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Fluoroquinolones the fluoroquinolones (see Chapter 31) buy plaquenil canada arthritis in lower back management, specifically moxifloxacin and levofloxacin buy discount plaquenil 200 mg online arthritis back, have an important place in the treatment of multidrug-resistant tuberculosis buy cheap plaquenil online arthritis rheumatology. Azithromycin may be preferred for patients at greater risk for drug interactions, since clarithromycin is both a substrate and inhibitor of cytochrome P450 enzymes. Bedaquiline is administered orally, and it is active against many types of mycobacteria. Elevations in liver enzymes have also been reported and liver function should be monitored during therapy. Drugs for Leprosy Leprosy (or Hansen disease) is uncommon in the United States; however, worldwide, it is a much larger problem (ure 32. Dapsone also is used in the treatment of pneumonia caused by Pneumocystis jirovecii in immunosuppressed patients. The drug is well absorbed from the gastrointestinal tract and is distributed throughout the body, with high concentrations in the skin. Adverse reactions include hemolysis (especially in patients with glucose-6-phosphate dehydrogenase deficiency), methemoglobinemia, and peripheral neuropathy. Its redox properties may lead to the generation of cytotoxic oxygen radicals that are toxic to the bacteria. Patients typically develop a pink to brownish-black discoloration of the skin and should be informed of this in advance. Eosinophilic and other forms of enteritis, sometimes requiring surgery, have been reported. Thus, erythema nodosum leprosum may not develop in patients treated with this drug. The patient received self-administered isoniazid, rifampin, pyrazinamide, and ethambutol. Two weeks following initiation of therapy, the patient is concerned that her urine is a “funny-looking reddish color. Rifampin (as well as rifabutin and rifapentine) and its metabolites may color urine, feces, saliva, sputum, sweat, and tears a bright red-orange. Patients should be counseled that this is an adverse effect which is not harmful, but can stain clothes and contact lenses. At his regular clinic visit, he complains of a “pins and needles” sensation in his feet. Isoniazid can cause peripheral neuropathy with symptoms including paresthesias, such as “pins and needles” and numbness. Which vitamin should have been included in the regimen for this patient to reduce the risk of neuropathy? Concurrent administration of pyridoxine (vitamin B ) prevents the neuropathic actions of6 isoniazid. The relative deficiency of pyridoxine appears to be due to the interference of isoniazid with its activation and enhancement of the excretion of pyridoxine. He has had no seizures in 5 years; however, upon return to clinic at 1 month, he reports having two seizures since his last visit. Rifampin is a potent inducer of cytochrome P450–dependent drug-metabolizing enzymes and may reduce the concentration of carbamazepine. Ethambutol and especially pyrazinamide both may increase uric acid concentrations and have the potential to precipitate gouty attacks. Pyrazinamide- and ethambutol-induced hyperuricemia may be controlled by use of antigout medications, such as xanthine oxidase inhibitors. He states that he feels fine, but now is having difficulty reading and feels he may need to get glasses. Optic neuritis, exhibited as a decrease in visual acuity or loss of color discrimination, is the most important side effect associated with ethambutol. Visual disturbances generally are dose related and more common in patients with reduced renal function. Her physician recently noticed that she appears confused and anxious, and has a slight tremor. Peripheral neuropathy is one of the most common adverse effects seen with the drug. Clofazimine is a phenazine dye and causes bronzing (the skin pigment color will change color, from pink to brownish-black), especially in fair-skinned patients. This occurs in a majority of patients, and generally is not considered harmful but may take several months to years to fade after discontinuing the medication. Overview Infectious diseases caused by fungi are called mycoses, and they are often chronic in nature. Mycotic infections may involve only the skin (cutaneous mycoses extending into the epidermis), or may cause subcutaneous or systemic infections. Unlike bacteria, fungi are eukaryotic, with rigid cell walls composed largely of chitin rather than peptidoglycan (a characteristic component of most bacterial cell walls). In addition, the fungal cell membrane contains ergosterol rather than the cholesterol found in mammalian membranes. These structural characteristics are useful targets for chemotherapeutic agents against mycoses. Fungi are generally resistant to antibiotics; conversely, bacteria are resistant to antifungal agents. The incidence of mycoses such as candidemia has been on the rise for the last few decades. Simultaneously, new therapeutic options have become available for the treatment of mycoses. In spite of its toxic potential, amphotericin B remains the drug of choice for the treatment of several life-threatening mycoses. Mechanism of action Amphotericin B binds to ergosterol in the plasma membranes of fungal cells. There, it forms pores (channels) that require hydrophobic interactions between the lipophilic segment of the polyene antifungal and the sterol (ure 33. The pores disrupt membrane function, allowing electrolytes (particularly potassium) and small molecules to leak from the cell, resulting in cell death. Antifungal spectrum Amphotericin B is either fungicidal or fungistatic, depending on the organism and the concentration of the drug. It is effective against a wide range of fungi, including Candida albicans, Histoplasma capsulatum, Cryptococcus neoformans, Coccidioides immitis, Blastomyces dermatitidis, and many strains of Aspergillus. Resistance Fungal resistance to amphotericin B, although infrequent, is associated with decreased ergosterol content of the fungal membrane. Amphotericin B is insoluble in water and must be coformulated with sodium deoxycholate (conventional) or artificial lipids to form liposomes. The liposomal preparations are associated with reduced renal and infusion toxicity but are more costly. Amphotericin B is extensively bound to plasma proteins and is distributed throughout the body.

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Moving the cut‐off to 1 in 100 may reduce the sen­ sitivity to 65% but also increase the specificity to 98% purchase 200 mg plaquenil with amex arthritis definition of. Not all women want to undergo screening so any pro­ These numbers are only hypothetical order 200mg plaquenil with mastercard arthritis bent fingers treatment, and the true effect gramme must recognize those wishing to ‘opt out’ purchase genuine plaquenil on line arthritis relief herbs. In this case cut‐off is therefore a compromise between high sensitivity these women can have an early scan but the fetal nuchal and high specificity. It is important to realize that using the same screening test with the same cut‐off in populations with different First‐trimester combined screening maternal age may result in different sensitivities and spe­ programmes cificities. The typi­ would probably be less confused with a suggested cut‐off cal changes associated with fetal Down’s syndrome are and a simple result of high or low risk. It is present in all fetuses in the late first are performed between 11 and 13 weeks of gestation, and early second trimester, and then gradually disap­ or at a crown–rump length of 45–84 mm. This starts with the estimation of the a priori the fetal nuchal skin but not fluid collection. The An individualized risk or post‐test odds is calculated most commonly used protocol is listed in Table 6. Moving the Most risk calculation algorithms provide adjustment for cut‐off will change the sensitivity and specificity at the these factors, to maximize the test performance. For example, assuming that the sensitivity oratories performing Down’s syndrome screening bio­ and specificity are 75% and 95%, respectively, at a cut‐off chemistry should have continuous internal and external of 1 in 250, moving the cut‐off to 1 in 400 may increase quality assurance programmes (such as the United the sensitivity to 85% but also reduce the specificity to Kingdom National External Quality Assessment Service, First Trimester Antenatal Screening 61 Table 6. Since the throughput of an accredited sonog­ the measurement must be taken at a gestation between 11 rapher is much lower than that of an accredited weeks and 13 weeks 6 days biochemical laboratory, an ultrasound‐only approach is the measurement must be taken when the fetal crown–rump more difficult to implement in populated‐based screen­ length is between 45 and 84 mm ing programmes. Only one individualized risk screenings to ensure that the biochemical laboratories is calculated when information from all markers is avail­ they are using are well qualified and have satisfactory able. Screening centres plicated logistic and administrative arrangements, higher should participate in appropriate quality assurance chance of dropout, and high chance of deviation from programmes. Variations of first‐trimester combined screening Special conditions the common variations include the following. For higher‐order increased frontomaxillary facial angle, the presence of pregnancies, no reliable data are available for adjust­ aberrant right subclavian artery and many others, have ment of biochemistry. Ultrasound‐based screening is been found to be associated with fetal Down’s syndrome. However, if the sec­ of this approach is that the test result is immediately ond sac contains a dead fetus, the serum marker levels available, and the assessment is fetus‐specific. It is par­ are affected unpredictably and no reliable adjustment ticularly useful in cases of multiple pregnancies, or a can be made. In fact, those with For those with additional abnormalities, specific absence of nasal bone generally have a normal exter­ genetic tests, such as Noonan syndrome tests, may be nal appearance. However, pregnant women can be reas­ nasal bone will become visible with increasing gesta­ sured that if a detailed second‐trimester scan is com­ tion. Although absence of nasal bone is a strong pletely normal, the chance of having a healthy normal marker for fetal Down’s syndrome, the great majority baby is about 96%. If the fetal karyotype is normal, there is no clinical significance associated with this sonographic Common questions and misconceptions marker. Most individuals will still the final decision whether to have a diagnostic test or be screened negative when combined with biochem­ not is wholly a decision of the couple, which is a balance istry, and have a normal baby. For those with 45X who survive, the major problems are ovarian failure, amenorrhoea, infertility and short stature. Therefore, a dedicated screening programme for this condition alone is not ● Clinicians have a duty to ensure that all sonographic justified. Since the majority of pregnancies with Amniocentesis is typically performed at or after 15 weeks trisomy 13 and 18 results in either spontaneous preg­ of gestation. Amniocentesis at earlier gestation is not nancy losses or early neonatal death, a dedicated screen­ recommended as a routine test because of higher associ­ ing programme solely for these conditions is not justified ated fetal loss rate, but may be offered in exceptional sit­ and is not cost‐effective. Trisomy 13 is also associated avoiding the placenta and the fetus whenever possible. These lous treatment in the laboratory to isolate pure chorionic common defects include central nervous system villi to avoid maternal contamination. The excess risk is Mosaicism occurs either because of post‐fertilization negligible after 11 weeks of gestation. In the majority of cell culture and full karyotyping, or rapid karyotyping, or cases, discordances between fetal and placental chromo­ both. The major disadvantage is the long reporting time, nario, there could be complete discordance in chromo­ 10–14 days or longer in most laboratories. However, the limitation of such practice major complications, such as bowel perforation, internal needs to be explained clearly to the couples concerned bleeding or haemorrhage, have been reported but are and they should be given a chance to request a full karyo­ extremely rare. The most commonly quoted figure for typing or chromosomal microarray if they are willing to amniocentesis‐related fetal loss is 1%, based on a single pay for that additional information. If rapid karyotyping confirms aneuploidy, karyotyping However, most recent studies have suggested a much should always be performed to determine if the aneu­ lower complication rate. For typical trisomy 21, the risk of recurrence is the procedure‐related risks of miscarriage for amniocen­ about 0. Robertsonian translocations, the recurrent risk is low for de novo events, and is 10–15% if maternally inherited. The posi­ In a normal pregnancy, both the placenta and the fetus tion of placenta and gestational sac, the fetal sex and the develop from the same fertilized egg. Therefore, theo­ presence of any markers of structural anomalies should retically, they should all have the same genetic composi­ be recorded clearly to avoid sampling of the same gesta­ tion. Mosaicism refers to the presence of two or more tional sac or placenta twice and to allow correct identifi­ population of cells with different genetic or chromo­ cation of the abnormal fetus when fetal reduction is somal constitutions in one individual. First Trimester Antenatal Screening 65 trophoblastic chromosomal constitutions are identical Summary box 6. It is a highly accurate screening test for fetal within a maternal plasma sample are sequenced, and then Down’s syndrome, with both sensitivity and specificity compared against the human genome to determine their over 99%. It is a relatively sentation of chromosome 21 is calculated, and compared simple test from the perspective of clinicians and preg­ against the expected value, or compared against the per­ nant women. It has been shown that the rela­ between genes and have no known biological effect. However, there is no evi­ still lead to a slight increase in the proportion of chromo­ dence that this approach provides any superiority in some 21 fragments in the maternal plasma. Such small performance as a screening test for fetal Down’s syn­ difference can be detected using the latest molecular drome. This method is not suitable in maternal plasma is from the trophoblastic cells of the for donor egg pregnancies, and may not be feasible in placenta. All relevant clinical data are either lacking or limited and published studies on cost‐effectiveness support the use of will not be elaborated further here. However, placental mosaicisms and lower levels of maternal mosa­ most published studies include pregnant subjects at 12 icisms than conventional screening tests, which could weeks or beyond.

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Pericardial fluid distributes anterior to the descending aorta on the parasternal long-axis view order cheap plaquenil on-line arthritis in dogs pain management, whereas pleural fluid is posterior to the aorta (Chapter 17 Video 17 generic 200 mg plaquenil visa arthritis starting in my fingers. Assessment for Pericardial Tamponade 2D echocardiography is useful for identifying findings consistent with pericardial tamponade (Chapter 17 Video 17 order online plaquenil rheumatoid arthritis knee icd 9. The right ventricle fills during diastole, so a collapse of the right ventricle during diastole is abnormal. The presence of chamber compression does not in itself indicate that there is tamponade physiology, nor does its absence rule it out. The presence of a swinging heart within large pericardial effusion is suggestive of pericardial tamponade, as is respirophasic variation of chamber size on M-mode obtained with the sample line placed through the right ventricle and left ventricle from the parasternal long- axis view. This is manifested with respirophasic variation of mitral valve and tricuspid valve diastolic inflow velocities. A greater than 30% respirophasic variation of mitral valve E wave velocity is characteristic of pericardial tamponade measured from the apical four-chamber view. Both 2D and Doppler echocardiography are helpful in identifying the patient with pericardial tamponade. Because there are sufficient confounders, echocardiographic findings, though helpful, should never be considered diagnostic. Pericardial tamponade remains a clinical diagnosis that may or may not be supported by echocardiographic findings. Guidance of Pericardiocentesis Ultrasonography is the preferred method for safe performance of pericardiocentesis when compared to fluoroscopic guidance. Because fluoroscopy is a 2D imaging technique, the position of the liver; the relationship of the needle to the myocardium; and the relationship of the lung to the needle trajectory is less certain than with ultrasonography imaging. Pericardiocentesis performed with ultrasonographic guidance uses the same principles as those of thoracentesis and paracentesis. The fluid collection is identified, and the operator determines a safe site, angle, and depth for needle insertion while avoiding injury to adjacent anatomic structures. The operator needs to be skilled at image acquisition and interpretation, because an injury to the myocardium or coronary artery is a catastrophic complication of pericardiocentesis (Chapter 17 Video 17. Site Selection and Preparation Using ultrasonography, the best site is determined by where the most fluid is found. The best site is often found on the lateral chest using the apical four-chamber view (Chapter 17 Video 17. When the effusion is predominately posterior in location, changing the patient’s body position may distribute the fluid into a more favorable position. The left lateral decubitus position may shift the fluid for an improved apical view, whereas a semisupine position may improve the subcostal view. The distance between the site of needle penetration into the pericardium and the heart is an important determinant of safety. The heart changes in size throughout the contractile cycle; cardiac “swinging” is a common phenomenon in severe tamponade, and the respirophasic translational movement of the heart is accentuated during the respiratory cycle. As a result, the thickness of the pericardial effusion may change a major extent during cardiac movement. A reasonable approach is to require at least 1 cm of fluid depth between the heart and the planned needle entry point into the pericardial fluid. Fortunately, aerated or consolidated lung is easy to identify and therefore easy to avoid (see Chapter 11 on Lung Ultrasonography). Color Doppler examination of the planned needle trajectory is mandatory when using the parasternal approach, in order to avoid the internal mammary vessels. A pleural effusion may occur concomitantly with the pericardial effusion, and may block access to the pericardial fluid. In this situation, it is best to drain the pleural effusion, and then to determine the best approach to the pericardial effusion. Using the calipers function, the depth of needle penetration is measured from a frozen image on the ultrasound screen. This reduces the period between the final scan and needle insertion, thereby allowing the operator to maintain recent memory of the angle of approach during needle insertion. The transducer with sterile sleeve is part of the field setup, thereby allowing scanning during the procedure, because the operator may choose to reconfirm site, depth, and angle for needle insertion following sterile site preparation. The angle of needle insertion for device insertion duplicates the angle of probe angle that identified the safe trajectory for needle insertion. Confirmation of wire or catheter insertion may be accomplished by direct visualization using 2D ultrasonography. If there is a question of proper position, several milliliters of agitated saline may be injected through the catheter to document catheter position. Similar to thoracentesis and paracentesis, pericardiocentesis does not require real-time guidance with ultrasonography. However, it is important to have the transducer with sterile cover in place for immediate use throughout the procedure, in case there is a need to rescan and document successful device insertion. Pitfalls: Common and Uncommon Skin compression artifact is a common problem, because it may cause an underestimation of the depth for needle insertion. This occurs in the obese or edematous patient when the operator pushes the probe into the skin while searching for a safe needle insertion site. Measurement of needle insertion distance is made while compressing the skin and underlying soft tissue. On removal of the probe pressure, the skin rebounds, such that the needle insertion is underestimated. During actual needle insertion, the operator is appropriately concerned, if there is no fluid obtained at the depth measured from the ultrasound machine screen. The solution to this problem is to rescan the patient, confirm the angle of insertion, and estimate the compression artifact more accurately. Another cause for difficulty is movement of the mark that designates the appropriate site for needle insertion. Skin is movable, so the injudicious application of force by the operator’s hand may shift the skin mark. The needle should be inserted at the mark without any tension applied to the area that might shift the mark position. Similarly, a “dry tap” might result from inaccurate duplication of the angle at which the transducer was held, or an inaccurate skin mark. Generally, it is easier to duplicate a perpendicular transducer angle than one that is acutely angled. This favors an anterior or lateral chest wall approach (if fluid is accessible), because the transducer is often perpendicular to the chest wall when scanning in these areas. Overly vigorous probing of the anterior costal cartilage (if using a parasternal approach) may also block the needle with cartilage, causing the operator to insert the needle too deeply, with potential complications to the patient. A large anterior pericardial fat pad may be mistaken for a pericardial effusion by the inexperienced ultrasonographer.

Bolus doses of propofol in the range of 1 to 2 mg per kg induce loss of consciousness within 30 seconds plaquenil 200mg fast delivery cure arthritis with diet. Maintenance infusion rates of 100 to 200 μg/kg/min are adequate in younger subjects to maintain general anesthesia cheap 200mg plaquenil arthritis reiki treatment, whereas doses should be reduced by 20% to 50% in elderly individuals cheap 200mg plaquenil overnight delivery arthritis in feet supplements. Propofol depresses ventricular systolic function and lowers afterload, but has no effect on diastolic function. In pigs, propofol caused a dose-related depression of sinus node and His-Purkinje system functions, but had no effect on atrioventricular node function or on the conduction properties of atrial and ventricular tissues. In patients with coronary artery disease, propofol administration may be associated with a reduction in coronary perfusion pressure and increased myocardial lactate production. Propofol decreases cerebral oxygen consumption, cerebral blood flow, and cerebral glucose utilization in humans and animals to the same degree as reported for thiopental and etomidate. Injection pain is less likely if the injection site is located proximally on the arm or if the injection is made via a central venous catheter. The emulsion used as the vehicle for propofol contains soybean oil and lecithin and supports bacterial growth; iatrogenic contamination leading to septic shock is possible. Accordingly, triglyceride levels should be monitored daily in this population whenever propofol is administered continuously for more than 24 hours. Not only does etomidate lack significant effects on myocardial contractility, but baseline sympathetic output and baroreflex regulation of sympathetic activity are well preserved. Etomidate depresses cerebral oxygen metabolism and blood flow in a dose-related manner without changing the intracranial volume–pressure relationship. Etomidate is particularly useful (rather than thiopental or propofol) in certain patient subsets: Hypovolemic patients, multiple trauma victims with closed head injury, and those with low ejection fraction, severe aortic stenosis, left main coronary artery disease, or severe cerebral vascular disease. Etomidate may be relatively contraindicated in patients with established or evolving septic shock because of its inhibition of cortisol synthesis (see below). Etomidate, when given by prolonged infusion, may increase mortality associated with low plasma cortisol levels [6]. Even single doses of etomidate can produce adrenal cortical suppression lasting 24 hours or more in normal patients undergoing elective surgery [7]. These effects are more pronounced as the dose is increased or if continuous infusions are used for sedation. Etomidate-induced adrenocortical suppression occurs because the drug blocks the 11β-hydroxylase that catalyzes the final step in the synthesis of cortisol. Since then, there have been several studies that have attempted to confirm or refute the safety of etomidate in critically ill patients, including those with sepsis. Unfortunately, some of these studies purportedly confirmed the danger of etomidate, whereas others support its continued use in patients with sepsis. Giving hydrocortisone to patients with septic shock may decrease overall mortality in patients who received etomidate for intubation as compared to other hypnotic agents [11]. Ketamine Description Ketamine induces a state of sedation, amnesia, and marked analgesia in which the patient experiences a strong feeling of dissociation from the environment. It is unique among the hypnotics in that it reliably induces unconsciousness by the intramuscular route. In the usual dosage, it decreases airway resistance, probably by blocking norepinephrine uptake that in turn stimulates beta-adrenergic receptors in the lungs. In contrast to many beta-agonist bronchodilators, ketamine is not arrhythmogenic when given to asthmatic patients receiving aminophylline. Ketamine may be safer than other hypnotics or opioids in unintubated patients because it depresses airway reflexes and ventilatory drive to a lesser degree. It may be particularly useful for procedures near the airway, where physical access and ability to secure an airway is limited (e. In patients with borderline hypoxemia despite maximal therapy, ketamine may be the drug of choice, because ketamine does not inhibit hypoxic pulmonary vasoconstriction. Because pulmonary hypertension is a characteristic feature of acute respiratory distress syndrome, drugs that increase right ventricular afterload should be avoided. In infants with either normal or elevated pulmonary vascular resistance, ketamine does not affect pulmonary vascular resistance as long as constant ventilation is maintained, a finding also confirmed in adults. Emergence phenomena following ketamine anesthesia have been described as floating sensations, vivid dreams (pleasant or unpleasant), hallucinations, and delirium. Pre- or concurrent treatment with benzodiazepines or propofol usually minimizes or prevents these phenomena [12]. Because ketamine increases myocardial oxygen consumption, there is risk of precipitating myocardial ischemia in patients with coronary artery disease if ketamine is used alone. On the other hand, combinations of ketamine plus diazepam, ketamine plus midazolam, or ketamine plus sufentanil are well tolerated for induction in patients undergoing coronary artery bypass surgery. Hypotension has been reported following ketamine administration in hemodynamically compromised patients with chronic catecholamine depletion. When administered with aminophylline, however, a clinically apparent reduction in seizure threshold is observed. Midazolam Description Although capable of inducing unconsciousness in high doses, midazolam is more commonly used as a sedative. Along with its sedating effects, midazolam produces anxiolysis, amnesia, and relaxation of skeletal muscle. Recovery from midazolam is prolonged in obese and elderly patients and following continuous infusion because it accumulates to a significant degree. In patients with renal failure, active conjugated metabolites of midazolam may accumulate and delay recovery. Although flumazenil may be used to reverse excessive sedation or ventilatory depression from midazolam, its duration of action is only 15 to 20 minutes. In addition, flumazenil may precipitate acute anxiety reactions or seizures, particularly in patients receiving chronic benzodiazepine therapy. Midazolam causes dose-dependent reductions in cerebral metabolic rate and cerebral blood flow, suggesting that it may be beneficial in patients with cerebral ischemia. Because of its combined sedative, anxiolytic, and amnestic properties, midazolam is ideally suited both for brief, relatively painless procedures (e. Ventilatory depression is even more marked and2 prolonged in patients with chronic obstructive pulmonary disease. Small (<10%) increases in heart rate and small decreases in systemic vascular resistance are frequently observed after administration of midazolam. Because recovery of cognitive and psychomotor function may be delayed for up to 24 hours, midazolam as the sole hypnotic may not be appropriate in situations where rapid return of consciousness and psychomotor function are a high priority. Dexmedetomidine Description Dexmedetomidine is the first α2-adrenoceptor agonist specifically marketed as a sedative. The primary site of its action as a sedative is in the locus coeruleus, where its effect is to mimic physiologic sleep [13]. In rats, dexmedetomidine produces analgesia at the spinal cord level by activating descending inhibitory pathways originating in the midbrain, thereby reducing pain impulses that would otherwise ascend in the cord. Dexmedetomidine produces intense sedation, although it cannot reliably produce amnesia, hypnosis, or general anesthesia [14]. As would be expected, dexmedetomidine lowers blood pressure and heart rate, and dramatic decreases have occasionally occurred in patients without preexisting cardiovascular disease. Higher doses of dexmedetomidine can produce an initial increase in blood pressure that is believed to result from stimulation of α2B-adrenoceptors.

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