text:
visitor info
explore the ruins
photo gallery
explore the baths
read a 1906 program
Welcome to a hallowed place in San Francisco, modern ruins on the edge of the continent. Crashing waves, labyrinthine structures, wild lilies, cliff-lodged cypress trees reaching towards the ocean, a thundering cave, and but a single signpost warning you of getting thrown off rocks and dying.
What's New
The Ruins
Beyond the striking location and colorful history, it's especially remarkable for such a place to exist in a country where few structures past their best days survive.
It's allowed to be harrowing and wild in a time and place where shampoos carry warnings and most interesting things are cordoned off for your protection. Here's the playground for those who love crumbling stone clubhouses, jutting pipe monkeybars, stairways that lead you off cliffs and shifting sandboxes that get swallowed by surf.
The GGNRA includes the Marin Headlands, Point Reyes National Seashore, Angel Island, Alcatraz, and other sensory feasts.
The Baths
Sutro Baths opened March 14, 1896 with a $1 million pricetag an extravagant public bathhouse envisioned and developed by the eccentric one-time mayor of San Francisco, Adolph Sutro. After working its way through its many lives (Playland, 1960s ice rink, etc..) burned down while being demolished on June 26, 1966. In 1980 the Golden Gate National Recreation Area (GGNRA) bought the land for $5,500,000.
"... rival in magnitude, utility and beauty, the famous abluvion resorts of Titus, Caracalla, Nero or Diocletian...
"Five hundred dressing rooms ... spacious elevators and broad staircases ... pavilions, balustrades, promenades, alcoves and corridors adorned with tropical plants, fountains, flowers, pictures, ... the collected treasure of foreign travels... a portico with four Ionic columns and pilasters which lead to a noble staircase, wide, gradual of ascent, bordered with broad-leaved palms, the flowering pomegranate, fragrant magnolias ... [touching] the very rim of the reveling waves.
Eugenia Kellogg Holmes, Adolph Sutro: A Brief Story of a Brilliant Life
This site is maintained by Jill Corral. For official queries, please contact the National Park Service's
Presidio Visitor Center
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MAXILLARY PREMOLARS (buccal) L
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L Maxillary right first premolar
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Part 1 | Comparative Tooth Anatomy
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a C.
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Mesial root is wide faciolingually with blunt tip Crown is wider faciolingually
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b. Surface Morphology of Primary Incisors from the Labial View Labial surfaces of maxillary central incisors are smooth; usually, there are no depressions. Mandibular incisors are also relatively smooth (but may have very shallow depressions on their labial surfaces in the incisal third). c. Root-to-Crown Proportion of Primary Incisors from the Labial View Prior to root resorption, all primary incisor roots are much longer relative to the crown length than on secondary incisors (Appendix 9f). Primary incisor roots are about twice the length of the crown. The roots of maxillary lateral incisors appear proportionally even longer. On primary extracted or shed teeth, there is usually some root resorption (evident in Fig. 6-9B). Often the entire root is gone. 2. PRIMARY INCISORS FROM THE LINGUAL VIEW Refer to Figure 6-10. a. Cingula of Primary Incisors from the Lingual View The cingula of primary maxillary central incisors are often proportionally large, so that prominent lingual fossae are limited to only the incisal and middle thirds of the lingual surface. The lingual surfaces of mandibular incisors have a more subtle cingulum and a subtle lingual fossa.
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Probe locks horizontally; does not catch furcation roof Probe hooks onto roof of furcation and must be rotated to disengage, but probe cannot be passed to another tooth aspect Periodontal literature reviews: a summary of current knowledge. Chicago: The American Academy of Periodontology, 1996. Proceedings of the 1996 World Workshop in Periodontics, 1996. The Annals of Periodontology. Chicago: The American Academy of Periodontology, 1996.
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Sectioned teeth showing pulp cavity shapes relative to the external tooth surface. A. Mesiodistal section of a maxillary central incisor showing only two of its three pulp horns. B. Faciolingual section of a maxillary incisor. C. Faciolingual section of a maxillary first premolar with two roots and two obvious pulp horns, one under each cusp. D. Faciolingual section of mandibular first premolar. E. A mandibular first molar sectioned mesiodistally through its three buccal cusps.
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A. Radiograph of a mandibular left second premolar showing the shape of the root canal as though sectioned mesiodistally. B. Radiograph of a maxillary first premolar reveals the two root canals (filled with a filling material that makes the canals appear whiter). This is a similar view as a premolar sectioned mesiodistally. C. Maxillary first premolar sectioned faciolingually, mesial side removed (young tooth). The curvature of the tips of the roots prevented cutting the root canals in one plane. The two pulp horns are sharp; there is little, if any, secondary dentin; and the floor of the pulp chamber is rounded. The buccal pulp horn is considerably longer than the lingual horn. Notice the floor of the pulp chamber, which has two openings, one for each canal. Also, note the constriction of the pulp chamber near the cervix.
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F. I Average hinge opening = 22.4 mm
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elsewhere in the body could also be used to reduce pain in the muscles of mastication, and these include applying ice for several minutes followed by moist heat to relax muscles. Jaw muscle exercise may also be helpful once the muscle pain has been eliminated.
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A. ESTABLISH AN OUTLINE FORM When caries extends close to the pulp, it may be advisable to protect the vital tissues of the tooth (odontoblasts, blood vessels, and nerves within the pulp) with dental liners and cement bases prior to placing the final restoration (Fig. 10-9). Various dental materials have been developed for this purpose. When used in the appropriate combination and in the correct order, they can prevent bacterial penetration, provide thermal insulation, sedate the pulp, or stimulate the production of secondary dentin.
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Models of conservative class II amalgam preparations. A. Occlusal views: Left: MO-A (mesio-occlusal amalgam) preparation on tooth No. 30. Left-center: MO-A, DO-A (mesio-occlusal and disto-occlusal amalgam) preparation on tooth No. 3 with the oblique ridge intact. Right-center: MOD-A (mesio-occlusodistal amalgam) preparation on tooth No. 5. Right: DO-A (distoocclusal amalgam) preparation on tooth No. 28 with the transverse ridge intact. B. Proximal views of class II amalgam preparations. Left: MOD-A preparation on tooth No. 4. Right: MO-A preparation on tooth No. 30. Note the convergence of the buccal and lingual walls toward the occlusal for retention and resistance form. When the decay process has progressed deeper and wider, the prepared walls by necessity will be farther apart than these. C. Conservative slot preparation involving the distal and occlusal surfaces of typodont tooth No. 28; note the amalgam restoration (MO-A) in a similar slot preparation on the mesial and occlusal surfaces. This conservative preparation may be preferred to reach interproximal caries when there is proximal caries without any occlusal involvement.
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Part 2 | Application of Tooth Anatomy in Dental Practice
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351 Root length
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The cingulum is normally centered on, or slightly distal to, the root axis line. Do you find any straight lines (ruler-straight, that is) on any tooth other than those lines that have been produced by attrition? This would be most unusual. Using the same approach, you will be able to draw other types of teeth. Labeling the grooves, the fossae, and the ridges on the occlusal surfaces of the posterior teeth will help to fix the morphology in your mind.
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inferior and anterior from the mandibular foramen. The mylohyoid nerve rests in this groove. The temporal crest is a ridge of bone extending from the tip of the coronoid process onto the medial surface of the ramus and terminating near the third molar. The tendon from the fibers of the wide, flat, fan-shaped temporalis muscle attaches here. The inferior one fourth of the temporal crest is called the internal oblique line. It is most important as a radiographic, rather than an anatomic, landmark. It appears on radiographs as a short, curved line somewhat inferior to the image of the external oblique line. The retromolar fossa is a roughened shallow fossa distal to the last molar and bounded medially by the lowest portion of the temporal crest and laterally by the external oblique ridge. The retromolar triangle is in the lowest most anterior, and only horizontal, portion of the retromolar fossa. The most posterior fibers of the buccinator muscle (a pouch-shaped cheek muscle) attach within this retromolar triangle on a slight ridge of bone called the buccinator crest. Genial [JEE ne al] and mental spines or tubercles are located on either side of the midline on the internal surface of the mandible. Two large muscles (the genioglossus and the geniohyoid) attach to these spines and the elevated, roughened bone near them. The mylohyoid ridge extends downward and forward from the molar region to the genial tubercles. It is not synonymous with the internal oblique line as incorrectly stated in some radiographic textbooks. The mylohyoid muscle, which forms part of the floor of the mouth, attaches from the mylohyoid ridge on the right medial side of the mandible to the ridge on the left medial side (somewhat like a hammock). The mylohyoid ridge separates two fossae, one above and one below. A very broad, shallow sublingual [sub LING
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• Describe and demonstrate the function of each of these muscles. • List other factors that contribute to the position of teeth and movement of the mandible. • Describe the location and list the functions of the groups of muscles that contribute to facial expression. • Buccinator [BUCK si na tor] attaches on the buccinator crest (posterior to the mandibular third molar) and adjacent soft tissue, forming a pouch in the cheeks. When contracting, it pulls the cheek inward to keep food on the chewing surfaces of teeth during chewing. • Upper oral group includes the zygomaticus [ZI go MAT i kus] major and minor, levator labii [LAB e e] superioris, and levator anguli oris. All contribute to raising the upper lip and/or angle, as in smiling. The risorius [ri SO ri us] retracts (spreads) the angle of the mouth. (The levator labii superioris alaeque [a LY kwe] nasi dilates the nostrils, as in contempt.) • Lower oral group (including the depressor labii inferior and depressor anguli oris) contracts to lower the lower lip or angle, as in a frown. The mentalis [men TA lis] is located in the chin and raises or protrudes the chin as in a pout.
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ASA and infraorbital MSA and infraorbital
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ASA nerve*
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In order to anesthetize the tissues of the palate, you need to block one or two nerves. The greater (anterior) palatine nerve innervates most of the palate (all tissue covering the hard palate lingual to molars and premolars) and the nasopalatine nerve for tissue lingual to the anterior teeth. Recall that both of these nerve branches split off of the maxillary nerve while in the pterygopalatine space, and then pass through the nasal passageways before entering the palatal tissue. The nasopalatine nerve passes from the pterygopalatine space along the nasal septum in the nasal cavity, and into palatal mucosa through the incisive foramen (Fig. 15-23), which is located immediately under the bump of very firm tissue called the incisive papilla (Fig. 15-24). This papilla is located on the palate just lingual to the midline between the maxillary central incisors. Since this tissue is very firm, only a small amount of anesthetic can be applied into this tissue, and this injection can be most painful. Applying pressure over the injection site with the handle of a mirror or with the end of a cotton-tipped applicator for 15 to 20 seconds prior to injecting can minimize this discomfort.
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Appendix Page 7 Proposed by Willoughby D Miller in1882. He stated that caries is caused by acids produced by microorganisms of the mouth. "Dental decay is a chemico-parasitic process consisting of two stages , the de-calcification of enamel , which results in its total destruction and the de-calcification of dentin as a preliminary stage,followed by dissolution of the softened residue"
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159 Digital fiberoptic Trans illumination
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Figure 13. Layers of Stomach [1] The stomach wall is composed of the same basic layers as the rest of the GI tract, with certain modifications. The surface of the mucosa is a layer of simple columnar epithelial cells called surface mucous cells. The mucosa contains a lamina propria (areolar
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Fig. 25◊The interior of the right atrium and ventricle.
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Intraperitoneal fossae
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160 The tip of the anterior superior spine of the ilium is easily felt and may be visible in the thin subject. The greater trochanter of the femur lies a hand's breadth below the iliac crest; it is best palpated with the hip abducted so that the overlying hip abductors (tensor fasciae latae and gluteus medius and minimus) are relaxed. In the very thin, wasted patient the greater trochanter may be seen as a prominent bulge and its overlying skin is a common site for a pressure sore to form in such a case. The ischial tuberosity is covered by gluteus maximus when one stands. In the sitting position, however, the muscle slips away laterally so that weight is taken directly on the bone. To palpate this bony point, therefore, feel for it uncovered by gluteus maximus in the flexed position of the hip. At the knee, the patella forms a prominent landmark. When quadriceps femoris is relaxed, this bone is freely mobile from side to side; note that this is so when you stand erect. The condyles of the femur and tibia, the head of the fibula and the joint line of the knee are all readily palpable; less so is the adductor tubercle of the femur, best identified by running the fingers down the medial side of the thigh until they are halted by it, the first bony prominence so to be encountered. The tibia can be felt throughout its course along its anterior subcutaneous border from the tibial tuberosity above, which marks the insertion of the quadriceps tendon, to the medial malleolus at the ankle. The fibula is subcutaneous for its terminal 3 in (7 cm) above the lateral malleolus, which extends more distally than the stumpier medial malleolus of the tibia. Immediately in front of the malleoli can be felt a block of bone which is the head of the talus. The tuberosity of the navicular stands out as a bony prominence 1 in (2.5 cm) in front of the medial malleolus; it is the principal point of insertion of tibialis posterior. The base of the 5th metatarsal is easily felt on the lateral side of the foot and is the site of insertion of peroneus brevis. If the calcaneus (os calcis) is carefully palpated, the peroneal tubercle can be felt 1 in (2.5 cm) below the tip of the lateral malleolus and the sustentaculum tali 1 in (2.5 cm) below the medial malleolus; these represent pulleys respectively for peroneus longus and for flexor hallucis longus.
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The anatomy and surface markings of the lower limb
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Deep structure
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The deep structure of the medulla is best shown by reference to diagrams representing the cross-sectional appearance of the medulla at the level of the sensory decussation and the lower part of the IVth ventricle (Figs 241, 242).
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(Fig. 265) The 8th nerve consists of two sets of fibres: cochlear and vestibular. The cochlear fibres (concerned with hearing) represent the central processes of the bipolar spiral ganglion cells of the cochlea which traverse the internal auditory meatus to reach the lateral aspect of the medulla, at the cerebellopontine angle (together with VII), where they terminate in the dorsal and ventral cochlear nuclei. The majority of the projection fibres from these nuclei cross to the opposite side, those from the dorsal nucleus forming the auditory striae in the floor of the 4th ventricle, those from the ventral nucleus forming the trapezoid body in the ventral part of the pons. Most of these efferent fibres terminate in nuclei associated with the trapezoid body, either on the same or the opposite side, and then ascend in the lateral lemniscus to the inferior colliculus and the medial geniculate body; from the former, fibres reach the motor nuclei of the cranial nerves and form the pathway of auditory reflexes; from the latter, fibres sweep laterally in the auditory radiation to the auditory cortex in the superior temporal gyrus (Fig. 247). The vestibular fibres (concerned with equilibrium) enter the medulla just medial to the cochlear division and terminate in the vestibular nuclei. Many of the efferent fibres from these nuclei pass to the cerebellum in the inferior cerebellar peduncle together with fibres bypassing the vestibular nuclei and passing directly to the cerebellum. Other vestibular connections are to the nuclei of III, IV, VI and XI and to the upper cervical cord (via the vestibulospinal tract). These connections bring the eye and neck muscles under reflex vestibular control.
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1◊◊Division of the hypoglossal nerve, or lesions involving its nucleus, result in an ipsilateral paralysis and wasting of the muscles of the tongue. This is detected clinically by deviation of the protruded tongue to the affected side. 2◊◊Supranuclear paralysis (due to an upper motor neurone lesion involving the corticobulbar pathways) leads to paresis but not atrophy of the muscles of the contralateral side. A.D.C. Vaan Diml
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ad lib = freely at pleasure PO = by mouth PR = by rectum OS = left eye OD = right eye qd = daily (this is a dangerous abbreviation and should not be used; see "Dangerous Practices," page 39) PRN = as needed T ˙ = one ˙ T ˙ = two ˙ T ˙ ˙ = three qhs = every night at bedtime bid = twice a day tid = three times a day q6h = every 6 h
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Increased: AMI, liver disease, Reye's syndrome, muscle trauma and injection, pancre4 catheterization, brain damage, renal infarction
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Increased: RA (variable finding), rheumatic fever, various neoplasms (gastrointestinal,
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Acute 3–6 Months Increased: Multiple myeloma (myeloma immunoglobulin increased, other immunoglobulins decreased); Waldenström's macroglobulinemia (IgM increased, others decreased); lymphoma; carcinoma; bacterial infection; liver disease; sarcoidosis; amyloidosis; myeloproliferative disorders
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• Males 65–175 mg/dL (SI: 11.64–31.33 mmol/L) • Females 50–170 mg/dL (SI: 8.95–30.43 mmol/L) • To convert mg/dL to mmol/L, multiply by 0.1791 • Collection: Tiger top tube
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Decreased: Iron deficiency anemia, nephrosis (loss of iron-binding proteins), normochromic anemia of chronic diseases and infections
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Estimated WBC (per mm3)
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4.73–5.49 [4.73–5.49] 4.15–4.87 [4.15–5.49] 4.8 4.7 4.6 4.5 4.6 4.7±0.9 5.1 5.1±1.0
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5 Creatinine clearance is one of the most sensitive indicators of early renal insufficiency. Clearances are ordered for patients with suspected renal disease and are useful for following patients who are taking nephrotoxic medications, (eg, gentamicin). Clearance normally decreases with age. A creatinine clearance of 10–20 mL/min indicates severe renal failure, and a clearance of <10 mL/min usually indicates the need for dialysis. To determine a creatinine clearance, order a concurrent serum creatinine and a 24-h urine creatinine. A shorter time interval can be used, for example, 12 h, but remember that the formula must be corrected for this change and that a 24-h sample is less prone to collection error.
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1. The chancre is cleansed with a saline-moistened swab and a slide is touched on the lesion and examined under darkfield illumination within 15 min of applying the specimen to the slide. 2. The organisms resemble tight corkscrews and are 1–1¹ ₂ times the diameter of an RBC in length.
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7 Clinical Microbiology Branching, beaded, rods; anaerobic Spore forming rod (continued )
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Oxacillin; ceftriaxone if gonococci
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Chloroquine phosphate Mefloquine or doxycycline
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9 Fluids and Electrolytes Normal serum sodium × TBW Measured serum sodium Fresh-Frozen Plasma (FFP)
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Clinician's Pocket Reference, 9th Edition
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6. 7. 8.
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service, or a temperature greater than or equal to 101°F rectally or 100°F orally in an infant or immunocompromised patient. When evaluating a patient for a fever, consider if the temperature is oral, rectal, tympanic, or axillary (rectal and tympanic temperatures are about 1° higher and axillary temperatures are about 1° lower than oral); has the patient drunk any hot or cold liquids or smoked around the time of the determination; and is the patient on any antipyretics. Differential diagnosis of fever and fever of unknown origin are discussed in Chapter 3.
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1. A Foley catheter and a nasogastric or oro gastric tube must be in place. Prep the abdomen from above the umbilicus to the pubis. 2. The site of choice is in the midline 1–2 cm below the umbilicus. Avoid the site of old surgical scars (danger of adherent bowel). If a subumbilical scar or pelvic fracture is present, a supraumbilical approach is recommended. 3. Infiltrate the skin with 1idocaine with epinephrine. Incise the skin in the midline vertically, and expose the fascia. 4. Either pick up the fascia and incise it, or puncture it with the trocar and peritoneal catheter. Caution is needed to avoid puncturing any organs. Use one hand to hold the catheter near the skin and to control the insertion while using the other hand to apply pressure to the end of the catheter. After entering the peritoneal cavity, remove the trocar and direct the catheter inferiorly into the pelvis. 5. During a diagnostic lavage, gross blood indicates a positive tap. If no blood is encountered, instill 10 mL/kg (about 1 L in adults) of lactated Ringer's solution or NS into the abdominal cavity. 6. Gently agitate the abdomen to distribute the fluid and after 5 min, drain off as much fluid as possible into a bag on the floor. (Minimum fluid for a valid analysis is 200 mL in an adult.) If the drainage is slow, try instilling additional fluid, carefully repositioning the catheter. 7. Send the fluid for analysis (amylase, bile, bacteria, hematocrit, cell count). See Table 13–5 for interpretation. 8. Remove the catheter and suture the skin. If the catheter is inserted for pancreatitis or peritoneal dialysis, suture it in place. 13 Bedside Procedures
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Volume of air in the lungs after maximal inspiration Measured after maximum inspira-
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present but have no relation to the QRS of the PVC. The QRS is usually >0.12 s with a left bundle branch pattern. A compensatory pause follows a PVC that is usually longer than after a PAC (Figure 19–14). The RR interval between beats 1 and 3 is equal to that between beats 3 and 5. Thus, the pause following the PVC (the fourth beat) is fully compensatory. The following patterns are recognized: • Bigeminy. One normal sinus beat followed by one PVC in an alternating fashion (Figure 19–15) • Trigeminy. Sequence of two normal beats followed by one PVC • Unifocal PVCs. Arise from one site in the ventricle. Each has the same configuration in a single lead. (See Figure 19–14.) • Multifocal PVCs. Arise from different sites; therefore, have different shapes (Figure 19–16) Clinical Correlations. PVCs occur in healthy persons and with excessive caffeine ingestion, anemia, anxiety, organic heart disease (ischemic, valvular, or hypertensive), secondary to medications (epinephrine and isoproterenol; from toxic level of digitalis and theophylline),
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Atrial flutter with atrioventricular (AV) block (3:1 to 5:1 conduc- the ECG paper) P wave >2.5 mm in height and >0.12 s wide (three small boxes on
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AVF Hypothermia: Sinus bradycardia, AV junctional rhythm, or ventricular fibrillation common. 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 (Figure 19–35) WPW Syndrome:
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Isolated diastolic hypertension is associated with three general disease categories: • Renal disease • Endocrine disorders • Neurologic disorders
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Indications TABLE 20–4 Normal Pulmonary Artery Measurements Parameter
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the REF. Once REF and CO are known, the EDVI can be calculated. The EDVI is another measure of preload, and it allows a more accurate assessment of volume status regardless of pulmonary status. For example, a patient with severe ARDS may have markedly elevated peak inspiratory pressures. Although the CVP and PAOP may be falsely elevated, the EDVI is measuring a volume, not a pressure, allowing a more precise determination of volume status across a wide variety of clinical situations. The normal range for EDVI is 80–120 mL.
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pacity (See Figure 20–11):
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432 Acute Renal Failure 20 Dilution
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For laypersons 1. Second rescuer identifies him or herself. Verify that EMS has been notified. If so, second rescuer gets into position opposite first rescuer. If EMS not notified, the second rescuer does so before assisting first rescuer. 2. First rescuer continues CPR. 3. If and when first rescuer tires, second rescuer takes over one-person CPR as described in the preceding section. For health care professionals 1. Sequence to continue from one-rescuer CPR as mentioned in previous section. Second rescuer identifies him or herself and gets into position for compressions. 2. First rescuer completes compression and ventilation cycle (15 compression and two ventilations). 3. First rescuer then checks for spontaneous pulse and breathing, states: "No pulse...continue CPR," then ventilate once (1.5–2 s). 4. Second rescuer resumes compressions at same rate of 80–100/min.("1 & 2 & 3 & 4 & 5 & pause," ventilate) Ratio of five compressions to one breath. If airway is protected, do not pause for ventilations. 5. When ready to switch, rescuer doing compressions says "switch & 2 & 3 & 4 & 5 &." 6. Both rescuers change position simultaneously immediately after ventilation. 7. Rescuer who will perform ventilations opens airway and performs a 5-s pulse check. 8. If no pulse, give ventilation. Rescuer states "No pulse...continue CPR."
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VF/VT Attempt defibrillation (up to 3 shocks if VF persists) 2
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A B B B C C C D • Propanolol (Inderal)
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Reduction of cholesterol, triglycerides and apolipoprotein B HMG-CoA reductase inhibitor DOSAGE: 0.4 mg/d in the evening SUPPLIED: Withdrawn by manufacturer NOTES: May cause myopathy, monitor LFT regularly Cholestyramine (Questran)
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Cyanocobalamin [Vitamin B12]
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Angina pectoris, prevention of reinfarction, HTN, AF or flutter, and PAT Calcium channel-blocker DOSAGE: Oral: Initially, 30 mg PO qid; ↑ to 180–360 mg/d in 3–4 ÷ doses PRN. SR: 60–120 mg PO bid; ↑ to effect to max dose 360 mg/d. CD: 120–360 mg/d (max 480 mg/d). IV: 0.25 mg/kg IV bolus over 2 min; may repeat the dose in 15 min at 0.35 mg/kg. May begin cont inf of 5–15 mg/h SUPPLIED: Tabs 30, 60, 90, 120 mg; SR caps 60, 90, 120 mg; CD caps 120, 180, 240, 300, 360 mg, 420 mg; inj 5 mg/mL NOTES: Contra in sick sinus syndrome, AV block, and hypotension; Cardizem CD, Dilacor XR, and Tiazac not interchangeable
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BPH and androgenetic alopecia Inhibits 5α reductase DOSAGE: BPH: 5 mg/d PO [Proscar]. Alopecia: 1 mg/d PO [Propecia] SUPPLIED: Tabs 1, 5 mg NOTES: Decreases PSA levels; may take 3–6 mo to see effect on urinary symptoms
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Androgen-responsive metastatic breast cancer Inhibition of secretion of LH and FSH by feedback inhibition DOSAGE: 10–40 mg/d SUPPLIED: Tabs 2, 5, 10 mg NOTES: Toxicity symptoms: Virilization, amenorrhea and menstrual irregularities, hirsutism, alopecia and acne, nausea, and cholestasis. Hematologic toxicity symptoms: Suppression of clotting factors II, V, VII, and X and polycythemia. ↑ libido, headache, and anxiety COMMON USES: ACTIONS: DOSAGE:
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Nalidixic Acid (NegGram)
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COMMON USES: Duodenal and gastric ulcers, Zollinger–Ellison syndrome, GERD, and H. pylori infections ACTIONS: Proton-pump inhibitor DOSAGE: 20–40 mg PO qd–bid SUPPLIED: Caps 10, 20, 40 mg NOTES: Combination (ie, antibiotic) therapy necessary for H. pylori infection
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Penicillin G Procaine (Wycillin, others)
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(continued ) BRONCHODILATORS Caffeine Trough: just before next dose Adults 5–15 µg/mL Neonate 6–11 mg/mL 5–15 µg/mL Adults 3–4 h 20 µg/mL Neonates 30– 140 h Nonsmoking adult-8 h >20 µg/mL Children and smoking adults -4 h
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WHAT CONCLUSIONS CAN BE DRAWN FROM THE RESEARCH? According to Levin128, to verify a causal relationship between a variable (e.g. religious involvement) and a health outcome (e.g. mortality), three questions must be answered. Is there an association? If so, is the relationship valid? If so, is it causal? Regarding the first question, a majority of nearly 1200 studies have found a direct relationship between religious involvement and spirituality and better health outcomes25. The association between religious involvement and spirituality and better health outcomes seems valid. This association has been found regardless of study design (e.g. prospective, retrospective) and the population studied. In addition, religious and spiritual variables were not the primary or the only ones used in most studies. These study design features limit bias. Furthermore, recent well-designed studies have shown a direct relationship between religious involvement and spirituality and better health outcomes even after adjusting for potential confounding variables46. Whether religious involvement and spirituality cause better health outcomes is more difficult to determine. Levin128 describes nine features of a causal epidemiological association: strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experiment and analogy. For some of these features (strength, consistency, temporality, plausibility, analogy), the published studies support causality, whereas for the others, there is insufficient evidence. Even though the association between religious involvement and spirituality and better health outcomes appears valid, clinicians should be careful not to draw erroneous conclusions from the research findings (Table 1129). For example, the research does not tell us that religious people do not get sick or that illness is caused by lack of religious faith. Placebo effect: clinical perspectives and potential mechanisms
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11 22 30 21 40 18 168. Masuda T, Toi Y, Bando H, et al. Structural identification of new curcumin dimers and their contribution to the antioxidant mechanism of curcumin. J Agric Food Chem 2002; 50: 2524–30 169. Lim GP, Chu T, Yang F, et al. The curry spice curcumin reduces oxidative damage and amyloid pathology in an Alzheimer transgenic mouse. J Neurosci 2001; 21:8370–7 170. Akhondzadeh S, Noroozian M, Mohammadi M, et al. Salvia officinalis extract in the treatment of patients with mild to moderate Alzheimer's disease: a double blind, randomized and placebocontrolled trial. J Clin Pharm Ther 2003; 28:53–9 171. Itoh T, Shimada Y, Terasawa K. Efficacy of Choto-san on vascular dementia and the protective effect of the hooks and stems of Uncaria sinensis on glutamate-induced neuronal death. Mech Ageing Dev 1999; 111: 155–73 172. White HK, Levin ED. Four-week nicotine skin patch treatment effects on cognitive performance in Alzheimer's disease. Psycho-pharmacology 1999; 143:158–65 173. Fischhof PK, Saletu B, Buther E, et al. Therapeutic efficacy of pyritinol in patients with senile dementia of the Alzheimer type (SDAT) and multi-infarct dementia (MID). Neuropsychobiology 1992; 26:65–70 174. Cooper AJ, Magnus RV. A placebo-controlled study of pyritinol ('Encephabol') in dementia. Pharmatherapeutica 1980; 2:317–22 175. Burns A, Byrne J, Ballard C, et al. Sensory stimulation in dementia. Br Med J 2002; 325: 1312–13 176. Ballard CG, O'Brien JT, Reichelt K, et al. Aromatherapy as safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebocontrolled trial with Melissa. J Clin Psychiatry 2002; 63:553–8 177. Smallwood J, Brown R, Coulter F, et al. Aromatherapy and behaviour disturbances in dementia: a randomized controlled trial. Int J Geriatric Psychiatry 2001; 16:1010–13 178. Holmes C, Hopkins V, Hensford C, et al. Lavender oil as a treatment for agitated behaviour in severe dementia: a placebo controlled study. Int J Geriatric Psychiatry 2002; 17:305–8 179. Brooker DJR, Snape M, Johnson E, et al. Single case evaluation of the effects of aromatherapy and massage on disturbed behaviour in severe dementia. Br J Clin Psychol 1997; 36(pt 2): 287–96 180. Kilstoff K, Chenoweth L. New approaches to health and well-being for dementia day-car clients, family carers and day-care staff. J Nurs Pract 1998; 4:70–83 181. Gray SG, Clair AA. Influence of aromatherapy on medication administration to residentialcare residents with dementia and behavioral challenges. Am J Alzheimer's Dis Other Dementias 2002; 17:169–74 182. Bhattacharya SK, Bhattacharya A, Kumar A, Ghosal S. Antioxidant activity of Bacopa monniera in rat frontal cortex, striatum and hippocampus. Phytother Res 2000; 14:174–9 183. Vohora D, Pal SN, Pillai KK. Protection from phenytoin-induced cognitive deficit by Bacopa monniera, a reputed Indian nootropic plant. J Ethnopharmacol 2000; 71:383–90 184. Stough C, Lloyd J, Clarke J, et al. The chronic effects of an extract of Bacopa monniera (Brahmi) on cognitive function in healthy human subjects. Psychopharmacology 2001; 156: 481–4 185. Roodenrys S, Booth D, Bulzomi S, et al. Chronic effects of Brahmi (Bacopa monnieri) on human memory. Neuropsychopharmacology 2002; 27:279–81 186. Francina S. The New Yoga for People Over 50. Deerfield Beach, FL: Health Communications, 1997 187. Kishiyama S, Carlsen J, Lawrence J, et al. Yoga as an experimental intervention for cognition in multiple sclerosis. Int J Yoga Ther 2002; 12:57–62 188. Berger B, Owen D. Stress reduction and mood enhancement in four exercise modes: swimming, body conditioning, hatha yoga, and fencing. Res Q Exerc Sport 1988; 59: 148–59 189. Berger BG, Owen DR. Mood alteration with yoga and swimming: aerobic exercise may not be necessary. Percept Mot Skills 1992; 75: 1331–43
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Tissue injury, irritation or infection can induce inflammation. The classical observations of redness (rubor), heat (calor) and swelling (tumour), are invariably accompanied by pain (dolor). Each reaction contributes to the prevention of further insult and the resolution of damaged tissue. Post-operative pain exhibits the classical features of inflammatory pain. In some disease states, such as arthritis, the inflammation persists and causes chronic inflammatory pain. Inflammation and inflammatory pain are mediated by a plethora of diverse substances released by tissue damage itself and the subsequent cascade of inflammatory processes. Some inflammatory mediators directly activate and sensitize primary (1°) afferent nerve fibres (C and A␦). Others stimulate the release of further mediators from immune cells, attracted by yet other chemicals in the inflammatory 'soup', which is a term used to refer collectively to all the pro-inflammatory mediators. Immune cells are recruited to the site of injury and act as a potent source of growth factors and cytokines. These are important in the generation and maintenance of hyperalgesia. This system exhibits enormous potential for interaction and escalation between each of the contributing processes. The polymorphonuclear leucocyte, of which the neutrophil is most plentiful, appears to be the principle immune cell involved in the generation of inflammatory pain. Different components of the inflammatory 'soup' can activate or sensitize 1° afferent neurones, or induce the influx of immune cells at the inflamed site that release further pro-inflammatory mediators. Sensitization of 1° afferent neurones leads to a decreased threshold of pain activation and an increased response to a noxious stimulus. Electrophysiologically, in the 1° afferent nociceptor, this is evident not only by a lowered threshold for nociceptor activation, but also by increased spontaneous activity and an increased frequency of firing. These changes are manifest clinically as an increased response to a noxious stimulus: hypersensitivity. The resultant increase in afferent input to the spinal cord leads to the development and maintenance of secondary Resiniferatoxin (in trials)
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observations following the German invasion of France in 1915 which left a trail of patients with nerve injuries. Complex regional pain syndrome (CRPS) consists of a constellation of symptoms and signs in limbs, which usually follow traumatic injuries or events such as myocardial infarction or a stroke (Table 25.1). There are two types of syndrome: Motor dysfunction Inflammation and oedema
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radical antagonist) can prevent the onset of CRPS. Calcitonin may also confer some benefit (Bogduk, 2001). While SLE patients may present with pain of many aetiologies, the commonest are musculoskeletal and related to:
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Table 27.7 Monitoring for patients receiving opioids Suggested monitoring for children receiving opioids Analgesia Sedation Respiration Validated pain score: VAS Ͼ 3 requires intervention Sedation scale 0–4: Ͼ3 requires intervention Respiratory rate, pulse oximetry (in air): saturation Ͻ95% requires intervention in normal children Heart rate/blood pressure: set age appropriate parameters Nausea scale 0–3: Ͼ1 give anti-emetics The most unpleasant task prior to commencing a clinical trial is consideration of the potential problems associated with its instigation. If these problems are not satisfactorily dealt with before the trial, the trial will either fail or be very difficult to complete (Table 30.2). Never underestimate the resources needed to complete a trial. A successful trial depends upon everyone involved in the trial organisation understanding the benefits that will accrue from a well-run trial. It is not wise to believe that a trial can be planned and then delegated to hospital staff as an add-on to their daily routines. In large hospitals, with staff working in shifts, a delegated trial will never rate as high as the exercise of the daily duties. Thus, it will never receive the attention it needs for effective completion. Even highly motivated people lose their motivation over time when a trial drags out due to 'unexpected' problems consequent upon bad planning. Seasonal lack of patient recruitment (because nobody checked expected recruitment rates by comparison with historical data) is a frequently encountered example of poor planning in large-scale trials. A well-conducted clinical trial is best done by a trained team, dedicated to the task of trial completion, closely monitored by a project leader (or a single dedicated clinician). The last option can be extremely time consuming and expensive.
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of the IASP taskforce. Proceedings of the VI World Congress on Pain. Amsterdam, Elsevier. Keller, S., Ehrhardt-Schmelzer, S., Herda, C., Schmid, S. & Basler, H.D. (1997). Multidisciplinary rehabilitation for chronic back pain in an outpatient setting: a controlled randomised trial. Eur. J. Pain, 1: 279–292. McQuay, H.J., Moore, R.A., Eccleston, C., Morley, S. de C. & Williams, A.C. (1997). Systematic review of outpatient services for chronic pain control. Health Technol. Assess. Prog., 1(6). Pain Society Desirable Criteria for Pain Management Programmes. A report of a working party of the pain society, London 1996.
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Ineffective plasma level Figure 39.1 Simulated effective and non-effective dosage regimens showed by the black and the white, respectively, cyclic plasma concentrations. The non-effective dosage regimen (too low doses) infrequently reaches an effective plasma level allowing for breakthrough pain.
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– Acetylated (e.g. acetylsalicylic acid (aspirin)). – Non-acetylated (e.g. diflunisal). (b) Acetic acids – Indoleacetic acids (e.g. indomethacin, sulindac). – Phenylacetic acids (e.g. diclofenac). – Pyrroleacetic acids (e.g. ketorolac). (c) Coxibs (e.g. celecoxib, parecoxib, etoricoxib). (d) Fenamates (e.g. mefenamic acid). (e) Oxicams (e.g. piroxicam, meloxicam). (f) Phenazones (e.g. dipyrone). (g) Propionic acids (e.g. ibuprofen, naproxen). (h) Pyrazolones (e.g. phenylbutazone). (i) Others (e.g. paracetamol (acetaminophen)).
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Phenytoin inhibits glutamate release presynaptically, modulates calcium current which has activity at the NMDA receptor and increases gamma amino butyric acid (GABA) concentration. It is now infrequently used, although given intravenously may have some utility in the management of acute flare-ups of neurogenic pain. Carbamazepine modulates depolarisationdependent calcium uptake, increases release of 5-HT and also blocks NMDA receptor current. It remains the treatment of choice in trigeminal neuralgia, with about 70% of patients getting significant pain relief. It causes a reduction in both pain intensity and pain paroxysms, and also in triggering stimuli. Oxcarbazepine is a newer chemically related drug with a more favourable side effect profile. Sodium valproate probably elevates levels of the inhibitory GABA in the CNS and by potentiation of GABAergic functions (particularly in the brain) inhibits pain. Clinical evidence to support its use is sparse. Lamotrigine also has action at sodium channels. This mechanism probably suppresses the neuronal release of glutamate, an excitatory amino acid
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The treatment of pain has changed over the years from a disease- and site-based therapy to a mechanistic approach. The multiple mechanisms for pain sensation to be modified peripherally and in the central nervous system (CNS) provide many avenues for drug targets. This chapter aims to describe the variety of agents not covered elsewhere in this text.
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These agents have a long history in veterinary practice, where they have been used to provide local analgesia and sedation in a wide range of animals. Their role in human pain relief is now established. studies carried out in primary care settings reveal lower levels of depression than in pain clinics. The symptoms that suggest a depressive illness in patients with chronic pain include:
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Table 45.1 Comparison of the three main schedules used in diagnosing emotional aspects of pain Characteristic symptoms and signs Emotional conflict or psychosocial problems associated with pain disorder Belief of definite disease, unable to accept medical reassurance Multiple and variable symptoms for at least 2 years Depressive symptoms Severe depression with delusions of: disease, torture or deserved punishment Delusions of physical defect, disorder or disease Pain due to persistent muscle contraction ICD-10 DSM-IV IASP
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management options to allow clinicians and patients to judge for themselves. Explicit (or evaluative) evidence based guidelines include consideration of the clinical effect in the individual, but also benefit, risk and cost for defined populations. They may allow organisations and governments to make policy decisions for health care provision.
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The term concussion is relatively modern, although, having been coined back in the 16th century. According to the Oxford English Dictionary, the word concussion is derived from the Latin concutere. It refers to a clashing together, an agitation, disturbance or shock of impact. The term concussion therefore conveys the idea that a violent physical shaking of the brain is responsible for the sudden temporary loss of consciousness and/or amnesia. It is, in general, synonymous with the older expression commotio cerebri (Ommaya & Gennarelli, 1974; Levin et al., 1982), a term which still can be
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athletic fields. A one minute duration of symptoms became the cut-off point between a moderate and a severe concussion provided that there was a loss of consciousness. Moreover, all post concussion symptoms, not just LOC, should be considered important features of concussion that may be used as classifiers. They are all important in terms of managing individuals with brain injury because we do not want people return to play while they still have post concussion symptoms. Also, the symptoms such as post-traumatic amnesia, headaches, balance problems lasted less than thirty minutes were considered as primary classifiers of Grade 1. Table 8. ANN practice parameter (Kelly and Rosenberg) grading system. Grade 1 Transient confusion; no loss of consciousness; concussion symptoms or mental status abnormalities on examination resolve in less than 15 minutes Transient confusion; no loss of consciousness; concussion symptoms or mental status abnormalities on examination last more than 15 minutes Any loss of consciousness; either brief (seconds) or prolonged (minutes) Neuropsychological Assessment
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dog which was difficult to see because of the black and white background. After training individuals to see the dog, there were differences in the gamma band response suggesting differential responses to meaningful versuss nonmeaningful stimuli. Additional patterns of spontaneous EEG activity include delta activity (0.5-4 Hz), theta activity (5-7 Hz), and lambda and K-complex waves and sleep spindles, which are not defined solely in terms of frequency. Theta activity refers to EEG activity in the 4-8 Hz range. Grey Walter (1953) who introduced the term theta rhythm suggested that theta was seen at the cessation of a pleasurable activity. More recent research has theta associated with such processes as hypnagogic imagery, REM (rapid eye movement) sleep, problem solving, attention, and hypnosis. Source analysis of midline theta suggests that the anterior cingulated is involved in it generation (Luu & Tucker, 2003). Schacter (1977) in an early review of theta activity suggested that there are actually two different types of theta activity: First there is theta activity associated with low levels of alertness as would be seen as one falls asleep. And second, there is theta activity associated with attention and active and efficient processing of cognitive and perceptual tasks. This is consistent with the suggestion of Vogel et al (1968) that there two types of behavioral inhibition, one associated with a gross inactivation of an entire excitatory process resulting in less active behavioral states and one associated with selective inactivity as seen in over-learned processes. Delta activity is low frequency (.5-4Hz.) and has been traditionally associated with sleep in healthy humans as well as pathological conditions. The pathological conditions associated with dealt have included cerebral infarct, contusion, local infection, tumor, epileptic foci and subdural hematoma. The basis idea is that these types of disorders influence the neural tissue which in turn creates abnormal neural activity in the delta range by cutting off these tissues from major input sources. Although these observations were first seen with intracranial electrodes, more recent work has used MEG and EEG techniques. EEG delta activity is also the predominant frequency of human infants during the first two years of life.
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Window settings can be adjusted to reveal bony detail or soft tissues to greatest advantage. A CT scan takes a few minutes longer to obtain than a skull series. Multiple slices from the same CT scan can be analyzed to
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McCrory, P., Matser, E. et al.(2004). Sports neurology. The Lancet Neurology, 3, 435-440. Guskiewicz, K.,Weaver, N. et al. (2000). Epidemiology of concussion in collegiate and high school football players American Journal of Sports Medicine, 28, 643-650. Pellman, E. et al. (2994). Concussion in professional football: Epidemiological features of game injuries and review of the literature. Neurosurgery, 3, 54:81-96.
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Time Fig, 2. When the velocity is doubled, padding needed for protection (same acceleration) must be quadrupled. Area "cde" equals distance head moves after contact in coming to rest. Area "abc" is 4 times area 'cde". Re-drawn with permission from: Gurdjian, ES, Protection of the Head and Neck in Sports, JAMA, 182(5) pp. 509-12) "Copyright @ 1962, American Medical Association. All right reserved.
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Traditionally, the emotion of fear has been excluded from research related to general orthopedic and other injuries, including traumatic brain injuries, and has not been highly considered among injured athletes. One of the reasons is that athletes are generally perceived as "warrior type" individuals that do not harbor emotions such as fear. Athletes usually attempt to hide their fear because they feel coaches view fear as a weakness (Feigley, 1988). Both, the coaches viewing fear as a weakness and the athletes hiding their fear, are dangerous attitudes, considering that athletes parties share the same goal, and that is a healthy athlete who can offer their best effort. Coach Kaidanov: It should be definitely a mutual decision. The medical doctor should clear the athlete for participation based on their clinical signs and regulation. However, the coach should clear the athlete for specific types of activities without compromising the possibility of re-injury. Having said that that medical doctor overall is responsible for final decision based upon clinical symptoms resolution and his or her knowledge and experience dealing with specific sport activities. The medical doctor should predict possibilities of re-injury and make their call accordingly. Q6. There are a number of interventions recommended by sport psychology practitioners including: negative thought stoppage, cognitive restructuring, healing imagery, muscle relaxation, goal setting, etc. to speed up rehabilitation of injured athletes. What kind of coaching strategies would you recommend to enhance athletes' readiness for returning to full range of sport participation? Coach Ganter: / am an old school guy, and I do not have any knowledge or experience in any type of psychological rehabilitation. I think the greatest motivator is playing time and if they want to get back on the field and play, they are going to hurry up and get better. I think, if an injured athlete is worried about regaining a position or playing time, sometimes that will speed the process up too. I have no experience with people giving psychological coaching or anything like that in rehabilitation of my kids. Coach Jepson: I do a lot of visualization, like I said, specifically focused on physical skills that were associated with injury. I truly believe that a major cause of injury in gymnastics is improper techniques and errors in performance of a complex skill. So, gymnasts should be clear minded in terms of the understanding of the fundamental mechanics of skill they need to perform. Also, skill progression, especially in case of injury is critical to return to pre-injury status. We teach gymnasts to focus on the positive, rather than to think about the possibility of re-injury. Coach Sheppard: / think that properly framed, gymnastic oriented and injury recovery focused visualization is a tremendous coaching resource to speed up the rehabilitation of injured athletes. Visualization should include not only ''visual imagery per se'' but also skill imitation, feeling, sensing the recovery, feeling the pressure and tension in the injured joint producing the required skills. We use this a lot in our program, not only for performance enhancement but also as a part of the psychological intervention program for injured athletes. For example, we have a gymnast with an achilles
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a. Skeletal muscle is voluntary and striated. b. Smooth muscle is involuntary and nonstriated. c. Cardiac muscle is involuntary and striated. Cardiac muscle cells branch and fit together at intercalated disks.
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inferior vena cava 4. Blood enters general circulation by way of hepatic veins. Vitamins C, E, and A are believed to defend the body against free radicals, and therefore they are termed antioxidants. These vitamins are especially abundant in fruits and vegetables. The dietary guidelines shown in Figure 5.13 suggest that we eat a minimum of five servings of fruits and vegetables a day. To achieve this goal, include salad greens, raw or cooked vegetables, dried fruit, and fruit juice, in addition to traditional apples and oranges and such. Dietary supplements may provide a potential safeguard against cancer and cardiovascular disease, but nutritionists do not think it is appropriate to take supplements instead of improving intake of fruits and vegetables. There are many beneficial compounds in fruits that cannot be obtained from a vitamin pill. These compounds enhance each other's absorption or action and also perform independent biological functions.
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1. Do you think employers who pay for their employees' health insurance have the right to demand, or encourage, or support a healthy lifestyle? 2. Do you think all participants in a health insurance program should qualify for the same benefits, regardless of their lifestyle? 3. What steps are ethical to encourage people to adopt a healthy lifestyle?
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allergen 158 allergy 158 antibody 150 antibody-mediated immunity 151 antigen 150 antigen-presenting cell (APC) 154 antigen receptor 150 apoptosis 151 autoimmune disease 160 B lymphocyte 150 cell-mediated immunity 155 clonal selection theory 151 complement system 150 cytokine 154 cytotoxic T cell 155 delayed allergic response 158 edema 146 helper T cell 155 histamine 148 HLA (human leukocyteassociated) antigen 154 immediate allergic response 158 immune system 148 immunity 148 immunization 156 immunoglobulin (Ig) 152 inflammatory reaction 148 interferon 150 interleukin 157 kinin 148 lymph 146 lymph node 147 lymphatic system 146 lymphatic vessel 146 lymphoid organ 147 macrophage 148 mast cell 148 memory B cell 151 monoclonal antibody 158 natural killer (NK) cell 150 perforin 155 plasma cell 151 red bone marrow 148 spleen 147 T lymphocyte 150 thymus gland 148 tonsils 147 vaccine 156
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Each alveolar sac is made up of simple squamous epithelium surrounded by blood capillaries. Gas exchange occurs between air in the alveoli and blood in the capillaries (Fig. 9.5). Oxygen diffuses across the alveolar wall and enters the bloodstream, while carbon dioxide diffuses from the blood across the alveolar wall to enter the alveoli. The alveoli of human lungs are lined with a surfactant, a film of lipoprotein that lowers the surface tension and prevents them from closing. The lungs collapse in some newborn babies, especially premature infants, who lack this film. The condition, called infant respiratory distress syndrome, is now treatable by surfactant replacement therapy. There are altogether about 300 million alveoli, with a total cross-sectional area of 50–70 m2. This is the surface area of a typical classroom and at least 40 times the surface area of the skin. Because of their many air spaces, the lungs are very light; normally, a piece of lung tissue dropped in a glass of water floats. The trachea divides into the primary bronchi, which divide repeatedly to give rise to the bronchioles. The bronchioles have many branches and terminate at the alveoli, which make up the lungs. Pressure in lungs decreases, and air comes rushing in.
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Figure 9.12 Lower respiratory tract disorders.
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HCO3– H2CO3 H2O + CO2 Patients with renal failure sometimes undergo a kidney transplant operation during which a functioning kidney from a donor is received. As with all organ transplants, there is the possibility of organ rejection. Receiving a kidney from a close relative has the highest chance of success. The current one-year survival rate is 97% if the kidney is received from a relative and 90% if it is received from a nonrelative.
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maxilla mandible A motor neuron ends in neuromuscular junctions at a muscle fiber. At a neuromuscular junction, impulses travel down the T system of a muscle fiber, and calcium is released from the sarcoplasmic reticulum. Then the myosin filaments pull actin filaments within sarcomeres, units of a myofibril.
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A scanning electron micrograph showing an embryo implanted in the endometrium on day 12 following fertilization. The sex hormones greatly affect our appearance because they maintain the secondary sex characteristics. Some of these characteristics, such as fat deposition in females, help maintain homeostasis. In addition, it is now known that both estrogen and androgens have general metabolic effects that pertain to homeostasis.
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Taking Sides Decide your initial opinion by answering a series of questions. Then see if your opinion changes after completing the next two activities. Further Debate Read opposing articles that give you further information on this particular bioethical issue. Explain Your Position Answer another series of questions and then defend your original or changed opinion. You can e-mail your position to your instructor if he or she wishes.
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Morphogenesis begins as the cells of the morula form an empty ball of cells called the blastula. All animal blastulas have an empty cavity, but since the human blastula is called a blastocyst, the cavity is called the blastocyst cavity. In humans, an inner cell mass becomes an embryonic disk composed of two layers of cells. The lower layer of cells becomes the yolk sac. A cavity called the amniotic cavity occurs above the embryonic disk.
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Figure 18.6 The extraembryonic membranes.
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chorionic villi The uterus has contractions throughout pregnancy. At first, these are light, lasting about 20–30 seconds and occurring every 15–20 minutes. Near the end of pregnancy, the contractions may become stronger and more frequent so that a woman may think that she is in labor. However, the onset of true labor is marked by uterine contractions that occur regularly every 15–20 minutes and last for 40 seconds or more. A positive feedback mechanism can explain the onset and continuation of labor. Uterine contractions are induced by a stretching of the cervix, which also brings about the release of oxytocin from the posterior pituitary. Oxytocin stimulates the uterine muscles, both directly and through the action of prostaglandins. Uterine contractions push the fetus downward, and the cervix stretches even more. This cycle keeps repeating itself until birth occurs.
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Mader: Human Biology, Seventh Edition g.
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See Appendix A for answers.
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Human Genetics
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Mader: Human Biology, Seventh Edition Figure 21.4 DNA is double stranded.
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S • Cancer cells have characteristics that can be associated with their ability to grow uncontrollably. 444
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signaling protein Diagnosis of cancer before metastasis is difficult, although treatment at this stage is usually more successful. The American Cancer Society, Inc., publicizes seven warning signals that spell out the word CAUTION and that everyone should be aware of: C A U T I O N hange in bowel or bladder habits; sore that does not heal; nusual bleeding or discharge; hickening or lump in breast or elsewhere; ndigestion or difficulty in swallowing; bvious change in wart or mole; agging cough or hoarseness.
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Fossil Evidence southern regions and light-skinned persons living in northern regions absorb the same amount of radiation. (Some absorption is required for vitamin D production.) Other features that correlate with skin color, such as hair type and eye color, may simply be side effects of genes that control skin color. Differences in body shape represent adaptations to temperature. A squat body with short limbs and nose retains more heat than an elongated body with long limbs and nose. Also, almond-shaped eyes, a flat nose and forehead, and broad cheeks are believed to be adaptations to the last Ice Age. While it always has seemed to some that physical differences warrant assigning humans to different "races," this contention is not borne out by the molecular data mentioned in this chapter.
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Conservation biology is the scientific study of biodiversity and its management for sustainable human welfare. The present unequaled rate of extinctions has drawn together scientists and environmentalists in basic and applied fields to address the problem. Biodiversity is the variety of life on earth; the exact number of species is not known, but there are many more insects than other types of organisms. Biodiversity must also be preserved at the genetic, community (ecosystem), and landscape levels of organization. Conservationists have discovered that biodiversity is not evenly distributed in the biosphere, and therefore saving certain areas may protect more species than saving other areas.
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• • • Alternate tasks and incorporate short rest periods to avoid fatigue. Keep your garden small and easy to manage. Use adaptive equipment, such as handles with extensions, to minimize bending.
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• Arrange your desk and chair heights to facilitate maintaining proper posture, which reduces slumping of the shoulders and neck flexion. Use a chair that has good back support. Arrange your office so that your file cabinets, computer terminal, and other equipment are easily accessible. Use small lazy Susans on the desktop for pens, paper clips, tape, stapler, and so on. Use a phone device that allows the receiver to rest on your shoulder and frees your hands during extended conversations.
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Brain The brain receives only impaired sensations due to interruption before reaching the upper spinal cord. Spinal Cord
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Mrs. Beecher, a 76-year-old nursing home client, has just had a change in her antihypertension medications to felodipine 10 mg qd, a calcium channel blocker. Her blood pressure is 148/70. You give her the tablet with a large glass of grapefruit juice and caution her to swallow the tablet whole. Two days later Mrs. Beecher's blood pressure is 96/60.
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In many settings, needleless systems are being used. These involve a plastic tip on the syringe that can be used to enter vials and injection sites on IV tubing. Openings created by the tip reseal themselves. Needleless systems were developed because of the risk of injury and spread of blood-borne pathogens, such as the viruses that cause acquired immunodeficiency syndrome and hepatitis B. Syringes also are available in various sizes. The 3-mL size is probably used most often. It is usually plastic and is available with or without an attached needle. Syringes are calibrated so that drug doses can be measured accurately. However, the calibrations vary according to the size and type of syringe. Insulin and tuberculin syringes are used for specific purposes. Insulin syringes are calibrated to measure up to 100 units of insulin. Safe practice requires that only insulin syringes be used to measure insulin and that they be used for no other drugs. Tuberculin syringes have a capacity of 1 mL. They should be used for small doses of any drug because measurements are more accurate than with larger syringes.
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A Ulnar artery Median antebrachial vein Basilic vein Cephalic vein Basilic vein Dorsal venous arch
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usually excreted through the kidneys. With some drugs, such as many antimicrobials, a supplemental dose may be needed to maintain therapeutic blood levels of drug. Nursing Process
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Acetaminophen is usually safe in recommended doses unless liver damage is present or the person is a chronic alcohol abuser. Aspirin is usually safe in the small doses prescribed for prevention of myocardial infarction and stroke (antiplatelet effects). Aspirin and other NSAIDs are probably safe in therapeutic doses for occasional use as an analgesic or antipyretic. However, older adults have a high incidence of musculoskeletal disorders (eg, osteoarthritis), and an NSAID is often prescribed. Long-term use increases the risk of serious GI bleeding. Small doses, gradual increments, and taking the drug with food or a full glass of water may decrease GI effects. COX-2 inhibitor NSAIDs may be especially beneficial in older adults because they are less likely to cause gastric ulceration and bleeding. Older adults also are more likely than younger adults to acquire nephrotoxicity with NSAIDs, especially with high doses or long-term use, because the drugs may reduce blood flow to the kidneys. CHAPTER 10 DRUGS FOR MOOD DISORDERS: ANTIDEPRESSANTS AND MOOD STABILIZERS
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• Dysfunctional Family Processes: Alcoholism • Risk for Injury: Infection, hepatitis, AIDS related to use
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Drugs at a Glance: Selected Adrenergic Drugs (continued ) TABLE 18–1
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Generic/Trade Name Nonselective Blocking Agents Carteolol (Cartrol, Ocupress) Clinical Indications Routes and Dosage Ranges
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drug effects (eg, edema, tachycardia with alpha agonists and blocking agents; bradycardia, congestive heart failure, bronchoconstriction with beta blockers). • Interview regarding knowledge and use of drugs. Indirect-acting cholinergic drug Acetylcholinesterase
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311 Older anticholinergic drugs such as atropine are rarely used to treat Parkinson's disease because of their undesirable peripheral effects (eg, dry mouth, blurred vision, photophobia, constipation, urinary retention, and tachycardia). Newer, centrally acting synthetic anticholinergic drugs are more selective for muscarinic receptors in the CNS and are designed to produce fewer side effects. Trihexyphenidyl (Trihexy) is used in the treatment of parkinsonism and extrapyramidal reactions caused by some antipsychotic drugs. Trihexyphenidyl relieves smooth muscle spasm by a direct action on the muscle and by inhibiting the PNS. The drug supposedly has fewer side effects than atropine, but approximately half the recipients report mouth dryness, blurring of vision, and other side effects common to anticholinergic drugs. Trihexyphenidyl requires the same precautions as other anticholinergic drugs and is contraindicated in glaucoma. Biperiden (Akineton) and procyclidine (Kemadrin) are chemical derivatives of trihexyphenidyl and have similar actions. Benztropine (Cogentin) is a synthetic drug with both anticholinergic and antihistaminic effects. Its anticholinergic activity approximates that of atropine. A major clinical use is to treat acute dystonic reactions caused by antipsychotic drugs and to prevent their recurrence in clients receiving long-term antipsychotic drug therapy. It also may be given in small doses to supplement other antiparkinson drugs. In full dosage, adverse reactions are common.
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Route of Administration 5. What are the mechanisms by which exogenous corticosteroids may cause adrenocortical insufficiency and excess? 6. What adverse effects are associated with chronic use of systemic corticosteroids? 7. For a client on long-term systemic corticosteroid therapy, why is it important to taper the dose and gradually discontinue the drug rather than stop it abruptly? 8. Why is alternate-day administration of a systemic corticosteroid preferred when possible? 9. What are the main differences between administering corticosteroids in adrenal insufficiency and in other disorders? 10. When a corticosteroid is given by inhalation to clients with asthma, what is the expected effect? SELECTED REFERENCES
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used to treat hypocalcemia and to prevent and treat osteoporosis. These agents are described in the following sections; names and dosages of individual drug preparations are listed in Drugs at a Glance: Calcium and Vitamin D Preparations. Drugs used for hypercalcemia include bisphosphonates, calcitonin, corticosteroids, 0.9% sodium chloride intravenous (IV) infusion, and others. Those used for osteoporosis inhibit bone breakdown and demineralization and include bisphosphonates, calcitonin, estrogens, and antiestrogens. These drugs are described in the following sections; indications for use and dosages are listed in Drugs at a Glance: Drugs Used in Hypercalcemia and Selected Bone Disorders. SC, dosage individualized, 15 min before meals
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406 • Deficient Knowledge: Physiologic and psychological
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• Assess each client for current or potential vitamin disorders during an overall assessment of nutritional status. Specific assessment factors related to vitamins include the following: • Deficiency states are more common than excess states. • People with other nutritional deficiencies are likely to have vitamin deficiencies as well. • Deficiencies of water-soluble vitamins (B complex and C) are more common than those of fat-soluble vitamins. • Vitamin deficiencies are usually multiple and signs and symptoms often overlap, especially with B-complex deficiencies. • Vitamin requirements are increased during infancy, pregnancy, lactation, fever, hyperthyroidism, and many illnesses. Thus, a vitamin intake that is normally adequate may be inadequate in certain circumstances. • Vitamin deficiencies are likely to occur in people who are poor, elderly, chronically or severely ill, or alcoholic. • Vitamin excess states are rarely caused by excessive dietary intake but may occur with use of vitamin drug preparations, especially if megadoses are taken.
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and vegetables may be associated with factors other than vitamin C (eg, interactions between vitamin C and other components of these foods, food components other than vitamin C, or because people who eat fruits and vegetables also participate in other health-promoting activities).
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Folic acid and vitamin C are believed to have cardioprotective effects. Folic acid is important in the metabolism of homocysteine, a toxic amino acid and a major risk factor for heart disease. Homocysteine is normally produced during metabolism of methionine, another amino acid. Several B vitamins, including folic acid, are required for the metabolism of homocysteine to a nontoxic substance, and an increased blood level of homocysteine occurs with folic acid deficiency. Excessive homocysteine damages the endothelial lining of arteries and leads to plaque formation, arteriosclerosis, and thrombosis. Folic acid supplements can prevent or delay these effects by lowering blood levels of homocysteine. Although the FDA requirement that folic acid be added to cereal grain foods may be helpful, the folic acid intake that helps prevent cardiovascular disease is thought to be higher. Vitamin C is thought to help prevent cardiovascular disease by its antioxidant effects. The atherogenic effects of blood lipids, especially low-density lipoprotein (LDL) cholesterol (see Chap. 58), are attributed to their chemical breakdown or oxidation. Vitamin C may help to prevent oxidation of LDL cholesterol. Overall, however, the effects of vitamin C on prevention of coronary artery disease (CAD) are unclear. Some studies indicate an increased risk for CAD only with a severe vitamin C deficiency and that vitamin C has little effect on ischemic heart disease and stroke after adjustment for other risk factors. More research is needed before vitamin C supplements are recommended for cardioprotective effects. However, fruits and vegetables are natural sources of antioxidants and increased intake may be beneficial. For a number of years, vitamin E was thought to have antioxidant, cardioprotective effects similar to those of vitamin C. However, several studies failed to support this view.
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Flow rates depend largely on reasons for use. For example, if a client is receiving no oral fluids (NPO) or only small amounts, the flow rate is often 100 to 125 mL/h or 2400 to 3000 mL/24 h. If used as a vehicle for IV antibiotics, the rate is often 50 mL/h or keep open rate (KOR). If the client is dehydrated, 150 to 200 mL/h may be given for a few hours or until a certain amount has been given. (Restrictions in time or amount are necessary to avoid circulatory overload or pulmonary edema.) To dilute, disguise the unpleasant taste, and decrease gastric irritation To decrease gastric irritation Transient hyperkalemia may cause life-threatening cardiotoxicity. Severe pain and vein sclerosis also may result. Dilution decreases risks of hyperkalemia and cardiotoxicity. It also prevents or decreases pain at the infusion site. This is the safest amount and rate of potassium administration. It is also usually effective. Risks of hyperkalemia and life-threatening cardiotoxicity are greatly increased with high concentrations or rapid flow rates. Constant electrocardiogram monitoring is the best way to detect hyperkalemia. MgSO4 is available in concentrations of 10%, 25%, and 50% and in sizes of 2-, 10-, and 20-mL ampules, as well as a 30-mL multidose vial.
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501 Use in Children
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gram-negative infections for many years. The quinolones are also older drugs originally used only for treatment of urinary tract infections (see Chap. 36). The fluoroquinolones are synthesized by adding a fluorine molecule to the quinolone structure. This addition increases drug activity against gramnegative microorganisms, broadens the antimicrobial spectrum to include several other microorganisms, and allows use of the drugs in treating systemic infections. General characteristics, mechanisms of action, indications for and contraindications to use, nursing process implications, and principles of therapy for these drugs are described in this chapter. Individ-
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1. Acute and chronic urinary tract infections 2. Acute exacerbations of chronic bronchitis 3. Acute otitis media caused by susceptible strains of Hemophilus influenzae and S. pneumoniae 4. Shigellosis 5. Infection by Pneumocystis carinii (prevention and treatment) 6. Intravenous preparation indicated for P. carinii pneumonia, severe urinary tract infections, and shigellosis Methanaminehippurate (Hiprex) Nalidixic acid (NegGram)
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The macrolides enter microbial cells and attach to 50S ribosomes, thereby inhibiting microbial protein synthesis.
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4. Observe for drug interactions a. Drugs that increase effects of erythromycin: (1) Chloramphenicol (2) Streptomycin The combination is effective against some strains of resistant Staphylococcus aureus. The combination is effective against the enterococcus in bacteremia, brain abscess, endocarditis, meningitis, and urinary tract infection Probably inhibits metabolism of clarithromycin These agents raise gastric pH and slightly increase absorption of dirithromycin. Antacids decrease peak serum levels (continued )
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15 mg/kg (900) 10 mg/kg (600 mg) 50–70 mg/kg (4 g) 25–30 mg/kg (1.5 g) 50 mg/kg (2.5 g)
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✔ Most antiviral drugs are self-administered or dosed by caregivers in the home setting. Precautions to prevent viral infections from occurring or spreading are important because of the close contacts among members of a household. The home care nurse may be required to teach infection control precautions and to assess the immunization status of all household members. If immunizations are indicated, the nurse may need to teach, encourage, provide, or facilitate their administration. Home care of patients with HIV infection may include a variety of activities such as assisting with drug therapy for HIV or opportunistic infections, coordinating medical and social services, managing symptoms of infection or adverse drug effects, and preventing or minimizing opportunistic infections. Nurses may also be involved in disease state education of both patients and their families. As part of home care, the nurse should be prepared to triage and refer patients to hospitalization or hospice when indicated.
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SECTION 7 DRUGS AFFECTING HEMATOPOIESIS AND THE IMMUNE SYSTEM metabolite in the liver. As a result, pharmacologic action is decreased in clients with hepatic impairment. When azathioprine is used in liver transplantation, clients sometimes experience hepatotoxicity characterized by cholestasis, peliosis hepatis, nodular regenerative hyperplasia, and veno-occlusive disease. Liver function usually improves within a week if azathioprine is discontinued. • Cyclosporine reportedly causes hepatotoxicity (eg, elevated serum aminotransferases and bilirubin) in approximately 4% of renal and liver transplant recipients and 7% of cardiac transplant recipients. This is most likely to occur during the first month of therapy, when high doses of cyclosporine are usually given, and usually subsides with reduced dosage.
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Gwen, a 7th grader, comes to the health center at the middle school in moderate respiratory distress. Her respiratory rate is 36 and you hear audible wheezing without a stethoscope. Her inhalers (albuterol and Vanceril) are kept in the health center for administration during school hours. Gwen has not been in to use her inhalers for the last week. What is most important to do now to treat Gwen's asthma attack? What assessments/interventions might be important to assist Gwen in long-term management of her asthma? •
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Answer: Joan has the symptoms of a cold. Tell her to avoid combination products that may include medications she does not need and are generally more expensive. Because her cough is productive, an antitussive agent (cough suppressant) is contraindicated because expectorating retained secretions promotes recovery and prevents pneumonia and other respiratory complications. An expectorant, such as guaifenesin, may help liquefy respiratory secretions and aid their removal. A nasal decongestant could be used to decrease nasal stuffiness and discharge. Acetaminophen can be taken to reduce generalized discomfort. In addition to discussing medications, stress the importance of getting adequate rest and drinking lots of fluids.
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CHAPTER 52 ANTIDYSRHYTHMIC DRUGS Drugs at a Glance: Calcium Channel Blockers
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When diuretics are used to manage clients with edema, the underlying cause of the edema should be addressed, not just the edema itself. When managing such clients, it is preferable to aim for a weight loss of approximately 2 lb (1 kg) per day. Rapid and excessive diuresis may cause dehydration and decreased blood volume with circulatory collapse. In some clients, giving a diuretic every other day or 3 to 5 days per week may be effective and is less likely to cause electrolyte imbalances.
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Thrombosis may occur in both arteries and veins. Arterial thrombosis is usually associated with atherosclerotic plaque, hypertension, and turbulent blood flow. These conditions damage arterial endothelium and activate platelets to initiate the coagulation process. Arterial thrombi cause disease by obstructing blood flow. If the obstruction is incomplete or temporary, local tissue ischemia (deficient blood supply) occurs. If the obstruction is complete or prolonged, local tissue death or infarction occurs. Venous thrombosis is usually associated with venous stasis. When blood flows slowly, thrombin and other procoagulant substances present in the blood become concentrated in local areas and initiate the clotting process. With a normal rate of blood flow, these substances are rapidly removed from the blood, primarily by Kupffer cells in the liver. A venous thrombus is less cohesive than an arterial thrombus, and an embolus can easily become detached and travel to other parts of the body. Venous thrombi cause disease by two mechanisms. First, thrombosis causes local congestion, edema, and perhaps inflammation by impairing normal outflow of venous blood (eg, thrombophlebitis, deep vein thrombosis [DVT]). Sec- Sucralfate is a preparation of sulfated sucrose and aluminum hydroxide that binds to normal and ulcerated mucosa. It is used to prevent and treat peptic ulcer disease. It is effective even though it does not inhibit secretion of gastric acid or pepsin and it has little neutralizing effect on gastric acid. Its mechanism of action is unclear, but it is thought to act locally on the gastric and duodenal mucosa. Possible mechanisms include binding to the ulcer and forming a protective barrier between the mucosa and gastric acid, pepsin, and bile salts; neutralizing pepsin; stimulating prostaglandin synthesis in the mucosa; and exerting healing effects through the aluminum component. Sucralfate is effective in healing duodenal ulcers and in maintenance therapy to prevent ulcer
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Laxatives and cathartics are somewhat arbitrarily classified as bulk-forming laxatives, surfactant laxatives or stool softeners, saline cathartics, stimulant cathartics, lubricant or emollient laxatives, and miscellaneous. Individual drugs are listed in Drugs at a Glance: Laxatives and Cathartics.
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4. Dispose of contaminated materials (eg, needles, syringes, ampules, vials, IV tubing and bags) in puncture-proof containers labeled "Warning: Hazardous Material." 5. Wear gloves when handling clients' clothing, bed linens, or excreta. Blood and body fluids are contaminated with drugs or metabolites for about 48 hours after a dose. 6. Wash hands thoroughly after exposure or potential exposure. 7. Follow recommended procedures for cleaning up spills.
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As a nursing student, you are assigned to a unit where abortions are performed. Your religious and family upbringing has taught you that abortion is an immoral act. Do you have a right to refuse to participate in an experience involving abortion as a student? If so, how might you approach your instructor about this issue? Would this situation be different if you were a regular employee on a unit that performs abortions?
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Drugs at a Glance: Abortifacients, Prostaglandins, Tocolytics, and Oxytocics Neuroscientific Foundations for Rehabilitation
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A variety of spatial impairments affect patients undergoing neurorehabilitation. These range from right posterior parietal lesions that cause a hemineglect to the left parietal lesions of the Gerstmann syndrome that includes left/right confusion, finger agnosia, and the inability to report which finger is touched. Poor spatial localization by vision or touch may be detected on the patient's body, within the patient's peripersonal space, or beyond the patient's reach. Short-term or long-term spatial memory may be impaired. The neural network for these distributed functions includes the posterior parietal cortex, especially BA 7, which transforms visual, touch, and proprioceptive stimuli, the frontal eye fields and adjacent prefrontal cortex, and the cingulate region.99 Figure 9–6 shows the network effects of a thalamic infarction that deafferented the parietal region to produce contralateral spatial hemiinattention. Spatial information is represented by the patterns of firing of neuronal groups, which are sensitive, for example, to where a visual image falls on the retina, the angle of the head, and the location of the eyes in their orbits.365 The parietal regions project to the premotor cortex and putamen as an arm-centered and headcentered spatial coordinate system. Parietal projections also go to the frontal eye fields, superior colliculi, and other areas to control saccadic eye movements to locate objects in space, and send information to the entorhinal cortex, hippocampus, and DLFPC to hold memories about the location of items in space. The sum of these functions allows the perception and recall of space. The posterior parietal regions seem to provide a holistic impression of space.99 They assist in planning and
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Language Network NEUROPHARMACOLOGIC MANIPULATIONS
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Cell replacement in a circuit Contact with intact cells, altering their activity Myelination Provide diffusable molecules (e.g., neurotrophins) Provide nondiffusable molecules (e.g., neurotransmitters)
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EXPERIMENTAL CASE STUDIES 2–6: Pharmacologic Interventions for Plasticity
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47. 157. Liepert J, Bauder H, Miltner W, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000; 31:1210–1216. 158. Liepert J, Miltner W, Bauder H, Sommer M, Dettmers C, Taub E, Weiller C. Motor cortex plasticity during constraint-induced movement therapy in stroke patients. Neurosci Lett 1998; 250:5–8. 159. Nelles G, Jentzen W, Jueptner M, Muller S, Diener H. Arm training induced brain plasticity in stroke studies with serial positron emission tomography. NeuroImage 2001; 13:1146–1154. 159a. Carey JA, Kimberley T, Lewis S, Averbach E, Dorsey L, Rundquist P, Ugurbil K. Analysis of fMRI and finger tracking training in subjects with chronic stroke. Brain 2002; 125:773–788. 160. Levy C, Nichols D, Schmalbrock P, Keller P, Chakeres D. Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraint-induced movement therapy. Am J Phys Med Rehabil 2001; 80:4–12. 161. Dobkin B, Sullivan K. Sensorimotor cortex plasticity and locomotor and motor control gains induced by body weight-supported treadmill training after stroke. Neurorehabil Neural Repair 2001; 15:258. 162. Dobkin B, Davis B, Bookheimer S. Functional magnetic resonance imaging assesses plasticity in locomotor networks. Neurology 2000; 54(suppl 3):A8. 163. Dobkin B. Spinal and supraspinal plasticity after incomplete spinal cord injury: Correlations between functional magnetic resonance imaging and engaged locomotor networks. In: Seil F, ed. Progress in Brain Research. Vol. 128. Amsterdam: Elsevier, 2000:99– 111. 163a. Conforto A, Kaelin-Lang A, Cohen LG. Increase in hand muscle strength of stroke patients after somatosensory stimulation. Ann Neurol 2002; 51:122–125. 163b. Fraser C, Power M, Hamdy S, Rothwell J, Hobday D. Driving plasticity in human adult motor cortex is associated with improved motor function after brain injury. Neuron 2002; 34:831–840. 164. Price C. The anatomy of language: Contributions from functional neuroimaging. J Anat 2000; 197:335–359. 165. Heiss W-D, Kessler J, Karbe H, Fink G, Pawlik G. Cerebral glucose metabolism as a predictor of recovery from aphasia in ischemic stroke. Arch Neurol 1993; 50:958–964. 166. Heiss W-D, Kessler J, Thiel A, Ghaemi M, Karbe H. Differential capacity of left and right hemispheric areas for compensation of poststroke aphasia. Ann Neurol 1999; 45:430–438. 167. Weiller C, Isensee C, Rijntjes M, Huber W, Woods R, Diener HC. Recovery from Wernicke's aphasia: A positron emission tomographic study. Ann Neurol 1995; 37:723–732. 167a. Leff A, Crinion J, Scott S, Turkheimer F, Howard D, Wise R. A physiological change in the homotopic cortex following left posterior temporal lobe infarction. Ann Neurol 2002; 51:553–558. 168. Gabrieli J, Poldrack R, Desmond J. The role of left prefrontal cortex in language and memory. Proc Natl Acad Sci USA 1998; 95:906–913. 169. Cao Y, Vikingstad E, George K. Cortical language activation in stroke patients recovering from aphasia with functional MRI. Stroke 1999; 30:2331–2340.
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IV. Moving out of Synergy (hip at 0°) A. Knee flexion ____________ One-way ANOVA Two-way ANOVA
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Table 8–3. General Therapies for Dysphagia CONTRACTURES
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Low load dynamic splint; turnbuckle orthotic; serial casting
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After reviewing 124 investigations drawn from a literature search of studies done from 1960 to 1990, Ottenbacher and Jannell carried out a meta-analysis of 36 trials.203 These studies met the criteria of including hemiparetic patients with stroke who were given a rehabilitation service in a design that compared at least two groups or conditions for change in a quantifiable functional measure. Outcomes included gait, hand function, ADLs, response times, and visuoperception. From 173 statistical evaluations recorded on the 3717 acute and chronic patients in the 36 trials, the analysis showed that the average patient who received a program of focused stroke rehabilitation or a particular procedure performed better than approximately 65% of the patients in the comparison group. Larger treatment effect sizes were associated with an earlier intervention and younger patients. No association was found in the meta-analysis between the duration of a program and its outcomes. Most of these interventions were, however, rather brief. The authors point out that this synthesis of data is imperfect. The review could not assess the intensity of the interventions or how well they were carried out to be able to judge the integrity of each research study. The authors would not be in a position to detect systematic biases or account for missing data while evaluating the individual studies. In addition, the real impact of the changes in the wide variety of outcome mea-sures used to assess an even wider variety of stroke-related functional problems is unknown. Statistical significance in this meta-analysis does not imply that a change has clinical or functional importance and does not reveal how long a benefit lasted. None of the investigations led to an accepted intervention among therapists. Could the same outcome have been facilitated by any physical or behavioral art? If improvement depends on specific training methods, do gains in one neurologic impairment, say visuoperceptual skills, generalize to decrease disability, for example, in dressing and ambulation? Future clinical trials can draw upon the limitations of prior designs. Functional Electrical Stimulation
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pram, was effective within 3 to 6 weeks in 65% of patients who had become depressed 7 or more weeks after a stroke, compared to recovery in 15% who received a placebo.486 Fluoxetine produced a similar response rate in 4 to 6 weeks.483 Drugs that raise serotonin also diminish outbursts of crying in patients with emotional incontinence487 or apathy after a stroke. Drug dosages, especially for the elderly, should be gradually increased. Rather low dosages may be effective, such as 10 mg of fluoxetine or 25 mg to 50 mg of desipramine (see Chapter 8).
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Acute surgical and neuromedical interventions are based upon the quest to diminish or reverse sensorimotor impairments. The natural history and causes of early and late changes associated with movement give clinicians some of the data trends that aid discussions about impairments and disabilities with patients and the rehabili- 77. 78. 79.
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Trauma with obstruction
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tion in some correlative studies. Left anterior injuries, as in unilateral stroke, are associated with an early, transient depression.222 Other focal and diffuse injuries make it difficult to relate mood disorders to specific sites, however. In the Vietnam Head Injury Study, anxiety and depression were associated with a right orbitofrontal lesion and anger and hostility were related to a left dorsofrontal penetrating injury.223 Late-onset depression in CHI is more closely associated with premorbid psychiatric history and lower psychosocial function than with lesion location.222 Long-term depression and anxiety relate more to problems in social adjustment. A randomized trial comparing cognitive remediation to supportive day treatment for 8 weeks found that depression improved with both approaches.224 Cognitive remediation, which tends to confront patients with their impairments, did not worsen their emotional state or psychosocial adjustment. The effectiveness of psychotherapy is uncertain in the face of memory or language dysfunction and limited awareness of deficits. Although no large randomized clinical trials have compared antidepressant medications for patients with TBI, clinical experience points to the usual effectiveness of especially the selective serotonin reuptake inhibitors (see Chapter 8). PSYCHOSEXUAL DISORDERS Psychosexual dysfunction evolves in up to 50% of patients after TBI. Infrequent intercourse is the most common problem.225 Neuroendocrine dysfunction, pain, neurologic impairments, cognitive and behavioral dysfunction, alterations in libido, bowel and bladder incontinence, and psychosocial issues can often be managed.226 Hypersexuality and disinhibition of sexual activity sometimes follow a medial basalfrontal or diencephalic injury. The Kluver-Bucy syndrome is associated with bitemporal injuries. Change in sexual preference has been related to limbic lesions.227 SLEEP DISORDERS Sleep disturbances are common in the first few months and late after injury.228 Up to half of persons after TBI have difficulty initiating and maintaining sleep, while about one-third complain of somnolence. Management of sleep SALT
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1.12. Representation of Covalent Bond Formation (e.g., hydrogen molecule)
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A stratified epithelium has many layers and forms an effective protection from mechanical and chemical stress. They are found in the skin and lining the openings of lumens such as the mouth, anus, vagina, and urethra. The squamous, cuboidal, and columnar epithelium may be simple or stratified. Squamous Epithelium The squamous epithelium consists of cells that are flat and thin and somewhat irregular in shape. Simple squamous epithelium (see Figure 1.21A) is found in protected regions (being thin and delicate) where absorption takes place or where friction must be minimal. A specific name is given to the epithelium that lines body cavities—mesothelium. The simple epithelium lining blood vessels and heart are called endothelium. A stratified squamous epithelium has many layers. The skin is a good example. In areas such as the skin, where the barrier formed by the epithelium also
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Superficial and Deep Fascia 2.2. Layers of the Epidermis
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Chapter 2—Integumentary System The importance of touch as an avenue for healing of the mind and body cannot be underestimated. Studies of healthy, preterm infants have shown that massage facilitates growth and development.1 The internal state of mind directly affects the surface of the skin, evidenced by blushing when embarrassed or turning pale when frightened. Often, diseases of the mind and body
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Connective Tissue Technique Chapter 2—Integumentary System
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Cranium (8) Occipital (1) Parietal (2) Temporal (2) Sphenoid (1) Ethmoid (1) Face (14); Associated bones (7) Nasal (2); Auditory ossicles (6) Zygomatics (2); Hyoid (1); Frontal (1); Maxillae (2) Palatines (2) Lacrimals (2) Inferior conchae (2); Vomer (1); Mandible (1)
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Angle Body Base Mental protuberance Mental foramen Inferior border of ramus Oblique line
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Biceps brachii Serratus anterior
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Head of talus Navicular Lateral cuneiform Intermediate cuneiform
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Ligament of the costal tubercle Lateral costotransverse ligament
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Range of Motion Carpal bones Proximal
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Head of Fibula STRUCTURE OF SKELETAL MUSCLE Macroscopic Structure of Muscle
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Nucleus The Massage Connection: Anatomy and Physiology
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4.17. Cardiovascular Adaptations With Aerobic Training Many athletes experience the syndrome of overtraining. Here, the athlete fails to adapt to training, with deterioration of normal performance. The athlete has difficulty recovering completely after a workout. Muscle soreness and stiffness; increased susceptibility to infection; gastrointestinal disturbances; sleep disturbances; loss of appetite; overuse injuries; fatigue; altered reproductive function; and mood changes such as apathy, depression, and irritability are some other symptoms. These changes are attributed to biologic and psychological influences. Overtraining syndrome is described as two clinical forms: sympathetic (less common) and parasympathetic (more common). The sympathetic form may reflect a perpetual stimulation of the sympathetic system as a result of the interaction of increased training, competition, and other stresses of day-to-day living. The parasympathetic form is characterized by overstimulation of the parasympathetic system during rest and exercise. It may result from interactions between overload of the neuromuscular, endocrine, nervous, psychological, immunologic, and metabolic (glycogen depletion, amino acid imbalances) factors. There are changes in the function and relationship between the hypothalamus, pituitary, gonads, and adrenal glands. Overtraining may be prevented by adequate rest and recovery between training and proper nutrition and hydration during training. Athletes with overtraining syndrome may require weeks and sometimes even months of rest to recover.
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Superficial head: Flexor retinaculum and the tubercle of the trapezium bone Deep head: Capitate and trapezoid bones and the palmar ligaments of the distal row of carpal bones
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Muscles That Move the Thigh (Continued)
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(Iliacus and psoas are together known as the iliopsoas.) Semitendinosus
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Mylelinated region Bipolar neuron
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wrong direction, normal function does not return. Chances of recovery are high if the cut ends of the axon are in close contact. The rate of growth of axons is about 1 mm to 2 mm per day and recovery depends on the distance the axon has to regrow to reach the structure it originally innervated (see Figure 5.11). Many factors affect the chance of recovery. If the axon is cut close to the cell body, the cell body may die, with no chance of recovery. If a crushing type injury has occurred, partial or, often, full recovery enProximal end Schwann cell Myelin Axon Distal end Endoneurium Fragmented Schwann cell axon Droplets of myelin
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Intensity Discrimination
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The lumbosacral plexus (see Table 5.3) is formed from the ventral rami of segments T12 to S4 and nerves arising from this plexus supply the pelvic gir-
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This nerve may be injured during childbirth, resulting in weakness of the adductor muscles and loss of sensation in the medial aspect of thigh.
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Right side of body Posterior Choroid plexus Pineal gland Occipital lobe
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Central canal of spinal cord There is a gradual, progressive loss of hearing for high frequency tones and the ability to discriminate spoken words.
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Cerebellum 384
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Reproductive System
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In vitro fertilization is the process by which the mature ova is removed, fertilized with a sperm, and implanted in the uterus.
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The Massage Connection: Anatomy and Physiology
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with massage.8 Like breast massage, perineal massage is a specialized technique, accompanied by complex issues that need to be addressed. There is growing evidence to show that massage not only has positive effects on the mother but also on the neonates.9 For example, studies show that preterm infants gain more weight and infants who received massage therapy as newborns show greater weight gain and more optimal cognitive and motor development later.9,10 Massage certainly improves the overall sense of well-being and can help reduce some common complaints such as low back pain and of lower limb edema in pregnant women. It can help relax fatigued muscles that try to compensate for the shift in the center of gravity. Typically, a pregnant woman has a posture where the head is forward, chest is back, hip is tilted forward, the knees are locked, and the feet turned out. As a result, strain is placed on the neck and back muscles. In addition, the hormones secreted during pregnancy result in softening of the cartilage and ligament, increasing the tendency for joint instability and joint pain. Pregnant women who are confined to bed may benefit from the improved circulation, joint movement, and social contact that massage provides. The client's position may need to be adjusted according to individual comfort. In the first trimester, women may be comfortable in the prone or supine position. In the third trimester, clients may feel more comfortable lying on the side or sitting up. This is because, in the supine position, the pressure of the fetus on the inferior vena cava may cause light-headedness, nausea, and backache and pressure on the descending aorta may impede blood flow to the placenta. Also, pressure on the diaphragm may produce shortness of breath. Some women may find a prone position comfortable if proper bolsters are available. For proper support, the therapist should use towels and pillows to fill any spaces. A pillow under the knees may help reduce back pressure when the client is in a half-reclining position. When massaging a pregnant client, the therapist should focus on the neck, chest, lower back, hips, legs, and feet. Acupressure, acupuncture, reflexology, and other techniques can be incorporated to produce relaxation. Deep abdominal massage should be avoided throughout pregnancy. Deep massage and fascial techniques should be avoided over the low back, especially during the first trimester. As the joints are lax, joint mobilization techniques should be avoided throughout pregnancy and up to six months after delivery. Often, pregnant women complain of heartburn. In such cases, the massage should be scheduled at least 2 hours after the last meal to prevent regurgitation. There are some conditions where massage should be avoided or given with great caution during pregnancy. In general, these mothers are identified as hav- in blood in bile
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Hemostasis is the intrinsic process that the body uses to stop bleeding from an injured vessel. As soon as a vessel is cut or damaged, there is a reflexive constriction of the vessel triggered by chemicals such as serotonin that are present in platelet granules and the endothelium of blood vessels. The injured area attracts platelets, which then form a platelet plug.
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Right ventricle Lung Inferior vena cava Hepatic veins Liver
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The tissues are able to regulate, to some extent, their own blood flow. This capacity is referred to as autoregulation. Autoregulation can be compared to the
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Medulla oblongata (vasomotor center) Sensory nerves (pain; from muscle, etc.) Blood vessels Heart FIGURE 8.24. Factors That Affect the Activity of the Vasomotor Center. (green arrows, stimulation; and pink arrows, inhibition of the center)
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Anterior superficial By relieving stress, massage may boost the various functions of the immune system. The number of natural killer cells and their activity increase with massage, suggesting that massage may strengthen the immune system. A significant improvement in immune function has been shown in HIV-positive men after massage. This finding implies that massage can be used as an adjuvant therapy in those with immune-related disorders.
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Thorax Landmarks and Surface Markings of the Diaphragm
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Deoxygenated blood (contracting skeletal muscle) Deoxygenated blood in systemic veins (average at rest) 100 Percentage of hemoglobin saturation 7.4 80 pH = 7.6 7.2 60 Shift to right: ↑ Hydrogen ion ↑ CO2 ↑ Temperature ↑ DPG
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10.16. A Schematic Representation of the Regulation of Respiration
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Fundus Esophagus Cardia Greater curvature
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Digestive stimulants, such as ginger, rosemary, cinnamon leaf, peppermint, citronella, cardamom, and black pepper, have been used to treat constipation. The oils may be added to a warm compress placed over the abdomen to help relieve abdominal pain. Cinnamon and nutmeg oil have been used to treat diarrhea. They may be added to the bath water, massage oil, or to warm compresses to provide relief. Lavender has been found to be particularly useful in treating GI disorders such as colic and indigestion. It is important to note that these essential oils are used externally and should not be taken internally. The supervision and recommendation of a qualified health professional is required for such interventions.
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Chapter 11—Digestive System B
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