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By U. Hernando. Southeastern College.

The authors concluded that the blockages found by the heart catheterization simply do not correlate with blood flow restriction discount carbamazepine 100mg line, and noted that these results were “profoundly disturbing cheap carbamazepine 200 mg mastercard. Information cannot be determined accurately by conventional angiographic approaches cheap carbamazepine 400 mg with amex. The critical factor in whether a patient needs coronary artery bypass surgery or angioplasty is how well the left ventricular pump is working discount carbamazepine 400 mg online, not the degree of blockage or the number of arteries affected purchase carbamazepine 100 mg. The left ventricle (chamber) of the heart is responsible for pumping oxygenated blood through the aorta (the large artery emanating from the heart) to the rest of the body. Bypass surgery is helpful only when the ejection fraction, the amount of blood pumped by the left ventricle, is less than 40% of capacity. The results from large studies with these procedures, including the use of stents that release drugs to prevent blockage (drug-eluting stents), show the same lack of benefit as bypass operations. Complications arising from coronary bypass operations are common, as this surgery represents one of the most technically difficult procedures in modern medicine. Considering the cost of the procedure, the lack of long-term survival benefit, and the high level of complications, it appears that electing to have this surgery is unwise for the majority of patients. This is particularly true in light of the availability of effective natural alternatives to coronary bypass surgery. Numerous studies have shown that dietary and lifestyle changes can significantly reduce the risk of heart attack and other causes of death due to atherosclerosis (see the chapter “Heart and Cardiovascular Health”). Simple dietary changes—decreasing the amount of saturated fat and cholesterol in the diet; increasing the consumption of dietary fiber, complex carbohydrates, fish oils, and magnesium; eliminating alcohol consumption and cigarette smoking; and reducing high blood pressure—would greatly reduce the number of coronary bypass operations performed in westernized countries. In addition, clinical studies have shown that several nutritional supplements and botanical medicines improve heart function in even the most severe angina cases. Although this therapy is controversial, considerable clinical research has proved its efficacy. When an Angiogram Is Unavoidable When an angiogram or angioplasty is deemed necessary, the goal is then to prevent the damaging effects produced by this procedure. This can be accomplished with a high-potency multiple vitamin and mineral formula, along with additional vitamin C (minimum 500 mg three times per day) and CoQ10 (300 mg per day two weeks prior to surgery and for three months afterward). Vitamin C supplementation is rarely employed in hospitals, despite the fact that it may provide significant benefits; low vitamin C status is quite common in hospitalized patients. In a study analyzing the vitamin C status of patients undergoing coronary artery bypass, the plasma concentration of vitamin C was shown to plummet by 70% in the 24 hours after coronary artery bypass surgery; this level persisted in most patients for up to two weeks after surgery. Given the importance of vitamin C, this serious depletion may deteriorate defense mechanisms against free radicals, infection, and wound repair in these patients. Supplementation appears to be essential in patients recovering from heart surgery, or any surgery, for that matter. Return of blood flow (reperfusion) after coronary artery bypass surgery results in oxidative damage to the vascular endothelium and myocardium and thus greatly increases the risk of subsequent coronary artery disease. Coenzyme Q10 is recommended in an attempt to prevent such oxidative damage after bypass surgery or angioplasty. In one study, 40 patients undergoing elective surgery either served in the control group or received 150 mg CoQ10 each day for seven days before the surgery. The treatment group also showed a statistically significant lower incidence of ventricular arrhythmias during the recovery period. These results clearly demonstrate that pretreatment with CoQ10 can play a protective role during routine bypass surgery by reducing oxidative damage. Therapeutic Considerations Nutritional Supplements From a natural perspective, there are two primary therapeutic goals in the treatment of angina: improving energy metabolism within the heart and improving blood supply to the heart. These goals are interrelated, as an increased blood flow means improved energy metabolism and vice versa. It converts free fatty acids to energy in much the same way as an automobile uses gasoline. Defects in the utilization of fats by the heart greatly increase the risk of atherosclerosis, heart attack, and angina pain. Specifically, impaired utilization of fatty acids by the heart results in accumulation of high concentrations of fatty acids within the heart muscle. This makes the heart extremely susceptible to cellular damage, which ultimately leads to a heart attack. Carnitine, pantethine, and coenzyme Q10 are essential compounds in normal fat and energy metabolism and are of extreme benefit to sufferers of angina. These nutrients prevent the accumulation of fatty acids within the heart muscle by improving the conversion of fatty acids and other compounds into energy. Antioxidants Using antioxidant supplementation is important for patients with angina.

If you abbreviate a word in one reference in a list of references carbamazepine 200mg line, abbreviate the same word in all references generic carbamazepine 400 mg free shipping. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications carbamazepine 100mg mastercard. Designate the agency making the publication available as the publisher and include distributor information as a note buy carbamazepine 400 mg online. For publications with joint or co-publishers discount carbamazepine 400mg without a prescription, use the name provided frst as the publisher and include the name of the second as a note, if desired, such as "Jointly published by the Canadian Pharmacists Association". Audiovisual journal title with publisher having subsidiary part Journals in Audiovisual Formats 1019 Volume Number for Journal Titles in Audiovisual Formats (required) General Rules for Volume Number • Precede the number with "Vol. Audiovisual journal title without volume or issue numbers Issue Number for Journal Titles in Audiovisual Formats (required) General Rules for Issue Number • Precede the issue number with "No. Philadelphia: American Law Institute-American Bar Association Committee on Continuing Professional Education. Philadelphia: American Law Institute-American Bar Association Committee on Continuing Professional Education. Audiovisual journal title without volume or issue numbers Date of Publication for Journal Titles in Audiovisual Formats (required) General Rules for Date of Publication • Include the month and year the journal began to be published, in that order, such as May 2004 • Convert roman numerals to arabic numbers. Enter closing volume and issue information followed by a comma and the closing month and year. Specific Rules for Date of Publication • Multiple years, months, or days of publication • Non-English names for months • Seasons instead of months • Options for dates Journals in Audiovisual Formats 1023 Box 68. Oct 1999-Mar 2000 Dec 7, 2002-Jan 9, 2003 • Separate multiple months of publication and multiple days of the month by a hyphen Mar-Apr 2005 Dec 1999-Jan 2000 Feb 1-7, 2005 Jan 25-31, 2001 • Separate multiple seasons by a hyphen, as Spring-Summer. Audiovisual journal title with season in date Physical Description for Journal Titles in Audiovisual Formats (optional) General Rules for Physical Description • Enter the medium on which the audiovisual title is issued, in plural form, followed by a colon and a space. Example: Videocassettes: Journals in Audiovisual Formats 1025 • Give information on the physical characteristics of an audiovisual, such as color and size Specific Rules for Physical Description • Language for describing physical characteristics Box 72. Physical description of a journal in audiovisual format is optional in a reference but may be included to provide useful information to the reader. For example, the size of an audiovisual indicates what equipment is needed to view it. Examples: "Videocassettes:" and "Audiocassettes:" • Include physical characteristics, such as color and size. Audiocassettes are produced in a number of other sizes, but the standard size is used for scientifc journals. Size is usually omitted from the description of audiocassettes unless it deviates from the standard. Te speed of the audiocassette, provided in terms of inches per second, is used in the description instead. Standard audiovisual journal title that has ceased publication Language for Journal Titles in Audiovisual Formats (required) General Rules for Language • Give the language of publication if other than English • Capitalize the language name • Follow the language name with a period Specific Rules for Language • Journals appearing in more than one language Box 73. Audiovisual journal title published in multiple languages Notes for Journal Titles in Audiovisual Formats (optional) General Rules for Notes • Notes is a collective term for any useful information about the journal itself • If the journal was published under another title, provide the name preceded by "Continues: ". Sponsored by the Albert Einstein College of Medicine and Montefore Medical Center. Audiovisual journal title with examples of other notes Examples of Citations to Journal Titles in Audiovisual Formats 1. Standard audiovisual journal title that is still being published Pulse: Emergency Medical Update [videocassette]. Standard audiovisual journal title that has ceased publication Leadership in Hospital Governance [videocassette]. Audiovisual journal title with edition Video Rivista Italiana di Gastroenterologia (Edizione Endoscopia Digestiva) [videocassette]. Audiovisual journal title not in English Video Rivista Italiana di Gastroenterologia (Edizione Endoscopia Digestiva) [videocassette]. Audiovisual journal title not in English, with optional translation Video Rivista Italiana di Gastroenterologia (Edizione Endoscopia Digestiva) [Italian Video Review of Gastroenterology (Digestive Endoscopy Edition)] [videocassette]. Audiovisual journal title published in multiple languages Video-Revista de Cirugia [videocassette]. Audiovisual journal title with well-known place of publication Audio Journal of Oncology [audiocassette]. Audiovisual journal title with lesser-known place of publication Medical Outlook for Infertility Specialists [audiocassette]. Audiovisual journal title with unknown place of publication European Video Journal of Cardiology [videocassette]. Audiovisual journal title with well-known publisher Equine Video Journal [videocassette]. Audiovisual journal title with publisher having subsidiary part Resource: a Monthly Audio Digest of Current Issues in Health Care Risk Management [audiocassette]. Audiovisual journal title with volume and issue number Video Journal of General Surgery [videocassette].

Electronic mail message with position titles for author and recipient included in afliation 9 buy carbamazepine 100 mg line. Electronic mail message with e-mail addresses included in afliation Date for Electronic Mail (required) General Rules for Date • Begin with the year the message was sent • Convert roman numerals to arabic numbers quality carbamazepine 400mg. Electronic mail message with time included in date 1878 Citing Medicine Date of Citation for Electronic Mail (required) General Rules for Date of Citation • Give the date the message was frst seen • Include the year month and day in that order carbamazepine 100mg with visa, such as 2006 May 5 • Use English names for months and abbreviate them using the frst three letters order carbamazepine 400mg free shipping, such as Jan • Place citation date information in square brackets • End citation date information with a period placed outside the closing bracket Specific Rules for Date of Citation • Messages not in English Box 44 buy carbamazepine 400 mg visa. Electronic mail message with time included in date Extent (Pagination) for Electronic Mail (optional) General Rules for Extent (Pagination) • Give extent as the total number of screens, paragraphs, lines, or bytes, whichever is most practical • Precede the total with the word "about" for all except the number of paragraphs and place it in square brackets, as [about 5 screens] • If the message is printed, precede the page total with the word "about" and place it in square brackets, as [about 3 p. If the message contains an attachment in the form of a fle or a video, videocast, or podcast: • Begin with the phrase "Accompanied by" followed by a colon and a space • Give the number and type of items 2 Word fles 1 PowerPoint fle 1 videocast • End with a period • Place accompaniment information afer the date of citation and any extent provided Example: Patrias, Karen. Language for Electronic Mail (required) General Rules for Language • Give the language of the message if not English • Capitalize the language name • Follow the language name with a period Notes for Electronic Mail (optional) General Rules for Notes • Notes is a collective term for further information given afer the citation itself • Complete sentences are not required • Be brief Specific Rules for Notes • Messages containing an attachment • System requirements • Other types of material to include in notes Electronic Mail and Discussion Forums 1881 Box 48. If the message contains an attachment in the form of a fle or a video, videocast, or podcast: • Begin with the phrase "Accompanied by" followed by a colon and a space • Give the number and type of items 2 Word fles 1 PowerPoint fle 1 videocast • End with a period • Place accompaniment information afer the date of citation and any extent provided Example: Patrias, Karen. System requirements describe the particular sofware and hardware needed to view the message and/or its attachments. Notes is a collective term for any type of information given afer the citation itself. Examples include: • Any restrictions on use of the archived message Box 50 continues on next page... Describes ePath3D, a sofware tool for creating and managing illustrated 3D pathways for publications and presentations. Electronic mail message with a note Examples of Citations to Electronic Mail Note: Te examples below are derived from actual e-mail messages, but the names and addresses have been changed in most cases to preserve privacy. However, the term is commonly used as a generic for all mailing list applications. Mailing lists are usually subject-oriented and provide a forum for member discussion. Individuals join a list and post messages that are sent out to all the list members and receive messages sent by others. Like e-mail in general, messages posted to discussion lists are a form of personal communication and are not ofen accepted by editors and others for inclusion in a reference list. Most authorities recommend placing references to e-mail communications within the running text, not as formal end references. Te nature and source of the cited information should be identifed by an appropriate statement. Place the source Electronic Mail and Discussion Forums 1885 information in parentheses, using a term or terms to indicate that the citation is not represented in the reference list. Tese statements may include additional details, such as the reason for the communication. Because all discussion lists do not employ a standard method of saving or archiving messages, it is highly recommended that any message being considered for future citation be saved to disk or in print. Te rules below apply when a posting to a discussion list is included in a reference list rather than within the text as described above. Because of the lack of other information to include in a citation to an e-mail message, providing the full name for the author is recommended as well as clarifying notes on content. Some discussion lists post messages consisting entirely of referrals to publications for their members. Do not cite these as messages on the list, but locate the original publication and cite it. For further examples of formats for author names, titles, place of publication, and publisher see Chapter 1. An R afer the component name means that it is required in the citation; an O afer the name means it is optional. Author (R) | Author Afliation (O) | Title for Message (R) | Connective Phrase (R) | Title (R) | Address (O) | Content Type (O) | Type of Medium (R) | Place of Publication (R) | Publisher (R) | Date (R) | Date of Citation (R) | Extent (Pagination) (O) | Availability (O) | Language (R) | Notes (O) 1886 Citing Medicine Author of Message for Lists (required) General Rules for Author • Enter surname (family or last name) frst for the person initiating the communication • Capitalize surnames and enter spaces in surnames as they appear in the document cited. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Names in non-roman alphabets (Cyrillic, Greek, Arabic, Hebrew, Korean) or character-based languages (Chinese, Japanese). Romanization, a form of transliteration, means using the roman (Latin) alphabet to represent the letters or characters of another alphabet. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Treat letters marked with diacritics or accents as if they are not marked Å treated as A Ø treated as O Ç treated as C Ł treated as L à treated as a Box 56 continues on next page... An organization such as a university, society, association, corporation, or government body may be an author.

In the presence of acidosis within renal tubular cells due to chronic K+ a high salt diet discount carbamazepine 400 mg on-line, low K+ intake has also been implicated depletion also leads to H+ secretion and ammonia in causing hypertension [2] discount 400mg carbamazepine fast delivery. The combined effect of Neuromuscular dysfunction typically manifests as these processes that result from chronic K+ depletion skeletal muscle weakness carbamazepine 200 mg visa, usually in an ascending is fluid expansion with aldosterone suppression cheap 100 mg carbamazepine otc, and fashion buy carbamazepine 100mg lowest price, with worsening hypokalemia. Lower extremity mild metabolic alkalosis with acid urine, polyuria, and muscles are initially affected, followed by the quadri- polydipsia [53, 116]. Interestingly, K+ conservation is ceps, the trunk, upper extremity muscles, and later those not affected [106, 116, 145]. Reduced skeletal The microscopic structural abnormalities reported muscle blood flow may also result [2, 116]. Under such to result from chronic K+ depletion include interstitial conditions, exercise may lead to ischemia and result in fibrosis, tubular dilation and atrophy, and medullary cramps, tetany, and rhabdomyolysis [53, 75, 95, 116]. This is associated with Smooth muscle dysfunction related to hypokalemia reduced renal flow and glomerular filtration. A revers- typically includes nausea, vomiting, constipation, pos- ible lesion of the proximal tubular cells, characterized tural hypotension, and bladder dysfunction associated by the presence of intracytoplasmic vacuoles, is also with urinary retention [53, 95, 116]. Renal mineral handling is abnormal in several inher- Endocrine and metabolic perturbations associated ited syndromes associated with severe hypokalemia with hypokalemia include glucose intolerance, and K+ wasting, although not as a direct consequence growth restriction, and protein catabolism [53, 95, of hypokalemia. Marked hypercalciuria and nephrocalcinosis may dependent on K+ influx through specific channels, be seen in certain children with Bartter’s syndrome and this process is dampened by K+ depletion [2, 33]. Severe hypomagnesemia is often Hypokalemia- related impairment in glucose metabo- associated with exacerbations of Gitelman’s syndrome. However, this effect may be significant in those dren with Dent’s disease and proximal tubular disor- with subclinical diabetes, and marked in those with ders, collectively referred to as the Fanconi syndrome. Hence, unless patients are placed on K+-free intravenous fluids for prolonged periods along with The causes of hypokalemia are numerous and can dietary K+ restriction, insufficient intake is unlikely to be categorized mechanistically as due to the follow- be a primary cause of hypokalemia. Insufficient intake of K+ or Cl− as an isolated volume contraction may exacerbate hypokalemia due phenomenon is an exceedingly rare cause of hypoka- to secondary hyperaldosteronism [53, 116]. Either lemia, which is of primarily historical and research nonselective or β2-selective adrenergic agonists pro- interest. Deficient K+ intake is not apt to be a relevant mote intracellular uptake of K+ [31]. Hypokalemic clinical consideration with the current care of hospi- periodic paralysis is rare and occurs more often in talized children who manifest hypokalemia, which males. It may be sporadic or familial, usually with typically includes intravenous fluids that provide at autosomal dominant inheritance, and typically least 20 meq m−2 day−1 of K+ and much more chloride. Barium leads to hypoka- a high carbohydrate meal, after exercise, or following lemia by reducing cellular K+ conductance, thereby stressful events. During periodic paralysis, K+ is seques- The list of causes associated with ongoing body loss tered in myocytes, and a diminished sarcolemmal of K+ is lengthy, and is categorized into those that result Chapter 3 Dyskalemias 41 Table 3. These tests also help to categorize Increased β-adrenergic activity the cause of hypokalemia among those with excessive Hypokalemic periodic paralysis renal K+ loss. This is because the conditions in Table in extrarenal K+ loss, via the skin and gastrointestinal 3. These conditions may alternatively be classified intravenous fluids may reduce this phenomenon, the into those that are associated with low or normal blood salt replacement may mask the primary cause as well. All extrarenal causes of hypokale- and potassium supplementation in patients without large gastrointestinal losses, then a primary renal K+ mia fall in the first category, as well as many primary Renal K+ wasting conditions. This issue may be group with low-normal blood pressure are associated further analyzed by measuring urinary electrolytes, with secondary aldosteronism, which enhances kaliu- urinary osmolality, and concurrent plasma osmolality. Patients with increased blood pressure and hypoka- is strongly suggested by a urinary profile character- ized by K+ concentration ≤15 meqL−1, in the setting lemia, especially with metabolic alkalosis, may be categorized depending on the status of their plasma of adequate distal nephron sodium delivery (urine Na+ concentration > 25meq L−1) [53, 95, 116]. If the renin concentration or activity to screen for low-renin disorders [11, 93, 95, 135]. The use of this ratio is only valid if Ou ≥ Op and adequate distal nephron A detailed history and review of medical records is sodium delivery is assured (urine Na+ concentration necessary to clarify whether hypokalemia is due to >25 meq L−1). Important areas to investigate Hypokalemic disorders associated with excessive include growth parameters, medicine list (diuretics, kaliuresis may best be classified by the concomitant chemotherapeutic agents, antibiotics, etc. Those with diets, excessive sweating, polyuria, nighttime thirst, hypokalemic metabolic alkalosis are further tested for blood pressures, and chronic constipation or diarrhea. Important findings on physical chloride depletion, such as from protracted vomiting, examination include evidence of growth restriction, may lead to renal K+ loss [116]. In these cases the uri- adenopathy or abdominal mass, edema, weakness nary chloride concentration is low (≤15 meq L−1) and or abnormal neurologic findings, and either high or the exam suggests hypovolemia or normal volume sta- low blood pressure and heart rate, and evidence of tus. Disorders responsible for hypokalemic metabolic gastrointestinal or urologic surgery. Additionally, removal monitoring and frequent measurements of plasma or minimizing exposure to offending agents that cause K+ concentrations, and should be reserved for severe hypokalemia, and treating underlying medical condi- hypokalemia associated with cardiac or neuromuscular tions (adrenal tumors, leukemia, hyperthyroidism, dysfunction, digitalis toxicity, diabetic ketoacidosis, or diabetic ketoacidosis, etc.