In this case the potential changes are not picked up in the extracellular fluid immediately surrounding the cardiac cells but at the surface of the body selegiline 5 mg lowest price. How is it possible to detect any potential differences on the surface of the body? Consider a mass of cells at some instant during the cardiac cycle where an active region exists together with an inactive region discount 5mg selegiline otc. The diagram shows an active depolarized region (inside positive) on the left order 5mg selegiline amex, and a region still at rest (inside negative) on the right. As the depolarization spreads from left to right, intracellular current flow also proceeds from left to right, but the return flow of extracellular current outside the myocardial cells passes from right to left (curved arrow). When the source and the sink are physically very close together, or viewed from a great distance, they can be described as a current dipole. A dipole is an equal number of positive and negative charges separated by an infinitesimally small distance. A dipole has properties of magnitude (amplitude), sign (a certain sense, positive or negative) and direction (orientation in space). These features can be conveniently represented by a vector with corresponding properties. Typically, the vector representation of the dipole is used as a shorthand representation of the electrical forces generated by the wave of excitation. The magnitude, sign and direction of the dipole are symbolized respectively by the length of the arrow, the sign of the electromotive force is indicated by the arrowhead, and the orientation is represented by the direction of the arrow. It is a question of how closely the forces generated by the dipole are aligned with the optimal orientation of a particular recording configuration, known as a “lead”. The detector measures a potential difference between two different points in the space, with one point connected to the terminal called the positive electrode (red wire) and the other point connected to the other terminal, called the negative electrode (black wire). When the positive electrode sees a positive voltage relative to the other electrode, an upward (positive) deflection is registered. Graphically, a lead is represented by a straight line in space between the two terminals. The relative magnitude of the potential (E) recorded along a lead is given by the projection of the dipole moment (graphically represented by a vector) onto the straight line connecting the electrodes. By conventional geometry, this is proportional to the vector moment (m), and to the cosine of the angle between the vector and the line. Thus, when the heart vector is exactly parallel to the axis of lead, the projection is maximal. On the other hand, when the vector is perpendicular to the axis of the lead, the projection is minimal. In between orientations yield projections varying by cos which can range from 1 to 0. The projections of a vector can be considered as the "shadow" on the lead axis, with light falling in perpendicularly. The size of the shadow will depend on the angle of the vector with relation to the lead. When we attach the (+) electrode to the left arm (L) and the (-) electrode to the right arm (R), we are using one of the leads (lead I) first introduced by Wilhelm Einthoven centuries ago. One can think of the limb electrodes as ways of gaining access to electrical forces within the body trunk, in the case of lead I, along a vector running from right shoulder to the left shoulder. In a more diagrammatic fashion, each lead can be depicted as an arrow, where the arrowhead represents the positive terminal. The three leads are often shown as lying in a single frontal plane along a more or less equilateral triangle, as illustrated in Figure 5. Initially the depolarization is directed from left to right into the septum and from endocardium to epicardium. Somewhat later the main spread is downwards to the apex when the entire electrical front can be represented by the direction of arrow 2. Finally depolarization reaches the last portion of the heart in a posterior and left direction vector 3 and vector 4. Obviously, the vector evolves during the cardiac cycle in a continuous fashion with all intermediate positions before, after and between the positions 1,2,3. A continuous representation of the vector during the cardiac cycle is shown in vectocardiography as a complete loop. Vector 2 is of the same sign as the lead, and also larger than vector 1; it projects as a positive deflection, the positive R wave. Vector 4 is again of opposite sign and smaller and projects as the negative S wave. The cardiac vector is essentially oriented downwards and to the left, resulting in a loop as shown in Figure 9. During ventricular repolarization one would expect the vector to be exactly opposite to that during ventricular depolarization, i. However, the timing of repolarization is such that it proceeds from the outside to the inside: thus, the last part depolarized is the first to be repolarized. This restores the vector to be downward and thus in the same general direction as the R wave, i. The “normal” T vector loop is shown in Figure 10, although variations on this pattern are relatively common. Relative to this central terminal, the exploring electrode can be positioned on any particular site of the body. These unipolar leads (V leads) give rather small signals when the potential is thus recorded on either of the three corners of the triangle and referred to the Wilson central terminal. Later, Goldberger showed that the shape of these recordings is not substantially altered by interrupting the connection between the central terminal and the site to be studied. The resulting leads augment the amplitude of the recording by 50% and are therefore called the augmented unipolar limb leads. Vectocardiography considers the frontal, the sagittal and the transverse plane together. Six additional unipolar electrocardiographic leads -- the precordial leads -- provide information in the transverse plane. They use as reference the central terminal of Wilson and place the exploring electrode at six sites across the precordium. These precordial leads are called V1, V2, V3, V4, V5 and V6 as shown in Figure 11. By virtue of bringing the exploring electrode much closer to the heart the typical signals recorded from V1, V2, V3, V4, V5 and V6 cannot be correctly interpreted as projections of vectors on leads which are remote as compared to the size of the dipole.
Paget disease of bone: give the course either as: * 30mg weekly for 6 consecutive weeks (total dose 180mg) selegiline 5mg lowest price. Increase the dose according to disease severity buy 5 mg selegiline with amex, to a maximum total dose of 360mg (in divided doses of 60mg) discount 5mg selegiline otc. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Technical information Incompatible with Pamidronate disodium is incompatible with Hartmann’s and Ringer’s (contain Ca). Displacement value Negligible (Aredia) Stability after From a microbiological point of view, should be used immediately; however, preparation prepared infusions may be stored at 2--8 C and infused (at room temperature) within 24 hours. Monitoring Measure Frequency Rationale Hypersensitivity During and just after * Anaphylactic reactions, bronchospasm, reactions infusion dyspnoea, angioedema have occasionally been reported. Treatment can be repeated whenever "Ca recurs but may become less effective as the number of treatments increase. Additional information Common and serious Immediate: Angioedema and bronchospasm have been reported. Care should be taken to avoid extravasation or inadvertent intra-arterial administration. Other: Renal dysfunction, haematuria, asymptomatic and symptomatic #Ca (paraesthesia, tetany), pruritus, urticaria, exfoliative dermatitis, fever and influenza-like symptoms, malaise, rigors, fatigue and flushes (usually resolve spontaneously), eye disorders (uveitis, scleritis, conjunctivitis), jaw osteonecrosis (see above). Counselling Patients should be warned against driving or operating machinery after treatment with pamidronate as somnolence or dizziness may occur for up to 24 hours. Advise of the importance of taking calcium and vitamin D supplements as prescribed where these are indicated. Advise patients with risk factors for osteonecrosis of the jaw (see Pre-treatment checks) not to undergo invasive dental procedures during treatment. This assessment is based on the full range of preparation and administration options described in the monograph. Zollinger--Ellison syndrome (and other hypersecretoryconditions): initially 80mg (160mg if rapid acid control is required) then 80mg once daily, adjusted according to response; give daily doses above 80mg in two divided doses. Dose in hepatic impairment: in severe impairment, the daily dose should be reduced to 20mg. Inspect visually for particulate matter or discolor- ation prior to administration. Inspect visually for particulate matter or discolor- ation prior to administration. Aciclovir, adrenaline (epinephrine), amikacin, amiodarone, amphotericin, calcium gluconate, cefotaxime, ceftazidime, cefuroxime, ciprofloxacin, clindamycin phosphate, co-trimoxazole, dexamethasone, diazepam, digoxin, dobutamine, dopamine, esmolol, fentanyl, fluconazole, furosemide, gentamicin, glyceryl trinitrate, heparin sodium, hydralazine, hydrocortisone sodium succinate, insulin (soluble), labetalol, magnesium sulfate, meropenem, methylprednisolone sodium succinate, metoclopramide, metronidazole, midazolam, naloxone, noradrenaline (norepinephrine), octreotide, phenytoin sodium, piperacillin with tazobactam, propofol, tobramycin, vecuronium bromide, verapamil. Stability after From a microbiological point of view, should be used immediately; however: preparation * Reconstituted vials may be stored at 2--8 C for 12 hours. Serum vitamin B12 * In long-term therapy malabsorption of vitamin B12 has been reported. Pharmacokinetics Elimination half-life is about 1--2 hours but may be prolonged (up to 10 hours) in poor metabolisers and patients with liver impairment. Significant * Pantoprazole may #levels or effect of atazanavir (avoid combination). Pantoprazole is overdose extensively plasma protein bound and is therefore not readily dialysable. This assessment is based on the full range of preparation and administration options described in the monograph. Pre-treatment checks * Do not use in acute respiratory depression, where there is a risk of paralytic ileus, in "intracranial pressure and in head injury, in comatose patients, in heart failure secondary to chronic lung disease and phaeochromocytoma. Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving an initial dose, especially elderly patients or those of low bodyweight. Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving an initial dose, especially elderly patients or those of low bodyweight. Inspect visually for particulate matter or discolor- ation prior to administration and discard if present. Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving an initial dose, especially elderly patients or those of low bodyweight. Monitoring Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving an initial dose, especially elderly patients or those of low bodyweight. Measure Frequency Rationale Pain At regular intervals * To ensure therapeutic response. Monitor for side- * Can cause side-effects such as itching and nausea effects and toxicity and vomiting and constipation, which may need treating. Papaveretum | 643 Additional information Common and serious Common: Nausea and vomiting (particularly initially), constipation, dry mouth, undesirable effects urticaria, pruritus, biliary spasm, " or #pulse, hallucinations, euphoria, drowsiness. Counselling If the patient is pregnant or breast feeding she should inform her doctor. May cause drowsiness and dizziness that may affect the ability to perform skilled tasks; if affected do not drive or operate machinery. This assessment is based on the full range of preparation and administration options described in the monograph. Pre-treatment checks * Do not use in acute respiratory depression, where there is a risk of paralytic ileus, in "intracranial pressure and in head injury, in comatose patients, in heart failure secondary to chronic lung disease and phaeochromocytoma. Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving an initial dose, especially elderly patients or those of low bodyweight. Papaveretum with hyoscine hydrobromide | 645 Subcutaneous injection Preparation and administration 1. Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving an initial dose, especially elderly patients or those of low bodyweight. Technical information Incompatible with Not relevant Compatible with Not relevant pH 2. Monitoring Close monitoring of respiratory rate and consciousness is recommended for 30 minutes in patients receiving an initial dose, especially elderly patients or those of low bodyweight. Measure Frequency Rationale Pain At regular intervals * To ensure therapeutic response.
In functional disorder of the stomach accompanied by pain buy discount selegiline 5mg on-line, it is an excellent sedative generic 5mg selegiline fast delivery, and in intestinal disorders it is equally applicable purchase selegiline 5 mg on-line. It does not suppress secretions or disarrange the functional operations of the organs. In aching and painful irritation, or in the passage of gravel, it is a most soothing remedy. It is beneficial here also in painful hematuria, whether from cancer or tuberculosis, from profound congestion or nephritis. It is a soothing tonic to the uterine muscular structure, and in inertia and subinvolution it increases muscular power and energy and promotes contraction. It is a valuable sedative adjuvant to combine with the well known uterine tonics in general disorders of the pelvic organs amenable to medical treatment not of a surgical character, especially if the pains are of neuralgic or spasmodic character. It will allay abnormal sexual appetite, and will overcome the hysteria and emotional excitement which occur in some women at the menstrual period. In neuralgic dysmenorrhea it will occasionally cure patients who have been treated by other methods without results. There are few remedies that will excel it in this disorder, but the remedy must be given continuously, beginning before the expected paroxysm some little time and continued for a time after the paroxysm is relieved. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 91 It is an excellent remedy in gonorrhea with sexual hyperaesthesia. It controls violent erection and soothes the mental anxiety which aggravates the symptoms. It is soothing to irritable bronchial coughs and laryngeal spasm, and in coughs from tickling in the throat; also in whooping cough and in spasmodic coughs of whatever character. Co-operatives—The agent acts similarly in a general way to opium, gelsemium, passiflora, the bromides, chloral and hyoscyamus. Therapy—The agent has been noted for its influence in haematuria and other mild forms of passive hemorrhage. It is of some benefit as a mild diuretic, soothing irritation of the renal or vesical organs. In cases of uncomplicated chronic menorrhagia it has accomplished permanent cures, especially if the discharge be persistent and devoid of much color. The agent is also useful where uric acid or insoluble phosphates or carbonates produce irritation of the urinary tract. In the treatment of mild forms of intestinal hemorrhage or gastric hemorrhage from simple ulceration, the agent has been used with some benefit, also in atonic dyspepsia, diarrhea, both acute and chronic, and in dysentery and bleeding piles. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 92 Externally the bruised herb has been applied to bruised and strained parts, to rheumatic joints, and where there was ecchymosis or extravasations within or beneath the skin. Heinen of Toledo treats non-malignant abdominal tumors in women with better results by adding five drops of capsella three times a day to the other indicated treatment. In large doses it causes vomiting, purging and inflammation of the stomach and bowels, with dizziness, intoxication and feebleness of the nervous power. It produces rapid capillary determination of the blood to the part, and if taken into the stomach it promotes its own absorption and thus continues its further influence through the nerve centers. Belonging as it does to the solanaceae, its influence upon the nerve centers, although insidious and not in all its field of exercise readily distinguishable, is nevertheless active and most important, demanding its classification among the diffusible cerebral stimulants. It produces an increase of tone and a marked and comfortable sensation of warmth in the entire system, and a glow and sensation of increased nerve influence and more active circulation. The general or systemic influence is better obtained from the tincture or from the hot infusion, while local stomach or intestinal effects follow promptly upon the administration of the powder. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 93 Its influence upon the circulation is more marked in its local than its constitutional or central effects, although it does influence general capillary tone. It barely increases the pulse beat, although it materially alters its character and it does not influence the appreciable temperature. Specific Symptomatology—It is directly indicated in general enfeebled conditions, with impairment of nerve influence. In general atonic conditions, with relaxation of muscular fiber; in plethoric conditions and lethargic affections, with general impairment of tone, with deficiency of functional force, energy or activity—in these conditions, because of its local and general effects, it is markedly different from other stimulants. The indications are marked nervous depression, tendency to capillary stasis; dry, harsh tongue, with brown coating; scanty and glutinuous buccal secretion, tendency to tympanitic distension, cool extremities and gastric uneasiness. Furthermore with quinine in malarial troubles, with small doses of hydrochloric acid, excellent results have been obtained in rheumatism of malarial origin, coming on periodicidly. Therapy—Its influence upon the nervous system is shown by the fact that in general paresis, and in some cases of paralysis, local and general of central origin, it has rapidly promoted cures without the use of other agents. In one case after passive cerebral congestion, it was given in strong infusion, and the tincture applied to the paralyzed arm and muscles, and restoration of nerve influence followed in a few days with a generally improved condition of the nervous system. It certainly deserves a more extended use in these cases, because of the possibility of its being pushed to the extreme without danger of disturbance of function or structure, or impairment or derangement of any organ. It is a harmless agent, however used; if concentrated, local irritation should be avoided. It has long been combined with tonics, stimulants and general restoratives in seriously impaired nerve tone of the dipsomaniac, with results which were ascribed to other agents used. It has an influence in these cases which resembles that of strychnine, and yet is quite unlike it although fully as important. Ellingwood’s American Materia Medica, Therapeutics and Pharmacognosy - Page 94 In delirium tremens it produces a sedative influence, which results in quiet, rest, and frequently in deep sleep. In these cases it is best in hot infusion combined with warm beef-tea or other hot nutritious liquid food. If its use be continued it will replace the alcohol, and in its satisfaction of the unnatural demands of the stomach, will enable the patient, with proper adjuvants, to permanently overcome the taste for liquor. It must be given in conjunction with persistent and concentrated nutrition, and may be combined with hydrastine or strychnine or other nerve stimulants and tonics. It is also of much service in the treatment of the opium and morphine habits, and also that of cocaine. In languid and enfeebled states of the stomach, with inactivity of the peptic and other glands, whatever the cause, it is an immediate and direct stimulant. In atonic dyspepsia and flatulent colic, in atonic inactivity of the liver and other glandular organs which have a part in the stomach and intestinal digestion, its influence is immediate and most important. It is a common ingredient of pills and laxative granules, and it certainly improves the capillary circulation and nerve tone of the entire intestinal tract. In the stage of collapse of prostrating diarrheas and of exhausting fevers and in cholera, no agent is more efficient. It is useful in yellow fever, in typhus and in some cases of typhoid where there are great relaxation and muscular weakness, where there are sluggishness of the nervous system, torpor and insensibility, low muttering delirium and tendency to coma.