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By Q. Onatas. University of Southern Maine. 2018.

The points can be pressed in a circular manner Mind/body approaches with the thumbs buy cheap alendronate 35 mg online, while the head is allowed to hang for- ward and the patient takes slow buy generic alendronate 35 mg online, deep breaths order 70mg alendronate fast delivery. Reflexolo- Mind/body medicine has demonstrated that psy- gy also uses particular acupressure points on the hands chological factors play a complex role in asthma alendronate 70 mg generic. Mind/body tech- niques strive to reduce stress and help asthma sufferers Other treatments manage the psychological component of their condition proven 35 mg alendronate. Erik Peper at the Institute for Holis- Aromatherapists recommend eucalyptus, lavender, tic Healing Studies in San Francisco used biofeedback, rosemary, and chamomile as fragrances that promote a treatment method that uses monitors to reveal physio- free breathing. In Japan, a common treatment for asthma logical information to patients, to teach relaxation and is administering cold baths. A 1993 study by Kaiser Perma- ferers as well, as they strive to open and increase circula- nente in Northern California worked with 323 adults tion in the chest area. Half the patients got Arsenicum album, Kali carbonicum, Natrum sul- standard care while the other half participated in support phuricum, and Aconite. The support group patients had cut their asthma- related doctor visits in half after two years. Some other Allopathic treatment mind/body techniques used for asthma include relax- ation methods, meditation, hypnotherapy,, mental Allopaths recommend that asthma patients should imaging, psychotherapy, and visualization. Montelukast sodium (Singu- blesome symptoms, to maintain lung function as close to lair) is a drug taken daily that is used to help prevent normal as possible, and to allow patients to pursue their asthma attacks rather than to treat an acute attack. The 2004, the FDA approved an oral granule formula of Sin- best drug therapy is that which controls asthmatic symp- gulair for young children. In a typical course of immunotherapy, increasing The chief methylxanthine drug is theophylline. It amounts of the allergen are injected over a period of may exert some anti-inflammatory effect and is especial- three to five years, so that the body can build up an effec- ly helpful in controlling nighttime symptoms of asthma. There is a risk that this treatment When, for some reason, a patient cannot use an inhaler may itself cause the airways to become narrowed and to maintain long-term control, sustained-release theo- bring on an asthmatic attack. The blood levels of the astic about immunotherapy, although some studies have drug must be measured periodically, as too high a dose shown that it reduces asthmatic symptoms caused by ex- can cause an abnormal heart rhythm or convulsions. They are the drugs of Managing asthmatic attacks choice for relieving sudden attacks of asthma and for A severe asthma attack should be treated as quickly preventing attacks from being triggered by exercise. It is most important for a patient suffering an Some agonists, such as albuterol, act mainly in lung cells acute attack to be given extra oxygen. These necessary to use a mechanical ventilator to help the pa- drugs generally start acting within minutes, but their ef- tient breathe. A course of centration of albuterol was approved by the FDA for steroid therapy, given after the attack is over, will make a children ages two to 12. Steroids are drugs that resemble natural body hor- Long-term allopathic treatment for asthma is based mones. They block inflammation and are effective in re- on inhaling a beta-receptor agonist using a special in- lieving symptoms of asthma. Patients must be instructed in inhalation for a long period, asthma attacks become less proper use of an inhaler to be sure that it will deliver the frequent as the airways become less sensitive to aller- right amount of drug. Steroids are the strongest medicine for asthma, and for several weeks or months, it is worth trying to cut can control even severe cases over the long term and down on drug treatment, but this tapering must be done maintain good lung function. The last drug added should be the first to be cause numerous side effects, including bleeding from the reduced. Patients should be seen every one to six stomach, loss of calcium from bones, cataracts in the months, depending on the frequency of attacks. Patients using steroids for treatment at home, rather than in a hospital, makes for lengthy periods may also have problems with wound minimal delay and helps the patient to gain a sense of healing, may gain weight, and may suffer mental prob- control over the disease. Besides being how to monitor their symptoms so that they will know inhaled, steroids may be taken by mouth or injected, to when an attack is starting. They Leukotriene modifiers are among a newer type of also should have a written plan to follow if symptoms drug that can be used in place of steroids, for older chil- suddenly become worse, including how to adjust their dren or adults who have a mild degree of persistent asth- medication and when to seek medical help. They work by counteracting leukotrienes, which are tense treatment is necessary, it should be continued for substances released by white blood cells in the lung that several days.

The D1-receptor increases cyclic with the potency of individual agents to bind to this re- adenosine monophosphate (cAMP) formation by stim- ceptor; (3) some postmortem studies have reported in- ulation of dopamine-sensitive adenylyl cyclase; it is lo- creases in dopamine receptor density in brains of cated mainly in the putamen discount alendronate 35mg overnight delivery, nucleus accumbens cheap alendronate 70mg line, and schizophrenics who were not treated with antipsychotic olfactory tubercle purchase alendronate 35mg with mastercard. The other member of this family is drugs; and (4) clinical response to antipsychotic drug the D5-receptor generic alendronate 70 mg visa, which also increases cAMP but has a treatment is correlated with a decrease in homovanillic 10-fold greater affinity for dopamine and is found pri- acid generic alendronate 70mg mastercard, a primary dopamine metabolite, in cerebrospinal marily in limbic regions. If an abnormal- The D2-dopaminergic receptor decreases cAMP ity of dopamine physiology were solely responsible for production by inhibiting dopamine-sensitive adenylyl the pathogenesis of schizophrenia, antipsychotic drugs cyclase and opens K channels but can also block Ca would do a much better job in treating patients. It is located both presynaptically and postsyn- they are only partially effective for most and ineffective aptically on neurons in the caudate putamen, nucleus for some patients. Another member of diminished glutamatergic activity also plays a role in this family is the D3-receptor, which also decreases 34 Antipsychotic Drugs 399 cAMP formation but which has much lower expression, butyrophenone haloperidol (Haldol) is structurally dis- primarily in limbic and ventral striatal areas. The D4- tinct from the two preceding groups, offering greater receptor also inhibits adenylyl cyclase and is found in potency and fewer autonomic side effects. The binding affinity of an- diazepine clozapine (Clozaril) bears some structural re- tipsychotic agents to D2-receptors is very strongly corre- semblance to the phenothiazine group but causes little lated with clinical antipsychotic and extrapyramidal po- extrapyramidal toxicity. This discrepancy in the latency to therapeutic effect has been Pharmacokinetics hypothesized to be linked to drug-induced changes in dopaminergic activity: after initiation of therapy, Most of the antipsychotics are readily but incompletely dopamine turnover increases, but after continued an- absorbed, and many undergo significant first-pass me- tipsychotic treatment, tolerance develops and dopa- tabolism. This downward ad- thioridazine is in the range of 25 to 35%, while that of justment of dopaminergic activity is consistent with the haloperidol, which is less likely to be metabolized, has an decreased plasma concentrations of the dopamine oral bioavailability of about 65%. The antipsychotics are metabolite homovanillic acid, an observation that cor- highly lipid soluble and are about 95% bound to pro- relates temporally with the clinical response to drug teins. Until recently the and longer acting, and thus can be administered par- main focus in drug development was to discover agents enterally at intervals up to 3 weeks. The main routes of that were more potent and selective in blocking D2- metabolism are mediated by hepatic oxidative microso- receptors. Some metabolites, as clozapine and risperidone, have a weaker affinity for such as 7-hydroxychlorpromazine, retain measurable ac- D2-receptors and bind more strongly to 5-HT2 (5- tivity, but this effect is not considered to be clinically im- hydroxytryptamine) serotonergic receptors. Thus, lesser portant; an exception to this observation is the major activity at the D2-receptor relative to other transmitter metabolite of thioridazine, which is more potent than receptors may diminish untoward side effects such as the parent drug. However, the antipsychotics less potent antipsychotics are lower after several weeks also have variable antagonist actions at muscarinic, of treatment at the same dose, it is believed that these -adrenergic, and histaminergic receptors in brain and compounds may weakly induce their own metabolism. The antimuscarinic activities cause Also, the ability to metabolize and eliminate these drugs blurred vision, dry mouth, and urinary retention and has been shown to diminish with age. The antihistaminergic Pharmacological Distinctions actions of these drugs probably contribute to drowsi- ness and sedation also. Despite differences in potency, all commonly used an- tipsychotic drugs have approximately equal efficacy in equivalent doses. PHARMACOLOGY Prototype or representative members of the antipsy- Phenothiazines are classified on the basis of their chem- chotics are arranged in decreasing order of potency in istry, pharmacological actions, and potency. Generally, these trends are reversed as potency are generally more potent and pharmacologically se- decreases. For example, chlorpromazine and 400 IV DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM TABLE 34. Haloperidol can result from the use of the low-potency phenothi- and pimozide (Orap) act mainly on D2-receptors (ex- azines. Mean arterial pressure, peripheral resistance, trapyramidal toxicity) with negligible activity at D1- and stroke volume are decreased, while pulse rate is in- receptors. Abnormal electrocardiograms (ECGs) have (Zyprex) show marked clinical differences from the been observed, especially following thioridazine admin- other drugs. These findings include prolongation of the QT H1-receptors (autonomic and sedative side effects) than interval and abnormal configurations of the ST segment to either D2 (low extrapyramidal activity) or D1 sites. These effects are readily reversed upon drug receptors, retaining high potency with lesser potential withdrawal. Current drug development is directed toward a search for atypical antipsychotics like clozap- ine that have a broad spectrum of effects on other neu- CLINICAL USES rotransmitter receptors. The principal goals for the Other Pharmacological Actions management of a chronic schizophrenic disorder are the Antipsychotic drugs produce shifts in the pattern of minimizing of symptoms and the prevention of exacer- electrographic (EEG) frequencies, usually slowing them bations. This slowing is sometimes their ability to reduce the rate of relapse in the chronic focal or unilateral, which may pose diagnostic problems, condition by about two-thirds to three-quarters com- but the frequency and amplitude changes are readily ap- pared to no treatment.

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These include machine learning cheap 70 mg alendronate with mastercard, case-based reasoning alendronate 35 mg visa, genetic algorithms cheap 70mg alendronate mastercard, neural nets buy 70mg alendronate free shipping, intelligent agents buy alendronate 35 mg with mastercard, and stochastic models of natural language understanding, as well as the emerging compu- tation and artificial life. The central dogma in healthcare research is to ensure the patient to be the principle focus, from diagnosis and early intervention to treatment and care. Especially with the advent of the Internet, clinical knowledge management is a topic of paramount importance. Bali and his authors present in the book a number of discussions of the available technolo- gies to stimulate the future expansion. Knowledge repositories are increasingly getting larger in size and complex in structure, as seen for example, in the hospital information systems. Such massive data explosions require efficient knowledge management strat- egies, including the critical need to develop knowledge retrieval and data mining tools. The latter mostly consist of appropriate software-based techniques to find difficult-to- see patterns in large groups of data. The effective analysis and interpretation of such large amounts of data collected are being enhanced by applying machine vision tech- niques while at the same time we are looking at machine learning mechanisms to pro- vide self-learning instructions between processes. These are all some of the modern day innovations that are providing the capabilities to extract new knowledge from the existing knowledge. Healthcare is benefitting immensely from these applications, mak- ing it possible for healthcare professionals to access medical expert knowledge where and when needed. The design principles for the management of knowledge sharing and its global impact are a complex mix of issues characterized by varying cultural, legal, regulatory, and sociological determinants. What is especially important is to improve the overall health of the population by improving the quality of healthcare services, as well as by controlling the cost-effectiveness of medical examinations and treatment (Golemati et al. Professor Swamy Laxminarayan, Fellow AIMBE Chief of Biomedical Information Engineering Idaho State University, USA s. MARK TWAIN The key to the success of the clinical healthcare sector in the 21st century is to achieve an effective integration of technology with human-based clinical decision-making pro- cesses. By doing so, healthcare institutions are free to disseminate acquired knowl- edge in a manner that ensures its availability to other healthcare stakeholders for such areas as preventative and operative medical diagnosis and treatment. This is of para- mount importance as healthcare and clinical management continues its growth as a global priority area. A few basic statistics: the average physician spends about 25 percent of his or her time managing information and is required to learn approximately two million clinical specif- ics (The Knowledge Management Centre, 2000); in the UK, each doctor receives about 15 kg of clinical guidelines per annum (Wyatt, 2000); up to 98000 patients die every year as a result of preventable medical errors—in the USA, it is estimated that the financial cost of these errors is between $37. To further compound these pressures, biomedical literature is doubling every 19 years. These statistics illustrate how difficult it is for healthcare institutions and stakeholders to successfully meet information needs that are growing at an exponential rate. Knowledge Management (KM) as a discipline is said not to have a commonly accepted or de facto definition. However, some common ground has been established which covers the following points. KM is a multi-disciplinary paradigm (Gupta, Iyer & Aronson, 2000) that often uses technology to support the acquisition, generation, codification, and transfer of knowledge in the context of specific organisational processes. Knowl- edge can either be tacit or explicit (explicit knowledge typically takes the form of com- xii pany documents and is easily available, whilst tacit knowledge is subjective and cogni- tive). As tacit knowledge is often stored in the minds of healthcare professionals, the ultimate objective of KM is to transform tacit knowledge into explicit knowledge to allow effective dissemination. The definition of KM by Gupta, Iyer, & Aronson (2000) is one such description amongst many—whichever KM definition one accepts, one un- movable truth remains: healthcare KM has made a profound impact on the international medical scene. Of course, the notion and concept of management per se is nothing new in the clinical environment. Innovations and improvements in such disciplines as organizational be- havior, information technology, teamwork, informatics, artificial intelligence, leader- ship, training, human resource management, motivation, and strategy have been equally applicable and relevant in the clinical and healthcare sectors as they have been in others. Clinicians and managers have used many of these disciplines (in combination) many times before; they may have, inadvertently and partially, carried out knowledge management avant la lettre. Proactive and considered use of these previously unintentionally used KM compo- nents and techniques would reap enormous clinical and organizational benefits. Modernization and change on such a massive scale is similar to the choices faced following the purchase of a nearly derelict house. Or is the work so large that it would be more efficient to pull down the existing structure and start from scratch?

They often target global outcomes such as vitality order 70 mg alendronate visa, functionality and overall risk reduction rather than specific diseases purchase alendronate 35 mg online. Such a whole practice approach is not evaluable in the current gold standard scientific model of the single-agent double-blind randomized placebo-controlled trial with a well-defined disease endpoint buy generic alendronate 70mg line, and is difficult to study mechanistically alendronate 70 mg low cost. Thus cheap alendronate 70 mg with visa, the appropriate patients for a particular therapy may be impossible to identify except through therapeutic trial. Fortunately, because of the relatively high safety profile and low cost of many naturopathic treatments, there are lower barriers to therapeutic trials than with some drugs or operations. Combination treatment increases the response rate, as different agents acting by different mechanisms are more likely to find responses in a diverse population presenting with a similar symptom picture. Experimental study of the whole practice of naturopathic medicine with its general approach rather than single substances applied to a specific disease is as vanishingly rare as it is for studies of the entire practice of other nondominant whole systems of practice. Nevertheless, it is in such global study where their true benefit is likely to be found. The absence of such research is partly because the scientific methodologies used to evaluate such systems of medicine are not well 82–86 established or well accepted. Even in conventional medicine, the implicit algorithms of treatment that are the foundation of everyday clinical practice are rarely evaluated in scientific studies. Critical to the proper scientific evaluation of naturopathic medicine is the implementation of study designs that are capable of evaluating a complex approach to treatment which include the characteristics of individualized and multimodality treatments. With the inception of the National Center for Complementary and Alternative Medicine at the National Institutes of Health (NIH) in 1997 and with subsequent funding and the stimulated interest from Naturopathic medicine in neurological disorders 167 other NIH institutes, scientists and clinicians, scientifically sound methodologies are beginning to be developed and accepted to evaluate the safety and efficacy of holistic 82–85 systems of medicine. This means that an increasing number of studies on the safety and efficacy of such whole systems of practice can be expected in the future. Plantation work and risk of Parkinson disease in a population-based longitudinal study. Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. Medication cost reduction in children on the ketogenic diet: data from a prospective study. Food allergy and adult migraine: doubleblind and mediator confirmation of an allergic etiology. Histamine-free diet: treatment of choice for histamine-induced food intolerance and supporting treatment for chronic headaches. Nutritional factors in the aetiology of multiple sclerosis: a case-control study in Montreal, Canada. A randomized study of low fat diet with ω-3 fatty acid supplementation in patients with relapsing-remitting multiple sclerosis. Effect of dietary docosahexaenoic acid and phosphatidylcholine on maze behavior and fatty acid composition of plasma and brain lipids in mice. Docosahexaenoic acid supplementation improves the moderately severe dementia from thrombotic cerebrovascular diseases. Effects of creatine supplementation on exercise performance and muscular strength in amyotrophic lateral sclerosis: preliminary results. Two double-blind placebo-controlled pilot studies of eicosapentaenoic acid in the treatment of schizophrenia. Schizophr Res 2001; 49:243–51 Naturopathic medicine in neurological disorders 169 38. Evaluation of the effects of L-acetylcarnitine on senile patients suffering from depression. Melatonin in epilepsy: first results of replacement therapy and first clinical results. Melatonin effect on seizures in children with severe neurologic deficit disorders. Diet enriched with omega-3 fatty acids alleviates convulsion symptoms in epilepsy patients. Elevated polyunsaturated fatty acids in blood serum obtained from children on the ketogenic diet. Anticonvulsant effect of polyunsaturated fatty acids in rats, using the cortical stimulation model. L-5-Hydroxytryptophan in the prophylaxis of chronic tension-type headache: a double-blind, randomized, placebocontrolled study. MRI and neuropsychological improvement in Huntington disease following ethyl-EPA treatment. Melatonin in medically ill patients with insomnia: a double-blind, placebo-controlled study.

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