By S. Umbrak. College of the Atlantic. 2018.

Thus order 2mg artane visa, the term natural product has become almost synonymous with the concept of drug discovery purchase 2 mg artane with visa. In modern drug discovery and development processes artane 2 mg without a prescription, natural products play an important role at the early stage of ‘lead’ discovery, i. It is estimated that 61 per cent of the 877 small molecule new chemical entities introduced as drugs worldwide during 1981–2002 can be traced back to or were developed from natural products. These include natural products (6 per cent), natural product derivatives (27 per cent), synthetic compounds with natural-product-derived pharmacophores (5 per cent) and synthetic com- pounds designed on the basis of knowledge gained from a natural product, i. In some therapeutic areas, the contribution of natural products is even greater, e. In 2000, approximately 60 per cent of all drugs in clinical trials for the multiplicity of cancers were of natural origins. Despite the outstanding record and statistics regarding the success of natural products in drug discovery, ‘natural product drug discovery’ has been neglected by many big pharmaceutical companies in the recent past. The declining popularity of natural products as a source of new drugs began in the 1990s, because of some practical factors, e. Complexity in the chemistry of natural products, especially in the case of novel structural types, also became the rate-limiting step in drug discovery programmes. Despite being neglected by the pharmaceutical companies, attempts to discover new drug ‘leads’ from natural sources has never stopped, but continued in academia and some semi-academic research organizations, where more traditional approaches to natural product drug discovery have been applied. Neglected for years, natural product drug discovery appears to be drawing attention and immense interest again, and is on the verge of a comeback in the mainstream of drug discovery ventures. In recent years, a significant revival of interests in natural products as a potential source for new medicines has been observed among academics as well as several pharma- ceutical companies. This extraordinary comeback of natural products in drug discovery research is mainly due to the following factors: combinatorial chemistry’s promise to fill drug development pipelines with de novo synthetic small molecule drug candidates is somewhat unsuccessful; the practical difficulties of natural product drug discovery are being overcome by advances in separation and identification technologies and in the speed and sensitivity of structure elucidation and, finally, the unique and incomparable chemical diversity that natural products have to offer. Moreover, only a small fraction of the world’s biodiversity has ever been explored for bioactivity to date. For example, there are at least 250 000 species of higher plants that exist on this planet, but merely five to 10 per cent of these terrestrial plants have been investigated so far. In addition, re-investigation of previously investigated plants has continued to produce new bioactive compounds that have the potential for being developed as drugs. While several biologically active compounds have been found in marine organisms, e. Natural product drug discovery: the traditional way In the traditional, rather more academic, method of drug discovery from natural products, drug targets are exposed to crude extracts, and in the case of a hit, i. Every step of fractionation and isolation is usually guided by bioassays, and the process is called bioassay-guided isolation. The following scheme presents an overview of a bioassay-guided traditional natural product drug discovery process. Sometimes, a straightforward natural product isolation route, irrespective of bioactivity, is also applied, which results in the isolation of a number of natural compounds (small compound library) suitable for undergoing any bioactivity screening. However, the process can be slow, inefficient and labour intensive, and it does not guarantee that a ‘lead’ from screening would be chemically workable or even patentable. Dereplication is the process by which one can eliminate recurrence or re-isolation of same or similar compounds from various extracts. While in the recent past it was extremely difficult, time consuming and labour intensive to build such a library from purified natural products, with the advent of newer and improved technologies related to separation, isolation and identification of natural products the situation has improved remarkably. Natural product libraries can also be of crude extracts, chromatographic fractions or semi-purified compounds. However, the best result can be obtained from a fully identified pure natural product library as it provides scientists with the opportunity to handle the ‘lead’ rapidly for further developmental work, e. These approaches include the application of genomic tools, seeking novel sources of organisms from the environment, new screening technologies and improved processes of sample preparation for screening samples. In addi- tion, the recent focus on the synthesis of diversity-oriented combinatorial libraries based on natural-product-like compounds is an attempt to enhance the productivity of synthetic chemical libraries. The name ‘alkaloid’ derives from the word ‘alkaline’, which means a water soluble base. A number of natural alkaloids and their derivatives have been developed as drugs to treat various diseases, e. In fact, one or more nitrogen atoms that are present in an alkaloid, typically as 1 ,2 or 3 amines, contribute to the basicity of the alkaloid. The degree of basicity varies considerably, depending on the structure of the molecule, and presence and location of the functional groups. However, alkaloids can also be grouped together on the basis of their generic structural similarities. The following table shows different major types of alkaloid, their generic skeletons and specific examples. Piperine has various effects on human drug metabolizing enzymes, and is marketed under the brand name, 1 Bioperine , as an adjunct for increasing bioavailability of various dietary supplements, especially curcumin, one of the active ingredients of turmeric (Curcuma longa). It is a neurotoxin, causes respiratory paralysis and is toxic to all classes of livestock and humans. Nicotine Nicotine, molecular formula C10H14N2, is the major pharmacolo- gically active component of tobacco, Nicotiana tabacum, and is also found extensively in other species of the family Solanaceae, e. Nicotine is a hygroscopic oily liquid, and miscible with water in its base as well as its salt form. Nicotine possesses two nitrogenous ring systems: one is pyridine, but the other is a pyrrolidine ring system. Nicotine is a potent nerve poison, and is included in many insecticide preparations. The main symptoms of the withdrawal of nicotine intake include irritability, headaches, anxiety, cognitive disturbances and sleep disruption.

These drugs include Thalidomide cheap artane 2 mg free shipping, which causes abnormal limb development cheap 2mg artane free shipping, and cocaine cheap 2 mg artane overnight delivery, which causes miscarriages, fetal hypoxia (lack of oxygen), low-birth-weight infants, tremors, strokes, increase in stillbirth rates, congenital heart disease, skull defects, and other malformations. Adverse side effects of the drug on the fetus can be avoided by carefully checking the Pregnancy Category of the medication before the medication is administered to a pregnant woman. Regardless of the Pregnancy Category of the drug, always carefully observe the pregnant patient after administering medication to assure that the patient doesn’t show any observable adverse response. Pediatrics Special care must be given when administering medication to pediatric patients because their organs are immature and they might have difficulty absorbing, distributing, and excreting the medication. However, because the mother has already metabolized and excreted the medica- tion, less than the original dose is passed into breast milk. These medications include amphetamines, bromocriptine, cocaine, cyclophos- phamide, cyclosporine, doxorubicin, ergotamine, gold salts, lithium, methotrex- ate, nicotine, and phenindione. Organs in the neonate might be unable to handle the normal dose of some medications. For example, the stomach lacks acid, gastric emptying time is prolonged, the liver and kidneys are immature, and there is a decrease in pro- tein binding. The dose is calculated using the patient’s weight or the patient’s body surface area. Some over-the-counter medications specifies a dose based on the child’s age, but these are really based on the average weight of a child within that age range. The dose can become problematic if the child’s weight is lower or higher than that of the age group. If a child with a very low weight receives an age-related dose it might result in an undesirable adverse affect from the medication. When a child who is heav- ier than average receives a dose related to age, the drug may not have a thera- peutic effect. Before administering medication to a pediatric patient consult with the par- ents to assess if the patient has allergies to food, medications, and the environ- ment, a family history of allergies, an experience with medications and illnesses, or is taking any other medication or herbal remedies. Elderly More than 30% of all prescriptions and more than 50 percent of all over-the- counter medications in the United States are consumed by patients who are over 60 years of age. It is this group of patients who are three times more likely to be admitted to a healthcare facility for an adverse reaction to medication. There are several important reasons for such a high occurrence of adverse response to medication. These include: • Polypharmacy (multiple medications are prescribed without discontinuing current medication, causing an interaction between drugs); • Medication can impair the mental and physical capacity leading to acci- dental injury; • Age can increase the sensitivity to drugs and drug-induced disease; • Absorption of medication is altered due to an increase in gastric pH; • Distribution of the medication is affected because of a decrease in lean body mass, increased fat stores, a decrease in total body water, decreased serum albumin, and a decrease in blood flow and cardiac output; • Metabolism changes as enzymatic activity decreases with age, and liver function; • Excretion is impaired due to decreased kidney function. This includes all prescription drugs, over-the-counter drugs, home remedies, vitamins, and herbal treatments. Make sure that you determine the medications that have been prescribed and medications that the patient actu- ally takes. Some patients don’t take all of the medications that are prescribed to them because of the cost of the medication or some unpleasant or undesirable side effects. List all practitioners who prescribed medications for the patient, including the patient’s primary physician, orthopedist, and cardiologist. Ask the patient how they self-medicate, if they maintain a medica- tion schedule, and if they ever forget to take their medication. If they do, ask what medications they’ve skipped and what they do when they forget or skip a dose. Determine if the patient has any barriers to taking medication safely such as allergies, physical handicaps, memory loss, cultural beliefs, and financial con- straints. The elderly typically live on a fixed income and may be unable to pur- chase expensive medications—even if the benefit outweighs the cost. The assessment step collects data about the patient that is analyzed to arrive at a nursing diagnosis. A care plan is then devel- oped that describes what must be done to address the symptoms of the nursing diagnosis. The care plan is then enacted during the intervention step and the results are then evaluated. The care plan terminates if the goals of the plan are achieved or revised if the goals are not achieved. Before any medication is given to a patient, the nurse must assess a number of factors that include the drug order, drug actions, interactions, and contraindications. Educating the patient about medication is an important responsibility for the nurse. The nurse must explain why the medication is given and how the patient can self-medicate. The nurse must also make sure that the patient and the family know the signs and symptoms of adverse side effects from the medication as well as any toxic effects and dietary considerations to follow while taking the medication. Cultural factors typically influence the patient’s belief about health and can impact medication prescribed to treat a patient’s illness. The nurse must put aside his or her own opinion about those beliefs and work within those limita- tions when caring for the patient. Genetic, ethnic, and racial differences play a role in the physiological response to drugs. Some groups of patients are less responsive to certain medications be- cause of genetic factors; other groups of patients can experience a toxic effect because of hereditary traits. Drugs can have different effects on the very young and the elderly because of physiological changes in their bodies.

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It‘s easy for you to think that your math professor is “picky and detail-oriented‖ because that describes her behavior in class buy cheap artane 2 mg on line, but you don‘t know how she acts with her friends and family buy artane 2 mg free shipping, which might be completely different cheap artane 2mg amex. We are more likely to commit the fundamental attribution error—quickly jumping to the conclusion that behavior is caused by underlying personality—when we are tired, distracted, or busy doing other things [50] (Trope & Alfieri, 1997). An important moral about perceiving others applies here: We should not be too quick to judge other people. It is easy to think that poor people are lazy, that people who say something harsh are rude or unfriendly, and that all terrorists are insane madmen. But these attributions may frequently overemphasize the role of the person, resulting in an inappropriate and inaccurate [51] tendency to blame the victim (Lerner, 1980; Tennen & Affleck, 1990). Sometimes people are lazy and rude, and some terrorists are probably insane, but these people may also be influenced by the situation in which they find themselves. Poor people may find it more difficult to get work and education because of the environment they grow up in, people may say rude things because they are feeling threatened or are in pain, and terrorists may have learned in their family and school that committing violence in the service of their beliefs is justified. When you find yourself making strong person attributions for the behaviors of others, I hope you will stop and think more carefully. Would you want other people to make person attributions for your behavior in Attributed to Charles Stangor Saylor. Attitudes and Behavior Attitude refer to our relatively enduring evaluations of people and things(Albarracín, Johnson, & Zanna, [52] 2005). We each hold many thousands of attitudes, including those about family and friends, political parties and political figures, abortion rights, preferences for music, and much more. Some of our attitudes, including those about sports, roller coaster rides, and capital punishment, are heritable, which explains in part why we are similar to our parents on many dimensions [53] (Olson, Vernon, Harris, & Jang, 2001). Other attitudes are learned through direct and indirect [54] experiences with the attitude objects (De Houwer, Thomas, & Baeyens, 2001). Attitudes are important because they frequently (but not always) predict behavior. If we know that a person has a more positive attitude toward Frosted Flakes than toward Cheerios, then we will naturally predict that she will buy more of the former when she gets to the market. If we know that Charlie is madly in love with Charlene, then we will not be surprised when he proposes marriage. Because attitudes often predict behavior, people who wish to change behavior frequently try to change attitudes through the use of persuasive communications. If the listener wants to be entertained, then it is better to use a humorous ad; if the listener Consider the goals of the listener. Try to associate your product with positive stimuli such as funny jokes or attractive Use classical conditioning. Humorous and fear-arousing ads can be effective because they arouse the listener‘s Make use of the listener‘s emotions. Use the listener‘s behavior to modify One approach is the foot-in-the-door technique. People who are high in self- monitoring—the tendency to regulate behavior to meet the demands of social situations—tend to change their behaviors to match the social situation and thus do not always act on their attitudes [56] (Gangestad & Snyder, 2000). High self-monitors agree with statements such as, “In different situations and with different people, I often act like very different persons‖ and “I guess I put on a show to impress or entertain people. Low self-monitors are more likely to agree with statements such as “At parties and social gatherings, I do not attempt to do or say things that others will like‖ and “I can only argue for ideas that I already believe. Would you be willing to bet that she‘d never try smoking when she‘s out with her friends? Magritte‘s friends might be able to convince her to try smoking, despite her initial negative attitude, by enticing her with peer pressure. Behaviors are more likely to be consistent with attitudes when the social situation in which the behavior occurs is similar to [57] the situation in which the attitude is expressed (Ajzen, 1991). Although it might not have surprised you to hear that our attitudes predict our behaviors, you might be more surprised to learn that our behaviors also have an influence on our attitudes. It makes sense that if I like Frosted Flakes I‘ll buy them, because my positive attitude toward the product influences my behavior. But my attitudes toward Frosted Flakes may also become more positive if I decide—for whatever reason—to buy some. It makes sense that Charlie‘s love for Charlene will lead him to propose marriage, but it is also the case that he will likely love Charlene even more after he does so. Self- perception occurs when we use our own behavior as a guide to help us determine our own [58] thoughts and feelings (Bem, 1972; Olson & Stone, 2005). In one demonstration of the power [59] of self-perception, Wells and Petty (1980) assigned their research participants to shake their heads either up and down or side to side as they read newspaper editorials. The participants who had shaken their heads up and down later agreed with the content of the editorials more than the people who had shaken them side to side. Wells and Petty argued that this occurred because the participants used their own head-shaking behaviors to determine their attitudes about the editorials. The foot-in-the-door technique is a method of persuasion in which the person is first persuaded to accept a rather minor request and then asked for a larger one after that. In one demonstration, Guéguen and [60] Jacob (2002) found that students in a computer discussion group were more likely to Attributed to Charles Stangor Saylor. The idea is that when asked the second time, the people looked at their past behavior (having agreed to the small request) and inferred that they are helpful people. Behavior also influences our attitudes through a more emotional process known as cognitive dissonance. Cognitive dissonance refers to the discomfort we experience when we choose to behave in ways that we see as inappropriate (Festinger, 1957; Harmon-Jones & Mills, [61] 1999).

The police officer should identify the doctor to the person safe artane 2 mg, and the doctor should obtain witnessed informed consent generic 2 mg artane fast delivery. The physician must then determine whether there are any medical reasons why a sample of blood cannot be taken buy artane 2 mg. The sample should be divided equally between the two bottles and shaken to dis- 366 Wall and Karch perse the preservative (an additional needle through the rubber membrane helps to equalize the pressure). The bottles should be labeled and placed in the secure containers and caps applied. The driver is allowed to retain one sample, which is placed in an envelope and sealed. Under British law, a forensic physician may make up to three unsuccessful attempts at taking blood before the driver can reasonably refuse to give blood on grounds that the defendant has lost confidence in the doctor. Complex Defenses Numerous technical defenses have been advocated over the years, and doctors should be aware of the most common. In the United States, refusal leads to automatic license suspension and, in some states, may actually constitute a separate crime; police are under an obligation to ensure that drivers are made aware of that. The motorist must understand the manda- tory warning of prosecution if a specimen is not produced. Failure to under- stand, at least in the United Kingdom, is a reasonable excuse for the nonprovision of a sample (38). The decision regarding whether there is a medi- cal reason not to supply a sample of breath is left to the police officer and is summarized in case law. There is no provision or requirement at that stage for a doctor to be summoned or to give an opinion. Examples of medically acceptable reasons include mouth, lip, or facial injury; tracheotomy; rib injury; and neurological problems. Traffic Medicine 367 Many cases have been challenged on the basis that the person was unable to blow into the intoximeter because of respiratory problems. This article was particularly useful because most forensic physicians do not have access to spirometry but do have access to a simple peak flow reading in the custody situation. A more recent study (45) on the new Lion Intoxilyzer 6000 concluded that some subjects with lung diseases may have difficulty in providing evi- dential breath samples. However, these were subjects who would generally have been considered to have severe lung diseases. A recent fashionable defense is that the presence of a metal stud through a hole pierced in the tongue invalidates the breath alcohol test because of the prohibition against foreign substances in the mouth and because of the poten- tial for the jewelery to retain alcohol and interfere with the breath test. How- ever, experimental work has shown that the rates of elimination of mouth alcohol were no different in subjects with a tongue stud as opposed to controls and that for the purposes of breath alcohol testing, oral jewelery should be treated the same as metallic dental work and left in place without affecting the outcome of the breath test (46). Failure to Provide a Sample of Blood First, there must be a definite request to provide a sample of blood. Where the sample of blood is taken from is solely the choice of the forensic physician (or, in the United States, the emergency room physician). In Solesbury v Pugh (48), the defendant was found guilty of failing to supply a specimen as he would only allow a sample to be taken from his big toe, which the doctor was not prepared to do. In the United Kingdom, if the patient’s own doctor and forensic physi- cian are both present, the person can choose which doctor takes the sample. Similar rules apply in the United States, where statutes generally spell out that financial responsibility for such services rests with the driver and not the state. In the United Kingdom, if a blood sample is provided but the doc- tor spills the sample, then the law has been complied with on the basis that removal of the syringe from the vein by the doctor completes the provision of the specimen by the defendant (50). In the United Kingdom, a minimum of 2 mL of blood is required (the laboratory requires a minimum of 1 mL for analysis) for an adequate sample (51). If less than this is obtained, the sample should be discarded and another one attempted or the police officer advised that there is a medical reason why a sample of blood should not be provided and the urine option can then be selected. In the early 1980s, one police force purchased and used swabs containing alcohol with the result that numerous convictions were later overturned (52). Probably the most common defense for failure to provide a sample of blood is that of needle phobia. If this is alleged, a full medical history should be obtained and enquiry made of whether the person has had blood tests before, whether ears or other parts of the body have been pierced, or whether there have been foreign travel immunizations or any other medical or dental procedure undertaken in which an injection may have been administered. British appellate judges (53) have stated that “no fear short of phobia recognized by medical science to be as strong and as inhibiting as, for instance, claustrophobia can be allowed to excuse failure to provide a specimen for a laboratory test, and in most if not all cases where the fear of providing it is claimed to be invincible, the claim will have to be supported by medical evidence. Rix also gives some practical advice to police surgeons: be able to distinguish between repugnance and phobia, be able to distinguish between unwillingness and inability, document the history and examination with emphasis on the presence or absence of signs of anxiety, and ensure that the decision is based on firm medical evi- dence. Finally, record all this information, specifically note in the police record Traffic Medicine 369 whether a medical condition has been identified, and then verbally communi- cate this opinion to the police officers (55). Another common defense is that of consuming alcohol after the offense– the hip flask defense (56). It will be necessary for a scientist to prove that it was only the postdriving consumption that caused the analysis to reveal an alcohol level above the prescribed limit. Back calculations can only be approximate because they are based on average values, and although they are reasonable estimates for most people, they may occasionally fail to reflect accurately the situation of a particular individual, regardless of whether the calculation is for preincident or postincident drinking. Failure to Provide a Urine Sample If a woman is requested to provide a urine sample, it is important to have a female officer present because it has been held that because of the embarrassment that it could involve, the refusal to supply a sample of urine could be regarded as a reasonable excuse (58). However, any embarrassment at having to urinate in front of an officer of the same sex is not regarded as a reasonable excuse for not having supplied a specimen. Methadone and other opiates have an effect on the blad- der sphincter and can thus cause delayed bladder emptying; this effect could be considered a reasonable excuse for failing to provide a urine sample (59). In Sweden, Jones (56) reported the top 10 defense challenges for driving under the influence of alcohol (Table 2).

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Other environmental factors include: al- birth movement has also focused on easing the birth ex- cohol and drugs order artane 2mg on-line, consumed during the pregnancy buy artane 2 mg otc, and ex- perience for the infant purchase artane 2mg with visa. Heavy alcohol physician Frederick Leboyer described modern hospital consumption during pregnancy can trigger fetal alcohol birth as “torture of the innocent” and proposed measures syndrome in newborns, characterized by underweight, to make the transition to life outside the womb a more small eyes, a short upturned nose with a broad bridge, gentle one for the newborn. Thalidomide, lights and a quiet atmosphere in the delivery room, post- prescribed in the 1950s as a mild sedative, led to the birth poning cutting of the umbilical cord, and bathing the in- of 7,000 severely deformed babies, suffering from a con- fant in lukewarm water. Psychologists Otto Rank and dition called phocomelia, characterized by extremely R. Laing have elaborated on the idea of birth trauma short limbs that were often without fingers or toes. Spina bifida, a neural tube defect, is liefs that influence an adult’s behavior and attitudes. These factors include, for example, poor health, close properly during the first month of pregnancy. In anatomical abnormalities, prematurity, and unusual orien- worst cases, the spinal cord protrudes through the back. In some women, the “shunting” to relieve the fluid build up and redirect it pelvic space is too small for spontaneous birth of a baby, into the abdominal area. Sophisticated medical tech- and the delivery of the child is accomplished through a niques allow most children with spina bifida to live well surgical opening made in the mother’s abdominal wall and into adulthood. For a Health Service recommends that women of childbearing healthy mother and child, the risks of childbirth are ex- age in the U. Fritz Klein, a noted psychiatrist, has expanded the other two neural two defects: anencephaly or en- on Kinsey’s work, creating the Klein Sexual Orientation cephalocele. Amniocentesis or ultrasound testing can di- Grid, which takes into account seven different variables agnose spina bifida before birth. Klein’s variables provide a more detailed look at Sickle-cell anemia, Tay-Sachs, color blindness, one’s sexuality, examining preferences in attraction, be- deafness, and extra digits on the hand or feet are heredi- havior, fantasies, emotional involvement, social involve- tary birth defects passed on through generations by ab- ment, lifestyle, and self-identification. Birth defects may not impact each genera- for sexual development over time, an important element tion, but the abnormal gene is passed on. The Illustrated Book of Pregnancy and Klein’s grid, exploring only three, rather than seven, Childbirth. Sexual activities are actual behaviors such See also Fetal alcohol effect and syndrome as kissing, fellatio, and intercourse. Bisexuality Some studies of fraternal and identical twins show Sexual orientation defined as sexual involvement that identical twins are more likely to be bisexual than are with members of both sexes concurrently (within fraternal twins, suggesting a genetic basis for bisexual the period of one year) or any sexual attraction to predisposition. These studies have yet to be tested ade- or involvement with members of both sexes at any quately to be considered conclusive, however. Debate over why people are hetero-, homo-, or bi- Some define it narrowly as sexual involvement with mem- sexual is a fairly recent phenomenon. Identification by bers of both sexes concurrently (within a twelve-month sexual preference only began in the 19th century, and be- period or less). Today, however, there any sexual attraction to or involvement with members of is tremendous pressure for a person to declare a sexual both sexes at any time in one’s life. The idea of bisexuality is threatening to qualify as bisexual in its narrow definition. A comprehen- some people because sexuality is no longer clearly de- sive study, “Sex in America,” conducted in 1992 by the fined between homosexuality and heterosexuality. They are considered “too gay” to be cans who fit the broad definition of bisexuality, estimates straight, and “too straight” to be gay. Homosexual support groups may reject them if they reveal their het- Sigmund Freud believed that bisexuality was a erosexual sides; heterosexuals may reject them if they re- “disposition” common to all humans. Many bisexuals remain every individual has a masculine and feminine side, and in the closet, hiding their gender-encompassing feelings that each side is heterosexually attracted to members of from others, and sometimes even from themselves. Most people, however, according to ers lead dual lives, expressing their homosexual sides Freud, repress one side, becoming either hetero- or ho- with one group of friends, while reserving their hetero- mosexual. Alfred Kinsey posited a scale for human sex- sexual selves for a totally separate social circle. Conflict occurs that 30% of teenage suicides occur among gay and les- when the seer places unrealistic demands on him or her- bian youths, but the number of bisexual victims is un- self and the body. Fortunately, however, a movement has begun in pearance and may include body functions or other fea- recent years to promote a greater acceptance and under- tures. More studies are being done tional experiences, fantasies, feedback from others, and specifically on bisexuality or that include bisexuality as a plays a key role in a person’s self-concept. Most bi- How one’s physical characteristics correspond to sexuals are monogamous for all or part of their lives, and cultural standards plays a crucial role in the formation of those who engage in promiscuous behavior are not neces- body image. Daeg de Mott cultural standards and concepts can be very damaging, as few people attain an “ideal body,” no matter how it is de- fined, and those who depart drastically from the ideal Further Reading can suffer a sharply reduced sense of self-worth. New Psychologists are interested in body image primarily York: HarperPerennial, 1996. A seriously distorted or inappropriate body and Bisexual Identities Over the Lifespan: Psychological image characterizes a number of mental disorders. Bi Any Other this condition generally become preoccupied with a spe- Name: Bisexual People Speak Out. Boston: Alyson Publi- cific body part or physical feature and exhibit signs of cations, 1991. New York: magnifies a slight flaw into a major defect, sometimes The Haworth Press, 1993.

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Oxygen radicals are particularly destructive cheap artane 2mg with visa, with oxidation modifying proteins (Hipkiss 1989) discount 2mg artane overnight delivery, including cell membrane phospholipid discount artane 2 mg amex. Free oxygen radicals are released with hyperoxia (Davidson & Boom 1995), so that prolonged high FiO2 (above 0. Intensive care nursing 240 Hypoxic vascular epithelium releases endogenous nitric oxide (see Chapter 28); widespread tissue hypoxia (shock) therefore causes widespread nitric oxide release and systemic vasodilation. Cells surviving initial injury exist in grossly disordered internal environments; anaerobic metabolism causes peripheral accumulation of metabolic acids, free radicals, oxidative enzymes (e. Reperfusion injury can result from toxic products being flushed into the central cardiovascular system during recovery, potentially causing secondary (reperfusion) damage. Calcification Necrosis leads to microscopic calcium deposits; accumulation through persistent injury causes progressive tissue damage and rigidity, especially in renal, pulmonary, cardiovascular and gastric cells (Nowak & Handford 1996). Implications for practice ■ most critical pathologies originate at microcellular rather than macro-system level; understanding these processes enables nurses to understand the pathologies and treatments covered in many of the other chapters (e. Treatments should therefore focus on underlying mechanisms of disease rather than more easily observed effects. Understanding these microscopic mechanisms enables nurses to monitor and assess effects of treatments. This chapter has outlined the main mechanisms of cell dysfunction as a basis for understanding pathophysiologies described in the remainder of this section. Cellular pathology 241 Further reading Revision of normal cell physiology from a recent and appropriate anatomy text, such as Marieb (1995) or Guyton and Hall (1997), can provide a useful basis for understanding pathophysiology; Abbas et al. Mechanisms of key pathological processes can be complex, but some recent specialist articles usefully describe aspects such as free radicals (Davidson & Boom 1995) and treatments (Wardle 1997). On endotracheal suction his sputum is thick mucopurulant and arterial blood gases indicate hypoxia, hypercapnia and severe respiratory acidosis. His blood results include abnormalities in differential white blood cell count: Q. Include structures (and make brief notes on their functions) such as nucleus, cytoplasm, cytoskeleton, microtubules, endoplasmic reticulum, Golgi complex, ribosomes, mitochondria, lysosmomes, cell surface (or surface membrane) with its various structures and components (e. Review the cellular processes which caused this from his acute asthmatic attack (e. Cardiac disease may persist for years; when myocardial oxygen supply becomes inadequate, the myocardium infarcts. This chapter identifies the underlying pathophysiology and treatments (especially thrombolysis). Myocardial oxygen supply Five per cent of cardiac output enters the two coronary arteries (right and left) from the aorta. The left artery divides into the left anterior descending and circumflex (see Figure 24. At rest, myocardium normally extracts 70–80 per cent of available oxygen (Ganong 1995). Having more mitochondria than skeletal muscle, the myocardium relies on aerobic respiration (Clancy & McVicar 1995). Ischaemia is transient; if reversed (reducing oxygen demand, increasing oxygen supply, or both), the myocardium recovers; unreversed ischaemia will progress to infarction. Coronary artery disease begins in childhood and is well advanced in many by the age of 30 (Herbert 1991); symptoms usually only occur when coronary arteries are three- quarters occluded (Carleton & Boldt 1992). This leaves little physiological reserve between the onset of symptoms and ischaemic tissue death. About one-half of acute myocardial infarctions are due to occlusion of the left anterior descending artery, with a significant minority caused by right coronary artery perfusion, circumflex artery occlusion being a far less frequent cause of infarctions (Rowlands 1996a). The tunica intima becomes penetrable to lipids, especially cholesterol and low density lipoproteins, altering the integrity of vasculature (Todd 1997); as fats, fibrin, cholesterol and calcium are deposited (Wilson 1983), lipids are covered by fibrous caps of tissue from proliferating cells in the intima (Todd 1997) which enables platelet adhesion to prominences in arterial walls (Wilson 1983). Nitric oxide, an endogenous vasodilator that enables coronary arteries to meet increased demand, is only released from intact endothelium (Todd 1997). When obstruction causes ischaemia but is not extreme enough to provoke infarction, ischaemic myocardium, like Intensive care nursing 246 other muscle, experiences cramp (angina). The severe pain of angina is both a warning of impending infarction and a sympathetic agonist. As sympathetic stimulation causes coronary vasoconstriction, pain accentuates ischaemia. Therefore prompt and sufficient analgesia is both a humanitarian and physiological necessity. Weston (1996) suggests myocyte death depends upon work load (oxygen demand), prior episodes of ischaemia and collateral flow. Collateral circulation Like most body systems, the cardiovascular system is dynamic, changing to meet physiological needs. With progressive obliteration of flow, arteries can develop collateral circulation to bypass obstructions. Collateral vessels are small, weak and tortuous, offering temporary relief rather than permanent solutions, although they may limit infarct size. Oestrogen production during reproductive years protects women from atherosclerosis, making men under 55 up to four times more likely to suffer from coronary artery disease than women (Lessig & Lessig 1998). However, the earlier development of coronary artery disease in men also means earlier development of collateral circulation; the sudden reduction in oestrogen levels during and following menopause exposes women to rapid atherosclerosis (Sloane et al.

Cautions/contraindications Responsible practitioners of most complementary therapies have faced hostility from (among others) traditional medicine artane 2mg cheap. Without definitive evidence order 2 mg artane otc, therefore buy discount artane 2 mg on line, most reputable therapists apply therapies cautiously, creating extensive lists of contraindications and cautions for most therapies. While experienced practitioners may be prepared to treat patients in ‘caution’ groups, less experienced users are advised to avoid treating such patients (Rankin-Box 1988), both for the patients’ safety and their own (for example, indemnity claims). Dangers The popularity of complementary therapies has encouraged the introduction of some unscrupulous products (these are usually very dilute, and so ineffective). Most of the cheaper products have little value, although high prices do not necessarily guarantee Complementary therapies 445 quality. The use of ineffective products can easily discredit the potentially worthwhile interventions. The lack of regulation creates variable preparation for complementary therapy practice, ranging from ‘how-to’ books and single study days to degree and postgraduate courses. Selection can create dilemmas, the vested self-interests of writers and researchers sometimes decrying other, potentially valuable, approaches. As with any other aspect of their work, nurses should be constructively critical, remembering their individual professional accountability. This chapter offers insights into specialist application of some of the more widely used interventions, identifying some problems and professional issues surrounding the use of complementary therapies. Those wishing to practice complementary therapies, or use them themselves, should ensure a safe knowledge-base for practice, evaluating risks against benefits. The likely future regulation of complementary therapies may help to ensure their creditable practice and encourage a more reliable knowledge base. Further reading There are many texts on the various complementary therapies, most written with much enthusiasm, although some with more bias than objectivity; Rossa et al. The Nursing Times 1993 series of articles (since collected together in book form) also outlines many therapies. The journal Complementary Therapies in Nursing and Midwifery includes many useful articles. He has become increasingly withdrawn and depressed, has difficulty sleeping and discomfort from paraesthesia in lower limbs. Nursing values may conflict with norms and values of other groups, and changes are not always successful, but planning helps achieve success. Asking basic questions helps to clarify issues and motives, and so this chapter adopts a what? Include changes on your own unit, within the hospital, and wider changes in healthcare. As you read through this chapter, note down, section by section, how you would plan to bring this change about. After reading this chapter, you may have a workable plan which you can discuss with senior staff on your unit. The requirements by managers and courses for introducing change have created some negative structures and outcomes; change should grow from convictions that it is needed. Ideas may be gained from Intensive care nursing 448 courses, study days, reading, discussions with others, experience elsewhere, or (sometimes) out of the blue. Be clear about what you want to change (the exercise above should have crystallised your ideas). Internal stimuli depend on the motivation, ambition and values of the staff involved. Rationales for change probably precede the identification of the precise nature of changes. Having clarified what you intend to do, reconsider your initial motivation, identifying the existing problems and benefits of suggested changes. Changes without clear benefits may not be worth the effort and trauma of introducing them. Everyone is a potential change agent, capable of initiating, and possibly leading, change. Top-down change agents may be members of staff or outsiders; with bottom-up approaches, change agents are necessarily team members. Outsiders are usually authoritarian, although action research (Webb 1989), which has proved popular within nursing, helps people to reflect on and understand change better, and so aids the establishment of a change in practice (Pryjmachuk 1996). Outsiders need to establish either authority (power-coercive) or credibility (rational-empirical); insiders are usually already accepted group members. Ketefian (1978) suggested that change agents should: diagnose need identify and clarify issues develop strategies and tactics establish and maintain working relationships with staff This model recalls the nursing process, but usefully emphasises that interpersonal relationships are as important as the plan itself. Possible strategies include feedback education standards/guidelines/quality control Managing change 449 Ethical approval may be needed, especially if patients are involved in any research. Wright (1998) suggests that most literature on leadership derives from soci-ology, industry or politics, but if nursing really is unique (as it is often claimed) it may need to develop its own unique management models. However, Surman and Wright (1998) follow most nursing literature in citing Bennis et al. Orders should be followed because managers are senior (coercive); no further reason is required, and discussion is usually discouraged. Power-coercion is hierarchical, top-down, autocratic (Keyzer & Wright 1998), achieving strong, cost-effective leadership. Junior staff may not agree with the ideas, but know what those ideas are; change occurs quickly, and the power-base for decision- making is clear. National management of healthcare often adopts power-coercion, whether by government (Department of Health) or professional bodies. Benner’s (1984) novice may be more comfortable with clear power-coercive leadership; more advanced practitioners usually find power-coercion increasingly oppressive, with their own ideas and initiatives being cramped by others.