The motor nucleus lies in the lower pons medial to the descending nucleus and tract of the Vth cranial nerve anxiety 30 minute therapy discount 150mg effexor xr otc. They enter the internal auditory meatus and anxiety 8 year old cheap 37.5 mg effexor xr free shipping, passing through the facial canal of the temporal bone anxiety disorder treatment buy discount effexor xr 37.5mg on-line, lie in close proximity to the inner ear and tympanic membrane relieve anxiety symptoms quickly buy generic effexor xr 150mg on line. The facial nerve gives off several branches before exiting from the skull through the stylomastoid foramen anxiety symptoms face numbness cheap 150mg effexor xr free shipping. They run together as the nervus intermedius and accompany the facial nerve to the internal auditory meatus anxiety symptoms help 75 mg effexor xr with amex. The parasympathetic fibres (visceral efferent) pass in the greater petrosal nerve to the sphenopalatine ganglion and thence to the lacrimal gland to produce tears and in the chorda tympani nerve to the submandibular ganglion 8 tracks anxiety buy effexor xr 75mg online. Facial nerve Visceral afferent Parasympathetic efferent Facial nerve Chorda tympani nerve Tongue Nervus intermedius Pons Superior salivatory nucleus Nucleus and tractus solitarius Sublingual gland Submandibular ganglion/gland the chorda tympani nerve contains both parasympathetic efferent and visceral afferent fibres anxiety symptoms memory loss buy effexor xr 75mg amex. Visceral afferent fibres convey sensations of taste from the anterior two-thirds of the tongue. The geniculate ganglion contains the bipolar cell bodies of these afferent fibres. Supranuclear control of facial muscles the muscles in the lower face are controlled by the contralateral hemisphere, whereas those in the upper face receive control from both hemispheres (bilateral representation). Hence a lower motor neuron lesion paralyses all facial muscles on that side, but an upper motor neuron (supranuclear) lesion paralyses only the muscles in the lower half of the face on the opposite side. Clinical examination of the facial nerve (see page 15) In addition to examining for facial weakness and taste impairment, also note whether the patient comments on reduced lacrimation or salivation on one side, or hyperacusis (exaggeration of sounds due to loss of the stapedius reflex). Symptoms Pain of variable intensity over the ipsilateral mastoid precedes weakness, which develops over a 48-hour period. Impairment of taste, hyperacusis and salivation depend on the extent of inflammation and will be lost in more severe cases. Diagnosis Based on typical presentation and exclusion of middle ear disease, diabetes, sarcoidosis and Lyme disease. There is good evidence prednisolone given in high dosage in the acute stage (50 mg per day for 10 days) improves recovery. The role of antiviral therapy is less clear as conflicting results have been found in recent large trials. Eye care (shielding and artificial tears) is important in preventing corneal abrasion. In patients with complete paralysis, electrical absence of denervation on electromyography is an optimistic sign. The stapedius muscle can be affected producing a subjective ipsilateral clicking sound. Contractions are irregular, intermittent and worsened by emotional stress and fatigue. Most cases arise from vascular compression of the facial nerve at the root entry zone (in the same way as trigeminal neuralgia). Flickering of facial muscles results from spontaneous discharge in the facial motor nucleus. Sound waves are transmitted by the tympanic membrane and the ossicles to the oval window, setting up waves in the perilymph of the cochlea. Vestibular function: the vestibular system responds to rotational and linear acceleration (including gravity) and along with a visual and proprioceptive input maintains equilibrium and body orientation in space. Linear acceleration results in displacement of the otoliths within the utricle or saccule. The cochlear (acoustic) and vestibular divisions travel together through the petrous bone to the internal auditory meatus where they emerge to pass through the subarachnoid space in the cerebellopontine angle, each entering the brain stem separately at the pontomedullary junction. Third order neurons from the inferior colliculus on each side run to the medial geniculate body on both sides. Fourth order neurons pass through the internal capsule and auditory radiation to the auditory cortex. The bilateral nature of the connections ensures that a unilateral central lesion will not result in lateralised hearing loss. Second order neurons arise in the vestibular nucleus and descend in the ipsilateral vestibulospinal tract. Sensorineural deafness: failure of action potential production or transmission due to disease of the cochlea, cochlear nerve or cochlear central connections. Further subdivision into cochlear and retrocochlear deafness helps establish the causative lesion. Pure word or cortical deafness: a bilateral or dominant posterior temporal lobe (auditory cortex) lesion produces a failure to understand spoken language despite preserved hearing. Tinnitus may be (i) continuous or intermittent, (ii) unilateral or bilateral, (iii) high or low pitch. Vertigo may result from disease of the labyrinth, vestibular nerve or their central connections. Occasionally patients perceive a vibratory noise inside the head, transmitted from an arteriovenous malformation or carotid stenosis. Preganglionic parasympathetic fibres arise in the Medulla inferior salivatory nucleus and pass to the otic ganglion. General somatic sensory fibres innervate the area of skin behind the ear, pass to the superior ganglion and end in the nucleus and tract of the trigeminal Olivary nerve. Sensory fibres innervate the posterior third of the tongue (taste), pharynx, eustachian tube and carotid Corticospinal body/sinus and terminate centrally in the nucleus solitarius. Within the neck the nerve lies in close proximity to the internal carotid artery and internal jugular vein. The superior and inferior ganglia lie in the jugular foramen, the otic ganglion in the neck below the foramen ovale. Reflex bradycardia and syncope occur due to stimulation of vagal nuclei by discharges from glossopharyngeal. The central connections are complex though similar to those of the glossopharyngeal nerve. Motor fibres supplying the pharynx, soft palate and larynx arise in the nucleus ambiguus. Afferent fibres from the pharynx, larynx and external auditory meatus have cell bodies in the jugular ganglion and end in the nucleus and tract of the trigeminal nerve. Afferent fibres from abdominal and thoracic viscera have cell bodies in the nodose ganglion and end in the nucleus solitarius. Pharyngeal weakness Pharyngeal muscles are represented by the middle part of the nucleus ambiguus. Fibres to adductors and abductors of the vocal cords are supplied by the laryngeal nerves. Pharyngeal and palatal involvement cause marked dysphagia and nasal regurgitation. Bilateral recurrent laryngeal nerve lesions cause stridor and breathlessness on exertion. The cranial portion of the accessory nerve arises from the lowest part of the nucleus ambiguus in the medulla. The spinal part arises in the ventral grey matter of the upper five cervical segments, ascends alongside the spinal cord and passes through the foramen magnum. After joining with the cranial portion it exits as the accessory nerve through the jugular foramen. The supranuclear connections act on the ipsilateral sternomastoid (turning the head to the contralateral side) and on the contralateral trapezius. Unilateral lower motor neuron weakness produces a lower shoulder on the affected side (trapezius) and weakness in turning the head to the opposite side (sternomastoid). Since each nucleus is bilaterally innervated, a unilateral supranuclear lesion will not produce signs or symptoms. A bilateral supranuclear lesion results in a thin pointed (spastic) tongue which cannot be protruded. Polyneuritis cranialis Multiple cranial nerve palsies of unknown aetiology which spontaneously remit. Myasthenia gravis may present with a weakness of the bulbar musculature (see page 482). Tentorium cerebelli Midbrain Pons Medulla Occipital bone Cerebellum Cerebellar tonsil Inferior surface Cerebellar tonsil Vermis Midbrain Superior surface Primary fissure Superior vermis Medulla Flocculus Vagus nerve and Glossopharyngeal nerve roots Three major phylogenetic subdivisions of the cerebellum are recognised. The anterior lobe (paleocerebellum) Receives afferent fibres from (spinocerebellar pathways) in the spinal cord. Receives afferent fibres and projects efferent fibres from and to motor cortex/vestibular nuclei, basal ganglia and pons. Deep within the cerebellar hemispheres in the roof of the 4th ventricle, lie four paired nuclei separated by white matter from the cortex. These pass either to the deep nuclei of the cerebellum and thence to the brain stem, or to the vestibular nuclei of the brain stem. From there fibres relay back to the cerebral cortex and thalamus, or project into the spinal cord, influencing motor control. The patient complains of impaired limb co-ordination and certain signs are recognised: Ataxia of extremities with unsteadiness of gait towards the side of the lesion. Eye movements Nystagmus results from disease affecting cerebellar connections to the vestibular nuclei. In unilateral disease, amplitude and rate increase when looking towards the diseased side. Whether dysarthria results from hemisphere or midline vermis disease remains debatable. Involuntary movements Myoclonic jerks and choreiform involuntary movements occur with extensive cerebellar disease involving the deep nuclei. The presence and characteristics of such movements help localise to the site of neurological disease. If nystagmus is detected, note the type (jerk or pendular), direction (of fast phase) and degree. Nystagmus is: Rapid Pendular (lacks slow and fast phase) Increased when looking to sides Persistent throughout lifetime 184 Occurs in congenital cataract, congenital macula defect, albinism. Creates an imbalance between each side resulting in a slow drift of the eyes towards the damaged side (or side with the reduction in stimulus) followed by a fast compensatory movement to the opposite side. Physiological (i) Rotational acceleration produces nystagmus in the plane of rotation. Slow Fast Slow Fast (ii) Caloric testing sets up convection currents in the lateral semicircular canal producing a horizontal nystagmus (see page 65). Turning eyes away from the side of the lesion increases amplitude but does not change direction of nystagmus. In severe cases, the nystagmus is 3rd degree and gradually settles to 1st degree with recovery. The nystagmus may be horizontal, vertical, rotatory or dissociated (present in one eye only). This may be distinguished from labyrinthine disease by: Absence of delay before onset, lack of fatiguing with repetitive testing, and a tendency to occur with any rather than one specific head movement. Although nystagmus often occurs in cerebellar disease, the role of the cerebellum in its production remains unclear. The disorder characteristically occurs in multiple sclerosis but also in brain stem infarction, haemorrhage, trauma, syringobulbia and drug toxicity (phenytoin). Downbeat nystagmus Occurs with lesions around the aqueduct of Sylvius or cervicomedullary junction. See-saw nystagmus One eye intorts and moves up while the other extorts and moves down. Diagnosis depends on examination of the character of the tremor as well as the presence of other specific features. Pathological tremor occurs at rest or with movement, slow in rate, coarse in character, proximal or distal and often asymmetrical in distribution. The tremor may progress until handwriting becomes impossible and feeding difficult. Alcohol may temporarily abort the tremor; beta blockers may produce an improvement. Tremor during and maximal at the end of movement Tremor absent at rest; present during movement and maximal on approaching target. Such jerks occur repetitively in the same muscle groups and range from a flicker in a single muscle to contraction in a group of muscles sufficient to displace the affected limb. Several forms exist, some clearly related to epilepsy; others may be associated with damage to inhibitory mechanisms in the brain stem reticular formation. Myoclonus may result from pathological changes affecting a variety of different sites including the motor cortex, cerebellum and spinal cord. The movements may be accentuated or precipitated by visual, auditory or tactile stimulation. Repetitive stimulation may result in a crescendo of myoclonus which resembles a seizure. Physiological myoclonus occurs in sleep (hypnic jerks), with anxiety and in infants when feeding. This disorder is associated with degenerative changes in the olivary and dentate nuclei. Treatment Benzodiazepine drugs such as clonazepam may suppress myoclonic movements. Eyes open Eyes closed Sensory ataxia Stance normal Stance unsteady Vision compensates for proprioceptive loss. In mild cases: Tandem gait (heel-toe walking) is impaired; the patient falling to one or both sides. Sensory Disturbed conscious or unconscious proprioception due to interruption of afferents in peripheral nerves or spinal cord (posterior columns, spinocerebellar tracts). When walking, abduction and circumduction at the hip prevent the toes from catching on the ground. In paraplegia, strong adduction at the hips can produce a scissor-like posture of the lower limbs.
Because instructors do not necessarily need to possess the correct answer anxiety symptoms in 12 year olds effexor xr 37.5 mg lowest price, they need not be experts in the field being discussed anxiety meme buy effexor xr 150mg cheap. Rather anxiety getting worse effective 37.5mg effexor xr, the students become teachers and learn from each other through thoughtful discussion of the case anxiety symptoms ocd purchase effexor xr 150mg without a prescription. The cases in this book were prepared to correspond with the scientific information contained in the seventh edition of Pharmacotherapy: A Pathophysiologic Approach anxiety pregnancy buy cheap effexor xr 37.5 mg. Primary literature should also be consulted as necessary to supplement textbook readings anxiety symptoms paranoia buy effexor xr 37.5 mg with amex. Most of the cases in the casebook represent common diseases likely to be encountered by generalist pharmacy practitioners anxiety symptoms memory loss effexor xr 75mg. As a result anxiety coping skills effective effexor xr 75mg, not all of the Pharmacotherapy textbook chapters have an associated patient case in the casebook. On the other hand, some of the textbook chapters that discuss multiple disease entities have several corresponding cases in the casebook. Instructors may use this classification system to select cases for discussion that correspond to the experience level of the student learners. These levels are defined as follows: Level I-An uncomplicated case; only the single textbook chapter is required to complete the case questions. Prior clinical experience may be helpful in resolving all of the issues presented. These items indicate some of the functions that the student should strive to perform in the clinical setting after reading the textbook chapter, studying the case, preparing a pharmacotherapeutic plan, and defending his or her recommendations. The ability outcome statements provided are meant to serve as a starting point to stimulate student thinking, but they are not intended to be all-inclusive. In fact, students should also generate their own personal ability outcomes and learning objectives for each case. By so doing, students take greater control of their own learning, which serves to improve personal motivation and the desire to learn. Because pharmacists possess extensive knowledge of the thousands of prescription and nonprescription products available, they can perform a valuable service to the health care team by obtaining a complete medication history that includes the names, doses, routes of administration, schedules, and duration of therapy for all medications, including dietary supplements and other alternative therapies. Care should be taken to distinguish adverse drug effects ("upset stomach") from true allergies ("hives"). In some practice settings, only a limited and focused physical examination is performed. A suitable physical assessment textbook should be consulted for the specific procedures that may be conducted for each body system. In hospital settings, the presence and severity of pain is included as "the fifth vital sign. In particular, heritable diseases and those with a hereditary tendency are noted. This list is limited to commonly accepted abbreviations; thousands more exist, which makes it difficult for the novice practitioner to efficiently assess patient databases. Given the immense human toll resulting from medical errors, this section should be considered "must" reading for all students. These illustrations are provided as examples only and are not intended to imply endorsement of those particular products. Appendix A contains a number of commonly used conversion factors and anthropometric information that will be helpful in solving many case answers. Normal ranges for the laboratory tests used throughout the casebook are included in Appendix B. The normal range for a given laboratory test is generally determined from a representative sample of the general population. The upper and lower limits of the range usually encompass two standard deviations from the population mean, which includes a range within which about 95% of healthy persons would fall. The term normal range may therefore be misleading, because a test result may be abnormal for a given individual even if it falls within the "normal" range. Furthermore, given the statistical methods used to calculate the range, about 1 in 20 normal, healthy individuals may have a value for a test that lies outside the range. Reference ranges differ among laboratories, so the values given in Appendix B should be considered only as a general guide. All of the cases include some physical examination and laboratory findings that are within normal limits. For example, a description of the cardiovascular examination may include a statement that the point of maximal impulse is at the fifth intercostal space; laboratory evaluation may include a serum sodium level of 140 mEq/L. The presentation of actual findings (rather than simple statements that the heart examination and the serum sodium were normal) reflects what will be seen in actual clinical practice. More importantly, listing both normal and abnormal findings requires students to carefully assess the complete database and identify the pertinent positive and negative findings for themselves. A valuable portion of the learning process is lost if students are only provided with findings that are abnormal and are known to be associated with the disease being discussed. The patients described in this casebook have fictitious names in order to humanize the situations and to encourage students to remember that they will one day be caring for patients, not treating disease states. However, in the actual clinical setting, patient confidentiality is of utmost importance, and real patient names should not be used during group discussions in patient care areas unless absolutely necessary. To develop student sensitivity to this issue, instructors may wish to avoid using these fictitious patient names during class discussions. In this casebook, patient names are usually given only in the initial presentation; they are seldom used in subsequent questions or other portions of the case. When ethnicity is pertinent to the case, this information is presented in the social history or physical examination. Patients in this casebook are referred to as men or women, rather than males or females, to promote sensitivity to human dignity. The patient cases in this casebook include medical abbreviations and drug brand names, just as medical records do in actual practice. The advent of biotechnology has led to the introduction of unique compounds for the prevention and treatment of disease that were unimagined just a decade ago. Each year the Food and Drug Administration approves approximately two dozen new drug products that contain active substances that have never before been marketed in the United States. Although the cost of new therapeutic agents has received intense scrutiny in recent years, drug therapy actually accounts for a relatively small proportion of overall health care expenditures. Appropriate drug therapy is cost-effective and may actually serve to reduce total expenditures by decreasing the need for surgery, preventing hospital admissions, and shortening hospital stays. Several studies have indicated that improper use of prescription medications is a frequent and serious problem. Based on a decision analytic model, one study estimated that the cost of drug-related morbidity and mortality was more than $177 billion in 2000. Schools of pharmacy have implemented innovative instructional strategies and curricula that have an increased emphasis on patient-centered care, including more experiential training, especially in ambulatory settings. Many programs are structured to promote self-directed learning, develop problem-solving and communication skills, and instill the desire for lifelong learning. In its broadest sense, pharmaceutical care involves the identification, resolution, and prevention of actual or potential drug therapy problems. A drug therapy problem has been defined as "any undesirable event experienced by a patient which involves, or is suspected to involve, drug therapy and that interferes with achieving the desired goals of therapy. These drug therapy problems are discussed in more detail in Chapter 4 of the casebook. Because this casebook is intended to be used in conjunction with the Pharmacotherapy textbook, one of its purposes is to serve as a tool for learning about the pharmacotherapy of disease states. For this reason, the primary problem to be identified and addressed for most of the patients in the casebook is the need for additional drug treatment for a specific medical indication (problem 1. Other actual or potential drug therapy problems may coexist during the initial presentation or may develop during the clinical course of the disease. After the drug therapy problems are identified, the clinician should determine which ones are amenable to pharmacotherapy. Alternatively, one must also consider whether any of the problems could have been caused by drug therapy. In some cases (both in the casebook and in real life), not all of the information needed to make these decisions is available. These questions are applied consistently from case to case to demonstrate that a systematic patient care process can be successfully applied regardless of the underlying disease state(s). The questions are designed to enable students to identify and resolve problems related to pharmacotherapy. Determination of therapeutic alternatives After the intended outcome has been defined, attention can be directed toward identifying the types of treatments that might be beneficial in achieving that outcome. The clinician should ensure that all feasible pharmacotherapeutic alternatives available for achieving the predefined therapeutic outcome(s) are considered before choosing a particular therapeutic regimen. Useful sources of information on therapeutic alternatives include the Pharmacotherapy textbook and other references, as well as the clinical experience of the health care provider and other involved health care professionals. There has been a resurgence of interest in dietary supplements and other alternative therapies in recent years. The public spends billions of dollars each year on supplements to treat diseases for which there is little scientific evidence of efficacy. On the other hand, scientific evidence of efficacy does exist for some dietary supplements. Health care providers must be knowledgeable about these products and prepared to answer patient questions regarding their efficacy and safety. Identification of real or potential drug therapy problems the first step in the patient-focused approach is to collect pertinent patient information, interpret it properly, and determine whether drug therapy problems exist. Some authors prefer to divide this process into two or more separate steps because of the difficulty that inexperienced students may have in performing these complex tasks simultaneously. In the case of preexisting chronic diseases, such as asthma or rheumatoid arthritis, one must be able to assess information that may indicate a change in severity of the disease. This portion of the casebook contains 10 fictitious patient vignettes that are directly related to a patient case that was presented earlier in this casebook. Each scenario involves one or more questions asked by a patient about a specific remedy. Eleven different dietary supplements are included in this section: garlic, omega-3 fatty acids, Ginkgo biloba, St. Monitoring for adverse events should be directed toward preventing or identifying serious adverse effects that have a reasonable likelihood of occurrence. For example, it is not cost-effective to obtain periodic liver function tests in all patients taking a drug that causes mild abnormalities in liver injury tests only rarely, such as omeprazole. On the other hand, serious patient harm may be averted by outlining a specific screening schedule for drugs associated more frequently with hepatic abnormalities, such as methotrexate for rheumatoid arthritis. Design of an optimal individualized pharmacotherapeutic plan the purpose of this step is to determine the drug, dosage form, dose, schedule, and duration of therapy that are best suited for a given patient. Individual patient characteristics should be taken into consideration when weighing the risks and benefits of each available therapeutic alternative. For example, an asthma patient who requires new drug therapy for hypertension might better tolerate treatment with a thiazide diuretic rather than a -blocker. On the other hand, a hypertensive patient with gout may be better served by use of a -blocker rather than by use of a thiazide diuretic. Students should state the reasons for avoiding specific drugs in their therapeutic plans. For example, the dose of aspirin used to treat rheumatoid arthritis is much higher than that used to prevent myocardial infarction. The likelihood of adherence with the regimen and patient tolerance come into play in the selection of dosage forms. The economic, psychosocial, and ethical factors that are applicable to the patient should also be given due consideration in designing the pharmacotherapeutic regimen. An alternative plan should also be in place that would be appropriate if the initial therapy fails or cannot be used. Provision of patient education the concept of pharmaceutical care is based on the existence of a covenantal relationship between the patient and the provider of care. Patients are our partners in health care, and our efforts may be for naught without their informed participation in the process. For chronic diseases such as diabetes mellitus, hypertension, and asthma, patients may have a greater role in managing their diseases than do health care professionals. Self care is becoming widespread as increasing numbers of prescription medications receive over-thecounter status. For these reasons, patients must be provided with sufficient information to enhance compliance, ensure successful therapy, and minimize adverse effects. Additional information can then be provided as necessary to fill in knowledge gaps. In the questions posed with individual cases, students are asked to provide the kind of information that should be given to the patient who has limited knowledge of his or her disease. Instructors may wish to have simulated patient-interviewing sessions for new and refill prescriptions during case discussions to practice medication education skills. Factual information should be provided as concisely as possible to enhance memory retention. Identification of parameters to evaluate the outcome Students must identify the clinical and laboratory parameters necessary to assess the therapy for achievement of the desired therapeutic outcome and for detection and prevention of adverse effects. The outcome parameters selected should be specific, measurable, achievable, directly related to the therapeutic goals, and have a defined endpoint. If the goal is to cure a bacterial pneumonia, students should outline the subjective and objective clinical parameters. The intervals at which data should be collected are dependent on the outcome parameters selected and should be established prospectively. It should be noted that expensive or invasive procedures may not be repeated after the initial diagnosis is made. For example, it is insufficient to state that one will monitor for potential drug-induced "blood dyscrasias. Communication and implementation of the pharmacotherapeutic plan the most well-conceived plan is worthless if it languishes without implementation because of inadequate communication with prescribers or other health care providers. Permanent, written documentation of significant recommendations in the medical record is important to ensure accurate communication among practitioners. Oral communication alone can be misinterpreted or transferred inaccurately to others. This is especially true because there are many 6 drugs that sound alike when spoken but that have different therapeutic uses. Finally, there is often little suggestion provided as to the treatment information that should be conveyed to the most important individual involved: the patient. A pharmaceutical care plan is a well-conceived and scientifically sound method of documenting these activities. Chapter 4 of this casebook discusses the philosophy of care planning and describes their creation and use. A sample care plan document is included in that chapter for use by students as they work through the cases in this book. The Pharmacotherapy textbook contains a more comprehensive list of references pertinent to each disease state. The sites listed are recognized as authoritative sources of information, such as the Food and Drug Administration ( Students should be advised to be wary of information posted on the Internet that is not from highly regarded health care organizations or publications. For this reason, students may find it difficult at first to devise complete answers to the case questions. Appendix D contains the answers to three cases in order to demonstrate how case responses might be prepared and presented. The authors of the cases contributed the recommended answers provided in the appendix, but they should not be considered the sole "right" answer. Thoughtful students who have prepared well for the discussion sessions may arrive at additional or alternative answers that are also appropriate. With diligent self-study, practice, and the guidance of instructors, students will gradually acquire the knowledge, skills, and selfconfidence to develop and implement pharmaceutical care plans for their own future patients. The goal of the casebook is to help students progress along this path of lifelong learning. Follow-up questions directed toward ongoing evaluation and problem solving are included after presentation of the clinical course. These assignments generally require students to obtain additional information that is not contained in the corresponding Pharmacotherapy textbook chapter. Also, if they are involved in student professional organizations, they may need to do a service project that requires identifying an idea, developing a project plan, assigning tasks to different group members, and, finally, finishing the project and evaluating the results. On practice rotations, students often need to determine if a drug is causing an adverse event in a particular patient. To solve problems, we call upon our previous experiences with similar situations and we observe, investigate, ask appropriate questions, and finally come to a conclusion or resolution. Students who finish their formal training in health care must recognize that learning is a lifelong process. Scores of new drugs are approved every year, and innovative research changes the way that many diseases are treated. Drug use practices change yearly, and students will have the opportunity to pursue many different career paths. They must be prepared to take direct responsibility for patient outcomes by practicing patient-centered care.
Pralidoxime is ineffective as an antidote to carbamate anti-ChEs (physostigmine anxiety symptoms 9dp5dt purchase effexor xr 37.5 mg visa, neostigmine anxiety symptoms 9dp5dt 75 mg effexor xr mastercard, carbaryl anxiety guidelines effexor xr 37.5 mg sale, propoxur) in which case the anionic site of the enzyme is not free to provide attachment to it anxiety symptoms 6 dpo generic effexor xr 75mg with mastercard. It is rather contraindicated in carbamate poisoning anxiety symptoms 5 yr old effexor xr 150mg otc, because not only it does not reactivate carbamylated enzyme anxiety unspecified icd 10 cheap effexor xr 150 mg on-line, it has weak anti-ChE activity of its own anxiety symptoms going crazy generic effexor xr 37.5 mg mastercard. Chronic organophosphate poisoning Repeated exposure to certain fluorine containing and triaryl organophosphates results in polyneuritis and demyelination after a latent period of days to weeks anxiety blanket discount effexor xr 75mg with amex. Sensory disturbances occur first followed by muscle weakness, tenderness and depressed tendon reflexes-lower motor neurone paralysis. In the second phase, spasticity and upper motor neurone paralysis gradually supervenes. The mechanism of this toxicity is not known, but it is not due to inhibition of ChE; there is no specific treatment. Prominent effects are seen in organs which normally receive strong parasympathetic tone. However, these effects are not appreciable at low doses which produce only peripheral effects because of restricted entry into the brain. The site of this action is not clear-probably there is a cholinergic link in the vestibular pathway, or it may be exerted at the cortical level. Atropine, the prototype drug of this class, is highly selective for muscarinic receptors, but some of its synthetic substitutes do possess significant nicotinic blocking property in addition. Semisynthetic derivatives Homatropine, Atropine methonitrate, Hyoscine butyl bromide, Ipratropium bromide, Tiotropium bromide. Majority of the central actions are due to blockade of muscarinic receptors in the brain, but some actions may have a different basis. Higher the existing vagal tone- more marked is the tachycardia (maximum in young adults, less in children and elderly). This is suggested by the finding that selective M1 antagonist pirenzepine is equipotent to atropine in causing bradycardia. Moreover, atropine substitutes which do not cross bloodbrain barrier also produce initial bradycardia. Atropine abbreviates refractory period of A-V node and facilitates A-V conduction, especially if it has been depressed by high vagal tone. Eye the autonomic control of iris muscles and the action of mydriatics as well as miotics is illustrated in. Smooth muscles All visceral smooth muscles that receive parasympathetic motor innervation are relaxed by atropine (M3 blockade). Tone and amplitude of contractions of stomach and intestine are reduced; the passage of chyme is slowed-constipation may occur, spasm may be relieved. Enhanced motility due to injected cholinergic drugs is more completely antagonised than that due to vagal stimulation, because intramural neurones which are activated by vagus utilize a number of noncholinergic transmitters as well. Atropine has relaxant action on ureter and urinary bladder; urinary retention can occur in older males with prostatic hypertrophy. However, this relaxant action can be beneficial for increasing bladder capacity and controlling detrusor hyperreflexia in neurogenic bladder/enuresis. Glands Atropine markedly decreases sweat, salivary, tracheobronchial and lacrimal secretion (M3 blockade). Atropine decreases secretion of acid, pepsin and mucus in the stomach, but the primary action is on volume of secretion so that pH of gastric contents may not be elevated unless diluted by food. Since bicarbonate secretion is also reduced, rise in pH of fasting gastric juice is only modest. Relatively higher doses are needed and atropine is less efficacious than H2 blockers in reducing acid secretion. It is due to both inhibition of sweating as well as stimulation of temperature regulating centre in the hypothalamus. This is due to blockade of release inhibitory muscarinic autoreceptors present on these nerve terminals. The above differences probably reflect the relative dependence of the function on cholinergic tone vis a vis other influences, and variation in synaptic gaps in different organs. The pattern of relative activity is nearly the same for other atropine substitutes except pirenzepine which inhibits gastric secretion at doses that have little effect on other secretions, heart and eye. This is probably because atropine equally blocks M1, M2 and M3 receptors whereas pirenzepine is a selective M1 antagonist. Hyoscine this natural anticholinergic alkaloid differs from atropine in many respects, these are tabulated in Table 8. About 50% of atropine is metabolized in liver and rest is excreted unchanged in urine. Hyoscine is more completely metabolized and has better blood-brain barrier penetration. Most of these differ only marginally from the natural alkaloids, but some recent ones appear promising. Some ganglionic blockade may occur at clinical doses postural hypotension, impotence are additional side effects. Another desirable feature is that in contrast to atropine, it does not depress mucociliary clearance by bronchial epithelium. Thus, it is more suitable for regular prophylactic use rather than for rapid symptomatic relief during an attack. It acts on receptors located mainly in the larger central airways (contrast sympathomimetics whose primary site of action is peripheral bronchioles, see. Tiotropium bromide A newer congener of ipratropium bromide which binds very tightly to bronchial M1/M3 muscarinic receptors producing long lasting bronchodilatation. It has some ganglion blocking activity as well and is claimed to reduce gastric secretion at doses which produce only mild side effects. However, infants have exhibited atropinic toxicity symptoms and it is not recommended below 6 months of age. It also has antiemetic property: has been used in morning sickness and motion sickness. Valethamate: the primary indication of this anticholinergic-smooth muscle relaxant is to hasten dilatation of cervix when the same is delayed during labour, and as visceral antispasmodic, urinary, biliary, intestinal colic. The more likely site of action of pirenzepine in stomach is intramural plexuses and ganglionic cells rather than the parietal cells themselves. It is nearly equally effective as cimetidine in relieving peptic ulcer pain and promoting ulcer healing, but has been overshadowed by H2 blockers and proton pump inhibitors. Oxybutynin this newer antimuscarinic has high affinity for receptors in urinary bladder and salivary glands alongwith additional smooth muscle relaxant and local anaesthetic properties. Because of vasicoselective action, it is used for detrusor instability resulting in urinary frequency and urge 9. Isopropamide 5 mg oral; indicated in hyperacidity, nervous dyspepsia, irritable bowel and other gastrointestinal problems, specially when associated with emotional/mental disorders. Beneficial effects have been demonstrated in post-prostatectomy vasical spasm, neurogenic bladder, spina bifida and nocturnal enuresis. Anticholinergic side effects are common after oral dosing, but intravasical instillation increases bladder capacity with few side effects. Mydriatics Atropine is a potent mydriatic but its slow and long-lasting action is undesirable for refraction testing. It often produces unsatisfactory cycloplegia in children who have high ciliary muscle tone. Tolterodine: this relatively M3 selective muscarinic antagonist has preferential action on urinary bladder; less likely to cause dryness of mouth and other anticholinergic side effects. Flavoxate has properties similar to oxybutynin and is indicated in urinary frequency, urgency and dysuria associated with lower urinary tract infection. Darifenacin and Solifenacin are other relatively M 3 subtype selective antimuscarinics useful in bladder disorders. It is preferred for cycloplegic refraction, but children may show transient behavioural abnormalities due to absorption of the drug after passage into the nasolacrimal duct. It has been used orally as well as parenterally in intestinal, biliary and renal colics, irritable bowel syndrome, uterine spasms, etc. However, it is satisfactory for refraction testing in adults and as a short acting mydriatic for fundoscopy. Preanaesthetic medication When irritant general anaesthetics (ether) were used, prior administration of anticholinergics (atropine, hyoscine, glycopyrrolate) was imperative to check increased salivary and tracheobronchial secretions. Atropinic drugs also prevent laryngospasm, not by an action on laryngeal muscles, which are skeletal muscles, but by reducing respiratory secretions that reflexly predispose to laryngospasm. Peptic ulcer Atropinic drugs decrease gastric secretion (fasting and neurogenic phase, but little effect on gastric phase) and afford symptomatic relief in peptic ulcer, though effective doses always produce side effects. Orally administered atropinic drugs are bronchodilators, but less effective than adrenergic drugs; not clinically used. They dry up secretion in the respiratory tract, may lead to its inspissation and plugging of bronchioles resulting in alveolar collapse and predisposition to infection. Given by aerosol, it neither decreases respiratory secretions nor impairs mucociliary clearance, and there are few systemic side effects. Its time course of action makes it more suitable for regular prophylactic use rather than for control of acute attacks. Tiotropium bromide is an equally effective and longer acting alternative to ipratropium bromide. As mydriatic and cycloplegic (i) Diagnostic For testing error of refraction, both mydriasis and cycloplegia are needed. Tropicamide having briefer action has now largely replaced homatropine for this purpose. These drugs do not cause sufficient cycloplegia in children: more potent agents like atropine or hyoscine have to be used. Atropine ointment (1%) applied 24 hours and 2 hours before is often preferred for children below 5 years. Pulmonary embolism these drugs benefit by reducing pulmonary secretions evoked reflexly by embolism. Intestinal and renal colic, abdominal cramps: symptomatic relief is afforded if there is no mechanical obstruction. Atropine is less effective in biliary colic and is not able to completely counteract biliary spasm due to opiates (nitrates are more effective). Nervous, functional and drug induced diarrhoea may be controlled to some extent, but anticholinergics are not useful in infective diarrhoea. Spastic constipation, irritable bowel syndrome: modest symptomatic relief may be afforded. Pylorospasm, gastric hypermotility, gastritis, nervous dyspepsia may be partially suppressed. Oxybutynin, tolterodine and flavoxate have demonstrated good efficacy, but dry mouth and other anticholinergic effects are dose limiting. Atropinic drugs alternated with a miotic prevent adhesions between iris and lens or iris and cornea and may even break them if already formed. As cardiac vagolytic Atropine is useful in counteracting sinus bradycardia and partial heart block in selected patients where increased vagal tone is responsible. It is particularly valuable in highly susceptible individuals and for vigorous motions. A transdermal preparation applied behind the pinna 4 hours before journey has been shown to protect for 3 days. Side effects with low oral doses and transdermal medication are few, but dry mouth and sedation can occur: driving is risky. Hyoscine was used to produce sedation and amnesia during labour (twilight sleep) and to control maniacal states. To antagonise muscarinic effects of drugs and poisons Atropine is the specific antidote for anti ChE and early mushroom poisoning (see Ch. Atropine or glycopyrrolate is also given to block muscarinic actions of neostigmine used for myasthenia gravis, decurarization or cobra envenomation. Belladonna poisoning may occur due to drug overdose or consumption of seeds and berries of belladonna/datura plant. Dry, flushed and hot skin (especially over face and neck), fever, difficulty in micturition, decreased bowel sounds. Excitement, psychotic behaviour, ataxia, delirium, dreadful visual hallucinations. Hypotension, weak and rapid pulse, cardiovascular collapse with respiratory depression. Other general measures (maintenance of blood volume, assisted respiration, diazepam to control convulsions) should be taken as appropriate. Contraindications Atropinic drugs are absolutely contraindicated in individuals with a narrow iridocorneal angle-may precipitate acute congestive glaucoma. However, marked rise in intraocular tension is rare in patients with wide angle glaucoma. Caution is advocated in elderly males with prostatic hypertrophy-urinary retention can occur. This results in slower absorption and greater peripheral degradation of levodopa-less of it reaches the brain. On the other hand, extent of digoxin and tetracycline absorption may be increased due to longer transit time in the g. Antihistaminics, tricyclic antidepressants, phenothiazines, disopyramide, pethidine have anticholinergic property-additive side effects occur with atropinic drugs. Thus, autonomic ganglion is not merely a one transmitter-one cell junction, but a complex system capable of local adjustments in the level of excitability. Sympathetic as well as parasympathetic ganglia are stimulated, but larger doses cause persistent depolarization and ganglionic blockade. Nicotine is important in the context of smoking and tobacco chewing; its only clinical indication is short-term nicotine replacement in tobacco abstinent subjects. There is no therapeutic application of ganglionic stimulants, because no useful purpose can be served by stimulating both sympathetic and parasympathetic ganglia concurrently. It ameliorates the symptoms of nicotine withdrawal, but only partially suppresses the craving, because the intermittent peak nicotine blood levels that occur during smoking are not reproduced by the patch. Side effects of nicotine replacement therapy are headache, dyspepsia, abdominal cramps, loose motions, insomnia, flu-like symptoms and local irritation. Since varenicline is a partial agonist at these receptors, it provides some level of nicotine substitution, but blocks the reward effect of smoking. Clinically it has been found to reduce craving as well as nicotine withdrawal symptoms in those who stop smoking. Abstinence rates at one year of cessation are comparable to those of nicotine replacement and of bupropion. Side effects noted are mood changes, irrational behaviour, appetite and taste disturbances, sleep disorder and agitation. Clinical efficacy has been rated equivalent to nicotine replacement, and it has produced fewer side effects (see Ch. Sweat glands Relative autonomic tone and effects of ganglionic blockade on organ function Dominant tone Para-symp. Persistent depolarising blockers Nicotine (large dose) Anticholinesterases (large dose) the competitive ganglion blockers were used in the 1950s for hypertension and peptic ulcer, but have been totally replaced now because they produce a number of intolerable side effects (see Table 8. Trimethaphan It is an ultrashort acting ganglion blocker; has been occasionally infused i. Mecamylamine Either alone or in combination with nicotine patch, it has been tried for smoking cessation. It appears to block the reward effect of nicotine and improve abstinence rate compared to placebo. He gave the history of having difficulty in passing urine, poor stream, frequent urge to urinate and post-void dribbling for the last 3 years. Over the past few days he had been experiencing episodes of vertigo for which he was prescribed a medicine that he was taking for 2 days. Adrenaline (Adr) It is secreted by adrenal medulla and may have a transmitter role in the brain.
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The number of research subjects involved in the study were as many as 56 respondents by dividing 28 respondents from the stunting group and 28 respondents from the non-stunting group anxiety symptoms anxiety attacks effective 150 mg effexor xr. Most of the income in the family of low-stunting children under the Surabaya city minimum wage is Rp anxiety symptoms fatigue buy 150 mg effexor xr fast delivery. Low income is related to the source of income in the family which only comes from the father while the mother of the toddler is only a housewife anxiety 504 plan generic effexor xr 150mg on line. In addition anxiety symptoms shaking cheap effexor xr 75 mg with visa, mothers of children under five mostly graduated from elementary school so that the ability of mothers was lacking in finding ways to increase family income mood anxiety symptoms questionnaire order effexor xr 37.5mg with mastercard. Low economic status can have an impact on the inability to produce sufficient and quality food because of the low purchasing power (5)the prevalence of stunting and severe stunting in Brebes reached 26 anxiety quotes bible buy effexor xr 150mg with visa. These prevalences of stunting were higher than the stunting prevlence in Central Java Province (11 anxiety and alcohol effexor xr 75mg. Parental education can influence the ability to access information and knowledge related to parenting anxiety chest pain effexor xr 37.5 mg overnight delivery. Based on the characteristics of toddlers, namely birth weight and birth length, the percentage of toddlers Based on the results of the study it was found that the zinc adequacy rate affected the incidence of stunting (p = 0,000) because the result of p-value < 0,005 it means significant. Birth weight depends on maternal nutritional status during pregnancy and before conception(6). Based on the results of the study, it was found that the proportion of infants with a history of birth length was more or less in the stunting toddler group. Mothers who experience malnutrition will give birth to babies who are malnourished as well. Babies who experience a lack of nutrients during pregnancy can still be repaired with good intake so that they can grow according to their development. However, if the intervention is done late the toddler will not be able to catch up with the growth delay called failure to thrive. Likewise with normal toddlers there is a possibility of growth disruption if the intake is insufficient. Nutrition that is in accordance with needs will help the growth and development of children(7)especially occurred in developing and poor countries. Stunting can increase the risk of morbidity and mortality, and suboptimal brain development so that delayed motor development and mental retardation. Stuntingis a form of growth failure due to the accumulation of nutrient in sufficiency from the beginning of pregnancy until 24 months old. The purpose of this article was examined the incidence of stunting reduction and interventions of the policy. Discussions on these questions often centre on state censorship and legislative constraints. The role of the media themselves, however, and the deeplyingrained elements and historically-contingent norms and practices within public culture that shape the public sphere, have received a significantly lower level of attention. Despite recent legislative changes towards greater freedom of expression, major hurdles that limit democratic rights and freedoms persist in practice, as highlighted by the judicial trial (and the subsequent murder in January 2007in this study, it was found that children under five who lacked zinc consumption had an odds ratio of 11,67 times for stunting compared to children under five with sufficient zinc consumption. It was also proven by the research of (9) that children who had zinc deficiency were 2,67 times at risk of stunting. Zinc interacts with important hormones involved in bone growth such as somatomedin, osteoclasin, testosterone, thyroid and insulin, besides higher zinc concentrations in bone compared to other tissues show that zinc in bone is a very important substance during the growth stage and in times child development (3) the results showed that there was an effect on the level of calcium adequacy with stunting events similar to the study conducted by (10)is a linear growth retardation, which results from inadequate intake of food over a long period of time that may be worsened by chronic illness. Over a long period of time, inadequate nutrition or its effects could result in stunting. It was found that there was an influence between the level of calcium adequacy and the incidence of stunting. In toddlers whose calcium adequacy level has less risk of stunting 3,93 times greater than toddlers with sufficient levels of calcium sufficiency. Calcium concentrations in plasma, especially free calcium ions, are acted to transmit nerve impulses and muscle contractions, as well as catalysts for various biological reactions, such as B12 absorption, fat breakdown enzymes, pancreatic lipase, pancreatic insulin secretion, acetylcholine formation and(4) Calcium homeostasis is regulated primarily through an integrated hormonal system that controls calcium transport in the intestines, kidneys and bones. During growth, demands for bone mineralization are very high, very low calcium intake can cause hypocalcemia, despite the secretion of the maximal parathyroid gland, which can result in low bone mineralization matrix and new osteoblast dysfunction. West Borneo is one of the twenty provinces with the stunting prevalence above the national average. The lack of calcium is mainly caused by inadequate intake and or non-optimal calcium absorption. Some of previous research has showed that the level of calcium serum of children with stunting has signifi cantly lowered than the normal children. Objective: the aim of this study was to analyse the calcium serum level of the children with stunting aged of 24-59 months in Pontianak City. Statistical analysis was performed using ChiSquare, t-test, and logistic regression. Results: There was no signifi cance in serum calcium level between stunting and non stunting children (p=0,193 References 1. Kejadian Stunting pada Anak Berumur Dibawah Lima Tahun (0-59 Bulan) di Provinsi Papua Barat Tahun 2010. Permasalahan Anak Pendek (Stunting) dan Intervensi untuk Mencegah Terjadinya Stunting (Suatu Kajian Kepustakaan) Stunting Problems and Interventions to Prevent Stunting (A Literature Review). Conclusions Based on the results of research conducted, the family characteristics of stunting and non-stunting children are based on family income and the same level of education, namely low income and education level of elementary school mothers. Then the characteristics of stunting and non-stunting toddlers were low birth weight and the least height was in stunting toddlers. There is an influence of zinc and calcium adequacy levels on the incidence of stunting. Source of Funding: this is an article "influence of zinc and calcium adequacy levelon stunting toddler aged 24-59 months (in bulakbanteng health center, surabaya)" that was supported by self funding. Ethical Clearance: the study was approved by the institutional Ethical Board of Universitas Airlangga Faculty of Public health Research Ethical Clearance Commission. D, Cardiologist, Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Airlangga, Surabaya, Indonesia- Mayjend Prof Moestopo Street no 47, Surabaya, East Java, Indonesia, Phone no: +6281259808492 e-mail: dr. Obesity is defined as abnormal or excessive fat accumulation that may impair health, including increased risk of cardiovascular disease and hypertension that may induce Indian Journal of Public Health Research & Development, March 2020, Vol. Atrial and ventricular remodeling is common in obese patients, and this pathophysiological change plays a pivotal role in atrial and ventricular dysfunction. Doppler Echo cardiography: Trans thoracic two-dimensional and Doppler echo cardiographic examination was carried out by Vivid S6, Logic E9, and Vivid S60 Ultrasound instrument (General Electric) with 2nd-harmonic imaging and a 3. Patients were examined in the left lateral decubitus position, and data were acquired in the parasternal (longand short-axis views) and apical views (two chambers (A2C) and four chambers (A4C) and apical long-axis views). In every echo cardiographic evaluation, all parameters were derived according to current indications and considered in relation to their established reference ranges. Pulsed wave Doppler mitral velocity curves were obtained from the A4C view by positioning sample volume between the tips of the mitral valve leaflets in diastole. The ratio of mitral E peak velocity and averaged ratio of mitral to myocardial early velocities (E/e) was calculated. The correlation was evaluated with Spearman Rho analysis followed by multiple stepwise linear regression test to determine Beta Coefficient and R-square. Materials and Method Research Design: this retrospective study consisted of subject 18 years old with hypertensive heart disease evaluated at the Echocardiography Laboratory of the Department of Cardiology and Vascular Medicine Dr. Soetomo General Hospital, Surabaya, Indonesia between January 2018 and January 2019. Other exclusion criteria were significant aortic or mitral valve disease, severe mitral annular calcification, hypertrophic cardiomyopathy, secondary forms of 1644Indian Journal of Public Health Research & Development, March 2020, Vol. Discussion Obesity induces severalmodifications in cardiac structureand function, which are associated with hemodynamicvolume overload. Atrial and ventricular remodeling is common in obese patients, and this pathophysiologicalchange plays a pivotal role in atrial and ventricular dysfunction. Aditionally it will also affect the systolic and diastolic function of left ventricle. Full articles published in English language in the past 12 years reporting studies in adult obese individuals were considered. While many studies have shown that central obesity measurement is more robust predictors of cardiovascular outcomes, this suggested that more detailed metrics of central adiposity will be important to be considered in future studies. Secondly, our sample size was limited and not equally distributed between underweight, normoweight, overweight, and obese which might affect lack of significance in cardiac dimension measured through echocardiography. Conflict of Interest: the authors declare no conflict of interest Source of Funding: this research received no external funding Ethical Clearance: the research was conducted in accordance with the Helsinki declaration of 1975 as revised in 2000. Magyar K, Gal R, Riba A, Habon T, Halmosi R, 1646Indian Journal of Public Health Research & Development, March 2020, Vol. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: A systematic analysis for the Global Burden of Disease Study 2013. The Role of Echocardiography in the Evaluation of Cardiac Damage in Hypertensive Obese Patient. Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Longitudinal tracking of left atrial diameter over the adult life course: Clinical correlates in the community. Low body mass index correlates with low left ventricular mass index in patients with severe anorexia nervosa. Leftventricular hypertrophy and obesity: A systematic review and meta-analysis of echocardiographic studies. True uncomplicated obesity is not related to increased left ventricular mass and systolic dysfunction. Pika 4, Moscow, Russia, Abstract Context: Currently, attention deficit hyperactivity disorder remains very common among children. The ongoing attempts to correct this condition, including using an integrated approach through the use of several individually selected method at once, have not yet yielded satisfactory results. The technique turned out to be effective due to the integrated use of multimedia accompaniment and special techniques for switching the attention of children during classes. Keywords: Attention deficit hyperactivity disorder, learning to play chess, children, primary school age, chess, inclusive education. Introduction Living organisms inhabiting the planet, despite the serious successes of modern science, remain heavily burdened by various pathologies1. Despite the increased attention of science and practice of medicine to humans, significant pathological burden still remains at all ages and in all countries4. It significantly reduces the quality of life and can shorten its upcoming duration5. Its main symptoms are impaired attention and impulsiveness due to a lack of control over behavior. In the absence of adequate treatment, attention deficit hyperactivity disorder subsequently leads to a violation of social and emotional development and often to associative behavior6. Modern science is actively seeking approaches to the correction of attention deficit hyperactivity disorder. To achieve a good effect in such children, it is customary to use an integrated approach to correction through the use of several individually selected method at once7. In mild cases of attention deficit hyperactivity disorder, children seek to develop creative abilities in order to correct them. To this end, children with this syndrome often use chess training programs adapted to their capabilities8. This program allows you to adjust the condition of such children by providing them with information in small, logically completed blocks (1015 minutes each). Pauses between them are filled with physical activity, often in the form of outdoor games using chess attributes9. However, the development Corresponding Author: Anatoly Ivanovich Alifirov Department of Physical Education and Sport, professor, Russian State Social University, st. As a result, the children reflexively developed an attitude toward the training process. During the lesson, techniques were used that smoothly switched the attention of children from one type of activity to another. Emotional stability with the determination of the integral indicator of a vegetative response was recorded by the method of Suvorova V. Identification of the degree of anxiety was carried out on a scale of situational and personal anxiety Spilberger-Khanin11. Express diagnostics of the properties of the nervous system by psychomotor indices was determined by the method of the tapping test of E. Assessment of volitional self-control was carried out according to the method of A. The mathematical processing of the results with the calculation of the student criterion is applied. Material and Research Method the conduction of the research was approved by the local Ethics Committee of the Russian State Social University in May, 15th, 2018 (Record 7). The study was conducted in 2017-2018 on the basis of a chess school named after A. The study involved 16 boys of 7-9 years old with a diagnosis of attention deficit hyperactivity disorder. Its application was aimed at the development of basic mental characteristics: attention, memory, thinking; imagination, creativity, perseverance, determination and independence in decision making. These groups were formed by age, taking into account the psychological characteristics of each child. Within an hour of being in a group, each child was immersed in a developing learning environment with the help of individually adapted for the whole group of developing techniques of playing chess. This ensured Research Results and Discussion the results of the study of the considered characteristics of those examined with attention deficit hyperactivity disorder during their learning to play chess are presented in table 1. Table 1: Dynamics of personality parameters of children with attention deficit hyperactivity disorder during learning to play chess 1 2 3 4 5 Registered indicators Emotionalstability, points the degree of anxiety, points the presence of internal tension, points the level of social self-control, points the degree of social organization, points Initialdata 3. This was accompanied in their initial state by a low level of social self-control and a low degree of social organization. As a result of learning to play chess, children with attention deficit hyperactivity disorder have shown significant progress in mastering chess and the school curriculum. Regular classes in the game of chess ensured six months later in children with attention deficit hyperactivity disorder positive changes in all the parameters taken into account. Moreover, they experienced a decrease in the degree of anxiety from medium to low (by 13. Children with manifestations of attention deficit hyperactivity disorder are always at a low level of selfcontrol, there is low productivity of cognitive processes and their high overall emotionality. They almost never have the presence of life strategies focused on solving existing problems, and almost always there is a tendency to avoid problems and social indifference15. In many countries of the world, psychostimulants are most widely used in the treatment of attention deficit hyperactivity disorder. The effect of these psychostimulating agents is based on an increase in the content of dopamine and norepinephrine. Despite the large number of studies on the use of these psychostimulants in the treatment of attention deficit hyperactivity disorder, this issue is still accompanied by discussions about the likelihood of side effects16. In Russia, nootropic drugs have traditionally been used to treat attention deficit hyperactivity disorder. In the presence of attention deficit hyperactivity disorder accompanying the disorder, tics, tranquilizers are allowed17. The generally accepted position is that the treatment of attention deficit hyperactivity disorder should be comprehensive, that is, include both drug therapy and psychotherapeutic method. The leading link in the psychocorrection of children with attention deficit hyperactivity disorder is often considered changes in the behavior of adults - parents and teachers, with the replacement of non-adaptive approaches to their children with adaptive ones15,17. The author has developed a methodology for treating children with attention deficit hyperactivity disorder by teaching chess. The mechanism of teaching a game of chess is the directed activation of nonspecific activating systems of the brain and the intensification of the processes of morphofunctional development of immature elements of the cortex due to the normalization of neurodynamics. Apparently, this leads to a decrease in the degree of functional immaturity of the brain18. Such treatment allows, in the practical absence of undesirable side effects, to directionally change the functional state of the brain. Apparently, the upcoming effect is also associated with stimulation of energy exchange in the cerebral cortex and in the subcortical nuclei19, as well as with balancing the number of inhibitory and activating mediators formed and synaptically ejected in all zones of the cortex20. Apparently, the basis of the obtained results is such an important factor as the universal ability to morphofunctional plasticity inherent in the cerebral cortex. Many facts indicate a high plasticity of sensory functions, their ability to change their functional characteristics under the influence of training and exercises. By themselves, these facts indicate the presence of a deep interdependence between the two main mechanisms of higher nervous activity: analyzers and temporary connections. The facts of the exercise of sensory functions indicate that the development of conditioned reflexes from the analyzer increases its efficiency, makes the brain more adapted to various conditions of the physical and social environment16, 18. Hemispheric connections between different areas of the brain, which begin to work actively during the learning of a game of chess, are even more plastic than 1650Indian Journal of Public Health Research & Development, March 2020, Vol. Unlike the former, they are more inherent in individual characteristics, which are very closely related not only to cognitive abilities, but also to the nature of the activity performed. As a training effect on the brain, chess is considered the most physiological, "soft" and effective21. The increase in the adaptive capabilities of the cortex of the children observed in the study was manifested in an increase in their academic performance at school and in their receipt of sports categories in chess. In qualifying tournaments, the child fulfilled the norm of the 1st junior category in chess after six months of classes. The methodology turned out to be effective due to the integrated use of multimedia accompaniment and special techniques for switching the attention of the child during classes. Ethics Committee Resolution: the study was approved by the local ethics committee of the Russian State Social University on May, 15th, 2018 (Record 7). At the time of the start of classes, the child was diagnosed with attention deficit hyperactivity disorder. In the qualification tournament, after six months of classes, the child fulfilled the norm of the 3rd youth category in chess. In the qualification tournament, the child fulfilled the norm of the 2nd youth category in chess after six months of classes.
