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It may also improve gastro- Sucralfate is well tolerated but, because it contains aluminium, oesophageal sphincter function and accelerate gastric constipation can occur and in severe renal failure accumulation emptying; is a potential hazard. A 25-year-old male estate agent complains of intermittent heartburn, belching and sub-xiphisternal pain which has been present on most nights for two weeks. It was particu- larly severe the previous Saturday night after he had con- sumed a large curry and several pints of beer. Non-drug measures which may be useful include the following: Prescribe alginate/antacids. If the oesophagus occurs at night when swallowing is much symptoms have still not completely resolved, refer the reduced and acid can remain in contact with the mucosa patient for endoscopy. Nausea and sickness during the first trimester of pregnancy will respond to most anti-emetics, but are rarely treated with drugs because of the possible dangers (currently Act of vomiting unquantifiable) of teratogenesis. Vomiting is preceded by intestinal obstruction, intracerebral space-occupying lesion) usually cures the vomiting. This vomiting centre These act partly by their antimuscarinic action on the gut, as (Figure 34. The major efferent in preventing motion sickness and is useful in single doses for pathways from the vomiting centre are the phrenic nerve, the short journeys, as the anticholinergic side effects make it visceral efferent of the vagus to the stomach and oesophagus, unsuitable for chronic use. Hyoscine is an alternative to anti- and the spinal nerves to the abdominal musculature. Drowsiness, blurred vision, dry mouth and urinary the area postrema of the fourth ventricle which is sensitive to retention are more common at therapeutic doses than is the emetic stimuli such as radiation, bacterial toxins and uraemia. They have additional anticholinergic actions, and these con- Anti-emetic drugs can be classified pharmacologically as tribute to their anti-emetic effect. They should only be used when the cause promethazine, betahistine and cinnarizine. The main limita- of nausea or vomiting is known, otherwise the symptomatic tions of these drugs are their modest efficacy and common dose- relief produced could delay diagnosis of a remediable and related adverse effects, in addition to antimuscarinic effects. It is more Metoclopramide potentiates the extrapyramidal effects of sedative than cyclizine. Its effects on intestinal • Betahistine is used in vertigo, tinnitus and hearing loss motility result in numerous alterations in drug absorption, associated with Ménière’s disease. Phenothiazines barium to reach the caecum and decreases the number of used as anti-emetics include prochlorperazine, trifluoper- films required; azine, perphenazine and chlorpromazine. They are least effective in the treatment of motion sick- • symptoms of reflux oesophagitis may be improved, as it ness. All of them carry a risk of extrapyramidal disturbances, prevents nausea, regurgitation and reflux. These effects are more common in females and in in the management of acute nausea and vomiting due to cyto- the young. They are treated by stopping metoclopramide and toxic chemotheraphy, although they offer little advantage for giving benztropine or diazepam acutely if necessary (see also delayed emesis, occurring secondary to cytotoxic chemother- Chapter 21). It may be peripheral at abdominal visceral afferent neurones, or central within the Mechanism of action area postrema of the brain, or a combination of both. Metoclopramide increases the amount of acetylcholine Examples include ondansetron, granisetron, dolasetron and released at post-ganglionic terminals. It also decreases the sensitivity of the visceral nerves that carry impulses from the gut to the emetic centre. In an Pharmacokinetics attempt to reduce side effects and increase efficacy, a number Metoclopramide is well absorbed orally and is also given by of analogues, including nabilone, have been synthesized. There is some evidence that opioid pathways Glucocorticosteroids are not suitable for maintenance treatment are involved in these actions. Benzodiazepines given before treatment with cytotox- pository or enema preparations are as effective as systemic ics reduce vomiting, although whether this is a specific anti- steroids. Drugs currently available in this group are sulfasalazine, mesalazine, balsalazide and olsalazine. Although usually well tolerated, and Crohn’s disease include kinins and prostaglandins. The the adverse effects of sulfasalazine are nausea, vomiting, latter stimulate adenylyl cyclase, which induces active ion epigastric discomfort, headache and rashes (including toxic secretion and thus diarrhoea. All of the adverse effects associated with thromboxane A2 and prostacyclin by the gut increases during sulphonamides can occur with sulfasalazine, and they are disease activity, but not during remission. Toxic effects on red cells lates influence the synthesis and metabolism of these are common (70% of cases) and in some cases lead to haemoly- eicosanoids, and influence the course of disease activity. Temporary oligospermia with life-saving) and other non-specific treatment, glucocorticos- decreased sperm motility and infertility occurs in up to 70% of teroids, aminosalicylates and immunosuppressive drugs are males who are treated for over three years. Prednisolone and hydrocorti- ate sulfasalazine and in men who wish to remain fertile. Topical therapy in the form of a rectal drip, foam or enema of Key points hydrocortisone or prednisolone is very effective in milder Aminosalicylates and blood dyscrasias attacks of ulcerative colitis and Crohn’s colitis; some systemic • Any patient who is receiving aminosalicylates must be absorption may occur. Prednisolone is preferred to hydrocortisone as it has less min- • If there is suspicion of blood dyscrasia, stop aminosalicylates. Also, it is important to remember that many drugs is activated in the intestine of patients with inflammatory can cause constipation (Table 34. This forms the rationale for the use of immuno- In general, patients with constipation present in two ways: suppressive agents in the group of patients who do not respond to therapy with aminosalicylates or glucocorticos- 1. General indications for their use include patients who may be due to decreased colon motility or to dyschezia, or have been on steroids for more than six months despite efforts to a combination of both. It is usually sufficient to reassure to taper them off, those who have frequent relapses, those with the patient and to instruct them in the importance of re- chronic continuous disease activity and those with Crohn’s establishing a regular bowel habit. Patients with ulcerative colitis combined with an increased fluid intake and increased may benefit from a short course of ciclosporin (unlicensed bulk in the diet. Patients with unresponsive or chronically active alternative, non-absorbed bulk substances such as inflammatory bowel disease may benefit from azathioprine or methylcellulose, ispaghula or sterculia are helpful. The mercaptopurine, or (in the case of Crohn’s disease) once- other laxatives described below should only be tried if weekly methotrexate (these are all unlicensed indications).

Zderad were nursing visionaries who emphasized Their joint project was to create a new program synthesis and wholeness rather than reduction and that would encompass the community health com- logical/mathematical analysis generic extra super levitra 100 mg online impotence natural food. They challenged the ponent and the psychiatric component of the notion that the reductionistic approach is the graduate program cheap extra super levitra 100 mg overnight delivery erectile dysfunction 2014. This started a collaboration cheap extra super levitra 100 mg on-line erectile dysfunction nclex, di- touchstone of explanatory power, and they postu- alogue, and friendship that has lasted for over 45 lated an “all-at-once” character of existence in years. They shared and developed their concepts, nurses’ experiences of being in the world. They led approaches, and experiences of “existential phe- the way to many of the contemporary nursing the- nomenology,”which evolved into the formal Theory ories that emphasize the caring aspects of nursing of Humanistic Nursing. It speaks to the essences of nursing and embraces They were hired as “nursologists” by a forward- the dynamics of being, becoming, and change. It is also a theory that provides a three-pronged approach to the improvement of pa- methodological bridge between theory and practice tient care through clinical practice, education, and by providing a broad guide for nursing “dialogue” research. Nursing, as seen through Humanistic Nursing They worked with the nurses at Northport from Theory, is the ability to struggle with another 1971 until 1978 on this project, running workshops through “peak experiences related to health and suf- that incorporated their theory. In 1978 there was a fering in which the participants are and become in change in hospital administration that entailed a accordance with their human potential” (Paterson reorganization of services. According to Josephine Paterson and community, or from humanity for help Loretta Zderad, in nursing, the purpose of this dia- with some health-related issue. A nurse, a logue, or intersubjective relating, is, “nurturing the group of nurses, or the community of well-being and more-being of persons in need” nurses hearing and recognizing that call respond in a manner that is intended to In nursing, the purpose of this dialogue, or help the caller with the health-related intersubjective relating, is,“nurturing the need. What happens during this dialogue, well-being and more-being of persons in the “and” in the “call and response,” the need. Humanistic Nursing Theory is dialogue, the “and” in the “call and response,” the grounded in existentialism and emphasizes the “between,” is nursing. The method is phenomenological in- The new adventurer in Humanistic Nursing quiry (Paterson & Zderad, 1976 p. Engaging Theory may at first find some of these terms and in the phenomenological process sensitizes the in- phrases awkward. When I spoke to a colleague of quiring nurse to the excitement, anticipation, and the “moreness” and of “relating all at once,” she re- uncertainty of approaching the nursing situation marked, “Oh, oh, you’re beginning to sound just openly. Consider Josephine Paterson’s flective immersion in the lived phenomena” own description of humanistic nursing: “Our ‘here (Zderad, 1978, p. During this interchange, the nurse calls forth all If asked to conceptualize Humanistic Nursing that she is (education, skills, life experiences, intu- Theory succinctly, I would have to say, “call and ition, etc. Through this paradigm, Josephine Paterson the nurse must provide what it is that the patient is and Loretta Zderad have presented a vision of calling for. Remember the response of the nurse is nursing that is amenable to variation in practice guided by all that she is. This includes his or her settings and to the changing patterns of nursing professional role, ethics, and competencies. A nurse, a group of nurses, or the community Look at the conceptual framework of Human- of nurses hearing and recognizing that call respond istic Nursing Theory in Figure 11–1 to help explain in a manner that is intended to help the caller with and illustrate some of its basic concepts and as- the health-related need. It also Humanistic Nursing Theory, when we speak of includes past experiences with persons in the human beings, we mean patients (e. A person becomes a patient when he viduality as incarnate human beings who exist in or she sends a call for help with some health-related this particular space at this particular time, with problem. The person hearing and recognizing the circumscribed resources and in a physical body that call is a nurse. A nurse, by intentionally choosing to senses, filters, and processes our experiences to become a nurse, has made a commitment to help which we assign subjective meanings. In humanistic nursing we say to be a unique human being with his or her own that each person is perceived as existing “all at particular gestalt (see Figure 11–3). This task You can easily see that a nursing theory that is can be done with tenderness, dignity, and with based in the human context lends itself to phenom- masterful technical skills that make the procedure enological inquiry rather than reductionism, which almost unnoticeable. I once watched as a nurse po- attempts to remove subjective humanness and sitioned and suctioned a patient; as she performed strives to achieve detached objectivity. The early the task, she made sure that she also repositioned phenomenologists saw their goal as the examina- the little basket of flowers that she had placed by tion and description of all things, including the the patient’s bedside. The repositioning of the flow- human experience of those things, in the particular ers really had nothing to do with the technique of way that they reveal themselves. It showed that the nurse recognized the Phenomenology is not only a philosophy, but it patient as a unique human being, and she did is also a method—a method that can be integrated something special to make the experience less into a general approach or way of viewing the stressful and as comfortable as possible for the pa- world. Comfort in this instance refers to the idea that clined to cultivate it and make it a part of their through the relationship engendered and nurtured everyday approach to nursing. This method is no in intersubjective dialogue, there arises the possibil- less rigorous in its application than methods used ity for persons to become all that they can be in in experimental research to build theories. In The phenomenological movement of the nineteenth phenomenology, a statement’s validity is based on century was in response to what its proponents whether or not it describes the phenomenon accu- called the dehumanization and objectification of rately. The truth of all the statements resulting from the world by the logical positivists. These These will be taken up as we discuss the phases of phases are presented sequentially but are actually inquiry. The phases of humanistic In the first phase, the inquirer tries to open herself nursing inquiry are: up to the unknown and to the possibly different. It includes • Nurse complementarily synthesizing known the conceptual and experiential framework that others we bring into any situation with us, a framework • Succession within the nurse from the many to that is usually unexamined and casually accepted as the paradoxical one we negotiate our everyday world. This to bracket it purposefully so that we do not super- process of bracketing versus intuiting is not contra- impose it on the experience we are trying to relate dictory. This ity of phenomenology are based on the ongoing re- “holding in abeyance” does not deny our unique ferring back to the phenomenon itself. It is selves but suspends them, allowing us to experience conceptualized as a dialectic between the impres- the other in his or her own uniqueness. This shifting back and forth al- By intentionally bringing into present con- lows for sudden insights on the nurse’s part, a new sciousness, and acknowledging what we believe to overall grasp, which manifests itself in a clearer, or be true, we can then attempt to hold any precon- perhaps a new,“understanding. A a dialogue with her unbracketed view (see Figure personal experience that helped me to grasp the 11–4). As I entered each new country, I experienced the In the next phase, objectivity is needed as the nurse excitement of the unknown. Standing time how alert, open, and other directed I was in outside the phenomenon, the nurse examines it this uncharted world as compared to my own daily through analysis. According to Husserl (1970), who is considered the father of modern phenomenology, the attitude desired is that of the perpetual beginner. Bracketing prepares the inquirer to enter the un- charted world of the other without expectations and preconceived ideas. Even temporarily letting go of that which shapes our own identity as the self, however, causes anxi- ety, fear, and uncertainty. Labeling, diagnosing, and routine add a necessary and very valuable pre- dictability, sense of security, and means of conserv- ing energy to our everyday existence and practice.

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It is estimated that at least 15 percent of the adult population in Canada suf- fers from varicose veins. The heart pumps oxygenated blood from the lungs through the arteries to the cells throughout the body. Tiny one-way valves inside our veins function as trapdoors opening and closing with each muscle contraction to prevent the backflow of blood. Varicose veins result from damage to the valves or vein walls, leading to pooling of blood, vein swelling, and increased venous pressure. These veins spread out on the surface of the skin in a web-like fashion, hence their name. Varicose veins are not life threatening; however, they can increase the risk of developing a blood clot, which is a serious concern. Other factors that may contribute to or worsen varicose veins include: exposure to ex- cessive heat, use of birth control pills or estrogen, and wearing high-heeled shoes. Blood is rerouted through other veins and the damaged vein is absorbed by the body. Bypass: An artificial or transplanted vein is connected to the damaged vein to help improve blood flow. Compression stockings: These specially designed stockings provide firm support to improve blood flow back to the heart and prevent swelling in the legs. The incidence of varicose veins is higher in developed (Western) countries due to life- style factors: poor diet (low fibre), lack of activity, and obesity. The best food sources are fruits, vegetables, whole grains (oats and bran), legumes, nuts, and seeds (flaxseed and sunflower seeds). Foods to avoid: • Saturated fats (animal fats) and trans fats (fast food and processed food) can impede circulation in both the veins and arteries, cause free radical damage, and trigger inflam- mation. Activities that involve movement of the calf muscle will help pump blood back to the heart. Move around, flex your ankles, circle your foot, do calf raises, and shift your body weight. Top Recommended Supplements Diosmin: A flavonoid that improves the tone and strength of the blood vessels, reduces swelling, fights free-radical damage, and stimulates lymphatic flow. Diosmin has a quick onset of action (one to two weeks) and is not associated with any side effects or drug interactions. Horse chestnut seed extract: Promotes circulation, improves vein wall tone, and relieves V swelling. It may cause nausea and upset stomach and can enhance the effect of blood-thinning medications. Pine bark extract: A flavonoid that offers antioxidant activity, strengthens capillaries, improves circulation, and supports the integrity of collagen and elastin (proteins in connec- tive tissue that support organs, joints, blood vessels, and muscles). In addition to diosmin and pine bark, other antioxidants to consider are vitamins C and E, bilberry, and grape seed extract. Butcher’s Broom: Improves the strength and tone of the veins, acts as a mild diuretic, and has mild anti-inflammatory effects. Boost intake of fibre and antioxidant-rich foods, and reduce your intake of satu- rated fats, processed foods, and sodium. Exercise regularly, elevate your feet when resting, and avoid standing or sitting in the same spot. While the words “obese” and “overweight” are used synonymously, there is a great difference between these terms in both definition and associated health risk. This term can be misleading because it does not distinguish between body fat and lean muscle mass. For example, it is possible to be overweight without be- ing obese, such as a bodybuilder. Having a greater proportion of muscle mass would make this individual appear overweight according to standard weight/height charts, yet this person could have low body fat and be in good physical shape. There are several methods that are used to determine overweight, obesity, and the level of associated health risks. Body composition can be measured by: Bioelectric impedance: A machine is used to measure an electric signal as it passes through lean body mass and fat. This method is more effective than skin-fold caliper testing, but is not 100 percent accurate. Near infrared technology: Infrared light is shone on the skin (usually bicep area). The reflected light is measured by a special sensor, transmitted into the computer, and translated into percentage of body fat. This method is highly accurate, comparable to underwater weighing, but slightly more expensive than the above two methods. Skin-fold calipers: Measures the thickness of subcutaneous fat at various locations on the body. The measurements obtained are used in special equations to obtain an estimated percent fat value. This method is not very accurate and is dependent upon the skills and judgment of the person performing the test. Below are recommended body fat ranges for women and men along with the ranges considered to be overweight or obese: Women Men Normal 15–25 percent 10–20 percent Overweight 25. Studies have shown that an apple-shaped body, which is defined by abdomi- nal obesity or having a potbelly, greatly increases the risk of type 2 diabetes, high cholesterol and blood pressure, heart disease, stroke, and early death. Following are the waist measurements and their corresponding level of risk: Determinations for Body Fat and Weight | 423 For men: • Increased risk: Waist more than 38 inches (97 cm) • Substantially increased risk: Waist more than 40 inches (102 cm) For women: • Increased risk: Waist more than 32 inches (81 cm) • Substantially increased risk: Waist more than 35 inches (89 cm) Men often deposit weight in the waist region, whereas women tend to gain weight around the hips and buttocks, giving them the pear shape. Fat deposited primarily around the hips and buttocks does not carry the same risk as that gained around the midsection. In recent years, researchers have found that abdominal fat, which sur- rounds our internal organs, secretes compounds that trigger inflammation and insulin resistance, thus increasing the risk of heart disease, diabetes, and other problems.

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Te frst journal to which the paper was submitted cheap 100 mg extra super levitra fast delivery erectile dysfunction psychological treatment techniques, the Journal of Forensic Sciences buy generic extra super levitra 100mg line erectile dysfunction drugs and melanoma, rejected the paper buy cheapest extra super levitra erectile dysfunction doctor philadelphia, citing the inappropriate design of the workshop for statistical analysis. Perhaps unfortunately, considering the later misinterpretations, the article was submitted to other journals and was ultimately published in 2001 in the journal Forensic Science International. In the paper the authors stated that the primary objective of the study was “to determine the accuracy of examiners in distinguishing the correct dentition that make a bitemark,” and the secondary 356 Forensic dentistry objective was “to determine whether examiner experience, bitemark certainty, or forensic value had an efect on accuracy. Consequently, mathematical or statistical analysis of the opinions of workshop participants was not possible without assuming that a true cause-efect relationship existed in each of the cases. Bitemark Workshop #4 was neither designed as, nor can it be used as, a profciency test for forensic odontology. Tests of consistency and validity (necessary in a profciency examination) were neither accomplished nor attempted; and, as subsequent reviewers of the data correctly pointed out, the construction of the examination and the workshop was not designed to produce an examination that had statistical validity and statistical con- sistency. In 2002 the Supreme Court of Mississippi was consider- ing a petition for postconviction relief in a death penalty case involving alleged bitemarks. Included in the petition was this material described by the court: In support of this claim, Brewer presents the afdavit of Charles Michael Bowers, D. He urges that this Court should not tolerate a science that, as Brewer claims, is more likely than not to identify the wrong suspect. Tese results counter balance the years of assured self-confdence shown by the dentists testifying on bite mark Bitemarks 357 evidence. Tus, they were wrong nearly half the time they tried to identify the source of a bitemark. More specifcally, it is their false positive error rate—the tendency to conclude that an innocent person’s dentition matches the bitemark—that accounts for the bulk of that overall error rate. If this refects their perfor- mance in actual cases, then inculpatory opinions by forensic dentists are more likely to be wrong than right. Bowers claimed, a “study regarding the reliability of bite mark identi- fcation evidence,” nor did it “produce data on the accuracy of results in bite mark identifcation forensic casework. Te authors of the Forensic Science International paper correctly stated in closing, “Tis study, despite its limitations, has opened the debate into evidence-based forensic dentistry. Forensic odontologists must ensure that the techniques they employ are backed by sound scientifc evidence and that the decisions they present in Court serve to promote justice and to strengthen the discipline. Because the number of cases in the study was too few, the reasons can be neither properly analyzed nor clearly understood from these data. Sixteen, half of the participants, scored 92% or better overall, and twelve had no single score lower than 91%. It seems clear from these data, in spite of the shortcomings of the study’s design, that some participants were able to accurately analyze the material and were clearly more skilled in analysis of that material than others. Tis information supports the shared opinion of this chapter’s authors that bitemark analysis, when performed by some expe- rienced forensic odontologists, following appropriate guidelines, can be a very accurate discipline. It also illustrates, conversely, that some forensic dentists should not be independently or individually responsible for bitemark analysis cases until their skills are sufciently developed and demonstrated. Tese data further support the recommended requirements for seeking second opinions, the need for true profciency testing for forensic odontologists in bitemark analysis, and mandatory remedial education for those not performing well on those profciency tests. It may also indicate that the qualifcations required to apply for board certifcation should be modifed to include an increase in the level of bitemark analysis experience required and the mandated oversight of the bitemark-related activities of new diplomates. Greenwald discussed the relationships between the ego and cognitive biases in his 1980 article. He theorizes that those biases combine to negative efect, especially in individuals involved in “higher level organizations of knowledge, perhaps best exemplifed by theo- retical paradigms in science. Greenwald, Tavris, and others assert that an integral part of cognitive conservatism, resistance to certain kinds of change, is the tendency toward susceptibility to confrmation bias, a persistent problem in the identifcation Bitemarks 359 sciences. Most, but not all, of those who bear the responsibility for the errors made in these prob- lem cases steadfastly insist that others do not or cannot see what they see. Tey appear to have that cognitive disconnect consistent with the theories of Greenwald, a totalitarian ego. Forensic odontologists must learn to deal with these efects before the consequences appear in their work. Tey must recognize personal signs of ego-related hazards, and take draconian steps to reduce expectation or con- frmation bias. Tis can be greatly facilitated by continuing the development and positive modifcation of guidelines and protocols designed to minimize those efects. Additionally, periodically testing the profciency of forensic odontologists in bitemark analysis must become a requirement. Although errors occur in all endeavors, forensic scientists have a greater responsibility to minimize errors because of the consequences to people’s lives. Bitemark analysis has not been exempt from the challenges accompanying the advances in scien- tifc techniques and the learning curves associated with them. In the major- ity of the bitemark cases reported over the last ffy plus years in the United States, this evidence has been used primarily to link a suspected biter to a specifc victim. Bitemark evidence, however, has other advantages that are useful to the criminal justice system apart from the specifcs of linking a specifc individual to the crime or victim. A bitemark, on the other hand, is not accidentally or casually inficted and is an indication of intimate and violent interaction. If bitemark analysis can lead to the inclusion or exclusion of suspects, that is very powerful evidence indeed. For a bitemark to be useful for analysis it must contain abundant information and the teeth that made the mark must be very distinctive. Because of the high number of variables involved in bitemark evidence, the specifcity of associating a bitemark to a single suspect is low. For bitemarks these useful areas most ofen involve showing evidence of vio- lence. Bitemarks indicate violence, pain, a struggle, with the possibility of both ofensive and defensive bites. Additionally and importantly, bitemarks in skin may produce a profle of the biter. If the individual and specifc char- acteristics of the teeth are recorded in skin, forensic odontologists may be Bitemarks 361 able to determine tooth position, spacing between teeth, broken or missing teeth, and other individualizing features (Figures 14. With bites in other substrates, be they foodstufs such as cheese, cookies, bologna, or chewing gum, or nonfood items, like expanded polystyrene cups, pencils, or golf tees, with almost any item that can go into the mouth, forensic dentists may be able to isolate specifc individual tooth characteristics that are found in the teeth of the suspected biter. Although bites in material other than skin do not indicate violence, they may have the ability to show greater detail of both class and specifc individual dental characteristics. Te characterization of bites in human skin in relation to the time of death of victims is another area in which bitemark evidence may prove to be valuable. As in the 1975 Marx case with the bitemark on the nose, or in other cases where the three-dimensional nature of the marks, especially the retention of indentations from the teeth, played a prominent role, a forensic odontologist may be able to ofer an opinion related to when the wound was inficted in relation to the time of death. Forensic odontologists must be very careful to not overstate the signifcance or accuracy of this fnding, and limit the opinion, if and when indicated, to “around the time of death.

By S. Urkrass. University of Texas at Tyler.