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Studies Your assessment of Pamela Kindra reveals the following: indicate that endothelin antagonist drugs improve heart func- 118/92 tadalafil 2.5 mg cheap, 110 tadalafil 20mg mastercard, 32 and labored buy tadalafil 5 mg with mastercard. Respiratory assessment reveals tion, as measured by cardiac index; animal studies indicate coarse rhonchi and wheezing bilaterally. Urine output has been that structural changes of heart failure (eg, hypertrophy) may less than 30 cc per hour and she has gained 12 pounds over the be reversed by the drugs. After examining her, he orders tration (FDA) approved but only for treatment of pulmonary digoxin 0. Discuss specific indications for these drugs in the management of the rationale for your answer. CHAPTER 51 DRUG THERAPY OF HEART FAILURE 749 Assess a baseline ECG before digoxin therapy when Nursing Process possible. If a client is in normal sinus rhythm, later ECGs may aid recognition of digitalis toxicity (ie, drug-induced Assessment dysrhythmias). If a client has an atrial tachydysrhythmia Assess clients for current or potential HF: and is receiving digoxin to slow the ventricular rate, later • Identify risk factors for HF: ECGs may aid recognition of therapeutic and adverse ef- • Cardiovascular disorders: atherosclerosis, hyper- fects. For clients who are already receiving digoxin at the tension, coronary artery disease, myocardial infarction, initial contact, a baseline ECG can still be valuable because cardiac dysrhythmias, and cardiac valvular disease. Within the clinical syndrome of HF, clinical mani- fluid accumulation in lungs festations vary from few and mild to many and severe, • Imbalanced Nutrition: Less Than Body Requirements re- including the following: lated to digoxin-induced anorexia, nausea, and vomiting • Mild HF. Common signs and symptoms of mild HF are • Noncompliance related to the need for long-term drug ankle edema, dyspnea on exertion, and fatigue with or- therapy and regular medical supervision dinary physical activity. Edema results from increased • Deficient Knowledge: Managing drug therapy regimen venous pressure, which allows fluids to leak into tissues; safely and effectively dyspnea and fatigue result from tissue hypoxia. More extensive edema, dysp- Planning/Goals nea, and fatigue at rest are likely to occur. Additional The client will: signs and symptoms include orthopnea, postnocturnal dyspnea, and cough (from congestion of the respiratory • Take digoxin and other medications safely and accurately tract with venous blood); mental confusion (from cere- • Experience improved breathing and less fatigue and edema bral hypoxia); oliguria and decreased renal function • Maintain serum digoxin levels within therapeutic ranges (from decreased blood flow to the kidneys); and anxiety. Acute pul- especially during digitalization, when dosage is being monary edema indicates acute HF and is a medical emer- changed, and when other drugs are added to or removed gency. Causes include acute myocardial infarction, cardiac from the management regimen dysrhythmias, severe hypertension, acute fluid or salt over- • Keep appointments for follow-up monitoring of vital load, and certain drugs (eg, quinidine and other cardiac signs, serum potassium levels, serum digoxin levels, and depressants, propranolol and other antiadrenergics, and renal function phenylephrine, norepinephrine, and other alpha-adrenergic stimulants). Pulmonary edema occurs when left ventricu- Interventions lar failure causes blood to accumulate in pulmonary veins Use measures to prevent or minimize HF and atrial dys- and tissues. In the broadest sense, preventive measures in- dyspnea, hypoxia, hypertension, tachycardia, hemoptysis, clude sensible eating habits (a balanced diet, avoiding frothy respiratory tract secretions, and anxiety. In the client at risk for dysrhythmias: development of HF and dysrhythmias, preventive measures include the following: • Record the rate and rhythm of apical and radial pulses. Atrial fibrillation, the most common atrial dysrhythmia, is • Treatment of hypertension characterized by tachycardia, pulse deficit (faster apical • Avoidance of hypoxia rate than radial rate) and a very irregular rhythm. Administer oxygen, if needed, to relieve dyspnea, im- • Interview and observe for relief of symptoms (weight prove oxygen delivery, reduce the work of breathing, and loss, increased urine output, less extremity edema, easier decrease constriction of pulmonary blood vessels (which breathing, improved activity tolerance and self-care abil- is a compensatory measure in clients with hypoxemia). Pharmacologic Management • Interview regarding compliance with instructions for taking the drug. A combination of drugs is the standard of care for both acute • Interview and observe for adverse drug effects, especially and chronic HF. For acute HF, the first drugs of choice may include an IV loop diuretic, a cardiotonic-inotropic agent (eg, digoxin, dobutamine, or milrinone), and vasodila- PRINCIPLES OF THERAPY tors (eg, nitroglycerin and hydralazine or nitroprusside). This combination reduces preload and afterload and Goals of Management increases myocardial contractility. For chronic HF, an ACE inhibitor or ARB and a di- The goals for clients with asymptomatic (compensated) HF uretic are the basic standard of care. Digoxin, a beta- are to maintain function as nearly normal as possible and to adrenergic blocking agent, and spironolactone may prevent symptomatic (acute, congestive, or decompensated) also be added. When symptoms or decom- with normal sinus rhythm has been questioned, studies pensation occurs, the goals are to relieve symptoms, restore indicate improved ejection fraction and exercise toler- function, and prevent progressive cardiac deterioration. In addition, in clients stabilized on digoxin, a diuretic, and an ACE inhibitor or ARB, symptoms worsen if digoxin is dis- Nonpharmacologic continued.

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Butler argues that this method is preferable to the star system of only rewarding the child when they do not wet the bed generic tadalafil 10mg otc. He feels the child will be totally demoralized and stop trying if he or she accu- mulates too many consecutive nights of wetting the bed buy tadalafil 20 mg line. Pharmacological therapy This section is an introduction to the pharmacological treatments currently available in modern Western medicine to treat enuresis generic tadalafil 5 mg amex. The intent of this section is to educate the practitioner on possible treatments their patients may have received prior to coming to your office and to supply the practitioner with information to bet- ter educate their patients and their families on an effective treat- ment plan. Facts about current medications available to those suffering from enuresis: 1. These drugs are usually reserved for use in children older than seven years of age. Parents should not expect immediate results and should be made aware of the potential side effects of the medications by the prescribing physician. Most parents and modern medical doctors generally do not want to use medication as the first treatment of enuresis. Therefore, drug therapy is often only used in children who have shown no success with other treatments. Instead, these medications sometimes offer symptomatic relief that may provide relief from the bed-wetting until the child is able to wake on their own during the night to void. In the few cases when, due to family circumstances or there is a need for quick symptomatic relief, treatment with drug therapy can be a valuable option. All Western medications for bed-wetting treat enuresis by one of two approaches. One approach is to increase bladder capacity, and the second approach is to reduce the amount of urine produced by the kidneys. The most widely utilized classes of medication cur- rently prescribed for nocturnal enuresis are the tricyclic antide- pressants, anticholinergic drugs, and the synthetic analog of vaso- pressin, desmopressin. Tricyclic antidepressants (TCAs) Tricyclic antidepressants, including imipramine (Tofranil®), have been used in the past 25 years to treat enuresis. This antidepres- sant was prescribed more often in the past when psychological causes were considered normal. Although this drug has been pre- scribed extensively with results, its use continues to decrease. The possible mechanisms include an antidepressant effect, an antispasmodic and/or anticholinergic effect, alterations in sleep and arousal mechanism, and adrenergic neurotransmitter reuptake blockade. Initial success rates of 10-15% have been reported, and a large study (32) combining data from eight controlled, double-blind trials reported a long-term cure rate of 25%. However, the relapse rate is high when the patient dis- continues treatment. The optimal duration of therapy has not been determined, but the empirical approach taken by most doc- tors is to treat children for 3-6 months and then wean them from the medication by reducing the dosage. The use of imipramine continues to decrease in clinical practice of modern Western medicine because of the potential for major side The Western Medical Treatment of Enuresis 35 effects, including anxiety, insomnia, dry mouth, nausea, personali- ty changes, sleep disorders, such as nightmares, constipation, fatigue, and nervousness. Imipramine has also been associated with severe accidental overdoses in both patients and their sib- lings. Because this drug has adverse side effects and a history of overdose, this medication is not recommended as the preliminary therapy for bed-wetting in modern Western medicine. Desmopressin (DDAVP) This drug is a synthetic version of vasopressin and the preferred medication in modern Western medicine to treat enuresis. Vasopressin is a regulatory hormone that is normally produced by the body. The function of this hormone is to recycle water from the urine back into the bloodstream. The body normally produces a higher level of this hormone during sleep so that we do not make an excess of dilute urine while we sleep and, therefore, do not need to urinate. Desmopressin is used based on the controversial findings that bed-wetters produce less than normal amounts of vasopressin at night. This drug was first reportedly used to treat enuresis in the 1960s, and later studies showed that some of these children showed a decreased amount of antidiuretic hor- mone (ADH).

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Those patients with ITT estimate for outcome a strong preference are offered the treatment of CACE = ITT estimate for receipt of treatment their choice order 10 mg tadalafil with mastercard. So discount tadalafil 10 mg on line, for the comparison of two treat- (6) ments cheap tadalafil 5 mg fast delivery, A and B, for example, the patient prefer- This formula applies in situations where both ence trial finishes up with four groups: those who of the measures of outcome and treatment prefer A; those without preference who are ran- received are binary (i. In the context of the present discussion, the differences between means), or one is binary and comparison of the randomly allocated groups can the other quantitative. So, for the first example lead to an ACE or CACE estimate as described above, CACE = (70/100 − 50/100)/(70/100 − above. Like per protocol or as treated estimators, they do not appear to be able to provide estimates RANDOMISED CONSENT AND PATIENT of causal effects. And for this reason they can- PREFERENCE DESIGNS not be used to check the (external) validity of the estimates of causal effects provided by the ran- A serious issue in the design of RCTs concerns domised groups. Whether the difference between the amount of information given to the patient the two preference groups is the same as or com- about the aims of the trial. So-called informed pletely different from that provided within the consent is a prerequisite for most trials but it core RCT, so what? The treatment effect DEPRESSION 309 may, indeed, be different in those patients with- of two people (the patient and the therapist) out a strong preference (i. Added to rest cannot provide the valid information from this are the problems of the choice of adequate which we can test whether it is true. But per- control groups (in particular, the absence of haps readers should see the results of such a trial a convincing placebo) and the impossibility and decide for themselves. In use of a patient preference design is provided the critical appraisal of such trials we should by a recently published trial of counselling for not, perhaps, be searching for methodological depression. The aim been involved in as it does to the trials of other here is not to allow patient preference to influ- investigators). This has been tried by Torg- studies should be fully aware of all the method- erson et al. A meta- pursue all of the possibilities in terms of esti- analysis of a series of trials that have naıvely¨ mating treatment effects, the design offers ways, ignored random therapist effects, for example, at least partially, of testing the validity of the or ignored the structure of a group therapy assumptions necessary for the above CACE esti- trial, simply summarises the faulty analyses of mator, or, equivalently, looking for a poor prog- the originals. Unfortunately, the consumers of nosis/demoralising effect in the potential com- meta-analyses (particularly if they are produced pliers of the control group. Getting preference under the auspices of such august bodies as the information prior to randomisation would also Cochrane Collaboration) seem to place far too improve the precision of the estimates of the much faith in their findings. Consumers need to CACE, but this is well beyond the scope of be aware that the authors of systematic reviews the present chapter – for further information, see are capable of missing subtle (or not so subtle) Fisher-Lapp and Goetghebeur. Con- will also provide a suitable entry to the literature sumers should resist taking the conclusions of the on adjustment for partial compliance (i. Reporting guidelines such as CONSORT46,47 are having a for the estimation of the effects of psychotherapy are difficult. It is not safe to simply assume that substantial impact on the quality of clinical trials, the theoretical and logistical problems are similar and on the appraisal methodologies of system- to those of the average drug trial. Psychotherapy (at least however, the CONSORT recommendations only in its individual form) involves the interaction cover a small part of the key components of the 310 TEXTBOOK OF CLINICAL TRIALS trial. I tute of Mental Health Treatment of Depression Collaborative Research Program (1989). Arch Gen hope the present chapter succeeds in stimulating Psychiat (1989) 46: 971–81. Clinical trials in psychiatry: should REFERENCES protocol deviation censor patient data? Statistical methods for measuring out- tocol deviation patient: characterization and impli- comes. In: Tansella M, Thornicroft G, eds, Men- cations for clinical trials research. In: Wykes T, Tarrier N, Lewis S, eds, Out- Design and Analysis of Clinical Trials. London: come and Innovation in Psychological Treatment Imperial College Press (1999). Estimating causal effects of treatments ucation for depression: a multicentre randomised in randomized and nonrandomized studies.

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Thirty-four cases had enuresis more than one time per evening buy 10 mg tadalafil visa, five cases urinated one time every 2-3 days generic tadalafil 10mg with mastercard, and order tadalafil 2.5 mg with amex, in four cases, there was no regular pattern. Treatment method: Self-devised Fang Fu Shen Tang (Saposhnikovia Plus Codonopsis Decoction) consisted of: Fang Feng (Radix Saposhnikoviae), 6g Dang Shen (Radix Codonopsitis), 10-15g Ji Nei Jin (Endothelium Corneum Gigeriae Galli), 10g Mai Ya (Fructus Germinatus Hordei), 10g Chan Tui (Periostracum Cicadae), 5 pieces Jiang Can (Bombyx Batryticatus), 5-8g Shen Qu (Massa Medica Fermentata), 12g Sheng Ma (Rhizoma Cimicifugae), 3g Chai Hu (Radix Bupleuri), 3g Lian Xu (Stamen Nelumbinis), 3g Cong Bai (Bulbus Allii Fistulosi), 3g Niao Zhi Hui (ashed urine paper), 1g (dissolved after decoction) Niao Zhi Hui was prepared by laying a piece of bamboo paper under the child while they slept. It was then covered until the heat receded, collected, and stored for future use. Chinese Research on the Treatment of Pediatric Enuresis 85 If there was spleen-lung qi vacuity, Gao Li Shen (Korean Radix Ginseng) and Huang Qi (Radix Astragali) were added. If there was lower origin vacuity cold, one gram of Rou Gui (Radix Cinnamomi) was added. Each day, one packet of the above medicinals were boiled for 30 minutes in 350 milliliters of water until 250 milliliters of medicinal liquid was obtained. This was divided into two doses which were administered before eating at noon and in the evening. Discussion: Although enuresis is often caused by lower origin vacuity cold, Dr. Xu believes spleen-stomach vacuity weakness to be the root of this disease. If the spleen and stomach are vacuous and weak, there will be insufficient engenderment of the qi and blood. If there is a qi vacuity, the kidneys and bladder cannot perform their functions of warming, qi transformation, and securing and con- straining. On the other hand, if there is blood vacuity, then the residence of the heart spirit is not nourished and moistened. If the spirit is not quiet at night, then the child cannot contain their urine. Therefore, this self-devised formula supplements the spleen and fortifies the stomach, quiets the spirit and secures and contains. From Xuan Fei Wen Shen Tang (Diffuse the Lungs & Warm the Kidneys Decoction) in the Treatment of 38 Cases of Pediatric Enuresis by He Jian-hua & Zhang Ping, Chang Chun Zhong Yi Xue Yuan Xue Bao (Academic Journal of Changchun College of Chinese Medicine), 2000, #1, p. These patients were between 3-14 years old, and the course of disease ranged from two months to 10 years. All these patients categorized as presenting a pattern of kidney qi depletion and vacuity with non-diffusion and downbearing of lung qi. Treatment method: Xuan Fei Wen Shen Tang (Diffuse the Lungs & Warm the Kidneys Decoction) was composed of: Bu Gu Zhi (Fructus Psoraleae), 10g Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 10g Jin Ying Zi (Fructus Rosae Laevigatae), 10g Fang Feng (Radix Saposhnikoviae), 10g Gao Ben (Rhizoma Ligustici), 10g Shi Chang Pu (Rhizoma Acori Tatarinowii), 10g Fu Ping Zi (Herba Spirodelae), 10g Gan Cao (Radix Glycyrrhizae), 6g One packet of these medicinals was decocted in water and administered per day. Seven days equaled one course of treat- ment, and treatment was limited to four courses. Discussion: Within the above formula, Bu Gu Zhi and Yi Zhi Ren both supple- ment the spleen. However, these two medicinals are commonly used to supplement the kidneys and invigorate yang, warm the spleen and reduce urination. These two medicinals enter the lungs and bladder and have a markedly strong effect on diffusing the lungs, dissipating cold, eliminating wind, and overcoming dampness. Fu Ping Zi also promotes diffusion and effusion of the lung qi which then regulates the waterways. This medicinal is a Chinese Research on the Treatment of Pediatric Enuresis 87 warm medicinal and is well suited to balance cold and heat. Shi Chang Pu is used to aromatically transform dampness, open the orifices, and arouse the spirit. When all these medicinals are used together, they warm the kidneys, secure and constrain, and also warm the blad- der; they also promote the diffusion and effusion of the lung qi while not neglecting to pay attention to cold and warmth. From Observations on the Results of Treating 50 Cases of Pediatric Enuresis with Yi Niao Ling Fang (Effective Enuresis Formula) by Xi Yu-lian, Lu Xiao-yun & Da Chun-hua, Xin Zhong Yi (New Chinese Medicine), 2002, #12, p. These cases were between the ages of 5-12 years old, with a median age of 7.

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Study outcomes: Sixty-one cases were cured generic tadalafil 20mg with amex, 26 cases improved purchase tadalafil 10mg otc, and five cases got no effect buy 5 mg tadalafil. From The Treatment of 22 Cases of Pediatric Enuresis with Electro-acupuncture & Ear Press Magnets by Fan Jin, He Bei Zhong Yi (Hebei Chinese Medicine), 2002, #8, p. According to TCM pattern discrimination, 16 cases presented with kidney vacu- ity not securing and six cases presented with liver channel depressive heat. All these patients experienced enuresis during sleep which was either mild (one time per night) or severe (multi- ple times per night). Those with kidney vacuity not securing pre- sented with lassitude of the spirit, lack of strength, low back ache, cold limbs, a somber white facial complexion, and clear, long urination. Those with liver channel depressive heat presented with profuse dreams, grinding of teeth, agitation, vexation, easy anger, red lips and tongue, and scanty urine that had a fishy or animal smell. Treatment method: Electro-acupuncture was administered at the following main acu- points: Guan Yuan (CV 4) Zhong Ji (CV 3) San Yin Jiao (Sp 6) If there was kidney vacuity not securing, Tai Xi (Ki 3) and Shen Shu (Bl 23) were added. If there was liver channel depressive heat, Tai Chong (Liv 3) and Li Gou (Liv 5) were added. Electrical stimulation was added to the handles of the needle which were retained for 30 minutes. Supplementation method was used for the pattern of kidney vacuity not securing, and draining technique was used for the pattern of liver channel depressive heat. Treatment was given every other day for mild cases and was given daily for serious cases. The main ear points treated with magnets consisted of: Shen Men (Spirit Gate) Kidney Bladder Liver Subcortex Brain Point Chinese Research on the Treatment of Pediatric Enuresis 181 The magnets were two millimeters in diameter and were applied to the ear using a 0. These magnets were stimulated or pressed 20 times by the patient four times per day until there was distention or pain in the ear. If the enuresis returned, then the treatment was continued to obtain results. The longest course of treatment was three months, and the shortest was two weeks. Study outcomes: Four cases were cured, 17 cases improved, and one case did not improve, for a total amelioration rate of 95. From Clinical Observations of Using Electro-acupuncture to Treat 102 Cases of Enuresis by Xie Wan-dong, Xin Zhong Yi (New Chinese Medicine), 1989, #10, p. Twenty-four of these cases were between 4-7 years old, 55 cases were between 8-14 years old, and 23 cases were more than 15 years old. The course of disease was less than two years in 30 cases, 2-10 years in 52 cases, and more than 10 years in 20 cases. Treatment method: The main acupoints used in this study were: Guan Yuan (CV 4) Zhong Ji (CV 3) Qu Gu (CV 2) San Yin Jiao (Sp 6) was an auxiliary point. Treatment was given once per day, and five times equaled one course of treatment. Three days interval was given between each successive course of treatment. The needles were retained for 15-20 minutes and stim- ulated using a G6805 electro-acupuncture machine. If the patients body was smaller than normal and their tongue was pale with white fur, this indicated yang vacuity and the doctor would then add moxibustion. Miscellaneous From The Treatment of 42 Cases of Pediatric Enuresis with Spinal Pinch Pull Technique Combined With Cupping the Umbilicus by Yan Xiang-hong & Huang Ji-yan, An Mo Yu Dao Yin (Massage & Dao Yin), 2001, #1, p. There was enuresis once per night in 26 cases and 2-3 times per week in 16 cases. Thirty-two cases had already been treated with modern Western medicine with no success. Treatment method: The spinal pinch-pull technique was performed 5-8 times from Chang Qiang (GV 1) to Da Zhui (GV 14). The next tech- nique was to apply petroleum jelly to the lower back, and the doc- tor rubbed this area back and forth with the lesser thenar emi- nence of their hand until the child felt a warm sensation in the lower back. Altogether, the above techniques were done for 5-10 minutes each treatment. Cupping using the fire method was used to apply a cup to Shen Que (CV 8) for 2-5 minutes.

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