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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)

[t comes from the GREEK name "Epilepsia" which means "taking hold of or seizing". - It is a disorder characterized by: recurrent seizures. SEIZURES R ectment transient attacks of: R epresent: R esult from: ASSOCIATED WITH: somatic, psychic, or, autonomic clinical featmes. clinical features of abnormally hyperexcitable cortical neurons. paroxvsmal and excessive electrical neuronal discharges. EEG changes & may be disturbance of consciousness. same causes of convulsions 1. Idiopathic epile~ • It is the commonest cause. no cause can be detected ( 65 % ) • It may be associated with positive family history in some cases. • It starts in the l st & 2nd decades in the form of: -- Grand ma! epilepsy. Petit mal epilepsy. Myoclonic epilepsy. Atonic seizures. 2. Secondary epilepsy A. Local causes in the brain: l. Congenital: 2. Traumatic: cerebral palsy. a cause can be detected cerebral contusion or laceration. 3. Inflammatory: 4. Neoplastic: 5. Degenerative: 6. Vascular: encephalitis, brain tumours. mening1t1s, presenile dementia. brain abscess. stroke (especially hemon-hagic), hypertensive encephalopathy. B. General causes with secondary effects on the brain: I. Toxic: 2. Iatrogenic: 3. Metabolic: 4. Endocrinal: 5. Organ failure: 6. Heart disease: 7. Nutritional: - Alcohol, cocaine, lead. - Lidocaine, INH. - j glucose & ! glucose. - Hypoparathyroidism. - Hepatic failme. - Adam's Stoke's attacks. - Pellagra. - Botulism, tetanus. - Ambilhar, Amphetamine, Aminophylline. - j Ca & ! Ca. - Hype1thyroid crisis. - Renal failure. - Fallot's tetralogy. - j Na & ! Na. - Vitamin B6 deficiency. 8. Physical: 9. HYSTERICAL. - High fevers. - Heat stroke. 136 137 CLINICAL PICTURE 1. GENERALISED SEIZURES " Excessive electrical discharges from cortical neurons in BOTH hemispheres simultaneously " I. II. 1. Grand Mal Epile~: 1. Pre-ictal stage "attacks of tonic-clonic convulsions " (aura) It is a warning sign of a coming attack. It may be: • Somatic: • Psychic: • Autonomic: 2. Ictal stage Myoclonus, Hallucinations. Tachycardia, (seizure) Sudden loss of consciousness: Parasthesias. Sweating. for seconds to minutes. -- Tonic phase (few seconds) o The UL & LL: o o o o The HEAD: The JAWS: CYANOSIS: are extended. is retracted to one side & the eye balls rolled up. are firmly clenched, with biting of the TONGUE. due to impaired respiration. There may be incontinence of urine. Clonic phase (few minutes) o The UL & LL: o The HEAD: 3. Post-ictal stage - It may be: • Somatic: • Psychic: • Autonomic: Drug of choice: contract & relax repeatedly & rapidly. jerks forcibly. (sequelae) Todd's paralysis(< 24 hours, due to neuronal exhaustion). Confusion. Vomiting. Carbamazepine (Tegretol) or Phenytoin (Epanutin) Petit Mal Epilepsy: "attacks of loss of consciousness " " Absence " It starts in childhood & improves at puberty & usually disappears at the age of 20. 2. It is NOT PRECEEDED by aura & NOT FOLLOWED by sequelae. 3. It is usually PRECIPITATED by: hyperventilation 4. It is characterized by: or photic stimulation. sudden loss of consciousness of short duration (few seconds). 5. It may be associated with: • High frequency ( 50 attacks / day). • Falling to the ground without warning. • Jerky movements of the head & UL Drug of choice: (myoclonic petit mal). Valproate (Depakine) or Succinimide (Zarontin) 137 138 Ill. M oclonic Seizures: "attacks of involuntary clonic movements " - It is characterized by: sudden, jerky, shock-like INVOLUNTARY muscle contraction. • The jerks are bilateral contractions, mainly of the shoulders and arms. • However, some patients repmtjerking in the lower limbs, trunk, or head. - It may be of 2 types: - Occurs singly • Simple: • As a pait of: I Drug of choice: IV. Atonic seizures: (no loss of consciousness). - Grand mal epilepsy (aura). - Petit mal epilepsy. Valproate (Depakine) or Clonazepam (Rivotril) I - Transient attacks of brief loss of postural tone, often resulting in falls and injuries. 2. PARTIAL SEIZURES "Excessive electrical discharges from cmtical neurons in a ce1tain area in ONE hemisphere" A. Simple seizures: " No disturbance in consciousness " - The CP depends on the site of the hyperexcitable neurones in the cerebral cortex, whether in: "Motor area or Senso,y areas". 1. Motor fits: • Focal fits: • Motor jacksonian fits: 2. General Sensory fits: • Focal fits: • Sensory jacksonian fits: 3. Special Senso1y fits: • Visual hallucinations: • Auditory hallucinations: • Olfactory hallucinations: B. Complex seizures: - SITE: movement of part of a limb or the whole limb. movement of one side of the body (see before). parasthesia of part of a limb or the whole limb. parasthesia of one side of the body (see before). irritation of the visual sensory area. irritation of the auditory sensory area. initation of the uncus. " disturbance in consciousness " The hyperexcitable neurons are in the Temporal lobe "Temporal lobe epilepsy". - DURATION: The seizure lasts few seconds to few minutes. - The seizure starts with A ura, followed by A bsence, Automatism, Amnesia: 1. 2. 3. 4. A ura: A bsence: Automatism: A mnesia: Olfactory hallucinations, Deja-vu phenomenon, Sensation of fear. Absent patient with staring eyes (with no response to conversation). Involuntary Purposeless acts: motor ( eg, lip smacking, chewing) or verbal. No recalling of the seizure. 138 139 3. PARTIAL SEIZURES ~ GENERALISED SEIZURES " Partial seizures may spread to involve the whole brain .- secondarily generalised seizures " . HY-sterical epilepsY • Usually: • The cause: • Incidence: young neurotic Sj2 . psychological & there is no organic lesion. usually occurs in the presence of people. • It is associated with: • EEG: • It is not associated with: normal. • Missed ttt. • Menses. • Alkalosis. anxiety, palpitaion & hyperventilation. tongue biting or incontinence of urine. • Alcohol use & Drug abuse ( e.g. cocaine ). • S timulation by photons & Hyperventilation. • S leep deprivation & Stress & sudden withdrawal of antiepileptic drngs. INVESTIGATIONS 1. EEG: • It is the most specific test for epilepsy because it records the electrical activity of the brain. • It shows specific pattern: 2. LOCAL INVESTIGATIONS: "Epilepsy waves". "CT & MRI of the brain" • To identify or exclude a LOCAL CAUSE of seizures in the brain. 3. GENERAL INVESTIGATIONS: "Laboratory investigations" • To search for a GENERAL CAUSE of seizures, e.g. blood glucose. 139 140 TREATMENT A. General Measures: 1. 2. Moderation of the patient's physical activity. A void the precipitating factors ( Alcohol, hyperventilation, photic stimulation ...... ). 3. A ketogenic diet is encouraged because it will induce acidosis: - Acidosis is beneficial as it raises the threshold of stimulation of the brain cells. B. Specific Treatment: 2. 1. Treatment of the cause in secondary epilepsy. Anti-epileptic drugs: a) Always sta1t with one drug, then add another drug if there is no response. b) Always stop the drugs ONLY if: • The patient stays free of symptoms for at least 2 years. • The patient has a normal EEG. 3. Side effects of Anti-epileptic drugs: I . Skin rash. 2. 3. Bone marrow depression. Ataxia. Drug 1. Barbiturates (Pbenonobarbitone) 2. Hydantoin (Epanutin) 3. Carbamazepine 4. Clonazepam 5. Valproate 6. Succinamide ANTI-EPILEPTIC DRUGS NEW ANTI-EPILEPTIC DRUGS - These drugs are new dtugs that may be used in resistant seizures. 1. Lamotrigine: 200 - 400 mg/ day. 2. Felbamate: 3. Gabapentin: 400- 800 mg/ day. 600 - 1200 mg/ day. \ " General rules for use ": Dose 100-600 mg I day 100-600 mg / day 200-600 mg I day 2-6 mg I day 500-1500 mg I day 500-1000 mg / day Best indicated - Broad spectrum. - Not for petit mal. - Grand mal. - Motor Jacksonian fits. - Grand mal. - Motor Jacksonian fits. - Complex seizures. - Not for petit ma!. - Myoclonic. - Grand mat. - Broad spectrum. - Petit mat. 140 141 STATUS EPILEPTICUS DEFINITION - A medical emergency: 1. Repeated attacks of generalized convulsions, with lack of recove,y of consciousness, 2. Persistent attack of seizure lasting for at least 30 minutes. OR, - If the convulsions are not stopped rapidly, coma deepens & death may occur due to: heart failure or respiratory failure or brain damage or hyperpyrexia. - The most common causes are: sudden withdrawal of anti-epileptic drugs & stroke. TREATMENT A. General Measures: l. Take care of: " ABC " • Place the patient on the ground, to guard against falling from bed. • Mouth gag & 02 inhalation ( endo-tracheal intubation may be needed). • Record the vital signs regularly. 2. Take a sample of: - Venous blood: for the level of: - A.tierial blood: for the level of: 3. a nti-epileptic drugs, a lcohol. pH, p0 2, pC02, HC0 3. Give cerebral dehydrating measures: e.g. Frusemide, cone. Mannitol, Dexamethazone. B. Specific Treatment: - Phenytoin with diazepam (or clonazepam) immediately: 1. Phenytoin: 2. Diazepam: Clonazepam: seizures recur: 15 mg I Kg slow infusion. 5 mg slowly IV, to be repeated after 5 minutes if seizures recur: maximum dose: 20 mg. OR: 2 mg slowly IV, to be repeated after 5 minutes if maximum dose: 6 mg. - If seizures persist after 20 min. of Phenytoin & diazepam: 3. PHENOBARBITONE: - In resistant cases: 200 mg infusion. 4. GENERAL ANAESTHESIA: may be used.

New test on school subjects

Create multiple choice questions using the following information: In November, Mrs. Baker has Holling read The Tempest. Despite his preconceptions, Holling is captivated by all the "good stuff" in the play, especially the cussing, which he decides to learn by heart. He figures that Mrs. Baker could not have read the play herself; if she had, she certainly would not have let him have it. Holling is amazed when he discovers that his teacher not only has read the play, but she knows the bad parts as well. Mrs. Baker gives Holling a one-hundred-and-fifty question test on The Tempest, and assigns him to read the play again, telling him "there is a lot more to (it) than a list of colorful curses." The deadline set by Holling's classmates for him to bring them cream puffs arrives, but although Holling's father's company has won the Baker's Sporting Emporium contract, he refuses to extend an advance on his son's allowance. Desperate, Holling goes to Goldman's Best Bakery, offering to work for the money he lacks to buy the cream puffs. Coincidentally, Mr. Goldman, who is active in Long Island's Shakespeare Company, needs a boy to perform in their upcoming Extravaganza, and because of his work with Mrs. Baker, Holling fits the bill. Mr. Goldman gives Holling the required number of cream puffs in exchange, but sadly, while the students are at recess, Caliban and Sycorax, the escaped rats who inhabit the classroom walls and ceiling, come out and decimate the treats. Somehow, the disaster is blamed on Holling; he must clean up the mess, and his classmates decree that he still owes them cream puffs. The next Wednesday, Holling brings five cream puffs to school, which is all he can afford. In addition to facing his classmates' ire, he has to deal with the fact that, in the Shakespeare Company Holiday Extravaganza, he must play the part of Ariel, who is a fairy, and wear yellow tights with white feathers on an unmentionable part of his anatomy; "not a good thing for a boy from Camillo Junior High." To Holling's surprise, just when things are at their darkest, Mrs. Baker comes through for him, bringing cream puffs for the students on his behalf. That afternoon, Mrs. Baker and Holling discuss The Tempest, and whether or not Caliban, the "monster," deserves a happy ending. Holling argues that, as the antagonist, he does not, but Mrs. Baker muses whether Shakespeare might have shown, even in a monster, the capacity of humankind to use defeat to grow. Mrs. Bigio stumbles into the classroom at this point, emitting sounds of indescribable sadness; she has just learned that her husband has been killed in a futile reconnaissance mission in Vietnam. Two nights after his funeral, the Catholic Relief Agency, which houses Vietnamese refugees, including Holling's classmate Mai Thi, is the target of a hate crime. Holling reflects that Shakespeare, with his happy endings for nearly everyone in The Tempest, is wrong. He says, "sometimes, there isn't a Prospero to make everything fine...and...the quality of mercy is strained." In December, Camillo Junior High is awash in "signs of the season." Mrs. Baker, however, does not share the holiday spirit, but Holling is too absorbed with his problems with the Shakespeare Holiday Extravaganza to wonder why. As always, Holling seeks help from his family, but to no avail; his mother comments insipidly that his embarrassing costume is cute, his father tells him to wear it to please Mr. Goldman, who might one day need an architect, and his sister warns him that if news of his role gets to the high school, no one better find out they are related. The only thing that prevents December from being a total disaster is Mrs. Baker's announcement that Mickey Mantle will be signing autographs at the Baker Sporting Emporium. Unfortunately, Mrs. Baker also tells the class about Holling and the Shakespeare Extravaganza, and encourages the students to attend both events. Holling's classmates are intensely curious about his role as Ariel, whom he euphemistically describes as "a warrior." Mr. Goldman tells Mrs. Baker that Holling needs "some practice on interpretation", and she practices with him, playing the part of Prospero. Mrs. Baker is a terrific reader, and when she and Holling rehearse the part where Prospero releases Ariel from bondage, Holling is inspired, realizing what it means to be free "to create his own happy ending." On the night of the performance, Mrs. Baker, Mrs. Bigio, Danny Hupfer and his parents, Meryl Lee, and Mai Thi are in the audience to support Holling, unlike his own parents, who do not want to miss the Bing Crosby Christmas Special on television. Holling executes his part with such passion that his classmates are moved to tears, and do not even notice what he is wearing. When the show is over, Holling, finding the dressing room locked, rushes outside, still in costume, where his father is supposed to be waiting to take him to Baker's Sporting Emporium to see Mickey Mantle. Typically, his father is not there, and Holling, frantic, flags down a bus and begs the driver to take him to the Emporium. The driver takes pity on him and complies, getting him to the Emporium just in time, but when Holling approaches Mickey Mantle for an autograph, the famous player looks derisively at his costume and snaps rudely, "I don't sign baseballs for kids in yellow tights." Danny Hupfer witnesses this snub, and loyally returns his own autographed baseball to Mickey Mantle, saying, "I guess I don't need this after all." Holling and Danny leave together in silence, smarting because "when gods die, they die hard." During the days remaining until holiday break, Mrs. Bigio is especially cantankerous; her cafeteria cooking is unappetizing at best, and her comments to the students are impatient and unkind. Holling, remembering Mrs. Bigio's sadness when she received the news of her husband's death, does not complain, but he is bewildered at the sheer desolation he witnesses when Mrs. Bigio bitterly tells Mai Thi that she "shouldn't even be here...a queen in a refugee home while American boys are sitting in swamps on Christmas Day." After school on the last day before break, Mrs. Baker gives Holling, Danny Hupfer, and Doug Swieteck each a new baseball and mitt, and sends them to the gym, where, to their delight, they meet Joe Pepitone and Horace Clark in their Yankee uniforms, and receive tickets to Opening Day at the Stadium. Mrs. Baker's family knows what happened with Mickey Mantle, and wants to make it up to the boys. The next day, President Johnson declares a Christmas ceasefire in Vietnam, and the holiday season begins in earnest.

Growing up in Sioux Falls, South Dakota, a small city surrounded by endless plains, I've found unexpected echoes of home in China's smaller towns — from the warmth of locals in Huaihua, Central China's Hunan province, to the quiet charm of Yangshuo, South China's Guangxi Zhuang autonomous region. With an itch to see more of China's lesser-visited regions, I began planning a trip to the northwest with seven friends — five Americans, one Pakistani, one Zimbabwean, and one Colombian. We bought round-trip tickets from Shanghai to Yinchuan, Ningxia Hui autonomous region, for less than $120 each. From there, we planned to rent a car and drive to Xining in Qinghai, then on to Qinghai Lake, and finally to Lanzhou, Gansu. To make that possible, several of us applied for Chinese driver's licenses, a process that involved translating our US licenses into Mandarin and passing a short test on traffic laws. Within a day, we were licensed. As we piled into two rental cars in late March to begin our eight-day journey, it became clear that this wasn't just a road trip — it was the culmination of our four years in China, the Mandarin we had so diligently studied, and our ongoing effort to contribute to US-China people-to-people relations. Right away, we drew curious reactions. At the Yinchuan airport, taxi drivers offered us rides into the city, only to stare in astonishment when we told them we had rented cars. "You're driving? In China?" one driver asked, visibly surprised. It was a reaction we'd encountered multiple times during our trip, as foreign drivers are rare in China, especially in remote regions. In Yinchuan, we stocked up on snacks and adjusted to the chilly desert air. From there, we headed west, navigating wide highways framed by dramatic landscapes: arid plains, jagged mountains, and occasionally, a herd of sheep crossing the road. The vastness of the Northwest was humbling — and as someone who grew up on the wide-open prairies of South Dakota, it felt oddly familiar. One of the highlights of our trip was camping by Qinghai Lake, the largest saltwater lake in China. A few summers ago, Santiago Solano, one of my classmates from the US, cycled from Xi'an in Shaanxi to Urumqi in the Xinjiang Uygur autonomous region over the course of a month and met many kind strangers along the way. One of them was Geng San, a Tibetan lamb herder who managed a piece of land right next to Qinghai Lake and graciously invited us to camp there. "That's what China is — it's the people. The quiet generosity of an old Tibetan nomad who, years after we first met, still offered us a place to rest on his land," said Solano, who is also part of the group on this trip. But apparently, we underestimated just how cold it would be to camp next to Qinghai Lake in late March. It was deathly freezing. In preparation for the trip, we had ordered two tent kits and eight sleeping bags. However, when the temperature eventually dropped to — 10 C, all of us piled into the cars and turned the heaters on. So much for camping. From Qinghai Lake, we drove to Lanzhou, where we visited many food markets and tried every type of noodle on offer. Since we are college students, we rented a gaming hotel room — something I've only ever seen in China. At night, instead of attending local parties as we had before, we stayed in the hotel and gamed late into the morning. For me, the trip was as much about the journey as it was about the destinations. Driving through Northwest China gave us a unique perspective on the region's natural beauty and its people. At gas stations, shopkeepers greeted us with curiosity and kindness, often offering recommendations for nearby attractions. At roadside carts, we sampled local specialties, grabbing a quick skewer and a mango for the road. And at every stop, we were touched by the warmth and hospitality that make traveling in China so rewarding. As an American who has lived in China for several years, I'm often asked about my experiences here. Trips like this one remind me of the similarities between the two countries, despite their differences. Just as road trips are a quintessential part of American culture, they've become my favorite way to explore China. Whether it's driving through the rolling hills of South Dakota or the deserts of Ningxia, there's something universal about the freedom and camaraderie that come with having complete control over where you end up. Written by Charlie Howes, a 22-year-old American who has lived in China since 2019. He completed his final year of high school at Beijing No 80 High School and is currently studying at New York University Shanghai. He has founded a company in China focused on facilitating US-China trade and plans to continue living in Shanghai long term. He enjoys road trips, cycling around the world, learning languages, and meeting new people.

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