睿学教育Wisdome Education

Khaled M. Ziada, MD

• Assistant Professor of Medicine
• Gill Heart Institute
• Division of Cardiovascular Medicine
• University of Kentucky
• Director, Cardiac Catheterization Laboratories
• Lexington VA Medical Center
• Lexington, Kentucky

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This will im- prove metabolism (calorie burning) and blood sugar balance chinese arthritis relief hand movements 4 mg medrol order, which improves energy and mood arthritis neck pillow 16 mg medrol. If you aren’t very hungry in the morning hemophilic arthritis definition 16 mg medrol order otc, then have a light meal such as yogurt and berries or a protein shake. Don’t skip meals, even if you are trying to lose weight, since this causes fatigue, poor concentration, sluggish metabolism, and triggers food cravings. Water purified by reverse osmosis is best because tap water may contain high amounts of chlorine, which can be harmful to the stomach and bladder. Keep in mind that intense physical activity and heat exposure increases water loss and the need for more fluids. Fibre is critical because it can reduce your risk of chronic diseases, such as diabetes, heart disease, and certain cancers, plus it keeps your bowels regular, improves blood sugar control, and plays a role in weight man- agement. Dietary fibre is found in fruits, vegetables, beans, seeds, and whole grains such as wheat and oat bran. There is naturally occurring salt in dairy, seafood, vegetables, breads, and grains; however, the majority of our salt intake comes from processed and prepared foods, such as deli meats, condiments (ketchup), dressings and sauces (soy), and snack foods (chips, pretzels), so cut back on these foods and season food with herbs or flavoured oils and vinegars rather than using the salt shaker. It is also important for nerve and muscle function and supports cell structure and integrity. To boost potassium intake, eat more bananas, oranges and orange juice, avocado, peaches, and tomatoes. Excessive sugar intake has been linked to diabetes, obesity, elevated triglycerides, tooth decay, poor immune function, emotional swings, and other health problems. Refined (white) sugar contains propyl alcohol, which cannot be broken down in the body. Accumulation of this chemical in the intestines can disrupt diges- tion and be toxic to the body. The World Health Organization recommends restricting consumption of added sugar—including sugar from honey, syrups, and sweetened drinks/juices—to less than 10 percent of calories. Fruit contains natural sugar (fructose), but it also provides vitamins, minerals, and fibre. Artificial sweeteners such as aspartame and saccharin should be avoided because they have been linked to headaches, mental illness, brain damage, and cancer. It can provide up to 300 times the sweet- ening power of sugar without the calories. It is also highly addictive—abrupt withdrawal, even if you drink only one cup of coffee daily, can cause headaches, irritability, and fatigue within hours of missing your usual drink. Black tea and green tea contain approximately 35–45 mg, but the effects of caffeine are blunted by an amino acid (theanine), which has a calming effect. Alcohol and what it is mixed with floods the body with excess calories, which can contribute to weight gain. Next, work on slowly making healthier food choices, such as cutting out fast food, eating more vegetables, drinking more water, or limiting your sugar or caffeine intake. By gradually making changes, you will be more likely to stick with your nutritional plan. Take time to plan your meals, so that you are not reaching for fast food or un- healthy snacks. By following a healthy diet you will notice that you have more energy, a better mood, and an overall improved sense of well-being. You will notice recommendations throughout this book for exercise, as virtually every parameter of health can be im- proved with exercise. Numerous studies have shown that regular exercise cuts your risk of chronic, debilitating diseases such as heart disease (by reducing cholesterol and blood pressure), osteoporosis, cancer, diabetes, and prevents premature death! It is also essential to develop and maintain both a healthy body weight and muscular strength. Plus it offers emotional benefits, as exercise reduces stress and anxiety, and improves sleep and overall emotional well-being. With today’s busy, fast-paced lifestyle, exercise usually falls to the bottom of the priority list while it should be at the top. Lack of time is the most common excuse, so below I show you how to boost the activity in your lifestyle. Many people find they don’t have the energy to exercise, yet they don’t realize that exercise actually gives them more energy.

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Kd is the equilibrium Elementary aspects constant for the two processes of drug–receptor combination and dissociation arthritis rheumatoid medication buy discount medrol on-line. Kd may be found The possibility that time since dose changes the for both agonists and antagonists doxycycline for arthritis in dogs safe 4 mg medrol, although some- relationship between pharmacological effect size times the former poses more technical challenge and drug concentrations in plasma has been known due to alterations to the conformation of the bind- for a long time (Levy gouty arthritis in dogs medrol 4 mg order overnight delivery, 1964, 1966; Levy and ing site. When an agonist must model may be expressed as: occupy 100% of available receptors to cause Emax, its efficacy may be said to be unity. This model does not imal effect for an agonist with efficacy 1 (we call contain any information about efficacy and these partial agonists or agonist–antagonists). In the latter centration range, the relationship between effect case, the concentration–response curve lies to the and concentration is often observed to be curvi- left of the concentration–receptor occupancy linear. This log transformation of the concentration between observed concentration and effect size, axis facilitates a graphical estimation of the slope as examples from a considerable volume of litera- of the apparently linear segment of the curve: ture. The reader is referred to key texts for com- prehensive coverage of this topic (e. A more general form of the equation is the Levy (1964), Jusko (1971) and Smolen (1971, sigmoid curve: 1976) described the analysis of dose–response time data. Smolen Emax model, it is possible to account for curves (1976) extended the analysis to application which are both shallower and steeper than when of dose–response time data for bioequivalence n ¼ 1 (i. A half-life, bioavailability and potency can be very high exponent can be viewed as indicating an obtained simultaneously from the dose– all-or-none effect (e. Within a narrow con- assuming (a) first-order input/output processes centration range, the observed effect goes from all and (b) extravascular dosing, the kinetic model to nothing or vice versa. An exponent less than then drives the inhibition function of the dynamic unity (<1) sometimes indicates active metabolites model. A zero-order The corresponding inhibitory sigmoid Emax input and first-order output governs the turnover model is functionally described as follows: of the response. Many other types of examples each other (Segre, 1968; Wagner, 1968; Dahlstrom exist. The rate of The plasma kinetics of the analgesic were change of drug amount (Ae) in a hypothetical effect describable by the following expression after the compartment can be expressed as: intravenous bolus dose, with C0 ¼ 45:0 and À1 K ¼ 0:50 h : dAe ¼ kleA1 À ke0Ae dt À0:50t C ¼ 45:0e where A is the amount of drug in the central com- In the same study, effect measurements were partment of a pharmacokinetic model, linked to the recorded during 80 min, as shown in Figure 8. At steady state, Ce is directly proportional to the where K is the elimination rate constant. Note that the effect equilibration rate constant kleD ÀKt ke0t Ce ¼ ½e À e Š (ke0) may be viewed as a first-order distribution rate Veðke0 À KÞ constant. It can also be thought of in terms of the rate of presentation of a drug to a specific tissue, At equilibrium, the rates of drug transfer between determined by, for example, tissue perfusion rate, the central and effect compartments are equal: apparent volume of the tissue and eventual diffu- sion into the tissue. The results of the data fitting in k1eA ¼ ke0Ae this exercise with the analgesic are Emax 4. Effect compartment or link models are limited If the partition coefficient, Kp, equals Ce/C at equi- by their applicability to situations in which the librium (steady state), then we can rearrange the equilibrium between plasma and response is due above equation: to distributional phenomena. In reality, there is k V often a delay between occurrence of maximum 1e 1 Ve ¼ drug concentration in the effect compartment and Kpke0 maximum intensity of effect caused by slow devel- Substituting for V in the above equation opment of the effect rather than slow distribution to e (i. The plasma kinetics of (S)-warfarin were described by the fol- This is how the link-model relates the kinetics in lowing mono-exponential expression: plasma to the kinetics of drug in the effect compart- ment. The time to steady state is only governed by 120 the elimination rate constant and not the rate of infusion. It was also possible to estimate As stated before, the intensity of a pharmacologi- the half-life of the apparent first-order degradation. Rather, it may be the net allow for distributional effects embedded in the result of several processes only one of which is observed time delay of the onset of the effect influenced by the drug. The process that is influ- after warfarin administration, was published by enced by the drug must be identified and an Pitsui et al. Setting the baseline value of attempt be made to relate plasma drug concentra- clotting factor activity in the absence of warfarin tion to changes in that process. Warfarin provides a (P0) to a fixed mean of three predose measure- good example of this, as the anticoagulant (hypo- ments, the program can estimate that parameter. Precision increased of compounds emerging from medicinal chemistry when a finite lag time was included in the fitting. These detract from their value in chemical, structure– two cases, however, are especially relevant to the activity analyses). Neither does any of these relationship between animal work and phase I studies approaches uses results of invitro functional assays in which only the simplest effects, such as counter- which emerge from screening of the compounds in action of a painful stimulus or raising/lowering of a biochemistry laboratories.

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Sulphur: This remedy is very useful for those who have repeatedly used cortisone on eczema without success arthritis pain only on one side of body purchase medrol 4 mg visa. Intensely burning arthritis in my knee purchase medrol australia, itching arthritis glucosamine generic 4 mg medrol with amex, inflamed eruptions that are worse from warmth and bathing suggest a need for this remedy. Combination recommendation: Calendula Gel by Boiron Flu Gelsemium: Symptoms of fatigue and aching that come on gradually, increasing over several days, may indicate a need for this remedy. A headache may begin at the back of the neck and skull, and the person may feel chills and heat running up and down the spine. Anxiety, trembling, dizziness, perspiration, and moderate fever are other indications for Gelsemium. Use this at the first sign of flu symptoms that include fever, chills, body aches and pains, and headaches. Combination recommendation: PascoLeucyn by Pascoe Headache Belladonna: Major throbbing or pounding head pain that starts at the back of the skull or upper neck and spreads to the forehead and temple (especially on the right) may indicate a need for this remedy. Pupils may be di- lated, with sensitivity to light, and the person may either feel delirious or drowsy. Spigelia: Excruciating headaches usually present on the left side of the head, with vio- lent throbbing, or stabbing pains above or through the eyeball. The person may feel better from lying on the right side with the head supported, and keeping very still. Combination recommendation: Antimigren by Pascoe Infertility Folliculinum: Women who have challenges getting pregnant could find success with this remedy if they have irregular menstrual cycles that are often weeks delayed, with a heavy, clotty flow. Luteinum: Infertile women who need this remedy typically have either polycystic ovaries, fibroids, or endometriosis and often have estrogen dominance without even knowing it. Strong indications that this remedy is appropriate are early menstruation and short cycles, which represent a possible luteal phase defect. Combination recommendation: None known Menopause Lachesis: Intense hot flashes with purple-red flushing, palpitations, and feelings of pressure, congestion, and constriction may indicate a need for this remedy. The unique symp- tom of this picture is loquacity (extremely talkative), with a strong tendency to feel suspicious. Sepia: This remedy can be helpful if a woman’s periods are sometimes late and scanty. It is best used from the middle to the end of menopause (12–24 months after the last Homeopathy | 83 period). The uterus feels weak and saggy, and there may be cravings for vinegar and sour foods. Women who need this remedy usually feel dragged-out and weary, emotionally distraught, and fatigued. Combination recommendation: PascoeFemin by Pascoe Sprains/Strains Arnica montana: This is the most popular remedy in homeopathic literature and is best for recent traumatic injuries. Bellis perennis: This remedy is useful for deeper tissue injuries from falls, car acci- dents, and major surgery. If Arnica has been given for an injury—especially a strain or bruise—but has not had much effect, try Bellis perennis next. Combination recommendation: Traumeel by Heel Urinary Tract Infections Berberis vulgaris: This remedy is for severe cutting or burning pain that extends to the urethral opening, which may also burn at times when there is no attempt at urina- tion. After emptying the bladder, the person feels as if some urine still remains inside. Cantharis: A strong urge to urinate accompanied by cutting pains that are felt before the urine passes is a sign that this remedy is appropriate. Some describe the cutting feeling as a scalding sensation when only a few drops of urine pass at a time. Combination recommendation: Pascosabal by Pascoe Varicose Veins Carbo vegetabilis: When varicose veins are accompanied by general poor circulation with icy coldness of the extremities, and a bruised or marbled look, use Carbo veg. Hamamelis: This remedy can help when varicose veins are large and sore, and very weak and easily damaged, with a tendency to bleed. Normally when you swallow, the lower esophageal sphincter, which is a circular band of muscle around the bottom of the esophagus, relaxes to allow food and liquid to flow down into your stomach. If this valve becomes weak- ened or relaxes when it shouldn’t, stomach acids can flow up into the esophagus, causing heartburn.

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Client verbalizes an understanding of the relationship between emotional problems and physical symptoms arthritis rash 16 mg medrol purchase amex. If there is actual change in structure or function rheumatoid arthritis diet nz buy 16 mg medrol mastercard, encourage client to progress through stages of grieving arthritis and exercise buy medrol australia. Assess level of knowledge and provide information regarding normal griev- ing process and associated feelings. Knowledge of acceptable feelings facilitates progression through the grieving process. Use of touch may help him or her recognize acceptance of the individual by others and reduce fear of rejection because of changes in bodily structure or function. Self-care activities accomplished inde- pendently enhance self-esteem and also create the necessity for client to confront reality of his or her bodily condition. Provide positive reinforcement for client’s expressions of realistic bodily perceptions. Positive reinforcement en- hances self-esteem and encourages repetition of desired behaviors. Client demonstrates acceptance of changes in bodily struc- ture or function, as evidenced by expression of positive feel- ings about body, ability or willingness to perform self-care activities independently, and a focus on personal achievements rather than preoccupation with distorted body image. Possible Etiologies (“related to”) [Severe level of anxiety, repressed] [Low self-esteem] [Unmet dependency needs] [Regression to , or fixation in, an earlier level of development] [Retarded ego development] [Inadequate coping skills] Psychological stress [narrowed perceptual fields caused by anxiety] Defining Characteristics (“evidenced by”) [Loss or alteration in physical functioning suggesting a physical disorder (often neurological in nature) but for which organic pathology is not evident. Common alterations include paralysis, anosmia, aphonia, deafness, blindness] [La belle indifference] Goals/Objectives Short-term Goal Client will verbalize understanding of emotional problems as a contributing factor to alteration in physical functioning within 10 days. Monitor physician’s ongoing assessments, laboratory reports, and other data to maintain assurance that possibility of or- ganic pathology is clearly ruled out. Identify gains that the physical symptom is providing for the client: increased dependency, attention, distraction from other problems. These are important assessment data to be used in assisting the client with problem resolution. Do not focus on the disability, and allow client to be as inde- pendent as possible. Positive reinforcement would encourage continual use of the maladaptive response for secondary gains, such as dependency. Encourage client to participate in therapeutic activities to the best of his or her ability. Reinforce reality as required, but ensure maintenance of a nonthreatening environment. Help client to recognize that the physical symptom appears at a time of extreme stress and is a mechanism used for coping. Client may be unaware of the relationship between physical symp- tom and emotional stress. Help client identify coping mechanisms that he or she could use when faced with stressful situations rather than retreat- ing from reality with a physical disability. Use of assertiveness techniques en- hances self-esteem and minimizes anxiety in interpersonal relationships. Help client identify a satisfactory support system within the community from which he or she may seek assistance as needed to cope with overwhelming stress. Client verbalizes an understanding of the relationship between extreme psychological stress and loss of physical functioning. Client is able to verbalize adaptive ways of coping with stress and identify community support systems to which he or she may go for help. Ensure that nonjudgmental attitude is conveyed as nursing assistance with self-care activities is provided. A judgmental attitude interferes with the nurse’s ability to provide therapeutic care for this client. Feed client, if necessary, and provide assistance with con- tainers, positioning, and other matters, as required. Assist client with dressing, oral hygiene, combing hair, and applying makeup, as required.

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Photographic images can be recorded on flm emulsions that are sensitive to light wavelengths anywhere between 250 and 900 nm arthritis pain.org discount 4 mg medrol overnight delivery. Visible light rheumatoid arthritis eczema buy medrol cheap, which we see with our unaided human eye rheumatoid arthritis x ray pictures medrol 16 mg discount, comprises only from 400 to 760 nm. Most modern digital cameras and traditional photographic flms are specifcally designed to record images seen in the visible range of light as we see them However, it is also possible to record images we cannot see when specifcally illuminated in the shorter ultraviolet range (210 to 400 nm) and longer infrared range (750 to 900 nm). Since ultraviolet and infrared radiations are outside the visible range of the spectrum, they are commonly referred to as nonvisible light. Recent genera- tions of digital cameras have been designed to allow the recording of pat- terned injuries in skin using both visible light and nonvisible light. While the electronic transfer of light to magnetic recording media is very diferent than exposing photographic flm, for the most part, the techniques utilized for image capture are basically the same. Photography using nonvisible light requires special techniques to record the injury, including an occasional minor focusing adjustment called focus shif3 that provides correction for the optical properties of lenses that were designed primarily to be used for visible light photography (Table 11. It is this refection of visible light that accounts for the colors seen by the human eye. It is the absorption of all colored light by an object that makes that object appear black. A third reaction that occurs, especially when light strikes human skin, is the transmission and scattering of the energy associated with the light through successive layers of cells until the energy of the light is spent and has dissipated. Te fnal reaction, which occurs when light energy strikes an object, is a molecular excitation called fuorescence (Figure 11. Molecules in tissue absorb the energy from light and release that energy as a fuorescent glow. It only lasts as long as the light’s excitation energy is applied, usually about 100 nanoseconds (10–9 seconds). When light energy of various wavelengths strikes human skin, all four of the previously mentioned events can occur simultaneously. Depending on the wavelength of the source of the incident light and the confguration of the camera, lenses, and flters, it is possible to record, individually, any of the four reactions of skin to light energy (Figure 11. Ultraviolet light only penetrates a few microns into skin, whereas infrared light can penetrate skin to a depth of up to 3 mm. By varying the wavelength of incident light used for illumination and setting up the appropriate confgu- ration of the camera, lens, flters, and flm, it is possible to photograph any of the four events that occur. Tis ability creates an opportunity for interest- ing pictures, especially when looking at bruises and other injuries to skin. Sharp surface details can be seen with ultraviolet light, while images well below the surface of the skin can be seen using infrared light. Images created using refected visible light and fuorescence allow other potentially diferent appearances of the patterned injuries to be captured. Te techniques and photographic protocols for documenting injuries to human skin in visible and nonvisible light using flm and digital imaging are vastly diferent. Tese changes from normal to injured to healing states allow discriminatory recording of the contusions illuminated by light sources of various wavelengths. Since the healing process is long term and ongoing, it is sometimes possible to photograph an injury afer that tissue appears to have healed to the naked eye. Similarly, photographing the same injuries over time using both visible and nonvisible light techniques can yield diferent appear- ances of those injuries, which can sometimes add to their evidentiary value (Figures 11. Success in photographing healing bruises over time will depend on sev- eral variables, including the composition of the injured skin, the thickness of the skin, the wavelength and intensity of light used to photograph the damaged area, the equipment used, and the type of flm used. Depending upon the specifc injury, it may be necessary to photographically capture the injuries digitally or with flm, in color and black and white using visible light, as well as nonvisible light. Te injury may also vary in appearance in the photographs of each of these incident light sources and over time if photo- graphed serially. Te location and type of skin injured has profound efects on the ability to photograph the injuries. For example, thick skin of the palm of the hand is usually much easier to photograph immediately afer an injury than afer it has partially healed.

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It is thought by its practitioners to prevent specific diseases and maladies by keeping the energy meridians open and maintaining life energy Treatment with surgery The father of Indian surgery is said to be Sushruta arthritis gnarled fingers order medrol once a day. The book provides minute details of preoperative and postoperative care as well as other aspects of ayurvedic practice arthritis relief back pain generic 16 mg medrol amex. Sushruta described surgery under eight headings: • Incision (bhedana) • Excision (chedana) • Scarification (lekhana) • Puncturing (vedhya) Indian ayurvedic medicine | 209 • Probing (esana) • Extraction (ahrya) • Drainage or evacuation (vsraya) • Suturing (sivya) arthritis diet indian discount medrol 4 mg amex. Rasayana This is a specialised branch of clinical medicine in ayurveda meant for slowing the effect of ageing and to improve intelligence, memory, complexion, and sensory and motor functions. Numerous single and compound rasayana drugs possessing diversified actions, such as immuno- enhancement, free-radical scavenging, adaptogenic or anti-stress and nutri- tive effects, are described in ayurveda literature for their use in health promotion and management of diseases with improvement in the quality of life. Safety Safety of administered medicines Intrinsic toxicity13 The following examples illustrate the toxicity problems of certain tradi- tional Indian medicines. Khat (Catha edulis) Khat, pronounced ‘cot’, and also known as qat, gat, chat and miraa, is a herbal product consisting of the leaves and shoots of the shrub Catha edulis. There are many different varieties of Catha edulis depending upon the area in which it is 210 | Traditional medicine cultivated. The active principles are the two alkaloids, norpseudoephedrine (cathinine) and cathi- none. Although users say that the herb is not addictive, withdrawal has been known to cause lethargy and nightmares. In 1980 the World Health Organization classified khat as a drug of abuse that can produce mild-to-moderate psychological dependence, and the plant has been targeted by anti-drug organisations. However, use of khat was not without detrimental effects and should be discouraged. Fresh leaves of khat contain the alkaloid stimulants cathinone (S- ( )-a-aminopropiophenone) and cathine (S,S-( )-norpseudoephedrine) in addition to more than 40 alkaloids, glycosides, tannins and terpenoids. Although this offence has been identified there have been no successful prosecutions to date. Betel (Piper betle) Use of betel is discouraged in western countries because of its alleged carcinogenic and perceived dysaesthetic properties; nevertheless, betel is widely available in the west. Warning signs include ulcers that do not heal within 3 weeks, red and white patches in the mouth, and unusual swellings or changes in the mouth and neck. A betel quid comprises tobacco, Areca catechu, saffron and lime wrapped in a leaf from the plant Piper betle. An Indian ayurvedic medicine | 211 associated practice involves chewing betel nuts, with a mixture of areca nut, lime (calcium hydroxide) and tobacco – known as paan in south-east Asia, where the practice is most common. The nut produces mild psychoactive and cholinergic effects, including a copious production of a blood-red saliva that users spit out. Lead is regarded as an aphrodisiac, and has been used to counteract impotence in men with diabetes. The following are other examples: • The product al kohl is applied as an eye cosmetic; its main ingredient is lead sulphide. The authors recommend that these patients should be screened for lead exposure and strongly encouraged to discontinue metal- containing remedies. Following a systematic strategy to identify all stores 20 miles or less from Boston City Hall that sold ayurvedic products, Dr Robert Saper and colleagues at Harvard Medical School estimated that one of five ayurvedic products produced in south Asia and available in the area under study contained potentially harmful levels of lead, mercury and/or arsenic. Identification of medicines A number of problems that pharmacists and other healthcare providers may experience in identifying ingredients and assessing their potential toxicity in Asian remedies have been identified:24 • Typographical errors on the label • Inaccurate phonetic transliteration • Changes in nomenclature • Absence of generic names on the label • Undeclared ingredients and adulterants • Assessing the literature and finding information. Trease and Evans’ Pharmacognosy,13 to which frequent references are made in this chapter, provides an excellent and readily available source of information for traditional medicine practices. Potential interactions There is a substantial risk that patients will receive simultaneous western and traditional treatments. Patients seldom volunteer information concerning any traditional medicines being taken. A case has been reported in which a woman receiving chemotherapy for Hodgkin’s disease supple- mented her treatment with at least nine different ayurvedic medicines. Pharmacists can provide an extremely valuable function in this respect by intervening with advice whenever they consider it to be appropriate.

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The main factors in the first line of defense against in- fection are mechanical arthritis fingers bent buy genuine medrol, accompanied by some humoral and cellular factors arthritis pain depression buy medrol 16 mg. These defenses represent an attempt on the part of the host organism to pre- vent microorganisms from colonizing its skin and mucosa and thus stave off a generalized invasion arthritis pain relief in dogs buy discount medrol 16 mg line. The second line of defense consists of humoral and cellular factors in the blood and tissues, the most important of which are the professional phagocytes. Microphages contain both primary granules, which are lysosomes containing lysosomal enzymes and cationic peptides, and secondary granules. Both mi- crophages and macrophages are capable of ameboid motility and chemotac- tic migration, i. Other potentially chemotactic substances include secre- tory products of lymphocytes, products of infected and damaged cells or the N-formyl peptides (fMet-Phe and fMet-Leu-Phe). Particles adhering to the membrane are engulfed, in- gested and deposited in a membrane-bound vacuole, the so-called phago- some, which then fuses with lysosomes to form the phagolysosome. The bac- teria are killed by a combination of lysosomal factors: — Mechanisms that require no oxygen. Low pH; acid hydrolases, lysozyme; proteases; defensins (small cationic peptides). The Fc and C3b ligands bind to their specific receptors on the pha- gocyte surface. Humoral immunity is based on antitoxins, op- sonins, microbicidal antibodies, neutralizing antibodies, etc. Cellular immu- nity is based on cytotoxic T lymphocytes (T killer cells) and T helper cells. Congenital defects in the complement-dependent pha- gocytosis system are rare, as are B and T lymphocyte defects. One result of progress in modern medicine is that increasing numbers of pa- tients with secondary immune defects are now receiving hospital treatment. Such “problem patients” are frequently infected by opportunistic bacteria that would not present a serious threat to normal immune defenses. Often, the pathogens involved (“problem bacteria”) have developed a resistance to numerous antibiotics, resulting in difficult courses of antibiotic treatment in this patient category. They proliferate in varied profusion on the mucosa and most particularly in the gastrointestinal tract, where over 400 different species have been counted to date. The count of bacteria per gram of intestinal content is 101–105 in the duodenum, 103–107 in the small intestine, and 1010–1012 in the colon. Over 99% of the normal mucosal flora are obligate anaerobes, dominated by the Gram-neg. One way they do so is when organisms of the normal flora manage to penetrate into the host through microtraumas, resulting in a continuous stimulation of the immune system. Commensals also compete for living space with overtly pathogenic species, a function known as colo- Kayser, Medical Microbiology © 2005 Thieme All rights reserved. On the other hand, a potentially harmful effect of the normal flora is that they can also cause infections in immunocompromised individuals. General Epidemiology & Within the context of medical microbiology, epidemiology is the study of the occurrence, causality, and prevention of infectious diseases in the popu- lace. Infectious diseases occur either sporadically, in epidemics or pandemics, Kayser, Medical Microbiology © 2005 Thieme All rights reserved. The term mortality is used to describe how many deaths are caused by a given disease in a given population. Pathogens are transmitted from these sources to susceptible persons either directly (person-to-person) or indirectly via in- ert objects or biological vectors. Control of infectious diseases within a pop- ulace must be supported by effective legislation that regulates mandatory reporting where required. Further measures must be implemented to pre- vent exposure, for example isolation, quarantine, disinfection, sterilization, use of insecticides, and dispositional prophylaxis (active and passive immu- nization, chemoprophylaxis). The field covered by this discipline can thus be defined as medical problems involving large collectives. The rule of thumb on infectious diseases is that their characteristic spread depends on the virulence of the pathogen involved, the susceptibility of the threatened host species population, and environmental factors. Transmission, Sources of Infection Transmission Pathogens can be transmitted from a source of infection by direct contact or indirectly.

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Complementary therapies focus attention on the whole person gouty arthritis diet foods 4 mg medrol order mastercard, and recognise the complex interactions contributing to disease (literally rheumatoid arthritis chest pain order medrol 16 mg mastercard, dis-ease) destructive arthritis definition medrol 16 mg order overnight delivery. Such holistic and humanist perspectives make complementary therapies attractive to many nurses; the absence of regulation (compared with orthodox medicine) enables nurses to initiate complementary therapies. The resurgence of interest in complementary therapies therefore parallels the growth of the nursing profession’s autonomy and advocacy of therapeutic nursing. Until recently, the knowledge bases of most complementary therapies was largely limited to anecdotes and unsupported assertions. Complementary therapies are often sought when orthodox medicine fails to resolve chronic problems, although some people seek interventions purely for pleasure (e. Therapeutic touch This intervention, conceptualised into nursing by Krieger (1975), develops the traditional laying-on of hands, and is included here mainly because its name can create confusion. Neither the laying-on of hands nor Krieger’s Therapeutic Touch involve skin-to-skin contact. Building on Martha Rogers’ philosophy that humans are made up of energy, and that humans and their environments are continuously, simultaneously and mutually exchanging energy with each other (Sayre-Adams 1994), Therapeutic Touch attempts to touch the energy or force field of the person. Any intervention that increases qualitative staff-patient interaction is potentially beneficial. Qualitative touch (skin- to-skin contact) is much underused by nurses, and can significantly reduce sensory imbalance (see Chapter 3): touch can be therapeutic. Labelling Krieger’s intervention Complementary therapies 441 ‘Therapeutic Touch’ may imply that other nursing touch is not therapeutic—an erroneous presumption. Therefore, when discussing therapeutic touch nurses should clarify whether they mean it in Krieger’s sense or in the broader humane sense. Nursing without touch is a contradiction, but where ordinary touch becomes massage is unclear: washing patients arguably fulfils Feltham’s definition. Where guidelines and professional practice limit the use of massage, nurses should defend the value of touch (especially qualitative). Nineteenth century attempts to regulate masseurs (many with nursing backgrounds) within medicine eventually led to the Chartered Society of Physiotherapists, so that dilemmas of professional boundaries with massage are not new. Although physiological differences were insignificant, patients receiving aromatherapy described feeling better and less anxious. Hill (1993) justifiably questions how critically ill these patients were (over three-quarters could report effects), but such benefits on less critically ill patients are presumably transferable to those more sick. If nursing itself is therapeutic (person-to-person interaction, ‘presence’) then Dunn’s use of a number of nurses to measure the effects of specific interventions (e. Stevensen (1992) used twenty-minute foot massage on patients following cardiac surgery, both with and without neroli oil (relaxant). Other than relaxing respiratory rates, no physiological benefits were observed, but, when interviewed five days later, patients who had received the neroli oil massage reported psychological benefits. Likely (but unproven) physiological benefits include improved lymphatic drainage, returning plasma proteins to the circulation. Reflexology Although there are ancient precedents, modern Western reflexology derives from the work of William Fitzgerald, a nineteenth-century doctor who accidentally found that the Intensive care nursing 442 use of pressure could replace anaesthesia during minor operations (Griffiths 1995). Fitzgerald believed that organ malfunction resulted in tiny crystalline deposits of calcium and uric acid on the nerve endings of the feet, and that breaking down these deposits with massage would heal the organ (Griffiths 1995). Fitzgerald identified ten energy zones of life-force running longitudinally through the body (not too dissimilar to the twelve meridians of Ki), reflecting the organs in specific parts of the feet (and hands). Reflexologists can therefore treat any part of the body using specialised foot massage that breaks down the crystalline deposits. If reflexology’s assumptions are correct, it is possible that nurses manipulating feet and hands (e. Griffiths (1995) warns that reflexology initiates a ‘healing crisis’ which can last up to 24 hours, although this is less likely to occur with the gentler Western approaches than the more vigorous approaches used in the East. The absence of any reported complications suggests this may not be an actual problem, but it leaves a (currently) unanswered question. Shiatsu Although derived from the Japanese for ‘finger pressure’, Shiatsu practice has gained wider connotations; it usually treats the whole meridian system (of vital energy/life force) in order to harmonise Ki (Stevensen 1995). Like other variants of massage, shiatsu is best left to those with specialist knowledge. Aromatherapy Aromatherapy implies the use of essential oils with direct chemical effects, not just burning something which emits pleasant smells (although boundaries between pleasure and therapy can become blurred when evaluating psychological benefit): burning neroli (see Massage above) can reduce anxiety.

Nasib, 35 years: The diagnostic picture for bipolar depression is identical to that described for major depressive disorder, with one exception—the client must have a history of one or more manic episodes. He was a railway construction foreman who suf- In 1895, Calkins requested and took an examination fered a bizarre accident in 1848 when a three-foot-long equivalent to the official Ph. As a general rule, every effort is made to encourage the patient to take the medica- tion.

Mezir, 31 years: Exposure to stilbestrol in utero has also been associated with a Gastric emptying and small intestinal motility are reduced. Since Helicobacter pylori requires an alkaline environment, in stomach acid it produces urease to convert urea to ammonia (the alkaline environment it needs) and carbon dioxide (Cotterill 1996). In fact, our detection methods often measure low-avidity autoantibodies that may have no direct disease-causing effects.

Iomar, 48 years: Behavior borders on the psychotic, with the individual wavering in and out of reality. They are characterized by odd or eccentric behavior, by dramatic or erratic behavior, or by anxious or inhibited behavior. Their pervasive reliance on others, even for minor tasks or de- cisions, makes them exaggeratedly cooperative out of fear of alienating those whose help they need.

Hassan, 60 years: Contact dermatitis can be effec- tively treated with topical corticosteroids and/or antihistamines, such as diphen- hydramine. This has been ascribed to contaminated needles used in the treatment of schistosomiasis conducted between the 1950s and the 1980s (16). For the purposes of this exercise, develop the one patient goal that demonstrates a direct resolution of the patient problem identified in the nursing diagnosis.

Leif, 23 years: Summarize the ways that scientists evaluate the effectiveness of psychological, behavioral, and community service approaches to preventing and reducing disorders. But it turns out that what seem to be relatively small cognitive biases on the surface can have profound consequences for people. If samples cannot be transferred to the laboratory immediately, they should be kept in a cool, dark, dry environment, preferably at –20°C.

Ressel, 49 years: The free acid dif- fuses out of the cornea into the aqueous humour and lowers Mannitol (Chapter 36) is an osmotic diuretic. When dreams become a royal road to confusion: Realistic dreams, dissociation, and fantasy proneness. Paisley and Sparks (1998) argued that it is the perception by an individual that they need to change their behaviour which is critical.

Hengley, 38 years: An illness is treated with a medicine which could produce similar symptoms in a healthy person. It has been estimated that 5–8% of patients aged 65 yr and older suffer from dementia to an appre- ciable degree, with the proportion probably exceeding 20% in 80-yr-olds (98). Client shows no evidence of physical injury obtained during substance intoxication or withdrawal.

Brenton, 29 years: According to conditioning theory, these changes would be examples of placebo recovery. Report (or other evidence) of numerous stressors occurring in person’s life Psychological Factors Affecting Medical Condition ● 267 Common Nursing Diagnoses and Interventions* (Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice. Continue as necessary No Salicylic acid topically, or Coal tar topically, or Dithranol topically Yes Improving?

Derek, 41 years: New England Journal of Medicine 2006; 355: Further investigations revealed normal haemoglobin, 1037–46. In these studies, participants were induced by an experimenter to administer electric shocks to another person so that Milgram could study the extent to which they would obey the demands of an authority figure. Cardiovascular instability is caused by Intensive care nursing 366 ■ continuing massive fluid shifts ■ myocardial depressant factor (pancreatic hormone released in response to pancreatic ischaemia) ■ pericardial effusions ■ electrolyte imbalances.

Mufassa, 61 years: Fluconazole is used clinically will increase during concomitant treatment with fluconazole. Her own resolution, Nightingale a champion for women’s rights or a re- painfully arrived at, was to break from her family gressive force? Arthritis commonly affects the proximal interphalangeal and metacarpophalangeal joints and wrists, usually as arthralgia without any deformity.

Abbas, 33 years: Principles of Safe Supplementing | 69 Green Foods Most people find it difficult to consume the recommended seven to 10 servings of fruits and vegetables per day that provide our primary dietary source of vitamins and minerals. Because borderline patients set up such excessive and unrealistic expectations for others, they Despite some problems with quantifying bonding as are bound to be disappointed when their expectations a scientific phenomenon, there is a wealth of anecdotal aren’t realized. Conservation programs must be further optimized and implemented in other, non-acute healthcare settings such as long- term-care facilities.

Farmon, 52 years: Malaria is one of the most common concerning the suitability of drug therapy for malaria prophy- causes of serious illness in the returning traveller. Here’s a memory tool that only word-play students will love: “The thymus runs out of thyme. If pH is life-threatening and compensatory mechanisms cannot be adequately mimicked (e.

Abe, 55 years: The highly polar nature of the OÀÀH bond results in the formation of hydrogen bonds with other alcohol molecules or other hydrogen bonding systems, e. For example, the nurse may have been reared in an alcoholic family and have ambivalent feel- ings about caring for a client who is alcohol dependent. The 1 formation of a secondary library by omitting amino acid A from the initial set of amino acids but reacting these nine with all 10 amino acids in the first and second steps would produce 900 compounds.

Zuben, 54 years: For instance, people diagnosed with anxiety disorders also often have mood disorders (Hunt, [7] Slade, & Andrews, 2004), and people diagnosed with one personality disorder frequently suffer from other personality disorders as well. Wisemen, wisewomen: Methods of recuperation, preservation and management of the forest and varzea. Genetic variations – for example, the bioavailability of pharmacologically active, as well as being chemically hydralazine is about double in slow compared to fast reactive, and can be hepatotoxic.

Mannig, 53 years: For example, a patient who takes cascara—a laxative for constipation—and senna—also a laxative—along with Digoxin—which is used to treat an irregu- lar heart rhythm—can develop a toxicity. This relationship between occupational activity and coronary heart disease has also been shown in samples of both men and women (Salonen et al. The hypothalamus contains the centers for sexual reflexes; body temperature; water, carbohydrate, and fat metabolism; and emotions that affect the heartbeat and blood pressure.

Pakwan, 51 years: Coordinated body movement: Using major and turning considerably easier for many patients muscle groups rather than weaker ones and tak- and facilitates transfers into and out of bed. A type C personality is described as passive, appeasing, helpless, other focused and unexpressive of emotion. This is referred to as nasal con- gestion and is caused when the nasal mucous membranes swell in response to the rhinovirus.

Cobryn, 32 years: The desire to be thin can lead to eating disorders including anorexia nervosa and bulimia nervosa. During alternative activation of complement, the splitting of C3 occurs directly via the action of products derived from microorganisms, endotoxins, polysaccharides, or aggregated IgA. It was concluded that placebo effects seem to depend on the behaviours embedded in medical rituals.

Sivert, 26 years: Some advertising uses classical conditioning to associate a pleasant response with a product. With more complex molecular mechanics programs it is possible to superimpose one structure on top of another. If you’re an aural learner, you may learn best in the classroom as the teacher lectures.

Wenzel, 65 years: The theoretical ity of self-concept, self-esteem, private conscious- and empirical study of coping and adaptation pro- ness, and social anxiety. Eat lots of fibre-rich foods such as fruits, vegetables, legumes, nuts and seeds, whole grains, fish, and flaxseed. As it is more chronotropic than inotropic, it increases myocardial oxygen consumption and is very dysrhythmic.

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