By U. Altus. Trevecca Nazarene University. 2018.
Viruses are suspected order moduretic 50mg online, and so are chemical pollutants that we eat order moduretic 50 mg with mastercard, drink purchase moduretic 50 mg with visa, and breathe (such as insecticides and carbon monoxide) cheap 50mg moduretic with mastercard. Research with MPTP has led scientists to believe that substances that induce parkinsonism do it by reacting with a chemical in the brain to create other chemicals called free radicals that can destroy brain cells. In any case, something starts destroying the neurons (nerve cells) in a portion of the midbrain called the substantia nigra (pig- mented substance). These are the neurons that produce a chemi- cal called dopamine, a chemical transmitter of messages in the brain, which is sent to another area of the brain called the stria- tum, the area that controls movement, balance, and walking. In the striatum, dopamine counteracts (regulates) another chemical messenger, acetylcholine. In the normal person’s striatum, dopa- mine and acetylcholine are perfectly balanced. In the patient’s striatum, dopamine and acetylcholine are out of balance—acetylcholine is no longer being regulated. This imbalance between dopamine and acetylcholine causes the primary symptoms of Parkinson’s: rigidity of the muscles (stiffness), tremor (shaking) of the hands or sometimes the feet or parts of the face, bradykinesia (slowness of movement), loss of balance and coordination, and loss of "automaticity" (the ability to move auto- matically without having to think about it). Slowness and difficul- ties with balance and automaticity are responsible for the prob- lems of falling, festination (short, shuffling steps), sidestepping, retropulsion (walking backward), inability to stop, and inability to "get started. To control Parkinson’s symptoms, certain drugs can send needed dopamine to the brain; these are the dopaminergic medica- tions that contain levodopa (also called L-dopa). Another group 76 living well with parkinson’s of drugs can counteract acetylcholine in the striatum; these are called the anticholinergic medications. On the way to the striatum and at the striatum, as well as on cells that project down from the cortex of the brain, there are special receptors for dopamine. Med- ications called dopamine agonists can stimulate these receptors to be more efficient. Some dopamine agonists stimulate one type of receptor; others stimulate more than one. It is believed that in Parkinson’s disease, dopamine is also defi- cient in other parts of the brain. The areas in which these other deficiencies occur may determine which of the secondary symptoms a person with Parkinson’s may develop. Deficiencies of certain other chemical neurotransmitters may also be responsible for sec- ondary symptoms. Patients may develop a few (but usually not all) of the secondary symptoms: a stare reminding one of a facial mask, aches and pains, feelings of extreme restlessness, feelings of fatigue, diffi- culty swallowing (which can cause excess saliva to build up in the mouth, leading to drooling), speech difficulties, shallow breath- ing, watery eyes, dry eyes, a hunched or bent posture, or pro- longed feelings of depression. Still other secondary symptoms may include oily skin, constipation, difficulty voiding the bladder, the feeling of unusual hot and cold sensations (usually in an arm or a leg), sudden excessive sweating, forced closure of the eyelids, dizziness on arising from a bed or a chair, swelling of the feet, and impotence. An important secondary symptom is depression, which afflicts about 50 percent of people with Parkinson’s. In the past, parkin- sonian depression was thought to be merely the psychological con- sequence of facing life with a chronic disease. This remains true in some cases; however, scientists now believe there is a chemical medications and therapies 77 component—the depression that is so common in Parkinson’s may be caused by the same chemical problems in the brain that cause the disease. For years, antidepressant medications have been used both to improve the patient’s state of mind and to relieve symp- toms. Some scientists are evaluating whether depression in Par- kinson’s disease may also be caused by a decreased amount of serotonin, another substance in the brain. One person with Parkinson’s may develop only a few primary and secondary symptoms, which may be different from those developed by the next person. Each person’s Parkinson’s must therefore be treated individually, with medications and dosages tailored to his or her own set of symptoms and drug tolerances. Patients who are aware of the symptoms and the medications used to treat them will be more alert to their own symptoms, more apt to report these thoroughly to their doctors, and more apt to get the most appropriate treatment. If a doctor is not a Parkinson’s specialist, the patient may even be able to educate the doctor to some extent.
Surely we have all been practising evidence based m edicine for years cheap 50mg moduretic visa, except when we were deliberately bluffing (using the "placebo" effect for good m edical reasons) 50 mg moduretic free shipping, or when we were ill cheap moduretic 50mg with amex, overstressed or consciously being lazy? There have been a num ber of surveys on the behaviour of doctors cheap moduretic 50mg, nurses, and related professionals,7–10 and m ost of them reached the sam e conclusion: clinical decisions are only rarely based on the best available evidence. Estim ates in the early 1980s suggested that only around 10–20% of m edical interventions (drug therapies, surgical operations, X-rays, blood tests, and so on) were based on sound scientific evidence. A m ore recent evaluation using this m ethod classified 21% of health technologies as evidence based. Apart from anything else, they were undertaken in specialised units and looked at the practice of world experts in evidence based m edicine; hence, the figures arrived at can hardly be generalised beyond their im m ediate setting (see section 4. Let’s take a look at the various approaches which health professionals use to reach their decisions in reality, all of which are exam ples of what evidence based m edicine isn’t. Decision making by anecdote W hen I was a m edical student, I occasionally joined the retinue of a distinguished professor as he m ade his daily ward rounds. On seeing a new patient, he would enquire about the patient’s sym ptom s, turn to the m assed ranks of juniors around the bed and relate the story of a sim ilar patient encountered 20 or 30 years previously. N evertheless, it had taken him 40 years to accum ulate his expertise and the largest m edical textbook of all – the collection of cases which were outside his personal experience – was forever closed to him. Anecdote (storytelling) has an im portant place in professional learning20 but the dangers of decision m aking by anecdote are well illustrated by considering the risk–benefit ratio of drugs and m edicines. In m y first pregnancy, I developed severe vom iting and was given the anti-sickness drug prochlorperazine (Stem etil). W ithin m inutes, I went into an uncontrollable and very distressing neurological spasm. Two days later, I had recovered fully from this idiosyncratic reaction but I have never prescribed the drug since, even though the estim ated prevalence of neurological reactions to prochlorperazine is only one in several thousand cases. Conversely, it is tem pting to dism iss the possibility of rare but potentially serious adverse effects from fam iliar drugs – such as throm bosis on the contraceptive pill – when one has never encountered such problem s in oneself or one’s patients. Chapter 5 of this book (Statistics for the non- statistician) describes som e m ore objective m ethods, such as the num ber needed to treat (N N T) for deciding whether a particular drug (or other intervention) is likely to do a patient significant good or harm. Decision making by press cutting For the first 10 years after I qualified, I kept an expanding file of papers which I had ripped out of m y m edical weeklies before binning the less interesting parts. If an article or editorial seem ed to have som ething new to say, I consciously altered m y clinical practice in line with its conclusions. All children with suspected urinary tract infections should be sent for scans of the kidneys to exclude congenital abnorm alities, said one article, so I began referring anyone under the age of 16 with urinary sym ptom s for specialist investigations. The advice was in print and it was recent, so it m ust surely replace traditional practice – in this case, referring only children below the age of 10 who had had two well docum ented infections. H ow m any doctors do you know who justify their approach to a particular clinical problem by citing the results section of a single published study, even though they could not tell you anything at all about the m ethods used to obtain those results? H ow m any patients, of what age, sex, and disease severity, were involved (see section 4. If the findings of the study appeared to contradict those of other researchers, what attem pt was m ade to validate (confirm ) and replicate (repeat) them (see section 7. W ere the statistical tests which allegedly proved the authors’ point appropriately chosen and correctly perform ed (see Chapter 5)? D octors (and nurses, m idwives, m edical m anagers, psychologists, m edical students, and consum er activists) who like to cite the results of m edical research studies have a responsibility to ensure that they first go through a 6 W H Y READ PAPERS AT ALL? Decision making by expert opinion (eminence based medicine) An im portant variant of decision m aking by press cutting is the use of "off the peg" reviews, editorials, consensus statem ents, and guidelines. The m edical freebies (free m edical journals and other "inform ation sheets" sponsored directly or indirectly by the pharm aceutical industry) are replete with potted recom m endations and at-a-glance m anagem ent guides. But who says the advice given in a set of guidelines, a punchy editorial or an am ply referenced "overview" is correct?