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By: Vinay Kumar, MBBS, MD, FRCPath

  • Donald N. Pritzker Professor and Chairman, Department of Pathology, Biologic Sciences Division and Pritzker School of Medicine, The University of Chicago, Chicago, Illinois


Low-cost strategies for improving adherence increase effectiveness of health interventions and reduce costs symptoms xanax abuse order generic combivir on line. Health-care providers should be familiar with techniques for improving adherence and they should employ systems to symptoms 24 hour flu purchase combivir 300mg free shipping assess adherence and to treatment 5th metatarsal stress fracture purchase discount combivir on-line determine what influences it treatment 4 addiction combivir 300 mg cheap. Patient reasons In general, women tend to be more adherent than men, younger patients and the very elderly are less adherent, and people living alone are less adherent than those with partners or spouses. Patient disadvantages such as illiteracy, poor eyesight, or cultural attitudes (for example, preference for traditional or alternative medicines and suspicion of modern medicine) may be very important in some individuals or societies, as may economic factors. Disease reasons Conditions with a known worse prognosis (for example, cancer) or painful conditions (for example, rheumatoid arthritis) elicit better adherence than asymptomatic "perceived as benign" conditions such as hypertension. Doctor reasons Doctors may cause poor adherence in many ways ­ by failing to inspire confidence in the treatment offered, by giving too little or no explanation, by thoughtlessly prescribing too many medicines, by making errors in prescribing, or by their overall attitude to the patient. The doctor­patient interaction There is considerable evidence that the quality of the doctor­patient interaction is crucial to concordance. If they are in doubt or dissatisfied, they may turn to alternative options, including "complementary medicine". Prescription reasons Many aspects of the prescription may lead to non-adherence (non-compliance). It may be illegible or inaccurate; it may get lost; it may not be refilled as intended or instructed for a chronic disease. Also, the prescription may be too complex; the greater the number of different medicines, the poorer the adherence. Multiple doses also decrease adherence, especially if more than two doses per day are given. Not surprisingly, adverse effects like drowsiness, impotence, or nausea reduce adherence and patients may not admit to the problem. This has been reported in relation to generic drugs when substituted for brand-name drugs. The health-care system the health-care system may be the biggest hindrance to adherence. Long waiting times, uncaring staff, an uncomfortable environment, and unreliable drug supplies, are all common problems in many settings, and have a major impact on adherence. Some studies have confirmed the obvious, that patients furthest from the clinic are least likely to adhere to treatment in the long term. Explore problems, for example, difficulty with reading the label or getting the prescription filled. Encourage patients to bring their medication to the clinic, so that tablet counts can be done to monitor compliance. Encourage patients to learn the names of their medicines, and review their regimen with them. They differ from accidental or deliberate excessive dosage or drug maladministration (see section 4 for the treatment of poisoning). Thalidomide marked the first recognized public health disaster related to the introduction of a new drug. It is now recognized that clinical trials, however thorough, cannot be guaranteed to detect all adverse effects likely to be caused by a drug. Health workers are thus encouraged to record and report to their national pharmacovigilance centre any unexpected adverse effects with any drug in order to achieve faster recognition of serious related problems. Major factors predisposing to adverse effects It is well known that different patients often respond differently to a given treatment regimen. For example, in patients taking combinations of drugs known to interact, only a small number show any clinical evidence of interactions. Drugs which commonly cause problems in the elderly include hypnotics, diuretics, nonsteroidal anti-inflammatory drugs, antihypertensives, psychotropics, and digoxin. Some drugs are likely to cause problems in neonates (for example morphine), but are generally tolerated in children. Other drugs associated with problems in children include chloramphenicol (grey baby syndrome), antiarrhythmics (worsening of arrhythmias), and acetylsalicylic acid (Reye syndrome). Drug interactions Interactions (see also Appendix 1) may occur between drugs which compete for the same receptor or which act on the same physiological system. They may also occur indirectly when a drug-induced disease or a change in fluid or electrolyte balance alters the response to another drug. In addition, interactions may occur when one drug alters the absorption, distribution or elimination of another drug, such that the amount which reaches the site of action is increased or decreased. When two drugs are administered to a patient, they may either act independently of each other, or interact with each other. Interaction may increase or decrease the effects of the drugs concerned and may cause unexpected toxicity. As newer and more potent drugs become available, the number of serious drug interactions is likely to increase. Remember that interactions which modify the effects of a drug may involve non-prescription drugs, non-medicinal chemical agents, and social drugs such as alcohol, marijuana, tobacco, and traditional remedies, as well as certain types of food for example, grapefruit juice. The following table lists drugs under the designation of specific cytochrome P450 isoforms. A drug appears in a given column if there is published evidence that it is metabolized, at least in part, via that isoform. Alterations in the rate of the metabolic reaction catalysed by that isoform are likely to have effects on the pharmacokinetics of the drug. Certain drugs, when added to intravenous fluids, may be inactivated by pH changes, by precipitation or by chemical reaction. Benzylpenicillin and ampicillin lose potency after 6­8 hours if added to dextrose solutions, due to the acidity of these solutions. Some drugs bind to plastic containers and tubing, for example, diazepam and insulin. In these types of preparation, it is not always easy to identify the responsible plant or plant constituent. Refer to the drug and toxicology information service if available or to suitable literature. However, some drugs are taken with food, either to increase absorption or to decrease the irritant effect on the stomach. Prescription writing A prescription is an instruction from a prescriber to a dispenser. The prescriber is not always a doctor but can be a paramedical worker, such as a medical assistant, a midwife or a nurse. The dispenser is not always a pharmacist, but can be a pharmacy technician, an assistant, or a nurse. Every country has its own standards for the minimum information required for a prescription, and its own laws and regulations to define which drugs require a prescription and who is entitled to write it. Many countries have separate regulations for prescriptions for controlled drugs such as opioid analgesics. The following guidelines will help to ensure that prescriptions are correctly interpreted and leave no doubt about the intention of the prescriber. The guidelines are relevant for primary care prescribing; they may, however, be adapted for use in hospitals or other specialist units. Prescription form the most important requirement is that the prescription be clear. This will allow either the patient or the dispenser to contact the prescriber for any clarification or potential problem with the prescription. In many countries, the validity of a prescription has no time limit, but in some countries pharmacists do not dispense drugs on prescriptions older than 3­6 months. If there is a specific reason to prescribe a special brand, the trade name can be added. The pharmaceutical form (for example, "tablet", "oral solution", "eye ointment") should also be stated. Directions Directions specifying the route, dose, and frequency should be clear and explicit; use of phrases such as "take as directed" or "take as before" should be avoided. For preparations which are to be taken on an "as required" basis, the minimum dose interval should be stated together with, where relevant, the maximum daily dose. It is good practice to qualify such prescriptions with the purpose of the medication (for example, "every 6 hours as required for pain", "at night as required to sleep").


  • Sensitivity to light (photophobia)
  • Mesothelioma (benign-fibrous)
  • Adrenal gland disorders, including not releasing enough aldosterone, and a condition called primary adrenal insufficiency (Addison disease)
  • Esophageal ulcer
  • Chemical irritation
  • Lidocaine mouthwashes to numb the area and make eating more comfortable (for mouth sores)
  • Sinus infection (sinusitis)

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Loss of Veerya is the cause of many diseases medications zovirax purchase combivir line, early death symptoms depression order combivir 300 mg amex, loss of vigour treatment quadriceps tendonitis cheap combivir 300 mg on line, power and vitality symptoms diverticulitis buy line combivir. The power to contract and expand in the various parts of the body, digestion of food and all such functions of the body divine strength from Veerya. Just as butter is pervading the entire milk, just as sugar (sweetness) pervades the entire sugarcane, just as oil pervades in seasamum seeds, in the same way Veerya pervades the whole body. Pervading the entire body, strengthening it from within, Veerya protects it from all diseases. He who relies solely on observation, thinks more of differences than of similarities. The methods of investigation in Ayurveda are more synthetic leading to oneness, Adwaita, whereas the tendency in Modern Medicine is more analytical leading to dissipation of ideas. The mechanistic view of man prevailed progressively during the last two or three centuries, and any disease was considered to be a breakdown in the machine, which should be set right by adjusting or repairing the damaged parts. The attention to the part or organ assumes greater importance than the consideration of the whole man. Ayurveda considers man as a complex and inseparable combination of the material body, the senses, the mind and the soul. The decision depends upon the personality of every individual, which is unborn in all living creatures and persists as long as the organism lives. The constitutional factors leading to equilibrium or harmony are due to Sattwaguna. The mental and physical characteristics of every individual in health and disease are determined by the predominance of one or the other of these three qualities, Trigunas. Tridosha Theory Vata, Pitta and Kapha are the nutritive fluids that feed the living organisms through the nervous, digestive and lymphatic systems respectively. Clinically, these theories are very helpful to the diagnosis and successful treatment of the multifarious diseases of the mind and the body. These theories represent the synthetic psychosomatic conception of man, which deals with his mental and physical states including the effects of the vitamins, hormones, toxins, antibodies and all factors relating to the self and the environments of time and place. This means that the Ayurveda deals with both the known and the unknown as well, through its philosophy. The theories of Ayurveda have not been so far verified by modern research, because the instruments of Science have their own limitations, when they have to deal with living matter. Even the illiterate people and particularly women in India understand theories which they apply in their daily life. The practitioner of Modern Medicine refuses to understand them, because he has lost his moorings in the Indian Culture on account of the bias that he has been taught to acquire by his new education. Domestic Medicine It is not always that the aid of the physician is sought in our country immediately after the appearance of the first symptoms of disease. The people are able to classify the symptoms of the predominance of Vata, Pitta and Kapha respectively and apply some domestic remedies such as ginger, pepper, garlic, Neem, asafoetida and musk, whose properties are well-known to them, to check the respective fault in the earliest stage (Kriyaakaala) of the disease. This brings about the equilibrium which makes the invading agent powerless to grow in the unsuitable soil. Modern Research should help to enlighten us on the rationale of these domestic remedies, some of which are not yet recorded in the text books on Ayurveda. According to Ayurveda, there is nothing in this world which may not be used as a medicine -Na Jagati Anoushadham (Charaka). It all depends upon the capacity of the physician to discover and utilise the available material as a medicine or as an article of diet or otherwise. Modern Medicine appears to be concerned with advertisement of more and more medicines of doubtful value to cure diseases, whereas the long term purpose of the medical science should be to empty the hospitals. For this reason, Ayurveda was traditionally taught to every man and woman in India. Physiotherapy which promotes positive health is badly neglected in modern hospitals. Colossal Ignorance and Pride Even after the advance of Science, our ignorance of the secrets of nature is colossal. Many medical practitioners do not seem to realise the vastness of their ignorance. Instead of feeling humilitated by his utter powerlessness in many situations in his daily life, the proud young doctor is full of egoism (Ahamkara), due to his materialistic mentality. Emotions Cause Disease Emotions like anger, greed and hurry are potent sources of disease. Therefore one should develop control over these emotions which are the worst enemies of man. Otherwise, all material and spiritual knowledge will be useless- Jnana Vijnana Nashanam. Ayurveda teaches not only how to live a happy life, but also how to die a happy death with detachment, contentment and peace. Ayurveda advocates Varnashrama Dharma, a system of organisation of the whole human life into definite selfadjusting socio-economic units, so that, all people may be happy without any strife for selfish ends and may reach the Paramaartha. Every man supreme goal of spiritual progress- has to strive his best for the full attainment of the four values or aspirations of life namely, Dharma -Virtue or duty to self and society, Artha -acquisition of wealth or power, Kama -satisfaction of desires and Moksha -liberation from the bondage or attachment. But, I shudder to think, that a third-rate practitioner of Modern Medicine spreads into the villages of India, to replace the ennobling system of Ayurveda by materialistic and outlandish ideas quite unsuitable to our habits. The causes of diseases are beautifully summarised in Ayurveda into three groups, viz. Research should be conducted on the incidence of the seasons (Ritus) in India and their influence on the onset of diseases and of the pharmaco logical properties (Rasa, Guna, etc. Today, the methods of investigation of diseases are lop-sided giving no real attention to the man as a whole. The physician who depends too much on instruments and laboratories is unable to develop the most valuable faculty of intuition. Charaka says: "A physician who cannot enter into the innermost soul of the patient with the bright light of the lamp of his own knowledge cannot successfully treat any disease. The application of Modern Methods of Pharmacological technique conducted in collaboration with experienced Ayurvedic scholars is sure to result in the advancement of both Ayurveda and Modern Medicine. Literally, pharmacological, biochemical, clinical, psychological and philosophical research should all be conducted side by side. The methods of research in Ayurveda should not be to imitate what is done in other countries. Ayurveda has a good working hypothesis which has helped the successful practice of Ayurveda through the centuries and it is still a living force today with the Ayurvedic physician and the patient. The Siddha and Unani systems also follow the same fundamental principles and are popular with certain sections of the people. Conclusion Herein, I have laid emphasis on four points which are fundamental to the study of Ayurveda. The factor of personality is greatly responsible for the happiness or misery of the individual. A lthough ancient, it has th e capacity to grow and b e ever new, Puranama cha Punarnavam (C h arak a Siddhi). There are three main branches of Ayurveda and they deal with the causes, symptoms and treatment of diseases. Charaka, Sushruta, Vagbhata, Madhava and Sarangdhara were the great Rishis or Fathers of Ayurvedic medi cine. They consist of removing the injurious agent, soothing the injured body and mind, eradicating the cause. Besides, in Ayurveda great importance is given to the study of the various stages of variation of the three Doshas or humours of the body-Vatha, Pitta and Kapha. Several meta-analyses have documented the relative safety and probable efficacy of this phytomedicine. These included "allergic" skin reactions (27), increased Quick Values (prothrombin time) (16), gastrointestinal complaints (9), breakthrough bleeding (birth control pill) (8), plasma cyclosporin reductions (7), and others. Photosensitization, depicted by erythema (redness of the skin) with exposure to sunlight or other ultraviolet radiation, is possible, but relatively rare and is sometimes reported in fair-skinned individuals taking excessive dosages (1,800 mg/day). To prevent relapse, antidepressant should be continued at full therapeutic doses for at least 6 months after remission. To-date there are no reported cases suggesting clinically significant weakening in effect of the three drugs cited. A recent study received considerable media attention due to its negative findings on patients with severe depression; however, the study lacked an active control (no active drug was used to measure the response rate of severely depressed patients vs.

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On this day the radiation oncologist must calculate the exact dose activity to medications valium safe 300mg combivir be ordered based on (1) assessment of dosimetry and biodistribution obtained following the dosimetric dose medications japan buy genuine combivir on line, and (2) platelet counts obtained within 28 days prior to medications xr 300mg combivir overnight delivery dosing treatment vitamin d deficiency order generic combivir. Specific date may be selected based on patient parameters, availability of the radioactive component, or patient or physician convenience. Thyroid-protective agents: Have been administered every day and will continue for a Premedicate with acetaminophen 650 mg and diphenhydramine 50 mg. Follow with calculated therapeutic dose of I-131 tositumomab (calculated dose of I-131 and 35 mg tositumomab) as an infusion over 20 minutes. Dose of I-131 is administered based on platelet count as follows: Platelets equal to or greater than 150,000/mm3: Activity of I-131 calculated to deliver 75 cGy total-body irradiation. Platelets 100,000/mm3 to 149,000/mm3: Activity of I-131 calculated to deliver 65 cGy totalbody irradiation. I-131 tositumomab for the dosimetric step is supplied in a package containing one single-use vial (0. For the therapeutic step, it is supplied in a package containing one or two single-use vials, each containing not less than 20 mL of I-131 tositumomab solution at protein and activity concentrations of not less than 1. Availability of supplies must be confirmed by the radiation specialist before scheduling therapy. I-131 tositumomab: All supplies, preparation, calibration, confirmation of radiochemical purity, and administration of these doses in both the dosimetric and therapeutic steps will be provided by personnel authorized to handle radiopharmaceuticals and certified to administer this therapeutic regimen. Storage: Tositumomab: Prior to dilution, refrigerate 35-mg and 225-mg vials at 2° to 8° C (36° to 46° F). I-131 tositumomab: Stored in radiation therapy freezer at 220° C or below in original lead pots until removed for thawing before administration. Tositumomab 450-mg dose (dosimetric and therapeutic): If unit staff will be administering these doses, correlate timing with the radiation oncologist directing the procedure. Carefully prime this second infusion set from the 50-mL solution of tositumomab so as not to waste any drug. A single dose must be administered evenly distributed over 60 minutes via an infusion pump. Leave the primary line and filter extension intact; the pre-wetted filter must be used for delivery of the radioactive component. I-131 tositumomab 35-mg dose: Preparation, calibration, confirmation of radiochemical purity, administration, and disposal of these doses and the equipment used to deliver them in both the dosimetric and therapeutic steps will be provided by personnel authorized to handle radiopharmaceuticals and certified to administer this therapeutic regimen. An antineoplastic, radioimmunotherapeutic, monoclonal antibody­based regimen composed of the monoclonal antibody, tositumomab, and the radiolabeled monoclonal antibody (I-131 tositumomab). Determination of the effectiveness of the regimen is based on overall response rates in patients whose disease is refractory to chemotherapy and rituximab. Limitations of use: this regimen is indicated only for a single course of treatment. In addition, the specific physician administering I-131 tositumomab should either be participating in a certification program or have been certified in the preparation and administration of this therapeutic regimen. Follow institutional radiation safety practices and applicable federal guidelines to minimize radiation exposure during handling and after administration. Second and third imaging time points reflect decreased accumulation in the blood pool, liver, and spleen and may show uptake by the thyroid, kidneys, and other organs. Altered biodistribution on the first day may be visualized as little or no activity in the blood pool, intense uptake in the liver or spleen, greater uptake in the lungs than in the blood pool, or uptake suggestive of urinary obstruction. Altered biodistribution on the second and third imaging time points may suggest urinary obstruction, diffuse lung uptake greater than the blood pool, or total-body residence times of less than 50 hours and more than 150 hours. Should not be administered to patients with greater than 25% lymphoma marrow involvement, a platelet count less than 100,000 cells/mm3, or a neutrophil count less than 1,500 cells/mm3. Ability to generate a primary or anamnestic humoral response to any vaccine has not been studied. Patients who cannot tolerate the thyroid-blocking agents may not begin the regimen. Time to nadir was 4 to 7 weeks, and the duration of cytopenias was approximately 30 days. Anemia, neutropenia, and thrombocytopenia may persist for more than 90 days, and some patients died without recovering. Have occurred during or within 48 hours of infusion or up to 2 weeks after infusion. Patient Education: Avoid pregnancy; effective birth control is recommended for males and females during treatment and for up to 12 months following therapy. Maternal/Child: Category D: avoid pregnancy; may cause harm to the fetal thyroid gland, and radioiodide may cause severe, and possibly irreversible, hypothyroidism in neonates. Effective contraceptive methods are recommended for men and women during treatment and for up to 12 months following therapy. Elderly: Numbers in clinical studies insufficient to determine if the elderly respond differently from younger subjects. Anemia, asthenia, fever, infections (including bacteremia, bronchitis, pneumonia, septicemia, and skin infections), infusion reactions, nausea, neutropenia, and thrombocytopenia are most common. Other reported side effects that may be reported within days or be delayed included abdominal pain, anorexia, arthralgia, back pain, chest pain, chills, constipation, cough, diarrhea, dizziness, dyspepsia, dyspnea, fever, headache, hypotension, hypothyroidism, myalgia, nausea and vomiting, neck pain, pain, peripheral edema, pharyngitis, pruritus, rash, rhinitis, somnolence, sweating, vasodilation, weight loss. Post-Marketing: Axonal neuropathy leading to quadriparesis; hypersensitivity reactions, including fatal anaphylaxis. Discontinue entire regimen in patients who develop severe hypersensitivity reactions. Treat anaphylaxis with oxygen, antihistamines (diphenhydramine), epinephrine, and corticosteroids. If overdose occurs, monitor closely for cytopenias and radiation-related toxicity. Autologous stem cell transplantation has not been studied; consider timing in relation to dosing to minimize the possibility of irradiation of infused hematopoietic stem cells. May contain up to 100 mcg/L of aluminum; see tion of correct product based on minimum daily requirement and individual needs. Zinc: 100 mcg/kg/day for full-term infants and other pediatric patients up to 5 years of Reduce or omit dose in impaired renal function. Specific amounts required to initiate, facilitate, or maintain appropriate body systems. Molybdenum without copper supplementation contraindicated in copper-deficient patients. Selenium enhances vitamin E and decreases the toxicity of mercury, cadmium, and arsenic. Pretreatment may not be successful; hypersensitivity reaction and/or infusion reaction may recur. Combination therapies may require additional premedication; refer to product monographs. Adjuvant treatment of breast cancer: Administer according to one of the following dose regimens and schedules for a total of 52 weeks of trastuzumab therapy: 1. During and following paclitaxel, docetaxel, or docetaxel/carboplatin: Administer an initial dose of trastuzumab 4 mg/kg as an infusion over 90 minutes. Follow with a dose of 2 mg/kg as an infusion over 30 minutes at weekly intervals for the first 12 weeks when given in combination with paclitaxel or docetaxel or for 18 weeks when given in combination with docetaxel/carboplatin. Beginning 1 week after the last 2-mg/kg weekly dose of trastuzumab, administer trastuzumab 6 mg/kg as an infusion over 30 to 90 minutes every 3 weeks. As a single agent within 3 weeks of completion of multimodality, anthracycline-based chemotherapy regimens, administer an initial dose of trastuzumab 8 mg/kg as an infusion over 90 minutes. See clinical studies in prescribing information for different treatment regimens used. In all studies, trastuzumab was initiated after completion of the doxorubicin and cyclo- phosphamide treatment cycles. Follow with a maintenance dose of 2 mg/kg as an infusion over 30 minutes at weekly intervals. TrastuMetastatic breast cancer in combination therapy with paclitaxel: Trastuzumab dose as above.


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