By V. Iomar. Aspen University.

The ma- Adverse reactions to iodine can be divided into in- jor disadvantage associated with this therapy is the de- trathyroidal and extrathyroidal reactions quality 500 mg cipro antibiotics used for acne. At higher Potassium Perchlorate doses (50–500 mg/day) buy cipro 750 mg without a prescription virus 986 m2, iodide goiter or hypothyroidism or both may develop, but this usually requires long ex- The perchlorate ion of potassium perchlorate, KClO4,is posure. Extrathyroidal adverse reactions to iodine are a competitive inhibitor of thyroidal I transport via the relatively rare and generally not serious. This drug can cause fa- rash, which may be acneiform; drug fever; sialadenitis tal aplastic anemia and gastric ulcers and is now rarely (inflammation of the salivary glands); conjunctivitis and used. If administered with careful supervision, in limited rhinitis; vasculitis; and a leukemoid eosinophilic granu- low doses and for only brief periods, serious toxic effects locytosis. The compound is especially effective in treating iodine-induced hyperthyroidism, which may oc- cur, for example, in patients treated with the antiar- Oral Cholecystographic Agents rhythmic compound amiodarone. Perchlorate ion can The iodine-containing oral cholecystographic contrast also be used in a diagnostic test of I incorporation into agents (OCAs) include sodium ipodate (Oragrafin), Tg, the so-called perchlorate discharge test. During concomitant therapy, the dosage of the anticoagulant Lithium inhibits thyroidal incorporation of I into Tg, as may have to be increased. Similarly, patients receiving cardiac particular advantage over drugs of the thionamide class glycosides, such as digitoxin, may require a smaller dose. Iodide Drug Interactions derived from this source may enhance the effects of an- As the plasma levels of T4 and T3 fall after the adminis- tithyroid drugs and lead to iodine-induced hypothy- tration of antithyroid drugs, the catabolism of vitamin roidism. Iodine in topical antiseptics and radiological K–dependent clotting factors decreases, thus reducing contrast agents may act in a similar manner. All of the following are common adverse effects as- (A) Thiocyanate inhibits the binding of iodide to sociated with drug overdose of thyroid hormone re- thyroid hormone receptors. The following statements regarding the mechanism dietary iodine intake is insufficient and must be sup- of action of thionamide drugs in the treatment of plemented. There is another element in which a di- hyperthyroidism are true EXCEPT etary intake may be insufficient that is also associated (A) The clinical effects are apparent soon after ad- with thyroid hormone metabolism. What is the primary reason for administering - adrenergic receptor blocking drugs as adjunct ther- ANSWERS apy in the treatment of thyrotoxicosis? The cardiac effects (A, B, and C) are symptoms (A) They reduce the elevated thyroid hormone of hyperthyroidism, as is E. Selenium in the form of selenocysteine is re- mones result from an increase in number of - quired for three enzymes that remove iodide from adrenoceptors. There are no significant areas in (C) They elevate the levels of prostaglandins which dietary intake of sodium or potassium are through indirect mechanism. Fluorine deficiency is not associated with (D) The effects of elevated thyroid hormones are thyroid hormone metabolism. What is the basic mechanism of action of thiocyanate diated through the adrenergic nervous system, and in inhibiting iodide uptake by the thyroid gland? New insights into the of drugs do inhibit the action of the enzyme TPO thyroid-stimulating hormone receptor: The major and thus inhibit thyroid hormone synthesis. Case Study Hypothyroxinemia in a 36-year-old Woman with an Enlarged Thyroid Gland ara Gwynn, aged 38, complains to her family (total serum T4concentration T3 resin uptake) of Sphysician of weight gain, constipation, and 0. Significant findings upon physical examina- reduced total serum T4 concentration is not due to tion include the following: At 5 feet, 4 inches and a decrease in the concentration of serum thyroid 169 lb, she is moderately overweight. The accompanying ele- sure is 152/92; pulse, 59; neck is full, with an en- vation in the serum TSH concentration indicates larged (1. The responsiveness of her thyroid gland to TSH is Significant Results of Laboratory Studies subnormal, resulting in subnormal thyroid hor- mone synthesis and secretion. In addition, mild hy- tion of symptoms, the clinical effectiveness of the pertension, goiter, and delayed relaxation of deep thyroid hormone replacement may be monitored by tendon reflexes are among the common physical periodically measuring the serum TSH concentra- findings of hypothyroidism. The lowest dose of thyroid hormone that is tations of the clinical findings and what treatment needed to normalize the serum TSH concentration would you suggest? Most or all of the ANSWER: The results of the laboratory tests confirm symptoms of hypothyroidism should improve with the hypothyroxinemia (i. Schwartz DRUG LIST GENERIC NAME PAGE GENERIC NAME PAGE Alendronate 760 Pamidronate 760 Calcitonin 756 Parathyroid hormone 760 Calcitriol 760 Plicamycin 759 Cholecalciferol 757 Risedronate 760 Dihydrotachysterol 757 Tiludronate 760 Ergocalciferol 757 Zoledronic acid 760 Etidronate 760 The principal hormones involved in calcium metab- tion of growth factors, cytokines, and protein hormones. Plasma calcium exists in three such as the thyroid hormones, growth hormone, andro- forms: ionized (50%), protein bound (46%), and com- gens, estrogens, and the glucocorticoids also influence plexed to organic ions (4%). The three centration is normally tightly maintained within the primary target tissues for these hormones are bone, range of 4. These three hormones and their PTH and D3, which regulate bone resorption and cal- target tissues maintain serum calcium levels, extracellu- cium absorption from the intestine and kidney.

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All four types of histamine receptors maintain a wakeful state through an effect on H1- (A) Are found on the surface of mast cells and ba- receptors cheap cipro 500 mg online antibiotics for acne boils. Histamine-mediated bronchoconstriction sophils is mediated by H1-receptors cipro 500 mg fast delivery antibiotic jock itch, while histamine- (B) Are G protein–coupled mediated vasodilation occurs as a result of stimula- (C) Modulate adenylyl cyclase activity tion of H1- and H2-receptors. Jones takes fexofenadine 60 mg twice a day for ceptors belong to the G protein–coupled receptor seasonal allergies. Only H2-receptors are coupled to sinus infection and receives a prescription for eryth- adenylyl cyclase through the G protein G. Therefore, administering an inhibitor of (A) Exhibit no changes in fexofenadine elimination CYP3A4 would not affect fexofenadine elimination. Although scopolamine effectively combats mo- without risk of torsades de pointes tion sickness, it is an antimuscarinic agent, not an (E) Exhibit moderate anticholinergic effects com- antihistamine. Dimenhydrinate is an antihistamine monly seen with fexofenadine with significant antimuscarinic properties that are 5. Smith has severe motion sickness during air likely to contribute to its anti–motion sickness activ- travel. Chlorpheniramine, fexofenadine, and tripelen- you, his physician, would like to prescribe an anti- namine are antihistamines without significant effi- histamine to prevent motion sickness. Case Study Behavior Changes and the Bladder nisette Doe, a 28-year old woman, went to the 50 mg every 6 to 8 hours. What is a possible Aemergency department with abdominal explanation for the sudden onset of her inability to bloating and inability to void her bladder; she had void her bladder? Doe had or masses in the bladder, urethra, ureters, or not complained of anticholinergic effects prior to kidneys. She reported no significant side cholinergic effects of clozapine and diphenhy- effects as a result of this treatment. Hay DRUG LIST GENERIC NAME PAGE GENERIC NAME PAGE Albuterol 460 Metaproterenol 461 Beclomethasone 465 Nedocromil sodium 467 Bitolterol 460 Pirbuterol 460 Cromolyn sodium 467 Prednisone 465 Epinephrine 462 Salmeterol 462 Flunisolide 465 Terbutaline 462 Fluticasone 465 Theophylline 463 Ipratropium 464 Triamcinolone 465 Isoproterenol 462 Zafirlukast 465 Montelukast 465 Zileuton 466 The word asthma is derived from a Greek word The most important outcomes for successful therapy meaning difficulty in breathing. The clinical expression of asthma are as follows: of asthma varies from a mild intermittent wheeze or cough to severe chronic obstruction that can restrict • Prevent chronic and troublesome symptoms normal activity. Acute asthma attacks are triggered by a • Maintain (near) normal pulmonary function variety of stimuli, including exposure to allergens or • Maintain normal activity levels cold air, exercise, and upper respiratory tract infections. Thus, genetic factors probably contribute to the • Provide optimal pharmacotherapy with mini- exaggerated response of the asthmatic airway to various mal or no adverse effects environmental challenges. The most severe exacerba- tion of asthma, status asthmaticus, is a life-threatening Pathophysiology condition that requires hospitalization and must be treated aggressively. Unlike most exacerbations of the Asthma symptoms are produced by reversible narrow- disease, status asthmaticus is by definition unresponsive ing of the airway, which increases resistance to airflow to standard therapy. Other patients may struction, cardinal features of asthma include inflamma- have both allergic and nonallergic forms of asthma. In contrast to chronic obstructive pulmonary disease (emphysema and Airway Obstruction chronic bronchitis), the airway obstruction associated Three factors contribute to airway obstruction in with asthma is generally reversible. However, severe asthma: (1) contraction of the smooth muscle that sur- long-standing asthma changes the architecture of the rounds the airways; (2) excessive secretion of mucus airway. These changes, including smooth muscle hyper- and in some, secretion of thick, tenacious mucus that ad- trophy and bronchofibrosis, can lead to an irreversible heres to the walls of the airways; and (3) edema of the decrement in pulmonary function. In contrast, respiratory mucus accumulation lergy appears to underlie asthma in most children over and edema formation are likely to require more time to age 3 years and in most young adults; allergy-induced develop and are only slowly reversible. In contrast, a large number of patients, especially those who acquire Airway Inflammation asthma as older adults, have no discernible immunolog- ical basis for their condition, although airway inflamma- The recognition that asthma is a disease of airway in- tion remains a characteristic of the disease; this type of flammation (Fig. Mediators released during the inflammatory process associated with asthma cause bronchoconstriction, mucus secretion, and mucosal inflammation and edema. These changes reduce the size of the airway lumen and increase resistance to airflow, which leads to wheezing and shortness of breath. Bottom, The multitude of inflammatory cells (macrophages, eosinophils, mast cells, neutrophils) and neurotransmitters implicated in asthma pathophysiology.

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Studies indicate that the incidence of this disease in Caucasian and Native American populations is higher than in African- American discount 250 mg cipro mastercard treatment for dogs eating grapes, Hispanic generic cipro 750 mg online antibiotic pneumonia, and Asian populations. Signs and symptoms Untreated PKU patients develop a broad range of symptoms related to severely impaired cognitive func- tion, sometimes referred to as mental retardation. Other symptoms can include extreme patterns of behavior, delayed speech development, seizures, a characteristic body odor, and light body pigmentation. The light pig- mentation is due to a lack of melanin, which normally colors the hair, skin, and eyes. Melanin is made from the amino acid tyrosine, which is lacking in untreated cases of PKU. Physiologically, PKU patients show high levels of phenylalanine and low levels of tyrosine in the blood. Babies do not show any visible symptoms of the disease A technician is performing a test to screen for PKU. Diagnosis elevated phenylalanine levels may be caused by some medical condition other than PKU. Another, more accurate test procedure for procedure is referred to as the Guthrie test (Guthrie bac- PKU measures the ratio (comparison) of the amount of terial inhibition assay). In this test, PKU is confirmed by phenylalanine to the amount of tyrosine in the blood. PKU testing sis and genotype determination) can actually identify the was introduced in the early 1960s and is the largest specific types of PAH gene mutations inherited by PKU genetic screening program in the United States. Early diagnosis is criti- various mutations affect the ability of patients to process cal. This information can help doctors develop develop normally and avoid the complications of PKU. If the initial PKU test pro- duces a positive result, then follow-up tests are per- The severity of the PKU symptoms experienced by formed to confirm the diagnosis and to determine if the people with this disease is determined by both lifestyle GALE ENCYCLOPEDIA OF GENETIC DISORDERS 921 and genetic factors. In the early 1950s, researchers first health professionals recommend adding time released demonstrated that phenylalanine-restricted diets could tyrosine that can provide a more constant supply of this eliminate most of the typical PKU symptoms—except for amino acid to the body. Today, dietary therapy (also called patients show signs of learning disabilities even with a nutrition therapy) is the most common form of treatment special diet containing extra tyrosine. PKU patients who receive early and suggest that these patients may not be able to process consistent dietary therapy can develop fairly normal tyrosine normally. By comparison, untreated PKU patients ing as well as healthy and nutritious is a constant chal- generally have IQ scores below 50. Many patients with PKU, especially teenagers, Infants with PKU should be put on a specialized diet find it difficult to stick to the relatively bland PKU diet as soon as they are diagnosed to avoid progressive brain for extended periods of time. Some older patients decide damage and other problems caused by an accumulation to go off their diet plan simply because they feel healthy. A PKU diet helps patients However, many patients who abandon careful nutritional maintain very low blood levels of phenylalanine by management develop cognitive problems, such as diffi- restricting the intake of natural foods that contain this culties remembering, maintaining focus, and paying amino acid. Special PKU dietary mixtures or formulas are all patients with PKU should adhere to a strictly con- usually obtained from medical clinics or pharmacies. One promising line of PKU research involves the This means that it has to be obtained from food because synthesis (manufacturing) of a new type of enzyme that the body cannot produce this substance on its own. This medication would be taken orally and could small amounts of phenylalanine and higher quantities of prevent the absorption of digested phenylalanine into the other amino acids, including tyrosine. In general, medical researchers express concern about the great variation in treatment programs currently In addition, PKU diets include all the nutrients nor- available to PKU patients around the world. They have mally required for good health and normal growth, such highlighted the urgent need for new, consistent interna- as carbohydrates, fats, vitamins, and minerals. High pro- tional standards for proper management of PKU patients, tein foods like meat, fish, chicken, eggs, nuts, beans, which should emphasize comprehensive psychological as milk, and other dairy products are banned from PKU well as physiological monitoring and assessment. Small amounts of moderate protein foods (such as grains and potatoes) and low protein foods (some fruits and vegetables, low protein breads and pastas) are PKU and Pregnancy allowed. Sugar-free foods, such as diet soda, which con- Women with PKU must be especially careful with tain the artificial sweetener aspartame, are also prohib- their diets if they want to have children. That is because ensure that phenylalanine blood levels are under control aspartame contains the amino acid phenylalanine. Mothers Ideally, school-age children with PKU should be with elevated (higher than normal) phenylalanine levels taught to assume responsibility for managing their diet, are high risk for having babies with significant birth dis- recording food intake, and for performing simple blood orders, such as microencephaly (smaller than normal tests to monitor their phenylalanine levels. Blood tests head size), and congenital heart disease (abnormal heart should be done in the early morning when phenylalanine structure and function), stunted growth, mental impair- levels are highest.

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In the common situation of resource limitation and prioritisation it can be argued there may be a pragmatic need for “implied consent” purchase 750mg cipro free shipping antibiotic resistance threats in the united states 2015, with the patient having to actively indicate they want a particularly piece of information limited in its flow order cipro 250mg free shipping antibiotic classifications. Similarly it can be argued that it is misleading to even attempt to utilise the concept of informed consent to imply that a health service can truly offer a patient the option of control over their information flows. There may be clinical, statutory, regulatory or financial requirements that require a clinician or health service to pass certain information or partial information to other bodies. A clinician or health service can do their best to make a patient aware of the nature and purpose of the information they are collecting and how it may be utilised, but it is misleading to imply that the patient has total, un-coerced control over that information, for which they can freely offer or withdraw consent. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. The Challenge of Privacy and Security 81 Accordingly a patient may be advised that if they do not agree to their information being stored or shared in a particular way, the clinician or health service may not be in a position to offer them a service. Challenges to Privacy and Security Processes Healthcare, and indeed human physiology and disease progression are increasingly recognised for their complexity and non-linear dynamics, where there are limitations for reductionistic views and solutions that do not or can not recognise or adapt to that complexity (Plsek & Greenhalgh, 2001; Goldberger, 1996). This section will not attempt an exploration of the theory or to utilise the formal language of non-linear dynamics, but again, through the use of metaphor and perspectives, aims to convey some of that complexity, particularly as it relates to privacy and security and the implementation of electronic health knowledge management systems. Knowledge Neurones and the Therapeutic Knowledge Alliance From a distance and at a fixed point in time clinical information may appear to be exchanged in a simple linear chain like fashion. For example, organisation or person A communicates with organisation or person B who communicates with organisation or person C, and all may be expected to exchange the same information in a standardised format. Therefore conceptually, one might hope to control the flow of information by mapping these connections and asking a patient who trusted connections they consent or agree to have in their own particular chain and under what conditions information should flow along it. However in reality there are often a series of intermingling web-like connections, both within and between multiple organisations and their constituent individuals that are continually being realigned, reshaped and restructured over time. Additionally, as opposed to information being passed in a single standardised format, there are often different variants or segments of the information passed between each connection. Knowledge Neurones In addition to electronic health information systems storing text-based records clinicians utilise a multitude of other channels to transfer and manage health information. These include paper records, phones, personal digital assistants, pagers, voicemail, fax, e-mail, and not least conversation or personal and group interaction. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Electronic health knowledge management systems may assist the clinician in the continuous process of integrating these multiple channels and adding or discerning intelligence. The clinician may strengthen or utilise more channels perceived to add value and ignore or weaken channels perceived to add less value. Historically the “therapeutic alliance” concept has had an evolving meaning, but carries the sense of clinician and patient working together (Goldstein, 1999). Similarly, the earlier definition of a health knowledge management system attempted to convey the sense of GPs, allied health services, and patients and their supports all working together. We could consider each of these groups as forming their own knowledge neurones and conceptualise a “therapeutic knowledge alliance” comprising of a web of these inter- weaving knowledge neurones, all supporting each other and working together to make a healthy difference. Healthcare may involve a spectrum of clinical presentations or scenarios that have to be managed, which can be described as simple certainty to complex ambiguity (Figure 4). Certainty to ambiguity relates to the degree of perceived accuracy or certainty with regard to the diagnosis or diagnoses and the potential effectiveness of interventions or treatments. Traditionally, as clinicians have moved from simple certainty to complex ambiguity, they have utilised an increasing array of resources within their therapeutic knowledge Figure 4. Resources and uncertainty to be managed with increasing complexity and ambiguity Resources and uncertainties to be managed and co-ordinated Simple Complex Ambiguity Certainty Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. The quest for increasingly highly structured data runs the risk of adopting a cloak of scientific certainty that loses the art of dealing with this often-prevalent complex ambiguity in clinical practice. A specialist may have more factual knowledge or skill in a particular clinical area than a generalist or someone in training, but it is often their ability to recognise, adapt and cope with what they do not know, or what is not initially clear that provides their particular value. Intuition and learning from experience to cope with complex ambiguity is an aspect of the art of medicine that could arguably be just sophisticated learned pattern recognition and risk management that is and will be increasingly codifiable in electronic form. Indeed, a central aim of an electronic health knowledge management system should be to enhance and develop the capability of the health system and the individuals within it, to adapt and cope with varying degrees of complexity and ambiguity. However, at present there is a need to recognise the relative limitations of structured electronic data and guidelines, for dealing with complex ambiguous clinical scenarios, and to recognise the current reality of how clinicians cope with that complex ambiguity (Figure 5). Therapeutic knowledge alliance versus structured data and guidelines Relative Therapeutic Utility and Knowledge effectiveness Alliance and efficiency Structured data and guidelines Simple Complex Ambiguity Certainty Copyright © 2005, Idea Group Inc.

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