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By: F. Jorn, M.B. B.CH. B.A.O., Ph.D.

Co-Director, Sanford School of Medicine of the University of South Dakota

Randomized controlled trials impotence and diabetes 20mg levitra soft free shipping, using isolated variables erectile dysfunction statistics by age discount levitra soft 20mg line, are not appropriate for clinical assessments of such highly individualized treatments (Institute of Medicine erectile dysfunction doctor austin discount levitra soft 20mg otc, 2005). Nonetheless, effectiveness studies can be conducted on individualized therapies using practical clinical trials (Tunis et al. Controversy attends integrative medical investigations because different research and clinical traditions begin from very different worldviews and assumptions. A detailed and full critique of the widely varied approaches in integrative medicine is beyond the scope of this present discussion. Here, some biochemical and biophysical theories that suggest quite subtle energetic processes are present in the body will be surveyed-beyond the dynamics expected from biochemistry at states of thermodynamic equilibrium. Biochemistry is based on an understanding of the flow of energy that drives chemical reactions. When applied to chemistry, thermodynamics (literally meaning the power of heat) uses statistical descriptions of the behavior of large ensembles of molecules to predict the behavior of chemical syntheses. Physical properties of molecules can be combined to express internal energy, and thermodynamic potentials are used to describe the conditions necessary for equilibrium and spontaneous processes. Thus, thermodynamics describes how cellular biochemical systems respond to changes in their surroundings. New models in biophysics emphasize cooperative electrical activity of highly ordered ensembles of elements, at all scales of physiology: cells, tissues, organs, organ systems, as well as the whole body. These new insights can form theoretical bridges between some of the different medical traditions. For instance, acupuncture and homeopathy have plausible electromagnetic modes of action when viewed from the perspective of these new biochemical and biophysical models. After surveying these theoretical constructs, we will look further at some clinical applications of electromagnetic devices that claim to be using these subtle energetic processes for therapeutic benefit. Stimulus voltages are typically in the range of 10 to 100 V, and currents range from 10 to 100 mA, supplied from electrodes 234 the Scientific Basis of Integrative Medicine in contact with the skin. Current flow in diathermy involves complex processes, so patient observations of perceived heating and the rates of applied power are used to guide these therapies. As the oscillations decay, kinetic energy is distributed among surrounding molecules, increasing their motion- which is heat. More heat will be produced in tissue that conducts more easily, making the specific absorption rate greater. Diathermy is effective for heating deep muscle tissue because current flows more easily in muscle than in fat. The fundamental frequency often is delivered in pulses, which are more effective for producing charged particle oscillation. The power applied during therapy is thus a combination of pulse amplitude, duration, and frequency. Typical peak pulse amplitudes range from 100 to 1000 watts, in pulse durations of 25 to 400 msec and with the average power in the current delivered to the patient being a few watts (McMeeken and Stillman, 2002). Because this stress response can be triggered by both heat and weak electromagnetic fields, the thermal and nonthermal thresholds can be directly compared. According to biochemical tenets of conventional medicine, weak electromagnetic signals are not expected to interact with metabolic processes because the thermodynamics of biochemistry seem to require that thermal noise in the tissues would swamp such weak signals. In contrast to these expectations, acupuncture and homeopathy expect extremely weak signals to have profound effects for shifting physiological Energy Medicine 235 processes. The mechanisms of action for some models of acupuncture, described later in this chapter, include the minute electrical potentials of a few milliamperes provided by bimetallic battery potentials in the needles. In laboratory research and in some clinical devices, very low-power electromagnetic fields are used to change physiological processes. The small area of the stimulation makes the total power applied miniscule, when compared to a process like microwave diathermy. Biological effects of very weak electromagnetic fields also are found in laboratory research. The energy available from these fields is much smaller than the characteristic energies of chemical reactions and much less than would be conventionally expected to induce motion in charged particles with molecular masses.

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When deciding whether to use cyclophosphamide again erectile dysfunction at 20 purchase levitra soft 20 mg visa, the cumulative dose of cyclophosphamide already given should be taken into account erectile dysfunction treatment in rawalpindi purchase levitra soft 20mg with mastercard. Cumulative dosages above 36 grams have been associated with the occurrence of malignancies erectile dysfunction young living purchase 20mg levitra soft mastercard. Refractory disease can be treated by an increase in glucocorticoids (intravenous or oral), by the addition of rituximab if cyclophosphamide induction had been used previously, or vice versa. The causes of refractory disease include drug intolerance, non-adherence, concomitant morbidities complicating treatment, a secondary drive for vasculitis such as malignancy, drugs or infection, and true treatment failure. Progression of kidney failure can reflect chronic damage and does not necessarily imply active disease; a kidney biopsy can be considered to assess ongoing kidney disease activity. In the setting of diffuse alveolar bleeding with hypoxemia, plasma exchange should be considered in addition to glucocorticoids with either cyclophosphamide or rituximab. In the absence of hypoxemia, diffuse alveolar hemorrhage has a benign prognosis and responds as extra-pulmonary disease is controlled. Alveolar hemorrhage with hypoxemia has a high early mortality risk, and plasma exchange should be considered in addition to glucocorticoids with either cyclophosphamide or rituximab. Patients in the intensive care unit, such as those receiving assisted ventilation, have a particularly high risk of infection and death. Plasma exchange and highdose intravenous immunoglobulins can be considered in this setting. Biomarker studies are needed identify early markers of disease relapse, markers to guide the choice of therapy, including plasma exchange, markers to predict optimal dosing and dosing interval for rituximab, and surrogate markers of response. This recommendation places a relatively higher value on the various benefits associated with hydroxychloroquine use reported in observational studies (including lower rates of disease flares, progressive kidney damage, and vascular complications) and on the generally favorable 277 safety profile of hydroxychloroquine treatment. Hydroxychloroquine may accumulate in lysosomes and cause a form of phospholipidosis with accumulation of multilamellar zebra bodies in podocytes that can mimic the appearance of Fabry disease. The quality of the evidence is low because of study limitations, indirectness, or imprecision, but has been upgraded because of the large reported effect sizes. Values and preferences the potential benefits of preventing organ damage and vascular complications were judged as being important to patients. The Work Group also judged that the relatively low risk 278 of adverse events associated with hydroxychloroquine would also be important to patients. Therefore, the Work Group felt that nearly all well-informed patients in the target population would choose to receive hydroxychloroquine treatment in comparison to no treatment. Resource use and costs Hydroxychloroquine can be an expensive drug in some countries. Therefore, in lowresource settings, it may be acceptable to substitute structurally similar drugs such as chloroquine that have a similar mechanism of action but are less expensive. Regular evaluation of various risk factors and timely treatment are essential to prevent premature cardiovascular complications. Available zoster vaccine preparations include the liveattenuated vaccine Zostavax and the adjuvanted recombinant vaccine Shingrix. There are no data on the efficacy of the recombinant zoster vaccine in lupus patients, and there is concern whether the adjuvant might affect disease activity. There is also concern that polio vaccination has been associated with lupus flares, while the data on influenza vaccination are conflicting. Response to vaccination is reduced following exposure to high-dose immunosuppression. Counseling with regard to contraception and pregnancy should be done early in patients of child-bearing age. Bone health Corticosteroid therapy, especially when high doses are used for long durations, increases bone loss. For these patients, no specific immunosuppressive therapy beyond what is being given for non-kidney lupus is needed. However, all studies used concomitant high-dose corticosteroids, and these likely accounted for many treatment-associated adverse events. The results showed no statistically significant difference in efficacy both short- and long-term and an improved side-effect profile. A study in Japan reported a complete response rate of 80% after six months of treatment with a "multi-target" triple immunosuppressive regimen that included corticosteroids, reduced-dose cyclophosphamide, and tacrolimus. There is increasing evidence, based on data from observational studies,576, 652, 655-658 that effective induction of kidney response after initial therapy, especially a complete kidney response, is associated with more favorable long-term kidney outcomes.

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Rapid sequence intubation without a neuromuscular blocking agent in a 14-year old female patient with myasthenia gravis erectile dysfunction drugs used discount levitra soft 20 mg without a prescription. Our recent experiences with sarin poisoning cases in Japan and pesticide users with references to some selected chemicals erectile dysfunction blood pressure medication purchase levitra soft 20mg overnight delivery. Emergency Care Issues 102 6 Psychosocial Issues: From Diagnosis to Lifetime Management M yasthenia Gravis erectile dysfunction in diabetes management levitra soft 20 mg with mastercard, as a chronic disease, has Kimberly M. Johnson psychosocial aspects that are similar to those shared by other disease populations as well as aspects that are unique to the disorder itself. The newly diagnosed patient will spend a lifetime of cycling through these feelings as various life events create challenges for coping with the disease. It is important for the health care provider to incorporate the biopsycho-social approach to treating these patients as psychosocial issues can impact the management of the disease. The challenge for the health care provider is to identify triggers that may lead to problems in disease management, such as stress, extreme heat, medication side effects, etc. These changes can be frustrating and embarrassing for a patient who is very conscientious about being in the public eye. Changes in body image may lower self esteem and some may seek to cope by socially isolating themselves from the public. This may have an even greater impact for the patient who was socially active prior to diagnosis. A patient who withdraws socially may isolate themselves from the informal support network available. Further, a patient may ultimately selfdiscontinue the use of medications if they are dissatisfied with changes in body image associated with their use. A patient may opt out of having a thymectomy if having a surgical scar is an issue. Of critical concern is that the patient may not be forthcoming with this information to their treating physician. This may lead to disease management changes that would not have occurred otherwise and such changes may increase the Psychosocial Issues: From treatment risk. For example, the patient may self-discontinue their immunodulatory treatment and the unknowing physician "increases the medication dosage with the belief that the previous dose was ineffective. Should the patient resume taking the drug the dose may then be "toxic"; increasing the risk for an adverse reaction. It is helpful to assess feelings related to body image to gauge what is important to the patient so that treatment options can be tailored toward the best possible outcome. It is also worthy of noting that sometimes family members may not understand the impact that the disease and side effects of medications may have on a patient. One patient describes the scenario of her husband purchasing a spa membership for her as he found her weight gain while taking prednisone to be unacceptable. She underutilized this spa membership and her husband became angered by the "waste of money". As is noted in the section on Physical Therapy, exercise must be carefully planned for the patient with myasthenia to avoid overexertion and exacerbation of symptoms. The Lifeline emergency response system is a device that may be worn by the patient and when activated, signals calls to individuals that can quickly check on the patient (Lifeline, 2006). This alleviates the fear of not being 104 able to utilize a phone to contact emergency personnel in a crisis situation. The First Alert system can be installed and has an activation fee and monthly service fee. Many medical centers administer this service as well as local Council on Aging agencies. It is also a good idea for a patient to educate their local emergency personnel regarding potential respiratory/ communication issues so that emergency personnel can respond to a call in which a patient may not be able to effectively communicate their needs. Patients with myasthenia gravis should also consider purchasing a MedicAlert (or similar) bracelet ( The patient should keep the original documents in a secure place where they can be easily retrieved by family or friends should the need arise. A Living Will document does not allow for specifications in treatment such as "I would like to be on a ventilator for a week and if no improvement, taken off". In this case, the patient may appoint an individual to act as their health care agent during this time period.

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