By I. Urkrass. University of Guam.

Angiography: A rapid series of films obtained after a bolus contrast injection via percu- taneous catheter alesse 0.18 mg amex. Used to image the aorta purchase alesse 0.18mg on line, major arteries and branches order alesse 0.18mg online, tumors purchase alesse 0.18mg, and venous drainage via late “run-off” films. Significant (>70% occlusion) stenotic lesions seen: 30% involve single ves- sels, 30% involve two, and 40%, three vessels. Can discriminate angina secondary to aortic valve disease and that from CAD • Cerebral angiography. Evaluation of intra- and extracranial vascular disease, ather- osclerosis, aneurysms, and A-V malformations. Not used for detection of cerebral structural lesions (use MRI or CT instead) • Pulmonary angiography. Visualization of emboli, intrinsic or extrinsic vascular ab- normalities, A-V malformations, and bleeding due to tumors. Most accurate diag- nostic procedure for PE but only used if lung V/Q scan is not diagnostic BE: Examining the colon and rectum. Indications include diarrhea, crampy abdominal pain, heme-positive stools, change in bowel habits, and unexplained weight loss • Air-contrast BE. Done with the “double contrast” technique (air and barium) to bet- ter delineate the mucosa. Similar to the barium enema, but water-soluble contrast is used (clears colon more quickly than barium). If the Gastrografin leaks from the GI tract, it is less irritating to the peritoneum (does not cause “barium peritonitis”). Therapeutic in the evaluation of severe obstipation, colonic volvulus, perforation, di- verticulitis, or postop anastomotic leak Barium Swallow (Esophagogram): Evaluating the swallowing mechanism and in- vestigating esophageal lesions or abnormal peristalsis Cystogram: Bladder filled and emptied and a catheter in place. Used to evaluate bladder filling defects (tumors, diverticulum) and bladder perforation. Can also be done using CT scanning (see also VCUG) Enteroclysis: Selective intubation of the proximal jejunum and rapid infusion of con- trast. Better than an SBFT in evaluating polyps or obstruction (adhesions, internal hernia, etc). May be used to evaluate small-bowel sources of chronic bleeding after negative upper and lower endoscopy ERCP: Contrast endoscopically injected into the ampulla of Vater to visualize the com- 15 mon bile and pancreatic ducts in evaluating obstruction, stones, and ductal pattern Fistulogram (Sinogram): Injection of water-soluble contrast media into any wound or body opening to determine the connection of the wound or opening with other structures HSG: Evaluating uterine anomalies (congenital, fibroids, adhesions) or tubal abnormalities (occlusion or adhesion) often as part of infertility evaluation. Contraindicated during menses, undiagnosed vaginal bleeding, acute PID, or if pregnancy suspected. Patient in pelvic exam position, speculum placed and uterine os cannulated; then contrast injected ExU or IVP: Contrast study of the kidneys and ureters. Indications include flank pain, kidney stones, hematuria, UTI, trauma, and malignancy. Nephrotomograms often included that include cuts of the kidney to further define the three-dimensional location or nature of renal lesions or stones Lymphangiography. Iodinated oil injected to opacify lymphatics of the leg, inguinal, pelvic, and retroperitoneal areas. Used to test the integrity of the lymphatic system or evalu- ate for metastatic tumors (testicular, etc) or lymphoma 15 Imaging Studies 329 Myelogram: Evaluating the subarachnoid space for tumors, herniated disks, or other cause of nerve root injury. Using LP technique, contrast injected in the subarachnoid space OCG: Visualizing gallbladder in the evaluation of cholelithiasis or cholecystitis. Used infrequently PTHC: Visualizing biliary tree in a patient unable to concentrate the contrast media (bilirubin >3 mg/100 mL). Percutaneous Nephrostogram: In the management of renal obstruction, percuta- neous placement through the renal parenchyma and into the collecting system to relieve and or evaluate the level and cause of obstruction RPG: Contrast material injected into the ureters through a cystoscope. Indications in- clude allergy to IV contrast, a kidney or ureter that cannot be visualized on an IVP, filling defects in the collecting system, renal mass, and ureteral obstruction RUG: Demonstrates traumatic disruption of the urethra and urethral strictures SBFT: Usually done after a UGI series. Used in the work-up of diarrhea, abdominal cramps, malabsorption, and UGI bleeding T-Tube Cholangiogram: Resolution of swelling in some patients who have a T-tube placed in the common bile duct for drainage after gallbladder and common bile duct surgery.

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NEVER abbreviate U for units as it can easily be read as a zero buy alesse 0.18mg fast delivery, thus “6 U regular in- sulin” can be misread as 60 units cheap alesse 0.18 mg with amex. When poorly written cheap alesse 0.18mg without prescription, the tail of the “q” can make it read qid or four times a day buy cheap alesse 0.18 mg. The basic meta- bolic panel is similar to the SMA-6 except that the creatinine is also listed. Remember: “There are more uncommon presentations of com- mon diseases than common presentations of uncommon diseases. Amenorrhea is catego- rized as primary (never had menses) or secondary (cessation of menses). In children, the minimum dura- tion is 2 weeks and the temperature is at least 101. HEMATEMESIS AND MELENA Melena generally means that the bleeding site is in the upper GI tract (ie, proximal to the ligament of Treitz), but occasionally can be as distal as the right colon. Other laboratory tests can be found in the following chapters: Hematology, Chapter 5; Urine Studies, Chap- ter 6; Microbiology, Chapter 7; and Blood Gases, Chapter 8. With the institution of DRGs, it becomes imperative to understand appropriate, as well as economical, laboratory testing patterns. Laboratory testing should be guided by, but not a substitute for, an effective history, physical, and careful clinical assessment. Most laboratories offer AMA recommended “panel” tests, whereby multiple determina- tions are performed on a single sample. Although your lab may vary, some common chem- istry panels include: Basic Metabolic Panel: BUN, calcium, creatinine, electrolytes (Na, K, Cl, CO2), glucose Cardiac Enzymes: CK-MB (if total CK >150 IU/L), troponin Chem-7 Panel/SMA-7: BUN, creatinine, electrolytes (Na, K, Cl, CO2),glucose 4 Laboratory Diagnosis: Chemistry, Immunology, and Serology 55 Comprehensive Metabolic Panel: Albumin, alkaline phosphatase, ALT (SGPT), AST (SGOT), bilirubin (total), BUN, calcium, creatinine, electrolytes (Na, K, Cl, CO2), glu- cose, protein (total) Electrolytes: Sodium, potassium, chloride, CO2, (Na, K, Cl, CO2) Health Screen-12/SMA-12: Albumin, alkaline phosphatase, AST (SGOT), bilirubin (total), calcium, cholesterol, creatinine, glucose, LDH, phosphate, protein (total), uric acid Hepatic Function Panel: Albumin, alkaline phosphatase, ALT (SGPT), AST (SGOT), 4 bilirubin (total & direct), protein Lipid Panel: Cholesterol, HDL cholesterol, LDL cholesterol (calculated), triglycerides The Système International (SI) is a metric-based laboratory data-reporting system that is used internationally. The SI unit for expressing enzymatic activity is the “katal”; however, most countries have adopted units per liter (U/L) as an alternative measure of enzymatic activity. For most lab values, repre- sentative SI units have been included; however, each individual laboratory should be con- sulted for its “normal” values. If an increased or decreased value is not clinically useful, it is usually not listed. Be- cause each laboratory has its own set of normal reference values, the normals given should only be used as a guide. This section includes the method of collec- tion since laboratories have attempted to standardize collection methods; however, be aware that some labs may have alternative collection methods. ACETOACETATE (KETONE BODIES, ACETONE) • Normal = negative • Collection: Red top tube Positive: DKA, starvation, emesis, stress, alcoholism, infantile organic acidemias, iso- propanol ingestion ACID PHOSPHATASE (PROSTATIC ACID PHOSPHATASE, PAP) • <3. Secondary Adrenal Insufficiency: Caused by pituitary insufficiency or suppression by exogenous steroids, cortisol does not increase, but aldosterone does. Decreased: Cirrhosis, liver diseases, nephrotic syndrome, chronic glomerulonephritis, cachexia, burns, chronic infections and inflammatory states, myeloma ALDOSTERONE • Serum: Supine 3–10 ng/dL (SI: 0. Increased: Primary hyperaldosteronism, secondary hyperaldosteronism (CHF, sodium depletion, nephrotic syndrome, cirrhosis with ascites, others), upright posture Decreased: Adrenal insufficiency, panhypopituitarism, supine posture ALKALINE PHOSPHATASE • Adult 20–70 U/L, child 20–150 U/L • Collection: Tiger top tube; part of SMA-12 A fractionated alkaline phosphatase was formerly used to differentiate the origin of the en- zyme in the bone from that in the liver. Positive: SLE, drug-induced lupus-like syndromes (procainamide, hydralazine, isoni- azid, etc), scleroderma, MCTD, RA, polymyositis, juvenile RA (5–20%). Increased Direct (Conjugated): Note: Determination of the direct bilirubin is usually unnecessary with total bilirubin levels <1. Liberated when proinsulin is split to insulin; levels suggest endogenous production of insulin Decreased: Diabetes (decreased endogenous insulin), insulin administration (factitious or therapeutic), hypoglycemia C-REACTIVE PROTEIN (CRP) • Normal = none detected • Collection: Tiger top tube A nonspecific screen for infectious and inflammatory diseases, correlates well with ESR. Increased: Bacterial infections, inflammatory conditions (acute rheumatic fever, acute RA, MI, transplant rejection, embolus, inflammatory bowel disease), last half of pregnancy, oral contraceptives, some malignancies CA 15-3 Used to detect breast cancer recurrence in asymptomatic patients and monitor therapy. Lev- els related to stage of disease Increased: Progressive breast cancer, benign breast disease and liver disease Decreased: Response to therapy (25% change considered significant) CA 19-9 • <37 U/ml (SI:<37 kU/L) • Collection: Tiger top tube Primary used to determine resectability of pancreatic cancers (ie, >1000U/mL 95% unresectable) Increased: GI cancers such as pancreas, stomach, liver, colorectal, hepatobiliary, some cases of lung and prostate, pancreatitis CA-125 • <35 U/mL (SI: <35 kU/L) • Collection: Tiger top tube Not a useful screening test for ovarian cancer when used alone; best used in conjunction with ultrasound and physical examination. Rising levels after resection predictive for recur- rence Increased: Ovarian, endometrial, and colon cancer; endometriosis; inflammatory bowel disease; PID; pregnancy; breast lesions; and benign abdominal masses (teratomas) 4 Laboratory Diagnosis: Chemistry, Immunology, and Serology 61 CALCITONIN (THYROCALCITONIN) • <19 pg/mL (SI: <19 ng/L) • Collection: Tiger top tube Increased: Medullary carcinoma of the thyroid, C-cell hyperplasia (precursor of medullary carcinoma), small (oat) cell carcinoma of the lung, newborns, pregnancy, chronic renal insufficiency, Zollinger–Ellison syndrome, pernicious anemia. If it is not within nor- mal limits, a corrected calcium can be roughly calculated by the following formula. Aldosterone decreases 2 h later from baseline in normals or essential hypertension, but does not suppress in pa- tients with aldosteronism. For renovascular hypertension, the PRA increases >12 ng/mL/h and an absolute increase of 10 ng/mL/h plus a 400% increase in PRA if pretest level <3 ng/mL/h and >150% over baseline if the pretest PRA was >3 ng/mL/h.

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Carpal tunnel syndrome pain treated with low- level laser and microamperes transcutaneous electric nerve stimulation: a controlled study generic 0.18mg alesse with amex. Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized purchase 0.18 mg alesse free shipping, controlled trial buy alesse 0.18 mg otc. Use of electrical stimulation at acupuncture points for the treatment of reflex sympathetic dystrophy in a child: a case report buy 0.18mg alesse with visa. Clinical and biochemical observations during treatment of depression with electroacupuncture: a pilot study. The effects of high and low frequency electroacupuncture in pain after lower abdominal surgery. Ann Intern Med 2002; 137:965–73 7 Naturopathic medicine in neurological disorders Lynne Shinto and Carlo Calabrese Complementary Therapies in Neurology: An Evidence-Based Approach Edited by Barry S. Oken ISBN 1-84214-200-3 Copyright © 2004 by The Parthenon Publishing Group, London NATUROPATHIC MEDICINE John Sheel and Benedict Lust founded and named the practice of naturopathy at the end of the 19th century. Their aim was to coalesce several traditions of natural medicine including herbalism, diet therapy, hydrotherapy and homeopathy into a single practice that contrasted with the often harmful chemical interventions of the time. Naturopathic medicine is now a worldwide profession in the USA, Germany, Canada, the UK, Australia and India. In the USA and Canada, naturopathic medicine is a primary health- care profession which functions to promote health, and to prevent, diagnose and treat disease. The intent of a naturopathic doctor (ND) is to stimulate the self-healing capacities of the individual by using a number of therapeutic modalities which include botanical medicines, clinical nutrition and nutritional supplements, homeopathy, physical medicine (physiotherapy, hydrotherapy, manipulation) and psychological counseling. The practice is guided by principles most recently articulated by the American Association of Naturopathic Physicians (AANP) in 1989: (1) First, do no harm. The multifactorial nature of health and disease requires attention to the physical, mental, emotional, spiritual, social and ecological aspects of our nature. Diagnosis and treatment that are constitutional and holistic are among the foundations of naturopathy. The prevention of disease by the attainment of optimal health is a primary objective. Naturopathic medicine is practiced as either a complement or an alternative to conventional medicine under different circumstances. Licensed NDs are considered by many to be the most broadly trained in complementary and alternative medicine (CAM) practices and by some to be the best prepared for integration into the mainstream health- care system, owing to their education in both conventional biomedical sciences and a broad range of natural medicine modalities. Education and training Licensed NDs in the USA and Canada have almost always graduated from one of five accredited 4-year naturopathic colleges (Table 1). The four US colleges have been accredited by the Council for Naturopathic Medical Education (CNME) which provides for a standardized educational process. The 4-year training provided at these post- baccalaureate colleges includes lectures and laboratory work in the biomedical sciences and natural therapeutics. The first 2 years cover biomedical sciences and diagnostics including anatomy, biochemistry, physiology, histology, neuroscience, pathology, pharmacology, laboratory and clinical diagnosis and naturopathic philosophy. There are overviews as well on the philosophy and approach of other holistic medical systems such as ayurvedic medicine, and traditional Chinese medicine (TCM). The remaining 2 years focus on naturopathic therapeutic modalities with an emphasis on clinical coursework and experience. Courses include Table 1 Accredited naturopathic colleges in the USA and Canada Name Address and website Bastyr University 14500 Juanita Drive, NE, Kenmore, WA 98028 (425) 823–1300 http:// The five naturopathic colleges also house clinics for naturopathic treatment for a wide variety of disease conditions. Practical clinical training occurs primarily in these clinics where licensed NDs supervise and mentor students during clinical rotations. All the naturopathic colleges have postgraduate residency programs, but currently post-graduate residency is not required as part of training and licensing. Often, graduates will join the practices of experienced clinicians before setting out on their own. Licensing and scope of practice In the USA a naturopathic physician must be licensed to practice in at least one of 11 states and two US territories (Table 2). The license is typically broad, allowing naturopathic doctors (NDs, or in some jurisdictions NMDs) to diagnose and treat disease using any natural means.

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The major biological functions of angiotensin II (cardiovascular regulation) cardiac muscle cells and can exert a direct inotropic ef- are mediated through the ATI receptor buy discount alesse 0.18mg online. In addition purchase 0.18mg alesse fast delivery, angiotensin II can spite the increased presence of AT2 receptors in fetal stimulate the sympathoadrenal system and thereby in- tissues generic 0.18 mg alesse with visa, a lack of AT2 receptors appears to be compati- crease myocardial contractility alesse 0.18mg otc. Current evidence suggests that in general, on vascular smooth muscle, the ability of angiotensin to stimulation of the AT2 receptor appears to oppose increase the contractile force of the heart is far less po- those physiological actions of angiotensin II that are tent. In fact, angiotensin II may uct of the renin–angiotensin system, interacts with a decrease cardiac output through reflex bradycardia in- unique receptor termed the angiotensin IV receptor; this duced by the rise in peripheral resistance that it causes. Vascular Permeability PHARMACOLOGICAL ACTIONS Angiotensin II can cause a net fluid accumulation in tis- While the following discussion addresses the pharma- sues and has been shown to increase the permeability of cology of angiotensin II that is mediated through the the endothelium in large arteries and to widen the in- AT1 receptor, most of these responses also follow ad- terendothelial spaces in the aorta and in coronary, ministration of angiotensin III. Angiotensin 1-7 is giotensin II probably reflects the effect of elevated pres- considered to be biologically active and has been sure on the endothelial permeability barrier. The pep- demonstrated to exert effects that are similar to, oppo- tide also stimulates the release of the vasodilator site of, or totally distinct from those of angiotensin II. These actions of angiotensin II on cell growth in- volve interactions with other growth factors and are Renin Inhibitors relevant to the pathophysiology of both hypertension and congestive heart failure. The acid protease inhibitor pepstatin and some ana- logues of angiotensinogen can competitively inhibit the formation of angiotensin I by human renin. Highly spe- Central Nervous System cific renin inhibitors may prove beneficial as antihyper- Administration of angiotensin II into the vertebral cir- tensive agents or in the treatment of congestive heart culation increases peripheral blood pressure. Despite extensive efforts to develop renin in- pertensive action, mediated by the central nervous sys- hibitors, most compounds capable of inhibiting renin tem, is primarily the result of an increase in central are large peptidelike molecules that lack adequate efferent sympathetic activity going to the periphery. Inhibitors Angiotensin II produces changes in body hydration and thirst by a direct action in the central nervous sys- Many of the orally active ACE inhibitors are prodrugs. The administration of angiotensin II into the sep- These include perindopril, quinapril, benazepril, ramipril, tal, anterior hypothalamic, and medial preoptic areas enalapril, trandolapril, and fosinopril. Part of the volume response also may be caused by the antina- Captopril triuretic and antidiuretic effects of angiotensin II. Captopril (Capoten) is an orally effective ACE inhibitor Angiotensin II, administered into the central nerv- with a sulfhydryl moiety that is used in binding to the ous system, increases the release of luteinizing hor- active site of the enzyme. Captopril blocks the blood mone, adrenocortical hormone, thyroid-releasing hor- pressure responses caused by the administration of an- mone, -endorphin, vasopressin, and oxytocin from the giotensin I and decreases plasma and tissue levels of an- anterior pituitary. Pharmacological Actions Treatment with captopril reduces blood pressure in Sympathetic Nervous System patients with renovascular disease and in patients with Angiotensin II, acting at presynaptic receptors on nora- essential hypertension. The decrease in arterial pressure drenergic nerve terminals, potentiates the release of is related to a reduction in total peripheral resistance. Aside from its action on the nerve the hypotensive effect of inhibitors and the degree of terminals of postganglionic sympathetic neurons, an- blockade of the renin–angiotensin system. Many of the giotensin II can directly stimulate sympathetic neurons pharmacological effects of captopril are attributable to in the central nervous system, in peripheral autonomic the inhibition of angiotensin II synthesis. ACE is a relatively nonselective enzyme that also ca- tabolizes a family of kinins to inactive products (Fig. Bradykinin, one of the major kinins, acts as a va- Adrenal Cortex and Aldosterone sodilator through mechanisms related to the production Secretion of nitric oxide and prostacyclin by the vascular en- Angiotensin II stimulates aldosterone synthesis and se- dothelium. Increases in humans is not accompanied by an increase in glucocor- bradykinin concentrations after administration of ACE ticoid plasma levels. Chronic administration of an- inhibitors contribute to the therapeutic efficacy of these giotensin II will maintain elevated aldosterone secretion compounds in the treatment of hypertension and con- for several days to weeks unless hypokalemia ensues. However, alterations in bradykinin 18 The Renin–Angiotensin–Aldosterone System and Other Vasoactive Substances 211 Propranolol Methyldopa Indomethacin Prorenin Liver Kidney? Renin Angiotensinogen Renin inhibitors Prolylendopeptidase Angiotensin I Angiotensin I-7 Aase CE (des-Asp1) Angiotensin I Blood pressure Angiotensin converting enzyme inhibitors Angiotensin II CE Vasoconstriction Volume Saralasin Aase A Losartan Aldosterone Aase B Angiotensin III Adrenal Angiotensin IV gland FIGURE 18. Serum Captopril enhances cardiac output in patients with potassium levels are not affected unless potassium sup- congestive heart failure by inducing a reduction in ven- plements or potassium-sparing diuretics are used con- tricular afterload and preload. Other common adverse effects are fever, a persistent dry cough (incidence as high as 39%), initial dose hypotension, and a loss of taste that may result in Angiotensin II Inactive peptide fragments anorexia. More serious toxicities include a Interrelationship between the renin–angiotensin system and 1% incidence of proteinuria and glomerulonephritis; bradykinin. Since food reduces the bioavailability of captopril by 30 to 40%, administration of the drug an hour before thickness of the left ventricle in both normal and hy- meals is recommended.

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