Therefore symptoms enlarged spleen order duphalac cheap, to increase the stability priate formulative and packaging steps are of an emulsion treatment resistant schizophrenia order discount duphalac on-line, the globule or particle size usually taken to minimize such hazards to should be reduced as fine as is practically stability treatment junctional rhythm generic 100ml duphalac fast delivery. For light-sensitive emulsions treatment group purchase generic duphalac, light possible symptoms whiplash purchase duphalac in united states online, the density difference between the resistant containers are used medicine naproxen buy duphalac 100 ml. For emulsions internal and external phases should be mini susceptible to oxidative decomposition medicine ubrania discount duphalac 100 ml visa, anti mal treatment qt prolongation buy 100ml duphalac, and the viscosity of the external phase oxidants may be included in the formula should be reasonably high. Thickeners such tion and adequate label warning provided as tragacanth and microcrystalline cellulose to ensure that the container is tightly closed are frequently added to emulsions to increase to air after each use. Upward and bacteria can decompose the emulsify creaming takes place in unstable emulsions ing agent, disrupting the system. Even if the of the o/w or the w/o type in which the emulsifier is not affected by the microbes, internal phase has a lesser density than the the product can be rendered unsightly external phase. Downward creaming takes by their presence and growth and will of place in unstable emulsions in which the course not be efficacious from a pharma opposite is true. Because More destructive to an emulsion than fungi (molds and yeasts) are more likely to creaming is coalescence of the globules of the contaminate emulsions than are bacteria, internal phase and separation of that phase fungistatic preservatives, commonly combi into a layer. Separation of the internal phase nations of methylparaben and propylpara from the emulsion is called breaking, and ben, are generally included in the aqueous the emulsion is described as being cracked phase of an o/w emulsion. This is irreversible, because the amount of 12% to 15% based on the external protective sheath about the globules of the phase volume is frequently added to oral internal phase no longer exists. Mineral oil 500 mL Generally, for an emulsion containing about Acacia (finely powdered) 125 g two-thirds oil, the adult dose is 45 mL, about Syrup 100 mL 3 tablespoonsful. For children 2 to 6 years of Vanillin 40 mg age, 15 mL is usually sufficient, and for chil dren less than 2 years of age, 5 mL may be Alcohol 60 mL given. Castor oil is best taken on an empty Purified water, to make 1, 000 mL stomach, followed with one full glass of water. It is prepared by the dry gum method Simethicone Emulsion (4:2:1), mixing the oil with the acacia and adding 250 mL of purified water all at once to Simethicone emulsion is a water-dispersible make the primary emulsion. To this is slowly form of simethicone used as a defoaming added with trituration the remainder of the agent for the relief of painful symptoms of ingredients, with the vanillin dissolved in the excessive gas in the gastrointestinal tract. A substitute flavorant for the vanil Simethicone emulsion works in the stom lin, a substitute preservative for the alcohol, ach and intestines by changing the surface a substitute emulsifying agent for the acacia, tension of gas bubbles, enabling them to and an alternative method of emulsification coalesce, freeing the gas for easier elimina may be used as desired. The emulsion in drop form is useful for the emulsion is employed as a lubricat relief of gas in infants due to colic, air swal ing cathartic with a usual dose of 30 mL. The commer the usual dose of plain (unemulsified) min cial product (Mylicon Drops, AstraZeneca) eral oil for the same purpose is 15 mL. There are a number of com & Johnson Merck) as a therapeutic adjunct to mercial preparations of emulsified oil, with relieve the discomfort of gas. A lotion Castor Oil Emulsion is an emulsion liquid dosage form applied Castor oil emulsion is used as a laxative for to the outer surface of the body. Historically, isolated occurrences of constipation and in this term has also been applied to suspen preparation of the colon for radiographic and sions and solutions. The castor oil in the emulsions, or lotions, are used therapeu emulsion works directly on the small intestine tically to deliver a drug systemically. This and other example is Estrasorb (estradiol, Graceway), laxatives should not be used regularly or exces which contains estradiol for use in the treat sively, as they can lead to dependence for bowel ment of hot flashes and night sweats accom movement. It works by replacing excessive loss of water and body electrolytes, the hormones lost during menopause. It may contain an active phar descriptive, a prefix such as hydro for water maceutical ingredient intended for topical (hydrosol) or alco for alcohol (alcosol) may be application to the scalp. Gels are defined as semisolid systems consist Although there is no precise point at ing of dispersions made up of either small which the size of a particle in a dispersion inorganic particles or large organic molecules can be considered to be colloidal, there is a enclosing and interpenetrated by a liquid. A substance Gels are also defined as semirigid sys is said to be colloidal when its particles fall tems in which the movement of the dispers between 1 nm and 0. Colloidal particles ing medium is restricted by an interlacing are usually larger than atoms, ions, or mol three-dimensional network of particles or ecules and, generally, consist of aggregates of solvated macromolecules of the dispersed many molecules, although in certain proteins phase. A high degree of physical or chemical and organic polymers, single large molecules cross-linking may be involved. The increased may be of colloidal dimension and form col viscosity caused by the interlacing and conse loidal dispersions. One difference between quential internal friction is responsible for the colloidal dispersions and true solutions is the semisolid state. A gel may consist of twisted larger particle size of the disperse phase of matted strands often wound together by the colloidal dispersion. Another difference stronger types of van der Waals forces to form is the optical properties of the two systems. This turbidity is eas ents may not be completely molecularly dis ily seen, even with dilute preparations, when persed (soluble or insoluble), or they may the dispersion is observed at right angles to form aggregates, which disperse light. The a beam of light passed through the disper concentration of the gelling agents is mostly sion (Tyndall effect). When the gel mass consists of rations are opaque, depending on the con floccules of small, distinct particles, the gel is centration of the disperse phase. Also, the classified as a two-phase system and frequently particle size of the dispersed phase in some called a magma or a milk. Gels and magmas are pharmaceutical preparations is not uniform, considered colloidal dispersions because they and a preparation may contain particles contain particles of colloidal dimension. Many of the various types of colloidal disper Particle size is not the only important cri sions have been given appropriate names. The attraction or lack of attraction for a period of time, a phenomenon known between the disperse phase and the disper as thixotropy. When these are terminology has been developed to char added to the dispersing phase, there is little acterize the various degrees of attraction if any interaction between the two phases. Unlike lyophilic colloids, lyophobic materials If the disperse phase interacts appreciably do not spontaneously disperse but must be with the dispersion medium, it is said to encouraged to do so by special individualized be lyophilic, meaning solvent loving. Their addition to the dispersion degree of attraction is small, the colloid is medium does not greatly affect the viscos termed lyophobic, or solvent hating. Amphiphilic colloids form terms are more suitably used when reference dispersions in both aqueous and nonaqueous is made to the specific dispersion medium, media. Depending on their individual charac for a single substance may be lyophobic with ter and the nature of the dispersion medium, respect to one dispersion medium and lyo they may or may not become greatly solvated. For instance, However, they generally increase the viscos starch is lyophilic in water but lyophobic in ity of the dispersion medium with an increase alcohol. The various preparations composed or lack of attraction of the substance specifi of colloidal dispersions are prepared not cally to water. Generally speaking, because according to any general method but accord of the attraction to the solvent of lyophilic ing to the means best suited to the individ substances in contrast to the lack of attrac ual preparation. Some substances, such as tion of lyophobic substances, lyophilic col acacia, are termed natural colloids because loidal systems are easier to prepare and have they are self-dispersing upon addition to greater stability. Other materials that termed an association or amphiphilic colloid, is require special means for prompt dispersion formed by grouping or association of mole are termed artificial colloids. They may require cules that exhibit both lyophilic and lyopho fine pulverization of coarse particles to col bic properties. These substances disperse readily upon addition to the dispersion medium to form Terminology related to Gels colloidal dispersions. As more molecules of the substance are added to the sol, the vis A number of terms are commonly used cosity characteristically increases, and when in discussing some of the characteris the concentration of molecules is sufficiently tics of gels, including imbibition, swell high, the liquid sol may become a semisolid ing, syneresis, thixotropy, and xerogel. Gels owe Imbibition is the taking up of a certain their rigidity to an intertwining network of amount of liquid without a measurable the disperse phase that entraps and holds the increase in volume. A change in tempera up of a liquid by a gel with an increase in ture can cause certain gels to resume the sol volume. Syneresis occurs when the inter in volume or temperature, a type of non action between particles of the dispersed Newtonian flow. A xerogel is formed when phase becomes so great that on standing, the liquid is removed from a gel and only the dispersing medium is squeezed out in the framework remains. Syneresis is a gelatin sheets, tragacanth ribbons, and aca form of instability in aqueous and nonaque cia tears. Separation of a solvent phase is thought to occur because of the elastic con classification and Types of Gels traction of the polymeric molecules; in the swelling process during gel formation, the Table 14. Most inorganic hydrogels are two macromolecules is balanced by the swelling phase systems, such as aluminum hydroxide forces, determined by the osmotic pressure. Bentonite has also If the osmotic pressure decreases, as on cool been used as an ointment base in about 10% ing, water may be squeezed out of the gel. Most organic gels are the syneresis of an acidic gel from Plantago single-phase systems and may include such albicans seed gum may be decreased by the gelling agents as carbomer and tragacanth addition of electrolyte, glucose, and sucrose and those that contain an organic liquid, such and by increasing the gum concentration. At low pH, marked syneresis gels into hydrogels and organogels with occurs, possibly as a result of suppression some additional subcategories. Hydrogels of ionization of the carboxylic acid groups, include ingredients that are dispersible as loss of hydrating water, and the formation colloidals or soluble in water; they include of intramolecular hydrogen bonds. This organic hydrogels, natural and synthetic would reduce the attraction of the sol gums, and inorganic hydrogels. Sodium alginate has been pared by freshly precipitating the disperse used to produce gels that can be employed phase to achieve a fine degree of subdivision as ointment bases. The desired gelatinous pre a firm gel, stable between pH 5 and 10, is cipitate results when solutions of inorganic formed. As the commercial cellulose products used in oint microcrystalline particles of the precipi ments. They are available in various viscos tate develop, they strongly attract water to ity types, usually high, medium, and low. Included in by directly hydrating the inorganic chemi the hydrocarbon type is Jelene, or Plastibase, cal, which produces the disperse phase of the a combination of mineral oils and heavy dispersion. In addition to the water vehicle, hydrocarbon waxes with a molecular weight other agents as propylene glycol, propyl gal of about 1, 300. Petrolatum is a semisolid gel late, and hydroxypropyl cellulose may be consisting of a liquid component together used to enhance gel formation. The crystalline fraction pro between the disperse phase and the aque vides rigidity to the structure, while the ous medium in both magmas and gels, these protosubstance, or gel former, stabilizes the preparations remain fairly uniform on stand system and thickens the gel. They are soluble but the uniformity of the preparation is eas to about 75% in water and are completely ily reestablished by moderate shaking. Jellies should be shaken before use, and a statement are a class of gels in which the structural to that effect must be included on the label coherent matrix contains a high proportion of such preparations. They usually are and gels are used orally for the value of the formed by adding a thickening agent such as disperse phase. The examples of Gelling agents resultant product is usually clear and uni formly semisolid. Jellies should stearyl alcohol, colloidal silicon dioxide, be stored with tight closure because water ethylcellulose, gelatin, guar gum, hydroxy may evaporate, drying out the product. A pulverization to colloidal size with a colloid few of the more common ones are discussed mill or a micropulverizer. Maximum viscosity white to yellowish-white colored fibrous and clarity occur at pH 7, but acceptable vis powder. Cross-linking in aqueous systems, although other liquids with increased viscosity occurs upon the can be used. In water, a single particle of car addition of a calcium salt, such as calcium bomer will wet very rapidly, but like many citrate. Alginic acid can be dispersed in water other powders, carbomer polymers tend to vigorously stirred for approximately 30 min form clumps of particles when haphazardly utes. When this occurs, the slow diffu Carbomer (Carbopol) resins, first described sion of solvent through this solvated layer in the literature in 1955, are ingredients determines the mixing or hydration time. To in a variety of dosage systems, including achieve fastest dispersion of the carbomer, it controlled-release tablets, oral suspensions, is wise to take advantage of the very small and topical gels. They are fluffy device, like a simple sieve, that can sprinkle white dry powders with large bulk density. A neutralizer is added to thicken the gel Carbomer 934 is highly effective in thick after the carbomer is dispersed. Carbomer hydroxide or potassium hydroxide can be 934P is similar to 934 but is intended for oral used in carbomer dispersions containing and mucosal contact applications and is the <20% alcohol. Triethanolamine will neutral most widely used in the pharmaceutical ize carbomer resins containing up to 50% industry. Other neutralizer agents include ing, and emulsifying in both oral and topi sodium carbonate, ammonia, and borax. It is the most most stable at pH 2 to 10, and maximum sta efficient of all the Carbopol resins and has bility is at pH 7 to 9. An increase in the concentration of be dispersed with high shear in cold water carbomer may be required to overcome the before the particles can hydrate and swell to loss of viscosity. Generally, a maximum of 3% electrolytes tion is heated with moderate shear to about can be added before a rubbery mass forms. The viscos their viscosity, ultimately precipitating the ity of the product falls markedly below pH 5 polymer. Plastibase, or Jelene, is a mixture of 5% low Colloidal silicon dioxide can be used with molecular weight polyethylene and 95% other ingredients of similar refractive index mineral oil. Changes in pH is immobilized in the network of entangled may affect the viscosity: It is most effective at and adhering insoluble polyethylene chains, pH values up to about 7. Colloidal silicon which probably even associate into small dioxide (fumed silica) will form a gel when crystalline regions. Aqueous solutions of poloxamers gelatin with about three to five parts of an are stable in the presence of acids, alkalis, organic liquid that will not swell the poly and metal ions. Commonly used poloxam mer, such as ethyl alcohol or propylene gly ers include the 124 (L-44 grade), 188 (F-68 col, followed by the addition of the hot water grade), 237 (F-87 grade), 338 (F-108 grade), and cooling. Pluronic F-127 has low toxicity and good sol Methylcellulose is a long-chain substituted ubilizing capacity and optical properties, and cellulose that can be used to form gels in con it is a good medium for topical drug delivery centrations up to about 5%. Maximum clarity, full can be used to prepare gels in concentrations est hydration, and highest viscosity will be up to about 10%. If the preparation is other by secondary valency forces, and even acidic, benzoic acid may be used. Cross-linking of dissolved poly centrations will raise viscosity to the point of mer molecules also causes these solutions to salting out the sodium alginate; this occurs at gel. Tragacanth gum has been used to prepare Secondary valence forces are responsible for gels that are most stable at pH 4 to 8. The gelation temperature or gel point of gelatin is highest at the iso Gel Formulation considerations electric point. Water-soluble polymers have In a gel preparation, the powdered polymers, the property of thermal gelation, that is, they when added to water, may form temporary gel on heating, whereas natural gums gel on gels that slow dissolution. The thermal gelation is reversed on into these loose clumps of powder, their exte cooling. The globs or water in a gel and cause gelation at lower clumps of gel dissolve very slowly because concentrations. This is usually reversible; of their high viscosity and the low diffusion upon addition of water, the gels will reform. Because alcohol is not a solvent or precipitant, As a hot colloidal dispersion of gelatin it may cause precipitation or gelation, lower cools, the gelatin macromolecules lose kinetic ing the dielectric constant of the medium and energy. With reduced kinetic energy, or ther tending to dehydrate the hydrophilic solute. The Phase separation by adding alcohol may size of these association chains increases to cause coacervation. Gums, full hydration and maximum viscosity and such as agar, Irish moss, algin, pectin, and clarity. After bentonite peeling, and is effective in the treatment of magma has been allowed to stand undis acne. The process topical gel (Benzamycin Topical Gel, Dermik may be repeated indefinitely. As mentioned Laboratories), clindamycin topical gel (Cleocin earlier, this phenomenon is termed thixotropy, T Topical Gel, Pfizer), clindamycin and ben and bentonite magma is a thixotropic gel. The zoyl peroxide topical gel (BenzaClin, Dermik), thixotropy occurs only when the bentonite and benzoyl peroxide gel (Desquam-X 10 Gel, concentration is somewhat above 4%. Westwood-Squibb) used in the control and Bentonite magma is employed as a sus treatment of acne vulgaris; hydroquinone gel pending agent. Furthermore, because the suspend W Gel, Medtech), a keratolytic; and desox ing capacity of the magma is drastically imetasone gel (Topicort Gel, Taro) and aug reduced if the pH is lowered to about pH 7, mented betamethasone dipropionate topical another suspending agent should be selected gel (Diprolene, Schering-Plough), anti-inflam for drugs requiring a less alkaline medium matory and antipruritic agents.
In addition symptoms 5 days before your missed period safe duphalac 100 ml, the discard date treatment medical abbreviation discount duphalac 100ml amex, the need to shake the bottle and additional British National Form ulary w arnings w ould be highlighted symptoms melanoma order duphalac 100 ml on-line. W hich of the follow ing suspending agents w ould be unsuitable for use for a suspension intended for the oral route of adm inistration You are asked to prepare 100 m l of an unof cial suspension w ith a dose statem ent 15 m l tds ex aq medicine naproxen 500mg order duphalac now. In the dispensary you have a suspension that contains 120 m g of paracetam ol in each 5 m l spoonful medicine used for anxiety discount duphalac 100ml otc. How m uch suspension w ould you need to dispense 7 medications emts can give discount duphalac 100 ml line, to the nearest 100 m l symptoms xanax addiction buy 100ml duphalac amex, for a 2-w eek supply You are asked to prepare 150 m l of a suspension containing an indiffusible solid symptoms xylene poisoning generic 100ml duphalac with mastercard. Suspensions containing a suspending agent do not need a direction to shake the bottle. The am ount of suspending agent used depends on the am ount of pow der to be suspended. Diffusible suspensions contain an insoluble pow der that is light and easily w ettable. Adding a thickening agent to increase viscosity is the sim plest w ay to ensure uniform ity of dose in a suspension. Suspensions 63 Form ulation questions this section contains details of extem poraneous products to be m ade in the sam e w ay as the exam ples earlier in this chapter. You receive a prescription in your pharm acy w ith the follow ing details: Patient: Mr Edward Smith, 145 Oak Street, Astonbury Age: 57 Prescription: Ft Lotion Zinc Oxide 25% Puri ed Talc 25% Glycerin 5% Suspending Agent qs Water to 100% Directions: Apply prn for itching M itte: 50 ml chapter 4 Emulsions Overview Upon com pletion of this chapter, you should be able to: understand how to calculate the quantities of ingredients required to make a primary emulsion prepare an emulsion from rst principles select an appropriate container in which to package an emulsion prepare an appropriate label for an emulsion. Em ulsion form ulations for external use are alw ays given a different title that re ects their use. De nition An emulsion is essentially a liquid preparation containing a mixture of oil and water that is rendered homogeneous by the addition of an emulsifying agent. The emulsifying agent ensures that the oil phase is nely dispersed throughout the water as minute Oil (disperse phase) globules (Figure 4. The oily phase Water (continuous phase) (disperse phase) is dispersed through the aqueous phase Figure 4. They are stabilised but these tend to be those with oil-in-w ater dispersions, either or both phases external uses. Solids 65 66 Pharmaceutical Compounding and Dispensing KeyPoints m ay also be suspended in oral em ulsions. When issued for use, oral em ulsions should Advantages and disadvantages of em ulsions as dosage form s be supplied in w ide-m outhed bottles. Advantages Unpalatable oils can be Extem poraneous preparation administered in palatable form. In oral em ulsions prepared according Unpalatable oil-soluble drugs to the form ula and directions given for can be administered in extem poraneous preparation, the quantity palatable form. It is possible to include two incompatible ingredients, one in Stability of em ulsions each phase of the emulsion. Disadvantages Em ulsions can break dow n in the follow ing Preparation needs to be shaken w ays: well before use. This is the term applied w hen the disperse Bulky, dif cult to transport and phase coalesces and form s a separate layer. Redispersion cannot be achieved by shaking Liable to microbial and the preparation is no longer an em ulsion. The acid form ed denatures the em ulsifying agent, causing the tw o phases to separate. Cream ing In cream ing, the oil separates out, form ing a layer on top of the em ulsion, but it usually rem ains in globules so that it can be redispersed on shaking. This is undesirable as the product appearance is poor and if the product is not adequately shaken there is a risk of the patient obtaining an incorrect dose. Cream ing is less likely to occur if the viscosity of the continuous phase is increased. Phase inversion this is the process w hen an oil-in-w ater em ulsion changes to a w ater-in-oil em ulsion or vice versa. If the disperse phase KeyPoints exceeds this, the stability of the em ulsion Sum m ary of the problem s is questionable. As the concentration of the encountered by em ulsions disperse phase approaches a theoretical m axim um of 74% of the total volum e, phase Cream ing inversion is m ore likely to occur. Separation of the emulsion into two regions, one containing more of the disperse phase. Sum m ary of the problem s encountered Possible reasons for problem by em ulsions lack of stability of the system. Cracking the theory of em ulsi cation is based on the globules of the disperse phase the study of the m ost naturally occurring coalesce and there is separation of em ulsion, m ilk. If exam ined closely, m ilk the disperse phase into a separate w ill be seen to consist of fatty globules, layer. When a pharm aceutical em ulsion incompatible emulsifying agent is m ade, the principal considerations are the decomposition of the emulsifying agent sam. As w ith other liquid preparations Phase inversion for oral use, em ulsions w ill have in the From oil-in-water to water-in-oil or from water-in-oil to oil-in-water. There amount of disperse phase is also the need for a preservative, w hich is greater than 74%. In addition an the emulsion will not reform on em ulsion w ill also need an em ulsifying agent shaking. The only differences betw een the continental and dry gum m ethods are the proportions 68 Pharmaceutical Compounding and Dispensing of constituents w ithin the prim ary em ulsion (for exam ple, xed-oil em ulsions m ade by the continental m ethod w ould use a ratio of 4:3:2 rather than 4:2:1 w ith the dry gum m ethod). Internal em ulsions prepared by the dry gum m ethod should contain, in addition to the oil to be em ulsi ed: a vehicle Freshly boiled and cooled puri ed w ater is norm ally used because of the increased risk from m icrobial contam ination. Oils can be divided into three categories: xed oils, m ineral oils and volatile oils. Fixed oils Oil: 4 parts by volum e Aqueous phase: 2 parts by volum e Gum: 1 part by w eight M ineral oils Oil: 3 parts by volum e Aqueous phase: 2 parts by volum e Gum: 1 part by w eight Volatile (arom atic) oils Oil: 2 parts by volum e Aqueous phase: 2 parts by volum e Gum: 1 part by w eight these proportions are im portant w hen m aking the prim ary em ulsion, to prevent the em ulsion breaking dow n on dilution or storage. Emulsions 69 the quantities for prim ary em ulsions (in KeyPoints parts) are sum m arised in the key points box. The ratio of oily phase to aqueous phase to gum in a W et gum m ethod prim ary em ulsion the proportions of oil, w ater and em ulsifying agent for the preparation of the prim ary Type Oil Aqueous Gum em ulsion are the sam e as those used in the of oil Fixed 4 2 1 dry gum m ethod. Volatile 2 2 1 Using this m ethod the acacia pow der is added to the m ortar and then triturated w ith the w ater until the gum is dissolved and a Tips m ucilage form ed. The oil is then added to the m ucilage drop by drop w hilst triturating Accurate weighing and continuously. When nearly all the oil has m easuring of the com ponents in the prim ary em ulsion are been added the resulting m ixture in the im portant when m aking the m ortar m ay appear a little poor w ith som e prim ary em ulsion to prevent of the oil appearing to be absorbed. This can the em ulsion breaking down on be recti ed by the addition of slightly m ore storage or dilution. The trituration continues until all the oil has been added, adding extra sm all am ounts of w ater w hen necessary. When all the oil has been added triturate until a sm ooth prim ary em ulsion is obtained. In the m ain, this m ethod has fallen out of favour as it takes m uch longer than the dry KeyPoints gum m ethod. It should be noted that there is less chance of failure w ith this m ethod Clean, dry equipm ent provided the oil is added very slow ly and All equipment should be thoroughly in sm all quantities. It also m eans that the cleaned, rinsed with water and carefully dried before use, reasons for failure w hen using the dry particularly measures, mortars and gum m ethod (outlined above) have been pestles. Accurate quantities General m ethod of preparation of an Accurate quantities are essential. Have all ingredients ready Correct rate of addition is the preparation of an em ulsion has tw o m ain important. Transfer the oil into a large dry porcelain m ortar, allow ing all the oil to drain out. Caution: overm ixing generates heat, w hich m ay denature the em ulsifying agent and result in a poor product. When the product becom es w hite and produces a clicking sound, the prim ary em ulsion has been form ed. Dilute the prim ary em ulsion drop by drop w ith very sm all volum es of the rem aining aqueous vehicle. As a prophylactic against rickets, the dose of Cod Liver Oil is not m ore than 10 m l/day, allow ance being m ade for vitam in D obtained from other sources (British Pharm aceutical Codex 1973, p 124). The dose of this product on the prescription is 10 m l three tim es a day, giving a total daily dose of 30 m l. As the product w ill contain 30% cod liver oil, this gives a dose of (30 100) 30 = 9 m l cod liver oil per day. Calculation of form ula for preparation Prepare 200 m l of Cod Liver Oil 30% em ulsion. The follow ing m ethod w ould be used to prepare 200 m l of Cod Liver Oil 30% em ulsion from the form ula above: 1. Visually check that no undissolved Tips chloroform rem ains at the bottom of Rem em ber the accurate the m easure. Stir vigorously with the pestle in to ensure that there is no heat one direction only until the prim ary production that may denature the em ulsion is form ed. Stir and transfer to an am ber at emulsion until it is pourable to m edical bottle, label and dispense to ensure that the primary emulsion the patient. Choice of container Step 12: Even though there is a A plain am ber bottle w ith a child-resistant preservative in the preparation, freshly boiled and cooled puri ed closure w ould be m ost suitable as the water is used here as emulsions preparation is an em ulsion for internal are particularly susceptible to use. Advice to patient the patient w ould be advised to take tw o 5 m l spoonfuls three tim es a day before food. Calogen is an em ulsion for disease-related m alnutrition and m alabsorption states and contains arachis oil at a concentration of 50% (British National Form ulary 51st edn, p 801). Before deciding the form ula for the em ulsion, the type and quantity of avouring m ust be decided upon. The dose of the em ulsion is 15 m l bd w hich m eans each individual dose is 15 m l, therefore in 150 m l there w ould be 10 doses. Therefore: the am ount of freshly boiled and cooled puri ed w ater needed = 2 15 m l = 30 m l. Solubility w here applicable Not applicable as no solids w ill need to be dissolved during the preparation of this product. Flavouring w hen appropriate the prescriber has requested that the em ulsion is avoured w ith pepperm int avouring. Add approxim ately 90 m l of freshly boiled and cooled puri ed w ater to a 100 m l conical m easure. Stir gently and then accurately m ake up to volum e w ith freshly boiled and cooled puri ed w ater. Stir vigorously with the pestle in em ulsion is crucial for the full one direction only until the prim ary em ulsion to be satisfactorily em ulsion is form ed. Stir and transfer to an am ber at m edical bottle, label and dispense to the patient. Choice of container A plain am ber bottle with a child-resistant closure would be m ost suitable as the preparation is an em ulsion for internal use. Quantitative particulars Quantitative particulars are required as the product is unof cial. Advice to patient the patient w ould be advised to take three 5 m l spoonfuls tw ice a day. Use of the product Used as a laxative to treat constipation (British National Form ulary 51st edn, p 61). The prescription requests 15 m l of a 15% em ulsion to be taken three tim es a day. This dose is lower than the reference dose, but con rm ation of the condition of the patient (for exam ple, the patient m ay be elderly or in rm) and/ or the condition being treated (for exam ple, the product m ay be prescribed to treat m ild constipation) will indicate whether the 80 Pharmaceutical Compounding and Dispensing product is safe and suitable for the intended purpose. Therefore: the am ount of freshly boiled and cooled puri ed w ater needed = 2 10 = 20 m l. Stir gently and then accurately m ake Tips up to volum e w ith freshly boiled and Rem em ber the accurate cooled puri ed w ater. Visually check that no undissolved em ulsion is crucial for the full chloroform rem ains at the bottom of em ulsion to be satisfactorily the m easure. Stir vigorously w ith the pestle in one direction only until the prim ary em ulsion is form ed. Advice to patient the patient w ould be advised to take three 5 m l spoonfuls three tim es a day. In addition, the discard date and the need to shake the bottle w ould be highlighted to the patient. Therefore, the product and dose are suitable and suitable for the intended purpose. Solubility w here applicable As the m ethod for preparation is given in the British Pharm acopoeia for this product, it is not necessary to check each individual solubility. Vehicle/diluent As em ulsions are particularly susceptible to m icrobial contam ination, freshly boiled and cooled puri ed w ater w ill be used as per the product form ula. Add suf cient freshly boiled and cooled puri ed w ater in the form of ice to produce 35 m l and stir. Add this solution to the previously more soluble in organic solvents so is added to the chloroform prepared m ethylcellulose m ucilage containing mixture. M ake the volum e of the m ucilage accurately weighed, therefore m ixture up to 50 m l w ith freshly a trituration m ust be prepared. Pass through a hom ogeniser to m ake Therefore 5 ml of the trituration will the em ulsion m ore stable. Tips the stability of an emulsion is increased with smaller globule size of the disperse phase. Although many extemporaneously s prepared emulsions may not require the use of a homogeniser, this step may aid in retarding or preventing creaming of the emulsion on long standing. Choice of container A plain am ber bottle w ith a child-resistant closure w ould be m ost suitable as the preparation is an em ulsion for internal use. Discard date the product is an em ulsion and so w ill attract a 4-w eek discard date. Shake the bottle Do not use after (4 weeks) Mrs Daisy Marlow Date of dispensing 7. Advice to patient the patient w ould be advised to take tw o 5 m l spoonfuls three tim es a day. W hy is freshly boiled and cooled puri ed w ater used w hen preparing oral em ulsions Fill out the follow ing table: Proportion in prim ary em ulsion Type of oil Oil Aqueous Gum Fixed oil Volatile oil Mineral oil 5. W hat w ould the proportions of oil:aqueous:em ulsi er be if m aking a prim ary em ulsion containing a xed oil You receive a prescription in your pharm acy w ith the follow ing details: Patient: Miss Sophie Jones, 29 Star Terrace, Astonbury Age: 28 Prescription: Maize oil 30% v/v emulsion Directions: 15 ml tds M itte: 100 ml 16. You receive a prescription in your pharm acy w ith the follow ing details: Patient: Ms Petra Williams, 526 High Street, Astonbury Age: 45 Prescription: Castor Oil 30% v/v emulsion Directions: 20 ml nocte M itte: 50 ml chapter 5 Creams Overview Upon com pletion of this chapter, you should be able to: prepare a cream from rst principles incorporate solids and liquids into a cream base select an appropriate container in which to package a cream prepare an appropriate label for a cream. They are intended to be applied to the skin or certain m ucous m em branes for protective, therapeutic or prophylactic De nition W ater-in-oil cream s purposes, especially w here an occlusive effect (oily cream s) as bases is not necessary. These bases have good Term inology used in the preparation of emollient properties. They are cream s, ointm ents, pastes and gels creamy, white or translucent and rather stiff. The follow ing are com m on term s that are used w ithin the extem poraneous preparation of Oil-in-water cream s cream s and in the extem poraneous preparation (aqueous cream s) as bases of ointm ents, pastes and gels (see Chapter 6). They are the best this is the term applied to the incorporation, bases to use for rapid absorption and penetration of drugs.
Careful examination may demonstrate subtle atrophy of the supraspinatus and infraspinatus muscles medicine man movie order duphalac visa, which is a sign Clinical Findings of advanced disease medicine 93 3109 buy discount duphalac 100ml line. Tenderness at the insertion site of the Onset is usually abrupt and severely limits activities medications with sulfa cheap duphalac online mastercard. It is supraspinatus tendon (just below anterolateral acromion) is theorized that the disease becomes painful only when the cal common medicine naproxen order cheap duphalac online. Occasionally symptoms 39 weeks pregnant purchase duphalac 100 ml on line, with a complete tear symptoms 24 duphalac 100 ml discount, a defect can be cium is undergoing resorption; therefore symptoms night sweats purchase duphalac 100 ml amex, the patient may be palpated treatment xdr tb guidelines duphalac 100 ml cheap. Full-thickness tears are characterized by a decrease in abrupt onset and tenderness over the greater tuberosity. Although quite Radiographic evidence of a calcified tendon is best seen on variable, there is usually pain and slight weakness in patients plain films. The pain can radiate toward the control the arm as the patient brings the raised arm back deltoid insertion and it may be difficult to distinguish biceps to the side. Usually there is a history of repetitive overhead activity, which either initiates or aggravates symptoms. Changes seen the most common finding on physical examination is on plain films that may be consistent with rotator cuff dis tenderness over the tendon within the bicipital groove. Patients should be referred for physical therapy early in order to take advantage of pain-reducing modalities such as heat, B. Flexibility and strengthening of the shoulder (rotator cuff muscles), scapula, and surrounding Data supporting the sensitivity and specificity of provocative musculature are also helpful in treatment. The Speed and advised to avoid movements and activities that provoke Yergason tests may, however, be used to assist in making the symptoms. In the Speed test, the Once a rotator cuff tear has been confirmed, referral patient is asked to flex the arm against resistance with the should be made to an orthopedic surgeon. In the Yergason test, evidence of improved results with surgical repair for both the patient supinates against resistance with the elbow flexed partial and full-thickness tears. With either test, the presence of pain at the tend to have better outcomes than patients who have had bicipital groove indicates a positive test. Phys Med Rehabil Clin North Am snap detected at the bicipital groove as the tendon subluxes 2004;15:475. General Considerations Disorders of the biceps tendon have been labeled as either Treatment tendonitis or overuse syndromes (tendinosis). Biceps tendonitis is an inflammatory process involving the portion of the ten Initial treatment of biceps tendonitis is conservative, consist don located in the intertubercular groove. Physical ther overuse injury that begins with an influx of inflammatory apy is useful to strengthen the rotator cuff but should not be cells and progresses to exudation of fluid into the tendon aggressive during the acute pain stage. In either case, this tissue thickens and becomes more teroid injections are also useful in the treatment of biceps painful. Many investigators believe that biceps tendonitis is tendonitis, but direct injection into the biceps tendon should secondary to shoulder impingement and rarely occurs alone. Alternatively, some consider biceps tendonitis to be second Treatment of biceps instability is similar. Older, sedentary ary to biceps tendon instability in the bicipital groove which, patients may benefit from conservative therapy, including if present, is usually associated with subscapularis tendon injections; however, younger, more active patients should be pathology. Phys Anterior instability is categorized using two acronyms: Med Rehabil Clin N Am 2004;15:511. An avulsion of the anteroinferior glenohumeral ligament and labrum (Bankart lesion) is also General Considerations seen with a probable avulsion fracture. Treatment for this Ruptures of the proximal biceps tendon are most often found type of instability is surgical repair. If symptoms do not improve with reha Clinical Findings bilitation, surgical repair (inferior capsular shift) is indicated. Symptoms and Signs Clinical Findings History includes pain in the anterior shoulder just prior to a complete tendon rupture. There is commonly an associated tear of the shoulder pain, an unwillingness to move the affected arm, and cartilaginous labrum, so the patient may also complain of a tendency to cradle the arm. Inspection reveals a bulge (due to the displaced loca tion of the humeral head), as well as dimpling inferior to the B. In this test, the patient is supine with the arm in 90 degrees of abduction; the examiner then applies an external rotation stress. Patient Treatment apprehension due to subluxation of the humeral head is con Treatment of an isolated rupture of the long head of the sidered a positive test. Posterior pressure on the proximal biceps is conservative and nonsurgical if the patient is inactive humeral head can provide relief of symptoms if shoulder or would not be hindered significantly by loss of strength in instability is the cause of pain (relocation test). Imaging Studies therapy is useful to improve rotator cuff strength, if an asso Radiographs are required to confirm shoulder dislocations. General Considerations Treatment Shoulder instability can be viewed as any condition in which Treatment for a shoulder dislocation consists of pain man the balance of various stabilizing structures in the shoulder is agement and relocation. After relocation, the shoulder must disrupted, resulting in increased humeral head translation. Because younger patients with shoulder dislocations tions are most often caused by trauma and sports injuries, tend to have a high recurrence rate, surgical repair is war whereas in the elderly, falls are the predominant cause (usually ranted and early referral should be made in this population. The condition can arise with repetitive activity that elbow and are primarily overuse or repetitive stress disorders. Patients may complain of diffi Lateral epicondylitis is a tendinosis at the origin of the exten culty gripping items and often rub the area over the radial sor tendons on the lateral epicondyle of the humerus. Patients There is tenderness to palpitation just distal to the radial complain of pain over the lateral elbow that may radiate styloid. There is tenderness to palpation over the abduction and extension, or with thumb adduction into a origin of the extensor carpi radialis brevis tendon, which is closed fist and passive ulnar deviation (Finkelstein test). Pain is aggra over the tendons represents a positive test; however, the test vated with resisted wrist extension or forearm supination. The goals of treatment are to decrease inflammation, prevent adhesion formation, and prevent recurrent ten B. If pain continues, a medial epicondylitis; however, plain films of the elbow corticosteroid injection should be considered. Steroid injection may be repeated after 4-6 weeks if symptoms Differential Diagnosis are not 50% improved. If no improvement occurs after two injections within the year, a referral for surgical con Differential diagnosis of lateral epicondylitis includes radial sultation should be obtained. In addition, biomechan associated bony anomalies such as Osgood-Schlatter disease ics should be evaluated (ie, racquet grip, golf swing tech or tendinous calcification, the clinical relevance of these nique, etc). If pain Treatment is refractory, a steroid injection can be administered for either medial or lateral epicondylitis. Surgical treatment is With the understanding that patellar tendinopathy is more recommended if no improvement occurs after 3-6 months of accurately a degenerative tendinosis caused by overload conservative management. Recommendations include the use of Sellards R, Kuebrich C: the elbow: diagnosis and treatment of eccentric strengthening exercises, improving quadriceps and common injuries. Depending on the chronicity of General Considerations symptoms, recovery may require up to 6 months. Therefore, use of the term patellar tendinopathy define anterior knee pain not related to intra-articular should be encouraged over former terms such as patellar pathology, bursitis, tendonitis, fracture, patellar subluxation, tendinitis, and treatment should also be directed toward or Osgood-Schlatter disease. The patella is held in place by its nat Clinical Findings ural shape, by the trochlea, and by the tension of the medial and lateral patellar retinacula (Figures 37-1 and 37-2). Symptoms and Signs flexing or extending the knee, the muscles of the hamstring Clinically, patellar tendinopathy presents with the insidious and quadriceps function like reins to direct the patella within onset of well-localized anterior knee pain, primarily at the the trochlea and to rotate the tibia. Pain is exacerbated by activity, pro sits at the proximal aspect of the trochlea. Treatment is directed at altering patellar tracking, correcting biomechanical factors that lead to overuse, and decreasing Pathogenesis the intensity of the aggravating activity. Additionally, with damage to the chondral surface and those who have various patterns of muscle weakness have been reported in failed prolonged therapy. Research has not been convinc patellofemoral syndrome, iliotibial band syndrome, and degen ing in showing significant biomechanical differences erative meniscal tears. Anterior Cruciate Ligament Injury stairs, ascending hills, squatting, or sitting with the knee flexed for a prolonged period of time (theater sign). Maltracking of the patella and tension; however, more often injury occurs when the foot is chronic irritation of the patellar cartilage often produce ten planted and the knee twisted, forcing the tibia forward. It is paramount to note that chil Clinical Findings dren may have significant hip pathology that presents solely as knee pain; pediatric patients must therefore be considered A. Symptoms and Signs as a distinct population with a broader differential diagnosis. Imaging Studies is rapid (minutes to hours) as a large hemarthrosis develops Radiographs are usually not indicated unless pain is pro within the joint. The usual mecha supine and the relaxed knee in 30 degrees of flexion, the exam nism of injury is a posteriorly directed force on the proximal iner stabilizes the distal femur with one hand, grasps the tibia with a flexed knee, such as a fall on a bent knee with the proximal tibia with the other, and attempts to sublux the tibia foot plantar flexed, or a bent knee striking the dashboard in anteriorly. With either test, signifi the initial trauma may be subtle and subsequent symptoms cant anterior translation of the tibia or lack of a discrete end are frequently vague. Initial treatment includes a brief period of immobilization, Indications for expeditious surgical referral include combined protected weight bearing with crutches for 7-10 days, ligamentous injury, significant laxity, and avulsion fractures. Bracing may Harner C, Hoher J: Evaluation and treatment of posterior cruciate provide some subjective benefit. General consensus holds that in relatively inac Wind W et al: Evaluation and treatment of posterior cruciate tive individuals nonoperative treatment is a viable option. Effusion is slower to develop (24 swelling may be seen with isolated tears, but a significant 36 hours) and is generally moderate. They complain of pain with squatting and of painful laxity in full extension suggests concomitant soft tissue injury. Joint line tenderness over the affected Treatment meniscus is the best clinical indicator of a meniscal tear Treatment of isolated collateral ligament tears is primarily (74% sensitivity; 50% positive predictive value). Ice and use of a compression wrap control local provocative maneuvers have been developed to recreate swelling. Crutches and toe-touch weight bearing may be all impingement of the torn fragment. These tests include the that a patient with a high-grade sprain may tolerate initially. McMurray test and the Apley test, which are helpful but mar However, regardless of severity, the patient must be encour ginally sensitive or specific. Sports Initial treatment for isolated meniscal pathology includes Med 1996;21:147. Partial response to conser General Considerations vative measures warrants physical therapy. Indications for the lateral and medial menisci are C-shaped wedges of fibro surgical referral include failure to respond to nonoperative cartilaginous tissue with attachments at the anterior and treatment or recurrent episodes of catching or giving way. Younger patients often have associated General Considerations injuries, while adults older than 40 years frequently develop Ankle ligament sprains are the most common ankle injuries atraumatic tears related to degeneration. Medially, the deltoid ligament provides ing forces during a twisting or hyperflexion injury. Symptoms and Signs the Ottawa ankle rules provide high-yield criteria for ordering radiographs (level of evidence C). Usually after an acute injury, the ankle is too swollen or the patient Treatment too guarded to permit a diagnostic examination, and a repeat physical examination may be necessary several days after the Initial treatment of isolated, acute ankle sprains consists of initial injury. Options for supportive devices for ankle distal tibia with one hand, then grasps the calcaneus in the sprains are numerous. Although the use of an elastic bandage palm of the other hand, and applies an anterior force. The talar tilt test is performed by stabilizing the subjective instability and more rapid return to work and to tibia with one hand, then grasping the calcaneus in the palm sports. A lace-up ankle support seems to significantly reduce of the opposite hand and inverting or everting the hindfoot. Symptoms and Signs Worsening symptoms or lack of improvement in the first Patients present with complaints of dull pain along the mid several weeks after a lateral ankle sprain should prompt the dle or distal posteromedial tibia. Initially, pain may be present neus, distal fibula, fifth metatarsal, or navicular; and subtalar only at the beginning or the end of activity, and symptoms or Lisfranc sprain. If training continues, how Medial ankle sprains are caused by eversion and dorsiflex ever, pain may become more severe and persistent. These significant injuries are beyond the scope of Provocative maneuvers include passive dorsiflexion, active this chapter; however, readers are cautioned that symptoms plantar flexion, standing toe raises, and one or two-legged are prolonged and treatment is significantly more aggressive hop. Activities that do not cause discomfort may as it is far less generic and more accurately reflects the etiol be continued. Thereafter, training level may be increased gradu participate in jumping sports such as basketball and gym ally over a 3 to 6-week period as long as the patient remains nastics, and in military recruits. Although multiple muscle groups have been implicated and Surgical referral for fasciotomy is reserved for patients with the roles of inflammation versus bone remodeling have been extraordinarily resistant and painful symptoms. Am J Sports Med 2005; medial soleus contracts to plantar flex and invert the foot, 33:1241. The peak incidence in the general population is between the ages of 40 and 60 years. Treatment Fortunately, 80% of patients with plantar fasciitis will Pathogenesis improve, regardless of therapy. However, resolution of symp toms can take 6-18 months, and there is limited evidence the plantar fascia is a fibrous aponeurosis that extends supporting the value of many of the treatments. It pro initially it seems reasonable to recommend conservative, low vides static support of the longitudinal arch of the foot and risk interventions. Although data are limited, several Achilles and plantar fascia stretching program. Support for risk factors have been identified, including obesity, pes the use of ice, heat, massage, or strengthening of the intrinsic planus, pes cavus, and a tight Achilles tendon. More intensive Athletes commonly report a change in the intensity, dis treatments, including custom orthotics, night splints, and cast tance, or duration of their activity or an alteration in their immobilization, may be beneficial in patients with recalci running surface or footwear that accompanied the onset of trant symptoms. Therefore, this entity may more appropriately be considered a Aldrige T: Diagnosing heel pain in adults. Pain usually diminishes with rest but may Differences in bone growth and physiology make the pediatric recur at the end of the day. Pain is bilateral may sustain injuries similar to those seen in adults, they are in up to one-third of cases. Common Physical examination generally demonstrates tenderness pediatric musculoskeletal conditions will be highlighted here; along the anteromedial aspect of the calcaneus which however, fractures are beyond the scope of this chapter. Most cases caneus can be misleading; these are present in 15%-25% of occur between 4 and 8 years of age. Boys are more com the general population without symptoms, and many symp monly affected. Therefore, the detection a disorder of the growth and development of the proximal of heel spurs is of no value in either confirming or excluding femur resulting from excessive stress to the proximal femoral the diagnosis of plantar fasciitis. Both conditions may be found bilaterally in the same Extreme care must be taken not to mistake transient synovitis individual. While differentiation of these two entities may be difficult, early diagnosis of septic arthritis Clinical Findings is essential in avoiding potentially serious sequelae. Pain is often accompanied by an altered gait or limp, and it is usu Transient synovitis most commonly presents with unilateral ally worsened by activity. Typically, the child is well-appearing, but some tigation of knee pain in children should include a history and are mildly ill with a fever. The leg may be held in a flexed physical examination that addresses the hips as well. There is Physical examination may produce pain at the extremes mild restriction of hip motion. However, there are also a variety of abnormal radiographic findings which may include B.
Syndromes
Recently placed artificial joints
Do not eat or drink anything after midnight the night before your surgery.
Bright flashes of light, especially in peripheral vision
Failure of the gallbladder to empty bile properly (this is more likely to happen during pregnancy)
Wide-set eyes (hypertelorism)
Thyroid problems
Confusion
Using simple conversational techniques symptoms 6dp5dt discount duphalac 100ml line, and found that 52% had observed colleagues providing substan mastering a very manageable amount of medical information medications heart failure purchase genuine duphalac on line, dard care to patients because of sexual orientation treatment urticaria order duphalac. Assumption Solution Assumption about sexual orientation: Many patients are Learn to inquire about sexual orientation in a nonjudg neither exclusively heterosexual nor exclusively homo mental manner that recognizes the range of human diver sexual treatment plan for ptsd order duphalac 100 ml on line. Assumptions about sexual activity: Lesbian and gay male Take a specific symptoms 4-5 weeks pregnant duphalac 100ml otc, sensitive sexual history from all patients symptoms ulcer cheap duphalac 100ml on-line. Assumptions about contraception: the need for contracep Inquire about need (rather than assuming need) or lack tion arises from a wish to prevent pregnancy from hetero of need for all patients section 8 medications buy cheap duphalac on line. Assumptions about marriage: Lesbians and gay men may Inquire about significant relationships for all patients symptoms of appendicitis order duphalac with visa. Use have been, and may still be, married to persons of the the terminology that your patients choose. Assumptions about parenting: Lesbian and gay male cou Inquire about parenting wishes and choices, and be pre ples are often interested in and choose to bear and raise pared to discuss options. Young gay men, those who use the Internet to porting antiretroviral treatment following either occupational meet sexual partners, and those with substance abuse prob exposure or sexual exposure are limited. Johns such as Endolimax nana and Blastocystis hominis, should be Hopkins University Press, 2006. Curr Opin Infect Dis included in the differential diagnosis of enteritis and procto 2006;19(1):26-32. Unprotected receptive anal intercourse can lead to the tenes mus, rectal pain, and bleeding of proctitis, with common Web Sites pathogens being Neisseria gonorrhoeae, Chlamydia trachoma tis, Treponema pallidum, and herpes simplex virus. Other investigators have observed to the same guidelines used for heterosexual women. Ironically, the types that cause the most visu heterosexual women in a community setting. Sex Transm Infect ally apparent warts are usually the types with least risk for 2007;83;470-475. One study of lesbians revealed that 25% of respondents had not had a Pap test within the past 3 years, Prevention and 7. Individuals with abnormal men should be vaccinated against hepatitis A and hepatitis B. One British study of over 1000 gay men recruited from five gymnasiums found that 13. Alcohol, psychoactive drug, and tobacco use appear more Research to date has not explained causation. Significant social pressures may cause psychoactive substances more than heterosexual women. A patients to resort to steroids as a means to achieve an idealized recent meta-analysis found risk ratios of 4. Another review of tobacco use Prevention & Treatment found that smoking rates among adolescent and adult lesbians, gays, and bisexuals are higher than in the general By and large, prevention, clinical findings, complications, and population. Differences to who have unprotected anal intercourse are more likely to have consider with this population include the prevalence of a drinking problem and to drink more than gay men who do methamphetamine use, and its association with high-risk not have unprotected intercourse, and unprotected inter sexual behavior among some groups of gay men; concomitant course after drinking is more common with nonsteady sexual use of sildenafil (Viagra) or other treatments for erectile dys partners. Erectile dysfunction demonstrated include hallucinogens, nitrate inhalants, and treatments, either with or without other substance use, are cocaine and other stimulants. However, associations between drug use and high-risk sexual behavior exist only for current use, not past Center for Substance Abuse Treatment of the Substance Abuse drug or alcohol use. Addiction and looked at relationship status, relationship satisfaction, 2008;103(4):546-556. Drug Alcohol Depend support from friends, poor relationship satisfaction, and lack 2005;78:125. Clinical Findings Lack of social supports, lack of family support, and poor Symptoms and signs of depression in lesbian and gay male relationship quality are significant predictors of depression. Although depression is often associated with General Considerations decreased sexual activity, one study of gay men revealed 16% had heightened sexual interest while depressed. Other investigators have demonstrated cancer screening as heterosexual and non-gender-variant similar findings (eg, in a study of twins in which one brother patients. As discussed above, cervical cancer screening should reported same-sex partners after age 18 and the other did not). One study Parenthood options available to lesbians and gay men compiling survey data from almost 12, 000 women found les include adoption, artificial insemination, surrogacy, or het bians had greater prevalence rates of obesity and alcohol and erosexual intercourse. Existing evidence suggests that gay tobacco use, and lower rates of parity and birth control pill men and lesbians have parenting skills comparable to het use. When compared with children of heterosexual parents, In transgender patients, it is important to screen based on children of gay men and lesbians seem to be no different in current anatomy as well as use of hormonal therapy. Issues for breast, uterine, cervical, endometrial, and ovarian can that warrant physician awareness include parental legal rights cers. J Womens Health should maintain information about appropriate referrals to (Larchmt) 2004;13:1033. Clin Infect Dis Boivin J et al: Guidelines for counselling in infertility: outline ver 2006;43(2):223-233. Sex reassignment should be managed by multispecialty Bancroft J et al: Erectile and ejaculatory problems in gay and het erosexual men. The literature describing the health needs of transgender may alter this characterization at some future time. Terminology delay initiating sex reassignment therapy until the patient is at least 18 or 21 years of age, treatment in adolescence is well Terminology can be problematic when describing transgen tolerated for carefully selected individuals, does not lead to der individuals, reflecting evolving knowledge. In other usage, the term transgender complete psychological evaluation by a therapist experienced serves as an umbrella for patients experiencing discordance in working with this population. Surgical treat Intersex individuals are born with both male and female ment can involve the breasts, genitalia, and larynx. In caring Hormones induce feminization or virilization and suppress for an individual patient, the best approach for physicians is the hypothalamic-pituitary-gonadal axis. Cross-sex hor to determine how patients wish to be addressed and to monal treatment may have substantial medical side effects, understand how they conceptualize their gender. Limited research may increase the benefit-to-risk ratio by limiting hormone into the etiology of gender identity disorder suggests that it related bone loss. Am J Public etiology or classification, the needs of transgender patients Health 2001;91:869. Treatment Thyen U et al: Deciding on gender in children with intersex condi Perhaps the most important element of treatment is to have tions: considerations and controversies. Treat Endocrinol a multidisciplinary team experienced with transgender care 2005;4:1. Incorrect assump Adolescents tions about geriatric patient sexuality may lead physicians to fail to identify risk behaviors and to implement appropriate Lesbian and gay adolescents growing up in a loving, support education and/or screening tests. Physicians should be mind ive environment develop and mature in a manner similar to ful that many older lesbians and gay men remain sexually that of their heterosexual counterparts. However, lesbian and active well into their lives, with older gay men reporting less gay adolescents may be vulnerable to parental wrath and with condom use than their heterosexual counterparts. In certain instances, this can initiate a chain bians and gay men successfully navigate the aging process of events that leaves the youth homeless and vulnerable. Despite this, McMahon E: the older homosexual: current concepts of lesbian, homosexual adolescents are generally more similar to than gay, bisexual, and transgender older Americans. Clin Geriatr different from their heterosexual peers, face many of the Med 2003;19:587. There, Dr Cicely Saunders, a former nurse and and family centered rather than disease centered. Hospice social worker who had earned a medical degree, helped to provides a team composed of those trained to care for prob establish the underlying philosophy of hospice and palliative lems in a holistic manner: physician, nurse, social worker, medicine. She emphasized clinical excellence in pain and chaplain, bereavement counselor, nursing assistant, and vol symptom management; care of the whole person, including unteer. The hospice team meets weekly, under the direction of physical, emotional, social, and spiritual needs; and the need the hospice medical director, to review the care plans of all for research in this newly developing field of medicine. The hospice program is charged with providing Interdisciplinary team care became the norm, as it became medications for the relief of physical distress, durable medical clear that no one physician, nurse, social worker, or chaplain equipment, supplies, a multidisciplinary team to provide care, could address all the needs of the terminally ill person. Further, although the focus of care was clearly on the dying Palliative medicine has developed as a medical subspe individual, the needs of the family were also addressed. In 1982, the Congress created the compassionate communication regarding goals of treatment. By 2007, 4700 hospice programs were There are palliative care consultation teams in hospitals, providing health care services to the terminally ill and their nursing homes, and in outpatient clinics. The number of hospital-based palliative care consulta erage for curative and life-prolonging care related to the tion programs has increased linearly from 632 (15%) in 2000 terminal diagnosis and be certified by their physician and to 1027 (25%) in 2003 and continues to grow annually. If the hospice medical director programs offered 119 fellowships for advanced training. Pain this regimen can then be converted to the sustained release formulation based on the previous 24-hour dose, Pain can be classified physiologically as somatic, visceral, and titrated based on pain control. Because of the delayed onset of effect (12 hours) and cially for inflammatory conditions. Their use can decrease long half-life of this formulation, it cannot be titrated the amount of opioids required and hence decrease the inci quickly for rapid pain control. Often patch is approximately equivalent to 25-35 mg of oral mor described as sharp, electric shock-like, or burning in nature, phine sulfate over 24 hours). The choice because of their quicker onset of action and ease of titra of an adjuvant is usually dictated by the individual drug tion. Conversion to oral formulations can occur after pain side-effect profile, the potential for drug interactions, and is controlled. The total hourly dose and doses and usually within several days, as compared with the lockout interval between boluses are preprogrammed. Care have a higher risk of drug interactions and toxicity com must therefore be taken when converting from the oral to pared with gabapentin and pregabalin. In sometimes started prophylactically for the first several days elderly patients, it is generally safer to start at low doses and of opioid therapy. Some decreasing tumor-associated edema and by their anti-inflam of these therapies are described in Table 63-1. Addiction is a rare occurrence in patients with metastasis, and conditions in which the tumor is compressing terminal illness and in patients without a prior history of sensitive structures. If the need tions such as palliative radiation therapy for bone metastasis, arises for a rapid decrease in the opioid dose, administering nerve blocks (eg, celiac plexus block for pancreatic cancer), 25% of the stable dose can prevent withdrawal symptoms. Analgesic tolerance, like less invasive measures should be taken into consideration. Therapy Brief Description Recommendations Acupuncture Stimulation of defined points on the skin using a needle, 1. Acupuncture may provide pain relief in terminally ill patients electrical current (electroacupuncture), or pressure with cancer pain. Acupressure may reduce chemotherapy and radiation-induced energy imbalances and restore a normal, healthy flow nausea and vomiting. Massage has been shown to reduce stress and anxiety and enhance feelings of relaxation. Relaxation techniques can improve pain control in advanced meditation, biofeedback, and guided imagery techniques. The list of possible etiologies of nausea and vomiting is Drug therapy for specific causes of nausea and vomiting extensive. Treatment should be directed at correcting the includes the following: underlying pathology when possible. Dexamethasone is more potent and has lower About one-third of patients require more than one mineralocorticoid activity than other steroids, resulting in antiemetic for symptom control. Understandably, anxiety often that can be administered by several different routes, includ coexists with chronic dyspnea. If patients show benefit, long-acting diazepam or tion is not amendable to invasive procedures such as venting clonazepam can then be prescribed. Low-dose chlorpro gastrostomy, intraluminal stent, or surgical diversion, pallia mazine has also shown benefit in relieving both dyspnea tive medications can help relieve symptoms. When obstruction becomes complete, therapy is geared at decreasing intestinal motility Anorexia (poor appetite) and cachexia (severe weight loss) and decreasing secretions. Anticholinergics and somatostatin are prevalent distressing symptoms in patients with analogs are both effective for this purpose. Factors released either by the tumor or by of haloperidol, an anticholinergic, and octreotide can pre the host response appear to produce the anorexia-cachexia clude the use of nasogastric tube decompression for many syndrome. Cytokines implicated include tumor necrosis fac patients with complete intestinal obstruction. The syndrome is characterized by impaired metabolism of carbohydrates, protein, and lipids. Patients lose weight and Dyspnea can be present with or without hypoxia and, like appear malnourished despite adequate nutrient intake. With a broad differential There is an abundant amount of research in this field, but lit existing for dyspnea, reversible causes should always be tle effective drug therapy available. The optimal therapy is aimed at the pre for the anorexia-cachexia syndrome include megestrol sumed etiology. Palliative therapy can involve chemother acetate, corticosteroids, dronabinol, and anabolic steroids. Minor adjustments in the envi appetite and result in weight gain; doses start at 160 mg/d ronment, such as providing a fan and keeping the room and can be titrated to 800 mg/d if required. Corticosteroids, temperature cool, or a careful trial of supplemental oxygen such as dexamethasone, can be prescribed as an appetite can help dyspneic patients. Available palliative drug thera stimulant for patients in whom side effects of long-term pies include steroids, opioids, bronchodilators, diuretics, steroid use are of less concern. Significant weight gain is not seen can be used in combination, depending on the etiology of with corticosteroids in this population. The use of nebulized morphine sulfate is not Investigations are ongoing with respect to the use of omega more effective than placebo.
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