Mashal Ahmadi, MD
- Department of Emergency Medicine
- Kaiser Permanente
- San Jose, California
- Formerly, Senior Resident
- Denver Health Residency in Emergency Medicine
- Denver, Colorado
Evidence-based practice supports the excellence in service that nurses are committed to deliver in our day-to-day practice symptoms 2 dpo purchase genuine diamox line. The nursing community treatment of hemorrhoids buy diamox overnight delivery, with its commitment and passion for excellence in nursing care withdrawal symptoms purchase diamox australia, is providing the knowledge and countless hours essential to the creation and evaluation of each guideline treatment scabies buy generic diamox 250 mg line. Now comes the true test in this phenomenal journey: will nurses utilize the guidelines in their day-to-day practice After lodging these guidelines into their minds and hearts, knowledgeable and skillful nurses and nursing students need healthy and supportive work environments to help bring these guidelines to life. Guidelines should not be applied in a cookbook fashion but used as a tool to assist in decision-making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care. Nurses, other healthcare professionals and administrators who are leading and facilitating 1 practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment and documentation tools. It is recommended that the nursing best practice guidelines be used as a resource tool. This guideline has some suggested formats for such local adaptation and tailoring. Organizations wishing to use the guideline may decide to do so in a number of ways: Assess current nursing and healthcare practices using the recommendations in the guideline. Systematically develop a plan to implement the recommendations using associated tools and resources. Contact Information Registered Nurses Association Registered Nurses Association of Ontario of Ontario Nursing Best Practice Guidelines Project Head Office 111 Richmond Street West, Suite 1100 438 University Avenue, Suite 1600 Toronto, Ontario Toronto, Ontario M5H 2G4 M5G 2K8 Nursing Best Practice Guideline Caregiving Strategies for Older Adults with Delirium, Dementia and Depression Disclaimer these best practice guidelines are related only to nursing practice and are not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use 7 should be flexible to accommodate client/family wishes and local circumstances. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products. Copyright With the exception of those portions of this document for which a specific prohibition or lim itation against copying appears, the balance of this document may be produced, reproduced and published, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows: Registered Nurses Association of Ontario (2004). Caregiving Strategies for Older Adults with Delirium, Dementia and Depression table of contents Summary of Recommendations. Dementia and Depression If client is incapable, nurses should approach substitute decision makers regarding care issues. If there is no Power of Attorney, nurses should encourage and facilitate the process for older adults to appoint Power of Attorney and to have discussions about end of life treatment and wishes while mentally capable. Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. Opportunities for reflection on personal and organizational 14 experience in implementing guidelines. Interpretation of Evidence Levels of Evidence Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials. Introduction Caregiving Strategies for Older Adults with Delirium, Dementia and Depression Guiding Principles Assumptions It is the consensus of the guideline development panel that the following assumptions are critical starting points for any nurse working with the older adult, and were used as a framework for the development of this best practice guideline. Elder friendly programs and services should be developed reflecting their unique needs including the family and caregivers. Caregiving strategies will focus on the highest level of functioning and abilities of all older adults, with specialized support and services, implemented to optimize their 16 participation in life. Every older person (65 years and over) has a right to timely, accurate, and thorough comprehensive geriatric assessments and related caregiving strategies as indicated. Caregiving strategies for older persons with delirium, dementia and depression are complex and multi-faceted. Changes in mental status should guide the selection, administration and appropriate interpretation of assessment tools. Delirium, dementia and depression are not synonymous with aging, but prevalence increases with chronological age. Caregiving strategies are most comprehensive when conducted from an interdisciplinary approach and when family/significant others are welcomed as partners in the process. Age, educational level, and cultural background should be considered in the selection of care strategies. The assessment and development of caregiving strategies must be an individualized and dynamic process that responds to the changing needs of the older person. Pivotal to all care strategies is the knowledge that all behaviour is meaningful and requires skilled evaluation of the physiological, emotional, psychological, social and environmental antecedents that are contributing factors. Current and ongoing knowledge of evidence-based pharmacological interventions 17 regarding the classification, dosage, interaction and side effects of medication used in the treatment of delirium, dementia and depression is required to support positive outcomes for older adults. Caregiving strategies will be revised to meet the individual needs of the older adult. Putting Together Delirium, Dementia and Depression When the guideline development panel initially met, there was much discussion about the size of these 3 Geriatric Giants, particularly the evidence-based knowledge, the amount of literature that would need to be reviewed and whether each of these should be divided into three separate guidelines. The panel consensus was that all three topic areas should be kept together because of the overlap in symptomatology. The complex older adults seen in all care settings may present with one, two, or even all three of these conditions simultaneously. Hence, many of the assessment instruments need to be used together and intervention strategies for these conditions also overlap. Caregiving Strategies for Older Adults with Delirium, Dementia and Depression An effort has been initiated in this section to weave information and multi-component care strategies together specific to delirium, dementia and depression in older adults. The nurses role is to assess 18 for all three conditions within the context of the following tenets of care: Know the person Relate effectively Recognize retained abilities Manipulate the environment Excellence in care requires using best practice assessment (including screening and ongoing assessments over time), using standardized instruments, and measuring the outcomes of care. The care of older adults with delirium, dementia and depression is often complex due to the number of chronic illnesses (numerous medications, coping with reduced function), and any acute illness that the client may have superimposed on these conditions. Practice settings would benefit from the participation and expertise of advanced practice nurses for full implementation. Kaleidoscope of Care Strategies for Delirium, Dementia and Depression Evidence of Depression Determine suicidal ideation Determine urgency * Prevention factors Pharmacological Interventions. Details of caregiving strategies for delirium, dementia and depression can be found in chapters 1 to 4. In this fourth cycle of the project, one of the areas of emphasis is on the caregiving strategies for older adults with delirium, dementia and depression. This guideline has been developed to address the question of how best to care for older adults (65 years or older) with delirium, dementia and/or depression. The guideline focuses on: (1) Practice recommendations: directed at the nurse to guide practice regarding caregiving strategies for older adults with delirium, dementia and/or depression; (2) Educational recommendations: directed at the educational institutions and organizations in which nurses work to support its implementation; (3) Organization and Policy recommendations: directed at the practice settings and the environment to facilitate nurses practice; (4) Evaluation and monitoring indicators. It is expected that individual nurses will perform only those aspects of care for which they have received appropriate education and experience. It is acknowledged that effective healthcare depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and clients, ever mindful of the personal preferences and unique needs of each individual client. At the onset, the panel discussed and came to a consensus on the scope of the best practice guideline. A search of the literature for systematic reviews, clinical practice guidelines, relevant articles and websites was conducted. The panel identified a total of 21 clinical practice guidelines related to geriatric mental health assessment and management. These guidelines were reviewed according to a set of initial inclusion criteria, which resulted in elimination of nine guidelines. Guideline was strictly about the topic areas (delirium, dementia, and depression). Caregiving Strategies for Older Adults with Delirium, Dementia and Depression the resulting 12 guidelines were critically appraised with the intent of identifying existing guidelines that were current, developed with rigour, evidence-based and which addressed the scope identified by the panel for the best practice guideline. The expert consensus guideline series: Treatment of Agitation in Older Persons with Dementia. Practice guideline for the treatment of patients with Alzheimer disease and other dementias of late-life. Centre for Health Services Research & Department of Primary Care, University of Newcastle upon Tyne (1997). Intervention in the management of behavioural and psychological aspects of dementia.
Global medicine pouch best purchase for diamox, regional 5ht3 medications cheapest diamox, and national age-sex specific all-cause and cause specific mortality for 240 causes of death symptoms dizziness nausea order genuine diamox online, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013 symptoms schizophrenia cheap diamox 250mg online. The impact of chronic obstructive pulmonary disease on work loss in the United States. Siblings of patients with severe chronic obstructive pulmonary disease have a significant risk of airflow obstruction. Risk loci for chronic obstructive pulmonary disease: a genome-wide association study and meta-analysis. Combined Impact of Smoking and Early-Life Exposures on Adult Lung Function Trajectories. The natural history of chronic airflow obstruction revisited: an analysis of the Framingham offspring cohort. Associations of ambient air pollution with chronic obstructive pulmonary disease hospitalization and mortality. Lung function and incidence of chronic obstructive pulmonary disease after improved cooking fuels and kitchen ventilation: a 9-year prospective cohort study. Risk factors for chronic obstructive pulmonary disease in a European cohort of young adults. Differences in airway inflammation in patients with fixed airflow obstruction due to asthma or chronic obstructive pulmonary disease. The relationship of nonspecific bronchial responsiveness to respiratory symptoms in a random population sample. Histamine airway hyper-responsiveness and mortality from chronic obstructive pulmonary disease: a cohort study. Chronic bronchitis before age 50 years predicts incident airflow limitation and mortality risk. Pseudomonas aeruginosa and risk of death and exacerbations in patients with chronic obstructive pulmonary disease: an observational cohort study of 22 053 patients. Diagnosis of usual interstitial pneumonia and distinction from other fibrosing interstitial lung diseases. Cigarette smoke drives small airway remodeling by induction of growth factors in the airway wall. What drives the peripheral lung-remodeling process in chronic obstructive pulmonary disease Pulmonary Gas Exchange Abnormalities in Mild Chronic Obstructive Pulmonary Disease. Effects of tiotropium on hyperinflation and treadmill exercise tolerance in mild to moderate chronic obstructive pulmonary disease. Ventilation-perfusion imbalance and chronic obstructive pulmonary disease staging severity. Epidermal growth factor receptor-mediated innate immune responses and their roles in airway diseases. Quantitative Dual-Energy Computed Tomography Supports a Vascular Etiology of Smoking-induced Inflammatory Lung Disease. Heterogeneity of pulmonary perfusion as a mechanistic image-based phenotype in emphysema susceptible smokers. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently. Significant airflow limitation may also be present without chronic dyspnea and/or cough and sputum production and vice versa. Initially, the cough may be intermittent, but subsequently may be present every day, often throughout the day. Sputum production is often difficult to evaluate because patients may swallow sputum rather than expectorate it, a habit that is subject to significant cultural and sex variation. Furthermore, sputum production can be intermittent with periods of flare-up interspersed with periods of remission. The presence of purulent sputum reflects an increase in inflammatory mediators,9,10 and its development may identify the onset of a bacterial exacerbation, though the association is relatively weak. Wheezing and chest tightness are symptoms that may vary between days, and over the course of a single day. Audible wheeze may arise at the laryngeal level and need not be accompanied by abnormalities heard on auscultation. Alternatively, widespread inspiratory or expiratory wheezes can be present on auscultation. Some of the factors needed to achieve accurate test results are summarized in Table 2. This will often lead to lower values of the ratio, especially in pronounced airflow limitation. Spirometry measurements are evaluated by comparison with reference values22 based on age, height, sex, and race. The diagnostic algorithm was initially based on a single threshold, namely a z score of -1. Assessment of symptoms Here we present the two measures of symptoms that are most widely used. Skeletal muscle dysfunction is characterized by both sarcopenia (loss of muscle cells) and abnormal function of the remaining cells. Importantly, skeletal muscle dysfunction is a rectifiable source of exercise intolerance. Comorbidities can occur in patients with mild, moderate or severe airflow limitation,58 influence mortality and hospitalizations independently,82 and deserve specific treatment. Spirometry, in conjunction with patient symptoms and history of moderate and severe exacerbations, remains vital for the diagnosis, prognostication and consideration of other important therapeutic approaches. Note: In cases where there is a marked discordance between the level of airflow limitation and the perceived symptoms, a more detailed evaluation should be carried out to better understand lung mechanics. In these cases, exercise tests like the 6-minute walking distance may reveal that the patients are severely constrained and do need more intense treatment than the initial evaluation would have suggested. If peripheral arterial oxygen saturation is < 92% arterial or capillary blood gases should be assessed. Objectively measured exercise impairment, assessed by a reduction in self-paced walking distance92,93 or during incremental exercise testing in a laboratory,94 is a powerful indicator of health status impairment and predictor of prognosis; exercise capacity may fall in the year before death. Biomarkers are with characteristics that are objectively measured and evaluated as an indicator of normal biological or pathogenic processes or pharmacological responses to therapeutic interventions. Continued cautious and realistic interpretation of the role of biomarkers in the management of identified clinical traits is required. Such patients may report exacerbations of respiratory symptoms or even require treatment with respiratory medications on a chronic basis. Definition and classification of chronic bronchitis for clinical and epidemiological purposes. A report to the Medical Research Council by their Committee on the Aetiology of Chronic Bronchitis. The Presence of Chronic Mucus Hypersecretion across Adult Life in Relation to Chronic Obstructive Pulmonary Disease Development. Changes in body composition in patients with chronic obstructive pulmonary disease: do they influence patient-related outcomes Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Previous lung diseases and lung cancer risk: a pooled analysis from the International Lung Cancer Consortium. European Respiratory Society statement: diagnosis and treatment of pulmonary disease in alpha1-antitrypsin deficiency. How accurate are pulse oximeters in patients with acute exacerbations of chronic obstructive airways disease Six-minute-walk distance and accelerometry predict outcomes in chronic obstructive pulmonary disease independent of Global Initiative for Chronic Obstructive Lung Disease 2011 Group. Analysis of the factors related to mortality in chronic obstructive pulmonary disease: role of exercise capacity and health status. The endurance shuttle walk: a new field test for the assessment of endurance capacity in chronic obstructive pulmonary disease.
Purchase generic diamox. Cystic Fibrosis Nursing | Cystic Fibrosis Symptoms Causes Treatment NCLEX Review.
As the results presented in Tables 2-4 and 2-5 indicate medicine 7253 buy cheap diamox 250 mg on-line, benzo[a]pyrene has been thoroughly studied in genetic toxicology test systems medicine cabinets surface mount buy diamox 250mg free shipping. The results of in vivo studies indicate that many of the same types of adverse effects observed in vitro were seen in mice treatment algorithm order diamox 250mg with mastercard, rats medicine 2016 generic diamox 250 mg otc, and hamsters exposed to benzo[a]pyrene via the oral, dermal, or intraperitoneal routes. The available data also indicate that benzo[a]pyrene is genotoxic in both somatic and germinal cells of intact animals (Table 2-4). Because the genotoxic activity of benzo[a]pyrene is well established, it is frequently used as a positive control to demonstrate the sensitivity of various test systems to detect the genotoxic action of unknown compounds. Benzo[a]pyrene 7,8-diol-9,10-epoxide is thought to be the ultimate mutagenic/carcinogenic metabolite. However, human erythrocytes, which do not contain an effective cytochrome P-450 system, were more efficient than induced rat liver fractions in converting benzo[a]pyrene to a genotoxin as indicated by higher sister chromatid exchange and micronuclei frequencies observed in human lymphocytes co-cultivated with human erythrocytes (Lo Jacono et al. Superficially, the data from the studies conducted by Phillipson and Ioannides (1989) (indicating that neither benzo[a]pyrene nor benz[a]anthracene were mutagenic in S. However, it is important to note, as pointed out by Phillipson and Ioannides (1989), that the level of P-450 isoenzyme proteins in unexposed animals is relatively low. Support for this statement was provided by the data demonstrating that uninduced hamster liver fractions, which contain high cytochrome P-448 levels, converted both benzo[a]pyrene and benz[a]anthracene to mutagens. By inference, it can reasonably be assumed that repeated exposures are required to induce the requisite enzyme systems to metabolize these promutagens to ultimate mutagenic/carcinogenic forms. It can further be assumed that the tissues of any species, including humans, that contain the appropriate inducible enzyme system are at risk. The function of other enzyme systems in the biotransformation of benzo[a]pyrene should not be ruled out. Epoxidation is thought to be the major pathway for benzo[a]pyrene metabolism pertinent to macromolecular interaction. Further enhancement of bay region epoxides can occur by the formation of an intramolecular hydrogen bond between the oxygen molecule of the epoxide and an associated hydroxyl group. These metabolites are also more resistant to enzymatic detoxification by epoxide hydrolase and glutathione transferase. The hypothesis further predicts that structures with more reactive bay regions would probably be more genotoxic and more carcinogenic. It is cautioned, however, that while the use of structural relationships to predict potentially reactive compounds is a powerful tool, it is not infallible, nor does it replace in vitro or in vivo testing. The induction of chromosome aberrations only, at a single dose in Chinese hamster lung cells exposed to fluorene (Matsuoka et al. However, none of these compounds have been extensively studied in in vitro assays, and they have not been tested in vivo. Although isolated positive results were obtained, particularly in microbial systems, neither compound produced consistent genotoxic effects in mammalian cells in vitro, and both were negative in the limited in vivo studies that have been performed. There is ample evidence indicating that fluoranthene induced gene mutations in bacteria and human lymphoblasts and sister chromatid exchange in Chinese hamster ovary cells. However, fluoranthene did not induce sister chromatid exchanges in mouse bone marrow cells (Palitti et al. The occurrence of a bay region structure on the phenanthrene molecule suggests that this compound is genotoxic. However, the overall findings from the genetic toxicology studies do not support such a prediction. Similarly, the reported observation that the intraperitoneal injection of phenanthrene resulted in sister chromatid exchange induction in Chinese hamster bone marrow cells was not convincing (Bayer 1979; Roszinsky-Kocher et al. In both studies, the sister chromatid exchange increase over background was less than 1. As stated earlier, the occurrence of a bay region on the molecule in conjunction with the reactivity of the bay region appear to be the determinants of genotoxic/carcinogenic activity. It is, therefore, probable that the bay region on phenanthrene is not very reactive, which would account for the lack of genotoxicity and for the low carcinogenicity index (<2) assigned to this compound (Arcos et al. Similarly, quantum mechanical calculations indicate a low probability of carbonation formation for the bay region diol epoxide of phenanthrene (Jerina 1980). The lack of genotoxicity for phenanthrene is thought to be related to the metabolism of this substance to its 9,10-dihydrodiol. However, specific methylated phenanthrenes, which direct the metabolic fate of this tricyclic hydrocarbon towards the formation of a classical bay region dihydrodiol epoxide, have exhibited significant genotoxicity (LaVoie et al. Additionally, the presence of a halogen at the K-region site produced similar results, which further support the association between inhibition of 9,10-dihydrodiol formation and mutagenic potency of substituted phenanthrenes. The study authors concluded that derivatives of phenanthrene that can inhibit metabolism at this site have a greater probability of exerting genotoxic effects. Additionally, methylated derivatives of phenanthrene may act as tumor initiators, as shown on mouse skin (LaVoie et al. It is also of note that these three compounds, as well as benzo[a]pyrene, induced neoplastic cell transformation in at least one cell line (see Table 2-5). Both benzo[b]fluoranthene and indeno[1,2,3-c,d]pyrene are known to exhibit mutagenic activity in S. However, the few studies that were found were insufficient to draw meaningful conclusions. The final compound in this group, benzo[e]pyrene, contains two equivalent bay regions. In vivo, benzo[e]pyrene induced a marginal increase in sister chromatid exchanges but did not cause structural chromosome aberrations in bone marrow cells harvested from Chinese hamsters receiving two daily intraperitoneal doses of 450 mg/kg (Roszinsky-Kocher et al. Similarly, sister chromatid exchange frequencies were not increased in V-79 cells co-cultivated with rat mammary epithelial cells as the source of exogenous metabolic activation (Mane et al. The weak genotoxicity and the very weak carcinogenicity of benzo[e]pyrene appear to contradict the bay region diol epoxide hypothesis. Quantum mechanical analysis of the ringed structure strongly suggests the likelihood of carbonium ion formation and an associated chemical reactivity equivalent to the bay region diol epoxide of dibenz[a,h]anthracene (Wood et al. Similarly, synthetically prepared bay region tetrahydro-epoxides of benzo[e]pyrene were found to be highly mutagenic in bacteria and mammalian cells, suggesting that bay region diol epoxide(s), if formed, would also be mutagenic. However, the parent compound was not metabolized to a reactive state by Aroclor 1254 S9 or by purified cytochrome P-450 derived from rat livers induced with Aroclor 1254. Specifically, there was very little formation of the bay region 9,10-dihydrodiol and low conversion of authentic 9,10-dihydrodiol to the bay region diol epoxide. Subsequent studies with authentic bay region diol epoxides of benzo[e]pyrene showed that they had relatively low mutagenic and tumorigenic activity as a result of the diaxial conformation of the diol. Since structural-activity analysis suggests that the bay region diol epoxides would have biological activity, Wood et al. It is conceivable that benzo[e]pyrene would be genotoxic in species capable of carrying out the appropriate enzymatic steps. There was insufficient evidence to draw meaningful conclusions regarding the genotoxic potential of benzo[g,h,i]perylene, although some evidence does exist. The evidence does suggest, however, that fluoranthene possesses genotoxic properties while benzo[e]pyrene is either weakly mutagenic or nonmutagenic. The results of dermal studies indicate that benz[a]anthracene, benzo[a]pyrene, benzo[b]fluoranthene, benzo[j]fluoranthene, benzo[k]fluoranthene, chrysene, dibenz[a,h]anthracene, and indeno[l,2,3-c,d]pyrene are tumorigenic in mice following dermal exposure (Albert et al. The preferred biomarkers of exposure are generally the substance itself or substance-specific metabolites in readily obtainable body fluid(s) or excreta. However, several factors can confound the use and interpretation of biomarkers of exposure. The body burden of a substance may be the result of exposures from more than one source. The substance being measured may be a metabolite of another xenobiotic substance. It may be difficult to identify individuals exposed to hazardous substances that are commonly found in body tissues and fluids. This definition encompasses biochemical or cellular signals of tissue dysfunction. They also may not be directly adverse, but can indicate potential health impairment. The amount of 1-hydroxypyrene detected in urine samples taken during the weekend was less than that detected during the weekdays, when the exposure was presumably higher than on the weekends.
When you use it in trituration (tablet) form medicine 3202 generic diamox 250 mg amex, you give one to two tablets at a dose every one-half to one treatment warts discount diamox 250mg free shipping, two or three hours treatment advocacy center purchase generic diamox canada, etc medications made easy order diamox with visa. Put ten drops in a glass half full of water and take two teaspoonsful every one-half hour for three doses, then every three hours for twelve hours. Put ten drops in a glass half full of water and give one to two teaspoonfuls everyone-half to two hours. Give one tablet every two to four hours, when the parts look bluish and livid, with great weakness, much thirst and restlessness, with burning watery diarrhea. Give about two tablets every three hours when the edge of the tongue is ulcerated and whitish with violent burning pains. Give two tablets every three hours, when the ulcerated gums discharge a fetid matter; loose teeth or teeth feel long, much sticky saliva in mouth. Prepare:-Put ten drops in a glass half full of water and give one to two teaspoonfuls everyone to three hours. Put ten drops in one-half glass full of water and give one to two teaspoonfuls everyone to three hours. When the teeth are sore and feel too long; one to two tablets everyone to three hours. Ten drops of this in a glass half full of water and give one to two teaspoonfuls everyone to three hours, when there is fever, furred tongue, dry and hot skin. Good when the parts are much swollen, sore and very sensitive, darkish, with much sticky saliva in the mouth. Ten drops in a glass one-half full of water and give two teaspoonfuls everyone to three hours, in the first stage attended by fever, hot and dry skin. Is better in second stage, when there is some sweating, parts are red and swollen that interfere with swallowing. One to two tablets every one to two to three hours when suppuration is threatened and where there is constant throbbing and pain in the tonsil. One to two tablets everyone to three hours, when the trouble continues after suppuration, parts are dark red and much thick sticky saliva and foul breath. Ten to fifteen drops in one-half glass of water and give two teaspoonfuls every one to two hours when there is fever, marked inflammation of the tonsils, no spots as yet, red face and throbbing arteries. Put ten to fifteen tablets in a glass half full of water and give one to two teaspoonfuls every one to two hours, when the discharge is thick and stringy. Prepare and give same way as Kali bichrom when membrane is dark, foul odor, tongue thick and pasty. Put ten drops or fifteen drops in a half-glass of water and give when there is active and violent inflammation with full and rapid pulse, shivering and bilious vomiting. Where there is great soreness and burning, much thirst, vomiting, dry, red and cracked tongue. When there is a dull pain and nausea, but no active vomiting; especially good in cases from drinking. One to two tablets after meals when it is caused by intemperance, eating too highly seasoned food, too much tea and coffee. One to two tablets after meals, when it is caused by rich, greasy foods, such as cakes, pies, puddings, pork and greasy gravies. Ten drops in a half glass full of water; take one teaspoonful every ten minutes until better. One tablet every ten minutes until better when the vomit is watery, burning liquid, patient is very restless and thirsty. Put ten drops in a glass half full of water and give one to two teaspoonfuls everyone to three hours. When it is at the commencement, caused by cold, with dry skin, dry tongue and fever. One to two tablets every one to two hours, when the pains are burning, tearing, cutting in the bowels, restless and anxious, vomiting and thirsty. When the ordinary symptoms are accompanied by delirium or spasms with throbbing head. One to two tablets everyone to three hours with usual pains, pasty, coated tongue, foul breath, painful diarrhea with it. Caused by sudden suppression of piles, especially in drinkers and high livers, with lazy habits. One to two tablets every one to three hours, with retching, vomiting, intense thirst, great prostration. One to two tablets every one to two hours when there is pain before stool and relieved by the passage. When there is pain and it is not relieved by the passage, stool is sometimes slimy, bloody and very little in quantity. The person is very restless, thirsty, anxious, vomiting, and burning watery stool. Put ten drops in a glass half full of water; take two teaspoonfuls every hour or two; especially good in children with large watery mealy stools of so large quantity of mealy liquid that the mother wonders where it all comes from. For mucous, painful slimy stools, child strains at every stool, sometimes mixed with blood. One tablet every one to three hours, for watery burning vomiting and same kind of stools, very restless, thirsty and drawn looking. One to two tablets on tongue every fifteen minutes until better, when there is watery burning vomiting, with terrible thirst, great prostration. Put ten drops in a glass half full of water and give two teaspoonfuls every fifteen minutes until better. When the pains are cutting, pinching, cramping, as if the bowels were pierced with knives in the region of the navel and when the patient bends forward. One tablet every hour, when the pain is in the liver, patient vomits much bile and has a diarrhea, both bilious and fecal, with straining. Ten drops in a half glass of water, two teaspoonfuls every hour when the liver is too active, too much bile, colic is aggravated by the bilious vomiting-jaundiced skin, bitter taste in the mouth. As usual, prepared, and given every one to two hours, when the constipation is obstinate, hard abdomen, with intense pain, griping and pinching. Constipation with pain in the lower back and in the lower part of the rectum; piles may protrude and be sore. One drop of it four times a day when the piles are very painful, and in the lower part of the bowels, and lots of them. One tablet every two to four hours, after first remedy, when heavy odor from the breath, dry mouth, bitter taste, yellow (pasty) coated tongue, yellow color of skin. When severe pains in region of liver extending to the back; nausea, vomiting and constipation. Two tablets four times a day, when associated with white costive stools and depression of spirits. Is good for chronic liver disease, when there is a thick yellow coating on the tongue, pains, aching under right shoulder blade, also constipation. One tablet every hour for burning watery discharge from the nose; nose stopped up, discharge makes nose sore. Put ten drops in a glass half full of water, and give two teaspoonfuls every fifteen minutes in alteration with Spongia 3X trit. One to two teaspoonfuls everyone to three hours in first stage for the fever, etc. Chilly, dry throat and dry cough, soreness, and rawness beneath the breast bone, pain in the head. Better for old people and chronic cases, when the cough is loose and much rattling from mucus. Ten drops in a glass half full of water and two teaspoonfuls given every one to three hours for sudden tight, violent cough, with sore throat, headache and nose bleed. Ten drops in a half glass of water; a dessertspoonful after each paroxysm until they get better. This is indicated when the paroxysms are frequent but not so violent, and when they are worse at night; no fever, mucus of a thick greenish color; and when the cough produces a sparkle or spots before the eyes. Given same way, when the patient lies quietly, hurts to move, stitching pain in chest when coughing and attended by a pain in the head. Ten drops in a glass half full of water and two teaspoonfuls everyone to two hours, when there is much fever.