Thursday, March 31, 2016

Hepatitis panel


Hepatitis lab interpretation


Hepatitis:


With #: http://www.hepatitiscentral.com/hcv/labs/hbvcontents/
Monitoring w/ ab results: http://www.questdiagnostics.com/testcenter/testguide.action%3Fdc%3DCF_ViralHepatitis

Interpretation easy to read (a bit out-dated 2010):
http://oaml.com/PDF/2010/Hepatitis%20Results%20Interp.%20FINAL-Aug%2024%202010.pdf

http://www.hepb.org/pdf/understanding_blood_tests.pdf

http://www.cdc.gov/hepatitis/HBV/PDFs/SerologicChartv8.pdf

Hepatitis A

Mini-Case*: Pt's Hepatitis A came back positive results. Why don't you treat patient for Hepatitis A?

Thinking: it's positive. Why don't you treat?
Conclusion: Self-limited (look up self-limited in medical dictionary if you don't know what it is already). Supportive therapy only. Excellent prognosis.

More:
When to order:
- To help dx acute hepatitis cause
- Evaluate the need for hep A vaccine

What to order:
- Part of viral hepatitis panel.

What to collect:
- Blood sample




Resources:
Helpful chart to intepret different types of hepatitis lab test results:  http://oaml.com/PDF/2010/Hepatitis%20Results%20Interp.%20FINAL-Aug%2024%202010.pdf

Disclaimer about cases

All cases in this blog are fictitious. No real patient encounters. Any resemblance to real persons, living or dead, is purely coincidental. 
~Wonder Me!



FYI - I use my imagination to make up these cases in this blog. To help myself put things in perspectives, I try imagine how the info. I've learned can be in put in clinical cases. ~Wonder Me! 

My nicknames

So, I've decided to change from the elegant humbled 'Miss Student' nickname to 'Wonder Me' in inspiration of the 'Wonder Woman'. ~Wonder Me!

How to Fake Being More Confident When You’re Just Not Feeling It

Source: https://innovation.firstrepublic.com/2015/12/16/how-to-fake-being-more-confident-when-youre-just-not-feeling-it/


Bones: Wonder Woman! 

How to Fake Being More Confident When You’re Just Not Feeling It


Author: Kristin Wong, Contributor
Confidence can be an enviable quality . Being completely assured of yourself and your abilities gives you the courage to take risks and accomplish great things. But confidence doesn’t always come easy, and it can come and go depending on your mood. The good news: you can fake it pretty easily.
Remember, self-esteem and self-confidence are different . You can feel like you suck at everything you do and still be totally confident in getting the job done. And it works the other way, too. You can value your skills, but maybe you’re just not terribly confident using them around other people. The problem with that is that some social situations call for confidence: giving a speech, for example, or a job interview. Whatever the scenario, here are a few things to keep in mind to come across as confident when you’re just not feeling it.
Speak the Right Body Language
Body language is subtle, but it can send a powerful message without you even realizing it. For example, a few habits will automatically call you out you as lacking confidence:
  • Bad posture: slouching, hunched shoulders
  • Fidgeting
  • Crossed arms
Swapping those out with the right body language  can immediately help you appear more confident. Social psychologist Amy Cuddy talks about “high power poses. ” She suggests movements that are more open, spread out, and take up a bit more room help exude power. Consider the “Wonder Woman” pose, for example (or any of these other power poses ): the elbows are jutting out, taking up more space, and the feet are spread out. It’s a classic power pose. What’s more, practicing these “high power poses” can eventually help you feel more confident. This is where the tired old phrase, “fake it ‘til you make it” really does ring true.
Your shoulders can be surprising indicators of self-confidence, too. As former FBI counterintelligence agent Joe Navarro pointed out :
Over the years, after doing thousands of interviews, one of the things that I observed, which unfortunately had not been written about in the literature, was how the shoulders betrayed those who lacked confidence or who were outright lying. I found that when people are unsure of what they are saying or they lack confidence, their shoulders tend to reflect that uncertainty.
He points out that raising your shoulders, in almost a shrug, can be a dead giveaway that you’re uncertain and not confident. Instead, stand up straight and pull those shoulders back. It’s obvious, and probably advice your mother gave you, but it really can make a big difference.
It helps to practice, too. In preparing for a job interview, for example, it can help to practice walking into a room  to get a feel for your own body language (or even practice on a friend ). It might feel like a silly thing to do, but it can help you get comfortable in your own skin.

Master Eye Contact

Not enough eye contact can obviously indicate a lack of confidence, but too much eye contact can make you look like you’re trying too hard (or come across as aggressive). You want to maintain just the right amount, but finding that sweet spot really isn’t that difficult. As a general rule, try to make eye contact 60 percent of the time . Of course, that’s going to vary on the situation, but it’s less about the exact percentage and more about making sure you’re engaging with someone without coming across as overly intense.
It can help to ask close friends and family how they feel about your eye contact, too. That’s an easy way to find out if you make too much or too little. For the most part, though, we tend to make less eye contact when we lack confidence. Here’s a trick to help you remember: make a habit of noticing their eye color . When you meet someone and want to come across as confident, pair their name with their eye color. In doing so, you’ll give them more eye contact.
Learn the Components of Charisma
Confident people are often charismatic people ; the traits go hand in hand. While confidence is focused more on your own habits and behaviors, charisma is about how you treat and interact with others. In short, you want to be engaged.
We’ve previously discussed the book  The Charisma Myth , which suggests that charisma comes down to three things:
  • Being present in the moment with others
  • Exuding warmth by implying goodwill
  • Appearing powerful by coming across as someone who’s capable of impacting the world around you
The two-second rule  can help you with the first point. It’s simple: before replying when it’s your turn to talk, wait two seconds. For one, this shows you’re listening to and processing what the other person is saying. However, it also creates a subtle amount of tension, and when you reply, that shows you’re in charge of the tone and flow of the conversation, which creates a sense of power and confidence, hitting on the third point.
Asking questions is also a great, simple way to exude warmth and be present in an interaction with someone else. Interestingly, you’re also controlling the conversation when you ask questions, which, again, show power.
Charismatic people know how to keep the conversation going, too. Avoid awkward silences with the history/philosophy/metaphor rule . If you’re not sure how to respond to something, consider it from each of those angles. As blog Dumb Little Man explains :
Say you and your partner are on a roller coaster in a scene, and you suddenly have no idea what to say. Never fear! You can always rely on the good old HPM:
HISTORY – This reminds me of the last time I rode this coaster…
PHILOSOPHY – I HATE coasters dude! All the ups and downs make me wanna puke. But I go on one every day to prepare me for the ups and downs of life.
METAPHOR – Roller coasters are like cigarettes…
Remember, being charismatic is more about how your behavior impacts the people around you. Simply being present and making them feel important can make a huge difference. It exhibits warmth and power, which is charisma in a nutshell.
Sound Like You Know What You’re Talking About
Of course, if you want to come across as confident, you want to sound like you know what you’re talking about …even if you don’t. A few quick and easy ways to do that include:
  • Avoid blank words: “um,” “like,” “uh.”
  • Don’t jump at the first chance to speak. Take a moment and think about your reply.
  • Talk slowly and calmly.
Beyond that, you want to emphasize what you know. This is classic job interview advice. If you don’t have the best answer to a question, don’t try to lie or cover it up, but finish up your answer with what you do know instead. For example, “No, I don’t have a lot of public speaking experience, but I spent a lot of time leading meetings at my old job, and that helped me become comfortable talking in front of a crowd. That was a challenging part of my job, but I learned so much about how to put out fires in the process.”
This is just one silly example, but you get the idea. And it can work with other scenarios that call for confidence, too, like speeches, debates, or Q&As.
One thing most of us are guilty of is trying to prove other people wrong. It’s tempting to put people in their place, but it can also make you come across as lacking confidence. It’s one thing to clear the air about a question you’re asked, but dwelling on why you’re right makes it seem like you’re trying to prove yourself.
Sometimes trying to be confident when you’re not can come across as cocky, but that’s only because you overdo it. Confidence isn’t about being better than everyone else, it’s just about having the assurance to be able to be yourself. So it seems a little ironic to suggest pretending to be more comfortable in your skin. But there’s something to be said for the cliché, “fake it until you make it.” Sometimes going with the motions actually makes you feel them.
Ideally, you want to learn to develop confidence long-term , because it’s a useful trait that gives you the ability to try new things, take risks, and accomplish lofty goals . But we all have off days, and for those days, these tips can come in handy.

Cholesterol or lipid profile



Mini-Case*: Patient - My cholesterol is 295.... Don't remember what type of cholesterol. Aren't they all the same?

Thinking: Cholesterol values include Total cholesterol, LDL, HDL, VLDL, which one? What is what?
=> Conclusion: most likely to be 'Total cholesterol' if pt only can only report 1 # but not any other #'s.


Case*: Pt is 50y/o with diabetes. Which Cholesterol level to start on Simvastatin?
Answer: Cholesterol level doesn't matter. No need to obtain lipid panel test. Just start them on Simvastatin.

Case*:  Pt asks How does Simvastatin affect HDL and LDL?
Answer: Lower LDL but very miniscule effects on HDL








Why it works?

Blurb:



  • Total cholesterol
  • LDL (bad) cholesterol--the main source of cholesterol buildup and blockage in the arteries
  • HDL (good) cholesterol--helps keep cholesterol from building up in the arteries
  • Triglycerides--another form of fat in your blood

  • What is total cholesterol?

    Total Cholesterol (done by enzymes, measured directly from blood):  Total cholesterol can be measured directly from blood. Enzyme (cholesterol oxidase) is added to produce reaction byproducts, H2O2.  Enzyme (Peroxidase) is then added to produce color. This color is electromagnetically analyzed at 500nm. The intensity of this color is directly proportional to cholesterol concentration.

    Triglycerides (done by enzymes, measured directly from blood) - must be fasting for correct level of triglycerides

    HDL (done by special agents, measured directly from blood, read by color intensity produced from electromagnet)

    LDL: very expensive to measure directly from blood via ultra-centrifuge. So, use Friedwald equation (only correct if pt is fasting)

    LDL-Cholesterol: Most of the circulating cholesterol is found in three major lipoprotein fractions: very low density lipoproteins (VLDL), LDL and HDL.
    [Total chol] = [VLDL-chol] + [LDL-chol] + [HDL-chol]

    LDL-cholesterol is calculated from measured values of total cholesterol, triglycerides and HDL cholesterol according to the relationship: 
                              [LDL-chol] = [total chol] - [HDL-chol] - [TG]/5
     where [TG]/5 is an estimate of VLDL-cholesterol and all values are expressed in mg/dL. 



    ~Miss Student

    *All cases are fictitious. No real patient encounters. Just my rich imagination! :)


    Read lab values:
    Mnemonics: High Healthy HDL; Low Let it down LDL ~Miss Student



    Nutrition:




    Diet restrictions: 
    1 - No Alcohol 24hrs before tests (elevate #)
    2 - No eating 12 hrs before tests (elevate triglycerides)
    3 - No water restrictions

    Clinical procedure:
    - Blood lab test (venipuncture)
    - Red tube (fasting)

    Who should be screened?:
    In priority order:

    1. - All men over 35 y/o even in absence of any risk factors for CHD
    2. - Men & women >20 y/o with increased risks for coronary heart disease (CHD)
    Increased risk, for the purposes of this recommendation, is defined by the presence of any one of the risk factors listed below. The greatest risk for CHD is conferred by a combination of multiple listed factors.
    • Diabetes.
    • Previous personal history of CHD or non-coronary atherosclerosis (e.g., abdominal aortic aneurysm, peripheral artery disease, carotid artery stenosis).
    • A family history of cardiovascular disease before age 50 in male relatives or age 60 in female relatives.
    • Tobacco use.
    • Hypertension.
    • Obesity (BMI ≥30).
    10-year CVD risk factors: http://cvdrisk.nhlbi.nih.gov/

    Helpful link:
    http://www.gpnotebook.co.uk/simplepage.cfm?ID=x20030114211535665170: short need-to-know details for lipid profile info.
    (2) http://www.cdc.gov/nchs/data/nhanes/nhanes_03_04/l13_c_met_lipids.pdf: how to calculate total cholesterol => not how total cholesterol is usu. obtained since you can do measure total cholesterol by hands
    http://www.wikihow.com/Calculate-Total-Cholesterol => how lipid panel is really measured
    http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/lipid-disorders-in-adults-cholesterol-dyslipidemia-screening#consider


    Research Resources

    Research Resources

    Comfort theory - Rich site on Comfort Theory by Kolcaba. Many measurement tools in different languages for comfort theory.
    http://www.thecomfortline.com/index.html

    'Impact factor' - term explanation:Very rich info. on 'impact factors'. Helpful for selecting journals you want to submit ur manuscript in.
    http://guides.lib.uw.edu/friendly.php?s=hsl/impactfactors


    Patient education resources

    I will update this list regularly as I find new resources from school, class, work, etc. Check back regularly :)

    Patient Education Resources

    Asthma:
    Rules of 2 Poster - Asthma not under control: http://www.dcasthma.org/rules_of_two_poster.pdf

    Diabetes:
    Type 1 diabetes for peds - free ebook chapters online, also available in print for purchase: http://www.ucdenver.edu/academics/colleges/medicalschool/centers/BarbaraDavis/OnlineBooks/Pages/default.aspx

    National Diabetes Education - free brochures/books for diabetes for school personnel, etc.: http://www.niddk.nih.gov/health-information/health-communication-programs/ndep/Pages/index.aspx

    Diabetes Nutrition Placemat - 2-paged brochure with great familiar household portion-sizes, physical activities measurements: http://www.novacares.com/downloads/nutritional_placemat.pdf


    Lead Prevention: 
    Lead prevention from California public health branch: https://www.cdph.ca.gov/programs/CLPPB/Pages/healthinfo-CLPPB.aspx

    ~Miss Student

    Volume of distribution

    Tho it is NOT  true, try to think of Vd simply reflects the volume of drugs dispersed into body tissues.
    However, in fact,  grams of drugs/Vd = grams of drugs/plasma volume = plasma concentration
    Therefore => Vd = grams of drugs/plasma concentration 
    => Vd = is a proportionality factor, not a physiologic factor (2) 
    => The amount of solution/solvent a drug needs to dissolved into to reach similar concentration of its concentration in plasma

    Why does it matter? We need to know the Vd in order to calculate the desired loading dose (grams or mg) so that we can have the DESIRED drug concentration in the plasma.

    What Vd is really, like really? "The volume of distribution is the theoretical size of the compartment necessary to account for the total drug amount in the body if it were present throughout the body in the same concentration found in the plasma." (1)

    Sooo weird, like you have to know Vd to calculate the necessary dosage, then why how could the pharmacist figure out the Vd? They do that empirically I suspect by calculating the plasma concentration and the dosage given and then keep an index of these #'s (3) (after Wonder Me! googled a lot with key words such as how pharmacists calculate necessary volume of distribution, it linked me to a NAPLEX book. So helpful!)

    Clinical examples:
    - Digoxin must get into myocardial tissue with several compartments, what do you think its Vd wold be? Massive! (lots to get into tissue-binding)
    - Warfarin must stay in the blood (think: blood thinner! must stay in the blood to 'thin' blood!) => therefore it has a small loading dose (think: you don't want to give too much of a drug directly to the blood stream when it likes to stay in the blood and doesn't want to go anywhere else. Meaning it doesn't need to that much to get to be highly-concentrated in the blood!) => Needless to say it has a small Vd. 
    - Understanding Vd will help you get the desired Loading dose correctly!

    - (4): 
    DrugVD
    Warfarin8L
    Reflects a high degree of plasma protein binding.

    Theophylline, Ethanol30L
    Represents distribution in total body water.

    Chloroquine15000L
    Shows highly lipophilic molecules which sequester into total body fat.

    NXY-0598L
    Highly charged hydrophilic molecule.


    Blurb:
    Vd simply reflects the volume of drugs dispersed into body tissues. (NOT true)
    - High protein-bound (think Albumin in blood, think circulation and plasma, think big huge protein-drug complex unable to cross blood stream to leak into intracellular or interstitial fluid) drugs => Low Vd
    - High tissue-bound drugs => high Vd
    - High Vd => low plasma concentration
    - Low Vd => high plasma concentration


    This means the higher Vd, the higher the amount of drugs binding to body tissues and lower the amount of drugs 'swimming' freely in the blood plasma.
    This means the small Vd will have a high initial concentration as the drug just enters the plasma content but then it will become smaller in concentration.
    This means that the large Vd will have a low concentration (all drugs dispersed into the tissues).

    Helpful interactive site to illustrate this concept: http://www.icp.org.nz/icp_t3.html

    ~Wonder Me

    Citation:







    Impact factors

    Resource: http://guides.lib.uw.edu/friendly.php?s=hsl/impactfactors

    Very rich info. on 'impact factors'. Helpful for selecting journals you want to submit ur manuscript in.

    1st Nurse Practitioner NP clinical day

    What's it like for my 1st clinical day? Came in introducing self. Preceptor introduced me to staff for their names, their title, their special extra assets/capabilities. Oriented me to all rooms & the computer charting system they use. Shadowed preceptor for various patients. Learned about preventative medicine - implemented for all patients such as colonoscopy, vaccines, mammogram, etc. Saw patients. e-Charted SOAP notes. Preceptor reviewed my notes. Went over different questions and stuff.
    FYI - For confidentiality issue, I will NOT post any patient or cases I've seen or dealt with in clinical.

    The comfort theory by Kolcaba

    Source: http://www.thecomfortline.com/index.html

    Rich site on Comfort Theory by Kolcaba. Many measurement tools in different languages for comfort theory.

    dash diet

    DASH = Dietary Approaches to Stop Hypertension. 

    Source: https://www.nhlbi.nih.gov/health/health-topics/topics/dash

    Description of the DASH Eating Plan 

    DASH is a flexible and balanced eating plan that helps creates a heart-healthy eating style for life.
    The DASH eating plan requires no special foods and instead provides daily and weekly nutritional goals. This plan recommends:
    • Eating vegetables, fruits, and whole grains
    • Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils
    • Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils
    • Limiting sugar-sweetened beverages and sweets.
    Based on these recommendations, the following table shows examples of daily and weekly servings that meet DASH eating plan targets for a 2,000-calorie-a-day diet.
    Daily and Weekly DASH Eating Plan Goals for a 2,000-Calorie-a-Day Diet
    Food Group
    Daily Servings
    Grains
    6–8
    Meats, poultry, and fish
    6 or less
    Vegetables
    4–5
    Fruit
    4–5
    Low-fat or fat-free dairy products
    2–3
    Fats and oils
    2–3
    Sodium
    2,300 mg*
    Weekly Servings
    Nuts, seeds, dry beans, and peas
    4–5
    Sweets
    5 or less
    *1,500 milligrams (mg) sodium lowers blood pressure even further than 2,300 mg sodium daily.
    When following the DASH eating plan, it is important to choose foods that are:
    • Low in saturated and trans fats
    • Rich in potassium, calcium, magnesium, fiber, and protein
    • Lower in sodium

    Wednesday, March 30, 2016

    clinical tips

    I will update this regularly for anything I've learned from school, textbooks, &... life!:

    - Chronic lithium ingestion can lead to nephrotic diabetes insipidus which is the most common form of renal injury in lithium patients. NP management: ask psychiatrist to lower dose. If therapeutic effects for psych and psychiatrist doesn't want to lower dose => start on demopressein to treat DI. http://www.uptodate.com/contents/treatment-of-nephrogenic-diabetes-insipidus

    - When adjusting dosage for lithium => see pt every 8 days ideally or 2 weeks (easier for pt to remember 2 weeks) initially. Not for the rest of the time.

    - If pt is menopausal => ask about sexual difficulties due to dry vagina

    - Over 65 y/o => pneumoccoccal vaccine. Usu. missed unless pt has been in the hospital.

    - always promote diet & exercise in ALL patients

    - try NOT to use the affected arm of the pt w/ total mastectomy for invasive procedures due to risks for lymphedema See: http://www.hopkinsmedicine.org/healthlibrary/conditions/breast_health/lymphedema_following_a_mastectomy_85,P00148/

    insulin

    the curve of the lantus is not due to half-life. It's subQ. Active ingredient is insulin which as short-half life. The difference is the inactive ingredient that makes it release extendedly.
    This is why you can take NPH (intermediate-acting) with regular insulin (short-acting, just plain insulin). NPH = cloudy insulin with some inactive ingredients that make it distribute to fat very slowly. That's why you can inject insulin with NPH and it won't damage NPH.
    NPH injected to regular insulin => ruin it because you turn regular insulin into semi-NPH.
    => Clear before Cloudy.
    But you don't want to draw it and leave it there for 24 hrs? Not sure! What about pre-mixed insulin pen?

    Humulin (NPH/Regular insulin) => medium acting lasts longer for lunchtime, 2 injections but not really covers ppl in the correct way.

    ~Miss Student

    Tmax, Cmax, Half life

    All cases are fictitious, no real-life encounters. Imaginary cases! 

    Case: alcoholic withdrawal & anxiety => 2mg Ativan IV (big dose!) => neuro depression then resp. depression => given 1hr ago => pt says now I'm still nervous as crazy (Tmax = 0.5, half life 4-6 hrs => fictitious )=> give him Ativan again? Pt went thru Tmax and Cmax and still not sedates him, even tho half life is really long => give more? =>okay to give a little more but not too much => titrate.
    For some ppl used to Ativan who's very anxious and used to Activan => 2mg didn't touch him => may be able to give more than 1mg => actually u need to give like another 2mg.


    ~Miss student

    loading dose

    All cases are fictitious, no real-life encounters. Imaginary cases! 

    Case: pt: I don't want to wait 3-5 days for Claritin 5mg for me to go to parent's house which has a dog that I'm allergic to. What can I do? NP: Start pt on loading dose and then start on regular min dose. However, this is NOT a good thing to do & this is not a good thing to do to the body since the body doesn't like to go to extreme. So, only do loading dose when ER!

    Case: pt comes in w/

    Loading dose is usually done by the pharmacist in Hospital for the calculation.

    Ideal drug: short half life for loading dose. If it's not good, just stop it and let it go out of the body very quickly. Go too much => get rid quickly and easily. Ideal is meds is IV bc 100% bioavailibitliy, short-half-life => even w/ allergies => still good => come out quickly.

    ~Miss Student


    Tuesday, March 29, 2016

    The night before 1st clinical

    I'm quite exhausted today after 5-hr pharm and 4hr research and hours of traffic and studying with self and with pal. Tomorrow is clinical. Despite being exhausted, I decided to drag myself to Target to get some hygiene products since I've run out of them ... Even tho it's called clinical, I feel like it's more like a practicum. Our objective is simply to do physical examination and soap with some DDx. I feel like it's more like a practicum other than a clinical because Ur given a preceptor, it's not that ur gonna work with ur clinical instructor, it's a practicing practitioner! In RN clinical, you're rotating thru a bunch of clinicals working with your instructors. This ur by urself with the preceptor. All alone! In another post, another day, I'll post what u need bring for ur clinical.

    In RN school, it's not until the last semester that u had ur own preceptor 1:1. For NP school, u start working with ur preceptor immediately on the first day of the first clinical!!!

    Thinking back about the my practicum experience, I realize that I'll have to be self-starter and self-motivation a lot! I'm there to work and to learn! That's what it is! It's not socialization per se!

    I guess the best approach to graduate clinical is act as if ur working! Don't expect to be held hands or socialize but work and learn!

    HALF-LIFE

    - Need to know half-life so that you won't over-dosing your patient. This is bc a drug w/ a long half-life will build up to toxic level if you keep giving too much too frequent. However, a drug with a short half-life needs to be given more frequent.


    -Lithium half life 24 hrs, given once a day; => pt misses a dose; take 2 pills? no! problem? no!
    -All drugs reach steady state in 3-5 half life's.
    -If a drug has 2hr half life, how many half life does it take to go to 1/4? => 2 half life
    -half life amount: 1/2 (1hl), 1/4 (2hl), 1/8 (3hl), 1/16 (4hl), 1/32 (5hl), 1/64 (6hl), 1/128 (7hl)
    -if a drug has 1hr half life, pt misses the dose, frequency is every 6 hrs, => doesn't mean u should double the dose => it just tells you that you'd better not miss it. Probably good for ICU, probably not for home use.
    - You don't want to check the level until it reaches until it reaches the steady state.
    - You also don't want to change the dose until it reaches the steady state. Ex: Felbamate for anti-epileptics.
    - Half life for Claritin is 8-11hrs (http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20C)/CLARITIN.html
    ) => Patient: I need to go to my parent's house and they have a dog and I'm allergic to dogs. I took the Claritin the day I go to my parents and it didn't work => NP: you need to take Claritin 3-5 days before you go to your parents to make sure it works.



    Case: ICU pt 240BP=> long half life med  such as amlodipine - calcium channel blocker med which has 30-50 half life (but good for inpatient)? No, IV fast and short half life => give every hr so it's at steady state very quickly. Reach steady state pretty quickly => ideal BP. Too much meds, very sensitive pt => goes down too low => stop BP meds => how long does it take for the pt to get out of the system => takes more than 3-5 half life to go back.

    Case: 24mg Amlodipine for 80y/o in regular hospital floor  from 200mmHg down to 70mmHg bc it's good for outpatient use => terrible drug for ER since it takes a long time to get rid of from the body since it's takes so long => do NOT use long half life but good for short half life drug.


    ~Miss Student


    AUC

    AUC: gives you Cmax & Clearance time ~Wonder Me


    Pharmacokinetic parameters describing a typical plasma concentration time profile after an oral administration. Cmax, maximum concentration; tmax, time to Cmax; AUC, area under the curve; MEC, minimum effective concentration; MTC, maximum tolerated concentration.


    Cmax Tmax




    Cmax = C [drug]max in BLOOD.
    Cmax is a beautiful concept to understand. For ex., as an RN, you know the peak time of Humalog/Novolog is about 1.5hr-2hr. This means this would leave the pt most at risk for hypoglycemia 1.5-2hr after insulin administration. Therefore, if suspecting or worrying, you should check the patient 1.5-2hr for blood sugar after insulin adminstration time. When was an RN student (like a long time ago), it always bewildered me why for humalog/novolog which lasts for like 4-6hrs but pt is most at risk at 1.5-2hrs afterwards. It turns out that is when the drug is available most in the blood and therefore working very hard to get blood sugar down. Therefore, it's best to check the BS 1-2hrs after BS administration rather than later due to Cmax.

    However, Cmax Tmax Useful for IV meds and meds absorbed well. Cmax and Tmax kinda useful for insulin. But insulin is quite different in real life. SubQ Lantus 4 units => lasts about a whole day, not half life or short life. Extended release dose more like that.

    Extended-release pills (similarly to Lantus subQ)=> cannot really calculate Cmax or Tmax.

    Ex: 20mg Amlodipine to 80y/o pt (if you're idiot enuf to do it!) & pt is naive to this = >u wanna check at Cmax

    P.s.: Learning pharmacology makes it fun to read the monographs for drugs! You can understand more.


    References for Insulin Tmax:
    http://www.drugs.com/ppa/insulin-analogs.html
    http://pi.lilly.com/us/humalog-pen-pi.pdf
    http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20H)/HUMALOG.html
    http://www.accessdata.fda.gov/drugsatfda_docs/nda/99/21017_Humalog_biopharmr.pdf

    ~Miss Student

    bioequivalence

    Bioequivalence is different from bioavailability. It compares the Cmax & Tmax of generic drug with innovator drug.

    bioavailability

    Bioavailability: 

    Definition: "Bioavailability of a drug administered intravenously is by definition 100%. Bioavailability is less or equal to 100% for any other route of administration."(1)

    Formula: Bioavailability = (AUC oral / AUC iv) x 100%

    Clinical implication :
    - Use oral bioavailability to calculate needed oral dose. Ex: a drug of 10% oral bioavailability, you'll need an oral dose 10 times of the IV dose (2)

    Cite:
    (1) http://sepia.unil.ch/pharmacology/index.php?id=51
    (2) https://books.google.com/books?id=wYRRAAAAQBAJ&pg=PA5&dq=bioavailability+examples+clinical&hl=en&sa=X&ved=0ahUKEwiRgeSysPHLAhXGs4MKHW1iAKAQ6AEIMTAC#v=onepage&q=bioavailability%20examples%20clinical&f=false

    MCQ resources:
     Question #9: 
    http://global.oup.com/uk/orc/pharmacy/ifp_therapeutics/student/mcqs/ch01/



    MCQ by npprep.blogspot.com - Wonder Me!:
    1. What is the bioavailability of Valium IV?:
    a. 80%
    b. 100%
    c. unknown
    d. Needs more info.

    Correct answer: b. 100%



    2. What is the availability of  Oral Lithium?:
    a. less than 100%
    b. 100%
    c. over 100%
    d. 60%

    Correct answer: a. less than 100%



    3. You CANNOT determine bioavailability based on:
    a.  urinary excretion of the drug
    b.  enteral contents of the drug
    c.  plasma contents of the drug
    d.  parenteral contents of the drug


    Correct answer: b. enteral contents of the drug. Remember: generally, parenteral = IV, plasma ; enteral = PO; urinary excretion = amounts of drug excreted/eliminated

    4. An IV drug dose is _____ compared with oral drug dose?
    a. smaller
    b. larger
    c. same
    d. non-comparable

    Correct answer: a. smaller


    5. An oral drug dose is ____ compared with IV drug dose?
    a. smaller
    b. larger
    c. same
    d. non-comparable

    Correct answer: b. larger


    6. What would be the order of greater or lesser bioavailability of the dosage forms?
    a. PO > IV > rectal > topical
    b. IV > topical > rectal >PO
    c.  IV > rectal > PO > topical
    d. IV > PO > rectal > topical

    Correct answer: c.  IV > rectal > PO > topical


    7. Oral bioavailability is NOT dependent on:
    a. dosage
    b. first pass effect
    c. water solubility
    d. lipid solubility
    e. protein binding

    Correct answer: a. dosage  (remember: bioavailability is a percentage %, so it's not dose-dependent or grams-dependent)

    8. Bioavailability is dependent on:
    a. pharmaceutical formulation
    b. dosage
    c. absorption
    d. first pass effect

    Correct answer: a. pharmaceutical formulation (i.e., PO, rectal, IV, topical, ointment, etc.). Remember: absorption is due to first pass effect. A low bioavailability does NOT always mean low absorption rate. It could be absorbed very well but due to first pass effect, it's all eliminated from the body. Thus, it makes the drug bioavailability smaller.

    9.  If a drug has oral availability of 20%. The IV dose is 500mg. What's your oral dose?
    a. 1000mg
    b. 125mg
    c. 500mg
    d. 2500mg

    Correct answer:  d. 2500mg


    10. Food can increase the drug bioavailability:
    a. True
    b. False

    Correct answer: a. True. Remember: grape fruit & meds? 




    adulteration

    As I was reading the lecture about the Pure Food & Drug act (1906), I came across the word 'adulterated'. ???? Adulterated or Mislabeled = NOT pure => this act prohibits im-pure drugs!

    Study tips

    In the spirit of providing concrete (and hopefully helpful!) advice: Here are some ideas to to be as efficient as possible to process, digest, and retain the deluge of information medical school offers: (or any vocational school for that matter):

    ORGANIZATION:
    Divide & Conquer.  Categorize your study content into the following buckets:
    • Can I learn this right now in under 5-10 minutes?
    • Can I delegate this? (see teamwork below)
    • Can I put this off until later?

    After a full day of classes and workshops, many medical students find their study load to be dauntingly heavy, intimidating and disorganized.  The content to learn is often significantly more voluminous and complicated than that of college and many students find themselves in uncharted territory trying to expand their mental bandwidth.   

    Take an hour after classes to systematically divide your study load into these categories.  Once completed, take a breath and then conquer the first bucket:  

    Can I learn this right now in under 5-10 minutes? 

    Because these are low-hanging fruits, you will find that studying is manageable.  Learning items in this category should be at a quicker pace and in a short 1-2 hours, you'll have accomplished a significant amount.  Day by day, the baggy study load becomes organized and manageable which is KEY to efficiency.  This approach also provides much needed motivation to tackle the more complicated and dense materials.         

    Teamwork.  

    No one makes it alone.  Find your  team.  Your study group should be small enough where you must be a  participating active member and not a passive silent participant.  You  have to trust your team: trust them enough to be comfortably wrong.  

    When organizing your study load, consider which elements can be potentially delegated to the study group (particularly if you lack interest or strength in an area and one of your team members has a particular passion for that subject).  Why burn hours and mental anguish trying to understand renal pathophysiology when a friend can break it down for you in easy to understand principles and concepts?  Likewise, things may be delegated to you at which point you'll find yourself teaching: an invaluable way to reinforce learning.  An efficient and trusted team will shave off much waste and add significant value to your study time.  (My team was a  group of 4 trusted stalwarts: more than 10 years later we continue to  remain close in friendship).

    Can I put this off until later?  

    This is such an important element to organizing your material.  Prioritizing the timeliness of your curriculum is a necessary tool to achieving sustainability in an increasingly additive workload.  You minimize the waste of learning something that could have been put off at the cost of learning something you should have focused on due to an upcoming exam, rotation or workshop.  Simply by taking the time to categorize when something should be learned will help you stay focused, in-the-moment, and never behind. 


    BEHAVIORAL MODIFICATIONS:
    Most people believe your mind is your mind and there's little one can do to importantly augment how quickly you process information.  But here are some thoughts than can make incrementally small differences to give you an edge:
    • Sleep.  All nighters to cram has diminishing returns.  Lack of sleep and fatigue has been compared to a blood alcohol level of at least 0.1% in one Australian study.  Your performance (exam, verbatim recall, etc) and your coordination (procedures, surgery) will be significantly better after a restful sleep.  
    • Caffeine.  This is a drug.  Overuse predictably lends oneself to dependence.  The absence of this drug will predictably lead to a state of withdrawal and detract from performance and mental efficiency (headaches, moodiness, etc).  PEARL:  Use sparingly in key moments, caffeine will predictably AUGMENT mental efficiency.  A group of us in medical school never drank coffee on a regular basis.  We leveraged it by drinking it strategically right before an exam.  Our bodies never got accustomed to it and much like an intermittent drug, we felt the augmented mental alacrity when taking it sparingly (n.b. we never experimented with nor recommend "stay awake drugs" such as Provigil).    
    • Stop multitasking.  We live in an era where smartphones and tablets are constantly at our fingertips.  Distractibility, attention-deficiency and hyper-activity are real phenomenons that children, young adults and professionals struggle with in this information-accessible culture.  It is an addiction and the metaphorical quick-sand of efficient learning and productivity.  Set predetermined times of studying and breaks to minimize these hazardous distractions. 

    These tips aren't meant for everyone.  Learning styles are highly individualized - from toddlers  to medical students.  Visual, audio, oral, organized or procrastinator,  repetition or photographic...the key is to gain insight into your  personal styles and strengths (reference: Gardner's theory of multiple intelligences & Carl Jung's learning style dimensions).  Having achieved entrance to medical school, chances are you are well aware  of what works for you and what doesn't.  Don't re-invent!  Rather,  build on what has already made you successful thus far. 

    I hope some of this is helpful.  Now stop procrastinating and get back to studying!

    Monday, March 28, 2016

    Efficacy


    In pharmacology, efficacy (Emax) is the maximum response achievable from an applied or dosed agent, for instance, a small molecule drug https://en.wikipedia.org/wiki/Efficacy

    Efficacy is a drug's capacity to produce an effect (such as lowering blood pressure). For example, the diuretic furosemide eliminates much more salt and water through urine than does the diuretic hydrochlorothiazide. Thus, furosemide has greater efficacy than hydrochlorothiazide. https://www.merckmanuals.com/home/drugs/drug-dynamics/drug-action


    Not very useful for clinical settings. but more for clinical trials.