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The following casuzl support this premise. December 23, Free casual dating in harmony mn 55939 Ed, Just a note to thank you for helping with the insulin vial shapes and markings. From my letter to the Commissioner, Dr. Kessler, you can see what RNs and MDs are facing with the small print on the vials. Sometimes the print is so tiny, I use a magnifying glass to identify the words. It is really unsafe and I blame drug companies for not being creative enough to overcome this problem. I have diabetes type II and I appreciate very much what you are doing for us. Due to its clarity, it is being recarried. February 2, Dear Mr. A recent issue of Voice of the Diabetic was forwarded to me by one of your readers.
The article about insulin vial configurations caught my eye. Our institute has an agreement with the United Sates Pharmacopeia, Inc. The idea is to educate one another about medical errors in the hope that such knowledge will help reduce the incidence. We are in support of your proposal to change insulin vial configurations in order to reduce dosage errors. This would be helpful to health care practitioners as well as diabetic patients. Unfortunately, mistakes in choosing proper containers are occasionally made by practitioners, so we too could use the help that tactile features would provide. For example, we have had mix-ups reported where vials of regular insulin were improperly placed into an NPH cardboard outer package and later used accidentally for NPH.
While we recommend that the cardboard box be discarded when a new vial is opened, shaping the various insulin vials differently would add an important layer of safety. We are aware of other medication containers that provide tactile barriers against error. The Burroughs Wellcome Company packages the muscle relaxant Tracrium in a hexagonally shaped vial.
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Since this drug is used to induce complete paralysis during surgery, accidentally giving it to someone who is not simultaneously receiving artificial ventilation will cause respiratory arrest. The odd shape reduces the possibility that Tracrium will ever be confused with another drug. Thank you for your efforts to improve the level of safety of insulin administration. Please let me know Jessica daniels naked I can be of assistance.
A Review by Joseph Tripodi, D. From the Voice Editor: Although the following article is highly technical, it provides valuable information for laypersons as well as health professionals. For people with diabetes who are experiencing problems with digestion, this information may be beneficial. Sluts in southowram, many physicians will be able to better serve patients after reviewing this article. If you are a diabetic, I urge you to share this report with your doctor. He or she may be enlightened and better able to serve patients.
Gastroparesis is a motility disorder that results in delayed emptying of gastric contents without evidence of outlet obstruction. Diabetes mellitus remains one of the most common conditions associated with delayed gastric emptying, especially in those patients with known autonomic neuropathies. Providing relief of clinical symptoms while maintaining adequate nutrition and good blood glucose control is a challenging problem. Advances in the understanding of gastric motility and improvements in diagnostic techniques have aided the clinician in making the diagnosis. The recently developed drug therapies have dramatically altered the treatment strategy. Pathophysiology The stomach can be considered in two physiologic parts: The proximal stomach acts as a reservoir for food and adaptively dilates in response to gastric distention.
This adaptation occurs by inhibition of the basal gastric contraction and is abolished after vagotomy is performed. Free casual dating in harmony mn 55939 gastric contractions are regulated by a pacemaker found on the greater curve of the upper body. The pacemaker generates depolarizing events that are propagated to the pylorus cyclically at a rate of per minute. Action potentials are stimulated on top of these depolarizing events by the presence of food and neurotransmitters. Action potentials cause muscular contractions that increase in amplitude and velocity as they move distally. As the peristaltic wave approaches the antrum, the pylorus closes, causing mixing and grinding of solid food.
Solids are finally emptied after being altered to a chymelike consistency. Liquids are emptied down a pressure gradient created by the basal tonic pressure in the stomach. Indigestible solid material is emptied by a fasting electro-mechanical activity known as the migrating motor complex, which occurs every two hours. Busty naked mums which are important in the rate of gastric emptying are summarized in Figure 1. In diabetes, Sex partner in lahore abnormalities can account for abnormal gastric emptying.
These abnormalities include increased Tight babes fucking pyloric tone, the absence of the interdigestive migrating motor complexes, and the presence of antroduodenal incoordination. Some studies in people with diabetes have shown that morphological damage to the vagus nerve and elevated blood glucose levels may be responsible for delayed gastric emptying. Clinical Presentation Gastroparesis is usually a complication of long-standing insulin-dependent diabetes.
However, using modern diagnostic techniques, abnormal gastric motility can be detected in a greater number of patients and often before clinical symptoms are apparent. Liquids usually empty from the stomach quickly in the first 15 minutes in the majority of diabetic patients. This is due to the lack of the normal adaptive relaxation of the proximal stomach. It is the ingestion of solid foods that usually produces gastrointestinal symptoms in most diabetics with gastroparesis. Indigestible food matter retained in the stomach can lead to the formation of bezoars due to the lack of migrating motor complexes. Symptoms are often nonspecific and do not correlate well with the degree of delay in Free casual dating in randall ia 50231 emptying.
Epigastric pain, nausea, vomiting, early satiety, belching, postprandial fullness, and weight loss are among the symptoms that suggest the diagnosis. Gastroparesis is usually associated with other evidence of autonomic dysfunction such as postural hypotension, abnormal response to the Valsalva maneuver, bladder dysfunction, and impotence. Constipation and diarrhea may also be found. The presence of a succession splash over the left upper quadrant on physical exam may indicate a problem with gastric emptying, but it is neither sensitive nor specific for the diagnosis of diabetic gastroparesis.
A careful search should be conducted to determine the etiology of gastroparesis Figure 2. Upper-gastrointestinal endoscopy is recommended as the primary diagnostic procedure for this purpose. Endoscopy defines anatomic gastric outlet obstruction and can exclude morphological lesions, including ulcers or tumors. Endoscopy may also be therapeutic in the presence of bezoars or retained food particles. Endoscopy is not useful, however, for detecting motility disorders. Gastric emptying can be measured by intubative techniques, radiological techniques, or radioisotopic techniques. The saline load test is an intubative technique that requires the insertion of a nasogastric tube and instillation of cc of saline into the stomach.
Recovery of more than cc of fluid 30 minutes later is indicative of gastric retention. Though easy to perform, the test can only assess liquid emptying and therefore is of limited value in patients with diabetic gastroparesis as liquid emptying is usually normal in these patients. Radiological techniques assess the emptying of liquid barium sulfate or radiopaque solid meals. Unfortunately, only the time of complete emptying of the stomach can be measured, as residual barium cannot be accurately quantified. Furthermore, barium-impregnated food may not reflect solid emptying, as the barium granules rapidly disassociate into a liquid phase.
The radioisotope method using external scanning has proven to be a reliable, non-invasive technique for quantitatively measuring gastric emptying. The most widely used radioisotope is technetium 99m 99m Tc. Technetium 99m bound to sulfur colloid is injected into a live chicken. Ninety percent of the colloid is taken up by the liver. The liver is cooked and then ingested by the patient on an empty stomach as a test meal. In our hospital, the meal consists of 7. The radiation exposure is considered well within the tolerable range.
External scanning is begun at 1 minute and recorded continuously for 2 hours for solids and 20 minutes for liquids. It is also possible to record both liquid-phase and solid-phase gastric emptying simultaneously using dual radioisotopes. This diagnostic technique also allows assessment of response to prokinetic drugs. Most authorities now agree that the radioisotope gastric-emptying scan is essential to secure the diagnosis of gastroparesis. Measurements of gastric impedance using cutaneous electrodes or the use of real-time ultrasound have yet to achieve a role in clinical practice.
Treatment The main goal of therapy for gastroparesis is to promote gastric emptying of solid food. First, treatment should be directed toward correction of fluid and electrolyte imbalance. Large meals should be replaced by small meals, which are better tolerated in gastroparesis. Indigestible foods, such as green vegetables or other high-fiber foods, may induce postprandial symptoms and should be avoided. Associated factors contributing to delayed gastric emptying should be treated; these include concomitant peptic ulcer disease and reflux esophagitis. The administration of anticholinergic and narcotic drugs should be discontinued if possible.
Drug therapy remains the mainstay of treatment for this disorder, and several prokinetic drugs have recently been approved to expand the pharmacologic armamentarium. Bethanechol, a cholinergic agent, was used initially for the treatment of gastroparesis because earlier studies showed that it increased the frequency and amplitude of gastric contractions, but radionuclide studies failed to confirm accelerated transit times. The inconsistent data and an unfavorable side-effect profile has led many physicians to abandon its use as a prokinetic agent. Metoclopramide, a procainamide derivative, has strong cholinergic and antidopaminergic effects.
The drug significantly accelerates gastric emptying by inhibiting fundic receptive relaxation and coordinating gastric, duodenal, and pyloric motility. In diabetic gastroparesis, the drug also activates peristalsis by initiating previously absent interdigestive migrating motor complexes. Metoclopramide exhibits an antiemetic effect by passing through the blood-brain barrier and directly influencing the chemotactic trigger zone. Therapy with metoclopramide has been shown to evoke symptomatic relief of diabetic gastroparesis even without simultaneous improvement in gastric emptying. This improvement may be explained by its central effects on the chemotactic trigger zone.
The usual dosage is 10 mg orally four times a day, given approximately minutes before each meal and at bedtime. Improved gastric emptying of solids and liquids in diabetic gastroparesis has also been demonstrated with intravenous metoclopramide at similar dosages. Severe gastroparesis unresponsive to oral metoclopramide has been reported to respond to rectal administration. Although metoclopramide is effective initially, there are two uncontrolled studies on a small number of patients that indicate the therapeutic effect may partly disappear with long-term therapy. Further investigation needs to be done before a final recommendation can be made regarding long-term treatment.
Metoclopramide should not be used in patients with intestinal obstruction, perforation or hemorrhage, Parkinsonism, or epilepsy. Domperidone, a benzimidazole derivative, is a powerful prokinetic agent that acts by blocking dopamine inhibition of acetylcholine release at dopamine D2 receptors located on postganglionic cholinergic neurons. Short-term therapy with intravenous or oral domperidone improves gastric emptying of liquids and solids, but long-term administration enhances liquid emptying only. While gastric emptying of solids appears unchanged with long-term therapy, patients do have some symptomatic relief. The most commonly studied dose is 20 mg taken orally four times per day.
However, dosages as low as 10 mg four times a day were successful in improving symptoms in patients with diabetic gastroparesis that was unresponsive to metoclopramide. Intravenous administration has been associated with cardiac arrhythmias and is not recommended. A major advantage of the drug is that it does not cross the blood-brain barrier and therefore has fewer CNS side effects. Other side effects include dry mouth, transient skin rash, headache, diarrhea, and nervousness. Although domperidone has been used successfully in Canada, at this time it is not currently approved by the FDA for use in the United States. Cisapride, a substituted piperidinyl benzamide, is a new class of drug that does not have antidopaminergic properties but is believed to increase gastric motility by enhancing the release of acetylcholine from the myenteric plexus in the gut.
In vitro studies demonstrate that cisapride as well as metoclopramide have 5-hydroxytryptamine 5-HT4 receptor agonist activity, and this may in part explain their prokinetic activity. In healthy volunteers, cisapride has been found to increase antral and duodenal contractions and improve antroduodenal coordination. Studies in people with diabetes illustrate that the effects of cisapride both oral and IV are dose related and correlate well with plasma drug levels. The improvement of solid-phase gastric emptying with cisapride was greater than that with metoclopramide at similar doses. In contrast to metoclopramide and domperidone, long-term administration of cisapride has been associated with improved gastric emptying and symptom control for greater than one year.
Two placebo-controlled double-blind trials conducted exclusively on patients with diabetic gastroparesis have demonstrated accelerated gastric emptying and improved symptoms. However, in two other double-blind crossover placebo-controlled studies, there was no significant difference in gastric emptying or symptom improvement, but there was a trend toward decreased epigastric fullness and less diarrhea. These differences may reflect the limited number of patients studied or the presence of underlying medical problems that may have masked the therapeutic benefits. Perhaps higher dosages may be necessary to achieve sufficient drug levels for a desired clinical effect.
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