By I. Akascha. Minnesota State University Moorhead. 2019.

It is a constituent of some kidney stones Calculi – any abnormal concretion buy 40mg prednisolone fast delivery, commonly called a stone generic 5 mg prednisolone with visa, within the animal body prednisolone 40 mg cheap. A calculus is usually composed of mineral salts cheap 40mg prednisolone mastercard, and can be found in the gallbladder, kidneys, ureter, bladder, or urethra Candidiasis – infection of the skin or mucous membrane with any species of Candida. Candida grows in warm moist areas, causing superficial infections of the mouth, vagina, nails, and skin folds of healthy individuals. Sometimes very difficult to get rid of Cardiac arrest – heart stops due to many reasons with the main one being heart attacks Cardiomegaly – enlargement of the heart Cardiomyopathy – any disease that affects the heart muscle, diminishing heart performance Cardiovascular – pertaining to the heart and blood vessels Cardioversion – the restoration of normal sinus rhythm by chemical or electrical means. When preformed mechanically, the procedure relies on or the oral or intravenous administration of antiarrhythmic drugs. Electrical cardioversion relies instead on the delivery of synchronized shock of direct electrical current across the chest wall. It is used to terminate arrhythmias such as atrial fibrillation, atrial flutter, supraventricular tachycardia, and well tolerated ventricular tachycardia. Unlike defibrillation, which is an unsynchronized shock, applied during a dire emergency, electrical cardioversion is timed to avoid the T wave of cardiac repolarization to avoid triggering malignant arrhythmias. A patient will almost always require sedation and analgesia before the procedure Carnitine – a chemical important in metabolizing palmitic and stearic acids. It has been used therapeutically in treating myopathy due to carnitine deficiency. In children that are on Depakote, you need to have their Carnitine levels checked periodically due to the fact that Depakote pulls Carnitine from the body system Carpal tunnel – pain or numbness that affects some part of the median nerve distribution of the hand (the palmer side of the thumb, the index finger, the radial half of the ring finger, and the radial half of the palm) and may radiate to the arms. Patients may have a history of cumulative trauma to the wrist in carpenters, rowers, typists, computer users, or those who regularly use vibrating tools or machinery Cascara – It is the main ingredient in a laxative which is supposed to be fairly good 399 Cataplexy – a sudden brief loss of muscle control brought on by strong emotion or emotional response, such as a hearty laugh, excitement, surprise, or anger. Cataracts – opacity or cloudy looking of the lens of the eye or its capsule or both Catatonic – a phase of schizophrenia in which the patient is unresponsive, the tendency is to remain and assume in a fixed position, refusal to move or talk are characteristics Catecholamines – one of many biologically active amines, including Metanephrines, Dopamines, Epinephrine and Norepinephrine, derived from Amino and Tyrosine. It is composed primarily of secretions of the choroids plexi in the lateral ventricles and in the third and fourth ventricles in the brain. Openings in the roof of the fourth ventricle allow the fluid to flow into the subarachnoid spaces around the brain and the spinal cord. The flow of fluid is from the blood in the choroids plexi, through the ventricles, the central canal, the subarachnoid spaces, and back into the blood. Samples of the fluid may be removed by lumbar puncture Cerebrovascular – pertaining to the blood vessels of the brain especially to pathological changes Ceroids – morbid condition of membranes resembling wax-like scales 400 Cervical erosion – a wearing away of the cervix in the uterus of females Chemoreceptor trigger zone – a sense organ or sensory nerve ending that is stimulated by and reacts to certain chemical stimuli and that is located outside the central nervous system. The excess pigmentation often occurs in pregnant women, in women using oral contraceptives, or in patients with underlying liver disease. Sun exposure tends to worsen the condition Cholelithiasis - formation or presence of stones in the bladder or kidneys or bile- stones in the gallbladder or common duct Cholestatic – arrest of the flow of bile. This may be due to intrahepatic causes, obstruction of the bile duct by gallstones, or any process that blocks the bile duct Cholesterol – a sterol widely distributed in animal tissues. Found in egg yolks, various oils, fats, myelin in the brain, spinal cord and axons, liver, kidneys, and adrenal glands. It is synthesized in the liver and is a normal constituent of most gallstones and of atherosclerotic plaques found in arteries. Spores from the fungus circulate in the air, when the dirt is disturbed during construction, dust storms, or earthquakes. About 80% of those persons living in the southwest and western states have positive skin test, which identify those infected. Usually these infections are asymptomatic and require no treatment Cogwheel rigidity – an abnormal rigor in muscle tissue, characterized by jerky movements when the muscle is passively stretched. Synthetic derivatives of this agent are used medicinally to relax skeletal muscles during anesthesia and critical care Cyanosis – slightly bluish, grayish, slate like or dark purple discoloration of the skin due to presence of abnormal amounts of reduced hemoglobin in the blood Cycloplegia – paralysis of the ciliary muscle (eye). This can be an anticholenergic side effect of antipsychotic or antidepressant medications Cyst – a closed sac or pouch with a definite wall, which contains fluid, semi fluid or solid material, usually an abnormal structure resulting from developmental anomalies, obstruction of ducts, or parasitic infection, usually not cancerous Cystic Fibrosis – a potentially fatal autosomal recessive disease that manifests itself in multiple body systems including the lungs, the pancreas, the urogenital system, the skeleton, and the skin; it causes chronic obstructive pulmonary obstructive disease, frequent lung infections, deficient elaboration of pancreatic enzymes, osteoporosis, and an abnormal high electrolyte concentration in sweat. The street name for this is “speed” Diabetes Mellitus – a chronic metabolic disease marked by hyperglycemia (high sugar level). Diabetes results either from failure of the pancreas to produce insulin (type I Diabetes) or from insulin resistance, with inadequate insulin secretion to sustain normal metabolism (type 2 Diabetes). It is the greatest single cause of absence from school and work among menstrual-age women Dysmetria – an inability to fix the range of a movement, rapid and brisk movements made with more force than necessary, seen in cerebellar affections Dysostosis – defective bone formation Dyspepsia - Imperfect digestion, not a disease in itself, but symptomatic of other diseases or disorders, indigestion Dysphagia - inability or difficulty in swallowing, impairment of speech resulting from a brain tumor Dysphonic – difficulty in speaking, hoarseness Dysphoric – exaggerated feeling of depression and unrest without apparent cause Dyspnea – air hunger resulting in labored or difficult breathing usually accompanied by pain, insufficient oxygenation of the blood resulting from disturbances in the lungs, low oxygen pressure in the air, circulatory disturbances, hemoglobin deficiencies, acidosis, excessive sodium bicarbonate content of the blood, excessive muscular activity, lesions of the respiratory center, emotional excitation, asthma Dysrhythmia – irregular possibly painful heart rhythm due to a variety of reasons Dystonia – not having the ability to possess muscular tone or unable to have a state of normal tension or partial contraction of muscle fibers while at rest Dysuria – painful or difficult urination, symptomatic of numerous conditions, usually frequent urination, may be indicative of cystitis, neuralgia of the bladder, urethritis, ulcerated prostate in the male or prolapsed uterus in the female, pelvic peritonitis and abscess, pain and burning may also be caused by concentrated acid urine 406 E Ecchymosis – when blood leaks into the skin or mucous membrane, due to injury, clotting mechanism problems, etc. The patient loses consciousness and undergoes tonic contractions for approximately 10 seconds, followed by a somewhat longer period of clonic seizures accompanied by apnea; on awakening the patient has no memory of the shock. Acids, bases, and salts are common electrolytes Electrolyte imbalance – a condition of a solution needed for conduction of electricity for an electric current that is not balanced within the “normal” ranges causing a wide variety of other health problems, usually think of sodium, potassium, calcium, magnesium, etc Electron microscopy – a specific test used in the diagnoses of Batten Disease Embolism – obstruction of a blood vessel by foreign substance or a blood clot, diagnosing depends on the factors predisposing arteriosclerosis favors a thrombosis while atrial fibrillation, bacterial endocarditis, or thrombophlebitis points to embolism, nearly always embolism is due to blood clots Emulsion – a mixture of two liquids not mutually soluble. If they are thoroughly shaken, one divides into globules in what is called the discontinuing or dispersed phase; the other is then the continuous phase. Milk is an emulsion in which butterfat is the discontinuous phase Endometriosis – tissues located in various sites throughout the pelvis or in the abdominal wall, found more commonly in the ovary than elsewhere 407 Endotracheal – within or through the trachea Emesis – vomiting Emetic - medicines that produce vomiting Empiric – a practitioner whose skill or art is based on what has been learned through experience Emphysema – distention of tissues by air or gas in between the cells of the lung, a condition in which the alveoli of the lungs become distended or ruptured, usually the result of interference with expiration, or loss of elasticity of the lung Encephalin – a pentapeptide produced in the brain. It acts as an opiate and produces analgesia by binding to opiate receptor sites involved in pain perception. Encephalin may have a role in explaining the withdrawal signs of narcotic addiction Encephalopathy – disease of the brain Endocrine – an internal secretion, pertaining to a gland that produces secretion Endogenous - produced within a cell or organism, concerning spore formation within the bacterial cell Endorphins – a polypeptide produced in the brain that acts as an opiate and produces analgesia by binding to the opiate receptor sites involved in pain perception. The most active of these compounds is beta-endorphin Endoscopy – inspection of the cavities by use of the esophagus and the endoscope Enteritis – inflammation of the intestines, more particularly of the mucous and sub-mucous tissues usually of the small intestine Enuresis – incontinence, involuntary discharge of urine, complete or partial, diurnal or nocturnal, dependent upon pathologic or functional causes, although it may be voluntary as representative of a behavior pattern Enzymes – an organic catalyst produced by living cells but capable of acting independently of the cells producing them, they are complex substances which are capable of inducing chemical changes in other substances without themselves being changed in the process, protein in nature, found in the digestive juices acting upon food substances causing them to break down into simpler compounds, they are capable of accelerating greatly the speed of chemical reactions Eosinophil – a cell or cellular structure that stains readily with the acid stain, present in small numbers in normal conditions Epidermophyton floccosum – the causative agent of certain types of athlete’s foot Epidural - located over or upon the dura which is the space outside the dura mater of the brain and spinal cord 408 Epigastric - condition of the upper portion of the abdominal muscle of the stomach when skin of the epigastric region is scratched Epilepticus – continual grand mal seizures where immediate medical attention is required Epinephrine – the active principle of the medulla of the adrenal gland, occurring as a white or light brown powder, darkening on exposure to the air, it has been prepared synthetically, it is employed therapeutically as a vasoconstrictor, cardiac stimulant, to induce uterine contractions and to relax bronchioles, its effects are similar to those brought about by stimulation of the sympathetic division of the autonomic nervous system Epistaxis – nosebleed Eradication – laying open diseased part and scraping away diseased tissue Ergosterol – the primary sterol, or fat found in the cell membranes of fungi. Most antifungal drugs act on ergosterol to increase permeability of the cell wall of the fungus, promoting its destruction Eructation – producing gas from the stomach, usually with a characteristic sound; belching Erythema – a form of rash showing diffused redness over the skin, caused by capillary congestion, usually due to dilatation of the superficial capillaries as a result of some nervous mechanism within the body, inflammation, as a result of some external influence such as heat, sunburn etc. Esophagitis – inflammation of the esophagus Estrogens – any natural or artificial substance that induces estrus and the development of female sex characteristics; more specifically, the estrogenic hormones produced by the ovary; the female sex hormones. In a living cell a fatty acid occurs in combination with another molecule rather than in a free state. Essential fatty acids are unsaturated molecules that cannot be produced by the body and must therefore be included in the diet. The process results in the replacement of normal cells by fibroblasts and eventually, the replacement of normal organ tissue by scar tissue Flatulence - excessive gas in the stomach and intestines Fluid retention – failure of the body to expel fluids normally, occurring in kidney diseases, when the protein count of plasma falls below 4%, fluid cannot be attracted back into the blood stream and edema (swelling) occurs, retention of salt is another cause of fluid retention Fluorometer – a device for determining the amount of radiation produced by xrays. A device for adjusting a fluoroscope to establish the location of a target more accurately and to produce an undistorted image or shadow Focal – pertaining to the point of convergence of light rays or waves of sound, such as a focal infection is one occurring near a focus – as the cavity of a tooth Folliculitis – inflammation of a follicle, synonym would be acne, or inflammation of a puss filled follicle of the scalp resulting in irregular hair loss and scarring Fungi – a vegetable cellular organism that subsists on organic matter, such as bacteria and molds, many species are parasitic, thus disease, fungi are simple dependent plants, lacking chlorophyll, with simple life cycles including toadstools, molds, mushrooms, rusts, lichens, and yeasts Furunculosis – a condition resulting from furuncles or boils – a tender dome shaped skin lesion, typically caused by infection around a hair follicle with Staph aureus. When they first appear they are often superficial, but as they mature they form localized abscesses with 410 pus and necrotic debris at their core. Its extracts have been used medicinally in China for centuries and promoted as a memory aid. Its extracts and metabolites are antioxidants Glandular - pertaining to or the nature of the gland, treatment of the disease with endocrine glands of their extracts Glaucoma – disease of the eye characterized by an increase in the intra ocular pressure which results in atrophy of the optic nerve and blindness of two general types, primary which sets in without known cause, and secondary in which there is an increase in intra-ocular pressure due to other eye diseases, the acute type is accompanied by acute pain, the chronic type has an insidious Gliomas – an onset Glioma – a sarcoma (cancerous) of neurological origin; a neoplasm or tumor composed of neuroglia cells Glossitis – inflammation of the tongue Glutamate – a salt of glutamic acid that functions as the brain’s main excitatory neurotransmitter 411 Glycerol – a trihydric alcohol, present in chemical combination in all fats. It is made commercially by the hydrolysis of fats, especially during the manufacture of soap, and is used extensively as a solvent, a preservative, and an emollient in various skin diseases. The volume of erythrocytes (Red blood cells) packed by centrifuge in a given volume of blood. A substance that assists in or stimulates the production of blood cells Hematotoxicity – pertaining to septicemia or toxicity in the blood Hematuria – blood in the urine, urine may be slightly smokey, reddish or very red Hemianopia – blindness for one-half field of vision in one or both eyes 412 Hemiplegia – paralysis of only one half of the body, a brain lesion involving upper motor neurons and resulting in paralysis of the opposite side of the body Hemodialysis – process by which the blood is filtered through a machine when the body is unable to rid itself of natural body toxins for whatever reason Hemodynamics – a study of the forces involved in circulating blood through the body Hemoglobin – the iron containing pigment of red blood cells that carries oxygen from the lungs to the tissues Hemolytic anemia – pertaining to the breakdown of red blood cells to the point of being anemic Hemoptysis – expectoration (vomiting) of blood arising from hemorrhage of the larynx, trachea, bronchi, or lungs, attack sudden, salty taste, blood frothy, bright red Hemorrhage – abnormal discharge of blood, either external or internal, venous, arterial, or capillary from blood vessels into tissues into or from the body, venous blood is dark red, flow is continuous, arterial blood is bright red, flows in jets, capillary blood is of a reddish color, exudes from tissues Hepatic – pertaining to the liver Hepatitis – inflammation of the liver, virus, toxic origin, it is manifested by jaundice (yellowing of the skin or the whites of the eyes) and in some instances, liver enlargement, fewer and other systemic disorders are usually present Hepatobiliary – a combining word referring to the liver and the bile ducts Hepatocellular – pertaining to the cells of the liver Hepatomegaly – enlargement of the liver Herpes simplex – fever blisters, occurrence of clusters of blisters usually on the face (also may be on the genital area) marked by itching and localized pain, lesions will dry up in 10 - 14 days if left alone Hiatal hernia – protrusion of a portion of the stomach upward through the diaphragm.

Anorexia nervosa and a similar eating disorder called bulimia nervosa are discussed in Chapter 14 buy discount prednisolone 5mg online. Failure of the liver to produce albumin (a protein that regulates the amount of fluid in the circulatory system) safe prednisolone 40mg, combined with portal hypertension forces fluid to pass from the circulatory system and accumulate in the peritoneum order prednisolone 20 mg with mastercard. It may also be caused by toxins prednisolone 10 mg sale, infectious agents, metabolic diseases, and circulatory disorders. In this disor- der, functional hepatic cells are replaced by nonfunctioning f ibrous tissue that impairs the flow of blood and lymph within the liver, resulting in hepatic insuff iciency. It may also be due to surgery, such as gastric resection and ileal bypass, or antibiotic therapy. Obesity may be due to excessive intake of food (exogenous) or metabolic or endocrine abnormalities (endogenous). Morbid obesity is a disease with serious psychological, social, and medical rami- f ications and one that threatens necessary body functions such as respiration. After surgery in adults, a stomach tube remains in place and obser- -osis: abnormal condition; increase vation is maintained for signs of hemorrhage or blockage of the tube. Pathology 123 Diagnostic and Therapeutic Procedures This section introduces procedures used to diagnose and treat digestive system disorders. Descriptions are provided as well as pronunciations and word analyses for selected terms. It is also used to conf irm the presence and extent of varices in the lower esophagus and stomach in patients with liver disease. When polyps are discovered in the colon, they are retrieved and tested for cancer. Colonoscopy (Examination Polyp of entire length End of of colon) sigmoidoscopy (Examination of lower third Sigmoid colon of colon) Anus Figure 6-9. Bilirubin is a breakdown product of hemo- globin and is normally excreted from the body as bile. Excessive bilirubin causes yellowing of the skin and mucous membranes, a condition called jaundice. It also helps detect colon cancer and bleeding associated with diges- tive disorders. It is used for diagnosing obstructions, tumors, or other abnormalities of the colon. It is also used to diagnose tumors, cysts, inflammation, abscesses, perforation, bleeding, and obstructions. A band is then inserted that restricts food consumption and delays its passage from the pouch, causing a feeling of fullness. Staple lines Small stomach Staple lines Esophagus pouch Pouch Esophagus Duodenum A. Duodenum Arrows show pathway of food Shortened jejunum is now connected to the small stomach pouch Connection B. Stoma Colostomy performed to Colostomy bag attach healthy attached to stoma tissue to abdomen Figure 6-12. Antacids counteract or decrease excessive drugs include agents that relieve “cramping” (anti- stomach acid, the cause of heartburn, gastric dis- spasmodics) and those that help in the movement comfort, and gastric reflux. Complete each activity and review your answers to evaluate your understanding of the chapter. Learning Activity 6-1 Identifying Digestive Structures Label the illustration on page 109 using the terms listed below. Enhance your study and reinforcement of word elements with the power of DavisPlus. We recommend you complete the flash-card activity before completing Activity 6–3 below. Learning Activities 135 Learning Activity 6-3 Building Medical Words Use esophag/o (esophagus) to build words that mean: 1. Complete the termi- nology and analysis sections for each activity to help you recognize and understand terms related to the digestive system. Use a medical dictionary such as Taber’s Cyclopedic Medical Dictionary, the appendices of this book, or other resources to define each term. Then review the pronunciations for each term and practice by reading the medical record aloud. Eventually, she was diag- nosed as having cholecystitis with cholelithiasis and underwent cholecystectomy. This pain followed a crescendo pattern and peaked several weeks ago, at a time when family stress was also at its climax. It does not cause any nausea or vomiting, does not trigger any urge to defecate, and is not alleviated by passage of flatus. While referring to Figure 6–3, describe the location of the gallbladder in relation to the liver. How does the patient’s most recent postoperative episode of discomfort (pain) differ from the initial pain she described? Use a medical dictionary such as Taber’s Cyclopedic Medical Dictionary, the appendices of this book, or other resources to define each term. Then review the pronunci- ations for each term and practice by reading the medical record aloud. She was given nasal oxygen at 3 liters per minute and monitored with a pulse oximeter throughout the procedure. Through a previously inserted intravenous line, the patient was sedated with a total of 50 mg of Demerol intravenously plus 4 mg of Midazolam intravenously throughout the procedure. The Fujinon computed tomography scan videoendoscope was then readily introduced and the following organs evaluated. A representative biopsy was obtained from the gastric antrum and submitted to the pathology laboratory. Operative Report: Esophagogastroduodenoscopy with Biopsy 145 The patient tolerated the procedure well. Were there any ulcerations or erosions found during the exploratory procedure that might account for the bleeding? Upper Respiratory Tract • Describe the functional relationship between the Lower Respiratory Tract respiratory system and other body systems. Respiration • Pronounce, spell, and build words related to the res- Connecting Body Systems–Respiratory System piratory system. Medical Word Elements • Describe pathological conditions, diagnostic and Pathology therapeutic procedures, and other terms related to Chronic Obstructive Pulmonary Disease Asthma the respiratory system. Chronic Bronchitis • Explain pharmacology related to the treatment of Emphysema respiratory disorders. Influenza • Demonstrate your knowledge of this chapter Pleural Effusions by completing the learning and medical record Tuberculosis activities.

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Physicochemical factors associated with the drug moiety The physicochemical properties of a molecule which affect its absorption across the cornea are broadly the same as those affecting transepithelial absorption at any site and have been discussed extensively in Chapter 1 (Section 1 generic prednisolone 20 mg online. These factors influence the mechanism and rate of drug absorption through the cornea prednisolone 20mg without a prescription. This is well illustrated by efforts in developing topically effective carbonic anhydrase inhibitors such as dorzolamide through significant alternations in chemical structure buy discount prednisolone 40mg. Prodrug approach In ophthalmic research buy prednisolone 20 mg on-line, a prodrug is designed to be inactive with some degree of biphasic solubility as the cornea is a biphasic tissue in structure. It will be transformed into the active drug by either an enzymatic or a chemical processes in the eye. Due to its increased lipophilicity, 308 dipivefrin penetrates the corneal epithelium 10 times more readily than epinephrine. The higher penetration of the drug results in a smaller dose being required, thus reducing systemic side-effects. For potent drugs such as timolol, which has the potential to cause serious systemic side-effects, such a corresponding reduction would be clinically valuable. By other routes, this can be achieved by adhering a reservoir of drug as a membrane-controlled patch or osmotic pump on the epithelium (see Chapters 4 and 8). However, the function of the eye as a visual apparatus limits the possibility of such an attachment of these dosage forms to the cornea. To optimize ocular drug bioavailability by increasing concentration gradient of the drug, considerable efforts have been devoted to minimize solution drainage. This would improve drug residence time on the sclera and cornea, thereby modifying the drug pulse entry characteristics. Other techniques include the use of novel formulations allowing drugs to be delivered in a controlled manner over a long period. A suitable placement of an eyedrop and a reduced instilled volume also contribute to the improved ocular bioavailability. Viscous systems A popular approach to improve ocular drug bioavailability is to incorporate soluble polymers into an aqueous solution to extend the drug residence time in the cul-de-sac. It is reasoned that the solution viscosity would be increased and hence solution drainage would be reduced. They have common properties: • a wide range of viscosity (400 to 15,000 cps); • compatibility with many topically applied drugs; • increased stability of the lacrimal film. Bioadhesives Bioadhesion is an interfacial phenomenon in which a synthetic or natural polymer becomes attached to a biological substrate by means of interfacial forces. If it involves mucin or mucous-covered membrane, the narrow term mucoadhesion is employed. Bioadhesion has been used to enhance bioavailability of drugs via various other routes including oral (Section 6. Bioadhesion may offer several unique features: 309 • localizing a dosage form within a particular region, increasing drug bioavailability; • promoting contact with the absorbing surface, permitting modification of tissue permeability in a restricted region; • prolonging residence time and reducing dosing frequency. The presence of mucin in the eye allows bioadhesive polymers to thicken the tear film in the front of eye. The hydrophilic groups on mucoadhesive polymers and the large amount of water associated with mucin present two possible adhesion mechanisms: (i) hydrogen bonding and (ii) interpenetration of a swollen gel network with hydrated mucin. Many methods have been used for the assessment of bioadhesive properties, including fluorescent techniques and tensile tests. By using these methods, a number of natural and synthetic polymers have been discovered possessing mucoadhesive properties. Natural polymers Sodium hyaluronate is a high molecular weight polymer extracted by a patented process from sources including chicken coxcombs. It consists of a linear, unbranched, non-sulphated, polyanionic glycosaminoglycan, composed of one repeating disaccharide unit of D-sodium glucuronate and N-acetyl-D- glucosamine. Products based on hyaluronates are widely used in intraocular surgery as a substitute for vitreous humor and as an adjuvant to promote tissue repair. Hyaluronates show a topical protective effect for the corneal endothelium and other delicate tissues from mechanical damage through providing a stabilized hydrogel. Sodium hyaluronate with its unusual rheological quality, producing a rapid transformation from a liquid to a solid character with increasing stress frequency, appears to be beneficial for topical vehicles. The pseudoplastic behavior of hyaluronate solutions, where viscosity is higher at the resting phase, provides a thickened tear film, slow drainage and an improved distribution on the cornea during blinking. Furthermore, the carboxyl groups of hyaluronate form hydrogen bonds with sugar hydroxyl groups of mucin when sodium hyaluronate is applied in the eye, producing an intimate contact with the cornea. These unique properties give hyaluronates great potential in ocular drug delivery. Chondroitin sulphate is another polysaccharide derivative (glycosaminoglycan) with a repeat unit containing β-D-glucoronic acid and D-N-acetyl galactosamine, very similar to hyaluronic acid except for modification of the position of a hydroxyl group and the addition of sulphate groups to the galactosamine residue. Chondroitin sulphate has a good affinity to the corneal surface, preventing premature breakup of the tear film between blinks. Formulations containing chondroitin have been used for the treatment of dry eye and showed superiority to hyaluronic acid in treating severe cases of keratoconjunctivitis sicca. Synthetic polymers Carbomers are poly (acrylic acid) polymers widely used in the pharmaceutical and cosmetic industries. They have several advantages, including high viscosities at low concentrations, strong adhesion to mucosa without irritation, thickening properties, compatibility with many active ingredients, good patient acceptability and low toxicity profiles. These properties have made carbomers very valuable in the field of ophthalmic formulations. Artificial tear products and novel drug delivery systems based on carbomers have been extensively formulated. A recent scintigraphic study on Geltears (a Carbopol 940 based product) showed that the precorneal residence is significantly prolonged by carbomer gel when compared to the saline control. Phase transition systems The introduction in the early 1980s of the concept of in situ gel systems demonstrated that a considerable prolongation in duration of action could be obtained. In situ gelling systems have unique properties, which can make a liquid change phase to a gel or solid phase in the culde-sac upon its instillation into the eye. Three methods have been employed to induce phase transition on the eye surface: change in pH and temperature as well as activation by ions. Cellulose acetate phthalate forms a pH-triggered phase transition system, which shows a very low viscosity up to pH 5. The half-life of residence on the rabbit corneal surface was approximately 400 seconds compared to 40 seconds for saline. However, such systems are characterized by a high polymer concentration, and the low pH of the instilled solution may cause discomfort to the patient. When the solution is instilled onto the eye surface (34 °C) the elevated temperature causes the solution to become a gel, thereby prolonging its contact with the ocular surface. One of the disadvantages of such a system is that it is characterized by a high polymer concentration (25% poloxamer), and the surfactant properties of poloxamer may be detrimental to ocular tolerability. Gellan gum is an anionic polysaccharide formulated in aqueous solution, which forms clear gels under the influence of an increase in ionic strength. The gellation increases proportionally to the amount of either monovalent or divalent cations. The reflex tearing, which often leads to a dilution of ophthalmic solutions, further enhances the viscosity of the gellan gum by increasing the tear volume and thus the increased cation concentration.

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These treatment effects were stable at six month and one year follow-up (Hoyer et al purchase 10mg prednisolone with amex. Participants randomized to information-only received written information on anxiety disorders and a list of referral options 40 mg prednisolone overnight delivery. Follow-up data (6-months after treatment completion) indicated no significant differences in the reductions in anxiety sensitivity and insomnia between the two conditions discount 10mg prednisolone otc, suggesting that a longer intervention or more intense follow-up may be needed generic prednisolone 20mg with visa. They also suggested that more follow-up sessions should be integrated into telephone treatment (Brenes et al. According to investigators, these findings remained stable at the 12-month follow-up. Investigators also proposed the conceptualization of worry in psychodynamic psychotherapy as “a mechanism of defense that protects the subject from fantasies or feelings that are even more threatening than the contents of his or her worries” (Salzer et al. Second-line treatment options include buspirone (for augmentation), benzodiazepines, i. In addition, these guidelines cited strong evidence and recommended the benzodiazepines, alprazolam and diazepam, for treatment- resistant cases with no history of addiction and as adjuncts for immediate relief of anxiety during the initiation of other agents and for use in episodes of acute exacerbation. Moreover, all of these drugs precipitate response (50% improvement in symptom severity) in approximately two-thirds of patients and remission (a reduction in symptom severity clinical measurement scores to the normal range) in approximately one-half of the responders, or one-third of total patients (Collins et al. There was also some evidence for the efficacy of certain benzodiazepines, buspirone, imipramine, hydroxyzine and trifluoperazine (Baldwin, 2005). It addresses the needs of patients who may achieve a good response, partial response, non-response or loss of previous response (Davidson et al. This includes a careful evaluation for suicidality, insomnia, substance abuse, non-compliance, childbearing potential, elderly patient problems and cultural issues. A partial response should occur by the initial evaluation point after 4-6 weeks with adequate dosing. Current state of knowledge permits the prescriber to increase dose, augment, switch or wait longer when there has been a partial response. A switching strategy should be considered where adequate drug trial has not elicited at least a 25% symptom improvement from baseline using a valid clinical measurement scale. Recommended drugs are as follows:  Co-morbid depression – adequate dose of an antidepressant or augmentation with bupropion, buspirone, atypical antipsychotic, or the nutritional supplement, chromium picolinate. Other unwanted effects of benzodiazepines may include sedation, memory disruption and psychomotor impairment, with an associated increased risk of traffic accidents. Other safety concerns with the use of benzodiazepines in the elderly population have been noted due to the high incidence of falls, hip fracture, withdrawal difficulties and increased risk of cognitive impairment (Davidson et al. Researchers found that healthcare costs increased in patients following benzodiazepine treatment and noted that approximately half of the increase in costs was associated with known sequelae of long-term treatment with benzodiazepines, e. Results showed that both lorazepam and paroxetine treatments were effective in reducing anxiety-related psychiatric symptoms. They concluded that literature lends no support to the pattern favoring newer antidepressants over benzodiazepines in the treatment of anxiety disorders (Offidani et al. Also, these findings were inconclusive about buspirone’s long-term efficacy and its superiority to antidepressants, psychotherapy or kava (Chessick, 2007). Efficacy findings with the best levels of evidence support escitalopram, paroxetine-immediate release and sertraline. Researchers note that paroxetine has demonstrated efficacy in depression and in several anxiety disorders (e. Another study showed there were no differences in efficacy between escitalopram (10-20 mg. However, patients treated with paroxetine reported significantly more side effects (e. Researchers found a statistically significant difference in the mean cumulative response rate (i. Further study is necessary to assess safety and efficacy compared to longer term treatment (Lenze et al. Double-blind, placebo- controlled, comparison studies are needed to draw definitive conclusions (Kim, 2006). The adverse effects most frequently associated with duloxetine were nausea, dizziness and somnolence. Another study, which pooled data from two multi-center trials, evaluated the efficacy of duloxetine (60-120 mg. It showed that the drug is effective in reducing anxiety symptoms, pain severity and in improving patient functioning (Rynn, 2007). Additionally, patients who responded to duloxetine treatment and subsequently discontinued treatment experienced a worsening of painful symptoms (Beesdo et al. Another large (n=668) clinical trial of adult patients treated with duloxetine compared to placebo (n=495) showed an almost 2:1 rate of substantial return to normative functioning and quality of life, i. Non-inferiority trials are designed to analyze the amount of drug/placebo difference between two treatments. An independent expert consensus panel determined the statistical and clinical criteria for non-inferiority and clinical response (i. Published results of these early studies demonstrated that imipramine was effective in alleviating such symptoms as dysphoria, anticipatory negative thinking, apprehension and worry. This study was not able to assess the differences in efficacy between imipramine and venlafaxine, or venlafaxine and paroxetine, as there were no direct comparisons of these agents in this review. This review also noted findings suggesting that paroxetine and imipramine are similar in terms of efficacy and tolerability (Kapczinski, 2003). Further randomized placebo-controlled studies are needed to explore the utility of this agent in the treatment of anxiety disorders (Gambi, 2005). Using annual data from the 1996-2007 National Ambulatory Medical Care Survey, a study reported that across this 12-year period, antipsychotic prescriptions in visits for anxiety disorders increased from 10. In addition, authors reported that “across drug classes, antipsychotic medications ranked near the top in off-label use, drug safety concerns and inadequate supporting evidence” (p. Results showed significant reduction in anxiety symptoms, and while two patients reported mild akathisia (one was persistent), no patients developed dystonias (Simon, 2006). Out of the 63 patients who completed the study, there were no statistically significant ©2008-2014 Magellan Health, Inc. In addition, patients in the quetiapine group were 30% more likely to leave the study before completion. Investigators stressed that while quetiapine monotherapy may be efficacious, issues with adverse effects and tolerability must be considered in clinical practice (Lalonde et al. Treatment was initiated at 50 mg/day with dose adjustment made on the basis of efficacy and/or tolerability. Researchers cautioned that the results should be considered preliminary due to the small sample size, recommending further studies (Chen et al. Findings showed that combination zolpidem and escitalopram improved all measures of sleep to a significantly greater degree than escitalopram and placebo. Improvements were also seen in many measures of daytime functioning and quality of life. Zolpidem extended-release did not significantly augment the anxiolytic effects of the escitalopram and there was no associated rebound upon withdrawal of therapy (Fava et al. Adverse events were mild to moderate and limited to the first 2-3 weeks of treatment.

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