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Com- Because the drugs are highly toxic order tegretol 100 mg visa spasms muscle pain, every precaution must be taken mon methods include injecting the drug into the tubing of a to ensure accurate and safe administration 100mg tegretol for sale muscle relaxant depression. These devices require special care to maintain pa- for drug administration and catheter care 200mg tegretol fast delivery muscle relaxant tinidazole. For drugs to be given orally, the total dose of most drugs can be given at one time. Observe for therapeutic effects Therapeutic effects depend to a large extent on the type of malig- nancy being treated. Increased feelings of well-being anorexia, nausea, and vomiting for 2 to 3 wk after each cycle of c. Observe for adverse effects Antineoplastic drugs may have adverse effects on virtually any body tissue. These effects range from common to rare, from rela- tively mild to life threatening, and occur with usual dosage ranges. Hematologic effects: (1) Bone marrow depression with leukopenia For most drugs, WBC and platelet counts reach their lowest points (nadirs) 7 to 14 d after drug administration and return toward nor- (decreased white blood cell [WBC] count), thrombo- mal after 21 d. Normal leukocyte and platelet counts indicate re- cytopenia (decreased platelets), and anemia covery of bone marrow function. Anemia may occur later because (decreased red blood cell [RBC] count, hemoglobin, the red blood cell lives longer than white cells and platelets. Gastrointestinal (GI) effects—anorexia, nausea, vomiting, Nausea and vomiting are very common, usually occur within a few diarrhea, constipation, oral and intestinal mucositis and mu- hours of drug administration, and often subside within 12 to 24 h. Mucositis may occur anywhere in the GI tract; may interfere with nutrition and cause significant discomfort; may lead to infection, hemorrhage, or perforation; and may require that drug therapy be stopped. Integumentary effects—alopecia, dermatitis, tissue irrita- Complete hair loss may take several weeks to occur. Several drugs may cause phlebitis and sclerosis of veins used for injections, as well as pain and tis- sue necrosis if allowed to leak into tissues around the injection site. Renal effects: (1) Hyperuricemia and uric acid nephropathy When malignant cells are destroyed, they release uric acid into the bloodstream. Uric acid crystals may precipitate in the kidneys and cause impaired function or failure. Adverse effects on the kidneys are especially associated with methotrexate and cisplatin. Hyper- uricemia can be decreased by an ample fluid intake or by adminis- tration of allopurinol. Decreasing the dose or trogen [BUN] and serum creatinine; decreased creatinine frequency of administration, vigorous hydration, and amifostine clearance). It is attributed cystitis (blood in urine, dysuria, burning on urination) to irritating effects of drug metabolites on the bladder mucosa. Pulmonary effects—cough, dyspnea, chest x-ray changes Adverse effects on the lungs are associated mainly with bleomycin and methotrexate. With bleomycin, pulmonary toxicity may be severe and progress to pulmonary fibrosis. Cardiovascular effects—congestive heart failure (dyspnea, Cardiomyopathy is associated primarily with doxorubicin and re- edema, fatigue), dysrhythmias, electrocardiographic changes lated drugs. Central nervous system effects—peripheral neuropathy with This common effect of vincristine may worsen for several weeks vincristine, manifested by muscle weakness, numbness and tin- after drug administration. There is usually some recovery of func- gling of extremities, foot drop, and decreased ability to walk tion eventually. Endocrine effects—menstrual irregularities, sterility in men and women (continued) CHAPTER 64 DRUGS USED IN ONCOLOGIC DISORDERS 933 NURSING ACTIONS RATIONALE/EXPLANATION 4. Drugs that increase effects of cytotoxic antineoplastic drugs: (1) Allopurinol Allopurinol is usually given to prevent or treat chemotherapy- induced hyperuricemia.

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For this we need a published sion Collaborative Research Program (TDCRP)14 treatment manual and a well-validated method of involved the use of four treatment arms buy discount tegretol 100 mg line spasms pronunciation. Groups 1 measuring adherence to the therapy as described and 2 received CBT and IPT cheap 200mg tegretol with mastercard muscle relaxant cyclobenzaprine dosage, respectively cheap tegretol 200mg spasms 1983 imdb. CHOICE OF AN APPROPRIATE Finally, Group 4 received a pill placebo (again CONTROL GROUP administered double blind) and CM. Crits-Christoph and cerns regarding the use of a placebo on depressed Gladis13 consider this as perhaps the single most patients. The CM component provided guide- vexing problem for research into the outcome of lines, not only for the management of medication psychotherapy. It is important interventions were proscribed (especially those that when patients are invited to take part in an that might overlap with the two psychotherapies), RCT they are convinced that they will receive ade- the CM component approximated a minimal quate levels of advice, support and care if they are supportive therapy condition. Other- the essence of the imipramine–CM and wise, why should they consent to randomisation? It is also important that which could be used as a control group for the the test psychotherapy is being compared to a care evaluation of the efficacy of the psychotherapies. The therapists themselves of the effectiveness of each of the psychothera- should not undertake the assessment of outcome. When one asks used measures of depressive symptoms in RCTs questions about the effectiveness of psychother- for the treatment of depression. The condition is as vital to the comparison as is the HRDS is a clinician-rated measure, based on standardised package of therapy. There have been suggestions cific psychotherapy can do no better than the that different forms of therapy (drugs as opposed placebo–CM control should the psychotherapy to psychological treatments, for example) might be pursued as a treatment option? Beware of have a differential effect on these outcome mea- authors who make claims about the improvement sures (drugs doing better according to the HRDS of patients in a particular treatment group with- and the BDI favouring CBT, for example). In reality, it is hard to (explained by the fact that it contains non-specific imagine a convincing justification for a trial of elements of psychotherapy) seems to be missing the size and expense needed for such a test. Drop-outs and other sources of missing data lead to real problems for the valid estimation of the CHOICE OF ASSESSMENT METHOD effects of treatment. A detailed discussion of this AND OUTCOME MEASURES topic is beyond the scope of the present chapter, but it must be stressed that the only effective way It is very difficult to see how one could possi- of dealing with missing data is to ensure that bly design a so-called double blind RCT in the there are none. The patients effort to ensure that outcome data (however brief) are likely to know what is going on, unless they are collected on all of the patients randomised, have been deceived by their therapists, and it irrespective of their subsequent treatment history. What is the best way the patient (see, for example, Crits-Christoph of dealing with them in the statistical analy- et al. If we use a naıve¨ complete-case analysis centre RCT there are also likely to be differences (that is, base the inferences concerning causal in the effectiveness of the collaborating clinical effects on those patients with complete data) centres. Therapists in some centres may have then we are likely to have two problems: lack considerably more experience in the use of a of statistical efficiency (low statistical power) given treatment approach than in others, reflected, and bias. Bias may be caused, for example, by for example, in their degree of adherence to a the drop-outs not occurring completely at ran- given therapeutic model. Ideally, analyses should be available on all are treated as groups rather than individually available data (and should include where pos- there are also likely to be differences between sible all patients randomised to the competing groups arising not only from the characteristics treatment arms) and should compensate for the of the patients and of the therapist but also from observed patterns of drop-out. If they get dealing with the missing values include impu- on well together the group might thrive.

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However purchase 200 mg tegretol fast delivery muscle relaxant pain reliever, as with any electronic medical instrumentation cheap tegretol 100mg free shipping muscle relaxer 86 67, a major safety issue is electrical shock hazard generic tegretol 100 mg on line muscle relaxant metaxalone side effects. The objective of the device is to provide minimal electrical stimulation of retinal tissue using very low vol- tages and the smallest currents possible. During this procedure, the patient must be coupled to the external instrumentation. To protect the patient from any electrical shock, the patient is isolated from high voltages using optocouplers that are powered by low-voltage batteries. Neurophysiology of an IRP Many questions and concerns arise when interfacing an electronic device to neural tissue. One fundamental concern is that because the retina is a thin-layered structure, more than one layer may respond to electrical stimulation. Other questions involve electrode configurations, electrical currents, and pulse shapes, as well as the impor- tant issues of safety and biocompatibility. Preferential Stimulation of Retinal Cell Layers the advantage of stimulating retinal cells other than ganglions was mentioned ear- lier. Experimentally, it has been shown that phosphenes could be elicited in patients with advanced outer retinal degeneration via electrical stimulation (Potts and Inoue, 1970; Weiland et al. These electrically elicited responses require and indicate the presence of functioning retinal cells. As the human RGC axons exit the eye, they become myelinated and form the optic nerve. The cell bodies (somas) of these ganglion cells are mapped over the surface of the retina in a manner that approximates the projection of the visual world onto the surface of the retina. However, at any particular location on the sur- face of the retina, axons from distant sites overlay the individual ganglion cell bodies. If these superficial passing axons were preferentially stimulated, groups of ganglion cells from large areas of the retina would be excited. One might expect the visual perception of such a stimulus to appear as a wedge. On the other hand, if the gan- glion cell bodies or deeper retinal cells were stimulated, one would expect the visual perceptions to be focal spots. RP patients that were stimulated with 50–200-mm- diameter platinum disk electrodes reported seeing spots, not wedges, of light (Humayun et al. To explore the possibilities of retinal electrical stimulation, a computational model of extracellular field stimulation of the RGC has been constructed (Greenberg et al. The model predicted that the stimulation threshold of the RGC soma is 58– 73% lower than a passing axon, even though the axon was closer to the electrode. Nevertheless, a factor of less than 2 does not explain the source of visual perceptions observed during previous experiments with intraocular patients. Postmortem morphometric analysis of the retina of RP patients revealed that many more inner nuclear layer cells retain functionality. Early electrophysiological experiments showed that cathodic stimulation on the vitreous side of the retina depolarizes presynaptic end terminals of the photoreceptors (Knighton, 1975a,b) and bipolar cells (Toyoda and Fujimoto, 1984). Recently, latency experiments in frog retinas showed that higher currents stimulate the RGC directly, while lower currents activate other cells (photoreceptors, bipolar cells) (Greenberg, 1998). Another finding in those experiments was that shorter stimulating pulses (<0.