By M. Agenak. Champlain College.
Intravenous infusion Terminaton of an acute atack of cluster headache best malegra fxt 140mg, migraine: Adult- 0 cheap 140 mg malegra fxt visa. Contraindicatons Peripheral vascular disease malegra fxt 140 mg with mastercard, coronary heart disease purchase malegra fxt 140 mg mastercard, obliteratve vascular disease and Raynaud’s syndrome, temporal arterits; hepatc impairment, renal impairment, sepsis; severe or inadequately controlled hypertension, hyperthyroidism, pregnancy (Appendix 7c); lactaton; porphyria, ischaemic heart disease; angina pectoris. Precautons Risk of peripheral vasospasm; elderly; it should not be used for migraine prophylaxis; interactons (Appendix 6c). Warn patent to stop treatment immediately if numbness or tngling of extremites develops and to contact doctor, compromised circulaton; hypertension. Dose Oral The recommended oral dose is 25-100 mg, repeatable afer 2 hours upto a total dose of 200 mg over a 24 hour period. Parenteral 6 mg at onset subcutaneously, may be repeated once afer 1 h for maximum of 2 doses in 24 hours. Contraindicatons Ischaemic heart disease, hypertension; pregnancy (Appendix 7c); renal impairment. Specifc expertse, diagnostc precision, individualizaton of dosage or special equipment are required for their proper use The treatment of cancer with drugs, radiotherapy and surgery is complex and should only be undertaken by an oncologist. Where the conditon can no longer be managed with cytotoxic therapy, alternatve pallia- tve treatment should be considered. For some tumours, single-drug chemotherapy may be adequate, but for many malignancies a combinaton of drugs provides the best response. Cytotoxic drugs are ofen combined with other classes of drugs in the treatment of malignant conditons. Such drugs include hormone agonists and antagonists, cortcosteroids and immunostmulant drugs. Precautons and Contraindicatons Treatment with cytotoxic drugs should be initated only afer baseline tests of liver and kidney functon have been performed and baseline blood counts established. The patent should also be monitored regularly during chemotherapy and cytotoxic drugs withheld if there is signif- cant deterioraton in bone-marrow, liver or kidney functon. Contraceptve measures are required during therapy and possibly for a period afer therapy has ended. Cytotoxic drugs should be administered with care to avoid undue toxicity to the patent or exposure during handling by the health care provider. All waste, including patent’s body fuids and excreta (and any material contaminated by them) should be treated as hazardous. Extravasaton of intravenously administered cytotoxic drugs can result in severe pain and necrosis of surrounding tssue. If extravasaton occurs, aspiraton of the drug should frst be atempted, then the afected limb is elevated and warm compresses applied to speed and dilute the infusion or it is localized by applying cold compresses untl the infamma- ton subsides; in severe cases, hydrocortsone cream may be applied topically to the site of infammaton. The manufac- turer’s literature should also be consulted for more specifc informaton. Adverse Efects Cytotoxic drugs have a considerable potental to damage normal tssue. Specifc adverse efects apply, but a number of efects are common to all cytotoxics such as bone-marrow and immunological suppression. Furthermore, the concomitant use of immunosuppressive drugs will enhance susceptbility to infectons. Fever associated with neutropenia or immuno- suppression requires immediate treatment with antbiotcs. Nausea and vomitng: Nausea and vomitng following admin- istraton of cytotoxic drugs and abdominal radiotherapy are ofen distressing and may compromise further treatment. Symptoms may be acute (occurring within 24 h of treatment), delayed (frst occurring more than 24 h afer treatment), or antcipatory (occurring before subsequent doses). Delayed and antcipatory symptoms are more difcult to control than acute symptoms and require diferent management. Cytotoxic drugs associated with a low risk of emesis include etoposide, 5- fuorouracil, low-dose methotrexate and the vinca alkaloids; those with an intermediate risk include low- dose cyclophosphamide, doxorubicin and high-dose meth- otrexate; and the highest risk is with cisplatn, high-dose cyclophosphamide and dacarbazine. For patents at a low risk of emesis, pretreatment with an oral phenothiazine (for example chlorpromazine), contnued for up to 24 h afer chemotherapy, is ofen helpful. For patents at a high risk of emesis or when other therapies are inefectve, high doses of intrave- nous metoclopramide may be used. Note: High doses of metoclopramide are preferably given by contnuous intravenous infusion: an inital dose of 2-4 mg/kg is given over 15 to 20 min, followed by a maintenance dose of 3-5 mg/kg over 8 to 12 h; the total dose should not exceed 10 mg/kg in 24 h. Dexamethasone is the drug of choice for the preventon of delayed symptoms; it is used alone or with metoclopramide. Good symptom control is the best way to prevent antcipa- tory symptoms and the additon of diazepam to antemetc therapy is helpful because of its sedatve, anxiolytc and amnesic efects. Hyperuricaemia: Hyperuricaemia may complicate treat- ment of conditons such as non-Hodgkin’s lymphomas and leukaemia. Patents should be adequately hydrated and hyperuricaemia may be managed with allopurinol initated 24 h before cytotoxic treatment and contnued for 7 to 10 days aferwards. There is no drug treatment, but the conditon ofen reverses spontaneously once treatment has stopped. Alkylatng Drugs: Alkylatng drugs are among the most widely used drugs in cancer chemotherapy. Firstly, they afect gametogenesis and may cause permanent male sterility; in women, the reproductve span may be shortened by the onset of a premature meno- pause. Secondly, they are associated with a marked increase in the incidence of acute non-lymphocytc leukaemia, in partcular when combined with extensive radiaton therapy. Cyclophosphamide requires hepatc actvaton; it can there- fore be given orally and is not vesicant when given intrave- nously. Like all alkylatng drugs its major toxic efects are myelosuppression, alopecia, nausea and vomitng. It can also cause haemorrhagic cystts; an increased fuid intake for 24 to 48 h will help to avoid this complicaton. Cyclophosphamide is used either as part of treatment or as an adjuvant in Non- Hodgkin’s lymphomas, breast cancer, childhood leukaemia and ovarian cancer. However, severe widespread rash can develop and may progress to Stevens-Johnson syndrome or toxic epidermal necrolysis. Chlormethine (mustne) forms part of the regimen for treatment of advanced Hodgkin’s disease and malignant lymphomas. Its toxicity includes myelosuppression, severe nausea and vomitng, alopecia and thrombophlebits due to vesicant efect. Cytotoxic Antbiotcs: Bleomycin is used in regimens for the treatment of Hodgkin’s disease and testcular cancer. It has several antneoplastc drug toxicites; it is known to cause dose-related pneumonits and fbrosis which can be fatal and is associated with rare acute hypersensitvity reactons. It is used for acute leukaemias although other anthracyclines are more commonly used in these circumstances. The primary toxic efects are myelosuppression, alopecia, nausea, vomitng and dose-related cardiomyopathy. Antmetabolites and Related Therapy: Cytarabine is used in the treatment of acute leukaemia; chil- dren may tolerate high doses beter than adults. It causes myelosuppres- sion and the palmar-plantar syndrome (erythema and painful desquamaton of the hands and feet). It can be administered orally and myelosup- pression and nausea are the only important toxic efects. Methotrexate is used to treat a variety of malignancies and it plays a major role as an adjuvant for the treatment of breast cancer. Like 5-fuorouracil, methotrexate is myelotoxic, but nausea and vomitng are minimal. Calcium folinate is used to counteract the folate-antagonist acton of methotrexate and thus speeds recovery from meth- otrexate-induced mucosits or myelosuppression. Calcium folinate also enhances the efects of 5-fuorouracil when the two are used together for metastatc colorectal cancer. Vinca Alkaloids and Etoposide: The vinca alkaloids, vinblastne and vincristne, are prima- rily used in the treatment of acute leukaemias. Etoposide is an important component of the treatment of testcular carcinoma and is also used in several regimens for lung cancers and lymphomas. It causes myelosuppression and alopecia and it can cause hypotension during infusion. Other Antneoplastc Drugs: The enzyme asparaginase is an important component in the management of childhood leukaemia, but is not used in any other malignancy. Its toxicity profle is broad and the drug must be carefully administered because of the risk of anaphy- laxis.
The expression of personal preferences has included such items as line drawings (8 order 140 mg malegra fxt with mastercard, 34) cheap malegra fxt 140mg, food preferences (38 discount malegra fxt 140 mg on-line, 73 purchase malegra fxt 140mg otc, 95), ranking of camping equipment for a hypothetical trip (55, 56), and ranking men in order of desirability as President of the United States (108). Pictures that are subject to personal interpretation as the basis for composing a story (4), or unclear drawings that are named by the subject (88, 90, 131, 132, 133) comprise another type of problem. Making such judgments as the truthfulness of a person defending himself against charges of revealing a fictitious crime (25), the intelligence of people from photographs (49), the better one of two paintings (97), the driver at fault from a picture of an auto accident (129), or revealing of discrepancies in examination grades (93) constitute other tasks that have been used. Examples are requests for volunteers (9, 112, 113, 117) and for the endorsement of a petition (19); prohibitions, such as a poster forbidding entry to a building (45); a stoplight regulating pedestrian traffic (83); a sign prohibiting drinking from a fountain (78); a traffic light where turning signals are legal (5), or a command to stop a designated activity (53). The task involving the cutting of squares or other geometric forms under pressure from others to change the rate of production contains some elements of the direct request or prohibition stimulus (109, 110, 120). The first group includes the autokinetic problem (16, 21, 23, 30, 36, 42, 58, 69, 75, 79, 84, 85, 91, 101, 111, 121, 122, 124, 125, 130), estimation of the number of dots on a card or slide (37, 43, 74, 100), the number of beans in a jar (70), the length of rectangles (22, 65), the distance between rectangles (65), the length of lines (98, 102, 18), the length of a slot of light (11, 97), the distance traversed by a moving light (118), the number of flashes of light in a standard time interval (76, 77), the number of clicks of a metronome (18, 103, 105, 123), the weight of a series of standard objects (60), size estimation of unspecified objects (72), and recognition of simple visual objects (115). Discrimination tasks include judging which is the shorter of two lines (87, 89), whether there is an odor in a bottle of odorless water (28), and which square has the largest number of dots (74). Common information types of items (31, 126), and memory tasks (80, 113), have also been used. Framework or Social Background Properties of the situation other than stimulus materials and instructions for reacting to them contribute to the particular adjustment that occurs. The effect of context or framework in modifying the response that designated stimulus materials produce is well known -219- in sensory and perceptual research. The analogue of context or framework is often provided by the reactions of others to the same or comparable stimulus materials. Social background may vary from simple awareness of the reactions by others to direct efforts by others to exert influence on the critical subject. An example of the latter is the judging situation where others present give uniformly incorrect reports before the response of the critical subject. A response conforming to the social background provides an index of conformity, whereas a response consistent with the stimulus material provides an index of resistance to the influence exerted by others. Direct influence also is exerted in the situation requiring group members to agree on a single option from among a set of alternatives, with the influence usually exerted in the direction of converting the deviant member. For some of the studies the discrepancy is "spontaneous" or "natural" (28, 36, 52, 84, 111, 118, 121, 124, 125), e. The degree of convergence toward the responses of another person constitutes an index of conformity. In other experiments the reports of instructed subjects are controlled by the experimenter. Face-to-face and other methods of communicating the reports of others to the critical subject have been employed. He is given a fixed position in the sequence of responding, with responses of others prearranged by the experimenter (1, 3, 4, 6, 7, 11, 21, 23, 24, 30, 35, 38, 43, 48, 50, 51, 57, 58, 64, 69, 71, 75, 80, 87, 88, 89, 90, 91, 96, 97, 98, 100, 101, 102, 105, 107, 114, 115, 122, 126, 128). Incorrect ones may diverge from the correct or appropriate answer in varying amounts. Reports by others also may be at variance with one another, with some correct and others incorrect by varying degrees. In other situations, one instructed assistant engages in the designated action prior to the -220- subject and serves as a model for him (5, 19, 45, 53, 72, 78, 83, 86, 94, 95, 112, 113, 117, 130). A modification of the face-to-face situation is the simulation of a group through the use of tape recordings (10, 18, 20, 31, 61, 63, 91, 103, 106, 109, 110). A naive subject participates under the impression that he is a member of a group composed of several persons, each of whom, like himself, is alone in adjoining rooms. The subject hears the instructions of the experimenter, experiences the stimulus materials to be judged, and hears the responses by the others. He reacts at the proper time by writing his responses in the blank spaces left for his reports. Another variation of the basic face-to-face situation is one where several people are tested together, with partitions or booths separating them from one another. Each has a panel with a row of signal lights that record the responses of others (8, 34, 35, 71). The task is constant for all members, and usually consists of materials presented by slides projected on a wall so that all subjects can see them simultaneously. The experimenter controls the presumed responses of the other subjects through a master switchboard. All respond at the same time, with their responses recorded at the central control panel. Also used is the requirement for requesting or relinquishing pieces of a puzzle or game by one member when members exchange parts to complete the puzzle. The participant understands that he must complete his puzzle or task before the group goal is achieved. Then they interact by requesting necessary pieces from one another in order to finish. Both the Group Squares Puzzle (33) and a Bingo game (32) have been used in this manner. The experimenter is able to arrange the responses of "other" members to requests for pieces or parts. After a subject has correctly completed his individual task, he is subjected to pressures from some other member to yield a part so that someone else may complete a puzzle. The index of resistance to social pressure is the number of trials in which the subject refuses to yield. Influence without direct interaction is employed by the experimenter who communicates instructions to the subject on ways to change his performance so that he can contribute more appropriately -221- to the group task. This type of pressure has been applied in studies of slowdown in production of cutting paper objects (109), in utilizing information on an artillery problem (13), and in sending messages on telegraph keys (12). The experimenter either computes a norm actually representing the responses of members and reports it (22), or appears to compute a norm, but actually announces, according to a prearranged design, an incorrect norm for the reactions of the group (26, 49, 64, 66, 75, 77, 129, 131, 132, 133). The individual may be asked to indicate his position on a particular issue in private prior to the group discussion, at various points during its course or at the end of the discussion. Comparison of initial position with later positions provides a measure of susceptibility or resistance. Interaction in a group has been controlled through notes, ballots, or votes passed among members. Each participant writes notes to others in the group, which may be delivered so that "discussion" among members is uncontrolled (25, 41, 47). Under other conditions prearranged notes, ballots, or votes are substituted (40, 74, 116, 120, 127). Comparison of positions before and after exchange of notes provides an index of change. Properties of the Person Another set of factors associated with conformity inheres in the "state of the person" at a particular time. Such factors can be identified through reference to individual differences in previous experience, personality characteristics, or physiologic states. Contrasted with a novice, a specialist in dealing with a certain type of materials is more resistant to shifting. Individual differences in acceptance of conformity pressures related to properties of the person that have been investigated include experimentally created prior experiences, measures of physiologic states, and -222- indices of psychological experiences subsequent to behavior in the pressure situation. These experiences include differences in the degree of familiarity with the stimulus materials prior to the influence situation (49), differences in the characteristics of a prior task in which social influence has also been exerted (88, 90), experiences with other members, including cooperative efforts in which a response consistent with the false one reported by another in the situation is rewarded (76, 87, 90), individual experiences of success or failure (20, 58, 72, 75, 98, 100, 115), and experiences designed to increase insecurity (124) or decrease self-evaluation (119). One series of studies contrasted subjects of different ages (11, 38, 89); another compared men and women (25, 34, 79). Differences in physiologic states that have been evaluated include: degree of thirst (78); strength of food preferences (95); degree of sleep deprivation (42); and anxiety states as measured by degree of palmar sweat (64, 82). In several studies, it is impossible to determine whether the measure is regarded as a physiologic index or whether a physiologic difference represents a scale of psychological differences. Other measures used are checklists and ratings procedures (6, 11, 33, 34, 70), and clinical -223- diagnoses (36, 84, 125). Measures of originality have been constructed to determine individual differences in this dimension (8).