By H. Tempeck. Wofford College.

Identifying patients at nutrition risk is crucial because malnutrition is prevalent among hospitalized patients and has been associated with adverse clinical outcomes trusted 1 mg arimidex. Situa- tions that predispose a patient to malnutrition include recent and continuing nausea cheap arimidex 1mg with visa, vomit- ing buy 1mg arimidex visa, diarrhea arimidex 1mg free shipping, inability to feed oneself, inadequate food intake (cancer-related, others), decreased nutrient absorption or utilization, and increased nutrient losses and nutritional re- quirements. If needed, detailed nutritional assessment may be needed for some patients and is discussed in the following section. Although many patients are admitted to the hospital in a nutritionally depleted state, some patients become malnourished during their hospital stay. According to guidelines from the American Society for Parenteral and Enteral Nutrition, “patients should be considered malnourished or at risk of developing malnutrition if they have inadequate nutrient intake for 7 days or more or if they have a weight loss of 10% or more of their preillness body weight. Anthropometric evaluations include comparisons of actual body weight to ideal and usual body weight. Other anthropometric measurements, such as MAMC and TCF, have much 205 Copyright 2002 The McGraw-Hill Companies, Inc. Absolute lymphocyte count is sometimes used as a marker of visceral proteins and im- munocompetence. Visceral protein markers, such as prealbumin and transferrin, may be helpful in evaluating nutritional insult as well as catabolic stress. Although the most com- monly quoted laboratory parameter of nutritional status is albumin, the albumin concentration often reflects hydration status and metabolic response to injury (ie, the acute phase response) more than the nutritional state of the patient, especially in patients with intravascular volume deficits. Preal- bumin is superior as an indicator of malnutrition only because of its shorter half-life. Use of these serum proteins as indicators of malnutrition is subject to the same limitation, however, because they are all affected by catabolic stress. Patients can generally be classified as mildly, moderately, or severely nutritionally depleted based on these parameters. Caloric needs can be determined by one of two means: the Harris–Benedict BEE and the “rule of thumb” method. Total energy requirements = BEE ×Activity factor × Stress factor Use the following correction factors: Activity Level Correction Factor Bedridden 1. T h u s i s m o r e s e n s i t i v e i n d i c a t o r 1 0 – 1 5 m g / d L M i l d d e p l e t i o n o f a c u t e c h a n g e i n n u t r i t i o n a l s t a t u s t h a n i s 5 – 1 0 m g / d L M o d e r a t e d e p l e t i o n a l b u m i n o r T F N < 5 m g / d L S e v e r e d e p l e t i o n N o t r o u t i n e l y a v a i l a b l e L e v e l s a r e q u i c k l y d e p l e t e d a f t e r t r a u m a o r a c u t e i n f e c t i o n. A l s o d e c r e a s e d i n r e s p o n s e t o c i r r h o s i s, h e p a t i t i s, a n d d i a l y s i s, a n d t h e r e - f o r e, s h o u l d b e i n t e r p r e t e d w i t h c a u t i o n A b s o l u t e l y m p h o c y t e c o u n t 1 4 0 0 – 2 0 0 0 M i l d d e p l e t i o n M a y n o t b e v a l i d i n c a n c e r p a t i e n t s. DETERMINING THE ROUTE OF NUTRITIONAL SUPPORT Once nutritional support is indicated, the route for administration is chosen. Enteral supple- mentation by mouth or tube and parenteral nutrition are the main routes for providing nutri- tional support. Enteral Supplementation and Tube Feeding 11 Enteral nutrition encompasses both supplementation by mouth and feeding by tube into the GI tract. In addition, patients who have a functioning GI tract but for whom oral nutrition intake is contraindicated should be consid- ered for tube feedings. If the GI tract is functioning and can be used safely, tube feedings should be ordered in- stead of parenteral nutrition when nutrition support is necessary because it • Is more easily absorbed physiologically • Is associated with fewer complications than TPN • Maintains the gut barrier to infection • Maintains the integrity of the GI tract • Is more cost-effective than TPN • Contraindications to tube feeding can be found in Table 11–3. Parenteral Nutrition Parenteral nutrition usually offers no advantage to the patient with a functioning GI tract. Some patients, because of their disease states, cannot be fed enterally and require par- enteral feedings. When enteral feedings are started, it is often important to assess gastric residual volumes. The small-bore tubes do not allow for aspiration of residual volumes, however, which may be significant if gastric emptying is questionable. Thus, larger bore tubes are often used to start, and, once feeding tolerance is ensured, the tube is changed to a small-bore tube, which can be left in place comfortably for prolonged periods. Feeding di- rectly into the stomach (as opposed to the bowel) is often preferable because the stomach is the best line of defense against hyperosmolarity. Patients at risk for aspiration require longer tubes into the jejunum or duodenum.

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The examiner palpates the wrists to take the pulse in both radial arteries purchase 1 mg arimidex overnight delivery, noting amplitude and pulse rate generic 1 mg arimidex with visa. With the patient in this position buy arimidex 1mg without prescription, the examiner again palpates the wrists and evaluates the pulse in both radial arteries arimidex 1mg mastercard. Assessment: Unilateral weakness or absence of the pulse in the radial artery, ischemic skin changes, and paresthesia are clear signs of com- pression of the neurovascular bundle in the costoclavicular region (be- tween the first rib and clavicle). Procedure: The standing patient abducts both arms past 90° while retracting the shoulders. Assessment: Pain in the shoulder and arm, ischemic skin changes, and paresthesia are clear signs of compression of the neurovascular bundle, which is primarily attributable to changes in the scalene muscles (fib- rosis, hypertrophy, or presence of a small scalene muscle). Then the patient is instructed to rapidly flex and extend the fingers of each hand for one minute. Assessment: If one arm begins to droop after a few cycles of finger motion and ischemic skin changes, paresthesia, and pain in the shoulder and arm occur, this suggests a costoclavicular compression syndrome affecting neurovascular structures. Causes include osteophytes, rib changes, and anatomic variations in the scalene muscles. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. The affected arm is held in a middle position alongside the trunk with the elbow flexed 90°. The patient is asked to rotate his or her head toward the contralateral side (away from the side being examined). Assessment: Weakening or loss of the pulse in the radial artery, pain in the shoulder and arm, ischemic changes, and paresthesia are signs of a costoclavicular syndrome (compression of the subclavian artery be- tween the first rib and the clavicle) or of a scalene muscle syndrome (compression of the neurovascular bundle between the middle and anterior scalene muscles due to fibrosis or hypertrophy). Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Procedure: The patient is asked to supinate both arms and raise them to 90° while keeping his or her eyes closed. Procedure: The patient is supine and is asked to close his or her eyes and flex both hips and both knees. Assessment: The neurologic examination of the lower extremities in a patient capable of standing and walking begins with inspection of gait. With the Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Strength in the extensor digitorum and hallucis longus is tested by dorsiflexion of the toes (L5) against resistance, and strength in the triceps surae is tested by plantar flexion of the foot (S1) against resist- ance. It does so by highlighting those features of anatomy which are of clinical importance using a vertical blue bar, in radiology, pathology, medicine and midwifery as well as in surgery. It presents the facts which students might reasonably be expected to carry with them during their years on the wards, through their final examinations and into their postgraduate years; it is designed for the clini- cal student. Anatomy is a vast subject and, therefore, in order to achieve this goal, I have deliberately carried out a rigorous selection of material so as to cover only those of its thousands of facts which I consider form the necessary anatomical scaffolding for the clinician. Wherever possible practical appli- cations are indicated throughout the text— they cannot, within the limita- tions of a book of this size, be exhaustive, but I hope that they will act as signposts to the student and indicate how many clinical phenomena can be understood and remembered on simple anatomical grounds. Repre- sentative computerized axial tomography and magnetic resonance imaging films have been included, since these techniques have given increased impetus to the clinical importance of topographical anatomy. The continued success of this volume, now in its forty-seventh year of publication, owes much to the helpful comments which the author has received from readers all over the world. Harold Ellis 2006 xiii Acknowledgements I wish to thank the many students who have sent suggestions to me, many of which have been incorporated into this new edition. To Mrs Katherine Ellis go my grateful thanks for invaluable secretarial assistance. I am grateful to the following authors for permission to reproduce illus- trations: The late Lord Brock for Figs 20 and 21 (from Lung Abscess); and Professor R. Finally, I wish to express my debt to Martin Sugden and the staff of Blackwell Publishing for their continued and unfailing help. Harold Ellis xiv Part 1 The Thorax Surface anatomy and surface markings The experienced clinician spends much of his working life relating the surface anatomy of his patients to their deep structures (Fig.

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Theoretically purchase 1 mg arimidex free shipping, manganese may act as an anti- inflammatory agent by boosting the activity of SOD discount 1mg arimidex with visa. Side effects When taken in recommended dosages purchase arimidex 1mg without a prescription, manganese is not Preparations associated with any bothersome or significant side effects buy generic arimidex 1mg online. People who take oral contraceptives or antacids age 11 and over, the ESADDI for manganese is 2–5 mg a may require higher intake of manganese. More of the miner- GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 1287 Manic depression see Bipolar disorder KEY TERMS. Marigold see Calendula Calcium—A mineral necessary for strong bones and the proper functioning of organs and muscles. Osteoporosis—An age-related disease in which bones become fragile and prone to debilitating Marijuana fractures. Description Pancreas—An organ behind the stomach that pro- Marijuana (marihuana), Cannabis sativa L. The term hashish, is derived from the BOOKS name for the Saracen soldiers, called hashashins, who Murray, Michael T. Indian hemp cal Significance of Reduced Manganese and Zinc Levels grows to a height of about 4 ft (1. The hairy leaves are arranged Loss in Postmenopausal Women Supplemented with Cal- opposite one another on the erect and branching stem. The resinous blossoms have five NIH Osteoporosis and Related Bone Diseases National Re- sepals and five petals. Commerce in hemp, which was primarily valued for the Marijuana has been cultivated for thousands of years. By 1621, the British pharmacopoeia is a book containing a list of medicinal were growing cannabis in Virginia where cultivation of drugs, and their descriptions of preparation and use. In 1776, the Declaration of Inde- Cannabis was called a “superior” herb by the Emperor pendence was drafted on hemp paper. Cannabis was recommended as a treat- were advocates of hemp as a valuable cash crop. By period in Egypt, cannabis was used as a treatment for the 1850s, hemp had become the third largest agricultur- sore eyes. Census of that gious ceremonies, and recorded in Sanskrit scriptural year recorded 8,327 hemp plantations, each with 2,000 texts around 1,400 B. Restric- cannabis as a remedy to treat inflammation, earache, and tions on the personal use of cannabis as a mood-altering, edema (swelling of a body part due to collection of flu- psychoactive herb, were soon to come. They called the herb Controversy kannabis and inhaled the “intoxicating vapor” that result- The 1856 edition of the Encyclopedia Britannica, in its ed when it was burned. Utah was the first state to criminalize it, then Emperor Nero, named the herb Cannabis sativa and California and Texas. New York ry, the Chinese physician Hoa-Tho, used cannabis in sur- prohibited cannabis use in 1927. In ancient India, around 600, Sanskrit writers recorded a In 1937, the federal government passed the Marijua- recipe for “pills of gaiety,” a combination of hemp and na Tax Act, prohibiting the cultivation and farming of sugar. This use of cannabis as a Secretary of the Treasury Andrew Mellon, who was also durable and renewable source of paper fiber continued a banker for the DuPont Corporation. The By the 1300s, government and religious authorities, 1937 Marijuana Transfer Tax Bill prohibited industrial concerned about the psychoactive effects on citizens and medical use of marijuana and classified the flower- consuming the herb, were placing harsh restrictions on ing tops as narcotic, and restrictions on the cultivation its use. Cannabis cultivation con- United States, 1966 reported that 641,642 Americans tinued, however, because of its economic value. A little were arrested for marijuana offenses that year, with as more than a century later, the English Queen Elizabeth I many as 85% of these arrests for simple possession, issued a decree commanding that landowners holding 60 rather than cultivation or commerce. GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 1289 In a reversal of the state-by-state progression of crim- stituents of cannabis displayed antimicrobial action and inalizing marijuana that led to the 1937 Marijuana Trans- antibacterial effects in research studies. The components fer Tax Bill, there is a movement underway, state by state, CBC and d-9-tetrahydrocannabinol have been shown to to endorse the legalized use of medical marijuana. By destroy and inhibit the growth of streptococci and 1992, 35 states in the United States had endorsed referen- staphylococci bacteria. A growing body of scientific re- In 2002, the Dutch government announced that a search and many thousands of years of folk use support small trial would begin in the country to study the effects the importance of medical marijuana in treatment of a va- of medical marijuana on patients with multiple riety of illnesses, and the economic value of hemp in the sclerosis. After extending the number of participants in textile, paper, and cordage industries has a long history.

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