Mark Corson

By Z. Ivan. Franciscan University of Steubenville. 2018.

The reverse is true 22 for weak bases (with pK ′s in the range 5 to 11) order fluoxetine 20mg with mastercard, which are poorly absorbed purchase fluoxetine 20 mg visa, if at all order fluoxetine 10 mg line, in the stomach sincea they are largely ionized at low pH, but are well absorbed in the small intestine, where they are unionized. Strong bases, such as mecamylamine, are ionized throughout the gastrointestinal tract and are therefore poorly absorbed. Although the pH-partition hypothesis is useful, it must be viewed as an approximation because it does not adequately account for certain experimental observations. For example, most weak acids are well absorbed from the small intestine, which is contrary to the predictions of the pH-partition hypothesis. These discrepancies arise because the pH-partition hypothesis does not take into account the following: • the large mucosal surface area of the small intestine, which compensates for ionization effects; • the relatively long residence time in the small intestine, which also compensates for ionization effects; • even the ionized form of a drug displays limited absorption; • charged drugs, such as quaternary ammonium compounds, may interact with organic ions of opposite charge, resulting in a neutral species, which is absorbable; • bulk transport of water from the gut lumen to the blood, or vice versa, can drag water-soluble molecules with it, resulting in an increase or decrease in the absorption of water-soluble drugs respectively. A more complex relationship pertains for more complex and organized structures such as lipid bilayers, but again, drug diffusivity is inversely proportional (probably by an exponential relationship) to the molecular volume. This means that drug diffusivity across membranes is sensitive to molecular weight, since molecular volume is determined by a number of factors, including the molecular weight of the molecule. Therefore, in general, large molecules will diffuse at a slower rate than small molecules. However, molecular volume is also determined by: • the overall conformation of the molecule; • the heteroatom content that may be involved in inter- and intramolecular hydrogen bonding. Thus molecules which assume a compact conformation will have a lower molecular volume and thus a higher diffusivity. An important consequence of this property is that even if such molecules have a high molecular weight (i. Molecular size and volume also have important implications for the paracellular route of drug absorption. It would appear that tight junctions bind cells together very efficiently and can block the passage of even relatively small molecules. Gap junctions are looser and molecules up to 1,200 Da can pass freely between cells. Larger molecules cannot pass through gap junctions, suggesting a functioning pore size for the connecting channels of about 1. For example, an orally administered drug can be given as a tablet, capsule or suspension; drugs for parenteral administration can be given as suspensions, emulsions and microparticulate systems; delivery systems for drugs administered via routes such as the transdermal, buccal, nasal and vaginal routes include suspensions, creams, gels and patches. As described above, the epithelia present a significant physical and biochemical barrier to drug absorption. However, since drugs must generally be in solution before they can cross epithelia, in many cases the rate of absorption of the drug from the particular dosage form is controlled by how fast the drug dissolves in the fluids at the absorption site. When dissolution is the controlling step in the overall process, absorption is described as dissolution rate limited. Therefore the solubility of the drug constitutes an important physicochemical property affecting drug absorption. It has been estimated that 43% of new 24 chemical entities are sparingly soluble in water, thus it is not surprising that methods to increase the solubility of poorly soluble drugs constitutes an important area of research. Further information is also given in the relevant chapters describing the various routes of drug delivery. To briefly summarize here, the general relationship describing the dissolution process is given by the Noyes-Whitney equation (Equation 6. One of the most important implications of this equation is that a drug dissolves more rapidly when its surface area is increased, which is usually accomplished by reducing the particle size of the drug. Many poorly soluble, slowly dissolving drugs for oral drug delivery are therefore marketed in micronized or microcrystalline form, as reducing the particle size of the drug increases the available surface area. The ionized form of a drug molecule is the more water-soluble form, therefore the dissolution rate of weak acids increases with increasing pH, whereas the dissolution rate of weak bases decreases with increasing pH. Although it is the ionized form of a drug that is required for aqueous solubility, the unionized form is required for lipid solubility and transcellular passive diffusion. However, the unionized form has poor aqueous solubility, which mitigates against membrane penetration. In practice, a balance between the lipid and aqueous solubility of a drug is required for successful absorption. Various strategies to increase the solubility of a drug are given below; this subject is also discussed in detail in Chapter 6 (see Section 6. Salt formation Formation of a corresponding water-soluble salt increases the dissolution rate in the gastrointestinal tract. This phenomenon can be explained by considering that a weakly acidic drug is unionized in the stomach and therefore has a low dissolution rate. If the free acid is converted to the corresponding sodium or potassium salt, the strongly alkali sodium or potassium cations exert a neutralizing effect. Thus in the immediate vicinity of the drug the pH is raised to, for example, pH 5–6, instead of pH of 1–2 in the bulk medium of the stomach, resulting in an alkaline microenvironment around the drug particle. This causes dissolution of the acidic drug in this localized region of higher pH, which gives rise to overall faster dissolution rates. When dissolved drug diffuses away from the drug surface into the bulk of the gastric fluid where the pH is again lower, the free acid form may precipitate out. However, the precipitated free acid will be in the form of very fine wetted drug particles. These drug particles exhibit a very large total effective surface area in contact with the gastric fluids, much larger than would have been obtained if the free acid form of the drug had been administered. Examples of the use of soluble salts to increase drug absorption include novobiocin, in which the bioavailability of the sodium salt of the drug is twice that of the calcium salt and 50 times that of the free acid. For example, the minor tranquilizer clorazepate is a prodrug of nordiazepam and is marketed as a dipotassium salt that is freely soluble in water, in contrast to the poorly soluble parent, norazepam. Polymorphic forms Many drugs can exist in more than one crystalline form, for example chloramphenicol palmitate, cortisone acetate, tetracyclines and sulphathiazole, depending on the conditions (temperature, solvent, time) under which crystallization occurs.

Te major polysaccha- contains large fluoxetine 20mg overnight delivery, thin-walled cells that produce gel order fluoxetine 20 mg on-line, ride generic fluoxetine 10 mg line, acetylated mannan, is composed of one or the clear, mucilaginous, and aqueous extract of more polymers of various chain lengths with the inner central area of the leaf pulp (Fig. Te mechanical glucose and mannose in a 1:3 ratio (Channe extrusion of the mucilaginous gel from the inner Gowda et al. Chemically preserved fresh Aloe vera Polysaccharides in Aloe vera gel consist of gel stored at room temperature or incubated at linear chains of glucose and mannose molecules, 40 °C for 48 hours exhibited degradation in its 40 Aloe vera Table 1. Aloe vera latex contains Te Aloe vera whole leaf extract (sometimes four major C-glycosyl constituents: aloin A, referred to as whole leaf Aloe vera juice, Aloe aloin B, aloesin, and aloeresin A (Fig. Aloin A, a C-glycosyl anthrone, also aqueous extract of the whole leaf with lignifed referred to as barbaloin, is the major component fbres removed. Aloin A and its epimer, aloin B, also both the gel from the inner parenchyma leaf pulp referred to as isobarbaloin, have a 9-anthrone and the latex. Te restricted distribution of the skeleton and a β-D-glucopyranosyl substit- bitter latex within the margins of the leaves of uent. Aloesin, also known as aloeresin B, is a the Aloe vera plant suggests that this thin layer 5-methyl chromone with an 8-β-D-glucopyra- is the primary site of secondary metabolites nosyl substituent, and aloeresin A is a 5-methyl biosynthesis: compounds that do not function chromone with an 8-β-D-glucopyranosyl-2- directly in plant growth and development and O-trans-p-coumarol substituent. A wide variety of secondary compounds isolated from Aloe vera, including aloe-emodin, have been isolated from the Aloe vera latex the anthraquinone of barbaloin and isobarbaloin (Reynolds, 2004). In addition, the latex from Aloe vera contain little or no latex anthraquinones, carbon contains several aromatic compounds, such as adsorption changes the physical and chemical aldehydes and ketones (Saccù et al. Aloe vera sugar moiety in aloins is D-glucose, and studies decolorized whole leaf extract difers from the indicate that carbon atom 1 of the D-glucose gel in that it exhibits a degradation in rheological moiety is linked directly to carbon atom 10 of the properties and a loss of approximately 19–23% of anthracene ring in a β-confguration (Fig. Cleavage of the β-C-glucosyl liquid originating in the cells of the pericycle and bond results in the formation of aloe-emodin, adjacent leaf parenchyma, and fowing sponta- the cathartic principle of the latex, and other free neously from the cut leaf, allowed to dry with anthraquinones and anthrones (Boudreau et al. In commercial prod- material is used for medicinal purposes and its ucts containing whole leaf extract, a rapid dete- composition is specifed in several ofcial phar- rioration of aloin was detected during storage, macopoeias (see Section 1. Most of the published and colour caused by the anthraquinone compo- analytical methods (Table 1. Tis results in a product determination of the anthraquinone compounds termed “decolorized whole leaf extract” that has in the latex, and fewer and mostly qualitative quite diferent properties from the whole leaf methods are available for authentication. Aloe vera decolorized whole leaf extract To carry out an exhaustive quality control of is also referred to as “whole leaf Aloe vera gel” commercial Aloe vera gel products (e. Dentali (2013) noted or cosmetic uses), the following analyses should that an industry standard for aloin content of be carried out: (i) investigation of authenticity; decolorized Aloe vera whole leaf extract is < 10 (ii) test for identifcation of additives (to control ppm. Traditional uses include the literature for analysis and authenticity control external treatment of minor wounds and infam- of Aloe vera. Common addi- In recent times, the oral consumption of tives found in Aloe vera gel preparations, which Aloe vera has been promoted as prophylaxis can be detected by chromatographic methods, and therapy for a variety of unrelated systemic include preservatives such as benzoic acid and conditions. Te scientifc literature yields little sorbic acid, or antioxidants such as ascorbic acid to substantiate claims of usefulness for systemic (Lachenmeier et al. Several methods to conditions by the ingestion ofAloe vera (Boudreau control the gel material for contamination with et al. Aloe vera may also be used in medicine in many contemporary cultures, food supplements (Steenkamp & Stewart, 2007). Both (which combines both the gel and latex) and classes of Aloe vera leaf products, gel and latex, Aloe vera decolorized whole leaf extract (from are reported to possess a wide range of pharma- which most of the latex components have been ceutical activities. Te liquid samples all 46 Aloe vera contained either aloe-emodin or aloin A at ≤ 10 1. Unlike liquid prod- individual dose is the smallest amount required ucts, many solid and semisolid products (11 out to produce a sof-formed stool. For adults and of 30) contained one or both of the compounds, children aged more than 10 years, the dose is aloe-emodin and aloin A, at ≥ 10 ppm. Te European Medicines Agency suggests turizer in cosmetics and personal care prod- a maximum daily dose of hydroxyanthracene ucts (O’Neil et al. Other products containing Aloe vera of Aloe vera latex (Perkins & Livesey, 1993; Stolk include afer-shave gel, mouthwash, hair tonic, & Hoogtanders, 1999). It is difcult to estimate shampoo, and skin-moistening gel (Newton, rates of laxative abuse, and more so for cases of 2004). Aloe vera may be used in cosmetics for For medicinal use ofAloe vera gel, 25 to 100 mL marketing reasons (i. Te International Aloe Science Council a low level (Committee of Experts on Cosmetic recommended a total daily consumption of Aloe Products, 2008). For topical use, application of a cosmetic formulation containing pure Aloe vera gel is ofen used liberally on the > 0. Regulatory author- (a) Production process ities in Germany have proposed that cosmetic products for which claims are made regarding Aloe vera grows best in dry chalky soil or in a Aloe vera should contain at least 5 g of Aloe vera sandy loam (Grindlay & Reynolds, 1986). Aloe vera whole leaf extract is obtained by Te quality of Aloe vera plant products varies grinding the whole fresh leaves, without removal considerably due to diferences in growing, of the rind. Extraneous material and lignifed harvesting, processing, and storage techniques fbres are then removed by homogenizing and (Boudreau et al. Aloe vera has become an important plant vera decolorized whole leaf extract is the frst crop in Arizona and in the Rio Grande valley of processing step where an extract is intention- southern Texas (Boudreau et al. Aloe vera Te production processes for Aloe vera prod- decolorized whole leaf has lower rheological ucts include various steps such as crushing, values than the gel and has a lower content of grinding or pressing, fltration, decoloriza- complex carbohydrates than either gel or whole tion, stabilization, heat processing, and may leaf extracts (Pelley et al. A complete overview of production stable, a problem that may cause diferences was provided by Ahlawat & Khatkar (2011). Te in product potency; therefore, the gel or whole technology for processing of Aloe vera gel was leaf extracts can undergo a stabilization process reviewed by Ramachandra & Rao (2008). Tis process may involve Harvesting of the leaves of the Aloe vera pasteurization, ultraviolet stabilization, chemical plant is generally performed by hand, with the oxidation with hydrogen peroxide, addition of leaves cut from the base of the plant (Grindlay & chemical preservatives and additives, or concen- Reynolds, 1986). At the processing list showing the relative frequency of use of plant step, the leaves may be cleaned with water and ingredients within formulations fled with the a mild chlorine solution (Grindlay & Reynolds, United States Food and Drug Administration 1986).

Although other concepts are of necessity evoked to explain various phenomena in hypnosis 10mg fluoxetine otc, the actual occurrence of the trance state is related to the wish of the subject to enter hypnosis purchase fluoxetine 10mg line. This writer is a proponent of this approach discount fluoxetine 10mg online, and the critical comments in this report are undoubtedly colored by this viewpoint. It is important to recognize that almost no experimental work has been done that would support the validity of these various theoretical views, although there is some evidence already mentioned which tends to refute some of them. The general acceptance of the motivational view is based on the clinical impression of both experimentalists and clinicians that it accounts best for the major portion of the clinical data. Trance is commonly induced in situations where the subject is motivated a priori to cooperate with the hypnotist, for example, to obtain relief from suffering, to contribute to a scientific study, or (as in a stage performance) to become, temporarily at least, the center of attraction. Almost all the currently available knowledge about hypnosis has been derived from these situations, and it is well to keep in mind the source of these data when one attempts to evaluate the possible utility of hypnosis in situations differing from these. There is a small body of evidence stemming from the criminal cases in which hypnosis has allegedly played a role, which are radically different from those where hypnosis is normally observed. Because these situations may be more relevant to the questions of hypnosis in interrogation, this body of knowledge deserves particular attention and is discussed subsequently. Hypnosis in the Interrogation Situation The Induction of Hypnosis The initial problem in utilizing hypnosis for interrogation is to induce trance. Another arises when the subject is seeking psychiatric help and hypnosis is induced in the course of a clinical interview with no explicit mention of the process. The third situation involves a trance spontaneously entered by individuals who are observing trance induction in another subject. The older literature is replete with statements that hypnosis may readily be induced by giving suggestions to sleeping subjects in a low but insistent voice; the subject becomes gradually more responsive to the suggestions until eventually he enters a somnambulistic state of hypnosis [ Bernheim (9), Braid (14), Binet and Fere (12), etc. As so often the case in hypnosis literature, the statements appear to have been carried over from one textbook to another without any critical evaluation. He found considerable similarity between compliance to suggestions given during sleep and reactions to customary hypnotic techniques. It should be pointed out that, in his study, Barber requested permission from the subjects to enter their rooms at night and talk to them in their sleep. Several of them remarked that this was hypnosis, and one may reasonably assume that most, if not all, of the subjects perceived that trance induction was the purpose of the study. This study, therefore, tells us little about what would happen if a truly naive sleeping subject were exposed to such a situation. Casual experimentation by the author failed to demonstrate the feasibility of this technique. The sample consisted of only four subjects, three of whom awakened to ask belligerently what was taking place, whereas the fourth continued to sleep. Whether any increase in suggestibility over the normal waking state occurs has never been established. In another context, the trance phenomena seen among primitive people frequently occur in ceremonies involving prolonged stimulation by rhythmic drums. Many authors have emphasized the importance of monotonous rhythmic verbal suggestions, especially during the induction stage of hypnosis. Recently, Kroger and Schneider (38) have proposed the use of an electronic aid which gives a repetitive signal approximating the alpha range of ten cycles per second as an adjunct. Certainly, the use of such techniques or even of monotonous rhythmic speech is by no means necessary in order to induce hypnosis. All sophisticated discussions of hypnotic trance induction recognize that a successful response to a suggestion will facilitate further successful responses to suggestions. Ideally, the hypnotist times these suggestions to occur immediately preceding the time when the subject begins to experience heaviness. Thus he takes the credit for having induced the state of drowsiness that is an inevitable consequence of eye fixation. Mechanical aids of this type may facilitate induction only to the extent that they bring about an event that is attributed to the suggestive effect of the hypnotist. However, it is also possible, as some of the proponents of these techniques suggest, that a neurophysiological basis exists for the facilitation of hypnosis. In this context it is relevant that road hypnosis and the break-off phenomenon encountered by pilots occurs in individuals subjected to peculiar types of repetitive, rhythmic stimulation despite a high -175- motivation to retain alertness. An intriguing question on which no evidence exists is the relationship of hypnotizability and susceptibility to road hypnosis or the break-off phenomenon. Whether an actual relationship exists between the drowsiness which can thus be induced and hypnosis is highly questionable and remains to be investigated. What is a somewhat more likely possibility is that drowsiness may be induced even in the uncooperative subject which may be attributed to some hypnotic influences. This would then tend to make the subject more liable to respond to other suggestions. No investigation utilizing such procedures in recalcitrant subjects has been made. In a later section on "magic room" techniques, the implications of using this and related tools are explored. Studies by Adler and Secunda (1), Sargant and Fraser (62), Schneck (65), and Rosen (59) have used techniques of trance induction which were aimed at preventing the subject from knowing that he was being hypnotized. It is frequently possible to utilize the therapeutic situation in such a manner as to achieve a hypnotic state eventually. For example, the therapist may talk to the patient about relaxing, and the virtues of relaxing, or the virtues of concentrating, thus obtaining his fixation on one particular object. He may suggest that the patient will be more comfortable if he closes his eyes, that in this way the patient can relax more or concentrate better. Thus, in a suitable subject a deep level of hypnotic trance can be achieved in a relatively brief period of time without ever using the term hypnosis and without the subject ever being aware that hypnosis is taking place. Meares (46) uses the neurological examination in this fashion as a test for hypnotizability.

Dose Adult and adolescent over 16 years with low dose ritonavir discount fluoxetine 10 mg visa, 1g saquinavir every 12 h buy cheap fluoxetine 20mg on-line. Precautons Hepatc impairment (Appendix 7a); renal impairment; diabetes mellitus; haemophilia; pregnancy (Appendix 7c) and lactaton (Appendix 7b) (see notes above); interactons (Appendix 6d); hyperlipidemia generic fluoxetine 10 mg with visa, lactose intolerance, fat redistributon, immune reconsttuton syndrome. Adverse Efects Diarrhoea, buccal and mucosal ulceraton, abdominal discomfort, nausea, vomitng; headache, peripheral neuropathy, paraesthesia, dizziness, insomnia, mood changes, ataxia, musculoskeletal pain, asthenia; fever, pruritus, rash and other skin eruptons, rarely, Stevens-Johnson syndrome; other rare adverse efects include thrombocytopenia and other blood disorders; liver damage; pancreatts and nephrolithiasis; reports of elevated creatne kinase, raised liver enzymes and neutropenia when used in combinaton therapy; lipodystrophy and metabolic efects (see notes above); cyanosis, heart murmur; decrease appette; amnesia. Zanamivir Pregnancy Category-B Schedule X Indicatons Most efectve for the treatment of infuenza if started within a few hour of the onset of symptoms; they are to be used within 48 h (36 h for children) of the frst symptoms. Precautons Anaphylaxis; encephalits; pediatric, geriatric, lactaton, pregnancy (Appendix 7c). Adverse Efects Nausea, vomitng, abdominal pain, dyspepsia, diarrhoea; headache, fatgue, insomnia, dizziness; conjunctvits, epistaxis; rash; very rarely, hepatts, Stevens-Johnson syndrome and toxic epidermal necrolysis. Its socio- economic impact as a parasitc disease is outstripped only by that of malaria. Intestnal schistosomiasis is caused principally by Schistosoma mansoni as well as S. The later is an important predisposing cause of squamous cell cancer of the bladder. Praziquantel has transformed the treatment of schistosomiasis and is ofen efectve in a single dose, against all species of the parasite. It can be of partcular value in patents with mixed infectons and those who do not respond adequately to other drugs. It is also extremely well tolerated and well suited for mass treatment control programmes. Extensive use over several years has provided no evidence of serious adverse efects or long-term toxicity, nor has mutagenic or carcino- genic actvity been shown in experimental animals. Drugs stll widely used in the treatment of schistosomiasis include oxamniquine, which is efectve against S. It is preferable to delay treatment with oxamniquine in pregnant women untl afer delivery unless immediate interventon is essental. Due to lack of informaton on whether oxamniquine is excreted in breast milk, it is preferable not to administer it to nursing mothers. Dose Schistosomiasis: 40 mg/kg body weight is given in two divided doses 4 to 6 h apart in one day. May impair ability to perform skilled tasks, for example operatng machinery, driving. Adverse Efects Abdominal discomfort, anorexia, nausea, vomitng, malaise, headache, dizziness, drowsiness, rectal bleeding; rarely, hypersensitvity reactons, including fever, pruritus, eosinophilia (may be due to dead and dying parasites); ectopic rhythms, urtcaria, erythema, convulsions. It is only efectve if started at onset of infecton; it is also used for preventon of recurrence in the immunocom- promised patents. Valacyclovir, a prodrug of Acyclovir, can be given by mouth as an alternatve treatment for herpes simplex infectons of the skin and mucous membranes (including inital and recurrent genital herpes). Mainte- nance therapy with oral ganciclovir should be given to prevent relapse of retnits. Genital herpes simplex treatment; 200 mg 5 tmes daily for 5 days or 400 mg three tmes daily for three days. Herpes simplex preventon of recurrence; 200 mg 4 tmes daily or 400 mg twice daily reduced to 200 mg two or three tmes daily interrupted every 6 to 12 months. Intravenous infusion Severe inital genital herpes, Varicella zoster, Herpes simplex infecton; 5 mg/kg body weight every 8 h for fve days. Precautons Maintain adequate hydraton; renal impairment (Appendix 7d); lactaton (Appendix 7b); pregnancy (Appendix 7c); paediatrics. For infusion: Store protected from moisture in a sterile tamper evident container sealed so as to exclude micro-organisms at a temperature not exceeding 30⁰C. Antmigraine Drugs Chronic recurrent headache is associated with many disor- ders, both somatc and psychogenic. An accurate diagnosis must consequently be made before appropriate treatment can be initated for migraine. Untreated migraine atacks last for several hours and sometmes for as long as 3 days. Migraine headache is frequently accompanied by episodes of gastrointestnal disturbance including nausea and vomitng. The headache may be preceded or accompanied by aura (clas- sical migraine) which is characterised by visual disturbances such as fickering lines and fragmented vision or sensory disturbances such as tngling or numbness; rarely, hemiparesis or impaired consciousness may occur. Migraine without aura (common migraine) is the more common form occurring in about 75% of patents who experience migraine. Emotonal or physical stress, lack of or excess sleep, missed meals, menstruaton, alcohol and specifc foods including cheese and chocolate are ofen identfed as precipitatng factors; oral contraceptves may increase the frequency of atacks. Avoidance of such precipitatng factors can be of great beneft in preventng or reducing the frequency of atacks and should be addressed in detail. Women taking combined oral contraceptves who experience an onset or increase in frequency of headaches should be advised of other contra- ceptve measures. The two principal strategies of migraine management are treatment of acute atacks and prophylactc treatment. Prophylaxis can reduce the severity and frequency of atacks but does not eliminate them completely; additonal symptomatc treatment is stll needed. However, long-term prophylaxis is undesirable and treatment should be reviewed at 6-monthly intervals.