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By: Y. Zuben, M.B. B.CH. B.A.O., Ph.D.

Clinical Director, Tulane University School of Medicine

Act as agonists at opioid receptors (= -endorphin symptoms zoloft overdose generic 5mg frumil otc, = enkephalin symptoms bacterial vaginosis cheap frumil 5mg mastercard, = dynorphin) to 300 medications for nclex 5mg frumil mastercard modulate synaptic transmission-open K+ channels, close Ca2+ channels synaptic transmission. Pain, cough suppression (dextromethorphan), diarrhea (loperamide, diphenoxylate), acute pulmonary edema, maintenance programs for heroin addicts (methadone, buprenorphine + naloxone). Toxicity treated with naloxone (opioid receptor antagonist) and relapse prevention with naltrexone once detoxified. Can cause opioid withdrawal symptoms if patient is also taking full opioid antagonist (competition for opioid receptors). Can cause opioid withdrawal symptoms if patient is also taking full opioid agonist (competition for opioid receptors). Augustine "It is far more important to know what sort of person has a disease, than to know what sort of disease a person has. Operant conditioning Reinforcement Extinction Punishment Learning in which a particular action is elicited because it produces a punishment or reward. Target behavior (response) is followed by desired reward (positive reinforcement) or removal of aversive stimulus (negative reinforcement). Discontinuation of reinforcement (positive or negative) eventually eliminates behavior. Increase behavior Add a stimulus Positive reinforcement Decrease behavior Positive punishment Remove a stimulus Negative reinforcement Negative punishment Transference and countertransference Transference Countertransference Patient projects feelings about formative or other important persons onto physician (eg, psychiatrist is seen as parent). Doctor projects feelings about formative or other important persons onto patient (eg, patient reminds physician of younger sibling). A patient with cancer plans a full-time work schedule despite being warned of significant fatigue during chemotherapy. A victim of sexual abuse suddenly appears numb and detached when she is exposed to her abuser. Displacement Redirection of emotions or impulses to a neutral person or object (vs projection). Dissociation Temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress. Expressing extremely positive thoughts of self and others while ignoring negative thoughts. Largely unconscious assumption of the characteristics, qualities, or traits of another person or group. Demonstrating hostile feelings in a nonconfrontational manner; showing indirect opposition. Attributing an unacceptable internal impulse to an external source (vs displacement). Proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self-blame. Replacing a warded-off idea or feeling by an (unconsciously derived) emphasis on its opposite (vs sublimation). Involuntarily turning back the maturational clock and going back to earlier modes of dealing with the world (vs fixation). Involuntarily withholding an idea or feeling from conscious awareness (vs suppression). Believing that people are either all good or all bad at different times due to intolerance of ambiguity. Intentionally withholding an idea or feeling from conscious awareness (vs repression); temporary. A surgeon throws a tantrum in the operating room because the last case ran very late. A patient boasts about his physician and his accomplishments while ignoring any flaws. A resident starts putting his stethoscope in his pocket like his favorite attending, instead of wearing it around his neck like before. In a therapy session, patient diagnosed with cancer focuses only on rates of survival. Seen in children under stress such as illness, punishment, or birth of a new sibling (eg, bedwetting in a previously toilet-trained child when hospitalized).

For example treatment vertigo frumil 5 mg free shipping, the Aspergillus glaucus group was characterized by abundant medicine keri hilson lyrics order 5 mg frumil overnight delivery, typically green conidial heads treatment zenkers diverticulum order 5 mg frumil with amex, with perithecia (sic) generally present while the Aspergillus ochraceous group had yellow conidia and abundant cream to purplish-coloured sclerotia (Thom and Raper, 1945). Since 1905, the Botanical Code (which governs the naming of plants and fungi) has allowed two different names to be applied to the same organism, depending on whether it is viewed in its sexual or asexual stage. According to these rules, Aspergillus nidulans, the well-known genetic model, should be called Emericella nidulans. Some Aspergillus species regularly produce both sexual and asexual spores; in other species the sexual form is rare; for still others, sexual spores have never been seen ­ and perhaps never will be seen. The names used for currently accepted sexual genera with close phylogenetic relationship or known linkage to Aspergillus species (representative Aspergillus species given in parenthesis) are: Chaetosartorya (A. Rigid interpreters of nomenclatural rules believe that it is wrong to use the name Aspergillus to denote a fungus with a known sexual stage and that only the generic name associated with the sexual stage should be used. See Bennett (1985) for a more detailed description of the early history and jargon surrounding dual nomenclature and an analysis of the accompanying logical and practical dilemmas that is poses. The edited volume by Reynolds and Taylor (1993) contains a number of well referenced and pertinent essays about the `fungal holomorph. This mycological exceptionalism has caused regular and heated debates ever since the Botanical Code was formulated. Different generations of taxonomists have revised the rules pertaining to fungal nomenclature as better data have come along that inform our understanding of fungal speciation. Nevertheless, there are experts who seem to forget that rigid 6 Bennett caister. Despite the fact that such gene trees ­ especially those based on single genes ­ are error prone, despite the fact that different genes evolve at different rates, and despite the fact that horizontal gene transfer can muddy phylogenetic analysis, such analyses are largely robust and have revolutionized all taxonomic systems. It now seems likely that the aspergilli are all descended from one common ancestor, i. It is believed that that the ancestral form was sexually producing and that independent losses of sexual reproduction occurred repeatedly. These molecular phylogenetic analyses have ramifications for both classification and nomenclature. It can be assumed that fungi called Aspergillus are descended from the same ancestral groups as their named teleomorphs. From the perspective of classification, it means that the old form taxa categories. In theory, mycologists have done so and these taxa are no longer formally accepted. Aspergillus species now are classified firmly within the Ascomycota (Geiser et al. However, in practice the old terms for form taxa are still widely used and applied. Nonetheless, the question remains: Are all Aspergillus species anamorphs of some kind of ascomycete? Suppose some large and successful groups of aspergilli have evolved a purely clonal and asexual form of reproduction? Does it make sense to rename them based on a morphological structure they do not possess? Proliferation of jargon and frequent changes of specific and generic epithets do neither. Suprageneric classification Aspergillus presents several classification difficulties that are intertwined with its nomenclatural intricacies. Form genera are used in classifying fossil plants, but they also have had widespread application in the history of Aspergillus classification. Depending on the author, the group was ranked as a class (Deuteromycetes) or a subdivision/subphylum (Deuteromycotina). The fungi imperfecti sometimes were subdivided into form classes in which the moulds were grouped together as Hypomycetes (see for example, Ainsworth, 1973; Alexopoulos and Mim, 1979). Since all taxonomic classification schemes are human constructs designed to catalogue living things, many philosophical and practical objections are inherent in the concept of `natural categories (Hey, 2001). Such phylogenetic classifications seem more possible now that traditional morphological markers have been supplemented with nucleic acid sequences.

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In most cases symptoms questions order frumil with paypal, drug specific IgE has not been detected (either via skin testing or in vitro tests) symptoms vitamin d deficiency buy discount frumil 5 mg on-line. Hence medications 122 discount 5mg frumil with mastercard, it is unclear whether these reactions are anaphylactoid or represent true IgE-mediated allergy. Some of the reactions are believed to be secondary to the diluent or preservative, rather than the active drug. Evaluation should include skin testing with the corticosteroid in question, although its predictive value is uncertain. Because most (but not all) patients appear to be able to tolerate other corticosteroids, management should focus on finding an alternate agent for future use. If a patient with suspected allergy to a corticosteroid requires treatment with it, rapid induction of drug tolerance should be performed. Protamine Summary Statement 141: Severe immediate reactions may occur in patients receiving protamine for reversal of heparinization. Immediate generalized reactions to protamine, including hypotension, shock, and death, have been reported. Pretreatment with corticosteroids and antihistamines has been recommended, but no studies have shown this to be efficacious. Heparin Summary Statement 143: Hypersensitivity reactions to unfractionated heparin and low-molecular-weight heparin are uncommon and include thrombocytopenia, various cutaneous eruptions, hypereosinophilia, and anaphylaxis. Severe thrombocytopenia is caused by immune complexes, a component of which is heparin-dependent IgG specific for platelet factor 4. Low-molecularweight heparin does not cause anti­platelet 4 IgG-related reactions, but it may cause thrombocytopenia. Although immediate hypersensitivity reactions to unfractionated heparin and low-molecular-weight heparin are rare, anaphylactic and anaphylactoid reactions have been documented. However, patients may develop antihirudin antibodies, and a small percentage of such patients may experience anaphylaxis. This oversulfated chondroitin sulfate contaminant has been shown in vitro and in vivo to cause activation of the kinin-kallikrein pathway with generation of bradykinin, a potent vasoactive mediator, and generation of C3a and C5a anaphylatoxins. Local Anesthetics Summary Statement 144: Most adverse reactions to local anesthetics are not due to IgE-mediated mechanisms but are due to nonallergic factors that include vasovagal responses, anxiety, toxic reactions including dysrhythmias, and toxic or idiosyncratic reactions due to inadvertent intravenous epinephrine effects. Local anesthetics are either group 1 benzoic acid esters (eg, procaine, benzocaine) or group 2 amides (eg, lidocaine, mepivacaine). On the basis of patch testing, the benzoic acid esters crossreact with each other, but they do not cross-react with the group 2 amide drugs. It is not known what, if any, relevance this has on immediate-type reactions to local anesthetics. Graded challenge tests may then be performed using incremental concentrations of the local anesthetic that the dentist intends to use. This test reagent should not contain epinephrine or other additives, such as parabens or sulfites. When there is concern about a previously reported reaction, skin testing and incremental challenge with a local anesthetic is a reasonable approach in the evaluation of a possible reaction. Although there are slight differences in reported graded challenge procedures, a typical protocol is as follows. If the result is negative, successive injections (subcutaneous or intracutaneous) of 0. A placebo step may be added after the skin prick test and before challenging with the local anesthetic. With this protocol, there have been no serious allergic reactions reported after administration of local anesthetics if the skin test results and test dosing are negative. The investigators concluded that local anesthetic tests could be performed with formulations that contain either preservatives and/or epinephrine. Dentists and other health care professionals may develop contact dermatitis from local anesthetics. In the event that this occurs, patch testing should be performed to determine the degree of sensitization to the suspected local anesthetic and identify the agent(s) that is least likely to produce a reaction.

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Causes: · Physical trauma ­ Stabbing - Stick injury - Gunshot - Motor vehicle accident · Inadequacies in blood clotting which can be due to: A medicine x stanford cheap 5 mg frumil amex. Inadequate vitamin K leads to medications adhd order frumil visa clotting factor deficiency because this vitamin is important in the synthesis of the clotting factors by the liver symptoms uterine fibroids frumil 5mg with amex. Terminology: 1) Haemorrhage enclosed within a tissue or a cavity is knownas hematoma. Effects of haemorrhage: depend on the rate and amount of blood loss: · · If > 20% the total blood volume is rapidly lost from the body, it may lead to hypovolumic shock & death. Hemostasis and Blood Coagulation Hemostasis Definition: Hemostasis is the maintainence of the clot-free state of blood & the prevention of blood loss via the formation of hemostatic plug. Hemostasis depends on three general components: a) Vascular wall b) Platelets c) Coagulation pathways Whenever a vessel is ruptured or severed, hemostasis is achieved by several mechanisms: A. Vascular spasm Formation of platelet plug Formation blood clot as a result of blood coagulation Eventual growth of fibrous tissue in to the blood clot to close the hole in the vessel permanently. Remark: the student is advised to revise his physiology lecture note on the above topics. Thrombosis Under this topic, we will discuss the definition, pathogenesis, morphology, fates, & clinical significance of thrombi, in this order. Definition: Thrombosis is defined as the formation of a solid or semisolid mass from the constituents of the blood within the vascular system during life. Endothelial injury is particularly important in thrombus formation in the heart & arterial circulation. Some Examples: · Endocardial injury during myocardial infarction & eosinophilic endocarditis in which eosiophils release from their granules crystals called Charcot ­ Leyden damaging the endocardial endothelium. In hemodynamic stress like severe hypertension & turbulence of flow over scarred valves directly damaging the endothelium. Bacterial endtoxin & hyperchloestrolemia, radiation & cigarette smoking may be sources of endothelial injury. Irrespective of endothelial damage, the final event is exposure of the highly thrombogenic subendothelial extracellular matrix, mainly collagen & tissue factors up on which platelets undergo adherence & contact activation. B: Turbulence or Stasis (Alterations in normal blood flow) Under physiologic conditions normal blood flow is laminar, that is, the cellular elements flow centrally in the vessel lumen separated from endothelium by slowing moving clear zone of plasma. Disrupt the laminar flow and bring platelets in to contact with the endothelium b. Retard or make a time lag in the inflow of clotting factor inhibitors and permit the build up of thrombi. A dilated left atrium is a site of stasis & a prime location of thrombus development. C: Hypercoagulablity Definition: Hypercoagulability is any alteration of the coagulation pathway that predisposes to thrombosis. Hypercoagulability is a less common cause of thrombosis & & it can be divided into: 1. Secondary (Acquired) which, in turn, can be categorized into: A: High-risk for hypercoagulablity prolonged bed rest or immobilization Myocardial infarction Tissue damage (surgery, fracture, burns) ancers (Cancers release procoagulant tissue products to cause thrombosis) Prosthetic cardiac valves Disseminated intra vascular coagulation 73 B: Low risk factor for hypercoagulablity A trial fibrillation Cardiomyopathy Nephrotic syndrome Smoking Oral contraceptives Hyperestrogenic state eg. Morphology of Thrombi · · Thrombi may develop any where in the cardiovascular system. According to their location, thrombi can be divided into venous & arterial thrombi. The differences between arterial & venous thrombi are: Arterial thrombi a) Arise at the site of endothelial injury b) Grow in a retrograde fasion, against site of attachment. B: Embolization: the thrombus may dislodge and travel to other sites in the vasculature. Death of a tissue due to a decreased blood supply or drainage is called infarction. D: Organization and recanalization Organization refers to the ingrowth of endothelial cells, smooth muscle cells, and fibroblasts into the fibrin-rich thrombus. Organization is accompanied by the formation of capillary channels across the thrombus, re-establishing lumen continuity to some extent. The recanalization eventually converts the thrombus into a vasscularized mass of tissue which is later on incorporated as a subendothelial swelling of the vessel wall.

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