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By A. Norris. Golden Gate University.

Despite these facts discount hytrin 2mg online, there is a lack of knowledge of complementary therapies by many conventionally trained physicians hytrin 1mg on line. For all these reasons order hytrin 2 mg overnight delivery, it seemed an appropriate time to provide a book focusing on complementary therapies for neurological disorders buy hytrin 5 mg fast delivery. This book is targeted to any health-care provider who sees people with neurological diseases. While there are other books in the general area and even one for neurological disorders, the scientific level of all the chapters, especially those sections organized by disease states or conditions, should be accessible to even the most scientifically stringent, conventionally trained physicians, including neurologists. The first section discusses many of the complementary and alternative therapy modalities. The second section is structured similarly to conventional neurology textbooks; it is organized by disease states or conditions and reviews relevant evidence in a very conventional manner. The choice of topics for the first portion of this book was based in part on the amount of evidence available and on the amount of use. Some therapies were not chosen, because there was too little published clinical data regarding neurological disorders. These therapies may have well-established and wide medical use but not in neurology to any degree, or they may be used for neurological disorders but without much evidence. Music, dance and art therapy could all be considered aspects of mind-body medicine. These therapies are well-established complementary therapies with formal educational programs at the undergraduate or graduate level, national organizations ( While there are randomized controlled trials of these therapies for some indications, the evidence for most neurological disorders is limited. There are other complementary therapies such as use of magnetic fields and aromatherapy that have no specific chapter focused on these treatments, but relevant data are discussed in the disease-oriented chapters. There are several modalities that are usually considered more within the realm of conventional medicine and are not discussed in any detail; these include transcranial magnetic stimulation and hyperbaric oxygen. There are groups of complementary therapies, such as energy-based therapies, for which data are limited and these also are not discussed in any detail (e. Some of the chapters include historical perspectives; these are particularly the chapters on traditional Chinese medicine and ayurveda. The utility of modalities such as acupuncture does not depend on acceptance of the historical perspectives, and some even feel that this historical perspective may be impeding its scientific development. However, it is of some importance to know these historical perspectives and to refine the explanatory concepts with empirically testable theories on the mechanisms of action. The goal for this book is to be a useful resource to conventional or complementary health-care providers who are trying to optimize the health of their patients. Acknowledgements I would like to acknowledge all the clinical researchers whose published clinical trials and insights have produced the knowledge upon which this book is based, and all the government and non-government organizations that have funded the research discussed in this book. The US National Institutes of Health National Center for Complementary and Alternative Medicine has supported the Oregon Center for Complementary and Alternative Medicine in Neurological Disorders (ORCCAMIND) ( I have appreciated the discussions I have had with all the researchers at ORCCAMIND concerning many of the topics discussed in this book. I would like to thank all the members of my research staff who have been excellent at carrying out many research projects and allowing me to focus some time on this book. I would like specifically to acknowledge Andy Fish for organizing the chapters and correspondence from both the authors and CRC Press, and Shirley Kishiyama who helped with editing and graphics. DEDICATION To my family, for their love and support Color plates Plate 1 Regional cerebral blood flow changes in pain-related activity within primary somatosensory cortex (S1) and anterior cingulate cortex (ACC) associated with hypnotic suggestions for increased pain (↑), decreased pain (↓) and increased minus decreased- pain (↑–↓) intensity (Int), and unpleasantness (Unp) during the sensory-modulation experiment (from reference 54) and the affective- modulation experiment (from reference 53). Modulatory effects of suggestions for ↑ and ↓ pain (Int or Unp) are revealed by subtracting positron emission tomography (PET) data recorded during the warm hypnosis- control condition from the ↑ pain (Int or Unp) and the ↓ pain (Int or Unp) conditions and the ↑–↓ pain (Int or Unp) involved subtracting ↓ pain (Int or Unp) condition from the ↑ pain (Int or Unp) condition. Horizontal and sagittal slices through S1 and ACC, respectively, are centered at the activation peaks observed during the relevant suggestion condition.

Two types of bioavailability can be calculated cheap 2 mg hytrin overnight delivery, de- Thus order 2 mg hytrin fast delivery, the concept of half-life has considerable impor- pending on the formulations available and the informa- tance for determining dosing frequency or adjusting tion required generic 2 mg hytrin otc. Thus discount hytrin 5mg otc, each successive half-life removes less drug, but the concentration at the beginning of the period is reduced by 50% during the period. The absolute ability can change the dose numerator, which is re- bioavailability of a drug can be calculated as: quired to calculate total clearance. Frequently, however, Dose (AUC ) one wishes to calculate drug clearance but intravenous iv 0- other F administration is not feasible. In this situation, the ap- Doseother (AUC0- )iv parent clearance (also called oral clearance) can be es- where the route of administration is other than intra- timated by the following equation: venous (e. For calculation of absolute Dose F bioavailability, complete concentration-time profiles Clapp AUC are needed for both the intravenous and other routes of administration. This calculation is determined when two prod- F AUC ucts are compared to each other, not to an intravenous standard. This is commonly calculated in the generic The term apparent clearance is used because the drug industry to determine that the generic formulation bioavailability of the compound is unknown. Thus, bioavailability is not than the true systemic clearance because of this un- routinely calculated in an individual patient but re- known bioavailability. However, it is important to have an idea of how lated is that of renal clearance, or that portion of clear- formulations or routes of administration differ with re- ance that is due to renal elimination. Renal clearance is spect to bioavailability so as to allow proper dosage ad- calculated as: justment when changing formulations or routes of ad- Ae ministration. Calculation of renal clearance is Clearance is a pharmacokinetic parameter used to de- especially useful for drugs that are eliminated primarily scribe the efficiency of irreversible elimination of drug by the kidney. More specifically, clearance is defined as Because clearance estimates the efficiency of the the volume of blood from which drug can be completely body in eliminating drug, the calculation of clearance removed per unit of time (e. Clearance can involve both metabolism of drug to a Since this parameter includes both the volume of distri- metabolite and excretion of drug from the body. For ex- bution and the elimination rate, it adjusts for differences ample, a molecule that has undergone glucuronidation in distribution characteristics and elimination rates is described as having been cleared, even though the among people, thus permitting more accurate compar- molecule itself may not have left the body. However, as stated earlier, by drug can be accomplished by excretion of drug into the far the easiest clearance parameter to estimate is that of urine, gut contents, expired air, sweat, and saliva as well apparent (oral) clearance, since it does not require in- as metabolic conversion to another form. However, up- travenous administration, yet this parameter can be pro- take of drug into tissues does not constitute clearance. Total (systemic) Volume of Distribution clearance (Cl) can be calculated by either of the equa- tions given below: Vd relates a concentration of drug measured in the blood to the total amount of drug in the body. This Cl Vd ke mathematically determined value gives a rough indica- tion of the overall distribution of a drug in the body. In general, the greater the Vd, the greater where Vd is the volume of distribution (see below) and the diffusibility of the drug. One must give the drug intravenously to assure since its estimation may result in a volume greater than 100% bioavailability, because lack of 100% bioavail- the volume available in the body (~40 L in a 70-kg 52 I GENERAL PRINCIPLES OF PHARMACOLOGY adult). Following a single dose, concen- a highly lipid-soluble drug, such as thiopental, that can trations can be monitored until no longer analytically be extensively stored in fat depots may have a Vd con- detectable and a complete pharmacokinetic profile is siderably in excess of the entire fluid volume of the described. Thus, because of their physicochemical character- In clinical practice, drugs are more commonly ad- istics, different drugs can have quite different volumes ministered in multiple doses, with the second dose usu- of distribution in the same person. The final concen- drug does not distribute widely into tissues (though it trations of drug reached depend on the elimination rate does reach tissues to some degree to exert its action). In contrast, the time to reach steady widely throughout the body; in fact, it does distribute to state is affected by neither the dose amount nor dosing various tissues, such as the liver, lungs, eyes, and adipose frequency. Since the total volume of the body does not equal fected by the elimination rate (which is reflected in the 4200 L, it can clearly be seen that this is not a “real” vol- t1/2). Giving a larger dose or giving the dose more often ume but one that relates the blood concentration to the will not change the time needed to reach steady state amount of drug in the body. Just as it takes approximately five half-lives for a Protein Binding drug to be essentially (97%) eliminated, it also requires five half-lives for a drug to reach steady state.

Consider buy discount hytrin 1mg on line, for example buy hytrin 2 mg with visa, cohol level quickly becomes equivalent to the blood al- the number of televised sporting events that are spon- cohol level hytrin 5 mg discount. An addicted person buy hytrin 2 mg otc, under the (accounting for the increased likelihood of injury and al- influence of the addictive substance, is physically and cohol related injury statistics). At higher alcohol levels, a psychologically motivated to perpetuate the addiction. Vomiting may Therefore, intervention often starts when loved ones, occur, with a high risk of vomitus “aspiration” (inhaling recognizing the signs and symptoms, bring attention to vomit into the lungs), and may result in further compli- the problem and call for help. Still higher alcohol levels tion requires a whole family unit and outside assistance. Signs and symptoms of alcohol dependence and abuse may include the following: Effects of long-term (chronic) alcoholism • not remembering conversations or commitments Alcohol is considered a lethal poison, requiring con- • losing interest in activities that were once pleasurable tinuous detoxification by the liver. It is estimated that 30–40% of • drinking alone or secretly all men in their teens and twenties have experienced al- coholic blackout (loss of consciousness) as a result of • hiding alcohol in unusual places drinking a large quantity of alcohol. In an alcoholic • ordering doubles, drinking quickly, and drinking to be- blackout, all memory of time and behavior surrounding come drunk, intentionally the episode of drinking is lost. Alcohol causes sleep dis- 42 GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 turbances, thus affecting overall sleep quality. White blood cells (important for fighting infec- and tingling may occur in the arms and legs. Two condi- tions) decrease in number, resulting in a weakened im- tions that may occur either together or separately are mune system. Both are due to infections and is thought to account in part for an alco- the depleted thiamin levels found in alcoholics. As a result, acid from the stomach flows up- blood pressure negatively affects the kidneys. While ward into the esophagus, burning those tissues and caus- some studies demonstrate that one to two alcoholic ing pain and bleeding, or gastro-esophageal reflux dis- drinks per night improves heart disease risk values, ease (GERD). Inflammation of the stomach can also re- higher amounts and chronic intake produce high levels sult in bleeding (ulcers) and pain as well as a decreased of circulating fats, which increases the risk of heart dis- desire to eat. Heavy drinking results in an enlarged heart, coro- bleeding (hemorrhage) in an alcoholic is the develop- nary arterial disease (CAD), peripheral vascular disease, ment in the esophagus of enlarged (dilated) blood ves- weakening of the heart muscle, abnormal heart rhythms, sels, which are called esophageal varices (varicose veins a risk of blood clots forming within the chambers of the of the esophagus). These varices actually develop in re- heart, and a greatly increased risk of stroke. Strokes re- sponse to the toxic effect of alcohol on the liver, and are sult when a blood clot from the heart enters the circula- extremely prone to bursting and hemorrhage. A malnourished state arises from the loss of appetite Stroke may also result from a hemorrhage within the for food—due to caloric substitution of alcohol and its ef- brain, as weakened vessel walls give way and platelet de- fects on blood sugar levels—and interference with the ab- ficient blood pours through. Heavy drinking has a neg- mation of the pancreas (pancreatitis) is a serious and ative effect on fertility in both men and women, decreas- painful problem in alcoholics that disrupts carbohydrate ing testicular and ovarian size, interfering with sperm and fat digestion, and increases the risk of insulin resis- and egg production and viability, disrupting menstrual tance, weight gain, hyperlipidemia, diabetes, and pancreat- cycles, and reducing libido. A child born to an al- lized) within the liver, that organ is severely affected by cohol using woman has a great risk of being born with constant levels of alcohol. Alcohol interferes with the fetal alcohol syndrome, which causes distinctive cranial large number of important chemical processes that occur and facial defects, including a smaller head size, shorten- in the liver. As alcohol converts to blood sugar, which in ing of the eyelids, and a lowered IQ. Developmental dis- turn converts to blood fat, the liver begins to enlarge, fill- abilities, heart defects, and behavioral problems are also ing with fat, a condition called fatty liver. The liver may also become inflamed, a condi- criteria that can be of aid in diagnosing a substance tion called hepatitis, producing jaundice, fatigue, and abuse problem. These criteria are paraphrased here to re- elevated liver enzymes indicative of liver cell death and late to alcoholism. Alcohol can cause changes to any of the major role obligations at work, school, or home. Determining the exact quan- tity of alcohol that a person drinks is much less impor- • Recurrent alcohol use in situations in which it is physi- tant than determining how his or her drinking affects cally hazardous. Specific examples are driving an auto- health, relationships, jobs, educational goals, and family mobile and operating a machine while impaired by al- life. It consists clude arguments with a spouse about the consequences of four questions, with the first letter of each key word of intoxication, and alcohol-related physical fights.

If this value is exceeded this would mean that the RHA budget will cover the difference or transfer the cost to insurance companies and social welfare buy hytrin 1mg visa. In addition hytrin 1 mg without prescription, a regional healthcare authority will then have credible proof that national standards are outdated and require revision in order to support the system buy hytrin 2 mg online. As a result hytrin 1 mg with mastercard, this KPI has now a specific meaning linked to regional strategy and budgetary needs. Following that example, all financial KPIs are therefore an important perspective of BSC since they are the measurement of the financial viability of the regional healthcare authority. In fact, all KPIs should be associated with adequate metrics in order to be Table 2. KPIs in a regional healthcare setting No Financial KPI description No Process KPI description F1 Mean treatment cost per day P1 Length of stay F2 Mean cost of medical treatment per patient P2 Patient admission rate per medical unit F3 Mean cost of drugs consumption P3 Percentage of bed coverage F4 Mean cost of radiology testing P4 Vaccination rate F5 Mean cost of laboratory testing P5 Mean value of performed test per patient, per doctor F6 Mean cost of material consumption P6 Number of inpatients F7 Mean cost of surgical procedure P7 Number of outpatients F8 Mean operational cost per dept. P14 Number of dental care processes P15 Number of processed emergency cases P16 Number of unprocessed order entries on the same day P17 Number of preventive care visits P18 Number of home care monitored patients P19 Assessment of patient satisfaction No Customer (patient) KPI description No Learning and Growth KPI description C1 Mortality rate L1 Medical device usage growth C2 Morbidity rate L2 Healthcare professionals training rate C3 Number of medical staff per 1000 inhabitants L3 Employee Satisfaction rate C4 Number of beds per 1000 inhabitants L4 Number of doctors per bed C5 Accessibility of patients to the medical units L5 Number of nurses per bed C6 Time in a waiting list L6 Number of existing healthcare professionals versus expected job positions C7 Equity of delivered care L7 Personnel productivity rate C8 Number of readmission per patient L8 Number of medical interventions per doctor C9 Mean length of stay L9 Number of patient with re-examinations C10 Patient Satisfaction rate L10 Visits/ICD codes L11 Admissions per case type (ICD 10) L12 Dismissals per case type (ICD 10) Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. In order to meet and populate the above-mentioned KPIs a regional healthcare authority has to implement a complex information technology system in order to gather up all needed information. Then the information collected through the use of enterprise resource planning software, hospital information systems, clinical information systems, radiology information system, and laboratory information systems has to be processed and interpolated to produce the final metadata set from which the KPIs are driven. In other words, the model is complemented by a business intelligence solution similar to the one depicted in Figure 4. Figure 4 shows how data are collected from the various data sources, cleansed and homogenised, and finally redistributed to the knowledge workers and decision makers of the regional healthcare authority (Extraction, Transformation and Load—ETL). The data collection process is extremely important since it is a basic feature of success- fully populating the KPIs. In that sense both organizational and technological issues to achieve data quality should be considered. In the proposed setting, the regional healthcare authority has imposed on its healthcare units the use of specific classifica- tions, codifications and taxonomies such as the 10th edition of the International Classi- fication of diseases (ICD10). In addition, the proposed KPIs can be seen as attributes of structure, process or outcome (based upon the Donabedian approach) so that they can be used to draw an inference about quality. As such the KPIs are proposed, designed, tested and assessed by a panel of experts (executive officers of the RHA, practitioners). By implementing this organizational structure the quality level of the proposed KPIs is such that technological issues are greatly reduced. Regional healthcare authority business intelligence framework Administration and Control Data sources Knowledge workers outside data Data Mining Business Intelligence Server transaction data Data Staging & Storage Data Warehouse DBMS Internal data (MetaData) OLAP Stored Data Report/Query Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Key Performance Indicators and Information Flow 133 Future Trends Up to this point, this chapter has mostly dealt with organizational and strategic features of knowledge management in healthcare. In the proposed use case we have shown an ongoing implementation of a Balanced Scorecard Framework in a regional healthcare authority environment. This has been done intentionally wishing to state that the technological part on such an implementation is probably the less important issue. If one regards the future trends in knowledge management, one can see that a multitude of new tools are already proposed for use. This chapter will briefly set the focus on the trends that to our knowledge are the most promising and present more opportunities to healthcare organizations in creating effective performance management facilities. Service Oriented Architecture and Patient-Centered Architecture (Based on the Electronic Health Record) The term of patient-centered architecture has been already in the literature for some years. Many techniques have been used in the past such as Corbamed (Object Manage- ment Group, 2001) and Distributed Healthcare environment (DHE).

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