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Abstract The main focus of this research is to discuss the perspective of the teamwork and its impaction organizational performance and success. Also highlight the Meanings of Team and its work sprit towards batter organizational performance and specific to its impact on the success of organization that provided the basis for this research study. In this research study a thoroughly focus was on organization and teamwork. The aim of this research is to deliver a participative view of teamwork in the organization, and also discourses the major issues and emphases on the recent work that opens the basis to move research onward. There is much worth in taking a more focus on the essential areas of teamwork. The team signifies the spirit and working capacity of the employees as team to bring organization to the success. The various explanations, definitions, processes, dimensions, team size and benefits etc. regarding the above topic teamwork and organizational success is highlighted. Keywords: Teamwork, Success, Organization, Performance, Work Groups, Employees Introduction It is indeed human beings have learned in their beginning of life to work together as (Team) that have made such a remarkable developments as unique specie. Human beings have experience throughout their social history, lived, loved, grow younger to older and worked together in groups said West M.A. (2012).The mutual social knowledge of living and functioning together creates connection among people, society and families. When work is done cooperatively as a team it can achieve extremely extra work than individually. Team can be defined as in the human society to live, to work and to play and to cooperate with others for particular task. According to John W. Newstrom et al (1993) “team is the process of assessing performance of workers, passing information and exploring methods to increase performance”. If observe closely, one can discover the instances of The Government: Research Journal of Political Science Supplementary Edition Vol. III 88 The Government social (teams) they are functioning either effectively or ineffectively everywhere; organizations, schools, work place, home etc. “Coordinating the events of people is like sand house, making by using a sole particles of sand” expressed Belbin, R. M.(2010). Moreover it is one of the general myths that the skill of team member is more important than their vigor, attention and determination for the tasks. Another widespread myth is that the team members are not alone accountable for the achievements or failures of their tasks the truth is that the members are the small parts in the teams and their individual abilities effect on the various results in team. The working relationships exist among team that might sight these relationships at different levels of involvement or relationships among the members as they move towards the degree of communication, integration and commitment increases. Terry L.G. et al (1980) expressed that “The skills are essential if members have to work together efficiently in complex situations, only development of skills and relationships, involvement on the task regarding the particular task might be selected for reaching at target that is considered as a definition of a team”. Team often perform higher when they work together with sprit that enable them to achieve a collective goal at the workplace, it is not only benefits to the organization also affects the workers confidence and success. Cooperating on various tasks reduces workloads for all team members and enables them to share duties or ideas. Work as a team is the part of everyone's life, as one is a member of a family team, staff team, school team, and community teams etc., so as to understand how to work effectively as a team member. Especially there is a need when task is threatened with increasingly many problems for example; the energy problem has effects on organization, family life, and social development and the multi-dimensional nature of many problems require a scientific skill based problem solving approach. Terry L.G, et al (1980) expressed that “The skills, competencies and efforts of team by setting priorities the team can have better impact on the problems solving such efforts can reduce work load, work duplication, and produce a result better than separate efforts”. There are some processes of teamwork by adopting those the objectives can be achieved easily. Le Pine, et al, (2008) identified10 teamwork processes that fall in three categories following are those. TEAMWORK PROCESSES TRANSITION PROCESSES •Mission analysis •Goal specification •Strategy formulation ACTION PROCESSES •Monitoring progress toward goals •Systems monitoring •Team monitoring and backup behavior •Coordination INTERPERSONAL PROCESSES •Conflict management •Motivation and confidence building •Affect management Team Work 89 Teamwork process reduces the work stress on every member which permits members to complete given important task of organization; teamwork offers members an opening to pledge with each other. Also it develops relations between the members who start a teamwork they usually sense appreciated on productive accomplishment of task. It may be cited one of the best instances of surgical team; where surgeon is assisted by his team; nurses, anesthetist and experts etc., everyone knows that their success depends upon the teamwork. In addition they are devoted to the aim that is human life it is easy to succeed with best teamwork. The important role of manager is the team building, trust building, confidence building, in the team to achieve the task. In the Situation where all team members contribute the task, it develops the positive relationship in the team that improves the trust of team members.“Functions effectively members of team must be flexible, committed, trusting each other and help to each other’s in the progress and the achievement of goals” Expressed Plamínek (2008). The accountability of every member in the team must be increased so that they do not let each other down therefore they do their best for the achievements of their teams. In contrast, working alone on a task the pressure is generally high in team in those cases of small confidence impacts fewer on members. Team consists on members who always vary from each other’s in skills, knowledge and abilities but working together that is an opportunity for them to gain skills and knowledge from each other’s that they had never before. Working alone on a task is a challenge and using the ideas of each other brings them to come up with a mutual resolution and the achievement of the task. Nowadays theoretical development and research has rested largely a new trend that is emerging within the organizations as an essential process of teamwork. Teamwork has brought a new move in the research and development to the inputs and outputs that bound, constrain and impact on the team processes within organizations said Ilgen, D.R. (1999). The world is changes fast, any one set of instructions can’t be sufficient, changes needs flexible members, teams and organizations so as to be effective on task. This paper suggests that in teams members must use the exclusive human abilities. Cannon B.et al (1995) has précised dimensions of teams into three categories: Team dimensions 1-Cognitions: include associations, task team-mate characteristics, team mission, objectives, norms, and resources, team role interaction patterns, skills, roles, and team orientation. 2-Skills: consist on adaptability, shared situational awareness and mutual concept to conflict resolution. 90 The Government 3-Attitudes: symbolize motivation, collective potency, shared vision, team cohesion, mutual trust, collective orientation and importance of. Teamsize Researchers have given different approvals about the best size of team as Katzenbachetet al (1993) suggested that the teams should comprise on a dozen or so members which are enough to achieve a task. Although seven is the best size of the team in the organizational practices said Scharf, A. (1989). Several views of researchers are expressed in the literatures and it is difficult to decide which better is because their opinions are based on their own observations. The team size matters in the proper output and performance however from an empirical research it is also difficult to decide the suitable team size and what to accept. This study suggests that team size has a practical link with efficacy such as few or many member shave impact on the performance but size matters. Proper size of team improves the performance maximum stated Campion M. A et al (1996).These different results are expected due to the fact that appropriate team size is required for task, environment and situation where team works. However, larger teams can also experience coordination problems that delay performance. Sheppard, J. A. (1993) expressed that the question of best team’s size is a complex one; more research is required on this topic to explain the impact of team size on given definite task. Literature Review Across many different organizations and industries teamwork is focused to increase the performance of employees’ their unity and also create work culture. Organizations those regularly develop new ideas or products using a project-based approach and assemble teams in order to focus responsibilities to achieve the object. Researchers have given dissimilar meanings of “teams”. Dyer W.G. (2007) said that “teams are groups of people who trust in cooperation, if members are expert the success of goal is more possible”. It is essential due to the problemsolving cooperation added from many minds of team members working on a resolution of problems. Team members contribute their thoughts together to make exclusive plans for dealing with problems and this unity enhance the result due to interaction, trust and teamwork. Teamwork means a "work done by several companions with each doing a part but all subordinating personal prominence to the efficiency of the whole" Merriam, (2012). In addition combined employees are expected less hostile to each other and accepting more of each other’s decisions. Unity of employees can increase the flow of work in organization. When employee’s working together as a team, they learn from each other that awareness is based on their personal experiences and from coworkers; Team Work 91 employees from different departments may acquire knowledge from each other. The main object for organizations is to hold the team effort to achieve output and quality; team is a key to achieve quality productivity. According to Maddux et al (2003) “some of the organizations have major benefits from the use of teamwork which are showed in the following chart: Benefits of Teamwork 1 Improving quality of work life for employees 2 Reducing absenteeism and increasing turnover 3 Increasing innovation and change 4 Improving organizational adaptability and flexibility A real team is mostly one where members are allowed to take decisions that how to complete task. That authority enables them to control the work process, decreases the outside control and increases the sense of duty for work. Team always feels superiority on workplace and they rely on each other’s being there. Plamínek (2008) said that “affiliation with teamwork gives member a sense of belonging, interaction and recognition of success”. These actions support to remove the sense of loneliness of team member in organization. Effective teams can also improve efficacy through communication and trust between the team members, quality of work and decrease in absenteeism contribute to positive impact on team. Involving employees in teamwork helps the organization remain open to new ideas.“The world of organizations is shifting individualism is out and collectivism is in, power is out, empowerment is in.” stated G. M. Parker (1998). This study discovers the experiences and difficulties of teamwork that employees and organizations are facing nowadays due to big transformation and enlarged globalization. In recent years a remarkable amendment has been emerged in the belief of team working organizations. The modern study has explored that the scope of teamwork have been appeared in system rooted in belief, and employees accept changes that denoting a modern organizational system. The organizations which are responsive to the changes appear to achieve greater satisfaction. Although it may be suggested that, the managers should assess the values and beliefs of their employees to play more dedicated role in the development of organization by making sprit to face the modern challenges. Organizational cultural is much significant and it has the excessive impact on the performance of organization and employees’ but it is quiet arguable topic that the culture of teamwork can be developed according to the requirement. It is difficult to specify the relationships and to assess the reliable set of values to use as they believed symbol across the entire organizations. This review study focus that 92 The Government there is a great influence of organizational culture on the assumptions, values, and beliefs on the individuals’ considerations, actions and performances and so is vice versa, through learning, and training process. However the researchers believe that the organizational setup aids to unite employees of diverse cultures and dissimilar social backgrounds, traditions and have their own beliefs to work. Creating a positive teamwork culture it has several diverse aspects are goal setting, conflict resolution, empowerment, ability to accomplish tasks, measuring output and consideration for other teamwork cultures stated Pack L, et al April 27, (2012). Team work in the organization delivers employees the wisdom of unity; understand to each other’s, and reducing conflict. In addition teamwork in organization inspires employee for impartiality by affirming that no one is ignored in the organization and all treated equally. It is known that a team in organization is bound and sincere to work with dedication to bring the success. If the employees are committed and recognize the teamwork values and its benefits, as a part of the organization they can contribute a lot to the achievement of organization. One can finds the informal instances of team at these level, family, society, community, tribe and work groups etc., and formally team appears at the level of departments, functional groups, and other organizational units. The employees feel a greater sense of achievement for being a part of an organization, if they attain team work, having freedom to work not forced. The system gives best performance to achieve recognition and credit from their managers and it will increase their effort that helps them to contribute the organizational performance. Each team batter knows about their role and how to achieve tasks. The true spirit of teamwork gives benefit to organization in maintaining its standard by which it becomes identified. The team defines its specialty, and the way it is doing task that is perceived by the organization as well as its managers and it is secured by appreciation. Employees identify what they believe; that exist in their belief system and those understandings call them to change their views to develop and raise attention towards batter performance. The literature contains sufficient definitions of teamwork and the word team is used to denote a set of generally developed as to learn collective values, attitudes and cooperation to work. The study praises that the teamwork is mostly related with the team success for instance, Wagner (1995) described that “in the team individual is less valued and group is more valued, with”. It is found in the study that individualismcollectivism both regulates the relationships between team size, standing, and cooperation that have better effects on the cooperation of individualists rather than the cooperation of collectivists. Team Work 93 Conclusion The main concentration of this research paper is to examine more in-depth the fundamental of teamwork and its effectiveness to achieve the organizational goals. Teamwork provides vast amounts of knowledge and information, cultural differences each of these building a culture of teamwork and the skill to make the valuable solutions of the problems. To work efficiently, team members need a good understanding of how to do their job, to achieve goal and for that a basic way to ensure understanding is training, then they have to be motivated to do a job. Team is a vital activity of organization, when organization desires to perform sound it has to be confident that team functions effectively. Consequently it is compulsory to know how team performs, what manners within a team happen, and how they make decisions. If there is knowhow of teamwork events, it can be effective for the tasks that they have to accomplish. Organizations build up their own culture through tradition, history and structure these values can be accepted by team workers of an organization. The values and assumptions are the vital tools of organizations and are used as guidance for team. These have to do mostly with the basic dignity and worth of all members of team and the ability, necessity for them to solve the problems and work for the positive change. Through this review study is concluded that there is a good impact of teamwork on the organizations doings and success. Subsequently in recently developed literature there is a great focus amongst the social scientists and scholars’ in their discussion on the above topic teamwork. The above study is also an evidence of little effort to assess the significance of teamwork in organizations success. teams in organiz

President Xi Jinping, who is also general secretary of the Communist Party of China Central Committee and chairman of the Central Military Commission, visits Luoyang Bearing Group Co on Monday afternoon during his inspection of Luoyang, Henan province. During the visit, Xi called for continuous efforts to make the manufacturing industry even stronger to advance Chinese modernization. YAN YAN/XINHUA President Xi Jinping has stressed the importance of keeping businesses, employment, the market and expectations stable in the face of a complex international environment, saying that China will respond to various uncertainties with the certainty of its high-quality development. Xi, who is also general secretary of the Communist Party of China Central Committee and chairman of the Central Military Commission, made the remarks on Tuesday as he wrapped up a two-day fact-finding trip to Central China's Henan province. Speaking to provincial Party and government officials at a work briefing on Tuesday in Zhengzhou, the provincial capital, Xi said that high-quality development is essential to Chinese modernization. Faced with the complex external environment, it is necessary to firm up confidence, unwaveringly manage China's own affairs well, and steadfastly expand high-level opening-up, he said. He also urged Henan, one of the country's economic powerhouses, to further consolidate the foundation of its real economy, and promote the development of new quality productive forces suited to local conditions and led by technological innovation, in order to enhance the capacity of its modern industrial system to support high-quality development. When visiting Luoyang Bearing Group Co in the city of Luoyang on Monday, Xi said: "China has always adhered to the path of developing the real economy. From the past reliance on imported matches, soap and iron, to now becoming the world's largest manufacturing country with the most complete industrial categories, we have taken the right path." As a traditional manufacturing enterprise specializing in bearings, Luoyang Bearing Group's products are widely used in fields such as aerospace, construction machinery, wind power generation, rail transit, port machinery and ships. After learning about the company's efforts to accelerate the development of advanced manufacturing, Xi said that China must continue to strengthen the manufacturing sector, adhere to the principles of building self-reliance and strength, and master core technologies in key fields. "The hope is placed on you," he told the on-site workers. He also called for efforts to strengthen collaboration between industries, universities and research institutes, and cultivate a large number of high-quality talent. Despite internal challenges and increasing external shocks, China's manufacturing industry has withstood pressure and maintained stable growth. In April, the manufacturing sector saw its value-added output climb 6.6 percent year-on-year, with that of equipment manufacturing and high-tech manufacturing up 9.8 percent and 10 percent, respectively, according to data released by the National Bureau of Statistics on Monday. Advanced manufacturing is the high ground in global industrial competition and the main battlefield for technological innovation. Xi has repeatedly emphasized the need to upgrade the country's modernized industrial system, supported by advanced manufacturing. In a resolution adopted at the third plenary session of the 20th CPC Central Committee in July last year, it was clearly stated that China will move faster to advance new industrialization, promote the growth and expansion of advanced manufacturing clusters, and make the manufacturing sector higher-end, smarter and more eco-friendly. On Monday, Xi also visited the White Horse Temple, the first Buddhist temple in China, and the Longmen Grottoes, a UNESCO World Heritage site. Contact the writers at mojingxi@chinadaily.com.cn

Everyday conversation and writing is characterized not only by factual statements, but also expressions of one’s personal views, judgment, beliefs and convictions. In other words, we often make statements or assertions of fact, opinion, belief and even prejudice. This is because we often process and interpret factual evidence based on our own values, feelings, tastes, and experiences. Fowler H. Ramsay (1986), as outlined in the Colorado State University website, described assertion as a term generally used to refer to statements of fact, opinion, belief and prejudice. These types or categories of assertion are quite different from one another. A fact is a verifiable statement. It can be proven objectively by verified observations or the results of research among others. Because statements of fact can be double-checked for accuracy, there is general agreement about the truth they posit. On the other hand, an opinion is a personal judgment based on facts; hence, it is debatable and potentially changeable. The third category is called belief, which is a conviction based on cultural or personal faith, morality or values. A statement of belief may look similar with an opinion, but they are not based on evidence; that is why they cannot be contested or argued in a rational or logical manner. Lastly, there is the rather vague category called commonplace assertion. This is a stereotype, an oversimplification or a prejudice, which is a half-baked opinion based on insufficient or unexamined evidence, but it presented as if it were a fact. It is often accepted from others (families, friends, media etc.), making it too common to be questioned about its truthfulness. These categories of assertion are so prevalent in social media today, and the distinction between one another is slowly becoming unclear because of how netizens present everything as facts. This is why every social media needs to be a critical and informed reader to be able to verify the truthfulness of the information he/she comes across. In one of the previous modules, you learned about the language of research, advocacies and campaigns. Opinions and assertions are very important in advocacies and campaigns; hence, it would be advantageous for a writer, or even a speaker, to clearly express their views on important matters.

Chapter 22 Antihypertensive Drugs Hypertension Defined (JNC-8) Pharmacology Overview 7 main categories of drugs to treat HTN Adrenergic drugs (old friend) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Direct renin inhibitors A. Adrenergic Drugs: 5 Subcategories and where they act A1. Adrenergic neuron blockers (central and peripheral)- we won’t talk about this A2. Alpha1 receptor blockers (peripheral) A3. Alpha2 receptor agonists (central) A4. Beta receptor blockers (peripheral) A5. Combined α and β receptor blockers (peripheral) A2. Peripherally Acting Adrenergic DrugAlpha1 Blockers (we’ve met these) Doxazosin, prazosin, alfuzosin Block alpha1-receptors which causes BP to decrease Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels Main Use: benign prostatic hyperplasia (BPH) Alpha1 Blockers REMEMBER Tamsulosin (Flomax)* is an α1 blocker BUT *Tamsulosin is not used to control BP, just for BPH. A3. Centrally Acting Adrenergic DrugsAlpha 2 agonist Clonidine and methyldopa 1- Stimulate alpha2-adrenergic receptors. in the brain Decreases sympathetic outflow from the CNS which decreases NE production 2. Stimulate alpha2-adrenergic receptors in kidneys remember alpha 2 opposes alpha 1 Dilates peripheral blood vessels → lowers peripheral resistance → Results in decreased BP So ….Clonidine (Catapres) Used primarily for its ability to decrease blood pressure in an urgent setting Also use in opioid withdrawal as previously discussed Oral (multiple times a day), and topical patch formulations Do not stop abruptly as it may lead to rebound hypertension In reality, Clonidine and methyldopa Not prescribed as first-line home antiHTN drugs High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, and dizziness MIGHT be uses as adjunct drugs after other drugs have failed, in conjunction with other antiHTN such as diuretics A4. Adrenergic Drugs Selective Beta 1 Blockers Metoprolol, Atenolol Reduction of HR through β1 receptor blockade (remember adrenergic blocking of this receptor???) HR results in BP Cause reduced secretion of renin = BP A4. Adrenergic Drugs Selective Beta1 Blockers Nebivolol (Bystolic) Uses: hypertension and HF Action: blocks β1 receptors and produces vasodilatation, which results in a decrease in SVR High doses loses selectivity and blocks both β1 and β2 Less sexual dysfunction All BB- Do not stop abruptly; must be tapered over 1 to 2 weeks A4. Adrenergic Drugs NONSelective Beta Blockers Propranolol Acts equally on β1 and β2 Other uses include situational anxiety associated with public speaking, test taking As mentioned on previous slide, nebivolol at high doses becomes beta nonselective A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade) Examples are carvedilol (common) and labetalol (not as common) A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Carvedilol (Coreg) Widely used drug that is well tolerated Uses: HTN, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors Contraindications: severe bradycardia or unstable HF, bronchospastic conditions such as asthma, and various cardiac conduction problems Adrenergic Drugs Indications - HTN But also for Glaucoma (topical) BPH: doxazosin, prazosin, and terazosin (2 for 1) Management of severe HF when used with cardiac glycosides and diuretics Contraindications Acute HF- have to stabilize first MOAIs- yeah doesn’t everything interact with MAOIs? Peptic ulcers Severe liver/kidney disease Asthma (with beta blockers) Adrenergic Drugs: Adverse Effects Orthostatic hypotension 1st-dose syncope Rebound hypertension with abrupt discontinuation Most common: Dry mouth, drowsiness, constipation, sedation Interactions- always check for specific drug interactions Can cause additive CNS depression with alcohol, benzodiazepines, opioids Question #1 When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of what response? Hypotension Hyperkalemia Oliguria Respiratory distress Answer A Hypotension This is a key point in patient education These drugs have strong vasodilating properties and may cause severe hypotension, especially at the beginning of therapy. B. Angiotensin-Converting Enzyme Inhibitorsaka ACE Inhibitors or ACEi Large group of safe and effective drugs Currently are 10 ACEi Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic, loop diuretic, or Calcium Channel Blocker (CCB) You need to understand the basics ACE Inhibitors: Review RAAS ACE converts angiotensin I, formed through the action of renin, to angiotensin II Angiotensin 2 is a potent vasoconstrictor and also induces aldosterone secretion by the adrenal glands Aldosterone stimulates sodium resorption (H20 follows Na Both act to raise BP which causes kidneys to reduce renin production ACEi= Great drug to treat HTN BUT contraindicated in pregnancy (2nd,3rd trimester due to fetal renal damage) and breastfeeding first few weeks after birth B. ACE Inhibitors - PRIL Lisinopril (Prinivil) super common, often the 1st drug Enalapril (Vasotec) also common Captopril (Capoten) great if liver disease present Benazepril (Lotensin) Fosinopril (Monopril) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Primary Effects of the ACE Inhibitors Prevent Na (and H2O) resorption by inhibiting aldosterone secretion (volume reduction) (GO BACK TO RAAS DIAGRAM) blood volume decreases work of the heart preload, or the left ventricular end-diastolic volume which is important in HF ACE SUMMARY OF ACTIVITY 1) Prevent vasoconstriction caused by angiotensin 2 (2) Prevent aldosterone secretion  less sodium and water resorption Cardioprotective Effects of ACEi They slow progression of left ventricular hypertrophy (ventricular remodeling) after MI so considered cardioprotective ACE inhibitors have been shown to decrease morbidity and mortality in patients with HF Renal Protective Effects of ACEi ACE inhibitors: reduce glomerular filtration pressure by volume reduction Cardiovascular drug of choice for patients with diabetes since it helps protect kidneys by reducing pressure. Sometimes used low dose for kidney protection with DM without HTN B. ACEi Enalapril (Vasotec) Only ACEi available in both oral and IV Enalapril IV does not require cardiac monitoring Oral enalapril: prodrug (metabolized in liver) Improves patient’s chances of survival after an MI Reduces the incidence of HF B. ACEi Captopril (Capoten) Uses: prevention of ventricular remodeling after MI; reduce the risk of HF after MI Shortest half-life Must be administered multiple times throughout the day so this limits its use Not a prodrug so good for patient with liver disease Question #2 A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her provider has never told her that she has hypertension. What is the best explanation for this order? The doctor knows best The patient is confused This medication has cardioprotective properties This medication has a protective effect on the kidneys for patients with diabetes Answer D ACE inhibitors have been shown to have a protective effect on the kidneys because they reduce glomerular filtration pressure. This property makes them the cardiovascular drug of choice for patients with diabetes. Question #3 A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? Clonidine Prazosin Diltiazem Captopril Answer D Captopril Captopril is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ACE Inhibitors: Adverse Effects *Dry, nonproductive cough, which reverses when therapy is stopped. This is a class effect Dizziness- Note: First-dose hypotensive effect may occur Headache & Fatigue Possible hyperkalemia ** Angioedema: rare but potentially fatal Not safe in pregnancy-are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage C. Angiotensin II Receptor Blockers(ARB) Considered an alternative to ACEi Less likely to cause a dry cough and hyper K+ that is common with ACE inhibitors Angiotensin II Receptor Blockers: Mechanism of Action Go back to RAAS diagram! ARBs affect primarily 2 places 1. Vascular smooth muscle - blocks vasoconstriction 2. Adrenal gland -Selectively blocks the binding of Ang 2 to certain Ang 2 receptors inhibiting secretion of aldosterone Lowers volume retention and BP Angiotensin II Receptor Blockers -ARTAN Losartan (Cozaar)- very common Eprosartan (Teveten) Valsartan (Diovan) Irbesartan (Avapro) Candesartan (Atacand) Olmesartan (Benicar) Telmisartan (Micardis) Azilsartan (Edarbi) C. ARB Losartan (Cozaar) Beneficial in patients with HTN and HF Used with caution in patients with kidney or liver dysfunction and in patients with renal artery stenosis ***Not safe for breastfeeding women and should not be used in pregnancy (Cat C 1st trimester, Cat D 2nd-3rd trimester), potential fetal toxicity Appear to be equally effective for the treatment of hypertension and well tolerated ARBs less likely to cause cough and hyperK+ but can still happen Evidence that ARBs are associated with lower mortality after MI than ACE inhibitors Never take ACEi and ARBs at the same time* 5. Calcium Channel Blockers (CCB) Primary use: HTN, angina, some dysrhythmias Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in: Relaxed blood vessels to the heart Decreased peripheral smooth muscle tone Decreased SVResistance Decreased BP E. Diuretics First-line antiHTN in JNC 8 guidelines Decreases fluid volume The results from diuresis: preload, Peripheral resistance Overall effect  Decreased workload of the heart and decreased BP Thiazide diuretics are the most commonly used diuretics for HTN Ie hydrochlorothiazide (HCTZ), chlorthalidone We will discuss diuretics further in the chapter on diuretics F. Vasodilators Directly relax arterial or venous smooth muscle (or both) Results in: Decreased SVR Decreased afterload Peripheral vasodilation Indicated for treatment of HTN May be used in combination with other drugs F. Vasodilators Hydralazine (Apresoline) Orally: routine cases of essential hypertension Injectable: hypertensive emergencies BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients F. Vasodilators Sodium Nitroprusside (Nitropress) *Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Contraindications: severe HF, known inadequate cerebral perfusion (especially during neurosurgical procedures) F. Vasodilators Adverse Effects Hydralazine: dizziness, headache, tachycardia, edema, dyspnea, N/V/D, vitamin B6 deficiency, rash Sodium nitroprusside: hypotension, bradycardia, decreased platelet aggregation, rash G. Direct Renin Inhibitors Aliskirin (Tekturna) Blocks the RAS pathway at the point of activation. Inhibiting renin production prevents the downstream production of Ang II (potent vasoconstrictor) Adverse effects: N/V, severe hypotension, hyponatremia, hyperkalemia… Contraindicated in patients with DM taking ACEi or ARB Miscellaneous Antihypertensives Eplerenone (Inspra) Newer class of drugs called selective aldosterone blockers (remember RAAS?) Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain Indications: routine treatment of hypertension and for post-MI HF Contraindicated if serum potassium levels are high (above 5.6 mEq/L) A Special Form of HTNTreatment of Pulmonary Hypertension Sildenafil and Tadalafil Commonly used for erectile dysfunction Used for pulmonary hypertension but with different trade names Sildenafil: Revatio* (Viagra for ED) Tadalafil: Adcirca* (Cialis for ED)

Soils Southeast Asia, on balance, has a higher proportion of relatively fertile soils than most tropical regions, and soil erosion is less severe than elsewhere. Much of the region, however, is covered by tropical soils that generally are quite poor in nutrients. Often the profusion of plant life is more related to heat and moisture than to soil quality, even though these climatic conditions intensify both chemical weathering and the rate of bacterial action that usually improve soil fertility. Once the vegetation cover is removed, the supply of humus quickly disappears. In addition, the often heavy rainfall leaches the soils of their soluble nutrients, hastens erosion, and damages the soil texture. The leaching process in part results in laterites of reddish clay that contain hydroxides of iron and alumina. Laterite soils are common in parts of Myanmar, Thailand, and Vietnam and also occur in the islands of the Sunda Shelf, notably Borneo. The most fertile soils occur in regions of volcanic activity, where the ejecta is chemically alkaline or neutral. Such soils are found in parts of Sumatra and much of Java in Indonesia. The alluvial soils of the river valleys also are highly fertile and are intensively cultivated. Climate All of Southeast Asia falls within the warm, humid tropics, and its climate generally can be characterized as monsoonal (i.e., marked by wet and dry periods). Changing seasons are more associated with rainfall than with temperature variations. There is, however, a high degree of climatic complexity within the region. Temperatures Regional temperatures at or near sea level remain fairly constant throughout the year, although monthly averages tend to vary more with increasing latitude. Thus, with the exception of northern Vietnam, annual average temperatures are close to 80 °F (27 °C). Increasing elevation acts to decrease average temperatures, and such locations as the Cameron Highlands in peninsular Malaysia and Baguio in the Philippines have become popular tourist destinations in part because of their relatively cooler climates. Proximity to the sea also tends to moderate temperatures. Precipitation Much of Southeast Asia receives more than 60 inches (1,500 millimeters) of rainfall annually, and many areas commonly receive double and even triple that amount. The rainfall pattern is distinctly affected by two prevailing air currents: the northeast (or dry) monsoon and the southwest (or wet) monsoon. The northeast monsoon occurs roughly from November to March and brings relatively dry, cool air and little precipitation to the mainland. As the southwestward-flowing air passes over the warmer sea, it gradually warms and gathers moisture. Precipitation is especially heavy where the airstream is forced to rise over mountains or encounters a landmass. The east coast of peninsular Malaysia, the Philippines, and parts of eastern Indonesia receive the heaviest rains during this period. The southwest monsoon prevails from May to September, when the air current reverses and the dominant flow is to the northeast. The mainland receives the bulk of its rainfall during this period. Over much of the southern Malay Peninsula and insular Southeast Asia there is little or no prolonged dry season. This is especially marked in much of the equatorial region and along the east coast of the Philippines. While the dry and wet monsoons are important in explaining rainfall patterns, so too are such factors as relief, land and sea breezes, convectional overturning and cyclonic disturbances. These factors often are combined with monsoonal effects to produce highly variable rainfall patterns over relatively short distances. While many of the cyclonic disturbances produce only moderate rainfall, others mature into tropical storms—called cyclones in the Indian Ocean and typhoons in the Pacific—that bring heavy rains and destruction to the areas over which they pass. The Philippines are particularly affected by these storms. Plant life Tropical forests in Southeast Asia Tropical forests in Southeast Asia The seasonal nature and pattern of Southeast Asia’s rainfall, as well as the region’s physiography, have strongly affected the development of natural vegetation. The hot, humid climate and enormous variety of habitats have given rise to an abundance and diversity of vegetative forms unlike that in any other area of the world. Much of the natural vegetation has been modified by human action, although large areas of relatively untouched land still can be found. The vegetation can be grouped into two broad categories: the tropical-evergreen forests of the equatorial lowlands and the open type of tropical-deciduous, or “monsoon,” forests in areas of seasonal drought. The evergreen forests are characterized by multiple stories of vegetation, consisting of a variety of trees and plants. Although a large diversity of tree species is found in these forests, members of the Dipterocarpaceae family account for roughly half of the varieties. Deciduous forests are found in eastern Indonesia and those parts of the mainland where annual rainfall does not exceed 80 inches. Just as in the equatorial forest, a wide variety of species is normally the rule. Certain species, such as teak, have become highly valued commercially. Teak is found in parts of Indonesia, Myanmar, Thailand, and Laos. In addition to these two basic types of vegetation, other regional patterns reflect topography. Especially noteworthy are coastal and highland plant communities. Mangrove belts, of which there are more than 30 varieties, occur where silt is deposited in coastal areas. Upland forests dominated by maples, oaks, and magnolias are found especially on mainland mountain slopes. Human activity has been rapidly altering the stands of virgin forest in Southeast Asia. Most deforestation results from removal for fuelwood and clearing for agriculture and grazing. Although only a relatively small portion of the total land area has been permanently cleared for cultivation—e.g., in Java (Indonesia) and western Luzon (the Philippines)—in some areas shifting cultivation has brought about the replacement of virgin forest with secondary growth. In addition, nearly all countries have commercial logging industries; notable are those in Indonesia, Malaysia, Thailand, and Myanmar. A growing problem has been illegal logging. Thus, timber harvesting has come to contribute significantly to deforestation. Programs in social forestry and reforestation have yet to halt the rapid denuding of the landscape. Animal life Southeast Asia is situated where two major divisions of the world’s fauna meet. The region itself constitutes the eastern half of what is called the Oriental, or Indian, zoogeographic region (part of the much larger realm of Megagaea). Bordering along the south and east is the Australian zoogeographic region, and the eastern portion of insular Southeast Asia—Celebes (Sulawesi), the Moluccas, and the Lesser Sunda Islands—constitutes a transition zone between these two faunal regions. a classroom in Brazil More From Britannica education: Southeast Asia Southeast Asia is notable, therefore, for a considerable diversity of wildlife throughout the region. These differences are especially striking between the species of the eastern and western fringes as well as between those of the archipelagic south and the mainland north. The differences stem largely from the isolation, over varying lengths of geologic time, of species following their migration from the Asian continent. In addition, the tropical rain forests in many parts of the region, with their great diversity of vegetation, have made possible the development of complex communities of animals that fill specialized ecological niches. Especially numerous are arboreal and flying creatures. orangutans orangutansOrangutans (Pongo pygmaeus) in Sumatra, Indonesia. The distinction between the two faunal regions is best depicted by their mammal populations. In general, Australia is inhabited largely by marsupials (pouched mammals) and monotremes (egg-laying mammals), while Southeast Asia contains placental mammals and such hybrid species as the bandicoot of eastern Indonesia. Small mammals such as monkeys and shrews are the most numerous, while in many areas the larger mammals have been pushed into more remote areas and national preserves. Bears, gibbons, elephants, deer, civets, and pigs are found in both mainland and insular Southeast Asia, as are diminishing numbers of tigers. The Malayan tapir, a relative of the rhinoceros, is native to the Malay Peninsula and Sumatra, while the tarsier is found in the Philippines and parts of Indonesia. A number of rare endemic species are found in Indonesia and East (insular) Malaysia, including the Sumatran and Javan rhinoceros, the orangutan, the anoa (a dwarf buffalo), the babirusa (a wild swine), and the palm civet. As the pace of development accelerates and populations continue to expand in Southeast Asia, concern has increased regarding the impact of human activity on the region’s environment. A significant portion of Southeast Asia, however, has not changed greatly and remains an unaltered home to wildlife. The nations of the region, with only few exceptions, have become aware of the need to maintain forest cover not only to prevent soil erosion but to preserve the diversity of flora and fauna. Indonesia, for example, has created an extensive system of national parks and preserves for this purpose. Even so, such species as the Javan rhinoceros face extinction, with only a handful of the animals remaining in western Java

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