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By: G. Jack, M.B. B.CH. B.A.O., Ph.D.
Deputy Director, Sanford School of Medicine of the University of South Dakota
Magnesium chloride may be particularly useful in settings where magnesium deficiency is common xanthine medications buy epitol 100 mg low cost. These include prior chronic diuretic treatment symptoms of appendicitis order cheap epitol on line, hypocalcaemia treatment for bronchitis discount epitol 100 mg with visa, hypokalaemia medications via peg tube buy generic epitol online, alcoholism, diarrhoea, vomiting, drainage from a fistula, pancreatitis, hyperaldosteronism or prolonged infusion of intravenous fluid without magnesium supplementation. There is no simple test currently available to detect total body magnesium Drug interactions Tricyclic antidepressants block uptake 1 and so may potentiate the action of adrenaline. However, serial plasma magnesium determinations may be useful in preventing excessive dosing with accumulation and toxicity. Decide whether initial management might reasonably include each of the following: (a) (b) (c) (d) i. Mechanism of action Mg2 is a divalent cation and at least some of its beneficial effects are probably due to the consequent neutralization of fixed negative charges on the outer aspect of the cardiac cell membranes (as for Ca2). In addition, Mg2 is a vasodilator and releases prostacyclin from damaged vascular tissue in vitro. Answer (a) (b) (c) (d) False True True False Adverse effects and contraindications · Excessively high extracellular concentrations of Mg2 can cause neuromuscular blockade. Magnesium chloride should be used with great caution in patients with renal impairment or hypotension, and in patients receiving drugs with neuromuscular blocking activity, including aminoglycoside antibiotics. Comment this patient clearly has underlying heart disease and is acutely haemodynamically compromised by the dysrhythmia. Pharmacokinetics Magnesium salts are not well absorbed from the gastrointestinal tract, accounting for their efficacy as osmotic laxatives when given by mouth. Mg2 is eliminated in the urine and therapy with magnesium salts should be avoided or the dose reduced (and frequency of determination of plasma Mg2 concentration increased) in patients with glomerular filtration rates 20 mL/min. Case history A 66-year-old man made a good recovery from a transmural (Q-wave) anterior myocardial infarction complicated by mild transient left ventricular dysfunction, and was sent home taking aspirin, atenolol, enalapril and simvastatin. Three months later, when he is seen in outpatients, he is feeling reasonably well, but is worried by palpitations. Question Decide whether management might appropriately include each of the following: (a) consideration of cardiac catheterization; (b) invasive electrophysiological studies, including provocation of dysrhythmia; (c) adding flecainide; (d) stopping atenolol; (e) adding verapamil; (f) adding amiodarone. Answer (a) (b) (c) (d) (e) (f) True False False False False False Drug interactions Magnesium salts form precipitates if they are mixed with sodium bicarbonate and, as with calcium chloride, magnesium salts should not be administered at the same time as sodium bicarbonate, or through the same line without an intervening saline flush. Hypermagnesaemia increases neuromuscular blockade caused by drugs with nicotinic-receptor-antagonist properties. Case history A 16-year-old girl is brought to the Accident and Emergency Department by her mother having collapsed at home. As a baby she had cardiac surgery and was followed up by a paediatric cardiologist until the age of 12 years, when she rebelled. On examination, she is ill and unable to give a history, and has a heart rate of 160 beats per minute (regular) and blood pressure of 80/60 mmHg. It is appropriate to consider cardiac catheterization to define his coronary anatomy and to identify whether he would benefit from some revascularization procedure. Other classes of anti-dysrhythmic drugs have not been demonstrated to prolong life in this setting. If the symptom of palpitation is sufficiently troublesome, it would be reasonable to consider switching from atenolol to regular. He looks pale but otherwise well, his pulse is 155 beats per minute and regular, his blood pressure is 110/60 mmHg and the examination is otherwise unremarkable. Question Decide whether initial management might reasonably include each of the following: (a) (b) (c) (d) (e) (f) (g) i. Answer (a) (b) (c) (d) (e) (f) (g) False True False True False True False Comment Students who are studying for examinations often consume excessive amounts of coffee and a history of caffeine intake should be sought. Vagal manoeuvres may terminate the dysrhythmia but, if not, overnight observation may see the rhythm revert spontaneously to sinus. These symptoms are due to a combination of constriction of bronchial smooth muscle, oedema of the mucosa lining the small bronchi, and plugging of the bronchial lumen with viscous mucus and inflammatory cells (Figure 33.
If the tumour is widespread at presentation medications you can take while pregnant epitol 100 mg online, systemic chemotherapy is more likely to be effective than radiotherapy or surgery symptoms high blood pressure cheap epitol online mastercard, although these may be used to control local disease or reduce the tumour burden before potentially curative chemotherapy medicine you can give cats order generic epitol line. In approximately 50% of human cancers medicine hat mall best epitol 100 mg, genetic mutations contribute to the neoplastic transformation. Some cancer cells overexpress oncogenes (first identified in viruses that caused sarcomas in poultry). Oncogenes encode growth factors and mitogenic factors that regulate cell cycle progression and cell growth. Alternatively, neoplastic cells may overexpress growth factor receptors, or underexpress proteins. The overall effect of such genetic and environmental factors is to shift the normal balance to dysregulated cell proliferation. Unlike normal adult somatic cells, neoplastic cells are immortal and do not have a programmed finite number of cell divisions before they become senescent. The element of cell replication responsible for this programme is the telomere, located at the end of each chromosome. Telomeres are produced and maintained by telomerase in germ cells and embryonic cells. Telomerase loses its function in the course of normal cell development and differentiation. In healthy somatic cells, a component of the telomere is lost with each cell division, and such telomeric shortening functions as an intrinsic cellular clock. Approximately 95% of cancer cells re-express telomerase, allowing them to proliferate endlessly. These drug effects are not confined to malignant cells, and many anti-cancer agents are also toxic to normal dividing cells, particularly those in the bone marrow, gastrointestinal tract, gonads, skin and hair follicles. There are two main groups of cytotoxic drugs, classified by their effects on cell progression through the cell cycle (see Figure 48. Because of this, their dosecytotoxicity relationships follow first-order kinetics (cells are killed exponentially with increasing dose). Cytotoxic drugs are given at very high doses over a short period, thus rendering the bone marrow aplastic, but at the same time achieving a very high tumour cell kill. Their dosecytotoxicity curve is initially exponential, but at higher doses the response approaches a maximum (see Figure 48. Until the kinetic behaviour of human tumours can be adequately characterized in individual patients the value of this classification is limited. The distinction between cell cycle phase-non-specific and phase-specific drugs, although clear-cut in animal and in vitro experiments, is also probably an over-simplification. E 2F Log % cells surviving Log % cells surviving div ve Glucocorticosteroids is (a) Dose (b) Dose Figure 48. Acquired tumour drug resistance results from the selection of resistant clones as a result of killing susceptible cells or from an adaptive change in the neoplastic cell. The ability to predict the sensitivity of bacterial pathogens to antimicrobial substances in vitro produced a profound change in the efficacy of treatment of infectious diseases. The development of analogous predictive tests has long been a priority in cancer research. Such tests would be desirable because, in contrast to antimicrobial drugs, anticancer agents are administered in doses that produce toxic effects in most patients. Unfortunately, currently, clinically useful predictive drug sensitivity assays against tumours do not exist. Cytotoxic cancer chemotherapy is primarily used to induce and maintain a remission or tumour response according to the following general principles. It often entails complex regimens of two to four drugs, including pulsed doses of a cytotoxic agent with daily treatment with agents with different kinds of actions. Knowing the details of such regimens is not expected of undergraduate students and graduate trainees in oncology will refer to advanced texts for this information.
In short symptoms valley fever buy cheapest epitol and epitol, the aim should be healing of a patient and not merely eradication of the disease - symptoms medicine buddha buy 100mg epitol. Many a times when it becomes necessary to know the location treatment dvt buy genuine epitol on-line, extent and damage caused by a disease lying inside the body medicine allergic reaction discount 100 mg epitol free shipping, radiology- neuroradiology becomes helpful and and necessary. X-Ray: the "miraculous rays" X-Rays which could look-make structures inside the body were discovered in 1895 by a German scientist Mr: Roentegen. Thereafter these rays have been used in all possible innovative ways in the medical field. Sunrays, X-Rays, Microwave, Radio waves are all electro magnetic rays in scientific terminology. Radio and television waves do not have much energy and so though they are present all around us in innumerable numbers, they cannot harm us and we are still alive. The energy from the X-Rays is 10,000 to 15,000 times more powerful than light and therefore can penetrate through objects. An amazing fact of nature is that the human eye can perceive only the sun rays and the rest of the rays are invisible to us. The common X-Rays only give a rough picture of the skull or a one dimensional picture, but the depth of any feature cannot be judged. However, since we are now discussing about the diseases of the brain, it is necessary to know how X-Rays are helpful in this context. If there is a tumor in the brain, its depth and position can be determined by dividing the brain into imaginary parts like slices of bread, and each part is X-Rayed from various angles. The computer then calculates and creates a three- dimensional picture, which determines the depth and the size of the tumor very accurately. The stretcher like table on which the patient lies, can be moved in all directions upward, downward and side ways. The X-Ray tube lies in the middle of the tunnel, and rotates in a circular motion photographing the body part from each angle. These photographs are reflected on the detector, a computer carries out accurate calculations, divides the area into slices and then with the help of laser camera photographs are taken. The entire procedure takes about 15 to 30 minutes and during this time the patient has to lie still. The scanning procedure is painless and the patient just has to lie down still for a short period of time. In the diseases of brain like tumor or infection, a special drug called the Contrast Agent is injected intravenously to figure out the circulation of blood inside the diseased part. This iodine-based drug (Iodinised contrast) sometimes can make a person nauseate or temporarily increase his body temperature. A pregnant woman should inform the doctor of her condition prior to the examination. In 1972,a scientist called Damadian discovered the use of magnetic field in the examination of the human body. As the Tesla (power) increases, the accuracy, speed and minuteness of the machine also increase. The patient is positioned in such a way that the organ to be examined remains at the centre of the machine. Here the X-Rays are not used, instead radio frequency waves and strong magnetic field are used, this eliminates the fear of harmful radiation. Hydrogen protons are present in the water, which are present in a large quantity in the body. Each cell has a different number of protons and with the help of radio signals and advanced computers one can accurately calculate the various numbers of protons and thus differentiate each and every type of cell which can be photographed from every angle, with the help of a laser camera on a 14" x 17" photo film. Thus, in 30 to 45 minutes, 80 to 100 photographs of the brain from the different angles (X, Y, Z, axis) can be taken, which an expert radiologist analyzes and a report is given. Since the patient has to lie down in an enclosed cylinder, some of them may feel claustrophobic. In some diseases, a special drug (contrast) has to be used to specify some defects; this drug has very few side effects. Because of the strong magnetic field, things like watch, credit card, pen, rings etc.
Respiratory system (1) b-Adrenoreceptor antagonists increase airway resistance as a result of b2-receptor blockade treatment kennel cough order epitol 100 mg mastercard. Eye (1) b-Adrenoreceptor antagonists decrease the production of aqueous humor medicine pictures generic 100 mg epitol with visa, resulting in reduced intraocular pressure medications similar buspar generic epitol 100mg line. Including propranolol treatment glaucoma discount epitol online amex, many have low bioavailability (<50%) because of extensive first-pass metabolism; marked interpatient variability is seen, particularly with metoprolol. Propranolol (Inderal) (1) Propranolol is a competitive antagonist at b1- and b2-receptors. Metoprolol (Lopressor), betaxolol (Betoptic), bisoprolol (Zebeta), atenolol (Tenormin), acebutolol (Sectral), and esmolol (Brevibloc) (1) these drugs are somewhat selective b1-receptor antagonists that may offer some advantage over nonselective b-adrenoceptor antagonists to treat cardiovascular disease in asthmatic patients, although cautious use is still warranted. Labetalol (Normodyne and Trandate), Carvedilol (Coreg) (1) Labetalol is a partial agonist that blocks b-receptors and a1-receptors (3:1 to 7:1 ratio). Carvedilol also has mixed activity but is equiactive at b-receptors and a1-receptors. Timolol (Blocadren), levobunolol (Betagan), nadolol (Corgard), and sotalol (Betapace) (1) these drugs are nonselective b-receptor antagonists. Pindolol (Visken), carteolol (Cartrol), and penbutolol (Levatol) are nonselective antagonists with partial b2-receptor agonist activity. Cardiovascular system (see also Chapter 4) (1) b-Adrenoreceptor antagonists are used to treat hypertension, often in combination with a diuretic or vasodilator. Long-term use of timolol, propranolol, and metoprolol may prolong survival after myocardial infarction. This effect is thought to be related to the slowing of ventricular ejection and decreased resistance to outflow. Eye (1) Topical application of timolol, betaxolol, levobunolol, and carteolol reduces intraocular pressure in glaucoma. Other uses (1) Propranolol is used to control clinical symptoms of sympathetic overactivity in hyperthyroidism by an unknown mechanism, perhaps by inhibiting conversion of thyroxine to triiodothyronine. All agents (1) b-Adrenoreceptor antagonists should be administered with extreme caution in patients with preexisting compromised cardiac function because they can precipitate heart failure or heart block. Nonselective adrenoceptor antagonists (1) these drugs may cause bronchoconstriction, and thus they are contraindicated for asthmatics. Propranolol, and other b-receptor blockers, cause sedation, sleep disturbances, and depression. Botulinum toxin causes paralysis by (A) Inhibiting choline acetyltransferase (B) Blocking transport of choline into neurons (C) Blocking release of acetylcholine from storage vesicles 5. The patient is emergently intubated and given atropine and another medication that acts to reactivate acetylcholinesterase. Oxybutynin works by (A) Inhibiting acetylcholinesterase at musca(B) (C) (D) (E) rinic and nicotinic receptors Causing a neuromuscular blockade Antagonizing a1-adrenoceptors Binding to muscarinic receptors Activating b2-adrenoceptors (E) 4. A 66-year-old woman with a long history of heavy smoking presents to her doctor with complaints of shortness of breath and chronic coughing that has been present for about 2 years and has been worsening in frequency. The doctor decides to prescribe a bronchodilator agent that has minimal cardiac side effects, since the patient also has an extensive cardiac history. A 7-year-old boy is brought in by his parents for complaints of hyperactivity at school. After a detailed interview, the physician decides to give the boy amphetamine-containing medication for presumed attention hyperactivity disorder. Amphetamine (A) (B) (C) (D) (E) Inhibits epinephrine reuptake Indirectly acts on norepinephrine receptors Blocks effects of norepinephrine Directly acts on cholinoreceptors Inhibits serotonin reuptake (A) (B) (C) (D) (E) Albuterol Prazosin Atenolol Ipratropium Pseudoephedrine 14. From the list below, choose the depolarizing neuromuscular blocker most likely to be used in ``rapid sequence intubation,' a procedure that is done when the stomach contents have a high risk of refluxing and causing aspiration. What significant side effect of terazosin should the doctor warn a 69-year-old patient about? Ephedra (ephedrine) causes increased blood pressure by (A) (B) (C) (D) (E) Indirect action on cholinergic receptors Blockade of adrenergic receptors Stimulation of release of epinephrine Inhibition of reuptake of catecholamines Direct action on dopamine receptors 12. The local anesthetic used in the procedure did not contain any epinephrine, as it usually does for most surgical procedures. The reason for this is (A) Epinephrine causes increased blood loss during delicate surgery 16. He describes the pain as tight pressure and is demonstrably sweating and gasping for air.
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