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By O. Arakos. Irvine University College of Law.

One doubleblind study (with several methodological problems) carried out in Germany showed that the highly purified extract of Butterbur root might be effective in 28 the prevention of migraine headaches order 100mg kamagra oral jelly free shipping whey protein causes erectile dysfunction. Another double-blind generic 100 mg kamagra oral jelly with mastercard erectile dysfunction 34, placebocontrolled randomized trial was carried out in the USA and it confirmed the efficacy of this 29 product. Patients should be cautioned against using any Butterbur product other than the ® one used in these trials (Petadolex ) because of the toxic products that are difficult to remove. The available purified commercial product has been subjected to standard 30 toxicology and teratogenicity studies and has been shown to be safe. Guarana (Pauillinia cupana), a relatively recent import from Brazil, is being used for headache relief. However, daily caffeine consumption with a rebound phenomenon is one of the leading causes of frequent and refractory headaches. Guarana and all other caffeine- containing foods, drinks and medications should be avoided in patients with frequent headaches. Anecdotal reports suggest that ingestion of ginger (Zingiber officinale), ginkgo (Ginkgo biloba) or valerian root (Valeriana officinalis), all of which are well tolerated, may help some patients with headaches. Aromatherapy may not appear so far fetched if we consider how much of our brain is devoted to olfaction and that strong odors can almost instantly induce a migraine. A doubleblind study of healthy volunteers showed that an external application of peppermint extract raised the pain threshold and had musclerelaxing and mentally relaxing effect, while eucalyptus had a calming and relaxing effect and improved 31 cognitive performance without an analgesic effect. A study performed by the same group of researchers, using peppermint oil for tension headaches, showed positive 32 results. These studies give some scientific support to a variety of topical products being promoted for the treatment of headaches. Homeopathy is based on an unproved concept of using infinitesimally small amounts of substances which in large amounts can induce symptoms that are being treated. Since Complementary therapies in neurology 282 the treatment is extremely benign and relatively inexpensive it can be tried by patients who believe that it may help. Combination products The overall efficacy of supplements in clinical trials, while significantly higher than that of placebo, is fairly modest. This can be due to the fact that some patients respond well, while others do not respond at all. Combining several supplements may increase the chance that one of the ingredients will help, and it is possible that they have a synergistic ® ® effect. MigraHealth and MigreLief are products that combine 300 mg of magnesium, 400 mg of riboflavin and 100 mg of feverfew. TENSION-TYPE HEADACHES 33 Biofeedback is one of the most effective treatments for tension as it is for migraine headaches. Meditation, yoga and other mental exercises can help, but biofeedback is a more direct and a most time-efficient approach aimed at eliminating headaches. Well- trained staff and patient compliance with home exercises are essential for achieving a high success rate. Follow-up studies indicate up to 80–90% improvement 5 years after 4 completion of a biofeedback course. Children can learn to rid themselves of headaches in as few as three to four sessions. Acupuncture has a solid scientific basis confirmed in animal studies, but lacks the proof of large clinical trials. Acupuncture can stop an acute attack of tension-type headache or with a series of treatments relieve a chronic one. Regular aerobic exercise is an excellent way to reduce adverse effects of stress on the body and it usually prevents headaches. CERVICOGENIC HEADACHES Older patients Cervicogenic headaches are more common in older patients and are usually due to osteoarthritic changes in the cervical spine. Pain described as radiating from the neck or occipital area suggests this diagnosis. Pain of cervical spine origin, however, can sometimes be felt in the front of the head. Decreased sensation over the occipital area, often on one side, can accompany occipital neuralgia. Neck muscles are tender, frequently in spasm, and their movement can aggravate the pain. In many patients, immobilization by a soft cervical collar during the night is sufficient to stop the headaches. More often, a combination of a non-steroidal anti-inflammatory drug with a cervical collar and regular isometric neck exercises will provide relief. Local heat application, transcutaneous electrical nerve stimulation (TENS) and acupuncture may be effective. Headache 283 Whiplash injuries Another frequent cause of cervicogenic headaches is a whiplash injury commonly sustained in car accidents.

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Their usefulness in the m ore diovascular conditions characterized by hyperactivity of com plex unstable (preinfarction) angina is less definite kamagra oral jelly 100 mg line erectile dysfunction treatment home veda, smooth muscle (e cheap 100mg kamagra oral jelly with mastercard psychological erectile dysfunction drugs. However, their main ap- depending on the hem odynam ic status and the suscep- plications are as follows. Hypertension Cardiac Arrhythmias The prom inent depressant action of verapam il and dil- The calcium channel–blocking drugs are effective anti- hypertensive agents and enjoy widespread use as single tiazem at the SA and A -V nodes finds use in specific ar- m edication or in com bination. They are of proven efficacy in acute control lated to a decrease in peripheral resistance accom panied and long-term m anagem ent of paroxysm al supraventric- ular tachycardia (see Chapter 16). The m agnitude of their ef- conduction at the A -V node is em ployed in protecting fects is determ ined partly by pretreatm ent blood pres- sure levels; m axim um blood pressure lowering gener- ventricles from atrial tachyarrhythm ias, often in com bi- ally is seen 3 to 4 weeks after the start of treatm ent. These drugs possess som e distinct advantages relative to other vasodilators, including the following: PHARM ACOKINETICS 1. Their relaxant effect on large arteries results in A com parison of the pharm acokinetic properties of greater com pliance, which is beneficial in older these agents is listed in Table 19. Tolerance associated with renal retention of fluid and diltiazem undergo greater first-pass m etabolism rel- does not occur; an initial natriuretic effect is often ative to nifedipine, resulting in lower bioavailability of observed, especially with the nifedipine group of the form er two drugs. They do not have significant effects on the re- verapam il and diltiazem, whose m etabolites have phar- lease of renin or cause long-term changes in lipid m acological activity. Postural hypotension, first-dose effect, and re- thus requiring higher plasm a concentrations after oral bound phenom enon are not com m only seen. TOXICITY The com m on side effects seen in chronic therapy (Table enhancem ent of the action of other cardiodepressant 19. Their use is generally contraindicated in obstruc- dizziness, facial flushing, hypotension, and so forth. No consistent or doses of verapam il in elderly patients are known to significant changes in lipid and glucose levels have been cause constipation. Non–sustained release lowing the intravenous use of verapam il, include form ulations of nifedipine are contraindicated in hyper- m arked negative inotropic effects and depression of tension because of sym pathetic rebound that m ay ag- preexisting sick sinus syndrom e,A -V nodal disease, and gravate existing left ventricular dysfunction. W hich of the following statem ents m ost accurately ANSW ERS characterize the cellular action of the calcium chan- 1. The three pro- (A ) Their interaction with m em brane phospho- totypes, verapam il, nifedipine, and diltiazem, act at lipids results in a nonselective decrease of ion trans- three discrete sites at this channel. The other three drugs (dihydropyridines) are (B) They inhibit the Na –Ca exchanger in car- characterized by relatively selective vasodilator ef- diac and sm ooth m uscle. The vasodilatory effects of nifedipine are largely (D ) Their interaction with the sodium pum p results restricted to arteries (and consequently the after- in an inhibition of calcium transport. Skeletal m uscles depend on the m obilization of (B) Verapam il intracellular stores of calcium for their contractile (C) Nicardipine responses rather than transm em brane flux of cal- (D ) A m lodipine cium through the calcium channels. A ll of the following statem ents are applicable with skeletal m uscle weakness is not likely to occur. A ll of the following statem ents regarding the phar- calcium channel blocker drugs: A n up-to-date per- m acokinetics of calcium channel blockers are cor- spective on the proposed hazards. M echanism s of action of calcium channel (C) Their half-life is not altered by hepatic cirrho- antagonists. The sm ooth m uscle m em brane dur- cur with long-term use of calcium channel blockers ing atherogenesis: A potential target in atheropro- EXCEPT tection. H e sustained release, is characterized by relatively occasionally has angina precipitated by physical rapid onset of vasodilatory effects. H e also is a result of drug-induced periodic increases in develops flushing, dizziness, and nervousness shortly heart rate. W estfall D R U G L IS T GENERIC NAM E PAGE GENERIC NAM E PAGE Clonidine 236 Minoxidil 229 Diazoxide 229 Phentolamine 231 Guanabenz 236 Phenoxybenzamine 231 Guanethidine 233 Prazosin 231 Guanfacine 236 Propranolol 233 Hydralazine 228 Reserpine 234 -Methyldopa 235 Sodium nitroprusside 230 Metyrosine 235 H ypertension is one of the m ost serious concerns of erence is m ade to the stages of hypertension according m odern m edical practice. It is estim ated that in the to the recom m endations of the Sixth Joint National U nited States, as m any as 60 m illion people are hyper- Com m ittee on the D etection, Evaluation, and Treat- tensive or are being treated with antihypertensive m ent of H igh Blood Pressure. A m ong the growing population of elderly ered to be stage I, or m ild, if diastolic pressure is 90 to A m ericans, som e 15 m illion have high blood pressure. The level of blood pressure in itself is not a chief con- Stage II, or m oderate, hypertension is diastolic pressure cern, since individuals with high blood pressure m ay be of l00 to 109 m m H g and/or systolic pressure of 160 to asym ptom atic for m any years. Stage III, or severe, hypertension exists cance is that hypertension has been shown convincingly when diastolic pressure is 110 m m H g or greater and/or to be the single m ost im portant contributing factor to car- systolic pressure is 180 m m H g or greater. A s a working definition, m any cardiovascular risk, the ultim ate judgm ent concerning the severity of treatm ent centers consider that a diastolic pressure of hypertension in any given individual m ust also include 90 m m H g or higher or a systolic pressure of 140 m m H g a consideration of factors other than diastolic or systolic or higher represents hypertension. In this situation, the loop tension is secondary to a known organic disease, such as diuretics furosem ide and bum etanide are recom - renovascular disease or pheochrom ocytom a, therapy is m ended; they have greater intrinsic natriuretic potency directed toward correction of the underlying m alady. The therapy of prim ary, or essen- In situations of known renin–angiotensin–aldos- tial hypertension, as these cases are generally called, is terone involvem ent, such as in hypertension secondary often em pirical. The K -sparing action of spironolactone, tri- The second em ploys drugs that interfere with the am terene, and am iloride serves as the basis for their oc- renin–angiotensin system, and the third is aim ed at a casional use in the therapy of prim ary hypertension.

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The Arden syntax is currently the only “standard” means of encoding these rule-based systems (Arden discount kamagra oral jelly 100 mg on line erectile dysfunction statistics india, 2003) cheap 100 mg kamagra oral jelly impotence in women. The Institute for Medical Knowledge Interchange (IMKI), another recent entry into this field (IMKI, 2003), recently scaled back their operations while they seek additional funding and support. Condition-specific order sets and charting templates help clinicians remember and facilitate the entry of all related orders or answers to questions asked of a patient with a particular condition. Zynx, a recently formed company, is developing these ready-to-use, condition-specific order sets. In an early attempt to develop this sort of functionality, Epic Systems created their “Active Guidelines” application. A major distinguishing feature between the Active Guidelines (AG) effort and that of Enigma is that the AG user is still required to search for, read, interpret, and then decide which portion of the large, text-based guideline document applies to a specific patient and then select the appropriate recommendation. Another recent entry into this market space is Theradoc, a small company located in Salt Lake City, Utah ( Complex, physiologic models incorporate our best current understanding of human physiology along with evidence-based results of randomized clinical trials to generate patient- or population-specific predictions of future events. Archimedes, a complex model of diabetes and the entire healthcare system, is currently config- ured to allow specially trained clinicians to access this resource (Schlessinger, 2002). Artificial Intelligence (AI) systems have been developed to help clinicians com- plete their differential diagnosis list. To date these systems have not had wide- spread acceptance by clinicians, even though they have been shown to be at least as good and often better than un-aided clinicians (Bankowitz, 1989; Berner, 1994). Copying or distributing in print or electronic forms without written permission of Idea Group Inc. An Overview of Efforts to Bring Clinical Knowledge to the Point of Care 291 The following sections overview several attempts and describe which parts of the vision they either have or are currently focusing on. GLEE provides an internal event-driven execution model that can be hooked up with the clinical event monitor of a local clinical information system environment. It was developed at Columbia University and is currently only a research prototype. No tools exist for knowledge maintenance other than those proposed by the GLIF3 organization. GLARE provides expert physicians with an “intelligent” guideline acquisition interface. The interface has different types of checks to provide a consistent guideline: syntactic and semantic tests verify whether or not a guideline is well-formed. GLARE technology has been successfully tested in different clinical domains (bladder cancer, reflux esophagitis, and heart failure), at the Laboratorio di Informatica Clinica, Azienda Ospedaliera S. Currently, this application is not available for use by people outside of the research team. It is a stand-alone tool, that is, it has no integration with the existing CIS; it is only for HIV patients; and has no tools for knowledge based maintenance. PRODIGY I and PRODIGY II were implemented as extensions to proprietary UK electronic patient record systems. The PRODIGY system includes a proprietary guideline model, which in PRODIGY II was used to implement guidelines for the management of acute diseases. PREDICT integrates with existing clinical information systems using standard internet communication protocols, and allows Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. ChapterXVII Social Capital, AnImportant Ingredient toEffective KnowledgeSharing: Meditute, A Case Study Abstract Although these social capital dimensions are important in their own right, they are not mutually exclusive. Tsai and Ghoshal (1998), investigated the associations between the dimensions, they found: • Social interactions (structural) generate and strengthen trusting relationships (relational). Strong ties allow individuals to develop knowledge of each other and share points of view. Therefore an individual connected by strong ties is perceived as more trustworthy. Such an alignment and harmony of interests diminishes the chance of opportunistic behaviour that reduces trust. Individuals who share common goals are less likely to act in a contrary or self-interested manner. Through interaction, individuals learn and adopt the languages, values and visions of others in the social system. Johannessen, Olaisen, and Olsen (2002), found that there are four conditions that need to be fulfilled for any exchange to take place. They are: • Accessibility: the opportunity must exist to make an exchange • Anticipation: the parties in the exchange must anticipate the creation of value • Motivation: parties must be motivated.

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