Μεταξύ των παιχνιδιών που υπήρχαν στο βίντεο που παρακολουθήσατε, βρίσκονται:

πλαγγόνες, πήλινα ομοιώματα ζώων, αστράγαλοι, κρυφτό, διελκυστίνδα

σχοινάκι, άθυρμα, εφεδρισμός, πλαγγόνες, βιντεοπαιχνίδια, αστράγαλοι

εφεδρισμός, σχοινάκι, πήλινα ομοιώματα ζώων, εκατομμυριούχος, άθυρμα

αστράγαλοι, κρυφτό, πεσσοί, γιο-γιο, φιδάκι, πλαγγόνες, άθυρμα

διελκυστίνδα, πεσσοί, σβούρα, μονόπολη, αστράγαλοι, πλαγγόνες

Tα παιχνίδια στην αρχαία Ελλάδα

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)

GRANDMOTHER: Read Jimmy's card to me please, Penny. PENNY: "I have just arrived in Scotland and I'm staying at a Youth Hostel." GRANDMOTHER: Eh? PENNY: He says he's just arrived in Scotland. He says he's staying at a Youth Hostel. You know he's a member of the Y.H.Α. GRANDMOTHER: The what? PENNY: The Y.H.A., Mum. The Youth Hostels Association. GRANDMOTHER: What else does he say? PENNY: "I'll write a letter soon. I hope you are all well." GRANDMOTHER: What? Speak up, Penny. I'm afraid I can't hear you. PENNY: He says he'll write a letter soon. He hopes we are all well. "Love, Jimmy." GRANDMOTHER: Is that all? He doesn't say very much, does he? PENNY: He can't write very much on a card, Mum.

Στην ιστορία της Δ´ τάξης μάθαμε ότι το 146 π.Χ. οι Ρωμαίοι κατέκτησαν την Ελλάδα, ύστερα από μακροχρόνιους πολέμους. Από τα πρώτα χρόνια της κατάκτησής της όμως αντιμετώπισαν πολλές δυσκολίες στη διακυβέρνηση των κατακτημένων πόλεων. Γι’ αυτό, στο πρώτο διάστημα κατοχής της χώρας, εφάρμοσαν ιδιαίτερα σκληρά μέτρα για τη διοίκησή της. Πρώτη φροντίδα των Ρωμαίων ήταν να κρατήσουν τους Έλληνες διχασμένους και να τους εμποδίσουν να συνεργαστούν μεταξύ τους. Γι' αυτό, αμέσως μετά την κατάκτηση, καtάργησαν τα δημοκρατικά πολιτεύματα και τις συμμαχίες των ηττημένων πόλεων-κρατών. Εφάρμοσαν δηλαδή για τη διακυβέρνησή τους το «διαίρει και βασίλευε»1. Βασικό κριτήριο για τον νέο τρόπο διοίκησης κάθε πόλης ήταν η στάση που αυτή είχε τηρήσει στους ελληνορωμαϊκούς πολέμους. Έτσι: •Σε όσες συμμάχησαν μαζί τους ή δεν αντιστάθηκαν στις λεγεώνες2, τούς παραχωρούσαν ανεξαρτησία ή αυτονομία3 και ανέθεταν τη διοίκησή τους σε φιλορωμαίους Έλληνες. •Σε όσες όμως αντιστάθηκαν, φέρθηκαν ανελέητα. Γκρέμισαν τα τείχη τους, άρπαξαν θησαυρούς και έργα τέχνης, επέβαλαν βαρύτατους φόρους, αφόπλισαν και αιχμαλώτισαν τους κατοίκους τους. Στις πόλεις αυτές εγκατέστησαν μόνιμες ρωμαϊκές φρουρές και ανέθεσαν τη διοίκησή τους σε Ρωμαίους αξιωματούχους. Δυσάρεστες συνέπειες για τους Έλληνες όμως είχε και η διαρκής παρουσία ρωμαϊκού στρατού στον τόπο τους. Οι λεγεώνες τρέφονταν από τα προϊόντα της υπαίθρου και συχνά στρατολογούσαν τους κατοίκους της. Οι πληθυσμοί ένιωθαν ανασφαλείς και φοβισμένοι. Πολλοί εγκατέλειπαν τη γη τους και κατέφευγαν στις πόλεις. Κι εκεί όμως τους περίμεναν η φτώχεια, η διαρκής παρουσία και η απειλή των κατακτητών. 1. Οι Ρωμαίοι κυβερνούν τους Έλληνες 1 «διαίρει και βασίλευε»: χώρισέ τους και κυβέρνησέ τους. 2 λεγεώνα: ρωμαϊκό στρατιωτικό σώμα. 3 αυτονομία: δικαίωμα να διοικούνται με δικούς τους νόμους και άρχοντες. 1. Οι ρωμαϊκές λεγεώνες λεηλατούσαν συχνά την ύπαιθρο. Η υποδούλωση της Ελλάδας έχει δυσάρεστες συνέπειες για τους Έλληνες. Οι Ρωμαίοι, αρχικά, διοικούν τους κατακτημένους με σκληρό τρόπο. Κάθε πόλη αντιμετωπίζεται ανάλογα με τη στάση που τήρησε απέναντί τους. Οι Έλληνες και οι Ρωμαίοι 11 Α 2. Αιχμάλωτοι Έλληνες δουλεύουν στους ρωμαϊκούς δρόμους. 3. Ο Πολύβιος για την ερήμωση της υπαίθρου «Στην εποχή μας σε ολόκληρη την Ελλάδα επικρατεί απαιδία1 και ολιγανθρωπία. Αυτά ήταν αιτία να ερημωθούν οι πόλεις και να μειωθεί η παραγωγή αγαθών στην ύπαιθρο, μολονότι δεν είχαμε αρρώστιες ούτε υποφέραμε από συνεχείς πολέμους». Πολύβιου, Ιστορίαι 4. Χιλιάδες αιχμάλωτοι Έλληνες και ανεκτίμητα έργα τέχνης μεταφέρθηκαν στη Ρώμη, για να επιδειχθούν στους θριάμβους2 των νικητών στρατηγών. Όλα αυτά δημιούργησαν έντονη δυσαρέσκεια στους Έλληνες, οι οποίοι για πρώτη φορά βρέθηκαν υπόδουλοι σ’ έναν ξένο λαό. Γι’ αυτό πολλές φορές ξεσηκώθηκαν κατά των κατακτητών. Ο ρωμαϊκός στρατός όμως κατέπνιγε αυτές τις εξεγέρσεις και τι- μωρούσε σκληρά αυτούς που θεωρούσε πρωταίτιους.

T

Soggy Stepsisters Ada and Rachel were fighting again. Ever since Ada's mom married Rachel's dad, it seemed as though they couldn't stop. "Are you going to wear that?" Ada asked, pointing to Rachel's old pants. "I know we're on vacation, but this is taking it too far." "Yes," Rachel said. "We're going outside. But if you want to break an ankle in those shoes, go ahead." Ada sighed. "I think I'll be bored to death long before that." "Dad and I come to this cabin every year," Rachel snapped. "We love it." Ada laughed. "I guess you have nothing better to do." "Great!" Rachel said. "Now we're going to hear about New York again." "Girls!" said their dad. "Stop arguing. I'll make a deal with you. Get through this morning without fighting, and you can do whatever you want this afternoon." The girls looked at each other. "All right," they said. "Let's go out in the canoe," Rachel suggested. "Ugh," Ada said and then looked at her stepdad. "I guess." Rachel showed Ada how to paddle. "We need to work together," Rachel said. "This is dumb," Ada complained. "These life jackets are hot, and they look silly." Rachel said nothing as the canoe moved slowly out into the lake. "Paddle harder, Ada," Rachel called. Ada rolled her eyes and pretended not to hear. When they made it to the middle of the lake, Ada felt a gust of wind. She looked up. Dark clouds filled the sky. Rachel said, "We'd better turn around." The wind blew harder. "Why aren't we moving?" Ada yelled. "Paddle with me," Rachel yelled back. "One... two..." Ada was wild with fear. "Help!" she screamed. She stood up and waved her arms. "Ada, no!" Rachel yelled. "Sit down!" It was too late. The canoe rocked and flipped over. "What do we do?" Ada yelled, spitting out water. "Grab the canoe," Rachel told her. "We're going to have to swim it back to shore." "Can't we climb back in?" Ada gasped. "This is safer and easier," said Rachel. "It's not far, and we have life jackets on. Let's go!" They swam. Ada was scared, but Rachel helped her. "You're doing great," Rachel said over and over. Their parents came running as they got to shore. "What happened? Are you all right?" asked their mom. We're fine-thanks to Rachel," Ada said. "I guess it's good that you come to the cabin every year." She looked at her stepsister. "Thank you." Rachel smiled as she said, "Let's go change. You can help me pick out what to wear."

T.D.SAT Vocab W12

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