By Y. Gembak. Appalachian State University. 2018.

These conclusions are very similar to the results obtained by Swiss authors who reviewed a similar group of tests trusted triamterene 75 mg heart attack the alias club remix. Acupuncturists also offer their services to assist in pain manage- ment and the treatment of rheumatism 75 mg triamterene for sale arteria coronaria derecha. W hen it comes to controlling pain, it is easy to explain why acupuncture works, through gate-control and the production of endorphins. W e have two types of sensory nervous fibers: one type that conveys nerve impulses quickly, another that conveys them more slowly. Strong sensations depend on the slow fibers, while super- ficial sensations are passed along via the fast fibers. If a pain is conducted via the slow fibers, it can be short-circuited by fast impulses that saturate the intermediate networks and thus prevent the slow impulse from passing. This is the phenomenon that explains the magical effect of Mommy’ kiss on the child’s boo-boo. The feeling of a breath or soft kiss (superficial sensitivity) is conveyed by fast fibers and the nerve impulse blocks the feeling of pain (a stronger sensation) by shorting-circuit the relay. Acupuncture acts in the same way: the superficial sensation from the needle puncture saturates the system of transmission and keeps the deeper painful feeling from being perceived — but for that, you don’t need either the needle or the specific point. The second hypothesis explaining how the analge- sic effects of acupuncture might work, is based on the human organ- ism’s ability to secrete endorphins (natural morphines). This secretion is supposedly touched off when the acupuncture points are stimulated. I was head of a detoxification center treating drug addicts in 1977, and I met Dr. W en, of Taiwan, at an international conference organized by the ICAA (International Council of Alcoholism and Addiction). W en gave a presentation outlining how to get heroine addicts off the drug; he recommended using an electrical current to stimulate Point 54, the so-called "Lung Point", located in the patient’s ear. W e tested 17 patients and had total failure — and the same thing happened in another experiment, testing the ability of electrical stimulation to reduce pain in dentistry. But perhaps that was only due to a poor en- ergy transfer between Taiwan and the south of France! In abdominal and thoracic surgery, it has long been known that pain can be mitigated by electrically stimulating cer- tain points in the body; but these points have nothing to do with acu- puncture. Pain from operations on the esophagus can be eased by stimulating a Head’s zone above the thorax; the zone corresponding to the intestine is near the abdomen, and the bladder’s is even with the pubis. Stimulating the Head’s zone has a total or partial analgesic effect on the organ concerned, and that is how it was possible to perform the Caesarean deliveries that were presented as arguments supporting acu- puncture’s effectiveness. About two thirds of the "traditional" acupuncture points are located in these zones. For that reason, doctors at the University of Shanghai have given 59 Healing or Stealing? On November 5, 1985, the French television news opened with a documentary that was heralded as something that would revolutionize medicine. Researchers had found evidence of the existence of the me- ridian lines associated with acupuncture. Professors Albarède, de Vernejoul and Darras had measured the distribution of a radioactive isotope, Technetium 99, and used it as a tracer. They followed the product from the point of injection, all along the leg, to a location in the foot; this was supposed to prove that the meridian lines were real. The announcement had a particularly profound effect since this "discovery" was presented in a communication to the National Academy of Medi- cine, and the experts were affiliated with the Department of Biophysics and Nuclear Medicine at Necker Hospital. Amid the chorus of praise, a few voices were raised to express doubts as to the legitimacy of such proof, with the journal Science et Vie in the lead. Jean Michel Bader, showing the results of an experiment he had carried out in accordance with the protocol described by Drs. W hen a radioactive product was injected at any point in the human body, it spread throughout the body via the blood vessels; and this was true regardless whether the injection was given at an acupuncture point or elsewhere. The "discoverers" had reported that the product, when injected in places that are not acu- puncture points, did not spread; this can be explained by the fact that the experimenters had, in all probability, stopped the experiment at the 6 first glitch or had set the oscilloscope to eliminate any zones of low radioactivity, "bothersome" signs of the product’s dispersion.

W ith increasing years purchase 75mg triamterene with amex blood pressure chart and pulse, the privilege of being invited to write a foreword to a book by one’s ex-students becom es less of a rarity order 75 mg triamterene with mastercard heart attack from weed. Trisha G reenhalgh was the kind of m edical student who never let her teachers get away with a loose thought and this inquiring attitude seem s to have flowered over the years; this is a splendid and tim ely book and I wish it all the success it deserves. After all, the concept of evidence based m edicine is nothing m ore than the state of m ind that every clinical teacher hopes to develop in their students; D r G reenhalgh’s sceptical but constructive approach to m edical literature suggests that such a happy outcom e is possible at least once in the lifetim e of a professor of m edicine. Professor Sir D avid W eatherall xi In N ovem ber 1995, m y friend Ruth H olland, book reviews editor of the British Medical Journal, suggested that I write a book to dem ystify the im portant but often inaccessible subject of evidence based m edicine. She provided invaluable com m ents on earlier drafts of the m anuscript but was tragically killed in a train crash on 8th August 1996. A handful of academ ics (including m e) were enthusiastic and had already begun running "training the trainers" courses to dissem inate what we saw as a highly logical and system atic approach to clinical practice. Others – certainly the m ajority of clinicians – were convinced that this was a passing fad that was of lim ited im portance and would never catch on. First, students on m y own courses were asking for a sim ple introduction to the principles presented in what was then known as "D ave Sackett’s big red book" (Sackett D L, H aynes RB, G uyatt G H , Tugwell P. London: Little, Brown, 1991) – an outstanding and inspirational volum e that was already in its fourth reprint, but which som e novices apparently found a hard read. Second, it was clear to m e that m any of the critics of evidence based m edicine didn’t really understand what they were dism issing and that until they did, serious debate on the political, ideological, and pedagogical place of evidence based m edicine as a discipline could not begin. I am of course delighted that How to read a paper has becom e a standard reader in m any m edical and nursing schools and has so far been translated into French, G erm an, Italian, Polish, Japanese, and Russian. I am also delighted that what was so recently a fringe subject in academ ia has been well and truly m ainstream ed in clinical service in the U K. For exam ple, it is now a contractual requirem ent for all doctors, nurses, and pharm acists to practise (and for m anagers to m anage) according to best research evidence. In the three and a half years since the first edition of this book was published, evidence based m edicine has becom e a growth industry. D ave Sackett’s big red book and Trisha G reenhalgh’s little blue book have been joined by som e 200 other textbooks and 1500 journal articles offering different angles on the 12 topics covered xiii H OW TO READ A PAPER briefly in the chapters which follow. M y biggest task in preparing this second edition has been to update and extend the reference lists to reflect the wide range of excellent m aterial now available to those who wish to go beyond the basics. N evertheless, there is clearly still room on the bookshelves for a no-frills introductory text so I have generally resisted the tem ptation to go into greater depth in these pages. Trisha G reenhalgh xiv Preface to the first edition: Do you need to read this book? This book is intended for anyone, whether m edically qualified or not, who wishes to find their way into the m edical literature, assess the scientific validity and practical relevance of the articles they find, and, where appropriate, put the results into practice. M any of the descriptions given by cynics of what evidence based m edicine is (the glorification of things that can be m easured without regard for the usefulness or accuracy of what is m easured; the uncritical acceptance of published num erical data; the preparation of all-encom passing guidelines by self-appointed "experts" who are out of touch with real m edicine; the debasem ent of clinical freedom through the im position of rigid and dogm atic clinical protocols; and the overreliance on sim plistic, inappropriate, and often incorrect econom ic analyses) are actually criticism s of what the evidence based m edicine m ovem ent is fighting against, rather than of what it represents. D o not, however, think of m e as an evangelist for the gospel according to evidence based m edicine. I believe that the science of finding, evaluating and im plem enting the results of m edical research can, and often does, m ake patient care m ore objective, m ore logical, and m ore cost effective. If I didn’t believe that, I wouldn’t spend so m uch of m y tim e teaching it and trying, as a general practitioner, to practise it. N evertheless, I believe that when applied in a vacuum (that is, in the absence of com m on sense and without regard to the individual circum stances and priorities of the xv H OW TO READ A PAPER person being offered treatm ent), the evidence based approach to patient care is a reductionist process with a real potential for harm. Finally, you should note that I am neither an epidem iologist nor a statistician but a person who reads papers and who has developed a pragm atic (and at tim es unconventional) system for testing their m erits. If you wish to pursue the epidem iological or statistical them es covered in this book, I would encourage you to m ove on to a m ore definitive text, references for which you will find at the end of each chapter. Trisha G reenhalgh xvi Acknowledgments I am not by any standards an expert on all the subjects covered in this book (in particular, I am very bad at sum s) and I am grateful to the people listed below for help along the way. I am , however, the final author of every chapter and responsibility for any inaccuracies is m ine alone. To PROFESSOR D AVE SACKETT and PROFESSOR AN D Y H AIN ES who introduced m e to the subject of evidence based m edicine and encouraged m e to write about it. To D R AN N A D ON ALD , who broadened m y outlook through valuable discussions on the im plications and uncertainties of this evolving discipline. To the following m edical inform aticists (previously known as librarians), for vital input into Chapter 2 and the appendices on search strings: M R REIN H ARD T W EN TZ of Charing Cross and W estm inster M edical School, London; M S JAN E ROW LAN D S of the BM A library in London; M S CAROL LEFEBVRE of the U K Cochrane Centre, Sum m ertown Pavilion, Oxford; and M S VALERIE W ILD RID G E of the King’s Fund library in London. I strongly recom m end Jane Rowlands’ Introductory and Advanced M edline courses at the BM A library.

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Nocturia Another problematic symptom for many people with MS is that they may have to get up to urinate several times in the night discount triamterene 75 mg on-line blood pressure 9868. The usual medication for nocturia is desmopressin (DDAVP Nasal Spray) which reduces urine formation generic triamterene 75 mg with amex hypertension zolpidem. There are some circumstances where the drug should be used only very cautiously, or not at all – for example, in people with kidney or heart disease, or in older people. The antidepressant, imipramine (Tofranil), mentioned above in relation to treating urgency and frequency, taken just before going to bed, has also been found to be effective in many cases. Incontinence Incontinence, what appears to be the involuntary release of urine, may be a slight and an occasional problem in MS, or it may prove to be a continuous problem. However, in each case it provokes anxiety and concern, for socially as much as physically it can be a difficult and embarrassing symptom to have occur unexpectedly. Bladder spasms may be causing this difficulty – technically called ‘incontinence’ – or your bladder muscle PROBLEMS WITH URINATION AND BOWELS 49 may be so weak that you have released urine before realizing it. In addition, sometimes you might not at first realize that you are wet because of reduced sensations in your pubic area. Sanitary protection (absorbent pads) can be used, even if only for maintaining confidence when you are not near a convenient toilet. Pads and liners are available in a wide variety of shapes and styles to suit different people and different clothing styles, but there is much less choice when they are supplied on prescription. Waterproof undersheets and absorbent bed sheets can also be very convenient, to minimize the effect of occasional accidents. If these procedures and/or the drugs mentioned above in relation to urgency and frequency do not work, other professional investigations may well be needed to determine the cause of the problems, and how best they might be managed. Catheterization Although your major concern may be incontinence, there may also a problem with urine retention in the bladder as well – for the bladder may not completely empty, which can lead to serious infection. Thus as an extra precaution, if one of the causes of the incontinence is retention of urine in your bladder, the use of ‘intermittent self-catheterization’ (ISC) Figure 4. A catheter (a thin plastic tube) is threaded through your urethra – the opening at tip of the penis, or just above the vagina – into your bladder, and this drains any remaining urine. You will need to wash yourself thoroughly before using this technique, and you may need to use a lubricant (something like K-Y Jelly) to assist the access of the tube, but modern catheters are low friction types and need no lubricant (such as ‘Lofric’ and ‘Speedicath’ types). You should not use a catheter (tube) which appears to be worn, stiff or damaged in any way. Undertaken regularly, several times a day, this method usually helps substantially. A nurse or doctor will explain how to undertake this procedure, and how to clean the catheter thoroughly. For the most part, although the procedure may seem very difficult, many people adapt well to it, as long as it is seen as a routine process. If you are able to write and to feed yourself, even if you have some eyesight problems, ISC should be possible. There is another reason why ISC can be of value, in that regularly undertaken, it is a means of ‘training’ the bladder to fill and empty as the urine is released: the bladder muscle contracts, expanding again as urine fills the bladder. Urine retention and voiding problems As we have noted above, many people with MS have problems not only with urgency or frequency, but also with some urine retention in the bladder. If this is the case, do not reduce your fluid intake substantially, because this will increase the risk of urinary infection (urine as a waste product is not being diluted). A useful rule of thumb is the colour of your urine: if it is dark yellow to brown in colour, then almost certainly you are not taking in enough fluid. There are some useful guidelines which should help you: • Drink at least 2 litres (or just over 3 pints) of liquid a day. Cranberry juice will also help to provide the vitamin C lost through reducing the intake of citrus fruits/juices. PROBLEMS WITH URINATION AND BOWELS 51 Hesitancy and ‘full bladder’feeling Although this is a frustrating problem, often urination will start after a couple of minutes, so be patient! Sometimes tapping very lightly on your lower abdomen – but not too hard – will help; this often produces a reflex reaction of urination. There have recently been trials of a hand-held vibrating device which, when held against your lower abdomen if you are still sensitive in this area, seems to work quite well by increasing urinary flow and leaving less urine in your bladder. Of course, other time-honoured techniques may work, including turning a tap on and hearing the sound of running water!

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