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  • Associate Professor, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland

As otolaryngologists signs of arthritis in feet and knees generic naproxen 250 mg mastercard, we focus on disease processes that produce true vertigo (an illusion of motion) arthritis diet myths naproxen 500 mg visa, which is primarily associated with the balance organs of the inner ear rheumatoid arthritis hair loss order on line naproxen. When central vestibular disorders are considered arthritis in feet symptoms uk order line naproxen, the diferential diagnosis for dizziness becomes quite broad. Terefore, if your patient does not complain of the true illusion of motion, redirect your questioning to the evaluation of syncope or episodic hypotension. You may also want to consider imaging studies of the brain to rule out neoplasm, demyelinating disease, or a vascular abnormality. Vestibular Testing Vestibular testing can be performed to help determine whether the problem exists within the vestibular (balance) portion of the inner ear. Rotatory chair testing is the “gold standard” for diagnosing bilateral vestibular weakness. The patient is slowly spun in a rotating chair and dizziness is measured with optokinetic testing and a fxation test. Moving platform posturography is a method of quantifying balance, but should not be used alone to diagnose vestibular disorders. It is most useful in quantifying balance improvement (or worsening) following treatment for a The test is a variant of brainstem audio-evoked response and, if possible, should be performed during active Meniere’s attacks. This disorder is caused by sediment, such as otoconia (calcium carbonate crystals) that have become free foating within the inner ear. When the patient turns his or 50 her head quickly or into a certain position, this free-foating material moves the balance canal fuid (endolymph) in the inner ear and stimulates the vestibular division of the eighth cranial nerve. This motion creates an intense feeling of vertigo that lasts less than 60 seconds and passes when the material settles. Patients are usually able to describe the precise motion that precipitates this intense, brief episode of vertigo. Rolling over in bed is a movement that frequently initiates an episode and is a fairly specifc symptom. This disorder can occur without any specifc inciting event, but is ofen seen afer signifcant head trauma or an episode of vestibular neuronitis. Medical therapy with vestibular suppressants is inefective because the episodes of vertigo are so feeting, and should be discouraged. However, they are very rarely employed, as they can be associated with signifcant risk of hearing loss and other complications. The presumed position of the debris within the labyrinth during the maneuver is shown in panels A–D. The DixHallpike test is performed with the patient’s head rotated 45fi toward the right ear, and the neck slightly extended with the chin pointed slightly upward. Once the vertigo and the nystagmus provoked by the Dix-Hallpike test cease, the patient’s head is rotated about the rostral-caudal body 51 axis until the left ear is down (panel B). The patient should be kept in the fnal, facedown position for about 10–15 seconds. With the head kept turned toward the left shoulder, the patient is brought into the seated position (panel D). Once the patient is upright, the head is tilted so that the chin is pointed slightly downward. Vestibular Neuronitis Another common cause of vertigo is vestibular neuronitis or labyrinthisis. It is thought to be caused by infammation, secondary to a viral infection, of the vestibular portion of the eighth cranial nerve or of the inner ear balance organs (vestibular labyrinth). It is frequently associated with recent fu symptoms (upper respiratory infection). The patient will usually awaken with room-spinning vertigo that will gradually become less intense over 24–48 hours. During this period, the patient’s hearing is generally unchanged, and nausea with or without emesis is common. Treatment is symptomatic, including vestibular suppressant medications, antiemetic medications, and a short, tapering course of oral steroids. Meniere’s Disease Meniere’s disease is usually diagnosed by history when patients have a particular symptom complex. Patients develop intense, episodic vertigo, usually lasting from 30 minutes to four hours, and associated with fuctuating hearing loss, roaring tinnitus, and the sensation of aural fullness. The disease can be very difcult to treat because its course is very unpredictable. Patients can sufer from frequent attacks and then abruptly stop having symptoms, only to resume attacks years later. Treatment strategies have been focused on decreasing the endolymphatic fuid pressure within the vestibular portion of the inner ear. Salt restriction and thiazide diuretics are frequently used as frst-line agents. If this does not adequately control the patient’s symptoms, additional intervention can be used. Surgical options for incapacitated patients include endolymphatic sac decompression into the mastoid cavity, vestibular nerve section, and labyrinthectomy. Vestibular nerve section is an intracranial procedure that involves transecting the vestibular portion of the eighth cranial nerve near the brainstem. This procedure disrupts the aberrant vestibular signals from the afected ear, while preserving the patient’s current hearing thresholds. Labyrinthectomy disrupts the aberrant vestibular signals without the risks associated with an intracranial procedure, but it destroys any hearing in the operated ear. Because of this, labyrinthectomy is considered only if the patient’s hearing has declined to the point of not being useful, usually afer having Meniere’s disease for an extended length of time. Treatment of patients with Meniere’s disease must be managed in a stepwise fashion, with careful consideration given to the patient’s intensity of symptoms and frequency of attacks, as well as how the disease is afecting his or her life and overall general health. Sudden vertigo that develops without ear symptoms and lasts for 24–48 hours is most likely. It may occur spontaneously, following trauma or surgical proce55 dure, or as a result of malignant tumors of the pinna, the parotid gland, or the skull base. Paralysis involving all divisions of the nerve is peripheral, and that sparing the forehead is central. Facial paralysis is usually graded on a scale of 1 to 6, where 1 is normal and 6 is a faccid complete paralysis. Bell’s Palsy Bell’s palsy is very strictly defned as: Acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours and idiopathic. Terefore a careful patient history and physical examination is critical to avoiding misdiagnosis. The diferential diagnosis for facial paralysis is long and includes stroke, tumors of the parotid gland or skull base, systemic and infectious diseases, which must be ruled out before a diagnosis of Bell’s palsy can be made. It is estimated that 30% of patients who present with facial paralysis have an identifable cause and therefore are not Bell’s palsy. The clinical course of Bell’s palsy is quite characteristic with sudden onset, and the patient ofen noticing Figure 8. The recovery is this patient has suffered gradual, but complete spontaneous recovery can be paralysis of the right facial expected in more than 70 percent of the cases with nerve; hence, the asymmetry when he attempts to smile. Facial supranuclear tracts would spare the forehead and paresis or paralysis is thought to result from facial represent a “central seventh. A shotgun approach to diagnosis using laboratory testing and imaging is unwarranted, instead patient circumstances, patients with an atypical presentation or course. Findings such as incomplete recovery afer three months, and multifocal neurological fndings should be more closely examined for other causes and the evaluating physician should maintain a low threshold for specialty referral. The Clinical Practice Guideline committee for Bell’s palsy strongly recommends a 10-day course of oral steroids, with a minimum of 5 days at high dose (prednisone 60mg for 5 days with a 5-day taper, or prednisolone 50mg for 10 days). Antifungal therapy may be added to steroids, but antifungal medication alone is not recommended. Eye protection is critical to avoid a corneal abrasion and is described at the end of chapter. Ramsay-Hunt’s Syndrome Another syndrome that includes facial nerve paralysis is Ramsay-Hunt’s or herpes zoster oticus. In this case, facial nerve paralysis is accompanied by severe pain and a vesicular eruption in the external auditory canal and auricle in the distribution of the facial nerve.

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Joint Commission: the Joint Commission on the Accreditation of Health Care Organizations arthritis medication prescription order 250mg naproxen amex. Low Protein Modified Food Product: A food product that is: (a) specially formulated to arthritis pain numbness cheap naproxen on line have less than one gram of protein per serving; and (b) intended to arthritis diet sugar generic naproxen 250 mg amex be used under the direction of a physician for the dietary treatment of an Inherited Metabolic Disease arthritis pain relief cvs buy cheapest naproxen and naproxen. Maintenance Therapy: That point in the therapeutic process at which no further improvement in the gaining or restoration of a function, reduction in disability or relief of pain is expected. Continuation of therapy at this point would be for the purpose of holding at a steady state or preventing deterioration. With respect to a pregnant woman who is having contractions, a Medical Emergency exists where: (a) there is not enough time to make a safe transfer to another Hospital before delivery; or (b) the transfer may pose a threat to the health or safety of the woman or the unborn child. Examples of a Medical Emergency include, but are not limited to: heart attacks; strokes; convulsions; severe burns; obvious bone fractures; wounds requiring sutures; poisoning; and loss of consciousness. Medical Food: A food that is: (a) intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation; and (b) formulated to be consumed or administered entirely under direction of a physician. Mental Health Center: A Facility, which mainly provides treatment for people with mental health problems. Mental or Nervous Disorders: Conditions which manifest symptoms that are primarily mental or nervous (whether organic or non-organic, biological or non-biological, chemical or non-chemical in origin and irrespective of cause, basis or inducement) for which the primary treatment is psychotherapy or psychotherapeutic methods or psychotropic medication. Mental or Nervous Disorders include, but are not limited to: psychoses; neurotic and anxiety disorders; schizophrenic disorders; affective disorders; personality disorders; and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems. But in no event shall the following be considered Mental or Nervous Disorders: (1) Conditions classified as V-codes in the most current edition of the Manual. These include relational problems such as: parent-child conflicts; problems related to abuse or neglect when intervention is focused on the perpetrator; situations not attributable to a diagnostic disorder, including: bereavement, academic, occupational, religious, and spiritual problems. These include, but are not limited to: mental retardation; academic skills disorders; or motor skills disorders. This includes, but is not limited to, treatment for: adult children of alcoholic families; or co-dependency. Optical Services: the following services when provided for lenses, including contact lenses, and frames: a. Out-of-Hospital: Services or supplies provided to a Covered Person other than as an Inpatient or Outpatient. Once that dollar amount is reached, no further such payments are required for the remainder of that Benefit Period. Partial Hospitalization: Intensive short-term non-residential day treatment services that are: (a) for Mental or Nervous Disorders chemical dependency; or Alcoholism; and (b) rendered for any part of a day for a minimum of four consecutive hours per day. Policyholder: the employer or other entity that: (a) purchased the Group Policy; and (b) is responsible for paying the premiums for it. Practitioners include, but are not limited to, the following; physicians; chiropractors; dentists; optometrists; pharmacists; chiropodists; psychologists; physical therapists; audiologists; speech language pathologists; certified nurse mid-wives; registered professional nurses; nurse practitioners; and clinical nurse specialists. Preventive Care: Services or supplies that are not provided for the treatment of an Injury or Illness. It includes, but is not limited to: routine physical exams, including: related X-rays and lab tests; immunizations and vaccines; screening tests; well-baby care; and well adult care. But the Practitioner may need to comply with certain procedures, including: obtaining Prior Authorization for certain services; following a pre-approved treatment plan; or procedures for making referrals. Provider: A Facility or Practitioner of health care in accordance with the terms of this Program. Routine Foot Care also includes: orthopedic shores and supportive devices for the foot. Routine foot care also includes: orthopedic shoes and supportive devices for the foot. Routine Nursing Care: the appropriate nursing care customarily furnished by a recognized Facility for the benefit of its Inpatients. Skilled Nursing Care: Services which: (a) are more intensive than Custodial Care; (b) are provided by an R. Skilled Nursing Facility: A Facility, which mainly provides full-time Skilled Nursing Care for ill or injured people who do not need to be in a Hospital. In some places, a Skilled Nursing Facility may be called an "Extended Care Center" or a "Skilled Nursing Center. Substance Abuse: the abuse or addiction to drugs or controlled substances, not including alcohol. Substance Abuse Centers: Facilities that mainly provide treatment for people with Substance Abuse problems or Alcoholism. Therapeutic Manipulation: the treatment of the articulations of the spine and musculoskeletal structures for the purpose of relieving certain abnormal clinical conditions resulting from the impingement upon associated nerves, causing discomfort. Chelation Therapy: the administration of drugs or chemicals to remove toxic concentrations of metals from the body. Chemotherapy: the treatment of malignant disease by chemical or biological antineoplastic agents. Dialysis Treatment: the treatment of an acute renal failure or chronic irreversible renal insufficiency by removing waste products from the body. Physical Therapy: the treatment by physical means to: relieve pain; develop or restore normal function; and prevent disability following Illness, Injury or loss of limb. Speech therapy to restore speech after a loss or impairment of a demonstrated, previous ability to speak. Speech therapy to develop or improve speech to correct a defect that both: (a) existed at birth; and (b) impaired or would have impaired the ability to speak. The Covered Person who is Totally Disabled must be under the regular care of a Practitioner. Vision Survey: A survey and analysis performed by a Practitioner acting within the scope of his/her license, including, but not limited to: a case history; complete refraction; coordination measurements and tests; visual field charting; and prescription of lenses, as needed. Waiting Period: the period of time between enrollment in the Program and the date when a person becomes eligible for benefits. War: Includes, but is not limited to, declared war, and armed aggression by one or more countries resisted on orders of any other country, combination of countries or international organization. That coverage is subject to the terms, conditions, limitations and exclusions stated in this Booklet. In this case, the Covered Services and Supplies provided by Out-of-Network Providers during the Inpatient stay will be covered at the InNetwork level. If you believe that you are not receiving the information to which you are entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (973) 504-6200 or (800) 242-5846. These payment methods may also include financial incentive agreements whereby some Providers are paid more (bonuses) or less (withholds), based on many factors. Some of these factors are: member satisfaction; quality of care; control of costs; and use of services. Common Accident Deductible If two or more Covered Persons in the same family are injured in the same accident, only one Deductible will be applied in a Benefit Period to the Covered Services and Supplies due to the accident. Out-of-Network For Child Dependents 15 years of age or younger: For the purchase of a hearing aid, benefits subject to Deductible and 60% Coinsurance, up to a maximum benefit combined In-Network and Out-of-Network of $1,000 per hearing aid, for each hearing-impaired ear, during any period of 24 consecutive months. Out-of-Network Outpatient and Out-of-Hospital Subject to Deductible and 60% Coinsurance. Out-of-Network Benefits payable are the same as for an office Visit to a Provider who is a doctor specializing in: family practice, general practice, internal medicine, or pediatrics. If you enroll your eligible Dependents at the same time, their coverage will become effective on the same date as your own. You should, however, contact your benefits representative quickly to replace the lost card. You cannot let anyone other than you or a Dependent use your card or your coverage. Types Of Coverage Available You may enroll under one of the following types of coverage: fi Single provides coverage for you only. If you marry, you should arrange for enrollment changes within 31 days before or after your marriage. If: (a) you gain or lose a member of your family; or (b) someone covered under this Program changes family status, you should check this Booklet to see if coverage should be changed. For example: fi If you are already enrolled, your newborn infant or adopted child is automatically included. Enrollment is requested within 31 days after: (a) the date of exhaustion of the coverage described in item (c)(i) above; or (b) termination of the coverage or employer contributions as described in item (c)(ii) above. You are covered under the Program (or have met any Waiting Period and are eligible to enroll but for a failure to enroll during a previous enrollment period).

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Rhinitis is characterized by 1 or more of the following dren below age 6 years symptoms: nasal congestion rheumatoid arthritis dogs purchase discount naproxen, rhinorrhea (anterior and posted Recommendation of considering second-generation antirior) arthritis diet webmd order 250 mg naproxen with amex, sneezing rheumatoid arthritis in 20s 500 mg naproxen mastercard, and itching arthritis in neck and headaches discount naproxen 250mg line. D histamines as safe agents for use during pregnancy d Use of intranasal corticosteroids for symptoms of allergic conjunctivitis associated with rhinitis Differential diagnosis of rhinitis and associated d Consideration of using a Rhinitis Action Plan conditions d Emerging diagnostic and surgical procedures, such as 2. Rhinitis should be classified by etiology as allergic or nonacoustic rhinometry and radiofrequency volumetric tissue allergic and differentiated from conditions that mimic sympreduction toms of rhinitis. Symptoms of allergic rhinitis may occur only during Associated allergic conjunctivitis specific seasons, may be perennial without seasonal exacer17. Allergic rhinitis is often accompanied by symptoms of allerbation, may be perennial with seasonal exacerbations, or gic conjunctivitis. Episodic allergic rhinitis is a new rhinitis category that detopical ophthalmic agents is useful for specific treatment notes allergic nasal symptoms elicited by sporadic exposures of associated ocular symptoms. The severity of allergic rhinitis ranges from mild and interantihistamines have similar effectiveness in relieving ocular mittent to seriously debilitating. Although there is no generally accepted method of grading the severity of rhinitis, the clinician may want to consider a graphic rating scale. Mixed rhinitis (combined allergic and nonallergic rhinitis) is Nonallergic rhinitis syndromes noted in approximately 44% to 87% of patients with allergic 20. Nonallergic rhinitis is characterized by periodic or perennial rhinitis and is more common than either pure allergic rhinitis symptoms of rhinitis that are not a result of IgE-dependent or nonallergic rhinitis. Allergic rhinitis affects 30 to 60 million people in the United States annually, including 10% to 30% of adults and as Vasomotor rhinitis many as 40% of children. The infiuence of early childhood exposure to infections, animals, and secondary tobacco smoke on the development of Rhinitis from foods and alcohol atopy and allergic rhinitis is still unknown. Food allergy is a rare cause of rhinitis without to loss of workplace productivity resulting from the disease associated gastrointestinal, dermatologic, or systemic maniare substantial. The symptoms of allergic rhinitis result from a complex a large number of viruses, but secondary bacterial infection allergen-driven mucosal infiammation caused by interplay with sinus involvement may be a complication. Symptoms between resident and infiltrating infiammatory cells and of acute infectious rhinosinusitis include nasal congestion, a number of vasoactive and proinfiammatory mediators, mucopurulent nasal discharge, pain and pressure, headache, including cytokines. Sensory nerve activation, plasma olfactory disturbance, postnasal drainage, and cough. Each type of response is characterized rial infections are suspected do not add diagnostic value. C by sneezing, congestion, and rhinorrhea, but congestion predominates in the late phase. The length of seasonal expodisease as demonstrated by absence of positive skin tests and/or specific IgE antibodies in the serum. C sure to these allergens is dependent on geographic location and climatic conditions. Perennial allergic rhinitis is caused by an IgE-mediated reaction to perennial environmental aeroallergens. These Occupational rhinitis may include dust mites, molds, animal allergens, or certain 26. Occupational rhinitis is rhinitis arising in response to airoccupational allergens, as well as pollen in areas where polborne substances in the workplace, which may be mediated len is prevalent perennially. An effective evaluation of the patient with rhinitis often inHormonal rhinitis cludes the following: a determination of the pattern, chronicity, and seasonality of nasal and related symptoms (or lack 27. Causes of hormonal rhinitis include pregnancy and menthereof); response to medications; presence of coexisting strual cycle–related rhinitis. Pregnancy rhinitis, when preconditions; occupational exposure; and a detailed environsent, is associated with significant nasal congestion, starts mental history and identification of precipitating factors. Evaluation of rhinitis therapy should include assessment of within 2 weeks after delivery. Drug-induced rhinitis may be caused by a number of medications, including angiotensin-converting enzyme 37. The nasal examination supports but does not definitely medicamentosa is a syndrome of rebound nasal congestion establish the diagnosis of rhinitis. Treatment of primary and secondary atrophic rhinitis inindicated to provide evidence of an allergic basis for the volves reducing crusting and alleviating the foul odor by patient’s symptoms, to confirm or exclude suspected causes continuous nasal hygiene, such as nasal lavage and crust deof the patient’s symptoms, or to assess the sensitivity to a bridement, and the use of topical and/or systemic antibiotics specific allergen for avoidance measures and/or allergen when purulent secretions or an acute infection is present. Skin tests are the preferred tests for the diagnosis of IgE-mediated sensitivity. The number of skin tests and the allergens Conditions that mimic rhinitis selected for skin testing should be determined on the basis of Nasal polyps the patient’s age, history, environment, and living situation, such as area of the country, occupation, and activities. Nasal polyps may occur in conjunction with chronic rhinitis or sinusitis and may contribute significantly to the patient’s symptoms. Nasal polyps should always be considered in the In vitro assays for specific IgE differential diagnosis of patients who present with invariant 40. The precise sensitivity of specific IgE immunoassays comnasal congestion and/or anosmia and its sequelae. Allergy as pared with skin prick/puncture tests is approximately 70% a cause of nasal polyps has not been established, but nasal to 75%. Immunoassays have similar sensitivity to skin tests polyps may occur in conjunction with allergic rhinitis. C in identifying those patients with nasal symptoms elicited after natural or controlled allergen challenge tests. Interpretation of specific IgE immunoassays may be confounded by variables such as potency of allergens bound 31. Signs and symptoms suggestive of rhinitis can be produced to solid support systems, cross-reactive proteins and glycoby other conditions, including nasal septal deviation, tuepitopes, specific IgG antibodies in the test serum, and mors, and hypertrophy of the nasal turbinates. In infants and young children, nasal congestion or obstruction can result from structural problems, such as cleft palate and adenoidal hypertrophy, or functional problems, such as Special diagnostic techniques laryngopharyngeal refiux. In selected cases, special techniques such as fiber optic nasal endoscopyand/or rhinomanometry may beuseful inevaluating Cerebral spinal fiuid rhinorrhea patients presenting with rhinitis symptoms. Refractory clear rhinorrhea may be a result of cerebral spinal quire special expertise for performance and interpretation. Nasal smears for eosinophils are not necessary for routine Ciliary dysfunction use in diagnosing allergic rhinitis when the diagnosis is 34. Avoidance is the most effective way to manage animal senbeen relied on as a clinical screening test, it cannot be relied sitivity. Nasal biopsy may be indicated when determining whether a ularly in inner-city populations. The best treatment for rhinitis triggered by irritants, such as mality in the ultrastructure of cilia. The measurement of total IgE and IgG subclasses for the diagnosis of allergic rhinitis has limited value and should not be routinely performed. The presence of b-2-transferrin in the nasal secretions is a Pharmacologic therapy sensitive method of confirming cerebral spinal fiuid rhinorOral antihistamines rhea. Second-generation antihistamines are generally preferred over first-generation antihistamines for the treatment of allergic rhinitis. First-generation antihistamines have signifSpecial testing considerations in children icant potential to cause sedation, performance impairment, and anticholinergic effects. Before prescribing or recommending a first-generation antihistamine, the physician should ensure that the patient Testing for comorbid conditions understands both the potential for adverse effects and the 49. A formal evaluation for obstructive sleep apnea may be conavailability of alternative antihistamines with a lower likelisidered in children and adults presenting with chronic rhinihood of adverse effects. Pulmonary function tests should be considered in patients ofenadine, loratadine, and desloratadine do not cause with rhinitis to assess the possibility that asthma might be sedation at recommended doses; loratadine and desloratapresent. D dine may cause sedation at doses exceeding the recommended dose; cetirizine and intranasal azelastine may cause sedation at recommended doses. Among the newer, nonsedating antihistamines, no single Tests without diagnostic validity agent has been conclusively found to achieve superior over51. C diagnostic validity for allergic rhinitis: cytotoxic tests, provocation-neutralization, electrodermal testing, applied kinesiology, iridology, and hair analysis. B (see ‘‘Allergy Intranasal antihistamines 9 Diagnostic Testing: An Updated Practice Parameter’’) 65. Intranasal antihistamines may be considered for use as firstline treatment for allergic and nonallergic rhinitis. Intranasal antihistamines are efficacious and equal to or suEnvironmental control measures perior to oral second-generation antihistamines for treatment of seasonal allergic rhinitis.

Treatment of fibroids: the use of beets (Beta vulgaris) and molasses (Saccharum officinarum) as an herbal therapy by Dominican healers in New York City rheumatoid arthritis white blood cells buy generic naproxen pills. Estimation of estrogenic and toxic potencies of sugar beet plant (Beta vulgaris) and silage in mice arthritis lupus diet buy naproxen 500mg visa. Prophylactic effect of a Beta vulgaris extract on experimental influenza infection in mice can arthritis in neck make you dizzy best purchase naproxen. Traditional Preparation: the leaves can be cooked (either as a vegetable or in a soup) or liquefied to is arthritis in the back a disability buy discount naproxen 500 mg on line make a fresh juice (zumo) and consumed as a nutritional foodstuff. Traditional Uses: Due to the disagreeable taste of the fresh juice, a small amount of fresh lemon/lime (limon) or carrot (zanahoria) juice can be added to make the juice more palatable and nutritious. In the Dominican Republic, the leaves are reputed to have wound-healing properties and are applied externally as a poultice (Liogier 2000). Availability: As a common vegetable, repollo can be purchased from most grocery stores, supermarkets and farmers’ markets in New York City. Leaves are fleshy, smooth and, at the top of the plant, are tightly wrapped around each other forming a cabbage head; in color, they are blue-green, pale whitish-green or purple with visible, white veination; leaf edges are straight or slightly wavy. Flowers grow in clusters at the top of the plant and are 4-petaled and whitishor golden-yellow. Extracts of this plant were shown to be nontoxic in animal studies (Yurtsever & Yardimci 1999). Contraindications: Thyroid conditions: Caution is advised in patients with conditions such as hypothyroidism and euthyroid goiter which diminish thyroid function because the ingestion of cabbage leaves can reduce or interfere with iodine absorption (Brinker 1998). Drug Interactions: Prothrombopenic anticoagulants: Anticoagulants such as bishydroxycoumarin (Dicoumarol), warfarin (Coumadin) and acenocoumarol may be antagonized or hindered by concomitant use of cabbage leaves due to their high Vitamin K content. Hypothyroid medications: Because cabbage leaves are goitrogenic, they may reduce thyroid iodine uptake and interfere with thyroid treatment (Brinker 1998). Indications and Usage: Repollo leaves can be eaten raw, prepared as a fresh juice or taken in pill form. Typical administration and dosage is 1 liter of juice taken daily for 3 weeks; duration of treatment not to exceed 6 weeks (Gruenwald et al. Evaluation of the gastric antiulcerogenic effect of Solanum nigrum, Brassica oleracea and Ocimum basilicum in rats. Traditional Preparation: For the common cold or flu, the bark (cascara or corteza) is prepared as a tea. Traditional Uses: this herbal remedy is attributed bitter and astringent properties. To treat menstrual disorders, uterine fibroids, delayed menses and painful periods, the bark is added to multi-herb preparations (botellas) that are used for treating a variety of women’s health conditions or taken as a simple decoction. In the 392 Dominican Republic, a decoction of the bark is used for treating stomach ache and abdominal pain (Germosen-Robineau 2005). Availability: In New York City, this plant is available for sale in select botanicas (Latino/Afro-Caribbean herb and spiritual stores) which specialize in selling medicinal plants from the Caribbean. Leaves are arranged in opposite pairs along branches and are narrowly oval to lance-shaped and grow 10 13 cm long with long leaf-stems. Flowers grow in branching, pendulous clusters with bell-shaped petals that are white in color with pink or purple fine lines. Fruits are long, slender capsules that split into 2 segments when ripe and contain numerous seeds adorned by a tuft of hairs at each end (Bailey Hortorium Staff 1976). Distribution: this plant is native to the Caribbean and is planted in South Florida (Bailey Hortorium Staff 1976). This plant is often cultivated as an ornamental tree for its showy flowers and is also used for timber. Daily administration of the extract for 30 days did not result in death during this study at doses of 6. Aqueous and organic fractions of the crude bark extract, administered orally at doses of up to 5 g/kg in mice did not induce observable signs of toxicity (Souza Brito 1995). Catalposide, a compound isolated from catalpa ovata, attenuates induction of intestinal epithelial proinflammatory gene expression and reduces the severity of trinitrobenzene sulfonic Acid-induced colitis in mice. Traditional Preparation: First, the spines are removed from the leaf to prevent injury, then the leaf is cut along the sides and opened to reveal a yellowish-greenish-gel inside. This gel is either placed in water for a period of time and then strained for use in internal preparations or applied topically to the affected area for external applications. Sometimes the entire leaf is cut open and placed directly on to a wound or other injury as a bandage to facilitate healing. For treating skin conditions such as cuts, scrapes, skin abrasions, sunburn, wounds, fungal infections and boils (nacios), the gel (cristal) is applied locally to the affected area. Sabila is also used for the common cold and flu (gripe) and is prepared by combining the clear gel from inside the leaf with any or all of the following additional ingredients: honey (miel), lemon/lime (limon), garlic (ajo), onion (cebolla) and/or shallots (cebollin). This mixture is liquefied in a blender and typically stored covered in a glass container in the refrigerator. As a remedy, this raw “syrup” preparation is administered orally in small amounts (by the spoonful). Another remedy for symptoms of the common cold (catarro or resfriado) and pulmonary infections is sabila gel added to coffee (cafe). Availability: Fresh leaves can sometimes be purchased from grocery stores and supermarkets. Aloe vera gel can be found at most pharmacies, drug stores, supermarkets and health food stores. The leaves have a succulent, thick, stiff texture due to the clear watery sap or “gel” that they contain and are lined with reddish-tipped, spinelike teeth along the edges. Flowers grow in dense, branching clusters and are yellow to orangish in color, tubular in shape and borne atop a long, leafless stalk (Acevedo-Rodriguez 1996). Distribution: Native to the Mediterranean and northern Africa, this plant has been naturalized in warm and arid conditions, can be found in disturbed areas throughout Latin America and the Caribbean and is cultivated widely (Acevedo-Rodriguez 1996). Rare cases of the following additional adverse reactions have been reported: arrhythmia, nephropathies, edema and accelerated bone deterioration. Due to the anthraquinone content of aloe latex, internal administration of this plant may stimulate uterine muscle activity or cause abortion (Gruenwald et al. Prolonged exposure of skin to the fresh gel or preparations made with the gel may result in contact dermatitis, skin irritation and hypersensitivity, so caution is recommended. Animal Toxicity Studies: Toxic effects were shown in animal studies when mice were administered 100mg/kg of an alcohol extract of Aloe vera in water for 3 months (Shah et al. However, the 397 relevance of this study is questionable because this plant is primarily used fresh or as a decoction rather than as an alcohol extract. Contraindications: Not to be used by pregnant or lactating women or by children under 12 years of age. Contraindicated for those with intestinal obstruction, inflammatory intestinal diseases such as Crohn’s disease and ulcerative colitis, any type of ileus, appendicitis and abdominal pain of unknown origin (Gruenwald et al. Caution is advised when taken internally for in high doses for prolonged periods of time as this may lead to damage to enteric nervous tissue, pigmentation in the intestinal mucosa (Pseudomelanosis coli), albuminuria, hematuria, electrolyte loss, potassium depletion and hypokalemia (Gruenwald et al. Drug Interactions: Cardiac glycosides and antiarrhythmic drugs: Because chronic use of Aloe can result in potassium loss which intensifies the effects of cardiac glycosides and antiarrhythmic drugs, concomitant use should be avoided and monitored for digoxin toxicity and potassium levels. Thiazide diuretics, loop diuretics, licorice and corticosteroids: due to increased potential for potassium deficiency when Aloe is used in combination with these drugs, avoid concomitant use. Antidiabetic agents: when taken with Aloe, can lead to increased risk of hypoglycemia; if administered concomitantly, monitor blood glucose levels and signs or symptoms of hypoglycemia (Gruenwald et al. Indications and Usage: Approved by the German Commission E for treatment of constipation (Blumenthal et al. Preparations of Aloe vera are available for internal use as capsules (250 mg, 470 mg), softgel capsules (1000 mg), powder, aqueous extracts and aqueous alcoholic extracts in powdered or liquid form. Recommended daily dosage is 20-30 mg hydroxyanthracene derivatives per day (calculated as anhydrous aloin); this translates as 0. For external use, fresh gel from the leaf or stabilized gel and cream preparations may be used as needed (Gruenwald et al. Relative efficacy of three medicinal plant extracts in the alteration of thyroid hormone concentrations in male mice. In vitro enzyme inhibition of crude ethanolic extracts derived from medicinal plants of Pakistan.

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