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By S. Ketil. Saybrook Graduate School and Research Center. 2018.

The effects of Implantation estrogens and progesterone on breast development are The lining of the uterus 10 ml astelin mastercard, that is order 10 ml astelin visa, the endometrium, is crit- most noticeable during puberty and pregnancy. The en- Estrogens can stimulate the release of growth hor- dometrium consists of a layer of epithelial cells overly- mone and exert a positive effect on nitrogen balance. Under the These effects contribute to the growth spurt during pu- influence of estrogen and progesterone, the endome- berty. Closure of the bone epiphyses signaling the end trium undergoes cyclical changes that prepare it for the of long bone growth is also estrogen mediated. Estrogens to high concentrations of progesterone and moderate maintain bone mass by inhibiting bone resorption by estradiol levels, the mitotic activity in the endometrial the osteoclasts. The action of progesterone on the tokines by peripheral blood cells and the osteoblasts endometrium converts it from a proliferative state to a that stimulate osteoclast activity. The epithelial cell structure assumes a women, declining estrogen levels give rise to a net in- more glandular appearance. Vascularization of the crease in osteoclast activity and loss of bone mass re- stroma increases, and some stromal cells begin to look sulting in the serious condition osteoporosis. Estriol is produced in high concentrations by Other Actions of Estrogens the placenta in pregnant women. The high levels of estrogens and progesterone associ- Under the influence of high levels of estrogen or pro- ated with pregnancy may alter liver function and glu- gesterone, the physicochemical composition of cervical cose metabolism. High circulating levels of estrogen can mucus may reduce sperm motility and provide a barrier cause mild glucose intolerance. Modifications at positions the formation of high-density lipoproteins and reducing C6 and C7 increase their progestational activity. Reductions in serum albumin Examples of these synthetic progestins include me- and antithrombin III synthesis can occur in the pres- droxyprogesterone and megestrol acetate (Megace). These compounds are metabolized in the same manner In males, estrogens stimulate the growth of the stro- as progesterone and are excreted in the urine. SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMs) SYNTHETIC AGENTS ACTING VIA ESTROGEN AND PROGESTERONE Selective ER modulators (SERMs) are nonhormonal RECEPTORS pharmacological agents that bind to ERs. A characteris- tic feature of the SERMs is that a given agent will act as Long-acting semisynthetic estrogens and progestins an estrogen agonist in one or more tissues and as an es- contain esterified lipophilic substituents. Esterification trogen antagonist in one or more other estrogen target of steroids prolongs their release from depot injection organs. Medroxyprogesterone acetate (Amen, Cyctin, rate (Clomid, Serophene) and raloxifene (Evista) are Provera, Depo-Provera) is a widely used long-acting examples of nonsteroidal SERMs. SERM is tamoxifen citrate, a drug formerly character- Synthetic steroid hormones retain the common ized as an antiestrogen. The two most thus is used as a treatment and chemopreventative for widely used synthetic steroid estrogens are ethinyl estra- breast cancer. Tamoxifen is a full agonist in bone and diol (Estinyl) and mestranol, found in oral contracep- endometrium, and prolonged use of tamoxifen leads to tives. Synthetic steroids containing an ethinyl substitution a fourfold to fivefold increase in the incidence of en- are metabolized more slowly. See Chapter 56 for a detailed discus- hormones have better oral absorption properties and ex- sion of the use of tamoxifen in breast cancer. Raloxifene (Evista) is a new SERM approved for Approximately 50% of a dose of mestranol is de- use in the treatment and prevention of osteoporosis be- methylated to form ethinyl estradiol. Subsequently, the metabo- estrogen antagonist in both breast and endometrial tis- lism of these two synthetic estrogens proceeds by means sues. The estrogenlike properties of raloxifene result in of the same pathways as the natural steroid hormones. Absorp- thetic steroid estrogens, in contrast to the natural estro- tion of raloxifene is impaired by cholestyramine. Tamoxifen, clomiphene, and raloxifene are orally ac- One chemical class of synthetic progestins is derived tive. The primary route of excretion of all three drugs is from testosterone and is referred to as the 19-nortestos- in the feces.

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Because scales such as the SHSS:C and the HGSHS:A can take over an hour to administer astelin 10 ml for sale, faster measures of hypnotic ability have been devised for 24 clinical assessment astelin 10 ml, such as the Stanford Hypnotic Clinical Scale, which requires approximately 20 min to complete. Explaining individual differences One way of understanding these individual differences in hypnotizability is to assume 25–27 that they reflect essential differences in trait-like cognitive ability. Support for this view comes from twin studies which 28 show a significant heritability index for hypnotizability. Thus, hypnotic responsiveness is primarily a product of culturally mediated attitudes and expectations which render the individual either more, or less, likely to enact 29 the role of hypnotic subject. An especially strong version of the expectancy theory argues that expectations are possibly the most important determinant of hypnotic responding. The authors interpreted their findings as supporting the notion that hypnotic susceptibility is primarily determined by response expectancy prior to and during the initial hypnosis experience. However, the results of two separate studies 31 conducted in our own laboratory failed to replicate these findings. In other words, the manipulation of response expectancy had no measurable effect on hypnotic responsiveness. This is not to say that expectancies play no role in determining the quality of hypnotic response, or that 32 clinical patients might not benefit from a preliminary training or instruction procedure, just as new psychotherapy patients benefit from preliminary information about the nature 33 of psychotherapy. Sociocognitive theorists commonly see hypnosis not as a function of altered mental states, but as a complex social interaction influenced by expectations, motivations and social demands. They support this position by demonstrating that many hypnotic responses can be elicited without the use of an induction. With the development of brain Complementary therapies in neurology 208 imaging techniques, researchers have increasingly been interested in demonstrating neurological signatures for hypnosis as an altered state. HYPNOSIS AND THE BRAIN With the advent of the electroencephalogram (EEG) in the 1920s, researchers soon had a tool with which to measure hypnosis-related changes in the cortical activity of the brain. More recent development of brain imaging techniques such as positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) have led to exciting new avenues of research related to hypnosis and the brain. In studying the physiological substrates of hypnosis, there are three main lines of attack. The second, perhaps more in line with Charcot, is to demonstrate baseline differences between people of varying hypnotic ability, that is, to show that the capacity for responding to hypnotic suggestions is reflected in the brain even before hypnosis. Some have argued that hypnosis is not a cohesive state, that at any moment a subject may be experiencing a direct motor suggestion, a challenge suggestion, a suggestion for a 8 positive or negative hallucination, or perhaps amnesia. Brain activity changes associated with the state of hypnosis If, as many researchers believe, the hypnotic induction produces a readiness to accept and respond to hypnotic suggestions, one should be able to observe changes in brain activity from the waking state as a result of the hypnotic induction. Given the historical and behavioral associations between hypnosis and sleep, researchers initially tried to 35 demonstrate similarities between sleep and hypnosis EEG recordings. After many unsuccessful attempts, researchers began to look for distinguishable traces in the various EEG bandwidths that would differentiate hypnosis from the waking state. Research on this topic has been continuing ever since, although consistent findings remain ephemeral. For some time, researchers associated increased alpha activity (8–13 Hz) with hypnosis, 36 but later reviews showed methodological problems with many of these initial studies. Though less common, some researchers have successfully differentiated hypnosis from the 39,40 waking state through PET techniques. Results from this line of research have shown that changes in regional cerebral blood flow (rCBF) in sensory and motor cortical areas, Hypnosis 209 the anterior cingulated cortex (ACC), brainstem and thalamus contribute to the experience of being hypnotized. Brain activity differences associated with hypnotic ability With improved measures of hypnotic responsiveness, researchers have increasingly favored examinations of the relationship between brain functioning and hypnotizability. Thus, rather than attempting to identify qualitative and quantitative shifts in brain activity as a result of the hypnotic state, they have focused on demonstrating differences in brain activity between subjects of varying levels of hypnotic susceptibility. In light of this, it has been argued that brain imaging studies of hypnosis should focus less on the state of hypnosis as a whole and more on the examination of physiological changes associated with specific hypnotic 8 suggestions. In one such study investigating hypnotically suggested positive auditory hallucinations, researchers demonstrated that, when subjects heard a sentence or hypnotically hallucinated hearing the sentence, their brain activity was quite different 45 from that during quiet baseline or when simply imagining the words being spoken. As subjects heard the real recording, and during the hypnotic hallucination of the recorded message, increased activation of a region in the right anterior cingulate was shown. Highly hypnotizable subjects were presented with a colored and a gray-scale pattern.

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Wyatt & Spiegelhalter (1991) describes a medical decision support system as a computer-based system using gathered explicit knowledge to generate patient specific advice or interpretation astelin 10 ml without prescription. The healthcare industry has witnessed a phenomenal growth and advances both in the areas of practice and research astelin 10 ml low price. This rapid growth of medical science has made the practice of medicine both challenging and complex. To address these challenges, the recognized medical standards organiza- tions developed medical practice guidelines to simplify the research findings to practical applications in order to improve the overall healthcare quality and delivery. Despite such initiatives, it has been difficult for the physicians to keep up with the guidelines and to tune it to their practice settings. A clear gap began to develop between developing of practice guidelines and the implementation of the same. Grimshaw and Russell (1993) identified that the knowledge dissemination and implementation strategies are critical to the impact the developed guidelines will have on the physician behavior. The natural evolution was to develop paper-based decision support workflow or protocols. Paper-based decision support models were developed and are widely used at most physician practices to apply the guidelines into practice. For example, dose recommendation models could require tedious calculations and can be error prone when performed manually. Also, paper-based models require education and training to the personnel performing those calculation and require an additional layer to review the calculations. Most paper-based models are used by the medical personnel as a batch work flow process. Thus computer-based decision support systems were developed to provide accurate guideline compliance and to enhance physician performance (Hunt, Haynes, Hanna, & Smith, 1998). Computerized decision support system can be extremely valuable for treatment or diagnosis support and compliance accuracy when used at the point of care (Lobach & Hammond, 1997). This feature of computerized medical decision support system is a key differentiator that makes the paper-based decision support models inferior. A well designed computerized medical decision support system can be used to provide patient specific support at the desired time and location with the adequate content and pace. When decision support systems are blended into the day-to-day practice workflow, these systems have the potential to function as a valuable assistant and also as an educational tool (Thomas, Dayton, & Peterson, 1999). The computerized decision support systems make decisions based on the clinical practice guidelines. Clinical practice guidelines are the rule-based knowledge that guides the decision makers in a medical setting. These guidelines have been developed over the years to reduce the variations among medical practices with a common goal to provide cost effective and high quality healthcare services (Field & Lohr, 1992). The availability of several decision support systems and the use of common knowledge and rules triggered the need for a common method of sharing the knowledge. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. While it is common among organizations to share the data and information between computer systems, sharing the knowledge was a challenge. The medical arena rose to the occasion and various associations were involved in development of a standard way of sharing the medical knowledge and clinical practice guidelines among systems. After reading this chapter, the reader should be able to: • Understand the complexity involved in medical decision making process • Identify the commonly used decision support techniques in medical decision support systems • Identify the characteristics of medical decision support systems • Identify the various phases of the decision making process • Identify the components involved in the development of a medical decision support system • Analyze the various decision support functions addressed by medical decision support systems • Know about the popular medical decision support systems in use around the world • Understand the importance of knowledge sharing standards in the medical deci- sion support arena • Know about the popular medical knowledge sharing standards • Understand the future trends in decision support in the field of medicine Background The invention of computers resulted from the dream of creating an electronic brain. This quest to artificial intelligence has driven several technological advances in various industries. The potential of intelligence and decision support in the area of medicine was set forth more than four decades ago by Lusted and Ledley (1959). While several computer systems have been developed to improve the administrative efficiency and medical records access, the significant challenges have always been in the development of medical decision support systems. Knowledge-based decision support systems acquire, formalize, and store the expert knowledge in a computer system and infer the represented knowledge in a problem area by modeling the decision process of experts. This expert system called MYCIN, provides decision support to physicians on treatment related advices for bacterial infections of the blood and meningitis.

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Chemically defined or elemental formulas provide the macronutrients in the predi- gested state cheap 10 ml astelin free shipping. Pa- tients with compromised nutrient absorption abilities or GI function may benefit from elemental type feedings generic 10 ml astelin with visa. Disease-specific (special metabolic) enteral formulas have been developed for various disease states. Products for pulmonary patients, such as Pulmocare, contain a higher per- centage of calories from fat to decrease the carbon dioxide load from the metabolism of ex- cess glucose. Patients with hepatic insufficiency may benefit from formulations (eg, Hepatic-Aid II) containing a higher concentration of the branched-chain amino acids and a lower concentration of aromatic amino acids in an attempt to correct their altered serum amino acid profile. Formulas containing only essential amino acids have been marketed for the patient in renal failure (Amin-Aid). A low-carbohydrate, high-fat product for persons with diabetes (Glucerna) is available that also contains fiber to help regulate glucose control. Other fiber-containing enteral feedings are available to help regulate bowel function (En- rich, Jevity). Initiating Tube Feedings Guidelines for ordering enteral feedings are outlined in Table 11–5, page 218. Determine fluid requirements and volume tolerance based on overall status and concur- rent disease states. Monitor and assess nutritional status to evaluate the need for changes in the selected 11 regimen. The tube feeding can be given into the stomach (bolus, intermittent gravity drip, or continu- ous) or into the small intestine by continuous infusion (Table 11–6, page 219). Enteral nutri- tion is best tolerated when instilled into the stomach because this method produces fewer problems with osmolarity or feeding volumes. The stomach serves as a barrier to hyperos- molarity, thus the use of isotonic feedings is mandated only when instilling nutrients di- rectly into the small intestine. The use of gastric feedings is thus preferable and should be used whenever appropriate. Patients at risk for aspiration or with impaired gastric emptying may need to be fed past the pylorus into the jejunum or the duodenum. Feedings via a je- junostomy placed at the time of surgery can often be initiated on the first postoperative day, obviating the need for parenteral nutrition. Although enteral nutrition is generally safer than parenteral nutrition, aspiration can be a significant morbid event in the care of these patients. Appropriate monitoring for residual volumes in addition to keeping the head of the bed elevated can help prevent this complica- tion. Any transient postoperative ileus can best be treated by waiting for the ileus to resolve. Metoclopramide or erythromycin may be useful pharmacologic ther- apy for postop ileus (Chapter 22). Patients who have been tolerating feedings and develop intolerance should be carefully assessed for the cause. Feeding intolerance is characterized by vomiting, abdominal distention, diarrhea, or high gastric residual volumes. Complications of Enteral Nutrition Diarrhea: Diarrhea occurs in about 10–60% of patients receiving enteral feedings. The physician must be certain to evaluate the patient for other causes of diarrhea. Formula- related causes include contamination, excessively cold temperature, lactose intolerance, os- molality, and an incorrect method or route of delivery. Constipation: Although less common than diarrhea, constipation can occur in the enter- ally fed patient. Patients with ad- ditional requirements may benefit from water boluses or dilution of the enteral formulation.

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