T. Rendell. Goshen College.

A further trial onset of stroke vardenafil 10mg with visa erectile dysfunction jacksonville fl, but an extension of this time limit to involving more than 800 patients also found reduced 4 generic 10 mg vardenafil otc erectile dysfunction doctor denver. Ten effectively achieved by using a combination of intra- percent of the total dose is administered as an intra- venous vitamin K and prothrombin complex concen- venous bolus with the remaining 90% delivered trate discount 10 mg vardenafil with amex impotence tumblr, or fresh frozen plasma trusted vardenafil 20mg erectile dysfunction kegel. Aspirin and other antiplatelets or anti- coagulants should be avoided for 24 hours following With intracerebral hemorrhage, thrombolysis is thrombolysis. Hypertension should be gradually Transcranial Doppler ‘sonothrombolysis’, micro- lowered. Raised intracranial pressure can be bubble and intra-arterial thrombolysis administration lowered if necessary. In order that patients obtain the full potential benefit of The efficacy of either dipyridamole, clopidogrel, acute stroke therapies, significant changes in the way or a combination of antiplatelet agents has not been stroke services are configured have been required. It is, however, good practice and an appreciation that patients with suspected stroke 239 to commence appropriate secondary prevention should be transported to an appropriate medical Section 4: Therapeutic strategies and neurorehabilitation antiplatelet therapy at the earliest opportunity in Intracranial pressure should be maintained at appropriate patients. A ‘U-shaped’ association between intracranial pressure can be lowered if necessary. Cerebrovasc Dis 2008; acute post-stroke period, the reduction should be 25:457–507. Recommendations for the Management of Measurement of blood glucose is mandatory for Intracranial Haemorrhage – Part 1: Spontaneous all patients with suspected stroke. Intravenous thrombolysis with between elevated admission plasma glucose and poor recombinant tissue plasminogen activator for acute post-stroke outcome, with increasing stroke severity, hemispheric stroke. The National Institute of Neurological Disorders and lowering of hyperglycemia following acute stroke. Tissue plasminogen routine use of insulin infusion regimens to control activator for acute ischaemic stroke. Randomised double-blind placebo Raised body temperature following stroke is controlled trial of thrombolytic therapy with commonly treated with antipyretic medication. Aspirin and clopidogrel compared years with acute ischaemic stroke: Canadian Alteplase with clopidogrel alone after recent ischaemic stroke or for Stroke Effectiveness Study. J Neurol Neurosurg transient ischaemic attack in high-risk patients Psychiatry 2006; 77(7):826–9. Anticoagulants ultrasound monitoring in stroke patients treated with for acute ischaemic stroke. Thrombolysis with Alteplase treatment in acute cardioembolic stroke: a meta- for acute ischaemic stroke in the Safe Implementation analysis of randomized controlled trials. Detrimental effect of blood pressure reduction in the first 24 hours of acute stroke 17. Glucose-potassium-insulin infusions in recanalization in the first hours after ischemic stroke. Treatment of post-stroke antithrombolytic therapy for ischaemic stroke: the hypertension. N Engl J Med 2005; Groups: The American Academy of Neurology affirms 352(8):777–85. Glucose and insulin therapy in acute acute ischaemic stroke in the Safe Implementation stroke; why delay further? Alteplase infusion followed by subcutaneous insulin treatment in compared with placebo within 3 to 4. Both high and temperature in acute stroke patients is an often blood pressure and low blood pressure were inde- neglected matter although it may have an important pendent prognostic factors for poor outcome. This chapter will summarize consideration that prolongation of the elevated blood the current knowledge regarding the management of pressure may be caused by more severe stroke as the above. However, in most of these studies The association between elevated blood pressure and antihypertensive agents were administrated several recanalization was evaluated in 149 patients after weeks after stroke onset. The authors concluded that namic and metabolic impact of pharmacologically when there is need for or no contraindication against increased systemic blood pressure on the ischemic early antihypertensive therapy, candesartan is a safe core and penumbra was evaluated in rats. Three months after treatment tions including 319 subjects, the small size of the trials began, the active treatment group had a significantly and the inconclusive results limit conclusion as to the lower mortality compared to the placebo group. According to region, but raises the risks of hemorrhagic trans- the American guidelines [21] it is generally agreed formation, cerebral edema, recurrence of stroke and hypertensive encephalopathy. There is an indication to treat blood pressure blood pressure in the acute phase of ischemic stroke only if it is above 220 mmHg systolic or if the mean 244 was found and more research is needed to identify the blood pressure is higher than 120 mmHg. No data are effective strategies for blood pressure management in available to guide selection of medication for the Chapter 17: Management of acute ischemic stroke and its complications lowering of blood pressure in the setting of acute hyperglycemia) or could not be fully classified due ischemic stroke. The recommended medication and to missing data in the oral glucose tolerance test. Several ongoing clinical trials such as pendent of age, stroke type and stroke size. How- these conditions, including impaired vascular tone ever, it is not clear whether hyperglycemia itself and flow, disruption to endothelial function, changes affects stroke outcome or reflects, as a marker, the at the cellular level, intracellular acidosis and severity of the event due to the activation of stress increased aggregation and coagulability. Pretreatment with insulin was found to limit the Among the factors found to contribute to the ischemia. Glucose level is an important risk factor for morbid- In one systematic study [24b] it was shown that ity and mortality after stroke, but it is unclear glucose pathology is seen in up to 80% of acute whether hyperglycemia itself affects stroke out- patients, many of them showing a high probability comes or reflects the severity of the event as a of previously unrecognized diabetes. The study was conducted among 933 hyper- pre-thrombolysis patients, an even more aggres- glycemic acute stroke patients who received glucose- sive approach may be advisable. In the treatment group significantly lowered glucose and blood pressure values were documented; however, Hyperthermia no clinical benefit was found among the treated Several animal studies [35, 36] demonstrated the cor- patients. The time window for treating post-stroke relation of elevated temperature and poor outcome in hyperglycemia still remains uncertain. Similar results were found in variety of methods of insulin administration, includ- human observations. Patients with hyperglycemia temperature was recorded every 2 hours for 72 hours (glucose > 6. Hypothermia was A randomized, multicenter, blinded pilot trial, introduced more than 50 years ago as a protective Treatment of Hyperglycemia in Ischemic Stroke measure for the brain [39]. The aggressive-treatment group was associ- hours after brain injury was not found to be effective ated with somewhat better clinical outcomes, which [41]. Other applications for which therapeutic hypo- were not statistically significant. According to the American high doses ranging between 3900 and 6000 mg daily guidelines [21], even lower serum glucose levels, pos- [42,43], caused only very mild reduction in body sibly between 140 and 185 mg/dl, should trigger temperature, ranging from 0. Despite the current recom- The clinical benefit of this reduction is not well estab- mendation, a more aggressive approach is advised, lished. The use of external cooling aids [44], such as especially in pre-thrombolysis patients. Many ques- cooling blankets, cold infusions and cold washing, tions surrounding the role of glucose lowering ther- aiming at a body temperature of 33 C for 48 to 72 apy remain unanswered [32]. What level of blood hours in patients with severe middle cerebral artery glucose is best for intervention? How long should the insulin Similar results, of decreasing acute post-ischemic Chapter 17: Management of acute ischemic stroke and its complications cerebral edema, were found in a small pilot study Summary of endovascular induced hypothermia [45]. The use Optimal management of hypertension following of an endovascular cooling device which was inserted stroke has not been yet established. A U-shaped rela- into the inferior vena cave was evaluated among tionship between baseline systolic blood pressure and patients with moderate to severe anterior circulation both early death and late death or dependency has territory ischemic stroke in a randomized trial. Stroke patients with impaired consciousness results suggest that this approach is feasible and that showed higher mortality rates with increasing blood moderate hypothermia can be induced in patients pressure. However, the current data do not support the pressure reduction as a secondary prevention of use of induced hypothermia for treatment of patients stroke is well established, but only a few trials have with acute stroke. However, these few peutic potential, hypothermia as a treatment for trials demonstrate a beneficial effect of lowering acute stroke has been investigated in only a few very blood pressure. According to the is still thought of as experimental, and evidence of American guidelines, indication to treat blood pres- efficacy from clinical trials is needed [47]. Glucose level is febrile or non-febrile patients with antipyretics is an important risk factor for morbidity and mortality not proven. In pre-thrombolysis In summary, hypertension, hyperglycemia and patients, an even more aggressive approach may be hyperthermia are common conditions following acute advisable. All three have a major and independent Hyperthermia within the first 24 hours from impact on the severity of outcome. Occasionally, the stroke onset was associated with larger infarct volume benefit of this impact is no less than that of more and worse outcome. Mild induced hypothermia “heroic” strategies such as intravenous and intra- was found to improve neurological outcome and arterial thrombolysis. Despite the lack of consensus reduce mortality following cardiac arrest due to on the data and optimal management, one should ventricular fibrillation, but the current data (few very carefully monitor these three “hyper links” and treat small studies) do not support the use of induced them appropriately. General stroke treatment recommendations Association recommendations in the acute stroke phase. A post-stroke seizure is defined as early if it Administration of anticonvulsants is recommended occurs in the first 2 weeks after the stroke. A seizure to prevent recurrent post-stroke seizures (Class I, occurring later is defined as late [49]. Prophylactic administration of The estimated rate of early post-ischemic stroke anticonvulsants to patients with recent stroke seizures ranges from 2 to 33% and that of late seizures who have not had seizures is not recommended varies from 3 to 67% [50–58]. In an observational study among 1428 patients Bisphosphonates (alendronate, etidronate and after stroke [58], 51 patients (3. In a prospective study comparing lamotrigine versus carbamazepine in 64 patients with post-stroke Post-stroke epilepsy is defined as at least two epi- epilepsy, lamotrigine was found to be significantly sodes of seizures. The overall rate is 3–4% of stroke tolerated and with a trend to be also more efficacious patients. Other predictors for post-stroke seizures found in various studies are cortical location, large infarct, There is no evidence to prefer one antiepileptic drug over the others, but it is advised to avoid evaluated clinically or radiologically, intracerebral phenytoin because of interactions with anticoagu- hemorrhage and cardiac emboli, most probably due lants and salicylates. Patients in this population most frequent and important neuropsychiatric conse- should be advised to avoid factors increasing the risk quence of stroke and has a major impact on func- of seizures, such as certain drugs [60]. Once again, the large variation risk factor for the development of seizures in stroke in frequencies is due to methodological differences, patients [61]. Late seizures are due to the development of A systematic review [68] of collected data from 51 tissue gliosis and neuronal damage in the infarct area observational studies conducted between 1977 and [63]. An interesting question is whether post-stroke 2002 found that the frequency of post-stroke depres- seizures worsen the outcome of patients after stroke. Patients with depression were followed for start treatment after the first episode and the second 2 years. According most of whom had minor depression with dysthy- to the common clinical approach, treatment should mia, rather than major depression, and adaptation be initiated only after the second episode. Beginning tralian study [70] found that among stroke patients treatment after early-onset seizures has not been asso- in rehabilitation the depressed ones were eight times ciated with reduction of recurrent seizures after dis- more likely to have died by 15-month follow-up than continuing the medication [64]. It is best to roanatomic mechanisms such as disruption of mono- avoid the old drugs, especially phenytoin, because of aminergic pathways and depletion of cortical biogenic their pharmacokinetic profile and interactions with amines, especially in the case of lesions in the left anticoagulants and salicylates [65]. A single study frontal and left basal ganglia territories [72], and has found neurontine to be a safe and effective treat- psychological mechanisms such as the difficulty in 250 ment; however, this recommendation should be taken adjusting to the new limitations and requirements of Chapter 17: Management of acute ischemic stroke and its complications the disease. Differences in the measurement of depression, stroke, but there is less evidence that these agents study design, and presentations of results may also can be effective in a major depressive episode or have contributed to the heterogeneity of the findings. Some studies have found Stroke is an important risk factor for dementia and aphasia as a risk factor, while others have not cognitive decline.

An assessment of the fundus and fetus forms the final part of the primary survey in the pregnant patient order vardenafil 20mg erectile dysfunction diagnosis code. Make a In the event of blood loss the maternal circulation is maintained brief assessment of the fundal height trusted vardenafil 20mg erectile dysfunction medication new zealand, noting any significant uterine by diverting blood away from the uterus with only minimal change tenderness buy cheap vardenafil 20mg on line erectile dysfunction in diabetes ayurvedic view. A fundal height below the umbilicus suggests that if the to the patient vital signs purchase 10mg vardenafil visa erectile dysfunction before 30. The pregnant patient may tolerate a loss fetus is delivered it is unlikely to survive. The introitus should then of up to 20% of their circulating volume without showing clinical be inspected for foetal parts, cord prolapse and significant bleeding. With continued blood loss and reduced ability to compensate due to limited cardiorespiratory reserve there will Box 28. This hypercoagulable state increases the risk of B Breathing deep vein thrombosis and pulmonary embolism. C Circulation D Disability E Exposure Uterus F Fundus / Foetus Uterine growth is the most important anatomical change and will clearly affect the presentation of abdominal disease and trauma. The most anterior presenting organ and therefore the most susceptible patient will often have hand-held maternity notes which may assist you in identifying potential problems. Gestation in weeks Estimated date of delivery Which hospital she is booked into Midwife or obstetric consultant care Complications in this pregnancy Nature of bleeding/pain/fluid loss/discharge Subjective assessment of foetal movements. It usually presents after 20 weeks, but can occur the practitioner has the requisite skills. The uterus should be palpated for tenderness, rigidity, contractions, • Severe pre-eclampsia is characterized by greatly elevated blood foetalpartsandmovements. Iftherehasbeenaspontaneousrupture pressure (>170/110 mmHg), proteinuria and one or more of of membranes the colour of the liquor should also be assessed for the following symptoms: severe headache, visual disturbance, blood or meconium staining. It generally occurs in the third Antenatal emergencies trimester, with 60% of cases reported in the intrapartum period Antepartum haemorrhage or within 48 hours after parturition. The incidence is higher Antepartum haemorrhage is vaginal bleeding after 24 completed in developing countries. The common causes are placental abruption lasting 90 seconds or less, but may be severe and recurrent. The result is Managementofseverepre-eclampsiaandeclampsiarequiresurgent bleeding from the maternal sinuses into the space between the transfer to an obstetric unit. Blood may remain concealed or left lateral position for transfer and oxygen applied if SpO2 <94%. Abruption Monitor the blood pressure en route and pre-alert the obstetric unit usually presents with severe abdominal pain and a hard, tender so that they can prepare drugs and/or theatre. Delay in presentation (up to 48 hours) is not uncommon shouldbemanagedinitiallywithbasicairwayadjucts(e. Further seizures can be prevented • Placenta praevia is when the placenta implants either completely by giving magnesium sulphate 4 g intravenously/intraosseously or partially across the cervical os. If magnesium sulphate is not available and the pregnancy because of intercourse or contractions the tearing of patient has recurrent or prolonged seizures consider parental or maternal blood vessels close to the cervical canal leads to blood rectal benzodiazepines. Emergency prehospital delivery Management of antepartum haemorrhage involves urgent Less than 1% of booked hospital deliveries are born before arrival at transfer to an obstetric unit. Neonatal consequences include a slightly higher perinatal access should be made en route and fluid resuscitation mortality rate (relative risk 5. Pre-eclampsia is a multisystem disorder consisting chiefly of elevated blood pressure (>140/90 mmHg), proteinuria with or First stage of labour The first stage of labour involves cervical effacement and dilatation to 10 cm. There will be an increase in frequency and intensity of Placental abruption Placenta previa contractions during this stage. Second stage of labour The second stage begins when the cervix is fully dilated and is completed with delivery of the baby. In the absence of a midwife able to perform a vaginal examination, the second stage will usually be recognized when the head becomes visible at the introitus (crowning). At this stage delivery is imminent and an emergency prehospital delivery should be prepared for. Allow the head to deliver with gentle support to the perineum Care of Special Groups: The Obstetric Patient 153 (a) (b) (c) Figure 28. Encouraging the mother to pant or breathe through her contractions at this stage will also help control the delivery of the head. If cord is seen around the neck it can be left alone as the body will usually deliver through the loops. The exaggerated Sim’s position should be used to transfer the patient with cord prolapse. The mother is laid on her left side with her head Third stage of labour flat and her buttocks elevated by pillows (Figure 28. The addition The third stage of labour begins with delivery of the baby and of head-down tilt may assist in relieving the pressure of the foetal ends once the placenta has been delivered. Use your fingertips to gently push the presenting of the baby the cord may be cut after it has finished pulsating part upwards and off the cord – this must be maintained during (or immediately if resuscitation is required). Alternatively, pass a urinary catheter and fill the bladder at 3 cm and 6 cm from the baby and divided between the clamps. The increase in bladder In most cases the third stage will be physiological unless Syn- size will elevate the presenting part. Any protruding cord should be tometrine (1-mL vial intramuscularly/intravenously) is available. Owing to the risk of cord rupture and uterine inversion, prehospital application of cord traction is discouraged unless the practitioner is experienced in this technique. Once deliv- Breech presentation ered the placenta should be kept for inspection by the midwife or This is where the presenting part is the feet or buttocks and occurs in obstetrician. The safest means of delivering a breech baby is by caesarean section and if labour is not well established the mother should be transferred urgently to hospital. If the presenting Intrapartum emergencies part is visible at the introitus a vaginal breech delivery will be Cord prolapse required. Urgent midwifery assistance should be requested while Cord prolapse is the descent of the umbilical cord through preparing for delivery. It occurs in <1% of deliv- position and once the breech is visible at the introitus, pushing eries and may lead to foetal hypoxia. Spontaneous delivery of the limbs and trunk is preferable to deliver the head can result in brachial plexus injury and must (Figure 28. Fortunately, most can be managed with the first two ing pressure to the popliteal fossa (Pinard manoeuvre). Avoid trying to ‘pull’ the baby out as this can result in the extension and trapping • McRoberts manoeuvre (Figure 28. The arms should be delivered by sweeping them across the baby’s Hyperflex her legs against the abdomen. Assess the effectiveness face and downwards or by the Lovset manoeuvre – rotation of of the manoeuvre with routine traction (one attempt) before the baby to facilitate delivery of the arms (Figure 28. The baby’s body should be supported direction, just above the maternal symphysis pubis using the heel onyourarm. With the other hand, gentle traction should be aspect of the anterior shoulder towards the foetal chest. Again applied simultaneously to the shoulders, using two fingers to flex assess the effectiveness of the manoeuvre with routine traction the occiput, i. If each of these measures fails the mother should be asked to assume the ‘all fours’ position with her head as low as possible and her bottom elevated. Two attempts should be made to deliver Shoulder dystocia the posterior shoulder with gentle downward traction. Failure of This is when the anterior shoulder becomes impacted behind the delivery at this stage should trigger urgent transfer (in the left lateral symphysis pubis and it occurs in 1% of deliveries. Care of Special Groups: The Obstetric Patient 155 Postpartum emergencies Postpartum haemorrhage This is defined as a blood loss of more than 500 mL after the second stage of labour is completed and can occur within the first 24 hours (primary) or up to 6 weeks following delivery (secondary). As around a litre of blood flows to the placental bed every minute at term it can be catastrophic and life threatening. Possible aetiology includes one of the four Ts: • tone – abnormalities of uterine contraction • trauma – to the genital tract • tissue – retained products of conception • thrombin – coagulation abnormalities. Perform a primary survey including palpation of the uterus (to assess tone) and examination for tears. Estimate the amount of blood loss and then double it to provide a more realistic estimate. Earlyintra- venous access and fluid resuscitation is important but should not delay transfer to hospital. Uterine inversion Inversion of the uterine fundus may occur spontaneously or more commonly as a result of uncontrolled cord traction during the third stage. The patient will complain of severe lower abdominal pain and the uterus may not be palpable as expected around the umbilicus. If a bulging mass is visible at or outside the vaginal entrance an immediate attempt should be made to reduce the uterus manually (Figure 28. The part of the uterus nearest the vagina should be squeezed and eased back into the vagina and the process repeated until the whole Figure 28. Shock can be treated with intravenous fluids en route and atropine (500 μgto 3 mg maximum) administered if bradycardic. Domestic violence, road traffic collisions and falls are the common- Anaesthesia & Intensive Care Medicine 2007; 8:326–331). Theuterusprovidessome access into the uterus are a 22 blade scalpel and pair of Tuffcut degree of protection to the mother from penetrating abdominal scissors. Universal protection including eye protection should be trauma, at the expense of the fetus. Initial evaluation is the same as for the non-pregnant patient Large sterile swabs will be required for packing the uterus after except the patient should be managed in the left lateral position to delivery. A maternity pack with umbilical clamps should be read- prevent compression of the inferior vena cava. Resuscitation of the ied along with equipment for neonatal resuscitation should it be mother provides resuscitation of the fetus. A midline incision (5 cm below the xiphisterum to 3 cm reviewed in hospital after any significant trauma. Protect the bowel and bladder from injury, remembering that the bladder will not have been Cardiac arrest in pregnancy emptied. Sterile Tuffcut scissors may be employed to reduce the Cardiac resuscitation in pregnancy is thankfully rare occurring in risk of injury. When making an incision on the uterus, are thromboembolism, cardiac disease, haemorrhage, hypertensive be careful not to cut the baby. Make an initial incision with the diseaseofpregnancy,sepsis,exacerbationofothermedicaldisorders scalpel (Figure 28. Survival rates are the same scissors cutting through the placenta if necessary (Figure 28. Clamp the cord and cut – pass the baby to a member of the team who can commence neonatal resuscitation.

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Indications: headache cheap 10mg vardenafil with amex erectile dysfunction los angeles, nausea purchase vardenafil 20mg mastercard erectile dysfunction doctors phoenix, constipation order vardenafil 20 mg amex causes of erectile dysfunction in 40s, hepatic cirrhosis order vardenafil 20 mg overnight delivery erectile dysfunction case study, dysmenorrhea aid in duodenal intubation, gastritis due to rigid os T6–7 Dilates the kidneys. Indications: interstitial L3 Stimulates gonads nephritis L5 Contracts urinary bladder. Indications: T7–8 Visceroptosis cystocele, chronic cystitis, enuresis T8 Contraindicated in emphysema S2 Contracts inguinal canal. Contraindicated in cholecystitis This is a synoptic chart of reflexes based upon Abrams (1912), Colson (1953), Cordingley (1925), Gregory (1922), Johnson (1946b) and Puderbach (1925). The milliamp rule limits the amperage density to 1 mA/square inch of the active electrode. Mechanism of action and physiological The smaller pad will demonstrate stronger polar effects effects as compared to the larger dispersive pad The galvanic current produces predictable elec- because, as the size of the electrode decreases, the trochemical and physiological effects at the site current density will increase. The negative pole will of cold applications and the negative pole to hot attract the positively charged hydrogen ions in the applications. There are twice as many hydrogen ions in a 544 Naturopathic Physical Medicine Table 12. Photograph courtesy of Amrex-Zetron Decreases nerve irritability Increases nerve irritability molecule of water and the hydrogen ion is much Indications: validation of efficacy = 4 smaller than the oxygen. Therefore, more bubbles that With the exception of hyperhydrosis, medical galva- are smaller will accumulate at the negative as com- nism is primarily utilized for musculoskeletal com- pared to the positive lead. As like charges repel application of galvanism generally focuses upon the one another, positively charged medications will be role of iontophoresis. Iontophoresis has been found delivered by the positive pole of the circuit and nega- useful in a variety of conditions such as bursitis, plantar tive by the negative. The galvanic current penetrates fasciitis, Peyronie’s disease, allergic rhinitis, edema, into the corium of the dermis only (about 1 mm), not Bell’s palsy, frozen shoulder, fibrositis, dissolution of very deeply into the tissues. The medication is then scar tissue, osteoarthritis, muscular spasm, arthritis, dispersed via capillary circulation to a larger amount tenosynovitis, healing of skin ulcers, lymphedema, of tissue. While the depth of penetration of the current carpal tunnel syndrome, epicondylitis and temporo- and the ionic dispersal are shallow, the field effect mandibular joint disorders (Agresta 2004). The effect of generated is thought by some to affect ionic molecules iontophoresis is generally considered dependent upon at a greater depth. Safety and contraindications Naturopathic indications and application: The galvanic current is relatively safe. Observation of validation of efficacy = 2 the milliamp rule reduces the likelihood of burning In 1955 the American Association of Naturopathic the patient from application of too high amperage. Electrode pads should not be applied applicable in proper form in practically every case over broken skin. Adjunctive galvanic treatment is also recommended The absorption of energy increases kinetic energy, in dysmenorrhea, abscesses, amenorrhea, adhesion and therefore heat increases cellular metabolism in the resorption, bronchitis, colitis, emphysema, endome- treatment field. This is considered the primary effect of tritis, reducing tonsillar swelling, uterine and intesti- diathermy treatment (Jaskoviak 1993d). Another type nal hemorrhage, incontinence, inflammation in its of diathermy application, pulsed short wave dia- second stage, pelvic inflammation, hepatitis, meningi- thermy, was developed in the 1960s. This type of appli- tis, menorrhagia, metrorraghia, migraine, neuralgia, cation allows a pulsed, non-continuous waveform. This theoretically creates an athermal treat- Cordingley (1937) also discusses two techniques that ment where the energy transferred does not apprecia- he describes as ‘general’ and ‘central’ galvanization. The effect of the General galvanization consists of one electrode treatment is theorized to be a product of the primary applied to the sacrum while the other is moved slowly field effect of the energy rather than the secondary along the spine and extremities. General galvani- Thermal effects zation is applied to enhance lymphatic circulation As the tissues resist the flow of current, the physio- (Post-Graduate Study of Naturotherapy 1938a). The result of the vibration is friction that Diathermy has been in continuous clinical use for creates a heating effect. Diathermy literally means ‘through 1–2 inches (2–5 cm) depending upon type of applica- heat’. The thermal effects increase tissue perfusion, is one of the deepest produced by physiotherapy increase capillary pressure and cell membrane perme- modalities (Jaskoviak 1993d). The heat is generated ability, relax muscles, increase transfer of metabolites by the resistance of the tissues to the passage of the across cell membranes, increase local metabolic rate, current. The current is an electromagnetic one in the increase pain threshold, increase range of motion and radio wave frequency. The first diathermy units had decrease tension in collagenous tissues, and enhance a relatively long wave and have been superseded by tissue recovery (Prentice 1998a, Starkey 1999d). The degree of heat delivered to the tissue by short For a period of time microwave diathermy units were wave units is not a quantified unit. Heating in tissue produced but have demonstrated some deleterious occurs as the equivalent of the current density squared health risk; their clinical use is uncommon today, and multiplied by the resistance. Doses are measured by their use not the subject of this section (Prentice 1988a, verbal communication from the patient as to the per- Starkey 1999d). The waveform can be delivered in a constant or pulsed fashion at a variety of intensity settings. The electromagnetic energy is a Athermal effects non-ionizing form of radiation produced at a high A field effect is proposed for pulsed short wave dia- frequency with low amplitude. The absorption of the thermy that is independent of thermal impressions electromagnetic energy by the tissues in the treatment and due solely to the influence of the electromagnetic field results in increased kinetic energy and therefore field. The high frequency of the diathermy wave in cellular ion levels and cell membrane potential, due 546 Naturopathic Physical Medicine Figure 12. Photograph courtesy of Mettler Electronics • a more rapid rate of fibrin fiber orientation and deposition of collagen • improvement in collagen formation • stimulation of osteogenesis • improved healing of the peripheral and central nervous systems. Photograph courtesy of Mettler Diathermy has been utilized for decades with a rela- Electronics tively strong safety record (Prentice 1998b). Most of the negative reported effects attributed to diathermy were associated with microwave diathermy and not to the influence of the wave on the cellular sodium with short wave diathermy (Prentice 1998b, Starkey pump that encourages normalization of the cells’ ionic 1999e). This proposed mechanism has not been sub- of pulsed diathermy is not only a validation of the stantiated (Sanservino 1980). Diathermy should not be applied, or only cautiously • increased number of white blood cells, so, directly over most metal implants (dental histiocytes and fibroblasts in a wound fillings and bridgework excluded), as metal selec- • improved rate of edema dispersion tively heats and can burn the patient. Likewise, dia- • enhanced fat activity thermy should not be used over anything wet, as the • encouragement of canalization and absorption water is likely to turn to steam, potentially resulting of hematoma in a burn. Dry towels should always be used and • reduction of the inflammatory process sensible precautions should be taken to ensure that Chapter 12 • Electrotherapy Modalities 547 the area to be treated is dried, so avoiding common thermy treatment is focused primarily upon its clinical errors. Most dental work is safe and no adverse increased local metabolism, muscle relaxation, trigger response to use over fillings or other dental implants point relaxation and increased tissue repair, including has been reported. Patients with a pacemaker or implanted neurological device Naturopathic indications and should not be allowed within a 25 feet (7. These previous indications are all quite useful in the Diathermy is not used directly over the abdomen of daily practice of a naturopathic clinical setting. There pregnant patients, and generally avoided with preg- are quite a number of other applications for which nancy primarily because of its temperature-elevating diathermy has been utilized. The balance of studies on pregnant physio- been reported in a variety of infectious processes and therapist diathermy operators has shown no con- especially various forms of pneumonia (De Groot sistent significant differences in pregnancy outcomes 1964, Kitaigorodskaia 1956, Ravitskii 1954, Saperov or newborn health when compared with controls 1974, Sergeev et al 1986, Uglov 1965). Diathermy (Guberan et al 1994, Larsen 1991, Lerman et al 2001, reduces the viscosity of mucus and is very useful for Taskinen 1990). In an early study of associated with negative outcome appear to involve diathermy, its introduction and use in hospitals the microwave forms of diathermy and the high decreased pneumonia mortality by 50% (Stewart volume of exposure for operators using diathermy 1923). A study on the usefulness of diathermy in all forms of upper re- mutagenicity for short wave radiofrequency has spiratory infections for several decades (Abbott et al demonstrated no negative effect (Hamnerius 1985). Later evaluation of the case reports of patients with pneumonia and high evidence led to a general consensus that the positive fever receiving diathermy treatments with excellent effects were indirect effects primarily of improved outcome have been published (Abbott et al 1945b). If tion of the vis medicatrix naturae and validation of the there is circulatory insufficiency, caution should be naturopathic approach of improving non-specific used with local treatment of an affected area. However, the latter to enhance the natural resolution of infectious admonition will probably change in the future because processes. He categorized that supports local hyperthermia and tumor treat- conditions into constitutional, local or infectious, and ment (Connor et al 1977, Hurwitz et al 2005, Laptev then described the incorporation of diathermy into 2004, Tilly et al 2005). For local conditions such as an ankle sprain in an otherwise healthy indi- vidual a short local application was recommended. If Constant short wave indications: there was constitutional weakness then treatment was validation of efficacy = 5 directed through the liver. Infectious conditions would Diathermy is used wherever deep heating is indi- require a combination of the two strategies – both cated. Photograph courtesy of • Lung abscess (Wolf 1935k) International Medical Electronics • Mastitis (Wolf 1935l) • Migraine (Wolf 1935m) not would benefit from the predictable physiological • Myocarditis (Wolf 1935c) response of the body to diathermy application. Post-dental surgical wound recovery (Aronofsky 1971), acute whiplash injury and skin grafts have demonstrated benefit. It is considered safe and has shown no increase A long list of positive clinical outcomes is described in microbial populations of affected tissues (Badea in the observational literature on short wave dia- et al 1993). Modern evaluation of these individual condi- with a strong recommendation for use in chronic tions is strongly recommended. A variety of applicators decubitus ulcer treatment (Comorsan et al 1993, Itoh such as rectal, vaginal and urethral sounds existed for et al 1991, Salzberg et al 1995). Improvement in fibro- the application of treatment to the various orifices of nectin synthesis with both local and hepatic treatment the body. It will be seen that the majority of the appli- has shown a positive influence in postsurgical healing cations involve infectious processes and those that do times (Arghiropol et al 1992). Beneficial application Chapter 12 • Electrotherapy Modalities 549 Interestingly, pulsed diathermy applied to metastasiz- ing melanoma cell cultures demonstrated increased cell death for a period of 4 minutes after exposure (Hakkinen et al 1975). It is one of the oldest physiotherapy devices and has been in use since the end of the 19th century. High frequency is essentially a modified Tesla coil that produces a high frequency, high voltage current at low amperage. The rapidly oscillating currents are applied to the body through vacuum glass electrodes. As the current for non-union fracture healing is substantiated by the moves through the electrode, the partially vacuumed observed positive influence on osteoblast differentia- atmosphere inside the glass ionizes and assumes color tion (Lohmann et al 2000) and a positive influence on dependent upon the degree of vacuum. This result is substantiated common color is violet and the units are commonly by research on liver enzymes that shows a beneficial referred to as ‘violet ray’ devices. Mechanism of action and physiological effects Naturopathic indications and When the electrode is applied to the body it induces applications: validation of efficacy = 2 a local current in tissues and creates a local heating The late naturopathic physician Dr Poesnecker effect as the tissues resist the current flow. The described clinical application of pulsed short wave increased resistance promotes increased tissue per- therapy using an indirect approach to enhance organ fusion locally. His treatment was body by thin gauze, electrical sparks will shower directed to hepatic, splenic, renal and adrenal tissue, the skin with a resulting counterirritation effect. If with the goal of enhancing organ metabolism and the electrode current is concentrated into a point it detoxification. He applied this indirect approach in can be used for fulguration and is the current used chronic disorders such as chronic fatigue syndrome in hyfrecation. The effects on tissue have been the higher pulse rates, which have less thermal dis- described as a ‘cellular massage’ (Hewlett-Parsons persion due to the increased frequency, for acute 1968).

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Culture may add to the problem by an emphasis on keeping super-fit order 20 mg vardenafil with mastercard smoking weed causes erectile dysfunction, although hypochondriacs are not noted for taking precautions against health hazards like quitting smoking or taking 1593 a proper diet buy discount vardenafil 20mg on-line statistics for erectile dysfunction. The differential diagnosis is wide and includes illness 1594 1595 phobia and delusional disorder cheap vardenafil 20 mg fast delivery erectile dysfunction medication patents, somatic type buy vardenafil 20mg line erectile dysfunction needle injection video. The patient classically relates her tale in excessive detail but without emotion (unlike the drama of somatisation disorder). Media coverage of illness or hearing of illness in another person may exacerbate health concerns. Underlying disorders include pain due to depression, the physical symptoms of anxiety, and undifferentiated somatoform disorder. The unreasonableness is clearly recognised by the patient and somatic symptoms are not a major component. Mitchill may have described the first case in 1816: Mary Reynolds, an English woman in Pennsylvania. The Bordeaux asylum surgeon Eugène Azam (1822-99) described the case of Félida, a seamstress, during the 1870s. Her primary personality was ‘present’ for the birth of her many children but it appears that it was the secondary personality who became pregnant! Some authors have reported on as much as 100 ‘recent cases’ and others have discovered it in 3. Reporting of individuals with 100 or many more ‘personalities’ have excited some commentators to suggest that there is a competition afoot! A significant proportion of cases report hearing voices that have an internal origin. Among the characteristics of the alternate personality are various mood states, various attitudes toward the primary personality, the same or opposite sex, or different chronological ages. Pierre Janet described the mechanism dissociation - elements of consciousness split off to assume an autonomous existence which analysts invoke for this and many other hysterical phenomena, such as amnesia and fugue states. Hypnosis has its enthusiasts as a diagnostic or therapeutic instrument in these cases,(Maldonado & Spiegel, 2003, p. The alternate personality tends to be blamed for promiscuity, self-mutilation, etc. Many psychiatrists hold that the disorder is iatrogenic and culturally dependent, whilst others believe that it is induced by media coverage. Merskey (1992) described the diagnosis as a ‘misdirection of effort which hinders the resolution of serious psychological problems in the lives of patients’. He retains the right to diagnose occasional changes in temperament (constitutional tendency to react to stimuli in a particular way; component of personality that is heritable, developmentally stable, based on emotion, and immune to social/cultural influence) or apparent personality style as dissociative in nature. Some authors decry the fact that many years passed before the condition was 1597 diagnosed. In dissociative (psychogenic) amnesia the person cannot recall important personal information, usually of a traumatic or stressful nature, and the amnesia is too extensive to be explained by ordinary forgetting. Freeman (1993) wrote that ‘it is probably impossible to distinguish [hysterical] amnesias from conscious malingering unless the patient confesses’. In dissociative 1599 (psychogenic – as distinct from that due to depression or epilepsy) fugue there is sudden, unexpected travel away from home or work, accompanied by inability to recall ones past and confusion about personal identity or the assumption of a new identity. Twilight (dreamy) states are characterised by disorientation for time and place and impaired short term memory, as if dreaming. Therapy (psychological, amytal, or hypnosis) is aimed at helping the patient to recall what happened leading up to the fugue. Brief fugues often resolve spontaneously whereas chronic cases may prove to beyond help. Other culturally determined fugues may include possession states in India, amok in Indonesia, latah in Malaysia, bebainan in Indonesia, and ataque de nervios in Latin America. Leading from these thoughts, it has been suggested, speculatively, that the automaticity of certain dissociative disorders might follow from the separation of self-identification/explicit memory from routine activity/implicit memory. The differential diagnosis of wandering includes psychogenic fugue (long journey, behaviour normal, amnesia – may be patchy – for episode, +/- assumption of new identity, may last for days), postictal fugue (less purposeful and briefer), depression, acute stress disorder, malingering, dementia, delirium, alcoholic ‘black-out’, head injury, and hypoglycaemia. Conversion The term ‘conversion’ assumes transformation of unconscious psychic conflict into a physical symptom. This is difficult ‘prove’ unless there is demonstrable temporal proximity between psychosocial stress and symptom onset or if similar circumstances previously led to ‘conversion’ in the same patient. Conversion disorder is commoner in females (married women in Lahore in one study: Chaudhry ea, 2005) than in males and usually, but not exclusively, commences in late childhood or early adulthood. More severe forms of sexual and/or physical abuse in childhood are reported more often by conversion disorder patients. Culturally sanctioned behaviour or experience would include ladies swooning in years gone by or ‘seizures’ during religious ceremonies. Conversion disorder appears to be more common in rural, less educated, non-Western societies, and may be influenced by lack of opportunity for protest. In people with normal vision this will produce involuntary (opticokinetic) nystagmus. Cases of so-called functional dysphonia have been said to have difficulty 1602 expressing their true feelings! When a supine patient flexes a thigh to lift the leg there is a downward contralateral leg movement that can be felt by the examiner’s hand held under the heel. A patient with psychogenic hemiparesis will show Hoover’s sign (lack of downward movement of the ‘unaffected’ leg when the patient tries to raise the ‘paralysed’ leg). Rutter and Hersov (1985) followed up children diagnosed as having conversion hysteria for 4-11 years and almost half were shown to have an organic disorder! Among the many conditions misdiagnosed as hysteria over the years are temporal lobe epilepsy and basal ganglia A-V malformations. In hysterical aphonia there is no vocal cord paralysis (only voluntary cord adduction is impaired) and the patient may be able to cough or hum. Many conversion disorder patients are subsequently found to have somatisation and other neurotic disorders. Also, Chaudhry ea (2005) followed up 107cases (83% female, mean age at start of 23. Stone ea (2005) conducted a systematic review of the literature and found that there has been a 4% rate of misdiagnosis of conversion symptoms since 1970. Hysterical overlay This term is often employed by psychiatrists to infer an inconsistent miscellany of symptoms, signs and behaviours reminiscent of classical hysterical syndromes but here occurring as a reaction to real organic disorder. It is not sufficient to diagnose conversion or dissociation simply on the basis of the non-finding of an organic disorder – positive evidence of a hysterical illness must be sought. Hysteria, in either its conversion or dissociation guises, is rare after 40 years of age, most cases starting before 35 years. Hysteria with onset in middle or old age may be a harbinger of another primary condition. Hysterical psychosis Some patients, who often have hysterical personality traits, were said to become abruptly and transiently psychotic when under stress. There could also be delusions, paranoid thinking, bizarre depersonalisation, and grossly unusual behaviour. Hirsch and Hollender (1969) suggested that the modern equivalent is borderline personality disorder with brief psychotic episodes. Familial cases may have an earlier onset (not 1606 all cases are familial), affect an excess of males, and be frequently comorbid with tics and 1607 developmental disorders, as well as anxiety, mood and disruptive disorders. With isolation the person is only aware of the affectless idea, the affect and impulse from the idea being repressed. In undoing, a compulsive act is done to prevent or undo consequences imagined to follow thoughts or impulses. Reaction formation involves patterns of behaviour and conscious attitudes exactly opposite to the underlying impulses. Magical thinking means that simply thinking of something causes it to happen (aggressive thoughts frighten the patient). The ambivalent patient harbours love and hate toward the object; this causes conflict that lead to undoing, paralysing doubts and so on. The patient suffers as a result of preoccupation with thoughts or actions that he knows to be inappropriate. He may think about harming someone, being contaminated with dirt or bacteria, or his mind may be filled with obscenities. Obsessional thoughts of harming others with knives may prompt the patient to avoid knives. This is not a true phobic avoidance since the fear is not of knives but of the idea of harming someone with them. Doubts may plague him, such as when he constantly checks to see if he really put that cigarette out. In other words what was seen as anxiety provoking (obsessions) now become anxiety reducing (compulsions)! Compulsions are repetitive behaviours (hand washing, ordering, checking, confessing etc. They also state that not everyone agrees with modern prevalence figures, critics pointing out the scope for exaggeration inherent in the Diagnostic Interview Schedule and use of lay people. For the majority of people such symptoms are often said not to be excessively upsetting, do not take up a large part of their waking hours, and do not significantly interfere with function. They draw a comparison between this situation and depression with and without psychosis. However, Jenike (1989) reported that 20% of the nuclear family have overt obsessive-compulsive neurosis and another 15% have a subclinical form of it. Head-to-head, these two types are characterised respectively by female/male preponderance, late/early age of onset, episodic/chronic course, mild/severe symptoms, frontal/visuospatial neuropsychological impairment, some increase in/excess of soft signs, a good/indifferent treatment response, and a different profile of associated conditions (mood, anxiety and eating disorders v developmental). An increased incidence of obsessive-compulsive symptoms occurs in Sydenham’s chorea and Tourette syndrome. Monoclonal antibodies identify a B- lymphocyte antigen (D8/17) which is a trait marker for susceptibility to rheumatic fever as a complication of group A streptococcal infection. Electrical stimulation research conducted in the early 1970s suggested that the cingulate area might be important in the genesis of compulsive movements. However, caudate volumes have been reported as normal if care is taken to exclude cases with neurological symptoms. There have been reports of increased frontal glucose metabolism and increased blood flow in the medial-frontal cerebral cortex. Statistical parametric mapping of segmented magnetic resonance images revealed increased regional grey matter density in multiple cortical (incl. The present author has found this to be easier in theory than in practice, so enmeshed may third parties become. Stress inoculation training consists of distraction, thought- stopping, and self-guided dialogue.