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By E. Marcus. Bethany College, West Virginia.

Considerations for Drugs with Minimal or Unknown Teratogenic Effect Breast-Feeding Drug Maternal Considerations Fetal Considerations Considerations Analgesics Whole category (aspirin 3mg stromectol otc, Y Lack of consensus regarding — — acetaminophen discount stromectol 3 mg otc, management of women who ibuprofen) have both antiphospholipid antibodies and a history of recurrent pregnancy loss reflects the wide range of clinical manifestations. Y A large cohort study concluded the antenatal use of nonsteroidal antiinflammatory drugs such as ibuprofen, naproxen, and aspirin but not acetaminophen increased the risk of spontaneous abortion. Y Compatible with demonstrate low-dose aspirin’s Y Associated with an breast-feeding. Considerations for Drugs with Minimal or Unknown Teratogenic Effect (continued) Breast-Feeding Drug Maternal Considerations Fetal Considerations Considerations Analgesics Y Prescribed to reduce the risk of Aspirin (continued) maternal thrombosis: – alone is not sufficient to prevent thrombosis. Y Use for prevention of preeclampsia also remains controversial: – several meta-analyses suggest a modest reduction in preeclampsia and intrauterine growth restriction. Considerations for Drugs with Minimal or Unknown Teratogenic Effect (continued) Breast-Feeding Drug Maternal Considerations Fetal Considerations Considerations Ibuprofen (Advil, Alaxan, Y Drug of choice for management Y Crosses human placenta. Y Compatible with Brofen, Motrin, of postabortal pain, acute Y Fetal levels are dependent on breast-feeding. Antibiotics Penicillin-G Y Penicillin and its derivatives Y Most penicillins cross Y Trace amounts enter (ampicillin, cephalosporins) are safe human placenta. Y Oxytetracycline (but not Y When penicillins and doxycycline) is associated fluoroquinolones are with an increased risk of contraindicated, erythromycin(a neural tube defects, cleft tetracycline-class agent without the palate, and cardiovascular fetal sequelae) is an alternative for defects. Considerations for Drugs with Minimal or Unknown Teratogenic Effect (continued) Breast-Feeding Drug Maternal Considerations Fetal Considerations Considerations Ciprofloxacin (Ciloxan, Y Bacteriocidal antibiotic Y Only a small fraction of Y Concentrated in human Cipro) belonging to the fluoroquinolones breast milk. Centers for Disease Control dysfunctions reported in and Prevention as first-line therapy children in utero. Y Because these studies gov/std/treatment/2006/updated- included a relatively small regimens. Y Excreted into human to treat bacterial vaginosis, Y Does not appear to have a breast milk. Considerations for Drugs with Minimal or Unknown Teratogenic Effect (continued) Breast-Feeding Drug Maternal Considerations Fetal Considerations Considerations Metronidazole (Flagyl) – metronidazole failed to prevent (continued) preterm birth in women with asymptomatic trichomoniasis. Nitrofurantoin Y Safe and effective for the Y Unknown whether it Y Actively transported into (Furadantin, treatment of asymptomatic crosses the human human milk. Y Clinical experience Macrodantin, recurrent urinary tract infections: Y Generally considered suggests that maternal oral Macrobid) – resistance rates are less than compatible with pregnancy. Y No evidence of being a with neonatal adverse – women with recurrent urinary human teratogen. Y Remains unclear how long a woman with asymptomatic bacteriuria should be treated; some suggest that short-term administration combined with continued surveillance for recurrent bacteriuria is sufficient. Azithromycin (Aruzilina, Y Treatment of choice for Y Less than 3% of maternally Y Small amounts are Zithromax) chlamydia. Y No adverse effects reported Y No neonatal adverse effects Y Proved an ineffective treatment to in humans. Y When combined with doxycycline, it reduces the risk of postcesarean endomyometritis. Considerations for Drugs with Minimal or Unknown Teratogenic Effect (continued) Breast-Feeding Drug Maternal Considerations Fetal Considerations Considerations Anucholinergics Whole category Y This class of pharmaceutical — — (albuterol, atropine, compounds reduces the effects dimenhydrinate) mediated by acetylcholine in the central and peripheral nervous systems. Albuterol (Proventil, Y Previously used for asthma control Y Crosses the human placenta, Y Unknown whether it enters Ventolin) during pregnancy. Y In some countries, the drug is used as when administered by a tocolytic agent but there is no inhalation. Y In general, long-term follow- up studies of infants exposed to beta-mimetic tocolysis are reassuring. Atropine (Atropen, Y No adequate reports or well- Y Rapidly crosses the human Y Unknown whether it enters Atropinol, Atropisol, controlled studies in pregnant placenta. Y Fetus will respond to the Y Generally used for treatment of direct administration of this symptomatic bradycardia and medication with tachycardia. Dimenhydrinate (Amosyt, Y Popular agent for the relief of Y Unknown whether it Y Excreted in small quantities Biodramina, Dimetabs, nausea and vomiting during crosses human placenta. Y No indication that this drug the kinetics are yet to be Y Recent randomized trial concluded increases the risk of fetal elucidated. Considerations for Drugs with Minimal or Unknown Teratogenic Effect (continued) Breast-Feeding Drug Maternal Considerations Fetal Considerations Considerations Whole category Y There is no consensus whether (methyldopa, lesser degrees of hypertension hydralazine, labetalol, require treatment during propanolol) pregnancy because (continued) antihypertensive therapy improves only the maternal, not the fetal, outcome in women with mild to moderate chronic hypertension. Y Breast-fed neonates are pregnancy, remaining a popular Y Considered safe for use normotensive. Y Other studies suggest the drug decreases placental vascular resistance in mild preeclampsia and in chronic hypertension.

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These approaches allow the patient to confront computer- generated representations of the phobic target trusted 3mg stromectol. The virtual environment is thought to create a sufficient “sense of presence” (Rothbaum et al purchase stromectol 3mg free shipping. One aim of the treatment is to change the cognitions regarding the trauma from negative to more positive (see Shapiro, 1989, 1995 for protocol details). In fact, some have argued that the effects of this technique are attributable entirely to the imaginal exposure component (Pitman et al. Patients are exposed to blood/injury stimuli in a graduated fashion while being instructed to tense their muscles in order to raise their blood pressure, thereby preventing fainting in the presence of blood or injections (Öst et al. Aims of this meta-analysis Our overarching objective was to provide a quantitative meta-analysis of the efficacy research on psychosocial treatments for specific phobia. Based on the available published studies, the following efficacy-related questions lent themselves to K. Our decision to synthesize the data in a qualitative meta-analysis to address these questions was based on several factors. First, single studies do not provide definitive evidence on which to influence policy or practice (Hedges & Olkin, 1985). For example, some studies show cognitive augmentation strategies clearly enhance exposure treatment (e. A first step toward assessing the utility of psychosocial treatments for specific phobias is to tease apart the relative contributions of treatment and non-specific factors. There is considerable variance in the effect sizes of psychosocial treatments relative to placebo and no-treatment controls. Because exposure treatments represent the most widely studied treatment of specific phobia, a sufficient number of studies were available to separately examine their efficacy relative to (a) no treatment; (b) a placebo control; and (c) psychotherapies that do not include an exposure component. Moreover, several studies manipulated parameters of exposure treatment to evaluate ways to enhance its efficacy. The decision to test these comparisons was based entirely on the availability of studies. Several studies of truly non-exposure psychosocial treatments were located, which allowed us to estimate their efficacy relative to no treatment. However, there were too few studies to compare non-exposure treatments to placebo. Effect size moderators The available studies were markedly heterogeneous on a number of dimensions, such as specific phobia subtype, treatment dose, and level of therapist involvement. For those comparisons showing statistically significant hetero- geneity, we examined whether these factors significantly influenced estimates of treatment efficacy. Unlike many other disorders, specific phobias can display significant symptom reduction in doses as low as a single session (e. An understanding of the dose– response relationship can be useful for both treatment planning and for a theoretical understanding of fear reduction. None of the studies meeting inclusion criteria investigated treatment efficacy across more than one specific phobia subtype. However, these conclusions were qualitative and were based on a very small number of studies. Consequently, we included phobia type as a putative moderator of treatment outcome. However, because of the public health significance associated with self-administered treatment delivery, we examined this exposure parameter as a putative moderator of treatment efficacy. Based on past research suggesting that date of publication may influence effect sizes of randomized treatment studies (Abramowitz, 1997), we examined whether date of publication moderated the effect sizes for the comparisons of interest. Selection of studies We began by searching all published reports of randomized treatment studies of psychosocial interventions for specific phobia. These searches were limited to peer-reviewed, English language journals, with only adult participants. We then examined the abstracts of these 988 articles, and identified 46 articles that provided descriptions consistent with the study inclusion criteria (see below). Next, we examined the reference sections of the 46 articles and selected an additional 14 articles that appeared to qualify for inclusion. Of the 37 remaining studies, eight studies did not report statistics that would allow for the calculation of effect sizes.

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David Lambert stromectol 3mg sale, Staff Pediatric Anesthesiologist Winnipeg Children’s Hospital Director of Pediatric Acute Pain Services order stromectol 3mg mastercard, Pediatric Palliative Care Rhonda Fusee, Program Support Manager, Pharmacy, St. Boniface Hospital Lindsay Filz, Clinical Pharmacist, St Boniface Hospital Matthew Bailly, Department of Clinical Health Psychology, University of Manitoba School of Medicine Tim Frymire, Coordinator of Spiritual Care, Riverview Health Centre Lisa Demczuk, Librarian, Victoria General Hospital, University of Manitoba National Reviewer: Dr. These guidelines are produced and published by the Winnipeg Regional Health Authority. These guidelines may be reproduced, in whole or in part, provided the source is cited. Acute Pain The normal, predictable, appropriate response to a noxious stimulus or disease process that threatens or produces tissue injury, and that abates following remission of the stimulus or healing of the injury. Addiction Is a chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is refected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by an inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of signifcant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. Adjuvant Co-Analgesics Nonopioid medications that enhance the analgesia provided by analgesics through mechanisms aimed at the source of transmission of pain, resulting in better pain control and/or fewer adverse efects than treatment with analgesics alone. Adverse Efect Can be termed as “side efect” when judged to be secondary to a main or therapeutic efect but also refers to an unpleasant symptom or event that is due to or associated with a medication such as impairment decline in the individual’s mental or physical condition, and/or functional or psychosocial status. Breakthrough Pain A transitory fare of pain of moderate to severe intensity occurring on a background of otherwise controlled pain. Cancer pain depends upon the type of cancer, the stage (extent) of the disease, and the pain threshold (tolerance for pain) of the patient with cancer. Ceiling Efect The property of increasing doses of a given medication to have progressively smaller incremental efect. It is often accompanied by emotional (depressive) symptoms but objective physiological signs are sometimes absent. Consultation Is an evaluation of a patient with recommended treatment options with the patient, then returning to primary care of physician for implementation of recommendations. Incident Pain Pain which comes on as a result of an action or activity (such as planned turns, transfers/ambulation, bathing, changing clothes, dressing changes, disimpaction). Incomplete Cross-Tolerance A person who has been taking an opioid for an extended period of time may develop a degree of tolerance to it; however, when converting to another opioid, only a part of this tolerance may carry over to the new drug. Therefore, after calculating the required dose of the new drug to achieve an equianalgesic efect, the dose may need to be lowered by up to 50%. Because it is difcult to predict on an individual basis what the equianalgesic dose should be, any opioid conversion requires close monitoring. Multi-Modal Treatments Is related to, having, or utilizing more than one mode or modality. For example, multi-modal pain management involves a variety of approaches including medications, behavioral and cognitive strategies. Neuropathic Pain Pain caused by a lesion or disease of the somatosensory nervous system. Neuropathic pain is divided into ‘peripheral’ (originating in the peripheral nervous system) and ‘central’ (originating in the brain or spinal cord). Neuropathic pain is often described as “burning, tingling, electrical, stabbing or pins and needles”. Glossary 3 Nociceptive Pain Arises from stimulation of pain receptors within tissue, which has been damaged or involved in an infammatory process. Nociceptive pain may be divided into: a) Somatic pain - generally well-localized pain that results from the activation of peripheral nociceptors without injury to the peripheral nerve or central nervous system, characterized by sharp, hot or stinging pain which is usually localized to the area of injury. It is felt as a poorly localized aching or cramping sensation and is often referred to cutaneous sites.

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