By V. Sanuyem. Lyme Academy of Fine Arts.
EDUCATION Over the past century purchase 20 mg benicar amex, chiropractic education evolved from a limited benicar 20 mg generic, 8-week course of study at the turn of the century to a full-fledged course of study lasting 4–5 academic years best benicar 20mg, preceded by 3–4 years of undergraduate education benicar 10 mg fast delivery. It would not be an exaggeration to say that success in the development of chiropractic education has played a large part in the growing acceptance of chiropractic as a profession. There have been several important milestones in the development of chiropractic education. None was more important than the recognition of the Council on Chiropractic Education (CCE) as the accrediting agency for chiropractic education by what was then the US Office of Education (now the US Department of Education) in 1974. The CCE established a minimum standard for admission and pre-professional requirements as well as prescribing minimum standards for facilities and the course of study in accredited chiropractic teaching institutions. Current standards require that all prospective students have a minimum of 2 years of pre-professional education, with specific requirements in the sciences and a minimum grade point average (GPA). The course of study in chiropractic schools is 4–5 academic years, with much of the final year being devoted to training in a supervised clinical setting (with defined standards for this clinical experience). The first 3–4 years of the program is evenly divided between the basic medical sciences and the clinical sciences. An accreditation process, under the direction of the CCE, with periodic reaccreditation, ensures that colleges continue to meet these standards. Many chiropractic schools have also received accreditation from their regional post-secondary accreditation body, permitting them to grant undergraduate degrees based on their course of basic science instruction. The CCE has also been instrumental, through involvement with the Councils on Chiropractic Education International, in helping to establish minimum education standards in other parts of the world. Under the guidance of the CCE, the great majority of the basic sciences are taught by professors with advanced degrees in the particular area of study. Most of the clinical sciences are taught by chiropractors, although there is a growing educational involvement of medical physicians and individuals with dual degrees. Additionally, an increasing Chiropractic 35 number of chiropractic students are receiving part of their clinical experience in medical facilities. The great majority of chiropractic students take a national board examination that is administered under the auspices of the National Board of Chiropractic Examiners (NBCE), which was established in 1963. This examination consists of a basic science part, a clinical part, a problem-solving portion and a practical examination. LICENSURE Chiropractic licensure is the responsibility of each state, subject to its own chiropractic practice act and the interpretations of that law. Therefore, there is some variability between states in the licensure requirements. Although the great majority of states require graduation from a chiropractic school accredited by the CCE, the role of the National Board examination in licensure varies. Many states require their own examination, often in addition to the National Board, prior to licensure. Furthermore, the requirements for postgraduate continuing education vary from state to state. All states permit direct access of patients to chiropractors as portal-of-entry providers. In the great majority of states, chiropractors are permitted to employ diagnostic measures necessary to ensure the suitability of patients for treatment. This includes the performance of physical examination procedures and the interpretation of laboratory tests. Most states also permit chiropractors to maintain and use radiological facilities. To a large extent this is the result of a long-standing boycott of chiropractors by radiologists who would not perform radiological tests at their request. The more recent co-operation between these professions has led to a decrease in the number of chiropractic offices maintaining their own radiographical facilities. Chiropractic schools have historically devoted a significant amount of training to the study of radiology, and studies have shown that the ability to interpret X-rays for pathological red flags by chiropractors is at 11 least as good as that of family physicians and orthopedic residents and specialists. Despite the relative uniformity of chiropractic laws, there remain a few states where chiropractors are permitted to recommend or prescribe medications and perform minor surgical procedures, and other states where they are not even permitted to perform such procedures as a prostrate physical examination. Most of these practice variations fly in the face of education, which has become increasingly uniform as the result of national accreditation.
(Support for this view comes from twin studies which 28 show a significant heritability index for hypnotizability cheap benicar 40mg with amex. Thus discount 20 mg benicar with amex, hypnotic responsiveness is primarily a product of culturally mediated attitudes and expectations which render the individual either more 40mg benicar visa, or less purchase benicar 20 mg, likely to enact 29 the role of hypnotic subject. An especially strong version of the expectancy theory argues that expectations are possibly the most important determinant of hypnotic responding. The authors interpreted their findings as supporting the notion that hypnotic susceptibility is primarily determined by response expectancy prior to and during the initial hypnosis experience. However, the results of two separate studies 31 conducted in our own laboratory failed to replicate these findings. In other words, the manipulation of response expectancy had no measurable effect on hypnotic responsiveness. This is not to say that expectancies play no role in determining the quality of hypnotic response, or that 32 clinical patients might not benefit from a preliminary training or instruction procedure, just as new psychotherapy patients benefit from preliminary information about the nature 33 of psychotherapy. Sociocognitive theorists commonly see hypnosis not as a function of altered mental states, but as a complex social interaction influenced by expectations, motivations and social demands. They support this position by demonstrating that many hypnotic responses can be elicited without the use of an induction. With the development of brain Complementary therapies in neurology 208 imaging techniques, researchers have increasingly been interested in demonstrating neurological signatures for hypnosis as an altered state. HYPNOSIS AND THE BRAIN With the advent of the electroencephalogram (EEG) in the 1920s, researchers soon had a tool with which to measure hypnosis-related changes in the cortical activity of the brain. More recent development of brain imaging techniques such as positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) have led to exciting new avenues of research related to hypnosis and the brain. In studying the physiological substrates of hypnosis, there are three main lines of attack. The second, perhaps more in line with Charcot, is to demonstrate baseline differences between people of varying hypnotic ability, that is, to show that the capacity for responding to hypnotic suggestions is reflected in the brain even before hypnosis. Some have argued that hypnosis is not a cohesive state, that at any moment a subject may be experiencing a direct motor suggestion, a challenge suggestion, a suggestion for a 8 positive or negative hallucination, or perhaps amnesia. Brain activity changes associated with the state of hypnosis If, as many researchers believe, the hypnotic induction produces a readiness to accept and respond to hypnotic suggestions, one should be able to observe changes in brain activity from the waking state as a result of the hypnotic induction. Given the historical and behavioral associations between hypnosis and sleep, researchers initially tried to 35 demonstrate similarities between sleep and hypnosis EEG recordings. After many unsuccessful attempts, researchers began to look for distinguishable traces in the various EEG bandwidths that would differentiate hypnosis from the waking state. Research on this topic has been continuing ever since, although consistent findings remain ephemeral. For some time, researchers associated increased alpha activity (8–13 Hz) with hypnosis, 36 but later reviews showed methodological problems with many of these initial studies. Though less common, some researchers have successfully differentiated hypnosis from the 39,40 waking state through PET techniques. Results from this line of research have shown that changes in regional cerebral blood flow (rCBF) in sensory and motor cortical areas, Hypnosis 209 the anterior cingulated cortex (ACC), brainstem and thalamus contribute to the experience of being hypnotized. Brain activity differences associated with hypnotic ability With improved measures of hypnotic responsiveness, researchers have increasingly favored examinations of the relationship between brain functioning and hypnotizability. Thus, rather than attempting to identify qualitative and quantitative shifts in brain activity as a result of the hypnotic state, they have focused on demonstrating differences in brain activity between subjects of varying levels of hypnotic susceptibility. In light of this, it has been argued that brain imaging studies of hypnosis should focus less on the state of hypnosis as a whole and more on the examination of physiological changes associated with specific hypnotic 8 suggestions. In one such study investigating hypnotically suggested positive auditory hallucinations, researchers demonstrated that, when subjects heard a sentence or hypnotically hallucinated hearing the sentence, their brain activity was quite different 45 from that during quiet baseline or when simply imagining the words being spoken. As subjects heard the real recording, and during the hypnotic hallucination of the recorded message, increased activation of a region in the right anterior cingulate was shown. Highly hypnotizable subjects were presented with a colored and a gray-scale pattern. Activity in the fusiform/lingual region (related to the perception of color) was shown when subjects were asked simply to perceive color as color versus Complementary therapies in neurology 210 when they were asked to perceive gray as gray. But, incredibly, when subjects were hypnotized, both the left and right hemisphere color areas were activated when they were asked to perceive color, regardless of whether they were actually shown the color or the gray-scale stimulus. What is more, subjects showed decreased activity in this same brain region when they were told to see gray-scale, regardless of whether they were actually shown the color or gray-scale stimulus.
Naloxone and naltrexone are pure opioid antagonists Buprenorphine synthesized by relatively minor changes in the morphine structure cheap 10mg benicar with visa. Alteration of the substituent on the piperidine Buprenorphine (Temgesic) is a mixed agonist–antago- nitrogen from a methyl group to a longer side chain nist and a derivative of the naturally occurring opioid changes the drug from an agonist to an antagonist generic benicar 10 mg line. Buprenorphine is highly lipophilic and is 25 to Opioid antagonists bind to the opioid receptor with 50 times more potent than morphine as an analgesic quality 20 mg benicar. The pure antagonists The sedation and respiratory depression it causes are block the effects of opioids at all opioid receptors benicar 10mg mastercard. Its respiratory depressant effects are not for naloxone blockade of the -receptor versus the - readily reversed by naloxone. All opioid an- with high affinity and only slowly dissociates from the tagonists will precipitate withdrawal in opioid-depend- receptor, which may explain the lack of naloxone rever- ent patients. Buprenorphine has more agonist than antagonist ef- Naloxone fects and is often considered a partial agonist rather than a mixed agonist–antagonist, although it precipi- Because of its fast onset (minutes), naloxone (Narcan) tates withdrawal in opioid-dependent patients. Its phar- administered IV is used most frequently for the rever- macological effects are similar to those produced by sal of opioid overdose. Indications for its use side effects of the opioids that are mediated by the - are similar to those of pentazocine, that is, for moderate receptor, such as hallucinations. Sublingual preparations are available, naloxone makes it necessary to administer the drug re- but have a slow onset and erratic absorption. The half-life of nalox- high doses of the drug are perceived by addicts as being one in plasma is 1 hour. It is rapidly metabolized via 26 Opioid and Nonopioid Analgesics 327 glucuronidation in the liver and cleared by the kidney. Hepatic metabolism Naloxone given orally has a large first-pass effect, which is slow and occurs via glucuronide conjugation to inac- reduces its potency significantly. Indications include use in postopera- The heart rate and blood pressure of the patient may tive settings to reverse respiratory depression and in rise significantly. Naloxone is approved for use in neonates to reverse respiratory depression induced by maternal opioid use. Drugs Used Predominantly In addition, naloxone has been used to improve circula- as Antitussives tion in patients in shock, an effect related to blockade of endogenous opioids. Other experimental and less well Certain opioids are used mainly for their antitussive ef- documented uses for naloxone include reversal of coma fects. Such drugs generally are those with substituents in alcohol overdose, appetite suppression, and allevia- on the phenolic hydroxyl group of the morphine struc- tion of dementia from schizophrenia. Naltrexone Dextromethorphan Naltrexone (Trexan) is three to five times as potent as Dextromethorphan hydrobromide is the D-isomer of naloxone and has a duration of action of 24 to 72 hours, levorphanol. However, the major metabolite, reports of abuse exist, but studies of abuse potential are 6- -naltrexol, is also a pure opioid antagonist and con- lacking. It has few side effects but does potentiate the tributes to the potency and duration of action of nal- activity of monoamine oxidase inhibitors, leading to hy- trexone. Dextromethorphan is subjective effects of abused opioids and is used to de- often combined in lozenges with the local anesthetic crease the craving for opioids in highly motivated re- benzocaine, which blocks pain from throat irritation covering addicts. In addi- Levopropoxyphene tion, it has been reported recently that naltrexone can Levopropoxyphene is the L-isomer of the analgesic ago- reduce the craving for alcohol in alcoholic patients. Levopropoxyphene is only Naltrexone also has been used with success in treating mildly antitussive and is rarely used. It is be due to blockade of -endorphin–induced respiratory available as the napsylate derivative (Novrad) and is depression. Side effects of the use of naltrexone are more fre- quently observed than following naloxone administra- Noscapine is a naturally occurring product of the opium tion. It is a benzylisoquinoline with no analgesic or sleeping, lethargy, increased blood pressure, nausea, other CNS effects. Its antitussive effects are weak, but it sneezing, delayed ejaculation, blurred vision, and in- is used in combination with other agents in mixtures for creased appetite. Nalmefene Benzonatate Nalmefene (Revex) is a long-acting injectable pure opi- Benzonatate (TessaIon) is related to the local anes- oid antagonist recently introduced in the United States.