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U. Osmund. Kutztown University of Pennsylvania.

In a traumatic tap buy vantin 100mg with visa, the number of RBCs in the first tube should be much higher than in the last tube purchase 100 mg vantin free shipping. In a subarachnoid hemorrhage buy vantin 100mg amex, the cell counts should be equal generic 200 mg vantin with mastercard, and xanthochromia of the fluid should be present, indicating the presence of old blood. Instruct the patient to remain recumbent for 6–12 h, and encourage an increased fluid intake to help prevent “spinal headaches. Complications • Spinal headache: The most common complication (about 20%), this appears within the first 24 h after the puncture. It goes away when the patient is lying down and is aggravated when the patient sits up. It is usually characterized by a severe throbbing pain in the occipital region and can last a week. It is thought to be caused by in- tracranial traction caused by the acute volume depletion of CSF and by persistent leakage from the puncture site. To help prevent spinal headaches, keep the patient re- cumbent for 6–12 h, encourage the intake of fluids, use the smallest needle possible, and keep the bevel of the needle parallel to the long axis of the body to help prevent 13 a persistent CSF leak. If the patient suddenly complains of paresthesia (numbness or shooting pains in the legs), stop the procedure. ORTHOSTATIC BLOOD PRESSURE MEASUREMENT Indication • Assessment of volume depletion Materials • Blood pressure cuff and stethoscope T A B L E 1 3 – 4 D i f f e r e n t i a l D i a g n o s i s o f C e r e b r o s p i n a l F l u i d O p e n i n g P r o t e i n G l u c o s e P r e s s u r e ( m g / ( m g / C e l l s C o n d i t i o n C o l o r ( m m H O ) 1 0 0 m L ) 1 0 0 m L ) ( # / m m 3 ) 2 N O R M A L A d u l t C l e a r 7 0 – 1 8 0 1 5 – 4 5 4 5 – 8 0 0 – 5 l y m p h o c y t e s N e w b o r n C l e a r 7 0 – 1 8 0 2 0 – 1 2 0 2 / 3 s e r u m 4 0 – 6 0 l y m p h o c y t e s I N F E C T I O U S V i r a l i n f e c t i o n C l e a r o r N o r m a l o r N o r m a l o r N o r m a l 1 0 – 5 0 0 ( “ a s e p t i c m e n i n g i t i s ” ) o p a l e s c e n t s l i g h t l y s l i g h t l y l y m p h o c y t e s i n c r e a s e d i n c r e a s e d P M N s B a c t e r i a l O p a l e s c e n t I n c r e a s e d 5 0 – 1 0, 0 0 0 I n c r e a s e d, 2 5 – 1 0, 0 0 0 i n f e c t i o n y e l l o w, m a y u s u a l l y 2 0 P M N s c l o t G r a n u l o m a t o u s C l e a r o r O f t e n I n c r e a s e d, D e c r e a s e d, 1 0 – 5 0 0 i n f e c t i o n o p a l e s c e n t i n c r e a s e d b u t u s u a l l y u s u a l l y l y m p h o c y t e s ( T B, f u n g a l ) 5 0 0 2 0 – 4 0 N E U R O L O G I C G u i l l a i n – B a r r é C l e a r o r N o r m a l M a r k e d l y N o r m a l N o r m a l o r S y n d r o m e C l o u d y i n c r e a s e d i n c r e a s e d l y m p h o c y t e s ( c o n t i n u e d ) T A B L E 1 3 – 4 ( C o n t i n u e d ) O p e n i n g P r o t e i n G l u c o s e P r e s s u r e ( m g / 1 0 0 ( m g / 1 0 0 C e l l s C o n d i t i o n C o l o r ( m m H O ) m L ) m L ) ( # / m m 3 ) 2 M u l t i p l e s c l e r o s i s C l e a r N o r m a l N o r m a l o r N o r m a l 0 – 2 0 l y m p h o c y t e s i n c r e a s e d P s e u d o t u m o r c e r e b r i C l e a r I n c r e a s e d N o r m a l N o r m a l N o r m a l M I S C E L L A N E O U S N e o p l a s m C l e a r o r I n c r e a s e d N o r m a l o r N o r m a l o r N o r m a l o r x a n t h o c h r o m i c i n c r e a s e d d e c r e a s e d i n c r e a s e d l y m p h o c y t e s T r a u m a t i c t a p B l o o d y, n o N o r m a l N o r m a l S I i n c r e a s e d R B C = p e r i p h e r a l x a n t h o c h r o m i a b l o o d ; L e s s R B C i n t u b e 4 t h a n i n t u b e 1 S u b a r a c h n o i d B l o o d y o r U s u a l l y I n c r e a s e d N o r m a l W B C / R B C h e m o r r h a g e x a n t h o c h r o m i c i n c r e a s e d r a t i o s a m e a f t e r 2 – 8 h a s b l o o d A b b r e v i a t i o n s : W B C = w h i t e b lo o d c e ll; R B C = r e d b lo o d c e ll; P M N s = p o ly m o r p h o n u c le a r n e u t r o p h i ls. Changes in blood pressure and pulse when a patient moves from supine to the upright position are very sensitive guides for detecting early volume depletion. Even before a person becomes overtly tachycardic or hypotensive because of volume loss, the demon- stration of orthostatic hypotension aids in the diagnosis. If the patient is unable to stand, have the patient sit at the bedside with legs dangling. A drop in systolic BP greater than 10 mm Hg or an increase in pulse rate greater than 20 (16 if elderly) suggests volume depletion. A change in heart rate is more sensitive and occurs with a lesser degree of volume depletion. Other causes include peripheral vascular disease, surgical sympathectomy, diabetes, and medications (prazosin, hy- dralazine, or reserpine). PELVIC EXAMINATION Indications • Part of a complete physical examination in the female • Used to assist in the diagnosis of diseases and conditions of the female genital tract Materials • Gloves • Vaginal speculum and lubricant • Slides, fixative (Pap aerosol spray, etc), cotton swabs, endocervical brush and cervi- cal spatula prepared for a Pap smear • Materials for other diagnostic tests: Culture media to test for gonorrhea, Chlamy- 13 dia, herpes; sterile cotton swabs, plain glass slides, KOH, and normal saline solu- tions, as needed Procedure 1. The pelvic exam should be carried out in a comfortable fashion for both the patient and physician. The patient should be draped appropriately with her feet placed in the stirrups on the examining table. Pre- pare a low stool, a good light source, and all needed supplies before the exam begins. In unusual situations examinations are conducted on a stretcher or bed; raise the pa- tients buttocks on one or two pillows to elevate the perineum off the mattress. Observe the skin of the perineum for swelling, ulcers, condylomata (venereal warts), or color changes. Inspect the vaginal orifice for discharge, or protrusion of the walls (cystocele, rec- tocele, urethral prolapse). Use a speculum moistened with warm water not with lubricant (lubricant will in- terfere with Pap tests and slide studies). Because the anterior wall of the vagina is close to the urethra and bladder, do not exert pressure in this area. With the speculum directed at a 45-degree angle to the floor, spread the labia and insert the speculum fully, pressing posteriorly. Inspect the cervix and vagina for color, lacerations, growths, nabothian cysts, and evidence of atrophy. Inspect the vagina for secretions and obtain specimens for a Pap smear, other smear, or culture (see tests for vaginal infections and Pap smear in item 7). Inspect the vaginal wall; rotate the speculum as you draw it out to see the entire canal. It is best to use whichever hand is comfortable to do the in- ternal vaginal exam.

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The doctor might also order a blood teroids is usually limited to a short amount of time with a test to determine the presence of HLA–B27 antigen if gradual weaning from the drug discount vantin 100mg with mastercard. If the gene is present generic 100mg vantin fast delivery, it could facilitate the accuracy of the In April 2002 buy cheap vantin 100 mg line, a study published revealed that a drug possible AS diagnosis order vantin 200mg amex. When a diagnosis is made, pa- already approved for patients with rheumatoid arthritis tients may be referred to a rheumatologist, a doctor who was successful in helping most AS patients as well. Patients may also be re- fliximab helped alleviate pain and improved functioning ferred to an orthopedic surgeon, a doctor who can surgi- in more than 80 % of patients in a clinical trial. Some serious side ef- fects did occur, so researchers continued to test the drug Treatment and seek Food and Drug Administration (FDA) approval To reduce inflammation, various herbal remedies, for Infliximab for AS patients. In the same year, scien- including white willow (Salix alba), yarrow (Achillea tists were testing another drug called Etanercept that also millefolium), and lobelia (Lobelia inflata), may be help- showed promising results in preliminary trials. Acupuncture, performed by a trained professional, Physical therapists prescribe exercises to prevent a has helped some patients manage their pain. Homeopath- stooped posture and breathing problems when the spine ic practitioners may prescribe such remedies as Bryonia starts to fuse and ribs are affected. Reported benefits include a decrease in pain, in- formed to straighten and realign the spine, or to replace crease in circulation, lymph flow improvement, and in- knee, shoulder, or hip joints. The major benefit of this ther- complicated procedure, with a potential for complica- apy could be that it provides further motivation for a reg- tions, this surgery is recommended cautiously even in se- ular excerise program, considered the most beneficial of vere cases. Diets of various regimens have been offered that in- Expected results clude supplements of fatty acids and antioxidants,as There is no cure for AS, and the course of the dis- with other arthritis diets. Generally, AS progresses for about doctors have theorized that certain foods should be elim- 10 years, then levels off. Most patients can lead normal inated from the diet in order to alleviate symptoms. Claims that sible problem foods include wheat, corn, milk and other homeopathic remedies have cured them have not been dairy products, beef, tomatoes, potatoes, and peppers. Various reports have surfaced in many books and Prevention articles that indicate a diet high in fiber and fresh fruits and vegetables—minus those listed above—and low in There is no known way to prevent AS. With twenty- sugar, meat, refined carbohydrates, and animal fats first century advances in gene therapy, the possibility ex- might help in the treatment of the symptoms, particularly ists for further determination of the factor that HLA–B27 with pain or swelling. Allopathic treatment Resources Nonsteroidal anti-inflammatory drugs (NSAIDs), BOOKS like naproxen (Naprosyn) or indomethacin (Indocin) are Brewer Jr. Spondylitis As- mation, or methotrexate (Rheumatrex), an immune-sup- sociation of America, 1994. Penn State University, Department of Orthopaedics and Reha- Ankylosing—When bones of a joint are fused, bilitation, M. Anorexia nervosa is an eating disorder characterized by unrealistic fear of weight gain, self-starvation, and PERIODICALS conspicuous distortion of body image. Anorexia nervosa was not officially classified as a ORGANIZATION psychiatric disorder until the third edition of DSM in Arthritis Foundation. In the 1970s and 1980s, anorexia was regarded as a disorder of upper- and middle-class women, but that generalization is also changing. More recent studies indicate that anorexia is increasingly common among women of all races and so- cial classes in the United States. Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychi- atric disorder. Moreover, the disorder may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation, stomach rupture, swelling of the salivary glands, loss of kidney function, osteoporosis, anemia and other abnormalities of the blood. Causes & symptoms Anorexia is a disorder that results from the interac- tion of cultural and interpersonal as well as biological factors. While the precise cause of the disease is not known, it has been linked to the following: Social influences The rising incidence of anorexia is thought to reflect the present idealization of thinness as a badge of upper- class status as well as of female beauty. In addition, the increase in cases of anorexia includes “copycat” behav- ior, with some patients developing the disorder from imi- tating other girls. The increasing influence of the mass media in spreading planation covers all cases. Anorexia nervosa has been in- and reinforcing gender stereotypes has also been noted. This rejection is variously interpreted as a desire to remain a child, or as The risk of developing anorexia is higher among a desire to resemble men as closely as possible.

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Isosorbide dinitrate and pentaerythritol tetrani- to reduce myocardial ischemia is still controversial (Fig buy 100 mg vantin mastercard. Although nitroglycerin dilates both peripheral ca- These compounds have a slower onset and slightly pacitance and resistance vessels 100mg vantin amex, the effect on the ve- longer duration of action than sublingually or buccally nous capacitance system predominates generic vantin 100 mg fast delivery. This reduces ventricular diastolic vol- lized in the liver by the enzyme glutathione organic ume and pressure and shifts blood from the central to nitrate reductase cheap vantin 200 mg free shipping. Although the metabolites of nitro- the peripheral compartments of the cardiovascular sys- glycerin are virtually inactive as vasodilators, two tem. These effects of nitroglycerin and other organic ni- metabolites of isosorbide dinitrate, isosorbide 2- trates are similar to those of mild phlebotomy, which mononitrate and isosorbide 5-mononitrate, do retain has been shown clinically to relieve acute anginal at- some vasodilator and antianginal activity. The latter esters and lar pressure and heart size results in a decrease in the their metabolites are water soluble and are readily ex- myocardial wall tension that is required to develop a creted by the kidney. Since blood flow to the subendo- cardium occurs primarily in diastole, the reduction in Pharmacological Actions left ventricular end diastolic pressure induced by nitro- There is little doubt concerning the effectiveness of ni- glycerin reduces extravascular compression around the troglycerin in the treatment of angina pectoris. This effect of nitro- pated physical or emotional stress, to prevent anginal glycerin on the distribution of coronary flow is impor- attacks. Sustained-release transdermal nitroglycerin has arteriolar smooth muscle, which leads to a decrease in been shown to deliver an antianginal effect for 2 to 4 both peripheral vascular resistance and aortic imped- hours following small doses and up to 24 hours after ance to left ventricular ejection (decreased afterload). The decreased resistance to ventricular ejection may Orally administered long-acting nitrates, including also reduce myocardial wall tension and oxygen re- nitroglycerin and various nitrate esters, nitroglycerin quirements. Considerable consequence of the reduction in cardiac preload and af- controversy surrounds the therapeutic use of the orally terload, and this results in a decrease in myocardial wall active agents because of their extensive first-pass me- tension. Oxygen supply to the subendocardium of isch- tabolism, and many clinicians consider them to be inef- emic areas is increased because extravascular compres- fective. In vestigations have demonstrated the efficacy of addition, nitroglycerin may increase blood flow to isch- transdermal nitroglycerin, although tolerance can be a emic areas by its direct vasodilator effect on eccentric problem with prolonged transdermal exposure to nitro- epicardial coronary artery stenoses and collateral blood glycerin. The drugs and dosage forms of organic nitrates vessels and by its action to inhibit platelet aggregation. Nitrate-induced Late Preconditioning Tolerance and Dependence Recent findings suggest a potential new action of ni- Repeated and frequent exposure to organic nitrates is trates in the treatment of patients with ischemic heart accompanied by the development of tissue tolerance to disease. The mechanism underlying the phe- persist in animals that displayed tolerance to the vascu- nomenon of nitrate tolerance is not as yet completely lar effects of nitroglycerin. Although this effect of nitro- understood but may be related to a nitrate-induced ox- glycerin has not been demonstrated unequivocally in idation of sulfhydryl groups via the formation of free patients receiving long-term nitrate therapy, these re- radicals, a decrease in the sensitivity of vascular smooth sults are provocative and may support new uses of ni- muscle soluble guanylate cyclase, or activation of the trates in patients or benefits that have until now re- renin–angiotensin system. To help avoid nitrate tolerance, clinicians should employ the smallest effective dose and administer the Clinical Uses compound infrequently. A daily nitrate-free period is Sublingual or buccal nitroglycerin is used either to ter- also recommended, particularly with use of the trans- minate an acute attack of angina or for short-term pre- dermal patches or ointment. Nitroglycerin is also the mainstay of the pharmacokinetic profile achieved with these sus- therapy for relieving acute coronary vasospasm because tained-release formulations should result in more effec- of its rapid onset of action. The Isosorbide dinitrate and pentaerythritol tetranitrate most commonly used agent is N-acetylcysteine (NAC), also can be taken sublingually, shortly before antici- which is hydrolyzed in vivo to cysteine. An ef- the antinitrate tolerance effect of this compound has fective dose of nitrate usually produces a fall in upright not been universally confirmed. Thus, further well- systolic blood pressure of 10 mm Hg and a reflex rise in controlled clinical studies are necessary to establish the heart rate of 10 beats per minute. Larger changes than effectiveness of sulfhydryl-containing compounds at these should be avoided, because a reduction in myo- preventing or reversing nitrate tolerance. The state of de- Since nitrite ions oxidize the iron atoms of hemo- pendence becomes manifest when exposure to nitrates globin and convert it to methemoglobin, there may be a is withdrawn suddenly. While methemoglo- who have become dependent on nitroglycerin have binemia does not follow therapeutic doses of organic ni- been reported to undergo angina, myocardial infarc- trates, it can be observed after overdosage or accidental tion, or even sudden death following removal from poisoning. Some of these patients showed symptoms of ischemic heart disease, even Cautions though their coronary arteriography was judged to be normal. Since it is possible that coronary vasospasm Chest pain that is not relieved by two or three tablets plays a role in the pathogenesis of angina that occurs within 30 minutes may be due to an acute myocardial in nitrate-dependent individuals, these patients should infarction. In addition, nitrate administration may result be cautioned to watch for increased chest pain when in an increase in intracranial pressure, and therefore, they withdraw from medication or discontinue their these drugs should be used cautiously in patients with exposure. Adverse Effects -Adrenoceptor Blocking Agents Vascular headache, postural hypotension, and reflex -Adrenoceptor blockade is a rational approach to the tachycardia are common side effects of organic nitrate treatment of angina pectoris, since an increase in sym- therapy.

Paper presented to the annual convention of the Association for Education in Journalism and Mass Communication discount vantin 100mg amex, Miami Beach order vantin 200 mg fast delivery, FL order vantin 200mg online. Copying or distributing in print or electronic forms without written permission of Idea Group Inc buy 200 mg vantin. The first 15 years: What has been learned about the Cancer Information Service and the implications for the future. The knowledge-creating company: How Japanese companies create the dynamics of innovation. Lessons learned about academic and public health collaborations in the conduct of community-based research. The control revolution: How the Internet is putting individuals in charge and changing the world we know. Four-nation survey shows widespread but different levels of Internet use for health purposes. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Clinical Decision Support Systems 251 ChapterXIV Clinical Decision Support Systems: Basic Principles and Applications in Diagnosis and Therapy Spyretta Golemati, National Technical University of Athens, Greece Stavroula Mougiakakou, National Technical University of Athens, Greece John Stoitsis, National Technical University of Athens, Greece Ioannis Valavanis, National Technical University of Athens, Greece Konstantina S. Nikita, National Technical University of Athens, Greece Abstract This chapter introduces the basic principles of Clinical Decision Support (CDS) systems. CDS systems aim to codify and strategically manage biomedical knowledge to handle challenges in clinical practice using mathematical modelling tools, medical data processing techniques and Artificial Intelligence (AI) methods. CDS systems cover a wide range of applications, from diagnosis support to modelling the possibility of occurrence of various diseases or the efficiency of alternative therapeutic schemes, using not only individual patient data but also data on risk factors and efficiency of available therapeutic schemes stored in databases. Computer-Aided Diagnosis (CAD) systems can enhance the diagnostic capabilities of physicians and reduce the time required for accurate diagnosis. Modern Therapeutic Decision Support (TDS) systems Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. CDS systems aim to improve the overall health of the population by improving the quality of healthcare services, as well as by controlling the cost-effectiveness of medical examinations and treatment. Introduction Advances in the areas of computer science and Artificial Intelligence (AI) allow the development of computer systems that support clinical diagnostic or therapeutic decisions based on individualised patient data (Berner & Ball, 1998; Shortliffe, Perrault, Wiederhold, & Fagan, 1990). Clinical Decision Support (CDS) systems aim to codify and strategically manage biomedical knowledge to handle challenges in clinical practice using mathematical modelling tools, medical data processing techniques and AI methods (Bankman, 2000). CDS systems cover a wide range of applications, from diagnosis support to modelling the possibility of occurrence of various diseases or the efficiency of alternative therapeutic schemes, using not only individual patient data but also data on risk factors and efficiency of available therapeutic schemes stored in databases. To diagnose a disease, a physician is usually based on the clinical history and physical examination of the patient, visual inspection of medical images, as well as the results of laboratory tests. In some cases, confirmation of the diagnosis is particularly difficult because it requires specialisation and experience, or even the application of interventional methodologies (e. Computer-Aided Diagnosis (CAD), defined as a diagnosis made by a physician who uses the output from a computerised analysis of medical data as a “second opinion” in detecting lesions, assessing disease severity, and making diagnostic decisions, is expected to enhance the diagnostic capabilities of physicians and reduce the time required for accurate diagnosis. The first CAD systems were developed in the early 1950s and were based on production rules (Shortliffe, 1976) and decision frames (Engelmore & Morgan, 1988). More complex systems were later developed, including blackboard systems (Engelmore & Morgan, 1988) to extract a decision, Bayes models (Spiegelhalter, Myles, Jones, & Abrams, 1999) and Artificial Neural Networks (ANNs) (Haykin, 1999). Recently, a number of CAD systems have been implemented to address a series of diagnostic problems. CAD systems are usually based on biosignals, including the electrocardiogram (ECG), elec- troencephalogram (EEG), electromyogram (EMG) or medical images from a number of modalities, including radiography, CT, MRI, and US imaging.

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