Mark Corson

By K. Sancho. New School University.

The reason for treating infection with antibiotics is that eradication of the infection will largely prevent recur- rence discount 50 mg imitrex fast delivery. Whether treatment of H pylori infection reduces or eliminates dyspep- tic symptoms in the absence of ulcers (nonulcer dyspepsia) is uncertain discount imitrex 100mg overnight delivery. Similarly cheap imitrex 50mg with mastercard, whether treatment of asymptomatic patients found to be H pylori positive is beneficial is unclear. If symptoms persist or alarm features develop, then prompt upper endoscopy is indicated. They promote ulcer formation by inhibiting gas- troduodenal prostaglandin synthesis, resulting in reduced secretion of mucus and bicarbonate and decreased mucosal blood flow. To diagnose this condition, one should measure serum gastrin levels, which are markedly elevated (>1000 pg/mL), and then try to localize the tumor with an imaging study. Free perforation into the abdominal cavity may occur in association with hemorrhage, with sudden onset of pain and devel- opment of peritonitis. Some patients with chronic ulcers later develop gastric out- let obstruction, with persistent vomiting and weight loss but no abdominal dis- tention. The pain is associated with nausea and vomit- ing, and any attempt to eat since has caused increased pain. Right upper abdominal pain of acute onset that occurs after inges- tion of a fatty meal and is associated with nausea and vomiting is most suggestive of biliary colic as a result of gallstones. Duodenal ulcer pain is likely to be diminished with food, and gastric ulcer pain is not likely to have acute severe onset. Although H pylori is clearly linked to gastric and duodenal ulcers and probably to gastric carcinoma and lymphoma, whether it is more common in patients with nonulcer dyspepsia and whether treatment in those patients reduces symptoms are unclear. This patient is hemodynamically unstable with hypotension and tachycardia as a consequence of the acute blood loss. Volume resusci- tation, immediately with crystalloid or colloid solution, followed by blood transfusion, if necessary, is the initial step to prevent irreversible shock and death. Later, after stabilization, acid suppression and H pylori treatment might be useful to heal an ulcer, if one is present. Patient in answer A has “red flag” symptoms: he is older than 45 years and has new onset symptoms. Patient in answer B may benefit from the reassurance of a negative endoscopic examination. This patient could be sent for an endoscopic examination if she does not improve following the therapy. Antibody tests show evidence of infection but remain positive for life,even after suc- cessful treatment. Helicobacter pylori eradication: equivalence trials and the optimal duration of therapy. This page intentionally left blank Case 5 A 65-year-old white woman is brought to the emergency room by her family for increasing confusion and lethargy over the past week. Her blood pressure is 136/82 mm Hg, heart rate 84 bpm, and res- piratory rate 14 breaths per minute and unlabored. On examination, she is an elderly appearing woman who is difficult to arouse and reacts only to painful stimuli. She is able to move her extremities without apparent motor deficits, and her deep tendon reflexes are decreased symmetrically. The remainder of her examination is normal, with a normal jugular venous pressure and no extremity edema. You order some laboratory tests, which reveal the serum sodium level is 108 mmol/L, potassium 3. She is afebrile and normoten- sive, and she has no edema or jugular venous distention. She is lethargic but is able to move her extremities without apparent motor deficits, and her deep tendon reflexes are decreased symmetrically. Know how to treat hyponatremia, and some of the potential complications of therapy. Considerations This elderly woman with small cell lung cancer presents in a stuporous state with hypotonic hyponatremia. She appears euvolemic, as she does not have findings suggestive of either volume overload (jugular venous distention or peripheral edema) or volume depletion. The patient does not take medications; thus, with the situation of hypotonic hyponatremia in a euvolemic state and with inappropriately concentrated urine, the most likely etiology is inappropriate antidiuretic hormone produced by the lung cancer. Because this individual is stuporous and the sodium level is severely decreased, hypertonic saline is required with fairly rapid partial cor- rection. Also, the target is not correction of the sodium level to normal but rather to a level of safety, such as 120 to 125 mmol/L. Depending on the rapidity with which the hyponatremia develops, most patients do not have symptoms until the serum sodium level is in the low 120 mmol/L range. The clinical manifestations are related to osmotic water shifts leading to cerebral edema; thus, the symptoms are mainly neurological: lethargy, con- fusion, seizures, or coma. Serum sodium concentrations are important because they almost always reflect tonicity, the effect of extracellular fluid on cells that will cause the cells (eg, brain cells) to swell (hypotonicity) or to shrink (hypertonicity). For pur- poses of this discussion, we use serum osmolality as a valid indicator of tonicity, which is almost always true, so we use the terms interchangeably. Whereas hypernatremia always reflects hyperosmolality, hyponatremia may occur in the setting of hyperosmolality, normal osmolality, or hypoosmolality (Table 5–1). Hyponatremia associated with a hypoosmolar state is more common and more dangerous.

Manipulation of the lumbar spine is associated with a Chapter 7 • Modalities cheap imitrex 50 mg without prescription, Methods and Techniques 219 Box 7 buy imitrex 25 mg low price. A similar 1988 study complications of the Canadian Memorial Chiropractic College clinic Stretching cheap imitrex 100 mg overnight delivery, shearing, kinking or crushing forces on the files for a 9-year period (Henderson & Cassidy 1988). An extensive 1993 often considered as possible mechanisms of injury literature review found risk of serious neurological (Gatterman 1990a, Plaugher 1993b, Terrett 1996b). A cadaver research study, looking at the biomechanical A sample of incidence of stroke in the world male strain from cervical manipulation, concluded: population: • the forces during manipulation were less than those • Finland: 310 per 100 000 persons per year (Sarti et al recorded during range of motion and diagnostic 1994) testing • Eastern Europe and former Soviet Union: 309–156 • the strains on the vertebral artery during manipulation per 100 000 persons per year were less than one-ninth of that required to achieve arterial failure • Western Europe: 100 per 100 000 persons per year • the movement of joints during cervical adjustment is • Trinidad and Tobago: 185 per 100 000 persons per done well within the normal range of motion and that year (Cinzia et al 2000). The authors acknowledge the inherent bias range of estimates as to what those risks might be. In 2001 makes this association difficult to study despite high the Canadian Medical Association Journal published volumes of chiropractic treatment’. It is also important to consider that many persons suffer spontaneous stroke from everyday activities such as • 1. A study in Stroke, based on the case while driving, holding a telephone against the shoulder, history of stroke patients (Rothwell et al 2001). A survey of California many more common activities (Rome 1999, Terrett neurologists (Lee et al 1995). A 1996 literature The wide difference in the statistics of risk of stroke review reported in Spine (Hurwitz et al 1996). A 1993 study in the spontaneous arterial dissection in the general population Journal of the Canadian Chiropractic Association raises questions as to the relationship between the two. Many observers erroneously make a connection between • 0 per 5 million manipulations. If a stroke occurred after a clinical files of the National College of Chiropractic manipulation, then according to Keating (1992), the performed between 1965 and 1980 (Jaskoviak manipulation must be the cause of the stroke: ‘To 1980). Do not continue to adjust a patient if any aggravating factor in an already compromised arterial possibility of vascular trauma has occurred. This theme is echoed repeatedly in studies evaluating It is a relative contraindication to manipulate a patient risk of manipulation. As an example, an editorial (Hill who: 2003) in the Canadian Journal of Neurological Sciences stated: • has a history of hypertension or other known risk factor for stroke or vascular disease Despite strong circumstantial reports and opinions, • has an elevated homocysteine level the quality of evidence that minor neck trauma • presents with a bruit including chiropractic neck manipulation causes • has a migraine vertebral or carotid artery dissection remains weak. Other commented on: authors have also identified manipulation with rotation Some patients suffer the hallmark neck pain of (Haldeman et al 2001, Michaud 2002) and extension dissection prior to neck adjustment and seek (Plaugher 1993b) to increase risk of stroke. Summary Identifying at-risk patients for stroke or vertebral dissection • About half of all patients will experience mild and transient adverse events after spinal manipulation. There is no valid screening test for risk of stroke (Cote • Manipulation of the cervical spine appears to be et al 1996, Terrett 1996d). To date, no particular factor associated with the possibility of cervical that is useful for physical screening has been identified radiculopathy, myelopathy and disc herniation. False- negative findings have been reported and the reliability • Manipulation of the lumbar spine is associated with a and validity of provocation tests have been unproven risk of cauda equina syndrome, disc herniation and (Bolton et al 1989, Ferezy 1988). The that of a vascular injury which leads to central nervous 90-day risk of stroke in this population is 10%. Patients with high homocysteine levels are twice as likely to experience spontaneous arterial dissection as • The risk of stroke with possible permanent those with normal levels (Gallai et al 2001, Graham neurological damage or death has been estimated to et al 1997, Pezzini et al 2002). The evidence is considered to be of a ‘post hoc, ergo proctor hoc’ Reducing the risk of stroke following nature. Light pressure over spongy edematous areas movement by crosswise and lengthwise stretching of and slightly firmer over fibrotic tissue the anchoring filaments that open the lymph capillar- 5. After the distal portion is that tissue damage is virtually impossible, the most treated, the practitioner proceeds back through the likely harm that might derive relates to incorrect pathway proximally to encourage further (and more usage, or the encouragement (via increased flow) of complete) drainage of the lymph (Chikly 1997). With sound anatomic knowledge, specific directions Validation of efficacy = 5 (see Table 7. Further reading Osteopathic pump techniques that provide intermit- tent compression (lymphatic pump, liver pump, etc. Foldi M, Strossenreuther R 2003 Foundations described later in this chapter can support and/or of manual lymph drainage, 3rd edn. Wittlinger H, Wittlinger G 1982 Textbook of • Blood and tissue fluid interchange – for Dr Vodder’s manual lymph drainage, vol 1: example, enhanced interstitial fluid plasma basic course, 3rd edn. Karl F Haug, protein, colloid, and leukocyte uptake into the Heidelberg lymphatic system (Ikimi et al 1996). Massage Indications/description Cautions (Wittlinger & Wittlinger 1982) Based on the huge range of conditions that have been • Acute infections and acute inflammation shown to benefit from therapeutic massage (see below (generalized and local) under heading ‘Validation of efficacy’) it might be • Thrombosis judged that the ‘indication’ for massage is that the • Circulatory problems individual is unwell (or wishes to remain well). There • Cardiac conditions are few modalities that are more naturopathic, since in its most generic form massage is non-invasive, • Hemorrhage almost totally safe, and virtually without contraindi- • Malignant cancers cations (see below). However, when massage incor- • Thyroid problems porates techniques based on soft tissue manipulation, • Acute phlebitis or when it becomes ‘deeper’ and has specific goals (deactivation of trigger points, reduction of fibrosis, Conditions that might benefit from lymphatic drain- etc. How • removed spleen the physical contact is applied is considered to incor- • major kidney problems or insufficiency porate the qualities of touch. The discussion earlier in the chapter regarding ‘load’ • menstruation (drain prior to menses) features should be recalled when considering the • gynecological infections, fibromas or cysts effects of the application of massage. The tissues between the hands are lifted and • there was significantly enhanced forced pressed downwards and together. Pressure is usually reductions in anxiety and depression (Field even throughout the strokes, which are applied et al 1998) with the whole hand in contact. It is performed by small blood pressure significantly (systolic and circular or vibratory movements, with the tips diastolic) and decreased heart rate, as well as of fingers or thumb. The heel of the hand may resulting in improvement in emotional state also be used. Alternatives • When a person is fatigued the duration and It may be hypothesized that forms of hydrotherapy depth of the application should be reduced. The biochemical influences of massage include altered stress hormone (cortisol) production (Field 2000).