Amantadine
Y. Jensgar. Medical College of Wisconsin.
Multiple drug use (b) Number of drugs administered (‘polypharmacy’) is extremely common buy 100 mg amantadine visa antiviral nucleoside analogues, so the potential for drug interaction is enormous. One study showed that on average 14 drugs were prescribed to medical in-patients 30 per admission (one patient received 36 different drugs). Many drugs are not curative, but rather ameliorate chronic 1–10 11–15 16 conditions (e. The populations of western (c) Number of drugs administered countries are ageing, and elderly individuals not Figure 13. Annals of Internal Medicine drug results in an adverse effect that is countered by the 1966; 65: 631. Isoniazid neuropathy is caused Drugs can be used in combination to enhance their effective- by pyridoxine deficiency, and is prevented by the prophylac- ness. The combination of a peripheral dopa that influence different components of the disease mechanism decarboxylase inhibitor (e. Other lower dose of levodopa than is needed when it is used as a sin- examples include the use of a β2 agonist with a glucocorticoid in gle agent, while reducing dose-related peripheral side effects the treatment of asthma (to cause bronchodilation and suppress of nausea and vomiting (Chapter 21). Combinations of antimicrobial drugs are used to prevent the selection of drug-resistant organisms. Drug resistance via synthesis of a Drugs can be used to block an undesired or toxic effect, as for microbial enzyme that degrades antibiotic (e. Another example is the use of the com- bination of ritonavir and saquinavir in antiretroviral therapy Many interactions are based on in vitro experiments, the (Chapter 46). Saquinavir increases the systemic bioavailabil- results of which cannot be extrapolated uncritically to the clin- ity of ritonavir by inhibiting its degradation by gastro- ical situation. This is especially true of drugs with ing the P-glycoprotein that pumps it back into the intestinal shallow dose–response curves and of interactions that depend lumen. Interactions are only likely to be clinically important when Therapeutic effects of drugs are often limited by the acti- there is a steep dose–response curve and a narrow therapeutic vation of a physiological control loop, particularly in the case of window between minimum effective dose and minimum cardiovascular drugs. The use of a low dose of a second drug toxic dose of one or both interacting drugs (Figure 13. This that interrupts this negative feedback may therefore enhance is often not the case. Examples include the combination most clinical situations, is so non-toxic that the usual dose is of an angiotensin converting enzyme inhibitor (to block the more than adequate for therapeutic efficacy, yet far below that renin-angiotensin system) with a diuretic (the effect of which which would cause dose-related toxicity. Consequently, a second is limited by activation of the renin-angiotensin system) in drug that interacts with penicillin is unlikely to cause either treating hypertension (Chapter 28). Instances where clinically important consequences do One large group of potential drug interactions that are seldom occur on introducing a drug that displaces another from clinically important consists of drugs that displace one tissue binding sites are in fact often due to additional actions another from binding sites on plasma albumin or α-1 acid glyco- of the second drug on elimination of the first. However, the simple expectation that reduces the renal clearance of digoxin by a separate mech- the displacing drug will increase the effects of the displaced anism. This is because drug clearance 26) displaces warfarin from binding sites on albumin, and (renal or metabolic) also depends directly on the concentra- causes excessive anticoagulation, but only because it also tion of free drug. Consider a patient receiving a regular main- inhibits the metabolism of the active isomer of warfarin tenance dose of a drug. When a second displacing drug is (S-warfarin), causing this to accumulate at the expense of the commenced, the free concentration of the first drug rises only inactive isomer. Consequently, any increased effect of the displaced bleeding by causing peptic ulceration and interfering with drug is transient, and is seldom important in practice. These include: • Drug interactions may be clinically useful, trivial or • warfarin and other anticoagulants; adverse. They may also enable • digoxin and other anti-dysrhythmic drugs; toxic effects to be minimized, as in the use of pyridoxine to prevent neuropathy in malnourished • oral hypoglycaemic agents; patients treated with isoniazid for tuberculosis, and • xanthine alkaloids (e. The frequency and consequences of an adverse interaction • Many interactions that occur in vitro (e. Every individual has a peculiar set of characteristics increased elimination by metabolism or excretion and that determine their response to therapy. In a smaller hyperkalaemia and other causes of cardiac dysrhythmia, study in a chronic-care setting, the prevalence of adverse unwanted pregnancy, transplanted organ rejection, etc. Historically, it took several years for nephrologists to appreciate that epilep- Inactivation can occur when drugs (e. These adverse events proved to be due to an also interact in the lumen of the gut (e. Most have a simple mechanism consisting interactions should lead to their prediction and prevention by of summation or opposition of the effects of drugs with, study in early-phase drug evaluation.
Compliance has excited an enormous amount of clinical and academic interest over the past few decades and it has been calculated that 3200 articles on compliance in English were listed between 1979 and 1985 (Trostle 1988) cheap 100 mg amantadine visa hiv infection by race. Compliance is regarded as important primarily because following the recommendations of health professionals is considered essential to patient recovery. However, studies estimate that about half of the patients with chronic illnesses, such as diabetes and hypertension, are non-compliant with their medication regimens and that even com- pliance for a behaviour as apparently simple as using an inhaler for asthma is poor (e. Further, compliance also has financial implications as money is wasted when drugs are prescribed, prescriptions are cashed, but the drugs not taken. This claimed that compliance can be predicted by a combination of patient satisfaction with the process of the consultation, understanding of the information given and recall of this information. Several studies have been done to examine each element of the cognitive hypothesis model. Patient satisfaction Ley (1988) examined the extent of patient satisfaction with the consultation. He reviewed 21 studies of hospital patients and found that 41 per cent of patients were dissatisfied with their treatment and that 28 per cent of general practice patients were dissatisfied. Ley (1989) also reported that satisfaction is determined by the content of the consultation and that patients want to know as much information as possible, even if this is bad news. For example, in studies looking at cancer diagnosis, patients showed improved satisfaction if they were given a diagnosis of cancer rather than if they were protected from this information. Participants were asked to read some information about medica- tion and then to rate their satisfaction. Some were given personalized information such as, ‘If you take this medicine, there is a substantial chance of you getting one or more of its side effects’ whereas some were given non personalized information, ‘A substantial proportion of people who take this medication get one or more of its side effects’. The results showed that a more personalized style was related to greater satisfaction, lower ratings of the risks of side effects and lower ratings of the risk to health. The authors coded recorded consultations for their humour content and for the type of humour used. They then looked for differences between high and low satisfaction rated consultations. The results showed that high satisfaction was related to the use of more light humour, more humour that relieved tension, more self-effacing humour and more positive-function humour. Patient satisfaction is increasingly used in health care assessment as an indirect measure of health outcome based on the assump- tion that a satisfied patient will be a more healthy patient. This has resulted in the development of a multitude of patient satisfaction measures and a lack of agreement as to what patient satisfaction actually is (see Fitzpatrick 1993). However, even though there are problems with patient satisfaction, some studies suggest that aspects of patient satisfaction may correlate with compliance with the advice given during the consultation. Patient understanding Several studies have also examined the extent to which patients understand the content of the consultation. Boyle (1970) examined patients’ definitions of different illnesses and reported that when given a checklist only 85 per cent correctly defined arthritis, 77 per cent correctly defined jaundice, 52 per cent correctly defined palpitations and 80 per cent correctly defined bronchitis. Boyle further examined patients’ perceptions of the location of organs and found that only 42 per cent correctly located the heart, 20 per cent located the stomach and 49 per cent located the liver. This suggests that understanding of the content of the consultation may well be low. Further studies have examined the understanding of illness in terms of causality and seriousness. Roth (1979) asked patients what they thought peptic ulcers were caused by and found a variety of responses, such as problems with teeth and gums, food, digestive problems or excessive stomach acid. Roth also reported that 30 per cent of patients believed that hypertension could be cured by treatment. If the doctor gives advice to the patient or suggests that they follow a particular treatment programme and the patient does not understand the causes of their illness, the correct location of the relevant organ or the processes involved in the treatment, then this lack of understanding is likely to affect their compliance with this advice. This study examined the effect of an expert, directive consulting style and a sharing patient-centred consulting style on patient satisfaction. This means that it is possible to compare the effects of the two types of consulting style without the problem of identifying individual differences (these are controlled for by the design) and without the problem of an artificial experi- ment (the study took place in a natural environment). Theoretically, the study examines the prediction that the educational model of doctor–patient communication is problem- atic (i. Background A traditional model of doctor–patient communication regards the doctor as an expert who communicates their ‘knowledge’ to the naïve patient. Within this framework, the doctor is regarded as an authority figure who instructs and directs the patient.
They are more frequently mentioned in Who’s Who publica- More specific research on the effects of birth order tions than individuals in any other birth position and are has generally focused on five ordinal birth positions: overrepresented among members of Congress and U generic amantadine 100 mg visa hiv infection rate singapore. Studies have consistently linked first-born dents are especially vulnerable to stress and tend to seek children and academic achievement. Adler found that there were more born National Merit Scholarship winners was found to first-borns than later-borns among problem children. While most psychoana- ly high level of success in team sports, and both they and lytical psychologists assign a moderate degree of impor- last-borns have been found to be better adjusted emotional- tance to the birth trauma in terms of its effects, some be- ly if from large families. Studies have also found middle lieve that the birth trauma is the prototypical basis of all children to be sensitive to injustice and likely to have aes- later anxiety neuroses. Generally trusting, accepting, and other- rience presents obvious difficulties in the precise deter- centered, they tend to maintain relationships successfully. The term birth trauma may also mean any physical in- The last-born child, never dethroned as the “baby” of jury to an infant that occurs during birth. As a group, last-borns are most successful Further Reading socially and have the highest self-esteem levels of all the Hotchner, Tracy. New York: Avon, 1990 first-borns or only children to join a fraternity or sorority. The Illustrated Book of Pregnancy and Like youngest children, only children are never displaced as Childbirth. With only adult models to emu- late within the family, only children are achievement-orient- ed and most likely to attain academic success and attend college. However, studies show that only children have the most problems with close relationships and the lowest need Birth for affiliation. In humans, the process of delivering a child from the uterus, usually by passage through the birth Sibling rivalry frequently erupts in households with canal at the end of pregnancy, normally after a ges- two or more children, competing for the time, attention tation period of about 267 days; also called parturi- and affection of parents. First borns may resent re- Childbearing is often viewed as the transition to sponsibility placed upon them for their siblings. Birth labor is divided into several children may feel “squeezed out” while last-borns may stages. During the latent phase (Stage 0), which lasts play on their baby position in the family. Mental health from several hours to as long as three days, uterine con- experts advise parents to listen to their children’s feel- tractions (either regular or irregular) are present, but the ings rather than deny their feelings or convince them to cervix has not dilated more than three or four centime- feel differently. The that parents find time to spend with each child and share first stage of labor begins with uterine contractions ac- in each child’s interests. Family Constellation: Its Effects on Personality opening is large enough to allow the passage of the child and Social Behavior. Birth Order Blues: How Parents Can Help sometimes much earlier), the sac containing the amniotic Their Children Meet the Challenges of Birth Order. The first stage can take up to 12 hours with first-time mothers, although it may be very rapid in women who have had several children. It can last many hours in obstructed labor, where the baby is unusually large or badly angled. Birth trauma The second stage of labor begins with the complete In psychoanalysis, birth provides the first experi- dilation and effacement (thinning) of the cervix and ends ence of anxiety in an individual’s life. The mother begins contracting her abdominal birth canal by strong uterine contractions called after- muscles voluntarily (“bearing down”), and the baby is birth pains. These contractions also help the uterus to re- expelled, usually head first, by a combination of this vol- turn to its normal size. The doctor examines the placenta untary contraction and the involuntary contractions of and amniotic sac to confirm that all tissue has been ex- the uterine muscles. The physician aids in the delivery pelled from the uterus, as serious complications may re- by guiding the infant’s head and shoulders out of the sult if fragments remain inside, especially hemorrhaging. About 2 to 3 percent of babies are born feet If parts of the placenta or sac are missing, the doctor re- first (breech babies). Finally, the episiotomy (if one has during the second stage of labor to speed delivery in been performed) is sutured with absorbable stitches. The order to ease either maternal exhaustion or infant dis- total duration of labor averages about 13 hours for first tress. Other medical techniques utilized include the epi- deliveries and about eight hours for subsequent deliver- siotomy, a surgical incision along the back of the vagina ies, although there are large individual variances from to enlarge the opening.
Maintain an open-minded attitude about all tion of books and tapes on alternative therapies are potentially new therapeutic interventions that gobbled up by an uncritical public that does not include those commonly referred to as alternative cheap 100mg amantadine amex hiv infection unaids. Do not ignore or ridicule the potential of the tific illiteracy and the rise of pseudoscience and placebo effect to produce marked therapeutic superstition, noting that “baloney, bamboozles, benefit. Do not accept all new therapies as efficacious on ripple through mainstream political, social, reli- first acquaintance. Political decisions allow licensing of alternative Claims of therapeutic efficacy should be ratio- practitioners without any scientific basis for accred- nally examined and tested. Congress has recently dismantled its alternative medical practices because one might own scientific oversight section, the Office of Tech- be embarrassed by the subsequent demonstra- nology Assessment. Sound, good quality receive compassionate care, and to establish a part- research is needed to determine the potential bene- nership with a provider in seeking health. Uncon- wort for depression—an overview and meta-analysis ventional medicine in the United States. Fogarty International Center For information on the National Academies, National Cancer Institute visit www. For information National Center for Complementary and on the Institute of Medicine, visit www. John’s wort Millettia reticulata millettia Ilex pubescens ilex Momordica charantia bitter gourd, karela Illicium verum star anise Morinda sp. Noni, Nonu Isiatis tinctoria isiatis Morus alba morus Juniperus sp juniper Musa sp. Franch chuan xiong Pimpinella anisum anise Lilium brownii lily bulb Piper longum long pepper Lindera strychnifolia lindera Pinellia seed Pinellia ternata Litchi chinensis litchi Piper methysticum kava Lobelia inflata lobelia Piper nigrum black pepper Lonicera japonica honeysuckle Plantago major/lanceolate plantain Lonicera japonica Thunb. Rubus chingii rubus Turmeric Curcuma longae Rubus idaeus aspberry leaves turnera diffusadamiana Ruta graveolensrue Tussilago farfara coltsfoot Salix alba white willow bark Uncaria rynchophyllauncaria stem Salvia officinalissage leaves Uncaria tomentosa cat’s claw, Sambucus nigra L. National Center for Complementary and Alterna- Table of Contents tive Medicine wishes to extend its sincerest grati- Acknowledgments tude to the many organizations and individuals Preface who contributed to the development of this plan. As Americans knowledgeable in the multiple traditions and disci- become increasingly activist in their pursuit of sus- plines that contribute to the healing arts. We bring to that our first strategic plan, Expanding Horizons of Health- endeavor a curiosity and open-mindedness, moti- care. I am deeply grateful to my colleagues and the vated by the prospect of enhancing the healthcare many organizations and individuals who have con- repertoire, while at the same time mindful of the tributed to its development. We are theria, influenza, pneumonia—made possible by also hopeful that advances in neuroscience will the development of vaccines and the advent of yield greater understanding of what happens in antibiotic drugs. To be sure, new and re-emerging acupuncture and meditation and what lies behind infectious diseases remain serious, both locally and the placebo effect. Conservative esti- care and concern that should characterize the mates put expenditures for alternative medicine physician-patient relationship, a dialogue that professional services at $21. The advertising and problems, allergies, fatigue, arthritis, and marketing of alternative and complementary medi- headaches. Qi gong in five major domains: alternative medical sys- (pronounced’chee gung’) is a component of tradi- tems; mind-body interventions; biologically based tional Chinese medicine that combines movement, treatments; manipulative and body-based meth- meditation, and regulation of breathing to enhance ods; and energy therapies5, with some overlap the flow of vital energy (qi) in the body to improve across categories. Ayurvedic medi- mainstream healthcare repertoire following cine, India’s traditional medical system, is an exam- demonstration of safety and efficacy by rigorous ple of an alternative system based on the principle scientific investigation. For example, before Nixon that health is achieved by restoring the innate har- went to China in 1971 and James Reston’s com- mony of the individual. It emphasizes the equal pelling memoir that same year6, acupuncture was importance of body, mind, and spirit. More from ancient Greece to the modern era was based recently, investigators have reported positive on the belief that ill health resulted from an imbal- results in the use of acupuncture to treat cocaine ance of the body’s four humors (blood, phlegm, addiction. Such drugs of botanical origin dence of benefit have led to the entry of certain include digitalis for the treatment of congestive mind-body interventions, for example, cognitive- heart failure and vincristine, and more recently, behavioral therapies and various means of stress taxol, for treatment of cancers. Still others await discovery and vali- ropractic approaches in which the spine (primarily) dation of their worth. To pur- Acupuncture for Addiction sue these investigations, we must train, encourage, 53. Further studies are needed to confirm these tices—truly expanding the horizons of healthcare. These practices can then be integrated into optimal interdisciplinary treatment plans developed in cooperation with patients.
