The reasons for this difference include products may cause the remedy to be ineffective purchase ciplox 500mg online virus kids ers. Controversy clouds the true incidence of Lyme dis- ease because no test is definitively diagnostic for the dis- Resources ease order 500 mg ciplox overnight delivery antibiotic breastfeeding, and many of its symptoms mimic those of so many BOOKS other diseases. It is caused by an in- fection transmitted by the bite of ticks carrying the Borrelia burgdorferi bacterium. The disease is also found in Scandi- be removed before the 24 hours or more of continuous navia, continental Europe, the countries of the former feeding needed to transmit Bb. Soviet Union, Japan, and China; in addition, it is possi- ble that it has spread to Australia. Causes & symptoms The risk for acquiring Lyme disease varies, depend- Lyme disease is a collection of effects caused by Bb. A Once Bb gains entry to the body through a tick bite, it tick passes through three stages of development—larva, can move through the bloodstream quickly. Only 12 nymph, and adult—each of which is dependent on a live hours after entering the bloodstream, Bb can be found in host for food. In the United States, Bb is borne by ticks cerebrospinal fluid (which means it can affect the ner- of several species in the genus Ixodes, which usually vous system). Treating Lyme disease early and thorough- feed on the white-footed mouse and deer (and are often ly is important because Bb can hide for long periods called deer ticks). In the summer, the larval ticks hatch within the body in a clinically latent state. That ability from eggs laid in the ground and feed by attaching them- explains why symptoms can recur in cycles and can flare selves to small animals and birds. It is the next stage—the tant to note, however, that not everyone exposed to Bb nymph—that causes most cases of Lyme disease. Nymphs are very active from spring through early sum- mer, at the height of outdoor activity for most people. Lyme disease is usually described in terms of length Because they are still quite small (less than 2 mm in of infection (time since the person was bitten by a tick length), they are difficult to spot, giving them ample op- infected with Bb) and whether Bb is localized or dissem- portunity to transmit Bb while feeding. Although far inated (spread through the body by fluids and cells carry- more adult ticks than nymphs carry Bb, the adult ticks ing Bb). Furthermore, when and how symptoms of Lyme 1252 GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 The first sign of lyme disease is usually an itchy rash around the site of the tick bite. Late disseminated disease and chronic Lyme People who experience recurrent bouts of symptoms disease over time are said to have chronic Lyme disease. Weeks, months, or even years after an untreated tick bite, symptoms can appear in several forms, including: Early localized Lyme disease • fatigue, forgetfulness, confusion, mood swings, irri- The most recognizable indicator of Lyme disease tability, numbness is a rash around the site of the tick bite. Often, the tick • neurologic problems, such as pain (unexplained and not exposure has not been recognized. The rash—erythema usually one-sided but may be on both sides), and a mim- migrans (EM)—generally develops within 3–30 days icking of the inflammation of brain membranes known and usually begins as a round, red patch that expands. The rash may look like a bruise on and other musculoskeletal complaints individuals with dark skin. Of those who develop Less common effects of Lyme disease are heart ab- Lyme disease, about 50% notice the rash; about 50% normalities (such as irregular rhythm or cardiac block) notice flu-like symptoms, including fatigue, and eye abnormalities (such as swelling of the cornea, headache, chills and fever, muscle and joint pain, and tissue, or eye muscles and nerves). However, a rash at the site can also be an allergic reaction to the tick saliva rather Diagnosis than an indicator of Lyme disease, particularly if the rash appears in less than 3 days and disappears only A clear diagnosis of Lyme disease can be difficult, days later. Sharp, intense pain may be ease may mimic other conditions, including chronic fa- relieved by applying an ice pack to the affected area. The patient may treat Lyme disease by visual- other diseases with many symptoms involving multiple izing Bb as looking like ticks swimming in the blood- body systems. Differential diagnosis (distinguishing stream being killed by the flame of a candle. Lyme disease from other diseases) is based on clinical evaluation with laboratory tests used for clarification, • Probiotics.

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Traditional ethnic diets H C H C H reflect these healthy combinations buy generic ciplox 500mg on line infection after dc, for example buy cheap ciplox 500mg antibiotics not helping uti, beans with corn or rice in Mexican dishes or chickpeas and H C H H C H lentils with wheat in Middle Eastern fare. Most fatty acids contain the maximum numbers of hydrogen atoms agree, however, that children, elderly people, pregnant and attached to carbons and no double bonds between carbon lactating women, and teenagers, who often do not get atoms. Consumed at a more rapid rate, alcohol enters the ture) developed a pyramid to represent the quantities of bloodstream and affects many cells, notably in the brain. When deliv- sion, and some suggested improvements include: ered in excess to the liver, alcohol can lead to the accu- mulation of fat as well as inflammation and scarring of liver ◗ Distinguish between unrefined and refined carbohy- tissue. Alcohol ◗ Distinguish between healthful unsaturated fats, which metabolism ties up enzymes needed for oxidation of nu- can be eaten in moderation, and less healthful saturated trients and also results in byproducts that acidify body flu- and processed (trans-) fats, which should be restricted. Fats, oils, sweets Although alcohol consumption is compatible with good health and may even have a beneficial effect on the Use sparingly cardiovascular system, alcohol should be consumed only Meat, poultry, in moderation. Milk, yogurt fish, dry beans, and cheese eggs, and nuts Checkpoint 20-7 What are typical recommendations for the rel- ative amounts of carbohydrates, fats, and proteins in the diet? Common food allergens are METABOLISM, NUTRITION, AND BODY TEMPERATURE ✦ 415 wheat, nuts, milk, shellfish, and eggs, but almost any food Calculation of body mass index (BMI) might cause an allergic reaction in a given individual. A low pro- nate method is to divide weight in pounds by the square of tein level in the blood plasma interferes with fluid return height in inches and multiply by 703. It is Underweight common knowledge that overweight and obesity have in- People who are underweight have as much difficulty creased in the past several decades in many countries. It is asso- shortens the life span and is associated with cardiovascular ciated with low reserves of energy, reproductive distur- disease, diabetes, some cancers, and other diseases. Scientists are studying the nervous and hormonal ◗ Nutrition and Aging controls over weight, but so far they have not found any effective and safe drugs for weight control. Because metabo- orous exercise at least four times a week is recommended lism generally slows, and less food is required to meet en- for health and weight control. Exercise helps to boost appetite and 416 ✦ CHAPTER TWENTY Box 20-3 • Health Professions Dietitians and NutritionistsDietitians and Nutritionists ietitians and nutritionists specialize in planning and su- anatomy and physiology. Most dietitians and nutritionists in Dpervising food programs for institutions such as hospi- the United States receive their training from a college or uni- tals, schools, and nursing care facilities. Dietitians and nutritionists also work in community the American population continues to age, the need for nutri- settings, educating the public about disease prevention tional planning in hospital and nursing care settings is ex- through healthy eating. In addition, many people now place an empha- food and nutrition has also led to new opportunities in the sis on healthy eating and may consult nutritionists privately. To perform their duties, dieti- For more information about this career, contact the American tians and nutritionists need a thorough understanding of Dietetic Association. These responses do ◗ Body Temperature not account for all the increase, however, nor do they ac- count for the much greater increase in metabolism after a Heat is an important byproduct of the many chemical ac- meal containing a large amount of protein. Under normal conditions, a number of regulatory devices keep body temperature constant within quite narrow lim- Checkpoint 20-8 What are some factors that affect heat pro- its. Factors Affecting Heat Production The rate at To illustrate evaporation, rub some alcohol on your which heat is produced is affected by a number of factors, skin; it evaporates rapidly, using so much heat from the including exercise, hormone production, food intake, and skin that your arm feels cold. The rate of heat loss and epinephrine (adrenaline) from the adrenal medulla, through evaporation depends on the humidity of the sur- increase the rate of heat production. When it exceeds 60% or so, perspiration METABOLISM, NUTRITION, AND BODY TEMPERATURE ✦ 417 does not evaporate so readily, making one feel generally lation because variations in the activity of these large tis- miserable unless some other means of heat loss is avail- sue masses can readily increase or decrease heat genera- able, such as convection caused by a fan. Because muscles form roughly one-third of the body, either an involuntary or an intentional increase in Prevention of Heat Loss Factors that play a part in their activity can form enough heat to offset a consider- heat loss through the skin include the volume of tissue able decrease in the temperature of the environment. Age Factors Very young and very old people are lim- If the temperature of the surrounding air is lower than ited in their ability to regulate body temperature when ex- that of the body, excessive heat loss is prevented by both posed to environmental extremes. Normal Body Temperature The normal tempera- Temperature Regulation ture range obtained by either a mercury or an electronic Given that body temperature remains almost constant de- thermometer may extend from 36. Temperature tends to be higher in the The Role of the Hypothalamus Many areas of the late afternoon and evening because of physical activity body take part in heat regulation, but the most important and consumption of food. Skin temperature obtained in the axilla 20 pothalamus control heat production in body tissues, (armpit) is lower than mouth temperature, and mouth whereas another group of cells controls heat loss. It is believed that, if it were possible to place a ther- through the brain and also on input from temperature re- mometer inside the liver, it would register a degree or ceptors in the skin. Other impulses are sent to the muscles the ice point is at 0 and the normal boiling point of water to cause shivering, a rhythmic contraction of many mus- is at 100, the interval between these two points being di- cles, which results in increased heat production. Usually, the presence of fever With further heat retention and more fluid loss, heat is due to an infection, but there can be many other causes, exhaustion occurs. Curiously enough, fever usually is preceded by a Heat stroke (also called sunstroke) is a medical emer- chill—that is, a violent attack of shivering and a sensation gency.

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Systemic effect: 4400 IU/kg IV over 10 min buy 500 mg ciplox otc antibiotics and yogurt, followed by 4400–6000 IU/kg/h for 12 h buy discount ciplox 500mg on-line xstatic antimicrobial. Migraines: 250 mg bid, ↑ to 1000 mg/d SUPPLIED: Valproic acid: caps 250 mg; syrup 250 mg/5 mL. Divalproex: EC tabs 125, 250, 500; caps 125 mg NOTES: Monitor LFT and follow serum levels (see Table 22–7, pages 631–634); concurrent use of phenobarbital and phenytoin may alter serum levels of these agents; ↓ dose in hepatic impairment Valrubicin (Valstar) COMMON USES: Intravesical treatment of BCG-refractory CIS when immediate cystectomy would be associated with unacceptable morbidity or mortality ACTIONS: Semisynthetic doxorubicin analogue; cytotoxic DOSAGE: 800 mg intravesically weekly for 6 wk SUPPLIED: Liq 200 mg/5 mL NOTES: Dilute 800 mg in approximately 75 mL NS; minimal systemic absorption with intact blad- der. Do NOT use within 1–2 wk of biopsy as systemic absorption can cause myelosuppression; can cause local bladder symptoms; contra with bladder capacity of < 75 mL or active UTI Valsartan (Diovan) COMMON USES: HTN ACTIONS: Angiotensin II receptor antagonist DOSAGE: 80 –160 mg/d SUPPLIED: Caps 80, 160 mg NOTES: Use with caution with K-sparing diuretics or K supplements Vancomycin (Vancocin, Vancoled) COMMON USES: Serious MRSA infections and in enterococcal endocarditis in combination with aminoglycosides in penicillin-allergic patients; oral treatment of C. Soft tissue necrosis possible with extravasation; dosage adjustment in hepatic impairment Vinorelbine (Navelbine) COMMON USES: Non-small-cell lung cancer (single agent or with cisplatin), breast cancer ACTIONS: Inhibits polymerization of microtubules, impairing mitotic spindle formation, semisyn- thetic vinca alkaloid DOSAGE: 30 mg/m2/wk SUPPLIED: Inj 10 mg NOTES: Toxicity symptoms: Myelosuppression (especially leukopenia), mild GI effects and infre- quent neurotoxicity (6– 29%), constipation and paresthesias (rare). Dosage adjustment in hepatic impairment Vitamin B1 See Thiamine (page 609) Vitamin B6 See Pyridoxine (page 596) Vitamin B12 See Cyanocobalamin (page 521) Vitamin K See Phytonadione (page 589) Warfarin (Coumadin) COMMON USES: Prophylaxis and Rx of PE and DVT, AF with embolization, other postoperative indications ACTIONS: Inhibits vitamin K-dependent production of clotting factors in the order VII-IX-X-II DOSAGE: See Table 22–10 (page 637) for anticoagulation guidelines. ACCP guidelines recommend initiation with 5 mg, unless rapid attainment of therapeutic INR is necessary (use 7. Com- mon warfarin interactions: Potentiates acetaminophen, alcohol (with liver disease), amiodarone, cimetidine, ciprofloxacin, co-trimoxazole, erythromycin, fluconazole, flu vaccine, isoniazid, itra- conazole, metronidazole, omeprazole, phenytoin, propranolol, quinidine, tetracycline. Inhibits bar- biturates, carbamazepine, chlordiazepoxide, cholestyramine, dicloxacillin, nafcillin, rifampin, sucralfate, high vitamin K foods Witch Hazel (Tucks Pads, others) COMMON USES: After bowel movement cleansing to decrease local irritation or relieve hemor- rhoids; after anorectal surgery and episiotomy DOSAGE: Apply PRN 22 SUPPLIED: Presoaked pads, liq 22 Commonly Used Medications 619 Zafirlukast (Accolate) COMMON USES: Prophylaxis and chronic Rx of asthma ACTIONS: Selective and competitive inhibitor of leukotriene D4 and E4 DOSAGE: 20 mg bid SUPPLIED: Tabs 20 mg NOTES: NOT for acute exacerbations of asthma, contra in nursing women; associated with hepatic dysfunction, which has been reversible on discontinuation Zalcitabine [DdC] (Hivid) COMMON USES: HIV patients intolerant of zidovudine and didanosine ACTIONS: Antiretroviral agent DOSAGE: 0. Pregnancy: 100 mg PO 5×/d until the start of labor, then during labor 2 mg/kg over 1 h followed by 1 mg/kg/h until clamping of the umbilical cord. Peak levels should be drawn 30 min after the dose is completely infused; trough levels should be drawn 30 min prior to the dose. Calculate estimated CrCl based on SCr, age, and weight (in kg), or a formal CrCl can also be ordered, if time permits. By using Table 22–8 (page 635), select maintenance dose (as a percentage of the cho- sen loading dose) most appropriate for the renal function of patient based on the CrCl and dosing interval. IMMUNIZATION SCHEDULE (SEE TABLE 22–9, PAGE 636) Perform active immunization of normal infants and children based on Table 22–9 (page 636). In addition, perform TB tine test at 15–19 mo and again at the entry to school (4–6 y). Hep B = hepatitis B vaccine; DtaP = diphtheria and tetanus toxoids and acellular pertussis vaccine. Usually determined 1 min after birth and again at 5 min, the score is the sum of points gained on assessment of color, heart rate, reflex irritability, muscle tone, and respirations. BODY SURFACE AREA Adult Figure A–1 is a nomogram for determining the body surface area of an adult. Children Figure A–2 is a nomogram for determining the body surface area of children. CANCER SCREENING RECOMMENDATIONS Table A–3 lists the recommendations from the American Cancer Society for cancer screen- ing programs in average risk, asymptomatic people. These are the recommendations of the ACS and may not be supported by other organizations. EPIDEMIOLOGY BASICS Number of persons who have a disease at one point in time Prevalence = Number of persons at risk at that point (continued on page 645) 639 Copyright 2002 The McGraw-Hill Companies, Inc. Source: United States Department of Agriculture and United States Department of Health and Human Resources, 1990. The point of intersection on the body surface line gives the body surface area (in m2). The point of intersection on the body surface line gives the body surface area (in m2). Appendix 645 (continued from page 639) Number of new cases of a disease over a period of time Incidence = Number of persons at risk during that period Sensitivity = Proportion of subjects with the disease who have a positive test = (a/a + c) Specificity = Proportion of subjects without the disease who have a negative test = (d/b + d) Predictive value = Positive: likelihood of a positive test indicates disease = (a/a + b) = Negative: likelihood of a negative test indicates lack of disease = (d/c + d) Disease + (Present) (Absent) (+) a b Test ( ) GLASCOW COMA SCALE The Glasgow Coma Scale (EMV Scale) gives a fairly reliable, objective way to monitor changes in levels of consciousness. Household 1 teaspoon (tsp) = 5 mL 1 tablespoon (tbsp) = 15 mL 1 ounce (oz) = 30 mL 8 ounces (oz) = 1 cup = 240 mL 1 quart (qt) = 946 mL Apothecary 1 grain (gr) = 60 mg 30 gram (g) = 1 oz 1 g = 15 gr SI PREFIXES AND SYMBOLS Factor Prefix Symbol 109 giga G 106 mega M 103 kilo k 102 hecto h 101 deka da 10–1 deci d 10–2 centi c 10–3 milli m 10–6 micro µ 10–9 nano n 10–12 pico p 10–15 femto f PERFORMANCE STATUS SCALES Table A–5 lists the most common performance scales used clinically. RADIATION TERMINOLOGY Measure Old Term SI Unit Activity curie becquerel (Bq) Absorbed dose rad gray (Gy) TEMPERATURE CONVERSION Table A–6 gives information for converting temperature from the Fahrenheit (F) scale to the centigrade, or Celsius (C), scale and vice versa. Professor Emeritus Professor Department of Pharmacology Department of Pharmacology University of Kiel University of Kiel Germany Germany Klaus Mohr, M.

Physical quadriplegia buy discount ciplox 500 mg antibiotic resistance pictures, and chronic indwelling bladder examination revealed a purulent urethral discharge catheter ciplox 500mg fast delivery antibiotics for uti during lactation. Both the nontreponemal (D) Inhibits RNA synthesis by binding to the - (Venereal Disease Research Laboratory) and fluo- subunit of DNA-dependent RNA polymerase rescent treponemal antibody tests were positive. She linking of peptides in cell wall murein (peptidogly- could not recall signs or symptoms of primary or can) secondary syphilis in the past year. Parents brought their 3-year-old boy to the outpa- vious syphilis serology tests for purposes of compar- tient clinic because of a facial rash. Which of the following would be the best was one of several children sent home from day care treatment for the patient? Physical examination re- (A) Benzathine penicillin G vealed a normal, healthy boy with discrete erythe- (B) Doxycycline matous papular eruptions on his cheeks. A 26-year-old woman, a kindergarten teacher, had (A) Dapsone pharyngitis last year treated with ampicillin for 3 (B) Dicloxacillin days. The carbapenems (imipenem streptococcal test of a pharyngeal specimen is posi- and meropenem) and the monobactam (aztreonam) tive. The history defines a patient with type I hibits RNA synthesis by binding to the subunit of allergic hypersensitivity to penicillin. Amphotericin should avoid drugs in the penicillin class, including B inhibits fungal cell membrane integrity by bind- penicillin, nafcillin, oxacillin, cloxacillin, dicloxacillin, ing to ergosterols to create pores. Isoniazid inhibits ampicillin, amoxicillin, ticarcillin, piperacillin, and KasA, a -ketoacyl carrier protein synthetase, and mezlocillin. The causative organism with a history of type I allergic response to penicillin is either Streptococcus pyogenes (group A) or S. Aztreonam may be used safely in patients with his- Doxycycline is used to treat skin infections with tory of type I allergic response to penicillin. The patient is pregnant and has latent syphilis of (bacillary angiomatosis), Borrelia burgdorferi (Lyme indeterminate duration. Benzathine penicillin G is the drug of (acne vulgaris), Vibrio vulnificus and Vibrio damsela first choice for treating latent syphilis. The question does and tetracycline are alternatives treatments for non- not provide historical or epidemiological informa- pregnant patients with latent syphilis. Ketoconazole is Spectinomycin is not effective against syphilis; it is a used to treat fungal infections of the skin (tinea treatment for disseminated gonorrhea in patients capitis, tinea cruris, tinea corporis, tinea pedis, tinea who are allergic to cephalosporins. The patient has exudative pharyngitis, presum- Penciclovir is a treatment for herpes simplex virus ably secondary to group A streptococcus. Ureidopenicillins and beta- Other reasonable alternatives are benzathine peni- lactam/beta-lactamase inhibitor combinations. Meropenem: An updated re- quinolones (ciprofloxacin, ofloxacin, enoxacin, view of its use in the management of intra-abdomi- lomefloxacin, gatifloxacin), and spectinomycin. Amphotericin B is an antifungal drug, and tion of bacterial penicillin-binding proteins and isoniazid is an antimycobacterial drug. Prevention of drug access to bacterial tar- transpeptidase and block cross-linking of peptides gets: Permeability barriers and active efflux. Piperacillin/tazobactam: (topoisomerase) and interfere with bacterial DNA An updated review of its use in the treatment of transcription and replication. An evidence-based hibits bacterial protein synthesis and acts at the 50S analysis of the likelihood of penicillin allergy. Relatives accompanied the patient and mm3 (10% neutrophils, 60% lymphocytes, 30% described a 1-day history of fever and intermittent monocytes). What is the best empirical fatigue, anemia, thrombocytopenia, and antibiotic therapy for this patient? The physician also noted the exposure family members who attended the reunion reported to a food-borne pathogen associated with dairy transient febrile gastroenteritis. The epidemiological risk assessment physical examination in the emergency department suggested the need for empirical antibiotic therapy revealed a stuporous man with temperature 103. Belknap DRUG LIST GENERIC NAME PAGE GENERIC NAME PAGE Amikacin 538 Netilmicin 538 Gentamicin 538 Streptomycin 538 Kanamycin 538 Tobramycin 538 Neomycin 538 CHEMISTRY MECHANISM OF ANTIBACTERIAL ACTION Aminoglycosides are hydrophilic, polycationic, amine- containing carbohydrates that are usually composed of The antibacterial actions of the aminoglycosides in- three to five rings. They tively charged aminoglycoside binds to negatively are often secreted by these actinomycetes as mixtures charged sites on the outer bacterial membrane, thereby of closely related compounds.

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