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By H. Bufford. Southern University, Shreveport-Bossier City.
There is no practical way to avoid psychological illness) and psychological stress discount amoxil 250mg online infection in gums. With active peptic ulcer dis- CHAPTER 60 DRUGS USED FOR PEPTIC ULCER AND ACID REFLUX DISORDERS 875 the treatment of heartburn. In some cases, clients may ease, helping the client follow the prescribed therapeu- depend on self-medication with over-the-counter drugs tic regimen helps to promote healing and prevent com- and delay seeking treatment for peptic ulcer disease or plications. For prescription or nonprescription uses, cimet- • Diet therapy is of minor importance in prevention or idine is preferably taken by clients who are taking no treatment of peptic ulcer disease. The those that prevent or decrease gastroesophageal reflux of choice of antacid should be individualized to find a gastric contents (eg, avoiding irritant, highly spiced, or preparation that is acceptable to the client in terms of fatty foods; eating small meals; not lying down for 1 to taste, dosage, and convenience of administration. Some 2 hours after eating; elevating the head of the bed; and guidelines include the following: avoiding obesity, constipation, or other conditions that 1. Most commonly used antacids combine aluminum increase intra-abdominal pressure). The combina- Evaluation tion decreases the adverse effects of diarrhea (with • Observe and interview regarding drug use. Calcium carbonate is effective in • Observe for signs and symptoms of complications. Antacids may be used more often now that low doses (eg, 2 antacid tablets 4 times a day) have been shown to be effective in healing gastric and duode- PRINCIPLES OF THERAPY nal ulcers. All of the low-dose regimens contained aluminum, and the aluminum rather than acid neu- Drug Selection tralization may be the important therapeutic factor. Compared with other drugs for acid-peptic disorders, All of the drugs used for acid-peptic disorders are effective low-dose antacids are inexpensive and cause few ad- for indicated uses; the choice of drugs may depend on etiol- verse effects. In addition, tablets are as effective as ogy, acuity, severity of symptoms, cost, and convenience. Antacids with magnesium are contraindicated in • Proton pump inhibitors are the drugs of first choice in renal disease because hypermagnesemia may result; most situations. They heal gastric and duodenal ulcers those with high sugar content are contraindicated in more rapidly and may be more effective in erosive diabetes mellitus. They are also effective in eradicating Simethicone has no effect on intragastric pH but may H. Alginic acid may be useful in clients with (Protonix IV) is a parenteral formulation. If infection is confirmed by appropriate diagnostic tests, agents to eradicate the or- ganisms should be drugs of first choice. The most rec- Guidelines for Therapy With Proton ommended drug regimen is a combination of a PPI and Pump Inhibitors two antibacterial drugs. Recommended doses of PPIs heal most gastric and PPIs for most indications, but are still widely used. Large gastric ulcers Cimetidine may be less expensive but it may cause con- may require 8 weeks. The drugs may be used to maintain healing of gastric and risks of toxicity with several commonly used drugs. A PPI and two antimicrobial drugs is the most effective tent on a weight basis and have a longer duration of ac- regimens for eradication of H. With GERD, higher doses or longer therapy may be In addition, they do not alter the hepatic metabolism of needed for severe disease and esophagitis. Over-the-counter H2RAs are indicated for can maintain symptom relief and esophageal healing. Peptic ulcers usually form in the prostol if pregnant and do not become pregnant while tak- stomach or first part of the small bowel (duodenum), ing the drug. If pregnancy occurs during misoprostol where tissues are exposed to stomach acid. Two common therapy, stop the drug and notify your health care provider causes of peptic ulcer disease are stomach infection immediately. Misoprostol can cause abdominal cramps with a bacterium called Helicobacter pylori and taking and miscarriage. Heartburn (also called gastro- are not equally safe in all people and should be selected esophageal reflux disease) is caused by stomach acid carefully.
Practi- patient tries to hold the arm still as resistance tioners emphasize normal postural alignment is applied by the therapist in an opposite di- prior to any movement discount amoxil 500 mg mastercard antibiotics and dairy. Proprioceptive neuromuscular facilita- ceed in a developmental pattern from rolling tion stretching techniques call for an isometric onto the side with arm and leg flexion on the contraction of the muscle under stretch, such same side, to extension of the neck and legs as the hamstrings, followed by a concentric while prone, to lying prone while supported by contraction of the opposing quadriceps muscle the elbows, and then to static and weight-shift- during stretch of the hamstrings, designated as ing movements while crawling on all four ex- contract-relax agonist-contract (CRAC). These mat activities are followed by sequence is thought to alter the responses of sitting, standing, and, finally, walking. Differ- muscle spindles in a way that increases the ent schools vary in their attempts to activate or maximum range of motion; stimulation may in- mimimize reflexive movements and to train crease in force produced by each muscle as functional movements during ordinary physi- well. Similar One of the potential problems with NDT is spiral and diagonal movement patterns are the delay of standing and walking until the pa- later used for functional activities and walking. These be- liefs, however, are not backed by data from Bobath clinical trials or by information drawn from cur- This NDT approach popularized by the Bo- rent theories regarding motor learning and baths aims to give patients control of abnormal practice-induced skills learning and associated patterns of posture and movement associated neuroplasticity. Abnormal movements provide abnormal sure across joints and allows weight bearing, sensory feedback, which reinforces limited, for example, on the arm through the extended nonselective, abnormal movement. They use pressure or support on key proximal limb or Brunnstrom trunk points to inhibit or facilitate movement. For example, the hemiplegic Specific techniques are recommended for each patient with flexor spasticity of an arm that of the 6 stages of recovery that emerge: (1) flac- rides up during walking is trained to bend for- cidity, (2) limb synergies with onset of spastic- ward in a chair with the arm hanging down. The subject slowly out of synergy, (5) selective over synergistic sits upright with the neck flexed while the arm movement, and (6) near normal control. When stages of recovery have been used as both de- the elbow starts to flex again, the patient re- scriptors and, inappropriately, as outcome peats these steps. During the early patients who have persistent hypotonia and stages of recovery, weight bearing, postural re- hemiplegia. Ankle-foot orthoses are discouraged, be- Rood cause braces are believed to facilitate abnormal tone. A survey of threshold receptors are thought to increase United Kingdom physiotherapsits found the tonic responses and low threshold receptors ac- Bobath approach preferred by 67% of senior tivate phasic ones. The Bobath therapists ing, tapping, applying pressure and resistance, said they delay task-related therapies if the pa- and truncal rocking and rolling. The response tient does not have normal tone and cannot use to cutaneous and other sensory inputs is used The Rehabilitation Team 223 to facilitate developmental patterns and then recovery of some motor control must take into purposeful movement. Bobath teaches that these increase abnormal Efficacy of Neurofacilitation Techniques movements, whereas Kabat encourages resist- The approaches of the pioneering schools of ance exercises, and Brunnstrom uses associ- physical therapy were derived from clinical ob- ated reactions early in treatment. At least one servations that drew upon narrow assumptions Brunnstrom technique for eliciting associated about motor control. This approach may both injury following a predictable sequence similar strengthen and improve the motor control of to infant development. None of these assump- hip movements, particularly if resistance is ap- tions can be taken as correct. For example, plied to the normal leg during gait training and techniques for shifting weight onto the affected during treadmill training with body weight hemiparetic leg prior to stepping has been a support. Joint Some of the neurophysiologic principles compression is considered to increase propri- used by the schools appear reasonable. Pre- oceptive and cutaneous stimuli, affect tone, dictable motor responses are elicited by reflex and help train the leg to participate in postural reactions, by vibration to stimulate a muscle tasks. One study, however, suggested that load- contraction,45 by cutaneous stimulation to fa- ing only accentuates the extensor synergy of cilitate a voluntary contraction,46 and by upper the lower leg muscles, rather than facilitating extremity weight-bearing through the ex- normal postural responses. Consider the whole limb precedes more selective move- tonic neck reflexes after a brain injury. Neck extension of motor recovery after hemiplegia by can facilitate extension of the affected arm and Twitchell,42 from which the Brunnstrom tech- flexion of the leg. Neck flexion may produce nique derives its stages, is often quoted as the flexion of the arms and extension of the legs. Manipu- paretic arm is supported to allow free move- lation of the reflexes has not been shown to en- ments of the forearm in a horizontal plane just hance the recovery or quality of movement and below shoulder level, however, flexion and ex- functional use of the limbs, however. The at- tension of the elbow and shoulder often can be tention the schools place on the use of sensory brought out independently. Many patients inputs to elicit and reinforce certain move- have extension of the elbow that comes in ear- ments (see Chapter 1) still has an important lier and better than flexion. Some of the other spe- 224 Common Practices Across Disorders cific hands-on methods of the schools of ther- proach of task-oriented motor learning attempts apy may produce a positive outcome, even if to put this notion into practice. The better-designed studies that have com- TASK-ORIENTED TRAINING pared these approaches have been carried out in patients with stroke (see Chapter 9).
Hepatic metabolism depends blood flow is impaired so that lidocaine molecules in mainly on blood flow and enzyme activity in the liver and pro- the blood are unable to reach drug-metabolizing liver tein binding in the plasma purchase amoxil 250 mg with mastercard bacteria 6 facts. Clients at risk for impaired liver cells, more drug stays in the bloodstream longer. Also, function include those with primary liver disease (eg, hepati- some oral drugs are normally extensively metabolized tis, cirrhosis) and those with disease processes that impair during their first pass through the liver, so that a rel- blood flow to the liver (eg, heart failure, shock, major surgery, atively small portion of an oral dose reaches the sys- or trauma) or hepatic enzyme production. Fortunately, although the liver is the drug molecules is shunted around the liver so that often damaged, it has a great capacity for cell repair and oral drugs go directly into the systemic circulation. Liver function tests should be monitored in clients with fects of drug therapy because of wide variations in liver or at risk for liver impairment, especially when clients function and few helpful diagnostic tests. Indicators of severe hepatic impairment, extrahepatic sites of drug me- hepatic impairment include serum bilirubin levels above tabolism (eg, intestine, kidneys, lungs) may become more 4 to 5 mg/dL, a prothrombin time greater than 1. In some clients, abnormal liver function test re- drug safety and effectiveness are listed here; known guide- sults may occur without indicating severe liver damage lines for particular drug groups are included in appropriate and are often reversible. During drug therapy, clients with impaired liver func- tion require close monitoring for signs and symptoms Drug Therapy in Critical Illness (eg, nausea, vomiting, jaundice, liver enlargement) and abnormal results of laboratory tests of liver function The term critical illness, as used here, denotes the care of (see 4, below). Critically ill clients are at risk for multiple organ effects on hepatic function. Hepatotoxic drugs should failure, including cardiovascular, renal, and hepatic impair- be avoided when possible. If they cannot be avoided, ments that influence all aspects of drug therapy. Overall, crit- they should be used in the smallest effective doses, for ically ill clients exhibit varying degrees of organ dysfunction the shortest effective time. Commonly used hepato- and their conditions tend to change rapidly, so that drug phar- toxic drugs include acetaminophen, isoniazid, and macokinetics and pharmacodynamics vary widely. Alcohol is toxic to the blood volume is often decreased, drug distribution is usually liver by itself and increases the risks of hepatotoxicity increased because of less protein binding and increased ex- with other drugs. Drug elimination is usually impaired be- In addition to hepatotoxic drugs, many other drugs cause of decreased blood flow and decreased function of the can cause or aggravate liver impairment by decreasing liver and kidneys. For example, nurses in emergency departments adrenergic blocking agents decrease hepatic blood flow often initiate and maintain treatment for several hours; nurses by decreasing cardiac output. Several drugs (eg, cimeti- on other hospital units care for clients who are transferred to dine, fluoxetine, ketoconazole) inhibit hepatic metabo- or from ICUs; and, increasingly, clients formerly cared for in 66 SECTION 1 INTRODUCTION TO DRUG THERAPY an ICU are on medical-surgical hospital units, in long-term neys, gastrointestinal (GI) tract, liver, and skin. Moreover, increasing numbers result, cardiovascular and central nervous system of nursing students are introduced to critical care during their (CNS) effects may be faster, more pronounced, and educational programs, many new graduates seek employment longer lasting than usual. If the drug is a sedative, ef- in critical care settings, and experienced nurses may transfer fects may include excessive sedation and cardiac to an ICU. Some general guidelines to increase If the client is able to take oral medications, this is safety and effectiveness of drug therapy in critical illness are probably the preferred route. However, many factors listed here; more specific guidelines related to particular drugs may interfere with drug effects (eg, impaired function are included in the appropriate chapters. Drug therapy in clients who are critically ill is often and drug–diet interactions may occur if precautions more complex, more problematic, and less pre- are not taken. For example, antiulcer drugs, which are dictable than in most other populations. One reason often given to prevent stress ulcers and GI bleeding, is that clients often have multiple organ impairments may decrease absorption of other drugs. Another reason is that critically tional solutions through a nasogastric, gastrostomy, ill clients often require aggressive treatment with or jejunostomy tube, there may be drug–food inter- large numbers, large doses, and combinations of actions that impair drug absorption. Overall, therapeutic ef- ing tablets or opening capsules to give a drug by a GI fects may be decreased and risks of adverse reac- tube may alter the absorption and chemical stability tions and interactions may be increased because the of the drug. However, few drugs are available in these for- therapy requires that all involved health care providers mulations. Nurses need to be especially diligent in ad- ution to body cells is unpredictable, the liver cannot ministering drugs and vigilant in observing client metabolize drugs effectively, and the kidneys cannot responses. Dosage requirements may vary considerably among sifications and are also discussed in other chapters. A standard dose may be effective, bials, cardiovascular agents, gastric acid suppressants, subtherapeutic, or toxic.
Accordingly discount 250mg amoxil with mastercard treatment for dogs galis, di¤erential recording of the optical properties of the cerebral cortex at two di¤erent wavelengths provides a signature that is altered by specific neural activity in a fashion that appears to be consistent with maps made with single-electrode electrophysiological techniques. Koulakov These optical visualization techniques provide virtually continuous images from the cortical surface, but these approaches su¤er from shortcomings in temporal reso- lution that today can be mitigated only by multielectrode recording techniques. Spe- cifically, single-microelectrode recordings allow the systems neuroscientist to record the responses of individual neurons (single units) with submillisecond time resolution and with single-neuron spatial resolution. This spatiotemporal resolution cannot be achieved with contemporary optical techniques. In order to extend this capability, electrophysiologists have developed arrays of electrodes that allow one to record simultaneously from large numbers of single units. In order to record from cell bodies deeper within neural tissues, Kruger (Kruger and Aiple, 1988), Wise (Wise and Najafi, 1991), Normann (Jones and Norman, 1992), Eckhorn (Eckhorn et al. These electrode arrays have enabled the simultaneous recording of multi- and single-unit activity from large numbers of neurons in anesthetized animals and in behaving animals. Furthermore, the signal-to-noise ratio of this technique allows one to directly record the neural activity patterns in limited areas of the cerebral cor- tex in real time, and in response to single presentations of sensory stimuli in only moderately restrained animals. It is hoped that the technique will allow systems-level neuroscientists to begin to understand the role of the temporal features of the ensem- ble responses in distributed neural processing. This chapter explores the use of an array of 100 penetrating electrodes (the Utah Electrode Array or UEA) to simultaneously record from large numbers of multiple and single units in the visual cortex of the anesthetized cat. This number of electrodes is su‰ciently large that imaging of the neural activity of localized regions of the ce- rebral cortex is becoming possible. While this microelectrode array currently is being used to study many di¤erent aspects of cortical information processing, we summa- rize here how it can be used to study three basic features of the cortical functional architecture: the neural representations of ocular dominance, orientation sensitivity, and spatial visuotopy. We also demonstrate its use in recording ensemble responses to single presentations of simple visual stimuli. The data obtained from these studies are directly relevant to the problems of devel- oping cortically based sensory and motor neuroprostheses where large numbers of individual neurons must be selectively recorded from or stimulated. We conclude the Imaging 2-D Neural Activity Patterns 45 chapter with a discussion of the use of these microelectrode arrays as a means for restoring a lost sensory sense in those with profound blindness. When implanted in motor pathways, these arrays could also enhance limited or lost motor function in individuals with spinal cord injury or with demyelinating disorders. Measurement Techniques and Instrumentation Experiments were performed under animal care and experimental guidelines that conformed to those set by the National Institutes of Health. Only a brief description of the animal preparation, maintenance, and surgical procedures is given here be- cause they have been fully described elsewhere (Nordhausen et al. Felines were inducted with Telazol, cannulated, intubated, and their heads immobilized. The animals were artificially ventilated and anesthesia was maintained with halothane (approximately 0. The visual cortex was ex- posed by a 1- to 2-cm-diameter craniotomy and the dura reflected. The pupils were dilated, the nictitating membranes were retracted, and the eyelids were sutured open. Gas- permeable contact lenses were placed in each eye to protect the corneas. The retinas were back-refracted onto a tangent screen and the locations of retinal landmarks were recorded on the screen to locate the area centralis (Bishop et al. An acute configuration of the Utah Electrode Array (Cyberkinetics Neurotech- nology Systems, Inc. An electron micrograph of the UEA and a light micrograph of the implant array system are shown in figure 3. The electrode impedance measured with a 1-kHz, 100-nA, sinusoidal signal ranged between 200 and 400 kW, with the typical impedance around 300 kW. The UEA was implanted to a depth of approximately 1 mm at the junction of the lateral and posterior lateral gyri. Neural activity as well as the state of the visual stimulus was recorded by a 100- channel data acquisition system (Cyberkinetics Neurotechnology Systems, Inc.
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