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Drugs at a Glance: Representative Antacid Products Antacids Components Magnesium Oxide or Aluminum Calcium Trade Name Hydroxide Hydroxide Carbonate Other Route and Dosge Ranges (Adults) Aludrox 103 mg/5 mL 307 mg/5 mL PO 10 mL q4h discount proscar 5 mg without prescription, or as needed Amphojel 300 or 600 mg/tab order proscar 5 mg otc, PO 10 mL or 600 mg 5 or 6 times daily 320 mg/5 mL Di-Gel 200 mg/5 mL Simethicone PO 2 tsp liquid q2h discount 5mg proscar free shipping, after meals or between 20 mg/5 mL meals buy discount proscar 5mg online, and at bedtime 5 mg proscar otc. Gelusil 200 mg/tab 200 mg/tab Simethicone PO 10 or more mL or 2 or more tablets after 25 mg/tab meals and at bedtime or as directed by physician to a maximum of 12 tablets or tsp/24 h Maalox 200 mg/5 mL 225 mg/5 mL PO 30 mL 4 times daily, after meals and at suspension bedtime or as directed by physician; maxi- mal dose, 16 tsp/24 h Mylanta 200 mg/tab, 200 mg/tab, Simethicone PO 5–10 mL or 1–2 tablets q2–4h, between 200 mg/5 mL 200 mg/5 mL 25 mg/tab, meals and at bedtime or as directed by 20 mg/5 mL physician Mylanta 400 mg/tab, 400 mg/tab, Simethicone Same as Mylanta Double 400 mg/5 mL 400 mg/5 mL 30 mg/tab, strength 30 mg/5 mL Titralac 420 mg/tab, Glycine PO 1 tsp or 2 tablets, after meals or as 1 g/5 mL 180 mg/tab, directed by physician, to maximal dose of 300 mg/ 19 tablets or 8 tsp/24 h 5 mL 870 SECTION 10 DRUGS AFFECTING THE DIGESTIVE SYSTEM Drugs at a Glance: Drugs for Acid-Peptic Disorders Generic/Trade Name Indications for Use Routes and Dosage Ranges (Adults) Histamine-2 Receptor Treatment of peptic ulcers and GERD, to Antagonists promote healing, then maintenance to prevent recurrence Prevention of stress ulcers, GI bleeding, and aspiration pneumonitis Treatment of Zollinger-Ellison syndrome Treatment of heartburn Cimetidine (Tagamet) Duodenal or gastric ulcer, PO 800 mg once daily at bedtime or 300 mg 4 times daily or 400 mg twice daily. Maintenance, PO 400 mg at bedtime IV injection, 300 mg, diluted in 20 mL of 0. COMBINATION REGIMENS Bismuth subsalicylate, PO bismuth 525 mg (2 tabs), metronidazole 250 mg (1 tab), metronidazole, and tetracycline 500 mg (1 capsule) 4 times daily for 14 d tetracycline (Helidac) Amoxicillin, clarithromycin, PO amoxicillin 1 g, clarithromycin 500 mg, lansoprazole 30 mg and lansoprazole (Prevpac) twice daily, morning and evening, for 14 d Ranitidine and bismuth PO 400 mg twice daily for 4 wk, with clarithromycin 500 mg citrate (Tritec) 3 times daily for the first 2 wk GERD, gastroesophageal reflux disease, including erosive esophagitis; GI, gastrointestinal; NSAID, nonsteroidal anti-inflammatory drug. Antacids people who ingest large amounts of aluminum-based antacids over a long period, hypophosphatemia and osteomalacia may Antacids are alkaline substances that neutralize acids. They develop because aluminum combines with phosphates in react with hydrochloric acid in the stomach to produce neutral, the GI tract and prevents phosphate absorption. Aluminum less acidic, or poorly absorbed salts and to raise the pH (alka- compounds are rarely used alone for acid-peptic disorders. Raising the pH to approximately Magnesium-based antacids have a high neutralizing capacity 3. Calcium compounds have a rapid onset of aluminum, magnesium, and calcium compounds. Aluminum compounds have a low compounds are rarely used in peptic ulcer disease. In droxide and magnesium hydroxide (eg, Gelusil, Mylanta, 872 SECTION 10 DRUGS AFFECTING THE DIGESTIVE SYSTEM Maalox). Once released, histamine causes con- such as simethicone or alginic acid. Simethicone is an anti- traction of smooth muscle in the bronchi, GI tract, and uterus; flatulent drug available alone as Mylicon. When added to dilation and increased permeability of capillaries; dilation of antacids, simethicone does not affect gastric acidity. It report- cerebral blood vessels; and stimulation of sensory nerve end- edly decreases gas bubbles, thereby reducing GI distention ings to produce pain and itching. Alginic acid (eg, in Gaviscon) pro- Histamine also causes strong stimulation of gastric acid se- duces a foamy, viscous layer on top of gastric acid and thereby cretion. Vagal stimulation causes release of histamine from decreases backflow of gastric acid onto esophageal mucosa cells in the gastric mucosa. The histamine then acts on recep- while the person is in an upright position. Aluminum-based antacids vent or reduce other effects of histamine but do not block his- also are given to clients with chronic renal failure and hyper- tamine effects on gastric acid production. The H2RAs inhibit phosphatemia to decrease absorption of phosphates in food. A single dose of an H2RA can inhibit acid secretion for 6 to 12 hours and a continuous intravenous (IV) infusion can inhibit secre- Helicobacter pylori Agents tion for prolonged periods. Clinical indications for use include prevention and treat- Multiple drugs are required to eradicate H. Effective combinations include two ease, esophagitis, GI bleeding due to acute stress ulcers, and antimicrobials and a PPI or an H2RA. With gastric or duodenal ul- component, two of the following drugs—amoxicillin, cla- cers, healing occurs within 6 to 8 weeks; with esophagitis, rithromycin, metronidazole, or tetracycline—are used. Over-the-counter oral A single antimicrobial agent is not used because of concern preparations, at lower dosage strengths, are approved for the about emergence of drug-resistant H. In addition, antimicrobial– and clients with impaired renal or hepatic function. Dosage antisecretory combinations are associated with low ulcer should be reduced in the presence of impaired renal function. Adverse effects occur infrequently with usual doses and A bismuth preparation is added to some regimens. They are more likely to occur with pro- muth exerts antibacterial effects against H. It also increases secretion of mucus and Cimetidine, ranitidine, famotidine, and nizatidine are the bicarbonate, inhibits pepsin activity, and accumulates in ulcer four available H2RAs. The regimen using metronidazole, a drug is distributed in almost all body tissues. Cimetidine bismuth compound, tetracycline, and an antisecretory drug is should be used with caution during pregnancy because it very effective in healing ulcers.

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The current probably stimulated dorsal and colleagues induced step-like locomotor ac- root fibers and purchase 5mg proscar with amex, perhaps 5 mg proscar fast delivery, dorsal column fibers cheap 5mg proscar overnight delivery. If considered in paral- sults of step training in the cat and in humans lel to the spinal transected cat experiments in after a complete SCI buy discount proscar 5 mg on-line. After a low thoracic Experimental Case Studies 1–2 buy 5 mg proscar otc, this rhythmic spinal cord transection, the segmental sensory activity suggests the possiblity that spinal auto- inputs discussed above have been used to train maticity in humans can be driven by locomo- cats183–186 and rats187 to step independently on tor-related sensory inputs that are recognized a moving treadmill belt over a range of speeds. Repetitive step training of a subject In people with a complete thoracic SCI who with a complete SCI may lead to greater am- are suspended with body weight support over plitude of the elicited EMG bursts and im- a moving treadmill belt while therapists move proved organization, as shown in Figure 1–7B. Electromyographic (EMG) activity from the flexor and extensor muscles of the legs in a subject with a com- plete thoracic spinal cord injury obtained during fully assisted treadmill stepping with 40% body weight support early (A) and late (B) after training. The level of weightbearing is shown at the bottom, highest during the phase of single and dou- ble-limb stance. The EMG about the ankle and knee muscles increased in amplitude, including the medial hamstrings (MH) and vastus lateralis (VL) at the knee and the soleus (SOL) and medial gastrocnemius (MG) at the ankle over the time of training, which suggests the recruitment of more motor units. The double burst that evolved in the tibialis ante- rior (TA) is typical of its normal pattern of firing. The rectus femoris (RF) came on only during stance and the iliopsoas (IL) fired at onset of swing (see Chapter 6 for details about normal firing patterns). Corticoreticu- ized using body weight–supported treadmill lospinal and corticovestibulospinal pathways training BWSTT) in people with incomplete are good candidates for leveraging the spinal SCI and hemiplegic stroke (see Chapter primitives. For walking, the SPINAL PRIMITIVES details of experiential practice in cats and The motoneurons and interneurons of the lum- rats198 and in humans174,179,195,199 are critical bar cord also participate in another type of or- for improving reciprocal stepping. As noted ganization that appears to simplify the problem earlier, important sensory inputs relate to the of motor contol. Bizzi and colleagues combined rate and degree of hip extension, the level of a spinal cord transection with electrical or limb weight bearing, the timing of interlimb chemical microstimulation of the ventral gray movements and of shifts in bearing weight at matter of frogs, rats, and nonhuman primates. Such inputs, provided stimulation of separate volumes of gray matter repetitively, may activate any conserved or- produced movements that the investigators ganization of primitives and CPG circuitry of quantified as force vectors. Within each vol- the cord and provide a clinical benefit (see ume or module, a discrete set of synergistic Chapters 6 and 9). This sensory information limb muscle contractions was elicited that di- also activates and reorganizes spared cortical rected the limb toward an equilibrium point. Functional neuroimaging stud- the leg in four positions within its usual work- ies reveal the details of the networks involved. By superimposing the to our knowledge of neuroplasticity after brain vectors of the force fields that were elicited and spinal cord lesions, are provided in Chap- across all the spinal modules, the investigators ter 3. Functional neuroimaging studies also re- calculated that the set of modules, which they veal the physiologic anatomy of the sensori- call primitives, stored the movements that motor network. This intrinsic spinal organization, ment representations in the primary sensori- which is likely to be present in man, permits motor cortex in remarkable detail. The primitives specific activities such as preparation for a presumably act together under the control of movement, internal generation of the move- supraspinal commands to create a rich reper- ment, and visualizing or imagining an action. When M1 or Association cortex and regions that represent other regional motoneurons fire in a direc- cognitive functions become more active as the 38 Neuroscientific Foundations for Rehabilitation task grows in complexity. Of great interest for after a cerebral, spinal, or peripheral nerve rehabilitation, PET, fMRI, TMS, and other injury. For example, a high level of synaptic activity in primary and secondary sen- Regional cerebral blood flow (rCBF) studies of sorimotor cortices accompanies the early stages normal subjects by PET reveal cortical areas of learning a motor skill. Activity increases in the con- used to monitor this gain in cerebral activity tralateral M1 and the premotor, SMA, ventral and its relationship to the success of the reha- premotor, and parietal cortical areas that are bilitation strategy. The toe activated the dorsal putamen ments by trial and error, revealed that the and the fingers localized more ventral and me- right-handed task activated the left dorsolateral dial. When a subject decides which fingers to prefrontal cortex (DLPFC) that includes BA 9 move or learns a finger tapping sequence, the and 46 and the right anterior cingulate cortex caudate and putamen become active rostral (BA 24 and 32). Passive movements of the hand and foot then, subjects must monitor their movements also activate sensorimotor cortices (see Chap- and maintain successful responses in their ter 3), which is useful for studying plasticity- working memories. Once subjects perform a related motor recovery over time when sub- skilled task automatically, they may be able to jects start with paralysis of a limb. When the sub- In a PET experiment that helps define the jects were asked to pay attention to their over- distributed motor system, subjects were stud- learned movements, the anterior cerebral re- ied under four conditions.

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Turner JA discount 5mg proscar fast delivery, Ersek M purchase proscar 5mg mastercard, Herron L buy discount proscar 5 mg on line, Deyo R 23:628–633 pincott-Williams & Wilkins purchase proscar 5 mg otc, Philadel- (1992) Surgery for lumbar stenosis: at- 35 purchase 5mg proscar with mastercard. Zucherman JF, Hsu KY, Hartjen CA et phia, pp 207–214 tempted meta-analysis of the literature. Postacchini F (1996) Management of Spine 17:1–8 multi-center study for the treatment of lumbar spinal stenosis. Verbiest H (1954) Radicular syndrome lumbar spinal stenosis with the X-STOP Surg Br 78:154–164 from developmental narrowing of the interspinous spacer: 1-year results. J Bone Joint Spine J (in press) (2003) Surgery of the lumbar spine for Surg Br 26:230–237 spinal stenosis in 118 patients 70 years 32. Spine 28:348–353 (1999) Spinous process osteotomies to facilitate lumbar decompressive sur- gery. Spine 24:62–66 REVIEW Jiri Dvorak Cervical myelopathy: Martin Sutter Joerg Herdmann clinical and neurophysiological evaluation Abstract The overall frequency of can lead to narrowing of spinal canal, troublesome neck pain is estimated with symptoms and signs of cervical to be about 34%, and it was observed myelopathy. For a diagnosis of radic- that the frequency of complaints last- ular and myelopathic syndromes, the ing 1 month or longer was higher in functional and neurological examina- women than in men. The prevalence tion is enhanced by neurophysiologi- increased with age, with regard to cal assessment. Dvorak (✉) selected population meets the crite- nosing nerve root compression and Department of Neurology, Schulthess rion for chronic neck pain: complaints anterior horn cell syndromes, and is Clinic Spine Unit, Lengghalde 2, 8008 Zürich, Switzerland lasting more than 6 months. For cervical myelopathy, as a Fax: +41-1-3857574, tance of morphologic, age-related routine examination sensory evoked e-mail: dvorak@kws. Sutter ever, the incidence and prevalence of tibial nerve and motor evoked poten- Department of Neurophysiology, cervical myelopathy is not known. It tials (MEPs) from the upper and Intraoperative Monitoring, could be that the structural transfor- lower extremities are recommended. Schulthess Clinic Spine Unit, Zürich, Switzerland mation of the intervertebral disc, the uncovertebral processes and the zyg- Keywords Cervical spine · J. Herdmann apophyseal joints is a process ac- Myelopathy · Diagnosis · Evoked Department of Neurosurgery, SPINE Unit, Heinrich-Heine-University, companied by disturbed function that potentials Düsseldorf, Germany ultimately not only induces pain, but lumbar spine, consisting of the annulus fibrosus and nu- Introduction cleus pulposus. However, it has been observed that in the first and second decades of life, before complete ossifica- Herbert von Luschka, a German anatomist, first pointed tion occurs, lateral tears do occur in the annulus fibrosus. The processus ar- These anatomical observations by Töndury document ticularis are covered by a thin layer of cartilage in healthy the fact that, with increased age, the disc cannot bear or subjects, and the uneven surfaces in between the zyg- transfer load due to ongoing dehydration, medial splitting apophyseal processes are filled in by an infolding of the of the disc and the disappearance of the nucleus pulposus joint capsule described by Penning and Töndury as menis-. These meniscoids consist of connective and cesses, a new cow-horn-like uncovertebral flattening takes fatty tissue, which is highly vascularized and innervated. It In healthy adults, the intervertebral discs in the cervical is obvious that such transformation of bony structures can spine have a structure similar to that of the discs of the lead to irritation or compression of the spinal nerve as well 100 as the vertebral artery, which of course can cause not only – Double crush lesion of the nerve root and peripheral intermittent or chronic pain and finally narrowing of the nerve spinal canal due to bony growth, but also demyelisation of – Rheumatoid arthritis with involvement of the cervical ascending and descending spinal pathways, due to a pos- spine sible deficiency of blood supply to the spinal cord. The neurological examination aims to differentiate be- Evidence of radiological degenerative changes of the tween nerve root and spinal cord compression. By the tion of cranial nerves, especially the eye movements with fourth decade of life, 30% of asymptomatic subjects show the aid of Frentzel goggles, is useful. There is clear evi- degenerative changes of the intervertebral discs, while by dence showing interaction between the receptors of the the seventh decade, up to 90% have developed degenera- cervical joint capsules and the vestibular organ [28, 29]. Similar findings were earlier pre- However, it is well established that the center projection sented by Kellgren and Lawrence [17, 19]. Therefore, it is of the cervical spine mechanoreceptors is close to the always important to interpret these radiological findings vestibular nuclei at the region of the brain stem, which in the light of the clinical picture. If symptoms and find- makes the clinical differentiation (cervical vs vestibular ings cannot be logically correlated, the presence of a dif- origin of dizziness) very difficult [26, 27]. Patients with referred pain in the region the neurosurgeon and the neurologist is required in the as- of trigeminus nerve pain commonly present an underlying sessment of the patient in the spine unit, in order to opti- pathology of the upper cervical spine, often observed in at- mally indicate and analyze the clinical, radiological and lanto-axial instability due to rheumatoid arthritis [38, 42]. Patients in patients suffering from compression of the cervical spi- with cervical spine disorders most commonly complain of nal cord. Radicular arm pain during ipsilateral local and referred pain, headache, dizziness or disturbance sidebending rotation and manual compression of the head of the equilibrium, paresthesias, and weakness in the up- is described as the Spurling test, and expresses itself as a per and lower extremities. In addition to the complete motion-induced radicular irritation/compression radiating neurological assessment, which includes an examination pain along the involved dermatoma.

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For most drugs cheap proscar 5 mg on line, safety during pregnancy has not consult a health care provider buy discount proscar 5mg. In regard to nontherapeu- been established effective 5 mg proscar, and all drugs are relatively contraindi- tic drugs discount proscar 5 mg with mastercard, recommendations include the following: cated buy cheap proscar 5mg. Alcohol should be used in moderation and nursing imal to avoid potential damage to the fetus. If women who are sexually active and not through breast milk, with the highest concentration using contraception take any drugs, there is a high risk about 30 to 60 minutes after drinking (60–90 minutes that potentially harmful agents may be ingested before if taken with food). Moderate to heavy drinking during pregnancy include alcohol, caffeine, and cigarette (2 or more drinks per day) can interfere with the abil- smoking. Caffeine intake should be limited to to drink (eg, wine with dinner), you can avoid breast- about three caffeinated beverages per day; excessive in- feeding for a few hours (until the alcohol has time to take should be avoided. Women who smoke should quit leave your system) or you can pump your milk before if possible during pregnancy, to avoid the effects of nico- drinking and give it to the baby after you have had the tine, carbon monoxide, and other chemicals on the fetus. You can also pump and discard the milk that ✔ Herbal supplements are not recommended; their effects is most affected by the ingested alcohol. Nicotine and an avoiding infection (personal hygiene, avoiding contact with active metabolite are concentrated in milk and the people known to have infections, maintaining indicated amounts reaching the infant are proportional to the immunizations). Ideally, ✔ Nondrug measures to relieve common health problems the mother who smokes would stop. If unable or un- include positioning, adequate food and fluid intake, and willing to stop, she should decrease the number of cig- deep breathing. The risk for ✔ Inform any health care provider from whom treatment is sudden infant death syndrome (SIDS) is greater when sought if there is a possibility of pregnancy. CHAPTER 67 DRUG USE DURING PREGNANCY AND LACTATION 977 small to cause significant effects; for others, effects on Nursing Notes: Apply Your Knowledge the nursing infant are unknown or potentially adverse. Drugs that are considered safe, those to be used with caution, and those that are contraindicated are listed in Rosa Sanchez is breast-feeding her 6-month-old son when she Box 67–3. After she has started taking over-the-counter cold remedies, she calls the consulting nurse to see if these med- 2. Give medications only when clearly indicated, weigh- ications will affect her ability to breast-feed her son. If you were ing potential benefit to the mother against possible the consulting nurse, how would you respond? For contraindicated drugs, it is usually recommended that the mother stop the drug or stop breast-feeding. Counsel pregnant women about the use of immuniza- lowest effective dose for the shortest effective time. The American Academy of Pediatrics (AAP) supports mumps, polio, rubella, yellow fever) should be avoided breast-feeding as optimal nutrition for infants and does because of possible harmful effects to the fetus. In some instances, mothers may hepatitis B (if the mother is high risk and negative for pump and discard breast milk while receiving thera- hepatitis B antigen) and toxoids (eg, diphtheria, tetanus) peutic drugs, to maintain lactation. Women with human immunodeficiency virus (HIV) in- globulins can be given to pregnant women who are ex- fection should not breast-feed. The virus can be trans- posed to hepatitis B, rabies, tetanus, or varicella. Most systemic drugs taken by the mother reach the in- Oxytocin is usually the drug of choice for induction or aug- fant in breast milk. For some, the amount of drug is too mentation of labor because physiologic doses produce a rhyth- BOX 67-3 DRUG EFFECTS IN LACTATION Overview antihistamines, antihypertensives (angiotensin-converting enzyme The American Academy of Pediatrics (AAP) recommends breast- [ACE] inhibitors, calcium channel blockers), butorphanol, caffeine feeding for optimal nutrition during the first year of life and is con- (in moderate amounts), corticosteroids (prednisolone or inhaled sidered the most authoritative source of information about drug products), cromolyn, decongestants (oxymetolazine nose drops effects in lactation. Most drugs have not been tested in nursing or spray), digoxin, famotidine, ibuprofen, insulin, levothyroxine, women and no one knows exactly how a given drug will affect a progestin-only birth control pills (the mini-pill), sucralfate nursing infant. Even the clinical practice guidelines from the AAP Drugs To Be Used With Caution During Lactation emphasize that the reported effects of drug safety or nonsafety are Alcohol (within 2 hours of breast-feeding), aluminum-containing often anecdotal and based on observations in a single infant or a antacids, amantadine, antianxiety agents (benzodiazepines), anti- few infants rather than well-designed studies. There is some degree of risk with any systemic medication psychotics (older or typical agents), aspirin, beta blockers (acebu- ingested by the mother. However, in many instances, the infant cause other adverse effects in nursing infants), diuretics, dys- may not receive sufficient drug to produce adverse effects. The lowest dose and the shortest effective duration are rec- infant], statins), methadone, metoclopramide, theophylline ommended.

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