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These groups include sulfhydryl discount 130 mg viagra extra dosage amex, carboxyl buy viagra extra dosage 200mg free shipping, cause bronchospasm and lung damage 130mg viagra extra dosage amex, including alve- amino buy 130mg viagra extra dosage, phosphoryl order viagra extra dosage 130mg with amex, and phenolic moieties. Asthmatic episodes can be exacerbated by sulfur of such groups with metals can lead to disruption of en- dioxide and sulfuric acid. Exposure to solvents is generally through in- halation of vapors, although direct skin contact also oc- Metal Selected features of toxicity curs. The concentration of solvent in air is determined by the vapor pressure of the solvent, the ambient tem- Arsenic Inorganic Diarrhea, hyperkeratosis, garlic breath, perature, and the effectiveness of ventilation systems. Once ab- Lead Peripheral and central neurotoxicity, kid- sorbed, they tend to concentrate in the brain, and CNS ney damage, anemia dysfunction is common at high exposures. Symptoms Mercury Pneumonitis, neuropsychiatric toxicity (ex- can range from confusion to unconsciousness. Solvents Elemental citability, emotional instability, depres- often undergo bioactivation and may cause systemic sion, insomnia), motor dysfunction (tremors) toxicity as a result of the formation of reactive interme- Organic Sensory neuropathy (dysarthia, paresthe- diates. Common targets for pesticides include insects, *Representative toxicities are presented; for most metals, other weeds (herbicides), fungi, and rodents. Nature of the toxici- pesticides often affects professional exterminators, agri- ties is dependent on level of exposure, whether the exposure is acute or chronic, and the route of exposure. In general, toxicity is related to the Insecticides form of the metal (inorganic, organic, or elemental), the route of exposure, and the route of excretion. This persistence allows toxic con- Solvents are generally classified as aliphatic or aro- centrations to build up in nontarget organisms. The respiratory distress syndrome appearing 1 or 2 weeks mechanism of inhibition is similar, but the reaction is re- after poisoning. Acute renal failure, liver toxicity, and gastroin- Herbicides and Rodenticides testinal damage are sequelae to diquat poisoning. Warfarin, a coumarin anticoagulant, is incorporated Herbicidal activity generally consists of interference into cornmeal for use as a rat poison. Thus, mam- sure results in sufficient inhibition of prothrombin syn- malian toxicity is generally low and not predictable thesis to cause fatal internal hemorrhage. In contrast, rodenticide target selectivity is not based on differences in biochemistry between humans and rodents but rather APPLICATIONS OF TOXICOLOGICAL on differences in physiology or behavior, especially PRINCIPLES feeding behavior. For example, an emetic may be in- cluded in a rodenticide formulation to promote vomit- Health professionals may be asked to provide an opin- ing in humans who accidentally consume the product; ion of the cause and effect relationship between expo- rodents do not have a vomit reflex. Certain noxyacetic acid (2,4-D) and 2,4,5-trichlorophenoxy- principles, including an assessment of temporality, acetic acid (2,4,5-T), were used in defoliating operations should be considered in such an evaluation. Do the 70 I GENERAL PRINCIPLES OF PHARMACOLOGY symptoms or disease follow the exposure within a properties, quantitative consideration of the total dose proper time frame? Was the dose high toxicological properties of the substance should be in- enough to produce health effects? Does the xenobiotic possess properties that can ity of alternate causes of the health problems must be logically be expected to cause the damage or disease in investigated carefully. If appropriate, drug side ation of the types of symptoms, injury, or disease that effects should be considered as a possible cause of the may occur after exposure can be predicted based on the adverse health effects. Lifestyle and avocations also available toxicological data or known biological activity must be evaluated. If the toxicity or disease does not fit ated by a thorough and frequently tedious review of into this known profile, a causal relationship between complete medical, occupational, and social records of the chemical and the problem should be questioned fur- the patient. Which of surrounded by chemical containers left by the pre- the following chemicals present in the workplace vious owners. On examination you noted bron- (A) Solvents used in dental adhesives choconstriction and profuse airway secretion, weak- (B) Fluoride used in oral rinses ness of the muscles, difficulty breathing, and CNS (C) Mercury used in the preparation of amalgams depression. A patient learned recently that she is about 5 weeks (A) Compound 1080 pregnant, but because she has been suffering from (B) Pyrethrin depression, she asks her physician for a prescription (C) Parathion for a drug to treat this problem. You are a staff physician at a major chemical manu- concerned that the fetus is at risk for toxicity from facturing company. What is the most crew has complained of being light-headed and likely adverse outcome if the woman began taking tired occasionally at work and that if it occurs, it the drug at this time? Exposure to one such pollutant, (B) Insecticide packaging area carbon monoxide, can result in which of the follow- (C) Label printing area ing conditions?

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Ashwaganda is celebrated as an adaptogen that will do all of the following: • boost strength • increase stamina and relieve fatigue • enhance sexual energy and rejuvenate the body • strengthen the immune system • speed recovery from chronic illness • strengthen sickly children • soothe and calm without producing drowsiness • clarify the mind and improve memory • slow the aging process The powdered root of ashwaganda is normally used for whole body tonics that improve general health and well being buy viagra extra dosage 120 mg. For most of these uses cheap viagra extra dosage 130 mg free shipping, ashwaganda is prepared as part of a rasayana generic viagra extra dosage 130mg fast delivery, or rejuvenating formula that contains many different herbs discount viagra extra dosage 150mg mastercard. The use of ashwaganda in multi-herb formulas makes it difficult for modern laboratory scientists to assess its specific effects as an adaptogen purchase viagra extra dosage 200mg free shipping. Disease-specific uses In addition to the whole body effects of ashwagan- da, the plant is used for many other specific conditions. Some researchers • chronic fatigue syndrome report that ashwaganda makes tumors more sensitive to • colds chemotherapy and radiation therapy without increasing side effects caused by these therapies. One drawback to arriv- • hemorrhoids ing at conclusive evidence in humans is that most people • hypertension take ashwaganda as part of a multi-herb tonic, making it • hypoglycemia difficult for researchers to attribute specific actions to any one particular component of the formula. Scientific • leprosy interest in ashwaganda is high, and laboratory studies • nausea continue to be performed. The usual cap- • tumors sule dosage is 300 mg of powdered root, taken once or twice a day. Ashwaganda tea can be made by boiling the roots external use, as it is thought to have antibacterial and an- for about 15 minutes. It is used to prevent infection in skin The fruit is often chewed to assist in convalescence from wounds and to treat skin diseases, including psoriasis, prolonged illness. The dose recommended depends on both the body Laboratory studies type of the person and the nature of his or her illness. University and medical researchers have been study- ing ashwaganda since at least the early 1960s. Chemical Precautions analysis shows that ashwaganda contains compounds Ashwaganda is not recommended for use by pregnant thought to have anti-tumor, anti-inflammatory, and anti- women. This effect has not been seen in The most rigorous laboratory tests have been done humans, but using the herb in moderation may be prudent. It will enhance the effect of any other cen- mans in the same way that it affects rodents. People operating consistent anti-inflammatory, anti-fungal, anti-stress, and heavy equipment or working in situations that require a sedative effects. In one well-known study, extracts of high level of alertness should keep this in mind when ashwaganda root were shown to significantly increase using ashwaganda. Side effects Experimenters have had mixed results in demon- strating anti-tumor and anti-cancer properties of ashwa- No undesirable side effects have been reported with ganda. GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 135 OTHER KEY TERMS “Withania somnifera aphrodisiaca. Decoction—A liquid extract of a herb, made by simmering or boiling the herb in water, then straining out the plant parts. Poultice—A soft moist mass of cloth, usually con- Asthma taining herbs, applied warm or hot to relieve pain or speed healing in a part of the body. Definition Psoriasis—A skin disease characterized by dry, Asthma is a chronic inflammatory disease of the air- scaling, whitish patches. This inflammation periodically causes Scabies—A contagious skin disease caused by a the airways to narrow, producing wheezing and breath- mite and characterized by small, raised, red, very lessness sometimes to the point where the patient gasps itchy pinprick bumps on the skin. This obstruction of the air flow either stops spon- Tincture—An alcohol-based extract of a herb pre- taneously or responds to a wide range of treatments. Description Vegan—Food products made without any animal Between 16 and 17 million Americans have asthma products such as meat, milk, or eggs. Blacks, Hispanics, American Indians, and Alaskan na- tives had higher rates of asthma-control problems than whites or Asians in the United States. Interactions The changes that take place in the lungs of asthmat- ics make their airways (the bronchi and the smaller bron- There are few, studies of how ashwaganda interacts chioles) hyper-reactive to many different types of stimuli with traditional Western medicines. In an asthma attack, the many years in combination with other Ayurvedic herbs muscle tissue in the walls of the bronchi go into spasm, without incident. Ayurvedic practitioners believe that and the cells that line the airways swell and secrete when ashwaganda is combined with other herbs in reju- mucus into the air spaces.

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Absorbable su- tures can be thought of as temporary; these include plain gut; chromic gut; and synthetic materials such as polyglactin 910 (Vicryl) discount viagra extra dosage 120mg on line, polyglycolic acid (Dexon) purchase viagra extra dosage 120mg visa, and poliglecaprone (Monocryl) purchase viagra extra dosage 130 mg with mastercard. These are resorbed by the body when left internally after a variable period (Table 17–1) generic viagra extra dosage 150 mg amex. Nonabsorbable su- tures can be thought of as “permanent” unless they are removed; these include silk order 120mg viagra extra dosage amex, stainless steel wire, polypropylene (Prolene), and nylon (see Table 17–1). Cutting nee- dles are used for tough tissues such as skin, and tapered needles are used for more delicate tissues such as the intestine. SUTURING PROCEDURE The following guidelines cover the repair of lacerations in the emergency setting. The choice of appropriate suture material is based on many factors, including location, extent of the laceration, strength of the tissues, and preference of the physician. for Terms of Use T A B L E 1 7 – 1 C o m m o n S u t u r e M a t e r i a l s A B S O R B A B L E S u t u r e ( B r a n d N a m e ) D e s c r i p t i o n T e n s i l e S t r e n g t h * A b s o r b e d † C o m m o n U s e s F a s t c a t g u t T w i s t e d / F a s t 3 – 5 d 3 0 d F a c i a l l a c e r a t i o n s i n c h i l d r e n a b s o r p t i o n P l a i n c a t g u t T w i s t e d / R a p i d l y 7 – 1 0 d 7 0 d V e s s e l l i g a t i o n, s u b c u t a n e o u s a b s o r b a b l e t i s s u e s C h r o m i c c a t g u t T w i s t e d / a b s o r b a b l e 1 0 – 1 4 d 9 0 d M u c o s a P o l y g l y c o l i c a c i d B r a i d e d / A b s o r b a b l e 1 4 – 2 1 d 6 0 – 9 0 d G I, s u b c u t a n e o u s t i s s u e s ( D e x o n ) P o l y g l a c t i n 9 1 0 ( V i c r y l B r a i d e d / A b s o r b a b l e 5 d 4 2 d S k i n r e p a i r n e e d i n g r a p i d R a p i d e ) a b s o r p t i o n P o l y g l a c t i n 9 1 0 ( V i c r y l ) B r a i d e d / A b s o r b a b l e 2 1 d 5 6 – 7 0 d B o w e l, d e e p t i s s u e P o l i g l e c a p r o n e 2 5 M o n o f i l a m e n t / 7 – 1 4 d 9 1 – 1 1 9 d S k i n, b o w e l ( M o n o c r y l ) A b s o r b a b l e P o l y d i o x a n o n e ( P D S ) M o n o f i l a m e n t / 2 8 d 6 m o F a s c i a, v e s s e l a n a s t o m o s i s A b s o r b a b l e P o l y g l y c o n a t e ( M a x o n ) B r a i d e d / A b s o r b a b l e 2 8 d 6 m o G I, m u s c l e, f a s c i a P a n a c r y l B r a i d e d / A b s o r b a b l e > 6 m o > 2 4 m o F a s c i a, t e n d o n s ( c o n t i n u e d ) T A B L E 1 7 – 1 ( C o n t i n u e d ) N O N A B S O R B A B L E S u t u r e ( B r a n d N a m e ) D e s c r i p t i o n C o m m o n U s e s N y l o n ( D e r m a l o n, M o n o f i l a m e n t S k i n, d r a i n s E t h i l o n N y l o n ( N u r o l o n ) B r a i d e d T e n d o n r e p a i r P o l y e s t e r ( E t h i b o n d, B r a i d e d C a r d i a c, t e n d o n T y c r o n ) P o l y p r o p y l e n e M o n o f i l a m e n t V e s s e l, f a s c i a, s k i n ( P r o l e n e ) S i l k G I, v e s s e l l i g a t i o n, d r a i n s S t a i n l e s s s t e e l M o n o f i l a m e n t F a s c i a, s t e r n u m * W h e n s u t u r e lo o s e s a p p r o x i m a t e ly 5 0 % s t r e n g t h. Skin is usually best closed by using interrupted sutures placed with good approximation with a minimum amount of tension or by a running subcuticular suture. Suture marks (“tracks”) are the result of excessive tension on the tissue or leaving the su- tures in for too long. Thus, the length of time and the technique used are probably more im- portant in determining the final result than is the suture used in most cases. Remove all foreign materials and devitalized tissues by sharp excision (debridement). Clean the wound with plain saline (antiseptic solutions used on wound cleansing should be discouraged because they can be toxic to viable cells). A useful technique in- volves irrigation with at least 200 mL of saline through a 35-mL syringe and a 19- gauge needle. In general, do not suture infected or contaminated wounds, lacerations more than 6–12 h old (24 h on the face), missile wounds, and human or animal bites without surgical consultation. Lidocaine and the other local anesthetic agents are available with epinephrine (1:100,000 or 1:200,000) added to produce local vasoconstriction that prolongs the anesthetic effect and helps decrease systemic side effects and bleeding. Epinephrine should be used with caution, particularly in patients with a history of hypertension, and should not be used on the digits, toes, or penis. When using local anesthetics, always aspirate before injecting to prevent intravascular injection of the drug. Symptoms of toxicity from local anesthetics includes twitching, restlessness, drowsiness, light-headedness, and seizures. Use fine-toothed forceps (Adson or Brown-Adson) with gentle pressure to handle skin edges to decrease trauma. The toothed forceps are less traumatic to the skin than other forceps with flat surfaces that may crush the tissue. On the face, simply covering with antibiotic ointment is often used, especially around the eyes or mouth. Finally, keep tetanus and antibacterial prophylaxis in mind, particularly for contami- nated wounds (Table 17–3, page 350). Critical to any suturing technique is making certain that the edges of the wound closely approximate without overlapping or inversion and that there is no tension. Remember “approximation without strangulation” or eversion T A B L E 1 7 – 2 L o c a l A n e s t h e t i c C o m p a r i s o n C h a r t f o r C o m m o n l y U s e d I n j e c t a b l e A g e n t s M a x i m u m D o s e P r o p r i e t a r y V o l u m e i n A g e n t N a m e s O n s e t D u r a t i o n m g / k g 7 0 - k g A d u l t * B u p i v a c a i n e M a r c a i n e, 7 – 3 0 m i n 5 – 7 h 3 7 0 m L o f S e n s o r i c a i n e 0. Source: Based on guidelines from the Centers for Disease Control and reported in MMWR. SURGICAL KNOTS There are two basic knot-tying techniques: the handed tie and the instrument tie. The two- handed tie is easier to learn than the one-handed tie, although one-handed ties may be more useful in certain situations (eg, with deep cavities or where speed is essential). Some pro- 17 grams frown on one-handed tying, especially for physicians early in their careers. Instru- ment ties are more useful for closing skin and for emergency room laceration repair.

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The bacitracins are not absorbed from the BACITRACIN gastrointestinal tract following oral administration discount viagra extra dosage 130 mg on-line. Structure and Mechanism of Action Clinical Uses Bacitracin is a mixture of polypeptide antibiotics pro- Bacitracin is highly active against staphylococci cheap viagra extra dosage 130 mg with visa, Strep- duced by Bacillus subtilis generic viagra extra dosage 150mg free shipping. Its high degree of thiazolidine nucleus attached through L-leucine to a pep- activity against the group A streptococci is used in the tide composed of both D- and L-amino acids generic viagra extra dosage 200mg with visa. Hydro- intravenous (IV) administration cheap 150 mg viagra extra dosage with amex, and about 55% is cortisone has been added to the combination for its an- bound to serum protein. Bacitracin preparations are ef- trough concentration between 5 and 15 g/mL, and the fective in the treatment of impetigo and other peak should stay below 60 g/mL to avoid side effects. Bacitracin has been used with limited success for avoid toxicity or ineffective treatment, especially in pa- eradication of S. Pediatric oncology pa- of serious nephrotoxicity, the parenteral use of baci- tients with normal renal function may require van- tracin is not justified. Similar studies in adult patients with hematological malignancies have suggested a larger GLYCOPEPTIDES: VANCOMYCIN dosage requirement as well, owing to an increased vol- AND TEICOPLANIN ume of distribution. After IV administration, vancomycin diffuses into serous cavities and across inflamed but not normal Structure and Mechanism of Action meninges. It can be used in the treatment of meningitis Vancomycin (Vancocin) is a complex tricyclic glycopep- with susceptible organisms. It is also given via ventricu- tide antibiotic produced by Streptomyces orientalis, loatrial or ventriculoperitoneal shunts when these be- while teicoplanin (Targocid) is derived from Actino- come infected. Teicoplanin has Renal excretion is predominant, with 80 to 90% of two major components: a phosphoglycolipid (A1) and an administered dose eliminated in 24 hours. Teicoplanin, like vancomycin, is not absorbed from They bind to the terminal carboxyl group on the D- the intestinal tract. Peak plasma levels are achieved alanyl-D-alanine terminus of the N-acetylglucosamine- about 2 hours after intramuscular administration. The N-acetylmuramic acid peptide and prevent polymeriza- drug distributes widely in tissues; plasma protein binding tion of the linear peptidoglycan by peptidoglycan is about 90%. Antimicrobial Spectrum The glycopeptides are narrow-spectrum agents that are Clinical Uses active against gram-positive organisms. Like van- comycin, teicoplanin is bacteriostatic against staphylo- Vancomycin and teicoplanin display excellent activity cocci, streptococci, and enterococci. Gram-positive against staphylococci and streptococci, but because of rods, such as Bacillus anthracis, Corynebacterium diph- the wide availability of equally effective and less toxic theriae, Clostridium tetani, and Clostridium perfringens, drugs, they are second-line drugs in the treatment of most are also sensitive to the glycopeptides. As antistaphylococcal agents they are less tides are not effective against gram-negative rods, my- effective than -lactam cephalosporin antibiotics, such cobacteria, or fungi. They have attained much wider use in recent years as a consequence of the emer- gence of methicillin-resistant S. In use of intravascular catheters and in patients with peri- neutropenic patients and others with altered gastroin- tonitis who are on continuous ambulatory peritoneal testinal mucosa with denudation, significant oral ab- dialysis. The combination of vancomycin and either Except for the treatment of staphylococcal enterocolitis streptomycin or gentamicin acts synergistically against and pseudomembranous colitis, it is administered intra- enterococci and is used effectively for the treatment or 554 VI CHEMOTHERAPY prevention of enterococcal endocarditis. Vancomycin in oral form can also be the effects of bacterial lipopolysaccharide (LPS) of used in patients in whom C. These antibi- not as effective as the -lactams, but its actions are similar otics also are toxic to mammalian cells. An increased prevalence of MRSA has resulted in a Antimicrobial Spectrum greater use of vancomycin for this disorder. High-grade resistance of pneumococci to penicillin may also neces- The polymyxins are active against facultative gram-neg- sitate vancomycin therapy. These strains are generally resistant to a Absorption, Distribution, and Excretion number of other antibiotics, such as penicillin, ampi- Polymyxin B and colistin are not well absorbed from cillin, and gentamicin, which limits treatment options. An intramuscular injection The possibility of transferring these resistance determi- of the polymyxins results in high drug concentrations in nants to other gram-positive organisms, like S. It is therefore necessary to limit the use enter the cerebrospinal fluid (CSF), even in the pres- of vancomycin to treatment of serious infections caused ence of inflammation. Elimination is decreased in patients with renal Adverse Effects disease, and drug accumulation can lead to toxicity.

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