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E. Bogir. Coleman College.

Someone who dropped out of the sessions half-way through and has not been seen since? These questions need to be answered to derive a baseline number for the success rate purchase indocin 50 mg fast delivery arthritis in big dogs. Methods other than self-report exist to assess smoking behaviour discount indocin 50 mg with visa arthritis pain relief nz, such as carbon monoxide in the breath, cotinine in the saliva. In order for success rates to be calculated, comparisons need to be made between different types of intervention (e. These groups should obviously be matched for age, gender, ethnicity and smoking behaviour. What about stage of change (contemplation versus precontemplation versus preparation)? What about other health beliefs such as self-efficacy, costs and benefits of smoking? For interventions aimed at changing drinking behaviour, these problems include: s What is the desired outcome of any intervention? Should the experts impose their view of success on a drinker, or should success be determined by them? Marlatt and Gordon (1985) developed a relapse prevention model of addictions, which specifically examined the processes involved in successful and unsuccessful cessation attempts. The relapse prevention model was based on the following concept of addictive behaviours: s Addictive behaviours are learned and therefore can be unlearned; they are reversible. Marlatt and Gordon examined the processes involved in the progression from abstinence to relapse and in particular assessed the mechanisms that may explain the transition from lapse to relapse (see Figure 5. If an individual sets total abstinence as the goal, then this stage represents the target behaviour and indicates a state of behavioural control. A high-risk situation is any situation that may motivate the individual to carry out the behaviour. Such situations may be either external cues, such as someone else smoking or the availability of alcohol, or internal cues, such as anxiety. Research indicates that the most commonly reported high-risk situations are negative emotions, interpersonal conflict and social pressure. This is in line with social learning theories, which predict that internal cues are more problematic than external cues. Once exposed to a high-risk situation the individual engages the coping strategies. Such strategies may be behavioural, such as avoiding the situation or using a substitute behaviour (e. According to previous experience the individual will either have positive outcome expectancies if the behaviour is carried out (e. Marlatt and Gordon (1985) argue that when exposed to a high-risk situation, if an individual can engage good coping mechanisms and also develop negative outcome expectancies, the chances of a lapse will be reduced and the individual’s self-efficacy will be increased. However, if the individual engages poor coping strategies and has positive outcome expectancies, the chances of a lapse will be high and the individual’s self-efficacy will be reduced. The abstinence violation effect The transition from initial lapse to full blown relapse is determined by dissonance conflict and self-attribution. Dissonance is created by a conflict between a self-image as someone who no longer smokes/drinks and the current behaviour (e. This conflict is exacerbated by a disease model of addictions, which emphasizes ‘all or nothing’, and minimized by a social learning model, which acknowledges the likelihood of lapses. This internal attribution may lower self-efficacy, thereby increasing the chances of a full-blown relapse. Marlatt and Gordon developed a relapse prevention programme based on cognitive behavioural techniques to help prevent lapses turning into full-blown relapses. This programme involved the following procedures: s self-monitoring (What do I do in high-risk situations? How these procedures relate to the different stages of relapse is illustrated in Figure 5. Therefore, an addiction to cigarettes is seen as separate and different to an addiction to alcohol. However, from a social learning perspective, it is possible to examine similarities between behaviours and to apply similar processes to the initiation, maintenance, cessation and relapse of behaviours such as exercise, sex, gambling and eating (e. Research has examined these behaviours independently of each other and, in addition, has also assessed the associations between them.

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These pairs of bases order indocin 25mg on-line arthritis relief dogs, which are referred to as complementary base pairs indocin 75mg low price arthritis deformed feet, form the internal structure of the helix. They are hydrogen bonded in such a manner that their flat structures lie parallel to one another across the inside of the helix. Its outer surface has two grooves, known as the minor and major grooves respectively, which act as the binding sites for many ligands. Interchanging of either the bases of a base pair and/or base pair with base pair does not affect the geometry of this structure. Reproduced by permission of Prentice Hall from Chemistry for Pharmacists and the Life Sciences by G Thomas structures are cyclic, and these compounds are also coiled and twisted into specific shapes. These shapes are referred to as supercoils, supertwists and superhelices as appropriate. The process is known as replication and occurs when cell division is imminent (Figure 1. It is believed to start with the unwinding of the double helix starting at either the end or more usually in a central section, the separated strands acting as templates for the formation of a new daughter strand. New individual nucleotides bind to these separated strands by hydrogen bonding to the complementary parent nucleotides. However, both daughter strands are formed at the same time in the 5’ to 3’ direction. This means that the daughter strand is, in theory, an exact replica of the parent strand. However, this smooth growth is not possible for the daughter strand that started from the 5’ of the parent strand. This strand, known as the lagging strand, is formed in a series of sections, each of which is still grows in the 5’ to 3’ direction. In this case unwinding continues in both directions until the complete molecule is duplicated. This code controls the production of the peptides and proteins required by the body. A number of medical conditions have been attributed to either the absence of a gene or the presence of a degenerate or faulty gene in which one or more of the bases in the sequence have been changed. Exon Intron Exon Intron Exon 240 120 500 240 250 bases bases bases bases bases Figure 1. The Human Genome Project, initiated in 1990, has identified all the genes that occur in humans and also the sequence of bases in these genes. These chains often form single stranded hairpin loops separated by short sections of a distorted double helix formed by hydrogen bonded comple- mentary base pairs (Figure 1. It proceeds smoothly with the 3’ end of the new strand bonding to the 5’ end of the next nucleotide (Fig. This information is in the form of a series of exons and introns complementary to those found in the parent gene. The introns are removed and the remaining exons are spliced together to form a continuous sequence of bases that are complementary to the gene’s exons. It binds to the ribosome, where it dictates the order in which the amino acids are linked to form the structure of the protein This information is carried in the form of a trinucleotide code known as a codon. The nature of a codon is indicated by a sequence of letters corresponding to the 5’ to 3’ order of bases in the trinucleotide. The strand is folded and twisted to form a series of single stranded loops separated by sections of double helix, which is believed to be formed by hydrogen bonding between complementary base pairs. The general pattern of loops and helixes is very similar between species even though the sequences of nucleotides are different. Describe the essential differences between (a) plasmalogens and sphingomye- lins and (b) cerebrosides, sulphatides and gangliosides. Describe the most common conformations of the rings found in saturated steroid ring systems. The discovery of a new drug requires not only its design and synthesis but also the development of testing methods and procedures, which are needed to establish how a substance operates in the body and its suitability for use as a drug.

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Pharmacokinetics Adverse effects Diamorphine is hydrolysed (deacetylated) rapidly to form 6-acetylmorphine and morphine buy indocin 75mg overnight delivery arthritis in upper back symptoms, and if given by mouth owes These differ from pure opioid agonists generic 25 mg indocin patterns of arthritis medication use in a community sample, including less respira- its effect entirely to morphine. This abdominal pain, hypotension, psychiatric reactions, as well as accounts for its rapid effect when administered intravenously seizures and withdrawal syndromes have been reported. Its main use is by mouth to replace causes similar respiratory depression, vomiting and gastro- morphine or diamorphine when these drugs are being with- intestinal smooth muscle contraction to morphine, but does drawn in the treatment of drug dependence. It once daily under supervision is preferable to leaving addicts to produces little euphoria, but does cause dependence. Pethidine is sometimes used in obstetrics abuse are related to parenteral administration, with its attend- because it does not reduce the activity of the pregnant uterus, ant risks of infection (e. The object is to reduce craving by (common to all opioids) is of particular concern in obstetrics, occupying opioid receptors, simultaneously reducing the as gastric aspiration is a leading cause of maternal morbidity. The slower onset follow- ing oral administration reduces the reward and reinforcement Pharmacokinetics of dependence. The relatively long half-life reduces the inten- Hepatic metabolism is the main route of elimination. Its effect has a rapid onset and if a satisfactory Codeine is the methyl ether of morphine, but has only about response has not been obtained within three minutes, the dose 10% of its analgesic potency. As a result, it has been used for many Naloxone is used in the management of the apnoeic infant years as an analgesic for moderate pain, as a cough suppres- after birth when the mother has received opioid analgesia sant and for symptomatic relief of diarrhoea. Naltrexone is an orally active opioid antagonist that is used in Pharmacokinetics specialized clinics as adjunctive treatment to reduce the risk of relapse in former opioid addicts who have been detoxified. Such Free morphine also appears in plasma following codeine patients who are receiving naltrexone in addition to supportive administration, and codeine acts as a prodrug, producing a therapy, are less likely to resume illicit opiate use (detected by low but sustained concentration of morphine. However, the drop-out rate is high due to non-com- codeine to morphine, and consequently experience less, if any, pliance. Its use is not recom- has not been extensively studied in non-addicts, and most of the mended. It antagonizes full agonists and can precipitate pain and cause The relief of pain in terminal disease, usually cancer, requires withdrawal symptoms in patients who are already receiving skilful use of analgesic drugs. For mild Like other opiates, buprenorphine is subject to considerable pain, paracetamol, aspirin or codeine (a weak opioid) or a pre-systemic and hepatic first-pass metabolism (via glu- combined preparation (e. It is important to use a large enough dose, if necessary given intravenously, to relieve the pain completely. Minor alterations in the chemical structure of opioids result in • It is much easier to prevent pain before it has built up than drugs that are competitive antagonists. This a smoother control of pain, without peaks and troughs of causes fear, which makes the pain worse. This vicious analgesia, which can still be supplemented with shorter circle can be avoided by time spent on pre-operative duration morphine formulations for breakthrough pain. Regular use of mild analgesics can be highly laxatives, such as senna, and/or glycerine suppositories should effective. Spinal administration ketorolac, which can be given parenterally) can have of opioids is not routinely available, but is sometimes useful for comparable efficacy to opioids when used in this way. Opioids are effective in visceral pain Key points and are especially valuable after abdominal surgery. Breakthrough pain can be treated by additional parenteral morphine is often needed initially, followed oral or parenteral doses of morphine. They are only required by a minority of – anti-emetics: prochloperazine, metoclopramide; patients, but should be available without delay when – laxative: senna. When • Prevention of post-operative pain is initiated during patients are provided with devices that enable them to control anaesthesia (e. The doctor – relief of left ventricular failure; on call prescribes morphine 10mg subcutaneously, four- – miosis (pupillary constriction); hourly as needed, and the pain responds well to the – suppression of cough (‘antitussive’ effect); first dose, following which the patient falls into a light – constipation; sleep. The Senior – for this reason gives a rapid ‘buzz’; House Officer was concerned not to cause respiratory depres- – may therefore have an even higher potential for sion, so did not prescribe regular analgesia, but unfortunately abuse than morphine; neither medical nor nursing staff realized that the patient – is more soluble than morphine.

Hypercalcaemia increases contractility; calcium antagonists can reduce excitability buy indocin 50 mg overnight delivery rheumatoid arthritis juvenile. Catecholamines increase depolarisation (increase duration of phase 4) in pacemaker cells order 25 mg indocin with visa arthritis in lower back and pelvis, hence causing tachycardia. Vagal stimulation (mediated through acetylcholine) slows depolarisation (decreases slope in phase 4) of pacemaker cells, causing bradycardia. Atrial/junctional dysrhythmias Sinus arrhythmia This occurs when inspiration increases intrathoracic pressure sufficiently to cause parasympathetic (vagal) stimulation, slowing sinoatrial rate; on expiration, the faster rate is restored. It occurs mainly in children and younger people; high ventilator tidal volumes may cause sinus arrhythmia. Bradycardic children should be given oxygen urgently (unless there are other obvious causes for bradycardia). Obvious causes should be removed, so that oxygen should be optimised (on avoiding oxygen toxicity, see Chapter 18). Drugs include ■ anticholinergics (atropine) block parasympathetic stimulation ■ sympathetic stimulants (adrenaline, isoprenaline). Severe refractory sinus bradycardia may necessitate pacing (temporary or permanent). Young children often have intrinsic (normal) rates exceeding 100 contractions/minute. Cardiac output is usually adequate with rates below 180 beats/min (bpm) provided venous return remains adequate, although rates above 140 bpm are usually treated. Tachycardia reduces diastolic time, and so reduces coronary artery filling time and left ventricular muscle oxygen supply, while increasing left ventricular workload and myocardial oxygen demand. Supraventricular tachycardia This severely compromises both cardiac output (rates of 160–250 (Cohn & Gilroy- Doohan 1996)) and myocardial oxygenation, usually necessitating treatment. Intensive care nursing 202 Ectopics Ectopic foci may be ■ atrial ■ junctional ■ ventricular Impulses may be premature (before expected impulses) or escape (expected complexes are absent, failing to overpace lower and slower foci, so ectopic impulses ‘escape’). Premature complexes may suppress underlying rhythms; escape rhythms are inherently slower than underlying sinus rhythm. Atrial ectopics These are premature electrical beats initiated in the atrial muscle outside the sinoatrial node. Treatment is usually initiated when there are more than six atrial ectopics per minute. P waves are absent, but ‘quivering’ may cause ‘f’ waves (Cohn & Gilroy-Doohan 1996)— fine, but visible, waves, suggesting some coordinated conduction and so good prognosis. Atrial flutter This is caused by macro re-entry circuits in the atrium (Creamer & Rowlands 1996), creating regular, but rapid, atrial impulses, P waves having distinctive saw tooth shapes (F waves). Atrial rate is often 300 (Creamer & Rowlands 1996), with regular atrioventricular block (usually 2:1). Increased atrioventricular conduction can cause palpitations, dyspnoea and potentially life- threatening tachycardias. Rapid atrial rates are normally blocked, so ventricular response remains normal, but any reduction in block causes supraventricular tachycardia. Cardioversion may restore stability, but curing the underlying problem necessitates ablation of aberrant pathways. Catheterisation and surgery share similar success rates, but catheterisation reduces length of stay, trauma and cost (Shih et al. Pacemaker rates slow as conduction pathways progress (‘lower is slower’); higher impulses normally overpace, lower impulses only escaping when higher impulses are absent. Intrinsic junctional rate is usually 40–60, although acceleration can occur (Cohn & Gilroy-Doohan 1996). Oedema from cardiac surgery often causes transient junctional rhythms (hence epicardial pacing wires). If bradycardia becomes symptomatic, treat as above (atropine, adrenaline, pacing). Formerly type 1 was named Mobitz type 1 or Wenkebach phenomenon; type 2 was called Mobitz type 2; these names, although technically obsolete, still persist in practice. Drugs used include: ■ atropine ■ isoprenaline (when unresponsive to atropine) If symptoms persist pacing may be needed.