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The ECG can show ST-segment depression (subendocardial ischemia) (Figure 19–28) purchase arimidex 1 mg with visa, ST elevation (transmural ischemia) (Figure 19–29) cheap 1mg arimidex overnight delivery, or symmetrically inverted (“flipped”) T waves (Figure 19–30) in the area of is- chemia (eg cheap 1mg arimidex with visa, inferior ischemia in II generic arimidex 1 mg online, III order 1mg arimidex overnight delivery, and F; anterior ischemia in V1 to V6; lateral ischemia in I, aVL; anterolateral ischemia in I, aVL, V5, and V6; anteroseptal ischemia in V1, V2, V3, and V4. Can be transmural (ST el- evation early, T-wave inversion, and Q waves late) or subendocardial (ST depression and T- wave inversion without evidence of Q waves). Deep T-wave inversion occurs and then replaces ST-segment elevation, and the T wave may return to normal. Note the ST elevation in helping to de- termine the acute nature of the infarction. ELECTROLYTE AND DRUG EFFECTS Electrolytes Hyperkalemia: Narrow, symmetrical, diffuse, peaked T waves. With severe hyper- kalemia, PR prolongation occurs, the P wave flattens and is lost, and the QRS widens and can progress to ventricular fibrillation (Figure 19–32). Hypokalemia: ST-segment depression with the appearance of U waves (a positive de- flection after the T wave) (Figure 19–33) TABLE 19–1 Localization of Transmural Myocardial Infarction on ECG Location Presence of Q Wave or Reciprocal ST of MI ST-Segment Elevation Depression Anterior V1 to V6 (also poor R-wave II, III, aVF progression in leads V1 to V6)* Lateral l, aVL, V5, V6 V1, V3 Inferior II, III, aVF I, aVL, possibly an- terior leads Posterior Abnormally tall R and T waves in V1 to V3 V1 to V3 Subendocardial No abnormal Q wave. ST-segment elevation in the anterior, lateral, or 19 inferior leads *Normally in V1 to V6, the R-wave amplitude gradually increases and the S wave de- creases with a “biphasic” QRS (R = S) in V3 or V4. With an anterior MI, there will be a loss of R-wave voltage and the biphasic QRS will appear more laterally in V4 to V6, hence the term poor R-wave progression. Hypercalcemia: Short QT interval Hypocalcemia: Prolonged QT interval Drugs Digitalis Effect: Downsloping ST segment Digitalis Toxicity • Arrhythmias. PVCs, bigeminy, trigeminy, ventricular tachycardia, ventricular fibril- lation, PAT, nodal rhythms, and sinus bradycardia. First-degree, second-degree, and third-degree heart blocks Quinidine and Procainamide: With toxic levels, prolonged QT, flattened T wave, and QRS widening 19 II V2 V3 FIGURE 19–33 Leads II, V2, and V3 in a patient with hypokalemia. A U wave is easily seen in V2 and V3, but difficult to distinguish from the T wave in II. MISCELLANEOUS ECG CHANGES Pericarditis: Diffuse ST elevation concave upward and/or diffuse PR depression and/or diffuse T-wave inversion (Figure 19–34) Clinical Correlations. Hypothermia: Sinus bradycardia, AV junctional rhythm, or ventricular fibrillation com- mon. Classically, J point (the end of the QRS complex and the beginning of the ST segment) elevated and an intraventricular conduction delay and a prolonged QT interval possible (Fig- ure 19–35) WPW Syndrome: A preexcitation syndrome caused by conduction from the SA node to the ventricle through an accessory pathway that bypasses the AV node. Classically, a short PR interval occurs along with a delta wave (a delay in the initial deflection of the QRS complex). Clinically, these patients commonly have tachyarrhythmias, such as atrial fibrilla- tion (Figure 19–36). The interactions between different dysfunctional organ systems is complicated and often overwhelming for the student or junior house officer. This chapter describes a system-by-system approach to dealing with the critically ill pa- tient. This ap- proach also allows the physician to integrate abnormalities within each system into a strat- egy for treating the patient as a whole. A complete but concise daily progress note will document this critical evaluation and integration process. ICU PROGRESS NOTE The ICU progress note is a concise, well-organized means of documenting the events of the past 24 h. Include all active problems, major inactive problems, significant past medical his- tory. Include vital signs, pulmonary artery catheter data, ventilator settings, laboratory and culture data. Prophylaxis (ie, DVT, ETOH, stress ulcer, etc) With each of the areas listed in item 9, try to anticipate and avoid complications G. It is written for a trauma patient but can easily be modified for any clinical setting. Sample ICU Progress Note PROBLEM LIST: • S/P MVA • Left pulmonary concussion • Left hemopneumothorax S/P left chest tube • Grade 4 splenic injury S/P splenectomy • Acute renal failure • ARDS • Complex past medical history: Hypertension Gout • Allergic: Morphine sulfate EVENTS OF PAST 24 HOURS: • Increasing FiO2 and PEEP • Renal Consult CURRENT MEDICATIONS • Dopamine • Fentanyl infusion • Ativan infusion • Pepcid 20 • Vancomycin FLOW SHEET DATA: • P 150 (NSR), BP 110/65, I/O: 3400/2210, (continued) 20 Critical Care 391 Sample ICU Progress Note (continued) • PAP 45/20, PCWP 14, CO 3. Chest tube in place • Gastrointestinal: Midline incision healing well, soft, nondistended, no guarding, + bowel sounds • Extremities: Warm well perfused ASSESSMENT: • Neurologic: Stable, continue sedation while on ventilator. Will obtain CXR this AM and wean FiO2 and increase PEEP as tolerated by BP and CO. CARDIOVASCULAR SYSTEM Cardiovascular instability is one of the most common problems faced in the ICU. Under- standing the approach to the evaluation of the cardiovascular system is essential to treating any critically ill patient. Inspection Inspection of the cardiovascular system is divided into three main areas: 20 Jugular Venous Distention • Daily examination of the patient in the ICU should include examination of neck veins to look for JVD.

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To enter of the circles or rings surrounding the center of the a labyrinth is to choose to walk a spiritual path buy arimidex 1mg on line. The labyrinth in Chartres Cathedral cheap arimidex 1mg otc, for exam- In addition to helping people open themselves to the ple cheap 1mg arimidex, is a classical eleven-circuit labyrinth generic 1mg arimidex visa. Three- and nonrational parts of the psyche cheap 1mg arimidex free shipping, labyrinth walking puts seven-circuit classical labyrinths have been constructed 1174 GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 in many parts of the United States, while one labyrinth in Precautions Denmark has 15 circuits. There are no special precautions needed for labyrinth walking other than allowing sufficient time for the experi- Walking the labyrinth ence. Most people find that the walk takes about 45 min- The actual procedure of labyrinth walking is divided utes or an hour, but some take two to three hours to com- into three phases or stages: the journey inward, a pause plete their journey. It is best to plan a labyrinth walk for a for prayer or meditation at the center, and the return jour- day or evening without a tight time schedule. There are no rules or guidelines for the pace or speed of labyrinth walking, although participants are asked to Side effects be respectful of others who may prefer a slower pace, and to move around them as gently as possible. Some people No physical or psychological side effects have been choose to dance, run, crawl on their hands and knees, or reported from labyrinth walking as of 2004. Labyrinths based on the Chartres model have six “petals” or semicircular Little research has been done within the mainstream spaces surrounding the center, which allows several peo- or alternative medical communities on labyrinth walking ple to remain for a few minutes to pray, contemplate, or in comparison to other forms of treatment. Smaller labyrinths may have room for only one however, it appears to be generally accepted as a form of person at a time in the center, and it is considered courte- mind-body therapy or spiritual practice that has few if ous to remain there only briefly. Some communities have Some published guides to labyrinth walking include also built outdoor labyrinths for the general public. In meditations to be used for labyrinth walking during the early 2000s, health spas and tourist resorts have pregnancy, or for blessing ceremonies at different sea- added labyrinths to their facilities in order to attract visi- sons of the year. Preparations Training & certification Although one need not be a member of any specific The Labyrinth Society (TLS), which was founded in faith or religious tradition to participate in labyrinth 1999, hosts an annual meeting that includes workshops walking, spiritual preparation is considered an important and speakers on labyrinth construction as well as the part of the activity. TLS does not, and relatively unstructured, most participants find that a however, offer licensing or training programs as of 2004; period of quietness to focus their attention on their jour- its membership code of ethics states, “Membership or ney is essential. Resources Participants are advised to wear comfortable shoes BOOKS and clothing for labyrinth walking so that they will not Artress, Lauren. Walking A Sacred Path: Rediscovering the be distracted by physical discomfort or concerns about Labyrinth as a Spiritual Tool. The Way of the Labyrinth: A Powerful Meditation woven into a rug; thus it is a good idea to bring along a for Everyday Life. New York: Penguin Compass Books, pair of clean cotton socks or soft-soled slippers. Description Left brain—The left cerebral hemisphere, which controls activity on the right side of the body in Not all products used in alternative healing come from humans. Lachesis is the venom of the bushmaster snake, for language use and mathematical calculation; it Lachesis mutus. A maze of Central and South America, growing to a length of 12 is considered a left-brain puzzle. It is the largest poisonous pit viper in the Mantra—A sacred word or formula that is repeat- Western hemisphere, and second in size in the world ed as an incantation to focus the mind and spirit, only to the king cobra. Maze—A network of paths or passages intended A large bushmaster can have fangs more than 1 in to confuse, with numerous choices at different (2. The bushmaster is also called the surucucu which controls activity on the left side of the body (sometimes spelled surukuku). It is associated with spatial and non- verbal concepts, intuition, emotions, and creativi- General use ty. Labyrinth walking is thought to stimulate the Homeopathic medicine operates on the principle right brain. A true same symptoms as the disease, while also working in labyrinth is unicursal in design. In opposition to traditional medicine, the law of infini- tesimals states that the lower a dose of curative, the more Schaper, Donna, and Carole Ann Camp. Frey, PhD • nervous system complaints 1176 GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 • circulatory complaints • varicose veins All these complaints exhibit certain patterns or • nose bleeds modalities that indicate they should be treated with lach- • slow-to-heal, bluish wounds esis. These symptoms may: • a throbbing sensation in various parts of the body • worsen after sleep and upon awakening • weak, irregular rapid pulse • worsen in the spring • palpitations • worsen after drinking hot beverages, taking hot baths, • fainting or direct exposure to the sun The main nervous system complaint treated by lach- • worsen if touched or if the body is constricted by tight esis is cluster headaches. These are headaches that pro- clothes duce pulsating waves of pain, often on the left side, or • worsen with alcohol consumption beginning on the left side then moving to the right. They • produce surging waves of pain often precede menstruation and improve once menses begins. Petit mal seizures and angina are also treated • move from the left side to the right side of the body with lachesis.

As the pregnancy continues generic arimidex 1mg on-line, a low be cautioned that a diagnosis of MGS often cannot be amount of amniotic fluid becomes apparent buy arimidex 1mg mastercard. Prognosis can vary if the baby kidneys make the abdomen appear and measure larger has atypical signs of MGS or if the baby has a different than usual purchase arimidex 1mg with amex. Elective termination of affected pregnancies white on an ultrasound instead of the usual gray color arimidex 1 mg without prescription. Measurement of the alpha-fetoprotein (AFP) level Prognosis from either maternal blood or amniotic fluid may help to detect an encephalocele (although most encephaloceles The prognosis for MGS is quite poor generic arimidex 1 mg on line. Those that are born living usu- measured in amniotic fluid after about 12 weeks of preg- ally die shortly after birth in the first hours, days, or nancy and in maternal blood after about 15 weeks of weeks of life. AFP elevation in either test increases the (underdeveloped lungs), infection (opening in the skull), chance of an encephalocele or other abnormality in the or organ failure (decreased function of kidneys and liver). MGS is variable and there have been a couple reports of 728 GALE ENCYCLOPEDIA OF GENETIC DISORDERS infants with milder symptoms living longer. One infant for normal growth and development, inhibits the work of with MGS lived until four months of age. The clinical signs and to seven months of age after surgical repair of a small symptoms of Menkes syndrome are a direct result of encephalocele. These two case reports show that longer Approximately 90–95% of patients with Menkes survival is rare but possible because of the variable syndrome have a severe clinical course. The mildest Resources presentation is now known as occipital horn syndrome PERIODICALS (OHS), which is allelic to Menkes syndrome: both con- Salonen, R. Mutations responsible for OHS primarily cause connec- ORGANIZATIONS tive tissue abnormalities and have significantly milder Meckel-Gruber Syndrome Foundation. Amie Stanley, MS Genetic profile Mediterranean anemia see Menkes syndrome is an X-linked recessive condi- Beta-thalassemia tion. The gene, which was identified in 1992, is located on the long arm of the X chromosome at band 13. It is extremely unusual for a female (with two MCAD deficiency X chromosomes in her cells) to be affected, although it has been reported. Males, who have only one X chromo- Melnick-Fraser syndrome see some, make up the overwhelming majority of patients. There is usu- ally a negative family history, or no other affected male family members. Definition On the other hand, the remaining two-thirds of Menkes syndrome is a sex-linked recessive condi- affected males are born to carrier mothers. Often, there is tion characterized by seizures and neurological deteriora- a family history of one or more affected male relatives (e. Affected males are often diagnosed within the are normal but face a risk of passing on the gene for first few months of life and die in early childhood. A carrier mother has a 25% risk of having an affected son, 25% risk of having Description an unaffected carrier daughter, 25% risk of having a nor- Menkes syndrome is also known as Menkes disease mal son, and a 25% risk of having a normal, non-carrier and “kinky hair syndrome. Their cells are able to birth but, by the age of several months, developed take in copper but the metal is unable to leave the cell and seizures and began to regress in their physical skills. It is Most symptoms of Menkes syndrome, such as skeletal now clear that this lack of copper, an essential element changes and abnormal hair, may be explained by the loss GALE ENCYCLOPEDIA OF GENETIC DISORDERS 729 of specific enzymes. However, the reasons for the brain Other degeneration are still not entirely clear. Unfortunately, • Abnormal hair, including the eyelashes and eyebrows almost every family studied has had a unique mutation. This makes genetic testing difficult, particularly if the • Light, even for family, skin and hair coloring (hypopig- mutation in the family has not yet been determined. On mag- Signs and symptoms nified inspection, it is short, sparse, coarse, and twisted. Infants with classical Menkes syndrome appear nor- It has been likened to the texture of a steel wool cleaning mal at birth and continue to develop normally for roughly pad. It shows an unusual orientation, referred to as pili the first eight to ten weeks of life. It is usually to three months of age, affected infants begin to lose pre- fragile and breaks easily. The hair of all affected individ- viously attained developmental milestones, such as head uals shows these characteristic changes; it is likewise control and a social smile.

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Sonsalla DRUG LIST GENERIC NAME PAGE GENERIC NAME PAGE Amantadine 370 Pergolide 369 Benztropine 370 Pramipexole 369 Biperiden 370 Procyclidine 370 Bromocriptine 369 Rivastigmine 371 Carbidopa 368 Ropinirole 369 Donepezil 371 Selegiline 369 Entacapone 370 Tacrine 371 Galanthamine 371 Tolcapone 370 Levodopa 367 Trihexyphenidyl 370 Neurodegenerative diseases are a group of disor- normal movements resulting from the loss of a specific ders characterized by neuronal loss and generally an ac- subset of striatal neurons; (4) amyotrophic lateral scle- cumulation of insoluble intracellular or extracellular rosis (ALS), in which progressive weakness and muscle material in certain brain regions. Most neurodegenera- atrophy are due to degeneration of spinal, bulbar, and tive disorders are of unknown etiology, affect the eld- cortical neurons. How- forms of these disorders; however, most are sporadic oc- ever, drugs used in the treatment of neurodegenerative currences (idiopathic) with genetic predisposition, envi- disorders only treat symptoms and do not cure or alter ronmental factors, and aging contributing as risk factors. It generally affects the elderly scribed as jerky resistance that has been likened to the and is estimated to afflict more than 1% of individuals movement of a cogwheel (cogwheel rigidity), is also an over the age of 65. Bradykinesia, an ial forms of parkinsonism with an autosomal dominant extreme slowness of movement, is the most disabling pattern of inheritance. These genes encode kinesia results in a typical stooped posture when the for -synuclein, a protein found in abundance in vesi- person is standing or walking and a characteristic cles and synaptic regions, and for parkin and ubiquitin shuffling gait marked by the absence of normal arm- carboxy-terminal hydroxylase, both of which are in- swinging movements. Inability to swallow leads to drooling, while bradyki- specific entities, such as viral inflammation (e. Orthostatic hypotension may also be ob- trauma, stroke, and poisoning by manganese, carbon served and may complicate therapy. Cognitive dysfunc- monoxide, pesticide, or 1-methyl-4-phenyl,-1,2,3,6-tetra- tion and dementia are also seen in a small percentage of hydropyridine (MPTP). Relatively smooth In postmortem examination of tissue, the substantia functioning of motor control is maintained until neu- nigra is readily identifiable because of the dark pigmen- ronal loss is such that it causes an 80% reduction of tation in the neurons that is the result of the accumula- dopamine in the striatum. At this time, clinical symptoms tion of neuromelanin, a substance whose neurochemical appear and then worsen with increasing neuronal loss. Lewy bodies are com- is, iatrogenic parkinsonism, which often is a complica- posed of many cytoskeleton and other proteins, includ- tion of antipsychotic therapy, especially following the ing -synuclein, ubiquitin, and synaptophysin. It is not use of the butyrophenone and phenothiazine drug clear whether the formation of these inclusions con- classes (see Chapter 34). Unlike idiopathic parkinson- tributes to neuronal degeneration or they are merely a ism, striatal content of dopamine is not reduced by ad- byproduct of degenerating neurons. In contrast, they produce a functional decrease in dopamine activity by blocking Basal Ganglia Anatomy the action of dopamine on postsynaptic dopamine re- ceptors. They are composed of several brain re- gions, including the neostriatum and the substantia ni- Clinical Findings gra (Fig. The are tremor, rigidity, and bradykinesia, although the time dopamine neurons originate in the substantia nigra pars of onset and the relative severity of each symptom may compacta and project to the neostriatum, where they differ in individual patients. Tremors are often unilat- synapse on the input glutamatergic terminals and on eral in onset, present at rest, and cease during voluntary striatal projection neurons that use the neurotransmit- movement. Several brain regions and numerous neurotransmitters are involved with the function and regulation of neuronal activity within the basal ganglia. The direct pathway (2) the striatum to SNpr) becomes less active, whereas the indirect pathway (3) striatum to globus pallidus to STN to SNpr) increases in activity. The consequence is an enhanced activation of SNpr outflow neurons (4), which exert an overall reduction of the thalamic–cortical pathway (5). DA, dopamine; Glu, glutamate, excitatory transmitter; GABA, - amino butyric acid, inhibitory transmitter; ACh, acetylcholine, excitatory intrastriatal transmitter. GP, globus pallidus; SNpc, substantia nigra pars compacta; SNpr, substantia nigra, pars reticulate; STN, subthalamic nucleus. Dopamine is a catecholamine (see Chapter 10 and The inability of the neurons to eliminate the oxidative Fig. Dopamine actions on D3 4 1 receptors ex- source of oxidative stress may be dopamine metabolism ert an excitatory effect, whereas the actions of (Fig. The stantia nigra created by the loss of dopamine actions loss of striatal dopamine produces an imbalance in in- within the striatum could lead to excitotoxicity that is formation processing in the neostriatum that modifies mediated by glutamate. Also impor- tant in neural transmission are the striatal interneurons Therapy of Parkinsonism that are found within the confines of the striatum, that use the excitatory neurotransmitter acetylcholine, and Since there is no cure for parkinsonism, the aim of phar- that modulate the activity of striatal output neurons. This is obtained through the use of drugs that either in- crease dopaminergic actions or diminish neuronal out- Possible Mechanisms flow from the striatum. These drugs include levodopa, of Neurodegeneration which increases brain dopamine levels; dopamine ago- The mechanisms responsible for the degeneration of nists, which directly stimulate dopamine receptors; dopamine neurons are not known, but hypotheses in- monoamine oxidase (MAO) inhibitors, which prevent clude effects such as oxidative stress and excitotoxicity. Dopamine itself does not cross the Levodopa and Carbidopa blood-brain barrier and therefore has no CNS effects.

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