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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Giora Pillar, MD, PhD
Is their sojourn here on earth part of a great sacrificial process wherein the Host associated with laws pertaining to our deepest ancestral nature continues to exert its influence When thinking man took his place in the physical world over eighteen million years ago arteria costa rica order 4mg perindopril fast delivery, these Cetacea were already evolved pulse pressure 60 mmhg perindopril 4 mg, already equipped with the bodily parts which would have pulse pressure 53 buy generic perindopril 2mg, had they remained upon land heart attack racing buy perindopril 4mg on-line, brought them into the mainstream of mammalian development leading to biological man. Instead, they adapted to (entered once again, perhaps) the realm of the ocean, the astral sea surrounding our globe. There, hunted and cursed, scarred and covered with the weight of barnacles, they have assumed (like the planet Uranus) a retrograde action in the evolutionary scheme of things and a horizontal position in regard to their axis or spine. The mysterious planet Uranus got its name through what was almost a fluke (if the pun may be permitted). Other names were proposed but it was Uranus which immediately caught on and for reasons scientific and, no doubt, occult became the name by which the world knows it. Whatever the forces working to bring about this appellation might have been, Uranus possesses several remarkable characteristics of great interest when correlated with the symbolism associated with Varuna-Ouranos and the whale. Recently twentieth-century man was afforded a close-up glimpse of the Blue Giant, with its retrograde motion and its mysterious coal-black rings. It is believed that the unusual motion and position of Uranus, as well as the presence of its many retrograde satellites, are due to a terrific "war" or explosion which not only ripped away great chunks of the planet but tipped it over and set it off in its peculiarly renegade pattern. Uranus, unlike Mercury, Venus, Jupiter or Saturn, is not in direct astral and psychic communication with mankind on this globe. According to arcane traditions, it is a guardian of another (unseen) septenary chain of globes within our system. It does not depend upon the physical sun like the other planets, receiving so little of its light and hearkening to a different axis of influence. Like the whale on earth serving as the vehicle on the physical plane for the Host known as Varuna-Ouranos, so too Uranus acts as a witness and vahan in our solar system for an unseen ancestral Host. Covered with a deep electrically charged ocean which is heavily laced with sal ammoniac, it represents an environment not only symbolic of the waters of chaos, but chemically suited to act as a solvent, a dissolving sublimate capable of releasing the "soul" or quicksilver of substances. As the medieval alchemists knew, sal ammoniac dissolves the existing order of things, not to merely "devour" them or render them chaotic but to release a more refined and essential Truth. So fire with water to compare, the ocean serves on high, Up-spouted by the whale in air, To express unwieldy joy. William Cowper Taking in gigantic draughts of the ocean and letting them out again, the whale plows its way along the sea lanes, participating on an unmatched scale in the business of alchemizing lower forms of life. Like Jonah passing three days within its belly, the triple stomach of the whale processes its food and converts it into a larger and more mysterious pattern. There is no way of knowing now how the complex ecosystem of the entire globe would be affected if whales were to disappear from its oceans. Nor is there any way we could anticipate how their absence would affect the spiritual and magnetic climate of life here. Their intelligence would indeed seem to come from afar, and man will be able to understand something about it only when he begins to be prompted by deeper vibrations within his own spiritual memory. In contemplating the life and history and all the rich symbolism associated with the whale, one moves closer to releasing such memories. The whale embodies the powers of regeneration immanent in the cosmic waters and floating unborn in the chaos of our minds. If we sense in its existence the wondrous network that binds us to the intelligence of the One Law, the wholeness of manifest life, its sojourn in this world will not have been in vain. Into the jaws of that meditation, Jonah, motivated by the fearless desire to save his fellows, entered to spend the required period before resurrection. In the fabled belly of the beast the new spiritual life is born, not to those who, like Ahab, mistake the necessary dissolution for evil and take it on as a foe, but to the patient watcher on the bow, the silent one who is willing to devour every form that ignorance takes within himself, whilst ever preserving and witnessing the Divine Immutable Law of Truth. A mariner on the bow one night Looked up to see the stars, He glimpsed a line of golden light Bound earthward from afar. The Light dispersed upon the waves, It marked a phosphor trail, And where it led he strained his gaze To see a breaching whale. Heaven on Earth; for blissful Paradise Of God the garden was, by him in the east Of Eden planted. Paradise Lost, John Milton East of the plains of California lettuce farmers or of ancient Eridu: where indeed is this Eden Did their fallen state echo with a poignant cry for innocence, passed down five thousand years Or was there then and equally now a place of unsullied purity wherein the waters of truth and love flow unfettered and the lion lies down with the lamb But many too have launched their vessel to seek the Blessed Isle or sight the shores of Arcady. Some have risked all in pursuit of Shangri-La hidden within pinnacled shrouds, whilst others have died along forgotten Gobi tracks, lost with the sands of their shifting vision, swallowed in the thirst of their dreams. Has it ever transferred its bliss to a jewelled garden hovering in the world just beyond its reach One of the most intriguing passages to be found in literary archives is that in which Christopher Columbus announced to his royal patrons his supposed discovery of the ascent to the gate of the long lost Garden of Eden. He described an island mountain from whose summit he believed the mighty rivers of Eden came rushing to the sea. Though he felt certain that no one could ever reach this peak without the permission and assistance of God, he was confident that it was indeed the terrestrial paradise and he wrote of the "Mouth of the Dragon" which would have to be braved in approaching it. Navigating just off the coast of Venezuela, Columbus thought that he had reached the fabled Land of Ind (the Indus) which did, indeed, lie east of Eden. But while he mistakenly discovered a new world, Mogul rulers of the fabled land itself were preparing to build pleasure gardens patterned after that which bloomed in the paradisaic poetry of Islam. Set within the confines of a walled square, the four rivers of the world streaming within the carved sandstone channels of such cantons of delight as Shalimar or Naseem Bagh, they would enable at least the consorts of privilege to enjoy a daily blessing of paradise on earth. The idea of paradise is universally stamped in the deepest consciousness of the human race. Often conceived as a walled garden, it has also been sought in a New Jerusalem or, as in the case of the Maori and Celtic peoples, in an Avalon under the sea. Many traditions have persisted in identifying paradise as an island floating on the ocean or surrounded by a lake and rivers. All point to a condition of primordial innocence or hard-won perfection as prerequisite to their entrance, the former suggestive of a Golden Age state, the latter of a spiritual goal. In the centre of the gardens of paradise there is a tree of life, from whose roots spring the four rivers that extend out in the direction of the four cardinal points. Commonly, this tree grows at the heart of a fountain or lake often situated at the top or base of a perfectly formed mountain. Such gardens are always enclosed or surrounded by something which makes entry very difficult. But within the enclosure all is at peace, animals and human beings speaking one language and all living in harmonious accord. The wall may be invisible and the gate unseen by all except one who has the eyes to see it. Whether called the Promised Land, El Dorado, the White Isle, the Green Isle, Shamballa, Arcadia, the Elysian Fields, Eden, Olympus or Jerusalem, they are all believed to be somehow accessible, somehow within the reach of the heroic few who strive mightily to find them. The Greek term paradeisos was first used by Xenophon, who borrowed it from the Persian word pairidaeza, which modern scholars say simply means "around" (pairi) "mould" (diz), pinpointing the wall enclosing the garden. This lack-lustre etymological designation could be happily set aside, but for now it is more relevant to note the importance of the idea to the ancient Persians and the fact that they, as well as the other peoples of Mesopotamia and the mountainous plateau to the north, had always looked eastward for its location. The old Semitic description spoke of the four rivers, naming the Nile, the Euphrates, the Indus and the Phison or Ganges, and spoke of Hawilah (India), the "goldbearing land". Within the heart of Asia itself people such as the Yakuts of Siberia described paradise as the dwelling place of the first man, the place of the tree whose crown is the tethering post of God, They believed that the first man approached the tree to learn the purpose of his life. A female visible within its trunk responded to his unspoken question and told him that he was to become the father of the human race. Among the neighbouring Buriats it was said that a snake called Abyrga waited at the foot of the Zambu tree which rose out of the milk sea of Narvo, from whence sprang the four rivers. Striking parallels spring to mind between these ideas and the story of the goddesses associated with the Yggdrasil tree (under whose roots the serpent Nidhogg abides), causing one to ponder the connection between Siberian and Eddie mythologies.
Physical examinations should include measurement of pressure heart attack damage proven perindopril 4mg, weight blood pressure chart what your reading means order perindopril 2mg with amex, pulse arteria en ingles perindopril 2 mg free shipping, and skin; and heart and lung exams (Feldman & Safer arrhythmia 2013 4 mg perindopril with amex, 2009). Specific lab monitoring protocols have been published (Feldman & Safer, 2009; Hembree et al. Hormone Regimens To date, no controlled clinical trials of any feminizing/masculinizing hormone regimen have been conducted to evaluate safety or efficacy in producing physical transition. As a result, wide variation in doses and types of hormones have been published in the medical literature (Moore et al. Rather, the medication classes and routes of administration used in most published regimens are broadly reviewed. As outlined above, there are demonstrated safety differences in individual elements of various regimens. It is strongly recommend that hormone providers regularly review the literature for new information and use those medications that safely meet individual patient needs with available local resources. Because of this safety concern, ethinyl estradiol is not recommended for feminizing hormone therapy. The risk of adverse events increases with higher doses, particular those resulting in supraphysiologic levels (Hembree et al. Patients with co-morbid conditions that can be affected by estrogen should avoid oral estrogen if possible and be started at lower levels. Some patients may not be able to safely use the levels of estrogen needed to get the desired results. This possibility needs to be discussed with patients well in advance of starting hormone therapy. Androgen reducing medications ("anti-androgens") A combination of estrogen and "anti-androgens" is the most commonly studied regimen for feminization. Androgen reducing medications, from a variety of classes of drugs, have the effect of reducing either endogenous testosterone levels or testosterone activity, and thus diminishing masculine characteristics such as body hair. They minimize the dosage of estrogen needed to suppress testosterone, thereby reducing the risks associated with high-dose exogenous estrogen (Prior, Vigna, Watson, Diewold, & Robinow, 1986; Prior, Vigna, & Watson, 1989). Blood pressure and electrolytes need to be monitored because of the potential for hyperkalemia. However, these medications are expensive and only available as injectables or implants. These medications have beneficial effects on scalp hair loss, body hair growth, sebaceous glands, and skin consistency. Progestins With the exception of cyproterone, the inclusion of progestins in feminizing hormone therapy is controversial (Oriel, 2000). Because progestins play a role in mammary development on a cellular level, some clinicians believe that these agents are necessary for full breast development (Basson & Prior, 1998; Oriel, 2000). Progestins (especially medroxyprogesterone) are also suspected to increase breast cancer risk and cardiovascular risk in women (Rossouw et al. Oral testosterone undecenoate, available outside the United States, results in lower serum testosterone levels than non-oral preparations and has limited efficacy in suppressing menses (Feldman, 2005, April; Moore et al. Because intramuscular testosterone cypionate or enanthate are often administered every 2-4 weeks, some patients may notice cyclic variation in effects. This may be mitigated by using a lower but more frequent dosage schedule or by using a daily transdermal preparation (Dobs et al. Intramuscular testosterone undecenoate (not currently available in the United States) maintains stable, physiologic testosterone levels over approximately 12 weeks and has been effective in both the setting of hypogonadism and in FtM individuals (Mueller, Kiesewetter, Binder, Beckmann, & Dittrich, 2007; Zitzmann, Saad, & Nieschlag, 2006). There is evidence that transdermal and intramuscular testosterone achieve similar masculinizing results, although the timeframe may be somewhat slower with transdermal preparations (Feldman, 2005, April). Especially as patients age, the goal is to use the lowest dose needed to maintain the desired clinical result, with appropriate precautions being made to maintain bone density. World Professional Association for Transgender Health 49 the Standards of Care 7th Version Other agents Progestins, most commonly medroxyprogesterone, can be used for a short period of time to assist with menstrual cessation early in hormone therapy. Bioidentical and compounded hormones As discussion surrounding the use of bioidentical hormones in postmenopausal hormone replacement has heightened, interest has also increased in the use of similar compounds in feminizing/masculinizing hormone therapy. There is no evidence that custom compounded bioidentical hormones are safer or more effective than government agency-approved bioidentical hormones (Sood, Shuster, Smith, Vincent, & Jatoi, 2011). Therefore, it has been advised by the North American Menopause Society (2010) and others to assume that, whether the hormone is from a compounding pharmacy or not, if the active ingredients are similar, it should have a similar side-effect profile. Because feminizing/masculinizing hormone therapy limits fertility (Darney, 2008; Zhang, Gu, Wang, Cui, & Bremner, 1999), it is desirable for patients to make decisions concerning fertility before starting hormone therapy or undergoing surgery to remove/alter their reproductive organs. Cases are known of people who received hormone therapy and genital surgery and later regretted their inability to parent genetically related children (De Sutter, Kira, Verschoor, & Hotimsky, 2002). These discussions should occur even if patients are not interested in these issues at the time of treatment, which may be more common for younger patients (De Sutter, 2009). Besides debate and opinion papers, very few research papers have been published on the reproductive health issues of individuals receiving different medical treatments for gender dysphoria. Another group who faces the need to preserve reproductive function in light of loss or damage to their gonads are people with malignances that require removal of reproductive organs or use of damaging radiation or chemotherapy. Lessons learned from that group can be applied to people treated for gender dysphoria. MtF patients, especially those who have not already reproduced, should be informed about sperm preservation options and encouraged to consider banking their sperm prior to hormone therapy. In an article reporting on the opinions of MtF individuals towards sperm freezing (De Sutter et al. Sperm should be collected before hormone therapy or after stopping the therapy until the sperm count rises again. In adults with azoospermia, a testicular biopsy with subsequent cryopreservation of biopsied material for sperm is possible, but may not be successful. Reproductive options for FtM patients might include oocyte (egg) or embryo freezing. The frozen gametes and embryo could later be used with a surrogate woman to carry to pregnancy. Studies of women with polycystic ovarian disease suggest that the ovary can recover in part from the effects of high testosterone levels (Hunter & Sterrett, 2000). While not systematically studied, some FtM individuals are doing exactly that, and some have been able to become pregnant and deliver children (More, 1998). Patients should be advised that these techniques are not available everywhere and can be very costly. Transsexual, transgender, and gender nonconforming people should not be refused reproductive options for any reason. A special group of individuals are prepubertal or pubertal adolescents who will never develop reproductive function in their natal sex due to blockers or cross gender hormones. At this time there is no technique for preserving function from the gonads of these individuals. World Professional Association for Transgender Health 51 the Standards of Care 7th Version X Voice and Communication therapy Communication, both verbal and nonverbal, is an important aspect of human behavior and gender expression. Transsexual, transgender, and gender nonconforming people might seek the assistance of a voice and communication specialist to develop vocal characteristics. Competency of Voice and Communication Specialists Working with Transsexual, Transgender, and Gender Nonconforming Clients Specialists may include speech-language pathologists, speech therapists, and speech-voice clinicians. In most countries the professional association for speech-language pathologists requires specific qualifications and credentials for membership. In some countries the government regulates practice through licensing, certification, or registration processes (American SpeechLanguage-Hearing Association, 2011; Canadian Association of Speech-Language Pathologists and Audiologists; Royal College of Speech Therapists, United Kingdom; Speech Pathology Australia; Vancouver Coastal Health, Vancouver, British Columbia, Canada). The following are recommended minimum credentials for voice and communication specialists working with transsexual, transgender, and gender nonconforming clients: 1. Specialized training and competence in the assessment and development of communication skills in transsexual, transgender, and gender nonconforming clients.
Moreover 2013 buy perindopril 4 mg with visa, only one study centre reported the data for 37 patients of the 78 originally recruited patients blood pressure medication hydralazine purchase perindopril 4mg without prescription. They used the adhesion of leukocytes and platelets in postcapillary venules of the inflamed colon which is mediated by P-selectin as parameter blood pressure in children buy generic perindopril 8mg online. Whether or not this effect was due to inhibition of leukotriene synthesis or due to another mechanism remains to be elucidated heart attack 911 call generic perindopril 8 mg with amex. Review 82 % out of treated patients went into remission whereas the remission rate for sulfasalazine treatment was 75 % [53]. Chronic colitis: this disease was characterised by the authors [60] as vague lower abdominal pain, bleeding per rectum with diarrhoea and palpable tender descending and sigmoid colon. In this study, thirty patients, 17 males and 13 females aged between 18 and 48 years, were included. Out of 20 patients treated with Boswellia oleogum resin, 18 patients showed an improvement in one or more of the following parameters: stool properties, histopathology as well as scanning electron microscopy, haemoglobin, serum iron, calcium, phosphorus, proteins, total leukocytes and eosinophils. Out of 20 patients treated with Boswellia oleogum resin, 14 went into remission; for the sulfasalazine-treated patients, the remission rate was 4 out of 10. In the control group, 6 out of 10 patients showed similar results with the same parameters. It is characterised by aqueous diarrhoea, histological thickness of the mucosa, and subepithelial collagen band. A difference between both treatments could not be proven to be statistically significant. However, clinical trials with standardised preparations and establishment of appropriate dosages are necessary. Increased production of leukotrienes both during episodes of asthma and in patients with stable asthma was shown [63]. The finding that leukotrienes have proinflammatory biological properties relevant to the pathogenesis of asthma has stimulated the development of many potential therapeutic compounds for blocking these actions. A leukotriene receptor antagonist (Montelukast) is the first mediator antagonist shown to be effective in treating clinical asthma and as such represents one of the most interesting new classes of antiasthma drugs in development at present. Review In Ayurvedic medicine, Salai guggal is used to treat respiratory disorders, i. The demyelination and perivascular mononuclear cell infiltration seen in the central nervous system seems to be a characteristic feature. Multiple sclerosis belongs to those diseases in which increased formation of leukotrienes is thought to play an important pathophysiological role. For testing of drugs, autoimmune encephalomyelitis was used in guinea pigs as an animal model. After daily intraperitoneal dosage of mixed acetylboswellic acids (20 mg/ kg) there was significant reduction of the clinical symptoms in guinea pigs between days 11 and 21. However, the inflammatory infiltrates in the brain and the spinal cord were not significantly less extensive in the treated animals than in the respective control group. So far, no clinical studies in the human disease of multiple sclerosis are available. Other Diseases There is a variety of other diseases where leukotrienes could contribute to their pathophysiology such as cystic fibrosis, adult respiratory distress syndrome, allergic rhinitis, lupus erythematosus, gout, Lyme arthritis, psoriasis, acute pancreatitis, liver cirrhosis, astrocytoma, multiple sclerosis, arteriosclerosis. It has not been studied so far whether or not boswellic acids may be of therapeutic benefit in these diseases. Side Effects There is only little published material as far as unwanted effects are concerned. Taking into account the use of oleogum resin of different Boswellia species in ancient times and nowadays, especially in Eastern and Asian countries, side effects appear not to be a spectacular matter. In the study dealing with ulcerative colitis [53], 6 out of 34 patients complained about retrosternal burning, nausea, fullness of abdomen, epigastric pain and anorexia. Evidence-Based Evaluation In an evidence-based systematic review including written and statistical analysis of scientific literature, expert opinion, folkloric precedents, historical pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing, Bash et al. Analysis of pentacyclic triterpenic acids from frankincense gum resins and related phytopharmaceuticals by high-performance liquid chromatography. A reversed phase high performance liquid chromatography method for the analysis of boswellic acids in Boswellia serrata. Stimulation of leukotriene synthesis in intact polymorphonuclear cells by the 5-lipoxygenase inhibitor 3-oxotirucallic acid. Pharmacology of an extract of salai guggal ex Boswellia serrata, a new non-steroidal anti-inflammatory agent. Anti-inflammatory activity of resins from some species of the plant family Burseraceae. A sensitive and relevant model for evaluating anti-inflammatory activity-papaya latex-induced rat paw inflammation. Immunomodulatory activity of boswellic acids (pentacyclic triterpene acids) from Boswellia serrata. Analgesic and psychopharmacolocigal effects of the gum resin of Boswellia serrata. Anticomplementary activity of Boswellia acids-an inhibitor of C3-convertase of the classical complement pathway. Boswellic acid, a potent anti-inflammatory drug, inhibits rejection to the same extent as high dose steroids. Inhibition of leukotriene B4 formation in rat peritoneal neutrophils by an ethanolic extract of the gum resin exudate of Boswellia serrata. Characterization of an acetyl-11-keto-beta-boswellic acid and arachidonate-binding regulatory site of 5-lipoxigenase using photoaffinity labeling. Effect of arachidonic acid reacylation on leukotriene biosynthesis in human neutrophils stimulated with granulocyte-macrophage colony stimulating factor and formyl-methionyl-leucyl phenylalanine. Granulocyte mediated hepatotoxicity after endotoxin stimulation depends on adhesion and elastase release. Naunyn Schmiedebergs Arch Pharmacol 2001; 363S: R14 37 Syrovets T, Buchele B, Krauss C, Laumonnier Y, Simmet T. Human genome screen to identify the genetic basis of the anti-inflammatory effects of Boswellia in microvascular endothelial cells. Analysis of 12 different pentacyclic triterpenic acids from frankincense in human plasma by high performance liquid chromatography and photodiode array detection. Effect of food intake on the bioavailability of boswellic acids from a herbal preparation in healthy volunteers. Determination of boswellic acids in brain and plasma by highperformance liquid chromatography/tandem mass spectrometry. Urinary excretion of connective tissue metabolites under the influence of a new non-steroidal anti-inflammatory agent in adjuvant induced arthritis. Y-40 138, a multiple cytokine production modulator, protects against D-galactosamine and lipopolysaccharide-induced hepatitis. Protection by boswellic acids against galactosamine/endotoxin-induced hepatitis in mice. Special extract of Boswellia serrata (H 15) in the treatment of rheumatoid arthritis.
Severe psychotic symptoms blood pressure 50 over 30 discount perindopril 4mg with amex, depression blood pressure chart log excel purchase 8 mg perindopril overnight delivery, comorbid substance use disorder blood pressure 210120 order perindopril 2mg without prescription, and adverse life events increase the risk of suicide in persons with schizophrenia (395 arrhythmia and stroke order 2mg perindopril overnight delivery, 698). Other major causes of death also include unnatural causes, such as accidents and traumatic injuries, and medical conditions, such as cardiovascular disorders and respiratory and infectious diseases (387). The incidence of schizophrenia appears to be stable across countries and cultures and over time (701), although there is some controversy on this point, with some studies showing significant variability (703). Earlier reports of declining incidence of schizophrenia over time have not been confirmed (699, 700, 702). The Epidemiologic Catchment Area study in the United States reported a lifetime prevalence rate of schizophrenia of 1. Studies of representative community samples assessed by structured diagnostic interviews in the United States yield estimates of the lifetime prevalence for schizophrenia of 0. Among persons age 65 years and older, the prevalence is probably 1% (528, 707, 708). There are, however, controversies about whether early-onset and late-onset schizophrenia are different or similar disorders. For men, the peak incidence of onset of schizophrenia has been determined to be between ages 15 and 25 years; for women, between ages 25 and 35 years (710). Men experience more negative symptoms and women more affective symptoms (309), although acute psychotic symptoms, either in type or severity, do not differ between the two genders (508, 720). More than 80% of patients with schizophrenia have parents who do not have the disorder (721). Twin studies have found a concordance rate among monozygotic twins of about 50%, compared to 9% for dizygotic twins and siblings (721, 723). Patients with an early onset of schizophrenia were more likely to have a history of birth complications than those with later onsets (744, 745). The mean age at onset of schizophrenia as well as the age at first admission was lower in patients who had a history of substance use and higher in patients without such a history (341, 751). Other risk factors have been associated with an increased risk for schizophrenia (691, 702). They include single marital status, a lower socioeconomic class (525), being raised in an urban environment (755, 756), environmental stress (525), and advanced paternal age (757, 758). Treatment of Patients With Schizophrenia 65 Copyright 2010, American Psychiatric Association. Schizophrenia is by far the most costly mental illness (759) and has been estimated to account for 2. Indirect costs to the patients, their families, other caregivers, and society must also be considered (762). In a British study, the annual indirect costs incurred through productivity loss by patients were estimated to be at least four times the direct costs (763). For each medication or medication class, the available data regarding efficacy are reviewed. Short-term efficacy has generally been measured by reductions in psychopathology (positive, negative, affective, and general symptoms) among treated patients during 6- to 12-week medication trials. An advantage of studies that measure psychopathological changes is that they clearly demonstrate how well a medication can achieve a reduction in the target symptoms. Long-term efficacy has usually been measured by reductions in either relapse or rehospitalization rates among treated patients and by levels of persisting or residual symptoms and general outcome over the course of several years. Relapse rates based on symptom reemergence have varied markedly from study to study, partly because different criteria for the types and severity of symptoms have been used to define relapse. Rehospitalization rates, which may also be used to determine rates of relapse, offer the advantage of reflecting both symptoms and functioning. However, rehospitalization rates are affected by other clinical and nonclinical determinants. In addition, these measures of outcome have been used to define the level of recovery of patients. Antipsychotic medications In this guideline the term "antipsychotic" refers to multiple medications (Table 2), including the first-generation antipsychotic medications and the second-generation agents clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole. In addition to having therapeutic effects, both first- and second-generation antipsychotic agents can cause a broad spectrum of side effects. Side effects of medications are a crucial aspect of treatment because they often determine medication choice and are a primary reason for medication discontinuation. Side effects can complicate and undermine antipsychotic treatment in various ways. The side effects themselves may cause or worsen symptoms associated with schizophrenia, including negative, positive, and cognitive symptoms and agitation (772). Most side effects of antipsychotic treatment result from actions on neurotransmitter systems and anatomic regions beyond those involved in mediating the intended therapeutic effects of the medication. Among the antipsychotic medications, differences in the risk of specific side effects are often predictable from the potencies and receptor binding profiles of the various agents. Some side effects result from receptor-mediated effects within the central nervous system. Side effects that are similar across several classes of agents, including both first- and second-generation antipsychotics, are discussed in Section V. Side effects unique to particular agents are discussed in the respective sections concerning those agents, as are other unique implementation issues. Suggested approaches for monitoring and clinical management of the side effects of antipsychotic medications are outlined in Table 1. Each of these studies compared one or more antipsychotic medications with either placebo or a sedative agent, such as phenobarbital (778), that served as a control. Nearly all of these studies found that the antipsychotic medication was superior for treating schizophrenia. These studies demonstrated the efficacy of first-generation antipsychotic medications for every subtype and subgroup of patients with schizophrenia. Moreover, in reviews of studies that compared more than one firstgeneration antipsychotic medication, Klein and Davis (779) and Davis et al. First-generation antipsychotic medications are effective in diminishing most symptoms of schizophrenia. In a review of five large studies comparing an antipsychotic to placebo, Klein and Davis (779) found that patients who received an antipsychotic demonstrated decreases in positive symptoms, such as hallucinations, uncooperativeness, hostility, and paranoid ideation. Patients also showed improvement in thought disorder, blunted affect, withdrawal-retardation, and autistic behavior. These findings-along with decades of clinical experience with these agents-indicate that first-generation antipsychotic treatment can reduce the positive symptoms (hallucinations, delusions, bizarre behaviors) and secondarily reduce the negative symptoms (apathy, affective blunting, alogia, avolition) associated with schizophrenic psychosis (297). In placebo-controlled comparisons (99, 776), approximately 60% of patients treated with first-generation antipsychotic medication for 6 weeks improved to the extent that they achieved complete remission or experienced only mild symptoms, compared to only 20% of patients treated with Treatment of Patients With Schizophrenia 67 Copyright 2010, American Psychiatric Association.
This arch is formed by the natural resting tension that exists in the finger flexors when the wrist is extended heart attack vol 1 pt 2 discount perindopril 2 mg overnight delivery. A transverse arch arrhythmia newborn purchase perindopril 4mg without a prescription, oriented perpendicular to the longitudinal arch heart attack 30 year old female perindopril 2 mg on line, traverses the hand from one side to the other arrhythmia kamaliya download purchase 4 mg perindopril amex. The arch is formed by the prominences of the muscles on the ulnar side of the hand F i g u r e 4 - 1 5. A, anatomic snuffbox; ft, extensor pollicis tongus; C, extensor pollicis brevis and abductor pollicis longus. A, distal flexion crease of index finger; B, proximal flexion crease of index finger; C web flexion crease of index linger; D, distal palmar crease; E. Deformities caused by flexor tendon laceration vary depending on the tendons involved. Laceration of the superficial tendon alone would produce only a slight break in the arcade of flexion, because the profundus tendon would still be able to flex both interphalangeal joints of the involved finger. The web flexion creases at the level of the web spaces are misleading because they mark the midpoint of the proximal phalanges. The true location of the volar aspect of the metacarpophalangeal joints is signified by the distal palmar creases. Because the palmar skin is the common site of interface between human beings and the surrounding environment, it is frequently subject to lacerations and penetrating injuries. These injuries, in turn, may lead to closed-space infections of the fingers and hand. Localized swelling and erythema of the fingertip, for example, may reflect a felon, the common term for a closed-space infection of the fingertip. Fusiform swelling extending along the middle and proximal phalanges into the distal palm may signify a closed infection of the flexor tendon sheath (sec. This fusiform swelling is one of the four classic signs of flexor tendon sheath infection, often called the four cardinal signs of Kanavel. These would result in localized painful swelling in the first web space or center of the palm, respectively. Epidermal inclusion cysts, the result of old penetrating injuries, may cause nodular swellings of the fingertips or other areas of the volar surface of the fingers. A nodular swelling at the level of the web flexion crease of the fingers is most commonly due to a ganglion of the flexor tendon sheath. These ganglia are normally only a few millimeters in diameter and thus only palpable, although large ones may occasionally be visible. Ganglia hurt because they often lay under the digital nerve and act like a stone pinching the nerve between it and an object carried in the hand. In most individuals two creases, known as the distal palmar flexion crease and the proximal palmar flexion crease, cross the hand. The more transverse portions of these two palmar flexion creases combine to identify the level of the metacarpophalangeal joints of the fingers (transverse palmar crease). Just deep to the palmar skin lies a layer of fascia known as the palmar aponeurosis. However, a visible nodule in line with the ring or little fingers may be the first sign of Dupuytrens disease. This condition, which is often familial and tends to occur in older men, can progress to the formation of longitudinal fibrous bands that gradually pull the involved finger or fingers into a progressively flexed, contracted position. The skin of the palmar surface of the hand is dramatically different from that of the dorsum. The palmar skin is thickened, hairless, and marked with discrete creases that identify the sites of no motion. This bound down thickened skin, not only protects the underlying structures such as the nerves, arteries and tendons, but allows for stability to the skeleton for grasping and manipulating objects. The thenar eminence is created by the muscle bellies of the major intrinsic muscles of the thumb including the flexor pollicis brevis, the abductor pollicis brevis, and the opponens pollicis. The ulnar nerve supplies deep head of the flexor pollicis brevis, whereas the rest of the thenar eminence is innervated by the median nerve. The hypothenar eminence is composed of the intrinsic muscles to the little finger. The smaller size of the hypothenar eminence reflects the reduced strength and opposability of this digit Figure 4-19. B, Laceration of both flexor profundus and superficialis tendons to the index finger. The hypothenar muscles include the abductor digiti minimi (quinti), which forms the medial border of the hand; the flexor digiti minimi (quinti); and the opponens digiti minimi (quinti); all are innervated by the ulnar nerve. Where the hand joins the forearm at the wrist, a series of flexion creases is usually visible. The distal flexion crease of the wrist marks the proximal limit of the flexor retinaculum (transverse carpal ligam e n t ^ the tough fascial tissue that forms the roof of the carpal tunnel. On the lateral border of the wrist, the prominence of the base of the first metacarpal is again visible along the lateral base of the thenar eminence. The tendon of the abductor pollicis longus forms the border of the contour of the wrist as it courses distally to insert on the base of the first metacarpal. Moving medially, the next tendon that is usually visible through the skin is that of the flexor carpi radialis. Between the abductor pollicis longus and the flexor carpi radialis lies the distal portion of the radial artery. Its pulsations are often visible on careful inspection, and this is a good place to palpate the pulse. Running just ulnar and parallel to the flexor carpi radialis tendon is the palmaris longus tendon. This structure, present in about 80% of individuals, can be brought out by asking the patient to pinch the tips of the opposed thumb and little finger firmly together with the wrist in slight flexion. The depression between the flexor carpi radialis and the palmaris longus tendons overlies the median nerve, which is not itself visible. At the ulnar side of the wrist, the pisiform bone creates a bony prominence at the base of the hypothenar eminence. The pisiform is a sesamoid bone within the flexor carpi ulnaris tendon, a structure that is usually visible and defines the medial border of the wrist. The prominence of both the flexor carpi ulnaris and the flexor carpi radialis tendons may be increased by having the patient flex the wrist against resistance. The ulnar artery and nerve lie just radial and deep to the flexor carpi ulnaris tendon. The examiner can feel the tendons move by palpating this spot and asking the patient to flex and extend the fingers. A swelling in this area is indicative of a synovitis that can be idiopathic or rheumatoid synovitis. These ganglia may vary in size from small ones, which are only palpable, to larger, visible ones of 1 cm or more. This perspective furnishes fewer distinguishing landmarks than the other aspects. The superior border of the dorsum of the hand is delineated by the straight contour of the shaft of the fifth metacarpal. A, distal flexion crease; B, abductor pollicis longus; C, palmaris longus; D, flexor carpi radialis; E, median nerve; F, pisiform; G, flexor carpi ulnaris; ft, ulnar artery and nerve; I radial artery; J scaphoid tubercle; K, trapezium; L basilar joint; M, longitudinal interthenar crease; N, flexor digitorum tendons; O. Volar to the metacarpal, the fleshy prominence of the hypothenar eminence bulges toward the examiner. More proximally, the bony prominence of the head of the distal ulna is usually visible on the dorsum of the wrist. In severe cases of rheumatoid arthritis, the carpal bones may sublux volarly with respect to the distal ulna and radius. This subluxation occurs more on the ulnar side than on the radial side, thus accentuating the prominence of the distal ulna. A, Prominence of flexor carpi radialis (solid arrow) and palmaris longus (open arrow) increased by active wrist flexion. Alignment Alignment may be first assessed with the fingers and the thumb fully extended and the wrist in a neutral position. Whether viewed from their dorsal or volar aspects, the fingers and the thumb should appear straight and in alignment with their respective metacarpals. Acute or malunited fractures of the phalanges are the most common cause of angular deviations from normal straight alignment. In this case, the rheumatoid synovitis disrupts the extensor hoods over the heads of the digital metacarpals, allowing the extensor tendons to slide to the ulnar aspect of each metacarpal and thus pull the fingers into flexion and ulnar deviation.
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