Cardura
By R. Jaffar. Hillsdale College. 2018.
The stomach 21 and duodenum (nausea buy discount cardura 2mg on-line hypertension and diabetes, belching cardura 2 mg on-line heart attack 30 year old female, upper abdominal discomfort) as well as 22 the small and large intestine (flatulence, cramplike abdominal pain, di- 23 arrhea) can be involved. Aromatic herbs also have bacteriostatic effects 7 and increase the local blood circulation. Because of its general efficacy and virtual lack of side effects, it is 10 still commonly recommended for adjunctive treatment at the onset of 11 and during acute ulcer episodes. Standardized 24 licorice root extracts made with diluted ethanol and containing no less than 25 4. The prepara- 28 tion is nearly as effective as whole licorice, but with fewer side effects. The patient 40 using flaxseed should drink plenty of fluids, at least 150 ml after taking the 41 herb. Alkaloids of the atropine group inhibit vagus 46 nerve activity, reduce gastric juice secretion, and diminish intestinal motil- 47 ity. They are therefore used to relieve spasms, gastrointestinal colic, and 48 gallbladder colic. As an alternative to the tea, this ther- 22 apy can also be performed using 30 to 50 drops of chamomile fluid ex- 23 tract or an appropriate commercial preparation, taken in a glass of hot 24 water. Take 2 to 4 380 mg 40 chewable tablets before meals for acute symptoms, 1 to 2 tablets as a 41 maintenance dose. Can be taken for several 44 months because the glycyrrhizinic acid content is very low. The symptoms occur in the intestinal lumen without sig- 8 nificant intestinal wall involvement. The following types can be dis- 9 tinguished: 10 • Epigastric meteorism with distended abdomen (most common type): 11 The stomach and intestine are often jointly involved. If the 27 problem is already long-standing, treatment must usually be continued 28 for several weeks before the preparations become effective. They 31 are sometimes combined with bitters, antiphlogistics, and/or tannin- 32 containing herbs, depending on the symptoms involved. They contain essential 47 oils that either induce spasmolysis or promote bowel motility and probably 48 also have antibacterial effects. Hence, they can be selected according to the taste pref- 24 erence of the patient. Apply 10 to 15 39 drops onto the stomach in a circular pattern, 2 to 3 times a day. Pour 1 cup of boiled water onto 1 teaspoon of the tea mixture, 10 then cover and steep for 15 minutes. Steep 1 to 2 teaspoons in 1 cup of boiled water for 10 minutes and 19 sip slowly while hot. Bloating, flatulence and occasional nausea can 3 occur when administered at high doses. Other side effects include harmless changes in the con- 6 sistency, color, and smell of stools. The efficacy of 12 many polypharmaceutical combinations containing milk thistle is rather 13 controversial. Commercial products usu- 33 ally contain up to 80% total silybinin and related compounds. Silybinin 34 stimulates the entire process of cellular protein synthesis, resulting in 35 regenerative effects. Its primary target organ is the liver, where silybinin 36 primarily accumulates due to its marked enterohepatic circulation. Pungent herbs remedies such as car- 12 away, pepper, and ginger root as well as bitters and antispasmodics also are 13 commonly used. Since most of these patients also suffer from constipation, 14 herbal laxatives are often helpful. They are variably effective in 3 increasing the secretion and release of bile (choleresis).
For a discussion of institution building purchase cardura 4 mg with amex hypertensive retinopathy, see David Rothman buy cardura 4mg lowest price blood pressure video, The Dis covery of the Asylum (Boston: Little, Brown, 1971). Michaelson, “T he Failure of American Medicine,” The American Scholar, 39, 4 (Autumn 1970), 702. Based on medical specialty trends and current residents in training, the num ber of physicians who practice as specialists will increase from roughly 50 percent today to 55 percent in 1980. See workpaper, “Medical Manpower Specialty Distribution Projections: 1975 and 1980,” Health Services Research Center, Institute for Interdisciplinary Studies, May 1971. The term “fragm entation” in this context means at least two things: first, that medical care is provided by many individuals, groups, and institutions. And second, health manpower is classified by rigid licen sure laws resulting in the lack of a rational pattern of manpower deployment and utilization. See also Committee for Economic Development, “Building a National Health-Care System,” New York, April 1973. See National Health Survey data, especially since 1968 when the Medicaid legislation was implemented. Eliot Freidson, “Professionalism: The Doctor’s Dilemma,” Social Policy, January/February 1971, 37. David Mechanic, “Health and Illness in Technological Societies,” Hast ings Center Studies, 1, 3 (1973), 11. In Great Britain, more than 97 percent of the population receives its care from the National Health Service. A thorough comparative review of the health care systems in the United States, England, and Sweden can be found in Odin W. Department of Commerce, Bureau of the Census, Statistical Abstract of the United States, 94th ed. The phenomenon of the multinational corporation has been widely reported in recent years. See, for example, Newsweek, November 20, 1972, and Peter Drucker, “The New Markets and the New Capitalism,” The Public Interest, Fall 1970, 44. These data are drawn from Colin Fraser Brockington, World Health (Baltimore: Penguin Books, 1958), p. Brian Abel-Smith, An International Study of Health Expenditure (Geneva: World Health Organization, 1967). The research is reported in Thelm a Moss and Kendall Johnson, “The Body Is an Energy Field,” Harpers, January 1973. See, for example, Rolf Alexander, Creative Realism (New York: Pageant Press, 1954); and Elmer E. White, “Acupuncture: The W orld’s Oldest System of Medicine,” Psychic, July 1972; and The Dimensions of Healing: A Symposium (San Francisco: The American Academy of Parapsychol ogy and Medicine, 1973), pp. The Varieties of Healing Experiences, transcript of the Interdisciplinary Symposium of The American Academy of Parapsychology and Medicine, San Francisco, October 30, 1971. Green, “Biofeedback for Mind-Body Self-Regulation: Healing and Creativity,” The Varieties of Healing Experiences, footnote 51, p. DiCara, “Learning in the Autonomic Nervous System,” Scientific Ameri can, January 1970, 30-39. Budzynski, Johann Stoyva, and Charles Adler, “Feedback-Induced Muscle Relaxation: Application to Tension Headaches," Journal of Behavioral Therapy and Experimental Psychology, 1 (1970), 205-211. DiCara, “Learning in the Autonomic Nervous System,” Scientific American, January 1970, 30-39. This information was drawn from “A Study of Psychic Surgery and Spiritual Healing in the Philippines,” an unpublished report, July 1973. See also Harold Sherman, Wonder Healers of the Philippines (Lon don: Psychic Press, 1967), and Thomas Valentine, Psychic Surgery (Chicago: Henry Regnery Company, 1973). Singh, “The Scientific Basis of Yoga," Journal of the American Medical Association, 222, 10 (June 5, 1972).
The magnitude of these changes these tracers relies on the labeling of the compounds in signal intensity relative to the resting conditions is with short-lived cyclotron-produced radioisotopes (e buy discount cardura 1mg on line heart attack gun. Approxi- subjects generic cardura 1mg fast delivery hypertension hypotension, and allows more rapid signal acquisition mately 1–3 mm from its origin, it has lost so much and more flexible experimental set-ups, it has become energy that it combines with an electron, resulting in the dominant technique for functional imaging. Pseudocolor-coded tomographic properties of hemoglobin depending on the blood images of the radioactivity distribution are then oxygen level. Typical in-plane resolution (full width at half-maximum) is Motor and somatosensory deficits <5 mm; 3D data accumulation and reconstruction Motor function may be impaired by damage to a permits imaging of the brain in any selected plane widely distributed network, involving multiple cor- or view. This means that mainly the different studies extremely difficult, and might help 50 amount of deoxyhemoglobin in small blood vessels explain the lack of a clear concept of “neuronal plas- is recorded, which depends on the flow of well- ticity” applicable to recovery from motor stroke Chapter 3: Neuroradiology Figure 3. Brain activity for hand grip compared to rest for individual subjects with corticospinal damage. A recent review con- suggesting an improved functional brain reorganiza- cluded that “motor recovery after stroke depends on tion in the bilateral sensory and motor systems [20]. The areas included mechanisms appearing even late in the course frontal and parietal cortices, and sometimes the basal (Figure 3. These results suggest that sensorimotor learned movements after focal cortical injury are functions are represented in extended, variable, represented over larger cortical territories, an effect probably parallel processing, bilateral networks [19]. It is of importance that the unaffected hemi- undamaged hemisphere can be observed, ipsilateral sphere actually inhibits the generation of a voluntary activation of motor cortex is consistently found to be movement by the paretic hand [23]. Reco- unaffected hand (as in normal subjects) were accom- very from infarction is also accompanied by sub- panied mainly by activation of the contralateral cere- stantial changes in the activity of the proprioceptive bral cortex. In addition to stronger intensity, the systems of the paretic and non-paretic limb, reflecting spatial extent of activation in motor cortex was an interhemispheric shift of attention to propriocep- enlarged, and activation on the ipsilateral side was tive stimuli associated with recovery [25]. These results indicate that recruitment of ipsilateral cortices During recovery from hemiparesis, a dynamic bi- plays a role in recovery. Overactivation in the primary and secondary motor area in five patients compared with normal controls 7 and 31 weeks after left capsular stroke during right thumb-index tapping. Decrease of initial bilateral overactivation to activation restricted to the primary sensorimotor cortex in the affected and primary motor cortex in the unaffected hemisphere. That the quality of recovery is mainly hemisphere caused by the lesion and contralateral dependent on undamaged portions of the language hemisphere caused by functional deactivation (dia- network in the left hemisphere and to a lesser extent schisis) (review in [26]). In right-handed individuals on homologous right hemisphere areas [28] can be with language dominance in the left hemisphere, the deduced from an activation study in the course after left temporo-parietal region, in particular the angular post-stroke aphasia [29]. Repeating words activated gyrus, supramarginal gyrus and lateral and transverse blood flow in 10 normal controls by more than 10% superior temporal gyrus are the most frequently and relative to resting condition in both upper temporal consistently impaired, and the degree of impairment gyri, by 5–10% in planum temporale and Heschl is related to the severity of aphasia. In patients with gyrus of both sides and in the lower part of the central aphasia attributable to purely subcortical strokes gyrus of the left side, and by less than 5% in the left deactivation of temporo-parietal cortex is regularly Broca area. This test procedure was applied to found, which is probably responsible for the aphasic 23 aphasic patients grouped according to the site of symptoms. Therefore, metabolism in the showed different patterns of activation in the acute hemisphere outside the infarct was significantly less and chronic phase, and their improvement was differ- in patients with a poor outcome of post-stroke apha- ent: whereas subcortical and frontal infarcts improved sia than in those with good language recovery, indi- considerably in several tests, temporal infarcts cating significant cell loss caused by the ischemic showed only little improvement. In addition, the in improvement of speech deficits were reflected in functionality of the network was reduced in patients different patterns of activation in the course after with an eventual poor outcome; during task perfor- stroke (Figure 3. Activation patterns in patients with left hemispheric stroke 2 and 8 weeks after stroke. In the case of subcortical and frontal infarction, the left temporal areas are reactivated correlating to better recovery of language function. These results were confirmed in comparable gous language regions during overt propositional studies [30–32]. This right hemisphere over-activation may in a Cochrane Review [34], improved performance in represent a maladaptive strategy and can be inter- aphasia tests for spontaneous speech, which was preted as a result of decreased transcallosal inhibition reflected in increased activation in the left temporal due to damage of the specialized and lateralized gyrus, the triangular part of the left inferior frontal speech areas. Effect of repetitive transcranial magnetic stimulation on activation pattern by verb generation. This The activation studies in the course of recovery approach might open a new therapeutic strategy for of post-stroke aphasia suggest various mechanisms post-stroke aphasia.
This well-conceived handbook should enhance the ability of every medical house officer to properly evaluate a patient in a timely fashion and to be stimulated to think of the evidence supporting the diagnosis and the likely outcome of therapeutic intervention cheap 1mg cardura with amex arrhythmia hyperkalemia. Pocket Medicine will prove to be a worthy addi- tion to medical education and to the care of our patients buy 1 mg cardura free shipping hypertension 55 years. The tremendous response to the previous editions suggests we were able to help fill an important need for clinicians. Of course medicine is far too vast a field to ever summarize in a textbook of any size. Pocket Medicine is meant only as a starting point to guide one during the initial phases of diagnosis and management until one has time to consult more definitive resources. Although the recommendations herein are as evidence-based as possible, medicine is both a science and an art. I am grateful for the support of the house officers, fellows, and attendings at the Massachusetts General Hospital. It is a privilege to work with such a knowledgeable,dedicated,and compassionate group of physi- cians. I always look back on my time there as Chief Resident as one of the best experiences I have ever had. I am grateful to several outstanding clinical mentors, including Hasan Bazari, Denny Ausiello, Larry Friedman, Nesli Basgoz, Mort Swartz, Eric Isselbacher, Bill Dec, Mike Fifer, and Roman DeSanctis, as well as the late Charlie McCabe and Peter Yurchak. Special thanks to my parents for their perpetual encouragement and love and,of course,to my wife,Jennifer Tseng,who,despite being a surgeon,is my closest advisor, my best friend, and the love of my life. I hope that you find Pocket Medicine useful throughout the arduous but incredibly rewarding journey of practicing medicine. Musculoskeletal and Miscellaneous Causes Disorder Typical Characteristics & Diagnostic Studies Chostochondritis Localized sharp pain. Can estimate O2 consumption using wt-based formula,but best to measure (espec if c metabolism,eg,sepsis). Gradient (∇) worse w/ c contractility (digoxin, -agonists),T preload,or T afterload. European) storage diseases:Gaucher’s,Fabry,Hurler’s,glycogen storage diseases diabetes mellitus • Endomyocardial processes chronic eosinophilic:Löffler’s endocarditis (temperate climates;c eos. Treatment (Circ 2008;118:e523 & Lancet 2009;373:956) • Management decisions are based on symptoms:once they develop surgery is needed. Hydroxocobalamin or sodium thiosulfate infusion for treatment of cyanide toxicity. Consider appropriateness of Pt involvement in exercise/sport,operating machinery,high-risk occupation (eg,pilot). Sensed A beat inhibits A pacing & triggers V pacing S tracking of intrinsic atrial activity. Use to ✓ ability to capture (place over when output inhibited by intrinsic rhythm. S retrograde A activation S tachycardia sensed by A lead S triggers V pacing S etc. Device infection (Circ 2010;121:458) • Presents as pocket infection (warmth,erythema,tenderness) and/or sepsis w/ bacteremia • Infection in 1⁄2 of Pts w/ S. Except for control of exercise-induced asthma,should not be used w/o inh steroid (may c mortality;Chest 2006;129:15 & Annals 2006;144:904). Clinical relevance of 2-receptor pharmacogenetic interaction not validated (Lancet 2009;374:1754). Useful in young Pts,exercise-induced bronchospasm;ineffective unless used before trigger or exercise exposure. Transcription of genes for 5-lipoxygenase pathway predicts response (Nat Genet 1999;22:168). Clinical manifestations • Chronic cough, sputum production, dyspnea; later stages S freq exac. Asbestos exposure also S pleural plaques,benign pleural effusion,diffuse pleural thickening,rounded atelectasis,mesothelioma,lung Ca (esp in smokers). Common causes:Strep pneumo,Staph aureus,Strep milleri,Klebsiella,Pseudomonas, Haemophilus,Bacteroides,Peptostreptococcus,mixed flora in aspiration pneumonia. Send panel 2 wk after complete anticoagulation,as thrombus,heparin,and warfarin results.
Spanish translations of drug labels are permitted (especially for products sold in Cali- While all such enforcement actions may be fornia buy discount cardura 1mg on-line blood pressure visual chart, Florida safe 1mg cardura blood pressure medication used in pregnancy, New York, and Puerto Rico), and appealed in the Federal Court, it is usually only some mandatory, equivalent Spanish vocabulary the last of these, forced product withdrawal, that appears in the regulations (e. Usually, after 3 or 4 years of being promoted for indications, dose sizes, or market experience, annual reports can then be routes of administration that are outside the ap- made. Almost all entry- ever, there is a sentiment widely expressed in level medical affairs positions can provide this if Europe that the long and technical labels promul- the post-holder expresses appropriate interest. When making ical department, and between the company and the judgments about how to amend labeling and what regulatory authority on subjective, interpretative may or may not be an acceptable precis when grounds. As a result, most scientists (and as The goal of the meeting usually determines the type medicine is now a science, physicians are included) of meeting, moderators and speakers, and the audi- working in the industry are encouraged to partici- ence. In addition, many firms will Once the goal or goals of the meeting are deter- organize satellite meetings around a major confer- mined and agreed, then the type of conference or ence, often a half-day or evening meeting. To promote new treatment To exchange scientific information Most scientists, including physicians, have never To educate been trained to organize, let alone achieve, publi- cation of scientific meetings, conferences, or sem- inars. While Special meeting to introduce new drug hands-on experience is the best tutor, this chapter Regulatory presentations Therapeutic review conferences is aimed at helping the initial effort and also giving Special subjects, e. In Europe and Japan, it is very im- Chairman of scientific program portant to select and match the chairs of the ses- Chairman of social activities sions and the speakers by their professional and/or Collaborators and members of advisory board, some specialty vs. A large-scale conference involving section Audience chairs, speakers and other participants (not includ- ing the audience) of 100 or more requires approxi- mately 1 year to plan and organize properly. For After the decision is made regarding the goals of these large conferences, staff and/or volunteer sup- the meeting, the next action is to select a chairper- port is a necessity. Early on one needs to ing and should have a general overview responsi- secure an up-to-date mailing list to reach the pro- bility for the scientific as well as the social program. If the meeting will have a large number of partici- If one must be compiled, be sure to leave adequate pants and the staff/volunteer support appears to be time for this task and regularly update it. It is sur- inadequate, hiring a professional meeting/event prising how many scientific people frequently move planner may be the proper direction to take. In selecting a location for terials, manage the registration, and organize social the meeting, one needs to be attentive to where the and companion events, amongst the many meeting prospective participants are concentrated. If a meeting planner is selected meeting is to be fairly short in duration (3 days or who is familiar with the location of the meeting, he/ less), the objective for the meeting may require that she can offer invaluable insight into activities, fa- the meeting be located in the area of the most cilities, and site selection in that area. This is the person who will determine attending a meeting that combines sightseeing the subjects for the meeting, lay out the program, and line up the speakers. Decide on sequential or concomitant sessions The program chairman usually circulates the Divide into logical subsections draft of a program to either the conference organ- Decide on styleÐinteractive or classroom type izers or the Scientific Program Advisory Board, if How much time to be spent on science vs. It is also often very important to secure Direct mail/invitation Proceedings/publications/ supplements appropriate balanced participation of different Program and documentation Conclusions/bulletins functions or countries. For larger meetings, 3±5 years obtained and to discuss menus, audiovisual re- advance facility selection may be required to lock quirements, and general meeting layout with the in favorable rates. It may be more or handouts for registration, as well as making sure less elaborate, depending on the scope and object- that the registration table at the meeting will be ive for the meeting. This will pinpoint the registration charge for with all speakers need to be checked as to special each participant and will allow the calculation of needs, audiovisual requirements, hotel reserva- the total cost of the meeting in order to get ap- tions, and transportation, and also to mail out the proval from the firm or sponsoring organization. Depending on the type and the underwritten, by registration fees, sponsorship or a purpose of the conference, one can opt for a simple combination of both. A determination of the summary with key conclusions to be circulated to timing and pattern of spending must be made, as all the participants and company managers, or one well as a calculation of when money will be released can arrange for a full transcript, with the possibility and acquired. During the meeting, staff In conclusion, helping to organize a scientific should be available to deal with equipment failure meeting is a time-consuming and a tough job and booking problems, man the telephone desk, requiring patience and an ability to take timely and be ready to assist both speaker and audience. In order to ensure con- or removal of products no longer considered to be tinued patient protection,it is therefore necessary safe,as a result of pharmacovigilance by com- to monitor the safety profile of marketed drugs panies and regulatory agencies. Physicians benefit continuously for new signals of concern that might by being able to prescribe the most appropriate prompt revisions in prescribing information. Type B reactions are un- listed in the local prescribing information,in an predictable idiosyncratic reactions which are usu- effort to inform patients and prescribers of any ally infrequent but can be very serious or fatal.
She did not ap- cal pain next to the outer edge of the left knee radiating to the upper pear acutely ill cardura 4mg for sale blood pressure what is high, and her vitals and labs were unremarkable cardura 2 mg mastercard pulse pressure medscape. Physical examination revealed that the left knee was next couple days, her pain progressed despite aggressive medication not infammatory or painful, and its mobility was normal. Introduction/Background: In the process of treating scoliosis X-ray is one of the objective methods of assessing the progress of therapy. Material and Methods: We evalu- 1 2 3 4 ated a group of 70 children diagnosed with idiopathic scoliosis in N. The children remained in 1Moscow Research and Practice Center of Medical Rehabilitation the two monthly turnusach apart semester. During the stay twice and Sports Medicin, Rehabilitation, Moscow, Russia, 2Federal State a day participated in therapy by the Fed. Analysis and evaluation Budget Institution “Russian Scientifc Center of Medical Rehabili- of X-ray were performed before treatment and at the end of the tation and Balneology”, Department of Physiotherapy Exercises, half-year stage. With images were evaluated Cobb angle, vertebral Москва, Russia, Federal State Budget Institution “Russian Scientifc3 rotation by raimondii test Risser, type of scoliosis by King-Moe. Center of Medical Rehabilitation and Balneology”, Department of Results: The results have been developed in the form of tables and Physiotherapy Exercises, Moscow, Russia, 4Moscow Scientifc Cen- charts, broken down by the scoliosis to 20°, 30°, 40° and above 40°. The results presented in the study are the evaluation of the effectiveness of the method the Fed. Yang study included 87 patients aged 23 to 59 years with radiculopathy First Affliated Hospital of Sun Yat-sen University, Department of who underwent decompression surgery on the lumbosacral spine Rehabilitation Medicine, Guangzhou, China in period from 3 months to 3 years. All patients were randomly Objective: To explore the characteristics of the fractional amplitude been divided into 3 groups of 29 people in each. Results: We detected a decrease in the se- Methods: Twelve healthy subjects (male: 7, female: 5; age: 23. Studies showed trunk muscles atrophy alent disease, which is associated with high costs to the society,and (multifdus, transversus abdominis, paraspinal and psoas) contributed it is still relatively diffcult to treat and to maintain treatment effect. These approaches have good biomechanical function, Material and Methods: Medical record data by convenience sampling are widely available and have a modest cost. Therefore, a randomised controlled the patient in positions of challenge against gravity through 360°rota- trial is required to compare the effectiveness of these treatments in tion and 0° to 60° inclination control, muscle contraction recorded by patients with lumber disc herniation. Results were recorded as degrees hundred and forty patients was randomly assigned to a four-week of the maximum inclination angle. Results: Fifty fve patients were in- treatment program based upon the McKenzie method or Lumbar cluded in this analysis, age range 20 to 79, mean age 47. Median of quality of life, and trunk fexion range of motion) will be obtained muscle strength based on 3D Newton was 22 with range from 10 to 55 at follow-up appointments at 1 and 3 months after randomisation. Con- The data will be collected by an assessor who will be blinded to clusion: Most patients showed low core muscle strength on 3D New- the group assignment. The selected studies were subjected to bicycle or treadmill while using mobile lumbar traction by Vertetrac, meta-analyses and risk of bias assessment. Results: 8 randomized and core muscle strengthening and stretching exercise using Red- controlled trials were included in the analyses. The results of the cord Sling devices, and choices of physical modality to reduce pain meta-analysis revealed that intermittent cervical traction has mild as needed. Core muscle strength evaluation with 3D Newton was done before The assessment of risk bias revealed that most of the included trials the frst therapy session and after 12 sessions, which were 4–6 weeks exhibited a moderate to high risk of bias. Results: In pre-intervention the core muscle strength was literature revealed that the effect of intermittent cervical traction for 20. After 12 times (average 4 weeks) intervention with exer- neck pain is still unclear but potentially effective. Conclusion: This study showed that rehabilitation program that combined physical modalities and exercises with 3D Newton increased core muscle strength. Further study needs to be done to cor- relate these changes with clinical complaints. Taping method especially kinesio taping has received popularity since 2008 Olympic Games’ frst seen application in top athletes, and Training Hospital, Physical Medicine and Rehabilitation, Istanbul, gain consistent focus in its application range. Knee intra-articular of unexpected perturbation when upright standing on force plate.
Good manufacturing standards are enforced by chlorphentermine discount cardura 4mg mastercard blood pressure hypertension, buprenorphine cardura 2mg lowest price blood pressure units, diethylpro- the Medicines Inspectorate of the Medicines pion, mazindol, meprobamate, pemoline, Control Agency. Certain products are diethylproprion, mazindol, meprobamate, pen- also available through outlets other than pharma- tazocine, phentermine and temazepam. Additional restrictions ments (except for phenobarbitone and temaze- on supply are imposed by the Misuse of Drugs pam) but not to the safe custody requirements Act 1971, and the Misuse of Drugs Regulations (except for buprenorphine, diethylproprion and substances that have a potential for abuse are temazepam) nor to the need to keep registers scheduled under three categories, Classes A, B (although there are requirements for the reten- and C: tion of invoices for 2 years). Class A includes: alfentanil, cocaine, dextro- (temazepam is now in Schedule 3) and pemoline, moramide, diamorphine (heroin), dipipanone, which are subject to minimal control. Schedule 5 includes those preparations which, because of their strength, are exempt from vir- tually all controlled drug requirements other This was later changed to `at least two other than retention of invoices for 2 years. Medicinal products developed from The member state which has issued a marketing the following biotechnologic processes: authorization for a proprietary medicinal product. Controlled expression of genes coding for bio- particulars and documents specified in Article 4 logically active proteins in prokaryotates and Table 28. In this procedure the initial or refer- ence member state that granted marketing approval Application for marketing approval, using either forwards the necessary documents for registration the centralized or decentralized procedure, has to Table 28. For example, there was no should set up a number of eight new advisory agreement on requirements for reproduction stud- committees, including a Scientific Committee on ies, carcinogenicity, studies etc. These two expert working groups on safety and efficacy committees are expected to meet 10 times/year were established to draw up guidelines (later, other and the Committee on Medicinal Products and expert working groups were established). It has to be borne in mind that the for registration between regulatory authorities, objective of Directive 65/65 was to advance the and thus reducing the need for duplicating studies. Currently, some and Line Extensions companies are withdrawing products from the market and replacing them with a new salt of the The bulk of national licensing activities relates to same active substance in an attempt to thwart gen- new formulations of older products, generics and eric products entering the market. The use of national In 1996, the Swedish Government proposed a drug regulatory authorities to do the work of rap- solution to the impasse affecting the use of the porteur and co-rapporteur would cease. The European system for granting marketing This would be a way forward, with synthesis of an authorization for medicinal products will continue overall view done by a standing expert committee. A guidances on the acceptability of foreign clinical major study of approved drug dosage and pharma- data, the technical document and electronic submis- cokinetics between the three regions was under- sions. They noted general, only Caucasians, Blacks, Asians and His- that the mydriatic response to cocaine was greatest panics may have measurable populations in a data- in Caucasians, less in Chinese and least in Blacks. Most Asians, especially Japanese (88± foreign workers, as much as 10% in Germany, 93%), are fast acetylators compared to 50% of and many resident Asian and African citizens of Caucasians and Blacks (Wood and Zhon 1991). In contrast, Japan is Fast acetylators may be at greater risk of isoniazide populated almost entirely by ethnic Japanese, truly hepatitis from toxic metabolites (Drayer and homogeneous, although a sizable non-national im- Reidenberg 1977), whereas slow acetylators may migrant population of other guest Asian workers respond better to treatment (sustained levels) but exists. The percentage of an ethnic or racial tensive mephenytoin metabolizers when taking di- population poorly metabolizing by this pathway azepam (mephenytoin pathway) still metabolized varies greatly; e. However, ethnic differences in the per- Clinically, this has been shown to make a differ- centage of body fat between the two groups could ence in a small study in males, involving 10Chinese also account for this. In this study, when dosage was and imipramine each have two major pathways, adjusted upwards to equilibrate to Caucasian and even poor metabolizers of any significant therapeutic blood levels, a greater response was pathways usually have alternative pathways, noted in the Chinese subjects (lower blood pressure which might be expected to show some increased and pulse rate) (Zhou et al 1990). In others, especially where the thera- by commonly used drugs, such as mephobarbital, peutic index is small, it may be criticalÐusually hexobarbital, diazepam, imipramine, and omepra- these drugs are titrated for efficacy and safety zol, but only 3±5% of Caucasians and 8% of Blacks and thus, the effect is avoided. In other cases, are poor metabolizers of mephenytoin, compared such as antihypertensive agents, the clinical effect to 15±20% of Chinese and Japanese populations of genetic differences may not be seen, because the (Kupfer et al 1988). The lack of digestive enzyme lactase in many Hispanics, especially Mexican-Americans and Af- Prescribing Differences rican-Americans, causes lactose intolerance, with nausea, diarrhea, and occasionally vomiting. Dinsdale et al (1995) tion and clearance), as well as the fact that the confirmed a similar pattern in prescriptions issued metabolism of some benzodiazepines appears to for analgesics for postoperative pain to be self-ad- be slower in Asians than in Caucasians (Kumana ministered by the patient, with Caucasians receiving et al 1987). One study (Zhang et al 1990) showed prescriptions significantly more frequently than mi- that Chinese subjects who were either poor or ex- norities ( p 0:01). There are individual excep- lations, due either to a sizeable representation of tions amongst patients and among drugs, even poor metabolizers present or to a genetic or ethnic- within these classes; e. Clozapine is associated with a- and b-blockers, can be equally effective in both the development of agranulocytosis in 20% of Ash- African-Americans and Caucasians and, as men- kenazi Jews, compared to 1% of the general popu- tioned previously, the Chinese appear twice as sen- lation treated for schizophrenia. This was found to sitive as Caucasians to propranolol (Oster et al be highly associated with specific linked genes, 1987; Zhou et al 1990) agranulocystosis and especially those of Ashkenazi Jewish origin (100%) (Leiberman et al 1990). It Another example of pharmacodynamic differ- has been postulated that Asians have fewer benzo- ences is that of reports on lithium in the manic diazepine and b-blocker receptors than Cauca- phase of bipolar depression. Downregulation of these receptors with age ing Japanese, are reported to have therapeutic (Salzman 1982) has been described and postulated blood levels at 0. If the Chinese are (Jefferson et al 1987; Yang 1987; Takahashi 1979); more sensitive to propranolol in spite of their high these findings, however, are disputed by Chang et catabolic rate, it might be linked to adrenergic al (1985).
