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You meat-eating and dairy-supplementing gym rats have been duped into thinking you have to consume lots of protein and animal foods to be strong and athletic buy generic forxiga on line. He was telling me about his weight issues and medical problems with diabetes cheap 10 mg forxiga overnight delivery, hypertension cost of forxiga, and kidney issues. He was a classic “dairy-aholic” and was stunned when I told him to elimi- nate the dairy, cut back on the meat, and eat more vegetables, and that he’d still be fine in the gym. I also told him he’d drop some weight and probably improve his diabetes and kidney function. He was fearful of not being strong and muscular if he cut back on those foods (meat and dairy, to which he was addicted). Americans have been brainwashed by the propaganda that you have to consume meat, poultry, fish, and dairy products to be healthy and strong. He or she doesn’t have hours and hours to train in the gym, is not an elite athlete train- ing for some type of competition, and is not a movie star trying to tweak a particular area of his or her body. That said, building lean body mass is not only healthy for our metabolism (blood sugar control and immune function), but also helps us function in our daily lives, especially as we get older. It is fast; there are no weights to put away; it is safe; you don’t need a partner or coach; it works different muscle groups in their full range of motion; it works the body symmetrically; it is easy for anyone to use after maybe one or two sessions of instruction; and it has some cardiovascular benefit (not a lot) if you keep moving. I included fifteen minutes because that is what it takes me: fifteen minutes at a consistent pace to do six different upper-body exer- cises and six lower-body exercises. Just do circuit training in the above-mentioned fashion for two months (along with a whole-food, plant-strong diet). If you want to speed up the process, do the circuit training every other day for a month. If you want to spend twenty-five to thirty minutes doing circuit training, do just ten to twelve different upper-body exer- cises and ten to twelve different lower-body exercises. The key is moving steadily between stations; alternate arm and leg exercises so you don’t fatigue a group of muscles. Do as many different ex- ercises as the machines allow before repeating an exercise so you work as many different muscle groups and go through as many different ranges of motion as possible. Keep the number of sets of exercises even between the upper and lower body to help keep some balance between the strength and bulk in our lower bodies compared to our upper bodies. When you can do fifteen or more repetitions easily, try increasing the weight, number of plates, or resistance on the machines. My goal is to give you fast, efficient, and safe ways to get to a very high state of health with minimal expense and time in your busy, modern lifestyle. If you lose weight at the same time, you will become doubly excited about seeing the fat go away and the curves come out of nowhere! I recommend warming up with your aerobic exercises prior to your circuit training to allow the muscles to be warm and have some blood flow going through them before challenging them. Then do anywhere from ten to thirty minutes of stretching after your circuit training. After doing this routine several months, you may adapt your warm-up and stretching any way you feel comfort- able. Circuit training with machines is just fast and efficient and can get you results quickly. As I mentioned, for fast results I would do the circuit train- ing every other day for a month or two. For older individuals, the muscle recovery may not be as quick, and every other day may create some extra soreness. If you’re too sore, don’t push yourself as hard and still go every other day, or put two days in between your circuit training regularly or periodically, depending on your soreness. It is true that some species of gorillas, especially lowland gorillas, eat a fair amount of ants and termites (maybe up to 3 percent of - 170 - the triad exercise program their diet) and get protein and certain trace minerals from these insects, but the bulk of their protein comes from massive quan- tities of leafy plant foods, stems, bark, and fruit when available. Mountain gorillas tend to have a more limited diet and eat fewer termites, ants and fruit, and more leafy foliage and other vegeta- tion. David Jenkins and colleagues after studying the diets of western lowland gorillas: “…The macronutrient profile of this diet would be as follows: 2. We suggest that humans also evolved consuming similar high foliage, high fiber diets, which were low in fat and dietary cholesterol. If you want to get “Gorilla Buff” fast, it isn’t all in the strength training you do. Building muscle under a layer of fat is still building mus- cle, but it isn’t getting the shape or the look you want. If you are overweight, you want to eat whole foods, although you might stay away from or reduce consumption of even whole-grain breads for a while since they are more calorie dense (see Chapter 13, Reduc- ing Caloric Density) than eating the basic cooked grains until you lean out. If overweight, do a daily aerobic program for thirty to sixty minutes, along with your every-other-day, fifteen- to thirty-minute circuit training program (six to ten upper-body exercises and six to ten lower-body exercises); and a ten- to fifteen-minute (or more) flexibility program daily for one or two months. If you want to - 171 - staying healthy in the fast lane spend more time in the gym, just increase the time of the aero- bics, number of exercises for your circuit training, and duration of stretching. Keep a picture of a four-hundred-pound muscular gorilla in your mind eating tons of greens and fruit, plus a few termites or ants, if you don’t believe you can be muscular eating lots of plant foods. One photo shows a large male sitting in a pond “sucking down” some type of green plant, stem first (p. So the next time someone asks you where do you get your pro- tein for muscles by eating only plant foods, ask them where do you think a gorilla gets its muscles (and the elephant, hippo, giraffe, and, yes, the cow)? Tell them the answer is in the January 2008 issue of National Geographic on page 99! Strength training is very important in this group to maintain function and indepen- dence and keep healthcare costs reasonable. They think I am a bit crazy, but they appreciate it when they get my “sense of urgency” for them to do some form of strength training so they can remain as independent as possible for as long as they can. The number one concern of older people, from my experience, is the worry and desire to remain independent. I think my older patients also appreciate that I don’t expect them to be falling apart. I expect them to really improve their strength and physical - 172 - the triad exercise program well-being. We need to expect our elderly to be strong, fit, and functional until the day they die. But the value of strength training as we grow older to help maintain body metabolism, our independence, strength, and over- all bodily functions is critical. When muscle mass is lost with aging due to lack of exercise (hormones and nutrition), bad things happen. Flexibility is essential to help prevent us from falling, straining things, creating injuries, and other problems that can make us more sedentary.

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Spondylolisthesis buy discount forxiga 10 mg online, spinal stenosis cheap 10 mg forxiga with amex, Introduction/Background: The aim of this study was to evaluate the piriformis syndrome and pelvic tumors are also causes sciataal- demographic and clinical characteristics of patients with lymphedema gia forxiga 10 mg generic. Material and Methods: A 45-year-old male presented with severe persistent pain in the up- total of 95 female patients were included in the study. It was record- per thigh–lower buttock region, swelling in the left lower extremity ed type of malignancy, side of lymphedema, stage of lymphedema, and had diffculty walking for 15 days. The tumor was diagnosed as non-mus- Results: The mean age of the study population was found 52. His muscle strength in the lower extremities was 5/5 malignancies were recorded as endometrial carcinoma (3 patients), bilaterally with an antalgic gait. Side of lymphedema was right not reduce the pain and it was resistant even fentanyl. Magnetic resonance imaging showed a le- main precipitating factor of lymphedema was exhausting work (28 sion of about 29×8 cm in diameter around the priformis muscle in patients). Other factors were surgery, chemotherapy, radiotherapy, the left pelvis that compresses left sciatic nerve. The Tru-Cut bi- travelling by bus or aircraft, trauma, omega 7, biting by insects. Results: The patient was consulted patients were not describe any precipitating factor for the lymphede- with an oncologist. Stemmer sign was matory oligo-arthritis involving both knee, left ankle and wrist for 3 found in 18 patiens. Physical examination revealed moderate anemia, tenderness cording was found in 11 patients. Conclusion: Malignancy related lymphedema is multifacto- myeloma, X-ray skull showed multiple lytic lesions, Urinary Bence rial, disabling. The evaluation, demographic and clinical characteris- Zones Protein was absent, Plasma Protein Electrophoresis- Monoclo- tics, and treatment are variable. Me- 1 1 2 1 1 ticulous history taking, thorough physical examinations and relevant J. Haig3 tient consultations from 1/1/2009–12/31/2013 at a tertiary referral 1Brunei National Cancer Center, Rehabilitation, Brunei, Brunei, based cancer center. Of those where disability/work accom- tients are complex and often diffcult to identify because of the vari- modations was discussed, 55/128 (48. The Cancer Rehabilitation Screening Tool referred for disability assistance specifcally. The Brunei National Cancer Center those where disability insurance was flled out, 11/63 (17. Outcomes of private disability insurance applica- lay, then back-translated by 5 bilingual Bruneians. The median form size Results: Back-translation showed high fdelity to the original Eng- was 33 items (standard deviation=25. Eighty-one patients, 44% inpatient, 58% female, average age and return to work are topics frequently discussed in our outpatient 51±15 (s. Colorectal (22%), breast (16%), physiatry clinic including many who were not originally referred lymphoma (12%) and lung (12%) cancers were most common, with for disability guidance. The majority of patients who applied for 63% widespread, 20% local and 17% unknown stage of cancer. Positive answers to pain questions (62%), function questions (73%) and future risk questions (64%) were found. Jee1 physicians,themajorchallengeis toroutinely identify rehabilitation 1Chungnam National University Hospital, Department of Rehabili- need. Also, because of the variable course of the disease, the ‘need’ tation Medicine, Daejeon, Republic of Korea for rehabilitation is different from the presence of certain conditions including pain or paralysis. So a simple function survey is not appro- Introduction/Background: To evaluate functional characteristics priate. Material and Methods: An expert committee of psychiatrists of swallowing and compare parameters for dysphagia in head oncologists, physical therapists, occupational therapists, speech-lan- and neck cancer patients after radiation therapy. Material and guage pathologists, rehabilitation psychologists, oncology nurses and Methods: Medical records of 32 cases with head and neck cancer rehabilitation nurses held a brainstorming session on potential func- from Jan 2012 to May 2015 referred for videofuoroscopic swal- tional needs of cancer patients. This survey was given to 82 bone marrow transplant inpa- the patients into 2 groups ; Early status group (< 1 month after ra- tients and used to assist in clinical rehabilitation screening. Results: We analyzed 32 cases (28 ing 12% and have stopped doing fun activities 30%. Sixteen patients (50%) were -Risk: Caregiver burnout 7%, good chance of repeat hospitalization located to the early status group and vice versa. The site of tumor 12%, considering a nursing home 2%, at risk for falling 5%, and have was oropharynx (n=12), oral cavity (n=6), hypopharynx (n=5), emotional or thinking problems that are not addressed 2%. The fnal question, ‘Do you have any other concerns that you tus group showed penetration or aspiration and 8 patients (50%) wish a rehabilitation doctor would address? Conclusion: Dysphagia was preva- marrow transplant inpatients have pain, function, or risk of disability lent 1 month after radiation therapy. Patients at late status group issues that are potential targets for rehabilitation consultation. Our study suggests, before starting rehabilitation, it is necessary 649 to evaluate swallowing function appropriately. Material and Methods: The purpose of this article is to report Korea, 2Daejeon Wellness Hospital, Medical Oncology, Daejeon, and discuss a case of primary non-Hodgkin’s lymphoma presented Republic of Korea with unilateral cervical radiculopathy in a 76-year-old woman. But there is little concern about early rehabilitative However, after patient underwent decompression sugrery, biopsy intervention for postoperative breast cancer patients. Results: Our patient re- release is known to be effective in controlling symptoms in patients ceived decompression surgery followed by serials of chemothera- with chronic myofascial pain syndrome. Outcome was favorable with partial remission of the neurogical ness of myofascial release therapy in breast cancer patients with symptoms. Surgery is indicated in all pa- study was conducted in Daejeon Wellness hospital in Korea. A review of the literature ual therapy including myofascial release therapy started in the frst of patients with primary bone lymphoma presenting with spinal 4~6 weeks after breast cancer surgery, and lasted for 4 weeks. The aim of this study was to investigate the physical func- ing myofascial release decrease shoulder pain intensity and im- tion and health-related QoL of patients undergoing pleurectomy/de- proved range of motion. Physical function was assessed using tests for hand-grip further study may show promising results. Hagino1 related QoL, physical functioning, role physical, bodily pain, and 1 vitality signifcantly decreased after P/D (p<0. Exercise per limb dysfunction within 1 year of operation in patients with capacity and pulmonary function decreased more than limb muscle head and neck cancer. Physicians, nurses, and rehabilitation staff medical records of 49 patients who underwent neck dissection for should note these fndings, which may provide insight into the de- head and neck cancer between 2012 and 2015 at the Tottori Uni- velopment of customized rehabilitation strategies for patients with versity Hospital. Patient characteristics and information regarding the presence of lymph node dissection, postoperative chemotherapy, radiation 654 therapy, complications, and albumin and total protein levels before and at 1 month after the operation were assessed. Results: The dysfunction tion, Nishinomiya, Japan, 2Hyogo College of Medicine, Division group consisted of 10 patients (20. Preoperative Japan, 3Hyogo College of Medicine, Department of Rehabilitation and 1-month postoperative albumin and total protein levels were Medicine, Nishinomiya, Japan signifcantly lower in the dysfunction group.

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Gas may or may not be present within the lesion buy discount forxiga 10 mg online, and there is no enhancement centrally within the lesion order forxiga master card. Uptake of indium-111-labeled leukocytes within the abscess can be seen generic forxiga 10mg mastercard, although false-negative results may occur if the patient has already been on antibiotic therapy, if the abscess is walled off, or if there is a poor inflammatory response (3,4). Mimic of Renal Abscess Renal cell carcinoma may mimic renal abscess on imaging examinations. Both are mass-like lesions within the kidney; however, unlike renal abscess, which does not enhance centrally, renal cell carcinoma typically demonstrates heterogeneous enhancement. Clinical and Radiologic Diagnosis of Psoas Abscess Primary psoas abscess is rare and usually idiopathic. Immunocompromised patients are at risk Radiology of Infectious Diseases and Their Mimics in Critical Care 79 for infection by opportunistic agents. Secondary psoas abscess is more common and may result from spread of infection from adjacent structures, including colon, kidney, and bone (6). Other findings include obliteration of normal fat planes as well as bone destruction and gas formation. Gas within a psoas abscess may also be related to an underlying bowel fistula, such as in Crohn’s disease or diverticulitis. Abnormal uptake on a Ga-67 scan may also be used for diagnosis, although other entities, such as lymphoma, also show increased uptake; this finding is therefore not specific. An indium-111 white blood cell scan alternatively can be used to confirm infection if needed and should be more specific, although percutaneous aspiration (and drainage) can be performed for more definitive diagnosis and therapy (6–8). Mimic of Psoas Abscess Differentiation from tumor, such as lymphoma, can be difficult with imaging alone, as both can present as low-attenuation lesions, although the presence of gas makes the diagnosis of abscess far more likely. Adjacent structures should be examined to determine if there is a source of secondary infection. In the case of lymphoma originating from para-aortic lymph nodes, a potential helpful differentiating feature is that there may be medial or lateral displacement of the muscle by tumor, rather than extension into the muscle, as would be seen in an abscess (9,10). Clinical and Radiologic Diagnosis of Prostate Abscess Prostatic abscess occurs as a complication of acute bacterial prostatitis. Diabetic and immunocompromised patients are especially prone to this complication. The symptoms are similar to acute bacterial prostatitis, including fever, chills, and urinary frequency, with focal prostatic tenderness on physical exam (11). Abscesses can occur anywhere in the prostate, although they are usually centered away from the midline. Findings on ultrasound include focal hypoechoic or anechoic masses, with thickened or irregular walls, septations, and internal echoes. Mimic of Prostate Abscess A potential mimicker of prostate abscess is prostate carcinoma. Prostate cancer is the most common noncutaneous cancer in American men and the second most common cause of male cancer deaths after lung cancer. Unlike prostate abscess, which can occur anywhere in the gland, prostate cancer occurs mainly in the peripheral zones. Ultrasound findings are somewhat similar to abscess in that carcinoma appears as an anechoic to hypoechoic mass. The contour is classically asymmetric or triangular with the base close to the capsule and extending centrally into the gland based on the pattern of tumor growth. Clinical and Radiologic Diagnosis of Liver Abscess There are three main types of liver abscess: pyogenic, amebic, and fungal. Pyogenic abscesses occur most often in the United States and are usually polymicrobial. Pyogenic liver abscesses occur by direct extension from infected adjacent structures or by hematogenous spread via the portal vein or hepatic artery. Clinical presentation may be insidious, with fever and right upper quadrant pain being the most common presenting complaints. The right lobe of the liver is more often affected secondary to bacterial seeding via the blood supply from both the superior mesenteric and portal veins. Untreated, the disease is usually fatal, but with prompt abscess identification and then antibiotic administration and drainage, mortality is significantly decreased (15). A commonly seen finding is the “cluster sign” representing a conglomerate of small abscesses coalescing into a single large cavitating lesion. Secondary findings include right pleural effusion and right lower lobe atelectasis. On ultrasound, the lesion is usually spherical or ovoid with hypoechoic, irregular walls. Centrally, the abscess may be anechoic or less often hyperechoic or hypoechoic, depending on the presence of septa, debris, or necrosis (3,7). Like abscess, these also appear more often on the right side of the liver when solitary. On ultrasound, the mass appears mixed in echogenicity and demonstrates increased vascularity on color Doppler interrogation. There is then washout of contrast on the portal venous phase, as the tumor is supplied almost exclusively by the hepatic artery, and, if performed, on the delayed phase (3,16,17). With gadolinium administration, the enhancement pattern varies from central to peripheral and from homogeneous to rim enhancing. Clinical and Radiologic Diagnosis of Splenic Abscess Splenic abscess is a rare entity with a high mortality rate. The most common etiology is hematogenous spread of infection from elsewhere in the body. There are a diverse array of pathogens, including bacteria (aerobic and anaerobic) and fungi (18). As with abscesses elsewhere in the abdomen and pelvis, there may be gas or an air-fluid level. Ultrasound demonstrates a hypoechoic lesion that may contain internal septations and low-level internal echoes, representing either debris or hemorrhage. Mimic of Splenic Abscess Splenic infarct may have a similar clinical presentation, including fever, chills, and left upper quadrant pain. Differentiating the two entities is important, as an infarct can be managed conservatively, whereas abscess requires antibiotic therapy and possibly drainage. Lack of mass effect on the splenic capsule may be a helpful differentiating factor from abscess. Unlike abscess, on follow-up cross-sectional imaging, an infarct should become better demarcated and eventually resolve, leaving an area of fibrotic contraction and volume loss. A deviation from this expected course suggests a complication such as hemorrhage or superimposed infection (19). Clinical and Radiologic Diagnosis of Cholangitis/Calculous Cholecystis Acute infection of the biliary system is often associated with biliary obstruction from gallbladder calculi. Obstruction leads to intraluminal distention, which interferes with blood flow and drainage, predisposing to infection. On ultrasound, cholangitis appears as thickened walls of the bile ducts, which may be dilated and contain pus or debris.

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Asthma is characterized by acute episodes of bronchoconstriction caused by underlying air- way inflammation buy 10 mg forxiga free shipping. A hallmark of asthma is bronchial hyperreactivity to numerous kinds of en- dogenous or exogenous stimuli generic forxiga 10 mg amex. In asthmatic patients 10mg forxiga with visa, the response to various stimuli is amplified by persistent inflammation. Antigenic stimuli trigger the release of mediators (leukotrienes, histamine, and many others) that cause a bronchospastic response, with smooth muscle contraction, mucus secretion, and recruit- ment ofinflammatory cells such as eosinophils,basophils, and macrophages (early-phase response). Late-phase response (which may occur in hours or days) is an inflammatory response; levels of histamine and other mediators released from inflammatory cells rise again and may induce bronchospasm. Nonantigenic stimuli (cool air, exercise, nonoxidizing pollutants) can trigger nonspecific bron- choconstriction after early-phase sensitization. Chronic bronchitis is characterized by pulmonary obstruction caused by excessive production of mucus due to hyperplasia and hyperfunctioning of mucus-secreting goblet cells. Rhinitis is a decrease in nasal airways due to thickening of the mucosa and increased mucus secretion. Rhinitis may be caused by allergy, viruses, vasomotor abnormalities, or rhinitis medicamentosa. Adrenergic agonists stimulate b2-adrenoceptors, resulting in relaxation of bronchial smooth muscle. These agentsalso inhibit the releaseof mediatorsand stimulate mucociliaryclearance. Adrenergic agonists are useful for the treatment of the acute bronchoconstriction (exacerba- tions) of asthma. Depending on biologic half-life of the drug, these agents are used both for quick relief and for long-term control. The use of short-acting, inhaled b2-adrenoceptor agonists on a daily basis, with increasing necessity of use, indicates the need for additional long-term pharmacotherapy. Albuterol, levalbuterol, pirbuterol, metaproterenol (1) These agents have enhanced b2-receptor selectivity. Nonselective agents (1) Isoproterenol is a relatively nonselective b-receptor agonist and a potent bronchodila- tor. Isoproterenol is most effective in asthmatic patients when administered as an inhal- ant. During an acute attack, dosing every 1–2 hours is typically required; oral preparations are administered 4 times daily (qid). Epinephrine can be administered as an inhalant or subcutane- ously (in emergency circumstances); onset of action occurs within 5–10 minutes, and duration is 60–90 minutes. Salmeterol (Serevent), formoterol (Foradil) (1) These agents are administered as inhalants but have a slower onset of action and a lon- ger duration of action than the short-acting preparations. Terbutaline is a moderately specific b2-agonist that is currently available for injection or as a tablet. As with the other mixed b-adrenoceptor agonists, systemic use is cardiostimulatory. These adverse effects are minimized by inhalant delivery of the adrenergic agonists directly to the airways. Structures of methylxanthines, including xanthine, caffeine, theophylline, and theobromine. For asthma, the most frequently administered methylxanthine is theophylline (1,3- dimethylxanthine). Because of the limited solubility of theophylline in water, it is complexed as a salt, as in ami- nophylline and oxtriphylline. Methylxanthines cause bronchodilation by action on the smooth muscles in the airways. The exact mechanism remains controversial; some data suggest that it is an adenosine- receptor antagonist (adenosine causes bronchoconstriction and promotes the release of histamine from mast cells). In addition, these drugs may decrease the entry and mobiliza- 2+ tion of cellular Ca stores. However, theophylline analogues that lack adenosine-antagonist activity maintain bronchodilator activity. Theophylline also has some anti-inflammatory properties and reduces airway responsive- ness to agents such as histamine and to allergens. Theophylline is effective in reducing the synergistic effect of adenosine and antigen stimula- tion on histamine release. Methylxanthines affect a number of physiologic systems, but they are most useful in the treatment of asthma because of the following: Chapter 9 Drugs Acting on the Pulmonary System 209 (1) These agents produce rapid relaxation of bronchial smooth muscle. Other systems (1) Methylxanthines have positive chronotropic and inotropic actions on the heart. Methylxanthines are readily permeable into all tissue compartments; these agents cross the placenta and can enter breast milk. Methylxanthines are metabolized extensively in the liver and are excreted by the kidney. Theophylline has a very narrow therapeutic index; blood levels should be monitored on the initiation of therapy. Theophylline has a variable half-life (t1/2), approximately 8–9 hours in adults, but shorter in children. Methylxanthines are considered adjuncts to inhaled corticosteroids and are used to treat acute or chronic asthma that is unresponsive to inhaled corticosteroids or b-adrenoceptor agonists; they can be administered prophylactically. Methylxanthines are used to treat apnea in preterm infants (based on stimulation of the central respiratory center); usually, caffeine is the agent of choice for this therapy. The adverse effects of methylxanthines include arrhythmias, nervousness, vomiting, and gastrointestinal bleeding. The combined use of these agents with b2-adrenoceptor agonists is now suspected to be re- sponsible for recent rises in asthma mortality. These agents are somewhat variable in their effectiveness as bronchodilators in asthma, but they are useful in patients who are refractory to, or intolerant of, sympathomimetics or methylxanthines. Ipratropium, a quaternary amine that is poorly absorbed and does not cross the blood-brain barrier, is administered as an aerosol; its low systemic absorption limits adverse effects. The adverse effects of atropine include drowsiness, sedation, dry mouth, and blurred vision; these effects limit its use as an antiasthmatic. Cromolyn sodium is disodium cromoglycate, a salt of very low solubility in aqueous solutions. The precise mechanism of action of these drugs is unclear, but they inhibit the release of mediators from mast cells; suppress the activation of neutrophils, eosinophiles, and mono- cytes; and inhibit cough reflexes. It must be administered by inhalation; it is available as a microparticulate powder or as an aerosol.

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