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soon followed by amitriptyline (Elavil) and then by desipramine (Norpramin) and nortriptyline (Pamelor) Another important dibenzazepine derivative is carbamazepine (Tegretol), which is widely used in the control of seizures but has also found a place in the treatment of lancinating neuropathic and myelopathic pain and possibly of depression and mood instability Subsequently, a number of additional antidepressant drugs were introduced Included here are variants of the conventional tricyclic drugs (amoxapine, protriptyline, trimipramine, doxepin), tetracyclics (maprotiline), bicyclics (zimeldine), and others (trazodone, bupropion) A full account of these drugs, which will not be attempted here, can be found in the monographs of Hollister and of Pirodsky and Cohn The mode of action of these agents is not fully understood, but there is evidence that they block the reuptake of amine neurotransmitters, both norepinephrine and serotonin Blocking this amine pump mechanism (called the presynaptic plasma transporter), which ordinarily terminates synaptic transmission, permits the persistence of neurotransmitter substances in the synaptic cleft and does no more than support the hypothesis that endogenous depression is associated with a de ciency of noradrenergic or serotoninergic transmission The tricyclic antidepressants and the serotoninergic drugs discussed in the next section, are presently the most effective drugs for the treatment of patients with depressive illnesses, the former being particularly useful for those with anergic depressions associated with hyposomnia, early morning awakening, and decreased appetite and libido The side effects of the tricyclic drugs are less frequent and far less serious than those of the MAO inhibitors The tricyclic (dibenzazepine) compounds are potent anticholinergic agents, which accounts for their most prominent and serious side effects orthostatic hypotension and urinary bladder weakness They may also occasionally produce CNS excitation leading to insomnia, agitation, and restlessness but usually these effects are readily controlled by small doses of benzodiazepines given concurrently or in the evenings Rarely, they may cause ataxia and blood dyscrasias As indicated earlier, the tricyclic drugs should not be given with an MAO inhibitor; serious reactions have occurred when small doses of imipramine were given to patients who had discontinued the MAO in the previous days or week It must be repeated that both the MAO inhibitors and the tricyclic antidepressants are dangerous drugs when taken in excess Tricyclic compounds are a frequent cause of accidental poisoning and a favored suicidal instrument of depressed patients It is common for the intoxicated patient to have taken several drugs, in which case chemical analyses of the blood and urine are particularly helpful in determining the drugs involved and in sorting out therapeutic and toxic concentrations Mortality from overdose is mostly due to cardiac disturbances, particularly tachyarrhythmias and impaired conduction (atrioventricular block) Treatment consists of gastric aspiration and instillation of activated charcoal and the addition of physostigmine to reverse serious arrhythmias; the short duration of action of physostigmine requires that frequent doses be given Dialysis is of no value because of the low plasma concentrations of the drug.

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When the hard drive found the appropriate information, it gave the data to the processor using either IRQ 14 or 15, depending on whether it was a primary or secondary hard drive Many of the files necessary to run the application were stored in RAM for faster access by the processor The cache controller, judging by the application, was able to predict which information the processor was likely to need and placed that information into the cache memory, from which the processor could retrieve it even more quickly When you typed the document, the keyboard used IRQ 1 to send the data to the processor When you saved the document, the processor used the hard drive s I/O address to instruct it to store the file When you printed the document, the processor sent the request to the printer, most likely using parallel communication

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are being developed at a rapid pace They act presumably by inhibiting the reuptake of serotonin and to a lesser extent of norepinephrine, somewhat like the effect of a tricyclic antidepressant This results in a potentiation of the actions of these neurotransmitters Because they do not bind as avidly as tricyclic drugs to the muscarinic and adrenergic receptors in the brain, they produce fewer side effects, but some patients complain of anxiety or insomnia when they are rst introduced As with the tricyclic agents, the concomitant administration of MAO inhibitors is hazardous There should be a period of at least 1 week between the administration of these two classes of drugs to allow for the washout of the last agent used Of the several related drugs such as venlafaxine (Effexor), nefazodone (Serzone), citalopram (Celexa), and bupropion (Wellbutrin), each has a novel structure that is not analogous to that of the other categories of antidepressants They are believed to act similarly to the SSRI class by inhibiting the reuptake of serotonin and norepinephrine These newer drugs share most of the side effects of the SSRI drugs, including the danger of concomitant MAO inhibitor administration The symptoms of a serotonin syndrome that results from excessive intake or from the concurrent use of MAO inhibitors include confusion, restlessness, myoclonus, shivering, and diaphoresis, as summarized by Sternbach The risk of seizures related to the taking of certain of these medications has been much discussed For the most part, the risk is quite small but there is little information to guide their use in known epileptics Several studies suggest that the frequency of convulsions may increase in such patients Buprioprion has been particularly associated with seizures in about 05 percent of patients treated at higher dose levels (over 400 mg per day) and this drug should not be used in individuals with a history of seizures The SSRI drugs are well tolerated, may be effective in a shorter time than the tricyclic agents, and are very popular at the moment, but their long-term therapeutic usefulness in comparison with their predecessors remains to be determined (see review of Richelson) Fluoxetine has also been used with bene t in a group of autistic children (page 890) Constipation, dry mouth, and reduced sexual potency are to be expected to some, but varying degrees Hyponatremia is a rare complication.

Once you have the list of the available ASM disks, you can use the CREATE DISKGROUP command shown next to create ASM diskgroups This example will create two ASM diskgroups DATA and RECOV Note that you do not require the FAILGROUP clause, since ASM will define a failure group for each Exadata Storage Server You are required to set the COMPATIBLERDBMS and COMPATIBLEASM attributes to 112010, and the CELLSMART_ SCAN_CAPABLE attribute to true This attribute enables the SQL offload processing on the objects that are placed in this ASM diskgroup

This gait is characteristic of the gluteal muscle weakness that is seen in progressive muscular dystrophy, but it occurs as well in chronic forms of spinal muscular atrophy, in certain in ammatory myopathies, lumbar nerve root compression, and with congenital dislocation of the hips In normal walking, as weight is placed alternately on each leg, the hip is xated by the gluteal muscles, particularly the gluteus medius, allowing for a slight rise of the opposite hip and tilt of the trunk to the weight-bearing side With weakness of the glutei, there is a failure to stabilize the weight-bearing hip, causing it to bulge outward and the opposite side of the pelvis to drop, with inclination of the trunk to that side The alternation in lateral trunk movements results in the roll or waddle In progressive muscular dystrophy, an accentuation of the lumbar lordosis is often associated Also, childhood cases may be complicated by muscular contractures, leading to an equinovarus position of the foot, so that the waddle is combined with circumduction of the legs and walking on the toes With unilateral gluteal weakness, often the result of damage to the rst sacral nerve root, tilting and drooping of the pelvis is apparent on only one side as the patient overlifts the leg when walking

Gait Disorder in Normal-Pressure Hydrocephalus (See also Chap 30)

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