By O. Volkar. Butler University. 2018.
Also 160mg kamagra super sale, drink 2 or 3 quarts of fluid daily generic kamagra super 160mg on-line, if blood tests help to determine when the drugs should be possible discount 160mg kamagra super fast delivery, and urinate often buy kamagra super 160mg on line, especially at bedtime. The drug is irritating to the bladder lining hands frequently and thoroughly. High fluid intake and fre- chills, sore throat, or cough, notify your oncologist. A dietitian can be ✔ With doxorubicin, the urine may turn red for 1 to 2 days helpful in designing a diet to meet your needs. This discoloration is harm- ✔ If your chemotherapy may cause bleeding, you can de- less; it does not indicate bleeding. Also, report to a crease the likelihood by shaving with an electric razor, health care provider if you have edema, shortness of avoiding aspirin and other nonsteroidal anti-inflammatory breath, and excessive fatigue. Doxorubicin may need drugs (including over-the-counter Advil, Aleve, and others), to be stopped if these symptoms occur. If you notice excessive bruising, bleeding gums ✔ With methotrexate, avoid alcohol, aspirin, and pro- when you brush your teeth, or blood in your urine or bowel longed exposure to sunlight. A stool softener or bulk laxative loss is temporary; your hair will grow back! For example, more malig- Numerous combinations have been developed for use in spe- nant cells are likely to be destroyed by combining cell cific types of cancer. Selection and scheduling of individual cycle–specific and cell cycle–nonspecific drugs. The drugs in a multidrug regimen are based on efforts to maximize first group kills only dividing cells; the second group effectiveness and minimize adverse effects. Characteristics of kills cells during any part of the life cycle, including the effective drug combinations include the following: resting phase. For example, one drug can be chosen to dam- so that maximal tolerated doses may be given. It is CHAPTER 64 DRUGS USED IN ONCOLOGIC DISORDERS 927 preferable to use drugs that are not toxic to the same soon as possible after surgery, given in maximal tol- organ system (eg, bone marrow, kidney) and to use drugs erated doses just as if advanced disease were present, that do not exert their toxic effects at the same time. Intravenous drug administration should be performed by sive drugs because it rarely causes myelosuppression. Infusion should be through a large, upper ex- pneumonitis and pulmonary fibrosis). When possible, veins of the antecubital fossa, wrist, dorsum of the hand, and the arm where an axillary lymph node dissection has been done should be Dosage Factors avoided. An indwelling central venous catheter is often inserted for clients with poor peripheral venous access Dosage must be calculated and regulated carefully to mini- or who require many doses of chemotherapy. With bleomycin, a test dose of 1 to 2 mg subcutaneously kidney and liver function, and previous chemotherapy or should be given before starting full doses. High doses, to the limits of tolerance of normal tissues to decrease severe hypersensitivity reactions with dys- (eg, bone marrow), are usually most effective. Doses are usually calculated according to body surface deaths have occurred despite premedication. With pa- area, which includes both weight and height, and ex- clitaxel, one regimen is oral dexamethasone 20 mg at pressed as milligrams of drug per square meter of body 2 12 and 6 hours before, with IV diphenhydramine 50 mg surface area (mg/m ). Doses also can be expressed as and cimetidine 300 mg, famotidine 20 mg, or ranitidine milligrams per kilogram of body weight (mg/kg). This reduces risk and severity of cytopenia, stomatitis, diarrhea, and renal or hepatic hypersensitivity reactions and fluid retention. Total dose limits for doxorubicin (550 mg/m2) and Hormonal Therapy bleomycin (450 units) should not be exceeded. Decreasing the hormones that stimulate tumor growth in Administration Factors these tissues can decrease symptoms and prolong survival. Dosage schedules are largely determined by clinical tors for estrogen indicates a likely response to hormonal ther- trials and should be followed as exactly as possible. Antineoplastic drugs are usually given in relatively estrogen receptors because it inhibits the interaction between high doses, on an intermittent or cyclic schedule.
Older volunteers tend to be more ant subjects buy discount kamagra super 160 mg on line, representative of the wider group likely than younger ones to be healthy and liv- ultimately receiving treatment buy kamagra super 160 mg mastercard, is the goal of all ing independently kamagra super 160 mg lowest price, of particular importance for who design and execute clinical trials generic 160mg kamagra super amex. Recruit- trials of interventions involving exercise since ing motivated participants is a problem for all volunteers may not be the subjects most likely clinical trials but particular difficulties are evi- 17 to benefit. Clinical tri- Rarely does one single strategy succeed in als are likely to involve more regular monitoring recruiting adequate numbers of representative and follow-up assessments than would routinely patients. It is important therefore that the char- take place in practice and this in itself may be too burdensome for older people who may have acteristics of participants are regularly monitored other health problems, which they may perceive throughout the trial, and compared to the gen- as more important, or lack access to transport. Such plete collection of data and more accurate pre- mixed-mode recruitment has produced represen- diction of patient compliance, again highlighting tative samples of high-risk older people for a trial of geriatric evaluation and management. Studies examining significant predictors of As with eligibility and recruitment, the means of enrollment into trials are equivocal in their find- gaining informed consent from subjects enrolling ings. A systematic review of literature on informed should be addressed at the design stage of the trial consent found evidence of impaired understand- and the information that the patient requires to give ing of the informed consent information in older informed consent is listed in Box 4. Available treatments and treatment informed consent for ambulatory trials has been on trial. Potential risks and benefits of treat- specific and it was tested on relatively young and ment. Concept of a clinical trial (includ- Family members have also been found to play ing randomisation, use of placebos, an important role in the informed consent pro- double-blind procedures). Discomforts or inconveniences associ- spouses, being associated with successful enroll- ated with assessments. Number of follow-up visits or extra found that the majority (96%) of those approached travel for trial. Reasons given by a subsample of those enrolled by the physician were predomi- Clinicians may see relaying the concept of a randomised controlled trial as admittance of igno- nantly the trust and respect subjects had for their rance about the best treatment for the patient, or doctor, though a small number admitted to agree- may make ageist assumptions concerning the abil- ing through fear. Further- Much healthcare provision is imperialistic and more, the clinical trial design is complex and even this may re-enforce the belief, held by some older if explained carefully, patients may not under- people, that all decisions relating to their treatment stand fully enough to give true informed consent. It should be remembered that A qualitative study, as part of a set of trials of not all older people however want active treatment the effectiveness of treatments for men with uri- in all cases and there may be reluctance to take nary retention and benign prostatic disease, found medication for certain conditions. A recent trial that, although information given was accurately of selective serotonin reuptake inhibitors in the CLINICAL TRIALS INVOLVING OLDER PEOPLE 59 treatment of depression and anxiety in community- gaining informed consent generally for trials, not dwelling older people found that, whilst 11 of just those specifically for dementia treatments. Within clinical inferring that the process by which older people care there has been encouragement for patients to make decisions to participate in clinical trials is a prepare advanced directives or living wills to cover complex one, meriting further research. At important factor in the decision by older peo- first sight this might appear a solution for dementia ple to enrol. Trials including invasive procedures research also, but the strong motivational factors such as venepuncture, which may be necessary to for individuals with clinical care are unlikely to determine compliance may not be seen as nec- be present for dementia research. A more realistic future ple suggests that, on the whole, older people will goal might be that people are encouraged to name participate in lengthy interviews and are keen to proxies and state broad beliefs about research in assist with research that they perceive will help advanced directives. This should, treatments and of expressing their contentment of course, be balanced by any inconvenience the with having a proxy make decisions on involve- patient might incur by extra visits. The two aspects of having sufficient sent, the proxies themselves lacking the capacity understanding to give consent without coercion are to understand the protocol in 18% of cases and in key, but if taken literally, for example by being almost one-third no functional proxy being found. At present this rigid regimes in homes are taken into consid- is noticeably lacking in many aspects of care. We eration when designing trials, particularly those have discussed the reasons why older people have of interventions. We cannot give any pose of the trial is likely to be vital to the success definitive solutions to ensure that older people of the study. More flexible timing of follow-up visits under-represented during recruitment. Some statistical packages for repeated be given, to gain informed consent. Consider measures data analysis–a common analysis for whether and when consent will need to be trials with regular follow-ups–ignore cases with obtained from a proxy. Newer techniques such as multi- • If possible offer home assessments or, where level modelling and random effects models can this is impossible, provide transportation to CLINICAL TRIALS INVOLVING OLDER PEOPLE 61 clinics at times convenient to the subject and 10. Int J Geriat Psychiatry (1997) • Design a realistic withdrawal rate into the 12: 227–31.
Some acupuncture points are very frequently used and their applications are quite varied: needling at these points may stimulate a global healing response that can affect many diseases cheap 160 mg kamagra super mastercard. Other points have only limited applications; needling at those points may affect only one of the signaling systems purchase kamagra super 160mg with visa. It is common for acupuncturists to combine the broad-spectrum points and the specific points for each treatment purchase kamagra super 160 mg amex. Some acupuncturists come to rely on a few of these broad-spectrum points as treatments for virtually all common ailments generic kamagra super 160 mg with amex. This modern explanation of how acupuncture works does not explain why the acupuncture points are arrayed along the traditional meridian lines. However, acupuncturists have identified other sets of points, such as those in the outer ear, which seem to be mapped to the whole body. The description, in the case of the ear, is of a layout of the body in the form of a homunculus (a miniature humanoid form). Such patterns might be understood more easily than the meridian lines, because the brain, which is adjacent to the ear, also has a homunculus pattern that has been identified by modern research. Similarly, acupuncturists have identified zones of treatment (for example, on the scalp or on the hand) that correspond to large areas of the body, and this may also be more easily explained because there are connections from the spinal col- umn to various parts of the body that might have secondary branches elsewhere. In fact, acupuncture by zones, homunculus, ashi points (places on the body that are tender and indicate a blockage of Qi circulation), and trigger points (spots that are associated with muscle groups) is becoming a dominant theme, as the emphasis on treating meridians fades. The new focus is on finding effective points for vari- ous disorders and for getting biochemical responses (rather than regulating Qi, though there is no doubt there is some overlap between the two concepts). During this modern period (since the 1970s), an increasing number of ways to stimulate the healing response at various body points have been advocated, con- firming that needling is not a unique method (the idea that the needle would pro- duce a hole through which pathogenic forces could escape has long been fading). In the past, the main procedures for affecting acupuncture points were needling and application of heat (moxabustion). Now there is increasing reliance on electrical stimulation (with or without nee- dling) and laser stimulation. Because the basic idea of acupuncture therapy is gain- ing popularity throughout the world while the practice of needling is restricted to certain health professions and is not always convenient, other methods are also becoming widely used. Laypersons and practitioners with limited training are ap- plying finger pressure (acupressure), tiny metal balls held to the skin by tape, mag- nets (with or without tiny needles attached), piezoelectric stimulus (a brief electric discharge), and low-energy electrical pulsing (such as the TENS unit provides with electrical stimulus applied to the skin surface by taped electrodes). Some of these methods may have limited effectiveness, but it appears that if an appropriate body site is stimulated properly, then the healing response is generated. For many nervous system functions, timing is very important, and this is the case for acupuncture. It has been shown in laboratory experiments that certain frequencies of stimulus work better than others, as might be expected for nervous system responses, but not expected for simple chemical release from other cells. Traditional and Modern Views Coexisting The traditional and modern understandings of acupuncture arise from signifi- cantly different world views and from application of different levels of technology. It is difficult to directly correlate the two, though one can say that many of the traditional observations and ideas have partial explanations by modern mechanisms. Still, the modern practitioner can become aware of and trained in the application of both approaches to acupuncture. A person to be treated can be analyzed from both perspectives and the treatment strategy can be devised according to the con- clusions derived from each perspective. Certain aspects of the case may be more amenable to traditional analysis and corresponding treatment, while other aspects are better suited to modern analysis and treatment approach. An individual who is suffering from a chronic pain syndrome might be analyzed in terms of which meridians are blocked: through treatment of appropriate points on the meridian, the pain might be alleviated. The same individual might be ana- lyzed according to which muscle groups are involved in the painful area and might be treated by acupuncture at points that specifically affect those muscles. An indi- vidual suffering from an autoimmune disorder might be analyzed according to which of the traditional organ systems are involved, with treatment of the associated me- ridians. The same individual might be analyzed in terms of the immune system disturbance and treated by stimulating points that have been identified as immune regulators. Because the traditional acupuncture approach has been shown to be effective in clinical trials conducted in China (and elsewhere in Asia), one can rely on the traditional methods. However, many practitioners in the West, with little or no prior exposure to Oriental philosophy but with experience and training in Western modes of analysis, may feel uncomfortable turning partly or completely to the tra- ditional Chinese view, and will, instead, focus on the modern understanding of this healing technique.
In the comparison group purchase kamagra super 160 mg otc, five cases were cured discount kamagra super 160 mg without a prescription, 17 cases improved order kamagra super 160mg, and eight cases had no improvement buy 160mg kamagra super. From A Clinical Study & Comparison on the Use of Varied Forms of Acupuncture & Massage for the Treatment of Occult Spina Bifida Enuresis by Hu Jun-xia et al. These patients were randomly divided into two equal groups—an acupuncture and massage treatment group and a Chinese medicine comparison group. Treatment method: The main acupoints for all members of the treatment group in Chinese Research on the Treatment of Pediatric Enuresis 143 order to supplement the kidneys, secure and contain were: Guan Yuan (CV 4) Shen Shu (Bl 23) Pang Guang Shu (Bl 28) Qi Jie Gu (Seven Joints & Bones) The area where the spina bifida was located Supplementation method was used on Guan Yuan, Shen Shu, and Pang Guang Shu, and the needles were retained for 15 minutes. After acupuncture, the lesser thenar eminence was used to rub Qi Jie Gu until it was red. After this, the area of the occult spina bifida was pressed and stretched. For members of the comparison group, the main points were: Shen Shu (Bl 23) Qi Jie Gu (Seven Joints & Bones) The area where the spina bifida was located Supplementation method was used at Shen Shu, and the nee- dles were retained for 15 minutes. However, the needles were stimulated only one time throughout the treatment. After acupuncture, Qi Jie Gu was rubbed with the lesser thenar emi- nence until red, and the area of the spina bifida was pressed and stretched. In both groups, treatment was given every other day, and 10 days equaled one course of treatment. It was also suggested that all other treatments for this disorder be discontinued during the treatment period. Study outcomes: In the treatment group, 16 cases were cured, 10 cases improved, and four cases had no improvement. In the comparison group, 15 cases were cured, 12 cases improved, and three cases had no improvement. From The Treatment of 36 Cases of Enuresis [By Comparing Acupuncture] to the Combination of Acupuncture and Zhi Yi San (Stop Loss [of Urine] Powder) by Yu Qing-zhi & Yu Yang, Zhong Yi Wai Zhi Za Zhi (The Chinese Medicine Journal of External Treatments), 2002, #6, p. The Chinese medicine group consisted of 18 cases all between the ages of 3-15 years old. Treatment method: All patients in both groups took the Chinese medicinals, but the first group also received acupuncture in addition to the herbs. Acupoints consisted of the following points: Guan Yuan (CV 4) Zhong Ji (CV 3) San Yin Jiao (Sp 6) Zu San Li (St 36) Bai Hui (GV 20) Zu Yun Gan Qu (Foot Motor Sensory Area on the scalp), bilateral The needles were retained in these points for 30-40 minutes. This treatment was done one time each day, and 10 days equaled one course of treatment. The Chinese medicinal formula taken by both the acupuncture and the Chinese medicine group was composed of: Fu Zi (Radix Lateralis Praeparatus Aconiti Carmichaeli) Rou Gui (Cortex Cinnamomi) Yi Zhi Ren (Fructus Alpiniae Oxyphyllae) Tu Si Zi (Semen Cuscutae) Wu Yao (Radix Linderae) Shan Yao (Radix Dioscoreae) Long Gu (Os Draconis) Wu Wei Zi (Fructus Schisandrae) Mu Li (Concha Ostreae) Chinese Research on the Treatment of Pediatric Enuresis 145 Shi Hu (Herba Dendrobii) Gan Cao (Radix Glycyrrhizae) The dosages of the above medicinals were based on the age and size of the child. These medicinals were decocted in water and taken in three divided doses per day, with 10 days equaling one course of treatment. Study outcomes: In the acupuncture group, 28 cases were cured, five cases markedly improved, two cases improved, and one case did not improve. In the Chinese medicine group, five cases were cured, 11 cases improved, and two cases did not improve. From Comparing the Treatment Results of Using Scalp Acupuncture, Hand Acupuncture & Chinese Medicinals in the Treatment of 129 Cases of Pediatric Enuresis by Huang Wei et. Eighty-one cases were less than eight years old, 42 cases were between 8-11 years old, and six cases were more than 11 years old. The course of disease was one year or less in 37 cases, 1-5 years in 71 cases, and more than five years in 21 cases. Sixty-one cases had enuresis on average one time per night, 43 cases had enuresis every other night, and 25 cases had enuresis three times per week. These 129 cases were randomly divided into three groups – a treatment group of 65, a comparison group #1 of 32, and a comparison group #2 also of 32. Treatment method: All members of the treatment group received scalp acupuncture at Zu Yun Gan Qu (Foot Motor Sensory Area) bilaterally.