By X. Ernesto. Unity College.

Improvement in fibro- the application of treatment to the various orifices of nectin synthesis with both local and hepatic treatment the body buy nizoral 200mg on line. It will be seen that the majority of the appli- has shown a positive influence in postsurgical healing cations involve infectious processes and those that do times (Arghiropol et al 1992) buy 200mg nizoral mastercard. Beneficial application Chapter 12 • Electrotherapy Modalities 549 Interestingly, pulsed diathermy applied to metastasiz- ing melanoma cell cultures demonstrated increased cell death for a period of 4 minutes after exposure (Hakkinen et al 1975). It is one of the oldest physiotherapy devices and has been in use since the end of the 19th century. High frequency is essentially a modified Tesla coil that produces a high frequency, high voltage current at low amperage. The rapidly oscillating currents are applied to the body through vacuum glass electrodes. As the current for non-union fracture healing is substantiated by the moves through the electrode, the partially vacuumed observed positive influence on osteoblast differentia- atmosphere inside the glass ionizes and assumes color tion (Lohmann et al 2000) and a positive influence on dependent upon the degree of vacuum. This result is substantiated common color is violet and the units are commonly by research on liver enzymes that shows a beneficial referred to as ‘violet ray’ devices. Mechanism of action and physiological effects Naturopathic indications and When the electrode is applied to the body it induces applications: validation of efficacy = 2 a local current in tissues and creates a local heating The late naturopathic physician Dr Poesnecker effect as the tissues resist the current flow. The described clinical application of pulsed short wave increased resistance promotes increased tissue per- therapy using an indirect approach to enhance organ fusion locally. His treatment was body by thin gauze, electrical sparks will shower directed to hepatic, splenic, renal and adrenal tissue, the skin with a resulting counterirritation effect. If with the goal of enhancing organ metabolism and the electrode current is concentrated into a point it detoxification. He applied this indirect approach in can be used for fulguration and is the current used chronic disorders such as chronic fatigue syndrome in hyfrecation. The effects on tissue have been the higher pulse rates, which have less thermal dis- described as a ‘cellular massage’ (Hewlett-Parsons persion due to the increased frequency, for acute 1968). It: et al 2005 Trock et al 1994) and chronic tinnitus, and inconsistent results are found with ankle sprains. Ben- • increases oxidation and local nutrition eficial observation in neural tissue repair has been (Matijaca 1919b) reported consistently in animal models (Raji 1984, Raji • produces hyperemia and stimulates circulation et al 1983, Sisken et al 1989). A study on Guillain–Barré in areas to which it is applied (this hyperemia syndrome demonstrated enhanced neurological tissue is believed to last from 10 to 24 hours) healing with pulsed short wave (Gorbunov et al 1995). Subsequently we will not rely on his- • increases the temperature where applied torical manufacturers’ recommendations and restrict • is topically germicidal, encourages leukocytosis ourselves to independent sources. The effect of the current is considered lubricants as the sparks may potentially cause igni- soothing and able to reduce inflammation (Boyle 1988, tion. Naturotherapy 1937c, Scott 1990), trachoma (Post- Graduate Study of Naturotherapy 1939b), arthritis Indications: validation of efficacy = 2 (Post-Graduate Study of Naturotherapy 1939c), mus- cular spasm, torticollis, low back pain, rheumatoid Contemporary conventional application of high- arthritis (Post-Graduate Study of Naturotherapy frequency current is primarily limited to dermatalogi- 1939b), peritonitis, pelvic adhesions, ovarian neural- cal diseases such as acne and atopic dermatitis, for gia, tic douloureux, neuritis, neuralgia, migraine, which it is considered safe and effective. Extensive therapeutic applica- apy 1938d), menstrual cramping, muscle tears, local- tions were recommended historically by manufactur- ized pain, fibroids, ovarian cysts (Blake 2006), ers of the units until prosecution in the 1950s in the bronchitis and nephritis (Scott 1990). The current is delivered using adhesive electrode pads or graphite- conducting fabric. An ampere is the rate of movement of electrons past a point in space and one millionth of an ampere is a microamp (μA). The body itself gener- ates microamperage current in every cell and mem- brane as part of its normal physiological activity. This current flow creates the polarity observed by Becker in the human system in which the body is polarized Figure 12. Photograph courtesy of more positively at the head, negatively at the feet, Silhouet-Tone more positive centrally and more negative distally Chapter 12 • Electrotherapy Modalities 551 of unmodulated direct current or non-specific fre- quency choices. The frequencies were resurrected from lists of frequencies used with wall current elec- trotherapy modalities used from 1914 to 1937. While published clinical outcomes and some preliminary animal research have been performed in order to sep- arate the effects of the microcurrent alone from any additional frequency-specific effect, further research is necessary. The research needed to separate the effects of the current alone from the additional effects of the frequency response is an area of interest but published clinical outcomes and some preliminary animal research are promising. Validation of efficacy = 4 Microcurrent has documented effects in increasing wound, tissue and fracture healing, decreasing pain Figure 12. Photograph courtesy of International and edema and treating myofascial trigger points and Medical Electronics neuropathic pain. Most microcurrent devices • Thirty hospital patients with non-healing ulcers are battery operated but some are plugged into a wall were divided into two groups, one treated with current source and current levels are stepped down to conventional wound dressings and one with microamperage. The Microcurrent creates its effects by delivering current latter group was given two 2-hour stimulation within a normal physiological range, making it par- periods per day. After 6 weeks of such ticularly consistent with naturopathic principles and treatments, the group treated with appropriate to a naturopathic practice. Most electrotherapy of wounds, using negative polarity over the devices deliver current in the milliamp range, or thou- lesions in the initial phase, and then alternating sandths of amps, to create their therapeutic effect.

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Nicardipine is a dihydropyridine calcium channel blocker with coronary and systemic vasodilatory effects cheap 200 mg nizoral visa. It does not cause heart block nizoral 200mg online, and can be used in most types of hypertensive emergencies, and is safe in pregnancy. It lowers blood pressure by arterial vasodilatation, renal vasodilatation and natriuresis. Hydralazine is an arterial vasodilator, which is not used widely now except in pregnancy. It is difficult to titrate, and since it increases heart rate and contractility, and myocardial oxygen consumption, it is contraindicated in myocardial ischaemia and aortic dissection. The high blood pressures result in natriuresis, and patients often have intravascular volume depletion. Oral drugs should be commenced, based on the patients co-morbid conditions once blood pressure is controlled. The choice of antihypertensives is based on the patient’s co-morbid conditions and compelling clinical indication, based on standard guidelines as for any hypertensive. Stroke: often it is difficult to determine whether the high blood pressure caused the stroke, or whether the stroke resulted in high blood pressure in an attempt to maintain cerebral perfusion. Nitroprusside and nitrates, being arterial vasodilators, may increase cerebral blood volume and so, intracranial pressure while lowering mean arterial pressure. Nimodipine is especially useful in subarachnoid haemorrhage, as it prevents secondary cerebral injury due to cerebral vasospasm. Left ventricular dysfunction: Nitrates are useful because of their venodilatory effects. Although beta blockers can be dangerous in unstable left ventricular systolic dysfunction, labetalol is useful in diastolic dysfunction, as it slows the heart rate, giving more time for diastolic filling. Diuretics are generally necessary, but should be given carefully in diastolic dysfunction because they may reduce left ventricular filling pressures. Hypertension in critical care 129 Handbook of Critical Care Medicine Aortic dissection: The blood pressure must be acutely lowered, to a systolic pressure of 100-110mmHg. The aim is to reduce the shear force on the aorta; a vasodilator must never be used alone as it may worsen the shear force. In patients whom beta blockers are contraindicated, trimethaphan may be used, though it has many adverse effects. Aortic dissection of the ascending aorta (type A) requires surgery, and that of the descending aorta (type B) can be managed medically. Labetalol has predominantly beta blocking effects, and should be used together with a vasodilator. Pre-eclampsia/eclampsia: Preeclampsia is diagnosed on the basis of pregnancy-induced hypertension (>140 mmHg systolic or >90 mmHg diastolic blood pressure confirmed by two separate measurements, occurring after 20 weeks gestation in a woman who was normotensive before 20 weeks gestation) and proteinuria (500 mg/l protein in a random specimen or an excretion of 300 mg per 24 h). If eclampsia is imminent, pregnancy must be terminated irrespective of the gestational age, as the risk to the mother is enormous. Labetalol, hydralazine and nicardipine are preferred drugs, as they maintain placental blood flow. Perioperative hypertension: Often, there is a need to control acute blood pressure elevations in patients undergoing surgery. Pain and anxiety may cause the blood pressure to rise, and reassurance, sedation and analgesia may be adequate. High blood pressures are of concern to the surgeon and anaesthetist however, hence often it is necessary to reduce blood pressures to reasonable levels prior to surgery. If urgent reduction of blood pressure is necessary, nitroprusside or nitrates are preferred, although nearly any of the agents can be used. Hypertension in critical care 130 Handbook of Critical Care Medicine Acute myocardial ischaemia Coronary artery disease accounts for 30% of deaths. A thrombus forms; in the case of unstable angina, this is an unstable clot, which does not fully occlude the vessel. If the thrombus completely occludes the vessel, acute myocardial infarction occurs. Acute myocardial ischaemia 131 Handbook of Critical Care Medicine Typically, the pain of myocardial infarction has the following features: x Severe x Constant x Retrosternal x Spreading across the chest. May radiate to the throat and jaw, down the ulnar aspect of both arms or to the interscapular area x Duration >20 minutes x Sweating, nausea, pallor, dyspnoea and anxiety often present The pain of unstable angina is similar, though often milder. Features of unstable angina often precede myocardial infarction, over a few days or hours. Classically, anginal chest pain waxes and wanes, worsening with exertion, and is associated with sweating. Acute myocardial ischaemia 132 Handbook of Critical Care Medicine Sometimes the pain is atypical and hence, more difficult to diagnose. Waxing and waning chest pain is always suspicious, especially if it worsens on exertion, even though the site is not typical. These patients may not have chest pain during an acute coronary event, but may have other symptoms such as dyspnoea, palpitations or collapse.

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Medication may be required to reduce the chances of inhalation in cases of oesophageal reflux discount 200mg nizoral. Two-thirds of the population have a seizure threshold of 100- 200 mC safe nizoral 200mg, but the range is probably 20-800 or so. Recovery from the treatment should also be noted regularly, as should response of the underlying disorder and cognitive status. Buchan ea (1992) found that deluded-retarded cases lost twice as many points on the Hamilton Depression Scale as did a group without these characteristics. It may reduce the frequency of petit mal attacks and terminate epilepsia partialis continua. Wells & Bjorkstein, 1989; Weller, 1992; Metzger, 1999; Weiner ea, 2001; Marangell ea, 2003, p. This author continues antidepressants as long as they were or could be helpful, especially with in-patients. There have been some concerns that lithium may be associated with delirium, catatonia or prolonged seizures, although opinion is ‘divergent’. Major depression with psychotic features in elderly female with advanced Parkinson’s disease and in situ deep brain stimulator 2009. Bipolar affective disorder I with psychotic symptoms in Fahr disease __________________________________________________________________________________________ Complications With adequate precautions significant problems are rare. Some authorities use labetalol (Trandate), a short-acting blocker of both alpha and beta receptors, to prevent tachycardia. Postictal delirium affects a minority of patients and usually abates in much less than an hour. Reassurance, gentle restraint, nursing in a quiet area, and, when necessary, medication (diazepam, midazolam, haloperidol) are the basis of management. Rarely one may encounter unilateral (Mason, 1955) or bilateral (O’Shea ea, 1996; O’Shea, 2001) foot drop for which many theories have been proposed, e. There is some evidence that a thrice weekly frequency may be superior in terms of speed of clinical response. Higher dose of muscle relaxant than usual may be needed in cases with osteoporosis. Weiner ea (2001) suggest that a wedge be placed under the patient’s right hip if the pregnancy is greater than 20 weeks duration in order to displace the womb from the great vessels. The remainder of this mostly chronic group was suffering from schizophrenia or schizoaffective disorder. Malitz & Sackeim, 1986) and many clinicians believe that higher doses of electricity are more effective than lower doses despite the fact that both produce a seizure. Therefore use the minimum amount of electrical energy required to induce a convulsion. One can reduce the amount of energy by a perpendicular rise and/or fall in stimulus amplitude to maximise the amount of energy transmitted at peak amplitude. Constant current, brief pulse equipment giving a train of voltage pulses constitutes a more satisfactory physiological stimulus. An Indian study found that lower (50 pulses/second) was more efficient in inducing a seizure than was a higher (200 pulses/second) stimulus pulse frequency (the lower frequency caused a greater reduction in seizure threshold) and there were no significant cardiovascular responses between the two frequencies. Kho ea (2004) found that 3410 high seizure energy index predicted rapid response in major depression. Until this debate is resolved seizure duration of at least 15 seconds is desirable. When maximum electrical 3414 stimuli fail to produce a seizure (‘missed or abortive seizure’) etomidate (or possibly ketamine ) may be employed. Shorting may occur due to excess scalp moisture and may be a reason for lack of a seizure. An oxygen source (brain oxygen requirements increase during a seizure; oxygen lowers seizure threshold, i. Hyperoxygenation does not harm the patient with chronic chest problems when given for brief periods only. If the patient fails to have a good seizure after the initial stimulus, then the patient should be hyperoxygenated and consideration should be given to whether the settings on the machine should be increased by, say, 25% – but poor electrode contact with the scalp is the commonest culprit! The dose of electricity is described in units of charge (Coulombs) rather than energy (Joules) because the former is independent of the variable impedance of patients and is more closely related to both the desired therapeutic and the unwanted cognitive effects. Ohm’s law states that voltage = current x resistance; 3417 voltage varies as a function of resistance/impedance. The minimum stimulus needed 3412 The initial tetanic stimulation of the masseter by the electrodes should not be mistaken for less than adequate muscle relaxation.. This author also remembers seeing psychiatrists using the heel of a shoe as a bite-block! Passage of the stimulus 3418 should be accompanied by an audible or visual signal.

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