L. Achmed. Mount Vernon Nazarene College.

However bupropion 150 mg low cost, not all class comparisons are clinically relevant: for example cheap bupropion 150mg on-line, comparison of intranasal anticholinergic (ipratropium) discount bupropion 150mg line, which treats rhinorrhea, to intranasal sympathomimetic decongestant, which treats nasal congestion. Ideally, for each relevant comparison, all drugs within each class would be compared. However, the evidence base is not complete in this respect, and the proportion of drugs represented for any class studied ranged 5 from five of five oral selective antihistamines to zero (intranasal sympathomimetic decongestants, anticholinergic [ipratropium], and nasal saline). Although a comparison of short-term (weeks) and long-term (months) effectiveness and harms is desirable, we sought evidence from real-world treatment of symptomatic patients. However, agreement is lacking about four other issues of importance to patients and clinicians: 1. Although there may be differences among drugs within the same class, previous comparative 3, 28, 38, 41-47 effectiveness reviews in allergic rhinitis have found insufficient evidence to support superior effectiveness of any single drug within a drug class. A direct consequence of the decision to conduct across-class comparisons is the inability to compare individual drugs across studies. Additionally, limited conclusions can be drawn about drug classes that are poorly represented by the drugs studied. To our knowledge, methodological approaches for meta- analysis of class comparisons based on studies of single treatment comparisons have not been published. How do effectiveness and adverse effects vary with long-term (months) or short-term (weeks) use? How do effectiveness and adverse effects vary with intermittent or continuous use? How do effectiveness and adverse effects vary with long-term (months) or short-term (weeks) use? How do effectiveness and adverse effects vary with intermittent or continuous use? Adverse events may occur at any point after treatment is received and may impact quality of life directly. Key Informants Key Informants are the end-users of research, including patients and caregivers, practicing clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience in making health care decisions. Key Informants are not involved in analyzing the evidence or writing the report and have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism. Key Informants must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their role as end-users, individuals are invited to serve as Key Informants and those who present with potential conflicts may be retained. Technical Experts Technical Experts comprise a multidisciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, or outcomes as well as identifying particular studies or databases to search. They are selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicting opinions are common and perceived as producing healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore, study questions, design and/or methodological approaches do not necessarily represent the views of individual technical and content experts. Technical Experts do not conduct analysis of any kind or contribute to the writing of the report; they do not review the report, except as given the opportunity to do so through the public review mechanism. They included allergists, family practitioners, pharmacists, and otolaryngologists. Technical Experts must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals are invited to serve as Technical Experts and those who present with potential conflicts may be retained. Technical Experts advised that the majority of the literature on this topic is published in English. Although the search was not limited by date, only systematic reviews published after 2010 were considered for potential incorporation of results into this review. In addition, the following Web sites were searched: the clinical trial registries of the U. Scientific Information Packets provided by product manufacturers were evaluated to identify unpublished trials that met inclusion criteria. The grey literature searching was carried out between April 5 and September 26, 2012. Drug classes, routes of administration, and specific drugs within each class are shown in Table 1. Antihistamines were classified into nonselective and selective subclasses based on their specificity for peripheral H1 histamine receptors. Thus, the focus of the review was across- class treatment comparisons, except when multiple routes of administration were available for a single drug class (e. We sought expert guidance to identify drug class comparisons most relevant for treatment decisionmaking. Trials that involved exposure chambers or allergen challenge interventions were excluded. Control of confounders, such as baseline comorbidities, baseline symptom severity, and pollen counts, was necessary. Detection bias was addressed through blinding of outcome assessors or clinicians to drug exposure. Pharmacologic treatments of seasonal allergic rhinitis Drug Class Oral Included Drugs Intranasal Included Drugs H1-antihistamine Nonselective  Acrivastine (in combination with pseudoephedrine only), brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyproheptadine, dexbrompheniramine, dexchlorpheniramine, diphenhydramine, doxylamine, promethazine, triprolidine Selective  Cetirizine, desloratadine, fexofenadine,  Azelastine, olopatadine levocetirizine, loratadine Corticosteroid *  Beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone furoate, fluticasone propionate, mometasone, triamcinolone Mast cell stabilizer  Cromolyn Leukotriene  Montelukast receptor antagonist Sympathomimetic  Phenylephrine, pseudoephedrine  Levmetamfetamine, decongestants naphazoline, oxymetazoline, phenylephrine, propylhexedrine, tetrahydrozoline, xylometazoline Anticholinergic  Ipratropium bromide *Oral corticosteroids are not reviewed in this report. The last three rows of the table indicate combination treatment comparisons included in this review (). Outcomes had to include patient-reported symptom scores and/or validated quality of life instruments; for comorbid asthma symptoms, pulmonary function tests also were required. Narrative reviews were excluded, but their bibliographies were searched if they were thought to have relevant references. References obtained through grey 13 literature searching were excluded if the study was not published in a peer-reviewed journal or if the full-text of the study could not be obtained. Additionally, systematic reviews and meta-analyses that specifically assessed adverse events associated with treatment comparisons of interest were sought. Table 4 lists systemic and local adverse effects of interest for making treatment decisions. Of particular interest were adverse effects associated with long-term 14 treatment exposures in locations where allergen seasons are of longer duration (e. Key Question 2: Systemic and local adverse effects of seasonal allergic rhinitis treatments Treatment Effect Intranasal corticosteroids Systemic effects: adrenal suppression, hyperglycemia, bone demineralization/fracture, growth delay in children Local effects: increased intraocular pressure, cataract formation, nasal septal atrophy, fungal infection, nosebleeds, stinging, burning, dryness, smell and taste abnormalities Selective and nonselective antihistamines Systemic effects: sedation, impaired school/work performance, traffic accidents Local effects: stinging, burning, dryness, bitter aftertaste Sympathomimetic decongestants Systemic effects: hypertension, palpitations, insomnia, anxiety Local effects: nosebleeds, stinging, burning, dryness, rhinitis medicamentosa Leukotriene receptor antagonists Systemic effect: headache Anticholinergic, cromolyn Local effects: nosebleeds, stinging, burning, dryness Key Question 3—Comparative Effectiveness and Adverse Effects of Treatments in Pregnant Women Treatment comparisons of interest included Pregnancy Category B oral and topical (intranasal) preparations and nasal saline, which is considered safe for use in pregnancy. Thus, we expected reporting of common treatment-related adverse events and adverse events associated with the physiologic changes of pregnancy, rather than teratogenic effects. The last three rows of the table indicate combination treatment comparisons included in this review (). Because of concerns about the use of sympathomimetic decongestants in children, comparisons of oral and nasal preparations as monotherapy were not included. Similarly, intranasal anticholinergic (ipratropium) was not included because Technical Experts indicated that this drug is rarely used in children younger than 12 years of age. Potential comparative harms of intranasal corticosteroids in this population (reduced bone growth and height) were of particular interest. Comparative effect on school performance in school-age children was an additional key outcome. For comparisons with sparse bodies of evidence, we considered inclusion of studies that mixed results for adults and children together. The last three rows of the table indicate combination treatment comparisons included in this review (). Study Selection Figure 2 shows the flow of data from article screening to data synthesis. Using the study selection criteria for screening titles and abstracts, each citation was marked as: (1) eligible for review as full-text articles; (2) ineligible for full-text review; or (3) uncertain. A training set of 25 to 50 abstracts was initially examined by all team members to ensure uniform application of screening criteria.

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The concepts of “overall health” and “wellness” means we must address the whole person if we are to improve our chances of facilitating the recovery of mental health trusted bupropion 150mg. Currently most psychiatric treatment attempts to readjust the individual’s neurological biochemistry through pharmacology discount bupropion 150mg otc. While these tools have a level of effectiveness and may be sufficient for some quality bupropion 150 mg, they collectively fall short of addressing “overall health. Reasons given are a preference for a “natural approach,” wanting treatments that are congruent with their own beliefs and values, and experiencing unpleasant side effects or poor results from orthodox treatment (Wu 2007). It means considering the full array of factors that can impact mental health, including: − Physical − Mental − Environmental − Spiritual − Energy influences It also means therapeutically addressing the individual through all channels that can affect mental health for the better, including: − Physical − Mental − Communication − Perceptual Each individual is unique. No human physiology is exactly like another, and no life experience is the same for any two people. So in our medical literature we almost never find a 100% response to any treatment. What may be effective therapy for one individual, such as the adjustment of neurotransmitters, may be ineffective or deleterious for another. Even within a single diagnosis such as schizophrenia, the combinations of possible contributing factors—physically, genetically, prenatally, and environmentally, just to name a few—could be almost infinite. If a woman with depression can get a 10% improvement each with nutrients, diet change, exercise, acupuncture, and yoga, we have a 50% gain without side effects and with improved physical health. Treating the Body It is easily observed that physical health affects mental health. Even in Dickens’ A Christmas Carol, published in 1843, he observed that one’s senses and perceptions could be altered by the body: “A little thing affects them. You [the ghost] may be an undigested bit of beef, a blot of mustard, a crumb of cheese, a fragment of an underdone potato. We have devoted a chapter to this subject but, suffice it to say, the importance of proper physical screening of psychiatric patients cannot be overemphasized. Additionally, as Dickens noted, diet plays a significant role in mental well-being and overall health. Lack of proper nutrition, food allergies that present with psychiatric symptoms (such as depression and anxiety), food additives that some individuals are sensitive to, and an excess of junk food can negatively affect mood and behavior, sometimes to a pathological level. Toxic exposures of many kinds can dramatically influence mood, perceptions, and actions. Dental issues, back pain, an improperly healed surgery, a hidden fracture, foot anomalies—any kind of pain- producing ailment—may go unnoticed by the physician, but shouldn’t. Also, many patients may fail to report the pain due to their inability to express themselves or because they have become accustomed to it. Perceptual issues, particularly hearing and vision impairment, can often go overlooked by doctor and client, yet they can result in psychiatric sequelae such as hallucinations, anxiety, depression, and confusion. In addition to treating physical disorders, clinicians can use the body as a channel for therapeutic intervention. Numerous nutrient therapies are efficacious for a panoply of psychiatric disorders. Some treatments, such as omega-3 fatty acids, have become so commonplace that they are now considered best practice in mainstream medicine. Herbal treatments have a role in psychiatric medicine and a number of them have been reported safe and effective in the literature. Exercise has been shown to be very effective as a mood elevator and lack of exercise can impair the quality of life for any psychiatric patient as well as retard recovery. Environmental Influences In the early 1900s, when psychoanalysis was the dominant force in psychiatry, Sigmund Freud wrote, “If a man has been his 18 | Complementary and Alternative Medicine Treatments in Psychiatry mother’s undisputed darling, he retains throughout life the triumphant feeling, the confidence in success, which not seldom brings actual success along with it. Many professions use chemicals that can have toxic effects on the brain, including farming, metal plating, laboratory work, mining, and certain types of manufacturing. Toxic waste, a paucity of certain nutrients in the region’s soil, political upheaval or other environmental threats can and do make a difference to mental well-being. Chronic exposure to power lines, for example, has been shown to increase suicide rates up to threefold in electrical workers (Wijngaarden 2000). Also, high-density negative ions in the air, as are seen near waterfalls, produce a 43% improvement in depression (Terman 2007). Spiritual Matters A survey of 1144 American physicians found that amongst all doctors, psychiatrists are the least likely to be religious. Additionally, nonpsychiatrist physicians who are religious are less willing to refer their clients to a psychiatrist (Curlin 2007). By contrast, only 15% of the American population defines itself as atheist, agnostic, or of no religious affiliation (Kosmin 2008). Individuals can suffer great anxiety and depression over a religious issue, be it guilt from transgressions, abortion, infidelity, pornography addiction, dishonesty, child abuse, divorce or other weighty matters. They may not think to mention such things to a psychiatrist since he is a doctor and not a priest/pastor/rabbi. People of Eastern faiths have additional issues and traditions that could trouble them and that are worth exploring. Such a person could benefit from religious counseling perhaps more so than any other form of treatment. Addressing the Mind Traditional treatment of mental and emotional issues involves psychotherapy, some form of practitioner-patient interchange that allows the client to discuss trauma and life issues with the hope of unburdening the individual to some degree or leading him/her towards solutions for the issues he/she faces. But other approaches have emerged—many from Asia—that provide a different look at the mind and living which offers therapeutic benefits. The concept of mindfulness or being in the present has been imported from India, China, and neighboring regions and encourages quieting the mind rather than engaging it or delving into it continuously for solutions. This practice of quieting thought can have many forms, including physical actions such as breathing exercises or taking walks and has become a popular method for calming anxiety, reducing obsessive thought, and relieving depression. Numerous modalities have arisen that utilize these pathways to manipulate mental processes in often simple but powerful ways Aromatherapy has been used effectively to calm and improve behavior. Lavender oil, for example, reduces agitation in 60% of dementia patients (Holmes 2002). It has been found helpful for many disorders and diminishes symptoms of schizophrenia (Talwar 2006) and depression (Maratos 2008). While numerous forms of the therapy exist, they generally consist of clients looking at lights or video screens programmed to shift brain wave patterns. Light therapy is now an established remedy for Seasonal Affective Disorder and is a simple option to medication for some. Massage therapy is a combination of touch and muscle manipulation that can have a relaxing effect. It has been found to significantly reduce symptoms of depression (Hou 2010) and anxiety disorder (Sherman 2010). Patients and caregivers who have hope have less depression and more reason to believe they will succeed (Cheavens 2006). A patient who is given one therapy as his only option can lose all hope if it fails. Many psychiatric patients live lives of quiet desperation, suffering side effects from meds they dislike but feeling they have no other choice. Even if a treatment fails, if other options are on the horizon, this expectation can keep a patient working toward wellness and putting one foot in front of the other on the road that may lead to partial or full recovery. It can even cause the patient to make improvements in his lifestyle as he strives to do his part in the recovery effort. Summary Of all the fields of medicine, few require as holistic a view as psychiatry. So many variables can impact mental and emotional function—and so many approaches can improve it—that the psychiatrist of today is hard-pressed to keep abreast of the investigational and therapeutic tools at his disposal. This means that pharmaceutical treatments in psychiatry, which can bring with them dramatic side effects such as metabolic syndrome, renal failure, anorgasmia, and obesity, are being reevaluated by some as to whether they should always be a first and only form of treatment. With an understanding of the therapeutic tools at his disposal, the clinician’s—and the client’s—chances of success are markedly improved. The Comprehensive Medical Exam in Psychiatry Dan Stradford Virtually every medical student has been taught, “When you hear hoofbeats, don’t expect to see a zebra,” a phrase coined by Dr. The gist is that when a physician sees symptoms, he should consider routine diagnoses, not exotic ones. Psychiatrists are often taught the same phrase regarding psychiatric symptoms that are created by non-psychiatric medical disorders—that although they exist, these conditions are, in fact, rare and unlikely. Unfortunately, this line of thinking has caused many serious medical conditions to go undiagnosed.

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Because of this the virus which has the very low molecular weight proteins escapes the immune response safe bupropion 150mg. Recruit other cells and molecule to destroy the pathogen (effectors function or Biological activity) 154 Fig buy bupropion 150 mg without a prescription. When the same IgG molecule subjected to pepsin cleavage it resulted with a divalent antigen binding Fab part and fragments of Fc portion discount bupropion 150 mg otc. There is a variable region present in the heavy and light C chain and called as variable (V) region, where antigen binding occurs. Antibodies are divided into fve major classes, IgM, IgG, IgA, IgD and IgE, based on their heavy chain constant region structure. IgG stimulates phagocytic cells, activates the complement system, binds neutrophils, and can neutralize toxins. Most importantly, it is the only antibody that can cross the placenta and confer immunity on the foetus. IgA has two light chains either kappa or lambda and two heavy chain of a type and consist of two subclasses IgA1 and IgA2, constitutes only 13% of the antibody in human serum, but predominant class of antibody in extravascular secretions. The IgA present in secretions (tears, saliva, nasal secretions and mammary gland secretions) is secretory IgA. It is found to produce immunity against tapeworms and present in the colostrums protects the baby from intestinal pathogens. IgM has two light chains either kappa or lambda and two heavy chain of m type constitutes 8% of the antibody in human serum, it is the largest of the immunoglobulins often referred as the macroglobulin because it has more than fve binding sites for antigen. It is the frst antibody to appear in the primary immune response therefore an useful indicator of recent infection. Plays a role in activating and suppressing lymphocyte activity and found large quantities in the cell walls of many B-cells. IgE is a reaginic antibody, has two light chains either kappa or lambda and two heavy chain of e type constitute less than 0. Specifcity antibody to combine with only one type of antigen, Binding site of antigen and antibody ( epitope and paratope), Binding forces of antigen and antibody – closeness between antigen and antibody and intermolecular forces, Affnity (attraction of Ag- Ab binding ) and Avidity (combining capacity of heterogenous antibodies with multivalent antigen). The frst interaction of an antigenic determinant (epitope) with its corresponding antigen binding site on an antibody is called a primary antigen- antibody reaction. The primary antigen-antibody reactions are rapid reaction, not dependent on electrolytes and not visible. If the primary antigen- antibody reaction is followed by the aggregation of antigen antibody complexes into macroscopically visible clumps is called the secondary antigen-antibody reaction and this aggregation phase may take hours to day to reach maximum. Immune precipitation occurs when antigen and antibody combine in solution and form a visible aggregate. The variation in the ratio of antibody- antigen leads to different levels of lattice formation, and thereby to different amounts of precipitate. This phenomenon, called the prozone phenomenon were antibody may excess, zone of equivalence of antigen- antibody or antigen may excess. Agglutination methods are qualitative or semi quantitative at best and its reaction can be used in many applications as it posses a high degree of sensitivity. In the direct agglutination reaction, the antigenic determinant is a normal constituent of the particle surface. In the indirect agglutination a molecule is ordinarily soluble is attached to a particle and rendered insoluble. Since the blood group antigen and antibody reactions result in the agglutination reaction the antigen is known as agglutinogen and the antibody is known as agglutinin. So your ‘blood group’ depends on type antigens which found on the surface of the red blood cell membrane. Since this antigen antibody involved in agglutination reactions the antigen is called as agglutinogen and the antibody is known as agglutinin. Blood group A If you belong to the blood group A, you have A antigens on the surface of your red blood cells and beta antibodies in your blood plasma. Blood group O If you belong to the blood group O (null), you donot have the A and B antigens on the surface of your red blood cells but you have both alpha and beta antibodies in your blood plasma. Since this antigen was found in Rhesus monkey frst they called this antigen as Rhesus antigen or Rh system. Basically, a sample of blood is mixed separately with anti-A antibodies, anti B antibody and Rh antibodies. If the red cells to clump together with anti-A antibodies, then it indicate the presence of A antigens in the blood cells and the person belongs to A group. Similarly if agglutination reaction occurs with anti B antibodies then it indicates the presence of B antigen. If no agglutination found with both antibodies of A and B then it indicates the absence of antigens and the person belongs to O group. Similarly if an anti Rh antibody shows agglutination with the given blood then it indicates the presence of Rh antigens on the blood cells. If the mother is Rh negative, and the fetus is Rh positive (inherited from a Rh positive father), when the fetal blood enters in to mothers body due to some reason the mother become sensitized. This condition is called ‘Erythro blastosis fetalis (Because erythroid (red blood cells) blast cells are found in the fetus). However, without treatment, this can become a serious problem in subsequent pregnancies as the mother’s immune 160 system will be ‘sensitized’ after the frst pregnancy. Isoantigens : An antigen of an individual which is capable of eliciting an immune response in individuals of the same species who are genetically different and who do not possess that antigen is called isoantigen. Antibody production starts at 3 months of age, reaches its highest level during adult and decreases with advancing age. Fill up the blanks : a) Infection acquired during hospital stay is called as ________ b) Recognition and destruction of cancerous cells is done by—————— c) Substances which are released by Cytotoxic T cells over the cells carrying the viral particles, are called as _______ d) Opsonization of bacteria is done by __________ part of the complement. Blood Blood is one of the most common specimen studied in various sections of the lab in search of blood related disorders and infections. Blood will clot within a few minutes after it is removed from the body unless an anticoagulant is used, which stops the process of clotting. Remove the pulp material carefully and strain the pulp material through two layers of muslin cloth to remove the coarse particles. Calculation Weight of the potato = 100g Weight of the starch = ___g Therefore, the amount of starch present in 100g of potato =___g Result The yield of starch from potatoes is_____g/100 g 2. Principle Casein is the main protein found in milk and is present at a concentration of about 30-40 gms/lit. Casein is insoluble in ethanol and ether and this property is used to remove unwanted fat materials from the preparation. The amount of casein weighted = X gms The amount of casein present in 100 ml of milk= X gms The percentage yeild = 100 x X/100 = Y gms Result The amount of casein present in 100 ml of milk = Y gms 3. Since all proteins contain peptide bond, this method is fairly specifc and there is little interference with other compounds. Stock standard solution 1g of protein (egg albumin) is weighed and made upto 100ml with distilled water. Concentration = l0mg / ml Working standard solution 10ml of the stock is diluted to 100ml using distilled water. From the values obtained, a standard graph is drawn using concentration of protein in X - axis and optical density in the Y - axis. Principle A solution of orthotoluidine in glacial acetic acid when treated with glucose produces a blue coloured product with an absorption maximum at about 640nm. A blank is also prepared simultaneously comprising 1ml of distilled water and 4 ml of orthotoluidine reagent. The amount of glucose present in the given blood sample is then calculated 169 Protocol for glucose estimation Blank Standard Plasma S. Optical density at 640 nm Graph Y axis T & T1 2 A Optical density at 640nm X axis 0 B Concentration of glucose in mg Calculation For T1 &T2 The optical density A of T1 & T2 corresponds to B mg of glucose 1. Sulphuric acid (1N) 171 Procedure Standardisation of Potassium permanganate 10ml of oxalic acid is pipetted out into a clean conical fask and 10ml of dilute sulphuric acid is added and heated to 60 ° C. Precipitation of calcium oxalate 2ml of serum is taken in a centrifuge tube and 2ml of distilled water is added followed by 1ml of 4 % ammonium oxalate. Tabular Column Titration I Standardisation of Potassium permanganate Standard Oxalic acid Vs Potassium permanganate S. No Volume Burette Volume of Indicator of Oxalic acid Initial Final Potassium (ml) permanganate (ml) (ml) (ml) 1. No of Oxalic acid Indicator permanganate (ml) Initial Final (ml) (ml) (ml) Test solution oxalic acid liberated 1.

Desde el interrogatorio podemos asegurar que el paciente que consulta por una claudicación intermitente de sus miembros inferiores es un fuerte candidato al infarto cardíaco y la trombosis cerebral order 150 mg bupropion free shipping. Del diagnóstico de claudicación intermitente dependerá la extremidad del paciente y su calidad de vida purchase 150 mg bupropion free shipping. Dolor en reposo El crecimiento lento y progresivo de los ateromas en determinado sector arterial discount 150mg bupropion otc, permite en el tiempo el desarrollo de colaterales, lo que no ocurre en las oclusiones agudas o súbitas. Este mediador químico se ha utilizado como tratamiento, inyectado localmente en el interior de las arteriales ocluidas, para favorecer el desarrollo de colaterales. Lo habitual es que los enfermos solo logren desarrollar algunas pocas colaterales que traten de suplir de alguna manera el grave déficit sanguíneo. Es frecuente que el ateroma, a punto de casi completar la oclusión arterial, se torne inestable y un trombo fresco, disparado por las plaquetas y la fibrina, concluya la obstrucción. Llegado este momento, el tronco arterial está ocluido y las pocas colaterales a duras penas sostienen la presencia de la extremidad que ha perdido su función. Ya el enfermo no puede caminar, el dolor que aparecía al caminar se ha vuelto constante. Es un dolor sostenido que anuncia la inminencia de la aparición de la lesión, por lo que también se denomina “dolor pretrófico”. El enfermo, además de tener un insoportable y continuo dolor, ni come ni duerme, pues al hacerlo se le aumenta. En el primer caso por el desvío de sangre hacia el proceso de la digestión que agrava la isquemia de la extremidad. Al dormir, las 62 contracciones cardíacas son menos intensas y frecuentes y disminuye aún más la irrigación del área comprometida. Sin saberlo, buscando una posición que lo alivie, al colocar la extremidad en declive, el enfermo sitúa su extremidad a favor de la gravedad y esto inicialmente favorece un tanto la llegada de sangre y de alguna manera logra dormitar a ratos. El edema compromete las colaterales, la progresión de la enfermedad también afecta sus orificios de salida o entrada del tronco arterial cada vez más enfermo y ya todo está prácticamente perdido. Lesión Con el tronco arterial severamente comprometido y las colaterales escasas y también afectadas, aparece la lesión isquémica. Su forma inicial es la úlcera y la siguiente y final, la gangrena, que indica la amputación. Es pequeña, parece una verdadera quemadura de cigarro, con la piel que la recubre de color negruzco y cuando se pierde deja un fondo extremadamente pálido. Son extraordinariamente dolorosas y su presencia nos está indicando que la extremidad se está perdiendo (capítulo 5). Si estas lesiones se extienden y unen, ya la gangrena, parcelaria o extensa, ha aparecido. Examen físico En la medida que la irrigación sanguínea se deteriora, las estructuras a las que está destinada, igualmente se deterioran. La piel isquémica, además de fría y pálida, es prolífica en signos físicos: Las glándulas sudoríparas, al no recibir sangre dejan de producir sudor y el resultado es una piel seca. Los folículos pilosos, que a diferencia de las anteriores microscópicas estructuras, sí muestran sus vellos, no reciben sangre por lo que comienzan a caerse. Los vellos inicialmente son ralos y finalmente desaparecen, mostrándose la alopecia. Las uñas, que son las estructuras más distales de la extremidad, se tornan vulnerables a la isquemia, por lo que es frecuente que se “entierren”, o aparezcan 63 a su alrededor, o en su lecho, pequeñas lesiones, inflamaciones, abscesos, infecciones, que en su conjunto reciben el nombre de paroniquias, donde paro significa proximidad y niquia se refiere a uña. Los espacios interdigitales son especialmente proclives a las micosis que en estado de isquemia se tornan peligrosas puertas de entrada de infecciones catastróficas. Otras lesiones de piel, como pequeñas cortaduras, golpecitos sin importancia aparente, arañazos, pinchazos, rasponazos, rozaduras de zapatos apretados, se convierten en ulceraciones crónicas de localización atípica, mal llamadas traumáticas, que no cicatrizan por estar comprometida la irrigación de la piel de la extremidad y pueden comprometer su viabilidad. Los músculos involucionan por el deterioro en su irrigación, además de su falta de ejercicio por limitaciones de la marcha. Lo más importante al examen físico es la búsqueda y localización de los pulsos arteriales. Existe una enraizada tendencia en todo alumno y profesional joven a restarle importancia a este importante hallazgo en el examen físico, de manera que se escribe con frecuencia después de un examen superficial o veloz: “todos los pulsos arteriales, presentes y sincrónicos”, como si siempre, o casi siempre, todos estuviesen presentes. Los pulsos arteriales deben buscarse con todo rigor en el examen físico de cualquier paciente. Paciente masculino de 57 años, fumador de 2 cajetillas diariamente, obeso, hipertenso, probablemente diabético y con hipercolesterolemia, pues ni él mismo 64 conoce que tiene su aorta abdominal ocluida y sufre de una enfermedad de Leriche. Fuma en la mañana uno o dos cigarrillos antes de desayunar exageradamente con huevos, tocino, mantequilla. Fuma otro cigarrillo mientras llega a buscarlo el chofer de la empresa de la cual es funcionario. Llega a la empresa, da igualmente unos 10 pasos hasta el ascensor que lo lleva al cuarto piso. Allí realiza su trabajo, sentado, con aire acondicionado, tenso por sus grandes responsabilidades y contrariedades, fuma continuamente. En el curso de los últimos seis meses ha notado que la uña del dedo grueso del pie derecho se ha enterrado en varias oportunidades y ahora lo ha molestado de nuevo por lo que decide buscar ayuda médica. Uña del pie encarnada El médico lo ve y ante la demanda del enfermo que le pide le “saque la uña” pues lo ha molestado frecuentemente en los últimos meses, anestesia su dedo y le extrae la uña. Al día siguiente el paciente acude de nuevo para curar la zona, pero no ha dormido nada por el intenso dolor que no se alivió con ningún analgésico. En el curso de los días todo el antepié se vuelve casi negro y el médico asustado y perplejo por la evidente gangrena, lo remite al Hospital donde lo amputan esa misma noche, a nivel del muslo, casi a nivel del pliegue inguinal al faltarle ambos pulsos femorales. Este caso por sus hábitos de vida, otros porque no 65 deambulan al tener limitaciones físicas: operados de cadera, ciegos, sordos, sufren de artritis. Ante cualquier enfermo que consulte por paroniquia debemos buscar la presencia de sus pulsos. Si los tiene, entonces es otra la causa de su uña enterrada: zapato apretado, uña mal recortada, un pisotón en el baile… 2. Antes de realizar cualquier intervención en una extremidad debemos asegurarnos de que los pulsos periféricos estén presentes. Ejemplos de intervenciones: extracción de uñas, biopsias de piel, resección de várices, lipomas, quistes, gangliones, correcciones de dedos, entre otros. Propia del hombre-joven-fumador que enferma sus venas superficiales y profundas, periféricas o viscerales, así como las arterias de mediano calibre en sus cuatro extremidades. Enfermedad de las extremidades, preferentemente superiores, de la mujer joven que sufre de crisis de Raynaud y sugiere colagenosis, en particular esclerodermia y lupus. La comunicación patológica entre una arteria y una vena de las extremidades, casi siempre producida por heridas penetrantes, roba la sangre que debe llegar a ella desencadenando la claudicación intermitente. La sangre secuestrada retorna a través de un cortocircuito que llevará más temprano que tarde a la insuficiencia cardíaca por gasto aumentado o la endocarditis bacteriana. Cualquier compresión que afecte el calibre de una arteria disminuye su flujo y puede producir claudicación intermitente. El sector más comprimido es el axilosubclavio, en la salida torácica y mucho más frecuentemente por una costilla cervical supernumeraria. En este caso la claudicación es de miembros superiores: al peinarse, tender la ropa, sostenerse en el ómnibus, o trabajar con los brazos elevados como los estomatólogos, pintores y mecánicos. Es frecuente el soplo sistólico por compresión extrínseca en la fosa supraclavicular. Existen numerosos procedimientos diagnósticos, invasivos o no, con ventajas y desventajas, para precisar el sitio, extensión y características de la obstrucción. De igual manera existen diversos procedimientos quirúrgicos destinados a mejorar el flujo arterial a una extremidad. Puede mejorarse el flujo de las colaterales por medio de la simpatectomía, mientras que el flujo troncular se mejora desobstruyendo la arteria enferma o derivándola mediante el procedimiento denominado by pass o puente. Más recientemente el desarrollo de endoprótesis ha permitido realizar revascularizaciones, especialmente en las zonas de aorta e ilíacas, por la vía endovascular, con mucho menos tiempo y riesgos, aunque con costos aún muy elevados. Definir las formas anatomopatológicas mas frecuentes y las manifestaciones clínicas específicas de cada uno de los territorios afectados: carotídeo y vertebral. Determinar las diferentes formas de tratamiento así como destacar la importancia del tratamiento preventivo. Enfatizar la necesidad absoluta de auscultar las arterias carótidas en todo examen físico en busca de soplos patológicos. Ellas tienen su origen dentro o fuera del cráneo, de ahí que se clasifiquen en intracraneales y extracraneales.

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