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By L. Grobock. Curry College.

A daily nitrate-free period is Sublingual or buccal nitroglycerin is used either to ter- also recommended generic 100 mg aurogra mastercard, particularly with use of the trans- minate an acute attack of angina or for short-term pre- dermal patches or ointment purchase aurogra 100mg amex. Nitroglycerin is also the mainstay of the pharmacokinetic profile achieved with these sus- therapy for relieving acute coronary vasospasm because tained-release formulations should result in more effec- of its rapid onset of action purchase 100 mg aurogra visa. The Isosorbide dinitrate and pentaerythritol tetranitrate most commonly used agent is N-acetylcysteine (NAC) cheap 100 mg aurogra with amex, also can be taken sublingually buy aurogra 100mg otc, shortly before antici- which is hydrolyzed in vivo to cysteine. An ef- the antinitrate tolerance effect of this compound has fective dose of nitrate usually produces a fall in upright not been universally confirmed. Thus, further well- systolic blood pressure of 10 mm Hg and a reflex rise in controlled clinical studies are necessary to establish the heart rate of 10 beats per minute. Larger changes than effectiveness of sulfhydryl-containing compounds at these should be avoided, because a reduction in myo- preventing or reversing nitrate tolerance. The state of de- Since nitrite ions oxidize the iron atoms of hemo- pendence becomes manifest when exposure to nitrates globin and convert it to methemoglobin, there may be a is withdrawn suddenly. While methemoglo- who have become dependent on nitroglycerin have binemia does not follow therapeutic doses of organic ni- been reported to undergo angina, myocardial infarc- trates, it can be observed after overdosage or accidental tion, or even sudden death following removal from poisoning. Some of these patients showed symptoms of ischemic heart disease, even Cautions though their coronary arteriography was judged to be normal. Since it is possible that coronary vasospasm Chest pain that is not relieved by two or three tablets plays a role in the pathogenesis of angina that occurs within 30 minutes may be due to an acute myocardial in nitrate-dependent individuals, these patients should infarction. In addition, nitrate administration may result be cautioned to watch for increased chest pain when in an increase in intracranial pressure, and therefore, they withdraw from medication or discontinue their these drugs should be used cautiously in patients with exposure. Adverse Effects -Adrenoceptor Blocking Agents Vascular headache, postural hypotension, and reflex -Adrenoceptor blockade is a rational approach to the tachycardia are common side effects of organic nitrate treatment of angina pectoris, since an increase in sym- therapy. Fortunately, tolerance to nitrate-induced head- pathetic nervous system activity is a common feature in ache develops after a few days of therapy. Based on their ability to reduce potension and tachycardia can be minimized by proper oxygen demand, all -blockers tested so far have also dosage adjustment and by instructing the patient to sit been shown to be effective in the treatment of second- 17 Antianginal Drugs 201 ary angina. Administration of these compounds results and thereby attenuate the myocardial response to stress in a decrease in frequency of anginal attacks, a reduc- or exercise (Fig. The resting heart rate is reduced tion in nitroglycerin consumption, an increased exercise by propranolol, but not to the same extent as is the de- tolerance on the treadmill, and a decreased magnitude crease in exercise-induced tachycardia. Overall, propra- of ST segment depression on the electrocardiogram nolol reduces myocardial oxygen consumption for a during exercise. Although the mechanisms responsible angina in the United States include propranolol and for this antihypertensive effect are not completely un- nadolol (Corgard), compounds that block both 1- and derstood, they are thought to involve (1) a reduction in 2-adrenoceptors equally, while atenolol (Tenormin) cardiac output, (2) a decrease in plasma renin activity, and metoprolol (Lopressor) are cardioselective 1- (3) an action in the central nervous system, and (4) a re- receptor antagonists. Thus, propranolol may ex- ert a part of its beneficial effects in secondary angina by decreasing three of the major determinants of myo- Mechanism of Action cardial oxygen demand, that is, heart rate, contractility, The myocardial response to exercise includes an in- and systolic wall tension. These Propranolol and other -blockers also have been effects are mediated in part by the sympathetic nervous shown to produce an increase in oxygen supply to the system. The mechanism re- antagonize the actions of catecholamines on the heart sponsible for this effect is most likely related to the Afterload Preload Heart rate Contractility Stenosis diameter Wall tension Site of occlusion Collateral vessel diameter Transmural blood flow epicardial Ischemic area endocardial FIGURE 17. Because subendocardial By attenuating the cardiac response to exercise, propra- blood flow and flow distal to severe coronary artery nolol and other -blockers increase the amount of ex- stenosis occur primarily during diastole, this increase in ercise that can be performed before angina develops. Finally, there is evidence that - Propranolol is particularly indicated in the manage- blockers can inhibit platelet aggregation. Absorption, Metabolism, and Excretion Propranolol may be combined with the use of nitro- Propranolol is well absorbed from the gastrointestinal glycerin, the latter drug being used to control acute at- tract, but it is avidly extracted by the liver as the drug tacks of angina. This organic nitrates theoretically should enhance the thera- effect explains the large variation in plasma levels of peutic effects of each and minimize their adverse effects propranolol seen after oral drug administration. Because of these interindividual variations in the ki- Propranolol and nadolol also have been used suc- netics of propranolol, the therapeutic dose of this drug cessfully in combination with certain calcium entry is best determined by titration. End points of titration blockers, particularly nifedipine, for the treatment of include relief of anginal symptoms, increases in exercise secondary angina. Caution should be used, however, tolerance, and plasma concentration of propranolol be- when combining a -blocker and a calcium channel tween 15 and 100 ng/mL. For additional details on the blocker, such as verapamil or diltiazem, since the nega- pharmacokinetics of propranolol and other -receptor tive inotropic and chronotropic effects of this combina- antagonists approved for clinical use in the treatment of tion may lead to severe bradycardia, arteriovenous angina pectoris, see Table 17.

Stimulus frequency had to be encoded temporally purchase 100 mg aurogra fast delivery, in the serial order of evoked spikes effective aurogra 100mg. Merzenich and colleagues made another important observation cheap aurogra 100mg line, that spike timing associated with the sine wave was more precise in trained animals compared to untrained monkeys discount 100 mg aurogra otc. Arguments in favour of the proposal reviewed above could be strengthened if a large number of neurons were studied and if neurons were studied in behaving animals during the flutter discrimination task generic aurogra 100 mg without a prescription. To this end, we trained monkeys to discriminate between flutter-stimulus frequencies and recorded many neurons with QA properties in areas 3b and 1 of S1. First, the majority of neurons from S1 were phase-locked to the input stimulus frequency (Figure 4. However, almost a third of QA neurons modulated their firing rates as a function of the stimulus frequency (Figure 4. The second important finding was that QA neurons that modulate their firing rates were affected by the task condition that is, they increased their transmitted information about the stimulus frequency during task performance. They suggest the presence of two sub- populations of QA neurons in S1 which behave differently in response to a periodic mechanical stimulus. QA neurons that respond periodically, might be closer to the input stimulus and those that modulate their firing rates might integrate the responses of the periodic neurons and transform them into a rate code. A 20 30 20 28 20 26 20 24 20 22 20 20 20 20 20 18 20 16 20 14 20 12 20 10 14 22 10 18 8 14 6 10 40 30 34 26 30 22 26 18 Hz f1 Hz f2 B 40 30 20 10 10 20 30 40 10 20 30 40 Stimulus frequency (Hz) C D 1 60 40 20 0 0 10 20 30 0. Each row of ticks represents a trial and each tick represents an action potential. Periodicity (± SD) as a function of the first (f1) and second stimulus (f2) frequencies. This is plotted as the probability that the second stimulus is judged higher than the first. Gray and black lines represent psychometric and neurometric functions, respectively. Threshold ratios (psychometric/neurometric thresholds) calculated from neurons with periodicity (gray bars). Open bars represent the threshold ratios between psychometric and neurometric thresholds calculated from a small number of neurons with modulations in their firing rate. A 20 30 20 28 20 26 20 24 20 22 20 20 20 20 20 18 20 16 20 14 20 12 20 10 14 22 10 18 8 14 6 10 40 30 34 26 30 22 26 18 Hz f1 Hz f2 B 100 75 50 25 10 20 30 40 10 20 30 40 Stimulus frequency (Hz) C D 1 30 20 10 0 0 10 20 30 0. Threshold ratios calculated between psychometric and neurometric thresholds for each neuron which varied the firing rate as a function of the stimulus frequency (open bars). Gray bars represent the threshold ratios between psychometric and neurometric thresh- olds calculated from a small number of neurons that show periodicity. NEURONAL CORRELATES OF FLUTTER DISCRIMINATION IN S1 A more direct test for the role of periodicity in flutter discrimination is measuring the discrimination capabilities of these subtypes of QA neurons associated with the psychophysical performance (Figure 4. A second test is to prove whether the evoked neural activity during discrimination in S1 cortex is sufficient for sensory performance. Finally, to test whether the temporal order of the spikes is important for sensory discrimination. These are incisive tests to validate the meaning of the neural encoding of the flutter stimuli in S1 cortex. The vibrotactile discrimination task requires the comparison of the second stim- ulus frequency against the first. According to this, the observer could use a simple rule: if the number of spikes during the second stimulus is higher than during the first stimulus, then second stimulus is higher than the first. The same rule can be used when considering the periodicity values: if the periodicity (estimated as the frequency with greatest power in a Fourier transform of the spiking responses) during the second stimulus period is higher than during the first stimulus, then the second stimulus is higher than the first. The effect is equivalent to determining the area under the curve ROC (receiver operating characteristic7) generated by the neuronal response distributions for each pair of stimulus frequencies, using both periodicity and firing rate values. In pairs of stimulus frequencies where the neuronal response distributions during the second stimulus are much higher than the neuronal distributions of the first stimulus, ROC values are close to 1. If the neuronal response distributions during the stimulus are much lower than the neuronal response distributions of the first stimulus, ROC values are close to 0; for overlapping distributions, intermediate ROC values are found. Psychophysical and neu- ronal discrimination thresholds are calculated as half the difference between the stimulus frequency identified as higher than the standard in 75% of trials and that frequency identified as higher in 25% of the trials. Neurometric functions based on periodicity or firing rate of single S1 neurons were directly compared to the psychometric thresholds. This is not the case when neuro- metric thresholds based on firing rate are compared to the psychometric thresholds (Figure 4. The goal of computing neurometric functions was not only to reveal the relationship between the neuronal responses of S1 to the mechanical stimulus, but also to discern whether these neural signals account for the psychometric behavior.

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Aston recovered from her injuries proven aurogra 100 mg, Rolf asked her to de- She graduated from University of California at Los An- velop a movement education program that would com- geles with a B buy generic aurogra 100 mg. Aston left Rolf and established her own techniques buy 100 mg aurogra with mastercard, which she called Aston-Patterning order aurogra 100mg free shipping. Five years later aurogra 100mg without prescription, while recovering from injuries sus- She has also developed a special program for older peo- tained during two consecutive automobile accidents, ple called the Aston-Patterning Fitness Program for Se- Aston met Ida Rolf, the developer of rolfing. Today Aston-Patterning is a registered trademark began working for Rolf, teaching a movement educa- tion program called Rolf-Aston Structural Patterning that of the Aston Paradigm Corporation of which Judith emphasized using the body with minimum effort and Aston is the director. Aston-Patterning assists people in finding more effi- Aston formed her own company called the Aston Para- cient and less stressful ways of performing the simple digm Corporation in Lake Tahoe, California. This com- pany provides training and certification for Aston practi- movements of everyday life to dissipate tension in the tioners. This is done through massage, alteration of the en- conditions affect body movement, foreshadowing the vironment, and fitness training. Over time, Aston has expanded her move- Description ment work to include a fitness program for older adults. Today, Judith Aston serves as director of Aston Paradigm Seeking to solve movement problems, Aston-Pat- Corporation. Rather it works with asymmetry in the human body to develop patterns of alignment and movement that feel right to the individual. Aston also introduced the idea of netics uses touch to release tension in the face and neck. Aston-Patterning sessions have four general compo- This massage is accompanied by education about the es- nents. Since clients typically work with an Aston-Pattern- Aston-Patterning requires more participation from ing practitioner for extended periods of time, it is impor- the client than many bodywork techniques. The massage tant that they feel comfortable with their specific practi- aspect of Aston-Patterning is designed around a three-di- tioner. Certified Aston practitioners recommend that mensional, non-compressive touch that releases patterns prospective clients make a get-acquainted visit before of tension in the body. GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 145 Precautions KEY TERMS Aston-Patterning can be quite demanding. Aston-Patterning: Ergonomics—A branch of applied science that co- • Heart conditions. Because diabetes affects blood circulation, furniture, machines, and other features of a living diabetics taking Aston-Patterning should ask the practi- or working environment with the needs and re- tioner to avoid massage of the legs and feet. It assists the body in reorga- terning may cause hairline fractures in brittle bones. Patterning is a member of the International Alliance of Healthcare Educators (IAHE), and Judith Aston is a fre- • Disorders requiring medications that affect the sense of quent speaker at IAHE conferences. The physical con- The Aston Training Center in Incline Village, Nevada, tact involved in Aston-Patterning may cause flashbacks offers courses and certification and promotes a code of or bring up emotional and psychological issues. As of early 2003 there are certified Aston-Pat- The Aston-Patterning program can, however, be mod- terning practitioners in fifteen states, with the largest con- ified to meet the needs of older adults, those in poor centrations in California, Colorado, and Washington. Aston Postural Assessment Handbook: Skills for Most clients of Aston-Patterning report a diminution Observing and Evaluating Body Patterns. San Diego, CA: of tension, improved ease of movement, and an enhanced Academic Press, Inc. The Best Alternative Medicine, Part side effects, the most common being pain and exhaustion. New York: Simon & Schus- To minimize side effects, clients should give the practi- ter, 2002. Research & general acceptance International Alliance of Healthcare Educators (IAHE). Little controlled research has been done on OTHER either the benefits or limitations of Aston-Patterning; as of Rast, Mechthild. Book Review: Aston Postural Assessment Work- early 2003, no reports have been published in any peer-re- book. Neuro-Developmental Treatment Association Network viewed medical, alternative medical, or bodywork journals. Its claims have been neither proven nor disproved, al- though anecdotally many clients report relief from pain Tish Davidson and tension as well as improved body movement. Frey, PhD 146 GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 can be used to cure chronic weaknesses of the lungs.

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No prescription drugs buy generic aurogra 100mg on line, creams purchase aurogra 100mg overnight delivery, oils generic 100 mg aurogra mastercard, or lotions • Association of Finnish Reflexologists are used on the skin buy cheap aurogra 100mg on line. It may even be self- • International Council of Reflexologists (HQ: San Diego aurogra 100mg with mastercard, administered in a limited form whenever desired. The USA) qualified reflexologist offers a clear and open disclaimer that reflexology does not constitute medical treatment in • Israeli Reflexology Association any form, nor is reflexology given as a substitute for • New Zealand Reflexology Association medical advice or treatment. The ultimate purpose of the • Polish Instytut of Reflexology (Polish Language) therapy is to promote wellness; fundamentally it is a form of preventive therapy. Dia- • Rwo-Shr Health Institute International (Malaysia) betes patients in particular are urged to approach this therapy cautiously. Likewise pregnant women are cau- • The South African Reflexology Society tioned emphatically to avoid reflexology during the early phases of altogether, as accidentally induced labor and subsequent premature delivery can result from Ongoing legislative debate ensued during the reflexology treatment. The reflexology community, along with legisla- order to determine the safety and appropriateness of reflex- tors and other bodywork practitioners, engaged in re- ology therapy for a specific health problem or condition. Organi- zations and individuals brought judicial appeals of cer- tain court cases that threatened the legitimate licensing Because reflexology is intended to normalize the of reflexologists as practitioners of alternative medi- body functions, the therapy does not cause a condition to cine. Most patients find that pain diminishes over the RAA documented in detail the disparities between re- course of the therapy. It has been noted, however, that flexology and massage, citing the purpose of reflexolo- some patients experience greater discomfort in the sec- gy, which is to stimulate internal body functions ond session than in the first session, because a significant (glands and organs) as opposed to the topical muscular easing of pain and tension is generally associated with and joint relief associated with massage. As a result, when pressure is date in 1998 the Association reported that 19 states had reapplied to the tender points of the foot during the sec- laws requiring the licensing of massage/reflexology ond session, the sensitivity has been heightened. Licensing laws established educational re- crease in sensitivity may cause minor additional discom- quirements and required candidates to pass written, fort for the patient. Also at issue was a trend among municipalities to license massage parlors (and reflexologists) under the business codes affecting the adult entertainment busi- Although only one controlled trial of reflexology ness. Kunz reported that judicial decisions in therapy, done in 1993, has been documented in medical two states—Tennessee and New Mexico—had excluded journals, this therapy is practiced worldwide at different the practice of reflexology practice from the laws per- levels of medical care. Those courts held that re- censed physicians may legally perform reflexology treat- flexology is a business separate and distinct from mas- ment. In contrast, the practice is a commonplace home- sage parlors, and deserving of its own respective licens- style remedy in the Netherlands. In Sacramento, California, reflexologists Reflexology” lists at least 66 professional organizations petitioned successfully to become licensed as practition- worldwide, including New Zealand and Malaysia. Asso- ers of somatic therapy rather than as providers of adult ciations include the following: entertainment. Likewise, in the Canadian province of • Academy of Reflexology Austria Ontario, a nonprofit organization to register reflexology Therapist Barbara Rowedder channelling energy into the head of a woman with AIDS during a Reiki treatment. Once complete relaxation is achieved, the second component of the exercise is the imagery, or visualiza- tion, itself. Relaxation imagery involves conjuring up pleasant, relaxing images that rest the mind and body. If an individual is considering relaxation therapy to These may be experiences that have already happened, alleviate physical symptoms such as nausea, headache, or new situations. A complete physical examination and com- about an upcoming situation, such as, prehensive medical history will be performed, and even surgery, or even a critical event such as an important if an organic cause for the symptoms is found, relaxation competition or a job interview. Individuals imagine exercises may still be recommended as an adjunct, or themselves going through each step of the anxiety-pro- complementary, treatment to relieve discomfort. Relaxation therapy should always take place in a quiet, relaxing atmosphere where there is a comfortable place to sit or recline. Some people find that quiet back- ground music improves their relaxation sessions. If an Biofeedback, or applied psychophysiological feed- instructional audiotape or videotape is to be used, the ap- back, is a patient-guided treatment that teaches an indi- propriate equipment should be available. The name The relaxation session, which can last anywhere biofeedback refers to the biological signals that are fed from a few minutes to an hour, should be uninterrupted. These sensors measure muscle ten- sion, brain waves, heart rate, body temperature, and translate the information into a visual and/or audible Most commonly practiced relaxation techniques are readout, such as a paper tracing, a light display, or a se- completely safe and free of side effects. By monitoring this relation- should be taught or performed by a qualified healthcare ship between mind and body, he can then use thoughts professional or instructor. These treatments may not be and mental images deliberately to manipulate heart beat, suitable for individuals with certain health conditions brain wave patterns, body temperature, and other bodily such as arthritis or. This is should consult with their healthcare professionals before achieved through relaxation exercises, mental imagery, engaging in these therapies.

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