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More specifi- effects include contracting smooth muscles in the bronchi cally pulse pressure of 80 buy discount microzide 25 mg, complement destroys cell membranes of body cells (producing bronchoconstriction and respiratory distress) heart attack racing order genuine microzide online, (eg blood pressure medication young age discount microzide 25mg fast delivery, red blood cells, lymphocytes, platelets) and pathogenic gastrointestinal (GI) tract, and uterus; stimulating salivary, microorganisms (eg, bacteria, viruses). The system is initi- gastric, bronchial, and intestinal secretions; stimulating sen- ated by an antigen–antibody reaction or by tissue injury. Histamine is the vated in a cascade type of reaction in which each component first chemical mediator released in the inflammatory response becomes a proteolytic enzyme that splits the next component and immediate hypersensitivity reactions (anaphylaxis). Activation yields products with profound in- When histamine is released from mast cells and basophils, flammatory effects. C3a and C5a, also called anaphylatox- it diffuses rapidly into other tissues. It then acts on target tis- ins, act mainly by liberating histamine from mast cells and sues through both histamine-1 (H1) and histamine-2 (H2) platelets, and their effects are therefore similar to those of receptors. C3a causes or increases smooth muscle contrac- cells in blood vessels and the respiratory and GI tracts. When tion, vasodilation, vascular permeability, degranulation of histamine binds with these receptors, resulting events in- mast cells and basophils, and secretion of lysosomal en- clude contraction of smooth muscle, increased vascular per- zymes by leukocytes. C5a performs the same functions as meability, production of nasal mucus, stimulation of sensory C3a and also promotes movement of WBCs into the injured nerves, pruritus, and dilation of capillaries in the skin. In addition, it activates the lipoxygenase ceptors are also located in the airways, GI tract, and other pathway of arachidonic acid metabolism in neutrophils and tissues. When histamine binds to these receptors, there is macrophages, thereby inducing formation of leukotrienes increased secretion of gastric acid by parietal cells in the and other substances that increase vascular permeability and stomach mucosal lining, increased mucus secretion and chemotaxis. It enables the body to pro- mine and other mediators) in the bloodstream. More actions, both types of receptors mediate hypotension (in specific reactions include increased vascular permeability, anaphylaxis), skin flushing, and headache. The peak effects of chemotaxis, and opsonization (coating a microbe or other histamine occur within 1 to 2 minutes of its release and may antigen so it can be more readily phagocytized). Thus, cytokines act locally and systemically to produce kotrienes, is derived from arachidonic acid metabolism and inflammatory and immune responses, including increased has multiple inflammatory activities. It is produced by mast vascular permeability and chemotaxis of macrophages, neu- cells, neutrophils, monocytes, and platelets. Two major types of cytokines are cells are widely distributed, PAF effects can occur in virtually interleukins (produced by leukocytes) and interferons (pro- every organ and tissue. Besides causing platelet aggregation, duced by T lymphocytes or fibroblasts). Interleukin-1 (IL-1) PAF activates neutrophils, attracts eosinophils, increases vas- mediates several inflammatory responses, including fever, cular permeability, causes vasodilation, and causes IL-1 and and IL-2 (also called T-cell growth factor) is required for the tumor necrosis factor–alpha (TNF-alpha) to be released. Migraine occurs more often in women than men and may be Dysmenorrhea—pain associated with menstruation; thought associated with menses. As joint cartilage deteriorates over time, ing hyperuricemia may be asymptomatic or may lead to urate there is less padding and lubricating fluid, underlying bone deposits in various tissues. In the musculoskeletal system, is exposed, and friction and abrasion lead to inflammation often in the feet, urate deposits produce periodic episodes of of the synovial membrane lining of the joint. In the comes unstable, more susceptible to injury, and less effi- kidneys, urate deposits may form renal calculi or cause other cient in repairing itself. Migraine—a type of headache characterized by periodic at- Pain in and around the knee occurs early in the disease tacks of pain, nausea, and increased sensitivity to light and process; joint stiffness, edema, and deformity occur as the sound. The disorder that affects hingelike joints, tissues around these etiology is unknown, but one theory is that certain circum- joints, and eventually other body organs (systemic effects). It stances cause an imbalance of chemicals (eg, serotonin, is considered an autoimmune disorder in which the body at- prostaglandins) in the brain. Juvenile rheumatoid arthritis is a sodilation, release of inflammatory mediators, and irritation chronic, inflammatory, systemic disease that may cause joint of nerve endings. Numerous circumstances have been im- or connective tissue damage and visceral lesions throughout plicated as triggers for the chemical imbalance and mi- the body. In inflamed sorbed into the bloodstream, the acetyl portion dissociates, tissues, COX-2 is induced by inflammatory chemical media- then binds irreversibly to platelet COX-1. This action pre- tors such as interleukin-1 (IL-1) and tumor necrosis factor vents synthesis of thromboxane A2, a prostaglandin deriva- alpha (TNF alpha). In the GI tract, COX-2 is also induced by tive, and thereby inhibits platelet aggregation. A small single trauma and Helicobacter pylori infection, a common cause of dose (325 mg) irreversibly acetylates circulating platelets peptic ulcer disease.

The construction of ments evoked by microstimulation of precentral cor- movement by the spinal cord arrhythmia kardiak purchase microzide 25mg amex. Selective activation and of a scalable and programmable hippocampal neural graded recruitment of functional muscle groups network multi-chip module blood pressure medication ratings discount microzide 25 mg line. Responses to spinal microstimu- neural interface for a cortical vision prosthesis heart attack jaw purchase discount microzide on-line. Vision lation in the chronically spinalized rat and their rela- Res 1999; 39:2577–2587. Exp Brain Res 1999; 129:401– practical robotic aid system for people with severe 416. Weng J, McClelland J, Pentland A, Sporns O, Stock- rosci 2000; 20:409–426. Science productivity and quality of care: Robot-aided neuro- 1999; 286:888–890. Volpe B, Krebs H, Hogan N, Edelstein L, Diels C, of a robot arm using simultaneously recorded neurons Aisen M. Devel- nication: self-regulation of slow cortical potentials for opment of robots for rehabilitation therapy: the Palo verbal communication. Electroencephalogr Clin ventional therapy techniques for the rehabilitation of Neurophysiol 1988; 70:512–523. Suffczynski P, Kalitzin S, Pfurtscheller G, Lopes da Phys Med Rehabil 2002; 83:952–959. Wolpaw JR, Birbaumer N, McFarland D, ing arm movement impairment after chronic brain Pfurtscheller G, Vaughan TM. Answering ques- training of paraplegic patients using a robotic ortho- tions with an electroencephalogram-based brain- sis. Hesse S, Werner C, Uhlenbrock D, Frankenberg S, C, Simpson R, Vanderheiden G, eds. An electromechani- Accessible Telecommunications, Information and cal gait trainer for restoration of gait in hemiparetic Healthcare Technologies: IEEE Press, 2002. Biol Cybern 1991; 65:147– environment training improves motor performance in 159. PART II COMMON PRACTICES ACROSS DISORDERS Chapter 5 the Rehabilitation Team THE TEAM APPROACH designations mean something different in the Rehabilitation Milieu every program of inpatient or outpatient care. PHYSICIANS Intensive does not imply a particular intensity Responsibilities of practice. Intensive may mean that a patient Interventions is assigned to 3 hours a day with therapists. In NURSES reality, the patient may actively participate in Responsibilities therapy for considerably less time. Compre- Interventions hensive may mean that most disciplines are PHYSICAL THERAPISTS represented, not that their activities aim to re- Responsibilities store a broad range of functions. To the pa- Interventions for Skilled Action tient, comprehensive care may mean satisfying OCCUPATIONAL THERAPISTS all health-related needs. Responsibilities Inpatient and outpatient therapy are con- Interventions for Personal Independence strained by the costs of care. The duration and SPEECH AND LANGUAGE THERAPISTS intensity of rehabilitation is also constrained by Responsibilities the ability of a therapist or a team to articulate Interventions for Dysarthria and Aphasia the value of continuing to work on an aspect NEUROPSYCHOLOGISTS of disability and to offer an evidence-based SOCIAL WORKERS practice to enhance gains. The length of inpa- RECREATIONAL THERAPISTS tient rehabilitation stays has been declining in OTHER TEAM MEMBERS the United States since 1985. This trend may SUMMARY continue with the institution of a Prospective Payment System under Medicare and Medic- aid (www. The oppor- and personal needs, require a team of profes- tunities to offer patients therapy beyond lim- sionals who partner in inpatient and outpatient ited compensatory skills for basic activities of settings. I will refer to the team of rehabilita- daily living (ADLs) depends upon research that tion specialists, such as nurses, physical thera- demonstrates evidence-based interventions. To- THE TEAM APPROACH gether, they practice the experiential art and science of the possible. In a Rehabilitationists provide what many pro- multidisciplinary model, each member with grams call intensive and comprehensive neu- specialty training treats particular disabilities.

These can be prevented by accompany opiate overdose and require specific treatment gradually withdrawing the offending drug blood pressure normal heart rate high order cheap microzide. CHAPTER 15 SUBSTANCE ABUSE DISORDERS 243 Signs and symptoms of withdrawal can be reversed im- CENTRAL NERVOUS mediately by giving the drug producing the dependence blood pressure of 1200 order discount microzide on line. SYSTEM STIMULANTS Therapeutic withdrawal blood pressure chart sg order microzide toronto, which is more comfortable and safer, can be managed by gradually reducing dosage over Amphetamines and Related Drugs several days. Clonidine, an antihypertensive drug, is some- times used to relieve withdrawal symptoms associated with Amphetamines and related drugs (see Chap. Except for the use of methylphenidate in nence from further opiate usage. Because this goal is rarely treating ADHD, however, the drugs are more important as met, long-term drug therapy may be used to treat heroin de- drugs of abuse than therapeutic agents. One method uses opioid substitutes to prevent with- drawal symptoms and improve a lifestyle that revolves around obtaining, using, and recovering from a drug. Methadone Amphetamine-Type Dependence has long been used for this purpose, usually a single, daily, Amphetamines and related drugs (eg, methylphenidate) pro- oral dose given in a methadone clinic. Proponents say that duce stimulation and euphoria, effects often sought by drug methadone blocks euphoria produced by heroin, acts longer, users. The user may increase the amount and frequency of ad- and reduces preoccupation with drug use. This allows a more ministration to reach or continue the state of stimulation. One normal lifestyle for the client and reduces morbidity and of the drugs, methamphetamine, may be chemically treated mortality associated with the use of illegal and injected drugs. Opponents say that methadone fects of amphetamines are similar to those produced by co- maintenance only substitutes one type of drug dependence caine and are largely dose related. In addition, a substantial percentage of those re- mental alertness, wakefulness, and increased energy. Large ceiving methadone maintenance therapy abuse other drugs, amounts may cause psychosis (eg, hallucinations and para- including cocaine. Another drug approved for maintenance therapy is lev- Acute ingestion of these drugs masks underlying fatigue omethadyl acetate hydrochloride, also called LAAM. LAAM or depression; withdrawal allows these conditions to emerge (Orlaam) is a synthetic, Schedule II opioid indicated only for in an exaggerated form. It is metabolized to long- pression reinforce the compulsion to continue using the acting, potent metabolites. Users may take them alone or to counteract the effects occur within 90 minutes, peak in about 4 hours, and last about of other drugs. Its main advantage over methadone is that it can be pattern of polydrug use in which CNS depressants, such as al- given three times weekly rather than daily. However, if given cohol or sedative-type drugs (downers), are alternated with on a Monday/Wednesday/Friday schedule, the Friday dose CNS stimulants, such as amphetamines (uppers). Also, initial dosage needs care- Treatment of Amphetamine-Type Abuse ful titration to prevent withdrawal symptoms but avoid over- dosage when peak effects occur. Patients must be informed Treatment of amphetamine-type abuse is mainly concerned about the delayed effects of the drug and the risks of over- with overdosage because these drugs do not produce physical dosage if they take other opiates. LAAM has proarrhythmic dependence and withdrawal as alcohol, opiates, and sedative- effects and an electrocardiogram should be done prior to start- hypnotic drugs do. Because amphetamines delay gastric emp- ing the drug and periodically during therapy. The client is likely to be hyper- antagonist that prevents opiates from occupying receptor sites active, agitated, and hallucinating (toxic psychosis) and may and thereby prevents their physiologic effects. Symptomatic tain opiate-free states in the opiate addict, it is recommended treatment includes sedation, lowering of body temperature, for use in conjunction with psychological counseling to pro- and administration of an antipsychotic drug. If the patient taking drugs must be used with great caution, however, because de- naltrexone has mild or moderate pain, nonopioid analgesics pression and sleep usually follow amphetamine use, and these (eg, acetaminophen or a nonsteroidal anti-inflammatory drug) after-effects can be aggravated by sedative administration. If the patient has severe pain and requires an opioid, it should be given in a setting staffed and equipped for cardiopulmonary resuscitation because respiratory depression Cocaine may be deeper and more prolonged than usual. In addition, pa- tients needing elective surgery and opioid analgesics should Cocaine is a popular drug of abuse.

Af- 2 after receiving a pill and a total of approxi- ter discharge from inpatient rehabilitation blood pressure medication bananas discount generic microzide canada, pa- mately 30 hours of speech therapy during the tients and their families often become aware of trial blood pressure log printable discount microzide 25 mg overnight delivery. The investigators screened 859 subjects modest cognitive limitations blood pressure medication extreme tiredness order microzide 25mg mastercard, but they cannot for inclusion over 4 years. The paucity of clusion of the interventions, the dextroam- brief, uniform, standardized tests with alter- phetamine group scored significantly better on nate forms that can be given serially to a pre- the PICA. The dominantly elderly population makes the for- optimal dose and timing of the noradrenergic mal investigation of cognitive dysfunction agent and its efficacy is a work in progress. A prospective study of 227 patients in New York City with ischemic stroke revealed cognitive impairments 3 Piracetam, a derivative of -aminobutyric acid, months after onset in 35% of patients and 4% but with no GABA activity, may facilitate of controls. The middle worth elaborating on the usefulness of relevant period, which can last from 3 to 12 months, measurement tools described in Chapter 7. Patients work on specific cognitive ability, and to categorize behavior. Neuropsychologic and language testing batter- ies for monitoring and planning interventions become more valuable at this stage than in pre- vious ones. The last stage can subsume many the GCS (see Table 7–3) defines the depth behavioral, cognitive, and mood problems of and duration of coma. Struc- used in most outcome studies of TBI and al- tured assessments produce different results lows distinctions regarding severity that have than may be found in real-life situations. For some prognostic meaning when given 6 hours example, disturbances in personality, in the after onset. The GCS is routinely used in emer- ability to attend to multiple environmental gency rooms and by acute trauma clinicians. It stimuli, and to shift logically from one concept should be collected daily if the score is less than to another may not be brought out by routine 15, until the patient is discharged from the hos- pencil-and-paper tests. On the GCS, the sum score of 13–15 is defined as a mild injury, 9–12 is a moderate TBI, and 8 or less is severe. The Extended GCS (GCS-E) was developed to include patients with mild concussion, adding an Amnesia Scale the Disability Rating Scale (DRS) (Chapter 7) with eight categories for the duration of PTA. This 100-point scale is given as soon as structured approach to use of the GOS im- the patient is alert and then daily until the score proves its reliability and lessens subjective ap- is normal. Stages of recovery beyond coma are often On the DRS, scores 15 on admission to re- described by the subjectively defined Rancho habilitation, 7 on discharge, and 4 at follow- Los Amigos Levels of Cognitive Functioning up 3 months after discharge predict the likely (Table 11–7). Simple yes–no answers may be the Mayo-Portland Inventory adds useful rat- possible to elicit. A confusional stage follows ings of emotional behavior to those of func- with PTA, limited attention, and easy dis- tional abilities and physical disabilities. Agitation, hostility, perseveration, Community Outcome Scale, which rates real- 520 Rehabilitation of Specific Neurologic Disorders Therapists may teach skills through proce- some of this procedural memory into the pe- dural memory processes, improve recall with riod of recovery from PTA. These more sophisticated attempts at or on enhancing memory outside of the train- memory remediation cannot be isolated en- ing session. For example, even when recovery is of optimal reinforcement of learning require generally good, the memory performance of further exploration in patients across the range many patients declines in the face of a dis- of contributors to memory impairments. With- performed worse when allowed to generate out this insight or concern about their sense of guesses that produced incorrect responses. During PTA, many patients show frequently deployed memory devices still used an increased rate of forgetting over the course by TBI patients five or more years after being of 30 hours on a visual recognition test com- trained in their use are listed in Table 11–16. Generalized use of a memory notebook Previous exposure to verbal and especially to depends heavily on sparing of procedural nonverbal information can, with cues and memory. Although internal aids may be of prompts, allow many amnestic patients after value within a structured task or setting, their TBI to recall that information, a phenomenon postinjury use often does not generalize to real- called. Patients can be primed to learn auto- with CHI found that a group given memory matic behavioral sequences for a motor, per- strategy training and another given drill and ceptual or cognitive skill, even though they may repetitive practice training on memory tasks recall only nonspecific knowledge about hav- subjectively rated their everyday memory as ing learned or having done the task. Tech- improved, compared to a no-treatment niques to acquire domain-specific knowledge group. For ex- years postinjury, half were employed, and they ample, patients were taught new computer had experienced a mean of 30 days of PTA.

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