Join Our Mailing List

What We Do
Preventive Program
Adult Education and Literacy
Youth Program
Legal Services Program
Health Program
Anti-Violence Program
Khalil Gibran International Academy
I Need To Be Heard!

Program Contact Information

Danny Salim
Anti-Violence Program Manager
(718) 250 - 5122


By A. Fasim. Massachusetts College of Art.

In this room there have this design discount hydrochlorothiazide 25mg with amex, as has the so-called shuttle is a flow of air to which the pollen is added walking test in which the patient walks at a and evenly distributed in the air by fans buy 12.5 mg hydrochlorothiazide overnight delivery. Both these studies are parallel RESPIRATORY 371 groups in design buy hydrochlorothiazide 25mg cheap, but effects can often be such an study might be order hydrochlorothiazide 12.5mg overnight delivery, e cheap hydrochlorothiazide 25mg. Studies in which the treatment is not fixed throughout the period under investigation. In LONG-TERM CLINICAL STUDIES WITH such studies we can either vary the dose DIARY CARDS of the investigational product, or vary the In a diary card study, the patient is provided with dose of some concomitant treatment. One a diary card to fill in various information about typical such study has an arm in which the status of his disease under investigation, often treatment is initiated with a high dose of a twice daily. For most asthma/COPD studies, given GCS, which is then reduced according the patients also measure PEF. It is important to some scheme until the patient is no that the patient uses the same peak flow meter longer controlled on the present dose. A throughout the study, since different brands have variant are the steroid sparing studies, in different scales, and there is a considerable which a fixed dose of some investigational within-brand variability as well. In addition treatment is given throughout the study period to this, some symptom scoring is requested. For inhaled GCS, oral steroid like wheezing, shortness of breath and cough sparing studies have been performed in this for asthma. Finally, for asthma/COPD studies, way, for other anti-inflammatory drugs like the use of rescue medication, usually a short- leukotriene modifiers inhaled steroid sparing acting β2-agonist, should be entered into the diary studies are relevant. With the increased use of IT, paper-based diary cards are more and more replaced with The usage of the diary card data varies between electronic counterparts, which has the potential these two types of data. In studies with fixed benefit of monitoring when the recordings are treatments they define the primary efficacy vari- done. Some such devices can also contain a ables, whereas in studies with varying treatment spirometer, which makes it possible to replace doses, dose changes are conditioned on the diary the somewhat variable PEF measurement with card variables and these therefore act only as con- the more accepted FEV1 measurement. The FEV1 measurements of megabytes, however, does not truly reflect its recorded with a portable spirometer should be information value. Data is not obtained in a very more valid than PEF data obtained by a peak controlled fashion. Morning values are generally flow meter and manually recorded on a paper- considered slightly sharper than evening values, based diary card. Our discussion will primarily since sleep is comparatively similar among relate to the old paper-based diary cards with a patients and data should be obtained and recorded concomitant peak flow meter. The day-to-day variability, for a symp- tomatic asthmatic, can be considerable. Studies in which treatments are fixed through- using the mean of all values over a prespecified out the period under investigation. An arm in period, as long as possible, generally provides 372 TEXTBOOK OF CLINICAL TRIALS us with a measure that has proven to be useful also of symptom scores and of the use of rescue in many clinical studies. Because of the intrinsic variability in measure is to use FEV1 measurements obtained at the underlying disease it is important to compute visits to the clinic. Though each individual FEV1 means over long periods, preferably the full measurement so obtained is much more reliable treatment period. This means that, for some drugs than a single PEF measurement, the overall mean at least, the mean will contain data from a period over a treatment period of daily recorded PEF of onset of action, though the effect of that will measurements obtained in the morning is, in our be minor in long-term studies. Simi- When using FEV1 obtained at visits to the larly it might be useful to compute the percentage clinic as primary variable in a long-term clinical of days with no rescue medication. Thus it is important that ally, one approach to the analysis of the data is to FEV1 is measured at approximately the same time compute the sum of the symptoms (as the nasal of day on each visit. To obtain maximal efficiency index score), but an alternative is to analyse them we also need to schedule the patients for visits simultaneously in a multivariate analysis. The possibility of enforcing this will very to define a patient to have control of the asthma, if much determine the effectiveness of the FEV1 there are no symptoms and the patient did not use variable in discriminating between treatments. The percentage of such days In COPD studies lung function is also of with asthma control can be a useful summary interest, but for this disease the symptomatic measure for some patient populations, typically benefit is stressed more. A variant of this is to define night sleep, breathlessness, coughing and chest mild exacerbations, or episodes, of asthma from tightness seem to be accepted symptoms to diary cards by looking for worsening of lung include in diary cards. The exact criteria for such blockage, rhinorrhea, sneezing and/or itchy nose episodes probably need to be adjusted to the which sometimes are combined into the nasal patient population under study, and to the study index score, which is the sum of them.

purchase 25mg hydrochlorothiazide amex

Progestins also diffuse freely into cells purchase 12.5mg hydrochlorothiazide with amex, trogen is ethinyl estradiol purchase hydrochlorothiazide 25 mg line, which is used in hormonal where they bind to progesterone receptors buy hydrochlorothiazide 12.5mg line. Ethinyl estradiol is well absorbed with Hormonal contraceptives act by several mechanisms 25mg hydrochlorothiazide. It is 98% bound to plasma proteins and releasing hormone discount hydrochlorothiazide 25 mg otc, which inhibits pituitary secretion of FSH its half-life varies from 6 to 20 hours. When these gonadotropic hormones are absent, ovu- undergoes extensive first-pass hepatic metabolism and lation and, therefore, conception cannot occur. Second, the is further metabolized and conjugated in the liver; the drugs produce cervical mucus that resists penetration of sper- conjugates are then excreted in bile and urine. Third, the drugs in- • Nonsteroidal, synthetic preparations are usually terfere with endometrial maturation and reception of ova that administered orally or topically. These overlapping mechanisms cally altered to slow their metabolism in the liver. They are also less bound to serum proteins than nat- urally occurring hormones. Norethindrone undergoes first-pass Estrogens metabolism so that it is only 65% bioavailable. It is metabolized in the liver and excreted in ciency states usually result from hypofunction of the urine and feces. Monophasic contraceptives contain fixed pituitary gland or the ovaries and may occur anytime amounts of both estrogen and progestin components. For example, in the adolescent girl Biphasics and triphasics contain either fixed amounts of with delayed sexual development, estrogen can be given estrogen and varied amounts of progestin or varied to produce the changes that normally occur at puberty. Biphasic and In the woman of reproductive age (approximately 12 to 412 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM 45 years of age), estrogens are occasionally used in the drugs decreased myocardial infarctions and deaths menstrual disorders, including amenorrhea and abnor- from cardiovascular disease. The difference was with a progestin, is used widely in the 12- to 45-year age attributed to decreased hormone production at meno- group to control fertility. The drugs are now recommended for short-term trogens are contraindicated because their use during use (eg, 2 years) to relieve menopausal symptoms, but not pregnancy has been associated with the occurrence of for long-term use for cardioprotective effects. A recent vaginal cancer in female offspring and possible harmful well-done study indicated that risks are greater than ben- effects on male offspring. Estrogens are prescribed to relieve symp- The part of the study concerned with estrogen replace- toms of estrogen deficiency (eg, atrophic vaginitis and ment only is scheduled to be completed in 2005. The early vasomotor instability, which produces hot flashes) part of the study did not indicate significantly increased and to prevent or treat osteoporosis. Such usage is usu- Progestins ally called estrogen replacement therapy (ERT) or HRT. In addition, ERT and HRT have been used long-term Progestins are most often used in combination with an estro- for cardioprotective effects because it was believed that gen in contraceptive products. They also are used to suppress BOX 28–2 HORMONE REPLACEMENT THERAPY IN POSTMENOPAUSAL WOMEN Background atively small, the investigators concluded that the drug combination For many years, postmenopausal women have been treated with produced more harm than benefit and should not be started or con- estrogen replacement therapy (ERT) to manage symptoms of tinued to prevent coronary heart disease (CHD) in healthy women. In addition, estrogen was thought to have cardio- The WHI study was done with healthy women, to see if the drugs protective effects, partly because the incidence of heart attacks in would prevent CHD from developing. The Heart and Estrogen/ women increased substantially after menopause and became sim- Progestin Replacement Studies, HERS and HERS II, involved ilar to the incidence in men. Several studies also indicated benefi- postmenopausal women with intact uteri who already had CHD. Because estrogen alone increases conclusion was that the hormones should not be started or contin- risks of endometrial cancer in women with an intact uterus, a pro- ued in women with CHD for preventive purposes. For individual women, the benefits in reducing symptoms of menopause, fractures from osteoporosis, and colon cancer must be Estrogen-Progestin Combinations weighed against the increased risks of CHD, thromboembolic Combined estrogen/progestin hormone replacement therapy be- stroke, venous thromboembolism, breast cancer, and cholecysti- came the standard of care for women with an intact uterus and was tis. In 2002, the prevailing opinion changed dramatically to disease increase with the duration of drug use. If the combined indicate that combined estrogen/progestin therapy should not be drugs are prescribed to relieve menopausal symptoms in women used to prevent cardiovascular disease in healthy postmenopausal who have not had a hysterectomy, they should probably be used women, because risks were greater than benefits. This part of the study was stopped after an tion, estrogen is generally thought to have beneficial effects on average follow-up period of 5 years (8 years planned), because of a serum cholesterol and bone density. However, there has been con- higher incidence of invasive breast cancer.

safe 25 mg hydrochlorothiazide

Inappropriate use or tak- dardized or even identified on the product label order 25 mg hydrochlorothiazide fast delivery. In addition hydrochlorothiazide 12.5 mg lowest price, components and active adverse effects or drug–supplement interactions discount 25mg hydrochlorothiazide otc. Some products (eg cheap hydrochlorothiazide 12.5mg mastercard, echinacea buy hydrochlorothiazide 25mg without a prescription, ents are standardized (meaning that the dose of medicine ephedra, feverfew, garlic, gingko, ginseng, kava, valerian in each tablet or capsule is the same). With or increase risks of bleeding; some have unknown effects herbal medicines especially, different brands of the same when combined with anesthetics, other perioperative med- herb vary in the amounts of active ingredients per rec- ications, and surgical procedures. Dosing is also difficult because a par- ✔ Store herbal and dietary supplements out of the reach of ticular herb may be available in several different dosage children. In this chapter, general infor- drugs (when such information is available). In later chapters, the nurse can ask about the use of specific supplements that may interact with the drug group(s) discussed in that chapter. For example, some GENERAL PRINCIPLES OF supplements are known to increase blood pressure (see DRUG THERAPY Chap. General Goals and Guidelines • One of the best sources of information is the National Center for Complementary and Alternative Medi- 1. The goal of drug therapy should be to maximize bene- cine (NCCAM) at the National Institutes of Health. Expected benefits should outweigh potential adverse NCCAM Clearinghouse effects. Thus, drugs usually should not be prescribed PO Box 8218 for trivial problems or problems for which nondrug Silver Spring, MD 20907-8218 measures are effective. Failure • Ask clients whether they use herbal medicines or other to consider these variables may decrease therapeutic dietary supplements. If so, try to determine the name, effects or increase risks of adverse effects to an un- dose, frequency and duration of use. Drug effects on quality of life should be considered in Drug Therapy in Children designing a drug therapy regimen. Quality-of-life issues are also being emphasized in research studies, Drug therapy in neonates (birth to 1 month), infants (1 month with expectations of measurable improvement as a re- to 1 year), and children (approximately 1 to 12 years) requires sult of drug therapy. Physiologic differ- ences alter drug pharmacokinetics (Table 4–2), and drug ther- General Drug Selection and apy is less predictable than in adults. Neonates are especially Dosage Considerations vulnerable to adverse drug effects because of their immature liver and kidney function; neonatal therapeutics are discussed Numerous factors must be considered when choosing a further in Chapter 67. Minimizing the number of drugs and the fre- for use in children have not been established. All aspects of pediatric drug therapy must be guided to treat severe hypertension or serious infections. Choice of drug is often restricted because many drugs binations are increasingly available and commonly used, commonly used in adult drug therapy have not been suf- mainly because clients are more likely to take them. The least amount of the least potent drug that yields ther- children than for adults. Some drugs are not recom- apeutic benefit should be given to decrease adverse re- mended for use in children, and therefore dosages have actions. For many drugs, doses for chil- opioid analgesic are both ordered, give the non-opioid dren are extrapolated from those established for adults. In drug literature, recommended dosages are listed in ture, these should be used. Often, however, they are ex- amounts likely to be effective for most people. For example, clients with and the amount needed for a specific dose must be cal- serious illnesses may require larger doses of some drugs culated as a fraction of the adult dose. The following than clients with milder illnesses; clients with severe methods are used for these calculations: kidney disease often need much smaller doses of renally a. Calculating dosage based on body surface area is lowed by a regular schedule of smaller (maintenance) considered a more accurate method than those based doses. When drug actions are not urgent, therapy may be on other characteristics. In general, different salts of the same drug rarely differ pharmacologically.

discount hydrochlorothiazide 12.5 mg with amex

During voluntary ankle plantar-flexion and co-contraction of ankle extensors and flexors: (i) the corticospinal command to soleus (Sol) motoneurones (MN) is conveyed through different pathways; and (ii) PAD interneurones (INs) transmitting presynaptic inhibition of homonymous and heteronymous Ia afferents (from quadriceps [Q]) to Sol motoneurones (MN) receive a suppressive corticospinal input during voluntary ankle plantar-flexion (thick continuous line) cheap 12.5mg hydrochlorothiazide otc, whereas they receive a facilitatory corticospinal drive during co-contraction of ankle extensors and flexors (thin dotted line) discount hydrochlorothiazide 12.5mg without a prescription. The number of counts (as a percentage of the number of triggers) is plotted against the latency after stimulation order hydrochlorothiazide 25 mg fast delivery. Note that the decrease in the peak during co-contraction affects the first bin buy hydrochlorothiazide 12.5mg online. Changes in presynaptic inhibition of Ia When the contraction was moderate (20% of MVC) hydrochlorothiazide 12.5 mg online, terminals on upper limb motoneurones no significant change was observed (Fig. This suggests that the reflex reinforce- bition of the FCR H reflex, and on heteronymous Ia ment produced by the Jendrassik manoeuvre is not monosynaptic projections from intrinsic hand mus- due to decreased presynaptic inhibition, as has been cles using the facilitation of the H reflex. This decrease in presynaptic inhibition differs from that observed in the lower limb. Investigations using single units (i) It is quantitatively less: at the onset of FCR con- traction, D1 inhibition for FCR is only moderately Alterations in presynaptic inhibition of Ia ter- reduced, whereas vibratory inhibition is completely minals on quadriceps, soleus and tibialis anterior suppressed for the contracting muscle at the onset motoneurones have been inferred from changes in of a lower-limb contraction. Similarly, the moder- the peak of homonymous or heteronymous mono- ate amount of increased heteronymous facilitation synaptic Ia excitation (in particular, its initial part) of the FCR H reflex (Fig. Compared with the control situation, at the onset of soleus contraction (Fig. The peak of presynaptic inhibition during tonic voluntary con- homonymous excitation in soleus produced by tractions (Fig. No change was observed there is, if anything, an increase in presynaptic inhi- inthepresynapticinhibitionofhomonymoustibialis bition of Ia terminals on soleus motoneurones at the anterior Ia terminals. Investigations using the soleus H reflex The slight depression of PAD interneurones medi- ating presynaptic inhibition of Ia terminals on FCR These investigations provide an example of non- motoneurones at the onset of various forearm vol- congruent results with the different methods used untary contractions is unlikely to be of corticospinal to assess presynaptic inhibition of Ia terminals. Instead support, and this seemed to confirm the increased the non-specificity of this depression is consistent presynaptic inhibition of quadriceps Ia terminals with reticulospinal depression acting on the last- on soleus motoneurones (Katz, Meunier & Pierrot- order PAD interneurones in the cat (cf. Changes in the het- Presynaptic inhibition of Ia terminals on various eronymous facilitation and in the D1 inhibition of lower limb motor nuclei has been compared when the soleus H reflex in the same direction raise the 364 Presynaptic inhibition of Ia terminals Fig. The peak of monosynaptic excitation elicited by stimulation of the femoral nerve (FN) inaQmotor unit ((b), FN at 1 × MT) and in a soleus unit ((c)FNat4× MT) is shown when standing with back support ( , control) and when standing without support ( ). Because the firing rate of the motor unit tested and its variability were similar in the two situations, a change in the size of the peak, and in particular of its initial 0. Modified from Katz, Meunier & Pierrot-Deseilligny (1988), with permission. Either way, this highlights that D1 inhibition in the heteronymous and homonymous Ia monosy- may not always be a reliable method to assess an naptic peaks was observed in single soleus motor increase in presynaptic inhibition. Increased presynaptic inhi- volley,butthereisnoclearenhancementoftheback- bition of soleus Ia terminals could play a role in ground Ia traffic in the peroneal nerve when sub- depressing the stretch reflex during balancing tasks jectsarestandingwithoutsupport(Anissetal. In addi- interneurones; and (iii) a change in the superim- tion,theincreasedpresynapticinhibitionofsoleusIa posed facilitation that creates two separate phases terminals could contribute to the depression of Motor tasks – physiological implications 365 reciprocal Ia inhibition, through presynaptic inhi- andhencethesmoothnessofthegait(cf. When standing withoutsupport,postureispotentiallyunstable,and Presynaptic inhibition of Ia terminals on contractions may be required in either of the antag- soleus motoneurones during walking onistic muscles operating at the ankle. This creates a Differences in the size of the H reflex at equivalent situation where a decrease in reciprocal Ia inhibition levels of EMG activity may be helpful in controlling body sway. The possibility of an increase in presynaptic inhibi- tion of soleus Ia terminals during gait first emerged from comparisons of the soleus H reflex during Changes in presynaptic inhibition walking and standing at the same level of on-going during gait EMG activity. Thisdifferencecouldreflectstronger of quadriceps EMG, and this suggests a decrease presynaptic inhibition of soleus Ia terminals during in presynaptic inhibition (Dietz, Faist & Pierrot- walking. This view is further supported by (1987) was also interpreted as increased presynaptic the differential effect on the on-going EMG activi- inhibition. The existence of a presynaptic gating of ties of the quadriceps and triceps surae of Ia exci- group I afferents has also been invoked to explain tation produced by tendon vibration (Verschueren the reduction of cortical somatosensory potentials et al. Vibration applied to the patellar tendon evoked by posterior tibial nerve stimulation during enhances the quadriceps EMG in early stance, while gait (Dietz, Quintern & Berger, 1985). Because the vibration to the Achilles tendon does not modify amplitude of the H reflex was even lower during dif- that of the triceps surae during gait. This differential ficultbeamwalking,itwasarguedthatthepresumed effectofvibration-inducedIaexcitationisconsistent increase in presynaptic inhibition of soleus Ia ter- with a differential control of presynaptic inhibition minals was then stronger (Llewellyn, Yang & Proc- on Ia terminals on the motoneurones of the two hazka, 1990). However, because differences in the muscles: increased for triceps surae motoneurones modulationsoftheEMGandHreflexmayhaveother (see below), but decreased for quadriceps motoneu- causes (cf. At this time the weight of the body is shifted to used to investigate possible changes in presynaptic the leg that is about to begin the stance phase, and a inhibition of Ia terminals during gait. Decreased Changes in D1 and D2 inhibition presynaptic inhibition of Ia terminals provides a safety factor for the quadriceps contraction, and this During the stance phase of gait, D2 and D1 inhibi- mightbeimportantincompensatingfortheuneven- tions are decreased with respect to values obtained ness of the ground. Later during early stance, pre- during voluntary contractions when sitting (Capa- synaptic inhibition of homonymous quadriceps Ia day, Lavoie & Cormeau, 1995;Faist, Dietz & Pierrot- terminals progressively increases, a change that Deseilligny, 1996).

10 of 10 - Review by A. Fasim
Votes: 82 votes
Total customer reviews: 82


The Arab-American Family Support Center is a 501(c)3 non-profit, non-sectarian organization that provides culturally and linguistically sensitive services to immigrant communities throughout New York City.  © 2017 All Rights Reserved.

AAFSC Brooklyn
150 Court Street, 3rd Flr
Brooklyn, NY 11201
T: 718 - 643 - 8000
F: 718 - 797 - 0410
E: info@aafscny.org
AAFSC Queens
37-10 30th Street, 2nd Fl.

Queens, NY 11101
T: 718 - 937 - 8000
F: 347 - 808 - 8778
AAFSC @ the Family Justice Centers
FJC Bronx (718) 508-1220
FJC Brooklyn (718) 250 - 5035
FJC Manhattan (212) 602-2800
FJC Queens (718) 575 - 4500
FJC Staten Island (718) 697 - 4300