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Bias creeps in because of the wide- spread use of the reference as an indicator of the worth of journals (see citation index) cheap 25 mg dipyridamole overnight delivery xopenex arrhythmia. In order to keep their place in the league tables dipyridamole 25 mg arrhythmia practice strips, wise editors make sure that articles from their own journals are quoted discount dipyridamole online hypertension 3rd trimester. As for individual writers, they should consider the following prin- ciples. Do not write by collecting references into piles and then stringing them together into some kind of order (see leaf shuffling). By all means immerse yourself in the 110 REFERENCES literature before you start to write, but during the process of writing make sure that references are kept out of sight. As the author you are responsible for ensuring that the references you cite are accurate, and this means reading them in the original as well as tracking them back to their first appearance. It is unlikely that anyone important will check them, but there is an important matter of principle: how much value can we put on a system that prizes itself on its integrity when a major part is full of inaccuracies? Read carefully what the Instructions to Authors says, and look at how references are handled by your target journal. It will also show that you are taking part in a continuing discussion that has been going on in its pages. If the editor or the reviewer disagrees with your choice, then you can remedy that easily. This is providing supporting information; it is not a public exami- nation (see false feedback loop). When you have calmed down, learn from what 111 THE A–Z OF MEDICAL WRITING you have done. There is a good chance you will be able to get the work published elsewhere. If you are writing for magazines and newspapers, you will rarely have the luxury of detailed feedback, so examine the rejection letter carefully. The editor may have given you a clear reason, such as having a similar story already in the pipeline, or a judgement that the topic has run its course. Was it for technical inadequacies (in which case you should be able to take remedial action) or was it because the editor had other articles that he thought were more suitable for the readership (in which case you need to think of an alternative customer)? It is always tempting to do this, but consider how much work you have already done, and how much you are learning from the expe- rience, painful though it may be. Another tempting option: all you have to do is write an eloquent letter showing the editor why the decision was wrong, and it will be immediately reversed. With academic publications, however, there is the chance of appeal in certain circumstances. If the editor says that publication of your paper is not a priority then, as with the editors of magazines and newspapers, you must respect that decision (see fairness). However, if you believe that your article has been turned down because the reviewer has made an error and given bad advice, then you should consider an appeal. Under no circumstances should you just blank out the name of the first editor and send it off to another.

Alcohol and sleeping pills should with some of the drugs and may produce a sunburn-type be avoided because they may cause excessive drowsi- of skin reaction purchase generic dipyridamole pills blood pressure yeast infection. In hot weather or climates buy dipyridamole line heart attack in dogs, being taken by the client buy generic dipyridamole 25mg on line blood pressure xls, to decrease risks of undesir- keep the client indoors and use air conditioning or fans able drug interactions. Describe the nursing role in preventing, recog- use, adverse effects, principles of therapy, and nizing, and treating overdoses of antidepres- nursing process implications. Analyze important factors in using anti- uptake inhibitors with tricyclic antidepressants. Critical Thinking Scenario Betty McGrath, 73 years of age, was recently widowed. She depended on her husband to handle their finances, maintain their home, and make major decisions. McGrath seems to be losing weight, stays home most of the time, complains she feels very tired, and sleeps much more than usual. MOOD DISORDERS Etiology Mood disorders include depression, dysthymia, bipolar dis- Despite extensive study and identification of numerous po- order, and cyclothymia (Box 10–1). Depression is estimated tential contributory factors, the etiology of depression is un- to affect 5% to 10% of adults in the United States and to be clear. It is likely that depression results from interactions increasing in children and adolescents. Two of the major theories of impaired ability to function in usual activities and relation- depression pathogenesis are described below. The average depressive episode lasts about 5 months, and having one episode is a risk factor for developing another Monoamine Neurotransmitter Dysfunction episode. Depression and antidepressant drug therapy are em- phasized in this chapter; bipolar disorder and mood stabiliz- Depression is thought to result from a deficiency of norepi- ing drugs are also discussed. This hypothesis stemmed from 163 164 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM BOX 10–1 TYPES OF MOOD DISORDERS Depression Obsession with death, thoughts of suicide Depression, often described as the most common mental illness, is Psychotic symptoms, such as hallucinations and delusions characterized by depressed mood, feelings of sadness, or emo- Dysthymia tional upset, and it occurs in all age groups. Mild depression oc- Dysthymia involves a chronically depressed mood and at least curs in everyone as a normal response to life stresses and losses two other symptoms (eg, anorexia, overeating, insomnia, hyper- and usually does not require treatment; severe or major depression somnia, low energy, low self-esteem, poor concentration, feelings is a psychiatric illness and requires treatment. Although the symptoms may cause also is categorized as unipolar, in which people of usually normal significant social and work-related impairments, they are not moods experience recurrent episodes of depression. Mania is characterized by excessive CNS stim- criteria for a major depressive episode as a depressed mood plus ulation with physical and mental hyperactivity (eg, agitation, con- at least five of the following symptoms for at least 2 weeks: stant talking, constant movement, grandiose ideas, impulsiveness, Loss of energy, fatigue inflated self-esteem, little need for sleep, poor concentration, rac- Indecisiveness ing thoughts, short attention span) for at least one week. Symptoms Difficulty thinking and concentrating are similar to those of acute psychosis or schizophrenia. Hypoma- Loss of interest in appearance, work, and leisure and sexual nia involves the same symptoms, but they are less severe, indicate activities less CNS stimulation and hyperactivity, and last 3 or 4 days.

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Monophasic contraceptives contain fixed pituitary gland or the ovaries and may occur anytime amounts of both estrogen and progestin components cheap 100mg dipyridamole with visa hypertension causes. For example cheap 25mg dipyridamole otc blood pressure chart for tracking, in the adolescent girl Biphasics and triphasics contain either fixed amounts of with delayed sexual development cheap dipyridamole 25mg online blood pressure chart stroke, estrogen can be given estrogen and varied amounts of progestin or varied to produce the changes that normally occur at puberty. Biphasic and In the woman of reproductive age (approximately 12 to 412 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM 45 years of age), estrogens are occasionally used in the drugs decreased myocardial infarctions and deaths menstrual disorders, including amenorrhea and abnor- from cardiovascular disease. The difference was with a progestin, is used widely in the 12- to 45-year age attributed to decreased hormone production at meno- group to control fertility. The drugs are now recommended for short-term trogens are contraindicated because their use during use (eg, 2 years) to relieve menopausal symptoms, but not pregnancy has been associated with the occurrence of for long-term use for cardioprotective effects. A recent vaginal cancer in female offspring and possible harmful well-done study indicated that risks are greater than ben- effects on male offspring. Estrogens are prescribed to relieve symp- the part of the study concerned with estrogen replace- toms of estrogen deficiency (eg, atrophic vaginitis and ment only is scheduled to be completed in 2005. The early vasomotor instability, which produces hot flashes) part of the study did not indicate significantly increased and to prevent or treat osteoporosis. Such usage is usu- Progestins ally called estrogen replacement therapy (ERT) or HRT. In addition, ERT and HRT have been used long-term Progestins are most often used in combination with an estro- for cardioprotective effects because it was believed that gen in contraceptive products. They also are used to suppress BOX 28–2 HORMONE REPLACEMENT THERAPY IN POSTMENOPAUSAL WOMEN Background atively small, the investigators concluded that the drug combination For many years, postmenopausal women have been treated with produced more harm than benefit and should not be started or con- estrogen replacement therapy (ERT) to manage symptoms of tinued to prevent coronary heart disease (CHD) in healthy women. In addition, estrogen was thought to have cardio- the WHI study was done with healthy women, to see if the drugs protective effects, partly because the incidence of heart attacks in would prevent CHD from developing. The Heart and Estrogen/ women increased substantially after menopause and became sim- Progestin Replacement Studies, HERS and HERS II, involved ilar to the incidence in men. Several studies also indicated benefi- postmenopausal women with intact uteri who already had CHD. Because estrogen alone increases conclusion was that the hormones should not be started or contin- risks of endometrial cancer in women with an intact uterus, a pro- ued in women with CHD for preventive purposes. For individual women, the benefits in reducing symptoms of menopause, fractures from osteoporosis, and colon cancer must be Estrogen-Progestin Combinations weighed against the increased risks of CHD, thromboembolic Combined estrogen/progestin hormone replacement therapy be- stroke, venous thromboembolism, breast cancer, and cholecysti- came the standard of care for women with an intact uterus and was this. In 2002, the prevailing opinion changed dramatically to disease increase with the duration of drug use. If the combined indicate that combined estrogen/progestin therapy should not be drugs are prescribed to relieve menopausal symptoms in women used to prevent cardiovascular disease in healthy postmenopausal who have not had a hysterectomy, they should probably be used women, because risks were greater than benefits. This part of the study was stopped after an tion, estrogen is generally thought to have beneficial effects on average follow-up period of 5 years (8 years planned), because of a serum cholesterol and bone density.

With immunosuppression best order dipyridamole blood pressure medication with the least side effects, the malignant cells are no prine and a corticosteroid discount dipyridamole 100 mg with visa blood pressure medication used in pregnancy. A corticosteroid may not be re- longer destroyed and thus are allowed to proliferate purchase dipyridamole with visa blood pressure medication gives me a headache. The consequences of immunosuppression may be lessened • Cyclosporine should be used cautiously with immuno- by newer drugs that target specific components of the immune suppressants other than corticosteroids to decrease risks response rather than causing general suppression of multiple of excessive immunosuppression and its complications. However, there is apparently still some risk of • Methotrexate may be used alone or with cyclosporine for infection and malignancy. When Use in Transplantation co-administered with prednisone and azathioprine, the maximum daily dose of prednisone is 0. When muromonab- tinues to evolve as new drugs, combinations of drugs, and CD3 is co-administered with cyclosporine, cyclosporine other aspects are developed and tested. Specific protocols dosage should be reduced or the drug temporarily dis- vary among transplantation centers and types of transplants. If discontinued, cyclosporine is restarted As a general rule, immunosuppressant drugs used in trans- 3 days before completing the course of muromonab- plantation are often used in highly technical, complex cir- CD3 therapy, to resume a maintenance level of immuno- cumstances to manage life-threatening illness. CHAPTER 45 IMMUNOSUPPRESSANTS 683 • Mycophenolate is used with cyclosporine and a corti- • Dosage of mycophenolate, Muromonab-CD3, sirolimus, costeroid. An advantage of tacrolimus is that corticosteroid therapy can often be Drug Administration Schedules discontinued, with the concomitant elimination of the adverse effects associated with the long-term use of the effectiveness of immunosuppressant therapy may be en- corticosteroids. For ex- ample, corticosteroids are most effective when given just before exposure to the antigen, whereas the cytotoxic agents Dosage Factors (eg, azathioprine, methotrexate) are most effective when given soon after exposure (ie, during the interval between Immunosuppressant drugs are relatively toxic, and adverse ef- exposure to the antigen and the production of sensitized fects occur more often and are more severe with higher doses. The newer drugs, basiliximab and da- Thus, the general principle of using the smallest effective dose clizumab, are started a few hours before transplantation and for the shortest period of time is especially important with continued for a few doses afterward. Factors to be considered in drug dosage decisions include the following: Cardiac transplant recipients are usually given azathioprine, • Azathioprine dosage should be reduced or the drug dis- cyclosporine, and prednisone. Tacrolimus may be used in- continued if severe bone marrow depression occurs stead of cyclosporine. Because rejection reactions are more (eg, reduced red blood cells, WBCs, and platelets on likely to occur during the first 6 months after transplantation, complete blood count [CBC]). If it is necessary to stop transvenous endomyocardial biopsies are performed at regu- the drug, administration may be resumed at a smaller lar intervals up to a year, then as needed according to the dosage once the bone marrow has recovered. When given suppressive drug therapy, depending on the time interval since long-term for maintenance of immunosuppression, the the transplant surgery. For several days post-transplantation, lowest effective dose is recommended.