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Given these considerations generic meclizine 25mg with visa treatment variable, potassium is not absorption buy 25mg meclizine visa symptoms jet lag. The pH of commercially available peritoneal dialysis routinely added to the dialysate buy 25 mg meclizine mastercard medicine remix. Once instilled cheap generic meclizine canada xerostomia medications side effects, the pH of the solution rises to values function, lactate is rapidly converted to bicarbonate, so that greater than 7. There is some evidence that the acidic pH of each mM of lactate absorbed generates one mM of bicarbonate. The rapid To avoid negative calcium balance— and possibly to suppress m etabolism of lactate to bicarbonate m aintains the high circulating parathyroid hormone— commercially available peri- dialysate-plasm a lactate gradient necessary for continued toneal dialysis solutions evolved to have a calcium concentration 150 Baseline Low-sodium dialysate High-sodium dialysate Step Linear Interstitial Exponential space BUN H O BUN H2O Cell Cell 2 Intravascular Decreased Stable osmolality space osmolality BUN H O 145 2 BUN Na H2O • Less vascular refilling •↓Peripheral vasoconstriction •Exacerbated autonomic insufficiency -inhibits afferent sensing -↓ CNS efferent outflow •Venous pooling secondary to↑ PGE2 140 Hypotension 1 2 3 4 Time, h of 3. This concentration is equal to or slightly greater than the ionized concentration in the serum of most patients. As a result, there is net calcium absorption in of administered calcium, contributing to the development of most patients treated with a conventional chronic ambulatory hypercalcemia. As a result, there has been increased interest in peritoneal dialysis regimen. As the use of calcium-containing using a strategy similar to that employed in hemodialysis, phosphate binders has increased, hypercalcemia has become a namely, lowering the calcium content of the dialysate. This complication has been particularly common in binders and more liberal use of 1,25-dihydroxyvitamin D to patients treated with peritoneal dialysis, since they have a much effect decreases in the circulating level of parathyroid hormone. In fact, the continual positive calcium balance Dialysate Na in Hemodialysis associated with the 3. The low bone turnover state typical of this disorder impairs accrual 2. The drop in serum osm olality as urea is rem oved leads to a shift of water into the intracellular com partm ent that prevents adequate Indications refilling of the intravascular space. This intracellular m ovem ent of Intradialysis hypotension Cramping Initiation of hemodialysis in setting of severe azotemia Hemodynamic instability (eg, intensive care setting) Contraindications Intradialysis development of hypertension Large interdialysis weight gain induced by high-sodium dialysate Hypernatremia Dialysate Buffer in Hemodialysis water, com bined with rem oval of water by ultrafiltration, leads to contraction of the Acid concentrate intravascular space and contributes to the developm ent of hypotension. H igh-sodium NaCl dialysate helps to m inim ize the developm ent of hypo-osm olality. As a result, fluid can be CaCl m obilized from the intracellular and interstitial com partm ents to refill the intravascular KCL M gCl space during volum e rem oval. O ther potential m echanism s whereby low-sodium dialysate Acetic acid contributes to hypotension are indicated. N a— sodium ; BUN — blood urea nitrogen; Dextrose PGE2— prostaglandin E2. Final dialysate FIGURE 2-2 NaHCO3 Na 137 mEq/L There has been interest in varying the concentration of sodium (Na) in the dialysate during concentrate Cl 105 mEq/L the dialysis procedure so as to minimize the potential complications of a high-sodium solution NaHCO Ca 3. The concentration of sodi- um can be reduced in a linear, exponential, or step pattern. This M ECHANISM S BY W HICH ACETATE BUFFER method of sodium control allows for a diffusive sodium influx early CONTRIBUTES TO HEM ODYNAM IC INSTABILITY in the session to prevent a rapid decline in plasm a osm olality sec- ondary to efflux of urea and other sm all-m olecular weight solutes. During the rem ainder of the procedure, when the reduction in Directly decreases peripheral vascular resistance in approximately 10% of patients osm olality accom panying urea rem oval is less abrupt, the dialysate Stimulates release of the vasodilator compound interleukin 1 is sodium level is set lower, thus m inim izing the developm ent of Induces metabolic acidosis via bicarbonate loss through the dialyzer Produces arterial hypoxemia and increased oxygen consumption? Decreased myocardial contractility Dialysate Composition in Hemodialysis and Peritoneal Dialysis 2. In som e but not all studies, sodi- um m odeling has been shown to be effective in treating intradialysis hypotension and cram ps [5-11]. Use of a sodium modeling program is not indi- cated in all patients. As a result the physician needs to be aware of the benefits as well as the dangers of sodium remodeling. The generation of car- -adrenergic receptor agonists bon dioxide causes the pH of the final solution to fall to approxi- m ately 7. The acidic pH and the lower concentrations in the final m ixture allow the calcium and m agnesium to rem ain in solu- tion. The final concentration of bicarbonate in the dialysate is FIGURE 2-4 approxim ately 33–38 m m ol/L. The current utilization of a bicarbonate dialysate requires a special- ly designed system that m ixes a bicarbonate and an acid concen- trate with purified water. The acid concentrate contains a sm all am ount of lactic or acetic acid and all the calcium and m agnesium. The exclusion of these cations from the bicarbonate concentrate prevents the precipitation of m agnesium and calcium carbonate that would otherwise occur in the setting of a high bicarbonate concentration. During the m ixing procedure the acid in the acid 2. Although bicarbonate is the standard buffer in use phosphate serum calcium secondary today, hem odynam ically stable patients can be dialyzed safely using hyperparathyroidism as acetate-containing dialysis solution. Since m uscle is the prim ary Low-phosphate diet If calcium is still low (800–1000 mg/d) after control of Treat with 1,25(OH) site of m etabolism of acetate, patients with reduced m uscle m ass 2 Phophate binders phosphate, treat with vitamin D tend to be acetate intolerant. Such patients include m alnourished 1,25-(OH)2 vitamin D and elderly patients and wom en. Use calcium-containing phosphate binders Dialysate Potassium in 1. Risk of adynamic bone disease Dialysate Composition in Hemodialysis and Peritoneal Dialysis 2. Since potassium is freely perm eable across the dialysis m em brane, m ovem ent of potassium from the intracellular space to the extracellular space appears to be the limiting factor that accounts for the sm aller fractional decline in potassium concentration at lower plasma potassium concentrations. Presumably, the m ovem ent of potassium out of cells and into the extracellular space is slower than the removal of potassium from the extracellular space into the dialysate, so a COM POSITION OF A disequilibrium is created. The rate of potassium removal is largely a function of its predialysis COM M ERCIALLY AVAILABLE concentration. The higher the initial plasma concentration, the greater is the plasma-dialysate PERITONEAL DIALYSATE gradient and, thus, the m ore potassium is rem oved. After the com pletion of a standard dialysis treatm ent there is an increase in the plasm a concentration of potassium secondary to continued exit of potassium from the intracellular space to the extracellular space in an Solute Dianeal PD-2 attem pt to re-establish the intracellular-extracellular potassium gradient. Sodium, mEq/L 132 FIGURE 2-7 Potassium, mEq/L 0 Chloride , mEq/L 96 Calcium , mEq/L 3. W ithout m echanism s to shift potassium into the cell, sm all potassium loads would lead to severe hyperkalem ia. These m ech- anism s are of particular im portance in patients with end-stage FIGURE 2-8 renal disease since the m ajor route of potassium excretion During a typical dialysis session approxim ately 80 to 100 m Eq/L is elim inated from the body by residual renal clearance and of potassium is rem oved from the body. A, Potassium (K) flux from enhanced gastrointestinal excretion. B, The m ovem ent of potassium between the intra- and extracellular spaces is con- trolled by a num ber of factors that can be m odified during the dial- ysis procedure [17,18]. As com pared with a glucose-free dialysate, a bath that contains glucose is associated with less potassium rem oval. The presence of glucose in the dialysate stim ulates insulin release, which in turn has the effect of shifting potassium into the intracellular space, where it becom es less available for rem oval by dialysis. Dialysis in patients who are acidotic is also associated with less potassium rem oval since potassium is shifted into cells as the serum bicarbonate concentration rises. Finally, patients treated with inhaled stim ulants, as for treatm ent of hyperkalem ia, will have less potassium rem oved during dialysis since stim ulation causes a shift of potassium into the cell.
Striatal meta- continual dose increases to sustain efficacy purchase discount meclizine line medicine in the middle ages. Thus order meclizine toronto symptoms synonym, treatment bolic rate and clinical response to neuroleptics in schizophrenia buy meclizine 25mg with mastercard medications 2355. Neuro- to its effects for treatment to sustain action generic meclizine 25 mg with mastercard medicinebg. The mechanism chemical evidence for antagonism by olanzapine of dopamine, of therapeutic action has always been thought related to the serotoin, adrenergic and muscarinic receptors in vivo in rats. Because the biology of TD Psychopharmacology (Berl) 1996;124:87–94. Extrapyramidal syndromes in nonhuman primates: Based on a continuation of this reasoning, other GA- typical and atypical neuroleptics. Psychopharmacol Bull 1991; BAmimetics have been tested in TD (60). The nonhuman primate model: focus on dopamine in TD, in which the GABA agonist action is potent enough D2 and serotonin mechanisms. Coppenha- to be antidyskinetic but the side effects are not limiting. Valproic acid has not been shown to be an effective thera- 11. Pharmacological characterization of tar- peutic agent in TD, presumably because of its low potency dive dyskinesia. Gamma-acetylenic and tetrahydroisoxazolopyridinol, have shown antidyski- GABA in tardive dyskinesia. Studies in older volunteers have not demon- Biochem Psychopharmacol 1980;24:335–340. Primate models of movement disorders of basal tested, it is generally believed that symptoms are more likely ganglia origin [Review]. Pharmacologic and neuro- tient than in the older one. Tardive dyskinesia: possible involve- such as propranolol or clonazepan, amantadine (5), and cal- ment of free radicals and treatment with vitamin E. Schizophr cium channel blockers, especially nifedipine (58). Tremorous mouth movements in rats administered chronic neuroleptics. Psychopharmacology developed into a therapeutic approach. Treatments for TD will always be needed, even though 19. The dose-response the incidence of new cases may fall significantly with time. Tiagabine inhibits haloperidol-induced oral dyskinesias in rats. J Neural Transm likely to be found in the GABAergic or the glutamatergic Gen Sect 1994;95:63–69. Chronic olanzapine or ser- tindole treatment results in reduced oral chewing movements in rats compared to haloperidol. Dopaminergic hypersensitivity and cholinergic hypofunction in the pathophysiology of tardive 1. Persistent vacuous chewing in rats following neuro- proposed circuit mechanism. Intermittent neuroleptic treat- dyskinesia among long-term outpatients maintained with neu- ment induces long-lasting abnormal mouthing in the rat. Eur roleptic medications: results of the Yale Tardive Dyskinesia J Pharmacol 1989;164:393–396. Ultrastructural corre- zation block as a model for the therapeutic actions of antipsy- lates of haloperidol-induced oral dyskinesias in rat striatum. Graybiel AM: Neurotransmitters and neuromodulators in the 48. Scopolamine fails to dimin- chotic drug administration. Pharmacol Biochem Behav 1986;25: ish chronic haloperidol-induced purposeless chewing in rats. Clonazepam in treatment of tardive oral dyskinesia lowing brain lesions and neuroleptic drug administration. Reductions of nigral glutamic acid in drug-naive and chronic haloperidol-treated rats. Pharmacol decarboxylase in rats withneuroleptic-induced oral dyskinesia. Association with persis- antipsychotic drugs and dopamine: direct binding assays. Proc tent neuroleptic- induced dyskinesia of regional changes in brain Natl Acad Sci USA 1975;72:4376–4380. Basal ganglia GABAA and dopa- schizophrenia relates to clinical features. Arch Gen Psychiatry mine D1 binding site correlates of haloperidol-induced oral 1995;52:657–667. The treatment of tardive dyskinesia and tardive tion of haloperidol-induced oral dyskinesias in the rat supports dystonia. Vitamin E for neuroleptic-induced ies with and without haloperidol. In search of treatment for tardive dyskinesia: review 60. Risk of tardive dyski- Database Syst Rev 2000;CD000203. Low incidence of tardive dyskinesia: a study in three rat strains. Psychopharmacol- persistent tardive dyskinesia in elderly patients with dementia ogy (Berl) 1990;102:474-478. Drug-induced oral dyskine- treatment improves tardive dyskinesia [Letter]. Lancet 1983;2: sias in rats after traditional and new neuroleptics. The incidence of tardive dyskinesia: observations from human and animal model tardive dyskinesia: the Hillside Prospective Study. Integrating inci- ment of tardive dyskinesia: a practical GABAmimetic strategy. Psychopharmacol Bull Am J Psychiatry 1990;147:445–451. Diagnosis and drug treatment of psychiatric aminobutyric acid abnormality in tardive dyskinesia: reduction disorders.
In contrast purchase meclizine 25 mg without prescription shakira medicine, Mar- Chapter 116: Psychopharmacology of Eating Disorders 1681 cus and associates (84) found that when combined with a 3 purchase meclizine line treatment definition math. Eating disorders: clinical presentation purchase 25 mg meclizine with amex medications that cause weight gain, classification and aetiological models meclizine 25 mg otc medicine cabinets recessed. In: Jimerson D, Kaye WH, behavioral weight loss program, fluoxetine was associated eds. The case for biology in aetiology of anorexia nervosa. The validity of frequency or weight in obese binge eaters. Stunkard and co-workers (86) found that the restricter distinction in anorexia nervosa: parental personality characteristics and family psychiatric morbidity. J Nerve Ment appetite suppressant d-fenfluramine, which has since been Dis 1982;170(6):345–351. Personality features of women with good outcome cebo among 28 obese women with BED in reducing binge from restricting anorexia nervosa. Psychosom Med 1990;52(2): frequency; however, surprisingly, not in promoting weight 156–170. Nevertheless, fluvoxamine compared with placebo was orexia nervosa after long-term weight restoration: response to associated with significant reductions in both binge fre- d-fenfluramine challenge. Personality and symptomatological features in young, in particular. Approximately one-third of obese individuals nonchronic anorexia nervosa patients. J Psychosom Res 1980; presenting to weight loss clinics meet diagnostic criteria for 24(6):353–359. BED; therefore, effective treatments for this disorder may 12. Personality variables and disorders in an- orexia nervosa and bulimia nervosa. J Abnorm Psychol 1994; be of widespread clinical utility. Am J Psychia- ber of important issues are unresolved. BED have disturbances in eating behavior by definition, 14. Ten-year follow-up of 50 patients with bu- and are typically overweight and exhibit symptoms of anxi- limia nervosa. Bulimia nervosa: a 5- ety and depression in clinical samples. Alterations in serotonin it is surprising that the response of these presumably related activity and psychiatric symptomatology after recovery from bu- symptoms to medication is at least somewhat inconsistent, limia nervosa. Outcome, recovery, relapse and mor- tality across six years in patients with clinical eating disorders. A major problem in the develop- Psychiatr Scand 1993;87(6):437–444. L-Dopa as treatment for anorexia ner- response of binge eating to nonspecific interventions, in- vosa. In part for this reason, the effects of medi- Press, 1977:363–372. Treatment of compulsive eating disturbances once medication has been discontinued. Am J Psychol 1974;131: the role of pharmacotherapy for BED currently unresolved, 428–432. The use of diphenylhydantoin in compulsive studies to examine the potential benefits of combining med- eating disorders: further studies in anorexia nervosa. New York: Raven Press, 1977: ication with psychological treatment, especially CBT. Naloxone in the treatment of REFERENCES anorexia nervosa: effect on weight gain and lipolysis. In: Kaplan HI, Freedman AM, noses in anorexia nervosa. Comprehensive textbook of psychiatry, vol 2, 3rd 712–718. A comparative psychometric family therapy in anorexia nervosa and bulimia nervosa. Arch study of anorexia nervosa and obsessive neurosis. Long term follow-up of therapy in the short-term treatment of anorexia nervosa. Neuroleptics in the short-term treatment of vosa in women with obsessive compulsive disorder. Int J Eating anorexia nervosa: a double-blind, placebo controlled study with Dis 1986;5:1069–1075. J Clin Psy- activity in anorexia nervosa after long-term weight restoration. Obsessive-compulsive disorder: psychobiologi- treatment of anorexia nervosa. Int J Eating Dis 2000;27(3): cal approaches to diagnosis, treatment, and pathophysiology. Antiserotonin-antihista- 9-tetrahydrocannabinol in primary anorexia nervosa. J Pharmacol Exp Ther 1961; chopharmacol 1983;3:165–171. Cyproheptatadine in an- crossover study of oral clonidine in acute anorexia nervosa. Biol Psychiatry 2001;49(7): cisapride accelerates delayed gastric emptying and increases antral 644–652. Does fluoxetine augment the Garner DM, Garfinkel PE, eds. Diagnostic issues in anorexia ner- inpatient treatment of anorexia nervosa? Effects of carbohydrate depressive illness: a review of 11 studies. Comp Psychiatry 1988; and protein meals on plasma large neutral amino acids, glucose 29:427–432. Am J Psychol weight subjects normalize after weight gain. Amitriptyline in the increases serotonin transporter (SERT) binding sites and SERT treatment of anorexia nervosa: a double-blind placebo-controlled mRNA expression in discrete regions of female rat brain.
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MALENKA The most fascinating and important property of the mam- SHORT-TERM SYNAPTIC PLASTICITY malian brain is its remarkable plasticity, which can be thought of as the ability of experience to modify neural Virtually every synapse that has been examined in organisms circuitry and thereby to modify future thought, behavior, ranging from simple invertebrates to mammals exhibits nu- and feeling. Thinking simplistically, neural activity can merous different forms of short-term synaptic plasticity that modify the behavior of neural circuits by one of three mech- last on the order of milliseconds to a few minutes (for de- anisms: (a) by modifying the strength or efficacy of synaptic tailed reviews, see 1 and 2). In general, these result from a transmission at preexisting synapses, (b) by eliciting the short-lasting modulation of transmitter release that can growth of new synaptic connections or the pruning away occur by one of two general types of mechanisms. One of existing ones, or (c) by modulating the excitability prop- involves a change in the amplitude of the transient rise in erties of individual neurons. Synaptic plasticity refers to the intracellular calcium concentration that occurs when an ac- first of these mechanisms, and for almost 100 years, activity- tion potential invades a presynaptic terminal. This occurs dependent changes in the efficacy of synaptic communica- because of some modification in the calcium influx before tion have been proposed to play an important role in the transmitter release or because the basal level of calcium in remarkable capacity of the brain to translate transient expe- the presynaptic terminal has been elevated because of prior riences into seemingly infinite numbers of memories that activity at the terminal. A second mechanism occurs down- can last for decades. Because of its fundamental importance, stream of calcium elevation in the presynaptic terminal and there has been an enormous amount of work describing involves some modulation of the biochemical processes in- the many forms of synaptic plasticity and their underlying volved in synaptic vesicle exocytosis. Synaptic transmission can either be enhanced or de- Paired-Pulse Facilitation and Depression pressed by activity, and these alterations span temporal do- mains ranging from milliseconds to enduring modifications When two presynaptic stimuli are delivered within a short that may persist for days or weeks and perhaps even longer. More lasting changes are thought to play impor- vals. Given these diverse functions, it is not sur- presynaptic plasma membrane, waiting to be released. Many prising that many forms and mechanisms of synaptic plastic- synapses at longer interstimulus intervals (20to 500milli- seconds) exhibit paired-pulse facilitation that is thought to ity have been described. In this chapter, I provide a brief result from the influx of calcium that occurs in response to overview of some of the forms of synaptic plasticity found the first action potential. Malenka: Department of Psychiatry and Behavioral Sciences, tial facilitation. However, with a single action potential, the Stanford University School of Medicine, Palo Alto, California. Furthermore, given that presynaptic pro- there is much interest in the possibility that transient modu- teins that may be involved in short-term plasticity may be lation, by activation of protein kinases, of some of the pre- abnormal in neuropsychiatric disorders (11), it is not unrea- synaptic phosphoproteins that are known to be involved in sonable to speculate that abnormal short-term synaptic dy- the control of transmitter release may play an important namics in specific neural circuits may contribute to the path- role in very short-term synaptic plasticity. For example, ophysiology of any number of mental illnesses. Whether a specific synapse displays paired-pulse facilita- During the last decade, there was enormous interest in eluci- tion or depression depends on the initial state of the synapse dating the mechanisms responsible for activity-dependent and its recent history of activation. Because these forms of long-lasting modifications in synaptic strength. The great plasticity largely result from changes in the probability of interest in this topic is largely based on the simple idea that transmitter release, synapses that begin with a very high external and internal events are represented in the brain as probability of release tend to show depression, whereas those complex spatiotemporal patterns of neuronal activity, the with a low probability of release exhibit facilitation. Consis- properties of which result from the pattern of synaptic tent with this idea, activation of presynaptic receptors that weights at the connections made between the neurons that cause a decrease in transmitter release almost always causes are contributing to this activity. The corollary to this hy- an increase in the magnitude of paired-pulse facilitation (or pothesis is that new information is stored (i. This simple idea was put forth by Ramon y Cajal almost 100 years ago, but experimental support for such a process was lacking until Facilitation and Depression Following the early 1970s, when it was demonstrated that repetitive Trains of Stimuli activation of excitatory synapses in the hippocampus caused Longer-lasting forms of plasticity are observed following re- an increase in synaptic strength that could last for hours or petitive or tetanic stimulation of synapses with prolonged even days (12,13). This long-lasting synaptic enhancement, (approximately 200-millisecond to 5-second) trains of stim- LTP, has been the object of intense investigation because uli applied at high frequencies (10to 200Hz). Augmentation it is widely believed that LTP provides an important key and posttetanic potentiation refer to enhancements of trans- to understanding the molecular mechanisms by which mitter release that can last anywhere from seconds (augmen- memories are formed (14,15) and, more generally, by which tation) to several minutes (posttetanic potentiation). Furthermore, the activity- are thought to result in large part to the buildup of calcium and experience-dependent refinement of neural circuitry concentration in the presynaptic terminal during the trains that occurs during development shares features with learn- of stimuli.
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