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By X. Brenton. University of Health Sciences College of Osteopathic Medicine. 2018.

Potential mechanisms by which magnesium can lower the threshold for migraines include such proven effects of lowered magnesium levels as vasoconstriction purchase top avana 80mg without prescription, reduced affinity of serotonin receptors and an easier activation of N- methyl-D-aspartate receptors order 80mg top avana amex. Stress has been shown to result in magnesium depletion cheap top avana 80mg fast delivery, which suggests a possible physiological explanation for the role of stress in triggering migraine headaches. Other potential causes of magnesium deficiency are genetic factors, gastrointestinal disorders (e. An intravenous infusion of 1 g of magnesium sulfate was given to 40 consecutive 20 patients with an acute migraine. Of the responders, 86% had low serum ionized magnesium levels, while of the non-responders only 16% had low values (Figure 1). Oral magnesium supplementation was attempted as prophylactic therapy of migraines in four double-blind 15,21,22 23 trials. The negative study appears to have used a poorly absorbed salt of magnesium, which resulted in diarrhea in 45% of patients in the active arm, compared with 22% in the placebo arm. These trials along with other supporting evidence establish magnesium as a proven treatment for migraine headaches. One of these positive double-blind trials was carried out in 22 children, while another one showed relief of menstrual migraines as well as 15 premenstrual symptoms as measured by the Menstrual Distress Questionnaire. Headache 281 Magnesium oxide, magnesium diglycinate and slow-release magnesium chloride appear to be well tolerated and well absorbed. The dose of magnesium for prophylaxis of migraines ranges between 200 and 400 mg of elemental magnesium. A recent anecdotal report suggested that a daily dose of 150mg of co-enzyme Q10 24 could be helpful in preventing migraine headaches. Herbal remedies Feverfew (Tanacetum parthenium) is the only herbal remedy that was submitted to 25,26 several double-blind trials. Fever few, when taken daily as a prophylactic therapy for migraines, was found to be better than placebo, but not dramatically effective. A review 27 of these trials indicated a trend towards efficacy of feverfew over placebo. A recent trial confirmed the efficacy of feverfew in patients with frequent (at least four in 28 days) 26 migraines in a dosedependent manner. Because feverfew is fairly safe and may help some patients, it is the herb to recommend to patients interested in herbal remedies. Butterbur root (Petasites hybridus) is a toxic plant, but in a highly purified form it recently became available in the USA. One doubleblind study (with several methodological problems) carried out in Germany showed that the highly purified extract of Butterbur root might be effective in 28 the prevention of migraine headaches. Another double-blind, placebocontrolled randomized trial was carried out in the USA and it confirmed the efficacy of this 29 product. Patients should be cautioned against using any Butterbur product other than the ® one used in these trials (Petadolex ) because of the toxic products that are difficult to remove. The available purified commercial product has been subjected to standard 30 toxicology and teratogenicity studies and has been shown to be safe. Guarana (Pauillinia cupana), a relatively recent import from Brazil, is being used for headache relief. However, daily caffeine consumption with a rebound phenomenon is one of the leading causes of frequent and refractory headaches. Guarana and all other caffeine- containing foods, drinks and medications should be avoided in patients with frequent headaches. Anecdotal reports suggest that ingestion of ginger (Zingiber officinale), ginkgo (Ginkgo biloba) or valerian root (Valeriana officinalis), all of which are well tolerated, may help some patients with headaches. Aromatherapy may not appear so far fetched if we consider how much of our brain is devoted to olfaction and that strong odors can almost instantly induce a migraine. A doubleblind study of healthy volunteers showed that an external application of peppermint extract raised the pain threshold and had musclerelaxing and mentally relaxing effect, while eucalyptus had a calming and relaxing effect and improved 31 cognitive performance without an analgesic effect. A study performed by the same group of researchers, using peppermint oil for tension headaches, showed positive 32 results.

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Dif- symptoms such as dyspnea (shortness of breath) and fa- ferences in pH order top avana 80mg mastercard, ischemia order top avana 80 mg amex, Na order top avana 80 mg with amex,K, and Ca can each tigue. Current guidelines for the treatment of CHF in- alter the likelihood of developing toxicity within the dicate that physicians must at least consider including same patient and between individuals. The rela- Mechanism of Action tionship between the heart and the kidney makes intu- Digitalis has the unique characteristic of increasing con- itive sense when one considers the importance of the tractility (positive inotropy) while decreasing heart rate kidney in maintaining an appropriate volume status (negative chronotropy). An analogy that may be useful to results from indirect as well as direct effects of digitalis consider is the situation in which an individual turns on glycosides on the heart. The kidney be- increases acetylcholine release, which in turn is coupled gins to elaborate hormones designed to retain fluid. Opening of this K Many of the problems in CHF result from an inappro- 15 Pharmacological Management of Chronic Heart Failure 155 priate neurohumoral activation by the kidney in re- ing duct of the kidney. Aldosterone enhances salt and sponse to perceived volume depletion from hemor- water retention at the expense of enhanced renal K rhage. Spironolactone enhances diuresis by normally compensatory in the short term for acute blocking sodium and water retention while retaining bleeding. Before diuretics were avail- tant use of the loop diuretic furosemide, which depletes able, rotating tourniquets were used to diminish venous K, dictates careful monitoring of serum potassium to return by ligating the lower extremities. This raises the travascular volume that would otherwise have accumu- intriguing possibility that spironolactone could mediate lated in the lungs. HYDRALAZINE AND NITRATES Loop Diuretics A major advance in the pharmacological management of CHF has been the demonstration that afterload re- Diuretics and their mechanisms of action will be dis- duction improved survival. Loop diuretics, such as reduction was developed for the treatment of mitral re- furosemide (Lasix), block the Na –K –2Cl symporter gurgitation. The resultant cular resistance, as reflected in lower arterial blood pres- effect is delivery of more Na to the distal tubule and sure, resulted in an increase in the percentage of blood enhanced urinary loss of Na and water. Unfortunately, that flowed from the left ventricle to the aorta as op- the resultant increase in urinary excretion of H and K posed to the left atrium (decreased regurgitant fraction). The potential for arrhythmias is The decrease in backup of blood into the lungs provided exacerbated by the loss of Mg and Ca and an un- considerable symptomatic relief from dyspnea, fatigue, derlying vulnerability of the myocardium in CHF. It was reasoned that patients with CHF However, loop diuretics are still part of the mainstay of often also have mitral regurgitation and might similarly therapy for CHF despite these potential problems and benefit from more forward (left ventricle to aorta), as the absence of well-controlled multicenter clinical trials. Moreover, tors were added to digitalis and furosemide was the first furosemide was accepted as the standard of care in all to demonstrate a significant improvement in survival in of the clinical trials that form the basis for recom- CHF. The use of the potassium- adrenoceptor blocking agent or the combination of sparing diuretic spironolactone has been shown to im- the direct vasodilator hydralazine and a nitric oxide– prove survival and is discussed below. There were fewer deaths among the patients on the combina- Spironolactone tion of hydralazine and nitrates. Patients taking prazosin did not benefit, probably because chronic therapy with Spironolactone (Aldactone) is the only diuretic that has prazosin results in tachyphylaxis. The mechanisms of ac- been shown in a double-blind multicenter prospective tion of prazosin, hydralazine, and organic nitrates are clinical trial to improve survival in CHF. It is unclear at present whether the addition of spirono- The relative ease of administration and superior effi- lactone to a combination of digitalis,ACE inhibitor, and cacy of angiotensin-converting enzyme inhibitors and a -blocker will also confer additional benefit. The demonstration of the sur- the epithelial cells in the late distal tubule and collect- vival benefit conferred by vasodilator therapy resulted 156 III DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM in a paradigm shift in the approach to CHF. The ognized that the way to improve survival in heart failure use of an ACE inhibitor results in the elaboration of was not by directly addressing the weakened heart more kinins and less angiotensin II. Thus, the benefits pump but rather by reversing the inappropriate periph- of ACE inhibitors may derive from their elaboration of eral vasoconstriction that results from neurohumoral more kinins in addition to their inhibition of an- activation. Captopril (Capoten) was the original prototype Efforts to elucidate the mechanisms responsible for product, and it was administered three times a day. Prospective multicenter double-blind tive pathways for forming angiotensin II independent of placebo-controlled clinical trials have repeatedly the conversion of angiotensin I to angiotensin II.

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The technical side is currently handled by direct observation and apprenticeship purchase 80mg top avana with amex, with progressive responsibility based on certain steps or levels buy cheap top avana 80 mg on line. One training tool is cadaveric dissection that provides residents the potential to improve anatomic understanding purchase 80mg top avana fast delivery, visuospatial perception, and motor skills. Cadav- eric dissections are interactive, three-dimensional, and relatively transferable to the operating room setting. However, dissection also has important limitations including significant costs (preparation, facilities, instructors, and equipment), limited avail- ability of specimens, and the substantial differences between living and cadaveric tissues. Finally cadaveric dissection involves a substantial time commitment and is not amenable to repeated rehearsal of a specific procedure. Animal dissection provides opportunities to improve visuospatial and motor skills, but the technique has both practical and ethical limitations and the anatomic differences are usually significant. Thus, current training involves a large amount of direct intraoperative assisting to allow direct visualization of human anatomy and exposure and small (but key) cadaveric and small animal dissection experience to augment the clinical experience gained over many years. Technical competence is achieved through “gradual delegation of earned responsibility for investigative and operative care to penultimate levels. Learn to relate and work effectively with colleagues in medicine and surgery and other health care professionals and ensure the development © 2005 by CRC Press LLC of a keen sense of responsibility and compassion toward patients and their families 5. Understand the impacts of neurosurgery on society including medical ethics, health care economics, law, prevention of disease, and promotion of health 6. Develop an understanding of clinical and basic research techniques includ- ing biostatistics and epidemiology Residents must assume graduated responsibility throughout the course of their residencies in terms of background knowledge, pre- and postoperative management, operative experience and independence in decision making. However, supervision is critical to a training program, and feedback from more experienced individuals is essential to education along with a constant and sincere effort to learn on the part of the resident. Patient care is the core background to neurosurgical education and thus intimate knowledge of patients forms the basis for informed decision making and increased participation by residents in patient care decisions and management. The objectives for technical competence build upon progressive training experience in neurosurgical procedures, usually in an apprenticeship mode under direct supervision. The current fixed length residency program is relatively short, compared to the large number of judgment skills, procedures, and care issues that must be adequately taught. For that reason, some flexibility in training length may be important to accommodate and overcome such differences. These limitations are compounded by insufficient exposure to and understanding of less common cases because residents commonly handle more common situations. The skills routinely taught in most residency programs are primarily aimed at a high quality clinical practice situations. They are not necessarily directed toward academic investigations in the fields of basic neuroscience, translational neuro- science, or clinical neuroscience. For many years, the minimum requirement for the adequate pursuit of quality basic neuroscience has been at least 3 to 5 years of experience beyond residency, at the graduate student (i. Unless a clinician investigator is competitive in obtaining funding, it is unlikely that research of sufficiently high quality will continue to make valuable contributions to neurosurgery and the wider field of neuroscience. Developing and maintaining adequate clinical credentials and sufficient research experience to be truly compet- itive are difficult challenges at both the resident trainee and faculty levels. These © 2005 by CRC Press LLC abilities are under-emphasized. The difficulties are compounded by the additional requirements for teaching and mentoring, as well as family commitments and obli- gations (Figure 16. Ethically, family commitments cannot be handled by a sub- stitute person and have a much higher priority than any of the other demands. This initial degree provides some training in clinical investigation and trial design and can provide a base upon which to build further training. Additional career pathways for clinical neuroscience investigation should include training in epidemiology and statistics as well as in clinical trial design and principles of translating neuroscience concepts into clinical utility.

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However buy top avana 80mg with amex, transforming growth factor-beta and hyaluronic acid-rich wound matrix play pivotal roles in scarless repair buy discount top avana 80mg line. The underlying molecular and cellular mechanisms that regulated the repair remain unclear discount top avana 80 mg line, but the ability of spinal cord cells to proliferate appeared important. If the precept from the fetal surgery is true, that the © 2005 by CRC Press LLC neurological sequelae in open NTDs are caused by intrauterine injuries, restoration of cord function should be attainable. In fact, the majority of research has revealed that an injured spinal cord can be restored by reconstituting or reestablishing molec- ular or cellular developmental mechanisms. Paramount for the regeneration of the spinal cord is that the neuron becomes “regeneration-capable” — it can restore the ability to demonstrate axonal growth and proper targeting. A number of genes have been shown to be constitutively expressed or upregulated in response to axonal growth. They have been termed “regeneration-associated genes” and their products include transcription factors such as c-jun, cytoskeleton components such as alpha tubulin, cytoplasmic growth cone proteins such as GAP-43 and CAP-23, and cell adhesion molecules such as NCAM and L1 that are important for growth cone guidance. CNS inhibition to axonal growth is broadly divided into nonper- missive factors related to myelin and the inhibitory nature of the gliotic scar. Proteins identified in CNS myelin (NI-35 and NI-250) have been shown to function as neurite inhibitory factors. They contain reactive astrocytes, microglia, oligodendrocytes, and meningeal cells that form gliotic scars that function as three-dimensional barriers to axonal growth. This finding is indicative of a change in pattern determination, along with a paucity of maturing neurons with evidence of significant inflammatory infiltrate, gliosis, and fibrosis consistent with secondary injury. Regenerative strategies in spinal cord injury include administration of trophic factors, gene therapy, and cell transplantation. Intrathecal administration of trophic factors such as neurotropin, nerve growth factor and glial-derived neurotrophic factor upregulated growth cone proteins such as GAP-43 and CAP-23, propagated axonal regrowth across an area of crush injury, and established functional connections. Trophic genes can be supplied ex vivo to an injured spinal cord by inserting genetically altered cells that produce trophic factors. Other classes of gene candidates are endogenous receptors or morphogens important in embryonic development. For example, retinoic acid (RA) is important in embryonic neural development69 and has been shown to stimulate embryonic neurite outgrowth. Cellular transplantation strategies are aimed at circumventing the inhibitory surround created by the gliotic scar. Candidates for transplantation are neural stem cells and fetal cells that have the potential to develop into mature neurons or glia and restore function by replacing or repairing axons and synaptic relays. The lack of understanding of cell connectivity and patterning and the way that environment responds to injury makes outcomes unpredictable, but unveils a focal point for future study. A final challenge to spinal cord regeneration of a NTD is that most of the studies examined models of acute injury. Reports indicate that 25 to 50% of neurons die as early as 4 weeks postaxotomy,132 while the remaining cells become atrophic. There is some evidence that trophic factors133 and fetal cell transplants134 can enhance survival, even if applied 1 year after injury. Since many patients with open and closed defects will present with neurological dysfunction within this time frame, attempts at spinal cord regeneration remain viable techniques to pursue. Centers for Disease Control, Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other NTDs, WMMR, 41:1–7, 1992. Recent advances in cellular and molecular biology techniques have led to the development of new hypotheses regarding this very important clinical problem. In some ways vasospasm is a misnomer because it implies a reactive vascular tone increase with secondary vessel narrowing. However, a critical difference between an ordinary vasospasm and the vasospasm of DCV is that vessels lose their © 2005 by CRC Press LLC sensitivity to most agents acting directly on vessel walls in DCV. For example, nitric oxide and nitroprusside, among other equivalent agents, normally act directly to significantly dilate smooth muscles in vessel walls, but have little effect in DCV. This contrary phenomenon occurs because the tension in the vessel wall is proportional to the luminal radius; therefore, as the radius of the spastic vessel decreases, the tension in the wall also decreases. Thus, human DCV occurs in a delayed fashion, shows severe luminal narrowing which is not a vasospasm in the usual sense of active muscle contraction, and cannot be relaxed except with mechan- ical dilatation via angioplasty from the luminal side.

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In one–third of patients generic 80 mg top avana overnight delivery, (Ledebouriellla divaricata) discount 80 mg top avana mastercard, Platycodon grandiflorum cheap top avana 80 mg free shipping, the artery narrows again within six months. A surgery, a detour is created with grafted or synthetic homeopath will prescribe remedies based on an in-depth blood vessels. Stress is known to worsen blood pressure and ather- osclerosis, and hasten the progression of the disease. Therapeutic relaxation techniques are, therefore, helpful Expected results adjuncts to treatment. Recommended approaches include Atherosclerosis can be successfully treated, but not yoga, meditation, guided imagery, biofeedback, and cured. In fact, a 2002 study showed that transcen- delayed, stopped, and even reversed by aggressively low- dental meditation, when combined with diet, exercise ering cholesterol and changing the diet. Prevention A healthy lifestyle—eating right, regular exercise, Allopathic treatment maintaining a healthy weight, not smoking, and control- ling hypertension—can reduce the risk of developing ath- Allopathic treatment includes medications, balloon erosclerosis, help keep the disease from progressing, and angioplasty, and coronary artery bypass surgery. By the end of 12 weeks, 48% of the Coronary angioplasty is performed by a cardiologist. New York and Toronto: American Heart Association and American Cancer Society, 1996. The problem is Patience Paradox rare in children and those who customarily go barefoot. The fungi multiply on the skin when it is irritated, weakened, or continuously moist. Blisters that which the skin of the feet, especially on the sole and break, exposing raw patches of tissue, can cause pain and toes, becomes itchy and sore, cracking and peeling away. It is also possible to spread the infection most people will have at least one episode with this fun- to other parts of the body via contaminated bed sheets, gal infection at least once in their lives. The fungi that cause physical examination and by examining a preparation of GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 151 skin scrapings under a microscope. Foods with a foot bath containing cinnamon has been shown to slow high sugar content should be avoided, including undilut- down the growth of certain molds and fungi, and is said ed fruit juice, honey, and maple syrup. The mixture can be then placed in a basin • The feet should be washed daily; care should be taken and used daily to soak the feet. The affected area should be • The feet need to be kept well ventilated, especially in swabbed with an herbal mixture twice daily or the feet the summer; bare feet and sandals are recommended. The tea bags can be soaked in water for about 10 minutes and then placed on the affected areas, or by mak- • Bathing shoes should be worn in public bathing or ing a tincture and directly rubbing the tea onto the toes. Several drops of the • A good quality foot powder should be used to keep the essential oils of tea tree, peppermint (Mentha piperita), or feet dry. Connecticut: McGraw–Hill Professional Publishing, tion is resistant, the doctor may prescribe an oral antifun- 1991. Patience Paradox 152 GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 three servings a week of high carbohydrate foods, such as Atkins diet a piece of fruit or slice of whole-wheat bread. It emphasizes meat, cheese, and Preparations eggs, while discouraging foods such as bread, pasta, fruit, and sugar. However, as with most diets, it is generally considered ap- propriate to consult with a physician and to have a physi- Origins cal evaluation before starting such a nutritional regimen. Atkins, a cardiologist and internist, devel- The evaluation should include blood tests to determine oped the diet in the early 1970s. It first came to public at- levels of cholesterol, triglycerides, glucose, insulin, and tention in 1972 with the publication of Dr. It quickly became a bestseller but unlike most other fad diets, has remained popular. Since then, Atkins authored a number of other books on his Adherence to the Atkins diet can result in vitamin diet theme before his accidental death in 2003. In his books, Atkins recom- mends a wide range of nutritional supplements, includ- ing a multi-vitamin. Among his recommendations, Benefits Atkins suggests the following daily dosages: 300-600 The primary benefit of the diet is rapid and substan- micrograms (mcg) of chromium picolinate, 100-400 tial weight loss. By restricting carbohydrate intake, the milligrams (mg) of pantetheine, 200 mcg of selenium, body will burn more fat stored in the body. According to Atkins, the diet can alleviate symp- tein derived from animal products.

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