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By B. Raid. Olivet College. 2018.

T he approach we have taken to health is limited by the borders o f our concepts; our thinking about health is limited by the quality of our ideas buy cheap arcoxia 90mg on-line. U nfortunately purchase arcoxia 120 mg without prescription, the systems we fashion from our ideas often live on long after the ideas themselves are extin­ guished arcoxia 120mg amex. O ur The Eras of Medicine 199 perceptions of health and the systems we construct out of those perceptions are consonant with our perceptions o f the world around us. If this is so, a reconstruction of where we have been and where we are should aid us in speculating about the future—a new paradigm and a new medicine. Each o f these eras can be assessed in three steps: first, by characterizing the dom inant world view relat­ ing to health; second, by identifying the most utilized m edi­ cal technologies; and finally, by adducing the prevailing health paradigm , which can be seen as an amalgam of the world view and the technology. An analysis o f these eras will generate some of the elements of a new paradigm for health in the future. Untoward events, including sickness and disease, resulted from disharm onies in these relationships. Disharmonies might arise from many causes, but chief am ong them was behavior offensive to the gods. Sickness was not an abnorm al condition requiring spe­ cialized care, but was a feature of a hard existence. It re­ sulted from imbalances in hum an beings’ relationship to their environm ent. This ostensibly mythical body of tradition contained “lessons” about the healthy life. T he second—rituals—sprang from the first, although repugnant curative practices (some of which were discussed earlier) were frequently incorporated. T he rituals were not always arbitrary; most o f them were based on empirical observations. This 200 T he Transform ations of Medicine occasionally entailed hum an or animal sacrifice as a means of propitiating the gods, as, for example, in the tradition of some Central American cultures, but m ore im portantly stressed self-sacrifice. Individuals or groups, presumably re­ sponsible for the affliction, subjected themselves to regimens designed to please or pacify the authorities. Most shamans—again I am using the term generically to embrace early healers from many cultures—played two m ajor roles. In their healing role with patients, shamans emphasized the symbolic aspects of healing, including the use of colorful regalia, sacrifices, spitting of blood, and the use o f fire. But since sickness was an event that could be used to instruct the larger community, shamans also organized cultural experi­ ences for the community, often around the sickness of a member. These “group healing ceremonies,” as Jerom e Frank calls them , mixed curative acts, such as pulse read­ ings, with culturally significant rituals. Prescientific medicine, as bizarre as it often appears, was also doggedly pragmatic. Man and nature co­ existed in an uneasy equilibrium that had to be restored before individual cures and community consensus could be achieved. Claude Levi-Strauss characterizes the paradigm this way: The Eras of Medicine 201 That the mythology of the shaman does not correspond to objective reality does not matter. The protecting spirits, the evil spirits, the supernatural monsters and magical mon­ sters are elements of a coherent system which are the basis of the natives’ concept of the universe. What she does not accept are the incomprehensible and arbitrary pains which represent an element foreign to her system but which the shaman, by invoking the myth, will replace in a whole in which everything has its proper place. But this is precisely what the doctor does; it is one o f the dom inant features of m odern medicine. Many factors have contributed to the rise o f today’s medicine; the parceling o f the body into pieces is only one. T he Cartesian thesis that m ind and m atter were divisible drove a wedge between the m ind and the body that persists in medicine today despite its repudiation everywhere else. And as a way of looking at the world, it was seized by medicine as a way of organizing its endeavor. It relied on magical formulations, but also on techniques consistent with observations o f man and nature indigenous to a given tribe or culture. But with the body freed of the larger m an and conceptualized as a machine, medicine at least had a manageable subject—the m etaphor of the body as a machine. T he sham an was a pivotal cultural 202 The Transform ations of Medicine figure who utilized both healing techniques and communal ceremony. But a sham an was not needed to tinker with a machine; what was needed was a mechanic. Although the m etaphor o f man as a machine is over­ worked, it is nonetheless central to an understanding of this period. As Thom as McKeown, an expert on the period, has said: The approach to biology and medicine established during the seventeenth century was an engineering one based on a physi­ cal model. Nature was conceived in mechanistic terms, which lead in biology to the idea that a living organism could be regarded as a machine which might be taken apart and reas­ sembled if its structure and function were fully understood. In medicine, the same concept lead further to the belief that an understanding of disease processes and of the body’s response to them would make it possible to intervene therapeutically, mainly by physical (surgical), chemical, or electrical methods. To think o f man as a machine does aid us in understanding something about bod­ ily function and about m an’s role in the universe, but it does not follow that treating the body as a machine will heal it. Medicine had largely passed beyond pre­ scriptions based on bodily hum ors, but its techniques were still unsophisticated in today’s terms. Bloodletting persisted, cauterization was used, and the use of purgatives was also common. But medicine rem ained outside the body, at least until it was clear that the body could not be understood without an exam ination o f its inner workings any m ore than, today, an automobile engine can be repaired without remov­ The Eras of Medicine 203 ing the hood. His rew ard was nearly universal denuncia­ tion by the church and by the academic world. It took approxim ately another 200 years before the investigation of what went on inside the skin was widely tolerated. And this did not occur until the m etaphor of the body as a machine was firmly planted. A ntiquarian notions such as the bodily hum ours coexisted with observations of actual function. It was now expected that knowledge would be a fund of observations rather than an elaboration of theological propositions. But until Virchow’s Cellular Pathology was published in 1858,11 medicine re­ m ained a tentative art moving alternatively through old wis­ dom and new findings. T he doctor had em erged, but a cohesive theoretical fram ework for medicine had not. T he first public health practitioner was the sham an, whose initiatives were crude, but pragmatic and probably effective. As an illustration, the sham an might direct that a residence contam inated by the illness of a resi­ dent be burned. But these measures, while conceptually consistent with pub­ lic health, were modest com pared to the measures launched in the nineteenth century.

The walls of small Neurosyphilis and neuroborreliosis and medium-sized arteries that traverse the exudate are invaded by inflammatory cells purchase arcoxia 120 mg with mastercard. Meningovascular syphilis cheap 60 mg arcoxia visa, caused Ischemic stroke is a relatively frequent complica- by T buy 120mg arcoxia overnight delivery. Strangulation and spasm of Stroke in syphilis develops as a result of inflam- blood vessels by an intense inflammatory exudate, matory infiltration of medium to large arteries. A diagnosis is based or M2 segment of the middle cerebral artery by the on serological testing of cerebrospinal fluid. Add- exudate causes large artery infarctions, whereas mul- itionally, syphilis can cause stroke by other mechan- tiple infarcts are most likely due to secondary isms, e. Neurocysticercosis Neurocysticercosis is the most common parasitic cen- Cryptococcal meningitis tral nervous system infection. The pork tapeworm The fungus Cryptococcus neoformans is a soil Taenia solium is prevalent worldwide, especially in pathogen with a high potential to invade the central developing countries. It causes an often fatal disease, despite Taenia solium lives as a tapeworm in the small intes- 265 antimycotic therapy. The cystic larval Section 4: Therapeutic strategies and neurorehabilitation form (termed cysticercus) is usually found in the pig. Patient history However, when humans ingest shed tapeworm eggs often reveals a typical herpetiform rash. The rash invasive larvae may develop in the intestines, pene- can precede the manifestation of stroke by up to trate the mucosa, enter the bloodstream, migrate to several months. Symptoms depend on localization and size of Randomized clinical trials for standard treatment the larvae and include seizures, headache, visual prob- are lacking. About 50% of ment includes intravenous acyclovir in combination patients develop arteriitis with associated lacunar with steroids. Two different types of infection perivascular space dilatation, rarefaction, pigment can be differentiated depending on the immune status deposition, and occasional perivascular inflammatory of the patient. In both involves large or medium sized intra- or extracranial cases, histopathological features include multinu- arteries. It 266 should be suspected in patients with ischemic lesions Vasculitis from infectious diseases, e. Chapter 18: Infections in stroke Mycotic aneurysms as cause of stroke Infectious diseases with similarities Mycotic aneurysms are caused by bacteria or to stroke – toxoplasmosis and malaria fungi and account for a minority (about 3%) of all encephalitis intracranial aneurysms. They develop in a significant fraction of patients with infective endocarditis Cerebral toxoplasmosis, an infection with the proto- (3–16%), due to microemboli that congest the vasa zoan parasite Toxoplasma gondii, mainly occurs in vasorum of the cerebral arteries. The parasite is transmitted by undercooked antimicrobial therapy is frequent (57%) but the meat or cat feces and taken up by the oral route. Reactivation of the dormant parasites during aneurysm formation; (1) septic microemboli to the an impaired immune response leads to lesions with vasa vasorum; (2) hematogenous seeding of bac- a necrotic central area, hyperemic border and some- teria to atherosclerotic vessels; (3) extension from times a thin fibrotic capsule. A feature that distinguishes a contiguous infected focus; and (4) direct contam- these lesions from an abscess is a hypertrophic ination through trauma of the arterial wall. Bacterial aneurysms lesions and, in contrast to acute ischemic stroke, onset are usually small, saccular, and localized at multiple is often subacute. Definite diagnosis ysms are the same as for infective endocarditis, requires histological demonstration of the organism mainly viridans group streptococci, S. Enterobacteriaceae, toxoplasmosis in immunocompromised patients, pri- in particular non-typhi Salmonella spp. The pathogenesis of cerebral malaria shares some Among the fungi, Aspergillus spp. The causative organism of malaria tropica is the An important virulence factor of Aspergillus spp. The mortality associated with erythrocytes stick to the endothelium of the cerebral intracranial aspergillosis is at least 85% and patients blood vessels and reduce the microvascular flow. Aside from aneurysm rupture, Aspergillus becomes less deformable and thus travelling through spp. As in stroke, the reduced blood flow impairs the delivery of substrates, which causes hypoxia, reduc- In patients with infective endocarditis and in tion of the blood–brain barrier, and ultimately brain immunocompromised patients, rupture of mycotic swelling. Section 4: Therapeutic strategies and neurorehabilitation regularly observed, but infarction, necrosis, and large The high frequency of aspiration pneumonia in hemorrhages are rare. In a murine model, stroke induces a severe Infectious diseases as immunodepression through over-activation of the complication of stroke sympathetic nervous system. Dampening of the sym- pathetic activation by propranolol prevented pneu- Early-onset infectious complications monia and bacteremia in 80% of the mice and Infectious complications after acute stroke are improved 7-day survival by 50% [41, 42]. In a prospective study of 3866 patients lation of the immune system during a life-threatening with ischemic stroke hospitalized in neurological condition seems paradoxical but it may serve to pre- stroke units in Germany, 7. Other studies report an patients need to be screened for potential aspiration even higher incidence of urinary tract infections of fluids or semi-solids and the diet should be and pneumonia, 24% and 22% respectively [35]. Other measures (position- Stroke-associated pneumonia is associated with a ing, oral hygiene, tube feeding) have been proposed for higher fatality and worse long-term clinical outcome the prevention of aspiration pneumonia. Preventive antimicrobial therapy is effective in a mouse model [45], and a few small clinical trials have Diagnostic work-up of infections been carried out to assess its usefulness. When clinical signs or laboratory testing results placebo started within 24 hours of stroke onset did (e. A diagnostic work-up is guided within 36 hours of stroke onset, was not sufficiently by the clinical signs and symptoms and should powered to show significant differences between the include blood cultures, urine culture, and a chest groups [47]. If pneumonia is suspected, sputum or tracheal antibiotic therapy further trials are needed. Microbiological speci- Therapy of aspiration pneumonia is largely mens should be obtained before antimicrobial dependent on antibiotic treatment. To guide further treatment, proper Pneumonia in stroke patients is most often caused specimens for microbiological analysis, preferably by dysphagia and secondary aspiration. In up to 70% bronchoalveolar lavage and blood cultures, should of stroke patients the cough and swallow reflexes be obtained. Asymptomatic occurrence of bacteria in Chapter 18: Infections in stroke the urine (bacteriuria) needs to be distinguished from Coccidioidomycosis. Rupture of a mycotic aneur- Initial treatment is strongly dependent on local ysm without adequate antimicrobial therapy is resistance patterns and should follow current guide- frequent. Urine cultures should be obtained Cerebral toxoplasmosis results in a slowly prior to the start of antimicrobial therapy. In common, mostly pneumonia and urinary tract cerebral malaria the infected erythrocytes stick to infections. Infectious complications after acute stroke are Chapter Summary common, mostly pneumonia and urinary tract infec- tions. Pneumonia in stroke patients is most often caused by dysphagia and secondary aspiration. To Acute infection in the week preceding stroke is an prevent aspiration pneumonia, post-stroke patients independent risk factor for cerebral infarction; the need to be screened for potential aspiration of fluids “infectious burden concept” states that the aggre- or semi-solids and the diet should be adapted gate burden of microbial antigens determines stroke accordingly.

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He gritted his teeth and ran every day for a year in the hopes of being able to get back to Cardiff University discount arcoxia 90 mg on line, where he had to give up his course buy arcoxia 120mg lowest price, but in fact he was completely ruined by that purchase 90 mg arcoxia with mastercard, his muscles were damaged and he kept falling from then on and had worse and worse falls, until he eventually shattered a knee-cap. Following the treatment on his knee and throughout the long winter, the Rudd family, who live on a farm in Dorset, were often snowed in. All these factors precipitated a relapse, which William was emotionally unable to contend with. Finally in February 1988, the day after he suffered a most serious, but quite separate, emotional set-back, William Rudd committed suicide. She then went on to make clear that she did not consider this cost to have been excessive. It is an expensive treatment because it involves one nurse to one patient, and the actual testing at the beginning is time consuming, and we quite understood that. Although she herself was seeing Dr Monro, it was her child, Jade, who was receiving the most focused treatment at the Breakspear. Blanche Panton was, at the time of her interview with Barry Wood, completely committed to the Breakspear and to Dr Monro. This put Blanche Panton in an impossibly sensitive position, with regard to any television programme critical of Dr Monro. She had nausea and pains in her abdomen from irritable bowel syndrome, and she had an often continuous cold. At her worst she was unable to walk up and down stairs without getting out of breath and her speech became slurred. When she finally got to see Dr Monro, in January 1989, both she and Jade were admitted to the Breakspear. Because of the poor state of her immune system, Blanche had become allergic to a wide range of substances. Dr Monro took Blanche and Jade into the Breakspear for a second stay, even though she had no insurance cover and no money at that time to pay for her treatment. During the second stay at the Breakspear it became apparent to Blanche Panton that she was too ill to look after Jade. Her ex-husband, with his parents, who were Christian Scientists, decided that, especially as she was undergoing medical treatment with which they did not agree, they should take Jade away from her. On that first visit, Wood stayed for an hour or so discussing her condition, and the treatment which she had received from Dr Monro. Blanche Panton did not hear from Wood for a month after that first meeting, until the early autumn, when he called again. Then, he told her that they were still working on the programme even though it had been delayed. Blanche Panton next received a phone call from Wood to confirm the time and date of a filmed interview. On the day agreed, a film crew arrived at her home with Wood and another man who seemed to be senior to him. While the film crew set up the cameras for the interview, Blanche Panton went into another room with Wood, where they discussed the interview. Blanche stressed the point that in her opinion the things which were being said about Jean Monro were essentially political. Blanche says that she was calm when the interview was filmed, telling Wood about the treatment which she and Jade had received, and about how that treatment had benefited her. As the interview went on, Blanche began to realise that it was changing direction. Both men were trying to get her to agree that the treatment she received from Dr Monro was cranky. They asked how many vitamin pills she took and how expensive they were, then filmed her going out into the kitchen to take them. They made it plain that they thought Dr Monro was making a lot of money, and began to suggest that Blanche was somehow a victim. Having spoken to her friend, Blanche was convinced that the programme would be quite different. Blanche Panton rang Barry Wood throughout the day that the programme was due to be screened. She made it clear that if the film was, like the Observer article, to be an attack upon Dr Monro, then she did not want her interview to be included. Her own secret fear was that if the film was a contentious one, attacking Dr Monro, it would adversely affect her chances of seeing Jade. The next time Wood rang Lorraine, it was to say that he was definitely making a programme on allergies; he asked Lorraine if she would like to participate in the programme. Lorraine Hoskin next heard that the programme had been scrapped; then in September Wood told Lorraine Hoskin that his producer had changed the emphasis of the programme. On hearing that the programme had been scrapped, she asked Wood if it was possible to re-consider. She did not know, of course, that Wood was actually going ahead, but now only with interviews which could be damaging to Dr Monro. Lorraine Hoskin next saw Wood at the Breakspear ten days before the programme was screened. By now, however, although still being co-operative, Dr Monro had become uneasy about the programme. Despite this, and as she had nothing to hide, she continued her co-operation, giving Granada full access to the Hospital. It was a perfect piece of film, giving evidence of the fact that some allergies had serious physical consequences. Because it showed Samantha being successfully treated by Dr Monro, it was also film which to some degree validated her work. Although Wood told her he would send it, he never did, nor was it included in the programme which was finally screened. The two patients who had actually been interviewed by Wood, Maureen Rudd and Blanche Panton, were both people whose stories were shadowed by drama, Maureen because her son had committed suicide and Blanche because her child had been taken from her care. Others who had been approached had turned down interviews, either simply because they were sceptical about the media, were involved in compensation cases, or felt that their health would suffer. She made the point that Wood and his colleagues could not even begin to understand the problems suffered by people with serious multiple allergies. Lady Colfox, who, by 1990, was playing a leading role in the Environmental Medicine Foundation, set up in 1985, 25 also saw the possible consequences. She wrote to Wood, making it clear that, in her opinion, a programme which suggested that there was no hope for allergy sufferers, or those suffering from chemical sensitivity, might lead to people taking their own lives. Film can have great power and for this reason it should be strictly accountable to, and overseen by, independent people.

This is an introductory course designed to provide Studies molecular biology of selected human graduate students with a comprehensive survey of pathogens in detail as examples of virus-induced modern cellular and molecular immunology order 60 mg arcoxia with mastercard. Student evaluation based on mid-term course consists predominantly of lectures but also and fnal exams 120 mg arcoxia free shipping. Discusses bacteriophage An advanced seminar and reading course devoted and baculoviruses and their use in vector biology discount arcoxia 60 mg visa, to the molecular and cellular mechanisms under- as well as viral vectors in gene therapy and anti- lying synaptic transmission and the regulation viral agents. Professor of Molecular Microbiology and The Sub-internship in Adult Neurology is an elec- Immunology tive rotation for students wishing additional expe- J. Faculty from multiple depart- Prerequisite: Basic clerkships in Neurology and ments. This section of the new Genes to Society course An elective clerkship in Pediatric Neurology is integrates content across several clinical disci- offered on both inpatient and outpatient Pediatric plines (neurology, neuropathology, neuroradiology, Neurology services. Examination of the nervous system, formulation of clinical problems, and initial triage and manage- E 5. Pediatrics may be requested as a Neurology peripheral nerve disease and focus for the inpatient ward experience at the East electromyography. All courses are dysfunctions; restless leg syndrome; circadian also open to students of the third and fourth rhythm disorders. Central issues include Cell fate specifcation and differentiation in the mentoring, misconduct in science, preparedness mammalian auditory system. Preparedness for a career in science Nerve muscle interactions in health and disease. Students outside the program Spatiotemporal regulation of protein kinases and may take this course independent of Neuroscience second messengers. This is the second half of a four-quarter course on * Holds primary appointment in Neuroscience; all oth- the cellular and molecular basis of neural function ers hold primary appointments in another department. Lectures will be A weekly lunchtime talk on current literature topics presented by faculty in the Neuroscience, Neurol- of special interest. Graduate students receive close ogy, Biomedical Engineering, Psychology, and faculty guidance in preparing presentations. When reg- Students in the Neuroscience Training Pro- istering for this course, please indicate the course gram are required to complete six elective number for which you will serve as a teaching courses by the end of their second year. This course will consist of lectures and discussions This is the frst half of a four-quarter course on concerning the application of molecular techniques the cellular and molecular basis of neural function in the study of neurologic and psychiatric illness- and the neural basis of perception, cognition, and es. Topics covered in this half include (1) analysis of abnormal genes, protein products and development and structure of the nervous system, neurotoxicity. Neuroscience, Neurology, Biomedical Engineering, Psychology, and Cognitive Science departments. Prerequisite: Completion of Neuroscience Cogni- The course will also include discussion sections tion I or consent of course director. Topics include patterning, differentiation of neurons and gila, mor- guidance mechanisms, target selection, synapto- phogen and growth factor signaling mechanism, genesis, dendritic growth, target derived signals, neuronal polarity, among others. Examples from activity dependent plasticity of synapse formation, vertebrate and invertebrate model systems will be and regeneration, among others. This course is designed to complement vertebrate and invertebrate model systems will be The Cellular and Molecular Basis of Neurodevel- covered. The structure and function of neurotransmitter related dysfunction of the nervous system, and neu- receptors, ion channels and synaptic vesicle pro- rodegenerative disorders such as Alzheimer’s and teins will be discussed. In addition, the molecular Parkinson’s diseases, are becoming major con- mechanisms involved in the control of synaptic cerns in our society. Recent advances in under- transmission such as the trans-synaptic regulation standing the molecular and cellular underpinnings of the function and expression of synaptic proteins of nervous system aging and neurodegenerative will be examined. Three hours per dispose to age-related neurological disorders, and week plus assigned reading. The course Classical studies elucidating the mechanisms of will consist of several introductory lectures and action of psychoactive substances led to seminal subsequent sessions in which hot topics in the feld discoveries about how the brain works. Thus, this course will be directed not only at present papers describing recent advances in this students who study the retina, but also to neurobi- dynamic feld of research. The third part of the course will focus ing critical features of a cell death pathway followed on diseases affecting retinal ganglion cells, focus- by journal review of recently published seminal ing principally on glaucoma, but also covering other papers. Kolodkin, Schramm, and A seminar and reading course devoted to current Sockanathan. Neural coding, the neural representation understanding the generation, logic of neuronal of images and information, and the neural mecha- connectivity in the spinal cord. Previous topics nisms of pattern recognition, association, percep- included an in-depth assessment of the corticospi- tion, memory and attention will be discussed. Future topics will include development and from the literature in each of these areas. First and A seminar and reading course that covers current second quarter every year. Visual, chemical and auditory Fusiform Face Area of the cerebral cortex we have transductions will be covered. It excels at recognizing objects and students not on their memorization of minutiae but substances, reconstructing space, analyzing sound on their understanding of fundamental principles. The neural mechanisms underlying these abilities are studied by a large community of systems and The goal of this course is to train neuroscien- cognitive neuroscientists. This research has gener- tists to effectively and clearly communicate ideas ated a rapidly evolving feld of high-profle discover- about nervous system function to a general audi- ies and lively debates between competing labora- ence. This course aims to convey a clear sense about neuroscience and shall interact with estab- of this feld by focusing on current experimental lished science writers. More importantly, they shall and conceptual controversies regarding organiza- develop, research and write both news and feature- tion and function in the vertebrate nervous system. Enroll- ed by two or more recent papers (selected by an ment limited to 10 students. Directed, independent reading and discussion of This is a seminar and reading course devoted to current neuroscience literature in a personalized the discussion of different type of stem cells. We will cover the basic biology trophic factors and retinoids, light, oxygen and of these stem cells as well as bioengineering and neuromodulators. The third block will be devoted application of these stem cells to potential treat- to photoreceptor physiology, including the visual ments of human diseases. This elective course is cycle, phototransduction, dark adaptation, spectral limited to 20 (25) students sensitivity and color mixture, electroretinography, and rod and cone response dynamics. The next Elective Course Co-Sponsored by Wilmer section, dealing with pathology of photorecep- Eye Institute and the Department of tors and related outer retinal structures, will cover Neuroscience. One The course will present a multidisciplinary approach lecture will be devoted to strategies for the search to the biology and pathology of photoreceptor cells.

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Reinjection and 24H image protocols have been developed to increase the detection of viable myocardium arcoxia 60mg with amex. About 30-50% of fixed defects on 4H redistribution images show reperfusion on reinjection or 24H images cheap arcoxia 60mg free shipping. Detection of coronary artery disease and identification of injured but viable myocardium Assessment of myocardium viability can be done using various single photon and positron labeled imaging agents purchase arcoxia 60 mg fast delivery. The advantages of a single acquisition include patient convenience, shorter length of image acquisition, and perfect registration of the images. Determination of extent of myocardial viability in patients with coronary artery disease. See Patient Preparation for Cardiac Stress Exam under Cardiac Stress Protocols (Section 10. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. See Patient Preparation for Cardiac Stress Exam under Cardiac Stress Protocols (Section 10. See Exercise, Adenosine, and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. Adult Dose: Resting scan: 8-10 mCi (dependent on weight) Stress scan: 25-30 mCi (dependent on weight) 3. See Patient Preparation for Cardiac Stress Exam and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. For patients with a high likelihood of major interference from attenuation artifact (> 280- 300#) due to their body habitus, a two day protocol using 25-30 mCi on each day should be used. See Patient Preparation for Cardiac Stress Exam and Exercise, Adenosine, and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. For logistical reasons, a low-dose stress, high-dose rest procedure can be used as deemed appropriate by the physicians. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. The 24-hour Tl-201 image in dual isotope myocardial perfusion scintigraphy: clinical utility and prognostic significance. See Patient Preparation for Cardiac Stress Exam and Exercise, Adenosine, and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. This procedure is not appropriate for patients with a high likelihood of major interference from attenuation artifact (> 280-300#) due to their body habitus; a two day protocol using 99m 25-30 mCi of a Tc pharmaceutical on each day should be used. See Patient Preparation for Cardiac Stress Exam and Exercise, Adenosine, and Dobutamine Stress Test under Cardiac Stress Protocols (Section 10. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. A rest only (“pain”) study is available 8 am to 10 pm weekdays using Tc if the patient can be injected during chest pain or within 30-40 minutes of pain relief;. If thallium is unavailable late in the day, a low dose stress/high dose rest Tc study is appropriate Weekends and Holidays 1. That physician will be a nuclear medicine physician-in-training (fellow/resident), a nuclear medicine attending, or a cardiology fellow who has been trained in nuclear cardiology (this is a negotiated settlement depending on which fellows are readily available). These patients will need to be assessed by the nuclear cardiology physician-in-training in consultation with the referring physician as to appropriateness before ordering a dose, and that physician is responsible for communicating with the on-call technologist and the physician who will be performing the stress procedure. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. Impact of acute chest pain Tc-99m sestamibi myocardial perfusion imaging on clinical management. See Patient Preparation for Cardiac Stress Exam and Exercise Stress Test under Cardiac Stress Protocols (Section 10. For patients with a high likelihood of major interference from attenuation artifact (> 280- 300#) due to their body habitus, a protocol using 30 mCi should be used. Reconstruct the images, reorient and display images along short axis, vertical long axis and horizontal long axis of the heart. Equipment: Dual head camera with 511 keV ultra high energy collimators Radiopharmaceutical Administration: 99m 99m 1. Time interval between administration and scanning: 60 minutes Patient Preparation: 1. See Patient Preparation for Cardiac Stress Exam under Cardiac Stress Protocols (Section 10. The computer will normalize each raw data group one at a time, correcting for decay, uniformity, and center of rotation. Approximately 90% of acute transmural infarcts will accumulate technetium pyrophosphate at 48 to 72 hours following the acute infarction. Subendocardial acute infarctions may accumulate pyrophosphate only approximately 50% of the time. The thorax is imaged in the anterior, left anterior oblique and left lateral projections at two hours 99m following intravenous administration of Tc pyrophosphate. At 24 hours, approximately 60% of acute transmural infarctions will accumulate pyrophosphate. After two weeks, most acute infarcts will no longer accumulate technetium pyrophosphate. Entities other than acute myocardial infarction have been shown to produce focal increased radionuclide activity: Cardioversion, metastasis, pericarditis with associated myocarditis, contusion, rib fracture, functional breast tissue in premenopausal females, breast tumor, amyloidosis. Patient is brought down to Nuclear Medicine department for the scan or it may be done portable if indicated. Time interval between administration and imaging: 90 minutes or more Patient Preparation: Check that the patient is not pregnant or breast feeding. Position patient under the camera for an anterior view, with a lead disk on tip of sternum. Feed patient before he/she leaves the department and advise re risk of late hypoglycemia. Infuse glc/insulin @ 3 ml/kg/hr for 60 minutes total; waste first 25 ml through tubing. Feed patient upon completion of imaging; warn patient that late hypoglycemia may occur and can be treated with food ingestion. Blood levels of Vit B12 and folate must have been obtained prior to Schilling test. Radiopharmaceutical Administration: 57 Radiopharmaceutical for Stage I: Co-labeled Vit B12 provided in a capsule containing approximately 0. Specimen Collection: Type:urine Amount: 24-hour urine collection Inadequate sample: less than 100 ml Container: urine plastic container for 24-hour urine collection Stable at room temperature for 24 hours after the end of the collection Unacceptable specimen: less than 100 ml Reagents: None Supplies: Plastic container for 24H urine collection Counting tubes Equipment: Gamma well counter Graduated cylinder Red-top tube Calibration: 57 Co standard is obtained from the radiopharmacy and contain 2% of the activity of the dose given to the patient in 1 ml volume.

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J Nat Prod 58 (1995) order 90mg arcoxia overnight delivery, 1024–1031; Wunderer H: Zentral und 40 peripher wirksame Antitussiva: eine kritische Übersicht generic arcoxia 90 mg mastercard. The inhabitants of the 46 47 region have used its leaves as a remedy for bladder and kidney disorders for 48 decades buy arcoxia 60mg on-line. The herb consists of the foliage 1 leaves and stem tips of Orthosiphon aristatus or Orthosiphon spicatus (T. In animal and human studies, the herb was found to have 10 an aquaretic effect (due to the combined effects of saponins and flavo- 11 noids). Its berrylike fruit (cones) have been used for aquaresis 36 and wound healing since ancient times. The herb consists of the ripe, fresh or 39 dried berrylike fruit ofJuniperus communisL. In animals, it was shown to have 46 mild antihypertensive and antiexudative effects. The herb consists of the 7 peeled, cut and dried rhizomes (usually with the root parts removed) ofPip- 8 er methysticum G. Anticonvulsive, neuroprotective, narcosis-enhancing, cen- 14 tral muscle relaxant, spasmolytic, analgesic, and local anesthetic effects 15 were observed in animals. The herb should not be taken for more than 3 20 months without the advice of a qualified health care practitioner. Disorders of complex movement with otherwise 27 unimpaired consciousness are initial signs of overdose, followed by fatigue 28 and a tendency to fall asleep. Kava increases the action of substances that affect 29 the central nervous system, e. A few studies yielded some indication of hepatotoxicity in relation to 31 administration of kava. Though this information is limited to date and still 32 awaits scientific evaluation, it is recommended to consider the following when 33 using kava products. It has a low incidence of side effects and its effects have 47 been relatively well investigated. The herb consists of the fresh or 7 dried foliage leaves of Melissa officinalis L. Proc Soc Exp Bio Med 124 (1995), 869; Mohrig A: 32 Melissenextrakt bei Herpes simplex – die Alternative zu Nucleosid- 33 Analoga. Z Phytother 15 (1994), 299–304; Schimmer O, Mauthner H: Poly- 22 methoxylated xanthones from the herb of Centaurium erythraea with 23 strong antimutagenic properties in Salmonella typhimurim. The herb consists of the dried, unpeeled 32 roots and stolons of Glycyrrhiza glabra L. The herb consists of the liquid de- 34 rived by boiling licorice root in hot water and thickening it by concen- 35 tration under vacuum (licorice juice). No clinical data on the 43 efficacy of licorice preparations in respiratory tract disease are available. Therefore, continuous use of 12 licorice preparations should not exceed 6 weeks and the use of licorice fluid ex- 13 tract and commercial licorice products should be medically supervised. Licorice should be used in combina- 21 tion with other expectorant or secretolytic herbs. The plant was originally native to Europe, but was later in- 33 troduced to North America and northern Asia. Depending on its site of origin, the herb may also contain convalla- 40 toxin (Western and Northwestern Europe) or convalloside (Northern and 41 Eastern Europe) or convallatoxin and convallatoxol (Central Europe). The herb increases the contrac- 44 tile force and velocity of the myocardium while extending the relaxation 45 time. It also reduces the heart rate, slows stimulus conduction, and increas- 46 es the excitability of ventricular muscles (positive inotropic, negative 47 chronotropic, negative dromotropic, and positive bathmotropic effects). Overdose can induce nau- 14 sea, vomiting, headaches, stupor and cardiac arrhythmias and can impair 15 color vision. Planta Med 58 (1992), A682; Laufke R: Planta Med 6 (1958), 237; 31 Loew D: Phytotherapie bei Herzinsuffizienz. Mucilage (10%) con- 42 taining arabinogalactans with a uronic acid component), essential oil 43 (0. The tannins, gly- 47 cosides, and essential oil in linden flower have antimicrobial effects in hu- 48 mans. The inhalation of steam enriched with linden flower extract was 49 more effective in improving the symptoms of uncomplicated colds than the 50 inhalation of steam alone (control group). The tea should be drunk while as hot as possi- 6 ble and is best taken during the afternoon. Because of its 40 irritant effects, individuals with nephritis, lower urinary tract inflammation or 41 decreased renal function should not use the essential oil. In fair-skinned indi- 42 viduals, lovage can cause increased sensitivity to ultraviolet light (phototoxic 43 effect of furanocoumarins). Plant Summaries—M ➤ Dosage and duration of use 1 – Tea: Steep 3–5 g of the herb (ca. The herb consists of the ray flowers 23 of the completely mature flower heads of Calendula officinalis L. Anti-inflammatory and immunostimulatory 15 effects have been shown in animals and in vitro. Deutsche Apotheker Ztg 135 (1995), 1147–1149; Wunderer H: 32 Zentral und peripher wirksame Antitussiva: eine kritische Übersicht. The herb consists of the dried, 38 chopped, peeled, or unpeeled roots of Althaea officinalis L. In animal experiments, the herb was found to 24 have a positive effect on the healing of peptic ulcers and to increase smooth- 25 muscle tone. This, in turn, increases the 16 rate of ribosomal protein synthesis and enhances the regenerative capacity 17 of the liver. Arzneim Forsch/Drug Res 45 (1995), 39 61–64; Tuchweber B et al: J Med 4 (1973), 327. The herb significantly improves the 7 symptoms of chronic joint disease by triggering cutivisceral reflexes and 8 improves the quality of life of cancer patients. Wheal forma- 32 tion and elevated body temperature are considered to be signs of the herb’s 33 immunostimulatory effects. Deutsche Apotheker 39 Ztg 136 (1996), 4330–4332; Beuth J, Lenartz D, Uhlenbruck G: Lektionop- 40 timierter Mistelextrakt. Z Naturforsch C52 (1–2) (1997), 42–44; Schmidt S: Unkonventionelle 46 Heilverfahren in der Tumortherapie. The herb consists of the aerial 4 parts (seeds or foliage leaves) ofTropaeolum majusor therapeutically effec- 5 tive preparations of the same. Isothiocyanates mainly accumulate 15 in and are eliminated via the respiratory air and urine. Prolonged intensive contact with the fresh 32 plant can cause skin irritation, as it has a slight potential for sensitization.

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One hour seminar generic arcoxia 90 mg fast delivery, Fridays buy arcoxia 60mg with visa, to comparative pathobiology of the major organ 12:00; all four quarters arcoxia 60mg cheap. Pathology and pathophysiology themes This is a weekly one hour diagnostic slide confer- that are shared across many species are covered, ence which focuses on the discussion of histologic particularly those relevant to mouse genetic models and electron microscopic examples of unknown and human disease. Participants describe A survey of the use of animals in research with the cases, give differential diagnoses, and discuss emphasis on biologic, nutritional and disease etiology and pathogenesis with the guidance of fac- factors which may interfere with interpretation of ulty members. The course provides a comprehensive, fully integrated coverage of the molecular basis of 260. The course will Opportunities to carry out special studies and emphasize small group learning and problem solv- research in various branches of molecular genetics, ing. The student will participate in “Journal Club”, immunology, and microbiology will be made avail- in which important papers in the front-line biomedi- able not only to candidates for advanced degrees cal literature will be discussed. Arrangements related to basic science concepts will be held at for such work must be made with individual mem- various days and times. The course aims course in Biochemistry or Cell Biology is strongly to expose students to some of the great experi- recommended. Recent topics have included: Ribosome function; molecular mechanisms of protein folding, evolutionary signifcance of introns, translation. Second quarter; 17 lectures; Tues & Growth and differentation factors in mammalian Thurs 9:00-10:30 a. Molecular biology of vision; developmental This short lecture course will cover fundamental neurobiology. Problem sets will be an integral learn- Molecular genetics of tumor suppressor genes ing tool in this course. The lecture portion of this Molecular basis of olfaction; mechanisms of course is repeated as part of Graduate Immunology neurogenesis. Third and fourth quarters, Proteolysis in membrane bilayers; cell signaling every other year. Open to students Prerequisite: Basic knowledge of molecular and who have had Medicine 250. Scheherazade and viral diseases, such as structure, replication, and virus-host cell interactions for the major virus Sadegh-Nasseri. This is an introductory course designed to provide Studies molecular biology of selected human graduate students with a comprehensive survey of pathogens in detail as examples of virus-induced modern cellular and molecular immunology. Student evaluation based on mid-term course consists predominantly of lectures but also and fnal exams. Discusses bacteriophage An advanced seminar and reading course devoted and baculoviruses and their use in vector biology, to the molecular and cellular mechanisms under- as well as viral vectors in gene therapy and anti- lying synaptic transmission and the regulation viral agents. Professor of Molecular Microbiology and The Sub-internship in Adult Neurology is an elec- Immunology tive rotation for students wishing additional expe- J. Faculty from multiple depart- Prerequisite: Basic clerkships in Neurology and ments. This section of the new Genes to Society course An elective clerkship in Pediatric Neurology is integrates content across several clinical disci- offered on both inpatient and outpatient Pediatric plines (neurology, neuropathology, neuroradiology, Neurology services. Examination of the nervous system, formulation of clinical problems, and initial triage and manage- E 5. Pediatrics may be requested as a Neurology peripheral nerve disease and focus for the inpatient ward experience at the East electromyography. All courses are dysfunctions; restless leg syndrome; circadian also open to students of the third and fourth rhythm disorders. Central issues include Cell fate specifcation and differentiation in the mentoring, misconduct in science, preparedness mammalian auditory system. Preparedness for a career in science Nerve muscle interactions in health and disease. Students outside the program Spatiotemporal regulation of protein kinases and may take this course independent of Neuroscience second messengers. This is the second half of a four-quarter course on * Holds primary appointment in Neuroscience; all oth- the cellular and molecular basis of neural function ers hold primary appointments in another department. Lectures will be A weekly lunchtime talk on current literature topics presented by faculty in the Neuroscience, Neurol- of special interest. Graduate students receive close ogy, Biomedical Engineering, Psychology, and faculty guidance in preparing presentations. When reg- Students in the Neuroscience Training Pro- istering for this course, please indicate the course gram are required to complete six elective number for which you will serve as a teaching courses by the end of their second year. This course will consist of lectures and discussions This is the frst half of a four-quarter course on concerning the application of molecular techniques the cellular and molecular basis of neural function in the study of neurologic and psychiatric illness- and the neural basis of perception, cognition, and es. Topics covered in this half include (1) analysis of abnormal genes, protein products and development and structure of the nervous system, neurotoxicity. Neuroscience, Neurology, Biomedical Engineering, Psychology, and Cognitive Science departments. Prerequisite: Completion of Neuroscience Cogni- The course will also include discussion sections tion I or consent of course director. Topics include patterning, differentiation of neurons and gila, mor- guidance mechanisms, target selection, synapto- phogen and growth factor signaling mechanism, genesis, dendritic growth, target derived signals, neuronal polarity, among others. Examples from activity dependent plasticity of synapse formation, vertebrate and invertebrate model systems will be and regeneration, among others. This course is designed to complement vertebrate and invertebrate model systems will be The Cellular and Molecular Basis of Neurodevel- covered. The structure and function of neurotransmitter related dysfunction of the nervous system, and neu- receptors, ion channels and synaptic vesicle pro- rodegenerative disorders such as Alzheimer’s and teins will be discussed. In addition, the molecular Parkinson’s diseases, are becoming major con- mechanisms involved in the control of synaptic cerns in our society. Recent advances in under- transmission such as the trans-synaptic regulation standing the molecular and cellular underpinnings of the function and expression of synaptic proteins of nervous system aging and neurodegenerative will be examined. Three hours per dispose to age-related neurological disorders, and week plus assigned reading. The course Classical studies elucidating the mechanisms of will consist of several introductory lectures and action of psychoactive substances led to seminal subsequent sessions in which hot topics in the feld discoveries about how the brain works. Thus, this course will be directed not only at present papers describing recent advances in this students who study the retina, but also to neurobi- dynamic feld of research. The third part of the course will focus ing critical features of a cell death pathway followed on diseases affecting retinal ganglion cells, focus- by journal review of recently published seminal ing principally on glaucoma, but also covering other papers. Kolodkin, Schramm, and A seminar and reading course devoted to current Sockanathan. Neural coding, the neural representation understanding the generation, logic of neuronal of images and information, and the neural mecha- connectivity in the spinal cord. Previous topics nisms of pattern recognition, association, percep- included an in-depth assessment of the corticospi- tion, memory and attention will be discussed.