Co-Director, Washington State University Elson S. Floyd College of Medicine
Inhibitors Angiotensin II produces changes in body hydration and thirst by a direct action in the central nervous sys- Many of the orally active ACE inhibitors are prodrugs quinoa antifungal fluconazole 150mg without a prescription. The administration of angiotensin II into the sep- These include perindopril fungus speed run purchase 50mg fluconazole free shipping, quinapril fungus gnats in dwc order 150 mg fluconazole amex, benazepril, ramipril, tal, anterior hypothalamic, and medial preoptic areas enalapril, trandolapril, and fosinopril. Part of the volume response also may be caused by the antina- Captopril triuretic and antidiuretic effects of angiotensin II. Captopril (Capoten) is an orally effective ACE inhibitor Angiotensin II, administered into the central nerv- with a sulfhydryl moiety that is used in binding to the ous system, increases the release of luteinizing hor- active site of the enzyme. Captopril blocks the blood mone, adrenocortical hormone, thyroid-releasing hor- pressure responses caused by the administration of an- mone, -endorphin, vasopressin, and oxytocin from the giotensin I and decreases plasma and tissue levels of an- anterior pituitary. Pharmacological Actions Treatment with captopril reduces blood pressure in Sympathetic Nervous System patients with renovascular disease and in patients with Angiotensin II, acting at presynaptic receptors on nora- essential hypertension. The decrease in arterial pressure drenergic nerve terminals, potentiates the release of is related to a reduction in total peripheral resistance. Aside from its action on the nerve the hypotensive effect of inhibitors and the degree of terminals of postganglionic sympathetic neurons, an- blockade of the renin–angiotensin system. Many of the giotensin II can directly stimulate sympathetic neurons pharmacological effects of captopril are attributable to in the central nervous system, in peripheral autonomic the inhibition of angiotensin II synthesis. ACE is a relatively nonselective enzyme that also ca- tabolizes a family of kinins to inactive products (Fig. Bradykinin, one of the major kinins, acts as a va- Adrenal Cortex and Aldosterone sodilator through mechanisms related to the production Secretion of nitric oxide and prostacyclin by the vascular en- Angiotensin II stimulates aldosterone synthesis and se- dothelium. Increases in humans is not accompanied by an increase in glucocor- bradykinin concentrations after administration of ACE ticoid plasma levels. Chronic administration of an- inhibitors contribute to the therapeutic efficacy of these giotensin II will maintain elevated aldosterone secretion compounds in the treatment of hypertension and con- for several days to weeks unless hypokalemia ensues. However, alterations in bradykinin 18 The Renin–Angiotensin–Aldosterone System and Other Vasoactive Substances 211 Propranolol Methyldopa Indomethacin Prorenin Liver Kidney? Renin Angiotensinogen Renin inhibitors Prolylendopeptidase Angiotensin I Angiotensin I-7 Aase CE (des-Asp1) Angiotensin I Blood pressure Angiotensin converting enzyme inhibitors Angiotensin II CE Vasoconstriction Volume Saralasin Aase A Losartan Aldosterone Aase B Angiotensin III Adrenal Angiotensin IV gland FIGURE 18. Serum Captopril enhances cardiac output in patients with potassium levels are not affected unless potassium sup- congestive heart failure by inducing a reduction in ven- plements or potassium-sparing diuretics are used con- tricular afterload and preload. Other common adverse effects are fever, a persistent dry cough (incidence as high as 39%), initial dose hypotension, and a loss of taste that may result in Angiotensin II Inactive peptide fragments anorexia. More serious toxicities include a Interrelationship between the renin–angiotensin system and 1% incidence of proteinuria and glomerulonephritis; bradykinin. Since food reduces the bioavailability of captopril by 30 to 40%, administration of the drug an hour before thickness of the left ventricle in both normal and hy- meals is recommended. ACE inhibitors lack meta- hibitors are contraindicated in patients with bilateral bolic side effects and do not alter serum lipids. Use under these circumstances Pharmacokinetics may result in renal failure or paradoxical malignant The onset of action following oral administration of hypertension. Its apparent biological Prodrug Angiotensin-converting half-life is approximately 2 hours, with its antihyperten- Enzyme Inhibitors sive effects observed for 6 to 10 hours. Most orally effective inhibitors of peptidyl dipeptide hydrolase are prodrug ester compounds that must be Clinical Uses hydrolyzed in plasma to the active moiety before be- Captopril, as well as other ACE inhibitors, is indi- coming effective. These drugs include benazepril cated in the treatment of hypertension, congestive heart (Lotensin), enalapril (Vasotec), fosinopril (Monopril), failure, left ventricular dysfunction after a myocardial moexipril (Univasc), quinapril (Accupril), perindopril infarction, and diabetic nephropathy. The ester group pro- of essential hypertension, captopril is considered first- motes absorption of the compound from the gastroin- choice therapy, either alone or in combination with a testinal tract.
Many medical centers have pastoral care departments staffed by chaplains who represent many religious faiths and Religious involvement fungus gnats jade plant buy 100 mg fluconazole otc, spirituality and medicine 239 denominations fungi definition simple purchase 100mg fluconazole with mastercard. Chaplains are important sources for presence fungus hydrangea leaves generic fluconazole 150 mg mastercard, support, counseling, sacramental needs and guidance regarding spiritual issues. Pastoral care departments also have access to community resources such as local congregations, spiritual care providers representing minority faiths, support groups and parish nurses. Religious involvement, spirituality, and medicine: implications for clinical practice. Complementary therapies in neurology 240 CONCLUSIONS Most patients have a spiritual life and regard their spiritual health and physical health as equally important. A large and growing number of studies have shown a direct relationship between religious involvement and spirituality and positive health outcomes, including mortality, physical illnesses, mental illness, HRQOL, and coping with illness (including terminal illness). Studies also suggest that addressing the spiritual needs of patients may facilitate recovery from illness. Although the relationship between religious involvement and spirituality and health outcomes seems valid, it is difficult to establish causality. While religiously involved persons embrace health-promoting behaviors, eschew risky behaviors and have strong support networks, these factors do not account for all of the salutary benefits of religious involvement and spirituality. Rather, these benefits are likely to be conveyed through complex psychosocial-behavioral and biological processes that are incompletely understood. Discerning, acknowledging and supporting the spiritual needs of patients can be done in a straightforward, ethical and non-controversial manner and may relieve suffering and facilitate recovery from illness. The spiritual history and the open-ended questions reviewed above help the clinician discern the spiritual needs of patients. Furthermore, such inquiry is a form of spiritual care, in that it allows patients to voice their spiritual and existential doubts. In addition, many other sources of spiritual care, especially chaplains, are available to address the spiritual concerns and needs of patients. Addressing the spiritual concerns and needs of patients may be a valuable adjunct to standard medical care. A brief spiritual beliefs inventory for use in quality of life research in life-threatening illness. Cultural considerations in the assessment and treatment of religious and spiritual problems. Religious commitment and health status: a review of the research and implications for family medicine. J Fam Pract 1991; 32:210–13 Religious involvement, spirituality and medicine 241 10. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Patient attitudes regarding physician inquiry into spiritual and religious issues. Experiments on distant intercessory prayer: God, science, and the lesson of Massah. Should academic medical centers conduct clinical trials of the efficacy of intercessory prayer? Systematic analysis of research on religious variables in four major psychiatric journals, 1978–1982. A systematic review of research on religion in four major psychiatric journals: 1991–1995.
The message that this joke gives is that people working together in an organization see things from their own perspectives fungus fix order on line fluconazole, which are formed by the knowledge that they have fungus gnats carnivorous plants buy fluconazole online. The minimum requirement for an organization to work as a single system is for perspectives to be coordinated fungus japanese maple generic fluconazole 50mg without a prescription, and this can only occur through knowledge sharing: one can only coordinate perspective when one knows what perspec- tives there are to coordinate. Positivists normally see knowledge as a commodity that has value to individuals within a social context. It can be identified, coded, transferred through communications, decoded, and then used. The message that is provided in this chapter is that this commodity model is not only inadequate, but is actually dangerous for organizations because it allows them to assume that no work has to be put into the process of knowledge sharing. The constructivist view of sharing knowledge centers on the notion that knowledge is fundamentally a property of individuals and shaped by their experiences and worldviews. As such, it cannot be transferred, and all communications carrying knowledge are seen as catalysts that simply initiate the creation of new local knowledge. Effective knowledge migration occurs when there is a strong relationship between the local semantic patterns of a message source and sink (referred to as semantic entangle- ment), and this requires human interaction and knowledge validation processes. Healthcare and Information and Knowledge Healthcare provision is a knowledge-intensive activity and the consequences of an organization failing to make best use of the knowledge assets at its disposal can be severe (Lelic, 2002). Knowledge and knowledge processes (including sharing) in healthcare have both an individual and an organizational dimension. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Patient attributes for whose benefit healthcare establishments are established, where knowledge and information can assist patients to appreciate their condi- tion and help them to maintain their treatments, and b. Staff members of a healthcare organization that can only properly satisfy an employment role if they have relevant knowledge. Organizational, where healthcare is benefited from knowledge and knowledge processes by enabling them to understand their own organizational capacity to maintain and improve quality patient services and to respond to the need to coherently create new knowledge by becoming a learning organization. Part of the knowledge process in the UK National Health Service (NHS) centers on a need to involve patients more in their own healthcare; and there are sound financial and medical arguments for this that satisfy the needs of both consultant practitioners and management. In traditional positivist culture that still operates in so many healthcare establishments, the patients are viewed as a commodity input to the healthcare system represented as objectivated2 “cases” rather than subjectivated individuals with their own learning needs. As a consequence, it is not unknown for patients to become invisible as their “cases” are discussed with a third party in their presence. Baldwin, Clarke, Eldabi, & Jones (2002) note that there is a call for healthcare professionals to engage more fully with their patients, and to see them more as some kind of partner in their healthcare rather than as a paternal authority. It is knowledge that provides the capacity for patients to understand their own conditions, recognize what constitutes relevant information, and contribute to the decision making process both in regard to primary and secondary care. There is also a need in healthcare organizations to ensure that staff are provided not only with the information and knowledge that enables them to effectively perform their tasks, but that they are also included within the organizational processes that enables them to become motivated and participate in organizational improvement. This human resource management approach is normal to techniques of Organization Development (Yolles, 1999). In healthcare organizations the nature of the knowledge processes that are undertaken can be expressed in terms of organizational quality. Stahr (2001), in a study on quality in UK healthcare establishments, uses the definition by Joss, Kogan, & Henkel (1994) to identify three levels of quality: technical, generic and systemic.
Chloroquine destroys the blood stages of the in- The main objective in the clinical management of pa- fection and therefore ameliorates the clinical symptoms tients suffering from an acute malaria attack is the seen in P fungus gnats do they bite buy cheap fluconazole 50mg line. Chloroquine also can clude such compounds as amodiaquine anti fungal rash generic fluconazole 100mg mastercard, chloroguanide fungus gnats kill home remedy order cheap fluconazole on line, be used prophylactically in areas where resistance does chloroquine, hydroxychloroquine, pyrimethamine, qui- not exist. These drugs have the potential chloroquine has been used in the treatment of rheuma- (excluding any drug resistance) for effecting a clinical toid arthritis and lupus erythematosus (see Chapter 36), cure; that is, they can reduce the parasitemia to zero. The term radical cure also has been used, and it, in con- The absorption of chloroquine from the gastroin- trast to clinical cure, implies the elimination of all para- testinal tract is rapid and complete. Desethylchloroquine is the major Primaquine is readily absorbed from the gastroin- metabolite formed following hepatic metabolism, and testinal tract, and in contrast to chloroquine, it is not both the parent compound and its metabolites are bound extensively by tissues. Peak plasma levels are reached in 4 to Dizziness, headache, itching (especially in dark- 6 hours after an oral dose, with almost total drug elimi- skinned people), skin rash, vomiting, and blurring of vi- nation occurring by 24 hours. In daily administration is usually required for radical cure higher dosages these symptoms are more common, and and prevention of relapses. In individuals with a genetically de- containing structures, prolonged administration of high termined glucose 6-phosphate dehydrogenase defi- doses can lead to blindness. Chloroquine should not be ciency, primaquine can cause lethal hemolysis of red used in the presence of retinal or visual field changes. This genetic deficiency occurs in 5 to 10% of black males, in Asians, and in some Mediterranean peoples. Hydroxychloroquine With higher dosages or prolonged drug use, gastroin- testinal distress, nausea, headache, pruritus, and Hydroxychloroquine (Plaquenil), like chloroquine, is a leukopenia can occur. Occasionally, agranulocytosis 4-aminoquinoline derivative used for the suppressive also has been observed. Adverse reac- Pyrimethamine (Daraprim) is the best of a number of 2,4- tions associated with its use are similar to those de- diaminopyrimidines that were synthesized as potential scribed for chloroquine. Trimethoprim patients with psoriasis or porphyria, since it may exac- (Proloprim) is a closely related compound. Pyrimethamine is well absorbed after oral adminis- tration, with peak plasma levels occurring within 3 to 7 Amodiaquine hours. An initial loading dose to saturate nonspecific binding sites is not required, as it is with chloroquine. Amodiaquine (Camoquin) is another 4-aminoquinoline derivative whose antimalarial spectrum and adverse re- However, the drug binds to tissues, and therefore, its rate of renal excretion is slow. Although the drug does un- chloroquine-resistant parasites may not be amodi- dergo some metabolic alterations, the metabolites aquine-resistant to the same degree. Parasites cannot use preformed folic acid and therefore must synthesize this compound from the following pre- Primaquine cursors obtained from their host: p-aminobenzoic acid Primaquine is the least toxic and most effective of the 8- (PABA), pteridine, and glutamic acid. The mecha- acid formed from these precursors must then be hydro- nism by which 8-aminoquinolines exert their antimalar- genated to form tetrahydrofolic acid. The latter com- ial effects is thought to be through a quinoline–quinone pound is the coenzyme that acts as an acceptor of a va- metabolite that inhibits the coenzyme Q–mediated res- riety of one-carbon units. The drug initial step whereby PABA and the pteridine moiety also kills the gametocytes in all four species of human combine to form dihydropteroic acid (see Chapter 44), malaria. Primaquine is relatively ineffective against the pyrimethamine and trimethoprim inhibit the conversion asexual erythrocyte forms. Primaquine finds its greatest of dihydrofolic acid to tetrahydrofolic acid, a reaction 53 Antiprotozoal Drugs 615 catalyzed by the enzyme dihydrofolate reductase. The conversion dihydrofolate reductase inhibitors, such as trimetho- of chloroguanide to the active metabolite is decreased prim (Bactrim, Septra) or pyrimethamine (Fansidar), is in pregnancy and also as a result of genetic polymor- a good example of the synergistic possibilities that exist phism in 3% of whites and Africans and 20% of Asians. Using drugs that inhibit at two different points in the same biochemical pathway produces parasite Quinine is one of several alkaloids derived from the bark of the cinchona tree.
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