaneous reflex pro- Fessard, 1978, and Fig. At threshold, the duced at rest by stimulation of tactile afferents response occurs with a latency of 120–130 ms, but. Thereflexelicited this decreases to ∼80–90 ms when the stimulus by weak electrical stimulation requires the temporal intensity (or the number of shocks in the train) is summation produced by trains of 6–10 shocks. The RII reflex is not eas- ily observed unless the subject is relaxed, and better Other withdrawal reflexes results are often obtained during a second session Withdrawal reflexes may be elicited in all lower when the subject is familiar with the experimental limb muscles when the adequate receptive field is conditions. Methodology 395 (a) (b) (c) (d) (e) (f ) (j) (g) h) (i) (p) (k) (l ) (q) (r) (m) (n) (s) Fig. With the highest intensity (s), the latency is only 24 ms, implying a central delay of 3. Modified from Shahani & Young (1971)((b)–(j)), and Kugelberg & Hagbarth (1958) ((l)–(s)), with permission. Gassel & Ott (1970) showed that other muscles the cutaneous modulation of the rectified on-going EMG of triceps surae closely paralleled the recovery However, in some subjects, sural nerve stimulation curve of the Achilles tendon jerk, and Meinck et al. However, the method has produced reflexes attributed to cutaneous affer- has been used mainly to explore the relatively weak ents in the flexor carpi ulnaris. Spike-triggered averagingoftheEMGagainstthedischargeofasingle cutaneous afferent requires the use of microneuro- Modulation of motoneurone excitability graphy to record the discharge of a single cutaneous afferent, but it has proved possible to investigate the the reflex effects of cutaneous afferents may be reflex effects evoked by natural stimulation of iden- documented by recording the modulation of the tified cutaneous mechanoreceptors (see above). Modulation of the PSTHs ModulationofthePSTHsofsingleunitsbycutaneous Modulation of the monosynaptic reflex volleys is of prime importance, because cutaneous Changes produced by cutaneous volleys in the afferents have been shown to have different effects amplitude of the H reflex or tendon jerk allow one on motoneurones of different types (cf. Similarly, withdrawal responses may be evoked by natural stimuli such as Modulation of the on-going EMG pinch or pinprick. However, in general, the spatial This method allows one to record rapidly the full and temporal summation required to produce the time course of the inhibitory and excitatory effects. Averaging the Radiant heat rectified on-going EMG provides reasonable tem- poralresolutionofthecutaneous-inducedresponses Radiant heat can be a noxious stimulus that can be and has been used to document the organisation of precisely localised and timed (cf. Ellrich, Steffens & (a) (b) (c) (d) (e) (f ) (g) (h) (i) (k) l ) m) (j) Fig. A (dashed line) and A (dotted line) afferents in the sural nerve and from the skin of the anterior aspect of the thigh activate excitatory and inhibitory spinal interneurones (IN) and transcortical pathways to biceps (Bi) and quadriceps (Q) motoneurones (MN). The vertical dashed line is the latency after which a A volley could act through a transcortical pathway (see p. Modified from Hugon (1973)((b)–(d)), and Hagbarth & Finer (1963)((e)–(m)), with permission.

Bengerd, 63 years: Decreased dyspnea, wheezing, and respiratory secretions Relief of bronchospasm and wheezing should be evident within a few minutes after giving subcutaneous epinephrine, IV aminoph- b. When renal blood flow is normal, these prostaglandins have Colchicine also should be given for several weeks to prevent limited activity. The physical or tasks with cues that are meaningful to the pa- occupational therapist may assist the subject to tient.

Ernesto, 49 years: Then, statistical inferences can be made about the activations in relation to the behavior that evoked changes in the BOLD signal. Concentration-dependent bacteri- cidal effects mean that the drugs kill more microorganisms In addition to the preceding recommendations, guidelines to with a large dose and high peak serum concentrations. For exam- ple, in a setting that is comfortable and affords privacy and as a result puts the patient at ease, a good interpersonal relationship with the clinician is more easily established, leading to a potentially more complete patient his- tory and therefore a faster and more accurate diagnosis.

Angar, 21 years: In addition to her in- Thrombolytic Therapy travenous antibiotics, you administer her usual dose of Coumadin that she takes for a history of pulmonary emboli. Healthcare Quality and the Patient 5 the Executive Summary of To Err Is Human begins with these headlines: • Betsy Lehman, a health reporter for the Boston Globe, died from an overdose during chemotherapy • Ben Kolb, an eight-year-old receiving minor surgery, died due to a drug mix-up • As many as 98,000 people die every year in hospitals as a result of injuries from their care • Total national costs of preventable adverse events are estimated between $17 billion and $29 billion, of which health care costs are over one-half These data points helped focused attention on patient safety and medical errors as perhaps the most urgent of the forms of quality defect. This discrepancy is also characteristic of conversion paralysis or malingering.

Murat, 40 years: Eur diol 19:15–19 spine: kyphoplasty and vertebroplasty Spine J 10:370–384 29. J Am Coll Cardiol (1986) 8: this chapter, we have reviewed these and other 1245–55. Acceptable re- • Reestablish normal bowel patterns after an episode of placement fluids during the first 24 hours include 2 to 3 liters acute diarrhea of clear liquids (eg, flat ginger ale, decaffeinated cola drinks or • Have fewer liquid stools with chronic diarrhea tea, broth, gelatin).

Ballock, 60 years: The right cochlear nucleus provides contralateral exci- tatory input to the left medial nucleus of the trapezoid body (MNTB), which in turn provides inhibitory input to the left LSO. The referrer may only select COGNITIVE BEHAVIOUR THERAPY 283 those possible participants who they view as Bentall et al. Clinical indications for use of anticholinergic drugs blocking or decreasing a parasympathetic response in these organs.

Tarok, 46 years: His health care provider prescribes niacin (nico- additional risk factors or primary familial hypercholes- tinic acid) to reduce his cholesterol level. Before you put the book down and start heading for the door, relax and sit tight. Plots of one joint angle versus another signal, temporal and distance measures are ob- during the step cycle provide a more dynamic tained, including speed, cadence (step fre- view of gait deviations.

Tizgar, 45 years: The patient received two treatments each week, and 2-4 treatments equaled one course. The Declaration of Helsinki has been that when the length of time needed to reach an updated and amended several times: Tokyo, 1975; endpoint is short, e. Tropho- zoites are active amebae that feed, multiply, move about, and PROTOZOAL INFECTIONS produce clinical manifestations of amebiasis.

Yokian, 62 years: Relationship of firing intervals of human motor units studies of nerve and reflex activity in normal man. Digoxin cir- ances (hypokalemia, hypomagnesemia, hypercalcemia), and culates mainly in a free state, with only 20% to 30% bound renal impairment. It is used to treat leukemia, vere tissue damage with extravasation (leaking of medication melanoma, and advanced ovarian cancer.

Masil, 39 years: Many children with a bed-wetting problem suffer from low self- esteem, shame, and guilt. Sacral and inferior lumbar endplates are parent bone density but also changes in the architecture of the tra- becular bone. The blood pressure the sample size was considerable, it was neces- component of ALLHAT showed that in an active sary to have a combination endpoint to achieve control trial, a very large sample size needed to be adequate power.

Milok, 27 years: There is thus GM Soleus a direct correlation with the fatigue resistance and an inverse correlation with the tetanic force pro- Ia afferent duced by the motor unit and with the size of the motoneurone(seeR. When agement to decrease the frequency and severity of anginal higher doses are given orally, more drug escapes metabo- attacks, decrease the need for sublingual nitroglycerin, and lism in the liver and produces systemic effects in approxi- increase exercise tolerance. Resistant microorganisms grow and multiply when sus- Serology identifies infectious agents indirectly by measuring ceptible organisms (eg, normal flora) are suppressed by anti- the antibody level (titer) in the serum of a diseased host.

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