Thomas L. Higgins, MD, MBA, FACp, fccm

• Professor of Medicine, Surgery, and Anesthesiology
• Tufts University School of Medicine
• Boston, Massachusetts
• Interim Chairman, Department of Medicine
• Departments of Medicine and Surgery
• Baystate Medical Center
• Medical Director, Inpatient Informatics
• Baystate Health
• Springfield, Massachusetts

Some of them are more active and building in nature treatment brown recluse bite generic 5mg eldepryl with visa, while others are more nourishing and purifying treatment uti order cheap eldepryl line. They can be done in an ascending order of difficulty moving from the more externally focused to the more internally focused medicine 219 purchase generic eldepryl pills, or they can be done simultaneously symptoms 3 weeks into pregnancy order cheap eldepryl on line, with less time devoted to each practice in order to make time for a set of exercises medicine mountain scout ranch eldepryl 5 mg overnight delivery. One also needs to consider the age and health of the practitioner; for younger women some exercises will need less time medicine advertisements purchase eldepryl 5mg fast delivery, whereas for older women there needs to be a strong focus on rebuilding the jing and bringing back strength and vitality to the older body. Finally one can do these exercises in the context of Taoist sexual practices with or without a partner, or one can choose to work within the context of celibacy. In this paper I am going to talk about the basic exercises which I feel are most beneficial to every woman. These include the jade egg exercises, the breast and ovary exercises; exercises designed to strengthen the endocrine system and create a supple spine such as Willow Waist, Soaring Dragon Feeds on Qi and Swimming Dragon; and exercises to prepare for or to induce the alchemical transformation of the being such as the Lesser Heavenly Circuit and the seated Eight Brocades. In addition I like to add Bone Breathing exercises along with Water and Fire purifications, especially during times of stress or ill health when more vigorous practices are too challenging. All of these exercises are important from the standpoint of bringing greater life force and vitality to the body, as well as forming the basis for more advanced Nudan practices. But even if the practitioner has only the goal of enhanced physical health and the retardation of the aging process these exercises are more than worth the time and energy that they require. In the beginning I recommend that practices be done in short sets of 20 to 30 minutes one or two times a day. The first thing that every woman needs to begin this work is to restore pelvic tone. One is that over 50% of American adults over the age of 50 years experience some degree of incontinence. One reason why this is such a problem for women is that many of us have gone through childbirth without any attention later to restoring the damage to the pelvic floor muscles. Not only is urinary incontinence a common outcome, but prolapses of the bladder, rectum and uterus can also occur. Even in women who have not experienced childbirth (or men for that matter) the process of aging can create a condition which in Chinese Medicine we call the collapse of Central Qi. In an extreme sense this is what we all experience in the moment of death when the body releases the lower orifices and the Po exits the body and returns to the earth; this in turn means that the organizing principle for our physical life force is no longer present and the body will begin immediately to decay. Mortification sets in, the Hun and Shen exit and the process of death is complete. Thus the ability to have pelvic tone forms not only the basis for physical health, it is essential for sealing in the life force if one is to create the longevity necessary for Nudan. A small drilled egg of some stone about the size and shape of a pigeon egg should be inserted in the vagina for several hours a day. In the beginning a woman can simply insert the egg and then go about her day; later if she wishes she can learn to perform rhythmic internal contractions to move the egg up and down or to rotate the egg internally. The highest levels of the work involve weight lifting with small weights which can be suspended from the egg. This is actually amusing as the real problem is most generally that it is difficult to keep the egg in place when one is a beginner. One can attach a bit of dental floss or embroidery silk and pull the egg out if necessary. The gentle movement of the egg against the inner walls as the woman walks around will stimulate improved vaginal tone, increased secretions (which is very helpful for the older woman) and both increased tone and differentiation of the muscles of the pelvic floor. The advantages of increased pelvic tone are obvious; the advantages of differentiation are perhaps less so, but are equally important. One of the difficulties in moving energy down the internal pathway from the ovarian palace (Qi Hai) along the shared internal pathways of the Chong Mai, Du Mai and Ren Mai to the perineum at Hui Yin, and then onward to the Wei Lu pass, is that most women have very poor sensing of their anatomical structures and only the most vague ability to visualize them. Being able to sense and move energy entails having a clear ability to sense the body accurately, image it clearly and feel what is actually going on. When one can wear the egg and forget its presence yet then urinate without the egg precipitously falling out, one knows that the floor of the pelvis has strengthened and that one has gained the ability to open the urethra while simultaneously keeping the tone of the vaginal sphincter, an act which requires real differentiation of the actual structures. While this may not seem immediately important, it is in fact vital in doing the internal movement of energy required for the Lesser Heavenly Circuit. It also has the side benefit of ameliorating many of the irritations of menopause, as well as improving sexual functioning. Any woman who has worked with an egg can tell you that the strength and suppleness of her vaginal walls improves in one to two weeks of daily practice involving no more than simply wearing the egg. And if a woman is prone to urinary issues when sneezing or exercising, the egg will produce a cure in short order. For those who are choosing to do Nudan as part of the broader practices of Daoist sexual practice the egg will greatly increase their ability to induce the Valley Orgasm. They include massage of the breasts and ovaries with accompanying visualizations and breathing. Descriptions of these exercises are readily available in a variety of books, again I might recommend Cultivating Female Sexual Energy, or alternatively, the work of Hsi Lai in the White Tigress Manuals. The Tigress lineage stresses restoration of tone and beauty to the breasts, which most women enjoy and which the exercises certainly do; other authors stress their health benefits. Certainly they are important because they are an excellent prophylactic against breast cancer. By mobilizing the energy and breaking up stagnation they prevent cancer; more importantly to the broader work, they help to awaken and restore the Qi of the chest. This is something that is often poorly understood because this work has been largely taught by men for men; for women there are certain essential differences and the fact that we must center our Qi in the heart is one of them. Besides breaking up stagnation and preventing cancer, stimulating the breasts reawakens the life force and promotes a younger physiology. It is also important for those women who wish to move on to the practice of Cutting off the Dragon or menstrual cessation, which is to say drawing the creative force of the ovaries upward to the breasts where it can be stored for the alchemical work of creating the immortal body. This involves rubbing and pressing the ovaries while breathing and visualizing light and heat entering them. In pre menopausal women the main focus on the heating of the ovaries would be in the pre ovulation part of the cycle when the ovaries are building their heat. During the days of ovulation special focus should be on drawing the energy upward. In post-menopausal women the focus is on rebuilding the life force of the ovaries. This may trigger a resumption of menstrual cycling, an event that is unsettling at first for both the women and their physicians. However texts assure us that this is a normal stage in Nudan, and that the woman need only to focus on drawing the energy upward and after a while her cycles will cease again but she will be locked into a permanently physiologically younger state. The total required time for the Doe exercises once one has mastered them should be from 10 to 30 minutes. These exercises are especially important if one is choosing to do the sexual alchemical practice of generating the three peak medicines. In order to produce the sexual elixir of the Middle Peak a woman has to achieve a strong sensitivity to the energy of the breasts. Learning how to compress or pack energy into the ovaries is important for older women who need to restore themselves, or for younger women who wish to increase their sexual force or to produce a very strong baby. This practice can be added on after the warming exercises and requires only a few minutes of concentrated breathing and muscular contractions. Once again, the actual exercise involves learning how to differentiate and work with the body. Anyone who has ever seen a belly dancer who can contract their abdominal muscles in a rhythmic way from the solar plexus down to the pubic bone has witnessed a form of this exercise. By simultaneously contracting the abdominal muscles while moving the energy down and while drawing the perineum up, the practitioner compresses the Qi and can direct it into the ovaries. They accomplish the first level of alchemical work, which is to restore and conserve jing. There are many Qi Gong exercises that address this level, but in Nudan there is a particular emphasis on exercises that promote a supple spine and that stimulate the fat-burning of the abdominal region. Another way of looking at this from the more modern scientific point of view is that these exercises stimulate the endocrine system. When we consider that the endocrine system fundamentally determines the aging of the body, we can understand why Nudan/Neidan has such a focus on the preservation of youthfulness. Whether or not one chooses to view this metaphorically, still it is clear that promoting a physiology that at the very least is pre-menopausal or pre-andropausal is a very good thing. The exercises that I have found most useful for this work are Willow Waist, Swimming Dragon (which is a variant of Willow Waist, more commonly done by men) and Soaring Dragon Feeds On Qi, which I believe is both a preparation for Swimming Dragon and also a way of opening the Eight Extraordinary Channels. These exercises are readily accessible in the works of Hsi Lai, Master Shih and in various other internet sources, so I will not describe them here other than to discuss their effects. One might do 5 minutes of Soaring Dragon Feeds on Qi and 15 minutes of Swimming Dragon, or 20 minutes of Willow Waist. Willow Waist is the most physically challenging, and also involves a complex internal visualization to activate and blend the three elixir fields. Often I alternate between the exercises depending on my energy level, doing one set on one day and the other on another. Willow Waist can also strain the thighs and the knees until one has built up strength. What is important however is that one begins to learn how to move the Qi: up the spine, down the front of the body, through the central channel, through the energy field, and in the case of Willow Waist, activating the elixir fields and blending them. The exercises that help one to do this are the Lesser Heavenly Circuit (also known as the Microcosmic Orbit) and the seated Eight Brocades. Both of these are extremely focused internal meditations, although the Eight Brocades involves movements as well. One master with whom I studied told me that he thought that the Lesser Heavenly Circuit was too difficult for beginners and that it took years to make progress in moving the energy; my own experience is that daily practice yields results fairly quickly. Sensations of heat moving up the spine occur for most women in the early stages, later on women report remarkably consistent internal imagery. Energy improves and vitality increases, menstruating women often report that their cycles improve with there being a reduction in physical symptoms and shorter, more moderate flow. Detailed descriptions of how to do the Lesser Heavenly Circuit are found in a number of sources, but my personal favorite is again Master Chia. He includes many useful diagrams, movements and preparatory exercises that help the practitioner to really locate where the various energy points are on the body. One difficulty that I have observed is that oddly enough this exercise is harder sometimes for women who have been doing visualization practices for years. They imagine the movement of Qi, but they are not really sensing and feeling in the physical and energy bodies. It is important to actually feel what you are doing, and to know where the actual structures are that you are attempting to effect. The imaginal body is the Hun, and while important in the modulation of emotions, it is not the primary body of energy. Another additional note that I would like to add here is that for women it is really important to focus on the descending aspect of the Qi. Any woman who is fully orgasmic can have a notion of what the upward flow of Qi is like; the descending of the Qi through the core of the body is actually where the most work needs to be done for most of us. A frequent concern that is voiced about these more advanced practices is that they can cause health problems. What is more true is that they can alter the course of what is already a deranged process, moving it toward greater health but temporarily increasing symptoms. For example some changes that might occur might be that initially there may be an increase in bleeding accompanied with clots and brownish blood if the woman has had Qi stagnation. If on the other hand her periods were irregular, skipped or very light because of blood deficiencies, the woman is also likely to see an increase in the amount of blood, length of her periods and frequency. The heavier flow in both cases is a good thing, because the body is moving toward a healthier state. Some women also report slight cramping in the ovaries at the midcycle in the earlier phases of the work. This is probably due to the increased heat in the ovaries; as the practice continues and the energy is drawn upward this symptom will discontinue. As practice continues the periods should move toward what is considered optimal in Chinese Medicine, which is to say that they have no cramping, bloating or other symptoms associated with them, and they arrive unheralded by anything other than a moderate but strong flow of bright red blood without clots or pain. They will over time shorten in length, in part because the body is becoming more efficient at shedding its lining, and may last only for two or three days. This change alone makes the practices worth doing in my opinion; the fact that modern woman consider it normal for menstruation to be a burden accompanied by a raft of unpleasant changes is truly unfortunate, given that it can be corrected. Infertility issues may also be resolved, especially as heat and life force builds up in the ovaries. Younger women in my study group all reported positive changes in their menstruation. Several women with abnormal bleeding due to fibroids (or in one case endometriosis) reported that over time their periods became more and more normal.

Little evidence supporting effcacy of other widely used treatments (sedating antidepressants and Insomnia disorder is defned in the International Classifcation non-prescription agents) was found medicine cards buy generic eldepryl canada. When but the consensus recommendation was that such treatment 4 medications at target buy eldepryl in india, the disorder meets the symptom criteria but has persisted for when used medicine xl3 buy genuine eldepryl line, should be accompanied by cognitive-behavioral less than three months treatment episode data set 5 mg eldepryl overnight delivery, it is considered short-term insomnia medications xanax purchase eldepryl 5mg amex. Other drugs symptoms yellow fever order 5mg eldepryl free shipping, In medically and psychiatrically ill populations, as well as in such as sedating antidepressants or anticonvulsant medications older age groups, the prevalence is signifcantly higher. Chronic were recommended as second or third-line agents, particu insomnia is associated with numerous adverse effects on func larly when comorbidities. Other, non-prescription drugs such as over-the counter onstrate marked impairment in functional status among those antihistamine sleeping aids and herbal/nutritional agents were with chronic insomnia. More recent investigations suggest although degradation of improvement following discontinua that chronic insomnia is associated with increased risk for car tion of hypnotic was noted to be of concern. Clinical Practice Guideline: Insomnia of chronic insomnia are complicated by many confounding an orexin receptor antagonist (suvorexant) have entered the variables, but virtually all analyses of these costs indicate United States market. However, they able in 1970 and rapidly supplanted the use of barbiturates also note a lack of awareness and/or availability of alternative and similar compounds for treatment of insomnia. Their review found that eszopiclone, They reported a small effect size for improvement in sleep zolpidem, and suvorexant improved short-term outcomes, quality (d = 0. However, some of these analyses report treat is 13, while the number needed to harm is 6, thereby signifcant increases in treatment-emergent adverse events and indicating an unfavorable risk/beneft ratio for this popula raise concerns regarding their relative risk:beneft ratio. Total sleep time is defned as the total time spent in bed, minus sleep latency and wake after sleep onset. Wake after sleep onset is defned as the sum of wake times from sleep onset to the fnal awakening. Number of awakenings is defned as the number of awakenings after sleep onset, excluding the fnal awakening. Task force members with a Level 2 confict were required to recuse themselves from any related Doxepin discussion or writing responsibilities. Based on their expertise, the task force developed a list of patient-oriented clinically relevant Zolpidem outcomes that are indicative of whether a treatment should be recommended for clinical practice. Prior nifcant, were defned for each outcome by task force clinical to appointment, the content experts were required to disclose judgement, prior to statistical analysis (Table 3). Searches were performed on April 26, 2011 (search 1), May 12, 2014 (search 2), October 15, 2014 (search 3), and January 25, 2016 (search 4). Of the 129 accepted publications, 46 were included spot check for the literature searches to ensure that important in the statistical and meta-analysis. If outcome and meta-analyses, when the change-from-baseline standard data were not presented in the format necessary for statistical deviation was provided or could be calculated from the pro analysis. If the necessary data were not available from accepted papers were used for statistical and meta-analysis. It is essential that the recommendations which follow be interpreted within the appropriate context of clinical prac tice. Remarks are intended to provide con along with management of comorbidities and non-pharmaco text for the recommendations. The overall evidence for suvorexant dence in a variety of factors related to the intervention includ was weakly in favor of its effectiveness for the treatment of ing (1) the availability of specifc data regarding effcacy; (2) sleep maintenance insomnia only. As a result, the quality of evidence for a vast ma quency of adverse events was not signifcantly increased ver jority of available data is downgraded due to potential publi sus placebo. There was no evidence of daytime residual or cation bias associated with such sponsorship; (4) a paucity of withdrawal symptoms. Absent such information, it is diffcult to as clinical judgement, the task force determined that the majority sign a high degree of confdence to estimations of beneft:risk of patients would use suvorexant over no treatment. Additional outcomes data from Herring also on individual patient characteristics, comorbidities, and 2012 and 2016 are discussed below as supporting evidence. Herring 201654 conducted two randomized placebo-con trolled parallel trials of 3 months each. Orexin receptor agonists Only data from trial 1 were available for statistical analyses. The dosages of interest for this analysis were 20 suvorexant as a treatment for sleep maintenance insomnia mg for younger adults and 15 mg for older adults. The statistical analyses and recommen Sleep latency: Herring 201255 found a reduction of 2. The quality of evidence was low due to impre and moderate quality of evidence due to imprecision and po cision and potential publication bias. The quality of evidence was low due to overall Quality of evidence: the overall quality of imprecision and potential publication bias. Frequency of daytime somnolence was increased in erate due to potential publication bias. Uchimura and colleagues60 employed a similar cross sleep onset and number of awakenings revealed trends toward over design with eszopiclone doses of 1, 2, and 3 mg, zolpidem improvement which fell below the defned level of clinical sig 10 mg and placebo in 65 patients. Zammit Six studies assessed the effects of eszopiclone 3 mg for and colleagues61 examined eszopiclone 2 and 3 mg vs. Patient evidence for these studies as a whole was downgraded to very reported data were collected for nights 1, 15, 29, 43, and 44. The greatest reduc colleagues56 studied 388 older adults for 12 consecutive weeks tions were reported in the extended 6-month trials of Krystal of nightly eszopiclone 2 mg. Scharf amined outcomes in perimenopausal/menopausal women who and colleagues59 administered 1 and 2 mg of eszopiclone or exhibited hot fashes and manifested either sleep onset or main placebo nightly to 231 older adults for two weeks, employing tenance problems. The quality of evidence was moderate ies were industry sponsored, resulting in further downgrading due to potential publication bias. The two investigations of meno mg, individual studies reported results which are consistent pausal women found eszopiclone-placebo mean differences for with those of the 2 mg dosage. Clinical Practice Guideline: Insomnia impairment in digit symbol substitution at either 2 mg or 3 mg. The lack of evidence for effcacy of zaleplon 5 tenance insomnia, with limited or no consistent evidence of mg makes any potential benefts equivalent to its minimal po adverse events in excess of placebo, with the possible excep tential harms. Therefore, benefts were deemed to Based on clinical judgment, the task force determined that marginally outweigh harms. Data for studies was downgraded to low due to imprecision and po zaleplon 20 mg were not considered here because this is not an tential publication bias; both studies were industry supported. Similarly, subjective sleep quality showed quality of evidence was downgraded for imprecision. The overall evidence for downgraded further due to the risk of publication bias since zaleplon 5 mg did not support its effcacy for treatment of any the study was industry-funded. The resultant quality of evi insomnia symptoms, based on self-report studies only. Treatment Self-reported sleep latency was reported in one study,68 emergent adverse events showed no signifcant difference from which showed a reduction compared to placebo at the end of placebo for zaleplon 10 mg or 5 mg, and only one study sug treatment ( 11. Clinical Practice Guideline: Insomnia Additional studies not included in the primary analysis study weeks showed no difference between groups. Ancoli-Israel69 conducted a randomized, evidence was downgraded for publication bias. Precision and double-blind, multi-center study of the effcacy of zaleplon 5 heterogeneity could not be formally evaluated. Quality of the evidence was down analyses could be conducted on data from studies of zaleplon. Still other meta-analysis of these studies was not possible due to the man studies presented data for key outcomes only in graphical form. These studies showed no consistent evi the quality of evidence was downgraded for imprecision, due dence of a zaleplon placebo difference at the 10 mg or 5 mg to the relatively large confdence intervals which cross the clin dose of zaleplon. The effects of zaleplon 5 mg versus placebo on subjective HarmS: No meta-analysis was conducted on harms. Six studies included adequate data for of 2 nights per intervention with intervening washout. Clinical Practice Guideline: Insomnia zolpidem 10 mg or placebo for two weeks to 21 adults with versus placebo was at the signifcance threshold (mean differ diffculty initiating or maintaining sleep. Subjects received zolpidem for 28 days, followed of a three-way crossover study of zolpidem sublingual 1. Subjects underwent sleep studies on cebo to subjects with sleep maintenance insomnia following the frst two nights of each treatment week. Walsh80 studied 205 elderly adults with to imprecision and potential publication bias. Eight studies insomnia with the same inclusion criteria and design, employ reported adequate data for meta-analysis of patient-reported ing a 6. The quality of ev idence for individual outcomes ranged from moderate to very Wake after Sleep onSet: Two studies reported adequate low, therefore the overall quality of evidence was very low. This exceeds the threshold for clinical signif possible for six side effects: amnesia, dizziness, sedation, cance. Morning alertness and performance impair heterogeneity and potential publication bias. Walsh80 found a dif formally assessed sleepiness following administration of zol ference of 2. Hajak104 treated 1,507 subjects with sleep onset or maintenance Triazolam for the Treatment of Chronic Insomnia insomnia with triazolam 0. The triazolam and placebo Because only one study96 contained data of suffcient quality, groups included 28 subjects who completed daily sleep diaries. The quality of evidence for Rickels107 studied 50 subjects with sleep onset or maintenance this study was high. Sleep latency: In the only study with adequate data for Number of awakenings was insignifcantly decreased. This reported sleep diary reductions from baseline placebo levels was followed by 14 nights in which subjects chose to self-admin of 55 min and 24 min in two separate triazolam 0. Many included dosages which fell below the clinical signifcance threshold of 30 min and was are higher than current recommended dosages. In summary, meta-analysis data are available for temaze Bowen100 observed a statistically signifcant reduction in sub pam 15 mg only. Hajak104 studies (see below), the task force judged that the benefts of te reported that speech disorder was the only adverse effect, mazepam 15 mg appear to be greater than the potential harms. Wilson117 conducted an mazepam in the treatment of insomnia was included in the sta actigraphic evaluation of 38 subjects with complaints of poor tistical analysis. Subjects received a single night of placebo and a single night At the 20 mg dosage, three trials92,113,117 reported subjective of temazepam 20 mg with one-week intervening washout. Over, benefts were deemed to outweigh harms for te Quality of Sleep: Meta-analysis was conducted for sleep mazepam 15 mg. Two studies found statistically signifcant improvement in Melatonin agonists sleep quality ratings for temazepam 30 mg. Based on clinical judgment, the task force determined that the majority of well HarmS: Limited data on adverse effects of temazepam 15 informed patients would use ramelteon over no treatment. Heffron115 found eon in the treatment of chronic primary insomnia was included 329 Journal of Clinical Sleep Medicine, Vol. Roth and colleagues120 studied 100 older adults (age > 65 in meta-analysis supported these results. The quality of evidence and therefore the quality of evidence was downgraded for im was downgraded to low due to heterogeneity and the risk of pub precision. Ad heterogeneity across studies (I2 = 96%), and due to the risk of ditional studies which assessed subjective sleep quality found no publication bias since all these studies were funded by indus difference between ramelteon and placebo groups. Subjective sleep latency from these investiga falling well below the clinically signifcance threshold for ob tions was comparable to objective latencies with mean differ jective sleep effciency of 5%. The data were also downgraded for imprecision, due to the rel Summary atively large confdence intervals, which cross the clinical sig nifcance thresholds for multiple outcomes. The evidence suggests low; therefore, the overall quality of evidence was very low. Roth and colleagues reported on next-day re Meta-analysis of side effects included headache, diarrhea, sidual pharmacological effects of ramelteon in an older adult somnolence and upper respiratory infection at 3 mg, and head population. Quality was low due to imprecision and poten enings) for 3 mg127,129,130 and the 6 mg dose (+0. Quality of these data was low due to imprecision patientSvalueS and preferenceS: Based on its clini and potential publication bias. In all, 75% of trazodone subjects ity of evidence for this study was moderate due to potential reported some adverse event(s), compared to 65. Based on its clinical judgement, the task force determined that, despite Anticonvulsants the absence of signifcant effcacy for trazodone 50 mg and the paucity of information regarding harms, the majority of patients Tiagabine for the Treatment of Primary Insomnia would be likely to use trazodone compared to no treatment. Recommendation 10: We suggest that clinicians not use Discussion tiagabine as a treatment for sleep onset or sleep maintenance Walsh78 investigated the effcacy of trazodone 50 mg versus insomnia (versus no treatment) in adults. Subjects were administered either trazodone or Summary placebo in double-blind fashion for 14 consecutive nights. Meta-analysis of adverse effects showed no difference be tween tiagabine and placebo on headache or nausea. Given the Quality of Sleep: On a 4-point scale (1 = excellent, absence of demonstrated effcacy on numerous critical out 4 = poor) sleep quality was not signifcantly improved versus come variables (with slight trending toward mild worsening placebo ( 0. Clinical Practice Guideline: Insomnia Discussion signifcant heterogeneity, imprecision and potential bias (in Three studies were included in the meta-analyses of ti dustry sponsorship) for some critical outcomes. Tiagabine 4, 6, visual analogue scales for sleepiness/alertness at the 4 mg 8, or 10 mg or placebo was administered on two consecutive dose. Quality of evidence or patient-reported outcome variables reached clinical sig was very low due to heterogeneity, imprecision and potential nifcance thresholds. This judgement is measures due to imprecision and potential publication bias based on the absence of evidence for clinically signifcant improvement.

While feedback on performance and compliance may drive further efforts forward medicine 014 purchase eldepryl 5 mg free shipping, if teams become too focused on measurement details it can hinder the overall program treatment urticaria purchase eldepryl line. It is best to design rules that assist your team in making your plans work; for example medicine 4839 purchase generic eldepryl pills, assign credit for completion of bundle elements where your team has determined there are true contraindications to bundle elements symptoms for pregnancy order eldepryl 5mg otc. Some teams have preferred to use a sampling approach to assess compliance with the Ventilator Bundle medicine omeprazole 20mg discount eldepryl 5 mg otc. For example treatment alternatives best 5mg eldepryl, some teams use spot checks of compliance three times per week, whereas other teams have chosen daily assessments of compliance at designated times. Regardless of the method, be sure to maintain the standard over time for accurate results. Approach the work with the knowledge that picking and choosing bundle elements will not work. Discourage the tendency to select interventions that seem easy at the expense of more difficult options also included in the bundle. Your aim is 100% compliance with every bundle element for every patient; partial compliance is the equivalent of non-compliance. Remember, though, to give credit for compliance if a bundle element is not given for clinically appropriate reasons, provided that the discussion with the team occurred and it is clearly documented. Not only will this show dedication to the project; when the momentum becomes apparent, clinical staff will be aware of the progress. In fact, the goal of bundling therapies together aims to create a linkage between practices that makes the overall process more effective. Certainly, in terms of monitoring compliance with the Ventilator Bundle, picking and choosing items would be unwise. The practice of comparing rates of disease entities or patterns of therapy across institutions is commonly known as benchmarking. Fortunately, none of the work required to improve the care of ventilated patients requires a comparison of rates between institutions. In addition, as long as you establish methods in your institution to determine the patterns and methods of your regular data collection, your results will be consistent over time with respect to your own performance and your own improvement, which is our primary interest. Presumably, any improvements you make would be reflected in any benchmarking work that you do for other agencies. You should also learn what strategies hospitals reporting improvement have used; even if their definition or their population is a bit different from yours, if they have measured consistently over time they may have some great lessons from which you can learn. Once you have measured 45 degrees for that bed, place a piece of colored tape on the wall behind the bed and verify compliance during vent checks. No specific exclusion criteria exist, but good clinical judgment should be exercised in conjunction with a close reading of the evidence cited in the How-to Guide. Instead, teams interested in improving their performance should develop these standards in conjunction with their clinical staff and apply them uniformly over time. In so doing, teams will have an accurate standard whereby they can measure their own progress in comparison to the only standard that is truly meaningful: their own data. As an example, some institutions have proposed criteria for excluding patients from various parts of the bundle. One institution excludes patients from interruption of sedation if any of the following criteria apply: Open abdominal wound in which fascia is not closed, unless ordered by a physician. Workable inclusion criteria, exclusion criteria, measurement systems, and protocols all require customization at the local level to be effective. The only key factor in all of these decisions is that the standards, once decided, are adhered to over time. In the study, an investigator interrupted the sedation each day until the patients were awake and could follow instructions or until they became uncomfortable or agitated and were deemed to require the resumption of sedation. The use of subjective and objective criteria may be helpful in maintaining the desired level of sedation, despite changes in medical personnel and sedation goals. Motor Activity Assessment Scale: A valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. However, these scales are not substitutes for the standard of interruption of sedation. In the Kress trial, patients were in fact subjected to both a sedation scale and interruption of sedation. The Ventilator Bundle has primarily been tested on intubated patients, rather than those with tracheostomies, so we not have specific evidence to adequately tell you the effect of the Ventilator Bundle on this population. These patients may still benefit from the Ventilator Bundle components depending upon acuity. You should decide locally whether these patients should be included in your measurement, depending on factors such as these. Should we apply the Ventilator Bundle to long-term or chronically ventilated patients The Ventilator Bundle was developed and tested in the intensive care setting, and the evidence supporting the elements are primarily in those populations. We would recommend that you not include this type of patient in Ventilator Bundle compliance measures. Part of the aim of a bundle strategy is to implement solutions that are rapidly and readily available to hospitals. In addition, there is a tendency among providers to do all possible interventions, when a select few might be effective to minimize risks. In addition, we encourage teams to maximize their implementation of the existing items in the Ventilator Bundle first before adding other approaches. The solution may in fact be doing just these items very well, instead of doing additional items fairly well. The Ventilator Bundle was designed as part of an overall strategy to improve the care of ventilated patients. Some hospital patients need help breathing, either because they have just had a major operation or because they are very ill. Two of the items in the bundle help prevent other serious complications that can occur when a patient is on a ventilator: stomach ulcers and blood clots. How family members can help: Ask the nurses and doctors these questions: Are you going to raise the head of the bed when [patient] is on the ventilator Because of rapid changes in medicine and information, the information in this Fact Sheet is not necessarily comprehensive or definitive, and all persons intending to rely on the information contained in this Fact Sheet are urged to discuss such information with their health care provider. Daily Sedative Interruption and Daily Assessment of Readiness to Extubate 3. We recommend that you use some or all of them, as appropriate, to track the progress of your work in this area. In selecting your measures, we offer the following advice: Whenever possible, use measures you are already collecting for other programs. Try to include measures that your team will find meaningful, and that they would be excited to see. Process Measure(s): Ventilator Bundle Compliance Measure Information Comments: Note that this measure is the same as that used in the 100,000 Lives Campaign, although, in preparation of the launch of the 5 Million Lives Campaign, some edits have been made to clarify the instructions. The Joint Commission has stopped data collection on these measures but still endorses them; more information can be found on the Joint Commission website. Avoid smoking and drinking of alcoholic beverages, especially on an empty stomach. The following foods should be avoided during the acute stage of dyspepsia or peptic ulcer and taken sparingly during intermissions by those liable to frequent attacks. By trial and error the patient can find out which of the foods listed below should be avoided thereafter. Alcohol, strong tea and coffee, cola beverages, gravies and soups made from meat extracts. Raw and unripe fruit and dried fruits, nuts and the pips, skins and peel of all fruit. Refined and well-cooked foods, eg: corn flour, semolina, ground rice and oat flour. Vegetables, potatoes, creamed or mashed, and green and yellow vegetables which may be sieved and pureed with butter. Great heterogeneities and possible publication bias were found among the trials which pre clude certain conclusions. Keywords: Yunnan Baiyao, haemorrhage, ulcer, meta-analysis Introduction ders and bleeding caused by trauma or surgery [7, 8]. Orally administration of conjugated estro Haemorrhage is an undesirable event occurring gens is used for gynaecological bleeding, gas after trauma, surgery or ulcer [1-3]. It haemostatic drugs for rhexis haemorrhage might cause urinary tract bleeding and cannot include antifbrinolytic amino acids (amino be used for undiagnosed abnormal genital caproic acid and tranexamic acid), aprotinin, bleeding [9, 10]. For treating upper gastrointes desmopressin, and conjugated estrogens etc tinal ulcer, proton pump inhibitors and hista [4]. Specifcally, antifbrinolytics such as mine H2-receptor antagonists have been widely aminocaproic acid, tranexamic acid and apro used. Non-steroidal anti-infammatory drug tinin are widely used for rhexis haemorrhage (mesalazine) is commonly used for ulcerative like gynaecological, upper gastrointestinal, uri colitis. Honey and Vaseline have been typically nary tract and oral bleeding but cannot be used used for oral, skin and venous ulcer [11-16]. Desmopressin inal formula developed in 1902 by Qu acts through von Willebrand factor and is used Huangzhang. According to publications [17-21] for bleeding in patients with coagulation disor and information from the U. Food and Drug Yunnan Baiyao on haemostasis and antiulcer Administration. It has also been into the meta-analysis, studies had to conform shown to regulate immune function and anti to all the following criteria: 1) trial: randomized infammation [19]. Dichotomous data included no improvement Material and methods and improvement. If ordinal data were given to defne the degree of improvement, they were Data sources and search strategies transformed into dichotomous data as improvement by combining all the number of We searched (without languages, countries and patients that shows different degrees of publication status restrictions) the electronic improvement. For each item of the following: 2-detail ed mentioned, 1-simply mentioned, 0-not men tioned. Studies with score > 13 were arbi trarily defned as at low risk of bias, while those with score 13 were at high risk of bias. Data synthesis and analysis Included studies were categorized according to the type of treatment interventions, type of symptoms (haemor rhage or ulcer), and locations of disease (nose, oral cavity, skin, Figure 1. Meta-analysis rhage, the outcome was defned as follows: 2, was carried out using Review Manager Software full recovery, bleeding was stopped within 7 5. The number of patients duce wider confdence intervals and more con with a score of 2 or 1 was added together and servative estimates [29]. We reanalysed the data excluding studies dichotomous outcomes (response or no at high risk of bias to test how robust the results response to therapy). We As was shown in Figure 1, our search initially also consulted authors of the original studies to generated 244 citations. We obtained 77 papers for detail as experimental group and the group of cimeti evaluation. After consulting the author, 2 stud dine as control group, as this intervention was ies were abandoned. The bility criteria and were included in this meta scores of quality assessment ranged from 5 to analysis. After 464 Int J Clin Exp Med 2014;7(3):461-482 Yunnan Baiyao on haemostasis and antiulcer Table 1. Among these 7 studies, 2 assessed ulcerative the routine haemostatic drug used was carba colitis. The routine haemostatic drugs used were famotidine, ranitidine, 2 studies assessed peptic ulcer. The rou 2 studies assessed skin ulcer caused by bed tine haemostatic drugs used were Vitamin C, sore. Cure the primary disease, omeprazole 40 mg 4 days Concealment of allocation Not mentioned 2011 i. Not Concealment of allocation Not mentioned 2012 powder 4 g with physiological saline 20 ml through mentioned and blinding unclear, gastric canal randomized Zhou Y Fluid replacement, blood transfusion, fasting, wash Fluid replacement, blood transfusion, fasting, 5 days Concealment of allocation Not mentioned 2006 the stomach, Losec 40 mg b. The routine hae One study assessed lower gastrointestinal mostatic drugs were epinephrine and antibiot haemorrhage. The routine haemostatic drugs routine haemostatic drugs used in both groups 477 Int J Clin Exp Med 2014;7(3):461-482 Yunnan Baiyao on haemostasis and antiulcer Figure 4. The clini plus routine antiulcer drugs was effective in cal trial may be conducted under the principles treating ulcerative colitis. Thus sensitivity analysis ulcerative colitis by anti-infammation and pro results using this cutting point should not be moting intestinal epithelial wound-healing and considered defnite. For most of the trials, the meth od of randomization was not reported clearly, Strengths and limitations and few trials reported blinding of assessors of outcomes. Sensitivity searched most of the database resources or analysis was also conducted according to the the selected publication of positive results in a risk of bias of these trials. Limitations of our meta-analysis, as with any systematic review and meta-analysis, arose Acknowledgements from the quality and reporting of the trials included.

Syndromes

• Broken bone
• Place a diaper on the infant and cover the bag. The infant should be checked frequently and the bag changed after the infant has urinated into it. It may take a few attempts to collect a sample from an active infant.
• Dietary restrictions
• Remove electrical cords from floor surfaces.
• You have urinary frequency or urgency, but you are not pregnant and you are not drinking excessive amounts of fluid
• Bone pain or tenderness if the cancer spreads to the bone
• Vision loss

Unfortunately treatment 2nd 3rd degree burns buy discount eldepryl on-line, these gures do not give any detail about pain arising from the nervous system illness and treatment generic eldepryl 5mg with mastercard, except for the information about head and neck pain in the European survey 4 medications buy eldepryl with a visa. Certain neurological disorders causing pain have been examined in terms of the incidence of pain medicine abbreviations 5 mg eldepryl sale. For example Kurtzke (11) estimated that the annual incidence of herpes zoster infection in the United States was 400 per 100 000 of the population symptoms kidney disease order eldepryl discount. A study of the incidence of post-herpetic neuralgia in 1982 revealed a gure of 40 per 100 000 (12) symptoms thyroid purchase eldepryl cheap. Further information from Bowsher (13) indicated that the number of individuals with post-herpetic neuralgia increases with age so that 40% of people over 80 years of age who acquire acute herpes zoster will suffer from chronic post herpetic neuralgia. In populations in which ever greater numbers are living to 80 years and more, there is likely to be a signi cant increase in individuals suffering from post-herpetic neuralgia. One third of patients with multiple sclerosis develop neuropathic pain states, of whom trigeminal neuralgia occurs in 5%, and another one third develop other forms of chronic pain (3). There is an increase in the incidence of trigeminal neuralgia in patients with cancer and other diseases that impair the immunological systems. It is signi cant that one third of cancer patients have a neuropathic component to their pain as do a similar proportion of patients with prolonged low back pain (14). It should be noted that stump pain arises from a severed nerve in the limb and may be caused by a local neuroma or by tethering of the severed nerve to local tissues. In contrast, phantom limb pain is central neuropathic pain and more difficult to treat. Central stroke pain is de ned as neuropathic pain that follows an unequivocal episode of stroke. For most patients the pain develops gradually during the rst month but delays of many months have been recorded. The pain is incapacitating, distressing and often even more so than other symptoms. Headache disorders have also been the subject of intensive epidemiological research (see Chapter 3. Poor relief of acute pain is a recognized risk factor for the development of chronic pain after various forms of surgery, for example herniotomy, mastectomy, thoracotomy, dental surgery and other forms of trauma. The majority of such patients experience persistent pain one year after the causative event, indicating that acute neuropathic pain is a very de nite risk factor for chronic pain. Hernia repair is followed by moderate to severe pain in 12% of patients one year postoperatively and is of the somatic or neuropathic type (17). Breast surgery of various types gives rise to the experience of phantom breast and pain with or without a phantom. Information about the incidence and prevalence of pain generally, and neurologically related pain in particular, is almost totally lacking for developing countries, although there is no reason to believe that conditions that give rise to pain such as stroke, multiple sclerosis, various forms of headache and other disorders vary in nature. There may well be differences, however, in the extent to which some disorders are present, for example multiple sclerosis is less common in developing countries, whereas others are not encountered in the Western world, such as certain forms of poisoning by neurotoxins from foods, and leprosy which is a cause of neuropathic pain. The nature of the pain, which is often neuropathic in type, means that the sufferer has a disabling condition that in time may be primarily the result of pain, which is difficult to relieve. As such, it poses a signi cant health problem in terms of its personal, social and economic consequences. Pain re ects pathophysiological changes in the nervous system and they, together with changes that usually occur in patientsemotions and behaviour, have led to the conclusion that, in such cases, chronic pain is a speci c health-care problem and a disease in its own right. This diagnostic category is not fully accepted among clinicians because many continue to believe that pain must be a symptom of an ongoing disease or injury. Current research reveals, however, that the pathophysiological changes mentioned persist when signs of the original cause for pain have disappeared. The signs and symptoms of chronic pain, once it has evolved into a disease, are listed in Box 3. The combination of these features of the condition reveal the potential for physical impairment, disability and handicap which collectively form the basis of signi cant degrees of burden for both the patient and the family. Therefore many doctors, nurses and others dealing with patients in pain enter their professional careers inadequately equipped to deal with the most common symptom and cause of considerable suf fering worldwide. Politicoeconomic barriers the availability of drugs for the treatment of pain is a problem in over 150 countries. Frequently, pain management has a low priority, because the chief focus of attention is infectious diseases and, often, there are exaggerated fears of dependence with very restrictive drug control policies. In addition, in developing countries, the cost of medicines generally and therefore problems in their procurement, manufacture and distribution, add further barriers to their use. A treatment gap In many countries, therefore, there is a treatment gap, meaning that there is a difference between what could be done to relieve pain and what is being done. That gap exists in a number of devel oped countries, primarily because of poor pain education and the often limited and patchy nature of specialized facilities for pain treatment. Additionally, in developing countries these problems are far greater and the gap is far wider because of the lack of education, access to appropriate drugs for pain relief and facilities for pain management. The treatment gap can be reduced worldwide by improving pain education, increasing facilities for pain treatment and access to pain-relieving drugs. In the case of opioid analgesics, an increase in their availability and the employment of correct protocols is a matter of urgency. Also, no stricter measures should be enacted than those requested by the international drug conventions and international recommendations (20) on the use of opioid medicines. Management of pain of neurological origin the range of treatments available for pain directly caused by diseases of the nervous system includes pharmacological, physical, interventional (nerve blocks, etc. Treatments for pain are used in association with other forms of treatment for the primary condi tion, unless of course pain is itself the primary disorder. There are many studies of the medical treatment of peripheral neuropathic pain (21). There are far fewer studies published on the treatment of central neuropathic pain, for example post-stroke pain. Opioids have been shown to have some efficacy in neuropathic pain but there are speci c contraindications for their use. Topical agents may give local relief with relatively little toxicity; they include lidocaine and, to a lesser extent, capsaicin cream, particularly in the treatment of post-herpetic neuralgia. In selected cases, electrical stimulation techniques such as transcutaneous electrical stimulation or dorsal column stimulation may be used, but the latter in particular is expensive which clearly limits its use. However, the latter route requires administra tion by a trained specialist and therefore is unlikely to be freely available in developing countries. In relation to that, prejudice has the opioids that could provide such relief have been cat developed consisting of an unjusti ed fear of psychological egorized as controlled substances. They are therefore dependence of patients on opioid medication and an unjus subject to stringent international control and rendered ti ed fear of death caused by opioids. They ac for by many international bodies (the International Narcot count for about 80% of the world population. Annually, up ics Control Board, the United Nations Economic and Social to 10 million people suffer from lack of access to controlled Council, the World Health Assembly, etc. Nearly one billion of the people living today the programme, as proposed, will focus on regulatory will encounter this problem sooner or later. Most of them barriers, the functioning of the estimate system for import are pain patients. These causes stem essentially from an imbalance and law enforcers will exchange their views and the prob between the prevention of abuse of controlled substanc lems they encounter. It will train civil servants responsible es and the use of such substances for legitimate medical for submitting estimates and, in doing so, train health-care purposes. Furthermore, it will For almost 50 years the focus was on the prevention of develop other activities, including advocacy. Research reveals that such therapies are effective in the reduction of chronic pain and absenteeism from work (22). Relaxation techniques, hydrotherapy and exercise are helpful in the management of painful conditions that have a musculoskeletal com ponent. There is good evidence that multimodal treatment and rehabilitation programmes are effective in the treatment of chronic pain (23, 24). All health-care workers who treat pain, especially chronic pain, whatever its cause, can expect about 20% of patients to develop symptoms of a depressive disorder. Among patients attending pain clinics, 18% have moderate to severe depression when pain is chronic and persistent. It is known that the presence of depression is associated with an increased experience of pain whatever its origin and also reduced tolerance for pain. Therefore the quality of life of the patient is signi cantly reduced, and active treatment for depression is an important aspect of the manage ment of the chronic pain disorder. Service delivery the management of neurological diseases is primarily a matter for specialist medical and nursing staff, both in developed and developing countries. In contrast, speci c facilities for pain man agement, especially chronic pain management outside neurological centres, are much less well organized and are often absent, especially in developing countries. The relief of pain should be one of the fundamental objectives of any health service. Good practice should ensure provision of evidence-based, high quality, adequately resourced services dedicated to the care of patients and to the continuing education and development of staff. Multidisciplinary pain centre the centre comprises a team of professionals from several disciplines. Multidisciplinary pain clinic the clinic is a health-care delivery facility with a team of trained professionals who are devoted to the analysis and treatment of pain. Pain clinic Pain clinics vary in size and staffing complements but should not be run single-handed by a clinician. Modality-orientated clinic the clinic offers a speci c type of treatment and does not conduct comprehensive as sessment or management. They are met to a much lesser extent in developing countries, where other health priorities, costs of treatment and availability of trained personnel are all contributing factors to the relative lack of resources. Nevertheless, strenuous efforts to improve services for people in pain are being made in many developing countries. Even though services for neurological disorders are better provided, many patients with pain of neurologi cal origin may never reach such centres. There is therefore a great need for health-care providers to devote more resources to pain relief in general, which in turn will bring about an improvement in the treatment facilities available for neurological patients with pain. Its Special Interest Group on Neuropathic Pain provides a forum for scienti c exchange on neuropathic pain and other types of pain that are related to neurological disorders (26). In Germany, a medical subspecialty, specialized pain therapy, is supervised by a licensed training centre and carried out after nishing a residency in one of the traditional medical specialties. More general training in pain management does exist but it is very variable within and between specialist medical areas and between countries. Training programmes for nurses who will specialize in pain management are growing steadily. Such programmes exist mainly in relation to palliative care, post-operative pain management and the work of pain clinics in developed countries but, increasingly, also in countries in the developing world. Physiotherapy is a discipline in which pain management is an integral part of the working day and therefore should be a major aspect of the training of all physiotherapists. Clinical psychologists have a major role in the treatment of chronic pain patients. Usually they specialize in pain management after a period of postgraduate training in general clinical psychol ogy and practise either independently or in specialist pain centres. Very few clinical psychologists are available for work with patients in pain, whether attributable to neurological conditions or not, in developing countries. However, specialist training in pain management for medical practitioners who work in hospitals or the community in developing countries is spreading gradually. Neurologists and non-neurologists who have responsibility for patients with neurological disorders should ensure that pain is assessed carefully and recorded in terms of its origins, nature and severity as part of an overall clinical assessment prior to diagnosis and management. Postgraduate training is also neglected in many countries, though specialization in pain management is increasing steadily, particularly in developed countries. There is a need to continue and expand postgraduate training in pain management and to develop specialized pain management centres. Recognized international guidelines for the use of powerful analgesics should be observed and unduly restrictive regulations should be suitably modi ed to ensure availability on a reasonable basis. Guidelines should be made available on the use of co-analgesic drugs and other treatments used to relieve or control very severe pain. Classi cation of chronic pain: descriptions of chronic pain syndromes and de nitions of pain terms, 2nd ed. Persistent pain and well-being: a World Health Organization study in primary care. Screening of neuropathic pain components in patients with chronic back pain associated with nerve root compression: a prospective observational pilot study. Therapeutic outcome in neuropathic pain: relationship to evidence of nervous system lesion. A 5-year follow-up evaluation of the health and economic consequences of an early cognitive behavioural intervention for back pain: a randomized controlled trial. Treatment outcome of chronic non-malignant pain patients managed in a Danish multi disciplinary pain centre compared with general practice: a randomized controlled trial. Special Interest Group on Neuropathic Pain of the International Association for the Study of Pain

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