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By: Z. Bram, M.B. B.CH. B.A.O., Ph.D.
Clinical Director, VCU School of Medicine, Medical College of Virginia Health Sciences Division
It is very difficult to isolate critical treatment elements in complex interventions and use of some elements in isolation may underestimate their importance if the components are dependent on each other or interact with each other blood pressure chart over 60 buy generic aceon 8 mg online, or if individuals vary in the degree to which specific components are necessary or sufficient to gain improvements pulse pressure 65 generic 8mg aceon amex. Thus, critical intervention components often cannot be elucidated, particularly in a relatively poor and heterogeneous body of research. Strength of Evidence In most cases, the strength of evidence was insufficient or low. The evidence that hyperventilation reduction breathing techniques can reduce asthma symptoms and reliever medication use was judged moderate, as was evidence that hyperventilation reduction approaches are unlikely to improve pulmonary function. Results were primarily limited to 6 months or less, so applicability is limited to short-term outcomes. However, given the evidence supporting a beneficial effect of hyperventilation reduction training on reliever medication use, in particular, patients with poorly controlled asthma who are motivated to use complementary and alternative methods to reduce their use of medication and avoid overuse of reliever medications may be good candidates to try these techniques, if they can find a practitioner with the appropriate training. There are approximately 50 certified Buteyko practitioners in the United States, practicing in at least 21 states. Most practitioners were located in complementary and alternative medicine settings. Some trials showed a benefit of treatment related methods that were not described as "Buteyko," specifically, conducted by respiratory therapists who were not Buteyko practitioners but had special training in hyperventilation reduction methods. Even among Buteyko practitioners, however, there is disagreement as to what constitutes necessary and sufficient training, so some certified practitioners likely would not be universally recognized as having the appropriate training. Participants in the hyperventilation reduction trials were on average using relievers more frequently than twice per week at baseline, generally averaging about two puffs per day or more. This was achieved without increases in asthma symptoms, exacerbations, or declines in lung function. For people whose asthma is not well controlled, hyperventilation reduction techniques may provide a lowrisk approach to achieve better control and avoid overuse of reliever medications. Participants in the trials were admonished only to reduce the use of controller medications in consultation with their medical providers, and this is a very important safety consideration for all users of these techniques. Inflammation may increase with reduction in controlled medications without the patient realizing it, and lead to longer term exacerbations. Hyperventilation reduction techniques may be a useful asthma management tool, along with medication and other components such as environmental controls, symptom monitoring, and a plan for handling exacerbations. The body of evidence for yoga is smaller and at higher risk of bias than the evidence for hyperventilation reduction techniques, but there is limited evidence suggesting that intensive yoga training may reduce asthma symptoms and improve lung function. Patients who would like to undertake intensive training need not be discouraged, but again should not change their use of asthma medication without consulting with their medical provider. Limitations There were several limitations and potential limitations to our review, both in our approach to the review and in the evidence base. In terms of our approach, potential limitations include the fact that we did not include non-English publications, that we excluded "poor-quality" publications, that we excluded trials that used relaxation training as a comparison group, that we relied on personal communication with authors for some data, and that we were unable to locate seven publications that could possibly have been eligible for inclusion in the review. There were no trials rated as "good" quality and a number of trials could barely be considered "fair" quality. There was only one trial that could be considered large, and more than half of the trials included 25 or fewer participants per treatment group. Outcome reporting was very heterogeneous and inconsistent, with important outcomes missing in many trials, and outcomes assessment was not consistently blinded. In addition, there was little consistency of asthma-related terms used in these trials, and terms were sometimes used vaguely or differently, making it difficult to characterize interventions. Other strengths include extensive input from experts during protocol development, rigorous adherence to inclusion/exclusion rules, and conservative use of meta-analysis. Future Research Additional evidence would improve our understanding for all intervention types. Future trials should detail breathing retraining techniques, as described by Bruton,46 and these trials should include asthma symptoms outcomes, reliever medication use, quality of life, and pulmonary function at minimum. For hyperventilation reduction techniques, top priorities for future research include replication of results of the large, good-quality trial with intensity-matched comparator, trials that attempt to isolate the necessity or efficacy of specific components of treatment, and trials focused on hyperventilation reduction techniques in children. A well-designed and executed replication of a high-intensity yoga breathing approach in the United States, without additional nonyoga components would be an important next step for the use of yoga in asthma. American Lung Association - Epidemiology and Statistics Unit Research and Program Services Division. Vital signs: asthma prevalence, disease characteristics, and self-management education - United States, 2001-2009.
Spirometry results did not change over time in either the trial of prolonged exhalation using a training device52 or in any of the treatment groups in the biofeedback trial (Appendix D blood pressure patch buy cheap aceon on line, Evidence Table 5f) blood pressure zantac buy 2 mg aceon. Benefits were more likely to be seen if the control group did not involve breathing training of any kind or relaxation techniques (42% positive vs. These data are preliminary, however, and only valid for hypothesis generation and did not account for effect size. Seven trials reported on adverse events,51,53,55,57,58,61,62 five of which examined a hyperventilation reduction approach compared with either a control or another breathing retraining approach,51,53,55,57,58 and two examined yoga interventions. Quality and applicability issues: hyperventilation reduction breathing techniques versus control Excluded Those With Other Resp. Quality and applicability issues: hyperventilation reduction breathing techniques versus control (continued) Excluded Those With Other Resp. Quality and applicability issues: hyperventilation reduction breathing techniques versus nonhyperventilation reduction breathing techniques Excluded Those With Other Resp. Quality and applicability issues: hyperventilation reduction breathing techniques versus nonhyperventilation reduction breathing techniques (continued) Excluded Those With Other Resp. Quality and applicability issues: yoga breathing techniques versus control Blinding of Outcomes Assessment Excluded Those With Other Resp. Quality and applicability issues: yoga breathing techniques versus control (continued) Blinding of Outcomes Assessment Excluded Those With Other Resp. Quality and applicability issues: inspiratory muscle training versus control Blinding of Outcomes Assessment Excluded Those With Other Resp. Quality and applicability issues: inspiratory muscle training versus control (continued) Blinding of Outcomes Assessment Excluded Those With Other Resp. Quality and applicability issues: other nonhyperventilation reduction breathing techniques versus control Excluded Those w/ Other Resp. All trials were rated "Fair"; further gradation is provided as follows: +++ = Minor quality issues, but not meeting criteria for "Good" quality; ++ = Between +++ and + trials in quality; + = Substantial quality issues, but no clear fatal flaw 58 Summary and Discussion Overview of Main Findings Available evidence suggests that selected intensive behavioral approaches that include breathing retraining exercises may improve asthma symptoms and reduce reliever medication use in motivated adults with poorly controlled asthma. This suggestion, however, was based primarily on evidence from small, methodologically limited trials with widely heterogeneous samples. The evidence was further compromised by the relatively short followup and inconsistent outcome reporting (Table 15). Primary outcomes (symptom reduction and reliever medication use) were also self-reported, making them susceptible to social desirability bias. The largest, most coherent body of evidence for a specific breathing training technique assessed hyperventilation reduction techniques and showed they reduced asthma symptoms and reliever medication use. Yoga was the only technique with evidence that it may improve pulmonary function and symptoms. However, quality issues in these trials limit confidence in results and applicability to the U. The yoga practiced in these trials was likely more intensive than would available to most patients in the United States, for example 4 hours per day for 2 weeks, or daily 70-minute sessions for 6 months. Additionally, yoga may not have the same cultural significance in the United States as it does in India. Trials that matched treatment groups for number of hours of contact were less likely to show benefit than those providing extra hours of contact for the intervention group. These observations, however, should be considered hypothesis-generating rather than definitive for numerous reasons, including the lack of accounting for effect size and the high heterogeneity on numerous dimensions in these trials, which precludes clear isolation of the effects of any specific elements. Specific mechanisms of action for breathing training may be less important than enhanced selfefficacy, self-monitoring, and anxiety management.
Usually hypertension 39 weeks pregnant aceon 4mg without prescription, though not invariably prehypertension systolic normal diastolic purchase aceon 2 mg on-line, this behaviour is recognized by the individual as pointless or ineffectual and repeated attempts are made to resist it; in very long-standing cases, resistance may be minimal. Autonomic anxiety symptoms are often present, but distressing feelings of internal or psychic tension without obvious autonomic arousal are also common. There is a close relationship between obsessional symptoms, particularly obsessional thoughts, and depression. Individuals with obsessive-compulsive disorder often have depressive symptoms, and patients suffering from recurrent depressive disorder (F33. In either situation, increases or decreases in the severity of the depressive symptoms are generally accompanied by parallel changes in the severity of the obsessional symptoms. Obsessive-compulsive disorder is equally common in men and women, and there are often prominent anankastic features in the underlying personality. The course is variable and more likely to be chronic in the absence of significant depressive symptoms. Diagnostic guidelines For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. Includes: anankastic neurosis obsessional neurosis obsessive-compulsive neurosis Differential diagnosis. Differentiating between obsessive-compulsive disorder and a depressive disorder may be difficult because these two types of symptoms so frequently occur together. In an acute episode of disorder, precedence should be given to the symptoms that developed - 117 - first; when both types are present but neither predominates, it is usually best to regard the depression as primary. In chronic disorders the symptoms that most frequently persist in the absence of the other should be given priority. Although obsessional thoughts and compulsive acts commonly coexist, it is useful to be able to specify one set of symptoms as predominant in some individuals, since they may respond to different treatments. They are very variable in content but nearly always distressing to the individual. A woman may be tormented, for example, by a fear that she might eventually be unable to resist an impulse to kill the child she loves, or by the obscene or blasphemous and ego-alien quality of a recurrent mental image. Sometimes the ideas are merely futile, involving an endless and quasi-philosophical consideration of imponderable alternatives. This indecisive consideration of alternatives is an important element in many other obsessional ruminations and is often associated with an inability to make trivial but necessary decisions in day-to-day living. The relationship between obsessional ruminations and depression is particularly close: a diagnosis of obsessive-compulsive disorder should be preferred only if ruminations arise or persist in the absence of a depressive disorder. Underlying the overt behaviour is a fear, usually of danger either to or caused by the patient, and the ritual act is an ineffectual or symbolic attempt to avert that danger. Compulsive ritual acts may occupy many hours every day and are sometimes associated with marked indecisiveness and slowness. Overall, they are equally common in the two sexes but hand-washing rituals are more common in women and slowness without repetition is more common in men. Compulsive ritual acts are less closely associated with depression than obsessional thoughts and are more readily amenable to behavioural therapies. This subcategory should be used if the two are equally prominent, as is often the case, but it is useful to specify only one if it is clearly predominant, since thoughts and acts may respond to different treatments. Less severe psychosocial stress ("life events") may precipitate the onset or contribute to the - 118 - presentation of a very wide range of disorders classified elsewhere in this work, but the etiological importance of such stress is not always clear and in each case will be found to depend on individual, often idiosyncratic, vulnerability. In other words, the stress is neither necessary nor sufficient to explain the occurrence and form of the disorder. In contrast, the disorders brought together in this category are thought to arise always as a direct consequence of the acute severe stress or continued trauma. The stressful event or the continuing unpleasantness of circumstances is the primary and overriding causal factor, and the disorder would not have occurred without its impact. Reactions to severe stress and adjustment disorders in all age groups, including children and adolescents, are included in this category. Although each individual symptom of which both the acute stress reaction and the adjustment disorder are composed may occur in other disorders, there are some special features in the way the symptoms are manifest that justify the inclusion of these states as a clinical entity.
Syndromes
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In October of that year I was approached by a Japanese television network seeking an on-camera expert to investigate the apparent release of the nerve agent blood pressure medicine purchase aceon 2 mg otc, sarin pulse pressure 41 4mg aceon, during the previous June in the city of Matsumoto. In the course of my studies there, I concluded that the nerve agent attack had been deliberately planned and executed by an unknown but technically sophisticated group; that this attack had probably been a demonstration or field-test of a newly acquired capability; and that, in all likelihood, the terrorists would use sarin again, probably striking at a higher profile objective. In a report published in January of 1995 in both Japan and the United States, I speculated that a likely target might be the Tokyo subway at rush hour. In the six months following the now infamous March 20, 1995 poison gas attack on the Tokyo subway, I visited Japan eight more times and Russia once, gathering the information presented in this paper. Over the next several minutes, the packages began to leak a toxic chemical mixture including a significant quantity of sarin. The original plan of attack had been to place the nerve gas on six different trains on three separate lines, all converging on the center of Tokyo. Because of an insufficient supply of sarin, the attackers chose to attack only one train on the Chiyoda line, so as a result there were only five trains attacked. Some initial reports suggested more than 5,500 victims, but Tokyo authorities now lean toward the lower number. Of those 3800 injured, approximately 1,000 required hospitalization, some of those victims still being hospitalized at this time. Japan Ground Defense Force chemical troops mobilized and moved from their base, located approximately two hours north of Tokyo, into the center city within four hours of being notified. Interestingly, neither the medical community nor the fire and emergency agencies had been pulled into the planning process. Police determined, for one reason or another, that it was not necessary to have them involved. It is also perhaps not surprising that a significant number of the casualties were firefighters and transit personnel who went into subway stations in an effort to try and address the problem that morning. Within hours of the subway attack, Japanese police publicly focused their attention on a relatively obscure religious sect, the Aum Shinrikyo ("Supreme Truth"). Police raids and arrests began within 48 hours and have continued to the present day. Since March of 1995, there have been at least five additional gas attacks on train stations in Japan, as well as dozens of scares and false alarms involving everything from sewer gas to mis-adjusted gas cooking stoves. Two of the follow-on train station incidents were nuisance attacks, the work of a copycat inspired by the subway attack, involving a tear gas or mace-type compound. In three other instances, however, attacks linked to the Aum Shinrikyo cult involved the use of devices designed to produce cyanide gas. Because of these acts, documented with relentlessly singular focus by the omnipresent Japanese media, fear is a lingering element in the country. Small wonder the Japanese have come to refer to 1995 (which was also marked by a continuing weak economy and the destructive Kobe earthquake) as having been their annus horribilis, or "horrible year. Although the Tokyo attack caught most people around the world by complete surprise, it did not occur without warning. In fact, there were actually a number of highly visible warnings and precursors, which can only lead an observer to one possible conclusion: the Tokyo attack was anticipated. There is overwhelming reason to assume that Japanese authorities had specific knowledge of the danger posed by the Aum Shinrikyo, probably months before the attack. By comparison, there is little question that foreign intelligence services, including the Central Intelligence Agency and the rest of the American intelligence community, either misunderstood or simply dismissed a number of threat warnings. The failure to note and anticipate the threat of Aum Shinrikyo, however, continues to raise questions about our capacity to anticipate and deter other, more subtle terrorist threats. For those who paid attention, the indications that something was very wrong in the Land of the Rising Sun were obvious. A mysterious terrorist attack involving the unprecedented use of nerve gas, this incident received virtually no media play outside of Japan. The results of a police investigation, not made public until January 1, 1995, revealed the presence of a unique degradation product of sarin.
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