Trimox

By P. Silvio. University of Wisconsin-Stout.

The use of dexamethasone generic 500 mg trimox, as well as other steroids proven 500 mg trimox, in treating the pregnant asthmatic was not associated with adverse mater- nal or fetal effects (Schatz et al. There were no adverse effects of in utero expo- sure to dexamethasone observed in infants in a long-term follow-up by the Collaborative Group on Antenatal Steroid Therapy (1984). The teratogenic effects of dexamethasone in animal species are similar to those of cortisone. Also, Jerome and Hendrickx (1988) administered 10 mg/kg dex- amethasone daily between days 22 and 50 in six pregnant rhesus monkeys and observed cranium bifidum and aplasia cutis congenita in one and three fetuses, respectively. As discussed with prednisone previously, first trimester exposure may be associated with a very small risk of oral clefts (see Chapter 4). Congenital anomalies were not increased in frequency among infants born to 151 and 191 women who used cromolyn sodium during the first trimester (Rosa, personal communication) (Schatz et al. Older reports of its use during pregnancy indicate no adverse fetal effects (Dykes, 1974; Wilson, 1982). Atropine readily crosses the placenta to the fetal circulation and may cause fetal vagal blockade with subsequent fetal tachycardia (Hellman and Fillisti, 1965; Kanto et al. No increase in congenital defects among 401 offspring of women with exposure to atropine during early pregnancy, or 1198 infants whose mothers used the drug any- time during pregnancy was found (Heinonen et al. Antibiotics Upper respiratory infections should be treated aggressively in the pregnant asthmatic patient, as in the nonpregnant patient (see Chapter 2). Erythromycin is probably a safe alternative in the patient who is allergic to penicillin. However, hepatotoxicity has been observed in pregnant patients treated with the estolate salt of erythromycin (McCormack et al. Briefly, diphenhydramine, chlorpheniramine, pheniramine, and tripelen- namine are generally considered safe for use during pregnancy. A few studies have shown that expectorants and mucolytics are efficacious in the treatment of asthma. It is of utmost importance that these agents, as well as theophylline mixtures containing iodides, not be used during pregnancy, because the iodine blocks the synthesis of thy- roxine in the fetus, resulting in hypothyroidism or congenital goiter (Carswell et al. Other drugs used to treat asthma are also contraindicated for use during pregnancy (Table 5. The beta- adrenergic agonists are a critical element of first-line pharmacological therapy (Cunningham, 1994). Supplemental oxygen should be administered, as needed, to maintain a pO2 greater than 60 mmHg. Intravenous hydration is also important, along with respiratory care to remove the tenacious secretions. If initial spirometry indicates severe obstruction, an intra- venous bolus of 125 mg methylprednisolone should be considered. It has been recommended that corticosteroids should be part of the initial therapy for women with severe, acute asthma (Cunningham, 1994; National Heart, Lung and Blood Institute, 1991). After two or three doses of epinephrine or inhaled beta-agonists, if the wheezing is not corrected, then intravenous aminophylline may be indicated. Dosing should be based on theophylline levels, if the patient has been receiving oral theophylline (it should be noted that theophylline requirements decrease as pregnancy advances; see Table 5. The patient should be admitted to the hospital if she demonstrates a poor spirometric response to therapy, has no symptom improvement, or has pneumonia or pneumothorax. Endotracheal intubation and mechanical ventilation should be considered when signs of respiratory failure present. Patients who respond quickly to such therapy should be discharged on an intensified reg- imen. A tapering schedule of oral corticosteroids should be given if intravenous steroids were used. Close follow-up should be arranged to reassess their clinical condition and possible adjustments in medication. Opiates, sedatives, and tranquilizers are contraindicated in asthmatics because they cause alveolar ventilatory depression, and are associated with respiratory arrest imme- diately after use (Table 5. Beta-adrenergic blockers and parasympathetic agents should also be avoided in asthmatics because they can cause bronchospasm. Chronic asthma Chronic asthma patients need additional steroid therapy for coverage during the stress of labor if they have received oral steroid therapy for more than 2 weeks within the pre- vious year to prevent adrenal crisis. Corticosteroids should be given in cases of severe or mild asthma with wheezing that is unresponsive to bronchodilators. Beclomethasone dipropionate is effective and safe when prolonged steroid use is necessary. Beta-agonist by inhalation every 3–4 h as needed is used for outpatient management of chronic asthma, along with inhalation steroids such as beclomethasone (Cunningham, 1994). Cromolyn sodium can be given chronically by inhalation, and is fairly effective in improving the symptoms of an asthmatic. An added benefit with cromolyn use is a decreased requirement for other antiasthma agents. Cromolyn therapy is best begun during remissions because it requires several days to reach an effective dosing regimen.

An example with Tc–99m In the example shown (to the right) buy generic trimox 250 mg on-line, Tc-99m was added to methylene- diphosphonate cheap 250mg trimox fast delivery, which is absorbed by the bone-forming cells (the osteo- blasts). The picture makes it possible to study diseases of the skeleton, such as bone cancer. In order to un- derstand this we refer to chapter 2 where we discussed the different ways an unstable nucleus could attain a more stable state. We mentioned that in the ordinary b-decay, a neutron was transformed into a proton and an electron, which was emitted. This is a favorable reaction since the neutron mass is lager than the proton mass. The opposite reaction where a proton is transformed into a neutron is how- ever, a more diffcult process. We can however, attain this goal via two different routes; 1) electron capture and 2) positron emission. For all natural isotopes, electron capture is the usual process – because the energy between the par- ent and daughter is less than 2m c2 (m is the electron mass). However, for a number of artifcially e e induced isotopes positron emission takes place. The fate of the emitted positron is; after Illustration of the annihilation being slowed down, it will meet an elec- tron, and then either annihilate directly, or 511 keV photon form a short-lived “positronium atom”. The fnal process is an annihilation where the mass of the two particles is trans- formed into g-ray photons. A very important point is that the photons fy off in opposite directions (see the illustration to the right). We observe the two photons by detectors 180 degrees apart (coincidence measurements). We know Courtesy of Arnt Inge Vistnes from this observation that the annihilation process has taken place somewhere along the line shown in the illustration. One coincidence observation yield a line whereas two or more observations in other directions give a point (or a small area) where the radioactivity has its origin. Information on how tissue and organs functions on both the molecular and cell level. It is also possible to study changes in the brain that follows Alzheimer disease and epilepsy. Positron and positronium In connection to positron emission – we have to mention the “atom” positronium. When the positron has lost its kinetic energy and meet an electron, it is a possibility that they will exist for a short mo- ment almost like an atom (see illustration). It can be mentioned that the frst theoretical work on positro- nium was carried out by Aadne Ore in 1949. Ore was con- nected to the group of biophysics at the University of Oslo – in fact he was the one that started this group. Positronium can be either orto-positronium (parallel spins) or para-positronium (opposite spin). Aadne Ore Para-positronium decays in two photons, both with energy (1916 – 1980) 511 keV whereas orto-positronium decays in three photons (combined energy is 1. Modell av Positronium Ore published the work in two articles; “Annihilation of Positrons in Gases” and “Ortho-Parapositronium conversion”. Coinsidences for two opposite detectors are measured and a picture is recon- structed. The isotopes must be hooked on special chemicals that can transport the positron emitter to places of interest. C – 11 connected to acetate has been proposed as a tracer for prostate tumor cells. The use of F-18 F-18 can be made in a cylotron by irradiating O-18 enriched water with protons. The reaction can be written: 18 18 O +=p F +n 8 9 After the production of F-18 we have to work fast since the halfife is only a couple of hours. We know that the active cancer cells need more sugar than other cells in the body. There- fore, we hook on F-18 to glucose – and the sugar molecule will transport F-18 to the active cells – the cancer cells. Photons with energy 511 keV are measured in coinsidence by detectors 180 degrees from each other. Two different tumors were localized; a sarcoma in the right scapula (shoulder blade) and a lymphoma in the right axillary lymph. The cancers were treated by radiation and the result is seen on the series of pictures – the sarcoma to the left and the lymphoma to the right. You see that the large sarcoma in the right scapula is radioresistant – independent of the radiation dose given. The lymphoma in the right axillary lymph is however radiosensitive and is eliminated after a dose of 40 Gy. The images were taken before the start of radiotherapy (0 Gy), after 8 Gy (early treatment) and after 40 Gy (late treatment).

The heart has its own planes whose long axis lies about 45º off the body plane axes cheap trimox 500mg otc. Its relations are the lungs laterally generic trimox 500 mg overnight delivery, the trachea and esophagus and vertebral bodies posteriorly, the thymus and great vessels superiorly. A small part lies immediately behind the ribs where the Introduction To Cardiac & Tomographic Anatomy Of The Heart - Norman Silverman, M. This can be palpated clinically in the 4th left intercostal space in the mid-clavicular line just below the left nipple. The heart is surrounded by the pericardial sac, part of the primitive coelomic cavity into which it invaginates during embryogenesis. Thus the heart lies in a space (the pericardium), which has visceral and parietal layers, the visceral layer being the epicardium and the parietal layer the fibrous pericardium. On the outside of the heart on the pericardial surface lie the two phrenic nerves (left & right) which lie anterior to the hilum of the lung and transmit the vascular and bronchial elements to it. The Vagus nerves run posterior to the hilum of the lung on the esophageal surface. Sympathetic innervation is via the lower cervical and superior thoracic ganglia, and the parasympathetic innervation via the Vagus nerves. The fibers course over the connective tissue to the vascular and muscular sites along the cardiac vessels. The anterior surface is made up of the right atrium and the great systemic veins on the right. The right atrial appendage (right auricle) and the right ventricle form the major anterior surface. The anterior descending coronary artery is a delimiting artery between the two ventricles and, with its accompanying vein, lies on the junction of the ventricular septum with the left and right ventricles. A small part of the left ventricle and atrium make up the rest of the anterior surface. On X-ray, the right heart is made up, from top to bottom, of the superior vena cava, the right atrium, and the inferior vena cava. The left heart border, from top to bottom, is made up of the aortic knuckle, the main pulmonary artery, the left atrial appendage and the left ventricle. Posteriorly the heart is largely comprised of the left ventricle and left atrium on the left, with lesser portions of the right-sided chambers making up the posterior surface. The posterior descending coronary artery and its accompanying vein is the vascular bundle delimiting the attachment of the ventricular septum to the myocardium of the left and right ventricles. The fatty tissue around the heart lies largely in association with the vascular bundles. When the heart is removed from the pericardial sac, the anchoring vessels are seen as the support of the heart within the pericardium. These spaces between the vessels form the transverse and oblique pericardial sinuses. The coronary veins arise from the oblique vein lying over the left atrium (the vein of Marshall - a remnant of the anterior left-sided cardinal vein from embryogenesis) and the vena comitantes (accompanying vein) of the left anterior coronary artery called the great cardiac vein. This vein then forms the coronary sinus, which runs in the posterior coronary groove toward the right atrium picking up the lesser and least cardiac veins and other tributaries as it courses toward its termination in the coronary sinus which leads into the right atrium. The term Introduction To Cardiac & Tomographic Anatomy Of The Heart - Norman Silverman, M. The muscle of the heart is structured in a complex manner to act as a squeezing structure, and the cardiac valves act as one-way directional valves in a pump, (slide 7-8). There are four valves: the two between the atria and ventricles are termed the atrioventricular valves, and the two between the ventricles and great arteries are termed the aortic and pulmonic valves. The atrioventricular valves prevent reflux of blood into the atria during ventricular Systole and allow atrioventricular filling in Diastole. The mitral (bicuspid) valve lies on the left and the tricuspid valve on the right. The mitral valve is so called because of its resemblance to a bishop’s Mitre (Latin). The mitral valve has a large anterior (aortic) leaflet, which extends deeply into the ventricle. Its circumferential diameter is 1/2 of the posterior cusp that has 3 small divisions. Effective closure is achieved by the anterior leaflet coapting along the zone of commissural apposition. At their free edges the atrioventricular valves are supported by chordae tendineae (tendinous cords) which are like tree branches. They divide from their origin at the papillary muscles, form primary, secondary and tertiary chordae, which then attach to the commissures (spaces of apposition between the valves) rather than to individual valvar leaflets. During cardiac contraction the papillary muscle contracts first, tensing the valvar apparatus so that the force of contraction does not rupture the valves.

When given in full doses the fulness of the capillary circulation induced produces a flushing of the face buy generic trimox 500 mg online, a bright redness of the skin discount trimox 250 mg overnight delivery, which in sufficient dose is general over the entire body. This resembles very closely the erythematous rash of scarlet-fever, and from this fact the Homeopathists have one of their guides in prescribing this agent for that disease. It suppresses the secretions of all the organs, especially of the mucous membranes, inducing dryness of the throat and mouth and a tendency toward constipation. The evidences of cerebral fulness are: restless excitation, mental exhilaration, headache, dilated pupils, intolerance of light, impairment of vision, uncertainty of muscular movement, the latter finally amounting to incoordination, with motor paralysis. There is delirium of a talkative character, in some, cases violent or furious, with illusions and hallucinations. In extreme delirious excitement, if the dose is a fatal one, there is feeble pulse, cold skin shallow respiration, and paralysis of the inhibitory nerves of the heart and heart-muscle, resulting in death. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 61 In the influence of this remedy upon the capillaries of the skin, loading them up so actively, there is a contributory influence upon the capillaries of the spinal cord, which decreases the amount of blood in this locality, exercising often an exceedingly beneficial influence, especially when the patient suffering from spinal or cerebral congestion has cold skin, cold extremities, a cold, clammy sweat, dilated pupils, and great sluggishness of action. It is a pure stimulant to this organ, through its influence on the cardiac muscle and accelerator nerves. Notwithstanding the lack of proof in the laboratory, in the individual there is more force in the pulse, and there is extreme activity, as stated above, in the capillary circulation, especially when there is profound congestion, with cold relaxed skin, difficult breathing from pulmonary hyperemia, with a small compressible pulse and a deathlike pallor, followed, in extreme cases, by cyanosis. Then the stimulating influence of 1/ or 1/ of a grain of atropine will show itself unquestionably in a 80 60 very few moments. Strychnine expends its influence upon the nerve-centers, but the influence of atropine is upon the peripheries in an unquestionable manner, making it probably the most active of the diffusible stimulants. It thus relieves the pulmonary hyperemia, overcomes cyanosis and promotes free, deep breathing. Specific Symptomatology—There is a characteristic syndrome present in congestive types of many diseases which rationally indicates the need for belladonna. Preliminary congestion is a common condition in very many diseases and the influence of this drug, in antagonizing congestion and in producing a normal and effective equalization of the circulation brings it first to the mind of those who are studying actual conditions, in an endeavor to decide upon the needed remedy. The syndrome referred to consists in chilliness, mental dulness, and inactivity; dull eyes with dilated pupils, eyes partly open when asleep; skin cool and relaxed, with occasional free sweating; cool extremities; general sluggish capillary circulation. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 62 The Homeopathists claim that belladonna is especially indicated where the patients are full-blooded; seldom in anemic patients. Children, very active and with big brains, who are disturbed nights by night-terrors or dreams or show other evidences of restlessness are relieved by belladonna. The remedy acts best in full-blooded patients, where there is active localized heat, pain, redness, and swelling, evidences of local inflammation. When there are a full, bounding pulse, dull flushed face, dull eyes, dilated pupils, and throbbing carotids, the remedy is beneficial. Negroes, and those in warm climates, are especially susceptible to the action of belladonna. Belladonna is not a specific fever-remedy, but in a febrile disorder there is some local engorgement somewhere; there is local capillary hyperemia and, if the remedy is not contraindicated by an already too active condition of the capillary circulation, it will be found of service in all acute congestive disorders with temperature. I have made it a practice for thirty-five years to combine this remedy with the directly indicated fever- remedy, until the symptoms of local engorgement were overcome, then to continue with the fever-remedy alone. When so prescribed, the influence of the remedy to restrain secretion need not be considered, as this influence is usually antagonized by the agent that is used to control the temperature. This is especially true of aconite administered in conjunction with it, which makes a most reliable combination. Given early with aconite, when fever alone is present, hyperemia does not occur and the inflammation is aborted. If the disease is localized in any organ, displaying the phenomena named above, its influence often is quickly apparent. In diphtheritis, tonsillitis, croup, bronchitis, pneumonia, pleuritis and peritonitis, belladonna stimulates the capillary circulation in the engorged organs, thus quickly preventing the local effects of the acute congestion or inflammation. At the same time it has a marked influence upon the fever when used in conjunction with the other indicated measures. If half a drop of the tincture of belladonna be given every two hours, alternated with one grain of alum in syrup, excellent results often are obtained. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 63 In the therapeutics of all continued fevers this agent has an essential place in some stage of the fever. In the sthenic stage of these fevers, combined with aconite, it is sufficient for many of the indications. If there is an intermission or a marked remission, it may be continued alone, during the period. In typhoid fever, it is an important auxiliary during almost the entire duration of the fever. It stimulates the heart to diffuse the blood uniformly throughout the entire capillary circulation, and thus prevents cerebral engorgement. The brain symptoms exhibit many of the belladonna indications and are quickly relieved by it. In meningeal inflammation, both of adults and children, it is often sharply indicated.