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If excessive noradrenergic transmission is a causal factor in anxiety glucotrol xl 10 mg diabetes medications glucophage, then it would be predicted that a lesion of central noradrenergic neurons would have an anti-anxiety effect in behavioural models of this condition quality glucotrol xl 10mg blood glucose quantitative test. Unfortunately buy glucotrol xl 10 mg on-line diabetes type 1 news, the behavioural effects of such lesions are notoriously inconsistent and there are many reports of negative findings (e. This suggests that the central noradrenergic system is actually needed to express the anti-anxiety effects of some drugs, but not others. Finally, many early studies suggested that benzodiazepines attenuate the increase in turnover of noradrenaline in the brain caused by stressful stimuli such as footshock and restraint (Taylor and Laverty 1969; reviewed by Stanford 1995). It has also been reported that they prevent the phasic increase in firing rate of neurons in the locus coeruleus caused by such stimuli (Rasmussen and Jacobs 1986). However, recent microdialysis studies suggest that the actions of these drugs might not be so straightforward. Anti-anxiety doses of the benzodiazepine, diazepam, reduced spontaneous efflux of noradrenaline but had no effect on the noradrenergic stress response on exposure to a novel environment (Dalley, Mason and Stanford 1996). This points to an important limitation of many studies in this area, namely that stimuli used to investigate the neurochemical effects of test anti- anxiety drugs are usually crude and involve somatosensory stress, often involving physical discomfort. This approach disregards the criteria, defined by Gray (1987; discussed above) for the types of environmental stimuli that trigger anxiety in rodent models or humans. In fact, surprisingly few studies have investigated the effects of anxiogenic stimuli on neurochemical changes in the brain. This is probably because techniques of sufficient sensitivity to detect the neurochemical changes provoked by these procedures have been developed only recently. In one such study, using in vivo microdialysis, exposure to an aversive novel environment (a brightly lit, novel arena) increased the concentration of extracellular noradrenaline (suggestive of increased noradrenaline release) in both the rat frontal cortex and the hypothalamus. However, if animals were trained to associate the sound of a tone (which becomes a conditioned cue) with imminent transfer to the aversive environment, a different pattern of noradrenaline responses ensued. After a series of such conditioning trials, the sound of the tone alone increased the concentration of extracellular noradrenaline in the rat frontal cortex, but not the hypothalamus (McQuade and Stanford 2000). This suggests that the noradrenergic innervation of these two brain areas might have different roles in the response to conditioned and unconditioned aversive environmental stimuli. They also suggest that noradrenergic neurons innervating the frontal cortex are recruited in the response to anxiogenic environmental signals (of the type described by Gray) whereas those projecting to both brain regions could have a role in coordinating or triggering the flight/fight response to unconditioned stimuli. Clearly, different components of the central noradrenergic system could have different roles in anxiety, a possibility that is considered in more detail later. Equally inevitably, many confounding factors have come to light which undermine this simplistic explanation of anxiety. In recent years, attention has been directed to the azapirones such as gepirone, ipsapirone and, in particular, buspirone since this is the only one which is available clinically as an anti-anxiety agent. It was developed as a neuroleptic, because it is a dopaminergic D2 receptor antagonist, but turned out to be more effective as a treatment for anxiety. A solution to this problem was offered by the suggestion that buspirone is a full agonist at presynaptic receptors but only a partial agonist at postsynaptic sites. An alternative suggestion was that there is a greater receptor reserve on cell bodies than post- synaptically. However, it must be remembered that, since buspirone is a partial agonist, its postsynaptic effects will depend on the degree of tonic activation of the target receptor(s). Unfortunately, it is still unclear whether this is due to a presynaptic action (i. Moreover, an important limitation of much of this work is that buspirone is effective in humans only after prolonged administration and yet most experimental studies have investigated its behavioural sequelae only after acute drug administration. The outcome of the few chronic studies that have been attempted seems to differ across different models, with buspirone being ineffective in the plus-maze but effective in conflict tests (see Handley 1995). In short, evidence for either an excess or a deficit in sero- tonergic transmission as a causal factor in anxiety in humans is equally (un)convincing (Bell and Nutt 1998). To achieve this, an integrated view of the relevant brain systems is required, together with an appreciation of how their function is regulated. Detailed justification of this theory is beyond the scope of this chapter but can be found in Gray (1987). This system arrests ongoing behaviour and increases vigilance, as is evident in animal models of anxiety (e. Ascending noradrenergic and serotonergic inputs are thought to activate this behavioural inhibition system, with these two monoamines playing complementary roles. Moreover, there is extensive evidence that anti-anxiety drugs prevent activation of the behavioural inhibition system by blunting monoaminergic transmission in the hippocampus. Gray (1987) proposes that the central grey is normally inhibited by the (ventromedial) hypo- thalamus and that the influence of the hypothalamus is governed in opposing ways by the behavioural inhibition system and the amygdala. Whereas the former augments hypothalamic inhibition of the flight/fight response, the latter inhibits it, thereby releasing the flight/fight response (Fig. In the former region, they are thought to augment active avoidance of aversive signals by exaggerating the amygdalar response to conditioned aversive stimuli (Deakin and Graeff 1991; Graeff et al. Inputs from the behavioural inhibition system also augment the activity of the (ventromedial) hypothalamus which suppresses the flight/ fight response generated in the periaquaductal grey. In contrast, the amygdala inhibits hypothalamic activity and releases the flight/fight response. Anti-anxiety drugs are thought to inhibit monoaminergic activation of the behavioural inhibition system cortex, which is thought to process the perception of sensory information, and the hippocampus, which processes contextual (environmental) cues. It is suggested that a reduction of serotonergic transmission in this area releases the flight/fight response. Under normal conditions, activity in this system is governed by higher centres in the forebrain (the cortex and hippocampus) so that, when interpretation of prevailing stimuli deems it appropriate, the flight/fight response is suppressed. It could also explain why patients often report that they are woken up during the night by their panic attacks. Activity within the defence system is governed by higher centres, such as the frontal cortex and hippocampus. Serotonergic neurons projecting from the dorsal Raphe nucleus are proposed to activate the amygdala (‡) thereby promoting the response to conditioned aversive stimuli (anxiety). A deficit in serotonergic transmission to this brain region is thought to underlie panic. In fact, this has been offered as an explanation for the panic attacks experienced by some patients given buspirone. It could also explain the increase in panic attacks in the early stages of treatment with antidepressants. Obviously, any explanation of anxiety must account for the actions of benzo- diazepines. According to this scheme, benzodiazepines might activate this latter system and generate spurious safety signals (see Handley 1995).

Acetylcysteine is the antidote to acetaminophen in overdose and should be administered within 12 hours for maximum effectiveness buy glucotrol xl 10 mg without prescription diabetes in dogs and ketones. It enhances the elimination of the reactive metabolite N-acetyl~benzoquinoneimine glucotrol xl 10 mg free shipping diabetes eating plan, which is responsible for liver dam- age buy 10 mg glucotrol xl otc metabolic disease drug discovery. Acutely, it can act as an enzyme inhibitor, but chronic use may lead to enzyme induction. The chronic ingestion of more than average amounts of ethanol induces the formation of the P-450 isozyme that converts acetaminophen to its reactive metabolite. Thus, more than normal amounts of N-acetyl-benzoquinoneimine would be formed in an overdose situation, resulting in enhanced hepatotoxicity. Heparin is a mixture of sulfated polysaccharides with molecular weights of 15-20,000 daltons. Consequently, the extrinsic pathway and protein C system are inactivated, whereas the intrinsic system remains active for a few days. Transient protein C deficiency can be induced by treatment with warfarin, which promotes hypercoagulation through the action of the intrinsic pathway. Thrombolytics Also called fibrinolytics, these agents lyse thrombi by catalyzing the formation of the endogenous fibrinolytic plasmin (a serine protease) from its precursor, plasminogen. Antiplatelet drugs inhibit this process, thus reducing the chances of thrombi formation. The major drugs are aspirin, ticlopidine, c1opidogrel, abciximab, eptifibatide, and tirofiban. Following a myocardial infarction, a patient is stabilized on warfarin, the dose being adjusted to give a prothrombin time of 22 seconds. Which of the following statements regarding potential drug interactions in this patient is accurate? Which of the following statements is true regarding the parenteral administration of streptokinase? A woman who has a mechanical heart valve and who is taking warfarin informs you that she hopes to get pregnant in the near future. What advice should she receive regarding her antithrombotic medication during the anticipated pregnancy? Warfarin binds extensively (98%) but weakly to plasma proteins and can be displaced by other drugs (e. Vitamin K restores levels of prothrombin and several other coagulation factors, but the action is slow (24 to 48 hours). The peak effect of heparin is not reached for several hours, and continued use over several days has no effect on thrombin levels. Its onset of anticoagulation activity is slow, and its impact on individual coagulation fac- tors depends on their half-lives. The intrinsic pathway continues to function for 2 to 3 days, causing a state of hypercoagulability and possible vascular thrombosis. Streptokinase is thrombolytic (or "fibrinolytic") because it activates plas- minogen, resulting in the increased formation of plasmin. All thrombolytics can cause bleeding, which may be counteracted to some extent by administration of antifibrinolysins, such as aminocaproic acid. Discontinuing warfarin is appropriate during pregnancy because it is a known teratogen that causes bone dysmorphogenesis. The patient will need continued protection against thrombus formation, and heparin (or a related low molecular weight compound) is usually advised, despite the fact that the drug will require parenteral administration and can cause thrombocytopenia. Mode of Action of Sulfonylureas Mechanisms: - Normally, K+ efflux in pancreatic ~ cells maintains hyperpolarization of membranes, and insulin is released only when depolarization occurs. The oral antidiabetic drugs are the sulfonylureas, metformin, acarbose, thiazolidinediones, and repaglinide. By blocking K+ channels in the pancreatic ~ cells, the sulfonylureas stimulate insulin release. Metformin enhances tissue sensitivity to insulin and inhibits liver gluconeogenesis. Acarbose inhibits intestinal a-glucosidase, thereby slowing glucose absorption and decreasing insulin demand. The thiazolidinediones (glitazones) act via peroxisome proliferation activating receptors that control insulin-responsive genes. They are less hypoglycemic than the sulfonylureas, but they still induce weight gain and edema and have potential liver toxicity. The glucocorticoids are used to treat Addison disease and adrenal insufficiencystates, as a supplement in infantile respiratory distress syndrome, and in adrenal hyperplasia. The clinicaluses of anastrozole (decreases estrogen synthesis), danazol (decreases ovarian steroid synthesis), clomiphene (decreases feedback inhibition), and the selective estrogen-receptor modulators tamoxifen and raloxifene are considered. The progestin-like drugs, their use in contraception and in hormonal replacement therapy, and their adverse effects are considered. The pharmacology of oral contraceptives and their adverse effects, drug interactions, and benefits are pointed out. Androgens Clinicallyuseful androgen analogs include methyltestosterone and 17-alkylderivatives. The clinicaluses and their potential complications are presented in greater detail for the thioamides (propylthiouracil and methimazole) and iodine. Alendronate is effective for treatment of postmenopausal and steroid-induced osteoporosis. The principal potential side effects are gastrointestinal distress and esophageal ulcers. Regarding drug management of hyperthyroidism, which one of the following statements is accurate? The release of insulin from the pancreatic B cell would most likely be inhibited by which of the following? Which of the following has been used in the treatment of adrenal malignancies but is more likely to be identified as a progestin-receptor antagonist that acts as an abortifa- cient? In a patient with type 2 diabetes, which of the following is most likely to cause hypogly- cemic reactions? Which one of the following is least likely to increase insulin requirement in a diabetic patient? What is the drug of choice for management of adrenal glucocorticoid-induced osteo- porosis? Thioamides used at conventional doses in Graves disease are slow to act; they inhibit iodination and the coupling reactions in hormone synthesis and do not affect the release of stored thyroxine. Use of iodide in hyperthyroidism is only temporary because the thyroid gland "escapes" from its actions within a week or two. Nephrogenic diabetes insipidus (decreased response of vasopressin receptors) is treated with thiazides, except in the case of that induced by lithium, when amiloride is preferred (because thiazides increase blood levels of lithium). The release of insulin from the pancreas is stimu- lated by insulinogens (glucose), sulfonylurea hypoglycemics (glipizide), activators of beta-Z adrenoceptors (e. The only receptor that, when activated, inhibits insulin release is the alpha-Z receptor, which could be stimulated by clonidine or methyldopa.

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Because the elec- trons are much lighter than the nuclei order 10 mg glucotrol xl with visa blood sugar 88, they move faster and emit more radiant energy than the nuclei buy glucotrol xl 10 mg lowest price diabetes diet coke bad. At high temperatures trusted glucotrol xl 10 mg diabetes y embarazo, some of the electromagnetic radiation is in the visible region, and the body is observed to glow. When electromagnetic radiation impinges on an object, the charged par- ticles (electrons) in the object are set into motion and gain kinetic energy. Other materials, such as quartz and certain glasses, transmit the radiation without absorbing much of it. Such reflecting and transmitting materials cannot be heated efficiently by radiation. The rate of emission of radiant energy Hr by a unit area of a body at temperature T is 4 Hr eσT (9. The temperature is measured on the absolute scale, and e is the emissivity of the surface, which depends on the temperature and nature of the surface. Emission and absorption of radiation are related phenomena; surfaces that are highly absorptive are also efficient emitters of radiation and have an emissivity close to 1. Conversely, surfaces that do not absorb radiation are poor emitters with a low value of emissivity. A body at temperature T1 in an environment at temperature T2 will both 4 emit and absorb radiation. The rate of energy emitted per unit area is eσT , 1 4 and the rate of energy absorbed per unit is eσT. If a body at a temperature T1 is placed in an environment at a lower tem- perature T2, the net loss of energy from the body is 4 4 Hr eσ T − T (9. Diffusion is the main mechanism for the delivery of oxygen and nutrients into cells and for the elimination of waste products from cells. On a large scale, diffusive motion is relatively slow (it may take hours for the colored solution in our example to diffuse over a distance of a few centimeters), but on the small scale of tissue cells, diffusive motion is fast enough to provide for the life function of cells. Although a detailed treatment of diffusion is beyond our scope, some of the features of diffusive motion can be deduced from simple kinetic theory. Consider a molecule in a liquid or a gas which is moving away from the starting point 0. The molecule has a thermal velocity v and travels on the average a distance L before colliding with another molecule (see Fig. As a result of the collision, the direction of motion of the molecule is changed randomly. On the average, however, after a certain number of collisions the molecule will be found a distance S from the starting point. A statistical anal- ysis of this type of motion shows that after N collisions the distance of the molecule from the starting point is, on the average, S L N (9. A frequently used illustration of the random walk examines the position of a drunkard walking away from a lamppost. If the length of each step is 1 m, after taking 100 steps he will be only 10 m away from the lamppost although he has walked a total of 100 m. After 10,000 steps, having walked 10 km, he will be still only 100 m (on the average) from his starting point. Let us now calculate the length of time required for a molecule to diffuse a distance S from the starting point. Therefore, the mean free path of a diffusing molecule is short, about 10−8 cm (this is approximately the distance between atoms in a liquid). Gases are less densely packed than liquids; consequently, in gases the mean free path is longer and the diffusion time shorter. In a gas at 1 atm pressure, the mean free path is on the order of 10−5—the exact value depends on the specific gas. Consider a cylinder containing a nonuniform distribu- tion of diffusing molecules or other small particles (see Fig. Although this solution for the diffusion problem is not exact, it does illustrate the nature of the diffusion process. The net flux from one region to another depends on the difference in the density of the diffusing particles in the two regions. The flux increases with thermal velocity v and decreases with the distance between the two regions. In our previous illustration of diffusion through a fluid, where L 10−8 cm and v 104 cm/sec, the diffusion coefficient calculated from Eq. By comparison, the measured diffusion coefficient of salt (NaCl) in water, for example, is 1. Thus, our simple calculation gives a reasonable esti- mate for the diffusion coefficient. The diffusion coefficients for biologically important molecules are in the range from 10−7 to 10−6 cm2/sec. Oxygen, nutrients, and waste products must pass through these membranes to maintain the life functions. In the simplest model, the biologi- cal membrane can be regarded as porous, with the size and the density of the pores governing the diffusion through the membrane. If the diffusing molecule is smaller than the size of the pores, the only effect of the membrane is to reduce the effective diffusion area and thus decrease the diffusion rate. If the diffusing molecule is larger than the size of the pores, the flow of molecules through the membranemaybebarred. The permeability depends, of course, on the type of membrane as well as on the diffusing molecule. Permeability may be nearly zero (if the molecules cannot pass through the membrane) or as high as 10−4 cm/sec. Many membranes, for example, are permeable to water but do not pass molecules dissolved in water. As a result water can enter the cell, but the components of the cell cannot pass out of the cell. In the type of diffusive motion we have discussed so far, the movement of the molecules is due to their thermal kinetic energy. Some materials, however, are transported through membranes with the aid of electric fields that are gen- erated by charge differences across the membrane. We have shown that over distances larger than a few millimeters diffusion is a slow process. Therefore, large living organisms must use circulating sys- tems to transport oxygen nutrients and waste products to and from the cells. The evolution of the respiratory system in animals is a direct consequence of the inadequacy of diffusive transportation over long distances. At rest, an average 70-kg adult requires about 70 Cal of energy per hour, which implies a consumption of 14. It has been determined that in a person only about 2% of oxygen consumed at rest is obtained by diffusion through the skin.

Nausea and vomiting or ‘morning sickness’ are common symptoms of pregnancy during the first trimester order glucotrol xl with a visa diabete 97, but most pregnant women do not require antiemetic therapy discount 10 mg glucotrol xl overnight delivery diabetes insipidus nclex questions. Frequent small meals may prove a beneficial way to manage nausea without medical intervention 10mg glucotrol xl with mastercard diabetic diet indian menu. Fortunately, hyperemesis gravidarum, the most severe form of pregnancy-associated nau- sea and vomiting occurs in only a small percentage of gravidas. Women with hypereme- sis gravidarum may require hospitalization and intravenous hydration, and antiemetic therapy. One of the most effective antiemetic agents for nausea and vomiting associated with pregnancy was doxylamine plus pyridoxine (Bendectin). When antiemetics are indicated, promet- hazine suppositories (or occasionally orally) in doses of 25 mg should be used. Other agents which may prove useful for hyperemesis gravidarum are described in Box 12. Such agents as prochlorperazine, promethazine, chlorpromazine, and thiethylperazine may be associated with extrapyramidal side effects manifested by dystonia, torticollis, and oculogyric crisis. If it occurs, this unusual syndrome of adverse effects can be treated with diphenhydramine (Benadryl). Importantly, chlorpromazine may be associated with significant hypotension when given intravenously. In severe cases of hyperemesis gravidarum in which other agents are largely ineffec- tive, ondansetron (Zofran) 32 mg intravenously as a single dose may be effective. It is also available in oral form (8 mg twice a day), but this is much less likely to be effective in cases of hyperemesis gravidarum where almost everything taken orally is vomited. Reflux esophagitis Reflux esophagitis resulting in heartburn or pyrosis is very common in pregnancy and is thought to be secondary to decreased gastroesophageal sphincter tone with resultant 236 Nutritional and dietary supplementation during pregnancy Table 12. Therapy consists primarily of one of the antacid preparations dis- cussed in the previous section. Frequent small feedings and elevation of the head of the bed at night may be beneficial. An H -receptor antagonist or omeprazole, as well as2 metoclopramide, may also prove useful for severe forms of reflux. Esomeperazole and omeprazole are the most popular treatments for reflux esophagitis, and omeprazole is well studied during pregnancy. Peptic ulcer disease Peptic ulcer disease is not common during pregnancy and active ulcer disease may actu- ally improve during pregnancy. The mainstay of therapy in patients with ulcer disease is reduction of gastric acid production. It is not generally recommended that pregnant women with inactive or asymptomatic disease be treated with ‘prophylactic’ antacids. The H -receptor antagonists cimetidine and ranitidine inhibit gastric acid secretion and2 may be used to treat peptic ulcer disease in pregnant women. Cimetidine is usually given in a dose of 300 mg orally four times a day, while ranitidine is usually given in a dose of 150 mg orally twice a day. Diarrhea Most cases of acute diarrhea require no specific therapy other than ensuring adequate hydration. When antidiarrheal therapy is required, the combination of kaolin and pectin 238 Nutritional and dietary supplementation during pregnancy a Box 12. Kaolin plus pectin, 60–120 cc of regular strength orally after each diarrheal episode. Then 10 mL or 1 caplet after each diarrheal episode, not exceeding 40 mL or four caplets in 24 h. If this fails and a stronger medications is indicated, an opioid-like preparation can be utilized (Box 12. However, narcotic preparations should not be used chronically, especially in pregnant women. Traditional antidiarrheal medication should be used cautiously in pregnant women with diarrhea of an infectious etiology (i. It is generally accepted that infections may be increased in severity or prolonged when treated with these agents. Diarrhea secondary to bacterial agents may or may not need specific antimicrobial therapy, and, when necessary, therapy should be directed towards the specific organism (see Chapter 2, Antimicrobials during pregnancy: bacterial, viral, fungal, and parasitic indications). Therapy need not be delayed until after the first trimester as first-trimester use of metronidazole does not increase the risk for congenital anomalies. Celiac disease Celiac disease is a characterized by diarrhea, bloating, anemia, weight loss, and gluten intolerance. Usually, folic acid, iron, and other essential nutrients are not adequately absorbed from the gastrointestinal tract. One large series of 94 women with celiac disease during pregnancy showed that with untreated celiac disease there were nine times more miscarriages than among women on a gluten-free diet. Low birth weight was approximately six times more frequent among untreated women compared to those maintained on a gluten-free diet. Severity of celiac disease during pregnancy was apparently not related to pregnancy outcome; maintenance of a gluten-free diet during gestation was the important determi- nant of pregnancy outcome (Ciacci et al. Inflammatory bowel disease Ulcerative colitis and Crohn’s disease commonly occur in pregnant women. Among 30 percent of more than 1000 pregnant women with inactive inflammatory bowel disease, Key references 239 the condition worsened during pregnancy. Of the 320 patients with active disease at the start of pregnancy, 143 (45 percent) became worse, 84 (26 percent) remained the same, and 93 (29 percent) improved (Miller, 1986). Ulcerative colitis, a chronic disease of unknown etiology, is associated with two life- threatening conditions: fulminant disease and adenocarcinoma of the colon. Ulcerative colitis therapy includes sulfasalazine (Azulfidine), glucocorticoids, azathioprine, and mercaptopurine. Sulfasalazine is comprised of sulfapyridine and aminosalicylic acid, and usually used for mild or moderate disease (Hanauer, 1996). Sulfapyridine, a sul- fanamide, crosses the placenta (Azad and Truelove, 1979) and theoretically could cause hyperbilirubinemia or kernicterus, but there are no publications of these complications. Azathioprine, an immunosuppressant, may be necessary in the small number of patients who do not respond to the usual regimen. Cyclosporine has also been used to treat patients refractory to intravenous steroids (Hanauer, 1996). Aminosalicylate, metronidazole, corticosteroids, azathioprine, and cyclosporine may also be used to treat pregnant patients with Crohn’s disease. Delivery outcome after the use of acid-suppressing drugs in early pregnancy with special reference to omeprazole. Use of cimetidine, omeprazole, and ranitidine in pregnant women and pregnancy outcomes. However, pruritic urticarial papules and plaques of pregnancy, her- pes gestation, and papular dermatitis of pregnancy do occur and are unique to pregnancy.

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