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Observe for drug interactions Few clinically significant drug interactions occur because many antiparasitic agents are administered for local effects in the GI tract or on the skin order detrol 4 mg otc. Drugs that alter effects of chloroquine: (1) Acidifying agents (eg cheap detrol 1mg amex, ascorbic acid) Inhibit chloroquine by increasing the rate of urinary excretion (2) Alkalinizing agents (eg, sodium bicarbonate) Potentiate chloroquine by decreasing the rate of urinary excretion (3) Monoamine oxidase inhibitors Increase risk of toxicity and retinal damage by inhibiting metab- olism. Drugs that alter effects of metronidazole: (1) Phenobarbital, phenytoin These drugs induce hepatic enzymes and decrease effects of metronidazole by accelerating its rate of hepatic metabolism. Drugs that decrease effects of atovaquone and trimetrexate: Although few interactions have been reported, any enzyme- Rifampin and other drugs that induce CYP450 drug-metabo- inducing drug can potentially decrease effects of atovaquone and lizing enzymes in the liver trimetrexate by accelerating their metabolism in the liver. How would you instruct a mother regarding treatment Answer: Explain that malaria is transmitted by mosquito bites, and prevention of reinfection with head lice or pin- and thus it is important to limit exposure to mosquitoes (by worms? What are adverse effects of commonly used antipara- shirts, sleeping in screened or well-netted areas). Mosquitoes sitic drugs, and how might they be prevented or mini- are most active at dusk and dawn, so prevention is especially mized? Prophylactic medications must be started 2 weeks before entering infested areas and continued for 8 weeks after return. The medication should be taken on the same day of the week at approximately the same time. If acute symp- SELECTED REFERENCES toms appear (headache, malaise, fever, chills), additional medica- tion can be taken to treat the infection. What groups are at risk for development of parasitic infec- Greenwood, B. Opportunistic infections in patients with and pa- tients without acquired immunodeficiency syndrome. How would you assess for a parasitic infection in a client Disease, 34, 1098–1107. Discuss roles of various white blood cells in nisms, and immune mechanisms. OVERVIEW are still used, but they are misleading because secretion of many lymphokines and monokines is not limited to lympho- All blood cells originate in bone marrow in stem cells that cytes and monocytes as these terms imply. In general, secre- are capable of becoming different types of blood cells. As tion of cytokines occurs after activation of a particular cell and these pluripotential stem cells reproduce, some reproduced lasts a few hours to a few days. Although several cells can se- cells are exactly like the original pluripotential cells and are crete cytokines, helper T cells and macrophages are the main retained in bone marrow to maintain a continuing supply. However, most reproduced stem cells differentiate to form Cytokines act by binding to receptors on the membranes of other types of cells. The early offspring are committed to be- numerous types of target cells. A cytokine may bind to re- come a particular type of cell, and a committed stem cell that ceptors on the membrane of the same cell that secreted it will produce a cell type is called a colony-forming unit (CFU), (autocrine action), it may bind to receptors on a target cell near such as CFU-erythrocyte or CFU-granulocyte. Hematopoietic the cell that produced it (paracrine action), and, occasionally, growth factors or cytokines control the reproduction, growth, it may bind to target cells in distant parts of the body (endocrine and differentiation of stem cells and CFUs. After binding, the cytokine-receptor com- the processes required to produce fully mature cells. Overall, cytokines are involved in numerous physiologic responses, including hematopoiesis, HEMATOPOIETIC CYTOKINES cellular proliferation and differentiation, inflammation, wound healing, and cellular and humoral immunity. Cytokines (Table 42–1) are substances produced by bone Cytokine actions and functions are affected by several fac- marrow stromal cells, activated helper T cells, activated tors. First, although the immune response to an antigen may macrophages, and other cells. They regulate many cellular include the production of cytokines, cytokines do not act in activities by acting as chemical messengers among cells. Instead, they affect whatever Some cytokines are growth factors that induce proliferation cells they encounter that have cytokine receptors and are able and differentiation of blood cells. Cytokine receptors are often expressed on a cell a large group of proteins that are structurally and functionally only after that cell has interacted with an antigen, so that cy- diverse. They were initially named and defined by their action tokine activation is limited to antigen-activated lymphocytes. The term cytokine includes lymphokines in laboratories by analysis of the effects of recombinant cy- secreted by lymphocytes and monokines secreted by mono- tokines, often at nonphysiologic concentrations, and added cytes and macrophages.

What are the thoughts and feelings that I want to resonate long after the last page is read? The show taught me that many men and women—perhaps you are one of them—are looking for a quick fix and a fast way to transform their bodies generic detrol 1mg on line. I told my clients that they had to stick with me for at least six weeks before they would see major results generic detrol 2mg overnight delivery. The Extreme Makeover challenge of training and transforming four women in a short period of time opened up a new universe to me. I realized that many people, given the right exercise and nutrition plan, can achieve stunning results in as little as two weeks. Even more important, if they stick with the right maintenance plan, something the Extreme Makeover show does not develop, they can maintain these results for life. The basic philosophy of the show not only included diet and exercise (which I would be in charge of), but also extensive plastic sur- gery, including nose jobs, brow lifts, liposuction, and face-lifts. That said, I agreed to participate, and the process helped me to develop the program that eventually grew into this book. I felt that I could show these women and millions of viewers that one could have a makeover, and a pretty comprehensive one at that, by adhering to the sound eating and exercise principles of my program. Not only was I going to transform their bodies, but I was going to empower them by teaching them how to maintain their results throughout their lives. I was asked to help women completely make over their bodies in just 14 to 21 days. Generally, I suggest a much longer program for body transformation, one that lasts about six weeks. Yet, because the Extreme Makeover show wanted extreme results in an extremely short period of time, I modified the 1 IIII Copyright © 2005 David Kirsch. TLFeBOOK traditional nutrition and fitness program that I generally prescribe to my clients. Although all the women had cosmetic surgery, they all agree that it was the workout and the nutrition regimens that still resonate in their everyday lives. They all still follow my training program, albeit maybe not as rigorously, and adhere at least to a certain degree to my nutrition plan. What if I could convince others to embrace the notion that ultimate makeovers were attainable and could be realized with sweat and determination—but no plastic surgery? EXTREME VERSUS ULTIMATE RESULTS My objective here is not to bash the Extreme Makeover show. I think the human element in the show is compelling and makes for good television. If you are still going to reach for the burger and fries, then all the liposuction in the world will not keep you skinny. For this program, your nutrition plan is just as important—if not more 2 THE ULTIMATE NEW YORK BODY PLAN TLFeBOOK important—than your exercise plan. The biggest distinction between my Ultimate Body Plan and the Extreme Makeover program is that I not only train you, but I also feed you and teach you how to incorporate nutrition prin- ciples into your everyday life. With empowerment, you will have the courage, willpower, and fortitude to stay the course. THE ULTIMATE MAKEOVER After working on the Extreme Makeover show, I began introducing this faster, more extreme program to clients. I had many clients who were very fit and who ate well, but who wanted to take their bodies to the next level. They wanted to look great for bikini season or sculpt their best body for a wedding or upcoming reunion. I would have talked you out of your desire for fast results and into embarking on a longer, six-week program designed to last a lifetime. Even for the Extreme Makeover show, I was at first skeptical of how much could be accomplished in so short a period of time. I feel blessed for the opportunity to have worked with these amazing women. Even after all these years of personal training, I, too, learned a valuable lesson. As long as you accept that change—any change—will include physical, mental, and spiritual transformation, then you can do it. You might be asking yourself how or why I chose two weeks as the length of time for The Ultimate New York Body Plan.

I like the motion and the way it engages the quadriceps purchase detrol 2 mg without prescription, hips purchase 4 mg detrol overnight delivery, and butt while taking stress out of your knees. The goal here is to aim for time and endurance first and then intensity. I often see people positioning their torsos straight upright, which places too much emphasis on the quadriceps. Stick your butt out as much as possible since this will shift the focus into your butt, hamstrings, and outer thighs and out of your quadriceps. Jump Rope If you like to jump rope, work up to 30 minutes (or more if you can). ULTIMATE TIP: To stoke the cardio fires, alternate push-ups or jumping jacks with shoulder presses or frog jumps in between jump rope sets. Vary your speed and, if possible, try to add a cross-country element to it if there are any hills around. If you are unable to do this speed or duration, try another form of cardio more appropriate for your fitness level (elliptical machine, rowing machine, jump rope, or even jumping jacks with shoulder presses). ULTIMATE TIP: Make your run a little more challenging by running back- ward every once in a while. You may also turn to your side and cross right foot over left and left foot over right. You may remem- ber that drill from football, baseball, or field hockey practice. THE ULTIMATE NEW YORK BODY PLAN EXERCISE PROGRAM 53 TLFeBOOK MAKING THE BEST OF EACH WORKOUT To get the most out of the Ultimate Body Plan exercise program, follow these pointers. Most people train unconsciously, disengaging their minds as they work out. Watching television, day- dreaming, or chatting with a friend as you exercise causes you to tune out the subtle yet important signals your body sends to you. When you fail to engage your mind, you simply go through the motions of an uninspired work- out that feels dull not only to your mind but also to your muscles. By staying engaged and in the moment, you will be able to safely extend your edge, challenging yourself every step of the way. So take a tip from the yogis and bring your awareness inside your body throughout your sessions. By staying in the moment, you will actually feel your muscle fibers changing, shaping, and elongating. I recently had a moment with a female client who in my opinion was not getting the most out of her workout sessions. I had one of those necessary conversations and spoke to her about what I thought was happening and not happening in her daily training routines. Upon closer investigation I realized that she not only had a portable e-mail device with her, but she carried her cell phone, listened to music, and channel surfed on the television. She was also bringing too much of her outside work and environmental stress onto the gym floor. She is definitely on her way to more focused, efficient, and ultimately more effective workouts. Whereas 12 frog jumps might put one person on the couch for the rest of the day, they might do nothing for someone else. Also, how strong you feel on a Monday can change by Tuesday or Wednesday. You may need to do more or fewer reps or sets of various exercises based on how your body is responding that day. Aim for healthy muscle exhaustion, working to your maximum perceived rate of exertion (MPRE). Be mindful that although it may not seem very challenging in the beginning, your body will soon be cooking, your heart pumping, and your energy rocking. Remaining strong, focused, and steady will carry you through the program. This will help you to work the muscles around your joints while protecting your joints. Land on soft legs (knees), keeping your brain in your butt, and take the impact of the landing in your heels and drive it up through your hamstrings and throughout your legs.

Conversely generic detrol 1mg without a prescription, de- creased serum potassium increases the likelihood of digoxin- 1 discount 1mg detrol. Some of the fixed-dose combinations of hydro- diuretic, and other measures to prevent hypokalemia are chlorothiazide and a potassium-sparing diuretic con- often used to maintain normal serum potassium levels (3. Clients who do not achieve an adequate diuretic re- Prevention and Management sponse with usual doses of an oral drug may need larger of Potassium Imbalances doses or an IV drug. With torsemide, which is highly bioavailable after oral Potassium imbalances (see Chap. Hypokalemia and hyperkalemia are cardiotoxic and clients may be switched from one route to the other should be prevented when possible. In liver disease, small doses of all diuretics are usually may occur with potassium-losing diuretics (eg, hydro- indicated because diuretic-induced electrolyte imbal- chlorothiazide, furosemide). Bumetanide may be a daily of hydrochlorothiazide) useful alternative, because it can be given in smaller b. Sustained-release tablets are usually better mide, the initial dose is usually metolazone 2. Giving a potassium-sparing diuretic along with the sired response is achieved. If an adequate diuretic effect potassium-losing drug occurs with the first dose of metolazone, the dose of d. Hydrochlorothiazide vocate this approach as preferable to supplemental 50 mg may also be used with furosemide and may be potassium or combination diuretic therapy, but its safer than metolazone because of its shorter duration effectiveness is not clearly established. Use in Edema You are working on a cardiac unit, caring for clients after bypass When diuretics are used to manage clients with edema, the surgery. Vellara has Lasix 80 mg ordered bid to pull off extra fluid underlying cause of the edema should be addressed, not just that is retained from the surgery. When managing such clients, it is prefer- you look through the chart as you document the medication you gave. You note that the nursing assistant has charted the following: able to aim for a weight loss of approximately 2 lb (1 kg) per Vital signs: 142/88 (lying) 108/60 (sitting), AP 96 and regular, day. CHAPTER 56 DIURETICS 827 minimal daily requirement of potassium is unknown, kidneys and may increase the incidence of patent ductus arte- usual recommendations are 40 to 50 mEq daily for riosus and neonatal respiratory distress syndrome. Potassium loss with diuretics may furosemide may be given with indomethacin to prevent non- be several times this amount. In both tations for having high potassium content; actually, preterm and full-term infants, furosemide half-life is prolonged large amounts must be ingested. To provide 50 mEq but becomes shorter as renal and hepatic functions develop. Some of these closely monitored in children because of frequent changes in foods are high in calories and may be contraindi- kidney function and fluid distribution associated with growth cated, at least in large amounts, for obese clients. Ototoxicity, which is associated with high Also, the amount of carbohydrate in these foods may plasma drug levels (>50 mcg/mL), can usually be avoided by be a concern for clients with diabetes mellitus. Hyperkalemia (serum potassium level >5 mEq/L) may cause less ototoxicity and thus may be preferred for chil- may occur with potassium-sparing diuretics. The fol- dren who are taking other ototoxic drugs (eg, premature and ill lowing measures help prevent hyperkalemia: neonates are often given gentamicin, an aminoglycoside anti- a. The sium supplements in clients with renal impairment half-life of bumetanide is about 2 hours in critically ill infants b. Avoiding excessive amounts of potassium chloride and 1 hour in children. Maintaining urine output, the major route for elimi- potassium loss and hypokalemia. Spironolactone accumulates nating potassium from the body in renal failure, and dosage should be reduced. Use in Children Use in Older Adults Although they have not been extensively studied in children, diuretics are commonly used to manage heart failure, which Thiazide diuretics are often prescribed for the management often results from congenital heart disease; hypertension, of hypertension and heart failure, which are common in older which is usually related to cardiac or renal dysfunction; bron- adults. Older adults are especially sensitive to adverse drug chopulmonary dysplasia and respiratory distress syndrome, effects, such as hypotension and electrolyte imbalance.