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By X. Julio. Medical College of Ohio.

The group treated with acupuncture at distant sites had a significant immediate improvement in motion-related pain and in range of motion order 1mg estrace fast delivery, Complementary and alternative medicine treatment of back and neck pain 293 while the local dry needling showed only a marginally significant immediate improvement in range of motion purchase 2mg estrace fast delivery, with no change in pain. Acupuncture summary Acupuncture is among the most widely studied of the CAM therapies for painful spinal conditions (Table 1). Despite some promising studies showing possible superiority of needle acupuncture over sham treatment such as laser therapy, there is a general opinion amongst scientists reviewing this literature that there remains insufficient evidence to determine its effectiveness for back and neck pain. Owing to the generally poor quality of studies, it has been recommended that future studies of acupuncture should focus on 22 devising and employing an appropriate placebo intervention. Massage Massage is the manual application of force to soft tissues of the body and uses a number of different techniques ranging from gentle rubbing of the skin (effleurage) to very vigorous forms of kneading of the deep tissues, as performed in Swedish massage. Additionally, some forms of massage (such as shiatsu) may be applied according to principles of meridianbased therapy, akin to acupuncture. With the exception of one 23 study that reported that acupuncture-based massage was better than Swedish massage, there is insufficient evidence to assess the value of one form of massage from another. Massage for back pain 24 A recent systematic review evaluated eight randomized clinical trials of massage compared to several other forms of treatment for low back pain. The authors reported that overall, massage was superior to sham treatment, relaxation treatment, acupuncture and selfcare, and similar in effect to corsets and exercise therapy. Although the duration of observed effects was short in most of these studies, one study reported relative improvement at the 17 24 1-year follow-up. The conclusion of this systematic review was that massage might be beneficial for subacute and chronic low back pain. In some of the more promising trials, massage was particularly beneficial when combined with exercise and patient education, though the effect of each intervention could not be assessed. Two recent studies of massage for low back pain were not included in this systematic 25 review. Predye randomized 98 patients with subacute low back pain (1 week to 8 months) to massage plus exercise, massage alone, exercise alone, or sham laser treatment. There were six treatments delivered over 1 month, with outcome measures (pain, function and range of motion) assessed at the conclusion of treatment and 1 month later. Both of the massage groups performed significantly better than the sham laser group, and the massage-only group was better than the exercise-only group at the end of treatment on the disability score (but not in terms of pain). As reported in other studies, the combination of massage and exercise was significantly better than either therapy alone. Complementary therapies in neurology 294 17 In a study by Cherkin and colleagues 262 patients with chronic low back pain were randomized in a managed-care setting to acupuncture, massage, or self-care educational materials. Patients were permitted to receive up to ten treatments of acupuncture or massage over 10 weeks. The main outcome measures included subjective symptom rating, overall health (SF-12), and disability (Roland Morris Disability Scale). After 10 weeks, massage was superior to self-care in terms of symptoms and disability and superior to acupuncture in terms on disability. At the 1-year follow-up, massage remained superior to acupuncture but not self-care. For patients assigned to the massage treatment group, the cost of subsequent care administered by the managed care organization was 30. The authors also included a measure of satisfaction and reported that 74% of patients rated massage as very helpful, compared with 46% for acupuncture, 17% for the self-education book and 26% for the self-education video. Massage for neck pain There has been only one randomized clinical trial that specifically examined the 19 effectiveness of massage for neck pain. This study randomized 177 patients with neck pain to short courses of treatment with massage, needle acupuncture, or laser acupuncture. The group treated with acupuncture had slightly lower pain levels than both of the other groups 1 week post-treatment, though these differences disappeared after 3 months. Furthermore, the group treated with massage was no different from the group treated with laser acupuncture at any time point. Massage summary The literature does provide some evidence that massage therapy may be beneficial for lower back pain at least in the short-term, and especially when combined with exercise and self-care education. Although massage therapy remains a widely used CAM therapy for neck pain, there is currently insufficient evidence in the literature for a proper assessment of its efficacy for this condition. Mobilization Mobilization refers to the use of low-velocity mechanical or manual force that is applied to increase the mobility of a particular area, whether of a single joint (specific mobilization) or an entire body region, such as the neck or lumbar spine. There are several types of mobilization procedures that may differ in terms of the amount of force applied (very gentle versus rigorous), the frequency or length of application, the specific methods employed to produce the motion (small oscillations versus large movements), and their specific goal (neuromuscular rehabilitation versus breaking up of chronic fibrous adhesions).

All of the subjects were completely independent in personal care and household management generic 2 mg estrace with visa, and were well integrated into the community purchase 2 mg estrace visa. One subject played for the symphony and was out on medical disability, one subject played for a travelling performance group but was working at a desk job when physical therapy was initiated, and the third subject was a full time music student who was home for two quarters and was working part time as a waitress. All subjects participated in measurements pre and post treatment including magnetoencephalography and clinical testing as described in Experiments I and II22 (Byl et al. Consequently, the total period of treatment as well as the number of visits with a physical therapist varied across subjects (23 visits for subject #1, 19 visits for subject # 2, and 23 visits for subject #3). At baseline, somatosensory evoked responses were similar on the right and left sides for controls except the spread of the digits on the dominant hand were greater than the nondominant hand on the z-axis. On both hands, the order and location of the digits on the z-axes followed a predictable pattern with D2-D5 progressing from inferior to superior. For the subjects with FHd, both the amplitude and the spread of the digits on the x,y, and z axes were reduced on the affected side compared to the unaffected side and the digits were not sequentially organized from inferior to superior for D1-D5 on the z axis on either side. Compared to controls, the FHd subjects had a shorter SEF latency, the neuronal burst was higher on the affected and unaffected sides for subjects #1 and #3, and the amplitude was lower in the early phase (30–70 msec) for subjects #2 and # 3. The location of the hand repre- sentation on the x, y, and z axes were different for FHd subjects and controls. Bilaterally, the spread of the digits on the x, y, and z-axes was greater for the subjects with FHd (who were all musicians) than the controls. In general, the reference controls achieved comparable clinical performance bilaterally and across digits except motor reaction time was slower for digits 4 and 5. The controls did have some postural asymmetry and indicated their health some- times interfered with daily activities (scoring 89. On the other hand, at baseline, the subjects with FHd demonstrated reduced accuracy and slowing in sensory processing compared to controls on both the affected and unaffected sides. On the motor performance tests, subjects #1 and #3 performed with reduced motor accuracy on both sides with prolonged processing time. On the affected side, Task Specific Motor Control Scores were approximately 50% of that measured on the unaffected side. Subjects #2 and #3 had limited finger spread between D3–D4 and D4–D5 on the affected side (25 degrees on the affected side compared to 35–45 degrees on the unaffected side). Compared to controls, the subjects with FHd were more likely to have poor posture, positive signs of neurovascular entrapment and decreased strength in the lumbricals (on both sides). Two of the subjects with FHd also had limited shoulder internal rotation bilaterally (45–55º). The subjects with FHd were not working at their usual © 2005 by Taylor & Francis Group. They reported difficulty with functional activities (ranging from 63–90% of maximum performance on the functional independence test). However, for the three subjects with FHd, there was a general increase in the spread of the digits and the area of representation on the cortex on the trained side (larger than control subjects). The order of the digits (D1–D5) on the affected side approximated an inferior to superior progression from D1 to D5, but they were still less orderly than controls. The amplitude of the evoked somatosensory potential, integrated over time, was increased and similar to controls on the affected side. On the clinical tests, the subjects with FHd performed between 80–90% on the target task. Motor reaction time did not change significantly on either the affected or unaffected side but was similar to controls. The subjects with FHd improved in motor accuracy 27–42%, performing at similar accuracy as controls, however, the time needed to complete the task was still longer than controls. There were mea- surable improvements in accuracy on all of the sensory tests (25–50%), performing similarly or better than controls. However, the time required to perform the tests remained longer than controls for two of the subjects.

This Blood alcohol concentration (mg/dL) after the consumption stimulation is expressed as decreased social and psycho- of various amounts of alcohol (for an adult of about 150 lb) estrace 2 mg for sale. The behavioral and physiological ef- tance in the metabolism of ethanol in humans cheap estrace 2 mg otc, it may be fects are associated with different blood ethanol concen- involved in some of the reported interactions between trations. As the blood ethanol concentration begins to in- ethanol and other drugs that are also metabolized by crease, behavioral activation, characterized by euphoria, this system. Microsomal mixed-function oxidases may talkativeness, aggressiveness, and loss of behavioral con- be induced by chronic ethanol ingestion. Because trol, generally precedes the overt CNS depression in- ethanol is metabolized in the liver, it can interfere with duced by ethanol. At progressively higher blood ethanol the metabolism of other drugs by blocking microsomal concentrations, the stage of relaxation is transformed hydroxylation and demethylation. Drug classes whose into decreased social inhibitions, slurred speech, ataxia, metabolism is most affected include the barbiturates, decreased mental acuity, decreased reflexive responses, coumarins, and anticonvulsants, such as phenytoin. Liver damage resulting from chronic abuse of ethanol In moderation, however, there is no evidence that the ju- can impair metabolism of a variety of drugs. Other Body Systems The ethanol content in the urine is normally about 130% of the blood concentration and is quite constant; In general, ethanol in low to moderate amounts, is rela- the expired air contains about 0. A moderate amount ethanol level, a concentration that also is remarkably of ethanol causes peripheral vasodilation, especially of consistent. On the other hand, ethanol consumption in high Mechanism of Action concentrations, as found in undiluted spirits, can induce A great deal of attention has been focused on a class of hemorrhagic lesions in the duodenum, inhibit intestinal proteins termed the ligand-gated ion channels as being brush border enzymes, inhibit the uptake of amino important to the mechanism of action of alcohol. This flux of ions largely determines the degree of ability to inhibit secretion of antidiuretic hormone from neuronal activity. Two distinct types of ligand-gated the posterior pituitary, which leads to a reduction in re- ion channels are particularly sensitive to concentrations nal tubular water reabsorption. Ethanol produces a number of depressant effects on Ethanol intoxication is probably the best-known form the myocardium. A seri- themselves and others, particularly if they attempt to ous clinical entity, alcoholic cardiomyopathy, has also drive or operate machinery. Ethanol intoxi- hibition of gastric secretion and irritation of the gastric cation is sometimes mistakenly diagnosed as diabetic mucosa. Ethanol irritates the entire gastrointestinal coma, schizophrenia, overdosage of other CNS depres- tract, which may lead to constipation and diminished sant drugs, or skull fracture. Other pathological effects in- monly associated with excessive ethanol consumption is clude pancreatitis and peripheral neuropathy. Hypothermia gonadal failure is often found in both men and women, frequently results, with body temperature falling toward accompanied by low blood levels of sex hormones. This problem can be A variety of pathological problems involving the particularly severe in the elderly, who normally have CNS have been described in chronic alcoholics, the difficulty regulating their body temperature. Brain damage from chronic the hangover, a condition characterized by headache, ethanol consumption can be especially severe in the nausea, sweating, and tremor. The fetal alcohol syndrome has three primary features: microcephaly, prenatal growth Treatment for Acute Intoxication deficiency, and short palpebral fissures. Other character- Generally, no treatment is required for acute ethanol in- istics include postnatal growth deficiency, fine motor toxication. Allowing the individual to sleep off the ef- dysfunction, cardiac defects, and anomalies of the exter- fects of ethanol ingestion is the usual procedure. A definite risk of producing Hangovers are treated similarly; that is, no effective fetal abnormalities occurs when ethanol consumption remedy exists for a hangover, except for controlling the by the mother exceeds 3 oz daily, the equivalent of amount of ethanol consumed. For example, prompt treat- ment is required if the patient is in danger of dying of Treatment for Alcoholism respiratory arrest, is comatose, has dilated pupils, is hy- pothermic, or displays tachycardia. The immediate concern in the treatment of alcoholics is Treatment for severe ethanol overdose is generally detoxification and management of the ethanol with- supportive. Once the patient is detoxified, long- lieved by intravenous administration of hypertonic term treatment requires complete abstinence, psychiatric mannitol. Hemodialysis can accelerate the removal of treatment, family involvement, and frequently support ethanol from the body. If ethanol is taken after disulfiram administration, blood acetalde- hyde concentrations increase 5 to 10 times, resulting in Alcoholism vasodilation, pulsating headache, nausea, vomiting, se- Alcoholism is among the major health problems in most vere thirst, respiratory difficulties, chest pains, orthosta- countries. In certain tive drugs, is expressed as drug-seeking behavior and is cases, marked respiratory depression, cardiac arrhyth- associated with a withdrawal syndrome that occurs after mias, cardiovascular collapse, myocardial infarction, abrupt cessation of drinking.

Another way is to incorporate the clinical knowledge directly into the clinical information system used by clinicians while giving care discount estrace 1mg mastercard. Once it is there 1mg estrace with visa, the CIS system can automatically prompt the clinician or the clinician can request help. Recently, a third model for system development has been proposed that enables the clinician to request help from an outside source. Using such a system, a clinician is still completely in-charge of making the request for information and the information can be automatically configured based on a sub-set of patient information (Cimino, 1996). The following diagram (Figure 1) is an attempt to illustrate both the key types of information or knowledge that investigators have focused on along with their mode of interaction [i. The boxes (yellow) represent the type of knowledge and the labels on the links (green) represent some of the key projects or concepts vendors have focused on this particular Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. The aim of this figure is to highlight the myriad attempts that have been made to develop clinical knowledge management applications and to help everyone understand how different clinical knowledge resources and applications are both related in terms of what they are trying to accomplish and different in the resources they utilize. Although this diagram is fairly complex, it is only a small, imperfect and incomplete representation of the entire clinical decision support landscape. The first section focuses on “library-type” applications that enable a clinician to look up information in an electronic document. The second section describes a myriad of “real-time clinical decision support systems”. These systems generally deliver clinical guidance to clini- cians at the point of care within the CIS. The third section describes several “hybrid” systems, which combine aspects of knowledge-based clinical decision support systems with library-type information. Finally, section four looks at various attempts to bring clinical knowledge in the form of computable guidelines to the point of care. Library-Type Applications: Front-Ends to Applications That Directly Interact with Clinicians Bibliographic Databases (DBs) Biomedical bibliographic databases contain on the order of millions of records, each representing a unique scientific journal article that has been published. Each record typically contains the title of the article, the authors, their affiliation(s), and the abstract of the article. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. An Overview of Efforts to Bring Clinical Knowledge to the Point of Care 289 For the last 30 years, the National Library of Medicine has maintained the MedLine database, the most common bibliographic database used in clinical medicine. During that period, various attempts have been made to develop easy to use and reliable interfaces to this vast resource including Grateful Med (Cahan, 1989) and COACH (Kingsland, 1993). PubMed relies on a sophisticated free-text query processor to map freetext user queries to MeSH terms, when appropriate, and returns a highly relevant set of documents. For example, Ovid has developed an interesting MeSH mapper and query expander that has gathered outstanding reviews from highly trained librarians. Knowl- edge Finder has developed a fuzzy mapping algorithm that has also generated some good reviews. Unfortunately, none of these systems consistently enables clinicians to retrieve more than half of all the relevant articles on any particular topic (Hersh, 1998). In addition to these variations on a search interface, several projects have used automated differ- ential diagnosis generators, such as DxPlain, as an interface to the bibliographic DBs. Finally, the Science Citation Index uses the reference list at the end of every scientific article published to generate linked lists of references. Such a scheme can also identify particularly noteworthy articles since these articles are referenced many more times. Interestingly, the Google search engine uses this same concept to generate its index of relevant web sites. It does this by keeping track of the number and quality of referring web sites rather than references at the end of the article (Brin, 1998). Other Clinical Reference Materials In addition to access to the bibliographic literature, clinicians could use other clinical reference information.

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