By Y. Khabir. University of Washington.
I told him that I was such as ma huang (or ephedra) to assist with weight interested in alternative medicine cheap sildalis 120mg free shipping, to which he loss may be efﬁcacious but when used improperly responded buy cheap sildalis 120mg on-line, “Show me the evidence effective 120 mg sildalis,” and quickly are potentially dangerous (there have been more changed the subject buy 120mg sildalis with visa. Other treatments are Although I was somewhat disappointed by this newly invented or conceived. Although some of reaction, his statement ultimately turned out to be these treatments will ultimately be shown to be of one of those seemingly innocent comments that value, individuals who seek to take advantage of a unintentionally have a profound effect. I began vulnerable public are often marketing fraudulent pondering the challenge of integrating alternative products or interventions. The Internet has led to medicine into conventional medicine and the con- increased empowerment of the public through ventional medical establishment. I began to appre- access to an endless amount of medical informa- ciate more fully the need for additional research on tion. Only through that research seemingly endless amount of inaccurate or poten- can conventional medical providers know which tially misleading health information. Only Traditionally the public has turned to physicians through that research can the public truly know and other health care providers for reliable infor- which treatments are safe and effective. But multiple Ultimately I decided to pursue a two-year studies have shown that the majority of people research fellowship and a master’s degree in public who use alternative medicine do so without telling health with the goal of obtaining the skills neces- their physicians or other health care providers. Good research takes years and costs sig- the subject matter and a desire not to appear unin- niﬁcant amounts of money. This omission often gives the impression cies are funding research on alternative medicine. At times physicians may be dis- the Study of Complementary and Alternative Med- missive of such therapies because of a perception icine under the National Institutes of Health, and that there is a lack of credible and authoritative evi- the amount and quality of research on alternative dence of their effectiveness. However, Patients, on the other hand, tend to believe that the various types of alternative treatments avail- it is unimportant for health care providers to know able are also increasing. They research is conducted, there will always be numer- often believe that the alternative therapy is irrele- ous treatment options available that have little or vant to the biomedical treatment course. They may no data beyond anecdotal evidence to support their think that a decision to pursue an alternative treat- use. There will always be treatments being utilized ment does not require input from the conventional that will ultimately be shown to be safe and effec- medical establishment, since they believe these tive as well as ones that will be harmful and futile. Still others hesitate Many treatments are from healing traditions to speak openly about their use of or desire to use that have developed over hundreds, if not thou- alternative medicine because of concern that their sands, of years through a process of trial and error questions may be dismissed or they may be viewed on thousands of patients. If undergo a conventional medical evaluation as well the public cannot turn to the conventional medical as see an acupuncturist, nutritionist, massage ther- establishment, turn to their own physicians or apist, clinical herbalist, or mind-body practitioner other health care providers for reliable information (licensed clinical social worker or Ph. The conventional medical estab- the more I ﬁnd myself returning to the principles I lishment has an obligation to protect the public found to be most effective in maintaining my own from harm without limiting access to potentially health and quality of life. That path always Clearly the public’s desire for and utilization of tends to have physical, mental, and spiritual com- alternative medicine are increasing. In the I will see someone with low back pain who not United States, more than $27 billion is spent only gets a referral for acupuncture, but also is sent annually on alternative medicine. The public has to the nutritionist because of obesity and the freedom of choice to pursue alternative treat- unhealthy eating habits, to the Wellness Center to ments. However, without reliable, credible sources address deconditioning and a sedentary lifestyle, of information, it is challenging for the individual and to the mind-body practitioner to learn medita- to make informed health care decisions. Discussing tion or guided visualization to address poorly man- one’s use of alternative medicine with one’s health aged stress. I ask patients to ask themselves, “What care provider is an opportunity to share values, gives my life meaning? The relevant but also contribute to strengthening the answer for most people is not solely contained in a health care provider–patient relationship. In 1998, after ﬁnishing my training, I for a more academic environment, where I could was fortunate enough to have the opportunity to focus on teaching not only patients, but also health pursue my dream of a more integrated health care care providers. I found myself eager to get involved system and was hired to develop a program in in the research that will provide the evidence- alternative medicine for the Saint Barnabas Health based framework for integrative medicine to grow Care System in New Jersey. Therefore, in July 2002 I accepted the posi- tion, we chose to call the clinical center the Siegler tion of executive director for the Center for the Center for Integrative Medicine, as opposed to Study of Alternative and Complementary Medicine Alternative or Complementary Medicine. Conventional medicine is going through a whether the treatment is conventional or alternative. A more humane physician who respects It is through comprehensive, reliable information patient autonomy is replacing the paternalistic, all- that one is able to begin to ﬁnd the correct path. As science increases our It is for that reason that I am honored to be able understanding and our ability to treat disease as to write this Foreword. It is my hope that this ref- never before, we continue to be forced to recon- erence will be used as a tool to help people inform sider that science. The hormone replacement con- themselves and get onto the right path: a tool that troversy is one example of this. We continue to health care providers can use to educate them- struggle with ﬁnding a balance among science, eco- selves, a tool that will help foster communication nomics, and patient-centered humanistic care. Few would argue that a more patient-centered health care system in which —Adam Perlman, M. His ﬁrst From the most preposterous to the most solid, comment was “How many volumes? One book hardly scratches the surface; sociology classes that self-preservation is a primary therefore my objectives were to compile up-to-date human drive, and today we add to our efforts for information on and explanations of as many alter- self-preservation what has become universally native, complementary, or integrative healing known as the connection between mind and body. In fact, any numerous books on the subject—from single topics method involving mind-body-spirit is often the to comprehensive references—already existed, was alternative. In the precise spirit of alterna- whatever treatments work for an individual, a tive medicine, I wished to offer readable entries healer who accurately perceives and offers those that would not only inform, but perhaps also particular treatments, and the willingness of both inspire people to have a go at a healing method healer and patient to supplant illness with well- that might turn out to be effective for them but ness. As Norman Cousins wrote in Anatomy of an Ill- that they had never heard of before. I also wished ness: “Your heaviest artillery will be your will to to present the seemingly inﬁnite possibilities for live. From here, titude of ideas and disciplines that have been I would like to think at least one reader might invent established by great thinkers past and present. In yet another effective healing method and make cer- the course of such gathering I found myself riveted, tain to let me know about it for the next edition. Andrea Campbell; Sarita (“Bunny”) “Rumson gang”; Dorie Leonardi; Cynthia Schooley, Schuler, M. I also Thoma; and all the physicians, nurses, and other respectfully acknowledge my late mentors Sal health care givers who share their knowledge and Foderaro, Clarence Holbrook Carter, and Dr. And it is not because tional therapy, hypnosis, osteopathy, relaxation the mechanism is working wrongly, that I am ill. I techniques, guided imagery and visualization, am ill because of wounds to the soul, to the deep aromatherapy, homeopathy, meditation, yoga, emotional self” (The Complete Poems of D. The public This is testimony to what a good portion of the calls these “alternative medicines,” resonating population now refers to as “the mind-body con- with the part of the Constitution of the World nection. Traditional medicine has accomplished and Included are a great number of ‘systems,’ including continues to accomplish phenomenal strides in manipulative medicine, ayurveda, shiatsu, hypno- all aspects of medicine. However, many patients sis, biofeedback, acupuncture, acupressure, holistic who found no relief from traditional treatment medicine, macrobiotics, rolﬁng, Christian Science, began to seek help elsewhere—that is, in modal- reﬂexotherapy, homeopathy, aroma therapy, and ities that claimed no hard and fast scientific faith healing. This is not to say that, were these proof, but only a huge sweep of anecdotal suc- methods subjected to scientiﬁc study, all of them cess. Word spread, and now vis- ‘cures’ but still unproven because they haven’t its to a chiropractor are covered by most leading been scientiﬁcally tested or because tests show health insurance companies. In other words, chi- they’re ineffective or harmful,” and complementary ropractic entered and took root in the main- to “treatments used to support other evidence- stream, as have acupuncture, acupressure, and based therapies. Instead of curing cancer, comple- xvii xviii The Encyclopedia of Complementary and Alternative Medicine mentary treatments help control symptoms, reduce quantum physics, the biochemical molecules that stress, or improve well-being. His famous E = mc2 mathemati- native medicine practices, many of which are still cally described how matter and energy were resented or denounced by the American Medical interrelated. But many medical schools through- were, in fact, two different forms of the same out the country now see fit to include courses on thing. At the time Einstein came up with this con- patients’ emotional issues, nutrition (not histori- clusion, few scientists could entirely understand cally a standard medical-school course), and the its magnitude. Since all energy vibrates and like, and acknowledge that, indeed, there is a oscillates at different rates, then, at least at the mind-body connection working at top speed.
To see how much of this information is seeping in 120 mg sildalis, answer the following questions: 1 discount sildalis 120mg with visa. Produce lymphocytes Poking at the Nodes Lymph nodes (see Figure 11-2) are the site of filtration of the lymphatic system sildalis 120mg with visa. Also sometimes incorrectly referred to as lymph glands — they don’t secrete anything discount sildalis 120mg otc, so technically they’re not glands — these kidney-shaped sacs are surrounded by connective tissue (and therefore are tough to spot). Lymph nodes contain macrophages, which destroy bacteria, cancer cells, and other matter in the lymph fluid. Lymphocytes, which produce an immune response to microorganisms, also are found in lymph nodes. The stroma (body) of each node is surrounded by a fibrous capsule that dips into the node to form trabeculae, or septa (thin dividing walls) that divide the node into compartments. Reticular (net-like) fibers are attached to the trabeculae and form a framework for the lymphoid tissue and lymphocytes (white blood cells) in clus- ters called lymphatic nodules. Inside the node is a cortex where most of the lymphocytes gather, and at the center is a medulla, which is less dense than the cortex but also contains lymphocytes. The outer cortex consists of lymphocytes arranged in masses called lymphatic nodules, which have central areas called germinal centers that produce the lymphocytes. Lymph fluid enters the node on its convex side through afferent (inbound) vessels that have valves opening only toward the node. Lymph circulates through the node, where it’s filtered and then allowed to depart through efferent (outbound) vessels in the hilus with valves pointing exclusively away from the node. The following are the primary lymph node regions: Head Neck Upper extremities Lower extremities Chapter 11: Keeping Up Your Defenses: The Lymphatic System 185 Abdomen and pelvis Viscera Thorax Capsule Afferent valve Afferent lymphatic vessel Germinal center Primary nodule Efferent lymphatic vessel Figure 11-2: A lymph node. Wolters Kluwer Health — Lippincott Williams &Wilkins Nodes in the head drain lymph from the scalp, upper neck, ear, parts of the eye, nose, and cheek. Axillary nodes found in the armpit receive lymph from the upper arm, while the lymphatic vessels on the radial side of the arm supply nodes in the clavicle region. Lymph nodes in the abdominal and pelvic region filter fluid from the lower body regions, reproductive organs, and thighs. Viscera nodes or gastric lymph nodes function in the drainage of the digestive organs. Each node acts like a filter bag filled with a network of thin, perforated sheets of tissue — a bit like cheesecloth — through which lymph must pass before moving on. White blood cells line the sheets of tissue, including several types that play critical roles in the body’s immune defenses. This filtering action explains why, when infec- tion first starts, lymph nodes often swell with the cellular activity of the immune system launching into battle with the invading microorganisms. The cortex of each lymph node contains monocytes and two types of lymphocytes: B cells and T cells. Monocytes within the lymph nodes develop into large invader-eaters called macrophages that are capable of destroying a variety of microorganisms and sometimes even cancer cells. B cells don’t attack pathogens directly but instead may produce molecules called antibodies that do the dirty work. Or they may instruct other cells called phago- cytes (literally “cells that eat”) to attack the invaders. T cells are lymphocytes that started out in the bone marrow but matured in the thymus gland (hence the name T cells) before moving on to the lymph nodes and spleen. The correct answer is the central lymph nodes are found is the nervous system (brain and spinal cord). Remove erythrocytes Chapter 11: Keeping Up Your Defenses: The Lymphatic System 187 10. T cells get their name because they start out in the bone marrow and mature in the a. Tailbone Having a Spleen-ded Time with the Lymphatic Organs While the lymph nodes are the most numerous lymphatic organs, several other vital organs exist in the lymphatic system, including the spleen, thymus gland, and tonsils. Like lymph nodes, it has a hilus through which the splenic artery, splenic vein, and efferent (remember “e” for “exit”) vessels pass. Also like lymph nodes, the spleen’s surrounded by a fibrous cap- sule that folds inward to section it off. Arterioles leading into each section are sur- rounded by masses of developing lymphocytes that give those areas of so-called white pulp their appearance. On the outer edges of each compartment, tissue called red pulp consists of blood-filled cavities. Unlike lymph nodes, the spleen doesn’t have any affer- ent (access) lymph vessels, which means that it doesn’t filter lymph, only blood. Blood flows slowly through the spleen to allow it to remove microorganisms, exhausted erythrocytes (red blood cells), and any foreign material that may be in the stream. When blood circula- tion drops while the body is at rest, the spleen’s vessels can dilate to store any excess volume. Later, during exercise or if oxygen concentrations in the blood begin to drop, the spleen’s blood vessels constrict and push any stored blood back into circulation. But the spleen’s primary role is as a biological recycling unit, capturing and breaking down defective and aged blood cells to reuse their components later. Iron stored by the spleen’s macrophages goes to the bone marrow where it’s turned into hemoglobin in new blood cells. By the same token, bilirubin for the liver is generated during break- down of hemoglobin. The spleen produces red blood cells during embryonic develop- ment but shuts down that process after birth; in cases of severe anemia, the spleen sometimes starts up production of red blood cells again. Fortunately, the spleen isn’t considered a vital organ; if it’s damaged or has to be surgi- cally removed, the liver and bone marrow can pick up where the spleen leaves off. T cell central: The thymus gland Tucked just behind the breastbone and between the lungs in the upper chest, the thymus gland was a medical mystery until recent decades. Its two oblong lobes are largest at puberty when they weigh around 40 grams (somewhat less than an adult mouse). Through a process called involution, however, the gland atrophies and shrinks to roughly 6 grams by the time an adult is 65. Prior to birth, fetal bone marrow produces lymphoblasts (early stage lymphocytes) that migrate to the thymus. Shortly after birth and continuing until adolescence, the thymus secretes several hormones, collectively called thymosin, that prompt the early cells to mature into full-grown T cells that are immunocompetent, ready to go forth and conquer invading microorganisms. Within each lobule is a cortex made of T cells held in place by reticular fibers and a central medulla of unusually onion-like layered epithelial cells called thymic corpuscles, or Hassall’s corpuscles, as well as scat- tered lymphocytes. Chapter 11: Keeping Up Your Defenses: The Lymphatic System 189 Opening wide and moving along: The tonsils and Peyer’s patches Like the thymus gland, the tonsils, which are misunderstood masses of lymphoid tissue, are largest around puberty and tend to atrophy as an adult ages. Unlike the thymus, however, the tonsils don’t secrete hormones but do produce lymphocytes and antibodies to protect against microorganisms that are inhaled or eaten. Although only two are visible on either side of the pharynx, there are actually six tonsils: the two you can identify, which are called palatine tonsils; two more called adenoids or pharyngeal tonsils in the wall of the pharynx; and two in the posterior one-third of the tongue called lingual tonsils. Invaginations (ridges) in the tonsils form pockets called crypts, which trap bacteria and other foreign matter. Peyer’s patches, also called aggregate glands or agminate glands, are masses of lymph tissue just below the surface of the ileum, the lowest section of the small intestine. When harmful microorganisms get into the intestine, Peyer’s patches can mobilize an army of B cells and macrophages to fight off infection. The lymphatic organ that stops growth during adolescence and atrophies with aging is the a. Lymphoid tissue located in the pharynx that protects against inhaled or ingested pathogens and foreign substances is called the a. The lymphatic organ responsible for removal of aged and defective blood cells is the a. The lymphatic organ that secretes hormones to make T lymphocytes immunocompetent is the a. Once in the lymphatic system, interstitial fluid becomes known as _______________. The lymph nodes of the lower extremities drain the _______________, _______________, and _______________.
Explore the patient’s worried about what would have happened had he self-expectations and assist the patient in deter- died buy 120 mg sildalis with mastercard. Explore the about my mortality generic 120mg sildalis amex, and I sure don’t think much importance of learning to accept oneself and about God discount 120 mg sildalis with visa. How might the nurse use blended nursing skills to is paying off my school debts and making money discount 120mg sildalis otc. The nurse could check Health Problem: Spiritual distress: spiritual anxiety with social services or look into community services Etiology: Challenged belief and value system that would allow her to attend her church services Signs and Symptoms: Recent massive heart attack; and other community support groups. What would be a successful outcome for this ily but, “for the last couple of years all I’ve been patient? What intellectual, technical, interpersonal, and/or about his religious belief system and re-evaluated ethical/legal competencies are most likely to bring sense of priorities. Encourage patient to continue to share concerns source of patient support, strength, or conﬂict, about his religious beliefs and value system. Arrange for patient to talk with the hospital’s plan of care Jewish chaplain in the morning. Normalize this experience by sharing with the ships, even in times of distress, crisis, and conﬂict. Respite care, meals-on-wheels, parish nursing, com- Evaluative Statement: Patient slept last 2 nights after munity support groups meeting with Rabbi White and reports being “less anxious” about “religion. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Sleeping department; history of establishing therapeutic rela- peacefully at present. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. This publication is sponsored by Davistown Museum Department of Environmental History www. Comments, criticisms, and suggestions are welcomed and may be directed to: curator@davistownmuseum. Biocatastrophe Lexicon: An Epigrammatic Journey Through the Tragedy of our Round-World Commons. Biocatastrophe: The Legacy of Human Ecology: Toxins, Health Effects, Links, Appendices, and Bibliographies. Ménage à Trois in the Sea Surface Microlayer: Nanoparticles as Vectors of Environmental Chemicals. The venues for their identification are the same hospitals, clinics, and research laboratories that lead to the pioneering adaptation of antimicrobial organisms to fight infectious diseases in developed and developing nations. The bibliographies are introduced by an overview of the historical context of the growth of antibiotic resistant microbes, including in ancient microbiomes of the distant past, and a synopsis of other infections of interest. Commentary includes observations about the human biome and the environmental, economic, social, and public health sources of resistant bacteria now rapidly spreading throughout the health care systems of the world and the communities they serve. In other countries, a much smaller percentage of the population has access to the sophisticated medical facilities that characterize developed nations. The potential impact of pandemics derived from a wide variety of microorganisms pose increasing public health threats as world population and frequency of international travel increase, factors supplementing the rising threat of antibiotic resistant diseases. The world is now, in effect, getting smaller just as its supplies of potable fresh water, including 3 fossil water, are being rapidly depleted, a topic to be further explored in volume 6 of this publication series. The answer lies in that huge panorama of microbiomes that are the basis for life on Earth. This vast landscape, which includes all aquatic and terrestrial environments, has its roots in ancient bacterial communities that can be traced back billions of years. Many now lost microbes once inhabited ancient bacterial microbiomes in all trophic levels of the biosphere. Their descendents continue to live in all the microbiomes that characterize the biosphere, one of hundreds of millions of which is the human gut. Human intestines are characterized by as many as 100 trillion microorganisms belonging to 200 or more microbial species. Thousands of years before the development of industrial agriculture and before the evolution of hospital-acquired infections, ancient environmental reservoirs of resistance characterized all microbiomes, including the microbial communities characterizing the human gut (stomach and intestines), skin, the vaginal environment, the lungs and nose and the oral environment of the mouth. A number of annotated citations in this text highlight these ancient reservoirs of bacteria and the change in the genes that evolved to counteract or control other bacterial infections. A whole new world of manmade environmental chemicals now characterizes our hemispheric water supply, including all biomes whose key constituent is water. Only a small percentage of the total volume of these effluents can be biodegraded or bioconverted to other metabolites by the creative diversity of our many microbial communities. The ecological, as well as the social, political, and economic context of our biosphere in crisis can now be summarized by an historical observation: (x) the growing impact of “antibiotic winter. Many pandemics have been halted by the vaccines produced by the world medical community. Polio, smallpox, and _____ head the list of dangerous plagues that are now medical history. The rapid spread of Lyme disease is an example of a viral infection that, unlike bacterial infections, cannot be treated with antibiotics, even though they use them a lot. All bacterial and viral infections are occurring in the context of a rapidly 5 growing world population and an expanding global consumer society. Contemporary society is now characterized by growing income inequality and a dramatic lack of funding for basic infrastructure maintenance. This lack of __________________ combines with growing political paralysis, at least in the United States, and a lack of informed consensus, all of which encourages the growing health care inequality that the world population now faces. Despite a dedicated and innovative med-techno-elite, the reality of the ecological impact of our beloved petrochemical-industrial-consumer product culture is the unfortunate downside of the glowing florescence of humanity in the Anthropocene. Humanity in the Anthropocene has developed pyrotechnical petrochemical technologies, which are the basis for the evolution of a sophisticated global industrial society. The phenomenon of microbial resistance occurs in the context of the evolution of this industrial society, which now spreads ecotoxins of every description throughout the hemispheric water cycle. Effective antibiotic treatments have been a key component of the evolution of modern society. We now enjoy a multitude of cascading Industrial Revolutions that include the many benefits of the Age of Plastics, the _____________ of the Age of Digital Technology, and the many inventions of the Age of Nanotechnology. The growing production and use of pharmaceuticals, an essential component of our sophisticated techno-medical health care systems, now also produce ubiquitous trace components of a multiplicity of organic chemicals in our surface and public water supplies. The plumes of pharmaceuticals now moving through our public water supply are accompanied by numerous antibiotic resistant species that now characterize the human biome. These antibiotic resistant species have evolved from many sources ranging from the ancient human microbiome to the growth of industrial agriculture. Misuse, and especially overuse, of antibiotics in the many communities served by _____________________ , especially including assisted living facilities, is another notable source of the evolution of antibiotic resistant bacteria. The context of the threat of antimicrobial resistance is a component of a world water crisis that reflects the impact of an industrial-military-consumer society on our vulnerable hemispheric water cycle. Our very high in the sky Googled historical overview might include the once fertile Babylonian Crescent (Tigris-Euphrates river valley), or the many sailing ships and timber framed wharfs characterizing the Wooden Age. At this point in the history of the Anthropocene there were no vaccines to counteract the many pandemics and infections 7 that were occurring. The source and ____________ of the Bubonic plague were not th well understood until the 20 century. The rapid increase in the quantity and varieties of chemical fallout had to await the multiplicity of cascading Industrial Revolutions that gave birth to military and industrial society and the growth of modern global consumer society. We can observe multiple oceanic gyres of plastic debris, or the brown tones characterizing oceanic eutrophication. The growing complexity of society below is part of a deteriorating environment characterized by anthropogenic chemical warfare against a finite round world biosphere. We see from our Google perch the growing presence of ±470 cities with over a million inhabitants. The chemical war we are waging on our water cycle and worldwide social unrest and warfare highlight the need for a sophisticated and dedicated medical community and ____________________________ important governmental agencies.
Assessment of sity of Pennsylvania (Penn) in 1954 purchase 120 mg sildalis with amex, where he began to Young Children buy sildalis 120mg mastercard. In his research trusted sildalis 120 mg, Beck attempted to discover a corre- Know About 150 of the Most Common Medical purchase 120 mg sildalis amex, Education- lation between depression and masochism. Beck cognitive method involves a person using rational thoughts to overcome fears rather than delving into the 1921- American neurologist and father of cognitive therapy. In cognitive therapy the fears of the client are carefully examined and con- fronted rationally. Beck was born in Providence, Rhode Is- Beck and his wife, Phyllis, a Superior Court Judge in land, on July 18, 1921, the third son of Russian Jewish Philadelphia, have four children and eight grandchildren. For years his main Beck’s childhood typified middle-class America, com- supporter was his wife, at a time when his beliefs were plete with his involvement in Boy Scouts and athletics. Throughout his career he has continued to From this mediocrity rose one of America’s ground- meet his critics by encouraging them to test his theories breaking psychotherapists. Rather than being a boorish scientist too known as cognitive therapy, which is used for cases smug to be proven wrong, Beck welcomes any challenges ranging from depression and panic attacks to addictions, in his pursuit of what is best for his patients. A life-threatening staph infection at Prozac and other modern anti-depressant drugs have the age of eight changed his life. More com- transformed from a very active young man to a quiet one plicated problems bring people to their doors at the be- who preferred reading to playing football. These are problems developed a fear of hospitals, blood, and even the scent that might take more than the usual eight to ten sessions a of ether, which made him feel as if he would faint. Even- relatively simple case of depression would take to re- tually, he overcame those fears rationally. Beck insists that his cognitive approach can be to be concerned about the faint feeling, but just to keep used to treat psychotic disorders,even those as serious active,” he later recounted. A prolific writer, Beck has authored several books and articles both on his own as well as under collaboration. His books include Prisoners of Hate (1999), Depression: Clinical, Experimental, and Theoretical (1980), Cognitive Therapy and the Emotion- al Disorders (1979), and Depression: Causes and Treat- ment (1972). The Beck Depression Inventory and Scale for Suicide Ideation are among two of the widely used tools that he developed for use by therapists. After the publication of this work, and with the general support of the medical community, Beers became a leading fig- Clifford Beers ure in the movement to reform the treatment of, and at- 1876-1943 titudes toward, mental illness. In the same year his American reformer and founder of the mental hy- book was published, Beers founded the Connecticut giene movement. Society for Mental Hygiene (a name suggested by the psychologist Adolf Meyer, another supporter of Clifford Whittingham Beers was born in New Beers’s efforts). This organization lobbied for im- Haven, Connecticut, studied at Yale University, and proved treatment of mental patients and heightened began a professional career in the insurance industry. In 1909, Beers or- 1900 he was institutionalized for a mental breakdown ganized the National Committee for Mental Hygiene after a suicide attempt and diagnosed as manic-depres- and served as its secretary until 1939. Confined to both public and private institutions establish the American Foundation for Mental Hygiene over a three-year period, Beers found the treatment of in 1928. When his ef- Beers’s influence eventually spread beyond the forts to complain directly to hospital administrators United States. Hincks were ignored, Beers smuggled letters out to state offi- found a mental hygiene society in Canada, the Canadian cials, and his efforts met with some success. Beers was ac- Beers was able to return to his career, but continued to tive in organizing the International Congress on Mental work on behalf of reforming the treatment of the men- Health in 1930, and three years later received an award tally ill. Beers’s autobiogra- a popular autobiographical study of his confinement phy remained popular and influential, having gone into and recovery, which was praised by the prominent psy- 26 printings by the time of his death in 1943. A treatment approach, based on the principles of operant conditioning, that replaces undesirable be- haviors with more desirable ones through positive This famous urban legend was perpetuated by a or negative reinforcement. The box was, in fact, a cli- Behavior modification is based on the principles of mate-controlled, baby-sized room that Skinner built, operant conditioning, which were developed by Ameri- called the “aircrib. In his research, sorbing wood, had a humidifier, an air filter, and was he put a rat in a cage later known as the Skinner Box, in temperature-controlled by a thermostat. Dissatisfied which the rat could receive a food pellet by pressing on a with traditional cribs, Skinner built the box to keep his bar. The food reward acted as a reinforcement by new daughter warm, safe, and quiet without having to strengthening the rat’s bar-pressing behavior. Skinner was quoted in studied how the rat’s behavior changed in response to dif- New Yorker magazine as saying his daughter “…spent fering patterns of reinforcement. By studying the way the most of the next two years and several months there, rats “operated on” their environment, Skinner formulat- naked and happy. The Skinner considered his discovery applicable to a wide box-like structure and people’s misunderstandings about range of both human and animal behaviors and intro- behavioral psychology contributed to the misconception duced operant conditioning to the general public in his that Skinner was experimenting on his daughter and also 1938 book, The Behavior of Organisms. People got the impression that Skinner was raising his child in a box similar to the kind he used to of problems in both adults and children. One behavior modification technique that is widely Behavior therapy used is positive reinforcement, which encourages certain behaviors through a system of rewards. In behavior ther- A goal-oriented, therapeutic approach that treats emotional and behavioral disorders as maladaptive apy, it is common for the therapist to draw up a contract learned responses that can be replaced by healthier with the client setting out the terms of the reward system. In addition to rewarding desirable behavior, behav- ior modification can also discourage unwanted behavior, In contrast to the psychoanalytic method of Sig- through either negative reinforcement, or punishment. The removal of reinforcement altogether is called havior therapy focuses on observable behavior and its extinction. This technique re- work, including the classical conditioning principles of moves the expected reward of parental attention. Behavior Modification: What It Is and How to concept of operant conditioning, in which behavior is Do It. By the Further Information 1970s, behavior therapy enjoyed widespread popularity Association for the Advancement of Behavior Therapy. Handbook of As an initial step in many types of behavioral thera- Behavior Therapy with Children and Adults: A Develop- py, the client monitors his or her own behavior carefully, mental and Longitudinal Perspective. The therapist’s role is often similar to An Empirical Approach to Mental Health Problems. Behavior Therapy: work assignments” and provides advice and encourage- Application and Outcome. A number of specific techniques are commonly used Further Information in behavioral therapy. Human behavior is routinely moti- Association for the Advancement of Behavior Therapy. Rules are established that specify particular behaviors that are to be reinforced, and a reward system is set up. With children, this sometimes takes the form of Behaviorism tokens that may be accumulated and later exchanged for A theory of human development initiated by Amer- certain privileges. Just as providing reinforcement ican educational psychologist Edward Thorndike, strengthens behaviors, withholding it weakens them. For example, a child who ha- Behaviorism is a psychological theory of human de- bitually shouts to attract attention may be ignored unless velopment that posits that humans can be trained, or con- he or she speaks in a conversational tone. The client is exposed to an that humans and animals acquire behaviors through the unpleasant stimulus while engaged in or thinking about association of stimuli and responses. Eventually the behavior itself laws of learning to explain why behaviors occur the way becomes associated with unpleasant rather than pleasant they do: The Law of Effect specifies that any time a be- feelings. One treatment method used with alcoholics is havior is followed by a pleasant outcome, that behavior the administration of a nausea-inducing drug together is likely to recur. The Law of Exercise states that the with an alcoholic beverage to produce an aversion to the more a stimulus is connected with a response, the taste and smell of alcohol by having it become associat- stronger the link between the two. In counterconditioning,amaladaptive 1936) groundbreaking work on classical conditioning response is weakened by the strengthening of a response also provided an observable way to study behavior. A well-known type of coun- though most psychologists agree that neither Thorndike terconditioning is systematic desensitization, which nor Pavlov were strict behaviorists, their work paved the counteracts the anxiety connected with a particular be- way for the emergence of behaviorism. This method is often used in the treatment of The birth of modern behaviorism was championed people who are afraid of flying. Modeling, another treat- early in the 20th century by a psychologist at Johns Hop- ment method, is based on the human tendency to learn kins University named John Watson. A desired behavior is Behaviorism, Watson made the notorious claim that, performed by another person while the client watches. Freudian psychoanalytical theories of development, which many people found threatening.
This is harder to achieve than venous occlusion because of the higher pressure in the arterial system and the thick- ness of the arterial walls; however buy 120 mg sildalis with mastercard, the effects of occlusion will become apparent much quicker buy 120mg sildalis fast delivery. Saukko and Knight (14) record that occlusion of the carotid circula- tion for 4 min or more may result in brain damage cheap 120mg sildalis amex, and Reay et al cheap sildalis 120mg fast delivery. A sleeper hold is applied when the upper arm compresses one side of the neck and the forearm the other and the larynx rests in the “V” formed by the elbow. Vagal stimulation 340 Shepherd results in bradycardia, which may progress to asystole or, in some cases, imme- diate asystole. Conversely, Kowai (17) concluded that the use of the choke hold could take between 10 and 20 s to cause unconsciousness, and, therefore, it was safe. Clearly, they did not experience the vagal effects of this hold in their experiments. Neck holds are commonly used in many forms of wrestling or martial arts, and in these situations, they are seldom associated with fatalities, possi- bly because of the ability of the person held to indicate his or her willingness to submit to a referee and so cause the hold to be released. No such author- ity is present during a restraint by police; perhaps this is why fatalities are recorded in this situation. In the United Kingdom, the use of neck holds by police during restraint is specifically prohibited and officers are warned dur- ing their training of the potentially fatal effects of applying any pressure to the neck. The pathological examination of deaths associated with compression of the neck requires a detailed and careful dissection of the neck structures (18). The finding of injuries to the muscular, cartilaginous, vascular, or neural com- ponents of the neck must be interpreted in the light of the restraint events, the actions of the restrainers, and the subsequent resuscitation, if any. Pressure on the neck to maintain an airway after cardiac or respiratory arrest may result in bruising, which could be confused with pressure before or, indeed, causing that arrest. Therapeutic insertion of cannulae during active resuscitation by paramedics or in the hospital commonly leads to marked hemorrhage in the neck that, although it is unlikely to be confused with bruising caused by a neck hold, may mask any bruising that was present. Pressure on the neck is not, of course, the only mechanism whereby an individual may suffer anoxia or asphyxiation. Any action that partially or completely occludes the mouth and/or the nose will result in difficulty in breathing and may result in asphyxiation. The features of these other causes of asphyxiation, traumatic or restraint asphyxia, are discussed in Subhead- ing 11. Homicide There have been numerous cases where individuals have been murdered in the cell by another inmate. Such deaths are most commonly associated with blunt trauma, but strangulation, stabbing, and other methods may be employed Deaths in Custody 341 if suitable weapons are available. It is also evident that individuals have been deliberately assaulted and killed by police officers during arrest and detention. The forensic physician should always be aware of the possibility that police may have used excessive force or that deliberately homicidal injuries may have been inflicted. If injuries are present on any individual in their care, these injuries must be carefully documented and, if they are beyond that which the physician considers reasonable in the circumstances, their concerns should be expressed immediately to a senior officer, to a legal representative of the detainee, and an official complaints procedure. The physician also has the duty to ensure that no further harm comes to that person. The methods used are variable but reflect the materials available to the indi- vidual at that time. Hanging To effect a hanging suicide, the individual must have two things: an object that can be made into a noose and a point on which to tie it. In addition, the individual must be able to place his or her body so that his or her body weight can be used to apply pressure to the neck via the noose. The materials and objects that can be made into a noose are many and vary from the obvious (ties, belts, shoelaces, etc) to the unusual (underwear, shirts, etc). To attempt to reduce the possibility of hanging suicides many police station cells have been redesigned and attachment points for the noose (pipes, bars, etc) have been removed or covered. However, the lack of these obvious points did not deter some individuals who placed the bed on end and used the upper end as the fixing point. Installation of fixed beds or benching should preclude the use of that method in future. It must be remembered that hanging can still be achieved, although is clearly more difficult, from a low suspension point, and any protrusion from a wall or fitment in a cell can potentially be used as the upper attachment for the noose. In addition to removing the fixing points, attempts have been made to remove the items that have been used as nooses in the past and belts, shoelaces, etc. Paper clothing has been used, although this has not been entirely successful because it entails removing all of the individual’s clothing, which is clearly impractical in many cases and may raise problems with human rights. If made strong enough to withstand any degree of wear, the paper clothing would also be strong enough to act as a noose. Given the speed with which hanging can be effected, it is most unlikely that anything other than a permanent watch over the suicidal detainee would provide a foolproof method to prevent hanging in a cell. A cycle of 15-min- utes checks will allow more than ample time for an individual to hang himself or herself and cannot be considered to be adequate protection against this type of suicide. Ligature Strangulation Because the possibility of suspension is reduced by the changes in the design of the cells, the possibility of other forms of self-asphyxiation are likely to increase. Self-strangulation by ligature is considered to be possible but dif- ficult (14); because the pressure has to be applied to the neck in these cases by the conscious muscular effort of the hands and arms, it follows that when consciousness is lost and the muscular tone lessens, the pressure on the liga- ture will decrease, the airway obstruction and/or the vascular occlusion will cease, and death will generally be averted. However, if the ligature is knotted or if the material is “non-slip” and looped around itself, then it is possible for the individual to apply the pressure to the neck and for that pressure to be maintained even after consciousness is lost and, as a result, death may follow. As with hanging, the key to preventing these deaths lies in careful evalu- ation and, if necessary, the removal of clothing and observation. Incised Injuries All prisoners should be carefully searched before incarceration, and any sharp objects or objects that could be sharpened must be removed. The extent of the search will probably depend on the mental state of the individual, and the possibility of an intimate search to exclude weapons concealed in the vagina or rectum should be considered in those individuals who are considered most at risk. Even if the individual is found before death has occurred, the effects of pro- found blood loss may make death inevitable, despite resuscitation attempts. Drugs When considering the possibility of suicide using drugs while in police custody, the two key factors are, once again, evaluation and searching. Care- ful searching (possibly including intimate searches in some cases) will pre- vent the ingestion of drugs by an individual after he or she has been placed in Deaths in Custody 343 the cell. The forensic physician must always be aware of the possibility that excessive quantities of a drug or drugs were taken before arrest and detention and may exert their effect when the individual is in the cell. Definition The exact definition of this syndrome remains elusive, despite many publications apparently describing similar events (19,20). Indeed, the many different names given to these apparently similar conditions (Bell’s mania, agitated delirium, excited delirium, and acute exhaustive mania) throughout the years indicate that it is a syndrome that may have many different facets, not all of which may be present in any single case. However, all of these descriptions do comment on the high potential for sudden collapse and death while the individual is in the highly excited states that they all describe. It is now accepted that such syndromes do exist, and although it is now com- monly associated with use and abuse of cocaine (21), it is important to note that it was described in 1849 well before cocaine use and abuse became com- mon (19). Features The clinical features of excited delirium are generally accepted to be the following: • A state of high mental and physiological arousal. In addition to these clinical observable features, there will certainly also be significant physiological and biochemical sequelae, including dehydration, lactic acidosis, and increased catecholamine levels (22). These biochemical and physiological features may be such that they will render the individual at considerable risk from sudden cardiac arrest, and the descriptions of cases of individuals suffering from excited delirium (23) indicates that the sudden death is not uncommon. Shulack (23) also records that: “the end may come so sud- denly that the attending psychiatrist is left with a chagrined surprise,” and continues: “the puzzlement is intensified after the autopsy generally fails to disclose any findings which could explain the death. In the context of restraint associated with death in cases of excited delirium, the presence of injuries to the neck may lead to the conclusion that death resulted from asphyxia, but this interpretation needs careful evaluation. What is perhaps of greater importance is that in all of the cases described in the clinical literature (19,20,23–25), there has been a prolonged period of increasingly bizarre and aggressive behavior, often lasting days or weeks before admission to hospital and subsequent death. The clinical evidence avail- able for the deaths associated with police restraint indicates that although there may have been a period of disturbed behavior before restraint and death, the duration of the period will have been measured in hours and not days. This change in time scale may result from the different etiology of the cases of excited delirium now seen, and it is possible that the “natural” and the “cocaine-induced” types of excited delirium will have different time spans but a common final pathway. The conclusion that can be reached concerning individuals displaying the symptoms of excited delirium is that they clearly constitute a medical emergency. The police need to be aware of the symptoms of excited delirium and to understand that attempts at restraint are potentially dangerous and that forceful restraint should only be undertaken in circumstances where the indi- vidual is a serious risk to himself or herself or to other members of the public.
Attitude and behavior Special assistance may not be limited to educational Attitude is a feeling buy generic sildalis 120mg, belief sildalis 120mg amex, or opinion of approval settings generic sildalis 120mg otc. Inatten- action or reaction that occurs in response to an tion purchase 120mg sildalis otc, shifting activities every five minutes, difficulty event or internal stimuli (i. Under other circumstances, that same man ly offer courses in discipline and behavior management. There are also a number of popular Ideally, positive attitudes manifest well-adjusted be- books that are informative and helpful. For example, someone may re- main in an abusive and potentially deadly domestic situa- Doreen Arcus, Ph. Behavior can be influenced by a number of factors Further Reading beyond attitude, including preconceptions about self and Barkley, R. Attention Deficit Hyperactivity Disorder: A others, monetary factors, social influences (what peers Handbook for Diagnosis and Treatment. New York: Guil- and community members are saying and doing), and dord Press, 1990. Driven to Distraction: Recog- about improving the public school system in their town, nizing and Coping with Attention Deficit Disorder from but if it means a hefty increase to their property taxes, Childhood through Adulthood. New York: Simon and they may vote against any improvements due to the po- Schuster, 1994. The Hyperactive Child, Adolescent, and Adult: At- supporter, showing that their actions (i. New York: attending parent-teacher organization meetings) are Oxford University Press, 1987. Cognitive therapy attempts to change irrational Further Information ways of thinking. One research study found that antismoking cam- Advertising, political campaigns, and other persuasive paigns targeted at teenagers can have a higher success media messages are all built on the premise that behavior rate when adolescent peers are used as instructors. Paula Ford-Martin The fields of social and behavioral psychology have researched the relationship between attitude and behav- ior extensively. The more psychologists can understand Further Reading the relationship between attitude and behavior and the Byrne, Donn and Robert A. The important social problems such as racism, gender bias, psychology of attitudes. It is also a key part of public health edu- cation initiatives, particularly in the case of preventive Attitudes and attitude change medicine. Campaigns promoting positive attitudes to- An attitude is a predisposition to respond cogni- wards prenatal care, abstinence from drug use, smoking tively, emotionally, or behaviorally to a particular cessation, sunscreen use, organ donations, safe sex, can- object, person, or situation in a particular way. In effect, social Attitudes have three main components: cognitive, af- marketing is “selling” attitudes and beliefs and ideally fective, and behavioral. The cognitive as- Changing behavior to influence attitudes pects of attitude are generally measured by surveys, inter- In 1955, clinical psychologist and educator George views, and other reporting methods, while the affective Kelly introduced his psychology of personal constructs. Behavior, on the other vidual looks at the world through his or her own unique hand, may be assessed by direct observation. Behavior does not always conform to a person’s feel- These constructs change and adapt as the individual is ings and beliefs. At the heart of may be suppressed because of a competing attitude, or in Kelly’s theory is the idea that individuals can seek new deference to the views of others who disagree with it. A experiences and practice and adapt new behaviors in classic theory that addresses inconsistencies in behavior order to change their attitudes (or constructs) towards the and attitudes is Leon Festinger’s theory of cognitive dis- world. He recommended that therapists encourage their sonance, which is based on the principle that people pre- patients to try out new behaviors and coping strategies; fer their cognitions, or beliefs, to be consistent with each he and others that followed frequently found that pa- other and with their own behavior. Inconsistency, or disso- tients would adapt these useful new behavior patterns nance, among their own ideas makes people uneasy and subsequently change their attitudes. For example, smokers forced to deal with the sometimes a result of social or peer pressure. While opposing thoughts “I smoke” and “smoking is dangerous” adult behavior generally follows from held attitudes, for are likely to alter one of them by deciding to quit smok- children, attitudes are often shaped by observed behavior. Test subjects ers and, to a degree, build their attitudes and beliefs from in hundreds of experiments have reduced cognitive disso- this learned behavior. There is, however, evi- quire many of their attitudes by modeling their parents’ dence of a direct link between self-esteem and attitude attitudes. People with low self-esteem are often not atten- uli is another method of attitude formation and one widely tive enough to absorb persuasive messages, while those used by advertisers who pair a product with catchy music, with high self-esteem are too sure of their own opinions soothing colors, or attractive people. The most easily ing, which utilizes rewards, is a mode of attitude forma- persuaded individuals tend to be those with moderate tion often employed by parents and teachers. Attitudes are levels of self-esteem, who are likely to pay a reasonable also formed through direct experience. It is known, in fact, amount of attention to what those around them say and that the more exposure one has toward a given object, remain open enough to let it change their minds. The medium of persuasion also influences attitude change (“the medium is the message”). Face-to-face One of the most common types of communication, communication is usually more effective than mass com- persuasion, is a discourse aimed at changing people’s at- munication, for example, although the effectiveness of titudes. The first any one component of communication always involves of these is the source, or communicator, of a message. The effects of persuasion be effective, a communicator must have credibility based may take different forms. Sometimes they are evident on his or her perceived knowledge of the topic, and also right away; at other times they may be delayed (the so- be considered trustworthy. In addition, people may often similarity between communicator and audience, the change their attitudes only to revert over time to their greater the communicator’s effectiveness. This is the original opinions, especially if their environment sup- principle behind politicians’ perennial attempts to por- ports the initial opinion. This practice has come to include dis- veloped by psychologist William McGuire, focuses on a tinguishing and distancing themselves from “Washing- chronological sequence of steps that are necessary for suc- ton insiders” who are perceived by the majority of the cessful persuasion to take place. They must then sage itself, the method by which the message is present- yield to the argument, and retain it until there is an oppor- ed is at least as important as its content. Attitude: Your Most Priceless Posses- provokes fear; and whether it presents its strongest argu- sion. New York: Cambridge University Press, present an identical message to two different groups, the 1986. The Psychology of Attitude Change and still vary because audience variables such as age, sex, Social Influence. Philadelphia: Temple University Press, and intelligence also affect attitude change. Some have at- tributed it to the superior verbal skills of females which may increase their ability to understand and process ver- Attraction, interpersonal bal arguments. Others argue that it is culturally deter- A favorable attitude toward, or a fondness for, an- mined by the greater pressure women feel to conform to other person. The effect of intelligence on attitude change is in- Both personal characteristics and environment play conclusive. According to another theory, a who come into contact regularly and have no prior nega- person will choose a partner who will enhance his or her tive feelings about each other generally become attracted own self-image or persona. Researchers generally ac- to each other as their degree of mutual familiarity and knowledge a specific set of courting or flirting behaviors, comfort level increases. Initially, first meet also determines how they will feel about each both men and women use varied repertoires of body lan- other. One is more likely to feel friendly toward a person guage to signal interest and/or availability. Women draw attention to themselves and opinions two people share, the greater the probabili- by tossing or playing with their hair, tilting their heads, ty that they will like each other. The first that disagreement on important issues decreases attrac- connection is generally made through eye contact, often tion. One of the most important shared attitudes is that an intent gaze which is then lowered or averted. If the liking and disliking the same people creates an especial- eye contact is positively received, a smile often follows ly strong bond between two individuals. If the attrac- tion progresses, the next step is casual touching in in- Personality type is another determinant of interper- nocuous areas such as the shoulder, wrist, or forearm. In areas involving control, such as dom- The final step in the initial romantic attraction is known inance, competition, and self-confidence, people tend to as mirroring or body synchrony, which is a matching of pair up with their opposites.
However generic sildalis 120 mg with mastercard, as with other body tissue order sildalis 120 mg otc, reperfusion injury (see Chapter 23) from calcium and oxygen radicals can reverse recovery generic sildalis 120 mg without prescription. Glomerulonephritis purchase sildalis 120mg line, inflammation of glomerular basement membrane, causes increased glomerular permeability. Large particles, such as erythrocytes and plasma proteins, may be filtered (Joynes 1996) or, with cellular debris, obstruct tubules, causing further back pressure (and damage) to glomeruli. Caused by obstruction between the kidneys and meatus (such as bladder tumours, renal/bladder calculi or an enlarged prostate), the resulting back pressure reduces filtration (Carlson 1995) and can cause intrarenal damage. As renal function fails, the volume of urine falls, while serum urea and creatinine levels rise. As damaged tubules begin to recover function and new (immature) tubule cells grow, filtration improves and obstruction to flow is removed. As selection tubular reabsorption of fluid and solutes is poor, large volumes of dilute urine are passed (up to 5 litres/day). Urea and creatinine levels fall, urine volumes return to normal, and electrolyte balance is restored. The main complications to body systems which result from renal failure are: Cardiovascular : ■ pericarditis ■ hyperkalaemia ■ acidosis ■ dysrhythmias ■ anaemia ■ hypertension (from renin) Nervous system : ■ confusion (from uraemia) ■ twitching ■ coma Intensive care nursing 316 Respiratory : ■ acidosis ■ pulmonary oedema ■ hiccough ■ compensatory tachypnoea Gut : ■ nausea ■ diarrhoea ■ vomiting Metabolic : ■ electrolyte disorders (see above) ■ toxicity from active drug metabolites ■ vitamin D deficiency Passively and actively, peritubular reabsorption of sodium in exchange for potassium and/or hydrogen ions maintains homeostasis, and so renal failure usually causes electrolyte imbalance: potassium : hyperkalaemia often occurs, although polyuria can cause hypokalaemia sodium : hyponatraemia may occur, especially with polyuric failure hydrogen : failure to excrete hydrogen ions causes metabolic acidosis Hypocalcaemia, hypophosphataemia and hypomagnesaemia can also occur (Carlson 1995). Many of these electrolytes affect cardiac and other muscle cell conduction so that dysrhythmias and generalised muscle twitching/weakness may occur. Muscle weakness will limit the effectiveness of patient-initiated breaths and weaning. Acid-base : normal renal function maintains acid-base balance by reabsorbing bicarbonate and excreting hydrogen atoms; urinary pH, normally about 5, can be as high as 8. Acidosis stimulates tachypnoea to compensate metabolic acidosis with respiratory alkalosis, but respiratory failure will limit effectiveness; excessive triggering (e. With nephritis, albumin is filtered due to: ■ loss of glomerular capillary negative charge ■ increased glomerular bed permeability (inflammatory response). Renin initiates the renin-angiotensin-aldosterone cascade: angiotensin (a systemic vasoconstrictor) and aldosterone (increasing tubular reabsorption of sodium and water) increase systemic blood pressure and volume. Restoration of afferent arteriole perfusion Acute renal failure 317 pressure inhibits further renin release. This homeostatic mechanism therefore maintains renal perfusion pressure during hypovolaemia. Autoregulation fails when mean arteriole blood pressure falls below 70 mmHg (Carlson 1995); prolonged and profound hypotension frequently complicates critical illness. Similarly, prerenal failure from renal artery stenosis causes systemic hypertension which may compound cardiovascular complications. Anaemia complicates renal failure due to: ■ lack of erythropoietin (Schobersberger et al. Management Too often prerenal failure remains undertreated, and so progresses to intrarenal failure; early intervention can prevent many complications. If renal failure is suspected, cardiovascular status should be optimised by providing adequate fluids. This necessitates using large-molecule fluids, such as hydroxethyl starches (unless patients are receiving renal replacement therapy, these can cause fluid overload, and so haemodynamic status should be closely monitored) rather than cheaper low molecular weight colloids (see Chapter 33). Once blood volume and pressure are optimised, a fluid challenge helps to identify any failure of renal function. Although much debated, the choice between colloid and crystalloid for fluid challenges is probably less important than ensuring that glomerular beds receive sufficient volume to filter; fluid challenge should determine whether urine is produced, and so fluids well below renal threshold (crystalloid) are appropriate. However, fluids below capillary threshold will also be filtered into other body tissues, including alveoli. Pulmonary oedema can soon result from overload of low molecular weight fluids (such as crystalloid), so that fluid challenge volumes should be limited to sufficient to diagnose the problem. If kidneys do not respond to fluid challenges, then medical management involves drugs (see below). Traditional dietary management aims to compen-sate for electrolyte imbalances and reduce glomerular workload (and so damage) by restricting protein (a ‘renal’ diet) (Uldall 1988), although this approach is now questioned. When conservative measures fail, some form of continuous renal replacement therapy (see Chapter 35) is needed. There are a number of possible new developments which may in time become established ways to manage renal failure, and these are discussed at the end of this chapter. Intensive care nursing 318 Diuretics Frusemide blocks sodium reabsorption in the ascending loop of Henle; as reabsorption of water is passive, retention of sodium in filtrate increases urine volume. Increased intraluminal flow may prevent or remove tubular obstruction from debris (Adam & Osborne 1997). Frusemide is ototoxic and so should be given slowly; with high-doses this necessitates continuous infusion. Mannitol, an osmotic diuretic, also vasodilates renal blood vessels (Joynes 1996). Reducing interstitial fluid reduces tubular swelling, while increasing intraluminal flow clears obstructing debris (Joynes 1996). McHugh (1997) suggests that high-dose mannitol can reduce duration of dialysis, although this remains to be established. Stimulation of dopamine receptors causes dilation, increasing glomerular blood flow, so increasing filtration volumes. Dopamine does increase urine volume, but animal studies suggest that dopamine- mediated vasodilation only occurs with normal perfusion, urine volumes being increased by dopamine inhibition of sodium reabsorption in distal tubules (which contain more dopamine receptors than juxtaglomerular apparatus) rather than increasing glomerular filtration (Ervine & Milroy 1997). Ervine and Milroy (1997) recommend dopexamine (at 2 mg/kg/min) to increase renal blood flow (this level exceeds recommended dose ranges). Currently, there is growing evidence that dopamine treats staff and fluid balance charts rather than patients; it may have a place in removing fluid overload and preventing tubular obstruction, but dobutamine and other inotropes are increasingly replacing renal dopamine. Renal rescue A protocol from Charing Cross Hospital (London) aims to achieve normo-volaemia, normotension and decreased ion pumping in the ascending loop of Henle by optimising fluid management (Palazzo & Bullingham 1994); this is effectively recognising and treating prerenal failure before it progresses. While management of multisystem-failure patients needs a holistic rather than a reductionist perspective, renal rescue protocols appear to be promising. Exogenous human atrial natriuretic peptide (extracted factor) can be given to improve creatinine clearance, reducing the need for dialysis and reducing mortality (Rahman et al. Urodilatin (a renal peptide, similar to atrial natriuretic factor) improves diuresis without causing systemic hypotension (Cedidi et al. Insulin-like growth factor Animal studies show that this hormone (also called somatomedin C) stimulates anabolism, protein synthesis and renal perfusion. Rhabdomyolysis Awareness of rhabdomyolysis (muscle necrosis) is poor, but improving, yet it causes up to one-quarter of all cases of acute renal failure (Cunningham 1997). The causes of muscle damage include ■ crush injuries ■ thermal injury ■ infection ■ prolonged immobilization. Myoglobin, the oxygen-carrying iron-containing pigment in skeletal muscle, is released; weighing 17 kDa, this is below renal threshold and so is filtered (colouring urine deep red or brown). While mortality from primary renal failure is encouragingly low, mortality from multisystem failure remains high. Renal failure is failure of renal function, and so it causes fluid overload, electrolyte imbalances, acid-base imbalances and other metabolic complications; these further complicate underlying pathologies. Further reading Most applied physiology texts include overviews of renal failure, although recent changes in practice limit the value of older texts. Among journal articles, McHugh (1997) gives a useful general perspective; Stewart and Barnett’s (1997) paediatric article is also useful. Uldall’s (1988) classic book on renal nursing is useful for basic principles, although its age necessitates cautious reading for changes in practice. Clinical scenario David Sinclair is a 58-year-old film critic who is known to suffer from hypertension, angina and gout. Mr Sinclair collapsed at home and was found by neighbours after lying on the floor for approximately 18 hours. A urinary catheter was inserted and Mr Sinclair produced less than 15 ml/h of dark cloudy urine. Examine his abnormal values and risk factors and give a rationale for Mr Sinclair having pre-, intra- or post-renal failure. As part of the multidisciplinary team, nurses should therefore understand how factors, such as likely extravasation, affect patients. Body fluid may be divided as: ■ extracellular ■ intracellular Extracellular fluid is further divided into ■ intravascular ■ interstitial Fluid balance is homeostasis of total body water. Although this chapter focuses on intravascular fluid resuscitation, these compartments are dynamic, not static, and problems with one compartment may compound other problems: critical illness is often complicated by both hypovolaemia and interstitial oedema.