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There are receptors found on cell membranes or within a cell which natural hormones and neurotransmitters can bind to and cause a specific effect discount antivert 25 mg with mastercard medications derived from plants. Drugs can bind to these sites in ways that either cause an effect (agonists) or block an effect (antagonists) cheap 25 mg antivert overnight delivery symptoms during pregnancy. A partial agonist does not produce a full effect – if there is a high concentration of partial agonists, they may bind to a receptor site without producing an effect. However, in doing so, they may block that receptor to other agonists and so act as an antagonist – so partial agonists have a ‘dual’ action. One action of histamine is to stimulate 130 Action and administration of medicines gastric secretion. Ranitidine can block the action of histamine, reducing gastric acid secretion by about 70 per cent. Another way in which drugs can act by interfering with cell processes is by affecting enzymes – enzymes can promote or accelerate biochemical reactions and the action of a drug depends upon the role of the enzyme it affects. For example, uric acid is produced by the enzyme xanthine oxidase, which is inhibited by allopurinol. High levels of uric acid can produce symptoms of gout and allopurinol works by reducing the synthesis of uric acid. For example, thiazide diuretics reduce the reabsorption of sodium by the kidney tubules, resulting in an increased excretion of sodium and hence water. Cancer drugs act by interfering with cell growth and division; antibiotics act by interfering with the cell processes of invading bacteria and other micro-organisms. We will look at two of the most common routes of administration: oral and parenteral. Administration of medicines 131 Oral administration For most patients, the oral route is the most convenient and acceptable method of taking medicines. Drugs may be given as tablets, capsules or liquids; other means include buccal or sublingual administration. The disadvantages are that: • absorption can be variable due to: • presence of food; • interactions; • gastric emptying; • there is a risk of ‘first-pass’ metabolism; • there is a need to remember to take doses. As mentioned before, a major disadvantage of the oral route is that drugs can undergo ‘first-pass’ metabolism; taking medicines by the sublingual or buccal route avoids this as the medicines enter directly into the bloodstream through the oral mucosa. With sublingual administration the drug is put under the tongue where it dissolves in salivary secretions; with buccal administration the drug is placed between the gum and the mucous membrane of the cheek. If viewed from above, the level may appear higher than it really is; if viewed from below, it appears lower. Oral syringes are available in various sizes, an example are the Baxa Exacta-Med® range. Oral syringe calibrations You should use the most appropriate syringe for your dose, and calculate doses according to the syringe graduations. However, there are concerns with this ‘dead space’ when administering small doses and to babies; the ‘dead space’ has a greater volume that that for syringes meant for parenteral use. If a baby is allowed to suck on an oral syringe, then there is a danger that the baby will suck all the medicine out of the syringe (including the amount contained in the ‘dead space’) and may inadvertently take too much. A part of the oral syringe design is that it should not be possible to attach a needle to the nozzle of the syringe. Remember, from the section on pharmacokinetics, the elimination half-life is the time taken for the concentration or level of a drug in the blood or plasma to fall to half its original value. Drugs with very short half-lives disappear from the bloodstream very quickly and may need to be administered by a continuous infusion to maintain a clinical effect. Methods of intravenous administration Intravenous bolus This is the administration of a small volume (usually up to 10mL) into a cannula or the injection site of an administration set – over 3–5 minutes unless otherwise specified. Intermittent intravenous infusion This is the administration of a small volume infusion (usually up to 250mL) over a given time (usually 20 minutes to 2 hours), either as a one-off dose or repeated at specific time intervals. It is often a compromise between a bolus injection and continuous infusion in that it can achieve high plasma concentrations rapidly to ensure clinical efficacy and yet reduce the risk of adverse reactions associated with rapid administration. Continuous intravenous infusion This is the administration of a larger volume (usually between 500mL and 3 litres) over a number of hours. Continuous infusions are usually used to replace fluids and to correct electrolyte imbalances.

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Treatment of contacts and latent cases The same treatment should be administered to all symptomatic and asymptomatic contacts and to all latent cases (asymptomatic individuals with positive serologic test for syphilis) in endemic zones order antivert 25 mg with visa medications depression. Second stage Lesions appear 3 weeks after the initial chancre cheap 25 mg antivert otc medications with weight loss side effects, Pintids: plaques of various colours (bluish, • Mucous patches of the mouth common: occur in crops and heal spontaneously: reddish, whitish). May occur anywhere on very contagious ulcerated, round in form, • Frambesioma (papillomatous lesion, vegetal, the body. The After several years of latency: • Periostitis; painful, debilitating osteitis depigmentation is permanent, remaining after • Gummatous lesions of skin and long bones • Ulcerating and disfiguring rhinopharyngitis treatment. Leprosy is not very contagious with transmission through prolonged, close, direct contact, particularly between household members. Clinical features 4 Leprosy should be considered in any patient presenting with hypopigmented skin lesions or peripheral neuropathy. In suspect cases, conduct a thorough clinical examination: – skin and mucous membranes (patient must be undressed), – neurological examination: sensitivity to light touch, pinprick and temperature (hot-cold test), – palpation of the peripheral nerves. The Ridley-Jopling classification differentiates 5 forms based on several factors, including the bacteriological index. The Ridley-Jopling classification of leprosy Paucibacillary forms Multibacillary forms (least contagious forms) (most contagious forms)) Tuberculoid Borderline Borderline Borderline Lepromatous Tuberculoid Lepromatous T. Tuberculoid leprosy – The primary characteristic is peripheral nerve involvement: tender, infiltrated and thickened nerves; loss of thermal, then tactile and pain sensation. Lepromatous leprosy – The primary characteristic is multiple muco-cutaneous lesions: • macules, papules or infiltrated nodules on the face, ear lobes and the upper and lower limbs. Initially, there is no sensory loss; • involvement of the nasal mucosa with crusting and nose bleeds; • oedema of the lower limbs. Indeterminate leprosy (I) Form that does not fall in the Ridley-Jopling classification, frequent in children: a single well- demarcated macule, hypopigmented on dark skin, slightly erythematous on pale skin. Lesion heals spontaneously or the disease evolves towards tuberculoid or lepromatous leprosy. Lepra reactions – Reversal reactions: occur in patients with borderline leprosy, during treatment, when evolving towards tuberculoid leprosy. Acute painful neuritis (ulnar nerve) requires urgent treatment (see next page) as there is a risk of permanent sequelae. This reaction is seen exclusively in patients with lepromatous leprosy during the first year of treatment. Early antibiotic treatment prevents functional sequelae and transmission of the disease. Clinical features – Recurrent herpes labialis: tingling feeling followed by an eruption of vesicles on an erythematous base, located on the lips (‘fever blisters’) and around the mouth, they may extend onto the face. Recurrence corresponds to a reactivation of the latent virus after a primary infection. Chickenpox is the primary infection and herpes zoster the reactivation of the latent virus. Clinical features – Unilateral neuralgic pain followed by an eruption of vesicles on a erythematous base, that follow the distribution of a nerve pathway. Seborrheic dermatitis Seborrheic dermatitis is an inflammatory chronic dermatosis that can be localized on rich areas rich with sebaceous glands. Clinical features – Erythematous plaques covered by greasy yellow scales that can be localized on the scalp, the face (nose wings, eyebrows, edge of the eyelids), sternum, spine, perineum, and skin folds. Pellagra Pellagra is a dermatitis resulting from niacin and/or tryptophane deficiency (in persons whose staple food is sorghum; patients with malabsorption, or during famine). Clinical features Classically, disease of the ‘three Ds’: dermatitis, diarrhoea and dementia. In endemic areas, vitamin A deficiency and xerophthalmia affect mainly children (particularly those suffering from malnutrition or measles) and pregnant women. Disorders due to vitamin A deficiency can be prevented by the routine administration of retinol. Clinical features – The first sign is hemeralopia (crepuscular blindness): the child cannot see in dim light, may 5 bump into objects and/or show decreased mobility. Treatment It is essential to recognise and treat early symptoms to avoid the development of severe complications. Vision can be saved provided that ulcerations affect less than a third of the cornea and the pupil is spared.

It seems logical order antivert 25 mg on-line treatment junctional tachycardia, therefore buy generic antivert 25 mg on line treatment yeast infection men, that the best way to minimise such harms is by limiting the availability of the drug that causes them, and thus minimising use—the key goal of supply side drug prohibition and enforcement. However, accurate measurements of illicit drug availability are diffcult to come by, and so the relative success or failure of such regimes is hard to judge. Moreover, limiting legal availability of a given drug can—coun- ter-intuitively—increase rather than decrease the harms that it creates, by gifting its distribution and sale into the hands of criminal profteers and cultures that have no interest in serving the broader social good. Almost no data is systematically collected on drug availability anywhere, beyond inference from price and purity data, occasionally through user surveys, or more commonly via meaningless proxy measures, such as levels of drug seizures. Even if such data were to be gathered, the mostly covert and informal nature of the illicit drug trade would make it very diffcult to achieve a reliable overview of drug availability. Unlike illicit availability, legal product availability, in its various forms, can be very precisely measured and controlled. This can be managed through the nature and intensity of regulatory controls deployed and the strictness of, and resources directed towards, their enforcement. Policy can thus be adapted to different or changing policy priorities, or changes in public mood. At a practical level, policy can evolve according to the needs of different environments, and respond swiftly to changing circumstances and emerging challenges. Some readers may baulk at the restrictive and intrusive nature of some of the regulations outlined below. It is the aim of this book to show that a range of options is available to control production, supply and use in a legally regulated regime. It is the more or less democratic will of the people affected that will determine the fne tuning of restrictions as applied in any given scenario. However, it is to be assumed that more restrictive regimes would be applied in the initial phase of legal regula- tion, with a view to lightening the regulatory touch further down the line, guided by evidence of its effectiveness, and as more positive social norms and controls evolved (see: 4. One of the many harms created by a blanket prohibition is the reduction in the range of choice of drugs available to consumers. The consequence of an illicit market governed almost exclusively by the need to maximise profts, is that it becomes increasingly dominated by the more concen- trated, potent and risky drug products and preparations that offer the greatest profts—injected heroin, crack cocaine, and methamphetamine for example. When control by criminal profteers is replaced with a legal regime controlled by public health and state authorities, we would expect that much lower strength versions of drugs would be more widely available. There is plenty of evidence, especially from the alcohol feld, to 38 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices demonstrate that most users rationally tend to choose milder versions. Emerging regulatory approaches have the fexibility and options for control to take account of the wider range of drugs available. A crucial point to emphasise is, therefore, that public management of drug availability ensures that regulatory models and additional controls can be deployed differentially, at different levels of intensity, depending on the risks of a given product or activity. It is not just that the greater risks associated with a given drug and/or population of users (or potential users) justifes greater regulation on practical risk reduction grounds, but that the differential application of regulatory controls can create an availability gradient that corresponds to the risk gradient of different drugs/preparations, behaviours and environments in which they are consumed. This availability/risk gradient can support broader public health and harm reduction goals by progressively discouraging higher risk prod- ucts, preparations and behaviours, and‘nudging’patterns of use towards less risky products, preparations and behaviours, and in the longer term fostering social norms around more responsible and less harmful use. As already touched upon, illicit drug culture is not neutral in this regard; in many instances it actively pushes use in the opposite direc- tion, towards increasingly harmful products, preparations, behaviours and environments (see, for example, discussion of coca and cocaine products in 5. Prohibition—and the illicit drug markets and cultures it has fostered— undermines social norms and controls that can encourage more responsible drug using decisions and discourage more harmful or risky ones. What is now evident from the experience of the past half century or more is that prohibi- tion, when used as a tool for public health education and improvement, 39 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation fails in this goal. This failure occurs because prohibition cedes control of drug availability to those least qualifed or incentivised to manage it responsibly, motivated solely by proft maximisation. The key point to emphasise is that regulated availability affords the opportunity for control which is absent under prohibition. Controlled availability does not automatically translate into increased availability. Rather than the one size fts all approach of prohibition, legal regulation creates opportunities for nuance and fexibility through differential application along a range of policy vectors. That fexibility will help policy makers balance the need to regulate current, prohibition-driven patterns of use in the short term, with longer term policies that will encourage new lower-risk patterns of use. With legal regulation and management of currently illicit drugs, the opportunity exists not only to arrest this general trend towards harm maximisation created by prohibition, but to begin to reverse it and in the medium to long term, move decisively in the opposite direction.

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