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By F. Tippler. American Academy of Art.

First and foremost one should determine if the animal is sighted  The history with these animals will commonly include frequent trauma and difficulty navigating at night or in dim light discount pantoprazole 40mg mastercard. Vision Testing The menace response is a learned response which will not generally be present in foals less than two weeks of age cheap pantoprazole 40 mg without a prescription. A hand or finger(s) thrust is made toward the eye pantoprazole 40mg for sale, avoiding setting up stimulating air currents, or touching tactile hairs (vibrissae). Therefore, the seventh cranial nerve and orbicularis oculi muscle must also be intact along with visual pathways up to and including the cortex. When performing this test the examiner should stand on one side of the animal to assure that his hand motion is not in the visual field of the contralateral eye. The strength of the blink response can be amplified by actually touching the periocular region on the first one or two thrusts and then stopping short of this on the next two or three. Some animals need to be reminded, if you will, that the thrusted finger may touch them. Vision Testing  Throwing cotton balls, wads of cotton or a glove in the air can be helpful in visual assessment but it is not always reliable. Vision Testing  The end point with this method would be head motion and /or reflex blink, which can be subtle. The examiner needs to be assured that the object thrown is large enough to be seen, that the object does not make a noise, set up stimulating air currents, nor is thrown into the visual field of the opposite eye. A few repeated responses are necessary to avoid interpreting a coincidental blink or head motion with a positive sign. Vision Testing  Throwing Cotton Balls Gross Evaluation  Symmetry  Ocular discharge  Normal Position of the Upper Eyelid Cilia  Ptosis  Blepharospasm  Photophobia  Surface Topography  Pupillary symmetry Symmetry  Evaluate symmetry of the head and facial expression. Ocular discharge  Ocular discharge if present should be characterized as serous, mucoid, purulent, hemorrhagic, seromucoid, mucopurulent, or serosanguinous. Normal Position of the Upper Eyelid Cilia  The position of the upper eyelid cilia normally should be directed nearly perpendicular to the corneal surface. Blepharospasms  Blepharospasm (forced blinking) is usually a sign of ocular pain and commonly is also associated with an ocular discharge. Photophobia Ocular pain that results in blepharospasm can stem from superficial sites (eg: cornea) or deep intraocular ones (eg: uvea-ciliary spasm). Surface Topography  Surface topography of the periorbital and ocular structures such as eyelid creases and folds, as well as the supraorbital fossal depression may be accentuated or lost. Conditions resulting in enophthalmia such as a painful globe or a globe undergoing atrophy (phthisis bulbi) and loss of orbital contents due to emaciation, muscle atrophy (denervation, post inflammatory) would emphasize these topographical structures. Surface Topography  Conversely, conditions that would increase the orbital contents such as inflammation, hemorrhage or obliterate these. Careful comparison of both orbital and peri- ocular areas, along with the appreciation of these surface topographical structures, can assist in the early recognition of ocular problems. Palpation  Palpation of the orbital zone is also important to confirm topographical changes and characterize them as hard or soft, moveable or fixed, and sensitive or insensitive. Percussion of the frontal and maxillary sinus area may be indicated, especially in animals with orbital disease. A stethoscope is helpful to critically assess the sounds generated during percussion and certainly comparison of both sides will identify subtle fluid accumulations. Retropulsion  Retropulsion or pushing the globe deeper into the orbit through the closed eyelids is a technique that is used to determine if there is an abnormal amount of orbital contents. Resistance to retropulsion, especially as compared to the contralateral orbit would signify increased orbital mass and perhaps a localization of a focal swelling could be identified with this method combined with the direction of any apparent deviation of the globe. This technique would not of course be used in an eye that is in danger of rupture. The maximal amount of valuable information gained from the findings of these procedures results when the examiner is familiar with the normal bony and soft tissue anatomy. Palpation  Palpation used in a stimulatory manner (Palpebral Reflex) to evaluate sensory and motor nerve function is important to evaluate the fifth, sixth and seventh cranial nerves. Touching the periocular area should normally produce a blink reflex, verifying that the fifth and seventh cranial nerves are intact as well as the orbicularis oculi muscle. Corneal Reflex  Touching the cornea with the wisped end of a cotton tipped applicator (Corneal Reflex) will evaluate the ophthalmic branch of the fifth nerve and a normal reflex will elicit a head jerk, blink and retraction of the globe with secondary prolapse of the third eyelid. Pupillary symmetry  Pupillary symmetry can be evaluated by viewing the animal head on from about 6 feet through a direct ophthalmoscope set a 0 diopters and stimulating a tapetal reflex. At the same time, the fellow pupil should also constrict, resulting in the consensual pupillary light reflex. Observation of this reflex may require a second person due to the lateral placement of the globes. The equine pupil responds slower than the cat or dog and as with all animals, its presence does not confirm sight. Finnoff Transilluminator Excitement or opacity of the ocular media from blood, pus or cataract will not override the reflex from a bright focal light source. Inexpensive Lights Intermediate Examination Process  Now a more through evaluation of the external eye can be done and systemic analgesic/sedatives could be given at this point if deemed necessary, which will not affect the subsequent portions of the examination. Use of an neck twitch or lip twitch is also often necessary during the moment of more uncomfortable examination procedures. Such as, at the time the periocular nerve block injections are made, eversion of the eyelids, especially the third eyelid and perhaps when the nasolacrimal system is flushed. Close Inspection For the majority of the examination minimal restraint is usually optimal and holding the horse by the halter seems to work well. Close evaluation of the eyelid margins, conjunctiva, cul de sacs and cornea for abnormalities can effectively be done with a bright light source and magnification. A head loupe such as an "Opti-Visor" is very helpful in addition to an adequate light source. The otoscope will provide a 3 x – 5x magnification and a powerful light source all in one. Opacities in the Ocular Media  With the direct ophthalmoscope set at 0 diopters and viewing the eye from a distance of about one to two feet, an evaluation of the of the ocular media for opacities. Opacities in the Ocular Media  The best situation is when the pupil is dilated artificially with tropicamide (1%) – do not use atropine for diagnostic purposes. This will allow the examiner to briefly evaluate the lens and vitreal space in this indirect manner for synechia, cataracts, vitreal floaters and retinal detachments. Opacities in the Ocular Media  Later, when it is more appropriate to use a mydriatic, this indirect examination with the direct ophthalmoscope can be repeated when the pupil is large. Opacities that are anterior to the center of the lens will move in the same direction of the globe and ones posterior to the center of the lens will move in the opposite direction. Retinal detachments, if large will be seen easier with this method than looking directly. Ocular Opacity Focal Beam Examination  Using a focal beam and or a slit beam directed into the eye at an angle evaluate the anterior chamber. Evaluation of the chamber contents and depth are essential as well as the character of the pupillary margin with regard to adhesions of the iris to the lens and pigment deposits on the anterior surface of the lens and the physical condition of the corpora nigra.

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From the right atrium purchase genuine pantoprazole on-line, blood moves into the right ventricle buy pantoprazole pills in toronto, which pumps it to the lungs for gas exchange buy pantoprazole 20 mg low cost. At the base of the pulmonary trunk is the pulmonary semilunar valve, which prevents backflow of blood into the right ventricle during ventricular diastole. As the pulmonary trunk reaches the superior surface of the heart, it curves posteriorly and rapidly bifurcates (divides) into two branches, a left and a right pulmonary artery. To prevent confusion between these vessels, it is important to refer to the vessel exiting the heart as the pulmonary trunk, rather than also calling it a pulmonary artery. The pulmonary arteries in turn branch many times within the lung, forming a series of smaller arteries and arterioles that eventually lead to the pulmonary capillaries. The pulmonary capillaries surround lung structures known as alveoli that are the sites of oxygen and carbon dioxide exchange. Once gas exchange is completed, oxygenated blood flows from the pulmonary capillaries into a series of pulmonary venules that eventually lead to a series of larger pulmonary veins. These vessels branch to supply blood to the pulmonary capillaries, where gas exchange occurs within the lung alveoli. Pulmonary Arteries and Veins Vessel Description Pulmonary Single large vessel exiting the right ventricle that divides to form the right and left pulmonary trunk arteries Pulmonary Left and right vessels that form from the pulmonary trunk and lead to smaller arterioles and arteries eventually to the pulmonary capillaries Pulmonary Two sets of paired vessels—one pair on each side—that are formed from the small venules, veins leading away from the pulmonary capillaries to flow into the left atrium Table 20. The aorta and its branches—the systemic arteries—send blood to virtually every organ of the body (Figure 20. It arises from the left ventricle and eventually descends to the abdominal region, where it bifurcates at the level of the fourth lumbar vertebra into the two common iliac arteries. The aorta consists of the ascending aorta, the aortic arch, and the descending aorta, which passes through the diaphragm and a landmark that divides into the superior thoracic and inferior abdominal components. At the base of the aorta is the aortic semilunar valve that prevents backflow of blood into the left ventricle while the heart is relaxing. After exiting the heart, the ascending aorta moves in a superior direction for approximately 5 cm and ends at the sternal angle. Following this ascent, it reverses direction, forming a graceful arc to the left, called the aortic arch. The aortic arch descends toward the inferior portions of the body and ends at the level of the intervertebral disk between the fourth and fifth thoracic vertebrae. Superior to the diaphragm, the aorta is called the thoracic aorta, and inferior to the diaphragm, it is called the abdominal aorta. The abdominal aorta terminates when it bifurcates into the two common iliac arteries at the level of the fourth lumbar vertebra. Components of the Aorta Vessel Description Largest artery in the body, originating from the left ventricle and descending to the abdominal region, where it bifurcates into the common iliac arteries at the level of the fourth Aorta lumbar vertebra; arteries originating from the aorta distribute blood to virtually all tissues of the body Initial portion of the aorta, rising superiorly from the left ventricle for a distance of Ascending aorta approximately 5 cm Graceful arc to the left that connects the ascending aorta to the descending aorta; ends at Aortic arch the intervertebral disk between the fourth and fifth thoracic vertebrae Descending Portion of the aorta that continues inferiorly past the end of the aortic arch; subdivided into aorta the thoracic aorta and the abdominal aorta Thoracic aorta Portion of the descending aorta superior to the aortic hiatus Abdominal aorta Portion of the aorta inferior to the aortic hiatus and superior to the common iliac arteries Table 20. These sinuses contain the aortic baroreceptors and chemoreceptors critical to maintain cardiac function. The coronary arteries encircle the heart, forming a ring-like structure that divides into the next level of branches that supplies blood to the heart tissues. As you would expect based upon proximity to the heart, each of these vessels is classified as an elastic artery. The brachiocephalic artery is located only on the right side of the body; there is no corresponding artery on the left. The brachiocephalic artery branches into the right subclavian artery and the right common carotid artery. The left subclavian and left common carotid arteries arise independently from the aortic arch but otherwise follow a similar pattern and distribution to the corresponding arteries on the right side (see Figure 20. Each subclavian artery supplies blood to the arms, chest, shoulders, back, and central nervous system. It then gives rise to three major branches: the internal thoracic artery, the vertebral artery, and the thyrocervical artery. The internal thoracic artery, or mammary artery, supplies blood to the thymus, the pericardium of the heart, and the anterior chest wall. The vertebral artery passes through the vertebral foramen in the cervical vertebrae and then through the foramen magnum into the cranial cavity to supply blood to the brain and spinal cord. The paired vertebral arteries join together to form the large basilar artery at the base of the medulla oblongata. The subclavian artery also gives rise to the thyrocervical artery that provides blood to the thyroid, the cervical region of the neck, and the upper back and shoulder. The right common carotid artery arises from the brachiocephalic artery and the left common carotid artery arises directly from the aortic arch. The external carotid artery supplies blood to numerous structures within the face, lower jaw, neck, esophagus, and larynx. The internal carotid artery initially forms an expansion known as the carotid sinus, containing the carotid baroreceptors and chemoreceptors. Like their counterparts in the aortic sinuses, the information provided by these receptors is critical to maintaining cardiovascular homeostasis (see Figure 20. The internal carotid arteries along with the vertebral arteries are the two primary suppliers of blood to the human brain. Given the central role and vital importance of the brain to life, it is critical that blood supply to this organ remains uninterrupted. Recall that blood flow to the brain is remarkably constant, with approximately 20 percent of blood flow directed to this organ at any given time. The locations of the arteries in the brain not only provide blood flow to the brain tissue but also prevent interruption in the flow of blood. Both the carotid and vertebral arteries branch once they enter the cranial cavity, and some of these branches form a structure known as the arterial circle (or circle of Willis), an anastomosis that is remarkably like a traffic circle that sends off branches (in this case, arterial branches to the brain). As a rule, branches to the anterior portion of the cerebrum are normally fed by the internal carotid arteries; the remainder of the brain receives blood flow from branches associated with the vertebral arteries. The internal carotid artery continues through the carotid canal of the temporal bone and enters the base of the brain through the carotid foramen where it gives rise to several branches (Figure 20. One of these branches is the anterior cerebral artery that supplies blood to the frontal lobe of the cerebrum. The right and left anterior cerebral arteries join together to form an anastomosis called the anterior communicating artery. The initial segments of the anterior cerebral arteries and the anterior communicating artery form the anterior portion of the arterial circle. The posterior portion of the arterial circle is formed by a left and a right posterior communicating artery that branches from the posterior cerebral artery, which arises from the basilar artery. The basilar artery is an anastomosis that begins at the junction of the two vertebral arteries and sends branches to the cerebellum and brain stem. The internal carotid artery first forms the carotid sinus and then reaches the brain via the carotid canal and carotid foramen, emerging into the cranium via the foramen lacerum. The vertebral artery branches from the subclavian artery and passes through the transverse foramen in the cervical vertebrae, entering the base of the skull at the vertebral foramen. Aortic Arch Branches and Brain Circulation Vessel Description Single vessel located on the right side of the body; the first vessel branching from the aortic Brachiocephalic arch; gives rise to the right subclavian artery and the right common carotid artery; supplies artery blood to the head, neck, upper limb, and wall of the thoracic region The right subclavian artery arises from the brachiocephalic artery while the left subclavian Subclavian artery arises from the aortic arch; gives rise to the internal thoracic, vertebral, and artery thyrocervical arteries; supplies blood to the arms, chest, shoulders, back, and central nervous system Internal thoracic Also called the mammary artery; arises from the subclavian artery; supplies blood to the artery thymus, pericardium of the heart, and anterior chest wall Arises from the subclavian artery and passes through the vertebral foramen through the Vertebral artery foramen magnum to the brain; joins with the internal carotid artery to form the arterial circle; supplies blood to the brain and spinal cord Thyrocervical Arises from the subclavian artery; supplies blood to the thyroid, the cervical region, the artery upper back, and shoulder The right common carotid artery arises from the brachiocephalic artery and the left common Common carotid artery arises from the aortic arch; each gives rise to the external and internal carotid carotid artery arteries; supplies the respective sides of the head and neck External carotid Arises from the common carotid artery; supplies blood to numerous structures within the artery face, lower jaw, neck, esophagus, and larynx Arises from the common carotid artery and begins with the carotid sinus; goes through the Internal carotid carotid canal of the temporal bone to the base of the brain; combines with the branches of artery the vertebral artery, forming the arterial circle; supplies blood to the brain Arterial circle or An anastomosis located at the base of the brain that ensures continual blood supply; formed circle of Willis from the branches of the internal carotid and vertebral arteries; supplies blood to the brain Table 20. As it passes through the thoracic region, the thoracic aorta gives rise to several branches, which are collectively referred to as visceral branches and parietal branches (Figure 20.

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Mold can also exist for years in locations such as heating purchase pantoprazole pills in toronto, ventilation pantoprazole 20 mg low cost, and air conditioning systems purchase discount pantoprazole, causing continuous exposure at home or work. Depression and Anxiety It is well established that inflammation and inflammatory mechanisms play a critical role in major depression. Elevations in proinflammatory cytokines and other inflammation-related proteins are common in depressive disorders (Raedler 2011). It should not be too surprising then to find that 71% of people with depression also have a history of allergies (Bell 1991). It is also known that depression scores increase with the exacerbation of allergy symptoms and that cytokines are elevated in the prefrontal cortex in victims of suicide (Postolache 2007). There is an overwhelming preponderance of studies showing the relationship between allergies and depression (and anxiety). The causal relationship includes the triggering of the immune system and cytokines, the impairment of sleep through nasal obstruction resulting in psychiatric symptoms, and the negative effect on cognitive function associated with allergies (Sansone 2011). Gastrointestinal inflammation also may be a significant contributing factor to depression (Fehér 2011). Given that allergies commonly impact the respiratory and cardiovascular systems, it comes as no surprise that restricted breathing or asthma with accompanying tachycardia, so frequently found with allergies, is a common trigger for anxiety 62 | Complementary and Alternative Medicine Treatments in Psychiatry and panic attacks. As with depression, as allergy scores increase, so do anxiety symptoms (Postolache 2008). Additionally, it’s been found that allergic rhinitis worsens existing psychiatric symptoms. The behavior of somatization, compulsion, depression and anxiety in patients with a history of eczema or asthma is much more obvious than in patients without such a history. Nasal obstruction has a conspicuous impact on somatization, compulsion, interpersonal sensitivity, depression, anxiety and psychosis, while nasal itching contributes to somatization, depression and anxiety (Lv 2010). An inflammatory reaction atrophies the villi lining of the small intestine, resulting in reduced ability to absorb nutrients, minerals and the fat-soluble vitamins A, D, E, and K. Until recently, the standard approach to finding celiac disease has been to wait for people to complain of symptoms and to come to the doctor for investigation. We may need to consider looking for celiac disease in the general population, more like we do in testing for cholesterol or blood pressure. Standard testing includes blood levels of the antibodies anti-endomysium and anti-tissue transglutaminase. If 64 | Complementary and Alternative Medicine Treatments in Psychiatry these are positive, an endoscopic biopsy of the small intestine is done to confirm the diagnosis (U Chicago Tests). Poisons and Toxins A poison is a substance that can cause disturbance to an organism through chemical reaction or other activity on a molecular scale. Thus, mercury is a poison and mycotoxins— metabolites produced by molds—are toxins. It is incumbent upon the practitioner to consider this factor when a patient presents with psychiatric symptoms. A particularly revealing question is, “Does anyone in your (neighborhood, factory, home, etc. Most medical students are told how the phrase “mad as a hatter” comes from the fact that mercury used by hat makers of old commonly resulted in a deteriorating psychosis. However, the list of substances that cause psychiatric symptoms is actually quite long—with new ones being The Role of Allergies, Poisons, and Toxins in Psychiatry | 65 discovered continuously—and far too extensive for us to cover in this brief publication, though we can give some examples. Hydrogen sulfide—common to volcanic eruptions, tanneries, and some paper mills—can affects mood states and the psychological stress response. In animal studies, it has been shown to alter levels of the neurotransmitters serotonin, norepinephrine, dopamine, aspartate and glutamate. Carbon disulfide, also a neurotoxin, has been linked to personality changes, mood disorders and suicides in occupational settings. A Duke University study, looking into why two neighborhoods in North Carolina had 10 times the state’s suicide rate and 6. Hydrogen sulfide levels reached as much a ten times the acceptable standard (Duke Medicine 2004). When farm workers receive what they consider to be a toxic level of exposure to pesticides with organophosphates, it has been found they have nearly six times the rate of depression as the general public (Stallones 2002). Particulate air pollution, a pervasive exposure in modern urban environments, has been found to alter brain structure and cause cognitive impairment and depressive symptoms. Mice exposed to pollutants at the same levels of modern city inhabitants were found to have not only depressed states, but elevated cytokine expression in the hippocampus and altered dendrite growth (Fonken 2011). The treatment for toxic exposure will vary depending on the substance but the first line of defense would be, if possible, removal of the offending material. In the case of occupational or 66 | Complementary and Alternative Medicine Treatments in Psychiatry habitat exposures, difficult choices may be involved requiring finding new employment or changing living quarters. Summary With allergies increasing and toxic exposures on the rise in our increasingly industrialized world, psychiatric symptoms from these environmental causes are also becoming more prominent. A wise physician, on the lookout for such risk factors, could save a patient years or even a lifetime of misdiagnosis and add years of more healthful living to what might otherwise be an existence of slow and mysterious decline. Breathing Technique, Mindfulness, and Yoga Christine Berger Abdominal Breathing Abdominal breathing, also called diaphragmatic breathing or belly breathing, is a core activity of meditation and yoga practices and an important therapeutic technique in its own right. Various Eastern religious and philosophical traditions cite the breath as a bridge connecting mind-body-emotions-spirit (Brown 2009). Anxious or depressed individuals breathe only from the upper chest, in a shallow fashion, whereas individuals who have an integrated mind-body system breathe deeply, from the diaphragm. Therefore, for clients with anxiety disorders or depression, it follows that breath training can serve as an empowering adjunctive treatment for these mental health challenges (Weil 2006). In fact, according to Philippott et al, cited by Brown and Gerbarg, changing breath patterns therapeutically “can account for at least 40% in feelings of anger, fear, joy and sadness” (Brown 2009). When practiced, it appropriately energizes the sympathetic nervous system on the inhale, and the exhale appropriately engages the parasympathetic system (Brown 2009). Proper breathing manages energy, breath volume, and adjusts other biological systems such as the endocrine, digestive, circulatory and neurochemical. Regulation of breath regulates heart function through the vagus nerve (Edwards 2008). The Impact of Breathing on Anxiety and Depression While Americans often think of yoga as a series of meditative postures, the system of yoga includes an emphasis on various breathing techniques which induce a variety of desired states. They were especially curious about the mechanisms of change from this form of breathing. The authors emphasize the importance that healthcare providers comprehend the research and clinical evidence of these therapeutic benefits. It consists of 4 parts: 3-stage slow resistance breathing (Ujjayi), bellows breath, om chanting, and cyclical breathing. Ujjayi has been shown to increase parasympathetic activity through vagal afferent inputs to the brain and improves heart rate variability. In addition, it improves low respiratory sinus arrhythmia, which has been associated with depression, anxiety, panic and obesity. Brown and Gerbarg also found evidence suggesting that yogic breathing has powerful physiological and psychological effects which may contribute to longevity (Brown 2009). A breathing training style called the Papworth Method, used to treat asthma and its accompanying anxiety, produced significantly less anxiety and depression in a treatment group as compared to a control group after five sessions and at a one-year follow-up (Holloway 2007).

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