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A lesser-known detoxifying herb is neem, traditionally used to treat fevers and inflammation.It also is rich in antioxidants and is useful for a variety of chronic disorders including inflammatory conditions and liver problems.Another important Ayurvedic detoxifier is aloe vera juice.Many people today who are labeled with the diagnosis of chronic fatigue or systemic candidiasis are considered by Ayurveda to have ama accumulations. Perhaps a bridge between the long-standing natural healing systems and modern medical science is the recognition that free radical molecules can damage healthy tissues, leading to an accumulation of chemicals that interfere with normal cellular function. Smoking, high-fat diets, environmental toxins, radiation, and potent chemicals can increase the production of free radicals, accelerating the development of illnesses ranging from Alzheimer's disease to cancer, from arthritis to heart disease. Many of the herbs traditionally used to detoxify the body contain antioxidant components and phytochemicals that help the body neutralize damaging free radical molecules. Allspice, clove, oregano, pepper, rosemary, sage, and turmeric have all been shown to possess potent antioxidant abilities. Herbs and spices were used in ancient times to reduce food spoilage. Today we are learning that they help protect our cells from damaging reactive molecules. Among the most important detoxifying Ayurvedic herbs is ginger. One of its Sanskrit names is _vishwabhesaj_ , which is translated as "universal medicine." From an Ayurvedic perspective, ginger enhances all phases of digestion and helps to reduce the accumulation of ama. From a scientific viewpoint, ginger has antioxidant properties and can reduce nausea and enhance digestive enzymes. Another important Ayurvedic detoxifier is aloe vera juice. It also is rich in antioxidants and is useful for a variety of chronic disorders including inflammatory conditions and liver problems. A lesser-known detoxifying herb is neem, traditionally used to treat fevers and inflammation.Neem is protective against yeast and bacterial infections and has been used in the treatment of malaria.It can induce abortions and should not be used by pregnant women.Several herbs have been gaining attention for their possible protective role in conditions of liver damage.

Another important anaplerotic reaction is the synthesis of oxaloacetate from pyruvate by pyruvate carboxylase.22.18 α-Keto acids and their corresponding α-amino acids.Fig.Most of the 20 amino acids are degraded to TCA cycle intermediates.Under most conditions, however, excess dietary amino acids are metabolized to their corresponding α-keto acids.However, the equilibrium of the NAD+-dependent malate dehydrogenase reaction is so unfavorable (see Table 22.5) that an elevated [NADH]/[NAD+] ratio, especially during hypoxia, can impair the formation of oxaloacetate, depriving citrate synthase of this substrate. ## The TCA cycle provides a pool of metabolic intermediates Several TCA cycle intermediates are precursors for biosynthetic reactions (Fig. 22.17). Most of them are tissue specific. For example, the synthesis of glucose from oxaloacetate occurs only in liver and kidneys, and the synthesis of heme from succinyl-CoA is most active in bone marrow and liver. Fig. 22.17 Some reactions of tricarboxylic acid cycle intermediates. , fuel supply; , biosynthetic reaction; , anaplerotic reaction. The removal of TCA cycle intermediates for biosynthesis can create a shortage of oxaloacetate as a substrate for the citrate synthase reaction. Therefore biosynthetic reactions that consume TCA cycle intermediates must be balanced by reactions that produce them. This latter type of reaction is called "anaplerotic" (from Greek words meaning "to fill up"). The three α-keto acids pyruvate, α-ketoglutarate, and oxaloacetate are structurally related to the amino acids alanine, glutamate, and aspartate (Fig. 22.18). When the amino acids are in demand, they can be synthesized from the α-keto acids. Under most conditions, however, excess dietary amino acids are metabolized to their corresponding α-keto acids. Most of the 20 amino acids are degraded to TCA cycle intermediates. Fig. 22.18 α-Keto acids and their corresponding α-amino acids. Another important anaplerotic reaction is the synthesis of oxaloacetate from pyruvate by pyruvate carboxylase.22.19).First CO2 binds to biotin, forming carboxy-biotin.This endergonic reaction (ΔG0′ = + 19.7 kJ/mol or + 4.7 kcal/mol) is fueled by the hydrolysis of ATP to ADP + phosphate (ΔG0′ = − 30.5 kJ/mol or − 7.3 kcal/mol), resulting in a standard free energy change of − 10.9 kJ/mol or − 2.6 kcal/mol).

With excess oestrogen in the body, the liver is put under immense pressure to despatch the overload, as such quantities is toxic.Foods and substances that cause oestrogen-dominance in both women and in men.Right: Oestrogen levels are pronounced during the follicular stage and remain elevated throughout the menstrual cycle.Left: Normal oestrogen levels.Oestrogen-dominance is a silent epidemic that causes a host of troublesome symptoms including ovarian cysts, endometriosis, weight gain, premature wrinkles, high cholesterol, difficult PMS, hair loss and of course migraines. Oestrogen-dominance also affects men, in that it causes excess breast tissue, loss of libido, depression and certain cancers. The thyroid function might be normal, but the effects of oestrogen-dominance feel much like hypothyroidism. And so the migraine is set up for the next time the body temperature returns to normal. In terms of human thermegonesis, this abrupt shift in body temperature (and hormones) is as mighty as the Spring Tide. So the symptoms of oestrogen-dominance and hypothyroidism can be quite similar, as both describe an underperforming endocrine system. And both can trigger migraines. If you wish to check your own body temperature, a guide is provided in chapter 7. Before progressing further, let's learn more about the causes of oestrogen-dominance. Oestrogen-Dominance in Detail We are surrounded with foods and products that behave like oestrogen in the body, which can cause the body temperature to further drop. Such chemicals are known as xenoestrogens. These include, sugar, alcohol, grains, junk food, non-organic protein, dairy and soy. Add plastic bottles, contraceptives, cosmetics and detergents that contain parabens, phthalates and BPA. The xenoestrogens therein mimic how oestrogen behaves in the body, exacerbating oestrogen-dominance. Oestrogen and progesterone levels throughout the menstrual cycle. The green line provides a comparison in oestrogen levels. Left: Normal oestrogen levels. Right: Oestrogen levels are pronounced during the follicular stage and remain elevated throughout the menstrual cycle. Foods and substances that cause oestrogen-dominance in both women and in men. With excess oestrogen in the body, the liver is put under immense pressure to despatch the overload, as such quantities is toxic.So with stress, junk food, contraceptives, alcohol and chemicals in the mix, little wonder migraine awaits in the wings.Over-Production of the Adrenal Stress Hormones To further exacerbate oestrogen-dominance, stress causes the burn-up of progesterone in the name of a key stress hormone, known as cortisol.

Until a protein assay is developed to determine the effect on protein expression, interpretation of this result is based on clinical observation.Missense mutations, or mutations in which a change in a nucleotide results in the substitution of one amino acid for another, may or may not affect the protein function of the gene product.2007) found that in these identified high-risk families, even women who test negative for the familial BRCA1/BRCA2 mutation have a two- to threefold increased lifetime risk (by age 70) of breast cancer consistent with genetic modifiers. A result is uninformative when an affected individual tests negative, yet their family history is suggestive of the breast and ovarian syndrome. In families in which a true autosomal dominant cancer syndrome is present, but no mutation has been located, either the family carries a mutation in a different susceptibility gene or there is a mutation on the BRCA1 or BRCA2 gene that is not detectable by current testing methods. In families for which no mutation is identified, yet there is a pedigree suggestive of hereditary cancer, risk assessment and management of cancer risk must be based on the family history. A negative test result in an individual not affected with cancer may also be uninformative when they are tested before an affected relative. Until the affected relative is tested, it is impossible to know whether the results were negative because they did not inherit the cancer susceptibility gene or because there is no such mutation in the family. If affected relatives are unavailable to clarify the results, risk assessment should again be based on the family history of cancer. The final possible result for individuals undergoing BRCA1 and BRCA2 analysis is a variant of uncertain significance. Variants occur in 10 % of the samples that are analyzed at Myriad Genetics, Inc. (Salt Lake City, UT) (Frank et al. 1998). This result is most commonly reported when a missense mutation is identified. Missense mutations, or mutations in which a change in a nucleotide results in the substitution of one amino acid for another, may or may not affect the protein function of the gene product. Until a protein assay is developed to determine the effect on protein expression, interpretation of this result is based on clinical observation.Receiving a result of a variant of unknown significance leaves the clinician with limited information about cancer risks, and medical decision making must be individualized in these situations.

See **Mobitz I heart block**.Wenckebach heart block.See **pilar cyst**.wen.**Wells' syndrome** _(Callen et al, 2000)_ welt [OE, _wealtan,_ to roll], a raised ridge on the skin, usually caused by a blow, or occurring in dermatographism.Also called [**eosinophilic cellulitis**.A single episode lasts 2 to 6 weeks, and recurrences or exacerbations are common.well-being [AS, _wyllan_ \+ _beon,_ to be], achievement of a good and satisfactory existence as defined by the individual. well-differentiated lymphocytic malignant lymphoma /-dif′ ren′shē·ā′tid/, a lymphoid neoplasm characterized by the predominance of mature lymphocytes. Also called **lymphocytic lymphoma, lymphocytic lymphosarcoma,** **lymphocytoma**. Wellens' syndrome, the electrocardiographic signs of critical proximal left anterior descending coronary artery stenosis in patients with unstable angina. The signs are: normal or minimally elevated enzyme; little or no S-T segment elevation; no loss of precordial R waves; and progressive, deep, symmetric inversion of the T waves in leads V2 and V3, and sometimes in other leads. The signs are seen when the patient is without pain and represent reperfusion following transient occlusion. wellness, a dynamic state of health in which an individual progresses toward a higher level of functioning, achieving an optimum balance between internal and external environments. Wells' syndrome /welz/ G.C. Wells, British dermatologist, 20th century], cellulitis with erythema, edema, and often blistering of the skin accompanied by eosinophilia, flame figures, and a mild fever. A single episode lasts 2 to 6 weeks, and recurrences or exacerbations are common. Also called [**eosinophilic cellulitis**. **Wells' syndrome** _(Callen et al, 2000)_ welt [OE, _wealtan,_ to roll], a raised ridge on the skin, usually caused by a blow, or occurring in dermatographism. wen. See **pilar cyst**. Wenckebach heart block. See **Mobitz I heart block**.Onset occurs within the first year of life, with the condition usually apparent at birth.Symptoms include congenital hypotonia; absence of stretch reflexes; flaccid paralysis, especially of the trunk and limbs; lack of sucking ability; fasciculations of the tongue and sometimes of other muscles; and often, dysphagia.

There is usually tissue loss.Third degree: Deep blistering, with purple blood-containing fluid in the blisters.There is little, if any, tissue loss.Second degree: Superficial blistering, with clear (yellowish) or milky fluid in the blisters, surrounded by redness and swelling.These are recognized as follows: First degree: Numbness, redness, and swelling; no tissue loss.It's best to use your own hand or the victim's uninjured hand to test the temperature. Circulate the water to allow thawing to proceed as rapidly as possible. When adding more hot water, take the body part out, add the water, test the temperature, and then reimmerse the part. It's best to use a container in which the body part can be immersed without touching the sides; for instance, a 20-quart (20-liter) pot will accommodate a foot. If the skin is frozen to mittens or metal, use heated water to remove them. Never rewarm the tissues by vigorous rubbing or by using the heat of a campfire, hand warmers, meals ready-to-eat (MRE) heaters, camp stove, or car exhaust, because you have a high likelihood of damaging the tissues. If the victim is hypothermic, attend first to the hypothermia. Thawing should not be undertaken until the core body temperature has reached 95° F (35° C) (see page 281). Thawing of the tissues usually requires 30 to 45 minutes. It is complete when the skin is soft and pliable, and color (usually quite red; rarely, bluish) and sensation have returned. Allowing the limb to move in the circulating water is fine, but massage may be harmful. Moderate to extreme burning pain may occur during the last 5 to 10 minutes of rewarming, particularly if the frostbitten tissue was numb before rewarming. Thawed frostbite may be present in a number of stages, much like a burn injury. These are recognized as follows: First degree: Numbness, redness, and swelling; no tissue loss. Second degree: Superficial blistering, with clear (yellowish) or milky fluid in the blisters, surrounded by redness and swelling. There is little, if any, tissue loss. Third degree: Deep blistering, with purple blood-containing fluid in the blisters. There is usually tissue loss.There is always tissue loss.Sensation may remain until blisters appear at 6 to 24 hours after rapid rewarming.These often don't extend to the ends of fingers and toes (Figure 210).Leave these blisters intact.After thawing the skin, protect it with fluffy, sterile bandages (aloe vera lotion, gel, or cream should be applied, if available).

The diagnosis is clinically evident during labor, during delivery, or within 48 hours of delivery.Patients will demonstrate moderate to severe pulmonary hypertension, right ventricular failure, and, in severe cases, left ventricular failure.Prolonged fetal heart rate deceleration, indicating fetal distress, is the most reliable sign of fetal extrusion.80 Emergency ultrasonography may reveal a protruding amniotic sac, hemoperitoneum, or the site of myometrial rupture; however, good sensitivity data are lacking.93 Management. : If uterine rupture is suspected, delivery should be hastened to limit fetal hypoxia. Emergency cesarean section is the best method to speed delivery and to repair the injury. The ACOG guidelines for uterine rupture identify a 30-minute window of opportunity that maximizes fetal outcome.94 At surgery, the maternal condition dictates whether uterine repair or hysterectomy is indicated. In the absence of opportunity for emergency laparotomy, appropriate interventions remain speculative. Uterotonic agents may exacerbate the rupture and are contraindicated. #### Amniotic Fluid Embolism Amniotic fluid embolism is a rare and catastrophic complication of labor and delivery. The incidence rate is 6.0 and 14.8 per 100,000 in primigravid and multiparous deliveries, respectively.95 Although the mechanism is not well understood, it is thought to involve the spread of amniotic fluid through the maternal vasculature, activating either a complement or anaphylactic cascade. Cesarean delivery, forceps- or vacuum-assisted delivery, uterine rupture, eclampsia, placenta previa, and placental abruption have been found to have a significant association with amniotic fluid embolism. Patients will demonstrate moderate to severe pulmonary hypertension, right ventricular failure, and, in severe cases, left ventricular failure. The diagnosis is clinically evident during labor, during delivery, or within 48 hours of delivery.DIC occurs in approximately 50%, and both maternal and fetal mortality rates are high.Treatment is generally supportive and may include assisted ventilation, central hemodynamic monitoring, vasopressors or inotropes, and blood products.96–99 #### Postpartum Endometritis Perspective.: Puerperal infections affect 5% of all vaginal deliveries and 10% of all cesarean sections.

**Figure 18.2** Variance explained in the target samples on the basis of score profiles derived in the entire ISC for five significance thresholds (P ValueThreshold < 0.1, 0.2, 0.3, 0.4, and 0.5, plotted left to right in each study).As in schizophrenia, enrichment of cis e-QTL were found when testing the top ~ 1,000 SNPs in novel human cerebellar postmortem brain tissue (P < 0.001).Pathway analysis in the PGC-BD sample showed significant enrichment in the GO category of voltage-gated calcium channel activity (GO:0015270) in an analysis that controlled for many of the potential biases caused by not accounting for SNP density, gene density, and gene size. Three calcium channel subunits were included in this category, CACNA1C, CACNA1D and CACNB3. The first two encode the major L-type alpha subunits found in the brain, consistent with prior literature regarding the role of ion channels in bipolar disorder, the mood stabilizing effects of ion channel modulating drugs, and the specific treatment literature suggesting direct efficacy of L-type calcium channels blockers in the treatment of bipolar disorder (Casamassima et al., 2010). ODZ4, located on chromosome 11, encodes a member of a family of cell surface proteins, the teneurins. These genes are likely involved in cell surface signaling and neuronal pathfinding. NCAN is an extracellular matrix glycoprotein that is brain expressed. Ncan-/- mice show abnormalities in a variety of behavioral paradigms, some of which are often used as models of mania, such as increased exploratory behavior and increased amphetamine-induced hyperactivity (Miro et al., 2012). ANK3 codes for a multifunctional protein, which forms a critical component of the axon initial segment and of nodes of Ranvier with described functions in the developmental and physiological regulation of neural activity including the assembly of voltage-gated sodium channels. As in schizophrenia, enrichment of cis e-QTL were found when testing the top ~ 1,000 SNPs in novel human cerebellar postmortem brain tissue (P < 0.001). **Figure 18.2** Variance explained in the target samples on the basis of score profiles derived in the entire ISC for five significance thresholds (P ValueThreshold < 0.1, 0.2, 0.3, 0.4, and 0.5, plotted left to right in each study).CAD, coronary artery disease; CD, Crohn's disease; HT, hypertension; RA, rheumatoid arthritis; T1D, type I diabetes; T2D, type II diabetes.Used with permission from Purcell, Wray (2009).Phenotypic aspects, such as clinical symptom dimensions, of the categorical disease diagnosis are beginning to emerge.

The influential acupoints on the back of the Kidney Organ (Shen Shu, BL-23) lie directly over the lower parts of the kidneys.They rest, protected against the ribs, between the levels of T11 and L3.It can be seen how the kidneys are situated in the upper part of the back of the abdomen.The component parts of the urinary system are illustrated in Figure 4.3a-I.Some forms of inflammatory arthritis are erosive, and powerful medical approaches should be considered to prevent progression and permanent joint damage A28.3 | Features of polymyalgia rheumatica (PMR): prolonged pain and stiffness and weakness of the muscles of the hips and shoulders associated with malaise and depression. Refer urgently if there is a sudden onset of a severe, one-sided, temporal headache or visual disturbances | PMR is an inflammatory condition of the muscles of the shoulders and hips that predominantly afflicts people over the age of 50. Because it is inflammatory in nature there may be associated malaise, but the main symptoms are pain and weakness of the shoulder and hip muscles. Difficulty in standing from a sitting position is a classic sign of hip weakness There is an increased risk of the serious condition of temporal arteritis (see A23.5). Referral is advised so that the patient can be offered the medical treatment of corticosteroids 4.3 | The Urinary System ---|--- 4.3a The physiology of the urinary system The urinary system consists of the kidneys, the ureters, the bladder and the urethra. An alternative name is the renal system, although strictly speaking, renal (from the Latin term for kidney) is a term that refers to the kidneys alone. The Greek word for kidney is nephron, and hence the study of the kidneys is called nephrology. The component parts of the urinary system are illustrated in Figure 4.3a-I. It can be seen how the kidneys are situated in the upper part of the back of the abdomen. They rest, protected against the ribs, between the levels of T11 and L3. The influential acupoints on the back of the Kidney Organ (Shen Shu, BL-23) lie directly over the lower parts of the kidneys.The bladder sits protected within the pelvis.Note from the diagram how small the bladder is.Even when uncomfortably full the bladder rarely rises very much higher than the level of the pubic symphysis (the region of acupoint Qu Gu, RN-2).

Hematogenous spread to lung, bone, and brain is uncommon and occurs late in the course of the disease.Lymphatic spread to regional nodes is common.Cervical malignancies are squamous cell carcinomas (85%) and adenocarcinomas (15%) that spread primarily by direct extension to adjacent organs and tissues.CT is useful in staging advanced disease and detecting recurrence.As frequent findings, their CT features should be recognized. FIGURE 18-10 Bladder stones. Three calculi are seen as oval high-attenuation objects within the bladder lumen. • Leiomyomas appear as homogeneous or heterogeneous masses that may be hypodense, isodense, or hyperdense relative to enhanced myometrium (Fig. 18-11). Diffuse enlargement of the uterus and lobulation of its contour are common. • Coarse, dystrophic mottled calcifications within the mass are common and characteristic. • Cystic degeneration produces interior low density and may convert the mass into a large cavity. • Pedunculated leiomyomas may appear as adnexal rather than uterine masses. Parasitic leiomyomas are separate from the uterus, having twisted and detached from the uterine pedicle and implanted on the peritoneum. • Lipoleiomyomas are variant tumors consisting of smooth muscle, fibrous tissue, and mature fat. CT shows foci of fat attenuation (below –30 Hounsfield units, HU) within the tumor. • Rare leiomyosarcomas cannot be accurately differentiated from leiomyomas by CT appearance alone. Rapid growth of a uterine mass in a postmenopausal woman suggests malignancy. Leiomyosarcomas appear as large masses with prominent irregular low-attenuation areas of necrosis and hemorrhage. The appearance of leiomyosarcoma overlaps that of benign leiomyoma with extensive degeneration. ### Carcinoma of the Cervix Although CT has been used to stage cervical carcinoma, magnetic resonance (MR) is preferable in most instances. CT is useful in staging advanced disease and detecting recurrence. Cervical malignancies are squamous cell carcinomas (85%) and adenocarcinomas (15%) that spread primarily by direct extension to adjacent organs and tissues. Lymphatic spread to regional nodes is common. Hematogenous spread to lung, bone, and brain is uncommon and occurs late in the course of the disease.A, Axial computed tomography (CT) shows a large leiomyoma (L) extending anteriorly from the uterus (U).B, Sagittal postcontrast CT image of another patient shows a more subtle leiomyoma of the posterior wall (arrowheads) with inhomogeneous enhancement and a single punctate calcification.The endometrium (arrow) is slightly lower in attenuation than the enhanced myometrium.

It is important to take a history from the patient and undertake a thorough clinical assessment in order to diagnose these problems, since specific management is likely to be necessary and should resolve the problem.Alternatively, a patient may develop new pain resulting from a post-operative complication, for example pleuritic chest pain associated with a post-operative chest infection.* Is it possible to reduce the incidence of chronic pain related to surgery? # Assessment There are four main groups of patients which have prolonged pain following surgery. Diagnosis of the problem and institution of appropriate management depends on taking a careful pain history and examination (Box 8.1). Failure to ask questions about the site and character of the pain make accurate diagnosis much harder. Some additional tools are also available if appropriate to the situation; these include neuropathic pain questionnaires such as the self-report Leeds Assessment of Neuropathic Symptoms and Signs (s-LANSS) (Chapter 6). * * * Box 8.1 Taking a Pain History * Patients own verbal report of pain (where possible) * Circumstances associated with onset of pain * Pain intensity at rest and on movement (using pain assessment tool) * Character (intermittent or constant) * Location and radiation * Exacerbating and relieving factors * Effect of pain on other activities including sleep * Current medications and other treatments for pain * Associated symptoms (e.g. nausea) * Previous or coexisting pain/medical conditions * Vital signs – respiratory rate, pulse, blood pressure, SpO2 * Behavioural signs (facial expressions, crying, restlessness, guarding or rubbing of the affected area) * * * # Aetiology of Prolonged Pain Following Surgery ## Surgical Causes The duration of pain following surgery will be protracted if surgical complications arise, such as a wound infection, where pain will remain in the surgical area. Alternatively, a patient may develop new pain resulting from a post-operative complication, for example pleuritic chest pain associated with a post-operative chest infection. It is important to take a history from the patient and undertake a thorough clinical assessment in order to diagnose these problems, since specific management is likely to be necessary and should resolve the problem.It has been shown, however, that prolonged wound pain due to infection or haematoma is one of the risk factors for development of chronic postoperative pain (Figure 8.2).Figure 8.2 A complicated post-operative course with wound infection may predispose to persistent pain.

Changes in glucose concentrations can induce modifications in the fibrin network that promote thrombosis.89 Fibrin clots in patients with diabetes are altered in structure, with a more compact structure, decreased pore size of the clot matrix itself, and resistance to fibrinolysis, resulting in longer time to clot lysis as compared with healthy controls.90 Furthermore, improving glycemic control in T2DM has been suggested to result in a more benign clot structure.91 The balance between clot formation and dissolution involves important offsetting action between tissue plasminogen activator (t-PA) and PAI-1. t-PA, produced by ECs, mediates the conversion of plasminogen to plasmin and is the main factor responsible for initiating the fibrinolytic process. PAI-1 regulates fibrinolysis by binding to t-PA, blocking the conversion of plasminogen into active plasmin, and thus inhibiting fibrinolysis. It is interesting to note that PAI-1 is also produced by adipocytes, making it of obvious significance as a potential link between diabetic adiposity and CVD. In general, both t-PA and PAI-1 are linked to increased risk of CV events as well as a worse postevent prognosis,92,93 although this issue is not without controversy.94 PAI-1 is elevated in insulin-resistant states, correlates strongly with components of the metabolic syndrome, and may predict future T2DM.95,96 Hyperglycemia and hyperinsulinemia, by increasing expression and activation of proinflammatory forces such as the transcription factor NF-κB as well as PAI-1, reduce the activity of t-PA and shift fibrinolytic balance toward thrombosis.For example, thrombin-activatable fibrinolysis inhibitor (TAFI) is a proenzyme activated by the thrombin-thrombomodulin complex.TAFI inhibits fibrinolysis by cleaving lysine residues on fibrin, thus preventing t-PA and plasminogen binding.

Sacrificing an internal carotid artery may limit options in treating a contralateral lesion.As mentioned earlier, cavernous and paraclinoid aneurysms are often not found in isolation.Magnetic resonance imaging (MRI) Head with contrast demonstrated left internal carotid artery aneurysm ( _A_ ); cerebral angiogram confirmed presence of wide neck, giant, cavernous segment aneurysm ( _B_ , AP; _C_ , lateral); treatment performed with single flow diverter ( _arrows_ ) ( _D_ ); 6-month follow-up angiography demonstrated complete aneurysm occlusion ( _E_ ); 12-month follow-up MRI demonstrated complete involution of cavernous mass ( _F_ ). #### Occlusion of the internal carotid It was Barney Brooks in 1930 who pioneered the intravascular approach to treating cerebral pathologic abnormality when he embolized a carotid cavernous fistula by inserting a piece of muscle into the internal carotid artery. By 1974, Serbinenko published a series of 82 patients treated with detachable balloon therapy to occlude the carotid artery.31 Occlusion of the carotid has survived into the modern era as a durable and viable solution to treating aneurysms of the cavernous segment. Typically, carotid occlusion is performed with partial coiling of the aneurysm and full-thickness coiling of the carotid.32 Internal carotid artery occlusion results in complete thrombosis of the aneurysm in nearly 100% of the aneurysms.1,2,33 Symptomatic improvement of presenting cranial nerve deficits has been reported as high as 100%.1 Reports of permanent neurologic deficit following internal carotid occlusion rage from 2% to 4.4%.1,2,33 Endovascular occlusion of the internal carotid artery does have some drawbacks. As mentioned earlier, cavernous and paraclinoid aneurysms are often not found in isolation. Sacrificing an internal carotid artery may limit options in treating a contralateral lesion.If the patient does not pass, it is advisable to perform a high-flow extracranial to intracranial (EC-IC) bypass before internal carotid artery sacrifice.

B-mode imaging alone is insufficient in evaluating the postthrombotic patient because a recanalized vein will have a normal sonomorphologic appearance in about 30% of cases.The findings may range from complete recanalization with a normal sonographic appearance of the venous wall to persistent thrombotic occlusion with luminal narrowing, residual thrombi of various size, wall sclerosis, and synechia. The severity of reflux due to incompetent valves is assessed by spectral Doppler sampling with Valsalva's maneuver or compression testing. If the sonographic examination shows not only postthrombotic changes but also newly obstructed venous segments (hypoechoic thrombus and dilatation of the vein compared with the accompanying artery), this is a sign of recurrent thrombosis (Fig. 3.25c) – especially if the proximal thrombus end is surrounded by flow. In contrast, flow signals in the center of a thrombosed vein depicted by color duplex indicate older thrombosis with beginning recanalization. Impaired venous drainage due to thrombus surrounded by flow or residual thrombus in a recanalized vein with a narrow lumen is identified by the absence of respiratory phasicity in the Doppler waveform (Fig. 3.19). #### 3.1.6.2 Chronic Venous Insufficiency While thrombosis can be evaluated by B-mode imaging alone, Doppler ultrasound is necessary for the hemodynamic assessment of the severity of insufficient venous return in chronic venous incompetence. A high-resolution transducer nicely depicts venous wall sclerosis by an increase in echogenicity and thickening of the wall in the presence of a patent lumen; it also serves to identify valves damaged and immobilized by the sclerotic process. B-mode imaging alone is insufficient in evaluating the postthrombotic patient because a recanalized vein will have a normal sonomorphologic appearance in about 30% of cases.3.26), or a vein that has become dilated after recanalization due to the pressure and volume overload resulting from incompetent valves (see Figs.A3.34 and A3.39–A 3.41).If recanalization is delayed, serial ultrasound will show residual mural thrombi or a thickened wall, from which residual thrombus cannot be differentiated by ultrasound.

More rarely, a ranula may extend through the mylohyoid muscle (a 'plunging ranula') into the upper neck requiring both intraoral and cervical approaches to facilitate complete removal.It is usual to have to excise the sublingual gland as part of this procedure and surgery is best carried out under general anaesthesia.In the latter, mucus is still contained by the epithelium lining the duct, which swells to form an epithelial-lined cyst (Figure 16.2). Figure 16.2 Salivary mucocele of lower lip. Signs and Symptoms These cysts usually present as painless, smooth, bluish swellings containing fluid. At intervals they burst, discharging their contents, but if untreated they heal and form again. In the floor of the mouth, a cyst may arise from the sublingual gland and grow to a considerable size and is called a ranula (Figure 16.3). Figure 16.3 Ranula (mucocele) in the floor of mouth. Treatment of Cysts Mucocele Treatment involves delicate enucleation. An incision is made by drawing a scalpel blade lightly over the swelling and through the mucosa for a short distance beyond the lesion on each side. Alternatively an elliptical incision can be made to reduce the chance of rupture. The cyst is gently freed by blunt dissection and the gland concerned is also removed to prevent recurrence. Due to the fragile lining the lesion may burst during surgery. Other glands seen in the wound, which may already be traumatised, should be removed lest their ducts become blocked by scar tissue and give rise to new cysts. Primary closure is achieved by using superficial mucosal sutures. Ranula The ranula is more difficult to treat and care must be taken during floor of mouth surgery to avoid damage to the submandibular duct and lingual nerve. It is usual to have to excise the sublingual gland as part of this procedure and surgery is best carried out under general anaesthesia. More rarely, a ranula may extend through the mylohyoid muscle (a 'plunging ranula') into the upper neck requiring both intraoral and cervical approaches to facilitate complete removal.It is worth remembering that malignant tumours arise more commonly in minor salivary glands than in major glands, so intraoral glandular swellings should be regarded with suspicion.Figure 16.4 Pleomorphic salivary adenoma in the palate.An incisional biopsy has been performed.

Take hot baths with lavender, juniper, pine, or nutmeg to warm, reduce pain, and encourage the healing process.Rosemary is stimulating and analgesic, and can be massaged into the area to relieve pain and stiffness.Wintergreen oil is good for muscular pains: massage into the affected area.( _seepages 133–157_.)Wrap warmly afterward.The ligaments connecting the vertebrae are stretched or torn, causing prolonged pain and disability. **CAUTION** A stiff neck accompanied by headache, nausea, vomiting, and abnormal sleepiness may indicate meningitis, and immediate medical attention is required. ##### TREATMENT **Ayurveda** Barberry can be taken internally for pain. ( _seepage 18_.) Mustard oil relieves muscular pains and stiffness. Turmeric and St. John's wort are also excellent for relieving stiffness, pain, and inflammation. **Chinese Herbalism** The cause of stiffness and "freezing" may be caused by weak yang qi, external Cold and Damp. Useful treatments include cinnamon twigs and turmeric. ( _seepage 44_.) **Traditional Home and Folk Remedies** Drink celery juice to ease nerve pain. ( _seepage 71_.) Apply fresh horseradish to the affected area (do not leave on for long, or it will numb and burn). Apply bruised juniper berries to muscular swellings. Local heat will help to relax tense muscles. **Herbalism** St. John's wort has sedative, painkilling properties. It can be drunk as an infusion or applied to the affected area in an oil. Valerian can reduce tension and help you to sleep. The following herbs reduce inflammation and relieve pain: Jamaican dogwood, St. John's wort, vervain, and white willow. ( _seepages 110, , and _.) **Aromatherapy** A drop of juniper, mustard, or pepper oils, diluted in some carrier oil, can be massaged into the affected area. Wrap warmly afterward. ( _seepages 133–157_.) Wintergreen oil is good for muscular pains: massage into the affected area. Rosemary is stimulating and analgesic, and can be massaged into the area to relieve pain and stiffness. Take hot baths with lavender, juniper, pine, or nutmeg to warm, reduce pain, and encourage the healing process.Causticum, for dull pain at the nape of the neck, together with stiffness between the shoulders.Bryonia, for pain made worse by the slightest touch.Dulcamara, for pain at the top of the nape of the neck, as if from lying in an awkward position.Lacnanthes, for pain down the right side of the neck, and in the upper arm and elbow.**Flower Essences** Rub Rescue Remedy cream into the affected area.

But without the HVA, the guilt would last a lot longer.They're only cold sores, and they go away even without treatment.In the UK, it's largely been left to the HVA to fight the stigma of herpes, and many of its supporters are in long-term relationships thanks to the support and advice it gives out.Type 1 antibodies give you a lot of protection against the symptoms of type 2 infection, so if one person in a couple has genital herpes, and the other has a blood test showing antibodies to type 1, he or she is very unlikely to be troubled by type 2 infection, even if it occurs. If your partner has type 2 antibodies, even better. For the few people who get recurrent, severe herpes, acyclovir works well to suppress attacks. It's now been around so long, has had a name change (aciclovir), and is cheap as chips. A whole month's supply costs the NHS just £9, though many doctors are reluctant to give it because they still think of the very expensive wonder-drug launched twenty-seven years ago and they don't know much about herpes. A lot of women treated for recurrent thrush have herpes. If you want good advice and great support, go to the Herpes Viruses Association (HVA). Founded over twenty-five years ago to counter the herpes hype, the HVA has been a beacon of sanity, destigmatising cold sores wherever they occur and counselling, supporting and educating those with herpes and those who treat it. Unfortunately, the Department of Health has just cut its funding, so its survival depends on donations. The HVA is so valuable to patients, partners and health professionals that I became a patron. Shortly after acyclovir was launched and herpes hype hit a peak, a study of 375 people with genital herpes found that half had suffered from depression, thirty-five per cent avoided intimate relationships, thirty-five per cent reported decreased sex drive, ten per cent gave up sex completely and fifteen per cent had suicidal thoughts. In the UK, it's largely been left to the HVA to fight the stigma of herpes, and many of its supporters are in long-term relationships thanks to the support and advice it gives out. They're only cold sores, and they go away even without treatment. But without the HVA, the guilt would last a lot longer.** It may well be soon, but it so easily could have been different.Back in 2007, a vaccine called Gardasil was launched that protects girls and women who've yet to have sex from viruses that cause both cervical cancer and genital warts.

# **Ear Infections** Ear infections, as observed in Chapter 14, are the number-one reason why parents bring their children to the pediatrician.Zinc-rich foods include poultry, baked potato, brown rice, lentils, oatmeal, peas, salmon, spinach, whole wheat bread, and yogurt.As noted in Chapter 13, zinc is a mineral critical for maintaining proper immune function and skin health.The simple act of keeping the child's head elevated, especially during sleep, can significantly reduce the pressure on the sinuses and nasal passages. Cool mist humidifiers can decrease the irritation of the upper airway (although be mindful of a humidifier's ability, as mentioned in Chapter 12, to exacerbate dust mite population growth). Vapor rubs are popular, age-old remedies, too, but be aware of the possibility of accidental ingestion. Critical for cold relief at home is ensuring that your child gets plenty of fluids. Given bed rest and wholesome food, the body heals itself from colds with no need for antihistamines, decongestants, or fever-lowering drugs. Colds and viruses, just like fevers, are a part of life and a way for the immune system to respond appropriately to avoid future infections. Keeping the child comfortable is all that is required while letting nature run its course. # **More Cold Remedies** Vitamin C and zinc are two home remedies that are already familiar to many parents. Foods high in vitamin C, which, as mentioned in the nutrition chapter, acts as an antioxidant and assists the body in producing the connective tissue component collagen, include berries, broccoli, cantaloupe, carrots, green beans, honeydew melon, orange, papaya, peaches, peas, romaine lettuce, spinach, strawberries, sweet potatoes, and tomatoes. As noted in Chapter 13, zinc is a mineral critical for maintaining proper immune function and skin health. Zinc-rich foods include poultry, baked potato, brown rice, lentils, oatmeal, peas, salmon, spinach, whole wheat bread, and yogurt. # **Ear Infections** Ear infections, as observed in Chapter 14, are the number-one reason why parents bring their children to the pediatrician.As noted, the drugs in many cases may lead to side effects, hard-to-treat and recurring infection, and a resistance to antibiotics.Equally problematic, when antibiotics kill bacteria, they may also kill many of the beneficial microflora in the intestines at the same time.

Tell the patient to keep a note of foods or medicines just ingested so that, in the event of recurrence, the culprit can be identified.It is usually very difficult to identify the allergen in a single episode of urticaria.The books usually state that psoriasis doesn't itch – but it certainly can, so don't let this symptom put you off the diagnosis.food or drug allergy) jaundice of any cause iron deficiency anaemia endocrine: diabetes mellitus, hypo- and hyperthyroidism renal failure (uraemia) lichen planus prickly heat **RARE** herpes gestationis dermatitis herpetiformis psychogenic (includes dermatitis artefacta) leukaemia and myeloproliferative disorders simple pruritus: no other cause found drug side effect (with or without rash) #### Ready reckoner #### Possible investigations _LIKELY :_ none. _POSSIBLE :_ urinalysis, blood glucose or HbA1c, FBC, ESR, U&E, LFT, TFT. _SMALL PRINT :_ none. Urine: dipstick for glycosuria (blood glucose or HbA1c if positive). FBC: will reveal iron-deficiency anaemia and polycythaemia; eosinophil count may be raised in allergic conditions; WCC may be very high in leukaemia; ESR may be elevated in lymphoma. U&E: will reveal uraemia. LFT: deranged liver enzymes and raised bilirubin in liver disease. TFT: both hypo- and hyperthyroidism can lead to skin changes which cause itching. ##### TOP TIPS An itchy, unidentifiable rash which is worse at night is likely to be scabies, particularly if any contacts are affected. Warn the patient that scabies treatment may take a week or two fully to relieve symptoms – otherwise, the patient may apply the treatment repeatedly, causing a chemical irritation and diagnostic confusion. The books usually state that psoriasis doesn't itch – but it certainly can, so don't let this symptom put you off the diagnosis. It is usually very difficult to identify the allergen in a single episode of urticaria. Tell the patient to keep a note of foods or medicines just ingested so that, in the event of recurrence, the culprit can be identified.Don't be tempted not to examine the itchy, malodorous self-neglected patient: poor personal hygiene may deceptively mask some other identifiable underlying cause.Beware of apparently florid eczema appearing for the first time in an elderly patient – this may be a manifestation of serious underlying pathology.Don't forget iatrogenic causes – enquire about any drugs recently prescribed.

leukocyturia /lo̅o̅′kəsīto͝or″ē·ə/ , the presence of white blood cells in the urine.See also leukocyte.Kinds include basophilia, eosinophilia, neutrophilia.Compare leukemia, leukemoid reaction, leukopenia.Also spelled leucocytosis.Extreme elevations may be associated with leukemia.leukocyte alkaline phosphatase (LAP), an enzyme present in lymphocytes that is elevated in various diseases such as cirrhosis and polycythemia and in certain infections. It is measured in the blood to detect these disorders and to differentiate chronic myelogenous (myelocytic) leukemia from leukemoid reactions. Normal amounts of this enzyme in a smear of fresh venous blood are 50 to 150 units. Also called neutrophil alkaline phosphatase. Leukocyte alkaline phosphatase reaction (Carr and Rodak, 2008) leukocyte emigration, the passage (diapedesis) of leukocytes through the endothelial gap junctions of blood vessels in inflammation. leukocyte migration inhibition factor. See macrophage migration inhibiting factor. leukocytic, pertaining to white blood cells. See leukocyte. leukocytic crystal. See Charcot-Leyden crystal. leukocytoclastic vasculitis /lo̅o̅′kəsī′təklas″tik/ , an allergic inflammation of blood vessels, characterized by deposits of fragmented cells, nuclear dust, necrotic debris, and fibrin staining in the vessels. Many patients develop skin lesions, particularly on the legs, accompanied by arthralgia and fever. The disorder is seen in rheumatoid arthritis and other diseases. Leukocytoclastic vasculitis: characteristic skin lesions (Callen et al, 2000) leukocytogenesis /-jen″əsis/ , the origin and development of leukocytes. leukocytopenia. See leukopenia. leukocytopoiesis. See leukopoiesis. leukocytosis /lo̅o̅′kōsītō″sis/ [Gk, leukos \+ kytos, cell, osis, condition] , an abnormally elevated total peripheral white blood cell count, often associated with bacterial infection. Extreme elevations may be associated with leukemia. Also spelled leucocytosis. Compare leukemia, leukemoid reaction, leukopenia. Kinds include basophilia, eosinophilia, neutrophilia. See also leukocyte. leukocyturia /lo̅o̅′kəsīto͝or″ē·ə/ , the presence of white blood cells in the urine.Also spelled leucoderma.Compare vitiligo.leukodystrophy /-dis″trəfē/ [Gk, leukos, white, dys \+ trophe, nourishment] , a disease of the white matter of the brain, characterized by demyelination.See also leukoencephalopathy.

This "neutralizes" (inhibits) viral replication.• The surface proteins are the **targets of antibody** (i.e., antibody bound to these surface proteins prevents the virus from attaching to the cell receptor).This interaction **determines the host specificity and organ specificity** of the virus.**_Viral Proteins_** • Viral surface proteins mediate **attachment to host cell receptors**.Most viruses appear as spheres or rods in the electron microscope. • Viruses contain **either DNA or RNA, but not both**. • All viruses have a **protein coat called a capsid** that covers the genome. The capsid is composed of repeating subunits called capsomers. In some viruses, the capsid is the outer surface, but in other viruses, the capsid is covered with a lipoprotein **envelope** that becomes the outer surface. The structure composed of the nucleic acid genome and the capsid proteins is called the **nucleocapsid**. • The repeating subunits of the capsid give the virus a symmetric appearance that is useful for classification purposes. Some viral nucleocapsids have **spherical (icosahedral) symmetry,** whereas others have **helical symmetry**. • All human viruses that have a helical nucleocapsid are enveloped (i.e., there are no naked helical viruses that infect humans). Viruses that have an icosahedral nucleocapsid can be either enveloped or naked. **_Viral Nucleic Acids_** • The genome of some viruses is **DNA,** whereas the genome of others is **RNA**. These DNA and RNA genomes can be either **single-stranded** or **double-stranded**. • Some RNA viruses, such as influenza virus and rotavirus, have a **segmented genome** (i.e., the genome is in several pieces). • All viruses have one copy of their genome (haploid) except retroviruses, which have two copies (diploid). **_Viral Proteins_** • Viral surface proteins mediate **attachment to host cell receptors**. This interaction **determines the host specificity and organ specificity** of the virus. • The surface proteins are the **targets of antibody** (i.e., antibody bound to these surface proteins prevents the virus from attaching to the cell receptor). This "neutralizes" (inhibits) viral replication.• The **matrix protein** mediates the interaction between the viral nucleocapsid proteins and the envelope proteins.• Some viruses produce **antigenic variants** of their surface proteins that allow the viruses to evade our host defenses.Antibody against one antigenic variant ( **serotype** ) will not neutralize a different serotype.Some viruses have one serotype; others have multiple serotypes.

See benign prostatic hyperplasia, prostatomegaly.prostatic hypertrophy.prostatic fluid, the secretion of the prostate gland, which contributes to formation of the semen.Currently, PSA is considered the most sensitive tumor marker for this type of cancer. prostatic /prostat″ik/ , pertaining to the prostate. prostatic calculus [Gk, prostates, standing before; L, calculus, pebble] , a solid calcification formed in the prostate. Typically small and multiple, prostatic calculi are often the product of chronic prostatitis and are usually composed of calcium carbonate and/or calcium phosphate. They are not clinically significant and do not require treatment. prostatic catheter, a catheter that is approximately 16 inches (41 cm) long and has an angled tip. It is used in male urinary bladder catheterization to bypass an enlarged prostate gland obstructing the urethra. Also called coudé catheter. prostatic ductule /duk″tyo̅o̅l/ [Gk, prostates \+ L, ductulus, little duct] , any of 12 to 20 tiny excretory tubes that convey the alkaline secretion of the prostate and open into the floor of the prostatic part of the urethra. The ductules are joined together by areolar tissue, supported by extensions of the fibrous capsule of the prostate and its muscular stroma, and wrapped in a delicate network of capillaries. prostatic fascia, a condensation of fascia around the anterior and lateral region of the prostate that contains and surrounds the prostatic plexus of veins and is continuous posteriorly with the rectovesical septum, which separates the posterior surface of the prostate and the base of the bladder from the rectum. prostatic fluid, the secretion of the prostate gland, which contributes to formation of the semen. prostatic hypertrophy. See benign prostatic hyperplasia, prostatomegaly.prostatic urethral polyps, presence of numerous polyps in the prostatic urethra, sometimes causing obstruction, seen in male children as a developmental anomaly and in older males in some inflammatory reactions.prostatic utricle, the part of the urethra in men that forms a cul-de-sac about 6 mm long behind the middle lobe of the prostate.

It can be a major life milestone for some—a time of psychoemotional reckoning, evaluation, introspection, and integration, as well as a time of starting a new phase in life.## Summary Menopause is a time of tremendous physical, emotional, and social change for women.Botanical therapies commonly used include adaptogens (see Chapter 5, the section Stress, Adaptation, the Hypothalamic-Pituitary-Adrenal Axis, and Women's Health), ashwagandha (Withania somnifera), eleuthero (Eleutherococcus senticosus), ginkgo (Ginkgo biloba), ginseng (Panax ginseng), dong quai (Angelica sinensis), motherwort (Leonurus cardiaca), St. John's wort (Hypericum perforatum), and blue vervain (Verbena officinalis). ### Vaginal Dryness Vaginal dryness, caused by reduced endogenous estrogen levels, is uncomfortable, increases susceptibility to infection, and has a negative effect on sexual experience with both physical and psychoemotional ramifications. Botanical therapies include topical emollient therapies to moisten and lubricate the vagina, as well as internal botanical protocol to increase estrogen, such as red clover (Trifolium pratense), chaste berry (Vitex agnus castus), licorice (Glycyrrhiza glabra), calendula (Calendula officinalis), American ginseng (Panax quinquefolius), wild yam (Dioscorea villosa), and black cohosh (Actaea racemosa). ### Heavy Bleeding Many women experience at least one episode of heavy vaginal bleeding, or "flooding," during perimenopause in the absence of pathology. Nonetheless, incidences of abnormal vaginal bleeding in a perimenopausal or menopausal woman should be investigated to rule out gynecologic cancer. Botanicals commonly used to manage dysfunctional uterine bleeding include yarrow (Achillea millefolium), lady's mantle (Alchemilla vulgaris), tienchi ginseng (Panax notoginseng), and shepherd's purse (Capsella bursa pastoris), among others. ## Summary Menopause is a time of tremendous physical, emotional, and social change for women. It can be a major life milestone for some—a time of psychoemotional reckoning, evaluation, introspection, and integration, as well as a time of starting a new phase in life.It is also a time of increased vulnerability to developing heart disease and osteoporosis, both of which can lead to major future debility and hardship.Therefore this is a time that practitioners working with women must be aware of and address the many nuances of change women face and the enormous opportunity for preventative care.

Protecting the brain's blood flow is critical to having a healthy mind.Researchers from Japan found that brain blood flow in certain areas of the brain was positively correlated with both intelligence and creativity.If he tends to be rigid and inflexible, we often see increased activity in an area of the frontal part of the brain called the anterior cingulate gyrus.DETAILED CLINICAL ASSESSMENTS SPIRITUAL * Sense of meaning and purpose * Why does my life matter? * Connection to higher power? * Who am I accountable to? * Connection to past generations * Connections to future generations * Connection to planet * Morality * Values ### STEP TWO: GET YOUR BRAIN ASSESSED You can do a great job doing a "Four Circles" assessment and still not fully optimize your brain. You also need to understand how your brain functions. At the Amen Clinics, we have three ways to evaluate brain function: * Brain SPECT imaging * Questionnaires * Online neuropsychological assessments #### Brain SPECT Imaging As mentioned, at the Amen Clinics, we do a study called brain SPECT imaging, which looks at blood flow and activity patterns. SPECT gives a direct look at how the brain works. In a scientific study we published last year, we found that getting a SPECT scan changed either the diagnosis or treatment plan in nearly eight out of ten patients. Having a scan helps us see more clearly what is happening in the brain that may be the cause of someone's emotional and cognitive struggles, such as when the brain works too hard, not hard enough, or if it has patterns consistent with brain trauma or toxic exposure. SPECT scans also help us see someone's strengths and vulnerabilities. For example, if someone has a tendency toward impulse control problems, we are more likely to see low activity in the front part of the brain, called the prefrontal cortex. If he tends to be rigid and inflexible, we often see increased activity in an area of the frontal part of the brain called the anterior cingulate gyrus. Researchers from Japan found that brain blood flow in certain areas of the brain was positively correlated with both intelligence and creativity. Protecting the brain's blood flow is critical to having a healthy mind.Without a scan or another measure of brain function, it is like throwing medicated-tipped darts in the dark at someone's brain.At amenclinics.com you can see hundreds of brain SPECT scans and read over 2,800 scientific abstracts on SPECT for a wide variety of behavioral, mood, learning, and mental health issues.In the next chapter I will discuss our work with SPECT and ADD in detail.

Doxycycline is not advised for pregnant women or children under age 8 years, and may cause increased skin sensitivity to sunlight.Unfortunately, there is not yet a useful vaccine against malaria. Avoidance of mosquito bites is key to prevention. Because the _Anopheles_ mosquito tends to feed during the evening and nighttime, it is particularly important to sleep under nets or screens; spray living quarters (with, for instance, a pyrethrin-containing product) and clothing (with, for example, permethrin 0.5%, Duranon, or Repel Permanone; or concentrated Perma-Kill 4 Week Tick Killer, diluted and applied to clothing); and wear adequate clothing and insect repellent (N,N-diethyl-3-methylbenzamide, called DEET) at these times (see page 390). If you travel to a region where _P. falciparum_ is resistant to chloroquine and pyrimethamine-sulfadoxine, prophylaxis (prevention) can be accomplished with mefloquine. The adult dose is 250 mg (salt) weekly. The pediatric dose varies according to the weight of the child: weight 15 to 19 kg, 63 mg; weight 20 to 30 kg, 125 mg; weight 31 to 45 kg, 188 mg; and over 45 kg, 250 mg. (For estimating purposes, 1 kg equals 2.2 lb.) Mefloquine should be started 1 to 2 weeks before travel, and then administered once a week during travel in malarious areas and for 4 weeks after you leave such areas. Mefloquine should not be taken during pregnancy. This drug should not be used by persons with psychiatric disease or history of depression or seizures. Side effects include nausea and vomiting, dizziness, mood changes, difficulty sleeping and nightmares, headache, and diarrhea. An alternative drug for travelers who cannot take mefloquine is doxycycline (the adult dose is 100 mg a day beginning 1 to 2 days before travel and continuing for 5 to 6 weeks after; the pediatric dose for those aged more than 8 years is 2 mg/kg of body weight a day, up to the adult dose). Doxycycline is not advised for pregnant women or children under age 8 years, and may cause increased skin sensitivity to sunlight.Chloroquine is recommended for travelers, particularly pregnant women and children who weigh less than 33 lb (15 kg), who cannot take mefloquine or doxycycline.If you use chloroquine for prophylaxis, you should also carry three tablets of Fansidar to be taken in the event of a flu-like illness or other unexplained fever, assuming the absence of an allergy to sulfonamide antibiotics.

• Influenza-like illness Bisphosphonates may cause a flu-like syndrome, particularly in the early phase of treatment.People with 10 prescriptions for bisphosphonates—or who had been prescribed bisphosphonates over a period of five years—had nearly double the risk of esophageal cancer compared with people with no bisphosphonate prescriptions.glass of ordinary (not mineral) water, first thing in the morning after getting out of bed, and at least 30 minutes before ingesting any other food, beverage, or medication, during which time the patient must consume an additional 2 oz. of water and cannot lie down until at least 30 minutes later after food has been consumed. The results of the 1-year findings in the Prospective Observational Scientific Study Investigating Bone Loss Experience in the US (POSSIBLE US), published April 2010, showed that 20% of women taking bisphosphonates reported gastrointestinal side effects when they began participating in the study. Side effects frequently became so severe that when the women were questioned again after 6 months, those using bisphosphonates were 139% more likely to have stopped taking the patent medicines.29 • Esophageal Cancer People who take oral bisphosphonates for bone disease for more than five years may be doubling their risk of developing esophageal cancer, according to a study published September 2010 in the British Medical Journal.30 The researchers analyzed data from the UK General Practice Research Database, which includes patient records for around six million people. They focused on men and women aged over 40 years, identifying 2,954 cases of esophageal cancer. Each case was compared with five controls matched for age, sex, general practice, and observation period. People with 10 prescriptions for bisphosphonates—or who had been prescribed bisphosphonates over a period of five years—had nearly double the risk of esophageal cancer compared with people with no bisphosphonate prescriptions. • Influenza-like illness Bisphosphonates may cause a flu-like syndrome, particularly in the early phase of treatment.The time to onset of severe muscle pain varied from one day to several months after starting treatment.When patients stopped taking alendronate, their myalgia usually—but not always—went away.32 • Deterioration of kidney function and kidney failure Studies have shown the bisphosphonates, especially zoledronic acid (sold under the trade names of Zometa® and Reclast®), are toxic to the kidneys.

Although the glutamate and GABA systems are often discussed separately, it is useful to consider how they work in concert, as reciprocal interactions are critical for fine control of neuronal circuits and brain function.Based on this heterogeneity it is not surprising that drugs that act on monoamine systems, including 5-HT selective reuptake inhibitor (SSRI) antidepressants, have limited efficacy with approximately one in three depressed patients responding to the first antidepressant prescribed (Trivedi, 2006). Nevertheless, there is still interest in developing drugs that act on the monoamine systems, with increased emphasis on dual or triple (i.e., 5-HT, NE, and/or dopamine) reuptake inhibitors. While such agents may have fewer side effects than earlier reuptake inhibitors, it is reasonable to question whether such drugs will be more efficacious than currently available antidepressants. The limited efficacy could be due to disease heterogeneity and the restricted role of monoamine depletion in the symptoms of depression, as discussed. In addition, the monoamines are considered to be modulatory neurotransmitter systems (Fig. 32.1), influencing the activity and function of other systems, in contrast to fast-acting glutamate and GABA. This could explain in part the limited efficacy and therapeutic time lag for the actions of antidepressants that work via the monoamine systems. This possibility is supported by recent studies demonstrating that novel antidepressants that act on glutamate neurotransmission (i.e., ketamine) produce rapid antidepressant actions in hard-to-treat depressed patients (Zarate, 2006) (see the following for further discussion of ­rapid-acting antidepressants and glutamate). ALTERATIONS OF GLUTAMATE AND GABA IN DEPRESSION In recent years the focus of depression research has shifted from the monoamine systems to the amino acid neurotransmitters glutamate and GABA. Although the glutamate and GABA systems are often discussed separately, it is useful to consider how they work in concert, as reciprocal interactions are critical for fine control of neuronal circuits and brain function.32.1).The tonic firing of GABA neurons is in turn controlled in part by glutamate receptors on these neurons.The delicate balance of glutamate and GABA transmission is necessary for normal brain function, and disruption of this homeostasis contributes to depression as well as other psychiatric illnesses.

Other Herbs for Cognitive Enhancement a. lemon balm, sage, vinpocetine, ginkgo, bacopa 7.Adaptogens a. Rhodiola rosea, Schizandra chinensis, Eleutherococcus senticosus, Panax ginseng, Withania somnifera (Ashwaganda), Lepidium meyenii (Maca) b. adaptogen combinations for complex cases 6.Cholinergic Enhancing Agents a. galantamine, citicholine, huperzine-A 5.| Keep liquid refrigerated Caution: cardiac stents** ADAPT-232 R. rosea E. senticosus S. chinensis | mild to extreme stress, combat stress | 2–3 tabs/day | Rare: overactivation, anxiety, insomnia Caution: bipolars Easy Energy R. rosea 70 mg E. senticocus S. chinensis A. Mandshurica R. carthamoides | mild to extreme stress, physical strength, calms patients who become agitated on activating herbs | 2–4 pills/day | Minimal: side effects of component herbs Caution: bipolars | | | D/C = discontinue; GI = gastrointestinal; # = decrease. *Common side effects are listed. There are additional rare side effects. Individuals with high blood pressure, diabetes, pregnancy (or during breast-feeding), or any chronic or serious medical condition should check with their physician before taking supplements. Patients taking anticoagulants should consult their physician before using supplements. **May increase risk of restenosis of cardiac stents in men only with baseline homocysteine less than 15 µmol/liter. * * * CHAPTER 4 OUTLINE 1. Key Concepts: Effects of CAM treatments on brain function 2. Neurodevelopment and Neuroprotection a. omega-3 fatty acids, vitamins, S-adenosylmethionine, picamilon 3. Mitochondrial Energy Production and Antioxidant Protection a. coenzyme Q10, idebenone, ubiquinol, acetyl-L-carnitine 4. Cholinergic Enhancing Agents a. galantamine, citicholine, huperzine-A 5. Adaptogens a. Rhodiola rosea, Schizandra chinensis, Eleutherococcus senticosus, Panax ginseng, Withania somnifera (Ashwaganda), Lepidium meyenii (Maca) b. adaptogen combinations for complex cases 6. Other Herbs for Cognitive Enhancement a. lemon balm, sage, vinpocetine, ginkgo, bacopa 7.Ergot Derivatives a. hydergine and nicergoline 9.Cognitive Enhancing Hormones a. DHEA, melatonin 10.Neurotherapy * * * CHAPTER 4 Disorders of Cognition and Memory Disorders of cognition and memory can been viewed as stemming from any combination of processes in which the impairment or accumulated damage to neurons exceeds the capacity for self-maintenance and repair.

Fungal etiology is rare except in patients with underlying immunodeficiency.Unusual bacteria such as Salmonella may be seen in patients with underlying sickle cell disease.Staphylococcus is the most frequently implicated bacteria in both adults and pediatric patients with osteomyelitis.Coronal T1-weighted (a), T2-weighted fat-suppressed (b), and sagittal proton-density-weighted (c) MR images of the left knee demonstrate prominent cortical thickening especially in the epiphyses (arrows). On lumbar spine MRI, hypointense thickening of the endplates is noted on T1-weighted sagittal (d) and T2-weighted sagittal (e) images ## 5.9 Sarcoidosis Sarcoidosis is a systemic inflammatory disorder in which noncaseating granulomas infiltrate multiple organ systems, including the bone marrow. Most patients with sarcoidosis have underlying chest disease, although isolated bone marrow involvement has been encountered when MRI is performed for routine joint or spine evaluation (Fig. 5.22). Sarcoid bone marrow lesions are frequently multiple and in most cases contain intralesional macroscopic fat (Fig. 5.23), a sign of benignity differentiating these lesions from metastatic disease. Fig. 5.22 A 37-year-old female with low back pain and no known malignancy or systemic disease. An MRI examination of the pelvis revealed several marrow-infiltrating lesions on T1-weighted axial (a) and STIR axial images (b). The largest lesion in the right ilium posteriorly (arrows) was biopsied under imaging guidance. Histologic evaluation revealed granulomas consistent with sarcoid Fig. 5.23 A 48-year-old male with known sarcoid. Multiple lesions are seen throughout the visualized lumbar spine on sagittal T1-weighted precontrast (a) and T2-weighted (b) and T1-weighted postcontrast (c) images. Fatty signal is noted in larger lesions (arrows), a sign of benignity ## 5.10 Infection Osteomyelitis is the infection of the bone and bone marrow. Staphylococcus is the most frequently implicated bacteria in both adults and pediatric patients with osteomyelitis. Unusual bacteria such as Salmonella may be seen in patients with underlying sickle cell disease. Fungal etiology is rare except in patients with underlying immunodeficiency.5.24).MRI is also helpful in the detection of associated abscesses that may occur in the bone marrow, subperiosteal region, or overlying soft tissues (Fig.5.25).On T1-weighted images, osteomyelitis shows hypointense signal compared to skeletal muscle.On T2-weighted and STIR images, a hyperintense signal corresponding to osteomyelitis with marked surrounding bone marrow edema can be seen.

In the history of science, Arabic medicine, Islamic medicine, Arab–Islamic medicine, Greco-Arab medicine, or Greco-Arab and Islamic medicine are terms that refer to medicine developed during the Golden Age of Arab–Islamic civilization (seventh to fifteenth century), which extended from Spain to Central Asia and India (Figure 1.1).Chapter 1 An Overview of Greco-Arab and Islamic Herbal Medicine 1.1 Introduction Natural products, such as plant, fungal, and bee products, as well as minerals, shells, and certain animal products, represent the oldest form of medical treatment. Currently, many of the commonly used drugs are of herbal origin and about 25% of the prescription drugs contain at least one herbal-derived active ingredient or synthetic compound, which mimics a plant-derived compound. There are over 80,000 plants that have medicinal uses throughout the world and usually a specific part of the plant is used for medical preparations such as tablets, infusions, extracts, tinctures, ointments, or creams. The pharmacological action of these medicines is often described in very general terms, such as carminative (an agent that prevents formation of gas in the gastrointestinal tract or facilitates the expulsion of said gas), laxative (an agent that induces bowel movements or loosens the stools), demulcent (an agent that forms a soothing film over a mucous membrane, relieving minor pain and inflammation of the membrane), antitussive (cough suppressants), or antiseptic (antimicrobial substances that are applied to living tissue/skin to reduce the possibility of infection). Unlike synthetic drugs, which usually consist of a single and often synthetic chemical, herbal-based medicines contain multiple constituents. In the history of science, Arabic medicine, Islamic medicine, Arab–Islamic medicine, Greco-Arab medicine, or Greco-Arab and Islamic medicine are terms that refer to medicine developed during the Golden Age of Arab–Islamic civilization (seventh to fifteenth century), which extended from Spain to Central Asia and India (Figure 1.1).Arab and Muslim scholars translated and integrated scientific knowledge of other civilizations into their own.As will be seen in the following chapters, however, Arab–Islamic medicine was not simply a continuation of Greek ideas but a venue for innovation and change.

Medical literature has an abundance of cases of successful use of plant medicines which warrant investigation in depth._Differential diagnosis_ : a malignant tumour infiltrates other body tissues, whereas a benign one does not spread or infiltrate.A spontaneous new growth – malignant (cancerous) or benign (non-cancerous).Neoplasm.**TUMOUR**._Liquid extract_ : 15-45 drops in water.It has a cleansing effect upon the lungs also, assisting removal of accumulated mucus and bringing a sense of relief for many hours. Lobelia emetics do not weaken but increase strength. _Fish oils_. Tuberculosis demands a high level of Vitamins A and D. Cod Liver oil was widely used for the disease in the 1920s for strength and building up tissue. **Diet**. The Catawbas Indians used Slippery Elm gruel and Alfalfa tea. Pasteurisation of milk considerably reduces risk of infection. _Vitamins_. A. B6, B12, Niacin, C, D. _Minerals_. Calcium, Iron, Phosphorus, Zinc. _Historical_. See entry: UMCKALOABO. ( _Steven's Cure_ ) _Note_. The phenomenal rise of the disease in recent years is directly related to the increase in HIV infections ( _World Health Organisation_ ). An increasing number of victims of AIDS show signs of tuberculosis; a skin test may prove positive while the person shows no signs of clinical disease. The AIDS virus activates previously dormant tuberculosis by weakening patients' defences. Treatment by general medical practitioner or tuberculosis specialist. **TULIP TREE**. _Liriodendron tulipifera L. French_ : Tulipier. _German_ : Tulpenbaum. _Italian_ : Tulipifero. **Action** : astringent, antiseptic, febrifuge, aromatic, stimulant, antiperiodic. Bitter tonic. **Uses, internal**. Intermittent fevers. _Topical_ : sore throat, mouth ulcers, spongy gums, infected teeth (decoction used as a mouth wash and gargle). **Preparations**. Thrice daily. _Decoction_ , inner bark. 15g (half an ounce) to 500ml (1 pint) water gently simmered 10 minutes; half-1 cup. _Liquid extract_ : 15-45 drops in water. **TUMOUR**. Neoplasm. A spontaneous new growth – malignant (cancerous) or benign (non-cancerous). _Differential diagnosis_ : a malignant tumour infiltrates other body tissues, whereas a benign one does not spread or infiltrate. Medical literature has an abundance of cases of successful use of plant medicines which warrant investigation in depth.Burdock root, Clivers, Chickweed, Comfrey, Chaparral, Fenugreek seeds, Greater Celandine, Red Clover, Wild (not cultivated) Violet, Thuja, Yellow Dock.A Slippery Elm poultice may soften hard (non-malignant) tumours.**Diet**.Gerson diet._Vitamins_.A. B12, C. P (bioflavonoids)._Minerals_.Chromium, Manganese, Nickel, Selenium, Molybdenum, Sulphur, Zinc.

However, the FDA restricts the amount of potassium available in over-the-counter potassium supplements to a mere 99 mg per dose because of problems associated with high-dosage prescription potassium salts. Yet salt substitutes such as the popular brands NoSalt and Nu-Salt are, in fact, potassium chloride and provide 530 mg potassium per 1/6 tsp. Potassium salts are commonly prescribed in the dosage range of 1.5 to 3 g per day, but at these high dosages they can cause nausea, vomiting, diarrhea, and ulcers when given in pill form. These effects are not seen when potassium levels are increased through the diet or through the use of potassium-based salt substitutes. This difference highlights the advantages of using foods or food-based potassium supplements rather than pills to meet the human body's high potassium requirements. Potassium supplementation is relatively safe, except for patients with kidney disease. Their inability to excrete excess potassium may result in heart arrhythmias and other consequences of potassium toxicity. Potassium supplementation is also contraindicated when a patient is using any of a number of prescription medications including digitalis, potassium-sparing diuretics, and the ACE inhibitor class of antihypertensive drugs. Caffeine Caffeine consumption from coffee, tea, and other sources can produce an immediate, short-lived increase in blood pressure, and regular coffee drinking has been associated with a slight increases in blood pressure, but it is generally thought that habitual coffee or tea drinkers develop a tolerance to the hypertensive effects of caffeine.– However, some studies showed that repeated administration of caffeine produced a persistent blood-pressure-increasing effect.Although the overall benefit of long-term avoidance of caffeine (from coffee, tea, chocolate, cola drinks, and some medications) on blood pressure is unclear, it appears that because some patients seem to respond quite favorably to caffeine avoidance, it should at least be attempted in patients with hypertension.

If a goiter is externally visible or palpable, it can be diagnosed in a clinical examination.The most obvious symptom of a goiter is a visible swelling, located at the base of your neck.But when goiter is accompanied by symptoms, you may have problems with swallowing, shortness of breath, a hoarse voice, tightness in your throat, coughing, or wheezing.FNA is considered safe in pregnancy. • Blood tests (TSH, Free T4, and Free T3), to evaluate thyroid function and look for signs of infection • Prescription of an antibiotic medicine that will treat the particular type of infection. (There are antibiotics that are considered safe to take during pregnancy.) • Drainage of the mass or lump While most patients respond to drainage and antibiotic treatment, in rare cases, surgical drainage or removal of the gland may be needed, which results in lifelong hypothyroidism. If surgery is needed, it would most likely be performed during the second trimester of pregnancy, or your physician may recommend waiting until after delivery to have the surgery, unless it is an emergency situation. _**Postpartum Thyroiditis**_ Postpartum thyroiditis is one of the more common types of thyroiditis affecting women after pregnancy. The diagnosis and treatment are discussed at length in Chapter 8. **Goiter/Enlarged Thyroid** A slight enlargement of the thyroid is normal during pregnancy. But when the thyroid becomes more significantly enlarged, it's known as goiter. Goiter may not cause any symptoms, and may not even be visible, except on imaging tests. But when goiter is accompanied by symptoms, you may have problems with swallowing, shortness of breath, a hoarse voice, tightness in your throat, coughing, or wheezing. The most obvious symptom of a goiter is a visible swelling, located at the base of your neck. If a goiter is externally visible or palpable, it can be diagnosed in a clinical examination.

Experiential Health in Old Age 6.The Meaning and Experience of Vulnerability in Old Age 5.Qualitative Methods as the Study of Meanings 4.Aging in the World of Meanings 3.Introduction 2.Vulnerability and Experiential Health in Old Age—A Qualitative Perspective 1.Chapter 5.Conclusion 5.Cover image 2. Title page 3. Table of Contents 4. Copyright 5. List of Contributors 6. Preface 7. Preface 8. Section I. Aging in Humans 1. Chapter 1. Werner Syndrome as a Model of Human Aging 1. Introduction and Historical Overview 2. Werner Syndrome as a Clinical Disease 3. Cancer in Werner Syndrome 4. Clinical Progression of Werner Syndrome 5. Diagnostic Criteria and Differential Diagnosis 6. The WRN Gene and Disease-Associated Mutations 7. Atypical WS/Other Heritable Progeroid Syndromes Distinct From WS 8. WRN Protein Function in Human Cells 9. The Relationship of Werner Syndrome to Normal Aging 10. Experimental Models of Werner Syndrome 11. Potential Therapeutic Targets and Strategies 12. Concluding Remarks 13. Print Resources 14. Web Resources 2. Chapter 2. Premature Aging Syndrome 1. Introduction 2. Hutchinson–Gilford Progeria and Werner Syndrome 3. Causative Genes and Molecular Mechanisms 4. Management and Therapeutic Approaches 5. Cell Culture Models 6. Mouse Models 7. Conclusions 3. Chapter 3. Models, Definitions, and Criteria for Frailty 1. Introduction 2. Models and Mechanisms 3. Definition 4. Criteria 5. Conclusion 6. Recommended Resources 4. Chapter 4. Immunological Methods and the Concept of Inflammaging in the Study of Human Aging 1. Introduction 2. Phenotypic Analyses 3. Functional Analyses 4. Inflammaging 5. A Dysregulatory Approach Integrating the Immune System and Other Systems 6. Conclusion 5. Chapter 5. Vulnerability and Experiential Health in Old Age—A Qualitative Perspective 1. Introduction 2. Aging in the World of Meanings 3. Qualitative Methods as the Study of Meanings 4. The Meaning and Experience of Vulnerability in Old Age 5. Experiential Health in Old Age 6.Chapter 6.Body Composition in Older Adults 1.Introduction 2.Overview and Understanding of Body Composition and Compartments 3.Aging-Related Changes in Body Composition 4.Measurement of Aging-Related Changes in Body Composition in Clinical Practice 7.Chapter 7.Using Computational Models to Study Aging 1.Introduction 2.

A repeat chest x-ray may be needed, and careful assessment of the type of therapy and remaining length of therapy will likely be required.Follow agency policy or notify the health care provider about the length change.If the length has changed, the catheter tip location has also changed and may no longer be in a vein appropriate for infusion.For a short _peripheral_ catheter, the transparent membrane dressings do not require routine changes; site rotation is every 72 to 96 hours. Tape and sterile gauze or a transparent membrane dressing can be used for midline catheters and all types of _central venous_ dressings. Tape and gauze dressings should be changed every 48 hours; transparent membrane dressings, such as Tegaderm, are changed at least every 7 days (Gorski, 2007). The initial dressing on a midline catheter or PICC is usually tape and gauze, changed within 24 hours after insertion because some bleeding is likely. Transparent membrane dressings can be used for subsequent dressing. Document all sterile dressing changes and IV site assessments in the appropriate patient record per agency policy. Nursing Safety Priority Action Alert Site protection may be needed for short peripheral catheters or for port access needles. Plastic shields can be placed over the site to prevent accidental bumping or pressure from clothing. Make sure you can easily assess the site frequently. Never place a restraint or opaque dressing over a peripheral IV site, especially when infusing an irritant or vesicant. When changing the dressing, remove it by pulling laterally from side to side. It can also be removed by holding the external catheter and pulling it off toward the insertion site. _Never pull it off by pulling away from the insertion site because this could dislodge the catheter!_ After removing the dressing from a midline catheter or any central venous catheter, note the external catheter length. Compare this length with the original length at insertion. If the length has changed, the catheter tip location has also changed and may no longer be in a vein appropriate for infusion. Follow agency policy or notify the health care provider about the length change. A repeat chest x-ray may be needed, and careful assessment of the type of therapy and remaining length of therapy will likely be required.While bathing, be sure that the unlicensed assistive personnel (UAP) cover the extremity.Plastic trash bags can be taped over the extremity; however, devices specially designed for this purpose are more convenient for the patient to use.Decision-Making Challenge Evidence-Based Practice; Safety You are a charge nurse on a busy medical unit where almost every patient has some type of IV therapy.

* Stroke is caused by bleeding in the brain or a blocked blood vessel, and is often the result of high blood pressure, diabetes, or problems of the circulatory system.Such seizures can be relatively minor or can be life-threatening.## Neurotransmitters and nerves Nerves use different neurotransmitters to transduce their signals: * Since the preganglionic nerve always excites the postganglionic nerve, the neurotransmitter used by all preganglionic nerves (to signal the postganglionic nerve) is acetylcholine (in both sympathetic and parasympathetic systems). * Norepinephrine is the neurotransmitter used by sympathetic postganglionic nerves to stimulate their target tissue into action (or inaction). * A few postganglionic neurons use acetylcholine, such as the nerves going to sweat glands to stimulate perspiration. * The single neurotransmitter used in the parasympathetic nervous system is acetylcholine. Its effect on the body is the result of signal transduction from muscarinic acetylcholine receptors and their downstream targets. # NERVOUS SYSTEM DISEASES AND DISORDERS ## Complexity Can Create Problems Difficulties with the nervous system (either CNS or PNS) can lead to profound muscle dysfunction as well as cognitive, behavioral, and social disorders. While there are too many to explain in this section, some of the more familiar disorders are described. ## Common nervous system disorders Given the complexity of the nervous system, it's not surprising that occasionally communication breaks down and neurological disorders result: * Epilepsy is a condition that occurs when abnormal electric signals from the brain create convulsions, affecting the way the body operates. Such seizures can be relatively minor or can be life-threatening. * Stroke is caused by bleeding in the brain or a blocked blood vessel, and is often the result of high blood pressure, diabetes, or problems of the circulatory system.### Parkinson's Disease Parkinson's disease results from lack of dopamine production or from a failure to detect this essential CNS neurotransmitter.Typically manifesting in adults over 50 years of age, symptoms begin with motor dysfunction including tremors, stiffness, and problems with walking.

With these hints, anyone who feels in need of skilled help in handling personality or emotional problems should be able to locate a competent, well-trained specialist.Genuine specialists in any branch of medicine, surgery or psychotherapy are highly ethical and do not believe in advertising.Any psychotherapist who has a neon sign outside his office is undoubtedly _not_ qualified.If this is not available, an inquiry can be forwarded to the headquarters of the American Psychological Association, 1333 Sixteenth Street N.W., Washington, D.C. 20036. There are now about 25,000 members in this Association. If none of the Directories mentioned above is to be found in the local library, the County Medical Society, the State Medical Society, or the American Medical Association (535 N. Dearborn Street, Chicago, Illinois 60610) may be consulted. The yellow pages of the telephone book must be used carefully in trying to locate a psychiatrist or psychoanalyst. Many well-qualified men in the field deliberately keep their names out of the sections headed "Psychiatrist" or "Psychoanalyst" in some cities, so as not to be confused with the unqualified people, many of them outright quacks, who claim to belong to these branches and so list themselves in the telephone directory. Genuine psychiatrists will be found listed, along with other physicians and surgeons, in the "Physicians & Surgeons, M.D." section of the yellow pages, and clinical psychologists are listed under "Psychologists." In some cities the listing in the telephone book also indicates whether or not a psychologist is licensed by the state to practice clinical psychology. In states where there is no Bureau of Professional Standards for psychologists, it is very difficult to know whether a psychologist listed in the telephone book has had proper training. This is best determined by checking with the American Psychological Association, unless a certain practitioner is recommended by a reliable professional man. Any psychotherapist who has a neon sign outside his office is undoubtedly _not_ qualified. Genuine specialists in any branch of medicine, surgery or psychotherapy are highly ethical and do not believe in advertising. With these hints, anyone who feels in need of skilled help in handling personality or emotional problems should be able to locate a competent, well-trained specialist.In many towns there are also recognized psychiatric and mental-health clinics, and veterans hospitals, to which the individual can go for psychiatric help and advice.Any such clinic will be glad to give the names of some private psychiatrists to anyone who feels the need of more intensive treatment than a clinic is able to give.

Midbrain atrophy and ventricular dilatation were confirmed as supportive of the diagnosis of PSP and asymmetric cortical atrophy supported the clinical diagnosis of CBD [] and this asymmetry is reflected in PET imaging (see later).The ability of imaging criteria to discriminate PSP from CBD has also been studied.Courtesy of Eytan Raz, Department of Radiology, New York University.An extension of one of these studies reiterated that high-field MRI is able to demonstrate iron in the brain and that parkinsonian disorders can present an abnormal distribution of iron or other paramagnetic substances in the basal ganglia. In 20 patients with PSP, 3 experienced neuroradiologists evaluated the MRI findings noting atrophy of the midbrain in 11 cases, and that this atrophy was best seen on axial or mid-sagittal images ([Figure 18.1). In 9 patients, however, the midbrain size was considered to be borderline or normal. They also suggested that the third ventricle was disproportionately large compared to the lateral ventricles in PSP and that midbrain atrophy resulted in concavity of the posterior part of the floor of the third ventricle []. **Fig. 18.1** T1-weighted MRI in progressive supranuclear palsy (PSP). (A) Sagittal and (B) Axial T1 images in a patient with PSP. The mid-sagittal T1 MRI shows atrophy of the midbrain with the characteristic 'hummingbird' appearance and the axial T1 MRI shows the 'morning glory' or 'Mickey Mouse' sign. Courtesy of Eytan Raz, Department of Radiology, New York University. The ability of imaging criteria to discriminate PSP from CBD has also been studied. Midbrain atrophy and ventricular dilatation were confirmed as supportive of the diagnosis of PSP and asymmetric cortical atrophy supported the clinical diagnosis of CBD [] and this asymmetry is reflected in PET imaging (see later).The main criticism of these studies is that most of them used crude and subjective methods for assessing the MRI abnormalities (usually just a radiologist's opinion, not always blinded to the clinical diagnosis).

A person who feels that "nothing I do matters" or that "I have no purpose in life" is very vulnerable to depression.In a sense, growth into adulthood and maturity is, by definition, a process of gaining personal control over everything from our bodies and emotions to our careers and relationships.In other words, depression arises from a sense of helplessness.**Table 2.8:** Organic Causes of Depression Cancer Chronic inflammation Chronic pain Diabetes Drugs Alcohol Anti-inflammatory agents Antihistamines Antihypertensives Birth control pills Cocaine Corticosteroids Marijuana Tranquilizers and sedatives Exposure to heavy metals (such as lead) Food allergies Heart disease Hypoglycemia Hypothyroidism Liver disease Lung disease Multiple sclerosis Nutritional deficiencies Premenstrual syndrome Rheumatoid arthritis Sleep disturbances Stress/low adrenal function For a more in-depth discussion about depression arising from organic disorders or from the use of drugs and medications, you might want to read my books _Natural Alternatives to Prozac_ (Morrow, 1996), _Natural Alternatives to Over-the-Counter and Prescription Drugs_ (Morrow, 1994), and the _Encyclopedia of Natural Medicine_ (Prima, 1998). If you are taking any medication, ask your doctor or pharmacist if the drug might cause depression as a side effect. For most health conditions, there are alternative natural medicines available that may produce better results with a lower risk of side effects than you will experience with drugs. ## **Attitude** Why are so many Americans depressed? I believe one of the main contributing problems is that these people feel that they personally lack the ability to control their world and how they respond to challenges. In other words, depression arises from a sense of helplessness. In a sense, growth into adulthood and maturity is, by definition, a process of gaining personal control over everything from our bodies and emotions to our careers and relationships. A person who feels that "nothing I do matters" or that "I have no purpose in life" is very vulnerable to depression.Evidence that helplessness can be learned—and more important, that it can be _un_ -learned—comes from laboratory research on animals.The pioneer in this field is Martin Seligman, Ph.D. During the 1960s Dr. Seligman conducted experiments in which caged rats were subjected to electric shocks.Some of the cages had switches that allowed the rats to turn off the shocks.

**Table 103.27** Clinical features of superficial venous thrombosis (Figure 103.23).###### Clinical features The clinical features of superficial venous thrombosis are outlined in Table 103.27.###### Predisposing factors These are the same as for DVT [3] and are outlined in Table 103.22.Mondor disease may also be a form of superficial venous thrombosis.###### Epidemiology ###### Incidence and prevalence Superficial venous thrombosis is a common condition. The actual prevalence and incidence is unknown. However, up to 25–35% of all hospitalized patients are thought to experience superficial phlebitis at the site of venous cannulae [1]. ###### Age The mean age of onset is 60 [2]. ###### Sex It is commoner in females (55–70% occurring in women). ###### Ethnicity There is no known racial predilection. ###### Associated diseases Migratory thrombophlebitis may be associated with an underlying carcinoma (such as pancreatic cancer) or Behçet disease. ###### Pathophysiology ###### Pathology The pathogenesis of superficial venous thrombosis is similar to that of DVT though trauma to the vein is thought to be the predominant trigger in the Virchow triad (stasis, increased coagulability and vessel wall injury). Several studies have described an association between superficial venous thrombosis and venous thromboembolism. Superficial venous thrombosis located in the main trunk of the saphenous vein has the strongest association with venous thromboembolism [2, 3]. Superficial venous thrombosis usually develops in the lower limbs. In 60–80% of cases, the GSV system is involved, and in 10–20% the SSV system [4]. The main cause of superficial venous thrombosis of the lower limbs is varicose veins, which are present in 70% of cases [5]. The main cause of superficial venous thrombosis in the upper limb is iatrogenic, for example intravenous catheters or infusion of drugs such as chemotherapy or heroin. Mondor disease may also be a form of superficial venous thrombosis. ###### Predisposing factors These are the same as for DVT [3] and are outlined in Table 103.22. ###### Clinical features The clinical features of superficial venous thrombosis are outlined in Table 103.27. **Table 103.27** Clinical features of superficial venous thrombosis (Figure 103.23).###### Investigations The aims of the investigations are to establish the extent of the thrombosis and to exclude involvement of the deep venous system.In patients without obvious risk factors for superficial venous thrombosis, studies to exclude hypercoagulability should be considered.

If your estrogen level is on the high side, more progesterone is needed to balance the effects.Your ideal progesterone level is also determined by your estrogen level.I rarely observe problems due to high progesterone.My target for men is between 1,500 and 2,500 pg/mL, although I frequently see even higher levels in patients who are using anti-aging therapies.Although it tends to strike later in life, osteoporosis is just as debilitating for older men as it is in postmenopausal women. By age 65, men are losing bone mass as fast as women their age. By age 75, osteoporosis is as common in men as it is in women. In fact, spinal and hip fractures due to osteoporosis are a major cause of disability and death in older men. Progesterone therapy for men remains a somewhat controversial issue. Progesterone researcher Dr. John Lee reports anecdotal evidence that men using progesterone cream have seen a decrease in their PSA (a marker for prostate dysfunction). Given progesterone's known ability to inhibit DHT, this is logical. Unfortunately, progesterone replacement for men is an area that has not yet been well researched, but it deserves greater attention. In my opinion, the biochemical evidence more than supports the use of low-dose progesterone therapy for men when it is needed to correct hormone levels and ratios. Maintaining healthy progesterone levels promotes prostate health and sexual function, and helps to prevent bone loss. The reference ranges for progesterone in men are generally quite low. For example, the laboratory I use considers a progesterone level between 300 and 1,000 pg/mL to be normal for a middle-aged man. By these standards, my patients Brian and Mark were both in the normal range with progesterone levels of 800 and 400, respectively. (As in women, progesterone levels in men tend to get lower and lower with age.) From my clinical experience, however, I have found that men with higher progesterone levels are healthier and more youthful. My target for men is between 1,500 and 2,500 pg/mL, although I frequently see even higher levels in patients who are using anti-aging therapies. I rarely observe problems due to high progesterone. Your ideal progesterone level is also determined by your estrogen level. If your estrogen level is on the high side, more progesterone is needed to balance the effects.For men, I aim for a ratio of fifteen to twenty-five times as much progesterone as estrogen.My experience has been that it takes only a very mild stimulus to lift progesterone levels in men.Therefore, I administer progesterone therapy with a very light touch.

In this type of allergy, the small intestine doesn't adequately digest a food component (typically a protein), and the immune system mistakes the remnant for a foreign invader and attacks it.I'm talking about a type of food allergy also called food intolerance or food sensitivity.She stopped a third time... the symptoms returned... she started ribose again... and the symptoms receded. Needless to say, she has continued to take ribose. ## Looking for other causes of fatigue Read the sections on Nutritional Deficiencies, Hypothyroidism, Adrenal Exhaustion, Male Menopause, Menopausal Problems, and Happiness Deficiency to look for other common and treatable causes of fatigue. The free online Symptom Analysis Program at www.endfatigue.com can help determine what is causing your fatigue and tailor an energy-optimizing regimen to your case. If your fatigue persists, consider seeing a physician at one of the Fibromyalgia and Fatigue Centers that are opening throughout the United States. The Web site is www.fibroandfatigue.com; the phone number is 866-443-4276. # Food Allergies _Real Causes_ * **Digestive Difficulties. ** This is the primary cause of food allergies: Because of intestinal infections and other digestive problems, proteins are incompletely digested before they're absorbed into the bloodstream, where the immune system reacts to them as if they were foreign invaders (page 130). * **Hormonal Imbalances. ** Imbalanced adrenal hormones weaken the immune system and contribute to food allergies (page 117). When I say "food allergy," I'm not talking about a classic food allergy to a food such as peanuts, which produces acute allergic symptoms such as hives and swelling. I'm talking about a type of food allergy also called food intolerance or food sensitivity. In this type of allergy, the small intestine doesn't adequately digest a food component (typically a protein), and the immune system mistakes the remnant for a foreign invader and attacks it.(And I think this type of food allergy can cause or complicate many diseases, including arthritis, asthma, ADHD, autism, epilepsy, inflammatory bowel disease, irritable bowel syndrome, and migraines.)

Temperature of 39.4°C, facial grimacing in response to movement, dressing saturated with purulent drainage A.The following is an example of SOAP charting for the nursing diagnosis 'risk of infection _related to_ traumatised tissue secondary to surgery' as it would be documented in progress/integrated notes: S. Wound is more painful today O.St Louis: Mosby; 1999.3rd edn.### SOAP charting If a problem-oriented approach is used for documentation, one method of evaluating and recording patient progress is referred to as SOAP charting. This type of progress note is problem-specific and incorporates the components described in Table 1-7. Because the problem list and the record are multidisciplinary, data associated with any identified problem may be recorded by any healthcare provider. In some institutions, however, nurses write SOAP notes in reference to a list of nursing diagnoses. The process of SOAP documentation is as follows: 1. Additional subjective and objective data are gathered related to the area of concern. 2. Based on old and new data, an assessment of the patient's progress towards the expected patient outcome and the effectiveness of each intervention is made. 3. Based on the reassessment of the situation, the initial plan is maintained, revised or discontinued. TABLE 1-7 Components of a problem-oriented progress note SOAP* | Explanation ---|--- **S** ubjective | Information supplied by patient or knowledgeable other **O** bjective | Information obtained by nurse directly by observation or measurement, from patient records or through diagnostic studies **A** ssessment | Nursing diagnosis or problem based on subjective data and objective data **P** lan | Specific interventions related to a diagnosis or problem considering diagnostic, therapeutic and patient education needs *Iyer P, Camp N. Nursing documentation: a nursing process approach. 3rd edn. St Louis: Mosby; 1999. The following is an example of SOAP charting for the nursing diagnosis 'risk of infection _related to_ traumatised tissue secondary to surgery' as it would be documented in progress/integrated notes: S. Wound is more painful today O. Temperature of 39.4°C, facial grimacing in response to movement, dressing saturated with purulent drainage A.Computerised documentation systems are usually referred to as an electronic patient record (EPR), electronic client record (ECR), computerised patient record (CPR) or electronic health record (EHR).These records are the patient's official chart.

They may be so panicked they just don't show up, in which case it's necessary to cancel the operation.They may experience extraordinary feelings of terror about the operation from the time they hear a diagnosis right up to when they arrive to check in for surgery.But some patients suffer from a recognized psychiatric condition called panic disorder.That's why most instances of general anesthesia are accompanied by the insertion of a breathing tube to ensure by mechanical means that an adequate supply of oxygen is going to the body at all times during surgery. When the diaphragm is paralyzed, this allows the anesthesiologist to take complete control over your breathing. If this lack of control over your own breathing frightens you, remember that the systems and equipment for doing the breathing for you are remarkably sophisticated. Concerns About Your Behavior While Under Local or Regional Anesthesia Are you afraid if you have local or regional anesthesia that you will move and cause the surgeon to cut in the wrong place? You should expect to get the kind of information and support from the medical team so that you are positioned properly and will not move in a potentially damaging way. At Columbia Presbyterian there is a surgeon who is one of the few in the country who performs delicate thyroid and parathyroid surgery in the neck under local anesthesia. Patients keep still with the help of careful instructions from the surgeon. In addition, sedation keeps you from moving around during surgery. General Anxiety Usually, the anxieties of a patient are diminished when he has been fully informed about anesthesia in advance of surgery, and sedated just before the operation. Relaxation techniques, like soothing tapes, can also help. But some patients suffer from a recognized psychiatric condition called panic disorder. They may experience extraordinary feelings of terror about the operation from the time they hear a diagnosis right up to when they arrive to check in for surgery. They may be so panicked they just don't show up, in which case it's necessary to cancel the operation.Once a patient is on beta blockers, the anesthesiologist takes this into account in deciding the best anesthetic agents to use during surgery.* * * The anesthesiologist does far more than inject you with an agent.She is there for the entire surgery, watching you, making sure your blood pressure, heart rate, and breathing are normal and that there is adequate oxygenation of your blood.

She assured him she was not abandoning him as he was upset that she would not be "navigating" him.She then did a warm handoff to his GI ONN at the affiliated facility.His AMC ONN called to confirm the plan and provided information about the medical oncology appointment.Sometimes as an ONN it is just easier to do things for the patient but that does not foster a therapeutic relationship or empower the patient to advocate for himself. AV needed to step up to the challenge [32]. During the discussion, the ONN outlined the boundaries on when to call or email and the expected time frame for a response. She provided the hours for AV to call as well as the on-call number for questions/concerns after hours. She also provided a list of colon cancer resources for AV should he need them. AV called the next day and decided on chemotherapy locally as the first step in his journey. His ONN connected with the GI ONN at the affiliated facility and was able to set him up with a medical oncologist who would administer the recommended FOLFOX (oxaliplatin with fluorouracil [5-FU] and folinic acid) chemotherapy regimen every 2 weeks for 4 cycles [31]. She provided education regarding his chemotherapy plan and discussed that he would be getting a port in his chest to receive his chemotherapy. She provided port teaching, and AV was happy with this plan as he did not want to get repeated peripheral sticks for his chemotherapy. This would be done locally. The ONN discussed his case with the GI ONN and did a handoff regarding his care. The two ONNs would continue to work collaboratively as AV's journey was far from over, and they shared how to manage his anxiety so that the teams were being consistent in the messages AV would receive. His AMC ONN called to confirm the plan and provided information about the medical oncology appointment. She then did a warm handoff to his GI ONN at the affiliated facility. She assured him she was not abandoning him as he was upset that she would not be "navigating" him.AV received four cycles of FOLFOX and returned to the AMC for his restaging scans as requested by his team.He saw the surgeon for a repeat sigmoidoscopy.The restaging scans and sigmoidoscopy showed an interval decrease in size of the rectosigmoid carcinoma with residual area of mural semi-annular thickening and decreased size of pelvic lymph nodes.There were no new sites of disease in the pelvis.

That's because the most common class of medications for pain relief in arthritis—nonsteroidal anti-inflammatory drugs (NSAIDs)—are estimated to kill 16,500 Americans yearly, usually from bleeding ulcers.# REAL CURE REGIMEN I prefer using natural rather than prescription therapies for arthritis.But the most important long-term solution is simply to feel what one is feeling, without resistance. (For more information on this approach, see Happiness Deficiency on page 72.) # Arthritis _Real Causes_ * **Chronic Inflammation. ** Arthritis is a form of chronic inflammation of the joints and the surrounding muscles, tendons, and ligaments, either from years of wear and tear (osteoarthritis) or from an autoimmune disease (rheumatoid arthritis) (page 155). * **Inactivity. ** Studies show that regular physical activity—such as brisk walking—decreases the risk of arthritis (page 68). * **Nutritional Deficiencies. ** Many Americans have low levels of the anti-inflammatory omega-3 fatty acids found in fish oil, contributing to the development of this inflammatory disease (page 34). Arthritis is the number-one cause of chronic pain and disability in the United States. Twenty-seven million Americans—65 percent of people age 65 and over—suffer with joint pain and stiffness from the wear-and-tear disease of osteoarthritis (OA). Another 2.5 million (most of them women) suffer with the red, hot, swollen, and painful joints of rheumatoid arthritis (RA), a joint-attacking autoimmune disease. My Real Cure Regimen for arthritis can result in dramatic pain relief and improved everyday functioning for people with either OA or RA—and often with very minimal or no use of drugs. # REAL CURE REGIMEN I prefer using natural rather than prescription therapies for arthritis. That's because the most common class of medications for pain relief in arthritis—nonsteroidal anti-inflammatory drugs (NSAIDs)—are estimated to kill 16,500 Americans yearly, usually from bleeding ulcers.(For more information on the downside of NSAIDs, please see Prescription Medications on page 103.)The natural program I recommend eases pain, decreases inflammation, and helps repair joints.It has four main components.1.Repair 2.Reverse inflammation 3.Restore function 4.

Fecal incontinence can also be a consequence of rectal prolapse (see left).Having rectal surgery, radiation therapy (see page 23), or an inflammatory bowel disease (see page 764) can cause scarring that makes the walls of the rectum stiff—the rectum can't stretch and hold the usual amount of stool.### _**Treatment**_ Treatment of a rectal prolapse depends on the person's age and general physical condition and on the severity of the prolapse. Rectal prolapse in children usually corrects itself with a high-fiber diet. In adults, a surgeon may implant a band of elastic, wire, or nylon around the muscle of the anus to enable it to support the rectum and keep it in place. Rectal surgery also may involve raising and repositioning the rectum or removing tissue from the rectum. More extensive surgery involves opening the abdomen and removing the displaced segment of the rectum. Surgery is not always successful, and rectal prolapse frequently recurs. ## **Fecal Incontinence** Fecal incontinence is the inability to retain stool (feces) in the rectum. Fecal incontinence may be caused by damage to the muscles or nerves of the anal sphincter or rectum, diarrhea, lack of elasticity of the walls of the rectum, or dysfunction of the pelvic floor. Damage to the muscles or nerves can occur during childbirth, especially if the doctor uses forceps or does an episiotomy (see page 533). Surgery of the anus or rectum (such as to treat hemorrhoids; see page 778) can also damage the sphincter. Straining during a bowel movement or having a stroke (see page 669) or another disorder that affects the nerves, such as diabetes (see page 889) or multiple sclerosis (see page 696), can also cause fecal incontinence. Having rectal surgery, radiation therapy (see page 23), or an inflammatory bowel disease (see page 764) can cause scarring that makes the walls of the rectum stiff—the rectum can't stretch and hold the usual amount of stool. Fecal incontinence can also be a consequence of rectal prolapse (see left).He or she may also order a series of tests such as manometry (see page 751) to check the tightness of your anal sphincter and the function of your rectum, an ultrasound (see page 111) to evaluate the structure of the anal sphincter, and electromyography to test for nerve damage.

4.Shake the whole unit vigorously three or four times.3.Insert the mouthpiece of the inhaler into the non-mouthpiece end of the spacer.2.Before each use, remove the caps from the inhaler and the spacer.Chart 32-8 Patient And Family Education: Preparing For Self-Management: How to Use an Inhaler Correctly* # With a Spacer (Preferred Technique) 1.32-6 shows a patient using a DPI.Fig.Some bronchodilators work by stimulating the beta2-adrenergic receptors on bronchial smooth muscle in much the same way that the sympathetic nervous system transmitters _epinephrine_ and _norepinephrine_ do; others work by blocking the parasympathetic nervous system. Bronchodilators include beta2 agonists and cholinergic antagonists. _Beta 2 agonists_ bind to the beta2-adrenergic receptors and cause an increase in the intracellular level of a substance called _cyclic adenosine monophosphate (cAMP)._ This substance sets pathways into motion that trigger smooth muscle relaxation. Short-acting beta2 agonists (SABAs) provide rapid but short-term relief. These inhaled drugs are most useful when an attack begins (as relief) or as premedication when the patient is about to begin an activity that is likely to induce an attack (GINA, 2010). Such agents include albuterol (Proventil, Ventolin), bitolterol (Tornalate), levalbuterol (Xopenex), pirbuterol (Maxair), and terbutaline (Brethaire). When inhaled from either a metered dose inhaler (MDI) or a dry powder inhaler (DPI), the drug is delivered directly to the site of action and systemic effects are minimal (unless the agent is overused). Teach the patient the correct technique for using an inhaled drug to achieve the greatest benefit. Chart 32-8 describes the proper way to use an MDI. Fig. 32-5 shows a patient using a "spacer" with an MDI. Spacer use increases the amount of drug delivered to the lungs. Chart 32-9 describes the proper care and use of a DPI. Fig. 32-6 shows a patient using a DPI. Chart 32-8 Patient And Family Education: Preparing For Self-Management: How to Use an Inhaler Correctly* # With a Spacer (Preferred Technique) 1. Before each use, remove the caps from the inhaler and the spacer. 2. Insert the mouthpiece of the inhaler into the non-mouthpiece end of the spacer. 3. Shake the whole unit vigorously three or four times. 4.5.Press down firmly on the canister of the inhaler to release one dose of medication into the spacer.6.Breathe in slowly and deeply.If the spacer makes a whistling sound, you are breathing in too rapidly.7.Remove the mouthpiece from your mouth, and, keeping your lips closed, hold your breath for at least 10 seconds and then breathe out slowly.8.Wait at least 1 minute between puffs.9.

She was on fentanyl patches on a college campus!That was her dream, and her boyfriend had been there a semester already.This would be her one semester at college.Her first question after we all cried was, "Can I go to college?"She wound up on oral etoposide every 3 weeks, and went in for an IV push of another drug."You have to take everything off the table that will take my hair."She didn't want to leave until she knew her mommy was ready._ _Jennifer had told me that she wasn't afraid to die, and this has been a great source of comfort to us. I believe that she was preparing for her death, even as we hoped for her remission. Before she went to the hospital, she spent all her money, gave away some of her possessions to her sisters, and said a final good-bye to her home, cats, teachers, and friends._ When it becomes clear that further treatment will not result in a cure, parents need to discuss with the child or teen what his or her goals and wishes are, and use that as a guide for medical and personal choices. _Meg was diagnosed just before the beginning of her senior year in high school, and finished treatment the next fall after her friends and twin sister had gone off to college. She had clean scans, and in January we went out to dinner with her best girlfriends just before they were all going to head out for their spring semester of_ _college. Meg went to the restaurant bathroom and found a lump in her groin. We got the relapse confirmation on January 20. The PET scans lit up and showed the cancer was everywhere. The doctor told her that there was nothing they could do other than give her chemo to keep her quality of life good for as long as it worked. He told her she would not live; it was treatable but not curable._ _She said she didn't want to lose her hair again. "You have to take everything off the table that will take my hair." She wound up on oral etoposide every 3 weeks, and went in for an IV push of another drug. Her first question after we all cried was, "Can I go to college?" This would be her one semester at college. That was her dream, and her boyfriend had been there a semester already. She was on fentanyl patches on a college campus!The doctors said certain locations were off limits as there wasn't good medical care in many of the places they wanted to go.The doctors agreed to Puerto Rico.Our friends and my husband's coworkers donated frequent flyer miles and hotel points to send them with first class airfare and to stay in a fancy hotel.They left on the trip on June 18.

Ephelide (freckle).Pigmentary changes of the photodamaged skin.The most common pigmented lesions in sun-exposed skin include ephelides (freckling), melasma, lentigo, mottled pigmentation and pigmented seborrheic keratosis, etc.[46] reported that a subject with high pack-years (>30 pack-years) and sun exposure (>2 h per day) in Japanese people had a 22 times higher risk to develop more severe skin wrinkling than a subject who never smoked and had less sun exposure (<2 h per day) at the same age. Figure 7 Effect of smoking on wrinkling in the brown skin of Koreans. (A) Non-smoker, 72 years old; (B) smoker, 81 pack-years, 74 years old. They have similar sun-exposure history and life style. Note the more severe wrinkles in the smoker. Skin color. : Skin color is one of the most important risk factors for skin aging and skin cancer. In Caucasians, the incidence rates of skin cancers and the severity of wrinkles are greater than in blacks. The brown skin of Asians seems to lie in between white and black skins. The increase of facultative skin color above the constitutive level, which we define as the Sun Exposure Index (SEI), might be an indicator of individual sun exposure throughout life [15]. In Korean skin, the SEI is also correlated significantly with sun exposure in both sexes [44]. It has been demonstrated that facultative skin color, but not constitutive skin color, increases with age in the brown skin of Asians (Table 1). After controlling for age and gender, it has been found that facultative skin color and SEI have a positive correlation with the severity of wrinkling in the brown skin of Asians [44]. #### 4.4.1.2 Dyspigmentation Whereas immediate and delayed pigmentation in exposed skin after single sunlight exposure is an acute response to UV radiation, freckling, mottled pigmentation, melasma and lentigo are responses to chronic solar exposure. The most common pigmented lesions in sun-exposed skin include ephelides (freckling), melasma, lentigo, mottled pigmentation and pigmented seborrheic keratosis, etc. Pigmentary changes of the photodamaged skin. Ephelide (freckle).[57].In the brown skin of Asians, freckling appears not to be less common than in Caucasians.In freckled skin, there is no increase in melanocytes as compared to nearby normal epidermis, although the melanosomes are long and rod-shaped, like those generally found in dark-skinned people [58,59].

However, some doctors are concerned that acetaminophen use has contributed to the recent increase in asthma in children and thus do not recommend its use in children with asthma or who have a family history of asthma.Typically, the following drugs are used: ■ Acetaminophen, given by mouth or by suppository ■ Ibuprofen, given by mouth Acetaminophen tends to be preferred.Children with a fever of unknown origin are much less likely to have a serious disorder than are adults. ### TREATMENT If the fever results from a disorder, that disorder is treated. Other treatment focuses on making children feel better. GENERAL MEASURES Ways to help children with a fever feel better without using drugs include ■ Giving children plenty of fluids to prevent dehydration ■ Putting cool, wet cloths (compresses) on their forehead, wrists, and calves ■ Placing children in a warm bath (only slightly cooler than the temperature of the child) Because shivering may actually raise the child's temperature, methods that may cause shivering, such as undressing and cool baths, should be used only for dangerously high temperatures of 106° F (about 41° C) and above. Rubbing the child down with alcohol or witch hazel must not be done because alcohol can be absorbed through the skin and cause harm. There are many other unhelpful folk remedies, ranging from the harmless (for example, putting onions or potatoes in the child's socks) to the uncomfortable (for example, coining or cupping). DRUGS TO LOWER FEVER Fever in an otherwise healthy child does not necessarily require treatment. However, drugs called antipyretic drugs may make children feel better by lowering the temperature. These drugs do not have any effect on an infection or other disorder causing the fever. However, if children have a heart, lung, brain, or nerve disorder or a history of seizures triggered by fever, using these drugs is important because they reduce the extra stress put on the body by fever. Typically, the following drugs are used: ■ Acetaminophen, given by mouth or by suppository ■ Ibuprofen, given by mouth Acetaminophen tends to be preferred. However, some doctors are concerned that acetaminophen use has contributed to the recent increase in asthma in children and thus do not recommend its use in children with asthma or who have a family history of asthma.These drugs are available over the counter without a prescription.The recommended dosage is listed on the package or may be specified by the doctor.It is important to give the correct dose at the correct interval.The drugs do not work if too little drug is given or it is not given often enough.

They are usually installed by dentists and may require follow-up visits for adjustment.These hinged bite plates pull the jaw forward during sleep.### Oral Bite Plates In recent years, a number of oral appliances have been approved for the treatment of mild to moderate sleep apnea.Similar studies have shown significant drops in hemoglobin A1C levels following CPAP treatment as well. ## Treating Sleep Apnea: CPAP and Beyond If you suspect you may have obstructive sleep apnea, talk to your primary care doctor about the possibility of getting tested for the condition. You may want to consult a board-certified sleep disorder specialist prior to testing and treatment. Testing for sleep apnea can be done in a sleep lab, requiring an overnight stay, but home tests are also available. If testing shows that you have sleep apnea, there are a number of different treatment options. ### Continuous Positive Airway Pressure (CPAP) Virtually anyone with sleep apnea can benefit from a CPAP machine. These devices, which typically cost several hundred dollars, feed air from a small air compressor into an airtight mask, increasing the pressure of the air being breathed—which in turn keeps the throat from collapsing. The downside: It can be difficult to tolerate, especially for extended periods of time. One in four people who try the device choose not to use at it all, and many more use it only intermittently. Fortunately, as noted previously, some studies show that using it even for a few days can produce glucose-control benefits that can last for an extended period of time. ### Variations on CPAP To increase adherence, a number of CPAP modifications have been introduced, including improved mask designs and humidifier attachments. One of these modified versions, known as _bilevel positive airway pressure_ , or BiPAP, increases air pressure as the user inhales then reduces it during exhalation, producing a more natural breathing sensation. ### Oral Bite Plates In recent years, a number of oral appliances have been approved for the treatment of mild to moderate sleep apnea. These hinged bite plates pull the jaw forward during sleep. They are usually installed by dentists and may require follow-up visits for adjustment.### Nasal Devices Another relatively new treatment is Provent, a disposable device that's attached to the nostrils at night, then thrown away in the morning.Approved several years ago for use in treating sleep apnea, it costs just a few dollars a day and works by restricting the amount of air you breathe out.

* Skeletal abnormalities more severe in cats with MPS VI than in those with MPS I; some MPS VI cats develop posterior paresis owing to spinal cord compression.* Affected animals may live several years, but locomotor difficulty is progressive.* Disease progresses; clinical signs apparent at 2–4 months of age.* Metachromatic granules (Alder-Reilly bodies) in blood leukocytes.Types of MPSs Reported in Dogs and Cats * MPS I–α-l-iduronidase deficiency; dermatan and heparan sulfate stored. * MPS II–iduronate sulfatase deficiency; dermatan and heparan sulfate stored; first MPS recognized in humans. * MPS IIIA–heparan N-sulfatase deficiency; heparan sulfate stored. * MPS VI–arylsulfatase B deficiency; dermatan sulfate stored; first MPS recognized in an animal. * MPS VII–β-glucuronidase deficiency; dermatan, heparan, and chondroitin sulfate stored. SIGNALMENT * Cats–MPS I and VII, domestic shorthair; MPS VI, Siamese and domestic shorthair. * Dogs–MPS I, Plott Hounds; MPS II, Labrador retrievers; MPS IIIA, wire-haired dachshunds and Huntaways; MPS VI, miniature pinschers, miniature schnauzers, and Welsh corgis; MPS VII, mixed breeds and German shepherds. * Both sexes equally affected by MPS I, III, VI, and VII; primarily males affected by MPS II. SIGNS * Dwarfism (except cats with MPS I). * Severe bone disease (dysostosis multiplex). * Degenerative joint disease, including hip subluxation. * Facial dysmorphia–more evident in Siamese cats, which normally have an elongated face, than in other cats. * Hepatomegaly (except cats with MPS VI). * Corneal clouding–a result of fine granular opacities in the corneal stroma, first apparent at approximately 8 weeks of age. * Large tongue (dogs). * Thickening of the heart valves. * Excess urinary excretion of GAG. * Metachromatic granules (Alder-Reilly bodies) in blood leukocytes. * Disease progresses; clinical signs apparent at 2–4 months of age. * Affected animals may live several years, but locomotor difficulty is progressive. * Skeletal abnormalities more severe in cats with MPS VI than in those with MPS I; some MPS VI cats develop posterior paresis owing to spinal cord compression.CAUSES & RISK FACTORS * MPS transmission is autosomal recessive, except MPS II, which is X-linked recessive.* In-breeding increases risk if the defective gene is present in the family.

Later, the technique was perfected; the juice of infected pus was transferred instead.The earliest technique was to grind some dried scabs taken from a smallpox patient and blow the powder into the nostril of the healthy person to be inoculated.Chinese people have been vaccinating against smallpox since the Northern Song dynasty (960–1127), and perhaps even earlier.Similarly, his cure for beriberi—vitamin B1 deficiency—consisting of taking vitamin B1-rich rice bran and apricot seeds with milk, may have been quite fortuitous. On the other hand, the belief that food and drinks that induce perspiration can cure a cold, or that the consumption of energy-rich sugar and honey promote the reconstruction of the liver after a bout of infectious hepatitis, are both clinically and theoretically sound. Consider, too, some of the discoveries of Chinese medicine: • In the last century or two the people of the West have learned about the importance of hygiene and the value of disinfectants. In China we have known about them for two thousand years. The disinfectant properties of garlic, for example, have been recognized since the Han dynasty (206 B.C.–A.D. 220). Furthermore, Chinese people have throughout their entire history been aware of the dangers inherent in dirt, and have always been fastidious about cleanliness. • In 1928 Alexander Fleming made what has been heralded as the greatest discovery of twentieth-century medical science: a mold, which he called penicillin, is an effective antibiotic, able to destroy many bacterial diseases. In China we have used molds and fungi against infections for at least 1340 years. • In nineteenth-century Europe it was discovered that a live virus low in virulence, when injected into a healthy person, will produce immunity in that person against the disease; the first vaccine to come into general use was that against smallpox. Chinese people have been vaccinating against smallpox since the Northern Song dynasty (960–1127), and perhaps even earlier. The earliest technique was to grind some dried scabs taken from a smallpox patient and blow the powder into the nostril of the healthy person to be inoculated. Later, the technique was perfected; the juice of infected pus was transferred instead.In China, silver paste was listed as a treatment for filling cavities in a materia medica of A.D. 659.A Ming dynasty materia medica from approximately A.D. 1500 actually specifies the ingredients used in Europe more than three hundred years later: One hundred parts of mercury to forty parts of silver and nine hundred parts of tin to form a paste that solidifies in the cavity.

These pains begin as an achy feeling, often in the upper abdomen or back.The 1st stage of labor begins with the onset of contractions of the uterus, called labor pains.## Stages of Labor **Labor** is the overall term for the process of delivering the fetus and the placenta and can be divided into 3 distinct phases.In a marginal placenta previa, the placental edge lies extremely close to the os and could impact NSVD. In partial placenta previa, the placenta does obstruct the os to a measurable degree. The placenta completely covers the os in complete placenta previa. Figure 6.7 Types of Placenta Previa _(A) Normal placenta. (B) Marginal placenta previa. (C) Partial placenta previa. (D) Total or complete placenta previa._ This condition can be completely unknown to the mother who has not received any prenatal care and does not present a problem to either the fetus or the mother until delivery. In the patient who has had prenatal care, the mother will be scheduled for a cesarean section at about the 38th week of gestation to minimize the possibility of the body initiating natural childbirth. There is only 1 way out of the uterus naturally for the infant, and in the case of placenta previa, it is through its own blood supply. As the cervix starts to dilate in preparation for natural childbirth, vaginal bleeding will begin and remain constant or increase over time. Treatment for the patient with placenta previa is the same as for abruption placenta: prepare for and treat for shock. In placenta previa, the paramedic should encourage the patient to breathe slowly and deeply through contractions to help the mother avoid pushing. Patients also may be transported in the knee-chest position, where the mother's knees and chest are in contact with the stretcher, and her pelvis is the highest part of her body. This will temporarily help minimize the pressure of the infant on the placenta and "buy time" to get to the hospital without more bleeding. ## Stages of Labor **Labor** is the overall term for the process of delivering the fetus and the placenta and can be divided into 3 distinct phases. The 1st stage of labor begins with the onset of contractions of the uterus, called labor pains. These pains begin as an achy feeling, often in the upper abdomen or back.Initially, the contractions may be as far apart as about 15 minutes, but they tend to get closer together as labor progresses.The timing of these contractions is typically measured from the beginning of a contraction to the beginning of the next, and the duration of a contraction is how long the pain lasts before fully subsiding.

Calcitriol (a hormone) assists in the absorption of calcium present in food in the intestines into the blood.Enzymes present in the kidneys and liver alter the molecules, producing calcitriol.* * * ## Medicines management ### Administration of medicines There are some medications that you may be asked to administer via the skin. These include ointments, lotions, creams and gels. The application of medicines via the skin through an adhesive patch is also used in a number of care areas. All of these medicines are subject to the same rules and regulations associated with the administration of any medicine. Medicines applied to skin are often needed to treat skin conditions, and they are known as topical medications; they are administered externally onto the body as opposed to being ingested or injected. Lotions are used to protect, soften and soothe and can provide relief from itching. Ointments are oil-based, and body heat causes them to melt after application; often, these medications are used to fight infection or relieve inflamed tissue. Gloves must be used when applying these medicines; they must be applied in thin, even layers unless the prescription states otherwise (Nair, 2014). Most skin medications are provided for use in tubes; one tube must only be used for one person in order to prevent cross-infection. There are some skin medicines that must be sterile for use; when this is the case, after application, the leftover medication must be discarded. When you are applying the medication you must take care that you do not increase discomfort by using too much pressure or rubbing areas that are inflamed or causing the person pain. * * * ### Synthesis of vitamin D The skin is actively involved in the production and synthesis of vitamin D. For vitamin D to synthesise effectively, activation of a precursor molecule in the skin by ultraviolet rays in the sunlight (ultraviolet radiation) is required. Enzymes present in the kidneys and liver alter the molecules, producing calcitriol. Calcitriol (a hormone) assists in the absorption of calcium present in food in the intestines into the blood.There are a variety of diseases or injuries that can easily be observed on the surface of the skin; for example, a skin rash, the presence of jaundice or cyanosis.It is the largest organ in the body in weight and surface area.The skin has the ability to reveal how we feel and what emotional state we may be in: humans blush, sweat and tremble.

In the present study, we observed that treatment of human oral cancer cell lines containing high levels of reactive oxygen (ROS) with D003 increased ROS levels twofold to threefold and induced apoptosis.Previously we reported that phytochemicals extracted from avocado meat selectively induced apoptosis in cancer but not normal, human oral epithelial cell lines.### **Anti-Inflammatory** _AV119, a Natural Sugar from Avocado gratissims, Modulates the LPS-Induced Proinflammatory Response in Human Keratinocytes._ Donnarumma G, Paoletti I, Buommino E, Et al. Inflammation. 2010 Oct 9 (Epub ahead of print). **Key Finding** : "Our data show that AV119, a patented blend of avocado sugars, is able to modulate significantly the proinflammatory response in human keratinocytes, blocking the NF-kB activation in human keratinocytes." ### **Atherosclerosis** _Hypoglycemia and hypocholesterolemic potential of Persea Americana leaf extracts._ Brai BI, Odetola AA, Agomo PU. J Med Food. 2007 Jun;10(2):356-60. **Key Finding:** "These results suggest that aqueous and methanolic leaf extracts of P. Americana (avocado) lower plasma glucose and influence lipid metabolism in hypercholesterolemic rats with consequent lowering of T-CHOL and LDL-CHOL, and a restoration of HDL-CHOL levels. This could represent a protective mechanism against the development of **atherosclerosis. ** " ### **Cancer (oral; prostate)** _Selective induction of apoptosis of human_ **_oral cancer_** _cell lines by avocado extracts via a ROS-mediated mechanism._ Ding H, Han C, Guo D, Chin YW, Ding Y, Kinghorn AD, D'Ambrosio SM. Nutr Cancer. 2009;61(3):348-56. **Key Finding:** "Avocados have a high content of phytochemicals with potential chemo preventive activity. Previously we reported that phytochemicals extracted from avocado meat selectively induced apoptosis in cancer but not normal, human oral epithelial cell lines. In the present study, we observed that treatment of human oral cancer cell lines containing high levels of reactive oxygen (ROS) with D003 increased ROS levels twofold to threefold and induced apoptosis._Chemoproventive characteristics of avocado fruit._ Ding H, Chin YW, Kinghorn AD, D'Ambrosio SM.Semin Cancer Biol.2007 Oct;17(5):386-94.**Key Finding:** "Our recent studies indicate that phytochemicals extracted with chloroform from avocado fruits target multiple signaling pathways and increase intracellular reactive oxygen leading to apoptosis.

Many agents, including toxins like alcohol and chronic viral infection, may cause cirrhosis.Cirrhosis of the liver: Irreversible liver damage with extensive scarring and distortion of normal structure, which interferes with liver function.Chloroquine: An anti-malarial drug to which many strains of Plasmodium falciparum have now become resistant.Attending physician: A senior physician who supervises physicians in training. AZT: Zidovudine. The first drug developed to treat HIV. It is still useful in combination with other drugs. Bacteria: Term for certain microorganisms that lack the ability to create food from light. They are larger than viruses and smaller than fungi and protozoa. Bilirubin: A yellow pigment that results from the metabolism of the red blood cell protein, hemoglobin. Black water fever: Kidney failure caused by malaria. Candida albicans: An organism similar to yeast, C. albicans normally causes minor infections. However, it can cause serious infections in severely ill patients whose immune functions are weakened. Centers for Disease Control (CDC): Now known as the Centers for Disease Control and Prevention, it is a federal government facility based in Atlanta, Georgia, that organizes monitoring and treatment programs for preventable diseases. Cerebrospinal fluid: The clear, colorless fluid that surrounds the spinal cord and brain and fills the interior cavities of these structures. Ceviche or seviche: Raw fish marinated in lime or lemon juice. Chagas disease: A chronic parasitic disease of the heart and esophagus transmitted by biting bugs and caused by the protozoan parasite Trypanosoma cruzi. Childbed fever: The old term for the infection of the reproductive organs and blood stream that commonly followed childbirth, particularly in contaminated settings. The usual cause was group A strep. Chloramphenicol: An antibiotic that has been known to cause aplastic anemia in rare cases. Chloroquine: An anti-malarial drug to which many strains of Plasmodium falciparum have now become resistant. Cirrhosis of the liver: Irreversible liver damage with extensive scarring and distortion of normal structure, which interferes with liver function. Many agents, including toxins like alcohol and chronic viral infection, may cause cirrhosis.CMV: See Cytomegalovirus.Cobras: Venomous snakes of the genus Naja.Cocci: See Coccidioidomycosis.Cocci meningitis: A form of coccidioidomycosis that attacks the lining of the brain.Coccidioidomycosis: The potentially fatal disease known as Valley Fever.Caused by inhalation of the spores of the fungus Coccidioides immitis, it can result in pneumonia and meningitis.

J Gen Intern Med 2006;21:1063.Potential outcome factors in subacute combined degeneration: review of observational studies.[PMID: 17180609] ### **Combined System Disease (Posterolateral Sclerosis)** #### **Essentials of Diagnosis** • Numbness (pins and needles), tenderness, weakness; feeling of heaviness in toes, feet, fingers, and hands • Stocking and glove distribution of sensory loss in some patients • Extensor plantar response and hyperreflexia typical, as is loss of position and vibratory senses • May develop myelopathy in severe cases • Serum vitamin B12 level low; methylmalonic acid and homocysteine levels high • Megaloblastic anemia may be present but does not parallel neurologic dysfunction #### **Differential Diagnosis** • Cervical spondylosis • Epidural tumor or abscess • Multiple sclerosis • Transverse myelitis of viral or other origin • Polyneuropathy due to toxin or metabolic abnormality • Tabes dorsalis • Nitrous oxide abuse #### **Treatment** • Vitamin B12 replacement, usually intramuscular #### **Pearl** _Pernicious anemia is not identical to vitamin B 12 deficiency; the former is an autoimmune disorder and is only one of many causes of deficiency of this vitamin._ ##### **Reference** Vasconcelos OM, Poehm EH, McCarter RJ, Campbell WW, Quezado ZM. Potential outcome factors in subacute combined degeneration: review of observational studies. J Gen Intern Med 2006;21:1063.J Clin Neuromuscul Dis 2008;10:42.

Yet each one comes with its own set of baggage.#### Knock Yourself Out From the list above you can see that today there are a good number of relatively safe and effective nonbarbiturate, nonbenzodiazepine sleep medications that can help you to fall asleep faster or stay asleep longer.But what if you have to get up early the next morning, or you awaken at midnight to use the bathroom? Well, here is where the trouble begins. In 2004 the British Medical Journal published a study that looked at the effects of sedative-type sleeping pills on people 60 years and older. (It included a series of studies performed between 1966 and 2003.) Surprisingly, researchers discovered that for every one person who reported getting a better night's sleep while using sleeping pills, two seniors reported injuries from a trip, slip, or fall, or from an automobile accident while they were under the influence of sleeping pills. Just over two decades ago, the sleeping pill industry took a turn away from benzodiazepines and toward sedative-hypnotic drugs. According to Dr. Michael Nelson of Wingate University's College of Pharmacology, sedative refers to a substance that moderates activity and excitement while inducing a calming effect, while hypnotic refers to a substance that causes drowsiness and facilitates the onset and maintenance of natural sleep. In 1988, Ambien, the first of the new sedative-hypnotic sleeping aids, was introduced in Europe. Five years later it made its debut in the United States. Since its introduction here, Ambien has become the most frequently prescribed sleep medication in the U.S. Other hypnotic drug introductions soon followed—Lunesta, Sonata... with more to come, no doubt. #### Knock Yourself Out From the list above you can see that today there are a good number of relatively safe and effective nonbarbiturate, nonbenzodiazepine sleep medications that can help you to fall asleep faster or stay asleep longer. Yet each one comes with its own set of baggage.#### Ambien (four-hour formula) and Ambien CR (extended release) #### Generic: Zolpidem As I mentioned earlier, Ambien was introduced to the U.S. market in 1993.By the year 2005 a stunning 26.6 million prescriptions were written for it in that year alone.With so many people taking this medication, some odd reports began to surface.

It functions to support and slightly raise the pelvic floor.The levator ani is innervated by branches of the pudendal plexus, which contains fibers from the fourth sacral nerve.The left and right levator ani muscles are divided ventrally but converge as a single sheet across the midline dorsally, forming most of the pelvic diaphragm.ADVERSE EFFECTS: Among adverse effects are insomnia, headache, dizziness, stimulation, hallucinations, flushing, irritability, dry nose, irritation of the nose and throat, palpitations, tachycardia, hypertension, angina, hypotension, arrhythmias, heartburn, nausea, vomiting, and muscle cramps. Common side effects include tremors, anxiety, and restlessness. levamisole, an immunomodulator used as an adjuvant treatment in combination with fluorouracil after surgical resection in patients with Dukes' stage C colon cancer. levarterenol bitartrate. See **norepinephrine bitartrate**. levator /livā′t r/ _pl._ **levatores** [L, _levare,_ to lift up], **1. ** a muscle that raises a structure of the body, as the levator ani raises parts of the pelvic diaphragm. **2. ** a surgical instrument used to lift depressed bony fragments in fractures of the skull and other bones. levator anguli oris, a deeply placed oral muscle arising from the maxilla that elevates the corner of the mouth and may help deepen the furrow between the nose and the corner of the mouth during sadness. levator ani, one of a pair of muscles of the pelvic diaphragm that stretches across the bottom of the pelvic cavity like a hammock, supporting the pelvic organs. It is a broad thin muscle that separates into the pubococcygeus and the iliococcygeus. It originates from the ramus of the pubic bone, the spine of the ischium, and a band of fascia between the pubis and the ischium; it inserts into the last two segments of the coccyx, the anococcygeal raphe, the sphincter ani externus, and the central tendinous point of the perineum. The left and right levator ani muscles are divided ventrally but converge as a single sheet across the midline dorsally, forming most of the pelvic diaphragm. The levator ani is innervated by branches of the pudendal plexus, which contains fibers from the fourth sacral nerve. It functions to support and slightly raise the pelvic floor.Compare **coccygeus**.levatores.See **levator**.levatores costarum, muscles of the thoracic wall that together with muscles between the vertebrae and ribs posteriorly alter the position of the ribs and sternum and so change thoracic volume during breathing.

• People with narcolepsy type 2 do not have cataplexy and have normal orexin-A levels (1).• 90–95% of patients with narcolepsy type 1 have low orexin-A in CSF (1).NARCOLEPSY Jesse A. Morse, MD, MBA • Naureen Rafiq, MD BASICS DESCRIPTION • Disorder characterized by excessive daytime sleepiness (EDS) often associated with cataplexy (sudden bilateral weakness of skeletal muscles) and other rapid eye movement (REM) sleep phenomena, such as sleep paralysis and hypnagogic hallucinations (e.g., vivid auditory or visual perceptions without an external stimulus that occur as one is falling asleep). • Frequently overlooked disorder, averaging 5 to 15 years from onset of symptoms prior to diagnosis (1) • Usually feel refreshed after a full night's sleep or a brief nap, but their sleepiness returns 1 to 2 hours later, especially when they are sedentary (1) • System affected: nervous EPIDEMIOLOGY Incidence • Onset usually 10 to 20 years old, average age = 24 years (2) • Bimodal distribution peak at 15 and 35 years of age • Predominant sex: male > female (1.6:1) • Incidence: 1/2,000 people (1) Prevalence • Narcolepsy type 1 (with cataplexy): 25 to 50/100,000 people • Narcolepsy type 2 (without cataplexy): 20 to 34/100,000 people • Western countries: 20 to 60/100,000 (2) • Highest in Japan, lowest in Israel (2) ETIOLOGY AND PATHOPHYSIOLOGY • Narcolepsy type 1 is a neurodegenerative disorder resulting from selective loss of neurons containing hypocretin (orexin) in the lateral hypothalamus; may be autoimmune (associated with influenza A, H1N1 vaccine, and Streptococcus pyogenes) (1) • Orexin-A neurons also regulate metabolism, feeding, reward and autonomic tone; weight gain and depression can result from dysfunction of this neuronal pathway (1). • 90–95% of patients with narcolepsy type 1 have low orexin-A in CSF (1). • People with narcolepsy type 2 do not have cataplexy and have normal orexin-A levels (1).• Possible involvement of immune system and environmental influences; onset is often in late spring.

Primary intracerebral hemorrhage: update on epidemiology, pathophysiology, and treatment strategies.J Clin Neuromuscul Dis 2008;10:42. [PMID: 19169089] ### **Hemorrhagic Stroke** #### **Essentials of Diagnosis** • Risk factors: Hypertension, excessive alcohol use, cocaine and methamphetamine abuse, antiplatelet or anticoagulation therapy • Sudden onset of neurologic deficit, variably including focal weakness, sensory abnormalities, visual field cut, aphasia, or altered mentation; often with headache • CT of the head will show intracranial hemorrhage immediately; MRI, MR angiogram, or catheter angiogram is often necessary to exclude an arteriovenous malformation, aneurysm, or underlying tumor • Check prothrombin time and platelet count immediately #### **Differential Diagnosis** • Head trauma • Hypertensive hemorrhage • Iatrogenic (therapeutic anticoagulation) or toxic (cocaine, methamphetamine) • Arteriovenous malformation • Cerebral amyloid angiopathy (in the elderly and those with Down's syndrome) • Hemorrhagic conversion of ischemic infarct • Primary or metastatic tumor • Septic emboli • Aneurysm • Dural venous sinus thrombosis • Vasculitis #### **Treatment** • If present, reversal of coagulopathy should be considered with factor IX complex or fresh-frozen plasma and vitamin K; platelets can be transfused if thrombocytopenic • Neurosurgical decompression often indicated for cerebellar hemorrhage • An external ventricular drain may be necessary for hydrocephalus or intracranial pressure monitoring • Blood pressure is usually lowered acutely #### **Pearl** _The most common locations for hypertensive hemorrhage are in the internal capsule, basal ganglia, thalamus, pons, and cerebellum._ ##### **Reference** Burns JD, Manno EM. Primary intracerebral hemorrhage: update on epidemiology, pathophysiology, and treatment strategies.

For example, one of our first clinical psychotherapy seminars ended with a senior psychiatrist's suggestion that we new residents avoid doing psychotherapy for the first few weeks and instead "just talk with the patients."In writing When the War Never Ends: The Voices of Military Members with PTSD and Their Families, Leah Wizelman follows Osler's example by reclaiming the subject of traumatic stress from the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association and countless other texts and research journals (as well as the hearing rooms of myriad disability claims programs) and insisting that we learn about it directly from people who actually live with it. This is altogether fitting because it is exactly the way in which the concept of psychological trauma and of posttraumatic stress disorder (PTSD) came to medical attention in the first place. In 1980, as a Yale psychiatry resident at the West Haven Veterans Affairs (VA) Medical Center, I met many veterans who would eventually be diagnosed with PTSD but that diagnosis had not yet been published in the DSM. PTSD became an official mental disorder with the release of the DSM-III later that year, but there is another honored tradition in medical education that delayed my use of the term until the very end of my training: doctors learn to formulate diagnoses from their teachers rather than from their textbooks. I first used the term PTSD three years later—and only after I heard my former VA ward chief give a lecture on it. Resident physicians are constantly called on to make decisions they have never made before, and even the most innocuous of these feels suffused with responsibility for the patient's life or death. For example, one of our first clinical psychotherapy seminars ended with a senior psychiatrist's suggestion that we new residents avoid doing psychotherapy for the first few weeks and instead "just talk with the patients."Even "just talking" with patients feels dangerous to new doctors who cannot yet count on their own experience or find "the right answers" in their medical texts.Wizelman therefore seems either brave or brazen in suggesting that we "just read" what service members, veterans, and their family members have to say.Isn't PTSD the province of mental health professionals?

but are very addictive and often cause troubling side effects such as fatigue, loss of libido, weight gain, and headaches, among others.All three classes of these medications can provide impressive benefits in combating depression, anxiety, etc.Enzymes called histone methyltransferases (HMTs) promote the transfer of one to three methyl groups from SAMe to specific amino acid locations along the linear histone proteins. For many years, histone methylation was thought to be a permanent modification. Very recently, two families of histone demethylating enzymes were discovered. Nutrients or drugs that promote or inhibit expression of these enzymes can have a major impact on neurotransmitter reuptake and synaptic activity. Epigenetics and Brain Functioning Healthy mental functioning requires a proper level of synaptic activity at receptors for serotonin, dopamine, norepinephrine, and other neurotransmitters. Proper synaptic activity depends on: The amount of neurotransmitter produced in brain cells The amount of synaptic neurotransmitters lost by diffusion or reaction with chemicals The availability of transporters that return synaptic neurotransmitters back into the original brain cell (reuptake) Decades of pharmaceutical research have shown that synaptic activity is dominated by the concentration of transporters. SSRI antidepressants, such as Prozac and Zoloft, inactivate transporters to increase serotonin levels within synapses. SNRI medications, such as Effexor, use the same mechanism to increase activity of both serotonin and norepinephrine. In contrast, benzodiazapine medications, such as Xanax and Valium, increase GABA activity by directly binding to GABA receptors, thus reducing the impact of excessive norepinephrine activity. All three classes of these medications can provide impressive benefits in combating depression, anxiety, etc. but are very addictive and often cause troubling side effects such as fatigue, loss of libido, weight gain, and headaches, among others.These are the same nutrients pioneered by Hoffer, Pfeiffer, and the author that have produced thousands of reports of recovery from schizophrenia, depression, anxiety, ADHD, and behavioral disorders.It is highly unlikely that this is a coincidence.In addition, epigenetics research has identified several other nutrients with potential for improving brain functioning.

In 61 of the patients, thrombosis was attributable to paraneoplasia, a central venous catheter, or a pacemaker probe.We analyzed 610 patients with arm swelling examined by duplex ultrasound, which demonstrated arm vein thrombosis in 96 cases.### 3.2.6 Duplex Ultrasound Findings and Their Diagnostic Significance The ultrasound findings in thrombosis are the same as in deep vein thrombosis of the legs: the vein appears markedly dilated and contains homogeneous or inhomogeneous structures, it cannot be compressed, and (color) duplex imaging depicts either no flow signals or, in the case of central thrombus, only flow near the wall. Any internal or external obstruction of venous drainage eliminates cardiac pulsatility and eliminates or reduces respiratory phasicity of flow. Therefore, in cases where methodological limitations prohibit adequate evaluation of the subclavian vein from the supraclavicular position, a Doppler waveform recorded in the axillary vein (from the infraclavicular fossa) can be used to exclude significant flow obstruction. Apart from the subclavian vein, the easily accessible axillary vein may be affected by thrombosis because blood from the arms is emptied into this vein through thoracic wall collaterals. Compression ultrasound is used to exclude thrombosis of the axillary vein (with the transducer in the infraclavicular fossa) and of the peripheral veins. As already mentioned, the compression test is unreliable in the subclavian vein, where flow has to be demonstrated directly by means of a Doppler spectrum. Sonographically, thrombophlebitis can be distinguished from deep thrombosis on the basis of the course of the vessel affected and its relationship to anatomic landmarks (accompanying artery of the same name). We analyzed 610 patients with arm swelling examined by duplex ultrasound, which demonstrated arm vein thrombosis in 96 cases. In 61 of the patients, thrombosis was attributable to paraneoplasia, a central venous catheter, or a pacemaker probe.Subsequently, flow obstruction was demonstrated in the costoclavicular space by duplex scanning with provocative maneuvers in five of the patients.In thehyperabduction test, the arm on the affected side is raised above the head while the Doppler spectrum is recorded in the axillary vein with the transducer in the infraclavicular fossa.

A person who doesn't know his or her identity is in more trouble than a person who doesn't know where he or she is, and that person is in more trouble than a person who can't give the correct date.Who are you?Where are we?Keep the child's airway open (see drawing on here), and do rescue breathing as needed. Do not force an object or your fingers into a person's mouth. This is likely to result in injury. It's not possible for the child to "swallow the tongue," and serious tongue bites are rare. Start to lower the child's fever with sponging. Never give a person having seizures anything by mouth. **Get immediate medical attention. ** Call 911. **Open airway. ** If a child is having a febrile (fever-related) seizure, pull the head back slightly. Do not force anything into the mouth. ### Stupor or Drowsiness A decreased level of mental activity short of unconsciousness is termed "stupor." A practical way of determining if the severity of stupor or drowsiness needs urgent treatment is to note the victim's ability to answer questions. If the victim is not sufficiently awake to answer questions concerning what has happened, then urgent action is necessary. Children are more difficult to judge, but the child who cannot be aroused needs immediate attention. # Emergency First Aid We haven't tried to teach complex first-aid procedures such as CPR (cardiopulmonary resuscitation) in this book. To use such procedures correctly, you need hands-on instruction and practice. Community organizations such as the American Red Cross and the American Heart Association offer training. ### Disorientation Disorientation is described in terms of time, place, and person—that is, according to whether the person can answer these questions correctly: What is the date? Where are we? Who are you? A person who doesn't know his or her identity is in more trouble than a person who doesn't know where he or she is, and that person is in more trouble than a person who can't give the correct date.The person who previously has been alert and then becomes disoriented and confused deserves immediate medical attention.### Shortness of Breath We discuss shortness of breath more extensively in its own section (here).As a general rule, emergency attention is needed if the person is short of breath even though resting.

As they recovered from the condition we had targeted, depression or obsessionality, some noticed gains in self-confidence and social ease.In the column I wrote for psychiatrists and later in Listening to Prozac, I reported on my patients' response to the new medication.The SSRIs did not typically cause constipation, dry mouth, and the rest, although some patients complained of nausea.These successes covered most of what mental health professionals relied on in the treatment of depression. One more irony emerged. This scrupulous effort, designed by topflight academics, had led to controversy and calls for reinterpretation. The contentious aftermath suggested that it was hard to conduct outcome research in a way that produced definitive or even convincing results. But the general understanding about the TDCRP was the reverse: it had demonstrated that randomized trials of depression treatment were feasible. As Gerry Klerman had hoped, they became the standard of evidence for psychotherapy. Interlude Tolerably Good WE ARRIVE AT the modern antidepressant era. In late 1987, while the NIMH trial data were being analyzed, Prozac was approved for use. Knowing that it took the world by storm, we may imagine that Prozac arrived to fanfare. In truth, journals reported a range of outcomes, including modest and discouraging ones. A typical overview concluded, "Although [Prozac] should be added to formularies, its use should be reserved for treatment of those who do not respond to or do not tolerate tricyclic agents." The new drug's promise was in the domain of side effects. Prozac was part of a class of medications that, because of the way they influence the brain's handling of neurotransmitters, were called selective serotonin reuptake inhibitors, or SSRIs. The SSRIs did not typically cause constipation, dry mouth, and the rest, although some patients complained of nausea. In the column I wrote for psychiatrists and later in Listening to Prozac, I reported on my patients' response to the new medication. As they recovered from the condition we had targeted, depression or obsessionality, some noticed gains in self-confidence and social ease.Would we all?About Prozac as a treatment for mood disorder, I had less to say.My summary verdict mirrored the profession's consensus: "a reasonable main effect, diminished side effects."My guess was that Prozac's special territory would be mild and chronic depression.

Large doses of opioids or sedatives can decrease deep breathing.Any condition that decreases deep breathing or suppresses a person's ability to cough can cause or contribute to atelectasis.If atelectasis persists for months, the lung may not easily re-expand.Infection is particularly likely if atelectasis persists for several days or more.Periodic deep breaths, which people take unconsciously, and cough also help keep alveoli open. Cough expels any mucus or other secretions that could block the airways leading to the alveoli. If the alveoli are closed for any reason, they cannot participate in gas exchange. The more alveoli that are closed, the less gas exchange occurs. Accordingly, atelectasis can decrease the level of oxygen in the blood. The body compensates for a small amount of atelectasis by constricting the blood vessels in the affected area. This constriction redirects blood flow to alveoli that are open so that gas exchange can occur. Causes A common cause of atelectasis is a blockage of one of the tubes (bronchi) that branch off from the trachea (windpipe) and lead to the lung tissue. The blockage may be caused by something inside the bronchus, such as a plug of mucus, a tumor, or an inhaled foreign object (such as a coin, piece of food, or a toy). Alternatively, the bronchus may be blocked by something pressing from the outside, such as a tumor or enlarged lymph nodes. Blockage from the outside can also occur if the pleural space (the space outside of the lung but inside of the chest) contains a large amount of fluid (pleural effusion) or air (pneumothorax— see Pneumothorax). When a bronchus or bronchiole becomes blocked, the air in the alveoli beyond the blockage is absorbed into the bloodstream, causing the alveoli to shrink and collapse. The area of collapsed lung may become infected because bacteria and white blood cells can build up behind (to the inside of) the blockage. Infection is particularly likely if atelectasis persists for several days or more. If atelectasis persists for months, the lung may not easily re-expand. Any condition that decreases deep breathing or suppresses a person's ability to cough can cause or contribute to atelectasis. Large doses of opioids or sedatives can decrease deep breathing.Atelectasis is particularly common after chest or abdominal surgery because the effects of receiving general anesthesia may be added to the pain of deep breathing, so people take only small breaths.Chest or abdominal pain from other causes (for example, from injury or pneumonia) also makes taking a deep breath painful.

But most of these copies are inactive.In the human genome, there are several hundred different transposable element families and subfamilies that together account for about 44% of the total human genome.Most insertions, however, are into noncoding regions and do not affect development.DNA fingerprints are produced by digesting chromosomes with a restriction enzyme to yield fragments that differ in the number of tandem repeats, and thus the relative migration rates of the fragments on an electrophoretic gel. (Reprinted with permission from Brooker RJ: _Genetics: Analysis & Principles_, 3rd ed. New York: McGraw-Hill, 2008.) **Figure 4-13**. An autoradiograph showing DNA fragments which show different migration speeds, interpreted in Figure 4-29. **Microsatellites** have become an even more widely used category of tandemly repeated sequences. They differ from minisatellites in the length of the repeated unit. Microsatellites are long repeats of two to six nucleotides (often di-, tri-, and tetranucleotide repeats). Changes in microsatellite copy number can have serious medical consequences. In other cases, microsatellites serve as genetic markers that can segregate along with (i.e., cosegregate with) a condition of interest and lead its molecular localization. ### **Transposable Elements** The study of transposable elements (TEs), sometimes called "jumping genes," was pioneered by Barbara McClintock who received the Nobel Prize for her work in 1983. They are common in most organisms and move by a variety of mechanisms. By transposing from one chromosome location to another, they can insert directly into a gene causing a mutation or diseases, including cancers. Most insertions, however, are into noncoding regions and do not affect development. In the human genome, there are several hundred different transposable element families and subfamilies that together account for about 44% of the total human genome. But most of these copies are inactive.**Transposons** carry out transposition as DNA copies, while **retrotransposons** spread after reverse transcription of an RNA molecule into DNA.These include **short interspersed nuclear elements** , called **SINEs** , that are less than about 500 nucleotides in length.

As a resident at Massachusetts General, he'd carried that belief to the extreme, never giving up on a cardiac arrest until a superior ordered him to stop.Death had always been Dr. Jason Howard's enemy.Cedric started to cry out when there was an explosion in his chest and darkness descended like a lead blanket.Someone was kneeling beside him, crushing his chest with his hands.But despite Dr. Howard's doomsday approach to Cedric's lifestyle, the doctor had admitted that the tests were okay. His cholesterol was not too high, and his electrocardiogram had been fine. Reassured, Cedric put off attempts to stop smoking and start exercising. Then, less than a week after his physical, Cedric felt as if he were coming down with the flu. But that had been only the beginning. His digestive system began acting up, and he suffered terrible arthritis. Even his eyesight seemed to deteriorate. He remembered telling his wife it was as though he had aged thirty years. He had all the symptoms his father had endured during his final months in the nursing home. Sometimes when he caught an unexpected glimpse of his reflection, it was as if he were staring at the old man's ghost. Despite the morphine, Cedric felt a sudden stab of white-hot, crushing pain. He felt himself receding into a tunnel as he had in the car. He could still see Dr. Howard, but the doctor was far away, and his voice was fading. Then the tunnel started to fill with water. Cedric choked and tried to swim to the surface. His arms frantically grappled the air. Later, Cedric regained consciousness for a few moments of agony. As he struggled back to awareness, he felt intermittent pressure on his chest, and something in his throat. Someone was kneeling beside him, crushing his chest with his hands. Cedric started to cry out when there was an explosion in his chest and darkness descended like a lead blanket. Death had always been Dr. Jason Howard's enemy. As a resident at Massachusetts General, he'd carried that belief to the extreme, never giving up on a cardiac arrest until a superior ordered him to stop.It was a personal affront.Glancing up at the monitor, which still showed normal EKG activity, Jason touched Cedric's neck.He could feel no pulse."Let me have a cardiac needle," he demanded."And someone get a blood pressure."A large cardiac needle was thrust into his hand as he palpated Cedric's chest to locate the ridge on the sternum.

Muscles and ligaments around the joint provide support and make it move.Special membranes surround the joint and cover it with a fluid that lubricates it.The joint capsule surrounds the joint and protects it.Cartilage covers the end of each bone and prevents the bones from rubbing together.A joint is the place where two bones meet.** The word "arthritis" means pain and swelling of the joints."It is hard to pinpoint how much drug-makers earn from arthritis because antiarthritis products also are taken for headaches, trick knees, and the many other guises of pain. But when one considers all the drugs that find use in fighting arthritis, the market bulges to something close to $3 billion in retail sales, according to analysts. Over-the-counter sales make up more than half of that total, but the swiftest growth comes from prescription drugs." The arthritis industry remains extremely lucrative today. The estimated annual cost of arthritis to the economy in terms of medical care and indirect costs such as lost wages is $150 billion. Additionally, according to the foundation, individuals with rheumatic disease average eight doctor visits per year, twice the average number for persons with other conditions. The arthritis establishment, which includes the pharmaceutical companies, special-interest organizations such as the Arthritis Foundation, and specialized medical personnel such as rheumatologists, physical therapists, and surgeons, has consistently maintained that arthritis is an incurable disease. Therapeutically, this translates into the possible need for physical therapy, ad hoc surgical intervention to replace joints, and a lifetime of medication that, even if it is effective at relieving pain, does nothing to address the cause or arrest the progression of the disease. Economically, addressing arthritis as an incurable disease is a prescription for steady long-term profits. # **What Is Arthritis? ** The word "arthritis" means pain and swelling of the joints. A joint is the place where two bones meet. Cartilage covers the end of each bone and prevents the bones from rubbing together. The joint capsule surrounds the joint and protects it. Special membranes surround the joint and cover it with a fluid that lubricates it. Muscles and ligaments around the joint provide support and make it move.There are many types of arthritis.Some of the most common are described below.# **Osteoarthritis** Osteoarthritis, also known as degenerative joint disease, is a widespread condition responsible for inflammation in specific areas of the body that could eventually cripple its victim.

The other 15% is associated with muscle (14%) and blood and body fluids (1%) as proteins, nucleic acids, ATP and lipids, functioning in cell membranes, acid–base balance and oxygen availability.**Phosphorus** Second only to calcium in abundance in the body, about 85% of phosphorus is found in the bones as part of the hydroxyapatite complex (Ca5(PO4)3OH).Calcitriol activates the synthesis of calbindin, a calcium-binding protein that facilitates movement of calcium from the brush border into the cytoplasm of the enterocyte, and extrusion from the basolateral portion in an active process. The second process by which calcium is absorbed in the small intestine typically occurs when the amount of calcium ingested is over 400 mg at one time. This process is non-saturable, passive and occurs between the cells (paracellular) in the jejunum and ileum, predominantly. When the concentration of blood calcium is below 8.5 mg/dl (normal serum calcium concentration is 8.5–10.5 mg/dl), PTH increases the release of calcitriol to stimulate increased renal reabsorption of calcium via a different calbindin protein. Finally, in bone, PTH will initiate activation of osteoclastic action by binding with its receptor on osteoblasts. Bone degradation is promoted by lysosomal proteases that cause bone demineralisation and release of calcium into the blood to cause blood calcium levels to increase. These three processes, increased calcium absorption in the gut and reabsorption in the kidney, coupled with bone demineralisation, cause blood calcium levels to increase back into the normal range. If blood calcium levels increase above 10.5 mg/dl, calcitonin is released from the parafollicular cells of the thyroid gland to cause osteoblastic activation, inhibition of osteoclasts and uptake of calcium into the bones for incorporation into the bone matrix. In addition, calcitonin also causes decreased kidney reabsorption, and activation of vitamin D leading to decreased blood calcium levels. **Phosphorus** Second only to calcium in abundance in the body, about 85% of phosphorus is found in the bones as part of the hydroxyapatite complex (Ca5(PO4)3OH). The other 15% is associated with muscle (14%) and blood and body fluids (1%) as proteins, nucleic acids, ATP and lipids, functioning in cell membranes, acid–base balance and oxygen availability.The Recommended Dietary Allowance (RDA) for phosphorus is 700 mg/day for males and females over age 19 years.Phosphorus is absorbed in its inorganic form after hydrolysis from organic forms occurs in the lumen of the small intestine, either by a saturable carrier-mediated active process that is promoted by calcitriol, or by a concentration-dependent diffusion process.

Systemic alkalizers include potassium citrate and citric acid, sodium bicarbonate, sodium citrate and citric acid, and tricitrates.**Alkalizers—** These drugs neutralize acidic properties of the blood and urine by making them more alkaline (or basic).Sometimes also called granulocytopenia.These include adapalene; alcohol and acetone; alcohol and sulfur; azelaic acid; benzoyl peroxide; clindamycin; erythromycin; erythromycin and benzoyl peroxide; isotretinoin; meclocycline; resorcinol; resorcinol and sulfur; salicylic acid gel USP; salicylic acid lotion; salicylic acid ointment; salicylic acid pads; salicylic acid soap; salicylic acid and sulfur bar soap; salicylic acid and sulfur cleansing lotion; salicylic acid and sulfur cleansing suspension; salicylic acid and sulfur lotion; sulfurated lime; sulfur bar soap; sulfur cream; sulfur lotion; tetracycline, oral; tetracycline hydrochloride for topical solution; tretinoin. **Acridine Derivatives—** Dyes or stains (usually yellow or orange) used for some medical tests and as antiseptic agents. **Acute—** Having a short and relatively severe course. **Addiction—** Psychological or physiological dependence upon a drug. **Addictive Drugs—** Any drug that can lead to physiological dependence on the drug. These include alcohol, cocaine, marijuana, nicotine, opium, morphine, codeine, heroin (and other narcotics) and others. **Addison's Disease—** Changes in the body caused by a deficiency of hormones manufactured by the adrenal gland. Usually fatal if untreated. **Adrenal Cortex—** Center of the adrenal gland. **Adrenal Gland—** Gland next to the kidney that produces cortisone and epinephrine (adrenalin). **Agranulocytosis—** A symptom complex characterized by (1) a sharply decreased number of granulocytes (one of the types of white blood cells), (2) lesions of the throat and other mucous membranes, (3) lesions of the gastrointestinal tract and (4) lesions of the skin. Sometimes also called granulocytopenia. **Alkalizers—** These drugs neutralize acidic properties of the blood and urine by making them more alkaline (or basic). Systemic alkalizers include potassium citrate and citric acid, sodium bicarbonate, sodium citrate and citric acid, and tricitrates.**Alkylating Agent—** Chemical used to treat malignant diseases.**Allergy—** Excessive sensitivity to a substance that is ordinarily harmless.Reactions include sneezing, stuffy nose, hives, itching.**Alpha-Adrenergic Blocking Agents—** A group of drugs used to treat hypertension.

Hemodynamics may be compromised by positioning of the heart, myocardial ischemia, ventricular arrhythmias, bleeding, and valvular regurgitation.** In contrast to on-pump surgery, off-pump surgery via a median sternotomy requires that the heart provide adequate systemic perfusion at all times.Monitoring considerations** **1.This entails the empiric administration of additional protamine for an elevated ACT, and transfusion of platelets, fresh frozen plasma, and occasionally cryoprecipitate. It is best to prioritize these products based on suspicion of the hemostatic defect while awaiting the results of coagulation studies. For example, platelet transfusions should be given first to patients on aspirin or clopidogrel or with uremia; fresh frozen plasma should be considered first for patients on preoperative warfarin, with hepatic dysfunction, or when multiple transfusions are given on pump; and uremic patients might benefit from desmopressin (see page 366). Cryoprecipitate is helpful in improving platelet function, especially when the fibrinogen level is low. Recombinant factor VIIa is particularly effective in achieving hemostasis when the coagulopathy is severe.165 **2. ** Although this particular approach will usually stem the "coagulopathic tide", it is more scientific and cost-effective to use point-of-care testing to assess the specific hemostatic defect and direct care accordingly.109 Systems are available to measure the PT, PTT, and platelet count, and several are capable of measuring platelet function as well. The thromboelastogram is a valuable test that evaluates the entire clotting process and is very effective in the bleeding patient in identifying the exact hemostatic defect that needs to be addressed (Figure 9.1, page 360). **3. ** Further comments on the prevention, assessment, and management of mediastinal bleeding are found in Chapter 9. **IX. Anesthetic Considerations During Off-Pump Coronary Surgery (Table 4.8) 166** **A. Monitoring considerations** **1. ** In contrast to on-pump surgery, off-pump surgery via a median sternotomy requires that the heart provide adequate systemic perfusion at all times. Hemodynamics may be compromised by positioning of the heart, myocardial ischemia, ventricular arrhythmias, bleeding, and valvular regurgitation.Continuous cardiac output and mixed venous oxygen monitoring --- 2.Transesophageal echocardiography 3.Antifibrinolytic drugs 4.Low-level heparinization with ACT >250 seconds 5.Short-acting anesthetic agents 6.Maintenance of systemic normothermia with use of warming devices 7.Arrhythmia prophylaxis with lidocaine and magnesium 8.Availability of pacing capability 9.

For a start, research into the depressive syndromes is underfunded.Despite my optimism, the task will not be easy.Robin Williams's death triggered extensive public discussion about mental illness, and about depression in particular. Much of that conversation, however, was focused on the tragic end of Williams's personal story. But, as _Nature's_ editors emphasized, what of "the chronic, debilitating (and recurring) struggle" that had gone before? How may we learn from the personal experience of depression? How is science helping and where is our research running aground? Why, in the face of this pervasive scourge, are we not doing more? The journal _Nature,_ which first appeared on the London newsstands in 1869, is today considered by many to be the leading international journal of scientific research. Thus it is highly significant for this venerable publication to devote a special issue to the societal burden of depressive disorder, let alone to promote such probing questions. It means, among other things, that big science has entered the public debate and accepted the challenge of inquiry. This brings hope in juxtaposition to Williams's tragic suicide. Just as did the necessity of fighting cancer, another malignancy, emerge from the shadows to take center stage two or three decades ago, so now is mental illness finally emerging. But, perhaps most important, _Nature's_ publication also signals that the technology of behavioral neuroscience is reaching the maturity essential to dissecting the complex interactions of brain mechanisms, behavior, and social experience that weave the web of mental life in both health and illness. Despite my optimism, the task will not be easy. For a start, research into the depressive syndromes is underfunded.Indeed the total budget spent on _all_ mental illness research was $2.2 billion, just over 40 percent of what had been provided for cancer research alone.A similar situation exists in the European Union where approximately €8 million are allotted annually for depression research against €205 million for cancer.

However, the neoplastic cells stain positive with antikeratin antibodies on immunohistochemical evaluation.The spindle cell variant is often difficult to differentiate from the surrounding stromal cells.Several uncommon variants of SCC have been described.The invasive margins of the neoplasm may show neurotropism (Figure 4.6G) as well as invasion of dermal and subcutaneous lymphatics.SCCs have an association with the overlying epidermis although this may not always be found on microscopic examination. Islands, cords, and trabeculae of neoplastic squamous epithelial cells invade the dermis and subcutis. The amount of keratin, seen as intracytoplasmic, eosinophilic fibrillar material (keratin tonofilaments), produced by the neoplastic cells is quite variable. When there is extensive keratinization, which may be orthokeratotic (Figure 4.6E) or parakeratotic (Figure 4.6 F), and in well‐differentiated neoplasms there is the formation of distinct keratin "pearls." In poorly differentiated neoplasms only a few cells may have intracytoplasmic eosinophilic keratin tonofilaments. Individual neoplastic cells have large, ovoid, often vesicular nuclei with a single, central, prominent nucleolus, abundant cytoplasm that varies from pale to brightly eosinophilic, and distinct cell borders. In more differentiated neoplasms it is possible to find intercellular desmosomes, particularly in areas where intercellular edema allows them to be more readily identified. The number of mitotic figures is variable, but they are more frequent in less well‐differentiated neoplasms. Invasion of the dermis and subcutaneous tissue may evoke a desmoplastic response. There is often an infiltrate of neutrophils into the islands of neoplastic squamous epithelium, while plasma cells and lymphocytes are found in the connective tissue stroma that surrounds the neoplastic epithelium. The invasive margins of the neoplasm may show neurotropism (Figure 4.6G) as well as invasion of dermal and subcutaneous lymphatics. Several uncommon variants of SCC have been described. The spindle cell variant is often difficult to differentiate from the surrounding stromal cells. However, the neoplastic cells stain positive with antikeratin antibodies on immunohistochemical evaluation.##### Growth and metastasis SCCs are usually slow growing.Most neoplasms, although invasive, do not show metastatic spread to regional lymph nodes; regional lymph node metastasis is most often found with poorly differentiated neoplasms or neoplasms that have been present for a considerable time before they are diagnosed or excised.

However, Horner's syndrome occurs in all of the most common domestic species and can indicate significant neurological disease.## Horner's Syndrome Horner's syndrome is best understood and most frequently diagnosed in the dog.Prognosis and treatment of neuro‐ophthalmic conditions depends upon the location and etiology of the lesion.Other severe septic infections, affecting the udder, respiratory tract, and uterus, can cause bacteremia that also cause anterior and posterior uveitis, chorioretinitis, and exudative retinal detachments (Figure 18.45). **Figure 18.45** (A) Severe chorioretinitis, retinal hemorrhage, and exudative retinal detachment secondary to bovine thromboembolic meningoencephalitis in a feedlot steer. Courtesy of Glenn Severin. (B) Previous septic choroiditis secondary to bacteremia in a cow. Note the destruction of the tapetum fibrosum and limited pigmentation in these previous inflamed areas. # 19 Neuro‐ophthalmic Syndromes Neuro‐ophthalmic syndromes occur as the result of an insult to the segments of the nervous system that innervate or influence the functions of the eye and adnexa. Neuro‐ophthalmology is a complex field, and although there are several syndromes recognized in veterinary medicine, their diagnosis and understanding can be difficult and incomplete. Patients with these syndromes present to either the ophthalmologist or the neurologist; often in large and referral veterinary practices these two disciplines will examine the patient, and combine their talents and experiences for the benefit of the patient. Optic neuritis that can be grouped with these syndromes is discussed in Chapter 13. Prognosis and treatment of neuro‐ophthalmic conditions depends upon the location and etiology of the lesion. ## Horner's Syndrome Horner's syndrome is best understood and most frequently diagnosed in the dog. However, Horner's syndrome occurs in all of the most common domestic species and can indicate significant neurological disease.It results in miosis, ptosis (drooping of the upper eyelid), enophthalmos (eye appears recessed), and protrusion of the nictitating membrane (Figure 19.1).With these clinical signs, anisocoria (difference in pupil size between the two eyes) and a narrowed palpebral fissure also occur.

Fig.64.3 and 64.4).In case of a small tumor it surgery is performed in the so called otological phase, the chance of preserving the function of the facial nerve is greater (Figs.Facial paresis is a rather late symptom, but small, intrameatal tumors may also cause early functional disorder in the facial nerve by compressing the vessels of the inner auditory tube.Blink Reflex It is a valuable tool in detecting changes in the function of the trigeminofacial reflex pathway. The presence of a tumor should be suggested if facial paresis occurs slowly or facial paresis is recurring. A tumor may be in the background of facial tics and spasm as well. Rarely, facial paresis of tumor origin may occur suddenly as well. Te most common tumors affecting the facial nerve: ### Benign Tumors neuroma, meningeoma, hemangioma, paraganglioma, congenital cholesteatoma, lipoma, hamartoma, arachnoid cyst, etc. ### Malignant Tumors lymphoma, leukemia, neuroblastoma, rhabdomyosarcoma, chordoma, metastasis in the intratemporal region, adenocystic carcinoma most commonly in the parotid gland, mucoepidermoid carcinoma, undifferentiated carcinoma, anaplastic carcinoma, Hodgkin disease, etc. Radical surgical removal of malignant tumors usually involves the removal of the facial nerve as well. Most recently, maintaining function is our goal as well as creating opportunities for subsequent reconstructive surgery, if it does not endanger ablasticity. The most common benign tumor is the neuroma of the statoacoustic nerve, which originates usually from the vestibular, or less commonly from the acoustic fibers. It may lead to tinnitus, decreased hearing, dizziness, facial paresis, trigeminal or lower cranial nerve symptoms, congestion, and visual impairment. Facial paresis is a rather late symptom, but small, intrameatal tumors may also cause early functional disorder in the facial nerve by compressing the vessels of the inner auditory tube. In case of a small tumor it surgery is performed in the so called otological phase, the chance of preserving the function of the facial nerve is greater (Figs. 64.3 and 64.4). Fig.64.4 MR image of an acoustic neuroma on the right side leading to facial nerve paresis Neuroma of the facial nerve is significantly less common.Miehlke and Pulec have collected 58 and 98 publications respectively regarding intratemporal neuroma of the facial nerve.Rejtő has described one, Székely four, and Piffkó three cases in the national literature.

Participants rolled the adductors (inner thigh muscles), hamstrings, quadriceps, iliotibial band (running along the outside of the thigh from the hip to the knee), and trapezius (an upper back muscle), self-adjusting the pressure applied to each muscle group by using their hands and feet to offset some of their bodyweight.Much like massage, foam rolling can help the muscles themselves to return to normal functioning if they're too tight, but much of the foam rolling benefit is thought to come from the action of fascia. Much more research is needed to better understand fascia and how foam rolling can affect it. For now, we can be fairly certain that foam rolling leads to neuromuscular relaxation. That means it can stimulate your brain to relax your muscles. While researchers get busy figuring out exactly what mechanisms are at play during foam rolling, let's focus on the fact that it feels great, eases tension in your muscles, and can potentially increase your mobility and accelerate your recovery after physical training. WHAT IS FOAM ROLLING USED FOR? Foam rolling is a way to release muscle tension and possibly even improve athletic performance. Research studies are beginning to look into specific benefits of foam rolling, including–perhaps surprisingly–arterial function.1 In one study, researchers investigated whether foam rolling particular muscle groups would affect arterial stiffness and vascular endothelial function. Endothelium is the inner lining of blood vessels. Participants were tested for brachial-ankle pulse wave velocity (a measure of arterial stiffness), blood pressure, heart rate, and plasma nitric oxide concentration (a measure of vascular endothelial function) after either foam rolling, or not foam rolling on separate days. Participants rolled the adductors (inner thigh muscles), hamstrings, quadriceps, iliotibial band (running along the outside of the thigh from the hip to the knee), and trapezius (an upper back muscle), self-adjusting the pressure applied to each muscle group by using their hands and feet to offset some of their bodyweight.This suggests that foam rolling can reduce arterial stiffness and improve vascular endothelial function.Other benefits often associated with foam rolling are increased blood flow to muscles, injury prevention, increased flexibility, and reduced soreness after workouts.

Severe or incapacitating cramping with ovulatory menses in the absence of demonstrable disorders of the pelvis is termed _primary dysmenorrhea.A symptom complex of cyclic irritability, depression, and lethargy is known as _premenstrual syndrome_ (PMS).A thorough history including the type, location, radiation, and status with respect to increasing or decreasing severity can help to identify the cause of acute pelvic pain. Associations with vaginal bleeding, sexual activity, defecation, urination, movement, or eating should be sought. Determination of whether the pain is acute versus chronic, constant versus spasmodic, and cyclic versus noncyclic will direct further investigation ( **Table 186-1** ). **TABLE 186-1 CAUSES OF PELVIC PAIN** ##### **Acute Pelvic Pain** Pelvic inflammatory disease most commonly presents with bilateral lower abdominal pain. Unilateral pain suggests adnexal pathology from rupture, bleeding, or torsion of ovarian cysts, or, less commonly, neoplasms of the ovary, fallopian tubes, or paraovarian areas. Ectopic pregnancy is associated with right- or left-sided lower abdominal pain, vaginal bleeding, and menstrual cycle abnormalities, with clinical signs appearing 6–8 weeks after the last normal menstrual period. Orthostatic signs and fever may be present. Uterine pathology includes endometritis and degenerating leiomyomas. ##### **Chronic Pelvic Pain** Many women experience lower abdominal discomfort with ovulation ( _mittelschmerz_ ), characterized as a dull, aching pain at midcycle that lasts minutes to hours. In addition, ovulatory women may experience somatic symptoms during the few days prior to menses, including edema, breast engorgement, and abdominal bloating or discomfort. A symptom complex of cyclic irritability, depression, and lethargy is known as _premenstrual syndrome_ (PMS). Severe or incapacitating cramping with ovulatory menses in the absence of demonstrable disorders of the pelvis is termed _primary dysmenorrhea.##### **Diagnosis** Evaluation includes a history, pelvic exam, hCG measurement, tests for chlamydial and gonococcal infections, and pelvic ultrasound.Laparoscopy or laparotomy is indicated in some cases of pelvic pain of undetermined cause.**TREATMENT Pelvic Pain** Primary dysmenorrhea is best treated with NSAIDs or oral contraceptive agents.

Chromosome segments can be analyzed for abnormalities or changes from normal positions.Chromosomes can be assessed for missing, extra, or broken chromosomes.Cellular or biochemical tests provide information about gene products made by a cell, tissue, or organ.Actual genetic testing can be performed at many levels.6-13 A typical pedigree showing a sex-linked (X-linked) recessive pattern of inheritance. ## Complex Inheritance and Familial Clustering Some health problems appear in families at a rate higher than normal and greater than can be accounted for by chance alone; however, no specific pattern occurs within a family. Although clusters suggest a genetic influence, it is likely that additional factors, such as gender and the environment, also influence disease development or disease severity. Such disorders include Alzheimer's disease, type 1 diabetes, and many others. These disorders are often called _complex_ and _multifactorial,_ because although an increased genetic risk may be present, the risk is changed by diet, lifestyle, exposure to toxins, infectious agents, and other factors. # Genetic Testing ## Purpose of Genetic Testing Many people are eager to have genetic testing but also are fearful of genetic testing. The lay public often believes that a single genetic test can "tell everything about a person." Although genetic testing has the potential to be that informative, this is not currently the case. _It is important to remember that no single person is genetically perfect._ Genetic testing can be performed with many different techniques. Some genetic tests are specific for a disorder. Others may show a gene variation but the significance of the variation may not be known. Unexpected information can be found during genetic testing. Some ordinary tests, such as blood typing and tissue typing, provide genetic information. Tests that measure the amount of an enzyme or protein also provide genetic information. Actual genetic testing can be performed at many levels. Cellular or biochemical tests provide information about gene products made by a cell, tissue, or organ. Chromosomes can be assessed for missing, extra, or broken chromosomes. Chromosome segments can be analyzed for abnormalities or changes from normal positions.At present, not all genes can be analyzed and the analysis of even one gene is limited by expense and availability.Specific base pairs can be evaluated for mutations.These tests are expensive, and the results may not be conclusive.Table 6-4 lists purposes of genetic testing for adults.

#### **Muscle Spindles & Tendon Organs** Striated muscles and myotendinous junctions contain sensory receptors acting as proprioceptors (L. _proprius_ , one's own + _capio_ , to take), providing the central nervous system (CNS) with data from the musculoskeletal system.The extraocular muscles of the eyes are commonly the first affected.In this case the single axon and all the muscle fibers in contact with its branches make up a **motor unit. ** Individual striated muscle fibers do not show graded contraction—they contract either all the way or not at all. To vary the force of contraction, the fibers within a muscle fascicle do not all contract at the same time. With large muscles composed of many motor units, the firing of a single motor axon will generate tension proportional to the number of muscle fibers it innervates. Thus, the number of motor units and their variable size control the intensity and precision of a muscle contraction. Key features of skeletal muscle cells, connective tissue, contraction, and innervation are summarized in Table 10–1. TABLE 10–1 Important comparisons of the three types of muscle. **MEDICAL APPLICATION** **Myasthenia gravis** is an autoimmune disorder that involves circulating antibodies against proteins of acetylcholine receptors. Antibody binding to the antigenic sites interferes with acetylcholine activation of their receptors, leading to intermittent periods of skeletal muscle weakness. As the body attempts to correct the condition, junctional folds of sarcolemma with affected receptors are internalized, digested by lysosomes, and replaced by newly formed receptors. These receptors, however, are again made unresponsive to acetylcholine by similar antibodies, and the disease follows a progressive course. The extraocular muscles of the eyes are commonly the first affected. #### **Muscle Spindles & Tendon Organs** Striated muscles and myotendinous junctions contain sensory receptors acting as proprioceptors (L. _proprius_ , one's own + _capio_ , to take), providing the central nervous system (CNS) with data from the musculoskeletal system.A muscle spindle is encapsulated by modified perimysium, with concentric layers of flattened cells, containing interstitial fluid and a few thin muscle fibers filled with nuclei and called **intrafusal fibers** (Figure 10–14).Several sensory nerve axons penetrate each muscle spindle and wrap around individual intrafusal fibers.

Which instruction should the nurse give to the client to assist in controlling the vertigo?** A client with Ménière's disease is experiencing severe vertigo.** A sensorineural hearing loss that occurs with aging **786.** A conductive hearing loss that occurs with aging **4.** Nystagmus that occurs with aging **3.** Tinnitus that occurs with aging **2.**1.** The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? **Select all that apply. ** **1. ** Avoid activities that require bending over. **2. ** Contact the surgeon if eye scratchiness occurs. **3. ** Place an eye shield on the surgical eye at bedtime. **4. ** Episodes of sudden severe pain in the eye are expected. **5. ** Contact the surgeon if a decrease in visual acuity occurs. **6. ** Take acetaminophen (Tylenol) for minor eye discomfort. **783. ** Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the test results documented in the client's chart, knowing that which is the range for normal intraocular pressure? **1. ** 2 to 7 mm Hg **2. ** 10 to 21 mm Hg **3. ** 22 to 30 mm Hg **4. ** 31 to 35 mm Hg **784. ** The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? **1. ** Cranial nerve I, olfactory **2. ** Cranial nerve IV, trochlear **3. ** Cranial nerve III, oculomotor **4. ** Cranial nerve VII, facial nerve **785. ** The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. The nurse understands that which describes this condition? **1. ** Tinnitus that occurs with aging **2. ** Nystagmus that occurs with aging **3. ** A conductive hearing loss that occurs with aging **4. ** A sensorineural hearing loss that occurs with aging **786. ** A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?** Increase sodium in the diet.**2.** Avoid sudden head movements.**3.** Lie still and watch the television.**4.** Increase fluid intake to 3000 mL a day.**787.** The clinic nurse is preparing to test the visual acuity of a client, using a Snellen chart.Which identifies the accurate procedure for this visual acuity test?**1.

Oxytocin is mainly synthesized in the hypothalamic paraventricular (PVN) and supraoptic (SON) nuclei and is released peripherally via the posterior pituitary in response to distension of the cervix and uterus during labor, leading to contractions of the uterine smooth muscles and succoring birth.MOTHER–INFANT ATTACHMENT From birth, mammalian infants rely heavily on the care and protection provided by the mother to reassure survival and proper development. Because the mother is the primary, or sole, caregiver for most mammalian species, the onus of maternal investment is great and tethered to infant survival. It seems that mother–infant interactions (e.g., childbirth, infant-related sensory cues, maternal care, and nursing) and the mother's own physiology are skewed to foster maternal attachment and a desire to give warmth, comfort, food, and protection. Mother–infant attachment also manifests via increased intrinsically rewarding properties of contact with offspring, increased protective behavior (i.e., maternal defense or aggression), and reduced stress via mother–infant interaction (i.e., infant buffering). Furthermore, some evidence suggests associations among these effects (e.g., maternal aggression and stress: Bosch and Neumann, 2012; Gammie et al., 2008). Development and maturation of a mother–infant attachment are regulated by a variety of neurochemical systems including, but not limited to, the oxytocin, dopamine, and corticotrophin-releasing hormone (CRH) systems, as well as the interaction between these neural systems (see Fig. 86.1B). NEUROANATOMY AND CHEMICAL SUBSTRATES In the peripartum period, the mother's physiology and infant behavior seem to facilitate mother–infant attachments, and oxytocin, a reproductive neuropeptide, may explain these effects. Oxytocin is mainly synthesized in the hypothalamic paraventricular (PVN) and supraoptic (SON) nuclei and is released peripherally via the posterior pituitary in response to distension of the cervix and uterus during labor, leading to contractions of the uterine smooth muscles and succoring birth.The fact that oxytocin is pivotal in these behaviors and reproductive functions in which maternal bonding occurs initially led to the suggestion that oxytocin may be involved in the bonding process as well (Nelson and Panksepp, 1998).

Some major exceptions are patients with transient airway obstruction, electrolyte disturbances, proarrhythmic effects of drugs, and severe metabolic abnormalities, most of whom may have a good chance of survival if they can be resuscitated promptly and stabilized while the transient abnormalities are being corrected.In the in-hospital setting, respirator support is usually not necessary or is needed for only a short time, and hemodynamics stabilize promptly after defibrillation or cardioversion. In _secondary VF_ in acute MI (those events in which hemodynamic abnormalities predispose to the potentially fatal arrhythmia), resuscitative efforts are less often successful, and in patients who are successfully resuscitated, the recurrence rate is high. The clinical picture and outcome are dominated by hemodynamic instability and the ability to control hemodynamic dysfunction. Bradyarrhythmias, asystole, and PEA are commonly secondary events in hemodynamically unstable patients. The in-hospital phase of care of an out-of-hospital cardiac arrest survivor is dictated by specific clinical circumstances. The most difficult is the presence of anoxic encephalopathy, which is a strong predictor of in-hospital death. A recent addition to the management of this condition is induced hypothermia to reduce metabolic demands and cerebral edema. The outcome after in-hospital cardiac arrest associated with noncardiac diseases is poor, and in the few successfully resuscitated patients, the postresuscitation course is dominated by the nature of the underlying disease. Patients with end-stage cancer, renal failure, acute central nervous system disease, and uncontrolled infections, as a group, have a survival rate of <10% after in-hospital cardiac arrest. Some major exceptions are patients with transient airway obstruction, electrolyte disturbances, proarrhythmic effects of drugs, and severe metabolic abnormalities, most of whom may have a good chance of survival if they can be resuscitated promptly and stabilized while the transient abnormalities are being corrected.This aggressive approach is driven by the fact that survival after out-of-hospital cardiac arrest is followed by a 10–25% mortality rate during the first 2 years after the event, and there are data suggesting that significant survival benefits can be achieved by prescription of an implantable cardioverter-defibrillator (ICD).

** PE-6 and TB-4 are potent points to aid the stomach.**P/Hs.** The great toe for the vagus nerve as its nerve fibres serve the stomach and whole digestive tract; it also regulates the acid and pepsin release.**A/A.** The thyroid/parathyroid to balance the levels of thyrocalcitonin; also ribcage relaxation. **P/Hs. ** PE-6 and TB-3 are both involved in normalizing the liver. LI-4 can be used as a calming point as it has an antispasmodic action. _Warning!_ LI-4 can be used only providing the person is not pregnant, as it is an empirical point to promote delivery during labour. **P/LL. ** GB-40 helps all the upper hypochondrium. **P/AS. ** Liver/gall bladder points. **P/AA. ** Centre of superior concha for abdominal pain. **P/OM. ** Sympathetic nervous system (antihelix), for all biliary colic. **P/TCM. ** Shenmen for pain relief. #### Gastritis ##### Symptoms Pain and discomfort are often similar to the pain of an ulcer; severe discomfort is felt in the upper abdominal area. This may occur immediately after eating, or within a short period of about 3 hours. This problem arises because of some irritation to the stomach lining, which becomes inflamed. This can be caused by many things such as: alcohol, smoking, or too much stress in everyday life. Occasionally it can be due to an autoimmune disorder, whereby the body's own antibodies destroy the tissue and inflammation manifests in the stomach lining, creating a problem. ##### Areas to work **M/R. ** The stomach area to neutralize the acid and any inflammation, allowing natural healing to take place. Treatment should always be aimed at approximately 2–3 hours after the main meal of the day, as this will help to balance the acid surge that occurs at this time, which is often the culprit of the annoying problem. **A/A. ** The great toe for the vagus nerve as its nerve fibres serve the stomach and whole digestive tract; it also regulates the acid and pepsin release. **P/Hs. ** PE-6 and TB-4 are potent points to aid the stomach.** ST-35, 36 and 39 will regulate the stomach's activity._Warning!_ ST-36 must not be used on young children.**P/AS.** All abdominal areas.**P/AA.** Apex of antitragus for inflammatory problems.**P/OM.** Subcortex and sympathetic nervous system, as both are involved in regulating the autonomic nervous system.Work the vagus nerve directly on the dorsal surface.**P/TCM.** Shenmen for pain relief.

**behavioral therapy:** A type of psychotherapy that works on the assumption that physical and emotional reactions occur when one thing or event is paired with another.Cells in the basal ganglia use dopamine as their primary means of communicating with other parts of the brain and body.Commonly known illnesses such as Parkinson's disease and Huntington's disease originate here.**anabolic steroids:** A class of drugs that mimic testosterone and are used to treat hormone deficiencies, low libido, severe weight loss from HIV and cancer, and anemia. They are also misused by health people to promote muscle growth. **astrocyte:** A type of cell in the brain that supports other brain cells that are responsible for thinking, feeling, and other basic "brain functions," by protecting, nourishing, and assisting their function **attention deficit disorder:** See attention-deficit/hyperactivity disorder **attentlon-deficit/hyperactivity disorder:** A psychiatric illness in which a person has difficulty with a number of mental functions, most notably focusing attention on uninteresting material and having difficulty filtering out surrounding distractions, having difficulty suppressing movements or words and needing to move about constantly. There are three subtypes: 1) primarily inattentive; 2) primarily hyperactive; and 3) combined inattentive and hyperactive. In adults, it is more common to see the primarily inattentive subtype, also commonly known as attention deficit disorder or ADD. Children are more commonly seen with the combined type. This condition is usually called by its simpler acronym ADHD. Note that there are many other conditions that can cause difficulty with concentration, such as depression, anxiety, drug effects, medication side effects, fatigue, and many others. **basal ganglia:** A part of the brain with many functions, including movement, as well as relaying brain signals between the body and the rest of the brain. Commonly known illnesses such as Parkinson's disease and Huntington's disease originate here. Cells in the basal ganglia use dopamine as their primary means of communicating with other parts of the brain and body. **behavioral therapy:** A type of psychotherapy that works on the assumption that physical and emotional reactions occur when one thing or event is paired with another.Behavior therapy works to extinguish the reaction by repeatedly exposing a person to one of the two things without the other until the associated reaction stops.In this example, exposing a person to a computer until the feelings about smoking crystal disappear, allowing a person to work at a computer safely without having overwhelming cravings to use drugs.

In small-cell carcinoma of the bronchus, for example, chemotherapy is now widely employed as the mainstay of treatment, with mediastinal irradiation, formerly the most widely used method of treatment, now increasingly used as consolidation post chemotherapy (see Chapter 12).Radiotherapy, as a powerful local tool, is often able to produce tumour control with minimal physiological disturbance, though without effect on occult metastases. It may not be possible to ensure satisfactory irradiation of the primary tumour and its lymph node drainage area if nodal metastases are known to be present, for example, in gynaecological, testicular or bladder tumours with known para-aortic involvement. Conversely, chemotherapy can seldom be relied upon to deal adequately with the primary tumour, though it does at least offer hope in dealing with occult metastatic disease. Combined therapy should then represent a logical approach; indeed it is clear that in a number of major squamous cell primary sites, synchronous chemoradiotherapy now represents the gold standard of treatment with radical intent (cervix, anus, vulva, oesophagus, head and neck; see specific chapters). Use of chemotherapy with curative intent after radiation failure represents a different form of combined therapy, since the treatments are separated in time. This approach is only likely to be successful in highly chemosensitive tumours such as Hodgkin's disease, in which chemotherapy for radiation failure is probably as successful as it is for primary therapy. A more recent concept, still relatively unexplored, is the use of 'adjuvant' radiotherapy in patients treated primarily by chemotherapy. In small-cell carcinoma of the bronchus, for example, chemotherapy is now widely employed as the mainstay of treatment, with mediastinal irradiation, formerly the most widely used method of treatment, now increasingly used as consolidation post chemotherapy (see Chapter 12).## Proton therapy This exciting approach, a type of particle therapy which uses a beam of protons rather than photons, has attracted great interest in recent years ([13], and see Ref.[14]).Its main advantage is the ability to more precisely localize the radiation dosage as a result of the totally different physics of energy deposition within the irradiated tissue.

* Produce a more effective, deeper level of analgesia * Reduce systemic toxicity The vasoconstrictors used in dental analgesic solutions are **epinephrine** ( **adrenaline** ), a naturally occurring hormone, and **felypressin** , a synthetic octapeptide which resembles the pituitary hormone vasopressin.* Extend the duration of pulpal analgesia.## ** _Sugar-free medication in prescribing practice_** Oral liquid medications that do not contain fructose, glucose or sucrose are described as 'sugar-free'. Preparations containing hydrogenated glucose syrup, mannitol, maltitol, sorbitol or xylitol are considered 'sugar-free' since there is evidence that they do not cause dental caries. When medication containing cariogenic sugars is prescribed it is important to advise the patient of appropriate dental hygiene measures. Sugar-free preparations should be used whenever possible, particularly in children if long-term medication is being prescribed. # Local analgesic agents The two classes of local analgesic agents are **esters** and **amides**. These differ in their mechanism of metabolism. Esters are rapidly metabolised in plasma by **pseudocholinesterases**. The breakdown of amides is more complex and hence slower. Amides in general need to be transported to the liver for breakdown. Some metabolism of prilocaine occurs in the lungs. Articaine is the exception as it undergoes initial degradation in plasma by esterases. The ester local analgesic agents are prone to induce allergy and are not generally used for dental injection, although some have use as topical agents. In general the amide agents have superior analgesic properties for application by infiltration. Local analgesic agents are often used with a vasoconstrictor, which will: * Reduce haemorrhage. * Extend the duration of pulpal analgesia. * Produce a more effective, deeper level of analgesia * Reduce systemic toxicity The vasoconstrictors used in dental analgesic solutions are **epinephrine** ( **adrenaline** ), a naturally occurring hormone, and **felypressin** , a synthetic octapeptide which resembles the pituitary hormone vasopressin.Epinephrine has superior vasoconstrictor properties to felypressin.The agents present in a typical dental analgesic cartridge are summarised in Table 10.1.**Table 10.1** Contents of an analgesic cartridge.

Chop whole cloves fine and suddenly the protective compound allicin is released.Garlic also benefits from a little help.That's why a drizzle of olive oil on cooked carrots or broccoli or a dab of yogurt on fresh fruit can vastly increase their healing powers.But scientists have learned that your body can't readily absorb beta-carotene unless you eat it with a little fat.They've always been thought to be healthy, mostly because they are so chock-full of vitamins and fiber. But it turns out that it's the phytonutrients in apples (found mainly in the skin) that are the powerhouses. In fact, they're so strong that one study of 40,000 women associated the quercetin and other phytonutrients in apples with a 13 to 22 percent lower risk of cardiovascular disease. In addition, the quercetin in apples (and pears) has been found to help improve lung function, reducing the risk of asthma and obstructive pulmonary disease. Or take red wine. We all know a glass with dinner can be a great relaxer, but who could have predicted that the resveratrol present in red wine could help make bad low-density lipoprotein (LDL) cholesterol less likely to stick to artery walls. Or that wine might even play a role in preventing diabetes. One of the most exciting discoveries is that some foods can literally stop the chemical changes that can lead to cancer. Watercress, for example, has been found to block some of the harmful effects of cigarette smoke. And strawberries, and other berries that contain ellagic acid, have been shown to block the harmful effects of cancer-causing chemicals in the body. And as if all this isn't enough to make you head for the produce aisle... scientists have also discovered ways to make the foods that we eat even more powerful. You may know, for instance, that beta-carotene (found in carrots, broccoli, mangoes, and other dark orange and dark green vegetables and fruits) is good for your heart. But scientists have learned that your body can't readily absorb beta-carotene unless you eat it with a little fat. That's why a drizzle of olive oil on cooked carrots or broccoli or a dab of yogurt on fresh fruit can vastly increase their healing powers. Garlic also benefits from a little help. Chop whole cloves fine and suddenly the protective compound allicin is released.And the list of foods and their seemingly magical healing powers goes on and on.At _Prevention_ , we've always believed that good health comes first from the farm, then the pharmacy.That's why we've spent so much time reviewing the latest scientific journals and talking with hundreds of the country's top doctors and food experts to bring you this important reference.

The respiratory system has a very large functional reserve, so decades of slow loss in lung function usually occurs (as in COPD caused by cigarette smoking) before shortness of breath prompts the individual to seek medical attention [24].About 90% of clinically-important COPD is caused by smoking.The FEV1 declines at a somewhat faster rate than the FVC (largely due to a loss of lung tissue elasticity), so the FEV1/FVC also declines with aging. Age-related impairments in respiratory physiology become most problematic during maximal exercise or in an episode of acute lung injury (e.g., pneumonia), as well as in individuals who already have a reduced ventilatory reserve due to lung disease. ### 24.6.2 Gender For a given exposure history (such as pack-years of smoking), women and men have a roughly equivalent risk of developing COPD [19–21]. Older women are more likely than older men to have asthma-like symptoms and to report dyspnea upon exertion (even after adjustment for other risk factors). ### 24.6.3 Genetic Risk Studies have identified some racial differences in susceptibility to asthma and COPD. However, large projects have had only limited success in determining the exact set of genetic polymorphisms that are responsible for increased susceptibility for developing these chronic airway diseases [22]. African-Americans are more likely to have a genetic polymorphism that increases their risk of asthma (at all ages) and reduces the effectiveness of the long-acting bronchodilators which are commonly used to control asthma (inhaled beta-agonists). Amongst Hispanics, a greater percentage of African ancestry correlates with lower FVC and a greater risk of asthma and asthma severity [23]. On the other hand, African-American women are less susceptible to the risk that cigarette smoking will cause COPD [19]. ### 24.6.4 Smoking About one in five people who begin smoking before age 20 will slowly develop COPD. About 90% of clinically-important COPD is caused by smoking. The respiratory system has a very large functional reserve, so decades of slow loss in lung function usually occurs (as in COPD caused by cigarette smoking) before shortness of breath prompts the individual to seek medical attention [24].### 24.6.5 Viruses All of the common respiratory viruses have been associated with asthma and COPD exacerbations: respiratory syncytial virus (RSV), parainfluenza viruses, coronaviruses, human metapneumovirus (hMPV) and rhinoviruses.

### Directions for future research The gaps in the current literature suggest directions for further research.Although mental QOL generally appears to be positively associated with PA, studies have not consistently assessed mental QOL.Further limitations include small sample sizes, variability in measures of exercise capacity, and few longitudinal studies investigating change in HRQOL over time.PH can also develop secondary to primary pulmonary diseases such as COPD or ILD. Among patients with COPD, mild comorbid PH is common. Symptoms of PH include shortness of breath upon exertion, dizziness, chest pain, swelling of the legs and ankles, and fatigue. Poorer exercise performance (measured by 6-minute walk distance) has been associated with lower QOL among patients with PH (Taichman et al., 2005), but increases in physical and mental QOL were observed among patients with PH who participated in 15 weeks of home-based exercise training following a 3-week in-hospital program (Mereles et al., 2006). ### Methodological problems/concerns in this line of research Limitations of the extant research include reliance on self-report measures of QOL, some of which have limited data on validity and reliability. Studies examining PA and QOL among patients with various pulmonary diseases generally use QOL measures that were validated for use in patients with COPD (e.g., SGRQ and SF-36), thereby limiting the validity of QOL assessment in some studies. Disease-specific measures of QOL have been developed for CF and asthma, but are not used regularly. In addition, most studies rely on convenience samples of patients from clinical or hospital settings, thereby reducing the generalizability of results to community settings. Further limitations include small sample sizes, variability in measures of exercise capacity, and few longitudinal studies investigating change in HRQOL over time. Although mental QOL generally appears to be positively associated with PA, studies have not consistently assessed mental QOL. ### Directions for future research The gaps in the current literature suggest directions for further research.Overall, there are relatively few RCTs evaluating the effects of exercise on QOL, although there are well-controlled studies among patients with CHD and COPD.Instead, most studies provide observational evidence of the relationship between PA and QOL.However, observational studies provide only preliminary evidence of the influence of PA levels on QOL.

† Only part of the WHI hormone trial, which had involved 16,000 women who had not had hysterectomies and were taking the estrogen/progesterone combination, was stopped in 2002.* The successful statin trials I discussed in the previous chapter were secondary prevention studies, although there is research on primary prevention with statins as well.* These first patients in 1981 and 1982 were not diagnosed with "AIDS" as there was no name for the disease initially, which may seem difficult to believe in an age where routine blizzards are now heralded with names on the Weather Channel even before they strike. The first well-known name for AIDS was GRID, or Gay Related Immune Deficiency. "AIDS" was proposed as a name in August 1982 to account for patients, among them Haitians and hemophiliacs, who had similar presentations but were not gay. More than anything else, it was the presence of AIDS in nongay populations that led most scientists to suspect that the disease was caused by a virus rather than recreational drugs then in use among gay men. * Technically, it's called a case-crossover design. * The most notorious example of the abuse of the off-label system involves the marketing of the drug Neurontin, which was informally pushed as a panacea for any number of ills, including bipolar disorder, chronic pain, alcohol withdrawal, and migraine headaches, among other problems. According to a 2009 article from _Bloomberg_ , US federal prosecutors asserted that $2.12 of $2.27 billion—or 94 percent—of Neurontin's revenues came from off-label use. Neurontin's initial FDA indication in 1994 was as an adjunct (that is, not even first-line) treatment for seizures; in 2002 a second approval was given for treatment of a condition called post-herpetic neuralgia, which is the sometimes severe pain that can follow an episode of shingles. * The successful statin trials I discussed in the previous chapter were secondary prevention studies, although there is research on primary prevention with statins as well. † Only part of the WHI hormone trial, which had involved 16,000 women who had not had hysterectomies and were taking the estrogen/progesterone combination, was stopped in 2002."HEALTH WATCH": HYPE, HYSTERIA, AND THE MEDIA'S OVERCONFIDENT MARCH OF PROGRESS To deal with the broader problem of anecdotes, what you need is a framework that tells you which anecdotes are almost surely wrong.—PAUL KRUGMAN The previous two chapters have looked explicitly at how uncertainty and our understanding of a treatment's effectiveness are inextricably and irrevocably linked.

* Focal overcoverage (in the anterior or posterior portion of the acetabulum): * On the AP radiograph the anterior acetabular rim may project lateral to the medial acetabular rim in acetabular retroversion, called the "cross-over sign".* Enlargement of the lateral coverage is demonstrated by a CE angle of >39°.##### Clinical Findings, Therapy Clinically, patients often describe a pain in the groin when rotating the hip, especially while sitting or during physical activities. In addition, pain can be present in the region of the greater trochanter radiating into the thigh. The surgical treatment of femoroacetabular impingement focuses on the removal of the cause, by removing the bony appositions from the acetabulum or the femoral head-neck junction and, rarely, by repositioning the retroverted acetabulum. ##### Imaging In general, standard radiographs in AP and in Lauenstein position are sufficient for radiographic assessment of femoroacetabular impingement. Sometimes the Rippstein view may be useful to detect changes in the anterior femoral head-neck junction and the faux-profile view for the evaluation of the anterior coverage of the femoral head or the posteroinferior portion of the hip joint in suspected contrecoup lesions. Radiologically, the following findings are characteristic for pincer and cam impingement. Radiological findings in pincer and cam impingement In pincer impingement the overcoverage can be focal, or it relates to the whole circumference of acetabulum. * General overcoverage: * Evidence of a coxa profunda in which the the medial acetabular rim lies pathologically medial to the ilioischial line. * This is defined as an acetabular protrusion if the femoral head additionally lies medial to this line. * Enlargement of the lateral coverage is demonstrated by a CE angle of >39°. * Focal overcoverage (in the anterior or posterior portion of the acetabulum): * On the AP radiograph the anterior acetabular rim may project lateral to the medial acetabular rim in acetabular retroversion, called the "cross-over sign".In cam impingement bony appositions at the border between the femoral neck and head may be seen: * Osseous appositions at the lateral head-neck junctions (the so-called "pistol-grip sign") can be well-delineated on AP radiographs.

• ECG changes are associated with hypothermia: slowing of sinus rate with T-wave inversion; QT, QRS, and PR interval prolongation; atrial and ventricular arrhythmias; hypothermic J waves (Osborn waves) characterized by a notching of the QRS complex and ST segment HYPOTHYROIDISM, ADULT Adithi Naidu, MD • Faraz Ahmad, MD • Jason Chao, MD, MS BASICS DESCRIPTION • Clinical and metabolic state resulting from decreased levels of free thyroid hormone or from resistance to hormone action • Primary (intrinsic thyroid disease) >95% of cases or central (secondary or tertiary resulting from hypothalamic-pituitary disease) • Subclinical or overt • Subclinical: serum TSH above the upper reference limit with a normal free T4 and normal hypothalamic-pituitary-thyroid axis (1)[A] • Overt: elevated TSH, usually >10 mIU/L with a subnormal free T4 EPIDEMIOLOGY Incidence • Women: 3.5 per 1,000 persons per year • Men: 0.6 per 1,000 persons per year • Risk of developing hypothyroidism in women with positive antibodies and elevated TSH was 4% per year and 2–3% per year in those with either alone. Prevalence • The National Health and Nutrition Examination Survey III (NHANES III), SHypo (subclinical hypothyroidism) 9.3%, overt 0.3% in an unselected U.S. population over age 12 years, between 1988 and 1994 with upper limit TSH 4.5 • Framingham study, 5.9% of women and 2.3% of men over age 60 years had a serum TSH >10 mIU/L. • British Whickham survey, 9.3% of women and 1.2% of men had a serum TSH >10 ETIOLOGY AND PATHOPHYSIOLOGY • Primary: abnormality at the thyroid gland (>95% of cases) • Most common cause worldwide: environmental iodine deficiency (1)[A] • Most common cause in the United States: Hashimoto thyroiditis (autoimmune thyroid disease [AITD]) – AITD is characterized pathologically by infiltration of the thyroid with sensitized T lymphocytes and serologically by circulating thyroid antibodies.

Oral agents should not be taken on the day of surgery because of the potential for unrecognized hypoglycemia under anesthesia.Significant drug interactions between these antihypertensive drugs and volatile and intravenous anesthetic agents can be expected, especially during induction of general anesthesia.103,107 The time at which antiglycemic agents were last taken should also be determined.Depending on a patient's risk factors and the results of screening tests, pretransplant management may take the course of optimizing medical management or of having the patient undergo a revascularization procedure. The benefit of revascularization is controversial. Data from the CARP trial, where revascularization was performed prior to vascular surgery, showed no benefit of revascularization compared to medical management. In the COURAGE trial, an examination of the subgroup of patients with chronic kidney disease found no benefit of PCI versus medical management.7,77,108 The high cardiac risk of these patients suggests that perioperative beta-blockade may be used as a means of decreasing perioperative risk during KTx. Several studies throughout the late 1990s established that perioperative beta-blockade provides significant protection from major cardiac events in high-risk, non-transplant patients. However, no prospective randomized trials have been conducted with perioperative beta-blockade in the kidney transplant population. Currently it is unknown whether such treatment can be applied safely to these patients, especially those with DM. Furthermore, patients needing antihypertensive treatment in addition to dialysis often require combinations of antihypertensive drugs (e.g., beta-blockers, ACE inhibiters, angiotensin receptor blockers) in large doses. Significant drug interactions between these antihypertensive drugs and volatile and intravenous anesthetic agents can be expected, especially during induction of general anesthesia.103,107 The time at which antiglycemic agents were last taken should also be determined. Oral agents should not be taken on the day of surgery because of the potential for unrecognized hypoglycemia under anesthesia.Coagulation status, as reflected by the prothrombin time, international normalized ratio, partial thromboplastin time, fibrinogen, and platelet count, is routinely assessed before surgery.Although ESRD patients may be consuming protein-restricted diets, it is rare for such diets to cause a significant clotting factor deficiency.

When plotting the fluorescent signal versus the cycle number, the higher the initial copy number is, the earlier the signal appeared out of the defined threshold line.This threshold is defined in general as 3–10 times the standard deviation of the background fluorescent signal.To normalize these quality variations, each target mRNA should be quantified in relation to the expression of the so-called housekeeping genes which are expressed at similar levels in all different cell types [14]. Commonly, two different real-time RT-PCR methods are performed routinely based on the real-time RT-PCR method using hybridization probes. One real-time PCR method is based on the TaqMan™ technology using TaqMan™ probes and the other one on the LightCycler® method using hybridization probes. The TaqMan™ probe has a 5′ fluorescent reporter dye, which is quenched by a 3′ quencher dye through Förster-type energy transfer (FRET). After hybridization to the template, the fluorogenic TaqMan™ probes will be hydrolyzed during PCR by the 5′ secondary structure-dependent nuclease activity of the Taq DNA polymerase [15]. After hydrolysis the release of the reporter signal caused an increase in fluorescence intensity that was proportional to the accumulation of the PCR product. The LightCycler® method uses two hybridization probes which hybridize at the template closely together with a distance of only 1–5 bases. The first probe is fluorescent labeled at the 3′ and the second probe at the 5′ site. Only after specific hybridization of both probes together to the template a fluorescent signal is released in proportion to the accumulated PCR product. Both systems then generate a real-time amplification plot based upon the normalized (background) fluorescent signal. Subsequently a threshold cycle is determined, i.e., the fractional cycle number at which the amount of amplified target reached a fixed threshold. This threshold is defined in general as 3–10 times the standard deviation of the background fluorescent signal. When plotting the fluorescent signal versus the cycle number, the higher the initial copy number is, the earlier the signal appeared out of the defined threshold line.The target mRNA expression in patient samples can be related to a standard curve of a control RNA (plasmid or leukemic cell line with the specific target fusion gene) with the same level of expression or in numbers of the copies of the target gene.In the following, the most commonly used qualitative and quantitative PCR methods for acute and chronic myeloid disorders are described in detail.

A 2007 study in the _International Journal of Sports Medicine_ noted that volunteers who took echinacea for four weeks had higher levels of antibodies, and in those who caught respiratory infections, symptoms lasted less than half as long as in those taking a placebo (about 3.4 days, compared to 8.6 days).Astragalus reduced production of several inflammatory markers in mouse cells, according to a 2008 study in the _Journal of Medicinal Food._ In other lab and animal studies, astragalus increased T cell counts in samples with low levels (common in older adults), enhanced antibody responses, and improved white blood cells' ability to eliminate harmful intruders. Additionally, astragalus restored the white blood cell response of older mice to levels normally found in younger mice and partially reestablished immune function in mice with tumors or other immune problems, noted a 2007 study in the _Journal of Ethnopharmacology._ In one of the few human studies, patients with depressed immune systems due to stomach trauma were given astragalus, which helped restore cellular immunity. And in a pair of studies investigating astragalus, echinacea, and licorice, researchers found that each of the supplements boosted immune cell activity for up to seven days (the combination was even more powerful). Look for standardized extracts of astragalus in liquid, capsule, or tablet form. Follow the daily dosing directions on the package. People who are on immune-suppressing drugs to treat cancer or who are organ-transplant recipients should not use astragalus. #### Shorten the Duration of Colds with Echinacea Also called purple coneflower, echinacea (E. purpurea and E. angustifolia) is one of the most-studied herbs for cold prevention. Lab and animal studies indicate it has antiviral and anti-inflammatory properties and activates white blood cells. And while studies in humans show echinacea doesn't prevent colds, it does seem to shorten their duration. A 2007 study in the _International Journal of Sports Medicine_ noted that volunteers who took echinacea for four weeks had higher levels of antibodies, and in those who caught respiratory infections, symptoms lasted less than half as long as in those taking a placebo (about 3.4 days, compared to 8.6 days).Take echinacea at the first sign of a cold, but don't use it continuously for more than ten days.Take one dropperful of tincture in water four times a day, or two capsules of freeze-dried extract four times a day, or follow the package directions.Don't use echinacea if you have an autoimmune condition such as lupus or rheumatoid arthritis.

Except in cases of allergy, sunscreen, and sun avoidance behaviour should be encouraged all year round.Patch and photo patch testing often identify multiple associated contact allergies, especially to Compositae plants (daisy family), perfumes, sunscreen, and colophony (pine trees and Elastoplast).Monochromator testing can implicate UVB, UVA, and visible light.Management includes sun avoidance, sunscreens, and topical or oral corticosteroids when severe. A course of desensitising TL‐01 (narrow‐band UVB) or psoralen with ultraviolet A (PUVA) (oral psoralen plus UVA) prior to sun exposure the following year can be effective. ### Solar urticaria This relatively rare photoallergic skin condition presents with rapid onset of an itchy, stinging erythema and urticaria following between a few seconds to a maximum of around 15 minutes of sun or artificial light exposure. Often patients can recall the exact date and time of the onset of solar urticaria. The rash is transient, resolving within minutes or hours after retreating from the light. UVA and visible wavelengths commonly trigger the reaction but UVB can be responsible too. The reaction is thought to be mediated by a photo‐modified cutaneous antigen. Solar simulator and monochromator light tests confirm the diagnosis. Solar urticaria can be debilitating and difficult to manage. Patients often avoid sunlight and can become reclusive. Sun avoidance, sunscreens with UVA protection, antihistamine, and TL‐01 narrow‐band UVB phototherapy may be helpful. Where conventional treatment has been unsuccessful, anti IgE drugs like omalizumab have been trialled with success. ### Chronic actinic dermatitis (CAD) Middle‐aged or elderly men are most commonly affected by this itchy, flaky, erythematous rash that typically affects the face, posterior and 'V' of neck, and the dorsi of hands (Figure 6.7). CAD is worse in summer but often persists throughout winter too. Monochromator testing can implicate UVB, UVA, and visible light. Patch and photo patch testing often identify multiple associated contact allergies, especially to Compositae plants (daisy family), perfumes, sunscreen, and colophony (pine trees and Elastoplast). Except in cases of allergy, sunscreen, and sun avoidance behaviour should be encouraged all year round.Some may require systemic corticosteroids.Methotrexate, azathioprine, and ciclosporin are sometimes useful too.**Figure 6.7** Chronic actinic dermatitis.### Sunprotection behaviour and sunscreens A patient‐centred approach to sun protection, considering Fitzpatrick skin type, personal skin cancer history, and relevant diagnoses, is crucial.