Effects of combined fluoxetine and counseling in the outpatient treatment of of PNUE and its stereoisomer as 5-HT2C receptor allosteric modulators. students: Motives, expectations, and relationship with psychoactive lifestyle drugs . Discontinue heparin therapy and obtain a baseline aPTT before .. The relationship between INR and bleeding risk is altered when argatroban and warfarin are .. mixture of R and S stereoisomers at a ratio of approximately We found 9 Couples Counseling Techniques that are proven to work. This guide can help you to find the right technique and the right counselor.
Let's see if I can somehow get from this guy to that guy. Let me flip this guy first. So let me-- a good thing to do would be to just flip to see the fastest way I could potentially get there.
Let me just flip it like this. So I'm going to flip out of the page, you can imagine. I'm going to flip it like this. So I'm going to take this methyl group and then put it on the right-hand side. And you can imagine, I'm going to turn it so it would come out of the page and then go back down.
So if I did that, what would it look like? I would have the carbon, this carbon here. I would have the methyl group on that side now. And then since I flipped it over, the bromine was in the plane of the page. It'll still be in the plane of the page, but since I flipped it over, the hydrogen, which was in the back, will now be in the front.
The hydrogen will now be in the front and the fluorine will now be in back because I flipped it over. So the fluorine is now in the back.
Stereoisomers, enantiomers, diastereomers, constitutional isomers and meso compounds
Now, how does this compare to that? Let's see if I can somehow get there. Well, if I take this fluorine and I rotate it to where the hydrogen is, and I take the hydrogen and rotate it to where-- that's all going to happen at once-- to where the bromine is, and I take the bromine and rotate it to where the fluorine is, I get that.
So I can flip it and then I can rotate it around this bond axis right there, and I would get to that molecule there.
So even though they look pretty different, with the flip and a rotation, you actually see that these are the same a molecule. So let's see, what do we have here? Let me switch colors. So over here, this part of both of these molecules look the same. You have the carbons on both of them. This carbon looks like a chiral center. It's bonded to one, two, three different groups. You might say, oh, it's two carbons, but this is a methyl group, and then this side has all this business over it, so this is definitely a chiral carbon.
And over, here same thing. It's a chiral carbon. And this has the same thing. It's bonded to four different things. So each of these molecules has two chiral carbons, and it looks like they're made up of the same things. And not only are they made up of the same things, but the bonds are made in the same way.
So this carbon is bonded to a hydrogen and a fluorine, and the two other carbons, same thing, a hydrogen and a fluorine. Carbon, it looks like it's a hydrogen. It's bonded to a hydrogen and a chlorine, so it's made up of the same constituents and they're bonded in the same way. So these look like-- but the bonding is a little bit different.
Over here on this one on the left, the hydrogen goes in the back, and over here, the hydrogen's in the front. And over here, the chlorine's in back, and over here, the chlorine's in front. So these look like sterioisomers. You saw earlier in this video, you saw structural isomers, made up of the same things but the connections are all different.
Stereoisomers, they're made up of the same thing, the connections are the same, but the three-dimensional configuration is a little bit different. For example, here on this carbon, it's connected to the same things as this carbon, but over here, the fluorine's out front, and over here-- out here, the fluorine's out front. Over here, the fluorine's backwards. And same thing for the chlorine here.
It's back here and it's front here. Now, let's see if they're related in a more nuanced way. You could imagine putting a mirror behind. I guess the best way to visualize it, imagine putting a mirror behind this molecule. If you put a mirror behind this molecule, what would its reflection look like?
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So if you put a mirror behind it, in the image of the mirror, this hydrogen would now, since the mirror's behind this whole molecule, this hydrogen is actually closer to the mirror. So then the mirror image, you would have a hydrogen that's pointed out, and then you would have the carbon, and then you would have the fluorine being further away. And same thing in the mirror image here.
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You would have the chlorine coming closer since this chlorine is further back, closer to the mirror, and then you would have the hydrogen pointing outwards like that. And then, obviously, the rest of the molecule would look exactly the same. And so this mirror image that I just thought about in white is exactly what this molecule is: You might say, wait, this hydrogen is on the right, this one's on the left. This is actually saying that the hydrogen's pointing out front, the fluorine is pointing out back, hydrogen up front, fluorine back, chlorine out front, hydrogen back, chlorine out front, hydrogen back.
So these are actually mirror images, but they're not the easy mirror images that we've done in the past where the mirror was just like that in between the two. This one is a mirror image where you place the mirror either on top of or behind one of the molecules.
So this is a class of stereoisomers, and we've brought up this word before. We call this enantiomers. So if each of these are an enantiomers, I'll say they are enantiomers of each other.Marriage Counselling - His Needs vs Her Needs - catchsomeair.us - LESSON 1/6 - Video Study
They're made up of the same molecules, so that they have the same constituents. They also have the same connections, and not only do they have the same connections, that so far gets us a steroisomer, but they are a special kind of stereoisomer called an enantiomer, where they are actual mirror images of each other. Now, what is this one over here in blue? Just like the last one, it looks like it's made up of the same things. You have these carbons, these carbons, these carbons and hydrogens up there.
Same thing over there. You have a hydrogen, bromine, hydrogen and a bromine, hydrogen, chlorine, hydrogen, chlorine, hydrogen, chlorine, hydrogen, chlorine. So it's made up of the same things.
They're connected in the same way, so they're definitely stereoisomers. Well, we have to make sure they're not-- well, let's make sure they're not the same molecule first. Here, hydrogen's in the front. There, hydrogen's in the back. Here, hydrogen is in the back. Here, hydrogen is in the front. So they're not the same molecule. They have a different three-dimensional configuration, although their bond connections are the same, so these are stereoisomers.
Let's see if they're enantiomers. So if we look at it like this, you put a mirror here, you wouldn't get this guy over here. Then you would have a chlorine out front and a hydrogen. So you won't get it if you get a mirror over there. But if we do the same exercise that we did in the last pair, if you put a mirror behind this guy, and I'm just going to focus on the stuff that's just forward and back, because that's what's relevant if the mirror is sitting behind the molecule.
Currently, routine lab tests do not test for the presence of rs Requesting testing of these additional CYP2C9 alleles, and including these genotypes in an expanded dosing algorithm improves warfarin dose prediction in African-Americans, while maintaining high performance in European-Americans Individuals who are most likely to benefit from genetic testing are those who have yet to start warfarin therapy.
However, genotype-guided warfarin dosing is controversial and is generally not carried out preemptively. Some studies have reported that, in general, the current use of genotype-guided dosing algorithms did not improve anticoagulation control in the first few weeks of warfarin therapy ; however, a recent study found genotype-guided warfarin dosing did improve the safety of starting warfarin, compared to clinically guided dosing Therapeutic Recommendations based on Genotype This section contains excerpted 1 information on gene-based dosing recommendations.
Neither this section nor other parts of this review contain the complete recommendations from the sources. Not all factors responsible for warfarin dose variability are known, and the initial dose is influenced by: Clinical factors including age, race, body weight, sex, concomitant medications, and comorbidities Genetic factors CYP2C9 and VKORC1 genotypes Select the initial dose based on the expected maintenance dose, taking into account the above factors.
Modify this dose based on consideration of patient-specific clinical factors. Routine use of loading doses is not recommended as this practice may increase hemorrhagic and other complications and does not offer more rapid protection against clot formation. Individualize the duration of therapy for each patient. In general, anticoagulant therapy should be continued until the danger of thrombosis and embolism has passed.
Typical maintenance doses are 2 to 10 mg once daily.
Stereoisomerism - Wikipedia
Dosing Recommendations with Consideration of Genotype Table 1 displays three ranges of expected maintenance warfarin sodium tablets doses observed in subgroups of patients having different combinations of CYP2C9 and VKORC1 gene variants. Please review the complete therapeutic recommendations that are located here: The genetic variation results in a reduction in the required dose and an increase in the risk of excessively severe inhibition of blood clotting during the first month of the treatment.
However, the effect is small and CT is also the most common genotype, meaning that the standard treatment will primarily be based on patients with this genotype.
From day 6 on the standard algorithm without genotype information can be used to calculate the dose. This can increase the risk of bleeding. Modified dose algorithms have been developed for patients of African or East Asian heritage. Genetic variation may lead to a decrease in the required maintenance dose. However, there is insufficient evidence that this causes problems when therapy is initiated as usual. Please review the complete therapeutic recommendations located here: In individuals with genotypes associated with CYP2C9 poor metabolism e.
The bulk of the literature informing these recommendations is in European and Asian ancestry populations, but consistent data exist for other non-African populations. If a loading dose is to be utilized, the EU-PACT loading dose algorithm that incorporates genetic information could be used.
Larger dose reductions might be needed in patients homozygous for variant alleles i. The data do not suggest an association between rs genotype and warfarin dose in non-African Americans, thus rs should not be considered in these individuals even if available. If these genotypes are not available, warfarin should be dosed clinically without consideration for genotype. Calculate warfarin dose using a validated pharmacogenetic algorithm, including genotype information for VKORC1 c. Larger dose reductions might be needed in patients who carry two variant alleles e.
In addition, rs is associated with warfarin dosing in African Americans mainly originating from West Africa. As noted above, for non-African ancestry, if a loading dose is to be used, the EU-PACT algorithm that incorporates genetic information could be used to calculate loading dose. The data do not support an impact on clinical phenotype for CYP4F2 on warfarin dosing in those of African ancestry and so no recommendation is made for use of CYP4F2 genotype data in blacks.
Please review the complete therapeutic recommendations, including recommendations for pediatric patients, located here: