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It is used for the treatment of galactorrhoea and cyclical benign breast disease spasms bladder buy discount zanaflex 4 mg on-line, as well as the treatment of prolactinomas muscle relaxant abuse buy zanaflex 2 mg mastercard. Cabergoline has actions and uses similar to those of bromocriptine muscle relaxant injection for back pain buy zanaflex australia, but its duration of action is longer muscle relaxant cyclobenzaprine high buy cheap zanaflex 2mg online. It has a different side-effect profile from bromocriptine and patients who may not tolerate the latter may be able to tolerate cabergoline and vice versa. Although bromocriptine and cabergoline are licensed to suppress lactation, they are not recommended for routine suppression or for the relief of symptoms of postpartum pain and breast engorgement that can be adequately treated with simple analgesics and support. All work by inducing uterine contractions with varying degrees of pain according to the strength of the contractions induced. Synthetic prostaglandin E2 (dinoprostone) is used for the induction of late (second-trimester) therapeutic abortion, because the uterus is sensitive to its actions at this stage, whereas oxytocin only reliably causes uterine contraction later in pregnancy. Dinoprostone is preferred to oxytocin for the induction of labour in women with intact membranes regardless of parity or cervical favourability. However, oxytocin is preferred for this, because it lacks the many side effects of prostaglandin E2 that relate to its actions on extrauterine tissues. These include nausea, vomiting, diarrhoea, flushing, headache, hypotension and fever. Oxytocin should not be started within six hours of administration of vaginal prostaglandins. A combination formulation of ergometrine and oxytocin (syntometrine) is used for bleeding due to incomplete abortion and in the routine management of the third stage of labour. This is administered by intramuscular injection with the delivery of the anterior shoulder. A useful alternative in severe postpartum haemorrhage in patients with an atonic uterus unresponsive to ergometrine and oxytocin is carboprost. Synthetic oxytocin is effective when administered by any parenteral route, and is usually given as a constant-rate intravenous infusion to initiate or augment labour, often following artificial rupture of the membranes. The side effects of oxytocin include uterine spasm, tetanic contractions, water intoxication and hyponatraemia, and uterine hyperstimulation. Oxytocin produces slow contractions with full relaxations between, whilst ergometrine produces faster contractions superimposed on a tonic persistent contraction (it is for this reason that ergometrine is unsuitable for induction of labour). If given intramuscularly, oxytocin acts within one to two minutes, although the contraction is brief, but ergometrine takes five minutes to act. Ergometrine can cause hypertension, particularly in preeclamptic patients, in whom it should be used with care, if at all. Prostaglandins are involved in a wide range of physiological and pathological processes, including inflammation (see Chapter 26) and haemostasis and thrombosis (see Chapter 30). Prostaglandin E2 has a potent contractile action on the human uterus, and also softens and ripens the cervix. In addition, it has many other actions, including inhibition of acid secretion by the stomach, increased mucus secretion within the gastro-intestinal tract, contraction of gastro-intestinal smooth muscle, relaxation of vascular smooth muscle and increase in body temperature. It preserves the patency of the ductus arteriosus until surgical correction is feasible. Conversely, in infants with inappropriately patent ductus arteriosus, indometacin given intravenously can cause closure of the ductus by inhibiting the endogenous biosynthesis of prostaglandins involved in the preservation of ductal patency. Cells in target tissues convert testosterone into the more active androgen dihydrotestosterone by a 5-reductase enzyme. Androgens have a wide range of activities, the most important of which include actions on: נdevelopment of male secondary sex characteristics (including male distribution of body hair, breaking of the voice, enlargement of the penis, sebum secretion and male-pattern balding); נprotein anabolic effects influencing growth, maturation of bone and muscle development; נspermatogenesis and seminal fluid formation. In impotent patients with low concentrations of circulating testosterone, replacement therapy improves secondary sex characteristics and may restore erectile function and libido, but it does not restore fertility. Alternatively, testosterone undecanoate or mesterolone can be taken by mouth; these drugs are formulated in oil, favouring lymphatic absorption from the gastro-intestinal tract. Delayed puberty due to gonadal deficiency (primary or secondary) or severe constitutional delay can be treated by testosterone esters or gonadotrophins. Care is needed because premature fusion of epiphyses may occur, resulting in short stature and such treatment is best supervised by specialist clinics. Occasional patients with disseminated breast cancer derive considerable symptomatic benefit from androgen treatment. They have generally been disappointing in therapeutics and have been widely abused by athletes and body builders. It has also been used to reduce sexual drive in cases of sexual deviation and in children with precocious puberty.
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In addition there is an endogenous fibrinolytic system that dissolves thrombus that has done its job muscle relaxant homeopathy buy zanaflex online now. Not surprisingly back spasms 35 weeks pregnant buy discount zanaflex 2mg line, these systems sometimes go wrong muscle relaxant ibuprofen buy 4mg zanaflex visa, resulting in bleeding disorders muscle relaxant and pregnancy order generic zanaflex line, such as haemophilia or thrombocytopenic purpura, or in thrombosis. Coagulation involves the sequential activation of a cascade of clotting factors which amplifies a small initial event to produce a macroscopic plug of fibrin. Two limbs of the coagulation pathway (intrinsic and extrinsic) converge on factor X (Figure 30. The unfractionated preparation is extracted from the lung or intestine of ox or pig, and is a mixture of polymers of varying molecular weights. Since the structure is variable, the dosage is expressed in terms of units of biological activity. Thrombocytopenia and related thrombotic events and antiheparin antibodies are less common than with unfractionated preparations. Once-daily dosage makes them convenient, and patients can administer them at home, reducing hospitalization. They are at least as effective as unfractionated heparin in the treatment of established deep-vein thrombosis and pulmonary embolism, and for myocardial infarction. It is administered either as an intravenous infusion (to treat established disease) or by subcutaneous injection (as prophylaxis). Intermittent bolus intravenous injections cause a higher frequency of bleeding complications than does constant intravenous infusion. For prophylaxis, a low dose is injected subcutaneously into the fatty layer of the lower abdomen 8- or 12-hourly. Coagulation times are not routinely monitored when heparin is used prophylactically in this way. Continuous intravenous infusion is initiated with a bolus followed by a constant infusion in saline or 5% glucose. Management of heparin-associated bleeding נAdministration should be stopped and the bleeding site compressed. The short t1/2 probably reflects rapid uptake by the reticulo-endothelial system and there is no reliable evidence of hepatic metabolism. Heparin also binds non-specifically to endothelial cells, and to platelet and plasma proteins, and with high affinity to platelet factor 4, which is released during platelet activation. The short t1/2 means that a stable plasma concentration is best achieved by a constant infusion rather than by intermittent bolus administration. A lower concentration is required to inhibit factor Xa and the other factors early in the cascade than is needed to antagonize the action of thrombin, providing the rationale for low-dose heparin in prophylaxis. As an antithrombin drug, it inhibits platelet activation by thrombin, but it can also cause platelet activation and paradoxical thrombosis by an immune mechanism (see below). It is administered by subcutaneous injection once a day, at a dose that depends on body weight. Adverse effects Adverse effects include: נbleeding ͠the chief side effect; נthrombocytopenia and thrombosis ͠a modest decrease in platelet count within the first two days of treatment is common (approximately one-third of patients), but clinically unimportant. The place of hirudin and its analogues in therapeutics is currently being established in clinical trials. Phenindione is an alternative, but has a number of severe and distinct adverse effects (see below), so it is seldom used except in rare cases of idiosyncratic sensitivity to warfarin. Preformed factors are present in blood so, unlike heparin, oral anticoagulants are not effective in vitro and are only active when given in vivo. This is formed by carboxylation of a glutamate residue in the peptide chain of the precursor. This is accomplished by cycling of vitamin K between epoxide, quinone and hydroquinone forms. This cycle is interrupted by warfarin, which is structurally closely related to vitamin K, and inhibits vitamin K epoxide reductase. Use the main indications for oral anticoagulation are: ננננdeep vein thrombosis and pulmonary embolism; atrial fibrillation (see Chapter 32); mitral stenosis; prosthetic valve replacements. Treatment of deep-vein thrombosis and pulmonary embolus is started with a heparin to obtain an immediate effect. This is usually continued for up to seven days to allow stabilization of the warfarin dose. The patient is warned to report immediately if there is evidence of bleeding, to avoid contact sports or other situations that put them at increased risk of trauma, to avoid alcohol (or at least to restrict intake to a moderate and unvarying amount), to avoid over-the-counter drugs (other than paracetamol) and to check that any prescription drug is not expected to alter their anticoagulant requirement.
The effect of message framing on breast self-examination attitudes spasms with stretching purchase zanaflex 2mg fast delivery, intentions muscle relaxant radiolab generic zanaflex 2 mg fast delivery, and behavior back spasms 20 weeks pregnant purchase line zanaflex. Context effects in the measurement of comparative optimism in probability judgments stomach spasms 6 weeks pregnant buy discount zanaflex 2mg. Asking sensitive questions: the effects of type of referent and frequency wording in counterbiasing methods. Questions and answers in attitude surveys: Experiments on question form, wording, and context. Response scales: Effects of category range on reported behavior and subsequent judgments. Asking questions: A practical guide to questionnaire design, New York: Jossey Bass. Thinking about answers: the application of cognitive processes to survey methodology, New York: Jossey-Bass. Are self-enhancing cognitions associated with healthy or unhealthy biological profi les? Page Moreau University of Colorado David Glen Mick University of Virginia Understanding creativity has been one of the most vexing challenges facing psychologists over the past 50 years. But more mundanely, creativity is also evident in the toil of an individual working to customize their pickup truck, or the clever way a mother uses hair spray to remove an ink stain. In everything from vehicles and homes to clothing and a mundane fi x for a stain, creativity permeates the consumption realm. Yet few attempts have been made to translate basic observation into theoretical treatise, and even fewer attempts have been made to empirically document the role of creativity in the consumer behavior literature. Our discussion will integrate considerations of creativity from the perspectives of the product, the process, the person, and the environment, and will consider the implications of each within the consumption realm. As basic as this defi nition appears, a modern understanding of creativity has been long in coming, and at various points emphasis has been on the creative person, the creative process, and the creative environment. To appreciate the modern conceptualization of creativity and how its various facets interrelate, it is useful to trace a brief history of creativity research. By the late 18th century a great deal of effort had been expended trying to decipher the source and nature of creative genius. This interest in creativity coincided with a time of great debate over the indemnity of individual freedom versus the need for social strictures and the rule of law. Even casual observation confirmed that creative individuals often flout convention and disdain rules, which are personality characteristics that would later become hallmarks of the creative person. The question was how to encourage creativity while maintaining a semblance of order. If the Renaissance demonstrated one thing, it was that creativity could not flourish in repressive societies. The inherent tension between creative expression and social prescription would ultimately culminate in the doctrine of individualism, if not the French Revolution itself (see Albert & Runco, 1999). The debate about creativity intensified with the onset of the Industrial Revolution. Intellectuals of the day hastened to point out that individuals were increasingly being subjugated to rote tasks and undifferentiated, sprawling urban areas that stripped all manner of creativity from daily life. It is notable that these early considerations of creativity made little attempt to distinguish between its individual and social aspects, seeing them as parts of an indivisible whole. As the discussions of creativity progressed, however, the social aspects of creativity were largely lost. For the most part, the modern study of creativity has been a study of the internal workings of the individual, stripped of social context. This was not always the case, and a number of prominent psychologists have recently commented on the need to put more of the social back into the psychology of creativity (Csikszentmihalyi, 1999; Hennessey, 2003). The treatment of creativity as a formal topic of scientific investigation is a 20th century development. The first half the 20th century can be characterized as the psychodynamic period of creativity research (Sternberg & Lubart, 1999). Great paintings, epic literature, monumental structures, all were displaced attempts to quell this inveterate conflict. Interestingly, and despite the fact that this psychodynamic tension should apply to anyone, creativity continued to be largely viewed as a unique ability possessed by a gifted few (the notion that it was somehow divinely imparted did, however, fall into decline). The psychodynamic period was characterized by case studies of eminent individuals in order to try and glimpse the wellspring of creative inspiration.
Key points Glucocorticosteroids ͠major side effects Adrenal suppression infantile spasms 2012 buy cheap zanaflex 2mg on line, reduced by once daily morning or alternate-day administration muscle relaxant 751 2 mg zanaflex with amex. The plasma t1/2 is approximately 90 minutes spasms during bowel movement purchase zanaflex 2mg with visa, but the biological t1/2 is longer (six to eight hours) spasms upper left abdomen cheap zanaflex 4 mg with visa. Key points Glucocorticosteroids ͠pharmacodynamics and pharmacokinetics נThey have a potent anti-inflammatory action which takes six to eight hours to manifest after dosing. They act as positive transcription factors for proteins involved in inhibition of the production of inflammatory mediators. Mineralocorticoid effects decrease as the antiinflammatory potency of synthetic glucocorticoids increases. Glucocorticosteroids have relatively short half-lives and are metabolized to inactive metabolites. Used in a wide range of inflammatory disorders of lung, gut, liver, blood, nervous system, skin and musculoskeletal systems, and for immunosuppression in transplant patients. The anti-inflammatory effect of prednisolone can improve inflammatory symptoms of connective tissue and vasculitic diseases (see Chapter 26), but whether this benefits the underlying course of the disease is often unclear. Treatment must therefore be re-evaluated regularly and if long-term use is deemed essential, the dose reduced to the lowest effective maintenance dose. Alternate-day dosing produces less suppression of the pituitaryΡdrenal axis, but not all diseases are adequately treated in this way. Prednisolone is considered in progressive rheumatoid arthritis when other forms of treatment have failed, or as an interim measure while a disease-modifying drug, such as methotrexate, has time to act. Low doses of prednisolone may be symptomatically useful in the short-term management of patients with severe articular symptoms from systemic lupus erythematosus and larger doses may be appropriate for limited periods in such patients with steroid-responsive forms of glomerulonephritis or with progressive central nervous system involvement. Other diseases where prednisolone may be indicated include severe asthma and some interstitial lung diseases. The immunosuppressant effect of prednisolone is further utilized in transplantation, usually in combination with ciclosporin or azathioprine, in order to prevent rejection (Chapter 50). Clinical features include nocturia, hypokalaemia, hypomagnesaemia, weakness, tetany, hypertension and sodium retention. Spironolactone and eplerenone are mineralocorticoid antagonists (see Chapters 31 and 36) that compete with aldosterone and other mineralocorticoids for the cytoplasmic mineralocorticosteroid receptor. They are used as potassium-sparing diuretics and to treat primary or secondary hyperaldosteronism in the contexts of hypertension and/or heart failure (Chapters 28 and 36). It binds to the mineralocorticoid steroid receptor and mimics the action of aldosterone. It undergoes significant presystemic metabolism, but unlike aldosterone is active by mouth. Uses Dexamethasone is powerfully anti-inflammatory, but is virtually devoid of mineralocorticoid activity. It has no glucocorticoid activity, but is about 1000 times more active than hydrocortisone as a mineralocorticoid. Aldosterone acts on the distal nephron, promoting Na /K exchange, causing sodium retention and urinary loss of potassium Adrenaline (epinephrine) is the main hormone produced by the adrenal medulla. It is used in emergency situations, such as cardiac arrest (Chapter 32), anaphylactic shock (Chapter 50) and other life-threatening disorders that require combined potent - and -agonist activity. It is used to prolong the action of local anaesthetics (via its vasoconstrictor action). Dipivefrine is a prodrug eye-drop formulation of adrenaline used to treat chronic open angle glaucoma (Chapter 52). Tumours of the adrenal medulla that secrete adrenaline and other pharmacologically active catecholamines (phaeochromocytoma) are treated surgically; in these patients preoperative blockade with phenoxybenzamine, a long-acting -blocker, followed by -blockade is essential. Glucocorticosteroids, primarily in the form of hydrocortisone (cortisol), are secreted in a diurnal pattern from the zona fasciculata. Case history A 32-year-old man presents after collapsing in the street complaining of severe lower abdominal pain. His relevant past medical history is that for 10 years he has had chronic asthma, which is normally controlled with 2-agonists and inhaled beclometasone 2000 g/day. Initial assessment shows that he has peritonitis, and emergency laparotomy reveals a perforated appendix and associated peritonitis. His immediate post-operative state is stable, but approximately 12 hours post-operatively he becomes hypotensive and oliguric.
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