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One of the most important implications of this equation is that a drug dissolves more rapidly when its surface area is increased gastritis duration bentyl 10mg, which is usually accomplished by reducing the particle size of the drug gastritis symptoms with back pain discount bentyl 10 mg visa. Many poorly soluble gastritis diet 91303 buy bentyl master card, slowly dissolving drugs for oral drug delivery are therefore marketed in micronized or microcrystalline form, as reducing the particle size of the drug increases the available surface area. The ionized form of a drug molecule is the more water-soluble form, therefore the dissolution rate of weak acids increases with increasing pH, whereas the dissolution rate of weak bases decreases with increasing pH. Although it is the ionized form of a drug that is required for aqueous solubility, the unionized form is required for lipid solubility and transcellular passive diffusion. However, the unionized form has poor aqueous solubility, which mitigates against membrane penetration. In practice, a balance between the lipid and aqueous solubility of a drug is required for successful absorption. Various strategies to increase the solubility of a drug are given below; this subject is also discussed in detail in Chapter 6 (see Section 6. Salt formation Formation of a corresponding water-soluble salt increases the dissolution rate in the gastrointestinal tract. This phenomenon can be explained by considering that a weakly acidic drug is unionized in the stomach and therefore has a low dissolution rate. If the free acid is converted to the corresponding sodium or potassium salt, the strongly alkali sodium or potassium cations exert a neutralizing effect. Thus in the immediate vicinity of the drug the pH is raised to, for example, pH 5–6, instead of pH of 1–2 in the bulk medium of the stomach, resulting in an alkaline microenvironment around the drug particle. This causes dissolution of the acidic drug in this localized region of higher pH, which gives rise to overall faster dissolution rates. When dissolved drug diffuses away from the drug surface into the bulk of the gastric fluid where the pH is again lower, the free acid form may precipitate out. However, the precipitated free acid will be in the form of very fine wetted drug particles. These drug particles exhibit a very large total effective surface area in contact with the gastric fluids, much larger than would have been obtained if the free acid form of the drug had been administered. Examples of the use of soluble salts to increase drug absorption include novobiocin, in which the bioavailability of the sodium salt of the drug is twice that of the calcium salt and 50 times that of the free acid. For example, the minor tranquilizer clorazepate is a prodrug of nordiazepam and is marketed as a dipotassium salt that is freely soluble in water, in contrast to the poorly soluble parent, norazepam. Polymorphic forms Many drugs can exist in more than one crystalline form, for example chloramphenicol palmitate, cortisone acetate, tetracyclines and sulphathiazole, depending on the conditions (temperature, solvent, time) under which crystallization occurs. This property is referred to as polymorphism and each crystalline form is known as a polymorph. At a given temperature and pressure only one of the crystalline forms is stable and the others are known as metastable forms. A metastable polymorph usually exhibits a greater aqueous solubility and dissolution rate, and thus greater absorption, than the stable polymorph. Amorphous forms The amorphous form of a drug has no crystalline lattice and therefore less energy is required for dissolution, so that the bioavailability of the amorphous form is generally greater than that of the crystalline form. For example, the amorphous form of novobiocin is at least 10 times more soluble than the crystalline form. Solvates Many drugs can associate with solvents to produce crystalline forms called solvates. Thus more rapid dissolution rates are often achieved with the anhydrous form of a drug. For example, the anhydrous forms of caffeine, theophylline and glutethimide dissolve more rapidly in water than do the hydrous forms of these drugs and the anhydrous form of ampicillin is about 25% more soluble in water at 37 °C than the trihydrate. Formulation factors The type of dosage form and its method of preparation or manufacture can influence drug dissolution and thus bioavailability. For example, there is no dissolution step necessary for a drug administered as a solution, while drugs in suspension are relatively rapidly absorbed because of the large available surface area of the dispersed solid.

Frequently gastritis diet ulcerative colitis purchase bentyl 10 mg, interviewees recommended that other consumers should refer to past experiences of pre-treatment gastritis treatment guidelines order bentyl in india, adherence or non-adherence to assist them with choices around medication use corpus gastritis definition bentyl 10mg discount, thus providing further evidence subjective experiences can influence adherence. In the below extracts, interviewees recommend that consumers compare how they feel when taking medication to how they feel when they are not, in order to encourage adherence: Molly, 18/02/2009 M: If they don’t take it you become uh, very sick. Ryan, 26/09/2008 L: Is there anything you think could be done to help people with adhering to their medication at all? I know you’ve mentioned the comparison between, like pointing out to someone, this is what you were like before you were on it and this is how you are now. R: Yeah but the person who takes the medication has to do their own bit of diagnosing. Say, ok this is how it is now, this is how it was then, obviously it’s better now so I have to keep taking the medication. In the first extract here, Molly directly associates non-adherence with becoming ill and constructs this as consistent with her past experiences. Ryan implicitly constructs non-adherence as a negative experience by comparing the present (adherence) with the past (non-adherence) and describing the former as “better”. In the context of being asked about interventions to address adherence, both interviewees indicate the usefulness of reflecting on past experiences of non-adherence and comparing these to 127 those when adherent. It is implied in both extracts that making such comparisons will facilitate consumers to make the association between medication adherence and stability, and that this will, in turn, motivate them to remain adherent. Both interviewees could be seen, thereby, to indirectly frame past experiences of non-adherence as important to reinforce future adherence, as they highlight the benefits of taking medication. In the second extract, Ryan also emphasizes the subjectivity of adherence choices, by stating that “the person who takes the medication has to do their own bit of diagnosing” in response to being asked about interventions. By diagnosing, Ryan seems to be referring to a process whereby the consumer makes the decision as to whether they need medication based on an appraisal of their experiences on and off medication. Interventions from external sources are, thus, implicitly constructed as less effective by Ryan, through his representation of adherence as a personal choice, influenced by personal experiences. Similar to the previous extracts, the below extracts more directly emphasise the importance of non-adherence experiences in assisting with future adherence. Oliver, 21/08/2008 L: And um, how do you think some of these, what could we do to get this across, do you think just tell people this, give people this sort of information? O: Yeah, well, what you should, if they don’t think they need it, you should say, alright then, don’t take it and then when they’re, something happens, goes wrong, use that as an example, like if they start hearing voices and that again, put ‘em on their medication and wait until they’re better and the next time they feel that they don’t need medication just bring back the time 128 when they did go off it and started falling in the dumps and all that and hearing voices and all that and bring that all up, say you do need it, this is what happens, it’s happened to you in the past, so you take it. I had a brother who was a doctor and he’d tell me how important it was that I stayed on them and in the end I decided not to. In both of these extracts non-adherence experiences are constructed as important influences on future adherence, as interviewees indicate that consumers can learn the association between adherence and stability by drawing on these experiences. Like the previous extracts, it is suggested that mere instruction to take medication, even in conjunction with information about the risks of non-adherence, is ineffective in assisting with adherence. Thomas summarises this position through the statement, “I think maybe you just have to learn the hard way”, framing adherence as something which is learned via a trial and error process. Thomas states that only once a consumer has experienced non-adherence and relapsed, can health workers then have a role in reminding consumers of this experience to assist with motivation for adherence. The following extract uses a metaphor to describe the learning process involved in adherence: 129 Travis, 19/02/2009 T: But everyone has to, at some stage, work this out for themselves, with a mental illness. It’s just like, you’re at uni, you can’t expect to go to uni for 6 months and then graduate, you’ve gotta go through it, you know what I mean? The above extract took place in the context of Travis talking about how consumers can be made aware of the importance of medication adherence. Travis constructs adherence as a process which is personal and involves learning from experiences (“everyone has to, at some stage, work this out for themselves, with a mental illness. They have to work it out and they have to start learning this stuff to progress”). Travis could be seen to imply that the process of becoming adherent cannot be hastened by outside intervention, but rather, is a natural, learning process which evolves with time; he uses the metaphor of university education to illustrate this. Specifically, through the metaphor of expecting an individual to graduate after a short period of time, Travis could be seen to highlight the irrationality of expecting consumers to be adherent immediately. He could additionally be interpreted to suggest that the process of learning about the need for medication is associated with experiences (“you’ve gotta go through it”). The following extracts strongly emphasise the subjectivity of experiences of mental illness and with medication, which contraindicate the effectiveness of general interventions: Cassie, 04/02/2009 C: Um, no that’s what the individual’s gotta learn for themselves.

O: Well they should ask you gastritis treatment probiotics purchase cheap bentyl online, have you got any problems gastritis diet 9 month purchase discount bentyl online, have you got any concerns gastritis no appetite buy bentyl 10 mg fast delivery, have you got any worried about anything, you know. O: Some of them, I don’t even feel like they care, they’re just like, “yeah yeah”. In the context of being asked about how health workers could assist consumers with adherence, Gary suggests that prescribers should ask consumers more questions, as they “don’t ask enough”, which is also illustrated through his elaboration that prescribers “just ask you how you, you know, they ask you how are your symptoms”. He indicates that prescribers’ questions focus on medication and dosage information and implies that prescribers fail to read notes prior to appointments. Gary could be seen to suggest that a past prescriber failed to assist him during a period of non-adherence by not asking enough questions and thereby assesses him negatively (“he wasn’t a very good one”). Oliver negatively appraises prescribers who fail to provide a personal (“they’re just like, yeah yeah”), considerate (“he didn’t care”) and thorough (“I was in there 10 minutes and she just sent me out”) service. Gary and Oliver provide examples of the types of questions that prescribers could ask consumers to assist with adherence and their general well-being, such directly asking about their adherence (“Are you still taking your medication? Oliver also 227 indicates that friendly rapport would be appreciated (“joke around, give a bit of advice”). It was surprising that some consumers indicated that their prescribers did not ask questions about adherence or potential stressors which could lead to relapse, given the established importance of relapse prevention amongst people with schizophrenia. This may reflect time constraints and a lack of resources in the mental health system, which prevents prescribers from being able to spend time gaining information about consumers they are treating. It could be argued that there may be a role for psychologists in providing a more personalized service for consumers, whereby they can discuss stressors and barriers to adherence for example. In the following extract, Oliver highlights the difficulties of establishing a therapeutic alliance in the context of the rotating system of psychiatrists at a medication clinic: Oliver, 21/08/2008 L: Ok so do you think that your relationship with your psychiatrist is important then? O: Yeah, it is important, but it’s like, every six months you swap and you get somebody new and it’s like, when you start to feel comfortable and talking to ‘em, they change it. I was like, “yeah, yeah, yeah, everything’s 228 fine, everything’s fine”, and I was like, I was, half the time I was miserable as fuck. Um, ok so until you’ve got that relationship you’re not gonna be as open with them, is that what you mean? Oliver acknowledges the importance of a positive therapeutic alliance but constructs seeing a new psychiatrist “every six months” as a barrier to this. He elaborates that as soon as he starts to feel “comfortable” enough to talk openly with his prescriber, “they change it”. Oliver explains that he experiences difficulties confiding in prescribers he does not know well and recalls that in the past, he failed to notify his prescriber that he was experiencing depressive symptoms (“I was like, “yeah, yeah, yeah, everything’s fine, everything’s fine”, and I was like, I was, half the time I was miserable as fuck. Oliver does not directly link a prescriber’s lack of knowledge of his background and unique circumstances to non-adherence. However, it could be argued that consumers may be more likely to become non-adherent if they endure symptoms or side effects as a result of not talking about their experiences with prescribers, as this limits the capacity of the prescriber to tailor the medication regimen to address consumer concerns. Oliver recommends that consumers see the same prescriber for a more extended period of time (“they gotta do it longer”) in order to improve communication in the therapeutic alliance. Arguably an aspect of collaboration, many interviewees highlighted the importance of prescribers tailoring their medication regimens to their unique situations in order to reinforce adherence. According to Sperry (1995), tailoring the treatment regimen refers to individualising or customising information and scheduling to the consumer’s personality style and circumstances and has been linked to adherence in research. Consistently, in the following extracts, interviewees talk positively about prescribers who tailor their regimens according to fluctuations in symptoms, the presence of situational stressors, side effects and their daily routines. Conversely, consumers often associated non- adherence with prescribers’ failure to consider their unique circumstances or concerns in developing or revising treatment regimens. Below, after having recalled a period of time when she experienced situational stress, Diana positively evaluates her prescriber’s response to this: Diana, 11/02/2009 D: So I put myself in a bit of a bad position and he came onto me and there was no one around you see and I didn’t know what to do but anyways, I got out of the situation. D: Coz I knew it was a trigger because everything that upsets me, I go, I get really crazy. I wasn’t sleeping and I was, wasn’t eating properly and that was affecting me really bad. And so your doctor then helped you through that, increased the dosage and- D: Yeah and then he took me off the medication as well. So he put me on it, and then he noticed I didn’t need it anymore and he said go on a lower dose. Diana describes how her prescriber “helped” her through a difficult situation, which represented a potential “trigger” for relapse, by increasing her medication dosage.

That there are others chronic superficial gastritis definition purchase 10mg bentyl amex, I doubt not prepyloric gastritis definition purchase 10mg bentyl mastercard, and probably some more positive gastritis symptoms foods avoid cheap bentyl 10 mg visa, but these would cause me to give Baptisia in any case. I have seen the gravest forms of disease rapidly fade away, upon the administration of Bi-carbonate of Soda when the common means had failed. There was a special indication for it; any one might see it, if he knew how and where to look. And now simple Soda becomes sedative where sedatives had failed, gives sleep where Opium had failed, establishes secretion, antidotes the blood-poison, or is actually antiperiodic where Quinine has proven a failure. If we wanted evidence badly, I might bring forward Chambers, Anstie, Bennett, Wunderlich, and others, to prove that very similar results have been obtained from the use of Muriatic Acid. With it alone, hundreds, yes, thousands of cases of typhoid and typhus fever have been treated with a mortality ranging from less than one per cent, to never more than three. I might give other examples, but these will suffice to awaken attention, and all that the subject wants is thought and investigation. That medicine will ever reach such perfection, that we will be able to select one remedy for the totality of disease in all cases, I do not believe, but that it may be done in a considerable number, I am quite certain. In the olden times, and with many now, medicine adds to the sufferings of the sick, and they dread more the unpleasantness of the doctor’s prescriptions than they do the disease. In looking over our Materia Medicas and Dispensatories, it would seem that our object has been to make the concoctions as nauseous as possible. In extemporaneous prescriptions it is the same; the combination of remedies, and the vehicle, combine to make the mixture unpleasant. It has been thought that sugar or syrup would cover up the unpleasantness of medicine, and hence it is most commonly used. The fact is, however, that with the majority of the sick the sweet is unpleasant, and nothing could be more objectionable than a nauseous sweet. The doctor don’t take his own medicines, and hence he does not know how objectionable they are, and he continues giving these unpleasant mixtures year after year, to the detriment of his patient, and his own pocket. It never had one atom of truth in it, and a very little experimentation will determine its falsity. Some medicines are very objectionable in their taste, but they are less disgusting to the patient alone, than when mixed with syrup or other vehicle. The best form of vegetable remedies is a simple tincture by percolation: the best form for all remedies, if possible, is the fluid form. It is not only the best as regards the medicinal action of the remedy, but is also the pleasantest as well. The best vehicle for the administration of a remedy, is water, and it also is the pleasantest. But few remedies are intended to exert a local influence upon the mucous coat of the stomach. All others must first gain entrance to the circulation, before their curative action can be obtained. To get into the blood by osmose, it is necessary that the agent be in solution, and of less specific gravity than the blood. If you do not have your remedy in solution before its administration, its getting into the circulation will depend upon the stomach supplying the necessary amount of fluid and effecting the solution. To the sick, there are but few of our remedies objectionable, if they are properly prepared with alcohol and given with water. The dose of properly prepared remedies is quite small, so that, added to fresh water in such proportion that the dose will be a teaspoonful, it is much diluted. Even if the taste is objectionable, there is evidence of cleanliness, and nothing to disgust. For years, I have made my prescriptions in one way - to a glass of fresh water adding the necessary amount of tincture or fluid medicine to make the dose a teaspoonful. In acute diseases the dose should be frequently repeated, hence it is necessarily small. As a rule, these doses exert a more marked curative effect than the larger ones commonly given.

Accompanying this is the general physiological response to stress gastritis zucchini order 10 mg bentyl amex, which includes rapid heartbeat gastritis green tea purchase 10 mg bentyl amex, breath-holding gastritis green stool buy bentyl 10mg visa, sweating, sleep disorders and fatigue. In Larry’s inner- voice dialogue, there was the obvious surface fear of being late for work and the potential consequences that being late might cause for him as an adult. However, the true fundamental fear, resided in his inner child’s response to this event. The most significant point here is that you have to dive deeper to truly understand what’s motivating your behaviour. For Larry, what actually was underlying his fear of being late for work was an earlier fear of not being good enough. His parents were very demanding and critical and nothing that Larry did was “good enough. By being ‘perfect’ and controlling himself and his surroundings as best he could, Larry was able to minimize being yelled at or punished back when he was a child. The possibility of arriving late for work triggered Larry’s fear surrounding childhood events that occurred relating to the completion of a task in a perfect way. You can see that the thoughts and actions he expresses, in his internal conversation, reflect learned behaviour from his childhood. You yourself, are also not operating entirely from an adult perspective, but carry your own inner child. If you can come to understand your own core-wounding experiences through a mindful dialogue with your inner child, you can see how these experiences and their aftereffects are manifested in all of your stress responses. A common roadblock to meaningful change is that you probably believe that you’re making conscious adult choices about how to act in this world. However, to a large extent, your behaviour is controlled by unrecognized, conditioned, habitual, childhood coping-strategies. You’re not truly present to the events in your life, but to your inner child’s interpretation of how the event fits with your internalized, parental belief system. You judge everything you experience in order to position yourself in relation to the world so as to ultimately feel loved and safe. Talking with your inner voice is a wonderful way to understand what’s truly driving your “adult” behaviour. You have the ability to connect with your inner child through dialogues with that inner voice. Engaging in the dialogues will allow you to discover the true motives underlying how you operate in this world. The inner child’s belief system is the origin of the automatic responses and stories that you tell yourself about internal and external sensations, perceptions, experiences and events. With additional insight, you can bring empathy, support and love to the process of trying to change. You can thereby diminish the power that your inner child has over your present day-to-day experiences. It will give you more control, more perspective and that elusive peace of mind that we all dream about. The next time you become aware of an inner voice or conversation with yourself that’s going something like, “Oh I shouldn’t have done that…” look for clues that it’s really a child talking. When you become aware of your inner child, extend compassion and understanding to the child you once were and use the occasion as an opportunity to explore why you think and act the way you do. Summary • You have an inner voice that’s always commenting to you during times of stress and directing the action to be taken next. This refers to childhood events, which were very emotionally traumatic and may have related to loss, rejection, abandonment, humiliation, betrayal and/or a sense of having been overwhelmed. If you were to develop mindfulness in relation to your own thoughts, you would Adiscover that you have an inner voice that is always talking to you, usually criticizing, comparing and judging everything that arises internally and externally. In this chapter, you’ll learn a helpful stress-reducing technique, which is how to talk to your inner voice. The purpose of the inner-child dialogue is to: • discover the underlying core belief system of the inner child • examine if the core belief system is true • identify the inner child’s feelings This is an important progression that ultimately helps you to change the limiting and painful belief system of the inner child. The inner-child dialogue is a useful technique for really understanding yourself and your stress, but if you’re new to it, it’s going to seem a little strange at first.

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