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By P. Cole. Lindsey Wilson College.

Te weight of soil above a collapsed cofn may produce damage to the rib cage or pseudotrauma in the anterior dentition or deli- cate bones of the maxillofacial area cheap 50mg avanafil with amex erectile dysfunction questions. Large and small mammalian scavengers leave characteristic dental markings order avanafil 100mg on-line erectile dysfunction treatment non prescription, usually perpendicular to the long axis of a bone. When recover- ing scattered remains, it is wise to ask what kinds of animals inhabit the area. Some familiarity with the dentition and the characteristic patterns of scavenging of animals within the area of search is useful. One colleague wryly noted that “if one wants to fnd remains in a large feld, one has only to instruct someone to ‘brush hog’ or till the area. Te most problematic instances of anthropogenic damage are those that produce recovery and processing artifacts. Shovels and trowels in the hands of inexperienced investigators may induce what appear to be blade or chopping defects. Cases involving remains that have been intentionally disarticulated by knife, saw, etc. On these occasions the initial examiner must carefully note and describe any additional cuts that have been made with the autopsy saw for sampling or other purposes, lest these be confused with original marks made by the assailant. Although most anthropogenic arti- facts are easily distinguished from perimortem damage, they ofen provide a skillful cross-examiner with opportunities to confuse a jury, and at the very least, may call into question the skills of those responsible for the recovery and analysis of the victim. Many states operate databases and missing persons clearinghouses for their own jurisdictions. Still other databases specialize in a particular demographic segment of the national population, e. Te latter contains reference samples consist- ing of nuclear and mitochondrial markers from relatives of missing persons as well as mitochondrial and, usually, genomic markers from unidentifed human remains. Or, the system may fnd several possible matches either for the same reason or because the original reference samples were taken from individuals who were not frst-degree relatives of the decedent. Given several possible matches, or one weak one, the anthropological and dental profles are used to parse the list or to strengthen the weak match. Most do not interact with others because of incompatible formats, propri- etary issues, or matters of confdentiality and access between jurisdictions and entities operating the various databases. Te most important limita- tion on the use of any database in identifying unknowns, live or dead, is its inclusiveness. Te best chance a missing individual or set of remains has of being identifed resides in whether these have been submitted to a database with as much accompanying information as possible. A signifcant problem arises because of the difering skill levels of those who initially develop the profle. If the unknown remains are sufciently complete and “fresh” to allow accu- rate determination of sex, age, ancestry, and stature visually, then a report from a pathologist may be sufcient for use as critical metadata. Errors in the assignment of ancestry or age, improper dental charting, or other misinformation entered into a database will likely result in false elimi- nation of a correct identity match, i. Although it is not always possible to accu- rately determine all of the features of the profle, an efort must be made. Many countries require that some form of personal identifer be entered into a national database; e. Tus, their value in large-scale searches for the missing and unknown remains is negligible. Te promise of databases will not be realized until the problems of accurate data entry and interconnec- tivity as well as broad public acceptance and participation are resolved. Increased use of anthropological fndings as metadata within a molecular and biometric database identifcation framework will mandate more comprehensive validation studies to strengthen ele- ments of the biological profle in a post-Daubert environment. Growing realization that “one size does not ft all” will result in the dissemination of taphonomic research facilities into an increasing number of biotic provinces, including montane, marine, andlacustrine environments, to address a variety of problems, from determination of postmortem interval to improved evidence location and recovery methods. Tese will translate into greater admissibility in an era of rising evidentiary standards. Tere will be a need for expansion of contemporary osteological study collections to support ongoing validation studies as well as research and teaching. Tese collections will need to be more diverse, and the 158 Forensic dentistry numbers of individuals in each population represented will have to increase to statistically useful levels. As improvements in public health and nutrition occur in third world populations, rapid secular changes in growth and life span will have to be refected in such collections. Particularly critical is the almost total absence of fetuses, neonates, and children in U. Tis will be remedied only through increased public awareness of need com- bined with improved and expanded remains solicitation programs. One can anticipate an expansion of the already prominent role of forensic anthropology in mass fatality incidents, whether natural or manmade, e. Perhaps most importantly, one can predict that agencies responsible for death investigation and identifcation will develop cadres of specialists, including anthropologists, odontologists, pathologists, molecular biologists, and others whose contributions form a seamless team approach to these problems on any scale. Te bone woman: A forensic anthropologist’s search for truth in the mass graves of Rwanda, Bosnia, Croatia, and Kosovo. Te Oklahoma City child disappearances of 1967: Forensic anthropology in the identifcation of skeletal remains. Te structure of the human symphysis pubis with special consideration of parturition and its sequelae. Skeleton keys: An introduction to human skeletal morphol- ogy, development, and analysis. Estimation of age at death in human males from quantitative histology of bone fragments. A method for assessment of maximum long bone length and living stature from fragmentary long bones. Identifcation of a killer by a defnitive sneaker pattern and his beating instruments by their distinctive patterns.

Hammel buy 50mg avanafil free shipping impotence emedicine, took the stand for the defense and testifed that she had erred in the original trial order avanafil 200mg with mastercard erectile dysfunction exam what to expect. She stated further that she originally had doubts about the orientation of the bitemark, and afer gaining more experience and reviewing the evidence, she realized her error. It took a great deal of courage for her to admit the error, but it was absolutely the right thing to do. Cristini had been arrested and charged with eight counts of frst-degree criminal sexual conduct allegedly involving a fve-year-old child. First, that eyewitness testimony may or may not be accurate—here the victim may have been wrong about the identity of the biters. She accused others that were later proven to be else- where at the time of the crime. Second, there is no scientifc basis for math- ematical degree of certainty with bitemark evidence on skin. Tird, unlike in other cases, one of the experts had the courage to take the stand and admit an earlier error. In the above detailed problem cases there was agreement among both the defense and the prosecution experts that these were indeed human bite- marks. Te disagreements were related to features and orientation of the bitemarks and to who could have or who could not have inficted the bites. Te problems were compounded in some cases by the use of mathematical degrees of certainty or overreaching statements of the value and certainty of bitemark evidence. Te most recent and highly publicized of Bitemarks 327 these cases is that of Kennedy Brewer in Mississippi. Brewer was convicted in 1995 of the murder and sexual assault of Christine Jackson. Te body of the three-year-old victim had been found in a nearby creek on a Tuesday morn- ing, the third day afer her Saturday night disappearance. Michael West, examined Christine Jackson on May 9, 1992, and wrote in his May 14, 1992, report that nineteen human bitemarks were found on the body, and that “the bitemarks found on the body of Christina [sic] Jackson are peri-mortem in nature. West later testifed that “indeed and without doubt” and that “to a reasonable degree of medical certainty” the teeth of Mr. Brewer made fve of those marks, and that it was “highly con- sistent and probable that the other fourteen bite mark patterns were also inficted by Brewer” (West in original trial transcript in Brewer v. Souviron, testifed that the patterned injuries on the body were not human bites at all but were patterns that were made by other means. Tere could be fsh activity or turtle activity or who—God knows what” (Souviron in original trial transcript in Brewer v. Neither profle included Brewer but did point to another man, Justin Albert Johnson, who, ironically, had also been an early suspect in Jackson’s murder. Johnson later confessed to killing Christine Jackson and another young girl who had been similarly sexually assaulted and murdered. In that earlier case, Levon Brooks had also been wrongly convicted based, in part, on Dr. He testifed that “it could be no one else but Levon Brooks that bit this girl’s arm. How can an “expert” ignore the circum- stances and disregard the crime scene information? How can patterns with no class or individual characteristics of human teeth in patterned injuries found on a body that had been in water for more than two days be judged to be human bitemarks? To then associate those patterns to a suspect with any level of certainty seems unthinkable. Perhaps, an understanding of alter- native explanations to human teeth causing the marks should have been considered more seriously, especially in a case in which human bitemarks seemed unlikely. Souviron provided viable and testable theories for possible alternatives—the marks may have come from activity by insects, fsh, turtles, or other sources not readily apparent. Wallace, suggested that crayfsh, which were very abundant in the stream where the victim was found, were likely suspects and could have lef such marks on the victim’s body through normal feeding activity. Incredibly, the odontologist in this case associated only the upper inci- sor teeth to all of the “bitemarks”; there were no lower teeth marks identi- fed. West performed a simple test to determine if the patterns on the skin were in fact bitemarks of the type Bitemarks 329 Figure 14. An incision through a mark will reveal if there is the subepidermal hemorrhage ofen associated with human bitemarks (Figures 14. Alternatively, either could have harvested tissue from one or more of the patterned injuries. West had a history of simi- larly outrageous fndings in other cases (Keko, Harrison, Maxwell). He had identifed shoe marks on human skin and knife handle rivets on the hand of a murder suspect. He had made dramatic, overreaching statements in court, including conclusions to absolute certainty, “indeed and without doubt,” and incredible estimates of his own error rates, “something less than my savior, Jesus Christ. Tat the liberty, and indeed the life, of a human being is ofen in question and may depend upon the quality of experts’ opinions is of paramount importance and cannot be overemphasized. We cannot be too cautious, too conservative, or too diligent when analyzing the potential asso- ciation of a suspect to a bitemark. We should also recognize that eyewitnesses may be wrong or may have reason to lie. Since that time more programs and more comprehensive programs 332 Forensic dentistry have become available. Tese include programs at the Armed Forces Institute of Pathology, the University of Texas Health Science Center at San Antonio, McGill University in Montreal, the Miami-Dade County Medical Examiner’s Ofce, the University of Detroit–Mercy School of Dentistry, and others.

An assessment of the external environment will provide an understanding of the changes occurring due to the assault References on the internal environment and a more Alligood best avanafil 200 mg erectile dysfunction treatment by ayurveda, M cheap 50 mg avanafil amex impotence with beta blockers. Models and theories: Critical thinking detailed assessment of the perceptive, organ- structures. Nursing theory: Analysis, application, this approach to describing, defining, and evaluation (4th ed. Clinical nursing: Pathophysiological and psy- organismic challenges that may not be imme- chological implications (2nd ed. Skin care strategies in a agenda and perhaps design public policy skilled nursing home. Journal of Gerontological Nursing, that might improve interventions in the con- 20(11), 28–34. Alternative nursing environments: Do they affect hos- nurses with a global perspective of the envi- pital outcomes? Optimizing wound healing: A practice with the current speed of health-care system within nursing’s domain. A tradition of caring: Use of Levine’s model vides an approach that educates good nurses in long-term care. An application of Levine’s nurse midwives, nurse anesthetists, and nurse conceptual model. The effects of waterbeds on entrepreneurs are encouraged to test the heart rate in preterm infants... Fatigue and prealbumin levels during the development of the art and science of nurs- weaning process in long-term ventilated patients (Doctoral dissertation, New York University, 2003). The four conservation principles of nurs- predictors of intravenous site symptoms. Nursing Science Quarterly, 1(1), The conservation model: A framework for nursing practice (pp. Energy conservation during skin-to- during rest, occupied bedmaking, and unoccupied bedmak- skin contact between premature infants and their mothers. Trophicognosis: An alternative to nursing clinical issues in critical care nursing (pp. Notes on nursing: What it is, and what it is the model for nursing diagnosis in a neurological setting. Symposium on a drug compendium: Nurse Theorist Conference, Edmonton,Alberta, Canada (cas- View of a nursing educator. Published simultaneously in American Journal of tional Congress of Nursing Law and Ethics. Berlin: Springer Nursing, 70(4), 799–803; and Amercian Journal of Hospital Verlag. Levine’s Conservation Model: Caring for Theoretical nursing: Development and progress (pp. Myra Estrin Levine: The conservation The nursing theorists: Portraits of excellence: Myra Levine. Application of Levine’s Conservation Model model: A framework for nursing practice. Effect of restricted mobility and domi- The Nursing Spectrum, Greater Philadelphia/Tri-State edition, nance on perceived duration. Hall and conceptual model of nursing, her work at the Loeb Cherkasky shared congruent philosophies regard- Center for Nursing and Rehabilitation, the implica- ing health care and the delivery of quality service, tions of her work for practice and research, and, which served as the foundation for a long-standing finally, our views about how Hall might reflect on professional relationship (Birnbach, 1988). In 1950, Cherkasky was appointed director of The purpose of this chapter is to share the story of the Montefiore Medical Center. During the early Lydia Hall’s life and her contribution to profes- years of his tenure, existing traditional convalescent sional nursing rather than to critique a nursing homes fell into disfavor. She inspired commitment and dedica- result of the emerging trends was the Solomon and tion through her unique conceptual framework for Betty Loeb Memorial Home in Westchester nursing practice that viewed professional nursing County, New York. Cherkasky and Hall collabo- as the key to the care and rehabilitation of patients. In the from the sale of the Loeb Home, plans for the Loeb mid-1930s, she enrolled at Teachers College, Center construction proceeded over a five-year pe- Columbia University, where she earned a bachelor riod, from 1957 to 1962. Although the Loeb Center of science degree in 1937, and a master of arts de- was, and still is, an integral part of the Montefiore gree in 1942. She worked with the Visiting Nurse physical complex, it was separately administered, Service of New York from 1941 to 1947 and was a with its own board of trustees that interrelated with member of the nursing faculty at Fordham the Montefiore board. Hall Under Hall’s direction, nurses selected patients was subsequently appointed to a faculty position at for the Loeb Center based on their potential for Teachers College, where she developed and imple- rehabilitation. Qualified professional nurses pro- mented a program in nursing consultation and vided direct care to patients and coordinated joined a community of nurse leaders. Hall frequently described the cen- time, she was involved in research activities for the ter as “a halfway house on the road home” (Hall, U. Over time, the effectiveness of Hall’s Aid, and other community associations (Birnbach, practice model was validated by the significant de- 1988). New York, was her most significant contribution to In 1967, Hall received the Teachers College nursing practice. Opened in 1963, the Loeb Center Nursing Alumni Award for distinguished achieve- was the culmination of five years of planning and ment in nursing practice. The circum- ideas about the nursing practice with numerous stances that brought Hall and the Loeb Center to- audiences around the country and contributed ar- gether date back to 1947, when Dr. In those articles, she re- Cherkasky was named director of the new hospital- ferred to nurses using feminine pronouns.

The obstruction must be relieved without delay; the method of choice is percutaneous nephrostomy and drainage 200mg avanafil fast delivery erectile dysfunction treatment yoga. In this procedure a catheter is inserted under imaging guidance through the right loin into the obstructed renal pelvis cheap 100mg avanafil with visa top 10 causes erectile dysfunction. Not only will this relieve the obstruc- tion but it allows the later injection of X-ray contrast to define the exact site of obstruction (percutaneous nephrostogram). This was done 48 h later and showed hold-up of the contrast at the vesico-ureteric junction, a typical place for a stone to lodge. The patient passed the stone shortly afterwards, as often happens if it is small enough; otherwise it would have to be removed surgically. Blood biochemistry revealed no underlying abnormality to cause the stones: calcium, phosphate, alkaline phosphatase and uric acid were normal. The probable cause of her renal disease is reflux nephropathy because of her sex, history of recurrent infections and the scar on the left kidney. Long-term management comprises prophylactic antibiotics, immediate treatment of acute urinary infections, control of hypertension and regular measurement of renal function. These should be supervised from a fixed base, despite the patient’s peripatetic existence. It settled over the next few hours but there is still a mild ache in the right side on deep breathing. She felt a little short of breath for the first hour or two after the pain came on but now only feels this on stairs or walking quickly. Four years ago something very similar happened; she is not sure but thinks that the pain was on the left side of the chest on that occasion. There is decreased tactile vocal fremitus and the intensity of the breath sounds is reduced over the right side of the chest. Pneumothoraces are usually visible on normal inspira- tory films but an expiratory film may help when there is doubt. There is no mediastinal displacement on examination or X-ray, movement of the mediastinum away from the side of the pneumothorax would suggest a tension pneumothorax. Although she had symp- toms initially, these have settled down as might be expected in a fit patient with no under- lying lung disease. A rim of air greater than 2 cm around the lung on the X-ray indicates at least a moderate pneumothorax because of the three-dimensional structure of the lung within the thoracic cage represented on the two-dimensional X-ray. The differential diagnosis of chest pain in a young woman includes pneumonia and pleurisy, pulmonary embolism and musculoskeletal problems. However, the clinical signs and X-ray leave no doubt about the diagnosis in this woman. Pneumothoraces are more common in tall, thin men, in smokers and in those with underlying lung disease. There is a suggestion that she may have had a similar episode in the past but it may have been on the left side. There is a tendency for recurrence of pneumothoraces, about 20 per cent after one event and 50 per cent after two. Because of this, pleurodesis should be con- sidered after two pneumothoraces or in professional divers or pilots. The immediate management is to aspirate the pneumothorax through the second inter- costal space anteriorly using a cannula of 16 French gauge or more, at least 3 cm long. Small pneumothoraces with no symptoms and no underlying lung disease can be left to absorb spontaneously but this is quite a slow process. Up to 2500 mL can be aspirated at one time, stopping if it becomes difficult to aspirate or the patient coughs excessively. If the aspir- ation is unsuccessful or the pneumothorax recurs immediately, intercostal drainage to an underwater seal or valve may be indicated. Difficulties at this stage or a persistent air leak may require thoracic surgical intervention. This is considered earlier than it used to be since the adoption of less invasive video-assisted techniques. In this woman the apical bulla was associated with a persistent leak and required surgical intervention through video-assisted minimally invasive surgery. Marijuana has been reported to be associated with bullous lung disease, and she should be advised to avoid it. He was unable to look after himself at home because of some osteoarthritis in the hips limiting his mobility. Apart from his reduced mobility, which has restricted him to a few steps on a frame, and a rather irritable temper when he doesn’t get his own way, he has had no prob- lems in residential care. He has been trying to get out of his bed and his chair, and this has resulted in a number of falls. Prior to this he had only been incontinent on one or two occasions in the last 6 months. He thinks that there is a conspiracy in the ward and that the staff are having secret meetings and planning to harm him. He is disorien- tated in place and time although reluctant to try to answer these questions. On a routine blood test 8 years ago he was diagnosed with hypothyroidism and thyroxine 100 mg daily is the only medication he is taking. The staff say that he has taken this regularly up to the last 36 h and his records show that his thyroid function was normal when it was checked 6 months earlier. They feel that he has dementia and that the home is not an appropriate place for such patients.

Be sure to ask about the degrees that the therapist has earned buy cheap avanafil 50 mg line how to treat erectile dysfunction australian doctor, and about the reputation of the center in which the therapy occurs safe avanafil 200 mg impotence specialists. If you have choices, try to find a person or location that you like, respect, and trust. Your sessions with the help provider will require discussing your family history, personality, and relationships, and you should feel comfortable sharing this information. Remember also that confronting issues requires time to reflect, energy to get to the appointments and deal with consequential feelings, and discipline to explore your issues on your own. The bottom line is that going for therapy should not be a difficult decision for you. All people have the right to appropriate mental health care just as they have a right to general health care. Just as you go to a dentist for a toothache, you may go to therapy for psychological difficulties. Furthermore, you can be confident that you will be treated with respect and that your privacy will be protected, because therapists follow ethical principles in their Attributed to Charles Stangor Saylor. The following provides a summary of these principles as developed by the American Psychological [3] Association (2010). Psychologists do not accept as therapy clients/patients persons with whom they have engaged in sexual intimacies, nor do they have sexual intimacies with former clients/patients for at least 2 years after cessation or termination of therapy. Psychodynamic Therapy Psychodynamic therapy (psychoanalysis) is a psychological treatment based on Freudian and neo-Freudian personality theories in which the therapist helps the patient explore the Attributed to Charles Stangor Saylor. The analyst engages with the patient, usually in one-on- one sessions, often with the patient lying on a couch and facing away. The goal of the psychotherapy is for the patient to talk about his or her personal concerns and anxieties,allowing the therapist to try to understand the underlying unconscious problems that are causing the symptoms (the process of interpretation). The analyst may try out some interpretations on the patient and observe how he or she responds to them. The patient may be asked to verbalize his or her thoughts throughfree association, in which the therapist listens while the client talks about whatever comes to mind, without any censorship or filtering. The client may also be asked to report on his or her dreams, and the therapist will usedream analysis to analyze the symbolism of the dreams in an effort to probe the unconscious thoughts of the client and interpret their significance. On the basis of the thoughts expressed by the patient, the analyst discovers the unconscious conflicts causing the patient‘s symptoms and interprets them for the patient. The goal of psychotherapy is to help the patient develop insight—that is, an understanding of the unconscious causes of the disorder (Epstein, Stern, & Silbersweig, 2001; Lubarsky & Barrett, [4] 2006), but the patient often showsresistance to these new understandings, using defense mechanisms to avoid the painful feelings in his or her unconscious. The patient might forget or miss appointments, or act out with hostile feelings toward the therapist. The therapist attempts to help the patient develop insight into the causes of the resistance. The sessions may also lead to transference, in which the patient unconsciously redirects feelings experienced in an important personal relationship toward the therapist. For instance, the patient may transfer feelings of guilt that come from the father or mother to the therapist. Some therapists believe that transference should be encouraged, as it allows the client to resolve hidden conflicts and work through feelings that are present in the relationships. The therapist listens while the client talks about whatever comes to mind, without any censorship or filtering. The therapist then tries to interpret these free associations, looking for unconscious causes of symptoms. The therapist listens while the client describes his or her dreams and then analyzes the symbolism of the dreams in an effort to probe the unconscious thoughts of the client and interpret their significance. The therapist uses the patient‘s expressed thoughts to try to understand the underlying unconscious problems. The analyst may try out some interpretations on the patient and observe how he or she responds to them. The patient‘s use of defense mechanisms to avoid the painful feelings in his or her unconscious. The patient might forget or miss appointments, or act out with hostile feelings toward the therapist. The therapist attempts to help the patient develop insight into the causes of the resistance. The unconscious redirection of the feelings experienced in an important personal relationship toward the therapist. For instance, the patient may transfer feelings of guilt that come from the father or mother to the therapist. One problem with traditional psychoanalysis is that the sessions may take place several times a week, go on for many years, and cost thousands of dollars. To help more people benefit, modern psychodynamic approaches frequently use shorter-term, focused, and goal-oriented approaches. In these “brief psychodynamic therapies,‖ the therapist helps the client determine the important issues to be discussed at the beginning of treatment and usually takes a more active role than in [5] classic psychoanalysis (Levenson, 2010). Humanistic Therapies Just as psychoanalysis is based on the personality theories of Freud and the neo- Freudians, humanistic therapy is a psychological treatment based on the personality theories of Carl Rogers and other humanistic psychologists. Humanistic therapy is based on the idea that people develop psychological problems when they are burdened by limits and expectations placed on them by themselves and others, and the treatment emphasizes the person‘s capacity for self-realization and fulfillment. Humanistic therapies attempt to promote growth and responsibility by helping clients consider their own situations and the world around them and how they can work to achieve their life goals. In his book, A Way of Being (1980), Rogers argued that therapy was most productive when the therapist created a positive relationship with the client—a therapeutic alliance.

High-dose adrenaline is these are beyond the scope of this book cheap 50 mg avanafil fast delivery erectile dysfunction treatment without side effects, and in practice no longer recommended in this situation avanafil 100mg discount erectile dysfunction medications for sale. In an acute setting (most commonly the immediate after- Ventricular dysrhythmias math of myocardial infarction), treatment to suppress ventricu- Ventricular ectopic beats: Electrolyte disturbance, smoking, lar ectopic beats may be warranted if these are running alcohol abuse and excessive caffeine consumption should be together to form brief recurrent episodes of ventricular tachy- sought and corrected if present. The only justification for cardia, or if frequent ectopic beats are present following car- treating patients with anti-dysrhythmic drugs in an attempt to dioversion from ventricular fibrillation. An effective plasma concentration is rapidly achieved by giv- Ventricular fibrillation: See above under Advanced life sup- ing a bolus intravenously followed by a constant rate infusion. Pacemaker insertion is indicated if bradycardia is unresponsive to atropine and is causing significant hypotension. Pharmacokinetics Oral bioavailability is poor because of presystemic metabolism Sick sinus syndrome (tachycardia–bradycardia and lidocaine is given intravenously. It is metabolized in the syndrome) liver, its clearance being limited by hepatic blood flow. Heart fail- ure reduces lidocaine clearance, predisposing to toxicity unless Treatment is difficult. The difference between therapeutic and often aggravate the other and a pacemaker is often needed. Some of these drugs are cause cardiac failure and/or attacks of unconsciousness shown in Table 32. Eye – Amiodarone causes corneal microdeposits in almost onist for intravenous use with a short duration of action (its elim- all patients during prolonged use. The antagonists are given more commonly by mouth when used for deposits are only seen on slit-lamp examination and the above indications. Patients sometimes • Raynaud’s phenomenon; develop blue-grey pigmentation of exposed areas. This is • uncompensated heart failure (β-blockers are actually a separate phenomenon to phototoxicity. This this can be fatal), lidocaine, disopyramide or other potentially serious problem usually but not always negative inotropes. Peripheral neuropathy – occurs in the first month of Use treatment and reverses on stopping dosing. Proximal Amiodarone is highly effective, but its use is limited by the muscle weakness, ataxia, tremor, nightmares, insomnia severity of its adverse effects during chronic administration. This is reflected in a very large volume of distribution emergency situations as discussed above, or orally if rapid (approximately 5000L). It is only slowly eliminated via the liver, with a t1/2 of Mechanism of action 28–45 days. In common with other cal- can cause severe bradycardia if used with β-adrenoceptor cium antagonists, it relaxes the smooth muscle of peripheral antagonists or verapamil. This reduces the ventricular response in atrial fibrillation and Sotalol has uses similar to amiodarone, but a different spec- flutter, and abolishes most re-entry nodal tachycardias. Mechanism of action Adverse effects and contraindications Sotalol is unique among β-adrenoceptor antagonists in 1. Gastrointestinal tract: About one-third of patients blocking activity of sotalol contraindicates its use in patients experience constipation, although this can usually be with obstructive airways disease, unstable heart failure, prevented or managed successfully with advice about peripheral vascular disease or heart block. Other adverse effects: Headache, dizziness and facial Diuretics predispose to torsades de pointes by causing elec- flushing are related to vasodilatation (compare with trolyte disturbance (hypokalaemia/hypomagnesaemia). These include class Ia anti-dysrhythmic drugs metallic taste in the mouth are uncommon. Histamine H1-antagonists (terfenadine, with β-adrenoceptor antagonists, which occurs especially astemizole) should be avoided for the same reason. In this setting it is given tically in patients with regular broad complex tachycardia intravenously over five minutes. This results in accumulation of intracellular smooth muscle by an A1 effect, especially in asthmatics. It 2 Na , which indirectly increases the intracellular Ca relaxes vascular smooth muscle, stimulates nociceptive afferent 2 content via Na /Ca exchange and intracellular neurones in the heart and inhibits platelet aggregation via 2 2 Ca storage. Slowing of the ventricular rate results from several Adverse effects and contraindications mechanisms, particularly increased vagal activity: Chest pain, flushing, shortness of breath, dizziness and nau- • delayed conduction through the atrioventricular node sea are common but short-lived. Chest pain can be alarming if and bundle of His; the patient is not warned of its benign nature before the drug • increased cardiac output due to the positive inotropic is administered. The cellular mechanism of this effect is the ventricular rate during atrial fibrillation may be acceler- not known. The circulatory effects of a bolus therapeutic dose of adenosine last for 20–30 Mechanism of action seconds, although effects on the airways in asthmatics persist for longer. Acetylcholine released by the vagus nerve acts on muscarinic receptors in atrial and cardiac conducting tissues. This increases K permeability, thereby shortening the cardiac Drug interactions action potential and slowing the rate of increase of pacemaker Dipyridamole blocks cellular adenosine uptake and potenti- potentials and cardiac rate. Theophylline blocks adenosine receptors and of acetylcholine at muscarinic receptors, and it thereby coun- inhibits its action. Adverse effects and contraindications Use Parasympathetic blockade by atropine produces widespread effects, including reduced salivation, lachrymation and sweat- The main use of digoxin is to control the ventricular rate (and ing, decreased secretions in the gut and respiratory tract, hence improve cardiac output) in patients with atrial fibrilla- tachycardia, urinary retention in men, constipation, pupillary tion. Digoxin is usually given orally, but if this is impossible, or dilatation and ciliary paralysis. It is contraindicated in if a rapid effect is needed, it can be given intravenously. Atropine can cause the t1/2 is approximately one to two days in patients with nor- central nervous system effects, including hallucinations. This is acceptable in many settings, but if clinical circum- Pharmacokinetics stances are more urgent, a therapeutic plasma concentration Although atropine is completely absorbed after oral adminis- can be achieved more rapidly by administering a loading dose. Its use may ‘buy time’ during which other meas- ures to lower the plasma potassium concentration (e.

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