By V. Sugut. Lutheran Bible Institute. 2018.
I had been dean for nearly ﬁve years when the average tenure was closer to two generic silvitra 120mg on line. Te sirens who had called me to medical administra- tion stopped singing their seductive songs buy generic silvitra 120mg. Te calmer and more familiar waters of clinical medicine called me again discount silvitra 120mg with amex. As a state medical school silvitra 120mg with visa, we had an obligation to consider the health of the people of the state. I began to wonder about the real causes of disease from a population basis. At the end of my deanship, I decided to redirect my clinical interests from pure endocrinology to a broader look at illness, par- ticularly at patients with symptoms but no medical disease. I had begun to ask myself, If these people do not have a medical disease, then what is their problem? He came from Pittsburgh, at the time a center and hub for faculty who were interested in the psychological as- pects of illness. Sapira led me patient by patient and week by week through an understanding of the fallacy of the mind-body dichot- omy. Before working with him, I had slowly begun to reject the dichotomy, but Sapira was able to reject it in a manner that also appealed to my need for scientiﬁc rigor. He was quick to point out that a stimulus or agent for disease was not limited to what could be visualized under a microscope or put in a test tube. Sounds, voices, sights, smells, colors, touches, and all the varied sensory stimuli that impinge on humans were legitimate material for scien- tiﬁc inquiry. Combine all of those into human communication and language and those complexes were equally legitimate material for scientiﬁc study—diﬃcult, but amenable to direct observation and study. I came to fully understand that the mind and the body were one—not separated, not disconnected. Sitting above all the molecules, tissues, organs, and mind of the human body was an integrated person. Tis person was connected to a family and perhaps to a spouse, and the family was connected to some social structure and society at large. All this social structure impinged on the person, and the person impinged on the social structure. Tere was a continuum all the way from so- ciety to the person to the organs and even down to the molecules. George Engel (1977) posited such a continuum and hierarchy of interlocking subsystems in his classic paper Te Need for a New Medical Model: A Challenge for Biomedicine. It may seem strange that I am describing my transition from a belief that the mind and body were separated to one that saw no separation. Even today, some physicians still func- tion as if the body and mind are separate and disconnected entities. Tis erroneous view is part of the explanation for our excessive use of procedures and technology. In addition to having an integrated model of humans and dis- ease, Sapira was also a superb teacher of interviewing techniques. Foremost, he was a ﬁrst-order bedside clinician and would later capture much of his wisdom in his masterpiece, Te Art and Sci- ence of Bedside Diagnosis (1999). At the beginning of mentoring me in interviewing techniques, Sapira had me see patients with him. He showed me that the longer the wait, the richer the material oﬀered by the patient. My allowing the anxi- ety level to rise in the patient elicited from the patient information that would not have come in response to a direct question. I also learned to notice that the last thing a patient said as I left the room was often the most revealing and important information of the en- tire session. I was learning to go deeper than the superﬁcial level of physical symptoms.
I had never seen a more severe case of untreated hypothyroidism generic 120mg silvitra with mastercard, which I conﬁrmed with a pro- tein-bound iodine level and a radioiodine uptake generic 120mg silvitra otc. To have a cur- able disease like hypothyroidism in one of your ﬁrst patients is like a dream come true cheap 120 mg silvitra with visa. To have a hypothyroid patient who is famous locally and well known to have lost her mind and will is nearly unbelievably lucky buy discount silvitra 120 mg. I suppose the development of the clinical state was so slow and insidious that it was just not seen as a change. I also discovered there was a widespread misconception about what hypothyroid pa- tients looked like. Whatever the reasons for missing the diagnosis, everyone thought Irene Johnson was senile and demented and just rapidly aging. Her skin returned to a silky texture and all the puﬃ- ness of her eyes and face went away. Within a few months, she returned to a fully active social life, was able to drive her car, and soon was again beating everyone at bridge. She had not been actually demented but was mentally very slow from her hypothyroid state. Even when 22 Symptoms of Unknown Origin she was hypothyroid, she was mentally accurate but just slow in responding. Once back to normal and out on the town, she could not tell enough people in a day what a terriﬁc doctor I was. She was a walking, talking, vis- ible advertisement for my practice, which grew rapidly. I was soon engulfed, the target of every patient who had been misdiagnosed or mistreated or misunderstood or who had done poorly, although I never had another medical home run quite like Irene Johnson. Early scientists discovered the thyroid gland by anatomic dissections of cadavers. Tey much later discovered that removal of the thyroid gland in animals led to identiﬁable meta- bolic changes: Metabolism slowed. Ten in the 1800s, the clinical state of hypothyroidism was described in humans when autopsies of patients showing an absence of the thyroid gland. Eventually, re- versal of the hypothyroid state was achieved by ingestion of the ground-up thyroid glands of pigs and cows. Many years later, the active agent was chemically determined to be thyroxine, later to be tri-iodothyronine. Before the chemical formula of the thyroxine molecule could be discovered, the entire atomic theory of matter and the complete periodic table of mineral elements had to be dis- covered and described, with the atomic weights of each identiﬁed and deﬁned. Te empirical formula of the thyroxine molecule was found to be C15 H10 I4 N NaO4x H20, with a molecular weight of 798. When I wrote that prescription for thyroid extract for Irene Johnson, I was standing on the shoulders of thousands of scien- tists who came before me. Each scientist drilled a bit deeper into the puzzle of the thyroid gland until ﬁnally we could make a syn- thetic molecule of thyroxine, give that tiny molecule to patients, and bring them back to physical normalcy. I remain in awe of the scientiﬁc method and the reductionistic method of inquiry that has led us to understand smaller and smaller components of nature. Drayton Doherty and Miss Cootsie 23 I want to make it as clear as I possibly can that this book is not a criticism of scientiﬁc reductionism. My point here is that scientiﬁc reduction is not the same process as clinical medicine. It is the sheer scientiﬁc power of the biomolecular model that has blinded so many as to its clinical limitations and restrictions. Doherty and I got to be close and good friends, and he was delighted to see my practice take oﬀ so rapidly. Like other doctors trained before World War II, he was weak in the advances that science had brought into clinical medicine. He often prescribed toxic strychnine and used inert tonics and gave a lot of unneeded vita- mins. He spoke of ill-deﬁned stimulants and stomatics and often still used calomel to purge the bowels of his patients. His practice was from another time and place and it bothered me intellectu- ally, although I never told him directly.
George is hard of hearing cheap silvitra 120 mg with mastercard, has some forgetfulness silvitra 120mg low price, and does not talk very much 120 mg silvitra for sale. Reﬂect on: How you will include George and Jennie in the teaching session purchase silvitra 120mg online. Teaching strategies to individualize for hearing deﬁcits and memory deﬁcits. OVERVIEW ual drugs, with routes of administration and dosage ranges, are listed in the Drugs at a Glance tables. The aminoglycosides have been widely used to treat serious gram-negative infections for many years. The quinolones are AMINOGLYCOSIDES also older drugs originally used only for treatment of urinary tract infections (see Chap. The fluoroquinolones are Aminoglycosides are bactericidal agents with similar pharma- synthesized by adding a ﬂuorine molecule to the quinolone cologic, antimicrobial, and toxicologic characteristics. This addition increases drug activity against gram- used to treat infections caused by gram-negative microorgan- negative microorganisms, broadens the antimicrobial spec- isms such as Pseudomonas and Proteus species, Escherichia trum to include several other microorganisms, and allows use coli, and Klebsiella, Enterobacter, and Serratia species. General character- These drugs are poorly absorbed from the gastrointestinal istics, mechanisms of action, indications for and contraindica- (GI) tract. Thus, when given orally, they exert local effects in tions to use, nursing process implications, and principles of the GI tract. They are well absorbed from intramuscular injec- therapy for these drugs are described in this chapter. Individ- tion sites and reach peak effects in 30 to 90 minutes if circula- 527 528 SECTION 6 DRUGS USED TO TREAT INFECTIONS Drugs at a Glance: Aminoglycosides Routes and Dosage Ranges Generic/Trade Name Characteristics Adults Children Amikacin (Amikin) Retains a broader spectrum of antibac- IM, IV 15 mg/kg q24h, 7. Hepatic coma PO 4–12 g daily in Used topically, often in combination divided doses with other drugs, to treat infections of the eye, ear, and skin (burns, wounds, ulcers, dermatoses) When used for wound or bladder irriga- tions, systemic absorption may occur if the area is large or if drug concen- tration exceeds 0. Netilmicin (Netromycin) Similar to gentamicin in antimicrobial IM, IV 4–6. However, systemic absorption may occur in the presence of inﬂamma- tory or ulcerative bowel disease. CHAPTER 35 AMINOGLYCOSIDES AND FLUOROQUINOLONES 529 Drugs at a Glance: Aminoglycosides (continued) Routes and Dosage Ranges Generic/Trade Name Characteristics Adults Children Streptomycin May be used in a four- to six-drug IM 15 mg/kg/d (maximum 1 g) or IM 20–40 mg/kg/d in two divided regimen for treatment of multidrug- 25–30 mg/kg two or three doses, q12h (maximum dose, resistant tuberculosis times weekly (maximum 1. They accumulate in high concentrations in the kidney effects occur within 30 to 60 minutes. They are poorly distributed to the central nervous 4 hours with normal renal function. After parenteral administration, aminoglycosides are widely Injected drugs are not metabolized; they are excreted un- distributed in extracellular ﬂuid and reach therapeutic levels changed in the urine, primarily by glomerular ﬁltration. Oral in blood, urine, bone, inﬂamed joints, and pleural and ascitic drugs are excreted in feces. Drugs at a Glance: Fluoroquinolones Generic/Trade Name Characteristics Routes and Dosage Ranges Cinoxacin (Cinobac) 1. Used only for UTI PO 1 g daily in two to four divided doses for 7–14 d 2. Effective against most gram-negative bacteria that commonly cause UTI (Escherichia coli, Klebsiella, Enterobacter, Proteus) Ciproﬂoxacin (Cipro) 1. Effective in respiratory, urinary tract, gastro- PO 250–750 mg q12h intestinal tract, and skin and soft tissue infec- IV 200–400 mg q8–12h tions as well as sexually transmitted diseases caused by chlamydiae and gonor- rhea organisms 2. Used as one of four to six drugs in treatment of multidrug-resistant tuberculosis Enoxacin (Penetrex) Used only for UTI and uncomplicated gonorrhea UTI, PO 200–400 mg q12h for 7–14 d Gonorrhea, PO 400 mg as a single dose Gatiﬂoxacin (Tequin) Indicated for pneumonia, bronchitis, sinusitis, skin PO, IV infusion 400 mg once daily and soft tissue infections, urinary infections, Give IV dose over 60 minutes; avoid rapid pyelonephritis, and gonorrhea administration Levoﬂoxacin (Levaquin) A broad-spectrum agent effective for treatment of PO, IV 250–750 mg once daily. Infuse IV dose slowly bronchitis, cystitis, pneumonia, sinusitis, skin and over 60 min skin structure infections, and pyelonephritis Lomeﬂoxacin (Maxaquin) Approved for bronchitis, urinary infections, and PO 400 mg once daily transurethral surgical procedures Preoperatively, PO 400 mg as a single dose, 1–6 h before surgery Moxiﬂoxacin (Avelox) Indicated for pneumonia, sinusitis, bronchitis, skin PO, IV 400 mg once daily. Infuse IV dose slowly over and soft tissue infections 60 min Norﬂoxacin (Noroxin) Used only for UTI and uncomplicated gonorrhea PO 400 mg twice daily Oﬂoxacin (Floxin) See ciproﬂoxacin, above PO, IV 200–400 mg q12h for 3–10 d Gonorrhea, PO 400 mg as a single dose Sparﬂoxacin (Zagam) Indicated for community-acquired pneumonia caused PO 400 mg as loading dose, then 200 mg once daily by Chlamydia pneumoniae, Streptococcus pneu- for 10 d moniae, or Hemophilus inﬂuenzae and acute bac- Renal impairment (creatinine clearance terial exacerbations of chronic bronchitis caused <50 mL/min), PO 400 mg as loading dose, by above organisms, Klebsiella pneumoniae, or then 200 mg q48h for a total of 9 d of therapy Staphylococcus aureus UTI, urinary tract infection. These are discussed in Chapters 65 and 66, Aminoglycosides penetrate the cell walls of susceptible bac- respectively. As a result, the bacteria cannot synthesize the proteins necessary for their function Contraindications to Use and replication. Aminoglycosides are contraindicated in infections for which less toxic drugs are effective.
Pattern of cutaneous in group II excitation from pretibial ﬂexors to quadri- inhibition of the propriospinal-like excitation to human ceps motoneurones order 120mg silvitra fast delivery. OnthecomparabilityofH-reﬂexesand motoneurones by group II muscle afferents purchase 120 mg silvitra otc. Electroencephalography and Clinical Neurophysiol- Brain Research buy 120mg silvitra fast delivery, 109 cheap silvitra 120 mg free shipping, 357–60. Investigationintonon-monosynapticcorticospinal GroupIprojectionsfromintrinsicfootmusclestomotoneu- excitation of macaque upper limb single motor units, Jour- rones of leg and thigh muscles in humans. Facilitation of transmission in heteronymous to forearm motoneurones in man. Patternofdescend- mand for human voluntary movement through cervical ing excitation of presumed propriospinal neurones at the premotoneurones. Neuronal organization and synaptic mission of voluntary movement in humans. JournalofPhysiology(London),517,287– neous inhibition of the descending command passing 300. Journal of Neurology, Neuro- propriospinal premotoneurons in recovering hemiparetic surgery and Psychiatry, 64, 166–71. Some mitted by interneurones activated by groups I-II afferents evidence for a mid-thoracic nucleus in the human motor in paraplegics. Dexterous ﬁn- Contralateral and ipsilateral EMG responses to transcra- ger movements in primate without monosynaptic cortico- nialmagneticstimulationduringrecoveryofarmandhand motoneuronal excitation. Both types of input are the agonists and the inhibition of the antagonists largely mediated through common spinal interneu- duringﬂexion–extensionmovementsathingejoints, rones (cf. In the pre- is accompanied by changes in transmission in sev- ceding chapters, changes in transmission in seg- eral pathways. This might give the impression that mental spinal pathways during various motor tasks there is some functional redundancy between the have been described, and the presumed origin of different spinal circuits. In addition, because of thedifferentfeaturesofthemovement(suchasforce, the focusing due to the stronger inhibitory control smoothness,selectivity,resistancetofatigue,timing, of propriospinal neurones in primates, it has been etc. The pathwaymaybepartiallytakenoverbyanotherpath- present chapter presents an overview of the relative way (see Chapter 12), but the smooth development contributions of different spinal pathways to var- offorceandaccurateachievementofthedesiredtra- ious natural motor tasks: isometric tonic contrac- jectoryofamovementstillrequiretheintegrityofthe tions, ﬂexion–extension movements at hinge and different pathways. Experimentaldataonwhichthisoverviewrelieshave (iii) It cannot be taken for granted that spinal been discussed in the preceding chapters, and refer- interneurones respond similarly to the phasic 511 512 Spinal pathways in different motor tasks artiﬁcial volleys generally used in the experiments drivenbyfusimotorneurones,(ii)thisafferentinﬂow described in the previous chapters and to a tonic has an overall autogenetic excitatory effect at spinal input, as in the normal modus operandi of the cen- levelandcontributessigniﬁcantlytomaintainingthe tral nervous system. In this respect, the newer tech- ﬁringof motoneurones,but(iii)ithasalimitedrole niques of cross-correlation and coherence analysis in compensating for muscle fatigue (see pp. This excitatory effect is not limited to homony- nals to be studied without external interference (see mous motoneurones. II excitatory connections are widespread and often (iv) Experiments described in the earlier chap- bidirectional in the lower limb and strong from dis- ters do not necessarily provide a quantitative assess- tal to proximal muscles in the upper limb, and their ment of the normal input to motoneurones, e. The motoneurone discharge is pro- Servo-assistance through monosynaptic ducedbythespatialandtemporalsummationofsev- Ia connections eralinputs,andremovalofanyonecouldhavealarge effect (e. Thebackgrounddischargeofspindlesprovidesthem with a dynamic working range, because their dis- charge can increase and decrease in response to Isometric tonic contractions external load variations. The resulting low gain for by descending tracts, but their maintained activity the stretch reﬂex helps to prevent oscillations and may be favoured by different spinal mechanisms clonus from developing (see Matthews, 1972;Rack, (cf. Many isometric contractions involve co-contraction of antagonistic muscles (see Group II excitation is not limited by post-activation pp. Fusimo- tor activation of primary and secondary endings Fusimotor-driven inﬂow from primary in s-assisted contractions can produce multiple and secondary endings mutual reinforcing interactions between the dis- charges from the two receptors, because lumbar Activation of α motoneurones propriospinal neurones mediating group II excita- Ample evidence has been provided that, during tion are co-activated by Ia afferents and transmit tonicisometriccontractions:(i)thereisanenhanced part of the corticospinal command to motoneu- inﬂow from primary and secondary spindle endings rones (see Chapter 7; see Fig. Changes in transmission in spinal pathways during voluntary contraction at a hinge joint. In this and subsequent ﬁgures, excitatory synapses are represented by Y-shaped bars and inhibitory synapses by small ﬁlled circles, excitatory interneurones by open circles and inhibitory interneurones by large ﬁlled circles. Group II afferents exciting MNs through propriospinal neurones (PN) in blue ((a), (b)). Ib afferents, with their presynaptic inhibition (PAD INs), and Ib inhibitory INs in brown (a). The descending command (i) activates MNs, MNs and PNs, all of which are also affected by afferent inputs, (ii) inhibits RCs, and (iii) suppresses transmission in Ib inhibitory pathways (Ib IN) by presynaptic gating (PAD INs).