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Drug that increases effects of fluconazole: (1) Hydrochlorothiazide Increases serum levels of fluconazole buy viagra vigour 800 mg, attributed to decreased renal excretion c cheap viagra vigour 800mg visa. Drugs that decrease effects of fluconazole: (1) Cimetidine Decreased absorption (2) Rifampin Accelerated metabolism from enzyme induction d generic 800mg viagra vigour with amex. Drugs that decrease effects of itraconazole and ketoconazole: (1) Antacids discount viagra vigour 800mg without prescription, histamine H2 antagonists, proton pump These drugs decrease gastric acid, which inhibits absorption of inhibitors itraconazole and ketoconazole. If one of these drugs is required, it should be given at least 2 h after the azole drug. Drug that increases effects of caspofungin: (1) Cyclosporine Increases serum levels f. Drugs that decrease effects of caspofungin: (1) Enzyme inducers (efavirenz, nelfinavir, nevirapine, Decrease serum levels by accelerating caspofungin metabolism. Drugs that decrease effects of griseofulvin: (1) Enzyme inducers (eg, rifampin) Enzyme inducers inhibit effects of griseofulvin by increasing its rate of metabolism. Drug that increases effects of terbinafine: (1) Cimetidine Slows metabolism and elimination of terbinafine so that serum levels are increased i. Drug that decreases effects of terbinafine: (1) Rifampin Causes rapid clearance of terbinafine Nursing Notes: Apply Your Knowledge How Can You Avoid This Medication Error? Answer: Nystatin works topically to treat fungal infestation in the Answer: Amphotericin B is very nephrotoxic. Little when his BUN is 48 mg/dL and his creati- nystatin remains in contact with the oral mucosa for as long as pos- nine is 3. What signs and symptoms occur with candidiasis, and vasive fungal infections: Focus on IDSA guidelines. Which fungal infections often mimic other respiratory didemia: Epidemiology, resistance, and drug therapy. What are nursing interventions to decrease adverse effects 101(8), 40–48. What are the differences between amphotericin B deoxy- Philadelphia: Lippincott Williams & Wilkins. What are the clinical indications for use of oral antifungal of invasive aspergillosis in a transplant intensive care unit: Evidence of person-to-person airborne transmission. Effects Aspergillus species recovered from a hospital water system: A 3-year of the antifungal agents on oxidative drug metabolism: Clinical relevance. Antifungal chemoprophylaxis after blood and mar- dynamics: Review of the literature and clinical applications. Discuss the drugs used to treat Pneumocystis in prevention and recognition of selected para- carinii pneumonia in clients with acquired sitic diseases. Teach preventive interventions to clients infestations and pediculosis in school-age planning travel to a malarious area. Critical Thinking Scenario You are the school nurse in an elementary school. There is an outbreak of head lice in one of the fourth grade classrooms. You are responsible for identifying infested students and developing prevention programs. Appropriate infection control measures to prevent the spread of head lice to other children in the classroom or family members. OVERVIEW tions for the mentally retarded, homosexual and bisexual men, and residents or travelers in countries with poor sanitation. A parasite is a living organism that survives at the expense Amebiasis is caused by the pathogenic protozoan Enta- of another organism, called the host. The effects of par- is inactive and resistant to a number of factors, including asitic diseases on human hosts vary from minor to major drugs, heat, cold, and drying. Parasitic diseases in this chapter are outside the body for long periods.

Bulk-forming laxatives are the most physiologic laxatives because their effect is similar The stimulant cathartics are the strongest and most abused lax- to that of increased intake of dietary fiber purchase viagra vigour 800 mg on line. These drugs act by irritating the GI mucosa and within 12 to 24 hours purchase viagra vigour 800mg fast delivery, but may take as long as 2 to 3 days to pulling water into the bowel lumen purchase viagra vigour 800mg amex. These drugs should not be used frequently or longer than 1 week be- cause they may produce serum electrolyte and acid–base im- Surfactant Laxatives (Stool Softeners) balances (eg cheap 800mg viagra vigour otc, hypocalcemia, hypokalemia, metabolic acidosis or alkalosis). Surfactant laxatives (eg, docusate calcium, potassium, or Oral stimulant cathartics include bisacodyl, cascara sagrada, sodium) decrease the surface tension of the fecal mass to castor oil, and senna products. As a result, a single bedtime dose tergent to facilitate admixing of fat and water in the stool. These agents pository products include bisacodyl, which produces effects have little if any laxative effect. They usually act within ritant, stimulant effects, glycerin exerts hyperosmotic effects 1 to 3 days and should be taken daily. Saline Laxatives Lubricant Laxative Saline laxatives (eg, magnesium citrate, milk of magnesia) are not well absorbed from the intestine. Consequently, they Mineral oil is the only lubricant laxative used clinically. It lu- increase osmotic pressure in the intestinal lumen and cause bricates the fecal mass and slows colonic absorption of water water to be retained. Distention of the bowel leads to in- from the fecal mass, but the exact mechanism of action is un- creased peristalsis and decreased intestinal transit time for the known. These laxatives may cause several adverse effects and is not recommended are used when rapid bowel evacuation is needed. Mineral oil enemas are sometimes used to magnesium preparations, effects occur within 0. Saline laxatives are generally useful and safe for short- term treatment of constipation, cleansing the bowel prior to Miscellaneous Laxatives endoscopic examinations, and treating fecal impaction. How- ever, they are not safe for frequent or prolonged usage or for Lactulose is a disaccharide that is not absorbed from the GI certain patients because they may produce fluid and elec- tract. It exerts laxative effects by pulling water into the in- trolyte imbalances. It is used to treat constipation and hepatic function are at risk of developing hypermagnesemia with encephalopathy. The latter condition usually results from alco- magnesium-containing laxatives because some of the mag- holic liver disease in which ammonia accumulates and causes nesium is absorbed systemically. Ammonia is produced by metabolism of dietary CHAPTER 61 LAXATIVES AND CATHARTICS 885 Drugs at a Glance: Laxatives and Cathartics Routes and Dosage Ranges Generic/Trade Name Adults Children Bulk-forming Laxatives Methylcellulose (Citrucel) PO 1 heaping tbsp 1–3 times daily with water PO 1 level tbsp 1–3 times daily with water (4 oz) (8 oz or more) Polycarbophil (FiberCon, PO 1 g 4 times daily or PRN with 8 oz of fluid; 6–12 y: PO 500 mg 1–3 times daily or PRN; Mitrolan) maximum dose, 6 g/24 h maximum dose, 3 g/24 h 2–6 y: PO 500 mg 1 or 2 times daily or PRN; maximum dose, 1. Lactulose decreases production Indications for Use of ammonia in the intestine. The goal of treatment is usually to maintain two to three soft stools daily; effects usually occur Despite widespread abuse of laxatives and cathartics, there within 24 to 48 hours. The drug should be used cautiously be- are several rational indications for use: cause it may produce electrolyte imbalances and dehydration. To relieve constipation in pregnant women, elderly Sorbitol is a monosaccharide that pulls water into the in- clients whose abdominal and perineal muscles have testinal lumen and has laxative effects. It is often given with become weak and atrophied, children with megacolon, sodium polystyrene sulfonate (Kayexalate), a potassium- and clients receiving drugs that decrease intestinal removing resin used to treat hyperkalemia, to prevent consti- motility (eg, opioid analgesics, drugs with anticholin- pation and aid expulsion of the potassium–resin complex. To prevent straining at stool in clients with coronary Laxative Abuse artery disease (eg, postmyocardial infarction), hyper- tension, cerebrovascular disease, and hemorrhoids and Laxatives and cathartics are widely available on a nonpre- other rectal conditions scription basis and are among the most frequently abused 3. One reason for overuse is the common misconception diagnostic procedures (eg, colonoscopy, barium enema) that a daily bowel movement is necessary for health and well- 4. To accelerate elimination of potentially toxic substances being, even with little intake of food or fluids.

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Cigarette smoking is attributed as related cancer incidence and death purchase viagra vigour 800 mg visa, as well as the cause of 80% to 90% of lung cancer cases viagra vigour 800 mg, with other diseases such as cardiovascular and other the risk for lung cancer among smokers being 20 pulmonary diseases cheap 800 mg viagra vigour with amex, appears to be in smoking to 30 times that among non-smokers order viagra vigour 800mg otc. Other risk cessation and prevention of taking up the smok- factors include exposure to asbestos and radon. Asbestos exposure, known to cause malignant mesothelioma, increases the risk for lung cancer, CLASSIFICATIONS especially among smokers. There are limited data on molecular and genetic profile as a risk factor, Lung cancer consists of four major histological and familial predisposition to lung cancer. Despite the significant reduction in smoking, Because of the unique biological features of small- especially among the male population since the cell lung cancer (SCLC), its staging and treatment Textbook of Clinical Trials. Green  2004 John Wiley & Sons, Ltd ISBN: 0-471-98787-5 160 TEXTBOOK OF CLINICAL TRIALS differ radically from the other three types of lung the TNM staging. Besides histological classification, lung can- A staging system entirely different from that cer is also classified according to the Tumour, for NSCLC is used for patients with small-cell Node and Metastasis (TNM) staging and the carcinoma of the lung. The TNM is clinically categorised into two stages: limited staging system is applied primarily to NSCLC and extensive. Limited-stage SCLC is defined and consists of three components, each accord- as tumours confined to one hemithorax and its ing to primary tumour (T), nodal involvement regional lymph nodes that can be encompassed (N) and distant metastasis (M) as summarised in a tolerable irradiation field. The International Staging Classi- SCLC is defined as any extent of disease beyond fication summarised in Table 11. TNM staging Primary tumour (T) TX Tumour proven by the presence of malignant cells in bronchopulmonary secretions but not visualised roentgenographically or bronchoscopically, or any tumour that cannot be assessed as in a retreatment staging T0 No evidence of primary tumour Tis Carcinoma in situ T1 A tumour that is 3. At bronchoscopy, the proximal extent of demonstrable tumour must be within a lobar bronchus or at least 2. Any associated atelectasis or obstructive pneumonitis must involve less than an entire lung T3 A tumour of any size with direct extension into the chest wall (including superior sulcus tumours), diaphragm, or the mediastinal pleura or pericardium without involving the heart, great vessels, trachea, oesophagus or vertebral body, or a tumour in the main bronchus within 2 cm of the carina without involving the carina T4 A tumour of any size with invasion of the mediastinum or involving the heart, great vessels, trachea, oesophagus, vertebral body for carina or presence of malignant pleural effusion; a satellite nodule within the same lobe Nodal involvement (N) NX Regional lymph nodes cannot be assessed N0 No demonstrable metastasis to regional lymph nodes N1 Metastasis to lymph nodes in the peribronchial or the ipsilateral hilar region, or both, including direct extension N2 Metastasis to ipsilateral mediastinal lymph nodes and subcarinal lymph nodes N3 Metastasis to contralateral mediastinal lymph nodes, contralateral hilar lymph nodes, ipsilateral or contralateral scalene or supraclavicular lymph nodes Distant metastasis (M) M0 No distant metastasis M1 Distant metastasis, including pulmonary nodule not in the same lobe as the primary tumour RESPIRATORY CANCERS 161 Table 11. International Staging Classification for First, it has a more rapid clinical course and lung cancer natural history, with the rapid development of metastases, symptoms and eventually death. Left Five-year survival (%) untreated, the median survival time is typically Clinical Pathological 12–15 weeks for patients with local disease and Stage TNM subset stage stage 6–9 weeks for those with advanced disease. IA T1, N0, M0 61 67 Second, it exhibits features of neuroendocrine IB T2, N0, M0 38 57 differentiation in many patients, which may IIA T1, N1, M0 34 55 be distinguishable histopathologically and is IIB T2, N1, M0; T3, N0, 24 39 associated with paraneoplastic syndromes. Third, M0 unlike NSCLC, SCLC is exquisitely sensitive to IIIA T3, N1, M0; T1–3, N2, M0 both chemotherapy and radiotherapy, although IIIB T4, any N, M0; any 13 23 resistant disease often develops. T, N3, M0 Due to sensitivity of patients with SCLC to IV Any T, any N, M1 1 – chemotherapy, it can pose challenges in design of clinical trials for drug development as will be discussed in some detail. INCIDENCE In the year 2002, 1 284 900 new cases of invasive CLINICAL TRIALS IN LUNG CANCER cancer were expected in the United States, excluding carcinoma in situ of any site except Clinical trials have resulted in significant seminal the urinary bladder and also excluding basal and trials which have led to changes in the man- squamous cell cancers of the skin. Those seminal studies is estimated to account for 13% (169 400 cases) in screening, chemoprevention and treatment are of all new cancer cases, 14% (90 200) in males outlined. The annual age-adjusted incidence rate of lung SCREENING AND EARLY DETECTION cancer in the male population has been in a steady decline since its peak in the early 1980s. Three US randomised screening studies failed to However, that in the female population appears detect an impact of screening high-risk patients to be still increasing, although the rate of increase with chest radiographs or sputum cytology on has slowed in the late 1990s. How- mas, including lung cancer with a relative risk ever, it has not been determined whether there of 0. Treatment of locally advanced NSCLC is one TREATMENT: NON-SMALL-CELL of the most controversial issues in the manage- LUNG CANCER ment of lung cancer. Treatment options include surgery for less-advanced disease, or radiother- Treatment of NSCLC is dependent primarily on apy, either of which has been given with or stage of disease at the time of diagnosis and stage, without chemotherapy for control of micrometas- in turn, is dependent upon the size of the tumour tases. Interpretation of the results of clinical tri- (T), location of nodal involvement (N), if any, and als involving patients with locally advanced dis- presence or absence of distant metastases (M). The ease has been clouded by a number of issues, current TNM staging classification is shown in including changing diagnostic techniques, differ- Table 11. X-ray films, or multiple nodal level involvement), In approximately 20% of patients with medical to clearly inoperable stage IIIB disease. No role of adjuvant chemotherapy treatment for stage II and selected IIIA NSCLC for stage I NSCLC has been identified. However, many of these patients will relapse, prompting numer- Chemoprevention: Patients with a resected stage ous trials evaluating the role of post-operative I NSCLC are at high risk of approximately 1% radiotherapy or chemotherapy.

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