Ion S. Jovin MD, ScD
When permethrin is administered orally to rats menopause gas bloating buy xeloda australia, it is rapidly metabolized and almost completely eliminated from the body in a few days women's health clinic perth northbridge order xeloda now. Only 3 to 6% of the original dose was excreted unchanged in the feces of experimental animals womens health resource center 500 mg xeloda mastercard. Permethrin may persist in fatty tissues women's health clinic john flynn generic xeloda 500mg, with half-lives of 4 to 5 days in brain and body fat. For more information about permethrin please contact the National Pesticide Telecommunications Network at 1-800-858-7378 *most studies quoted were conducted exclusively in animals this information has been taken directly from the following sources: City Health Information, "A West Nile Virus Supplement", the New York City Department of Health, June 2000, v19 s1. Venous insufficiency is treated with leg elevation, compressive stockings, and sometimes diuretics. If time is limited, the physician must decide whether the evaluation can be delayed until a later appointment (eg, an asymptomatic patient with chronic bilateral edema) or must be com pleted at the current visit (eg, a patient with dyspnea or a patient with acute edema [<72 hours]). Venous insufficiency affects there are at least 2 exceptions to this rule: pulmo 1,2 up to 30% of the population, whereas heart fail nary hypertension and early heart failure can both 3,4 ure affects only approximately 1%. Rare Causes of Leg Edema in the United States Unilateral Bilateral Acute (72 hours) Chronic Acute (72 hours) Chronic Primary lymphedema (congenital Primary lymphedema (congenital lymphedema, lymphedema praecox, lymphedema, lymphedema praecox, lymphedema tarda) lymphedema tarda) Congenital venous malformations Protein losing enteropathy, malnutrition, malabsorption May-Thurner syndrome (iliac-vein Restrictive pericarditis compression syndrome)51 Restrictive cardiomyopathy Beri Beri Myxedema Does the edema improve overnight Venous Physical Examination edema is more likely than lymphedema to im Key elements of the physical examination include 13 prove overnight. Findings Distribution of edema: unilateral leg edema is that may increase suspicion of sleep apnea in generally due to a local cause such as deep vein clude loud snoring or apnea noted by the sleep thrombosis, venous insufficiency, or lymphed partner, daytime somnolence, or a neck circum ema. Diagnostic Studies Tenderness: deep vein thrombosis and lipidema Laboratory Tests are often tender. A serum albumin Varicose veins: leg varicosities are often present below 2 g/dL often leads to edema and can be in patients with chronic venous insufficiency, but caused by liver disease, nephrotic syndrome, or venous insufficiency can occur without varicose 14 10 protein-losing enteropathy. Re helpful for ruling out (rather than ruling in) heart 23 ex sympathetic dystrophy initially leads to warm failure because the sensitivity is high (90%). Later the Idiopathic edema can be diagnosed in young skin is thin, shiny, and cool. However, tests to Signs of systemic disease: ndings of heart failure conrm idiopathic edema have been described (especially jugular venous distension and lung and may be helpful in difficult cases (Table 12,24 crackles) and liver disease (ascites, spider heman 5). Most patients are asymptomatic but a sensa 2 Imaging Studies tion of aching or heaviness can occur. This study was not designed venous pressure, basilar crackles on chest ausculta to determine whether borderline pulmonary hyper tion, gallop rhythm, and pitting edema. Treating sleep apnea might 23 improve the leg edema that results from pulmonary heart failure among dyspneic patients. Using a cutoff value of 100 pg/mL, this test had a sensitivity hypertension, but this also is unknown. Given these of 90% and specicity of 76% when compared with uncertainties, we recommend an echocardiogram 23 in patients who are at risk for pulmonary hyperten a clinical diagnosis by 2 independent cardiologists. Up to 50% pine) may be more likely to induce edema than of patients on calcium-channel blockers develop phenylalkylamines (verapamil) or benzothiazepines 14 (diltiazem). Beta blockers Clonidine Synonyms include uid-retention edema, ortho Hydralazine static edema, cyclical edema, and periodic edema. Idiopathic Progesterone edema leads to pathologic uid retention in the Testosterone upright position, and women typically notice a Other 30 Nonsteroidal anti-inammatory drugs weight gain of 1. Tests for Idiopathic Edema Morning and Evening Weights: Patients should weigh themselves nude and with an empty bladder before food or uids in the morning and at bedtime. In patients with idiopathic edema, less than 55% of water load is excreted in the upright position and more than 65% in the recumbent position. However, the distinction cannot always with this syndrome, and diuretic abuse is com be made because chronic venous insufficiency can 14 mon. Lymphedema Primary lymphedema is a rare disorder that is divided Deep Vein Thrombosis 21 Deep vein thrombosis classically results in an into 3 types according to age of presentation. Risk factors for deep Lymphedema praecox is usually unilateral and is vein thrombosis include cancer, immobilization 32 (especially following surgery or an injury), and a limited to the foot and calf in most patients. The most common causes of leg venous insufficiency, lymphedema, idiopathic lymphedema are tumor (eg, lymphoma, prostate edema, and obstructive sleep apnea. Chronic lymphedema is usu Most women experience some premenstrual edema ally distinguished from venous edema based on and weight gain. Edema is com Idiopathic Edema monly present in patients with preeclampsia but is Spironolactone is considered the drug of choice for no longer considered a factor in making the diag idiopathic edema because of the secondary hyper 36 nosis. If spirono Venous insufficiency lactone is not effective, low doses of a thiazide Chronic venous insufficiency is treated with leg diuretic (eg, hydrochlorothiazide, 25 mg daily) can elevation and knee-high compression stockings be added with close monitoring of the serum po 30 that provide 30 to 40 mm Hg pressure at the tassium. Patients who are refractory to recumbency, avoiding environmental heat, low salt compression stockings may improve with intermit diet, avoiding excessive uid intake, and weight loss 2 31 tent pneumatic compression pumps. It may be helpful to ask about nut seed extract (300 mg, standardized to 50 mg of depression, eating disorder, and surreptitious di escin, twice a day) has been found to be effective in uretic or laxative use. Compression stockings are several studies and can be obtained in health food usually not helpful and not tolerated. However, the benets are modest and the agent has not gained widespread accep system. Diuretics (eg, furosemide 20 to 40 mg once bound worsening of edema occurs and patients 49 a day with supplemental potassium) can be used for believe they must continue. How ment of suspected diuretic-induced edema is to ever, venous insufficiency is not a volume overload withdraw diuretics for 3 to 4 weeks after warning state, and long-term use of diuretics can lead to the patient that her edema will probably worsen 2 adverse metabolic complications. However, information gained from this part of the exam may complement subsequent radiologic studies. A search for liver disease is unnecessary in the absence of ascites because leg edema is a late nding in patients with cirrhosis. In patients with idiopathic edema who are not already taking diuretics or those who fail to improve off diuretics, spironolactone and thiazides can be used. Long-term furosemide use in patients with idiopathic edema has been associated with impaired renal function. If the edema does not improve with heparin, starting with 5 to 10 mg daily for 2 after 4 weeks, spironolactone can be initiated at a days with subsequent dosage based on a target dose of 50 to 100 mg daily and increased to a international normalized ratio range of 2. If anticoagu trolled, and prophylactic antibiotics may be lation is contraindicated, an inferior vena cava lter indicated for recurrent cellulitis. Warfarin can be initiated simultaneously the physician should rst rule out lipidema (fat. Approach to diagnosing lower idiopathic edema (in young women) and chronic extremity edema. Differential diagnosis, investigation, and current treatment of lower limb lymphedema. Body mass index is associated with the development of the post thrombotic syndrome. Swollen lower limb-1: gen exclusion of acute venous thrombosis and pulmonary eral assessment and deep vein thrombosis. Lipidema: a clinical entity boembolism after anticoagulation withdrawal in sub distinct from lymphedema. Du contributing to their efficacy in the treatment of plex scanning in the assessment of deep venous in venous insufficiency. Physical symptoms in premenstrual syndrome are related to plasma progesterone and 52. Below tion of deep-vein thrombosis by real-time B-mode knee elastic compression stockings to prevent the ultrasonography. This is an open-access artcle distributed under the terms of the Creatve Commons Atributon License, which permits unrestricted use, distributon, and reproducton in any medium, provided the original author and source are credited.
Any counseling services given in connection with a terminal illness will not be considered as mental health and substance abuse treatment for purposes of applying the mental health/substance abuse maximum visit limit menopause migraines purchase discount xeloda line. Oxford: Hospital Inpatient services for medically necessary womens health 31 meals in 31 days buy 500 mg xeloda with visa, acute-care includes: > Semi-private room and board menstrual cramps 5 weeks pregnant best 500mg xeloda, unlimited days womens health center shelton ct order cheap xeloda line, > General nursing care, > Services and supplies, including: Meals and special diets; Use of operating room and related facilities; Use of intensive care or cardiac care units and related services; X-ray services; laboratory and other diagnostic tests; Drugs; medications; biologicals; anesthesia and oxygen services; Short-term physical, speech and occupational therapy; radiation therapy; inhalation therapy; chemotherapy; Whole blood and blood products; and the administration of whole blood and blood products. Emergency room services are covered only if determined to be medically appropriate and there is not a less intensive or more appropriate place of service, diagnostic, or treatment alternative that could have been used. If your health plan, at its discretion, determines that a less intensive or more appropriate treatment could have been given, then no benefits are payable. Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section. In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable). Even though not incurred for treatment of an illness or injury, covered expenses will include expenses incurred by an eligible covered female for infertility if all of the following tests are met: A condition that is a demonstrated cause of infertility which has been recognized by a gynecologist, or an infertility specialist, and your physician who diagnosed you as infertile, and it has been documented in your medical records. January 1, 2017 Medical 145 the procedures are done while not confined in a hospital or any other facility as an inpatient. Expenses for diagnosis and treatment of the underlying medical condition do not count towards the lifetime maximum. Licensed Counselor Services Services of a licensed counselor for mental health and substance abuse treatment. January 1, 2017 Medical 147 Medical Supplies > Surgical supplies (such as bandages and dressings). However, transportation charges are included in the reimbursement for the product itself and are not separately reimbursable. Note: Routine harvesting and storage from stem cells from new born cord blood is not covered. However, Aetna covers stem cells for hematopoietic cell transplant when deemed medically necessary according to the following criteria: Aetna considers compatibility testing of prospective donors who are close family members (first-degree relatives. Note: the harvesting, freezing and/or storing umbilical cord blood of non-diseased persons for possible future use is not considered treatment of disease or injury. Blood product processing fees (typing, serology and cross-matching and blood storage) are also reimbursable. Blood and blood product administration services are reimbursable only on an outpatient basis when billed hourly or as a flat rate with total eligible charges capped at the average approved semi-private room rate. Prophylactic collection and storage of umbilical cord blood is considered investigational and not medically necessary when proposed for an unspecified future use for an autologous stem cell transplant in the original donor or for an unspecified future use as an allogeneic stem cell transplant in a related or unrelated donor. Oxford: Autologous blood banking services are covered only when they are being provided in connection with a scheduled, covered inpatient procedure for the treatment of a disease or injury. In such instances, the plan will cover storage fees for what Oxford determines to be a reasonable storage period that is medically necessary and appropriate for having the blood available when it is needed. Routine harvesting and storage of stem cells from newborn cord blood is not covered under any circumstances. This service is not proven to be clinically effective and, therefore, is considered to be unproven and not medically necessary. Medical Transportation Services Transportation by professional ambulance or air ambulance to and from the nearest medical facility qualified to give the required treatment. All requests for other out-of-the-country transportation require precertification and Medical Director review. The health plans cover professional ambulance service on a standard basis to transport the individual from the place where he/she is injured or stricken by disease to the first hospital where treatment is given. January 1, 2017 Medical 149 Nurse-Midwife Services of a licensed or certified nurse-midwife. Maternity-related benefits are payable on the same basis as services given by a physician. Nurse-Practitioner Services of a licensed or certified nurse-practitioner acting within the scope of that license or certification. Oral Surgery/Dental Services the plan pays first (the primary plan) for oral surgery if needed as a necessary, but incidental, part of a larger service in treatment of an underlying medical condition. The following oral surgeries are considered medical in nature and covered under the medical plan as necessary: > Treat a fracture, dislocation, or wound; > Cut out: Teeth partly or completely impacted in the bone of the jaw; Teeth that will not erupt through the gum; Other teeth that cannot be removed without cutting into bone; the roots of a tooth without removing the entire tooth; and Cysts, tumors, or other diseased tissues. The following services and supplies are covered only if needed because of accidental injury to sound and natural teeth that happened to you or your dependent while covered under this plan. Coverage is available for the following limited dental and oral surgical procedures: Oral surgery for the repair of sound natural teeth, jaw bones, or surrounding tissue which is related to accidental injury. Your Claims Administrator must be notified before the scheduled date (or as soon as reasonably possible) of any of the following: > the evaluation; > the donor search; > the organ procurement/tissue harvest; and > the transplant procedure. January 1, 2017 Medical 151 Donor charges for organ/tissue transplants > In the case of an organ or tissue transplant, donor charges are considered covered expenses only if the recipient is a covered person under the plan. If the recipient is not a covered person, no benefits are payable for donor charges. For Aetna, transplant services are covered as long as the transplant is not experimental or investigational and has been approved in advance. Transplants must be performed in hospitals specifically approved and designated by Aetna to perform the procedure. Each facility has been selected to perform only certain types of transplants, based on its quality of care and successful clinical outcomes. Any facility that is not specified as an Institute of Excellence network facility is considered a non-participating facility for transplant-related services, even if the facility is considered a participating facility for other types of services. For Anthem BlueCross BlueShield, coverage is based on the facility used for the transplant. Medical Care and Treatment Covered expenses for services provided in connection with the transplant procedure include: > Pretransplant evaluation for one of the procedures listed above; > Organ acquisition and procurement; > Hospital and physician fees; > Transplant procedures; > Follow-up care for a period of up to one year after the transplant; > Search for bone marrow/stem cell from a donor who is not biologically related to the patient. If a separate charge is made for bone marrow/stem cell search, a maximum benefit of $25,000 is payable for all charges made in connection with the search. Note: Coverage of donor costs is generally limited to medically necessary procedures, inpatient confinement. Expenses for travel and lodging for the transplant recipient and a companion are available as follows: > Transportation, including expenses for personal car mileage at the current federal rate of reimbursement, of the patient and one companion who is traveling on the same day(s) to and/or from the site of the transplant procedure for an evaluation, the transplant procedure, or necessary post-discharge follow-up; > Reasonable and necessary expenses for lodging for the patient (while not confined) and one companion. If the covered person chooses not to receive his or her care in connection with a qualified procedure pursuant to this organ/tissue transplant section, the services and supplies received by the covered person in connection with that qualified procedure will be paid under the plan if and to the extent covered by the plan without regard to this organ/tissue transplant section. January 1, 2017 Medical 153 Oxford Health Plans covers only those solid organ transplants that are non-experimental and non investigational. All solid organ transplants must be performed in facilities that Oxford has specifically contracted and designated to perform these procedures to be eligible for plan coverage. Expenses for travel and lodging for the orthopedic recipient and a companion are available as follows: > Transportation, including expenses for personal car mileage at the current federal rate of reimbursement, of the patient and one companion who is traveling on the same day(s) to and/or from the site of the orthopedic procedure for an evaluation, the orthopedic procedure, or necessary post-discharge follow up; > Reasonable and necessary expenses for lodging for the patient (while not confined) and one companion. Blue Distinction Centers meet stringent clinical criteria, established in collaboration with expert physician panels and national medical societies and are subject to periodic re-evaluation as criteria continue to evolve. There is no travel and lodging benefit for services rendered outside of a Blue Distinction Center. The plan covers a hidden ocular muscle condition where the eyes have a tendency to under converge or over converge.
Distal infection of the bones menstrual period tracker buy xeloda 500mg low cost, joints breast cancer yoga order cheap xeloda on-line, or other organs persistence of toxicity women's health clinic queen elizabeth xeloda 500mg free shipping, malaise menstrual 2 days late order xeloda paypal, anorexia, and wasting in the (eg, liver abscess) may occur in certain hosts with specific patient suggests the potential need for pleural decortication, organisms. Treatment Endotracheal intubation or mechanical ventilation may be indicated in patients with respiratory failure or in those Antimicrobial therapy should be guided by Gram stain of too debilitated or overwhelmed to handle their secretions. Reasonable coverage for pneumonia in the sick, For the immunocompetent host in whom bacterial pneumo immunocompromised, or debilitated patient, pending the nia is adequately recognized and treated, the survival rate is results of bronchoalveolar lavage or thoracoscopic biopsy, high. For example, the mortality rate from uncomplicated should include ceftazidime, clindamycin, vancomycin, a pneumococcal pneumonia is less than 1%. Depending on function following empyema is surprisingly uncommon, the circumstances and the level of illness, empiric antifungal even when treatment has been delayed or inappropriate. Hyperinflation of the lungs may occur when involvement of the small airways is prominent. Patients with prominent wheezing may have asthma, airway obstruction caused by foreign body Wheezing or rales. Complications General Considerations Viral pneumonia or laryngotracheobronchitis may predis Most pneumonias in children are caused by viruses. Bronchiolitis obliterans or viruses, and human metapneumovirus are responsible for severe chronic respiratory failure may follow adenovirus the large majority of cases. Bronchiolitis or viral pneumonia may contribute fever, radiographic findings, and the characteristics of to persistent asthma in some patients. Bronchiectasis, chronic cough or lung sounds do not reliably differentiate viral from interstitial lung diseases, and unilateral hyperlucent lung bacterial pneumonias. Furthermore, such infections may (Sawyer-James syndrome) may follow measles, adenovirus, coexist. Plasma cell granuloma may celes, abscesses, lobar consolidation with lobar volume develop as a rare sequela to viral or bacterial pneumonia. Treatment Clinical Findings General supportive care for viral pneumonia does not differ from that for bacterial pneumonia. Symptoms and Signs and should be hospitalized according to the level of their An upper respiratory infection frequently precedes the onset illness. Because bacterial disease often cannot be definitively of lower respiratory disease due to viruses. Rapid viral diagnostic tests may be a useful guide for such therapy (see Bronchiolitis section, earlier, regarding preven B. These high-risk patients and all children 6 months to 5 the peripheral white blood cell count can be normal or years of age should be immunized annually against influenza slightly elevated and is not useful in distinguishing viral from A and B viruses. Imaging uneventfully, worsening asthma, abnormal pulmonary func Chest radiographs frequently show perihilar streaking, tion or chest radiographs, persistent respiratory insuffi increased interstitial markings, peribronchial cuffing, or ciency, and even death may occur in high-risk patients such patchy bronchopneumonia. Lobar consolidation or atelecta as newborns or those with underlying lung, cardiac, or sis may occur, however, as in bacterial pneumonia. Differential Diagnosis Inclusion conjunctivitis, eosinophilia, and elevated Bacterial, viral, and fungal (P jiroveci) pneumonias should be immunoglobulins in some cases. C pneumoniae is often accom panied by coinfection with other pathogens, particularly S General Considerations pneumoniae and M pneumoniae. Pulmonary disease due to C trachomatis usually evolves Treatment gradually as the infection descends the respiratory tract. Infants may appear quite well despite the presence of signif Erythromycin or sulfisoxazole therapy should be adminis icant pulmonary illness. Hospitalization may be required for demic proportions in urban environments worldwide. C children with significant respiratory distress, coughing par pneumoniae is now recognized as a common cause of respi oxysms, or posttussive apnea. Prognosis Clinical Findings An increased incidence of obstructive airway disease and A. Rhinophar yngitis with nasal discharge or otitis media may have Brunetti L et al: the role of pulmonary infection in pediatric occurred or may be currently present. It can have a Darville T: Chlamydia trachomatis infections in neonates and young children. Often these lower respiratory tract illnesses are mild or asymptomatic, although this can occasionally be a serious pathogen. Endemic and epidemic infection which M pneumoniae can initiate or exacerbate chronic lung can occur. Although the lung is the primary infection site, extrapulmonary complications some Brunetti L et al: the role of pulmonary infection in pediatric times occur. Although cough is usually dry at the onset, sputum production may develop as the illness progresses. Laboratory Findings Symptoms of active disease (if present): chronic the total and differential white blood cell counts are usually cough, anorexia, weight loss or poor weight gain, normal. Acute and convalescent titers for M pneumoniae demonstrating a fourfold or greater General Considerations rise in specific antibodies confirm the diagnosis. Diagnosis of Tuberculosis is a widespread and deadly disease resulting mycoplasmal pneumonia by polymerase chain reaction is from infection with M tuberculosis. Imaging lesions, contiguous spread into adjacent thoracic structures, Chest radiographs usually demonstrate interstitial or bron acute miliary tuberculosis, acute respiratory distress syn chopneumonic infiltrates, frequently in the middle or lower drome, overwhelming reactivation infection in the immuno lobes. Because transmission is usually through respiratory droplets, isolated pulmonary parenchymal tuberculosis con Extrapulmonary involvement of the blood, central nervous stitutes more than 85% of presenting cases. Direct Coombs-posi tuberculosis is the focus of discussion here; additional man tive autoimmune hemolytic anemia, occasionally a life-threat ifestations of tuberculosis are discussed in Chapter 40. Coagulation tuberculosis has declined among all age groups in the United defects and thrombocytopenia can also occur. This trend has continued through tion, meningoencephalitis, Guillain-Barre syndrome, cranial 2006, the most recent year for which data are available. A However, the disease remains a significant cause of morbid wide variety of skin rashes, including erythema multiforme and ity and mortality worldwide. Supportive measures, including hydration, anti active disease, if present, might include chronic cough, pyretics, and bed rest, are helpful. Laboratory Findings and Imaging obstruction, sometimes with secondary bacterial pneumonia Anteroposterior and lateral chest radiographs should be or airway collapse resulting from hilar adenopathy. Culture for M tuberculosis is Because most children infected with tuberculosis are critical for proving the diagnosis and for defining drug asymptomatic, a clue to infection may be contact with an susceptibility. Although stains for acid-fast bacilli on this dren are also at high risk, as are those in contact with high material are of little value, this is the ideal culture site. Stains and cultures of bronchial secretions can sion (cancer chemotherapy or corticosteroids). When pleural effusions are the symptoms of active disease listed previously most often present, pleural biopsy for cultures and histopathologic occur during the first year of infection. Thereafter, infection examination for granulomas or organisms provide diagnos remains quiescent until adolescence, when reactivation of pul tic information. At any stage, chronic cough, young children, and lumbar puncture should be considered anorexia, weight loss or poor weight gain, and fever are useful in their initial evaluation. Of note, except in patients with complications or advanced disease, physical findings are few. Atypical tuberculous induration greater than or equal to 5 mm in patients who are organisms may involve the lungs, especially in the immuno at high risk for developing active disease (ie, immunocom compromised patient. Depending on the presentation, diag promised, those with a history of a positive test or radiograph, noses such as lymphoreticular and other malignancies, col children younger than 4 years, and those known to have close lagen-vascular disorders, or other pulmonary infections may contact with someone with active disease); greater than 10 be considered. Tine tests meningitis, osteomyelitis, arthritis, enteritis, peritonitis, and should not be used. Appropriate control skin tests, such as renal, ocular, middle ear, and cutaneous disease may occur.
Level of Evidence = Ia Discussion of Evidence Nurses women's health clinic dufferin lawrence buy xeloda 500 mg amex, in collaboration with other members of the healthcare team menstruation jelly like order xeloda 500 mg online, play a role in assessment and client education related to dietary risk factors and optimal dietary approaches women's health green coffee best purchase for xeloda. Nurses understand that social and cultural factors play an important role in adherence women's health boca raton buy generic xeloda 500mg line, and that there are multiple dietary approaches to the management of hypertension. A referral to a Registered Dietitian will assist with the complexities of individual client needs. This approach has significantly lowered blood pressure in persons with stage 1 (grade 1) hypertension and in those with high-normal blood pressure (Appel, Moore & Obarzanek, 1997; Conlin, 1999; Vollmer et al. Measures taken at 13 and 60 months showed that those participants given advice about a low sodium diet had reduced systolic and diastolic blood pressures compared with participants in the control group. The degree of reduction in sodium intake and change in blood pressure were not related; people on antihypertensive medications were able to stop their medication more often on a reduced sodium diet as compared with controls, while maintaining similar blood pressure control (Hooper, Bartlett, Davey & Ebrahim, 2004). While there is no clear correlation with elevated blood pressure, scientific evidence shows that the consumption of trans fat increases the incidence of coronary artery disease. The Heart and Stroke Foundation of Canada recommends that trans fat in processed foods be replaced as soon as possible, where feasible, by healthy alternatives such as monounsaturated and polyunsaturated fats, rather than with equal amounts of saturated fats (Svetkey et al. Caffeine is a powerful stimulant to the cardiovascular system, and the effects of drinking one cup of coffee are an increase in blood pressure and heart rate. It has been suggested that regular consumption of caffeine may contribute to a sustained elevation in blood pressure, which is a concern for those with hypertension (Jee, He, Whelton, Suh & Klag, 1999; Lane, Pieper, Phillips-Bute, Bryant & Kuhn, 2002). Bodyweight classification can be applied to all ethnic groups in Canada; however healthcare providers should be aware of limitations in applying this classification to non-white people. Central obesity, detected by waist circumference, is a marker of adverse cardiovascular outcomes (Williams et al. Central obesity has been defined by waist circumferences for various populations (International Diabetes Federation, 2005). The consensus panel of the International Diabetes Federation, who summarized these pragmatic cut-points, acknowledges that they were taken from a variety of sources, and require better data to link them to risk: Europid: >94cm for men and >80 cm for women; South Asian (Chinese, Malay and Asian-Indian populations): >90 cm for men and >80 cm for women; 43 Nursing Management of Hypertension Ethnic South and Central Americans: use South Asian recommendations until more specific data are available; Sub-Saharan Africans: use European data until more specific data are available; Eastern Mediterranean and Middle East populations: use European data until more specific data are available. Increased peripheral concentrations of insulin and increased triglyceride concentration is associated with abdominal obesity, and may be due to the direct deposition of free fatty acids in the portal vein from intra-abdominal adipocytes (Bronner, Kanter & Manson, 1995). The benefits of weight loss include: reducing the cost and side effects associated with antihypertensive medications, lowering cholesterol levels, decreasing glucose levels in individuals with diabetes, decreasing cardiovascular risks, and finally, improving clientsquality of life. According to a recent definition of the International Diabetes Federation (2005), for a person to be defined as having metabolic syndrome, they must have central obesity plus any two or more of the following: Raised triglyceride level: >150mg/dl (1. Weight reduction by calorie restriction is appropriate for the majority of hypertensive clients because many are overweight (Williams et al. Various studies have examined the impacts of weight loss on blood pressure: Low calorie diets have a modest effect on blood pressure in overweight individuals, but nearly 50% can expect a reduction of 5/5 mmHg or better in the short term (Williams et al. Larger reductions in blood pressure were achieved in populations that included subjects taking antihypertensive medications. In a multivariate analysis, which was standardized for the amount of weight loss, the effect on diastolic blood pressure was larger when body weight was reduced by physical activity compared with energy restriction (Neter, Stam, Kok, Grobbee & Geleignse, 2003). Registered dietitians are especially well positioned to assess the needs of the client with hypertension and often other underlying nutrition conditions, develop care plans that take into consideration multiple nutrition issues, use different counseling and behavioural change techniques to effect difficult lifestyle changes and monitor treatment and management strategies. Adherence to the weight loss program can be encouraged through education, correcting misconceptions, enhancing family and social support and frequent counseling and monitoring (Hamlin & Brown, 1999). Refer to further sections in this document for a detailed discussion of strategies to promote adherence, and to Appendix K for a description of the Canadian Body Weight Classification System. Discussion of Evidence Nurses are engaged in a professional therapeutic relationship related to their role in the healthcare system (College of Nurses of Ontario, 2004c), their education, and their contact with clients, to effectively assess and promote physical activity in individuals with hypertension. Assessment of physical activity level by the multidisciplinary team requires that the nurse consider how the following client specific variables affect current and future physical activity levels (Canadian Nurses Association, 2004): 45 Nursing Management of Hypertension Demographics. Some suggested questions include: During a typical week, how many times do you engage in physical activity that is long enough and intense enough to cause sweating and a rapid heart rate Generally, do you think your current fitness level is: Very Good Good Average Poor Very Poor Tremblay, Shephard, McKenzie & Gledhill, 2001 Individuals at different stages of change respond most effectively to different types of strategies. If a nurse is able to determine which stage an individual client is in at a given point, he/she can work to promote physical activity in a way that is most appropriate for that individual at that point in time. Many meta-analyses and reviews of intervention studies describing the effects of exercise on blood pressure have consistently shown that aerobic exercise training reduces resting systolic and diastolic blood pressure in both normotensive and hypertensive clients (Cooper, Moore, McKenna & Riddoch, 2000). Encouraging weight management along with exercise can help reduce blood pressure by 7 mmHg for systolic blood pressure and 5 mmHg for diastolic blood pressure (Blumenthal et al, 2000). A Food and Fitness Calculator is a useful tool that can indicate the relationship between the length of specific activities and the number of calories consumed from popular foods and burned during exercise (Refer to Appendix Q). The antihypertensive effect of training persisted as long as the training program. In contrast, the antihypertensive effect was no longer seen after detraining periods of 10 weeks. It is important that clients check with their healthcare provider before beginning an exercise program. In clients with severe hypertension or in those whose blood pressure is poorly controlled, heavy physical activity should be discouraged or postponed until appropriate drug therapy has been instituted and found to be effective (Williams et al. Written exercise advice was shown to be more effective than verbal advice alone in encouraging clients to adopt and sustain increased levels of physical activity over a six week period. The two most common reasons for being inactive are not enough time and not enough energy. It has been suggested that any activity appears to be helpful, but those who are more active appear to gain more benefit. A client can benefit just as much from three ten minute spurts of moderate activity as from a solid half-hour. Discussion of Evidence According to the Canadian Medical Association Hypertension Guidelines (1999) 75% of Canadians over the age of 15 consume alcohol, and 6. The evidence shows that excessive alcohol consumption raises blood pressure independent of other risk factors including smoking, age, sex, race, coffee use, level of education, prior heavy drinking history and the type of alcohol consumed (Boggan, 2003; Oparil & Weber, 2000). Attempting to define an absolute cause and effect relationship between alcohol and hypertension is complicated, as other factors come into play. Some of these factors include amount of alcohol ingested, chronic or binge drinking, underlying state of health and effects of alcohol on the myocardium. A study done by De la Sierra (1996, as cited in Estruch, 2003) indicates some people are sensitive to the pressor effects of alcohol. Some of these theories are listed below: increased intracellular calcium or other electrolytes in vascular smooth muscle (Boggan 2003; Estruch, 2003; Lip & Beevers, 1995; Oparil & Weber, 2000) inhibition of vascular relaxing substances. This tool is a series of four questions meant to assess for alcohol dependence in a non-threatening manner. The questions should be part of an overall health assessment and asked at every visit regarding recent alcohol consumption. A positive response to any one of the four questions would indicate to the healthcare professional that there is a suspicion of over consumption. This tool places the emphasis on heavy drinking and frequency of intoxication rather than signs of dependency. In its initial pilot in six different countries, the sensitivity averaged 80% and specificity averaged 98% for detecting excessive alcohol consumption (Haggerty,1994). If alcohol overuse is suspected or identified, the client should be counseled on the negative health effects and referral to an alcohol treatment specialist or program may be appropriate (Cushman, 2001). This list of tools is not all-inclusive, and some of the tools are designed for use with specialized populations or as part of a broader substance use evaluation. Research has shown that approximately half of clients with excessive alcohol use have blood pressure readings >160/90, and these values were found to normalize during abstinence. Similar trends were found within a broader population base leading researchers to believe the blood pressure effects of alcohol are due to alcohol consumed in the days immediately prior to measurement and the effect is rapidly reversible (Seppa & Sillanaukee, 1999). Furthermore, binge drinking was found to be a risk factor for stroke in young persons who consumed alcohol on weekends and holidays, prime drinking times. Although there is no direct evidence, this study would suggest a link between alcohol, hypertension and stroke (Seppa & Sillanaukee, 1999). Generic 500mg xeloda mastercard. Hear it from the Patient: Virginia Talks Women's Health Care Services. |
