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However buy genuine yasmin online birth control for 16 year old daughter, it is relatively easy to calculate the average value of the impulsive force Fav discount 3.03 mg yasmin mastercard birth control for women love. It can be obtained simply from the relationship between force and momentum given in Appendix A; that is order yasmin 3.03mg on line birth control for women dresses, mvf − mvi Fav (5. The change in momentum due to the collision is usually easy to calculate, but the duration of the collision t is difficult to determine precisely. If the colliding objects are hard, the collision time is very short, a few milliseconds. If one of the objects is soft and yields during the collision, the duration of the collision is lengthened, and as a result the impulsive force is reduced. Thus, falling into soft sand is less damaging than falling on a hard concrete surface. When a person falls from a height h, his/her velocity on impact with the ground, neglecting air friction (see Eq. If the impact surface is hard, such as concrete, and if the person falls with his/her joints rigidly locked, the collision time is estimated to be about 10−2 sec. The collision time is considerably longer if the person bends his/her knees or falls on a soft surface. Note, however, that the assumption of a 2-cm2 impact area is reasonable but some- what arbitrary. The area may be smaller or larger depending on the nature of the landing; furthermore, we have assumed that the person lands with legs rigidly straight. Exercises 5-2 and 5-3 provide further examples of calculating the injurious effect of impulsive forces. This is illustrated by examining the inflatable safety device used in automobiles (see Fig. In a collision, the bag expands suddenly and cushions the impact of the passenger. The forward motion of the passenger must be stopped in about 30 cm of motion if contact with the hard surfaces of the car is to be avoided. For a 70-kg person with a 30-cm allowed stopping distance, the average force is 70 × 103v2 3 2 F 1. If this force is uniformly distributed over a 1000-cm2 area of the passenger’s body, the applied force per cm2 is 4. At a 105-km impact speed, the average stopping force is 1010 dyn and the force per cm2 is 107 dyn. In the design of this safety system, the possibility has been considered that the bag may be triggered during normal driving. If the bag were to remain expanded, it would impede the ability of the driver to control the vehicle; therefore, the bag is designed to remain expanded for only the short time necessary to cushion the collision. If, however, the impact is sudden, as in a rear-end collision, the body is accelerated in the forward direction by the back of the seat, and the unsupported neck is then suddenly yanked back at full speed. Here the muscles do not respond fast enough and all the energy is absorbed by the neck bones, causing the well-known whiplash injury (see Fig. It was found in these cases that the body made about a 1-m-deep depression in the surface of the snow on impact. The credibility of these reports can be verified by calculating the impact force that acts on the body during the landing. It is shown in Exercise 5-6 that if the decelerating impact force acts over a distance of about 1 m, the average value of this force remains below the magnitude for serious injury even at the terminal falling velocity of 62. In the normal course of daily activities our bodies are subject mostly to smaller repetitive forces such as the impact of feet with the ground in walking and running. A still not fully resolved question is to what extent are such smaller repetitive forces particularly those encountered in exercise and sport, damaging. Osteoarthritis is the commonly suspected damage resulting from such repetitive impact. Chapter 5 Exercises 71 Osteoarthritis is a joint disease characterized by a degenerative wearing out of the components of the joint among them the synovial membrane and cartilage tissue. As a result of such wear and tear the joint loses flexibility and strength accompanied by pain and stiffness. After the age of 65, about 60% of men and 75% of women are to some extent affected by this condition. Over the past several years a number of studies have been conducted to determine the link between exercise and osteoarthritis. The emerging conclu- sion is that joint injury is most strongly correlated with subsequent develop- ment of osteoarthritis. Most likely this is the reason why people engaged in high impact injury-prone sports are at a significantly greater risk of osteo- arthritis. Further, there appears to be little risk associated with recreational running 20 to 40 km a week (∼13 to 25 miles). It is not surprising that an injured joint is more likely to be subsequently subject to wear and tear. A joint injury usually com- promises to some extent the lubricating ability of the joint leading to increased frictional wear and osteoarthritis. This simple picture would lead one to expect that the progress of osteoarthritis would be more rapidly in the joints of peo- ple who are regular runners than in a control group of non-runners. Osteoarthritis seems to progress at about the same rate in both groups, indicating that the joints possess some ability to self- repair. If the bones of one arm absorb all the kinetic energy (neglecting the energy of the fall), what is the minimum speed of the runner that will cause a fracture of the arm bone? Assume that the object is hard, that the area of contact with the skull is 1cm2, and that the duration of impact is 10−3 sec. Calculate the duration of the collision between the passenger and the inflated bag of the collision protection device discussed in this chapter. In a rear-end collision the automobile that is hit is accelerated to a veloc- ity v in 10−2/sec. What is the minimum velocity at which there is danger of neck fracture from whiplash? Use the data provided in the text, and assume that the area of the cervical vertebra is 1 cm2 and the mass of the head is 5 kg. Calculate the average decelerating impact force if a person falling with a terminal velocity of 62. Assume that the person’s mass is 70 kg and that she lands flat on her back so that the area of impact is 0. Assuming that the moving part of his hand weighs 5 kg, calculate the rebound velocity and kinetic energy of the bag. In particular, we will consider the hovering flight of insects, using in our calculations many of the concepts introduced in the previous chapters. The parameters required for the computations were in most cases obtained from the literature, but some had to be estimated because they were not readily available.

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It relieves the pain in wounds buy 3.03mg yasmin with visa birth control pills and menopause, and if there are not bad bruises yasmin 3.03 mg with mastercard birth control rod, it quickly relieves the soreness and favors the healing process discount yasmin 3.03 mg without a prescription birth control pills name brands. It is applicable to catarrhal mucous surfaces, to festering sores, local swellings, glandular inflammations and to epithelioma and carcinoma to correct the fetor. It is especially applicable to severe burns, to promote healing and to prevent the formation of a contracting scar. If the precipitate formed when the drug is added to water be olive-green, it is active; but its strength should always be tested by tentative doses. In some persons the drug causes excitement tending to acts of violence and crime; in others it excites merriment, or a maudlin state. In general it produces hallucination, perverts the natural perception of objects, intensifies the perception of sound, dilates the pupils, abolishes pain, and, in poisonous doses, causes spasms, convulsions, collapse, pale, clammy, insensible skin, extreme debility, feeble pulse, and finally paralysis of respiration. The habitual use of the drug causes bloating of the face, weak, tremulous limbs, injected eyes, imbecility, and ultimately death from marasmus. Those who use cannabis regularly, believe that in medicinal doses it is not poisonous. It can be safely given in full doses, the tincture in from Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 89 ten to twenty minims, and the solid extract in from one-half to two grains. Its best effects are secured when given in conjunction with alkalies in full doses or with mild aperients. Therapy—Cannabis Indica is sedative, narcotic, anodyne and, to a limited degree, anti-spasmodic. It is a remedy for disorders of motility, involuntary, irregular, muscular movements, especially if of a distressing character. It is a remedy to arrest or control pain, often acting advantageously in conjunction with other pain-quieting agents, intensifying, modifying or favorably influencing their action. It is a remedy for excitable and irritable hyperaesthetic conditions of the genito-urinary organs, with increased functional activity and uterine disorders. In many forms of urinary irritation, its action is prompt and satisfactory especially, Quincey says, where there are only a few drops passed frequently, constant unsatisfied desire, burning pain and vesical tenesmus. In the wakefulness of old age, in the restlessness of nervous exhaustion, and in melancholia, it is an important remedy. It takes high rank in affections of the brain and nerves of the head, especially if nervous vertigo be present, and in those attacks of hemicrania which occur periodically, very distressing, causing delirium and much prostration. It is especially applicable in sub-acute inflammation of the brain, in delirium tremens and in the hypochondria of the menopause. This remedy has received a great deal of attention in its adaptability to cerebro-spinal meningitis, and with varying but encouraging results, especially in the earlier stages of irritation and congestion. It is useful also in hydrophobia, and in large doses it is sometimes palliative to the distressing symptoms. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 90 It is useful in the distress of Potts’ disease and hip joint disease and in general rickets. In epilepsy, either alone or combined with the bromides, it has been given very extensively for several years. Cook of Seattle suffered from nervous breakdown with extreme exhaustion; tremor on awakening in the morning, with active functional heart disturbance. He took five drops of specific cannabis three times a day on the tongue, followed by a sip of water. Not only was the whole nervous excitability controlled, but the heart was restored to its normal action and the urinary irritability was overcome. It is of much use in paralysis agitans, in relief of the lightning pains of locomotor ataxia, and especially in chorea and in general muscular tremblings. In functional disorder of the stomach accompanied by pain, it is an excellent sedative, and in intestinal disorders it is equally applicable. It does not suppress secretions or disarrange the functional operations of the organs. In aching and painful irritation, or in the passage of gravel, it is a most soothing remedy. It is beneficial here also in painful hematuria, whether from cancer or tuberculosis, from profound congestion or nephritis. It is a soothing tonic to the uterine muscular structure, and in inertia and subinvolution it increases muscular power and energy and promotes contraction. It is a valuable sedative adjuvant to combine with the well known uterine tonics in general disorders of the pelvic organs amenable to medical treatment not of a surgical character, especially if the pains are of neuralgic or spasmodic character. It will allay abnormal sexual appetite, and will overcome the hysteria and emotional excitement which occur in some women at the menstrual period. In neuralgic dysmenorrhea it will occasionally cure patients who have been treated by other methods without results. There are few remedies that will excel it in this disorder, but the remedy must be given continuously, beginning before the expected paroxysm some little time and continued for a time after the paroxysm is relieved. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 91 It is an excellent remedy in gonorrhea with sexual hyperaesthesia. It controls violent erection and soothes the mental anxiety which aggravates the symptoms. It is soothing to irritable bronchial coughs and laryngeal spasm, and in coughs from tickling in the throat; also in whooping cough and in spasmodic coughs of whatever character. Co-operatives—The agent acts similarly in a general way to opium, gelsemium, passiflora, the bromides, chloral and hyoscyamus. Therapy—The agent has been noted for its influence in haematuria and other mild forms of passive hemorrhage. It is of some benefit as a mild diuretic, soothing irritation of the renal or vesical organs. In cases of uncomplicated chronic menorrhagia it has accomplished permanent cures, especially if the discharge be persistent and devoid of much color. The agent is also useful where uric acid or insoluble phosphates or carbonates produce irritation of the urinary tract. In the treatment of mild forms of intestinal hemorrhage or gastric hemorrhage from simple ulceration, the agent has been used with some benefit, also in atonic dyspepsia, diarrhea, both acute and chronic, and in dysentery and bleeding piles. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 92 Externally the bruised herb has been applied to bruised and strained parts, to rheumatic joints, and where there was ecchymosis or extravasations within or beneath the skin. Heinen of Toledo treats non-malignant abdominal tumors in women with better results by adding five drops of capsella three times a day to the other indicated treatment. In large doses it causes vomiting, purging and inflammation of the stomach and bowels, with dizziness, intoxication and feebleness of the nervous power. It produces rapid capillary determination of the blood to the part, and if taken into the stomach it promotes its own absorption and thus continues its further influence through the nerve centers.

Four months later yasmin 3.03mg lowest price birth control pills rash, after killing parasites buy yasmin 3.03 mg on-line birth control 3 months, her hand pain and gums were much better discount 3.03 mg yasmin with mastercard birth control for women 70s outfit. She had the dryer vent taped up tighter and this got rid of her as- bestos problem. She started on kidney herbs and in one month saw that her enlarged knuckles were beginning to go down. I explained to her that painful shoulders did not belong to the arthritis picture but had a gallstone etiology which she could easily fix in a single night at a later time (liver cleanse). She also had mid-back, upper back and lower back pain; again the upper back pain belonged to the liver problem. In 33 days her low back pain had improved a lot, she could wash her own hair again and she could sit down and get up from her living room floor Fig. Patricia Robinson, age 76, had pain in her knees, feet, lower back, hands and wrists. The parasite test still showed Ascaris and she was started on the parasite program. We also found fluoride (from toothpaste), iridium, samarium and palladium, all from her tooth implants. She was to remove as much metal as the dentist could replace, clean cavitations, and take thioctic acid, 2 a day, to help clear metal from her body. In four weeks the sharp pain in her back was gone and in three more weeks the pain in her hands was gone. Lynne Snyder, 72, had pain in every joint and had to be on pain medi- cine to keep moving. In ten days she could feel some new energy but her pains were terrible, especially her knees. She was taken off tomato juice, cranberry juice, citrus, pepper (she was using a lot), and given buttermilk as a beverage which she enjoyed. Rheumatoid Arthritis When inflammation and swelling affect your joints, besides pain, it is called rheumatoid arthritis. Their eggs are everywhere around us, in dust and dirt and the filth un- der fingernails and our own bowel movements. Rinse fingernails in alcohol after cleaning up bowel movements or changing diapers. Of course, you can kill them with a zapper (internally, not the ones under the nails) but that is after you have been infected. A pet that goes outdoors will quickly (the very next day) bring these roundworms into the house again. You may relieve your pain and begin to heal immediately after zapping but it is wise to do all the health programs, anyway. Stay on the kidney cleanse for three to six weeks and repeat a one- week session every few months to keep removing deposits which may also choose these sick joints to settle in. To summarize, do everything as for osteoarthritis, empha- sizing the roundworm parasites for elimination. But we can easily triple and quadruple our benzoic acid intake by consuming commercial beverages and pastries where benzoic acid is used as a preservative. All of it must be detoxified, though, and this gives us way too much hippuric acid. The kidneys are unable to excrete such overloads of hippuric acid, so it distributes itself in our organs. It is only sensible for persons with chronic pain not to consume benzoic acid (or benzoate) preserved foods. Many vegetables, notably the cabbage family, contain such cyanides, giving them protection from insects, disease, and grazing animals. In fact, it is the chemical used as a general reactant with amino acids in the well known Edman degradation reaction. This suggests that the liver is capable, again, of detoxifying the cyanides for you in a reasonable time and you may eat them again. Joint pain, or arthritis, was known in antiquity long before dogs and cats were household pets and giving us their parasites. Pigs and horses harbor these roundworms too and may have been the source at that time. Homeopathic treatments, as well as massage, heat and electronic devices also help. With this wide range of effective treatments dating to the distant past, why is none of them a permanent cure? The common roundworms are everywhere about us, sanitation is poor, and our civilized lifestyle leads to deposit formation that invites bacteria. But knowing this, you can stop your pain and remove the causes to become one of the first hu- mans to achieve a permanent cure. The drugs were no longer effective and she would need to do something else very soon. She had the typical causes: her body was toxic with mercury and nickel from tooth fillings. She had numerous roundworm parasites including two kinds of Ascaris, two kinds of hookworm, Strongyloides and Tri- chinella. She started on the kidney herbs, killed parasites with a frequency gen- erator and in two months noticed her swelling was receding. She was given a diet change; onto milk, fruits and vegetables, off other beverages, less meat and grains. Thigh Pain Inner thigh pain often stems from the sciatic nerve which is suffering pressure at the lower back. The correct treatment, after killing bacteria electronically, is to clean up the entire kidney area using the kidney herb recipe. If the pain recurs after clearing it several times, there must be a chronic source of bacteria. Since the kidneys are already cleaned, consider the teeth, as well as recurring parasites, and the liver. Clean the liver every two weeks until 2000 or more stones have appeared and no more appear. In fact, these bacteria regularly come from two sources: the kidneys and the teeth. This simplifies the treatment since neither of these places takes a long time to clear. Start yourself immediately on the kidney cleanse (page 549) to clean your kidneys. Cleaning these cavitations may give immediate pain relief in the hip (proving the bacterial source).

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These guidelines are consistent with the recommendations made in 2005 (Pentheroudakis and Pavlidis best 3.03 mg yasmin birth control zenchent, 2006) yasmin 3.03mg lowest price birth control pills generic. Chemotherapy is frequently recommended for either adjunctive therapy or treatment in advanced cases buy yasmin 3.03mg without prescription birth control calendar method. Women with axillary lymph node metastases appear to be the best candidates for adjunctive chemotherapy (Barnavon and Wallack, 1990). As detailed pre- viously in this chapter, chemotherapy with currently available antineoplastic agents car- ries an increased risk of congenital anomalies with first-trimester exposure, and fetal growth retardation is the major risk in the latter two-thirds of pregnancy, although long- term effects are unknown. Special considerations 143 The efficacy of breast carcinoma treatment during pregnancy appears to be enhanced little, if at all, by therapeutic abortion and prophylactic oophorectomy (Donegan, 1986). Therapeutic abortion might be a consideration if radiotherapy is deemed neces- sary or if chemotherapy is necessary during the first trimester. However, with proper shielding and focused radiotherapy above the maternal diaphram, it may be possible to minimize the adverse effects of radiation on the fetus (Pentheroudakis and Pavlidis, 2006). Leukemia Acute leukemia is extremely rare during pregnancy, occurring in approximately one in 100 000 pregnancies. However, it is among the most common neoplasms in young women (Caliguri and Mayer, 1989; Catanzarite and Ferguson, 1984; Koren et al. Review of 72 cases of leukemia during pregnancy (13 separate reports), 64 (89 percent) women had acute leukemia and eight (11 percent) had chronic or other forms of leukemia (Caliguri and Mayer, 1989). The survival rate was approximately 75 percent in one report of 45 pregnant women with acute leukemia (Reynoso et al. Antineoplastic drugs most commonly used to treat chronic leukemia include antimetabolites (methotrexate, thioguanine, mercaptopurine, and cytarabine), anthracy- cline antibiotics (daunorubicin and doxorubicin), and plant alkaloids (vincristine). Therefore, all antineoplastics have a very high potential for production of birth defects during embryogenesis because this period is character- ized by the highest rate of cell division (hyperplasia) in a human’s life. The prognosis for survival in the untreated woman is extremely poor, with life expectancy of less than 3 months (Catanzarite and Ferguson, 1984; Hou and Song, Table 7. Therefore, chemotherapy should be initiated immediately (even during the first trimester) once the diagnosis of acute leukemia is made. Among a series of 58 infants born to pregnant women who had either acute myelo- cytic or lymphoblastic leukemia, there were 31 (53 percent) premature births (including five stillbirths), and 23 (43 percent) full-term infants (two of whom were of low birth weight) (Caliguri and Mayer, 1989). No studies have been published of congenital anomalies among the infants born to women with leukemia during pregnancy. No con- genital anomalies have been reported among the 13 fetuses exposed to chemotherapy for leukemia during the first trimester (Caliguri and Mayer, 1989). Lymphomas and Hodgkin’s disease An estimated 40 percent of malignant lymphomas are of the Hodgkin’s variety and are the most commonly encountered lymphoma among pregnant women, and occur among approximately one in 6000 pregnancies. As with breast carcinoma, pregnancy does not seem to affect the prognosis for Hodgkin’s disease (Lishner et al. Both leukemias and lymphomas are known to metastasize to the placenta, but the empirical risk is unknown. Treatment of Hodgkin’s lymphoma, like that of most other malignancies, depends on the stage of the disease and the gestational age at which the disease is diagnosed. Staging is of paramount importance, and pregnancy may interfere with the types of diagnostic studies that can be performed. Most diagnostic radiographic procedures not involving the abdomen or fetus can be accomplished, if necessary, with minimal risk to the con- ceptus. Staging laparotomy lymphomas is somewhat controversial and difficult, if not impossi- ble, to accomplish in the latter half of pregnancy because the large uterus obstructs the operating field (Bloss and Miller, 1995). For early stages of lymphomas in the first half of pregnancy, several options are avail- able. Obviously, therapeutic abortion is one consideration, although it is not always nec- essary. Modified radiotherapy can be utilized if done at a significant distance from the shielded pelvis, i. If chemotherapy is deemed necessary, it is best to wait until after the first trimester. For patients with early-stage disease during the latter half of pregnancy, one reason- able option is simply to wait until after delivery to initiate therapy, especially if the patient is asymptomatic. Chemotherapy after the first trimester causes little known risk to the fetus except for pancytopenia and mild to moderate growth retardation. For patients with advanced disease, early treatment is obviously much more of a concern. Some physicians recommend therapeutic abortion if the advanced-stage lymphoma is diagnosed early in pregnancy (Jacobs et al. Special considerations 145 In a review of 15 pregnancies among women with Hodgkin’s disease (Jacobs et al. One patient developed a subdiaphragmatic relapse, and her treatment was delayed until after delivery. These data suggest that the prognosis for Hodgkin’s disease during preg- nancy is reasonably good for the mother. Nineteen pregnancies (reported in 15 publications) are published with first-trimester exposure to chemotherapeutic agents for treatment of lymphomas. Of these 19 pregnan- cies, 15 (79 percent) resulted in normal infants (three were exposed to mechlorethamine, two to thiotepa, and 10 to vinblastine). Another patient who received chlorambucil delivered an infant with unilateral renal agenesis. One patient who received procarbazine gave birth to an infant with multiple hemangiomas. Another patient who received polydrug therapy dur- ing pregnancy had an infant with an atrial septal defect (Jacobs et al. Melanomas Melanomas are one of the more common cancers that occur during pregnancy, with approximately three per 1000 deliveries (Gilstrap and Cunningham, 1996; Smith and Randal, 1969; Yazigi and Cunningham, 1990). It is important to note that melanoma is the tumor type with the highest risk to metastasize to the placenta and fetus (Anderson et al. Pregnancy does not seem to affect the growth or prognosis of melanoma, although pregnancy is associated with an increased level of melanocyte-stim- ulating hormone (Gilstrap and Cunningham, 1996; Holly, 1986; Yazigi and Cunningham, 1990). There was no difference in survival of 58 pregnant women with melanoma com- pared to nonpregnant controls with melanoma (Reintgen et al. Treatment usually comprises surgical resection, with or without lymph node dissection. A variety of chemotherapeutic agents are used, but their success rate is poor, with little success whether chemotherapy is given as adjuvant or primary therapy in metastatic disease. Other nongenital cancers Other nongenital types of cancer, such as colorectal carcinoma, gastric carcinoma, pan- creatic or hepatic cancer, and sarcoma, are rare during pregnancy (Gilstrap and Cunningham, 1996; Yazigi and Cunningham, 1990). Treatment during pregnancy is similar to that of nonpregnant women, with certain chemotherapeutic and radiation limitations as consideration for the pregnancy (as mentioned above). If the patient is in the first trimester, therapeutic abortion should be considered an option.

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Hypotensioncancause arrhythmias by the same mechanism or by causing reflex sympathetic stimulation cheap yasmin 3.03mg birth control pills 50 mcg. Thus order yasmin 3.03 mg with visa birth control pills how long before effective, antiarrhythmic drugs that decrease the inotropic state of the heart (beta blockers cheap generic yasmin canada birth control clinics, calcium blockers, disopyramide, or flecainide) or drugs that cause vasodila- tion (calcium blockers, some beta blockers, and the intravenousad- ministration of quinidine, procainamide, bretylium,oramiodarone) can occasionally lead to cardiac arrhythmias. Proarrhythmia in perspective Although the potential for antiarrhythmic drugstoworsencardiac arrhythmias has been known for decades, the potential magnitude of the problem has been recognized for only a few years. The hypothesis of the study was that suppressing these patients’ ambient ectopy would improve their mortality. Instead, the results showed that patients treatedwith encainideorflecainidehad afourfoldin- crease in the risk of suddendeath (patients treatedwith moricizine showednobenefit fromdrug treatment) and had asignificant in- crease in overall mortality. The increase in risk for fatal arrhythmias was not limited to the first fewdays or weeks of drug therapybut persisted throughout the follow-up period. Other trials have suggested, for instance, that uses of both quinidine for atrial fibrillation and Class I drugs in survivors of myocardial infarction have produced significant increases in mortality. As a result, most electrophysiologists have become convinced that the proarrhythmic effects of Class I drugsoutweigh the antiarrhyth- mic effects, at least in patients with underlying heart disease. Using antiar- rhythmic drugsalways involves the risk of making heart rhythm worse instead of better. One shouldprescribe these drugsonly if it is necessary for prolongation of survival or for amelioration of significantsymptoms. Most impor- tantly, whenever one is compelled to prescribe antiarrhythmic drugs, one should feel obligated to do whatever possible to minimize the risk of symptomatic or life-threatening proarrhythmia. Since reentrantventricular tachycardia(and therefore drug- inducedworsening of reentry) generally is seen only in the presence of underlying cardiacdisease, one must be especially cautious about using antiarrhythmic drugs in patients with heart disease. When prescribing antiarrhythmic drugs in this setting, it is importantto assure that serum electrolytes (especially potassium) are kept well within the normal range. In addition, cardiac function should be optimized because hemodynamic compromise canworsen arrhyth- mias. Not only 124 Chapter 9 does ischemia itself precipitate arrhythmias, but ischemia also ren- ders drug-inducedproarrhythmia more likely. Torsades de pointes probably occurs in individuals who are genet- ically pronetodevelop afterdepolarizations whenever their cardiac actionpotentials become prolonged. Patients started on therapy with such drugs should be placed on a cardiacmonitor for several days, be- cause torsades de pointes is most often first seenduring the initial 3 or 4days of therapy (although it can occuranytime). Serum potassium levels should also be watched carefully;infact, one shoulduse torsades de pointes producing agents with trepidationinpatients requiring potassium-wasting diuretics. Drug–drug interactions Antiarrhythmic drugs seem to produce more than their share of interactions with other drugs. Interactions generally are related to competitionwith other drugs for serum proteinsonwhichtobind or to drug-inducedchanges in hepatic metabolism. The major in- teractions between antiarrhythmic drugsand other agents (see the discussionsoftheindividual antiarrhythmic drugs) are summarized in Table 9. It is relatively rare for antiarrhythmic drugstosignif- icantly interfere with pacemakers. Two major problems caused by antiarrhythmic drugs are that they canchange the en- ergy required for successful defibrillation and they canchange the characteristics of the arrhythmiabeing treated. The effects of various drugsondefibrillation energy requirements are summarized in Table 9. In thisfinal sec- tion, that informationisapplied to the use of antiarrhythmic drugs in the treatmentofspecificcardiac arrhythmias. Chapter 10 reviews some basic principles that should be kept in mind whenusing an- tiarrhythmic drugs. On the basisofthegenerally limited efficacyofantiarrhythmic drugsaswell as their inherent propensity to cause serious problems, the first principle should be completely self-evident;namely, one should avoid using antiarrhythmic drugs whenever possible. Thus, when one has decided to prescribe an antiarrhythmic drug, the final step before actually writing the order should be to ask, “Does this patient really need this drug? Before prescribing an antiarrhythmic drug, the physician should be certain that the arrhythmia meets one of these two conditions. The second basic principle istokeep the goal of treatment clearly in mind and to tailor the aggressiveness of one’s therapyaccordingly. If one is treating an arrhythmiatoprevent death or permanent in- jury, for instance, a relatively aggressive approach may be appropri- ate and necessary. In theory, if the object istospare life and limb, one should err on the side of efficacy, perhaps willingly accepting the risk of certain drug toxicities. Inpractice, however, as we will see in Chapters 11 and 12, there are relatively fewinstances today where oneought to rely primarily on antiarrhythmic drugs to treat arrhythmias that threaten life and limb. In these cases, one generally shoulduse a stepwise strategy, beginning with milder, less risky forms of treatment, and carefully reassessing the risk-to-benefit ratio before each potential escalation of therapy. All too oftenphysicians pursue the treatment of relatively insignificant arrhythmias with Ninja-like intensity, an error that can result in unnecessary injury or death. The final basic principle of using antiarrhythmic drugs is that, if one feels compelled to expose a patient to the risk of the drugs, one should also feel compelled to take every reasonable precaution to reduce the risks. For instance, given the almost universal risk of proarrhythmia, one should oftenconsider placing patients on a cardiacmonitor while antiarrhythmic drugs are being initiated be- cause, although proarrhythmia can occuranytime during the course of treatment, a significant proportion of these events occur during the first 3 or 4days of drug usage. The accompanying tables summarize the factors that should be consideredinchoosing antiarrhythmic drugs for patients with and withoutsignificant underlying cardiacdisease. Pro- cainamide, for instance, shouldnot be usedinpatients with systemic lupus erythematosus; quinidine shouldnot be usedinpatients with chronic colitis;patients with severe lung disease (in whommild drug-inducedpulmonary toxicity goes a long way) ideally shouldnot receive amiodarone;patients with a history of heart failure should not receive drugs with negative inotropic effects. Beyond these obvious individual considerations, the presenceor absenceofunderlying heart disease is the most important variable in choosing an antiarrhythmic drug,because heart disease predisposes patients to reentrant circuits and, therefore, to proarrhythmia. Amiodarone rises in rank because of its relatively low risk of producing proarrhythmia. Sotalol and dofetilide carry a moderate risk of torsades de pointes for all patients. Amiodarone carries a substantial risk of significantend-organ toxicity for all patients, thoughonly a rela- tively small risk of proarrhythmia. The drug of choice in treating both atrial and ventricular tach- yarrhythmias dependson the presence or absenceofunderlying cardiacdisease. For ventricular arrhythmias, the primary con- siderationinpatients without underlying heart disease (i. As soon as one moves beyond these two classes of drugs, onebeginsaccepting asubstantial risk of proarrhythmia or other significant toxicity. On the other hand, for patients with underlying heart disease who require therapy for ven- tricular arrhythmias, efficacy(which here includes avoiding proar- rhythmia) is often the primary consideration. Thus, amiodarone is often the first drug considereddespite its potential for causing long-term end-organ toxicity.

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