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Surgi- cal decompression offers little discount 17.5mg lisinopril fast delivery blood pressure medication side effects, if any purchase lisinopril 17.5 mg fast delivery arteria epigastrica superficial, true relief of pain order 17.5 mg lisinopril fast delivery arteria 90 obstruida, with the longest survival reported at just over 5 months [67]. One has to keep in mind that treat- in PD was reported to range from 14% [48] to 30% [5]. PD has also been noted to be associated with an in- creased incidence of gout [40] and pseudogout [105]. These 43 Treatment of spinal stenosis Because antipagetic medical therapy is rewarding in the treatment of pagetic spinal stenosis syndrome, one should start with antipagetic drug treatment. Calcitonin, mithra- mycin, sodium etidronate, pamidronate disodium, and clo- dronate have been reported to either improve or to com- pletely reverse the clinical symptoms of spinal stenosis [1, 16, 36, 107]; however, relapse of spinal stenosis sympto- matology after medical antipagetic treatment is not un- common [32, 33]. Therefore, patients should be closely monitored and cyclical therapy should be continued if necessary until biochemical bone indices normalize. Severe spinal stenosis of lytic type has been shown to respond successfully to antipagetic treatment with clo- dronate [36]. It has been suggested that, for pagetic spinal stenosis in the lytic phase of the disease, administration of vitamin D and calcium supplements to improve mineraliza- tion of lytic pagetic spinal lesion causing canal block can enhance the effectiveness of bisphosphonate therapy [36]. If the symptoms persist, in spite of bone remodeling markers normalization, surgery is an alternative treat- ment. Decompression of spinal stenosis should be imple- mented promptly after failure of antipagetic therapy. The appearance of the other hand, the results of surgery have shown variable im- lesion may be misconstrued as sarcomatous degeneration (pseu- provement in 85% of patients [117], with frequent re- dosarcoma or pumice bone). The cortical margins are well defined lapses or failures, which may improve with subsequent in contrast to the usual appearance of sarcomatous transformation, medical antipagetic therapy [1, 16, 107]. Eur Spine J provement after laminectomy and were treated with fur- 10:370–384] ther antipagetic medical treatment exhibited marked im- provement of their symptomatology with sustained relief [50]. From our experience and from other reports, spinal surgery for pagetic spinal stenosis may fail to reverse the Treatment neurological deficit completely [15], and may be associ- ated with serious complications such as a mortality rate of Treatment of back pain 11% [117] and dangerously profuse, if not torrential, bleeding [116]. To avoid such catastrophes, we recom- One must be certain before attributing back pain to PD, mend the preoperative assessment of bone vascularity by otherwise the results of antipagetic treatment may not be means of radionuclide bone blood flow in the affected spi- rewarding [3]. We have found this test reliable, simple and re- suppressive therapy with EHDP (disodium etidronate) producible [11]. To decrease potential bleeding during was beneficial to 36% of patients in one report [4]. This surgery, if there is increased vascularity in the affected re- suggests that unless a well-defined lesion is related to low gion, we strongly recommend a course of medical an- back pain, antipagetic therapy is not expected to be effec- tipagetic treatment until the bone blood flow normalizes tive. This may take 2–3 months with calcitonin therapy, 3 months, a concomitant nonsteroidal anti-inflammatory or 2–3 weeks with mithramycin treatment [56, 57, 114]. In emergency situations, when the presenting back pain is mechanical or arthritic in embolization of the region may be indicated. Surgery for spinal stenosis, when indicated, should be tailored to the pathology responsible for neural compres- 44 sion. If neural compression is caused by the posterior ex- effect is characteristic of their overall action, their influ- pansion of vertebral bodies, an anterior approach with ence on cells is probably of greater importance. If neural compression mechanism of action appears to be complex [39], involv- is caused by posterior vertebral elements, then posterior ing several components: decompression should be the approach of choice [50]. A direct effect on osteoclastic activity acute onset of spinal compression seems to bear a graver 2. A direct effect on osteoclast recruitment prognosis than the more gradual development of symp- 3. An indirect effect on osteoclast recruitment mediated toms; the former tends to respond better to surgical de- by cells of osteoclastic lineage that are capable of stim- compression [126]. Surgery is also indicated as a primary ulating or inhibiting osteoclastic recruitment (macro- treatment when neural compression is secondary to patho- phages are osteoclast precursors), and logical fracture, dislocation, epidural hematoma, syringo- 4. A shorter osteoclast life-span due to apoptosis myelia, platybasia, or sarcomatous transformation. Bisphosphonates can be classified into nitrogen and non- nitrogen containing groups; two pharmacologic classes Pharmacologic treatment with distinct molecular mechanisms. Several bisphospho- nates have been investigated [56, 57], but only the follow- A pressing issue regarding treatment is whether physicians ing bisphosphonates have been approved for clinical use: should treat asymptomatic patients. The pre- up study of 41 cases of PD, antipagetic therapy that did not sent authors assessed the effects of an unpublished study normalize biochemical markers in 71% of patients did not of a higher dose (60 mg per day) of oral alendronate (Fosa- prevent new complications in 62% of patients [95], sug- max, Merck and Co. Ten patients had never been treated there are no conclusive data to support the theory that before, and 18 had previously received drug therapy. The complications are preventable by controlling bone-remod- mean period without treatment prior to alendronate was eling with drug therapy [133]. All patients nor- Five classes of drugs are available for the treatment of malized their alkaline phosphatase levels. Follow-up was PD: bisphosphonates, calcitonin, mithramycin (plicamycin), carried out on all 28 patients 2 years after the 3-month gallium nitrate, and ipriflavone. All but three were in remission, giving a rate of more effective than calcitonin in suppressing the histolog- 89. No side effects were noted in any of the patients ical and biochemical activity of PD. The response to therapy was similar between pa- is no longer considered the treatment of choice for this tients who had previously received antipagetic therapy and condition. Similarly, there was a marked radio- can be obtained only through clinical trials. The mechanism of action of bisphos- phonates on bone was originally ascribed to their physi- cochemical effect on hydroxyapatite crystals [38]. They bind strongly to hydroxyapatite crystals and inhibit both their formation and dissolution in vitro. Group II patients had previously received drug therapy Laboratory methods for clinical assessment expansion) and remodeling changes (phase of the disease and monitoring antipagetic drug treatment activity). Radionuclide bone blood flow can be used to monitor Biomechanical bone markers vascularity. Therefore, it can be used: Recently, the assessment and effectiveness of treatment of 1. Twenty-four hour kaline phosphatase (βAP), procollagen type 1 N-termi- retention scan, a more quantitative radionuclide assess- nal polypeptide (PINP), beta-carboxyterminal telopep- ment, can be used as an adjunct to bone scan [11]. Quanti- tide of type 1 collagen (SCTx); osteocalcin and serum tative bone scan scintigraphy allows early and objective as- bone sialoprotein sessment of PD when evaluating the effects of therapy. Ra- – In urine: hydroxyproline (Hyp), amino (NTX) and beta- diographic images should be obtained before treatment and carboxyterminal (CTX) telopeptides of collagen type I, every 1 to 2 years thereafter, to monitor the modeling (bone total pyridinoline (PYD) and deoxypyridinoline (DPD) 46 Markers of bone resorption representing degradation of expansion, and structural changes, leading to spinal steno- type I collagen are: N-telopeptides, C-telopeptides, hydroxy- sis and facet arthropathy, clinical entities that are not al- proline and collagen crosslinks-pyridinoline and dexopy- ways symptomatic. Bone formation markers include greater the likelihood that patients will suffer clinical spi- bone-specific alkaline phosphatase and N terminal and C nal stenosis and/or back pain. In the majority of cases the terminal extension peptides of procollagen and osteocalcin.

Why should live vaccines not be given to people whose Nursing Notes: Apply Your Knowledge immune systems are suppressed by drugs or diseases? Lifelong immunity is not provided for tetanus lisinopril 17.5 mg without prescription blood pressure medication with c, necessi- SELECTED REFERENCES tating booster injections every 10 years cheap lisinopril 17.5 mg with amex arteria iliaca comun. Adults often do not keep Ad Hoc Working Group for the Development of Standards for Pedia- good immunization records generic lisinopril 17.5mg with amex arrhythmia associates. Standards for pediatric immuniza- she has had a recent booster injection, a tetanus immunization tion practices. Association for Professionals in Infection Control and Epidemiology, Inc. Vaccination with measles, mumps and rubella vaccine and varicella vaccine: safety, toler- immunizing agents rather than single agents? What are common adverse reactions to immunizing agents, tion against varicella in healthy children. Pediatric Infectious Diseases and how may they be prevented or minimized? Describe the adverse effects and nursing hematopoietic and immune functions. Discuss the use of filgrastim and sar- uses, adverse effects, and nursing process gramostim in neutropenia and bone marrow implications. Reynolds, a 67-year-old who has had chronic renal failure for the last 7 years, is severely anemic. Her physician prescribes epoetin alfa (Epogen) to stimulate red blood cell production. You are responsible for teaching her about the drug, including subcutaneous administration. Reflect on: Review why renal failure causes anemia and how Epogen works to increase red blood cell counts. Consider decreased symptoms of anemia and ex- pected changes in laboratory values. Hematopoietic drugs are more accurately called immunorestoratives because and immunostimulant drugs (also called biologic response they help a compromised immune system regain normal modifiers) are given to restore normal function or increase the function rather than stimulating supranormal function. In ability of the immune system to eliminate potentially harmful AIDS, the human immunodeficiency virus (HIV) causes im- invaders. Those available for therapeutic use include colony- mune system malfunction, so the antiviral drugs indirectly stimulating factors (CSF; eg, darbepoetin alfa, epoetin alfa, improve immunologic function. These drugs, which are the primary focus of this GENERAL CHARACTERISTICS chapter, are described in the following sections and in Drugs at a Glance: Hematopoietic and Immunostimulant Agents. OF HEMATOPOIETIC AND Bacillus Calmette-Guérin (BCG) vaccine, used in the treat- IMMUNOSTIMULANT DRUGS ment of bladder cancer, is also discussed. Other drugs with immunostimulant properties are discussed in other chapters. Most hematopoietic and immunostimulant drugs are These include traditional immunizing agents (see Chap. Techniques of molecu- phages and T cells and is used with fluorouracil in the treat- (text continues on page 660) 657 658 SECTION 7 DRUGS AFFECTING HEMATOPOIESIS AND THE IMMUNE SYSTEM Drugs at a Glance: Hematopoietic and Immunostimulant Agents Generic/Trade Name Indications for Use Routes and Dosage Ranges Comments Hematopoietic Agents Darbepoetin alfa (Aranesp) Anemia associated with chronic SC, IV, 0. Collection of peripheral stem cells, SC, 10 mcg/kg/d for 6–7 d, with collection on the last 3 d of drug administration Severe, chronic neutropenia, SC 5 or 6 mcg/kg, once or twice daily, depending on clinical re- sponse and ANC Pegfilgrastim (Neulasta) To prevent infection in patients SC 6 mg once per chemotherapy with neutropenia induced by cycle. Do not give between cancer chemotherapy 14 d before and 24 h after cytotoxic chemotherapy. Sargramostim (GM-CSF) After bone marrow transplanta- Bone marrow reconstitution, (Leukine) tion to promote bone marrow IV infusion over 2 h, 250 function or to treat graft fail- mcg/m2/d, starting 2–4 h ure or delayed function after bone marrow infusion, Mobilization of stem cells in and continuing for 21 d peripheral blood so they can Graft failure or delay, IV infusion be collected. Course of treatment may be re- peated after 7 d off therapy if engraftment has not occurred. Mobilization of stem cells, SC or IV over 24 h, 250 mcg/m2/d CHAPTER 44 HEMATOPOIETIC AND IMMUNOSTIMULANT DRUGS 659 Drugs at a Glance: Hematopoietic and Immunostimulant Agents (continued) Generic/Trade Name Indications for Use Routes and Dosage Ranges Comments Interleukins Aldesleukin (interleukin-2) Metastatic renal cell carcinoma IV infusion over 15 min Adverse reactions are common (Proleukin) in adults* 600,000 IU or 0. Oprelvekin (Neumega) Prevention of severe thrombocy- SC, 50 mcg/kg once daily Start 6–24 h after completion of topenia with antineoplastic chemotherapy and continue chemotherapy that depresses until postnadir platelet count bone marrow function in is 50,000 cells/mm3 or clients with nonmyeloid malig- higher, usually 10–21 d. Give all doses three times weekly, with at least 48 h between doses Interferon beta-1b (Betaseron) Same as Interferon beta-1a SC, 0. Repeat once weekly for 6 wk, then give one dose monthly for 6–12 mo (TICE BCG) or one dose at 3, 6, 12, 18, and 24 mo (TheraCys). AIDS, acquired immunodeficiency syndrome; ANC, absolute neutrophil count. These genes are then inserted Some newer formulations (eg, darbepoetin alfa, pegfil- into bacteria (usually Escherichia coli) or yeasts capable grastim, and peginterferon alfa 2b) can be given less of producing the substances exogenously. An additional consideration is that the sub- genes that encode interferons, for example, has made it stances are powerful biologic response modifiers and possible to produce large amounts of these substances they can cause unanticipated adverse effects. Exogenous drug preparations have the same mecha- terferon beta-1b) are synthetic versions of deoxyribonu- nisms of action as the endogenous products described cleic acid (DNA) recombinant products. Despite extensive research efforts, relatively few surfaces of immature blood cells in the bone marrow cytokine-like drugs are available for clinical use. One and increase the number, maturity, and functional abil- of the difficulties in using cytokines is maintaining ef- ity of the cells. Interferons, called alfa, beta, or gamma fective dose levels over treatment periods of weeks or according to specific characteristics, also bind to spe- months. During a natural immune response, inter- cific cell surface receptors and alter intracellular activ- acting body cells produce adequate concentrations of ities. In viral infections, they induce enzymes that cytokines around target cells. However, achieving ad- inhibit protein synthesis and degrade viral ribonucleic equate local concentrations from injected, exogenous acid. CHAPTER 44 HEMATOPOIETIC AND IMMUNOSTIMULANT DRUGS 661 In addition to their antiviral effects, interferons also with chronic renal failure, and peak plasma levels occur in have antiproliferative and immunoregulatory activities. They can increase expression of major histocompatibil- ity complex (MHC) molecules, augment the activity of Colony Stimulating Factors natural killer (NK) cells, increase the effectiveness of antigen presenting cells in inducing the proliferation Filgrastim and sargramostim are drug formulations of gran- of cytotoxic T cells, aid the attachment of cytotoxic ulocyte colony stimulating factor (G-CSF) and granulocyte T cells to target cells, and inhibit angiogenesis. Because macrophage colony stimulating factor (GM-CSF), respec- of these characteristics, the interferons are used mainly tively, produced by recombinant DNA technology. In chronic he- used to stimulate blood cell production by the bone marrow in patitis C, interferon improves liver function in approxi- clients with bone marrow transplantation or chemotherapy- mately 50% of clients, but relapse often occurs when induced neutropenia. The drugs are being in- mote growth of blood vessels (angiogenesis) in clients with vestigated for additional uses. The drug apparently promotes growth are usually well absorbed, widely distributed, and elim- of arterioles around blocked areas in coronary arteries. In cancer, the exact mechanisms by which interferons because arterioles are larger and can carry more blood.

There are dozens of styles of Buddhism discount lisinopril amex arteria frontal, but they all share the common thread of performing meditation as a central exercise to refine the mind and spirit purchase 17.5mg lisinopril free shipping arteria jejunalis. Zen Buddhism order lisinopril mastercard heart attack 6 days collections, sort of a cross between Buddhism and Taoism (see Chapter 11) uses koans, or riddles, that cannot be solved by logic or intellect, but must be meditated upon theoretically until enlightenment occurs. Taoist methods of meditation borrow from the other styles and add their own unique flavor. Posture and Breathing A quick review of the basic postural and mechanical requirements of medita- tion is in order at this point, before we proceed to the actual meditation exercises. Just to summarize, here they are again: Whether sitting or standing in meditation, your head should be lifted slightly upward, as if being pulled up by a string. The tip of your tongue should be lightly touching the upper palate, just behind the upper incisors. You can adopt a Western method and just let the hands rest on your thighs or knees, palms down. If you go with Eastern methods, the palms are usually held facing up in your lap, the finger- tips almost but not quite touching. A variation of this pose is to lay the back of one hand in the palm of the other, the tips of the thumbs touch- ing lightly. This is said to ensure a continuous energy pathway, and is perhaps one of the most commonly seen positions when meditation is practiced. Especially in a seated meditation, diaphragmatic breathing is the preferred method. Remember to expand the lower abdomen, and then the chest, as you inhale; con- tract first the lower abdomen, and then the chest, as you exhale. The idea is to utilize the diaphragm located below the lungs to ensure a deep, relaxed breath. The breath will be playing yet another role in our meditations here—we will be observing the breathing cycle as a means of relaxing and focusing. Meditation Exercises In this section, we will learn eight different meditation techniques, two each from four different categories of meditation. The categories used here will be breath counting, visualization, relaxation, and healing. Once again, realize that there are dozens of categories of meditation, and that this section is meant to be only a sam- pler of the available techniques. If you wish to explore these methods in more depth, New Page Books has many meditation titles available. Breath Counting Breath counting is simply a method of meditation in which you count the num- ber of breaths you are taking. There are several variations that you can employ in this exercise: Count the inhale and exhale as one breath. TLFeBOOK M editation E xercises / 143 Count up only to a small number, say three or four. To perform the breath-counting meditation, sit in a comfortable chair with your feet flat on the ground, your back fairly straight, and your head upright. Your hands can be placed in any of the previously mentioned positions: on your knees, in your lap, in your lap with palms up, or in your lap with palms nested together and the thumbs lightly touching. Your eyes can remain open, you can close them completely or, as the Taoist monks often do, you can close them halfway. In fact, it is said that one monk would walk around the temple with a Stick of Enlightenment: when he came upon another monk who had fallen asleep during meditation, he would soundly whack him with the stick. Your concentration at this point is simply to breathe, slowly and evenly. Never hold your breath, at least not in these beginning exercises— breath-holding is an advanced technique, which can be troublesome for those with high blood pressure or heart problems. It may take a few minutes, but gradually, you should find yourself relaxing some- what more than usual. Let this feeling of peace wash over and through you like a cleansing spring rain, removing all of your troubles and con- cerns. Of course, even with this simple meditation, there are a few things to be on the lookout for. If you lose track of what number you are on, no problem—just start over at One. Another breath-counting meditation is similar to this one, but we will be count- ing backwards. This is somewhat akin to the methods used in hypnosis, where the client counts backwards from 100, and by the time he or she reaches the lower numbers, they are fully hypnotized. Start the breathing method used in the first meditation, making sure you are physically comfortable in your chair. No, simply forget about the counting, and simply enjoy the process of breath- ing. At this point, you can actually move into the Breath-Watching meditation, which is the first visualization meditation we will try. TLFeBOOK M editation E xercises / 145 Visualization Meditations Much has been written and claimed for visualizations. They are a way of direct- ing our intent, or our will, in whichever direction we desire. It is said that to make something happen, you must see it happening in your mind. For our purposes, we might be more interested in the ability of visualization to hone our concentration and allow us to forget our troubles for a while. In our first visualization meditation, Breath Watching, we will be doing just that: watching our breath. Breathe deeply and slowly, feeling the breath fill you up with lightness and health. Once you are settled in your breathing rhythm, you can start your visualization. Perhaps you can imagine that the air looks like a golden liquid, or a white vapor. My students have come up with all manner of ideas for what air looks like. As you continue your breathing, see the air around you in your chosen color and consistency. It travels down to your lungs, and actually goes all the way down to your lower abdomen, to a point just below your navel. By the end of the inhale, you should have a full breath of air, and your attention is directed at your lower abdomen. As you begin to exhale, follow the breath as it leaves your abdomen, goes through your body to the base of your spine, follows the spine all the way up to your head, and then travels over the top of your head and back out your nose into the world. That was one cycle of breathing, a simple enough thing really, but your mind followed an imaginary path- way throughout your upper body. Continue the exercise, watching the next inhale travel down the front of your body, and then up your spine, over your head, and out your nose on the exhale.

She had not been actually demented but was mentally very slow from her hypothyroid state 17.5 mg lisinopril sale blood pressure record card. Even when 22 Symptoms of Unknown Origin she was hypothyroid order 17.5 mg lisinopril overnight delivery blood pressure medication metoprolol, she was mentally accurate but just slow in responding purchase lisinopril 17.5mg amex blood pressure percentile by age. Once back to normal and out on the town, she could not tell enough people in a day what a terrific doctor I was. She was a walking, talking, vis- ible advertisement for my practice, which grew rapidly. I was soon engulfed, the target of every patient who had been misdiagnosed or mistreated or misunderstood or who had done poorly, although I never had another medical home run quite like Irene Johnson. Early scientists discovered the thyroid gland by anatomic dissections of cadavers. They much later discovered that removal of the thyroid gland in animals led to identifiable meta- bolic changes: Metabolism slowed. Ten in the 1800s, the clinical state of hypothyroidism was described in humans when autopsies of patients showing an absence of the thyroid gland. Eventually, re- versal of the hypothyroid state was achieved by ingestion of the ground-up thyroid glands of pigs and cows. Many years later, the active agent was chemically determined to be thyroxine, later to be tri-iodothyronine. Before the chemical formula of the thyroxine molecule could be discovered, the entire atomic theory of matter and the complete periodic table of mineral elements had to be dis- covered and described, with the atomic weights of each identified and defined. The empirical formula of the thyroxine molecule was found to be C15 H10 I4 N NaO4x H20, with a molecular weight of 798. When I wrote that prescription for thyroid extract for Irene Johnson, I was standing on the shoulders of thousands of scien- tists who came before me. Each scientist drilled a bit deeper into the puzzle of the thyroid gland until finally we could make a syn- thetic molecule of thyroxine, give that tiny molecule to patients, and bring them back to physical normalcy. I remain in awe of the scientific method and the reductionistic method of inquiry that has led us to understand smaller and smaller components of nature. Drayton Doherty and Miss Cootsie 23 I want to make it as clear as I possibly can that this book is not a criticism of scientific reductionism. My point here is that scientific reduction is not the same process as clinical medicine. It is the sheer scientific power of the biomolecular model that has blinded so many as to its clinical limitations and restrictions. Doherty and I got to be close and good friends, and he was delighted to see my practice take off so rapidly. Like other doctors trained before World War II, he was weak in the advances that science had brought into clinical medicine. He often prescribed toxic strychnine and used inert tonics and gave a lot of unneeded vita- mins. He spoke of ill-defined stimulants and stomatics and often still used calomel to purge the bowels of his patients. His practice was from another time and place and it bothered me intellectu- ally, although I never told him directly. He was just not scientific enough for my taste at that time, even though I respected him as a friend and father figure. He was completely accurate on assessing acute surgical abdomens, and he could listen to and understand people. Looking back, I would wonder if he had some object lesson in mind when he asked me to see her. Her name was Frances Conrad, but she was known affectionately to everyone for miles around as Miss Cootsie. Doherty could barely suppress a grin when he asked me to take over her care. Miss Cootsie was eighty-five years old and a legend in the med- ical community. Miss Cootsie was a well-known invalid and, like so many inva- lids, was seen as very weak and lacking the stamina required for the rigors of an office visit. About the only time invalids left their homes was for occasional Sunday afternoon automobile rides around town. Miss Cootsie lived upstairs in a large antebellum house in town with Little Cootsie, her spinster daughter, who was in her sixties. The first floor of the house had been shut down for use, for rea- sons I never discovered. A bath, added years before, now served as a combination kitchen and bath. Miss Cootsie was sitting in a rocking chair look- ing out the front window onto the lawn and street below. When I walked into the room, it was immediately apparent that Miss Cootsie had the largest goiter I have ever seen. It was the size of a grapefruit and it bobbed slightly with each heartbeat. Tere was no subject in endocrinology for which I was better prepared than the understanding and treatment of goiters. Here I was standing in front of the most magnificent goiter I had ever seen. Drayton Doherty and Miss Cootsie 25 ing to be famous when I shrank that goiter with medicine. Miss Cootsie quickly told me she had outlived three previous doctors before she took on Dr. She told me she had re- fused repeated offers of surgery for her goiter and that she would refuse surgery from me. She had an air of pure defiance about her and reminded me of Lionel Barrymore in one of his sterner roles. The workup in those days for thyroid disease was meager, but by those measures her overall thyroid hormonal function was normal. Her physical examination was also normal, as were her routine blood tests, which I drew and took back to the clinic lab. Tere were many series of articles in the literature of the 1960s about patients with goiters that had been shrunk with the adminis- tration of thyroid extract (thyroxin was not yet available). The the- ory was that the added thyroid hormone suppressed the pituitary secretion of thyroid-stimulating hormone, and without this stimu- lus for growth, the goiter would go away. I began Miss Cootsie on a small dose of thyroid extract, planning to increase the dose gradu- ally. Late one night, just before the two weeks were up, I got a call from the sheriff. Miss Cootsie was outside her house in her under- wear running up and down the street. I got over to the house, helped the sheriff and Little Cootsie catch Miss Cootsie, got her into the car, and drove her out to the hospital. Miss Cootsie was clearly hyperthyroid and wild, talking as fast as her mouth and lips would move.

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