Calcium Channel Blockers

Calcium Channel Blockers B. Trimble Calcium-channel blockers or calcium antagonist have several possible modes of action in hypertension. In general, these agents block the slow channel in the cell membrane and prevent calcium entry into the cell. This blocking action reduces the mechanical activity of vascular smooth muscle and leads to vasodilation. Another possible mode of action is that they block norepinephrine-mediated vasoconstriction. This may occur because alpha sympathetic vasoconstriction is produced by enhanced calcium influx into the cell. If calcium influx is decreased, then norepinephrine vasoconstriction is reduced. Another system regulated by intracellular calcium is the release of renin by the cells of the kidney. Because calcium-channel blockers inhibit renin release, the renin-angiotensin system may also be suppressed. Calcium-channel blockers prove to be useful in hypertensive patients who also have stable angina and spastic angina (Brunton, Chabner, Knollman, 2011). The vasodilation properties of calcium-channel blockers lead to a reduction in after-load, and their regional smooth muscle relaxant properties are useful in relieving coronary spasms. Calcium-channel blockers are also useful in treating patients who cannot take beta-blocking agents (Katzung, Mastes, Trevor, 2012). African-American patients may benefit more from CCBs as a first line of hypertensive treatment than others. Grapefruit products should be avoided as they interfere with normal operation of the medication. CCBs can also cause low blood glucose particularly those whose dosage is more than 60 mg daily. CCBs are mainly intended to be used for isolated systolic hypertension, and may be used in combination with other antihypertensive medications such as diuretics and ACE Inhibitors (Frank, 2008). Verapamil hydrochloride (Calan, Isoptin) is given in doses of 240-640 mg daily to control essential hypertension. The oral dose is almost completely absorbed from the gastrointestinal tract, and there is a large first-pass hepatic effect. Side effects include constipation, headache, flushing, peripheral edema, and AV nodal effects such as first- and second-degree heart blocks. Verapamil has significant negative inotropic effects and should not be used in patients with congestive heart failure. Verapamil applies antihypertensive results by decreasing systemic vascular resistance usually without orthostatic decreases in blood pressure or response tachycardia. Verapamil reduces arterial pressure at rest and at a given level of exercise by reducing the total peripheral resistance or afterload against which the heart works. The dosage should be titrated for the individual. The usual daily dose of sustained release verapamil, Verelan, is 240 mg daily, however, the initial dosage of 120 mg may be necessary for patients who may have an increased reaction (e.g. Elderly or small people). If adequate control is not obtained with 120 mg, the dose may be titrated in the following manner: 180-240-360-480 mg daily (Chen, et al., 2010). Nifedipine (Procardia) used for essential hypertension the dosage ranges between 10 and 20 mg given three times daily. Doses above 100 mg are not recommended (Chen, et al., 2010). The oral dose is rapidly and fully absorbed from the gastrointestinal tract, with the drug being metabolized in the liver, highly bound to plasma proteins with a half-life of approximately two hours. Nifedipine is more effective than verapamil in dilating peripheral blood vessels. Side effects include reflex tachycardias, stimulation of SA node, flushing, peripheral edema, and headache. CNS symptoms include tremors, nervousness, and mood changes (Wisloff, et al., 2012). Nifedipine and the other dihydropyridine agents (Norvasc, Caduet, Lotrel, Sular, Calan, Verelan, etc.) are more selective as vasodilators and have less cardiac depressant effect then verapamil and Diltiazem. It is recommended that short acting oral dihydropyridine not be used for hypertension due to the increased risk of myocardial infraction. Oral Nifedipine has been used in emergency treatment of severe hypertension (Chen, et al., 2010). Norvasc is a dihydropyridine; Norvasc usual dosage is 5 to 10 mg daily. Small, fragile, or elderly patients or patients with hepatic insufficiency may be started on 2.5 mg daily and titrated for response (Wisloff, et al., 2012). Diltiazem (Cardizem) dosage is between 30 and 90 mg three to four times daily. It is well absorbed by the gastrointestinal tract, with onset of action in less than 15 minutes, a peak effect in 30 minutes, and a half-life of approximately four hours. Vasodilation is limited almost exclusively to the coronary arteries. The most common side effects include AV block, dry mouth, headache, vertigo, rash, and edema (Chen, et al., 2010). Diltiazem SR is one of several preferred initial therapies for hypertensive patients with high risk of developing coronary artery disease including those with diabetes mellitus. It can be used as a monotherapy for initial management of uncomplicated hypertension with conventional tablets used three to four doses daily before meals and at bedtime. Again, elderly or smaller persons may require a lower dosage and titrate as needed for response (Frank, 2008). The algorithm for hypertension management according to The National Institute for Health and Clinical Excellence is as follows: KEY: A= ACE Inhibitor or Angiotensin II (ARB); C= Calcium Channel blocker; D= thiazide-like diuretics Step 1. Under age 55 years Over age 55 or Black person of African or Caribbean family origin of any age (C) Step 2. - (55 yrs.) Step 3. (55yrs) -Step 4. Resistant hypertension (A+C+D+ consider further diuretics OR Alpha blockers or Beta blocker) (The National Institute for Health and Clinical Excellence, 2011). References Brunton, L., Chabner, B., Knollman, B. (2011). Goodman Gilmans: The pharmacological basis of therapeutics (12 ed.). McGraw-Hill. Chen, N., Zhon, M., Yang, M., Guo, J., Zhu, C., Yang, J.,. .. He, L. (2010, August). Calcium channel blockers versus other classes of drugs for hypertension. doi:10.1002/1465/858.CD003654.pub4 Frank, J. (2008, May). Managing hypertension using combination therapy. American Family Physician, 77(9), 1279-1286. Retrieved from American Family Physician: http://www.aafp.org/afp/2008/0501/p1279 Katzung, B., Mastes, S., Trevor, A. (2012). Basic clinical pharmacology (12 ed.). McGraw-Hill. The National Institute for Health and Clinical Excellence. (2011, May 2011). Quick reference guide. Retrieved from NICE Clinical Guidelines: http://www.nice.org.uk/nicemedia/live/13561/56015/56015.pdf Wisloff, T., Selmer, R., Halvorsen, S., Fretheim, A., Novhein, O., Kristiansen, I. (2012, April 4). Choice of generic antihypertensive drugs for the primary prevention of cardiovascular diseasea cost-effectiveness analysis. doi:10.1186/1471-2261-12-26

Barilla JITD Program Essay

1. Diagnose the underlying causes of the difficulties that the JITD program was created to solve. What are the benefits and drawbacks of this program? Just In Time Distribution is a unique idea that the logistics director wanted to implement at Barilla. It was in response to the significant fluctuations in sales demand that Barilla was experiencing from their distribution centers. Exhibit 12 in the case shows how volatile the ordering could be. It looks very unpredictable using their current method of distribution, which is causing excess inventory and stockouts. By nature, their pasta products experience waves of high and low demand. Seasonal and promotional fluctuation was making it hard for Barilla to correctly forecast demand from their distributors. Furthermore, distributors did not have effective forecasting methods. They simply ordered their shipments when their stock was getting low. Barilla had no minimum order quantity nor did they have standing orders with distributors. Es sentially, JITD was created to better supply distributors with their product to eliminate stockouts and excess inventory. Stockouts cost the company valuable sales revenue when demand cannot be met and excess inventory results in additional holding costs. The major benefit to JITD is a steady revenue stream after demand fluctuation is mitigated. 2. What conflicts or barriers internal to Barilla does the JITD program create? What causes these conflicts? As Giorgio Maggiali, how would you deal with these? Support organizations within Barilla met the JITD proposal with resistance. Marketing and Sales departments each had separate concerns. If Barilla had an internal disruption in production such as a strike, distributors would have no excess inventory and stockouts would be likely. The Sales team pointed out that promotional periods would not have a place in this new supply chain model. Also, with a lack of inventory in the distributors holding area, there was a concern that competitors would move in to take the space, eventually pushing out Barilla. Because of the highly specialized manufacturing parameters that were required to produce Barilla products, inflexible production lines did not allow for meeting demand that changes often. Support organizations such as Sales and Marketing also had selfish concerns. With JITD, the need for sales representatives decreased to virtually nothing. After all, the forecast data that Barilla would in theory have, would essentially sell the products themselves. As the  director of logistics, Maggiali must present a favorable business case along with his Just In Time Distribution proposal. He must show the benefits that his plan would have on each of the supporting organizations to gain their support. His proposed JITD is a complete shift in Barilla’s business model. For this reason, I would present this method as a case that will increase sales revenue, lower manufacturing cost, and increase quality operations. Selling his management on these three aspects will allow them to see the increased profitability that will come as a result of JITD. 3. As one of Barilla’s customers, what would your response to JITD be? Why? As a customer of Barilla and distributor of their product, I would greatly appreciate the service that Barilla has offered to provide because I would see the opportunity that this proposed plan has the potential to offer. From saving floor space to cutting down on my lead times I would be a willing partner in their plan. I would, however, force them to sign a third-party proprietary agreement before handing over my demand and sales data. It is important that competitors not know the specifics of our operations as to keep my competitive advantage in the marketplace.

My Personal Learning Style Essay examples - 777 Words

My Personal Learning Style Wow! I have a personal learning style! If I had given any thought to my learning style prior to this course, I would have said simply, Some things are easy for me to learn, and some things are not. Now I can say, I am a grouper, a top-down learner, an owl, in the C-D quadrants, and my strong intelligences are linguistic, intrapersonal, and interpersonal. What all this means, still, is some things are easy for me to learn, and some things are not. But there I go again, simplifying the matter. My learning experience throughout grade school was cast in the Traditional method, employing rote, reward-and-punishment, and repetition, repetition, repetition. It was a one-size-fits-all approach, intended to†¦show more content†¦Secondly, some of us prefer to start with minute details and study from the bottom up, accruing information and data systematically, and building to a mastery of the topic. These people are considered stringers. 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The Dysfunctional Family The Glass Menagerie, Death Of A...

The dysfunctional family is apparent in many households in today’s society, for a dysfunctional family is described as any condition in which healthy family functioning is interfered (Kansas State). There are many reasons for why families become dysfunctional in America today, and statistics are staggering, showing that about half of all marriages end in divorce. Dysfunctional families can be caused either by parents who are insufficient in their efforts to raise their children, or it can be the children who misbehave and cause ruckus in the household. While healthy families tend to return to their normal lives after a time of intense stress or crisis, dysfunctional families experience chronic or longing problems that never seem to fade (Kansas State). The dysfunctional family is a theme that has been used in many plays and novels in literary history, such as The Glass Menagerie, Death of a Salesman, and Ordinary People. Like real life, there are causes to why the families in these works became dysfunctional, and there are distinct characteristics and qualities of each. The Jarretts, Wingfields, and Lomans, fall victim to the plague of an unhealthy, dysfunctional household, and there are causes, characteristics, and even cures of this burden. A dysfunctional family can be caused by deficient and inferior parents who lack basic care taking skills that are needed to raise a healthy and functional family. These kinds of parents tend to teach their children the wrongShow MoreRelatedA Comparison of Tennessee Williams ´ The Glass Menagerie and Arthur Miller ´s Death of a Salesman1158 Words   |  5 Pages The Glass Menagerie by Tennessee Williams and Death of a Salesman by Arthur Miller are two of the twentieth century’s best-known plays. The differences and similarities between both of the plays are hidden in their historical and social contexts. The characters of The Glass Menagerie and the Death of a Salesman are trapped by the c onstraints of their everyday lives, unable to communicate with their loved ones and being fearful for their future. There are a lot of comparisons thatRead MoreDysfunctional Families : A Dysfunctional Family2584 Words   |  11 Pages It is difficult to come by healthy families in modern society, for many families experience many hardships and tribulations all throughout life. The dysfunctional family is apparent in many households in today’s society, for a dysfunctional family is described as any condition in which healthy family functioning is interfered (Santa Clara University). There are many reasons for why families become dysfunctional in America today, and statistics are staggering, showing that about half of all marriages