By H. Raid. University of Southern California.

These medicines carry with them a risk of adverse reactions; the risk needs to be quantified and as far as possible minimised hydrochlorothiazide 25mg on line. Examples of intrinsic toxicity and quality issues associated with traditional Chinese and ayurvedic medi- cines are described in detail in Chapters 6 and 7 cheap hydrochlorothiazide 25mg overnight delivery. Kava-kava (see Chapter 10) is a recreational herb used widely by Pacific Islanders. There are an estimated 250 million people around the world using the herb each year. However, it is claimed that, in almost all cases, the adverse effects have not been defi- nitely attributed to kava-kava and in most cases they were associated with liver damage from alcohol or pharmaceutical drugs. Kava-kava has been reported by researchers at the University of Queensland as being safe and effective at reducing anxiety and improving mood. An issue under discussion by European regulatory authorities is whether the proposed herbal medicines directive (see Chapter 6) should extend to traditional medicines containing non-herbal ingredients, such as those used in Chinese and ayurvedic medicine. One issue identified by the forum is the lack of understanding of existing law by some of those operating in the ethnic medicines sector. Concurrent therapy Patients with chronic or recurrent conditions are particularly vulnerable because they tend to lose confidence in conventional medicine and resort to self-medication without informing their general practitioner. There can be no doubt that safety issues are of extreme concern as the use of traditional therapies increases in a largely uncontrolled manner. Travel by tourists and business people to long-haul destinations has brought increasing numbers of people into contact with other cultures. Whether you consider traditional medicine to have a part to play in modern medicine is for you alone to decide. The risks of participating in traditional Chinese medicine or ayurveda are certainly outweighed by the many benefits that are reported. Adverse reactions are relatively rare, although when they do happen they can be very severe. Perhaps the best solution is to control the practice, improve training and license the medicines. Practitioners of traditional medicine certainly need to be more aware of the problems of toxicity. In particular, they must learn that infrequent adverse drug reactions will not be recognised without a formal system of reporting. This is a significant deficiency and, until a formal mandatory system of reporting adverse reactions for traditional medicine becomes available, healthcare providers should be aware of the potential difficulties, advise the public of the dangers whenever necessary, and record and report any problems promptly in the mainstream literature. Practitioners of orthodox and traditional medicine need to be aware of the occurrence and dangers of dual treatment. Patients need to appreciate that they must disclose exactly what they are taking; such information should be recorded carefully because, as stated above, there is a risk that patients will receive simultaneous western and traditional treatments, particularly when self-treating. Veri- fying the quality of the training given in China and India by identifying appropriate qualifications and recognising them seems prudent. Traditional medicine and the orthodox healthcare provider Many healthcare providers may not relish the thought of taking a proactive interest in traditional medicine. However, given their role within the multi- cultural society in which most of us live, the possibilities of coming into contact with traditional Chinese medicine and ayurvedic medicine is possible for a number of reasons: • concern over interactions between traditional remedies and orthodox medicines • concern over using traditional remedies during pregnancy • concern over intrinsic toxicity of traditional remedies and cosmetics, and the safety of some procedures • the necessity of considering and understanding a patient’s total healthcare status when designing pharmaceutical care plans. The practice of traditional medicine involves concepts with which people in the west are generally unfamiliar. It may be that, with more understanding of the therapies involved, some can be incorporated into our own procedures, e. We may be able to understand better the needs of our immigrant communities and perhaps use approaches with which they feel more comfortable. A three-step process to assist orthodox healthcare providers in their approach to traditional medicine is presented in Chapter 3. Introduction to traditional medicine | 15 34 Biodiversity and sustainability Environmental awareness It is estimated that up to 40% of all pharmaceuticals in industrialised coun- tries are derived from natural sources. The search continues for more therapeutically active plant-sourced materials, not always to the satisfaction of host communities. Two centuries ago, orthodox medicine was offering digitalis and laudanum, but now there are thousands of powerful, efficacious drugs that save lives somewhere almost every second of the day. This lack of efficacy, together with patients’ growing unease over side effects of synthetic drugs, has coincided with an international growth in environmental awareness, particularly concern about the depletion of natural resources. In turn, this has led to a greater sensitivity to the delicate symbiotic balance that exists in nature. Disappearing rainforests Unfortunately the rain-forest is being destroyed at such a rate that thou- sands of species may become extinct before their medicinal potential can be examined. Five thousand years ago the rainforest covered 2 billion hectares, or 14% of the earth’s land surface.

Probably the most leading reason that herbs are not prescribed is that health insurance in the United States does not pay for these therapies discount hydrochlorothiazide 12.5 mg amex. Herbal therapies cannot be patented buy hydrochlorothiazide 12.5 mg on-line, which is a likely reason why the phar- maceutical industry hasn’t pushed the government and the medical community to use herbal therapies as treatment for diseases and symptoms of diseases. This creates an open and unregulated market for herbal therapies that lacks quality standards found in the pharmaceutical industry. In 1992, Congress instructed the National Institutes of Health to develop an Office of Alternative Medicine to support research studies of alternative thera- pies—including herbals. Interestingly, herbs are the raw material of old and new pharmaceutical med- ication. For example, the herb foxglove is the source for digitalis and the herb salicin is the source for aspirin. Although the therapeutic effect of herbs have been well known for thou- sands of years, there seems to be a lack of uniform information about them that describes their use, dosage, side effects, and contraindications. In addition, there aren’t any qualitative monographs that provide guidelines for compounding and standards of purity for herbal medication. One in five people in the United States who have taken prescription medication also have taken herbal medications. One such herb is fresh aloe, which can be used topically to treat burns and minor cuts. Herbs are living organisms that have a very short life after they are removed from their source of nutrition (that is, picked from the ground). Enzyme activity begins to cause the herb to decay immediately after the herb is harvested. Therefore, steps must be taken to preserve the herb by drying it in sunlight or by using another heat source. The most commonly used extraction technique is to first isolate the part of the herb that contains the therapeutic material and then soak that part in alcohol or water. Herbal oil is prepared by soaking the dried herb in olive oil or vegetable oil and heating the herb for an extended period of time. Oils promote the concentration of the therapeutic material and, if properly stored, extend the therapeutic life of the material for months. They are prepared in a way similar to herbal oils except once the dried herb is soaked in oil, melted wax is mixed with the oil. Once the herb blends with the water, the resulting tea can be stored in the refrigerator for later use as a drink, bath water additive, or applied topically in a compress to the skin. Chaparral tincture, for example, contains important ingredients that cannot be dissolved in water. Tinctures are also a con- venient way to take herbs that does not require kitchen preparation. Disagreeable- tasting herbs can be swallowed more quickly and can be masked with juice. Tinctures are made by soaking fresh or dried herbs in water or alcohol causing the water-soluble and fat-soluble components of the herb to concentrate. Herbal tablets are similar to herbal capsules except the dried, pulverized herb is combined with stabilizers and binders and then compressed into a tablet. A stabilizer is an ingredient that assures that the herb maintains its therapeutic effect. A binder is an ingredient that acts like glue to hold together the powdery mixture of herb and stabilizer. Syrups are made by drying the herb and soaking it in water or oil and then adding a sweetener to the mix. Hazards of Herbal Therapeutics Herbal therapies have a therapeutic effect and are acceptable interventions for diseases and symptoms. However, the lack of standards in manufacturing and lack of oversight by regulatory agencies exposes patients to potential hazards. Pharmaceuticals approved for distribution in the Untied States have under- gone rigorous testing that identifies the purity and concentration of the active ingredient that delivers the therapeutic effect. This also identifies the toxic lev- els that can cause serious and potentially lethal toxic effects. Anyone can sell herbal therapy without having to receive approval from a governmental agency or from the medical community. A major concern is the effect herbal therapy has on the patient who is also tak- ing prescribed medications. A prescriber should always ask what medication the patient is taking and review the patient’s chart before prescribing another medication. For example, a patient who takes cascara—a laxative for constipation—and senna—also a laxative—along with Digoxin—which is used to treat an irregu- lar heart rhythm—can develop a toxicity. For example, comfrey is used as an ointment to relieve swelling that is associated with abrasions and sprains. The herbal dietary supplement ephedra, commonly known as ma huang, is used as an energy boost and for losing weight. Ephedrine and pseudoephedrine are components of ephedra that have a stimulant and bronchodilation effect.

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Stasis dermatitis: This may be caused by varicose veins and chronic venous insuffi- ciency hydrochlorothiazide 12.5mg sale, which cause a buildup of fluid beneath the skin of the legs buy cheap hydrochlorothiazide 12.5mg. This fluid buildup interferes with your blood’s ability to nourish your skin and places extra pressure against the skin. While eczema can be uncomfortable to deal with, it is not contagious and can be managed well with a variety of conventional and natural methods. Symptoms vary in severity and include: • Dryness • Itching • Redness • Skin lesions (crusty, scaly patches) • Swelling In severe cases, fluid-filled vesicles, ulcers, or cracks may occur. If the skin becomes red and warm to the touch, it may be infected and require immediate medical attention. Eczema flare-ups can also be triggered by food additives (preservatives and E dyes) and spices. These products should not be used over the long term, as they may cause side effects such as burning, itching, blis- tering, easy bruising, and thinning of skin. Elidel (pimecrolimus) is a drug that affects the immune system and helps reduce flare-ups. Pumpkin and sunflower seeds also con- tain zinc, which is important for skin health. Foods to avoid: • Spices, dairy, caffeine, alcohol, and chemicals present in processed and fast foods may trig- ger flare-ups. Note: Since food allergies can cause eczema, consider an elimination diet (see Appendix D) to determine if dairy, wheat, or other common allergens are the source of your skin problems. Lifestyle Suggestions If you have contact dermatitis, avoid exposure to known irritants. For all forms of eczema, the following tips can help reduce flare-ups: • Use only hypoallergenic skin products, soaps, and detergents and rinse well with water. Look for creams that are thick and emollient and contain one or more of the following: chamomile; vitamins A, E, and C; calendula; licorice; and lavender. Complementary Supplements Celadrin: A mixture of fatty acids that reduce inflammation. Probiotics: Beneficial bacteria with immune-regulating properties; help improve digestion and reduce allergic reactions. Witch hazel: An astringent that helps dry up weeping eczema and reduces itching and inflammation. Probiotics may be helpful for those with digestive problems and to reduce allergic responses. However, because there is nowhere for this blood to exit the body, it becomes trapped, irritates surrounding tis- sue, and may cause scar tissue to form, which is painful. The actual cause is unknown; however, it is known that endometriosis is an estrogen- dependent condition and estrogen is necessary to induce or maintain endometriosis. One theory is that menstrual blood containing endometrial cells flows back through the fallopian tubes, and cells start to grow outside the uterus. Many women have E some retrograde menstrual flow, yet the immune system is able to clear the debris and prevent implantation and growth of cells. It is thought that a compromised immune system or environmental toxins (xenoestrogens) may be at play. Since endometriosis often occurs in those with a family history, it is possible that there could be a genetic flaw. Another theory is that endometrial cells are carried via the bloodstream to other sites in the body. While endometriosis can be painful, it doesn’t increase the risk of uterine cancer or ovarian cancer, and there are a number of lifestyle approaches and natural rem- edies that can be very helpful. Endometriosis can produce adhesions that can trap the egg near the ovary and prevent it from travelling through the fallopian tube to the uterus. Despite this, many women with endometriosis are still able to conceive, but it often takes them longer. Oral contraceptives are sometimes used to regulate hormone levels and control heavy bleeding. For women having difficulty conceiving, laparoscopic laser techniques can be done to shrink and remove lesions. Hysterectomy should be considered only as a last resort for those with severe symptoms that have not benefited from other conventional and natural approaches. Having this radical surgery does not guarantee an end to the symptoms and is associ- ated with various risks and complications. Dietary Recommendations Foods to include: • Increase intake of whole grains, fresh vegetables, and fruits. These foods are high in fibre and help balance levels of friendly bacteria in the intestine. Foods to avoid: • Alcohol, caffeine, refined foods, food additives, sugar, and saturated fats may affect hor- mone balance, impair immune function, and worsen symptoms. Lifestyle Suggestions • Have regular pelvic examinations and report any changes in symptoms to your doctor.

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We would particularly like to thank Laura Walsh generic 25 mg hydrochlorothiazide otc, senior editor cheap hydrochlorothiazide 25 mg with visa, and Stacy Lazar, editorial assistant, from Springer for their expert guidance and support throughout this mammoth project from design to production. Anderson Cancer Center, for believing in this work and making this collaboration possible. While every effort has been made to ensure the accuracy of information in this manual, the author, editors, and publisher are not responsible for omissions, errors, or any consequences that result from application of the information contained herein. Verification of the information in this manual remains the professional responsibility of the practitioner. Readers are strongly urged to consult other appro priate clinical resources prior to applying information in this manual for direct patient care. This is ix x Preface particularly important since patterns of practice and clinical evidence evolve constantly. We welcome any constructive feedback to help make this manual a more accurate, practical, comprehensive, and user friendly resource. Consider leuko sodes of fever, dyspnea, and productive cough triene antagonists or inhaled glucocorticoids if (brownish sputum). Other considerations include the distance between the top of thyroid cartilage need for non invasive mechanical ventilation and and suprasternal notch atend ofexpiration. Constrictive bronchiolitis (late, fibrotic, con Related Topics centric) is not responsive to glucocorticoids Cryptogenic Organizing Pneumonia (p. Not enough evidence to suggest smoking, cancer (high suspicion of occult malig any of the rules as superior. Clinical gestalt of nancy in patients who develop pulmonary embo experienced physician similar to use of rules. Unfractionated be very helpful as it provides clues to other potential heparin may be used concurrently diagnoses/pathologies as well. Treat by lung re expansion, peritoneal fluid into pleura because of negative sometimes requiring thoracotomy with decortication intrathoracic pressures and diaphragmatic defects. If high probability, sensory loss, decreased radial and brachial pulses, thoracotomy with resection or video assisted thora pallor of limb with elevation, upper limb atrophy, coscopy (for patients who cannot tolerate thoracot drooping shoulders, supraclavicular and infraclavi omy medically and physiologically) cular lymphadenopathy. Idiopathic pulmonary fibrosis (steroids plus clubbing (idiopathic pulmonary fibrosis, asbestosis, either azathioprine or cyclophosphamide). Perform respiratory and nal seizures, rapid eye movement behavior disorder cardiac examination (hypertension and pulmonary hypertension, restrictive lung disease). Treatment pentin, clonazepam, and oxycodone if precipitated options include respiratory stimulants, ventilatory by pain. If improvement >12% and 200 mL post bronchodilator, consider diagnosis of asthma (reversibility). As illustrated by the man restrictive disease below, scooping of the inspiratory curve (i. Majority of tears found in ascending History aorta right lateral wall where the greatest shear force Hypertension 1. Pulse defi absent or asymmetric peripheral pulse, limb cit or focal neurological deficits greatly increase ischemia likelihood of dissection. Type B (medical blood aorta, blurring of aortic margin secondary to local pressure control). Indicated if lar dysfunction with extensive regional wall motion cardiogenic shock with hemodynamic instability. Dia stent restenosis is due to fibrosis of coronary betic patients and those with reduced left ventricular vasculature and usually happens 3 months post function derive more benefit from bypass surgery procedure. A pulsus paradoxus >10 mmHg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. While the findings of this study are useful when assessing dyspneic patients suspected ofhavingheart failure, no individual feature issufficientlypowerfulinisolationtoruleheartfailure inorout. Therefore,anoverallclinical impression based on all available information is best. Non pharmacological treatments (diet, cular wall thickness >30 mm, and family history of exercise, smoking cessation)! Ifejectionfractionis<30 35%despite optimal although dyspnea, chest pain, syncope, and sudden medical therapy, consider revascularization, implan death may develop. Family history should be table cardioverter defibrillator, cardiac resynchroniza obtained. Maysee and is directly related to prognosis response in 20 min and complete response up to 4 h. As cuff pressure decreases, start to hear cent) " left ventricular volume (aortic regurgitation, the less intense beats (1:1 ratio).

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