Propranolol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

John Waterston MD, FRACP

• Consultant Neurologist, The Alfred Hospital, Melbourne, Vic
• Honorary Senior Lecturer, Department of Medicine, Monash University

Cholangiocarcinoma (bile duct carcinoma) is less common than hepatocellular carci noma cardiovascular workouts propranolol 20mg cheap. This form of hepatic cancer occurs most frequently in the Far East heart disease vs heart failure buy propranolol 40 mg on line, where it is associated with Clonorchis sinensis (liver fluke) infestation heart disease 100 years ago purchase propranolol 20mg free shipping. Cholelithiasis (gallstones) has a higher incidence in women and is often associated with obesity and multiple pregnancies cardiovascular disease zoonotic order propranolol online. Cholesterol stones are often solitary and too large to enter the cystic duct or the com mon bile duct. Gallstone ileus (intestinal obstruction caused by passage of a large gallstone through the eroded gallbladder wall into the adjacent small bowel) g. Characteristics include yellow cholesterol-containing flecks in the mucosal surface. The most common primary tumor of the gallbladder is adenocarcinoma, which is often associated with gallstones. Carcinoma of the extrahepatic biliary ducts and the ampulla of vater is less common than carcinoma of the gallbladder. The cause is activation of pancreatic enzymes, resulting in autodigestion of the organ, with hemorrhagic fat necrosis and deposition of calcium soaps, and sometimes formation of pseudocysts (parenchymal cysts not lined with ductal epithelium). Other pancreatic exocrine tumors include serous cystic neoplasms, mucinous cystic neoplasms, solid pseudopapillary neoplasms, and pancreatoblastomas. An 18-year-old man presents to his family jaundiced from birth despite aggressive physician for a routine physical prior to moving phototherapy and exchange transfu away for college. Tests from an outside laboratory bolic panel reveals a modestly elevated uncon confirm the total absence of glucuronyl jugated bilirubin but a near-normal aspartate transferase activity. The neonate most aminotransferase and alanine aminotransfer likely has which of the following ase. A 26-year-old woman presents to her pri thromboplastin time, as well as significantly mary care physician with fever, malaise, and increased serum ammonia levels. While on an international medical rota (a) Antimitochondrial antibodies tion, you encounter a pregnant woman in (B) antitrypsin 1 a rural village in India who presents with (C) Ceruloplasmin fever, jaundice, and malaise. A 56-year-old alcoholic man presents to accumulation of the emergency department with confusion (a) copper. A 36-year-old man from sub-Saharan (a) Abetalipoproteinemia Africa presents to the clinic with jaundice and (B) Alcohol right upper quadrant pain. A 63-year-old chronic alcoholic presents the liver, and serum fetoprotein is markedly with weight loss, anorexia, and abdominal elevated. A 43-year-old multigravida presents (a) Asterixis with nausea, vomiting, fever, and right (B) Gallstone ileus upper quadrant pain. Gilbert syndrome is typi cally mild and usually not detected until later in life. Hemolytic disease of the newborn is due to blood group incompatibility between mother and child, and the bilirubinemia is secondary to the inherently decreased glucuronyl transferase with superimposed hemo lytic anemia in the child, further overwhelming the conjugation machinery. Rotor syn drome is a relatively benign condition resulting in conjugated hyperbilirubinemia. Gilbert syndrome is an extremely common cause of clinically insignifi cant unconjugated hyperbilirubinemia. The hyperbilirubinemia is episodic, with increas es related to stress, fatigue, alcohol use, or recurrent infection. Both Dubin Johnson syndrome and Rotor syndrome cause conjugated hyperbilirubinemia. Infectious mononucleosis can cause liver damage, but would likely be accompanied by malaise and fatigue. The figure demonstrates the typical appearance of micronodular cir rhosis, the most common cause of which is alcoholism. Asterixis is a flapping tremor of the hands associated with hepatic encephalopathy. Caput medusae results from dilation of the periumbilical venous collaterals as a result of portal 261 262 Brs Pathology hypertension and activation of portal-caval anastomoses. Macronodular cirrhosis is usually a result of hepatitis B or hepatitis C infection. The recommended screening test for hemochromatosis is serum trans ferrin saturation, which is increased. Further molecular testing can be performed to look for mutations in the Hfe gene on chromosome 6. Decreased 1-antitrypsin levels are associated with liver disease, as well as panacinar emphysema. Wilson disease is a hereditary condition associated with the accumu lation of copper in the liver, brain, and eye. Accumulation of copper in the Descemet membrane of the eye results in the pathognomonic lesion known as the Kayser-Fleischer ring. Accumulation in the brain, specifically in the basal ganglia, results in motor symptoms. Eosinophilic hyaline inclusions, Mallory bodies, are seen in alcoholic liver disease. In addition, if they are subcapsular, they can rupture, causing intraab dominal hemorrhage. Aflatoxin B1 is a fungal metabolite found on moldy nuts and grain com monly found in southern Africa. Together they greatly increase the incidence of hepa tocellular carcinoma, the most prevalent cancer worldwide. Carcinoma of the ampulla of Vater is closely related to carcinoma of the extrahepatic biliary duct, and presents with jaundice and a palpably enlarged gall bladder, as opposed to stones, which typically do not cause an enlarged gallbladder. Sclerosing cholangitis is an inflam matory condition of the extrahepatic bile ducts that is often associated with chronic ulcerative colitis. Gallstone ileus is a complication of cholelithia sis when the gallstone erodes through the gallbladder into the adjacent small bowel. The Whipple triad is associated with insulinomas, tumors of the endocrine (rather than exocrine) pancreas. Resulting conditions include oligohydramnios, or decreased amniotic fluid, which occurs because the renal system fails to excrete fluid swallowed by the fetus. Unlike disorders with greater disruption of glomerular structure, proteinuria in the nephrotic syndrome is unaccompanied by increased urinary red cells or white cells. Electron microscopy is normal except for the disappearance or fusing of epithelial foot processes. It is a major cause of nephrotic syndrome and is clinically similar to minimal change disease, although it occurs in both children and older patients. The diagnosis should be suspected when the nephrotic syndrome is accompanied by azotemia (increased concentrations of serum urea nitrogen and creatinine). Granular deposits of immunoglobulin G (IgG) or C3 are apparent on immunofluores cence. There are two types: (1) Primary (al) amyloidosis occurs in patients with plasma cell dyscrasias and usually consists of monoclonal lambda light chains. The disorder is histologically defined by the formation of crescents between the Bowman capsule and the glomerular tuft, which result from deposition of fibrin in the Bowman space and from proliferation of parietal epithelial cells of the Bowman capsule; cells of monocytic origin are often involved. As in other disor ders with immune deposits, such as membranous glomerulonephritis, lupus glomerulopathies, and others, immunofluorescence is granular in appearance. Antiglomerular basement membrane antibodies (nonstreptococcal) are characteris tic in approximately 10% of cases; these cases often present clinically as Goodpasture syndrome.

Dependence exists along a continuum of severity implying the need for different treatments and outcome goals heart disease for women buy discount propranolol 40mg online. Substance-related harms in physical cardiovascular disease articles 2014 buy 80mg propranolol with visa, psychological capillaries exercise order propranolol on line amex, and social spheres belong to a separate domain blood vessels constrict order propranolol master card. Addiction has become a term without precise meaning, but is generally taken to include dependence, problem use, and any related harms. While social learning allows that anyone may become dependent on psychoactive substances and may also unlearn their depen dence, it does not preclude the possibility that substance use may cause deficiencies of endogenous neurotransmitters, which are usually reversible, or permanent damage to receptor structure and connectivity. Pervin6 explores this very issue in a study of four poly drug users: subjects were asked to describe situations (1) where they wanted to use drugs, (2) after they had used drugs, (3) where they wanted to use drugs but could not, and (4) unrelated to drug use, and then to associate affects from a prepared list with the four situations they described. The results also indicated that subjects discriminated between drugs suited to dealing with different affects. In two complementary reports, Johanson and Uhlenbuth7, 8 compared changes in mood among normal volunteers in a choice experiment between placebo, diazepam, and amphetamine. Amphetamine 5 mg was chosen significantly more often than placebo, 81% of possible choices, with increased scores for vigor, friendliness, elation, arousal, positive mood, and decreased scores for confusion. In contrast, diazepam 5 and 10 mg were chosen significantly less often than placebo, 28 and 27% of choices, respectively, with decreased scores on vigor and arousal and increased scores on confusion and fatigue. The point to underline here is that normal subjects are likely to have different effects to patient groups and the reinforcing potential of different substances will therefore vary between such groups: within matched subjects the reinforcing properties of different substances will also vary in strength. Using a choice paradigm, subjects maintained on methadone 50 mg daily, identified to subjects as capsule A, had the option of taking capsule B which, in different trials, contained either methadone 50, 60, 70, or 100 mg, in place of Capsule A. Capsule B was chosen 50, 73, 87, and 97%, respectively, of occasions: at the highest dose, subjects identified an opiate effect and a liking for the drug but no high or withdrawal was reported. The clinical implications are quantified by McGlothlin and Anglin10 in a 7-year follow-up of patients attending high vs. So, the dilemma is that prescriptions most liked by addicts, namely those that are more reinforcing, achieve good program retention and a degree of stability, but at the cost of slowing movement away from substance use and the associated subculture. The potency of psychoactive effect is not simply a function of dose or plasma level, but also depends upon receptor uptake characteristics. Although addicts identify buprenorphine as having an opioid effect and therefore potential for misuse, its binding affinity at the mu receptor and antagonist activity confer a quite different reinforcement profile to pure agonists such as diamorphine. Withdrawal from buprenorphine 8 mg daily does not precipitate an opiate withdrawal syn drome. Psychoactive effect alone is insufficient explanation of within drug-group differences of dependence forming potential: different pharmacokinetics are important. The benzodiazepines and opioids are the most fruitful source of investigation here because both drug-groups contain many different compounds that are widely used and misused. There are ethical problems in conducting laboratory experiments with potent drugs such as heroin and to avoid this problem Mello et al. Absorption rate and, therefore, immediacy of effect have similarly been shown to be important for benzodiazepines. Learning theory predicts the importance of absorption rate in that the most immediate positive consequence of a behavior (drug taking) is the most reinforcing. While potency and the speed of onset of effect are particularly important for initiating dependence, elimination rate assumes greater importance in building and maintaining depen dence. As a rule, the more quickly a drug is metabolized the sooner the user experiences a loss of effect and possibly also withdrawal symptoms. Edwards17 has described substances as existing along a continuum: highly plastic substances, that is to say those where the content of the effect is markedly influenced by environment, exist at one end. Plasticity has a bearing on the dependence-forming potential of substances; where the content of a drug effect is uncertain, repeated use is unlikely. It is interesting that the most popular recreational drugs, alcohol and cannabis, fall around the middle of the plasticity continuum, perhaps signalling a point which allows an agreeable interaction between drug and expectation effects. The Model of Change described by Prochaska and DiClemente18 is a motivational model widely used in the addiction field. The purpose of using the model is twofold: first, to understand what is going on for a patient at a given time; second, to inform the patient of the choice of interventions. People who are not motivated to change their substance use are said to be at the pre-contemplation stage, which is characterized by denial and rationalization of substance use and its consequences. There are two strands to treatment strategy at this stage: one is to minimize harm without expecting to change the substance use behavior (for example, by giving nutritional supplements or substitute prescribing). The second is to introduce conflict about the substance use (for example, by making links with untoward life events and thereby creating motivation for change). The temptation is to offer treatments aimed at changing substance use behavior before the patient is ready to change. The experience of significant conflict about substance use (for example, when an arrest is felt to be incompatible with a self-image of being a sensible and responsible person), or when the cost of substance use is causing family hardship indicates movement into the contemplation stage. At this stage, motivational interventions which may involve the use of simple clinical tools (for example, the decision matrix), or may draw on more sophisticated skills (for example, motivational interviewing), 19 are indicated. The action stage is reached when conflict is resolved and there is a commitment to change. A number of things will have happened at a psychological level: the person will believe that life will be better on stopping or controlling their substance use (positive outcome expectancy), they are able to change (self efficacy), and they will know how to change (skills learning). Elective detoxification is the most common medical intervention at the action stage. Maintenance of behavior change for alcohol misuse may be assisted by prescribing a sensitizing agent such as disulfiram or, for opiate misuse, prescribing an antagonist such as naltrexone. Pharmacological interventions are no more than an adjunct to the main task of achieving lifestyle change. Successful exit from the maintenance stage, recovery, requires that the patient has confidence and skills to deal with substance use cues. Achieving the right mix of pharmacology and psychology is more art than science, but an understanding of the underlying brain mechanisms, reviewed for clinicians by Nutt, 20 and a parallel understanding of motivation will help achieve safe and effective prescribing. The list is long, such is the diversity of interests vested in substance use and misuse. Everyone will have opinions about addiction including opinions about what doctors should prescribe. Doctors should seek the widest possible clinical freedom to manage addiction patients and to secure this freedom. It follows that prescribers must be sensitive to the prevailing medico-political views on what constitutes good practice. People who misuse substances, particu larly illicit substances, may have particularly forceful views about what doctors should prescribe, but these view are likely to change depending where a person is within their addiction career. It follows that prescribers must have an understanding of addictive behaviors and characteristics of addictive substances. The Model of Change (described above) is a simple, commonly used tool that offers a framework for prescribing and other interventions. For most people who have developed a moderate or severe dependence, pharmacotherapy will, at some time, be an important part of treatment. It follows that prescribers must have a repertoire of skills, including behavior therapy and psychotherapy or, alternatively, must work with a co-therapist. When working with a co therapist, the doctor must be satisfied with the reasons for prescribing and take responsibility for the prescription given. In contrast, specialists are likely to be circumspect about the place of pharmacotherapy and especially so when this means prescribing addictive drugs. Doctors may be required to justify their prescribing to a variety of authorities and are more likely to fall foul of legal action or audit because of precipate rather than delayed prescribing.

There are many types of bald bariatrician A physician who specializes in ness coronary artery bypass procedure effective 80 mg propranolol, each with a different cause coronary heart disease history trusted propranolol 80mg. See alopecia; alopecia areata; behavior modification arteries carry blood away from the heart cheap 20 mg propranolol mastercard, lifestyle changes blood vessels end to end generic propranolol 20 mg overnight delivery, and, when alopecia capitis totalis; alopecia, traumatic; indicated, the prescription of appetite suppressants alopecia universalis. Bariatrics also includes research into overweight, as well as its ball-and-socket joint A joint in which the causes, prevention, and treatment. The barium outlines the colon on the X-ray enlarge a narrowing in a coronary artery. Trench sulfate, which produces a visible image on X-ray fever was first recognized in the trenches of World film. Barium solution outlines organs of the body so War I, and it now occurs among homeless people, they can be seen as images on X-ray film. Also basal cell A small, round cell found in the lower known as upper gastrointestinal series. Basal cell carcinoma often occurs on Barr body A microscopic feature of female cells the face and neck, where the skin is exposed to sun that is due to the presence of two X chromosomes, light. These tumors are locally invasive and tend to one of which is inactive and crumples up. There is a small nucleus, putamen, and globus pallidus) that are but definite increased risk of cancer of the esopha responsible for involuntary movements such as gus (adenocarcinoma) in people with Barrett tremors, athetosis, and chorea. The basal meta bolic rate can offer clues about underlying health barrier method A birth control method that problems. For example, a person with an overly employs a barrier which prevents sperm from active thyroid has an elevated basal metabolic rate. This meas nearby glands, called the lesser vestibular glands, ure is now superceded by modern thyroid function the Bartholin glands act to aid in sexual intercourse. Transmission tary to one another (A and T, or G and C) and join occurs when infected louse feces are rubbed into. It may be caused by incomplete development of bladder control, a basement membrane A thin membrane that is sleep or arousal disorder, bladder or kidney dis composed of a single layer of cells. About 20 percent of 5 with coarse, bluish-black granules of uniform size year-olds wet the bed at least once a month; sur within the cytoplasm. A bee sting can trigger an allergic reaction, including life-threatening anaphy battered child syndrome A condition in which lactic shock. Avoidance and prompt treatment are a person has skeletal fractures, especially multiple essential for those who are allergic to bee stings. Hikers dating the reporting of suspected instances of child should wear long pants and shirts in risk areas. Victims with Mycobacterium bovis that is closely related to more serious symptoms can require intravenous Mycobacterium tuberculosis, the agent responsible fluids, oxygen, cortisone medicine, or epinephrine, for tuberculosis. For those who are the fingernails, or transverse depressions in the nail not allergic, stings are a minor nuisance unless they plate, from temporary disturbance of cell division occur in multiples. This species of bees has an bedbug A blood-sucking bug in the Cimex family unusual and dangerous natural defense mechanism that lives hidden in bedding or furniture and comes when disturbed. They bedsore A painful, often reddened area of degen attack in large numbers and for a longer period of erating, ulcerated skin that is caused by pressure time than is typical of the common European honey and lack of movement and is worsened by exposure bee. As a result, Africanized bees inflict more stings, to urine or other irritating substances. Untreated injecting a higher dosage of bee venom into their bedsores can become seriously infected or gan victims. Beef tapeworm does not invade surrounding tissue or spread to can be contracted from infected beef that is raw or other parts of the body; it is not a cancer. Half of men over age 50 develop symptoms of biofeedback, relaxation training, and hypnosis. Medical therapy includes drugs such behaviorism the science of studying and modi as finasteride and terazosin. Prostate surgery has fying animal or human behavior, often through traditionally been seen as offering the most bene behavior modification techniques. Upper abdominal dis beriberi Inflammation of multiple nerves comfort associated with excessive swallowed air (polyneuritis), heart disease (cardiopathy), and may extend into the lower chest, producing symp edema (swelling) due to a deficiency of thiamine toms that suggest heart or lung disease. Treatment includes protecting the eye on the Bernard-Soulier syndrome usually appears in the affected side from dryness during sleep. Massage of newborn period, infancy, or early childhood, with affected muscles can reduce soreness. Bernard cortisone medication, such as prednisone, is given Soulier syndrome is an inherited disease, transmit to reduce inflammation during the first weeks of ill ted as an autosomal recessive trait. Specific platelet function tests, as well as tests for the glycoproteins common to belly See abdomen. Also beta-adrenergic blocking drug See beta known as esophageal acid infusion test. Bezoars can block the digestive system, espe beta blocker A class of drugs that block the cially the exit of the stomach. A bezoar composed of effect of beta-adrenergic substances such as adren hair is called a trichobezoar. A bezoar composed of aline (epinephrine), that play a key role in the sym vegetable materials is called a phytobezoar. They have also become important bias In a clinical research trial, the effects that drugs in improving survival after a heart attack. Common exam to their effect on blood vessels, beta blockers can ples of bias include advanced knowledge of the lower the blood pressure and are of value in the treatment being given, strong desire of the treatment of hypertension. Other uses include the researcher for a specific outcome, or improper prevention of migraine headaches and the treatment study design. To avoid bias, a blinded study may be of familial or hereditary essential tremors. See also blinded study; double-blinded blockers reduce pressure within the eye and they study. Beta blockers include acebutolol (brand refers to bicarbonate of soda (sodium bicarbonate, name: Sectral), atenolol (brand name: Tenormin), baking soda), a white powder that is a common ingredient in antacids. Topical beta blockers for the eye include timolol ophthalmic solution (brand mmol/liter. The biceps beta carotene A protective antioxidant vitamin brachii is the well-known flexor muscle in the upper that is a natural component of carrots. Destruction of beta cells causes type 1 (insulin-dependent) diabetes melli can sometimes be bicornuate. There may be no symptoms of bicuspid aortic valve beta-2 microglobulin A nonspecific test that in childhood, but in time the valve may become nar rowed, making it harder for blood to pass through measures the amount of cell destruction present. It is considered to be one of the best ways to measure it, or blood may start to leak backward through the. Treatment depends on how the the urinary tract or the intestine, where they hatch valve is working. For a severely deteriorated valve, to form another form of the parasite, called replacement surgery may be necessary. An abbreviation commonly used on pre biliary Having to do with the gallbladder, bile scriptions that means twice a day. Biliary sand may eral arthritis affects joints on both the left and right be looked upon as a stage of growth between bilary sides of the body. The composition of biliary sand bile A yellow-green fluid that is made by the liver varies but is similar to that of gallstones, the most and stored in the gallbladder.

Syndromes

• Infections (strep, staph)
• Platelet transfusions
• Activated charcoal
• Creatinine - blood
• Pressure in the lower pelvis
• Collapse
• Grunting

This ratio was remarkably constant throughout the absorption cardiovascular disease leading cause of death worldwide purchase propranolol line, distribution and elimination phases of ethanol metabolism cardiovascular system university quiz propranolol 40 mg fast delivery. In the latter study heart disease screening order propranolol 40 mg amex, ethanol concentrations were found to be almost identical in unstimulated and stimulated (citric acid) saliva cardiovascular system quizlet purchase propranolol 80mg line. These authors also reported that ethanol concentrations in saliva paralleled capillary blood more accurately than venous blood concen trations and therefore, indicated that saliva was as useful as venous or capillary blood to reflect the intoxication state of an individual in the post-absorption state. In an experiment designed to reflect specimen collection consistent with an accident investigation, the prediction error always was found to be less than 20%. Recently, a number of rapid on-site tests for ethanol in saliva have been marketed. In contrast, cotinine, the major metabolite of nicotine has a half-life of approximately 17 h. Further, Curvall, et al105 determined that saliva nicotine concentrations did not reflect actual uptake of nicotine as accurately as saliva or plasma cotinine levels. Recently, Etzel107 reviewed 43 reports concerning the use of saliva cotinine measures to discriminate between smokers and non-smokers. Generally, non-smokers and those exposed passively had cotinine concentrations below 5 ng/mL, but heavy passive exposure may result in concentrations equal or greater than 10 ng/mL. Infrequent active smokers or regular active smokers with low nicotine intake had cotinine concentrations between 10 and 100 ng/mL, and regular active smokers had cotinine concentrations in excess of 100 ng/mL. The ability to categorize individuals into different risk groups by means of non-invasive cotinine saliva measurements provided objective criteria for use in future studies of the health effects of environmental smoke exposure. Saliva cotinine measurements were the most accurate in determining smoking status with a sensitivity of 96% and a specificity of 99%. Cotinine is the primary and preferred measure of cigarette smoke exposure in epidemiologic research. Initially, the metabolite was present in much lower concentrations (0 to 4 h), but matched or exceeded concentrations of the parent compound at later times (4 to 24 h). Saliva concentra tions of methaqualone and metabolite were approximately 10% of those observed in plasma. Meprobamate was reported to be present in saliva in nearly equal concentrations as found in plasma after oral administration. This depot produces elevated drug concentrations that can be detected for several hours. Thereafter, saliva drug concentrations generally reflect the free fraction of drug in blood. Also, many drugs are weak bases and saliva concentrations may be highly dependent upon pH conditions. Generally, there was a high correlation of saliva drug concentrations with plasma, especially when contamination of the buccal cavity was eliminated. There are many potential applications for saliva testing for drugs in the general areas of drug detection, treatment and forensic investigations. Saliva drug tests can reveal the presence of a pharmacologically active drug in an individual at the time of testing and significant correlations have been found between saliva concentrations of drugs and behavioral and physiological effects. It is anticipated that over the next decade, saliva testing for drugs will develop into a mature science with new applications. Future research is needed in pharmaco kinetic modeling of drug and metabolite excretion in saliva. Also, in order to evaluate the potential of saliva for use as a matrix for workplace drug testing, data on detection times of illicit drugs and their metabolites in saliva is needed. Following sympathetic nerve stimulation, sweat is excreted onto the surface of the skin and evaporated to release body heat. These glands originate deep within the skin dermis and terminate in excretory ducts emptying onto the skin or developing hair follicles. Eccrine glands are located on most skin surfaces, while apocrine glands are restricted to skin of the axilla, genitalia and anus. Sweat also contains albumin, gamma globulins, waste products, trace elements, drugs, and many other substances found in blood. Passive diffusion of drugs from blood to sweat is favored for lipid-soluble substances. Non-ionized basic drugs diffuse into sweat and become ionized as a result of the lower pH of this biological fluid. Basic substances may accumulate in sweat as compared to blood due to the pH differential between the two matrices. Some drugs may migrate across the dermal and epidermal layers into the stratum corneum. Theophylline123 was shown to migrate at a slow rate from interstitial fluid to the skin surface. He suggested that there was an additional source of urea incorporated into sweat other than that available in the plasma or interstitial fluid. He hypothesized that urea could have been synthesized by the sweat gland, or that a pool of urea existed in the skin which could contribute to that found in sweat. The amount of sweat excreted is highly variable both between individuals and within a single person, and is dependent upon their daily activities, emotional state and environment. Systematic collection of specimens is difficult because of the unequal distribution of sweat glands. Sweat can be collected noninvasively with gauze or filter paper, or with specialized collection devices. In 1980, Phillips125 reported development of an adhesive patch for the long-term collection of sweat (10 days). This patch was occlusive in design, trapping both the solute and water components permitting the determination of analyte concentration in sweat. A disadvantage of the occlusive patch design was the limited time the patch could be worn. It was suggested that it might be possible to monitor drug-taking behavior through use of the patch. This sweat patch was later utilized in the validation of self-reports of alcohol use. The device consists of an adhesive layer on a thin transparent film of surgical dressing to which a rectangular absorbent pad is attached. Sweat concentrates on the absorbent pad while oxygen, carbon dioxide, and water vapor escape through the trans parent film. Larger molecules are excluded by the molecular pore structure of the plastic membrane. The skin must be thoroughly cleaned with isopropyl alcohol prior to affixing the patch to prevent contamination of the patch or interference with the deposition or detection of analytes on the patch. Attempts to remove the patch prematurely or tamper with the device are readily visible to personnel trained to remove the sweat patch. Care must be taken not to contaminate the absorbent pad when removing and storing the patch prior to analysis. Sweat testing may serve as a useful tool in surveillance of individuals in treatment and probation programs due to the fact that monitoring illicit drugs in sweat on a weekly basis may provide sufficient detection sensitivity. Interest in measurement of drugs of abuse in sweat has recently increased due to the somewhat wider window of detection of drug use than provided by urine testing and from the desire to determine mechanisms of drug incorporation into hair. Deposition of drug into hair via sweat may account for the lack of dose-response relationships reported in some studies and for the presence of drug in distal segments of hair that do not correlate with the time of drug exposure. The predominant analytes generally found in sweat and hair are the parent compounds, rather than their more polar metabolites which usually predominate in urine.

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