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Escherichia coli 0157:H7 In the majority of cases purchase viagra line erectile dysfunction caffeine, the alloantibody produced is D order 100mg viagra fast delivery hot rod erectile dysfunction pills. C Storage pool deficiencies are defects of platelet characteristics/Platelet disorders/1 granules buy viagra 25mg with amex erectile dysfunction nutritional treatment. It is performed on whole blood diluted Hemostasis/Select methods/Reagents/Specimen with saline buy viagra 100 mg online erectile dysfunction clinic raleigh. Decreased platelet adhesion (dilated capillaries) of the mucous membranes Hemostasis/Apply knowledge of fundamental biological and skin. Lesions may develop on the tongue, lips, characteristics/Platelet disorders/2 palate, face, hands, nasal mucosa, and throughout the gastrointestinal tract. This disorder is an autosomal dominant condition that usually manifests in adolescence or early adulthood. Antithrombin is a physiological Hemostasis/Apply knowledge of fundamental biological anticoagulant. Coagulation defect of agranular platelets when viewed on a Wright’s- Hemostasis/Apply knowledge of fundamental biological stained blood smear. The percent (%) change from baseline aggregation is calculated and reported as % P2Y12 inhibition. Which of the following instruments can be used to Answers to Questions 22–23 evaluate platelet function? All of the above with normal platelet count and normal coagulation tests, or to assess the efficacy of antiplatelet drugs. Hemostasis/Selected methods/Reagents/Special tests/2 Platelet aggregometry is used for the diagnosis of 23. A platelet aggregometer demonstrates a monophasic aggregation curve uses platelet-rich plasma to measure platelet when used in optimal concentration? Epinephrine secretion (using a luminescent marker) in addition Hemostasis/Apply knowledge of fundamental biological to platelet aggregation. This coating activates the platelets in the moving sample, and promotes platelet adhesion and aggregation. If both tests are abnormal, it is likely that the patient has a platelet dysfunction, and further testing for inherited and acquired bleeding disorders is indicated. B Collagen is the only commonly used agent that demonstrates a single-wave (monophasic) response preceded by a lag time. Which test result would be normal in a patient Answers to Questions 1–6 with dysfibrinogenemia? D The level of plasma fibrinogen determined Hemostasis/Correlate clinical and laboratory data/ immunologically is normal. In a patient with Factor deficiency/3 dysfibrinogenemia, fibrinogen is not polymerized 3. X Hemostasis/Evaluate laboratory data to recognize health and disease states/Factor deficiency/3 53 54 Chapter 2 | Hemostasis 7. Von Willebrand’s disease is a disorder disorders is most consistent with these results? Hypofibrinogenemia of the patient’s plasma to correct any specific Hemostasis/Correlate clinical and laboratory data/ factor-deficient plasma. Each laboratory patient’s plasma is mixed with: should calculate its own normal ranges based on A. Normal control plasma Hemostasis/Apply principles of basic laboratory procedures/Coagulation tests/2 2. Which of the following is associated with an Answers to Questions 13–19 abnormal platelet aggregation test? Therefore, Which of the following disorders may be in von Willebrand’s disease (deficiency or functional indicated? In primary fibrinolysis, the fibrinolytic Hemophilia/2 system is activated and fibrin monomers are normal. Fibrinogen deficiency against the phospholipid-dependent coagulation Hemostasis/Correlate clinical and laboratory data/2 factors. An inherited disorder of coagulation healing and may cause severe bleeding problems. Fletcher factor (prekallikrein) deficiency may be Answers to Questions 20–23 associated with: A. One of the complications associated with a severe such as hemarthrosis (bleeding into the joints). Immune-mediated thrombocytopenia subtype 1, and 70%–80% of these cases are Hemostasis/Apply knowledge of fundamental biological associated with mild bleeding. Subtype 3 involves characteristics/Hemophilia/1 the total absence of the von Willebrand’s molecule and is associated with severe bleeding. Te most common subtype of classic von and 2B result in deficiency of intermediate and/or Willebrand’s disease is: high molecular weight portions of the von Willebrand A. It is a cofactor of heparin important naturally occurring physiological inhibitor D. They are either directed circulating anticoagulant is: against a specific clotting factor or against a group of A. D The lupus anticoagulant interferes with phospholipid-dependent coagulation assays 4. Phospholipid-dependent assays present in human milk; it is not recommended for pregnant and lactating women. Which statement about Coumadin (warfarin) is Antithrombin is a heparin (not warfarin) cofactor. D Heparin is a therapeutic anticoagulant with an Hemostasis/Correlate clinical and laboratory data/ antithrombin activity. Which combination of the tests is Quantitative fibrinogen assay, however, is not expected to be abnormal? Hemostasis/Correlate clinical and laboratory data/ Aspirin is another antiplatelet drug that inhibits Heparin therapy/3 platelet aggregation by blocking the action of the 10. Prasugrel protein that accelerates protein C activation Hemostasis/Correlate clinical and laboratory data/ 1,000-fold by forming a complex with thrombin. What test is commonly used to monitor warfarin Heparin inhibits thrombin, and therefore, causes a therapy? Ecarin time other vitamin K–dependent proteins such as proteins Hemostasis/Correlate clinical and laboratory data/ C and S. What clotting factors (cofactors) are inhibited by warfarin therapy for prophylaxis and treatment of protein S? C Urokinase is a thrombolytic drug commonly used to Clotting factors/2 treat acute arterial thrombosis. C The International Society of Hemostasis and Terapies/2 Thrombosis has recommended four criteria for the 16. Diagnosis of lupus anticoagulant is confirmed by diagnosis of lupus anticoagulant: (1) a prolongation which of the following criteria? Neutralization of the antibody by high corrected); (3) evidence that the inhibitor is directed concentration of platelets against phospholipids by neutralizing the antibodies D. B Lupus anticoagulant interferes with phospholipids in with the presence of lupus anticoagulant? Trombocytosis/thrombosis in a bleeding tendency unless there is a coexisting Hemostasis/Correlate clinical and laboratory data/ thrombocytopenia or other coagulation abnormality. Can be used as a fibrinolytic agent young age Hemostasis/Apply knowledge of fundamental biological D. Which of the following tests is most likely to be abnormal in patients taking aspirin? It prevents platelet Hemostasis/Correlate clinical and laboratory data/ aggregation by inhibition of cyclo-oxygenase. Inhibitors/2 Aspirin has no effect on the platelet count, platelet morphology, or prothrombin time. C Up to 22% of patients taking aspirin become resistant Aspirin resistance/2 to aspirin’s antiplatelet effect. C Laboratory tests for evaluation of thrombophilia are Antithrombotic therapy/2 justified in young patients with thrombotic events, in patients with a positive family history after a single thrombotic event, in those with recurrent spontaneous thrombosis, and in pregnancies associated with thrombosis. Decreased levels of prothrombin in plasma/ Hemostasis/Apply knowledge of fundamental biological thrombosis characteristics/Inhibitors/1 D. Increased levels of prothrombin in plasma/ bleeding Answers to Questions 25–30 Hemostasis/Correlate clinical and laboratory data/ Prothrombin/3 25. B Prothrombin G20210A is defined as a single-point mutation of the prothrombin gene, resulting in 26. Factor V Leiden promotes thrombosis by increased concentration of plasma prothrombin preventing: and thereby a risk factor for thrombosis. The thrombotic episodes generally occur Hemostasis/Correlate clinical and laboratory data/ before age 40. What is the approximate incidence of factor V gene that inhibits factor Va inactivation by antiphospholipid antibodies in the general protein C. D Currently, the platelet aggregation test is considered Hemostasis/Apply knowledge of fundamental biological the gold standard for evaluation of aspirin resistance. Which of the following laboratory tests is helpful no effect on platelet count and morphology. Hemostasis/Apply knowledge of fundamental biological characteristics/Inhibitors/2 32. Te Bethesda assay is used for which with different dilutions of the patient’s plasma or a determination? C Elevated plasma homocysteine is a risk factor for the development of venous thrombosis. Hyperhomocysteinemia may be a risk factor for: Homocystinemia may be inherited or acquired.

Only the outcome variable buy cheap viagra 100 mg impotence stress, represented by the Hill-Bone medication subscale was used in data analysis order viagra 50 mg otc erectile dysfunction melanoma, and the Cronbach‘s alpha was good ( purchase viagra 100mg fast delivery erectile dysfunction causes in young men. The Self-Care of Hypertension Index management subscale also had a low Cronbach‘s alpha of generic viagra 75mg erectile dysfunction injections trimix. This subscale was applicable to 34 of the 80 participants who reported trouble controlling their blood pressure in the past month. Again, the response pattern was inconsistent as participants did not answer similarly in how they managed their blood pressure. Lastly, the Therapeutic Reactance total scale and behavioral subscale had acceptable Cronbach‘s alphas, while the verbal subscale had low Cronbach‘s alpha related to a variance in participants‘ response pattern consistency. Frequencies were run on all variables to check for missing data and extreme values. There were no missing data, however, outliers were consistently found in most of the variables of study. To limit outlier influence, variables not previously categorized were divided into quartiles prior to statistical analysis (Mertler & Vannatta, 2010; Vogt, 2005). Because outliers do not follow the normal distribution, statistical models that do not require distribution assumptions, such as nonparametric and semiparametric models, were used for data analyses. Although nonparametric models avoid restrictive assumptions of normality, they may yield difficult interpretations and inaccurate estimates for a large number of regressors. However, semiparametric models combine components of both parametric and nonparametric models while retaining the flexibility of nonparametric models and providing the easy 115 interpretation of parametric models (Hardle, Muller, Sperlich, & Werwatz, 2004). Thus, nonparametric and semiparametric models were ideal statistical models for data analyses. Over half of the participants were not married (56%) and had a single, divorced, or widowed status. The majority of the sample was employed (67%), physically inactive (89%), overweight/obese (88%), and had a history of smoking (54%). Descriptive statistics in the form of percentages or means and standard deviations are displayed for the background variables (see Table 3), dynamic variables (see Table 4), and the health outcome, medication adherence (see Table 5). Medication subscale scores were used to determine adherent and nonadherent groups. The adherent group consisted of 20 (25%) participants (score of 9) and the nonadherent group consisted of 60 (75%) participants (score 10-36). Both groups were analyzed in relation to antihypertensive medication adherence or nonadherence and background variables associated with adherence. The Shapiro-Wilk test was used to assess normality (Norusis, 2008) of independent variables. In addition, calculated means, ranges, standard deviations, frequencies, skewness, kurtosis, and graphic plots were analyzed on all continuous data to assess distributions. This was suggestive of a normal distribution allowing use of the independent sample t-test (Gliner & Morgan, 2000; Polit, 1996) to determine if there was a significant difference between the adherent and nonadherent antihypertensive medication groups. Because there was evidence of nonnormality, a two-tailed Mann-Whitney U-test (Gliner & Morgan, 2000) was used to investigate differences between the adherent and nonadherent groups. The Fisher‘s exact test was used to examine the significance of association (contingency) between background and dynamic variables on medication adherence. The procedure follows a hypergeometric distribution under the null hypothesis of independence with fixed margins and is frequently used in place of a phi correlation coefficient when data are sparse (Bower, 2003; Huck, 2008). Fisher‘s exact test does not rely on normality assumptions and uses the exact distribution instead of a normal approximation (Polit, 1996). Variables not previously categorized were divided into quartiles (Q) prior to statistical analysis. Quartile derivations is advantageous because it limits outlier influence (Mertler & Vannatta, 2010; Vogt, 2005). In addition, Fisher‘s exact test could test the significance of the difference in proportions of background and dynamic variables on medication adherence when some of the expected cell frequencies fell below 5 (Polit, 1996). The results displayed in Table 7 show counts and frequencies of all variables as related to the outcome variable medication adherence and provide results of the Fisher‘s exact test. However, the lack of a statistically significant association in a simple contingency table analysis does not rule out ordinal effects or trends that may predict outcome. Influence of Background and Dynamic Variables on Medication Adherence Compliant Compliant Compliant Compliant None of Some of Most of All of Characteristics the time the time the time the time (>14) (13-14) (10-12) (9) Fisher‘s n(%) n(%) n(%) n(%) Exact Test Income Q1 <20,000 7 (37) 7 (33) 7 (35) 8 (40) Q2 ≥20,000- <35,000 1 (5) 7 (33) 7 (35) 3 (15) Q3 ≥35,000- <55,000 6 (32) 4 (19) 2 (10) 6 (30) Q4 ≥55,000 5 (26) 3 (14) 4 (20) 3 (15) 0. This is a semi-parametric regression procedure that examines the association between a set of predictor variables and an ordinal scale outcome variable. The higher scores represent the importance of the dimension (LeBreton & Tonidandel, 2008; Sachdev & Verma, 2004). Conditional maximum likelihood parameter estimates were determined iteratively using an integral approximation (Gail, Lubin, & Rubinstein, 1981). Model fit was assessed using standard regression deviance-based diagnostic plots (Pregibon, 1981). Continuous variables were categorized into quartiles based on the distribution among referent 133 participants. An ―optimal predictive model‖ was identified by retaining variables in a multivariable analysis only if, for at least for one level, p<0. The univariable background variables that predicted medication adherence were participant age and number of medications (see Table 8). In contrast participants who reported taking five to seven medications (Q3) were 3. However, participants who manifested major depressive symptoms were less likely to be adherent to antihypertensive medications as observed by a significant linear trend (P for trend=0. Variables retained in the ―optimal predictive model‖ included participant age, number of medications, and trust in health care provider (see Table 8). However, similar to the univariable case, a significant linear trend was not observed for ―number of medications. In summary, participant age was the only background variable that independently predicted nonadherence to antihypertensive medications in our ―optimal predictive model. Univariable predictors and the optimal predictive model for medication adherence are listed in Table 8. Spearman‘s rho was used to determine the correlation between therapeutic reactance and medication adherence. Based on the results of the Shapiro-Wilk test, there was no significant difference in the verbal subscale (p=. Because the sample size was not equal, Levene‘s test (Polit, 1996) for homogeneity of variance was conducted, and there was no significant difference in the variance of the adherent group and the nonadherent group for the mean verbal subscale (F=. The independent sample t-test revealed no significant difference in the verbal subscale for the adherent (M=29. The basic assumption of the M-C 1[10] is that participants who answer in a socially desirable manner are highly likely to answer in a similar manner on all self-report measures. Low scores on the M-C 1[10] scale reflect socially undesirable or honest answers, high scores reflect socially desirable or dishonest answers, and middle scores reflect a combination of both ("Social desirability scale"). Of all the participants, 63% (n=51) scored in the middle range (4-7) while 19% (n=15) scored in the low range (0-3), and 18% (n=14) scored in the high range (8-10). Participants who engaged in significant amounts of socially desirable responding were not discarded from the study. These data were used to provide a measure to gauge the likelihood that participants were providing honest responses to the self-report measure. Marlowe-Crowne Social Desirability (M-C 1[10] scale was significantly associated with three of the instruments used in this study (see Table 9). A weak negative association was noted with the verbal subscale and total scale of the Therapeutic Reactance Scale. This correlation implies that participants who demonstrated higher verbal and total scale reactance scores tend to be honest. These data imply that participants who reported nonadherence to medication-taking and those who 140 reported depressive symptoms were truthful. Participants were mostly single or married, with a mean age of 48 years and employed full-time. Cardiovascular disease risk factors such as physical inactivity, overweight/obese, and a history of smoking were prevalent in the sample. In the optimal predictive model, only age and trust in health care provider significantly predicted medication adherence. In addition, this study explored the relationship between reactant behaviors and medication adherence. This chapter provides an interpretation of the findings and implications for nursing practice. Element of Health Outcome: Adherence to the Recommended Health Regimen Medication adherence. In the current study, one-fourth of the sample reported total adherence to their antihypertensive medication regimen as indicated by a perfect adherence score (9) on the medication subscale of the Hill-Bone Compliance to High Blood Pressure Therapy Scale. In comparison, almost half of the nonadherent group reported they were not faithful in taking their antihypertensive medications consistently. In addition to adherence issues, the appropriateness of pharmacological management should be evaluated. However, in the optimal predictive model, only age and trust in health care provider significantly predicted medication adherence. Each of these predictors is discussed in more detail under the elements of client singularity. If we use these guidelines for Black women, almost one-third of the participants in this study would meet this criterion.

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A concoction is made for them that is called “complete nutrition” and we feed this meal after meal buy viagra 100 mg free shipping impotence lab tests, day after day buy genuine viagra causes of erectile dysfunction in late 30s, a most unnatural situation purchase 50 mg viagra with visa erectile dysfunction vascular causes. The liver is deluged with the same set of pollutants time after time and never gets a rest buy viagra 50 mg online erectile dysfunction vs impotence. This gives the liver a chance to catch up with detoxifying one pollutant while the new one builds up. If the liver is absolutely unable to handle something, you are informed quite quickly with an allergic reaction to the food. Cats and dogs with their monolithic diet get no opportunity to reject food (except by vomiting or starvation). It is not surprising they are getting cancer with increasing frequency, a situation where the liver can no longer detoxify isopropyl alcohol, a common pollutant in their food. But what if they like and prefer their monolithic “scientific”, “complete”, polluted diet? All change should be brought about slowly and with kindness for animals and humans alike. After your pets have stopped eating propyl alcohol polluted food and are not getting propyl alcohol in their shampoos, there is no way they can get cancer. Whatever cancer they have will clear up by this change in diet and by giving them the pet parasite program. By selecting wise habits your improved lifestyle pays you back for the rest of your life. After using the bathroom and washing your hands, treat your fingernails with alcohol. Add ½ cup 95% alcohol to ½ cup cold tap water or buy plain vodka, 80 to 100 proof. Ask your pharmacist to make it from scratch for you (there are only two ingredients and water, see Recipes). In long-ago days, all sheets, towels, table cloths, and underwear were separated and boiled. With the convenience of our electric washing machine, we tend to overlook the fact that underwear is always contaminated by fecal matter and urogenital secretions and excretions. Lime water (calcium hydroxide) or iodine based antiseptics seem obviously simple methods to accomplish this. Besides, your skin absorbs it from clothing, it is quite toxic to you, and can cause mental effects. They do not clean quite as well as modern detergents, but there is less static cling, eliminating the need to put more chemicals in your dryer. Better Kitchen Habits Once a day, sterilize the sponge or cloth you use to wipe up the table, counter tops and sink. This little piece of contami- nated cloth is the most infectious thing in the house, besides the toilet. Sometimes it has a slight odor at first, which may warn you, but most pathogens do not have an odor! As we wipe up droplets of milk, we give the milk bacteria, Salmonellas and Shigellas, a new home to multiply and thrive in. The cloth or sponge recolonizes the kitchen and dining room table several times a day. No doubt, the last thing you do before leaving the kitchen is squeeze it dry with your hands. In two hours they are already multiplying in the greatest culture system of all: your body! To sterilize the sponge: drop it into a 50% solution of grain alcohol at the end of each day. Another way to sterilize the sponge or cloth is to microwave it, after wetting it, for 3 minutes. Another strategy is to use a fresh cloth or sponge each day, putting the used one to dry until laundry day. The counter and table top have on them whatever is in the kitchen dust and on the wipe cloth. Vacuuming sends up a hurricane of dust and distributes bathroom dust to the kitchen and kitchen dust to the bedrooms. So if one person has brought in a new infection, the whole family is exposed to it in hours via the dust. The newly contaminated dust drops into your ready and waiting glasses on the table and the open foods. Teach children to cough and sneeze into a suitable col- lecting place like a tissue, not their hands. If you must cough or sneeze and a tissue is not within reach fast enough, use your clothing! Never, never your hands unless you are free to immediately dash into the washroom and clean the contamination off your hands. Teach children this old rearranged verse: If you cough or sneeze or sniff Grab a tissue, quick-quick-quick! Better Housekeeping Throw out as much of the wall to wall carpeting as you can bear to part with. Modern shoes, with their deep treads, bring in huge amounts of outdoor filth which settles deep down into the carpets. When you see how much filth is in the water and realize how much dirt you were living with, you might be willing to trade in the “beauty” of carpets for the cleaner living of smooth floors. Cobalt, which adds “lustre” to carpets, causes skin and heart disease after it has built up in your organs. Nothing controls fleas reliably, except getting rid of the carpets and cloth furniture (keep pets out of bedrooms). Fleas and other vermin in the carpet simply crawl below the wetness level when you wash the carpet. Spraying a grain alco- hol solution with lemon peel in it (it needs to extract for a half hour) on the damp carpet will reach and kill a lot of these, to- gether with the residual bacteria. Molds and bacteria that grow right on the air conditioning unit get blown about for all to inhale. Never, never use fiberglass as a filter or to insulate your air conditioner around the sides. All dirt brought into the house by shoes gets circulated throughout the house by forced air systems of heating or cooling. A return to linoleum floor covering for kitchen and bathroom and hardwood for other rooms would be a good step of progress for a health conscious society. Throw rugs at doors and bedside, easy to clean, would “catch the dirt” as was the original intention. Modern cloth furniture with its foam interior is a repository of filth and fumes and a constant source of infectious dust. You are picking up and removing highly infectious filth (Ascaris and pinworm eggs, pet parasites, “dander” and house mites). Use plain water or vinegar water (50%), not a chemical combination which further pollutes the air. In places like Chicago where you can smell the air as you approach the city, it is wiser to keep your windows shut. Central air conditioning and a plain carbon filter at the furnace location (see Sources) may be the best solution in spite of blowing dust around the house. Keep the vents to the bedrooms closed to re- duce the air turbulence there but leave the cold air return open. Clean the vents in other rooms each week along with floors and carpets by pulling up the grating and reaching down the passage as far as possible. If you believe the air is free of highway exhaust and indus- trial smoke open the windows every day. Asbestos, fiberglass, freon, radon and plain dust can be reduced to a minimum by keeping windows open. Buy such small quantities that you can afford to throw it all away when you are done with them. Move to the other end of the house and furthest away from an attached garage door. Getting Rid of Mites We do not tolerate external parasites like bedbugs, lice, ticks, leeches. Lice were originally “controlled” by frequent washing, louse combs, and ironing the seams of clothing. Never allow a pet into the bedroom or the dust will have tapeworm eggs as well as mites. Deep, soft, wall to wall carpets compromise an ancient concept: everything should be washable and cleanable, without throwing the dirt into the air for humans to inhale. Never shake bedding or rugs where the dust will blow back into the house behind you. The mucus in our lungs traps them and in a few days they die, only to release a drove of Adenoviruses (common cold virus) in us. These four clean-ups–dental, diet, body, home–are aimed at removing parasites and pollutants at their source. Jerome: The philosophy of dental treatment taught in America is that teeth are to be saved by whatever means avail- able, using the strongest, most long lasting materials. A more reasonable philosophy is that there is no tooth worth saving if it damages your immune system. If a patient has three mercury amalgam fillings placed in the mouth and a week later has a kidney problem, will she call the dentist—or the doctor?

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Try not to adjust your medicines buy viagra 50 mg cheap erectile dysfunction natural treatment options, or skip doses without discussing it with your Physician or Pharmacist – some medications can have serious side effects if they are stopped suddenly buy discount viagra 50 mg online impotence what does it mean. Many prescriptions medication can interact with each other as well as with other over the counter products and herbal remedies purchase 75mg viagra overnight delivery erectile dysfunction drugs natural. Make so your Physician and Pharmacist know what you are treating for and ask them about the possible interactions before you start them buy 100mg viagra fast delivery impotence of organic nature. Medicine Tip – people with asthma should not carry their inhalers in their pockets. Some patients have required surgery because they inhaled coins that have gotten stuck in their inhaler. Some find it helpful to keep a “medicine diary” they can take with them to their next Physician or Pharmacist’s visit – this can help with possible side effects you may be having or important questions you want to ask. Some medicines must be stored away from heat, light, or moistures, in order to keep their strengths. Trans dermal patches should not be thrown away where kids can find them and put them on like bandaids. Do not store medications in the glove box of your car – heat can destroy the medicine. Select your Pharmacist with the same care you choose your Physician – you want someone who will take the time to counsel you and not give you bad answers. You should expect written information from the pharmacy – keep it in a handy place that is easily accessible. If you are having trouble remembering to take your medications, it is important to tell your Physician – if you do not tell him, he may think the medication is not working and prescribe another medicine that is less effective and with more side effects – all you may need is a more convenient dosing schedule. Be sure to tell the Pharmacist at each visit if you are having any problems with your medications. Food and Drug Administration entitled, “Safe Medical Treatments: Everyone has a role. Regardless of the medication, you took a risk, because giving a drug safely involves many steps, some beyond your control. In this article, the explanation to what questions to ask to help minimize medication errors will be explained. It will test your critical thinking skills and help you get answers to the Who, What, When, Where, Why, and How of drug therapy. Accept an order only from a health care provider who has appropriate licensure and credentials to practice in your state and who’s authorized to prescribe drugs in your health care agency. Typically, this includes a Physician, Nurse Practitioner, Physician Assistant, and Dentist. Some facilities permit Clinical Pharmacists to order drugs and appropriate lab tests based on established physician approved protocols. Make sure the medication order contains all the necessary components: your child’s name plus the drug name, dose, frequency of administration, and route. If an order is illegible or you have questions, do not administer the drug until you call your Physician for clarification. Some orders are based on established protocols, such as bowel protocols in long term care facilities. If you receive such an order, be sure to specify the drug name, its dosage, frequency, time, and route on the medication administration record. Consult your agency’s policy for appropriate medication administration times; keeping in mind that scheduling should be flexible to meet the child’s needs. Some drugs should be taken with food or after meals to maximize their effectiveness or minimize adverse reactions. For example, if your child needs three cardiovascular drugs once a day, you may need to stagger them to prevent an adverse drug-drug interaction. Some cardiovascular drugs cause bradycardia and hypotension, and receiving three at once could increase the risks. The Pharmacist may recommend dosing times based on the physiologic processes that follow predictable patterns. For example, bronchial patency and airflow are typically decreased in the early morning and at their peak in the afternoon. For this reason, one dose of Theophylline in the evening may be more effective than multiple doses throughout the day. Similarly, some antihypertensive agents must be given at a specific time to reach their peak effect at the correct time. In a hospital, the pharmacy generally delivers needed drugs to each nursing unit at scheduled times. Your facility may use one of the approaches to dispense them: A unit dose system of individually wrapped doses kept in the medication cart. Stock medications commonly used for the patients in the unit; these drugs are kept on hand and replenished by the pharmacy as needed. Storing commonly used drugs or prescribed patient doses, it can automatically charge the patient and record that you gave him a drug and when. You need to know the therapeutic effect of any drug you give your child and whether it is appropriate for his condition. Also review pertinent data that affect whether you can safely administer it, such as blood pressure, lab results, and pain level for your child. If the ordered dosage is not within the recommended range, clarify the order with the Physician. When preparing a unit dose oral medication, do not open the package until you enter your child’s room. Always adhere to the “five rights” of medication administration: These five rights are especially important if more than the parents are giving your child medications. For a unit dose medication, check the label twice against the order on the medication record. Tell your child the name of any drug you are giving him and the reason if appropriate. This gives him a chance to point out anything unusual, such as he has already taken it or the dose is not what other nurses have been giving him. Make sure the ordered dose is within the recommended range and call your Physician for clarification if is not. Give the drug within an hour of its scheduled time or according to your time schedule. If consistent serum levels of a drug are critical, such as for anticonvulsants, antibiotics, anticoagulants, and analgesics, give the dose as close to the scheduled time as possible. A good rule of thumb regarding drug dosing for older adults is to “start low, go slow”. If your child is now an adult, he may take many drugs, as many older people do, polypharmacy may affect his responses. You should also be aware than an older adult might deny pain or fail to ask for an analgesic because he fears becoming addicted. If pain medication has been ordered for your child/adult, administer it on a continual regimen rather than as needed, depending on your particular situation. Drug dosing for older adults should start low and be titrated slowly to achieve the desired results. Drug distribution is determined by the amounts of fat, muscle, and water in the body. Older adults typically have more fat, less muscle, and less water stores than younger people. If a drug has an affinity for storage in fat (as do the Benzodiazepines, Diazepam and Lorazepam) the child/adult may retain the drug and respond adversely. Be sure that your child/adult has adequate subcutaneous tissue when selecting a site for subcutaneous injections or application of transdermal patches that deliver medication through subcutaneous tissue. Older adults tend to have lower serum albumin levels, so drugs that need protein to be effective such as Digoxin (heart) and Phenytoin (Dilantin) may not produce the desired response unless the child/adult receives supplemental protein. With aging, the kidneys’ ability to clear wastes and the liver’s ability to metabolize certain substances may decrease, causing drug metabolites to remain in the body. Be very careful in administering Meperdine (Demerol - pain) to your child/adult because it may accumulate and cause confusion and lethargy. If you observe responses to any drug, notify the Physician immediately to have the drug discontinued or the dose reduced. Also, assess your child/adult’s renal and liver function, study results regularly. For example, Opioids, Anticholinergics, Dopamine Antagonists, Antihypertensives, and Benzodiazepines can have a stronger effect than expected. Some older children/adults have lost teeth and may not have dentures; others may have swallowing problems caused by strokes or other health problems. For a child/adult like this, you may need to crush medications and add them to applesauce or pudding. You also could use a preparation called Thick It to thicken liquids to the consistency your child/adult may be able to swallow the liquids/medications. Request a swallowing evaluation and recommendation from the speech/language pathologist. Right documentation is often called the sixth “right” of medication administration. Most health care agencies use an administration record to document when drugs are given and most require you to write in the data. If the administration time differs from the prescribed time, not the times and explain why. If you do not give a medication, initial the appropriate space, circle your initials, and follow your agency’s policy to document why it was not given. If a medication error occurs, immediately assess your child for problems and monitor him continuously if necessary.

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Since this is a commonly encountered clinical problem buy viagra 100 mg mastercard erectile dysfunction pills amazon, all practitioners should have some famil- iarity with the diagnosis and management of flank pain purchase viagra uk erectile dysfunction doctor in bhopal. To generate a list of potential diagnoses for the patient who presents with pain or a mass in the scrotum buy viagra visa erectile dysfunction treatment new delhi. Be sure to: • Discuss testicular versus extratesticular origins • Discuss benign versus malignant causes • Discuss emergent versus nonemergent causes 3 purchase 25mg viagra overnight delivery buy erectile dysfunction drugs uk. Be sure to discuss the following issues: • Pain—presence, absence, onset, severity • Palpation—distinguish testicular from extrates- ticular (adnexal) mass • Transillumination 4. Cases Case 1 A mother brought her 15-month-old son in for evaluation because he has “only one testicle. Weiss Case 2 A 15-year-old boy presented to the emergency department with acute testis pain and nausea. Testicular development and descent are controlled intricately by the hypothalamus-pituitary-gonad axis (Fig. Testosterone regulates its own production by regaling feedback on the hypothalmus and pituitary. Scrotal development in males is a result of the testis and epididymis descending, causing the skin to stretch. Sperm fertility is enhanced by being stored in a cooler region within the scrotum rather than in the abdomen. Cryptorchid or “undescended testis” results in infertility if the testis is not placed in the scrotum. Scrotal Disorders 695 During early development, the testes originates in the abdomen near the kidney. During early embryologic development, the processus vaginalis is an invagination at the inguinal ring. The gubernac- ulum attaches superiorly onto the Wolffian duct and inferiorly into the inguinal canal. This descent from abdomen to scrotum explains why the testis lymphatic drainage is to the nodes below the renal hilum and the venous drainage is to the vena cava on the right and to the renal vein on the left. Cryptorchidism Cryptorchidism or undescended testis is defined as an abnormal descent of the testis and can be unilateral or bilateral. Two thirds of the cases are unilateral, while one third of the cases are bilat- eral. Initial visual inspection should reveal a scrotum that is devel- oped bilaterally. Often, slight groin pressure with the forefinger brings the testis down into the scrotum. If the testis is not palpated in the scrotum or groin, ultrasonography may be necessary to locate it above the inter- nal inguinal ring or within the abdomen. If the testis does not appear to be descending properly, surgical orchiopexy is the necessary treatment to place the testis in the scrotum, which allows appropriate testis maturation and eventual fertility. Most surgeons perform this procedure by the time the patient has reached 1 year of age. Cryptorchid testis is associated with inguinal hernia in 25% of patients due to a patent processus vaginalis. Orchiopexy usually is per- formed through an inguinal incision, allowing the surgeon to mobilize the testis and its blood supply to reach the scrotum. Case Discussion In the child in Case 1, there was no history of trauma or infection, and the mother stated that she had noted this condition for several months. The right testis was in a normal position within the scrotum; however, the left testis was in the groin, near the external ring, and could not be manipulated into the scrotum. The mother discussed the situation with the urologist and decided that her child should have an elective orchipexy. Weiss Scrotal Pain Scrotal pain can be due to several etiologies that range from chronic to surgical emergency. The differential diagnosis for a painful testis includes testis torsion, epididymitis, trauma, tumor, torsion of appendix testis or appendix epididymis, incarcerated hernia, and ureteral calculi. Occasionally, kidney stones that migrate to the distal ureter cause pain referred to the groin, but this pain usually is colicky in nature. Testis Torsion The patient who presents with acute testis pain should be treated as a surgical emergency. A patient who has a testis torsion and is not treated within 3 to 12 hours may suffer testis atrophy. Testis torsion occurs because the testis rotates or twists its blood supply, essentially strangling the testis. Testis torsion usually occurs in adolescent males, but it may be seen in cryptorchid testis or as a result of testis trauma. The patient’s history of torsion usually is consistent with sudden onset, acute pain, nausea, and vomiting. The patient should have a urinalysis, urine culture and sensitivity, and complete blood count Acute testis pain Duration Differential History and Physical – Torsion of testis – Epididymo-orchitis – Trauma – Hernia – Appendix – Torsion of Appendages Scrotal Trauma: ultrasound – Conservative – Surgery if testis is ruptured or Conservative therapy tunica albuginea is violated Hernia Surgery if incarcerated Epididymo-orchitis Torsion of testis Antibiotic – Surgical treatment treatment Torsion of appendage – Surgical or conservative management Algorithm 39. Physical examination of the patient with torsion reveals a tender, ery- thematous scrotum with a high or horizontal position of the testis. Epididymitis usually presents with gradual onset, white blood cells in the urine, and increased ten- derness behind the testis along the epididymis. The patient may have a history of recent sexual activity or symptoms of urinary infection or prostatitis. A testis torsion appears as hypovascular, while epi- didymitis appears as hypervascular. Since Doppler ultrasonography technology has improved, nuclear scanning rarely is necessary to confirm the diagnosis. For treatment, manual detorsion may be attempted if the torsion has occurred within a few hours. This consists of infiltration of the sper- matic cord near the external ring with lidocaine. The left testis is rotated counterclockwise manually, while the right testis is rotated clockwise manually. Manual detorsion usually is not effective because of the patient’s degree of pain. Emergent surgical scrotal exploration should be performed under general anesthesia. A scrotal incision is made, the spermatic cord is untwisted, and the testis is inspected. If the testis appears viable, it should be sutured in place to the surrounding tissue. The contralateral testis also should undergo orchiopexy during the same procedure. Torsion of the testicular appendages may mimic testis torsion and usually occurs in boys younger than 16 years of age. The appendix testis (remnant of the Müllerian duct) and appendix epididymis (remnant of the Wolffian duct) may twist and cause venous engorge- ment and infarction, producing the “blue-dot sign. If the pain persists or there is concern of testis torsion, emergent surgical exploration should be performed. Case Discussion The patient in Case 2 stated that the pain occurred suddenly about 2 hours previously and continued to be unbearable. Urinalysis was negative for white blood cells, and Doppler ultrasonography revealed decreased flow to the testis. The patient underwent emergent scrotal exploration in the operating room, where a testis torsion was found. The testis was sutured to sur- rounding tissue (orchipexy) to prevent future torsion and the con- tralateral testis also underwent orchiepexy. Epididymo-orchitis Acute epididymitis is extremely painful and may mimic the symptoms of testicular torsion. It is caused by urinary tract pathogens, such as gram-negative organisms, and often originates from prostatitis or an indwelling urethral catheter. Acute epididymitis also can be associated with sexually transmitted diseases, such as those caused by Chlamydia trachomatis or Neisseria gonorrhea. Laboratory findings reveal white blood cells in the urine and a pos- itive Gram stain. Ultrasonography reveals a hypervascular area consis- tent with the inflammatory response of infection. If a urinary pathogen is suspected, the patient should be given a quinolone or a trimethoprim sulfate until urine and blood culture sensitivities return. If a sexually transmitted disease is suspected, the patient should be given an injection of ceftriaxone followed by oral doxycycline or tetra- cycline. Depending on the severity of the infection, the patient may need pain medications, ice packs to the scrotum, and bed rest. Some patients progress to chronic epididymitis and require long-term antibiotic coverage and nonsteroidal antiinflammatory medication. Testis Masses Testis masses include benign lesions of the scrotum and testis tumors. They usually are benign, but they must be differentiated from testis tumors and inguinal hernias. Hydroceles in children usually are due to persistent patency of the processus vaginalis. Hydroceles in adults usually are due to fluid collection within the tunica vaginalis. They often are due to nonspecific epididymitis or orchitis or are a result of scrotal trauma. Occasionally, they can be related to testis cancer, tubercular epididymitis, or radiotherapy.

Strain is the level below the species b) Two members of the same strain are more similar to each other than either is to an individual that is a member of a different strain safe viagra 50 mg erectile dysfunction ear, even if all three organisms are members of the same species Bacterial species - A bacterial species is defined by the similarities found among its members cheap viagra amex impotence from anxiety. Properties such as biochemical reactions purchase 100 mg viagra free shipping erectile dysfunction treatment south florida, chemical composition order viagra line erectile dysfunction bathroom, cellular structures, genetic characteristics, and immunological features are used in defining a bacterial species. Identifying a species and determining its limits presents the most challenging aspects of biological classification for any type of organism. Monera ( the prokaryotes) Kingdom of Monera Three categories: - Eubacteria Are our common, everyday bacteria, some of which are disease – causing; also the taxon from which mitochondria originated. Distinctively, however, the members of Kingdom Protista are all eukaryotic while the mebers of kingdom Monera are all prokaryotic. Some members of protista are multicellular, however Kingdom protista represents a grab bag, essentially the place where the species are classified when they are not classified as either fungi, animals or plants. Kingdom Fungi Unlike pprotists, the eukaryotic fungi are typically non – aquatic species. They traditionally are nutrients absorbers plus have additional distinctive features. The domain system contains three members 9 ¾ Eukaryotes ( domain Eukarya ) ¾ Eubacteria ( domain Bacteria) ¾ Archaebacteria ( domain Archaea) Viral classification Classification of viruses is not nearly as well developed as the classification of cellular organisms. Today viruses tend to be classified by their chemical, morphological and physiological attributes (e. Binomial nomenclature is not employed to name viruses; instead viruses are named by their common names (e. The distinguishing features between Eukaryotic cell and Prokaryotic cell Features Prokaryotic cell Eukaryotic cell. Cellular element enclosed with in the cell envelope: Mesosomes, ribosomes, nuclear apparatus, polyamies and cytoplasmic granules. Cell wall Multi layered structure and constitutes about 20% of the bacterial dry weight. Young and rapidly growing bacteria has thin cell wall but old and slowly dividing bacteria has thick cell wall. It is composed of N-acetyl Muramic acid and N-acetyl Glucosamine back bones cross linked with peptide chain and pentaglycine bridge. Contains toxic components to host Bacteria with defective cell walls Bacteria with out cell wall can be induced by growth in the presence of antibiotics and a hypertonic environment to prevent lysis. Protoplasts: Derived from Gram-positive bacteria and totally lacking cell walls; unstable and osmotically fragile; produced artificially by lysozyme and hypertonic medium: require hypertonic conditions for maintenance. Spheroplast: Derived from Gram-negative bacteria; retain some residual but non-functional cellwall material; osmotically fragile;produced by growth with penicillin and must be maintained in hypertonic medium. L- forms: Cell wall-deficient forms of bacteria usually produced in the laboratory but sometimes spontaneously formed in the body of patients treated with penicillin; more stable than protoplasts or spheroplasts, they can replicate in ordinary media. Cell membrane Also named as cell membrane or cytoplasmic membrane It is a delicate trilaminar unit membrane. Mesosomes Convoluted invagination of cytoplasmic membrane often at sites of septum formation. Nuclear apparatus Well defined nucleus and nuclear membrane, discrete chromosome and mitotic apparatus are not present in bacteria ; so nuclear region of bacteria is named as nuclear body, nuclear apparatus and nucleoid. Besides nuclear apparatus, bacteria may have extra chromosomal genetic material named as plasmids. Plasmids do not play any role in the normal function of the bacterial cell but may confer certain additional properties(Eg. Virulence, drug resistance) which may facilitate survival and propagation of the micro- organism. Glycocalyx (capsule and slime layer) Capsule is gel firmly adherent to cell envelope. Capsule is composed of polysaccharide and protein(D-Glutamate of Bacillus anthracis) Features of capsule 1. Flagellum It is the organ of locomotion in bacterial cell and consists of thee parts. The basal body The basal body and hook are embedded in the cell surface while the filament is free on the surface of bacterial cell. Pili (fimbriae) It is hair like structure composed of protein (pilin) Two types (Based on function). Sex pili: The structure for transfer of genetic material from the donor to the recipient during the process of conjugation. Spores Resting cells which are capable of surviving under adverse environmental conditions like heat, drying, freezing, action of toxic chemicals and radiation. Classification of bacteria Bacterial classification depends on the following characteristics. Morphology of bacteria When bacteria are visualized under light microscope, the following morphology are seen. Bacilli (singular bacillus): Stick-like bacteria with rounded, tepered, square or swollen ends; with a size measuring 1-10μm in length by 0. Spiral: Spiral shaped bacteria with regular or irregular distance between twisting. Staining of bacteria Bacterial staining is the process of coloring of colorless bacterial structural components using stains (dyes). The principle of staining is to identify microorganisms selectively by using dyes, fluorescence and radioisotope emission. Staining reactions are made possible because of the physical phenomena of capillary osmosis, solubility, adsorption, and absorption of stains or dyes by cells of microorganisms. Individual variation in the cell wall constituents among different groups of bacteria will consequently produce variations in colors during microscopic examination. Whereas, cytoplasm is basic in character and has greater affinity for acidic dyes. Because dyes absorb radiation energy in visible region of electromagnetic spectrum i. Direct staining Is the process by which microorganisms are stained with simple dyes. A mordant is the substance which, when taken up by the microbial cells helps make dye in return, serving as a link or bridge to make the staining recline possible. It combines with a dye to form a colored “lake”, which in turn combines with the microbial cell to form a “ cell-mordant-dye- complex”. It is an integral part of the staining reaction itself, without which no staining could possibly occur. A mordant may be applied before the stain or it may be included as part of the staining technique, or it may be added to the dye solution itself. An accentuator, on the other hand is not essential to the chemical union of the microbial cells and the dye. It does not participate in the staining reaction, but merely accelerate or hasten the speed of the 26 staining reaction by increasing the staining power and selectivity of the dye. Progressive staining - is the process whereby microbial cells are stained in a definite sequence, in order that a satisfactory differential coloration of the cell may be achieved at the end of the correct time with the staining solution. Regressive staining - with this technique, the microbial cell is first over stained to obliteratethe cellulare desires, and the excess stain is removed or decolorized from unwanted part. Differentiation (decolorization) - is the selective removal of excess stain from the tissue from microbial cells during regressive staining in order that a specific substance may be stained differentiallyh from the surrounding cell. Differentiation is usually controlled visually by examination under the microscope Uses 1. Basic stains are stains in which the coloring substance is contained in the base part of the stain. Acidic stains are stains in which the coloring substance is contained in the acidic part of the stain. Eosin stain Neutral stains are stains in which the acidic and basic components of stain are colored. Simple staining method It is type of staining method in which only a single dye is used. Usually used to demonstrate bacterial morphology and arrengement Two kinds of simple stains 1. Apply a few drops of positive simple stain like 1% methylene blue, 1% carbolfuchsin or 1% gentian violet for 1 minute. Negative staining: The dye stains the background and the bacteria remain unstained. Differential staining method Multiple stains are used in differential staining method to distinguish different cell structures and/or cell types. Most bacteria are differentiated by their gram reaction due to differences in their cell wall structure. Gram-positive bacteria are bacteria that stain purple with crystal violet after decolorizing with acetone-alcohol. Gram-negative bacteria are bacteria that stain pink with the counter stain (safranin) after losing the primary stain (crystal violet) when treated with acetone-alcohol. Cover the fixed smear with crystal violet for 1 minute and wash with distilled water. Ziehl-Neelson staining method Developed by Paul Ehrlichin1882, and modified by Ziehl and Neelson Ziehl-Neelson stain (Acid-fast stain) is used for staining Mycobacteria which are hardly stained by gram staining method. Once the Mycobacteria is stained with primary stain it can not be decolorized with acid, so named as acid-fast bacteria. Prepare the smear from the primary specimen and fix it by passing through the flame and label clearly 2. Place fixed slide on a staining rack and cover each slide with concentrated carbol fuchsin solution.

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In all acute cheap 50 mg viagra mastercard erectile dysfunction ed treatment, and most chronic diseases purchase viagra 75 mg line erectile dysfunction 31 years old, our examination of the patient and our therapeutics will take this order: 1 buy 100mg viagra visa erectile dysfunction specialists. With reference to the condition of the stomach and intestinal canal - bringing them to as nearly a normal condition as possible purchase viagra 75 mg fast delivery erectile dysfunction treatment by yoga, that remedies may be kindly received and appropriated, and that sufficient food may be taken and digested. With reference to the presence of a zymotic poison, or other cause of disease - which may be neutralized, antagonized or removed. With reference to the processes of waste and excretion - that the worn out or enfeebled material may be broken down and speedily removed from the body. With reference to blood-making and repair - that proper material be furnished for the building of tissue, and that the processes of nutrition are normally conducted. We may illustrate this further by calling attention to the tongue as a means of diagnosing conditions of the stomach and intestinal canal, and of the blood. You will bear in mind that diagnosis - or determining the real condition of disease is the most important part of Specific Medication. And that it is not that rough diagnosis which will enable us to guess off a name for the associated symptoms, at which name we will fire our Materia Medica promiscuously. Hence, when we question the tongue, it is not with reference to a remittent or typhoid fever, an inflammation of lungs, or rheumatism, but it is - I want you to tell me the condition of the stomach and intestinal canal, and especially the condition of the blood. Now let us briefly see what it will tell us, with regard to the condition of the primœ viœ: If the tongue is heavily coated at its base with a yellowish-white fur, we know that there are morbid accumulations in the stomach; and we have to determine between the speedy removal by emesis, the slower removal by the Alkaline Sulphites, or the indirect removal by catharsis. If the tongue is uniformly coated from base to tip with a yellowish fur, rather full, moist, we have the history of atony of the small intestine, and we give Podophyllin, Leptandrin, and this class of remedies with considerable certainty. The therapeutics is plain: get rid of the irritation first, and be careful not to renew it by harsh medication. It is variously colored, but it looks as if a fly should light on it he would slip up and break his neck. It is the evidence of a want of functional power, not only in the stomach and bowels, but of all parts supplied by sympathetic nerves. We treat such a case very carefully, avoid all irritants, and use means to restore innervation through the vegetative system of nerves. The tongue tells us of acidity and alkalinity of the blood, and in language so plain that it can not be mistaken: The pallid tongue, with white fur, is the index of acidity, and we employ an alkali - usually a salt of soda, with a certainty that the patient will be benefited. Indeed one who has never had his attention directed in this way, would be surprised at the improvement, in grave forms of disease, from one day’s administration of simple Bicarbonate of Soda. The deep-red tongue indicates alkalinity, and we prescribe an acid with a positive assurance that it will prove beneficial. Grave cases of typhoid fever and other zymotic diseases, presenting this symptom, have been treated with Acids alone, and with a success not obtained by other means. But it makes no difference what the disease is, whether a recent diarrhœa, or a grave typhoid dysentery, if there is the deep-red tongue, we give Muriatic Acid with the same assurance of success. Impairment of the blood - sepsis - is indicated by dirty coating, and by dark-colored fur - brownish to black. When we have either the one or the other we employ those remedies which antagonize the septic process. The bitter tonics are indicated by fullness of tissue, with evident relaxation, impairment of circulation and muscular movement. We give Tincture of Chloride of Iron if the tongue is red, Iron by Hydrogen if the tongue is pale. The pale bluish tongue, expressionless, is the indication for the administration of Copper. You will notice that we have made this “unruly member” tell us a good deal, yet it might tell us more - it will tell us more when we thoroughly study it. My object is not to point out all that we might learn from it, but to show that it is possible to arrive at positive conclusions, from symptoms that are always definite in their meaning. We make the pulse tell us the condition of the circulation, and to some extent the nervous system that supplies it. One might suppose that diagnosis in this way would be a matter of great difficulty, as would the therapeutics based upon it, from the large number of remedies needed to meet these varying conditions of the several functions. The control of this life is centered in a common nervous system - the ganglionic - and through this the various parts and functions are united. Though it manifests itself in various ways, and though we study in detail as I have named, it is to grasp it at last as a unit, and oppose to it one or more remedies. In some cases we have a first preparatory treatment, to fit the patient for the reception of remedies which directly oppose disease. In other cases there are certain prominent symptoms indicating pathological conditions which may be taken as the key-notes of the treatment. As, when we have the full, open pulse, indicating Veratrum; the hypochondriac fullness, umbilical pains, and sallowness of skin, indicating Nux Vomica; the bright eye, contracted pupil and flushed face, calling for Gelseminum; or the dull eye, immobile pupil tendency to drowsiness, which calls for Belladonna. In some cases the indication for a special remedy, like one of these, is so marked, that we give it alone, and it quickly cures most severe and obstinate diseases. I would like to continue this subject further, for it is one in which I am greatly interested, and I know it is one in which you are interested, but the shortness of our session will not permit further remarks. But when we come together another year, with another year’s experience, we may discuss it again. The practice of medicine is proverbially uncertain, not so much possibly as regards the termination of disease, as regards the influence of medicine to palliate or arrest it. Instead of making this uncertainty a cardinal doctrine, a belief in which is absolutely essential to regularity, it seems to me it would be profitable to examine it carefully, and by analysis determine the “elements of uncertainty;” we might then hope to determine the “elements of certainty,” and by a simple process of reasoning, avoid error and attain truth. The most important factor in “medical uncertainty,” is undoubtedly our present nosology. The element of uncertainty lies here, that a name employed to designate a disease, may cover the most diverse pathological states. The case of to-day, and the case of to-morrow, though justly called by the same name, may require a widely different treatment; the remedies employed successfully in one, would increase the disease in the other. Every one of our readers may draw the evidence of the truth of these propositions from his own practice. The second “element of uncertainty” we find in the doctrine of idiosyncrasy, which is also a cardinal article of faith. We are gravely taught that in medicine one of nature’s laws - that “like causes produce like effects,” is inoperative; and, on the contrary, “that no man can possibly tell from the action of a medicine on one, what will be its influence upon another. The third “element of uncertainty” lies in the application of the Latin motto, post hoc ergo propter hoc - that which follows a medicine must be due to its influence. If a man recovers from sickness after taking Podophyllin or Quinine, it is due to these agents, and he probably would not have gotten well without them. But there is this singular fact here: whilst physicians are willing to credit their remedies with all relief from suffering, improvement and restoration to health, they are not willing to reverse it, and concede increase of suffering, prolongation of disease and death to the remedies, though the sequence is quite as natural in the one case as the other. It does seem strange that physicians should have so thoroughly believed that medicine saved the lives of the sick, that without it the majority, or all, would have died. Even now when all this is proven beyond cavil, by some of the best observers, we find the majority won’t believe it; even if they concede it in theory, they deny it in practice. The fourth element of uncertainty lies in the endeavor to get direct results from indirect agencies. You want to influence the circulation and the temperature, and you give remedies which produce emesis or catharsis. You want to elect Greeley, and you whip your neighbor because he “rah’s” for Grant. The fifth element of uncertainty is the administration of remedies in poisonous instead of medicinal doses. It is true that the poisonous action may be known with some certainty, but its influence upon disease is very uncertain. The poisonous action sets up a new process of disease in so far as it changes structure and function, and it may be curative according to the law of substitution. A medicinal action we understand to be one that restores function, and thus removes disease. Give your remedy in medicinal doses, and then you may expect direct and positive results in the relief of disease. These are the principal elements of uncertainty in regular medicine and in our school. To these we might add a number of minor ones, among which is a belief in “special providences,” inscrutable or otherwise. Indeed any one who is inclined to shift his responsibility upon his Creator, and to believe that the laws of nature can be suspended from any providence, has all the elements of uncertainty with him. The principal element of uncertainty in Homœopathic medicine is the making of pain a principal symptom, and the treatment of symptoms in place of pathological conditions. The cheerful trust in Nature of the high dilutionist is laudable, though we can’t say so much for their claim to all the glory of relief and recovery. This is but a rough sketch of the subject, which we present as good material for thought. In our next article, we will consider the “elements of certainty” in medicine, in the same order. In our last article we briefly discussed the “elements of uncertainty in medicine,” and we now propose to look at the other side - how may we attain certainty in medicine. We all agree that the practice of medicine in the past has been notoriously uncertain, and that there is yet great room for improvement. The first, and most important element of “uncertainty” is found in our present nosology, and the constant tendency to prescribe for names of disease. The first “element of certainty” will be, therefore, an entire avoidance of this error, diagnosing pathological conditions and prescribing for these.