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Imuran

By Y. Gamal. College of Saint Benedict.

Knowing this aim buy imuran master card, one can appreciate the origin of the delicate balance of herbs and spices so characteristic of Indian cuisine buy imuran now. A number of dietary incompatibilities are recognised: milk is 204 | Traditional medicine incompatible with bananas order imuran no prescription, fish with bread, while melons are claimed to be incompatible with most other foods. For hypertension, the instructions might be to drink one cup of mango juice, followed an hour or so later by half a cup of warm milk, a pinch of cardamom and nutmeg, and a teaspoonful of ghee. Cucumber is a diuretic and raita is a yoghurt-based spicy condiment that often features in Indian recipes. Ayurveda prescribes specific diets for several psychiatric disorders and for different drug therapies. It is made by soaking 10 raw almonds in water overnight, then peeling and blending them with a cup of warm milk. Administration of medicines It should be noted that, as with Chinese herbal medicine, the term ‘herbal medicine’ includes animal and mineral products as well as products derived from vegetable sources. In common with other complementary and alterna- tive therapies, the type and dose of medicine chosen are influenced by the individual’s constitution as well as by the nature of the disease. Other factors governing the choice of medicine include the age and strength of the patient, digestive capacity, degree of tolerance and psychological state. There are detailed descriptions of the methods by which medicines should be prepared. One technique, known as samskara (refinement), eliminates the toxicity of the source materials, rather like the aim of serial dilution in homoeopathy. Mixtures of medicines (sumyoga) may be administered to achieve a balanced preparation, one principle balancing another through synergism or antagonism, as with Chinese herbal medicine. The ayurvedic formula chyavanprash combines more than 25 finely powdered herbs in a base of honey and ghee. Plant-based medicines These are used by ayurvedic practitioners in a number of ways, among which are the following examples: • In the treatment of a gastric disturbance in a person exhibiting a pitta prakriti the usual remedies black pepper (Piper rotundum) and ginger (Zingiber officinale) would be administered judiciously or not at all, because they are both considered to increase pitta and may exacerbate the imbalance. This is prescribed for individuals who are Indian ayurvedic medicine | 205 elderly, malnourished, chronically ill or emaciated. The Chinese herb dong quai (Angelica sinensis) is used in the treatment of many gynaecological ailments. This product is rejuvenating and strengthening for all three doshas and all seven dhatus. Triphala comprises three of the most popular ayurvedic herbs: amalaki, bibbitakiu and haritaki. It is normally taken alone, mixed with honey or as a tea an hour after the evening meal. The medicines are supplied as mixtures of herbs in a dried form, or more usually with a suitable vehicle (anupana) to facilitate absorption. People with high cholesterol levels should be wary about taking large amounts of ghee. Only a few local hakims (traditional healers) produced their own remedies, using imported raw materials. Many of these remedies may be purchased over the counter, by mail order through Asian and English language newspapers and the internet, or brought back from visits to the subcontinent. However, finely ground deer horn as a paste may be applied to the thoracic region and is said to be of benefit in angina. The Indian subcontinent has been subject to countless invasions during its history, with diseases being imported from other geographical locations and techniques absorbed from other cultures. For medicinal use metals are traditionally taken internally after under- going rigorous purification to neutralise any toxic effects. Some examples of the medical uses of metals are: • Copper is a good tonic for the liver, spleen and lymphatics. Treatment with aromatherapy Sweet warming aromas such as musk and camphor can balance vata, while pitta is soothed by calming aromas such as sandalwood, jasmine and rose. Kapha is pacified by warming stimulating oils together with pungent oils such as eucalyptus, sage and thyme. Treatment with enema (basti) Basti introduces medicinal remedies, including sesame oil or herbal decoc- tions, in a liquid medium into the rectum. Medicated enemas pacify vata and alleviate many vata disorders, such as constipation, backache, arthritis and various nervous disorders. Indian ayurvedic medicine | 207 Treatment with massage Oil massage (Sanskrit: abhyanga) is an important treatment. While a person may perform massage on his own as part of his daily routine, trained masseurs are required to perform this therapy when it is used for disease management. A massage that is part of the daily routine lasts for 5–15 minutes, but when it is performed for treating diseases it may take about 45 minutes. Nauli is a method of massaging the internal organs, particularly the colon, intestines, liver and spleen. Indian head massage is another specialised form of massage, sometimes known as champissage from its Indian name champi, which is part of the wider ayurvedic medical approach. The head, neck and facial areas are massaged with the purpose of manipulating energy channels. The goal is to clear blocks in these energy channels that cause a build-up of negative energy which are purported to cause ailments. It claims to help stress, insomnia, ridding the body of toxins and promoting hair growth. Interest in ayurvedic massage has been growing in the west with the general trend towards holistic medicines creating a big tourist attraction in the south Indian state of Kerala. The devotees do not say that all commercialism is bad, but they do want ayurveda practised seri- ously, not turned into a side show for tourists. Boards advertising ayurvedic centres are dotted between the tourist cafés and souvenir shops on the beach at Kovalam. Most seem geared towards 1-hour massages, using oils, and most of the tourists here seem to see it as a chance to relax rather than a real medical treatment. Mind–body interventions Colour therapy Ayurvedic treatments make use of colour in their healing procedures. As the colours of the rainbow are perceived as correlating with the body tissues (dhasus) and the doshas, the vibratory energy of the colours may be used to establish psychological harmony and peace of mind. As colour is so impor- tant, patients are told to illuminate themselves and their environment in the appropriate coloured lighting. Treatment with precious and semiprecious stones Gems are thought to have healing properties that can be harnessed by wearing them as jewellery or by placing them in a suitable liquid overnight and drinking the solution. Treatment with meditation Meditation, the art of bringing harmony to body, mind and consciousness, is used to soothe the body and reduce stress. There should be no conscious effort – the mind should be allowed to relax completely (‘float’) as one listens to every sound. Treatment with yoga This is believed to calm the nervous system and balance the body, mind and spirit, as well as provide exercise.

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Ductus venosus between umbilical vein bypass of liver 4 Superior vena cava (of Arantius) and inferior vena cava circulation 5 Ascending aorta 6 Right auricle 2 generic imuran 50 mg visa. Foramen ovale between right and left bypass of pulmonary 7 Pulmonary trunk atrium circulation 8 Left primary bronchus 9 Left auricle 3 cheap imuran 50 mg without prescription. Ductus arteriosus between pulmonary trunk 10 Right ventricle (Botalli) and aorta 11 Left ventricle 12 Left common carotid artery 13 Trachea 14 Superior lobe of right lung 15 Left subclavian artery 16 Aortic arch 12 17 Ductus arteriosus (Botalli) 18 Inferior lobe of right lung 2 14 19 Left pulmonary artery with branches to the 15 left lung 3 20 Descending aorta 21 Left pulmonary veins 5 18 22 Inferior vena cava 23 Foramen ovale 7 17 24 Right atrium 25 Opening of inferior vena cava 8 19 26 Valve of inferior vena cava (Eustachian valve) 23 27 Opening of coronary sinus 21 28 Anterior papillary muscle of right ventricle 9 20 11 Heart of the fetus (schematic drawing) cheap 50mg imuran overnight delivery. Fetal Circulatory System 289 1 Internal jugular vein and right common carotid artery 2 Right and left brachiocephalic vein 3 Aortic arch 4 Superior vena cava 5 Foramen ovale 6 Inferior vena cava 7 Ductus venosus 8 Liver 9 Umbilical vein 10 Small intestine 11 Umbilical artery 12 Urachus 13 Trachea and left internal jugular vein 14 Left pulmonary artery 15 Ductus arteriosus (Botalli) 16 Right ventricle 17 Hepatic arteries (red) and portal vein (blue) 18 Stomach 19 Urinary bladder 20 Portal vein 21 Pulmonary veins 22 Descending aorta 23 Placenta Thoracic and abdominal organs in the newborn (anterior aspect). The greater omentum partly fixed to the transverse colon covers the small intestine. The liver, stomach, and superior part of 1 the duodenum are connected to the lesser omentum covering the omental bursa, the entrance of which is the epiploic foramen. The hepatoduodenal ligament contains 2 the portal vein, the common bile duct, and the hepatic arteries. The heart is in contact with the diaphragm (from Lütjen-Drecoll, Rohen, Innenansichten des menschlichen Körpers, 2010). Transverse section through the abdominal cavity at the level of the second lumbar vertebra (from below). Anterior Abdominal Wall 293 1 Left ventricle with pericardium 2 Diaphragm 3 Remnant of liver 4 Ligamentum teres (free margin of falciform ligament) 5 Site of umbilicus 6 Medial umbilical fold (containing the obliterated umbilical artery) 7 Lateral umbilical fold (containing inferior epigastric artery and vein) 8 Median umbilical fold (containing remnant of urachus) 9 Head of femur and pelvic bone 10 Urinary bladder 11 Root of penis 12 Falciform ligament of liver 13 Rib (divided) 14 Iliac crest (divided) 15 Site of deep inguinal ring and lateral inguinal fossa 16 Iliopsoas muscle (divided) 17 Medial inguinal fossa 18 Supravesical fossa 19 Posterior layer of rectus sheath 20 Transversus abdominis muscle 21 Umbilicus and arcuate line 22 Inferior epigastric artery 23 Femoral nerve 24 Iliopsoas muscle 25 Remnant of umbilical artery 26 Femoral artery and vein 27 Tendinous intersection of rectus abdominis Anterior abdominal wall with pelvic cavity and thigh (frontal section, male) muscle (internal aspect). The peritoneum and parts of the posterior layer of rectus sheath have been removed. Parasagittal section through upper 30 Intervertebral disc part of left abdominal cavity 3. Stomach 295 1 2 9 10 4 9 11 1 2 3 5 12 10 4 6 6 11 8 7 13 8 14 Muscular coat of stomach, outer layer (ventral aspect). Stomach and transverse colon have been removed, liver elevated; superior mesenteric vein is slightly enlarged. Parasagittal section through the left side of the abdomen 2 cm lateral to median plane. Liver 299 1 Fundus of gallbladder 2 Peritoneum (cut edges) 3 Cystic artery 4 Cystic duct 5 Right lobe of liver 6 Inferior vena cava 7 Bare area of liver 8 Notch for ligamentum teres and falciform ligament 9 Ligamentum teres 10 Falciform ligament of liver 11 Quadrate lobe of liver 12 Common hepatic duct 13 Left lobe of liver 14 Hepatic artery proper 15 Common bile duct Portal triad 16 Portal vein 17 Caudate lobe of liver 18 Ligamentum venosum 19 Ligament of inferior vena cava 20 Appendix fibrosa (left triangular ligament) 21 Coronary ligament of liver 22 Hepatic veins Liver (inferior aspect). It should be noted that the anatom- ical left and right lobes of the liver do not reflect the internal distribution of the hepatic artery, portal vein, and biliary ducts. With these structures, used as criteria, the left lobe includes both the caudate and quadrate lobes, and thus the line dividing the liver into left and right functional lobes passes through the gallbladder and inferior vena cava. The three main hepatic veins drain segments of the liver that have no visible external Liver (ventral aspect) (transparent drawing illustrating margins of peritoneal folds). In this case the accessory pancreatic duct represents the main excretory duct of the pancreas. Vessels of the Abdominal Organs: Portal Circulation 303 1 2 3 7 8 9 4 5 10 11 6 Tributaries of portal vein (blue) and branches of superior mesenteric artery (red) (anterior aspect). Stomach and transverse 33 Superior rectal artery colon have been removed and the liver elevated. Vessels of the Abdominal Organs: Inferior Mesenteric Artery 305 Vessels of the retroperitoneal organs. Direction of the inferior mesenteric artery and its anastomosis with the middle colic artery (arrow = Riolan’s anastomosis). Greater omentum and transverse colon have been reflected, the intestine partly removed. The normally retrocecally located vermiform appendix has been replaced anteriorly. Dissection of the Abdominal Organs 307 1 Diaphragm 2 Costal margin 3 Transverse colon 4 Ascending colon with haustra 5 Free taenia of cecum 6 Ileum 7 Cecum 8 Falciform ligament of liver 9 Liver 10 Stomach 11 Gastrocolic ligament 12 Jejunum 13 Sigmoid colon 14 Vermiform appendix 15 Terminal ileum 16 Meso-appendix 17 Mesentery Abdominal organs in situ. Ascending colon, cecum, and vermiform Variations in the position of the vermiform appendix. The transverse colon with mesocolon has been raised and the small intestine reflected. Dissection of the Abdominal Organs: Upper Abdominal Organs 311 Upper abdominal organs (anterior aspect). Thorax and anterior part of diaphragm have been removed and the liver raised to display the lesser omentum. Red arrows: 26 Pancreas routes of the arterial branches of celiac trunk to liver, stomach, 27 Lesser sac (omental bursa) duodenum, and pancreas (posterior aspect). The gastrocolic ligament has been divided and the whole stomach raised to display the posterior wall of the lesser sac. The lesser omentum has been removed and the lesser curvature of the stomach reflected to display the branches of the celiac trunk. Dissection of the Abdominal Organs: Upper Abdominal Organs 315 Arteries of upper abdominal organs (anterior aspect). The stomach, superior part of duodenum, and celiac ganglion have been removed to reveal the anterior aspect of the posterior wall of the lesser sac (omental bursa) and the vessels and ducts of the hepatoduodenal ligament. The gastrocolic ligament has been divided, the transverse colon and the stomach replaced to display the pancreas and superior mesenteric vessels. The stomach has been removed, the liver raised, and the duodenum anteriorly opened. Posterior Abdominal Wall: Root of the Mesentery and Peritoneal Recesses 319 Peritoneal recesses on the posterior abdominal wall. The 1 1 great center of the autonomic nervous system, the solar plexus (celiac ganglion, etc. In the male, the testis has moved out of the abdominal cavity and penetrated the 3 inguinal canal to be finally located within the extragenital organs. View of the female pelvis showing uterus with uterine ligaments, ovary, and urinary bladder (from Lütjen-Drecoll, Rohen, Innenansichten des 5 6 menschlichen Körpers, 2010). Retroperitoneal tissue, position of the right kidney Notice that the upper part of the kidney reaches the level of the (schematic drawing). Sections through the Retroperitoneal Region 325 1 Scalenus anterior, medius, and posterior muscles 2 Left subclavian artery 3 Left subclavian vein 4 Pulmonic valve 5 Arterial cone 6 Right ventricle of heart 7 Liver 8 Stomach 9 Transverse colon 10 Small intestine 11 Left lung 12 Left main bronchus 13 Branches of pulmonary vein 14 Left ventricle of heart 15 Spleen 16 Splenic artery and vein and pancreas 17 Left kidney 18 Psoas major muscle 19 Inferior vena cava 20 Renal vein 21 Body of twelfth thoracic vertebra and vertebral canal 22 Right kidney 23 Superior mesenteric artery 24 Superior mesenteric vein 25 Pancreas 26 Abdominal aorta 27 Left psoas major and quadratus lumborum muscles 28 Anterior layer of renal fascia of Gerota 29 Posterior layer of renal fascia 30 Perirenal fatty tissue 31 Abdominal cavity 32 Descending and sigmoid colon Parasagittal section through the thoracic and abdominal cavities at the level of the left kidney (5. The renal pelvis has been opened and the fatty tissue removed to display the renal vessels. Each kidney can be divided into five segments supplied by individual interlobar arteries known as end arteries. The anterior kidney surface reveals four segments; the posterior, only three (Nos. Kidney 327 1 Hepatic vein 22 2 Anterior and posterior vagal trunk 3 Inferior vena cava 4 Lumbar part of diaphragm 23 5 Right greater and lesser splanchnic nerves 6 Celiac trunk 16 7 Celiac ganglion and plexus 8 Superior mesenteric artery 9 Left renal vein 23 10 Right sympathetic trunk and ganglion 11 Abdominal aorta 12 Left sympathetic trunk 13 Esophagus (cut), left greater splanchnic nerve 14 Left suprarenal gland 15 Left renal artery 16 Renal pelvis 17 Renal papilla with minor calyx 18 Left testicular vein 19 Ureter 19 20 Psoas major muscle 21 Quadratus lumborum muscle 22 Lumbar vertebra (L2) 23 Renal calyx 24 Catheter 24 Renal pelvis with calices and ureter (X-ray, retrograde injection; by courtesy of Prof. Scanning electron micrograph showing glomeruli Architecture of vascular system of kidney and associated arteries. Part of the left psoas major muscle has been removed to display the lumbar plexus. Retroperitoneal Region: Autonomic Nervous System 335 56 Ganglia and plexus of the autonomic nervous system within the retroperitoneal space (anterior aspect). The penis includes the urethra and thus serves for both ejaculation and micturition.

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Several mechanisms are involved: Key points • enzyme induction purchase imuran now, so the hepatic metabolism of the anti- Status epilepticus epileptic is enhanced quality 50 mg imuran, plasma concentration lowered and efficacy reduced; If fits are 5 minutes in duration or there is incomplete recovery from fits of shorter duration order imuran amex, suppress seizure • enzyme inhibition, so the metabolism of the anti-epileptic activity as soon as possible. Assess the patient, verify the diagnosis and place them in the lateral semi-prone In addition to this, several anti-epileptics (e. Phenytoin, phenobarbital, topiramate and carbamazepine • If fits continue, transfer to intensive care unit, consult induce the metabolism of oestrogen and can lead to unwanted anaesthetist, paralyse if necessary, ventilate, give pregnancy: alternative forms of contraception or a relatively thiopental, monitor cerebral function, check pentobarbitone levels. Up to 70% of epileptics eventually enter a prolonged remission and do not require medication. Indivi- Status epilepticus is a medical emergency with a mortality of duals with a history of adult-onset epilepsy of long duration about 10%, and neurological and psychiatric sequelae possible which has been difficult to control, partial seizures and/ in survivors. Drug withdrawal itself may precipitate seizures, and the usually be achieved with intravenous benzodiazepines possible medical and social consequences of recurrent seizures (e. Despite the usually insignificant medical consequences, a Patients affected by drowsiness should not drive or operate febrile convulsion is a terrifying experience to parents. It is usual to reduce fever by giving paracetamol, removal of clothing, tepid sponging and fanning. Fever is usually due to viral infection, but if a bacter- dose should be reduced gradually (e. Uncomplicated febrile seizures have an excellent progno- Patients should not drive during withdrawal or for six months sis, so the parents can be confidently reassured. Rectal diazepam may be administered by par- Febrile seizures are the most common seizures of childhood. A ents as prophylaxis during a febrile illness, or to stop a pro- febrile convulsion is defined as a convulsion that occurs in a longed convulsion. Drugs and tonic–clonic seizures have been well controlled with carba- Therapeutics Bulletin 2003; 41: 41–43. Answer 1 Erythromycin inhibits the metabolism of carbamazepine, and the symptoms described are attributable to a raised plasma concentration of carbamazepine. Answer 2 This patient is not adequately protected against conception with the low-dose oestrogen pill, since carbamazepine induces the metabolism of oestrogen. The aura is associated with intracra- In the majority of patients with migraine, the combination of a nial vasoconstriction and localized cerebral ischaemia. Shortly mild analgesic with an anti-emetic and, if possible, a period of after this, the extracranial vessels dilate and pulsate in associ- rest aborts the acute attack. During a migraine attack, gastric stasis occurs and this oppose the effects of kinins, prostaglandins and histamine to impairs drug absorption. Several other idiosyncratic precipitating factors are rec- ognized anecdotally, although in some cases (e. Sedative anti- spondylosis, sleep (too much or too little), ingestion of tyramine- emetics (e. A scheme for the cranial circulation, thereby causing vasoconstriction predom- acute treatment and for the prophylaxis of migraine, as well as inantly of the carotids; they are very effective in the treatment of the types of medication used for each, is shown in Figure 23. Sumatriptan is also of value in cluster • are significantly symptomatic despite suitable treatment headache. Importantly, they can cause vasoconstriction in other for migraine attacks; vascular beds, notably the coronary and pulmonary vascula- • cannot take suitable treatment for migraine attacks. They should not be com- then withdrawn with monitoring of the frequency of attacks. Its bioavailability is only 14% when given orally due action of the β-blockers in this regard is uncertain, but they may to substantial presystemic hepatic metabolism. It is related be taken at any time during a migraine attack, but are most effec- to the tricyclic antidepressants. It affords good prophylaxis, but can cause drowsiness, appetite stimula- tion and weight gain. The anti-epileptic drugs topiramate and sodium valproate Migraine prophylaxis should be considered in patients who: (see Chapter 22) also have good effectiveness in the prophy- • suffer at least two attacks a month; laxis of migraine. Topiramate should only be initiated under • are experiencing an increasing frequency of headaches; specialist supervision. One evening she develops a particularly antagonist and calcium channel-antagonist activity. Approximately 30 minutes later, her is highly effective as migraine prophylaxis in up to 80% of headache starts to improve, but she feels nauseated and patients. It is used for severe migraine or cluster headaches notices that her fingers are turning white (despite being refractory to other measures. She is seen in the local Accident and Emergency Department where her headache has now disap- specialist hospital supervision because of its severe toxicity peared, but the second and fifth fingers on her left hand are (retroperitoneal fibrosis and fibrosis of the heart valves and now blue and she has lost sensation in the other fingers of pleura). The smallest dose that suppresses about 75% of the The problem is that the patient has inadvertently ingested headaches is used for the shortest period of time possible. No more than four Cafergot tablets should be taken during any 24-hour period (a maximum of eight tablets per week). The major toxicity of ergotamine is Key points related to its potent α-agonist activity, which causes severe Migraine and its drug treatment vasoconstriction and potentially leads to digital and limb ischaemia. Cardiac and cerebral ischaemia may also be pre- • The clinical features of classical migraine consist of aura cipitated or exacerbated. Treatment consists of keeping the followed by unilateral and then generalized throbbing limb warm but not hot, together with a vasodilator – either headache, photophobia and visual disturbances (e. Migraine: current • Up to 70% of acute attacks are aborted with simple therapeutic targets and future avenues. Topiramate, valproate, tricyclic antidepressants, cyproheptadine and, in exceptional cases only, methysergide may also be effective. It is the partial pressure of an The modern practice of anaesthesia most commonly involves anaesthetic agent in the brain that determines the onset of anaes- the administration of an intravenous anaesthetic agent to thesia, and this equates with the alveolar partial pressure of induce rapid loss of consciousness, amnesia and inhibition of that agent. Anaesthesia is maintained sia depends on factors that determine the rate of transfer of conventionally by the continuous administration of an inhala- the anaesthetic agent from alveoli to arterial blood and from tional anaesthetic agent and cessation of administration results arterial blood to brain (Figure 24. An opioid is often administered for anal- gesia, and in many cases a muscle relaxant is given in order to • Anaesthetic concentration in the inspired air – increases in the produce paralysis. A combination of drugs is normally used inspired anaesthetic concentration increase the rate of and the concept of a ‘triad of anaesthesia’ (Figure 24. None Agents with higher solubility in blood are associated with of the drugs in current use is flammable (unlike ether! It is a poor analgesic, but when co-adminis- pulmonary blood flow, as occurs in shock, hastens tered with nitrous oxide and oxygen, it is effective and con- induction. Although apparently simple to use, its little influence on induction with insoluble agents, as the therapeutic index is relatively low and overdose is easily pro- alveolar concentration is always high. Warning signs of overdose are bradycardia, hypoten- agents show significant increases in alveolar tension with sion and tachypnoea.

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