Hospitalized patients are susceptible to infection from wounds medicine wheel colors albenza 400mg with amex, indwelling urinary catheters and intravenous cannulae medicine 3604 purchase albenza 400 mg fast delivery. Clinical features Fever medicine you cant take with grapefruit order albenza 400 mg without a prescription, rigors and hypotension are the cardinal features of severe septicaemia symptoms women heart attack discount albenza 400 mg amex. Lethargy medicine go down purchase albenza 400 mg otc, headache and a minor change in conscious level may be preceding features treatment kennel cough trusted albenza 400 mg. In elderly and immunocompromised patients the clinical features may be quite subtle and a high index of suspicion is needed. Toxic shock syndrome is characterized by an abrupt onset of fever, rash, diarrhoea and shock. It is associated with infected tampons in women but may occur in anyone, including children. This is a rapidly fatal illness (without treatment) with a purpuric skin rash and shock. The following three diagnostic and three therapeutic steps in the bundle should be instituted within 1 hour of the initial recognition of sepsis. Antibiotic therapy should be appropriate for the probable site of origin of sepsis in accordance with local antibiotic policies. In some cases the source of sepsis will not be immediately apparent and empirical broad spectrum antibiotic cover will be required. Therapy should subsequently be rationalized on the basis of culture and sensitivity results. In severe sepsis and septic shock, significant attention should be paid to fluid resuscitation and often the patient will be best managed in a critical care environment. With the introduction of aggressive immunization policies, the incidence fell in the West (when immunization schedules were adhered to), but it remains common in developing countries, where it is associated with a high morbidity and mortality. It is spread by droplet infection and the period of infectivity is from 4 days before and up to 4 days after the onset of the rash (after which the infected person can return to work or school). The eruptive or exanthematous stage is characterized by the presence of a maculopapular rash, which starts on the face and spreads to involve the whole body. Complications these are uncommon in the healthy child but carry a high mortality in the malnourished or those with other diseases. Complications include gastroenteritis, pneumonia, otitis media, encephalitis and myocarditis. Rarely, persistence of Common viral infections 17 the virus with reactivation pre-puberty results in subacute sclerosing panencephalitis with progressive mental deterioration and death. Management the diagnosis is usually clinical but acute infection can be confirmed by saliva or serum testing for measles-specific immunoglobulin (Ig)M. Measles vaccine is given to children of 13 months (9 months in developing countries) to prevent infection. Mumpsnd Mumps is also caused by infection with a paramyxovirus, spread by droplets. Clinical features It is primarily an infection of school-aged children and young adults. Less common features are orchitis, meningitis, pancreatitis, oophoritis, myocarditis and hepatitis. During the prodrome the patient complains of malaise, fever and lymphadenopathy (suboccipital, post-auricular, posterior cervical nodes). A pinkish macular rash appears on the face and trunk after about 7 days and lasts for up to 3 days. Maternal infection during pregnancy may affect the fetus, particularly if infection is acquired in the first trimester. Diagnosis the diagnosis may be suspected clinically and a definitive diagnosis is made by demonstrating a rising serum IgG titre in paired samples taken 2 weeks apart, or by the detection of rubella-specific IgM. Complications are uncommon but include arthralgia, encephalitis and thrombocytopenia. There may be systemic infection in the immunocompromised host, and in severe cases death may result from hepatitis and encephalitis. Management Oral aciclovir, famciclovir and valaciclovir for 5 days are useful if started while lesions are still forming; after this time there is little clinical benefit. Topical antiviral preparations are available but are less effective in the treatment of anogenital lesions. Varicella zoster virus Varicella (chickenpox) Primary infection with this virus causes chickenpox, which may produce a mild childhood illness, although this can be severe in adults and immunocompromised patients. The rash, predominantly on the face, scalp and trunk, begins as macules and develops into papules and vesicles, which heal with crusting. Complications include pneumonia and central nervous system involvement, presenting as acute truncal cerebellar ataxia. Individuals are considered infective for 2 days before the appearance of the vesicles until the lesions crust over. Anyone over the age of 16 years should be considered for antiviral therapy with aciclovir (if they present within 48 hours) because they are more at risk of severe disease. A live vaccine is available for non-immune health workers and some other specific patient groups. Herpes zoster (shingles) After the primary infection, the varicella virus remains dormant in dorsal root ganglia and/or cranial nerve ganglia, and reactivation causes herpes zoster or shingles. A person with shingles (particularly if the rash is weeping) could cause chickenpox in a non-immune person after close contact and touch. Clinical features Pain and tingling in a dermatomal distribution precede the rash by a few days. The most common sites are the lower thoracic dermatomes and the ophthalmic division of the trigeminal nerve. Management Treatment is with oral acyclovir, valaciclovir or famciclovir given as early as possible. Treatment is with amitriptyline, gabapentin or topical agents such as capsaicin cream. If clinical symptoms are present they include fever, headache, sore throat and a transient macular rash (more common following administration of amoxicillin given inappropriately for a sore throat). There may be palatal petechiae, cervical lymphadenopathy, splenomegaly and hepatitis. In association with a compatible clinical syndrome, detection of heterophile antibodies to sheep red cells (the PaulBunnell reaction) or horse red blood cells (the Monospot test) is diagnostic. Corticosteroids are considered if there is neurological involvement (encephalitis, meningitis), when tonsillar enlargement causes airway obstruction or if there is severe aplastic anaemia. Lyme disease Lyme disease is a multisystem inflammatory disease caused by the spirochaete Borrelia burgdorferi and occasionally other Borrelia species. Neurological manifestations include meningoencephalitis and cranial or polyneuropathies. Acrodermatitis chronica atrophicans is a skin manifestation seen particularly in Europe. Patients may develop persistent non-specific symptoms following treatment but there is no objective evidence that this is due to persistent infection with Borrelia. Management Doxycycline 100 mg twice daily given for 14 days is the treatment of choice for early-stage disease with amoxicillin as an alternative. To prevent infection in tick-infested areas, repellents and protective clothing should be worn and ticks removed promptly from the site of a bite. Leptospirosisnd this zoonosis is caused by a Gram-negative organism, Leptospira interrogans, which is excreted in animal urine and enters the host through a skin abrasion or intact mucous membranes. Individuals who work with animals, take part in water sports or have occupational exposure which bring them into close contact with rodents (e. Following an incubation period of about 10 days the initial leptospiraemic phase is characterized by fever, headache, malaise and myalgia and conjunctival suffusion. Investigations Serology is most often used to confirm the diagnosis but in patients with appropriate environmental exposure, empirical treatment should not be delayed. Management Oral doxycycline is given for mild disease and intravenous penicillin or ceftriaxone for more severe disease. The complications of the disease may require renal replacement therapy or ventilatory support. Rickettsia A variety of Rickettsial species with wide geographical distribution can cause travel-related infection, but most commonly Rickettsia africae (African tickbite fever) or Rickettsia conorii (Mediterranean spotted or tick bite fever) is identified. Fever, malaise, lymphadenitis, rash and particularly eschar all suggest infection. Malaria is the most common cause of febrile illness in recent travellers and is potentially fatal; therefore, prompt assessment of these patients is necessary. Suspected cases should be discussed immediately with the local Infectious Diseases team and Health Protection unit as per local policy. Details of travel in rural and urban areas including types of accommodation used should also be recorded. Malaria prophylaxis has to be appropriate for the area visited and taken reliably without premature cessation. Appropriate prophylaxis with full adherence does not exclude malaria within the differential. Investigations the initial work-up of a febrile patient who has recently travelled is listed below. Malariand Malaria is a protozoan parasite widespread in the tropics and subtropics. Increasing prevention and control strategies have seen the global mortality rates for malaria drop by 60% since 2000. In endemic areas, mortality is principally in infants, and those who survive to adulthood acquire significant immunity. In hyperendemic areas, an exaggerated immune response to repeated malarial infections leads to massive splenomegaly, anaemia and elevated IgM levels. Aetiology Malaria is transmitted by the bite of infected female Anopheles mosquitoes. Occasionally it is transmitted in contaminated blood (transfusions, contaminated equipment, injecting drug users sharing needles). Rarely the parasite is transmitted by importation of infected mosquitoes by air (airport malaria). Plasmodium falciparum is responsible for most malaria-related deaths, and infection can rapidly progress from an acute fever with rigors to severe multiorgan failure, coma and death. Most often this occurs in people of African or South Asian origin and 50% of cases occur in patients who have visited friends and family in endemic areas. Pathogenesis the infective form of the parasite (sporozoites) passes through the skin and, via the bloodstream, enters the liver. After a few days the infected hepatocytes rupture, releasing merozoites into the blood where they are taken up by erythrocytes and pass through further stages of development, which terminate with the rupture of the red cell. Rupture of red blood cells contributes to anaemia and releases pyrogens, causing fever. Fever in the returned traveller 27 the onset of symptoms may be delayed (up to 3 months, 1 year in vivax malaria) in the partially immune or after prophylaxis. There is an abrupt onset of fever, tachycardia and rigors, followed by profuse sweating some hours later. These patients must be discussed with local infection experts and should be managed in a high-dependency or intensive care setting. Investigations the conventional method for diagnosing malaria is examination of a thick and thin blood film. Thick smears detect malaria parasites and thin smears are used for parasite identification and for quantification of the percentage of parasitized red cells (in P. Pregnancy testing should be undertaken in all women of childbearing potential, as falciparum malaria in pregnancy is more likely to be complicated, diagnosis can be difficult, treatment strategies are different and expert opinion should be sought. Assessment should include careful evaluation for the features of severe malaria in Table 2. Thrombocytopenia is common and in isolation does not reflect severe or complicated disease. Management Treatment of uncomplicated falciparum malaria Patients should be admitted to hospital at least for the first 24 hours as there can be rapid deterioration. Severe falciparum malaria (indicated by the presence of any of the features listed in Table 2. Parenteral therapy should be given to patients who have a >2% parasitaemia, are pregnant (following specialist advice) or in which the oral route is unavailable.
The regions (Hong Kong medicine emblem cheap albenza 400 mg free shipping, South Korea medications during labor best 400 mg albenza, and Taipei) with librarians that were active as curriculum facilitators chi royal treatment order 400mg albenza overnight delivery, tended to have more support medicine 20 buy albenza 400mg lowest price, recognition medications 230 buy cheap albenza 400mg line, and understanding from the principals and other teachers (see Tables M and N) symptoms testicular cancer albenza 400 mg without prescription. On the other hand, both Japan and Shanghai ranked at the 7 Texas Administrative Code. Guidelines for Collaborations Between Teachers and Librarians For all 5 regions, only very small percentages of libraries had written guidelines for collaborations between teachers and librarians (see Table O). Having very experienced librarians, who have been serving for 11 or more years still did not mean the written policies would be automatically developed (see Table D). It should be highlighted that for the regions with libraries that were high in circulation rates, active reading programmes, and resourceful in technologies, their successes seemed to be built upon good mutual understanding between the librarians and the teachers/principals, rather than on any written policies. Despite of the absence of any written guidelines, principals and teachers in Taipei, Hong Kong, and South Korea were comparatively more supportive and understanding towards the work carried out by the librarians (see Table N). In other words, successful collaborations between the teachers and librarian did not need to be formulated in accordance to wellwritten guidelines; on the contrary, having supportive teachers and principals seemed to be a more influential factor in this regard. Based on the same assumption, being a capable curriculum facilitator and an effective reading programme organizer might also be the best way to earn support and recognitions from the principals and other teachers. Degrees of Job Satisfaction With reference to the comparison of job satisfaction amongst the school librarians, ranking based on the average rating scores collected from question no. In addition, their job satisfaction also corresponded directly to their level of involvement in the school curriculum and the other reading incentive programmes (see Table P). Results indicated that librarians in both Japan and Shanghai suffered from the lowest level of satisfaction amongst all 5 regions. Most "shisho-kyoyu" teach a class in elementary school and a subject in the junior and senior high schools, taking care of the classroom as well. Therefore, "gakko-shisho", who might have certification of "shisho" and/or "shisho-kyoyu", might be hired as part-time clerical staff to take care of the school libraries and students in the libraries. In sum, the type of school library personnel is too uneven between the schools, and it seems that none of them is recognized as an established professionals. In reality, however, most of the shisho-kyoyu are actually fulltime homeroom/subject teachers and do not have enough time to spare for the school library activities. Gakko-shisho do most of the work in the school libraries, although many of them are underpaid and are not treated as professional educational staff members nor are respected adequately as professionals. Such low score was not proportional to the degree of satisfaction towards their own job and the working environment amongst the school librarians. In addition, although they were employed as full-time librarians, many of them had too many other non-libraryrelated subject courses to teach. For example, one respondent said that, "Teacher librarians in Hong Kong have too many lessons. Education Policies & Impacts on School Library Programmes All 5 regions have policies or guidelines developed by either their respective Ministry of Educations or the Education Bureaus - offering standards for guiding the school administrations and the librarians on the basic setup and running a school library. General Principles and Guidelines for Management Senior School Libraries in Taiwan Available. Guidelines for Implementing Elementary and Secondary School Libraries in Shanghai. For that reason, the support and understanding of the principal play a crucial role in the implementation of effective library programmes. According to the feedback given by a practicing school librarian in Hong Kong, "Compared with other non-academic subjects, such as P. In addition, there are many health and safety regulations concerning the students that these teachers must observe carefully. In the case of teaching music, one would need to be able to play the piano and teach basic music theory. Although both Shanghai and Japan had the highest percentage of schools with the largest collections of printed books, librarians in these 2 regions seemed to be lagging behind in many areas. For example, librarians in these 2 regions were very inactive in serving as reading programme and curriculum facilitators. In terms of number and the types of library-related technologies available, both Shanghai and Japan ranked at the bottom. Such negative attitudes might be caused by their lack of understanding or not valuing the pedagogical potential of the school librarians regardless of the lack of adequate school facilities and personnel. The major difference was that formal job-training programmes for practicing school librarians were simply absent in China. Whereas in Japan, certificate programmes are widely available; unfortunately, employment opportunities were given to a very small number of fully-certified school librarians (Nakamura 2012). The findings from Japan and Shanghai are support the results reported by De Vita (2002) and Roberson, Applin, and Schweinle (2005), that a large number of school libraries are understaffed, underfunded, and underutilized. They often become the first victims of budget cuts made by school administrators, as many of them do not understand the potential benefits of school libraries and librarians. Such negative factors might have explained the low degree of job satisfaction amongst the school librarians, as well as their overall working environment as a whole. In fact, the negative influences of exam-centric education on high Korean Library Standards Committee. For that reason, the school library and enquiry-based learning have almost no role to play in the overall curriculum. Chinese researchers further explained that school libraries are highly undervalued amongst school principals in Shanghai, since they do not contribute directly to the formal curriculum. Finally, many subject teachers are assigned or transferred to take up the school libraries without having any interests or professional qualifications/training in library work, with reasons ranging from poor health conditions to favouring a less stressful job before retirement. A combination of such factors have resulted highly-unfavourable working conditions and negative attitudes amongst school librarians in Shanghai. Ironically, fully-certified librarians were unable to devote full-time to library work, as many of them had to teach other non-library-related subject courses. Poor career path was another major factor that seriously discouraged the working morale amongst the school librarians. Reasons Behind Successful School Library Programmes in Taipei & South Korea As explained by the Taiwanese researcher, with the implementation of the library legislation for senior high schools in Taiwan, everyone is expected to have undergone some kind of formal or informal training before one is assigned to serve as a school librarian (see Table E). In addition, there is the Senior School Librarians Support Group set up by the Taiwan Ministry of Education. Such training programmes are well-received and the attendance is usually very high. In order to raise and unify the standards of the school library services, the Support Group has also developed an operational manual for senior school librarians in Taiwan to follow. Being a subject leader also means that they could focus entirely on their library duties. For such reasons, many teachers are willing to serve as school librarians with much joy and enthusiasm, which eventually led to quality programmes being carried out by the school librarians in Taipei. Research findings reflected that school library programmes in South Korea also excelled, and ranked second in many areas. The results from Hong Kong, Korea, and Taipei are supportive to that of findings of (Church, 2010; Hartzell, 2002; Haycock, 1999; Miller, 2005; Shannon, 2009) - the attitudes of the teachers and principals are the deciding factors of the library services in schools. Large library collections would not automatically lead to high circulation rates; on the other hand, instructional interventions, active participation in the curriculum and reading programmes of the school librarians were more influential factors in this regard. Optimistic career paths, compatible professional status, well-matched employment terms and conditions, and positive attitudes and support from school principals and teachers are no doubt the most important factors contributing to job satisfaction of the school librarians, regardless of the regions. Meanwhile, job satisfaction and the quality of library programmes are to some extent interrelated to each other. Readers need to be aware that the survey response rates in Japan were very low (did not meet the minimum 100-response quota). Findings from Japan and Shanghai indicated that there was a serious lack of library usage tradition within the school community. In these 2 regions, results also reflected that teachers and principals not familiar with the range and level of services that can be provided by the school librarians. It is unwise to remain unchanged and keep our focus on competing for excellent public examination results. As a result, we should voice our concerns that their roles are status have been neglected by the authorities and stakeholders. The Impact of School Library Services on Student Achievement and the Implications and the Implications for Advocacy. Perceiving Usefulness: the Perception of Users on School Libraries and Librarians in Hong Kong. Quality Learning and Teaching Resources and School Library Development - Bringing about Effective Learning. School Library Services: Learning How to Learn (-) Retrieved from rvices/teaching-resources/supporting-learning-and-teaching-throughsch-lib-services/index. The Usefulness of Comparative Librarianship in Relation to Nonindustrialized Countries. Journal of Korean Library and Information Science Society, 43(2), 203-225 Kirkpatrick, R. The negative influences of exam- oriented education on Chinese high school students: Backwash from classroom to child. Paper presented at the Annual Meeting of the Japan Association of Language Teachers (21st Nagoya, Japan, November 1995). General Principles and Guidelines for Management Senior School Libraries in Taiwan Retrieved from. A Study on the Performance and the Prospect of School Library Rehabilitation Project. Korea Biblia, 18(1), 117-146 Reading and Literacy Promotion for Children Legislation /. Factors Affecting the Job Satisfaction of Teac her-Librarians in Aided Secondary Schools of Hong Kong. School Types Hong Kong Shanghai Pusan / Seoul Elementary / 0 39 0 Primary Schools (0. Length of Experiences Hong Kong Shanghai Up to 5 years 6 - 10 years 11 years or more Total Responses 41 (37. Collection Hong Kong Shanghai Pusan / Taipei Sizes Seoul (titles) None 3 36 4 0 (2. Types of Reading Incentive Programmes Carried out by the School Librarian (Average rating based on a 4-point scale: from Never to Always). Types of Reading Hong Kong Shanghai Pusan / Taipei Osaka / Programmes Seoul Tokyo Conduct book talks 3. Collaborations with Other Teachers (Average rating based on a 4-point scale: from Never to Always). Types of Collaborations Hong Kong Shanghai Pusan / Taipei Osaka / Seoul Tokyo Administrative role 2. Administrative Duties Performed Daily (Average rating based on a 4-point scale: from Never to Always). Types of Hong Kong Shanghai Pusan / Taipei Osaka / Administrative Duties Seoul Tokyo Develop library 3. Teaching Duties Performed Daily (Average rating based on a 4-point scale: from Never to Always). Different Hong Kong Shanghai Pusan / Taipei Osaka / Teaching Duties Seoul Tokyo Plan / teach literacy skills 2. Curriculum Facilitator Duties Performed Daily (Average rating based on a 4-point scale: from Never to Always) Hong Kong Shanghai Pusan / Taipei Osaka / Seoul Tokyo Attend meetings of school 2. Degree of Support & Understanding from Principals & Teachers (Average rating based on a 4-point scale: from Never to Always). Degree of Support & Hong Kong Shanghai Pusan / Taipei Osaka / Understanding Seoul Tokyo of Colleagues Teachers understand my 3. Job Satisfaction as School Librarian (Average rating based on a 4-point scale: from Never to Always). Degree of Job Hong Kong Shanghai Pusan / Taipei Osaka / Satisfaction Seoul Tokyo Do you find your job as 2. To help navigate this changing landscape, global citizenship is an important life-skill for youths. Critical reading of translated literature provides an opportunity for youths to enhance their life-skills in reading the world and connecting their own experiences to others (Buck et al. Batchelder Award, global citizenship, global literature, human rights Introduction 21st Century learners live in a shrinking world with advances in technology and transportation (Friedman, 2005). Today more than ever, political, social and economic choices made in one corner of the globe hold implications for another (Zahabioun, Yousefy, Yarmohammadian, & Keshtiaray, 2013). Critical reading of translated literature provides an opportunity for youths to enhance their life skills in reading the world and connecting their 142 own identity and experiences into the world (Buck et al. Literature Review Critics of global citizenship have interpreted the term quite literally to mean residents of the globe with all of the advantages (or disadvantages) one might have as a citizen of a country like Australia or the United States of America (Liu, 2012). While the political focus of criticisms towards global citizenship are noted here, our study takes a broader view of the term, encompassing more empathetic and activist perspectives towards global citizenship as defined in the field of education. Brigham (2011) defines global citizenship in three ways: understanding the world and our connections among each other, seeing instances of social justice and equity, and acting by exercising political rights and challenging injustices.
These are followed by the tachycardia and decreased atrioventricular conduction time that would be predicted from blockade of postsynaptic muscarinic receptors in the sinus node medications affected by grapefruit generic albenza 400mg with amex. M1-selective agents (not currently available in the United States) may be somewhat selective for the gastrointestinal tract medications dictionary order albenza 400mg online. What fraction of atropine (an amine) is in the lipid-soluble form in urine of pH 7 treatment esophageal cancer buy cheap albenza 400 mg on line. Benztropine medications 4h2 buy albenza 400mg lowest price, biperiden medications peripheral neuropathy discount albenza 400mg free shipping, and trihexyphenidyl are representative of several antimuscarinic agents used in parkinsonism medications you cannot crush buy discount albenza 400 mg online. Although not as effective as levodopa (see Chapter 28), these agents may be useful as adjuncts or when patients become unresponsive to levodopa. Benztropine is sometimes used parenterally to treat acute dystonias caused by firstgeneration antipsychotic medications. Eye-Antimuscarinic drugs are used to cause mydriasis, as indicated by the origin of the name belladonna ("beautiful lady") from the ancient cosmetic use of extracts of the Atropa belladonna plant to dilate the pupils. Bronchi-Parenteral atropine has long been used to reduce airway secretions during general anesthesia. Although not as efficacious as agonists, ipratropium is less likely to cause tachycardia and cardiac arrhythmias in sensitive patients. It has very few antimuscarinic effects outside the lungs because it is poorly absorbed and rapidly metabolized. Gut-Atropine, methscopolamine, and propantheline were used in the past to reduce acid secretion in acid-peptic disease, but are now obsolete for this indication because they are not as effective as H2 blockers (Chapter 16) and proton pump inhibitors (Chapter 59), and they cause far more frequent and severe adverse effects. The M1-selective inhibitor pirenzepine is available in Europe for the treatment of peptic ulcer. Muscarinic blockers can also be used to reduce cramping and hypermotility in transient diarrheas, but drugs such as diphenoxylate and loperamide (Chapters 31, 59) are more effective. Bladder-Oxybutynin, tolterodine, or similar agents may be used to reduce urgency in mild cystitis and to reduce bladder spasms after urologic surgery. Tolterodine, darifenacin, solifenacin, fesoterodine, and propiverine are slightly selective for M3 receptors and are promoted for the treatment of stress incontinence. Toxicity A traditional mnemonic for atropine toxicity is "Dry as a bone, hot as a pistol, red as a beet, mad as a hatter. Predictable toxicities-Antimuscarinic actions lead to several important and potentially dangerous effects. Blockade of thermoregulatory sweating may result in hyperthermia or atropine fever ("hot as a pistol"). This is the most dangerous effect of the antimuscarinic drugs in children and is potentially lethal in infants. Sweating, salivation, and lacrimation are all significantly reduced or stopped ("dry as a bone"). Moderate tachycardia is common, and severe tachycardia or arrhythmias are common with large overdoses. In the elderly, important toxicities include acute angle-closure glaucoma and urinary retention, especially in men with prostatic hyperplasia. Other drug groups with antimuscarinic effects, for example, tricyclic antidepressants, may cause hallucinations or delirium in the elderly, who are especially susceptible to antimuscarinic toxicity. At very high doses, intraventricular conduction may be blocked; this action is probably not mediated by muscarinic blockade and is difficult to treat. Dilation of the cutaneous vessels of the arms, head, neck, and trunk also occurs at these doses; the resulting "atropine flush" ("red as a beet") may be diagnostic of overdose with these drugs. Severe tachycardia may require cautious administration of small doses of physostigmine. Contraindications the antimuscarinic agents should be used cautiously in infants because of the danger of hyperthermia. The drugs are relatively contraindicated in persons with glaucoma, especially the closedangle form, and in men with prostatic hyperplasia. Ganglion-Blocking Drugs Blockers of ganglionic nicotinic receptors act like competitive pharmacologic antagonists, although there is evidence that some also block the pore of the nicotinic channel itself. Hexamethonium (C6, a prototype), mecamylamine, and several other ganglion blockers were extensively used for this disease. Trimethaphan was the ganglion blocker most recently used in clinical practice, but it too has been almost abandoned. Because the affinity of the oxime group for phosphorus exceeds the affinity of the enzyme-active site for phosphorus, these agents are able to bind the inhibitor and displace the enzyme if aging has not occurred. A 27-year old compulsive drug user injected a drug he thought was methamphetamine, but he has not developed any signs of methamphetamine action. He has been admitted to the emergency department and antimuscarinic drug overdose is suspected. Which of the following is the most dangerous effect of belladonna alkaloids in infants and toddlers Two new synthetic drugs (X and Y) are to be studied for their cardiovascular effects. The drugs are given to three anesthetized animals while the blood pressure is recorded. The first animal has received no pretreatment (control), the second has received an effective dose of a long-acting ganglion blocker, and the third has received an effective dose of a long-acting muscarinic antagonist. Drug X caused a 50 mm Hg rise in mean blood pressure in the control animal, no blood pressure change in the ganglionblocked animal, and a 75 mm mean blood pressure rise in the atropine-pretreated animal. Drug X is probably a drug similar to (A) Acetylcholine (B) Atropine (C) Epinephrine (D) Hexamethonium (E) Nicotine Heart Vessels Glands Skeletal muscle has a short half-life. It was used intravenously to treat severe accelerated hypertension (malignant hypertension) and to produce controlled hypotension. Because ganglion blockers interrupt sympathetic control of venous tone, they cause marked venous pooling; postural hypotension is a major manifestation of this effect. Neuromuscular-Blocking Drugs Neuromuscular-blocking drugs are important for producing marked skeletal muscle relaxation that is important in surgery and in mechanical ventilation of patients. The net changes in heart rate induced by drug Y in these experiments are shown in the following graph. Which one of the following drugs has a very high affinity for the phosphorus atom in parathion and is often used to treat life-threatening insecticide toxicity Nicotine can induce both parasympathomimetic and sympathomimetic effects by virtue of its ganglion-stimulating action. Hypertension and exercise-induced tachycardia reflect sympathetic discharge with norepinephrine release and therefore would not be blocked by atropine. Exerciseinduced sweating is another sympathomimetic response, but it is mediated by acetylcholine released from sympathetic nerve fibers at eccrine sweat glands. Drug X causes an increase in blood pressure that is blocked by a ganglion blocker but not by a muscarinic blocker. The pressor response is actually increased by pretreatment with atropine, a muscarinic blocker, suggesting that compensatory vagal discharge might have blunted the full response. Drug Y causes an increase in heart rate that is blocked by a muscarinic blocker but reversed by a ganglion blocker. The description fits a directacting muscarinic stimulant such as acetylcholine (given in a dosage that causes a significant drop in blood pressure). An indirect-acting cholinomimetic (cholinesterase inhibitor, B) would not produce this pattern because the vascular muscarinic receptors involved in the depressor response are not innervated and are unresponsive to indirectly acting agents. Neither ganglion blockers nor muscarinic blockers cause miosis; they cause mydriasis. Both classes of cholinoceptor blockers increase resting heart rate and cause cycloplegia, because these are determined largely by parasympathetic tone. Postural hypotension, on the other hand, is a sign of sympathetic blockade, which would occur with ganglion blockers but not muscarinic blockers (Chapter 6). Which of the following signs would distinguish between an overdose of a ganglion blocker versus a muscarinic blocker Which of the following is an accepted therapeutic indication for the use of antimuscarinic drugs Which of the following is an expected effect of a therapeutic dose of an antimuscarinic drug Which one of the following drugs causes vasodilation that can be blocked by atropine Atrial fibrillation and other arrhythmias are not responsive to antimuscarinic agents. Antimuscarinic drugs tend to cause urinary retention and may precipitate or exacerbate glaucoma. Bethanechol (Chapter 7) causes vasodilation by directly activating muscarinic receptors on the endothelium of blood vessels. Pralidoxime has a very high affinity for the phosphorus atom in organophosphate insecticides. According to the HendersonHasselbalch equation, Log (protonated / unprotonated) = pK a - pH Log (P / U) = 9. List the major clinical indications and contraindications for the use of muscarinic antagonists. List one antimuscarinic agent promoted for each of the following uses: to produce mydriasis and cycloplegia; to treat parkinsonism, asthma, bladder spasm, and the muscarinic toxicity of insecticides Describe the mechanism of action and clinical use of pralidoxime. They are readily divided into subgroups on the basis of their spectrum of action (-, -, or dopamine-receptor affinity) or mode of action (direct or indirect). Spectrum of Action Adrenoceptors are classified as, or dopamine receptors; these groups are further subdivided into subgroups. Epinephrine may be considered a single prototype agonist with effects at all - and -receptor types. Alternatively, separate prototypes, phenylephrine (an agonist) and isoproterenol, may be defined. The just-mentioned drugs have relatively little effect on dopamine receptors, but dopamine itself is a potent dopamine-receptor 76 agonist and, when given as a drug, can also activate receptors (intermediate doses) and receptors (larger doses). Mode of Action Sympathomimetic agonists may directly activate their adrenoceptors, or they may act indirectly to increase the concentration of endogenous catecholamine transmitter in the synapse. Amphetamine derivatives and tyramine cause the release of stored catecholamines; they are therefore mainly indirect in their mode of action. Dopamine D2 receptors are more important in the brain but probably also play a significant role as presynaptic receptors on peripheral nerves. Repeated dosing of amphetamines results in the rapid development of tolerance and dependence. Very high doses of amphetamines lead to marked anxiety or aggressiveness, paranoia, and, less commonly, seizures. Some 2-selective agonists (eg, clonidine) cause vasoconstriction when administered intravenously or locally into the conjunctival sac. Eye the smooth muscle of the pupillary dilator responds to topical phenylephrine and similar agonists with contraction and mydriasis. Outflow of aqueous humor may be facilitated by nonselective agonists, with a subsequent reduction of intraocular pressure. Alpha2-selective agonists also reduce intraocular pressure, apparently by reducing synthesis of aqueous humor. Bronchi the smooth muscle of the bronchi relaxes markedly in response to 2 agonists, eg, isoproterenol and albuterol. These agents are the most efficacious and reliable drugs for reversing bronchospasm. Gastrointestinal Tract the gastrointestinal tract is well endowed with both and receptors, located both on smooth muscle and on neurons of the enteric nervous system. Genitourinary Tract the genitourinary tract contains receptors in the bladder trigone and sphincter area; these receptors mediate contraction of the sphincter. If used as drugs, these adrenoceptor agonists are relatively inactive by the oral route and must be given parenterally. Isoproterenol, a synthetic catecholamine, is similar to the endogenous transmitters but is not readily taken up into nerve endings. Alpha-Receptor Effects Alpha-receptor effects are mediated primarily by the trimeric coupling protein Gq. Direct gating of calcium channels may also play a role in increasing intracellular calcium concentration. Alpha2-receptor activation results in inhibition of adenylyl cyclase via the coupling protein Gi. Some evidence suggests that receptors may exert G-protein-independent effects after binding -arrestin. Effect on Skin, Splanchnic Vascular Resistance - Skeletal Muscle Vascular Resistance Renal Vascular Resistance - Mean Blood Pressure Drug Phenylephrine Isoproterenol Norepinephrine a Heart Rate a a, b Compensatory reflex response. Alpha1 agonists-Alpha1 agonists (eg, phenylephrine) contract vascular smooth muscle, especially in skin and splanchnic blood vessels, and increase peripheral vascular resistance and venous pressure. Because these drugs increase blood pressure, they often evoke a compensatory reflex bradycardia.
It acts on adenosine receptors and enhances the flow of potassium out of myocardial cells; it produces hyperpolarization of the cell membrane and stabilizes the cell membrane medicine 5113 v cheap albenza 400 mg with visa. Indications the main indication is reversion to sinus rhythm of atrioventricular junctional tachycardia treatment mononucleosis 400 mg albenza otc. In the non-emergency setting it should only be initiated under specialist supervision medicine buddha mantra proven albenza 400 mg. Unlike many other antiarrhythmic drugs treatment west nile virus generic 400 mg albenza with amex, amiodarone causes little or no myocardial depression treatment xdr tb guidelines cheap albenza 400 mg on line. Oral Oral administration is 200 mg three times daily for 1 week reduced to 200 mg twice daily for a further week; the maintenance dose is usually 200 mg daily or the minimum required to control the arrhythmia medications for ptsd discount 400mg albenza amex. Intravenous Intravenous administration is via central line catheter (in an emergency. As soon as an adequate response has been obtained, oral therapy should be initiated and the. Side effects Amiodarone therapy can be proarrhythmogenic in patients with significant structural heart disease. Thyroid function tests including T3 should be measured before treatment and then every 6 months of treatment. Liver toxicity can also occur, so liver biochemistry should be measured before and then every 6 months of treatment. Other side effects are reversible corneal microdeposits (drivers may be dazzled by headlights at night), phototoxic skin reactions (advise use of sunblock creams), slate-grey skin pigmentation, pneumonitis and peripheral neuropathy. Cautions/contraindications It is contraindicated in sinus bradycardia or sinoatrial heart block, unless pacemaker fitted, iodine sensitivity and thyroid dysfunction. Many drugs interact with amiodarone, including warfarin and digoxin (check British National Formulary for full list). It has a very long half-life (extending to several weeks) and many months may be required to achieve steady-state concentrations; this is also important when drug interactions are considered. It is a membrane-depressant drug that reduces the rate of entry of sodium into the cell (sodium channel blocker). This may slow conduction, delay recovery or reduce the spontaneous discharge rate of myocardial cells. Occasionally it is used in ventricular tachyarrhythmias resistant to other treatments. Interactions with other drugs, including -blockers and calcium-channel blockers, can occur (check British National Formulary for full list). It is also used for rate control in sedentary patients with atrial fibrillation/flutter. Check renal function and electrolytes before starting therapy; reduce dose in the elderly and in renal impairment. Intravenous infusion Intravenous infusion for emergency loading dose for atrial fibrillation or flutter 0. Side effects Side effects include nausea, vomiting, diarrhoea, conduction disturbances, blurred or yellow vision and ventricular arrhythmias. Side effects are common because of the narrow therapeutic index (the margin between effectiveness and toxicity). In suspected toxicity, measure plasma potassium concentration first and correct if hypokalaemia is evident. Plasma digoxin concentrations should be measured if toxicity is suspected; concentrations of > 2 mmol/L usually suggest toxicity. Contraindications Digoxin is contraindicated in arrhythmias associated with accessory conduction pathways. Blocking the normal pathway can increase the speed of conduction in the abnormal pathway and lead to ventricular arrhythmias. Diltiazem, verapamil, spironolactone and amiodarone inhibit renal excretion of digoxin; avoid with amiodarone and measure plasma levels with other drugs (see British National Formulary for full interaction list). Tetracycline, erythromycin and possibly other macrolides enhance the effect of digoxin. These effects reduce myocardial oxygen demand and give more time for coronary perfusion. Preparations and dose Most -blockers are equally effective, but there are differences between them which may affect the choice in particular diseases or individual patients. Sotalol use is limited to the treatment of ventricular arrhythmias or the prevention of supraventricular arrhythmias. Side effects Side effects include bradycardia, exacerbation of intermittent claudication, lethargy, nightmares, hallucinations, deterioration of glucose tolerance and interference with metabolic and autonomic responses to hypoglycaemia in diabetics. Cautions/contraindications these include bilateral renal artery stenosis, pregnancy, angio-oedema, severe renal failure, severe or symptomatic mitral or aortic stenosis and hypertrophic obstructive cardiomyopathy (risk of hypotension). Side effects these include postural hypotension, rash, abnormalities in liver biochemistry and hyperkalaemia. Caution/contraindications Lower doses should be given in liver and renal impairment, patients taking high-dose diuretics and the elderly (over 75 years). Caution should be applied in renal artery stenosis, aortic or mitral valve stenosis and in obstructive hypertrophic cardiomyopathy. Indications these drugs are used as a prophylaxis for and in the treatment of angina, as an adjunct in congestive heart failure and intravenously in the treatment of acute heart failure and acute coronary syndrome. Tablets (unlike spray) can be spat out if side effects occur (headache, hypotension). Side effects these are mainly due to vasodilating properties and are minimized by initiating therapy with a low dose. They include flushing, headache, postural hypotension, and methaemoglobinaemia with excessive dosage. Cautions/contraindications Nitrates are contraindicated in hypotension and hypovolaemia, hypertrophic obstructive cardiomyopathy, aortic stenosis, mitral stenosis, cardiac tamponade and constrictive pericarditis. Nitrates, calcium-channel blockers 501 Calcium-channel blockers this group of drugs includes different modified-release preparations of calcium-channel blockers that have different bioavailabilities, and so the brand should be stated on the prescription. Mechanism of action these drugs block calcium channels and modify calcium uptake into myocardium and vascular smooth muscle cells. In contrast, verapamil, and to a lesser extent diltiazem, are weak vasodilators but depress cardiac conduction and contractility. Nimodipine is for the prevention of ischaemic neurological deficits following aneurysmal subarachnoid haemorrhage. Side effects these are mainly due to vasodilator properties: flushing, dizziness, tachycardia, hypotension, ankle swelling and headache. Verapamil and diltiazem diminish cardiac contractility and slow cardiac conduction; thus they are relatively contraindicated in patients taking -blockers, left ventricular failure, sick sinus syndrome and heart failure. Potassium-channel activators Mechanism of action the mechanism of action here is a hybrid of nitrates (p. Potassium-channel activators cause an increase in potassium flow into the cell, which indirectly leads to calcium-channel blockade and arterial dilatation. Indications Use is indicated in cases of refractory angina in patients who are uncontrolled on standard regimens of aspirin, -blockers, nitrates, calcium antagonists and statins. Nitrates, calcium-channel blockers 503 Side effects these include headache (often temporary), flushing, nausea, vomiting, dizziness, hypotension, tachycardia. Cautions/contraindications Nicorandil use is contraindicated in left ventricular failure and cardiogenic shock. The lungs are each enclosed within a double membrane; visceral pleura covers the surface of the lung and is continuous at the hilum with the parietal pleura, which lines the inside of the thoracic cavity. The interpleural space between these layers normally contains only a tiny amount of lubricating fluid. The trachea divides at the carina (lying under the junction of manubrium sterni and second right costal cartilage) into right and left main bronchi. Within the lungs the bronchi branch again, forming secondary and tertiary bronchi, then smaller bronchioles, and finally terminal bronchioles ending at the alveoli. Mucus traps macrophages, inhaled particles and bacteria, and is moved by the cilia in a cephalad direction, thus clearing the lungs (the mucociliary escalator). Gas exchange occurs in the alveolus where capillary blood flow and inspired air are separated only by a thin wall composed mainly of type 1 pneumocytes and capillary endothelial cells and the capillary and alveolar basement membranes are fused as one. The pulmonary circulation delivers deoxygenated blood to the lungs from the right side of the heart via the pulmonary artery. Oxygen from inhaled air passes through the alveoli into the bloodstream and oxygenated blood is returned to the left heart via the pulmonary veins. The bronchial (systemic) system carries arterial blood from the descending aorta to oxygenate lung tissue primarily along the larger conducting airways. In contrast, carbon dioxide passes from the capillaries which surround the alveoli, into the alveolar spaces, and is breathed out. The accessory muscles of respiration are also 506 Respiratory disease recruited (sternomastoids and scalenes) during exercise or respiratory distress. Expiration is a passive process, relying on the elastic recoil of the lung and chest wall. During exercise, ventilation is increased and expiration becomes active, with contraction of the muscles of the abdominal wall and the internal intercostals. This generates efferent signals (via phrenic nerve and efferent branches of the vagus) to expiratory musculature to generate a cough. Cough lasting only a few weeks is most commonly due to an acute respiratory tract infection. Asthma, gastro-oesophageal reflux disease and postnasal drip are the most common causes of a persistent cough (Table 11. A postnasal drip is due to rhinitis, acute nasopharyngitis or sinusitis and symptoms, other than cough, are nasal discharge, a sensation of liquid dripping back into the throat and frequent throat clearing. Cough may be the only symptom of asthma when it is typically worse at night, on waking and after exercise. A chronic cough, sometimes accompanied by sputum production, is common in smokers. However, a worsening cough may be the presenting symptom of bronchial carcinoma and needs investigation. Mucoid sputum is clear and white but can contain black specks resulting from the inhalation of carbon. Yellow or green sputum is due to the presence of cellular material, including bronchial epithelial cells, or neutrophil or eosinophil granulocytes. Yellow sputum is not necessarily due to infection, as eosinophils in the sputum, as seen in asthma, can give the same Table 11. The production of large quantities of yellow or green sputum is characteristic of bronchiectasis. Common causes are bronchiectasis, bronchial carcinoma, pulmonary embolism, bronchitis and lung infections including pneumonia (rust-coloured sputum), abscess and tuberculosis. Rarer causes are benign tumours, bleeding disorders, granulomatosis with polyangitis (p. A chest X-ray should be performed in all patients, and subsequent investigations (e. It may be life-threatening due to asphyxiation and is an indication for hospital admission. Initial management includes administration of oxygen, placement of a large-bore intravenous catheter, blood samples (full blood count, clotting screen, urea and electrolytes), arterial blood gases and chest X-ray. Orthopnoea is breathlessness that occurs when lying flat and is the result of abdominal contents pushing the diaphragm into the thorax. Paroxysmal nocturnal dyspnoea is a manifestation of left heart failure: the patient wakes up gasping for breath and finds some relief by sitting upright. The mechanism is similar to orthopnoea, but because sensory awareness is depressed during sleep, severe interstitial pulmonary oedema can accumulate. In acute breathlessness, appropriate initial investigations include a chest X-ray, pulse oximetry and sometimes arterial blood gases. Simple lung function tests, pulse oximetry, a full blood count and a chest X-ray are the initial investigations for most patients with chronic breathlessness. Asthma is a common cause of wheezing and is likely when patients present with episodic wheezing, cough and dyspnoea which responds favourably to inhaled bronchodilators.
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