By I. Koraz. Daemen College. 2018.
The relationship of the radiologic changes buy generic silvitra 120mg impotent rage quotes, symptom change silvitra 120 mg on line erectile dysfunction of organic origin, and clinical pathology would all favour the development of a subchondral fracture. This stage corre- lated with the operative findings of a separated, sometimes free, os- teocartilagenous flap lying on depressed subchondral bone. As long as acetabular cartilage remains relatively normal, hemiarthroplasty is a reasonable therapeutic choice. The differences are best explained by describing the point of maximum joint reaction force and the anatomical contour of the glenoid compared to that of the acetabulum. The glenoid is flat, and the point of maxi- mum pressure on the head seems to occur when the arm has been raised about 908. At this point the scapula has rotated 308, so that the area of the head that is placed under maximum pressure is that contact- ing the glenoid when the humerus has been elevated 608. This area of contact is the site where the humeral head consistently collapses in avascular necrosis and where maximum wear and sclerosis occur in os- teoarthritis. Avascular changes with collapse of the articular surfaces in the el- bows of two paraplegic patients, as mentioned above, confirm the im- portance of pressure and load in the configuration of avascular necrosis of the humeral head. In their discussions of the aetiology of avascular necrosis, both Cruess  and Springfield and Enneking  pointed out that the alterations in the femoral head did not match the anatomi- cal configuration of the blood vessels in the femoral head nor the ran- dom site of infarction that might occur if the infarcts were due to ªslud- gingº. Since the location of the crescent sign and the later collapse at the head correspond to the point of maximum joint reaction force on the humeral head, Neer  believes the consistent location of the wedge-shaped area of infarction is largely due to pressure. To assist in describing the indications and treatment of this condi- tion, Neer has adapted the excellent classifications of Ficat and Ennek- ing to the shoulder. Stage I disease shows only subtle changes that are not always definitely diagnostic. There may be slight mottling of the trabecular pattern or an area of sub- chondral decalcification. Classification of avascular necrosis of the humeral head according to Neer  sickle cell disease) have more very early pain. Stage II disease has an articular surface that is grossly round when inspected at surgery, and although the articular cartilage can be intended on pressure in an area where it has lost the support of the subchondral bone, it returns to its normal shape. Tomograms and MRI are especially helpful in evaluating the extent of head involvement. The severe pain probably corre- sponds to minute fractures and the sudden slight collapse of sub- chondral bone. Stage III disease is characterized by an area of wrinkled and loose articular cartilage. This corresponds to the wedge-shaped area of fracturing and collapse of subchondral bone. Eventually the X-ray film shows a ªstep-offº phenome- non, and the diagnosis is quite obvious. Stage IV disease shows involvement of the articular surface of the glenoid due to the incongruity of the humeral head. As sec- ondary arthritic changes occur, a ring of marginal excrescences de- velops around the head, particularly inferiorly, and the articular sur- face of the glenoid becomes warn unevenly, as in osteoarthritis. Be- cause of the way the arms are used in everyday activities, the in con- gruous head presses more intensely on the posterior part of the gle- a 14. With the posterior subluxation, the posterior glenoid becomes rounded off and sclerotic, and an indentation develops in the head because of contact against the posterior edge of the glenoid. By this time, osteochondral bodies and a general synovitis of the joint are present. The extent of involvement was classified from the maxi- mum involvement shown on any single view. Four groups were defined: those with less than one quarter of the humeral head involved, those with involvement between one quarter and one half of the diameter of the humeral head, those with involvement between one half and three quarters of the humeral head, and those with more than three quarters of the diameters of the humeral head involved. In our present state of ignor- ance, it is helpful in making clinical decisions to classify the disease as low-grade, intermediate, or severe. Bone loss is apt to occur more slowly, and they may develop mar- ginal osteophytes similar to those seen in osteoarthritis. In the more severe form of rheumatoid arthritis, there may be rapid destruction of the joint surfaces with early ascent of the humerus and involvement of the rotator cuff.
If no reaction occurs cheap 120 mg silvitra with amex erectile dysfunction 20s, give the remainder of the dose in 1-mg increments to max of 10 mg SUPPLIED: Inj 10 mg/mL NOTES: Can cause severe cholinergic effects; keep atropine available Efavirenz (Sustiva) COMMON USES: HIV infections ACTIONS: Antiretroviral agent order 120 mg silvitra visa erectile dysfunction rates, nonnucleoside reverse transcriptase inhibitor DOSAGE: Adults. Refer to product information for dosing chart SUPPLIED: Caps 50, 100, 200 mg NOTES: Take hs, may cause somnolence, vivid dreams, dizziness; may cause rash Enalapril (Vasotec) COMMON USES: HTN, CHF, and asymptomatic LVD ACTIONS: ACE inhibitor DOSAGE: Adults. In acute cardiac settings, can be given via endotracheal tube if central line not available Epoetin Alfa [Erythropoietin] (Epogen, Procrit) COMMON USES: Anemia associated with CRF, zidovudine treatment in HIV-infected patients, and patients receiving cancer chemotherapy; reduction in transfusions associated with surgery ACTIONS: Erythropoietin supplementation DOSAGE: Adults & Peds. Surgery: 300 U/kg/d for 10 d prior to surgery SUPPLIED: Inj 2000, 3000, 4000, 10,000, 20,000 U/mL NOTES: May cause HTN, headache, tachycardia, nausea, and vomiting; store in refrigerator Epoprostenol (Flolan) COMMON USES: Pulmonary HTN ACTIONS: Dilates the pulmonary and systemic arterial vascular beds; inhibits platelet aggregation DOSAGE: 4 ng/kg/min IV cont inf; make dosage adjustments based on clinical status and package insert guidelines SUPPLIED: Inj 0. Initiate treatment with 500 µg/kg load over 1 min, then 50 µg/kg/min for 4 min; if inadequate response, repeat the loading dose and follow with maintenance infusion of 100 µg/kg/min for 4 min; continue the titration process by repeating the loading dose followed by in- cremental ↑ in the maintenance dose of 50 µg/kg/min for 4 min until the desired heart rate is reached or BP decreases ; average dose 100 µg/kg/min SUPPLIED: Inj 10, 250 mg/mL NOTES: Monitor closely for hypotension; ↓ or discontinuing infusion reverses hypotension in ≅30 min Estazolam (Prosom) [C] COMMON USES: Insomnia ACTIONS: Benzodiazepine DOSAGE: 1–2 mg PO hs PRN 22 SUPPLIED: Tabs 1, 2 mg 22 Commonly Used Medications 535 Esterified Estrogens (Estratab, Menest) COMMON USES: Vasomotor symptoms, atrophic vaginitis, or kraurosis vulvae associated with menopause; female hypogonadism ACTIONS: Estrogen supplementation DOSAGE: Menopause: 0. Repeated doses NOT recommended SUPPLIED: Tabs 25, 50 mg; powder for inj 50 mg NOTES: Contra in anuria; severe side effects reported Ethambutol (Myambutol) COMMON USES: Pulmonary TB and other mycobacterial infections ACTIONS: Inhibits cellular metabolism DOSAGE: Adults & Peds >12 y. Simplex: 125–250 mg PO bid SUPPLIED: Tabs 125, 250, 500 mg Famotidine (Pepcid) COMMON USES: Short-term Rx of active duodenal ulcer and benign gastric ulcer; maintenance therapy for duodenal ulcer, hypersecretory conditions, GERD, and heartburn ACTIONS: H2-antagonist; inhibits gastric acid secretion DOSAGE: Adults. Dose calculated from the narcotic requirements for the previous 24 h SUPPLIED: TD patches deliver 25, 50, 75, 100 µg/h NOTES: 0. Pain: 200 µg consumed over 15 min, titrate to appropriate effect SUPPLIED: Lozenges 100, 200, 300, 400 µg; lozenges on stick 200, 400, 600, 800, 1200, 1600 µg Ferric Gluconate Complex (Ferrlecit) COMMON USES: Iron deficiency in patients receiving supplemental erythropoietin therapy ACTIONS: Supplemental iron DOSAGE: Give test dose of 2 mL (25 mg Fe) infused over 1 h. Discontinue therapy when ANC >10,000 Finasteride (Proscar, Propecia) COMMON USES: BPH and androgenetic alopecia ACTIONS: Inhibits 5α reductase DOSAGE: BPH: 5 mg/d PO [Proscar]. Alopecia: 1 mg/d PO [Propecia] SUPPLIED: Tabs 1, 5 mg NOTES: Decreases PSA levels; may take 3–6 mo to see effect on urinary symptoms Flavoxate (Urispas) COMMON USES: Symptomatic relief of dysuria, urgency, nocturia, suprapubic pain, urinary fre- quency, and incontinence ACTIONS: Counteracts smooth muscle spasm of the urinary tract DOSAGE: 100–200 mg PO tid–qid SUPPLIED: Tabs 100 mg NOTES: May cause drowsiness, blurred vision, and dry mouth Flecainide (Tambocor) COMMON USES: Prevention of PAF/flutter and PSVT, Rx life-threatening ventricular arrhythmias ACTIONS: Class 1C antiarrhythmic DOSAGE: Adults. Myelosuppression (leukocytopenia, thrombocytopenia, and anemia); rash, dry skin, and photosensitivity frequent. Tingling in the hands and feet followed by pain (palmar-plantar 22 erythrodysesthesia); phlebitis and discoloration at inj sites 22 Commonly Used Medications 541 Fluorouracil, Topical [5-FU] (Efudex) COMMON USES: Basal cell carcinoma of the skin, actinic and solar keratosis ACTIONS: Inhibitor of thymidylate synthetase (interferes with DNA synthesis, S phase-specific) DOSAGE: Apply 5% cream bid for 4–6 wk SUPPLIED: Cream 1, 5%; soln 1, 2, 5% NOTES: Toxicity symptoms: Rash, dry skin, and photosensitivity Fluoxetine (Prozac, Sarafem) COMMON USES: Depression, OCD, bulimia, PMDD ACTIONS: SSRI DOSAGE: Initially, 20 mg/d PO; ↑to a max of 80 mg/24h; ÷ doses of >20 mg/d. PMDD: 20 mg/d SUPPLIED: Caps 10, 20 mg; tabs 10 mg; soln 20 mg/5 mL NOTES: May cause nausea, nervousness, and weight loss; hepatic failure dosage adjustment Fluoxymesterone (Halotestin) COMMON USES: Androgen-responsive metastatic breast cancer ACTIONS: Inhibition of secretion of LH and FSH by feedback inhibition DOSAGE: 10–40 mg/d SUPPLIED: Tabs 2, 5, 10 mg NOTES: Toxicity symptoms: Virilization, amenorrhea and menstrual irregularities, hirsutism, alope- cia and acne, nausea, and cholestasis. Hematologic toxicity symptoms: Suppression of clotting fac- tors II, V, VII, and X and polycythemia. Nasal: 1–2 sprays/nostril/d SUPPLIED: Nasal spray 50 µg/actuation Fluticasone Oral (Flovent, Flovent Rotadisk) COMMON USES: Chronic treatment of asthma ACTIONS: Topical steroid DOSAGE: Adults & adolescents. Maintenance: 90–120 mg/kg/d IV (Monday–Friday) SUPPLIED: Inj 24 mg/mL NOTES: Dosage must be adjusted for renal function; nephrotoxic; monitor ionized calcium closely (causes electrolyte abnormalities); administer through a central line Fosfomycin (Monurol) COMMON USES: Uncomplicated UTI 22 ACTIONS: Inhibits bacterial cell wall synthesis 22 Commonly Used Medications 543 DOSAGE: 3 g PO dissolved in 90–120 mL of water as single dose SUPPLIED: Granule packets 3 g NOTES: May take 2–3 d for symptoms to improve Fosinopril (Monopril) COMMON USES: HTN and heart failure ACTIONS: ACE inhibitor DOSAGE: Initially, 10 mg/d PO; may be ↑ to a max of 80 mg/d PO ÷ qd–bid SUPPLIED: Tabs 10, 20, 40 mg NOTES: ↓ Dose in elderly; may cause nonproductive cough and dizziness Fosphenytoin (Cerebyx) COMMON USES: Status epilepticus ACTION: Inhibits seizure spread in the motor cortex DOSAGE: Dosed as phenytoin equivalents (PE) Loading 15–20 mg PE/kg, maintenance 4–6 mg PE/kg/d SUPPLIED: Inj; 150 mg (= phenytoin 100 mg); 750 mg (= phenytoin 500 mg) NOTES: Requires 15 min to convert the prodrug fosphenytoin to phenytoin; administer at <150 mg PE/min to prevent hypotension; administer with BP monitoring; dosage adjustment/plasma moni- toring may be necessary in hepatic impairment Furosemide (Lasix) Used for emergency cardiac care (see Chapter 21) COMMON USES: Edema, HTN, and CHF ACTIONS: Loop diuretic; inhibits Na and Cl reabsorption in the ascending loop of Henle and the distal renal tubule DOSAGE: Adults. IV: 5 mg/kg IV q12h for 14–21 d, then maintenance of 5 mg/kg/d IV for 7 d/wk or 6 mg/kg/d IV for 5 d/wk. Prevention: 1000 mg PO tid SUPPLIED: Caps 250, 500 mg; inj 500 mg; ocular implant 4. Daily dosing becoming popular Gentamicin, Ophthalmic (Garamycin, Genoptic, Gentacidin, others) COMMON USES: Conjunctival infections ACTIONS: Bactericidal; inhibits protein synthesis DOSAGE: Oint apply bid or tid; soln: 1–2 gtt q2–4h, up to 2 gtt/h for severe infections 22 SUPPLIED: Soln and oint 0. Stimulates the release of insulin from the pancreas; increases insulin sensi- tivity at peripheral sites; reduces glucose output from the liver DOSAGE: 1–4 mg/d, up to max of 8 mg SUPPLIED: Tabs 1, 2, 4 mg Glipizide (Glucotrol) COMMON USES: Type 2 DM ACTION: Sulfonylurea. Stimulates the release of insulin from the pancreas; increases insulin sensi- tivity at peripheral sites; reduces glucose output from the liver DOSAGE: 5–15 mg qd–bid SUPPLIED: Tabs 5, 10 mg; ER tabs 5, 10 mg Glucagon Emergency care (see Chapter 21) COMMON USES: Severe hypoglycemic reactions in diabetic patients with sufficient liver glycogen stores or β-blocker overdose ACTIONS: Accelerates liver gluconeogenesis DOSAGE: Adults. Stimulates the release of insulin from the pancreas; increases insulin sensi- tivity at peripheral sites; reduces glucose output from the liver DOSAGE: Nonmicronized: 1. Initially, 4 mg PO bid; ↑ by 4 mg/d increments at 1–2-wk intervals up to 32 mg bid. Severe symptoms or agitation: 3–5 mg PO bid–tid or 1–5 mg IM q4h PRN (max 100 mg/d). Thrombosis Rx: Loading dose of 50–75 U/kg IV, then 10–20 U/kg IV qh (adjust based on PTT). Children: Loading dose 50 U/kg IV, then 15–25 U/kg cont inf or 100 U/kg/dose q4h IV intermittent bolus SUPPLIED: Inj 10, 100, 1000, 2000, 2500, 5000, 7500, 10,000, 20,000, 40,000 U/mL NOTES: Follow PTT, thrombin time, or activated clotting time to assess effectiveness; heparin has little effect on the prothrombin time; with proper dose, PTT is about 1. Leuka- pheresis: 250–700 mL SUPPLIED: Inj 6 g/100 mL NOTES: NOT a substitute for blood or plasma; contra in patients with severe bleeding disorders, se- 22 vere CHF, or renal failure with oliguria or anuria 22 Commonly Used Medications 549 Hydralazine (Apresoline, others) COMMON USES: Moderate to severe HTN ACTIONS: Peripheral vasodilator DOSAGE: Adults.
Similarly to the Oncken concept buy 120mg silvitra overnight delivery erectile dysfunction pills cost, we can expect to see the development of increasing levels of initiative and autonomous intervention by the computer or machine: 1 discount silvitra 120 mg amex erectile dysfunction of diabetes. Computer generated prompts asking whether you would like to go and look at more information on a particular subject, for example, in the form of a hypertext link; 3. General suggestions automatically provided as information, or guidelines, for example, general drug or evidence based medicine disease management informa- tion; 4. These may outline a specific course of action, but can be over ridden by various levels of clinician justification with clinician still effectively making decision; 5. These, for example, may relate to preventing life threatening drug interactions, or allergic reactions. Here the system or machine can be viewed as moving from realm of decision support into realm of decision making, (if only under mandate of an overarching organisational protocol); 6. The machine, only if specifically told or requested, will utilise data to make a decision, which the machine rather than the clinician then acts on; 7. The machine, automatically utilises data to make a decision, which it then acts on, but advises clinician on all actions immediately; 8. The machine, automatically utilises data to make a decision, which it then acts on, but clinician only advised immediately if exceeds certain parameters; 9. The machine automatically utilises data to make a decision which it then acts on, and reports to clinician at certain agreed periods; and 10. The machine automatically utilises data to make a decision, which it then acts on, with no active feedback to clinician. Moving along this spectrum, there is a progressive increase in machine control and decrease in immediate human control (Figure 8). The clinical user is given increasing levels of active advice and overview by the machine, in terms of patient data and specificity of medical evidence and treatment recommendations, while the machine gets decreasing levels of active immediate advice and overview of its use of patient data by the individual clinician user. In general relatively few Health Knowledge Systems have reached level 3, but there is the capacity for this to change rapidly with significant privacy and security implications. For example, what are the privacy and security implications of a “booking system” that could draw data from several sources and act on its own to decide on suitability or eligibility, and then instigate certain forms of care? However, as the machine becomes less dependent on immediate human overview, there will be an Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Machine versus human control Autonomy of Control Machine Control Human Control Passive Machine Intervention ACTIVE increasing need to consider the risks and benefits in respect of privacy and security. The lack of overview, and integrity of the data and processes by which decisions are made, will be a significant issue. However possibly of greater moment, will be how we perceive, value, or balance the impartiality versus heartlessness of a machine accessing our health information and making decisions based on protocols. Internationally, there is a growing awareness of the need for information system developments to undergo a Privacy Impact Assessment, underpinned by a state sanctioned privacy code (Slane, 2002). For example the New Zealand Privacy Impact assessment recommendations and underlying code sets out a number of principles in relation to unique identifiers, the purpose, source, and manner of collection, storage, security, access, and correction, and limits on storage, use, and disclosure of personal information. Internationally similar principles or rules are common to a myriad of legal, professional, and research codes and acts that relate to the collection, storage, and utilisation of health information. Assessing the impact, or future consequences of current actions, presents a particular challenge for health knowledge systems. The risk-benefit equation, used to assess how certain information is handled may change over time and we have to question how far forward we can see, or how far forward we are expected to see. Privacy and Security Objectives Privacy and security developments may be focused on addressing a number of key objectives or concerns including medico-legal or patient trust or confidence concerns, within the context of a belief that better integrated information will lead to better Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. However what is perceived best by or for an individual may be in conflict with what is perceived as best for the community. Each clinician and health service, depending on their location may be conceptually subject to a multitude of privacy and security codes and laws, for which in reality at the clinical coal face there is only limited compliance due to various combinations of lack of knowledge, attention, priority, will, ability, or perception of unacceptable costs and burden. There may be broad agreement that patient privacy should be protected, but a range of views as to what that pragmatically can or should mean in practice and how much any law or code may achieve this. For example, Marwick (2003) outlines similar views and responses as having greeted the introduction in the USA of the privacy rule of the Health Insurance Portability and Accountability Act.
It has similar pharmacological effects but is pre- high degree of cross-resistance among the anthracy- ferred to 5-ﬂuorouracil for hepatic arterial infusions be- clines buy silvitra 120 mg erectile dysfunction humor, vinca alkaloids silvitra 120 mg cheap impotence quoad hoc meaning, dactinomycin, and podophyllo- cause it is more extensively metabolized in the liver toxins (see Chapter 55). Doxorubicin is not absorbed orally, and because of The toxicities of 5-ﬂuorouracil vary with the sched- its ability to cause tissue necrosis must not be injected ule and mode of administration. Daily injection or continuous infusion is most is extensively metabolized in the liver to hydroxylated likely to produce oral mucositis, pharyngitis, diarrhea, and conjugated metabolites and to aglycones that are and alopecia. Neurological toxic- in the treatment of carcinomas of the breast, ovary, en- ity is manifested as acute cerebellar ataxia that may oc- dometrium, bladder, and thyroid and in oat cell cancer cur within a few days of beginning treatment. Some activity has been reported in Doxorubicin and Daunorubicin non–oat cell lung cancer, multiple myeloma, and adeno- The anthracycline antibiotics are fermentation products carcinomas of the stomach, prostate, and testis. Daunorubicin (Cerubidine) The most important toxicities caused by doxoru- is used to treat acute leukemias, while its structural ana- bicin involve the heart and bone marrow. Acutely, doxo- logue, doxorubicin (Adriamycin) is extensively em- rubicin may cause transient cardiac arrhythmias and ployed against a broad spectrum of cancers. Doxorubicin may 56 Antineoplastic Agents 647 cause radiation recall reactions, with ﬂare-ups of der- A potentially fatal lung toxicity occurs in 10 to 20% matitis, stomatitis, or esophagitis that had been pro- of patients receiving bleomycin. Less severe tox- risk are those who are over 70 years of age and have icities include phlebitis and sclerosis of veins used for had radiation therapy to the chest. Rarely, bleomycin injection, hyperpigmentation of nail beds and skin also may cause allergic pneumonitis. Because of its intense red toxicity is manifested by hyperpigmentation, erythe- color, doxorubicin will impart a reddish color to the matosus rashes, and thickening of the skin over the urine for 1 or 2 days after administration. Idarubicin Less common adverse effects include mucositis, alope- Idarubicin (Idamycin) differs from its parent com- cia, headache, nausea, and arteritis of the distal ex- pound, daunorubicin, by the absence of the methoxy tremities. Its mecha- nisms of action and resistance are similar to those of Mitomycin doxorubicin and daunorubicin; however, it is more lipophilic and more potent than these other anthracy- Mitomycin (mitomycin C, Mitocin-C, Mutamycin) is an clines. Idarubicin undergoes extensive hepatic metabo- antibiotic that is derived from a species of Streptomyces. Adverse reactions of idaru- It is sometimes classiﬁed as an alkylating agent because bicin are similar to those of its congeners. Mitomycin is thought to inhibit DNA synthesis through its ability to alkylate double-strand DNA and bring Bleomycin about interstrand cross-linking. There is evidence that The bleomycins are a group of glycopeptides that are enzymatic reduction by a reduced nicotinamide– isolated from Streptomyces verticillus. The clinical adenine dinucleotide phosphate (NADPH) dependent preparation, bleomycin sulfate (Blenoxane), is a mix- reductase is necessary to activate the drug. Bleomycin binds to DNA, The drug is rapidly cleared from serum after intra- in part through an intercalation mechanism, without venous injection but is not distributed to the brain. The drug produces both single- and double-strand mas of the stomach, pancreas, colon, breast, and cervix. It is thought that The major toxicity associated with mitomycin ther- the bleomycins, which are avid metal-chelating agents, apy is unpredictably long and cumulative myelosup- form a bleomycin–Fe complex that can donate elec- pression that affects both white blood cells and trons to molecular oxygen, thus forming the superoxide platelets. It is these highly reactive in- anemia, thrombocytopenia, and renal failure also has termediates that attack DNA and produce DNA strand been described. Renal, hepatic, and pulmonary toxicity breakage and maximum cytotoxicity in the late G2 and may occur. Its plasma half-life is Dactinomycin not affected by renal dysfunction as long as creatinine clearance is greater than 35 mL/minute. Dactinomycin (actinomycin D, Cosmegen) is one of a Bleomycin hydrolase, which inactivates bleomycin, family of chromopeptides produced by Streptomyces. It is an enzyme that is abundant in liver and kidney but is known to bind noncovalently to double-strand DNA virtually absent in lungs and skin; the latter two organs by partial intercalation, inhibiting DNA-directed RNA are the major targets of bleomycin toxicity. The drug is most toxic to proliferating cells, that bleomycin-induced dermal and pulmonary toxici- but it is not speciﬁc for any one phase of the cell cycle. The plasma disappear- testicular tumors, lymphomas, melanomas, and sarco- ance of vinblastine and vinorelbine is triphasic.
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