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By H. Marlo. Pacific Lutheran University. 2018.

She asks the physician if she can take any vitamins to decrease her risk for conceiving a fetus with anencephaly buy aceon 8 mg with visa. It is most appropriate for the physician to recommend which of the following vitamins? A 38-year-old man comes to the physician because of a 6-month history of occasional episodes of chest tightness purchase aceon 8 mg line, wheezing purchase 2mg aceon visa, and cough cheap 4mg aceon. Which of the following agents is most appropriate to treat acute episodes in this patient? A new drug, Drug X, relieves pain by interacting with a specific receptor in the body. Drug X binds irreversibly to this receptor, resulting in a long duration of action. Which of the following types of bonds is most likely formed between Drug X and its receptor? A 49-year-old man with hypertension comes to the physician for a follow-up examination. At his last visit 2 months ago, his serum total cholesterol concentration was 320 mg/dL. The most appropriate pharmacotherapy for this patient is a drug that has which of the following mechanisms of action? A 17-year-old girl is brought to the physician by her parents 30 minutes after having a generalized tonic-clonic seizure while playing in a soccer game. This patient’s use of additional medications should be monitored because of which of the following changes in drug disposition after starting pharmacotherapy? A 14-year-old boy is brought to the physician for examination prior to participating on his school’s soccer team. A slit-lamp examination shows the presence of brownish rings in the cornea, surrounding the iris. The most appropriate treatment at this time is a drug with which of the following mechanisms of action? A 60-year-old woman comes to the physician because she recently was diagnosed with non-small cell lung carcinoma and she wants to discuss possible treatment options. She tells the physician that she is concerned about the possible adverse effects of chemotherapy. The physician says that serious toxicity caused by antineoplastic drugs is seen in the bone marrow. A 38-year-old woman with an 18-year history of type 1 diabetes mellitus and progressive renal failure is being considered for dialysis. Which of the following medications is most appropriate to treat the anemia in this patient? A 47-year-old woman is admitted to the hospital for treatment of pneumococcal pneumonia. Within 10 minutes of the administration of antimicrobial therapy, her respirations increase to 30/min, and blood pressure decreases to 80/40 mm Hg. Her antimicrobial therapy is changed to gentamicin only, and her condition continues to improve. Administration of which of the following types of drugs is most likely to cause a similar adverse reaction in this patient? A - 61 - Physiology Systems General Principles of Foundational Science 5%–10% Immune System 1%–5% Blood & Lymphoreticular System 5%–10% Nervous System & Special Senses 1%–5% Skin & Subcutaneous Tissue 1%–5% Musculoskeletal System 1%–5% Cardiovascular System 15%–20% Respiratory System 10%–15% Gastrointestinal System 10%–15% Renal & Urinary System 10%–15% Pregnancy, Childbirth, & the Puerperium 1%–5% Female Reproductive & Breast 1%–5% Male Reproductive 1%–5% Endocrine System 5%–10% Multisystem Processes & Disorders 5%–10% - 62 - 1. A hormone is known to activate phospholipase C with subsequent release of calcium from internal stores. The release of calcium most likely occurs as a result of an increase in the concentration of which of the following intracellular second messengers? A 28-year-old man with a history of intravenous drug use comes to the physician because of a 6-week history of fever, nonproductive cough, chills, and progressive shortness of breath. Physical examination shows a white, patchy, loosely adherent exudate on the buccal mucosa bilaterally. She is removed from the water within 1 minute, but dry clothing is not available, and she is still cold and wet 20 minutes later. Which of the following mechanisms helps maintain the patient’s core temperature during the period following her rescue?

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Norepinephrine Dopamine Yaba tablets containing methamphetamine Alertness Concentration Reward Energy Attention Pleasure Fight or flight Motivation Stimulation Drive Mood Cognitive Anxiety function Impulse Aggression Irritability Appetite Sex Memory Compulsion Serotonin 32 6 generic aceon 4mg online. Amphetamine and methamphetamine found in illicit markets are predominantly produced in clandestine laboratories purchase 4 mg aceon otc. This is primarily related to the ease of synthesis and the availability of a variety of precursors and methods that can be used for their manufacture buy discount aceon 8 mg on-line. For instance aceon 4mg amex, insuflation causes quick absorption into the bloodstream through the mucosa and so enables a more rapid onset of efects than oral consumption. Amphetamine is also Dexies Crystal meth used in the treatment of narcolepsy and as an appetite suppressant [15]. Speed Glass Sulph Go-ey Mechanism of action and resulting efects Uppers Ice Whizz Meth Amphetamine and methamphetamine afect neurotransmitters through a number Shabu of mechanisms, namely by inducing the release and preventing the reuptake of Speed dopamine, norepinephrine and, to a lesser extent, serotonin. If not treated immedi- ately, it may lead to severe illness • Serotonergic syndrome and potential death. However, the more pronounced efect on the serotonin neurotransmitter system leads to some diferences in their overall O pharmacological efects and is likely to be responsible for the empathogenic/ entactogenic efects of “ecstasy” group substances [16, 17]. Numerous benzodiazepines have been synthesized for Downers use as pharmaceuticals and they can vary considerably in their potency and in the Nerve pills onset and/or duration of action. In total, 35 benzodiazepines are currently subject Canasson rouge to international control under the Convention on Psychotropic Substances of 1971. Benzodiazepines encountered on the illicit market are primarily diverted from legitimate trade rather than synthesized in clandestine laboratories. It is located in the brain and Flunitrazepam (Rohypnol®) Intermediate (10-24 hours) spinal cord and helps regulate brain activity by reducing Temazepam (Restoril®) Short (<10 hours) neurotransmission, which slows down normal functions of the body and culminates in depressant efects. Depressant efects can also Commonly Route of result from blocking the action used forms administration of excitatory neurotransmitters (e. Desired efects Undesired acute efects Efects of chronic use • Relief of tension, mental • Reduced mental activity • Development of stress and anxiety and alertness, tolerance, psychological • Positive feelings of drowsiness, lethargy and and physical calmness, relaxation impairment of clarity of dependence and well-being in thought and judgement • Headache, irritability, anxious individuals may occur confusion, memory • Improved coping with • Potential impairment of impairment, depression, situational pressures or muscle coordination, insomnia and tremor psychological problems dizziness, low blood • Abrupt cessation may pressure, or fainting lead to withdrawal • Relief of side efects associated with • Diminished emotional syndrome which can over-stimulation or responses to external include insomnia, withdrawal of other stimuli, e. Their medical use today is limited to anti-epileptics or adjuncts to anaesthesia in surgical procedures Amobarbital and less commonly as anti-anxiety drugs. As with benzodiazepines, individual O barbiturate drugs difer in the onset and duration of action and potency. As a result, they have been largely replaced on both the licit and illicit market O by the benzodiazepines. Phenobarbital 41 Currently, twelve barbiturates are subject to international control under diferent Common street names schedules of the Convention on Psychotropic Substances of 1971. It was N withdrawn from the pharmaceutical market in many countries as a result of problems of abuse. Hallucinogens Hallucinogens are a diverse group of naturally occurring and synthetic drugs that induce distorted states of consciousness, perception, thinking and feeling, accompanied by diferent degrees of auditory or visual hallucinations. They are also referred to as “psychedelics”, which ultimately produce synaesthesia6 [20] and altered perceptions of reality. Hallucinogens fall into several chemically related groups, including tryptamine (e. Several tryptamines occur naturally in a variety of plants, fungi or animals, and have a history of use as hallucinogenic snufs or drinks, for example, in the Amazon forest and the Caribbean. Their efects are very dose dependent, and their duration of action can be extremely short (a few minutes), particularly when smoked. Mescaline can also be synthesized clandestinely and is under Schedule I of the Convention on Psychotropic O Substances of 1971. O Mescaline 50 Commonly Route of Common street names used forms administration Mescaline Mescal button Big chief Buttons Oral consumption (chewed, or Dried, sliced and chopped in the Mesc Peyote soaked in water to produce an form of a button (mescal button) Moon Peyotl intoxicating liquid) Ground button of the cactus, Oral consumption in capsules Powder, in capsules or tablets Inhalation Mechanism of action and resulting efects The mechanism of action of mescaline is similar to other hallucinogens and its efects are mediated through its interaction with serotonin receptors (e. Desired efects Undesired acute efects Common street names Divine flesh Sacred mushrooms Alterations in thought, mood and • Physical efects include muscle Hombrecitos Shrooms sensory perception weakness, drowsiness and lack of coordination Magic mushrooms Teonanácatl • Fatal poisoning may occur due to mistaken identity of mushrooms • Tolerance may develop 52 8. These substances are in general structurally similar to mescaline (a phenethylamine) and amphetamine/methamphetamine. Their predominant efects are hallucinatory, but some of the substances can also have stimulatory efects [23]. These substances vary in O N potency, pharmacological efects and toxicity, and as such errors in dosage may O have fatal consequences [25].

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It enters the thigh Clinical features lateral to the femoral to supply the hamstring muscles Common peroneal nerve injury: Drop foot aceon 8 mg with visa, both dorsi- in the thigh cheap aceon 4 mg without a prescription. Its two divisions order aceon 2mg amex, then supply all the ante- flexion of the ankle and eversion of the foot are weak but rior compartment muscles of the thigh purchase aceon 4mg without prescription, namely quadri- not plantarflexion (gastrocnemius and soleus are much ceps femoris, which is a powerful extensor of the knee, more powerful plantarflexors of the foot). Sensation is and the skin of the medial and anterior surfaces of the lost over the front and outer leg and the dorsum of the thigh. Superficial branch injury: Foot eversion is lost, but Clinical features dorsiflexion is intact. Sensation is lost over the outer Weakness of knee extension and numbness of the medial side of the leg and foot. Hip flexion is only slightly and a small area of sensory loss on the dorsum of the affected and adduction is preserved. Evacuationofahaematomaordirectsuturingorgrafting Compartment syndrome however requires emergency of a cut nerve. If the nerve is cut or torn, it should be Chapter 7: Hereditary and congenital disorders 345 repaired. Asplintcanbeworntokeepthefootinaneutral ahemiparesis (one side of the body, arm more than position. If nerve damage is permanent, tendon transfers leg), quadriparesis (both sides, arms more than legs) or arthrodesis of the foot can help. Although the lesion is non- Infants may present with poor sucking ability, increased progressive, the brain is still maturing and the clinical or decreased tone, abnormal reflexes, convulsions or picture is therefore not static. The characteristic Aetiology features described above may not present until later in The precise cause of the damage may be difficult to iden- childhood. About 10–15% acquire the lesion at birth, and a similar proportion occur af- Complications ter the neonatal period. Causes Mental retardation in 60%, epilepsy in 30%, visual im- include: pairment in 20%, hearing loss in 20%, orthopaedic de- r Cerebral malformation. Management r Kernicterus (severe jaundice leading to brain damage Multidisciplinary assessment and supportive treatment: and seizures in the newborn). The features thopaedic surgery with post operative physiotherapy are clasp like hypertonia, brisk reflexes, ankle clonus r Soft tissue procedures to improve muscle balance and extensor plantar responses. The condition may be by re-routing or dividing tendons and muscles 346 Chapter 7: Nervous system r Bone operations to correct position and stabilise Epilepsy or mental retardation occur in up to 5% of pa- joints tients; 30–40% of patients develop a scoliosis which may 5 Neurosurgical techniques are occasionally used for se- require surgical intervention vere deforming spasticity to reduce spasm. Management Surgery for cosmetic reasons and to correct bone defor- Neurofibromatosis type 1 mity. Definition An inherited disorder characterised by multiple skin Neurofibromatosis type 2 neurofibromas,alsocalledVonRecklinghausen’sdisease. Definition Incidence Autosomal dominant condition characterised by the de- 1in3500 making it the most common autosomal dom- velopment of bilateral acoustic neuromas. It has complete An autosomal dominant condition caused by a muta- penetrance, but variable expression. This pro- tein acts as a tumour suppressor gene by an unknown Clinical features mechanism. Hearing loss may be sudden, vertigo is rare, Complications patientswithlargetumoursexperienceheadaches,visual There is an increased rate of benign and malignant disturbances, and ataxia. Plexiform neu- rofibromas may undergo malignant change (called Complications schwannomas or neurofibrosarcomas). Note that cuta- Patients also have a tendency to form other brain tu- neous neurofibromas do not undergo malignant change. Chapter 7: Hereditary and congenital disorders 347 Investigations Complications Pure tone audiometry reveals unilateral or asymmetrical Cardiac failure, arrhythmias including Wolf Parkinson sensorineural hearing loss, electric response audiometry White syndrome, renal cell carcinoma in less than 1%, shows characteristic prolonged I–V latency differentiat- liver angiomas (25% of patients but rarely symptomatic) ing the hearing loss from cochlear deafness. Renal ultrasound and echocardiogram may be Surgical resection is the preferred treatment via required. Management Annual review is recommended to assess seizure control and screen for development of new symptoms or com- plications.

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When the data were recalculated for men and women or whites and blacks discount 4 mg aceon free shipping, the results showed that men were referred more often (90 cheap aceon 2mg otc. All of the groups were equal in size and the out- come was not rare in the general population buy aceon 4 mg line. Second cheap aceon 8mg amex, the study was a clinical trial with the risk factors of race and gender being the independent variable and the refer- ral for catheterization, the dependent variable. Not only is the risk much smaller than reported in the news, but it approaches the null point suggesting lack of clinical significance or the possi- bility of a type I error. Ultimately, the original report using odds ratios led to a distortion in reporting of the study by the media. The effect of race and sex on physicians’ recom- mendations for cardiac catheterization. Misunderstandings about the effects of race and sex on physicians’ referrals for cardiac catheterization. Did the risk of the outcome increase with the quantity or duration of the exposure? Were patients similar for demo- graphics, severity, co-morbidity, and other prognostic factors? There is an excellent article by Hanley and Lippman- Hand that shows how to handle this eventuality. The maximum number of events that can be expected to occur when none have been observed is 3/n. One could expect to see as many as one adverse event in every 5 patients and still have come up with no events in the 14 patients in the initial study. The probability of no adverse events in one patient is 1 minus the probability of at least one adverse event in one patient. Another way of writing this is p(no adverse event in one patient) = 1–p(at least one adverse event in one patient). We can continue to reduce the actual adverse event rate to 1:10, and using the same process we get p(no adverse events in 14 patients) = (0. For example, studies of head-injured patients to date have shown that none of the 2700 low-risk patients, those with laceration only or bump without loss of consciousness, headache, vomiting, or change in neurological status, had any intracranial bleeding or swelling. Therefore, the largest risk of intracranial injury in these low-risk patients would be 3/2700 = 1/900 = 0. General observations on the nature of risk Most people don’t know how to make reasonable judgments about the nature of risk, even in terms of risks that they know they are exposed to. This was articu- lated in 1662 by the Port Royal monks in their treatise about the nature of risk. There 154 Essential Evidence-Based Medicine Table 13. People are more likely to risk a poor outcome if due to voluntary action rather than imposed action. They are likely to smoke and accept the associated risks because they think it is their choice rather than an addiction. Similarly, they will accept risks that they feel they have control over rather than risks controlled by others. Because of this, people are much more likely to be very upset when they find out that their medication causes a very uncommon, but previously known, side effect. One only has to read the newspapers to know that there are more stories on the front page about catastrophic accidents like plane crashes or fatal automo- bile accidents than minor automobile accidents. Patients are more willing to accept the risk of death from cancer or sudden cardiac death than death due to unforeseen complications of routine surgery. If there is a clear benefit to avoiding a particular risk, for example that one shouldn’t drink poison, patients are more likely to accept a bad outcome if they engage in that risky behavior.

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Characterised by swelling of the throat and tongue and a foamy discharge from the mouth purchase 4 mg aceon with amex. Recommended action if Contact and seek assistance from appropriate animal health professionals purchase aceon 2mg with amex. Diagnosis In animals safe 8mg aceon, anthrax is diagnosed using samples taken from superficial blood vessels or natural openings of dead animals and by examining blood smears on a microscope slide discount aceon 4mg on-line. Artificial media can be used to grow the micro- organism from a dead animal, hides, skin, wool or soil. Livestock In areas prone to anthrax a preventive strategy should be adopted involving thorough surveillance and annual vaccination of susceptible animals (usually cattle, sheep and goats). Vaccination is normally carried out 2-4 weeks before the onset of the known period of outbreaks. Any animals showing signs of anthrax must be treated and not used for food until several months after the completion of treatment. The live Sterne vaccine is effective but there is some concern over its ecological effect and possible pathogenicity in some species. Antibiotic treatment (penicillin or tetracycline) can be an option if animals show clinical signs of anthrax but often it is not a practical or feasible method of control. Culling of infected animals and removal of diseased carcases reduces contamination sources. When this is not possible, place the unopened carcases in heavy duty black plastic bags which are sealed and leave in the heat. Carcases infected with anthrax should not be moved, instead they should be disposed of using appropriate methods on site to prevent further environmental contamination. Above all, be alert, vigilant and maintain surveillance particularly during high risk times. Anthrax is a seasonal disease which may reoccur the following year and being prepared for potential outbreaks is vital. This includes early carcase detection along with minimising environmental contamination through proper carcase disposal and decontamination Wildlife species should be monitored for any interaction with livestock (e. Burning surrounding areas of bush to kill spores and disperse unaffected wildlife. Trained personnel and advisory information are required to effectively manage the control of an outbreak and attempts should be made to identify the source and mode of transmission in order to inform the response team. Prevention of anthrax in wildlife depends on recognising risk factors such as seasonality, density of susceptible hosts, rainfall patterns, history, soil type and so on (Sally MacKenzie). Wash hands with soap and water to remove the vast majority of spores and keep fingers away from the mouth and nose. Treat wounds or scratches as soon as possible to reduce cutaneous infection by spore contamination. In the presence of acute respiratory infections or other debilitation, be on alert for "flu-like" symptoms as pulmonary infections are most likely. In the unlikely event of contracting anthrax, treatment is highly effective with simple penicillin, erythromycin G, tetracycline and a variety of other antibiotics. The impacts can be greater where protected areas are smaller and where losses are proportionally greater. Outbreaks can put endangered species at risk of mass die-offs and rapid population decline. A number of significant, high mortality anthrax epidemics in wildlife have occurred in Africa over the last decades. These have included: thousands of hippopotamuses on the Zambesi; in Queen Elizabeth National Park, Uganda; and affecting a variety of species in Zimbabwe, Ethiopia, Tanzania; and endangered Grevy’s zebra Equus grevyi in Kenya. Some protected areas and other environments have recurrent infection where the epidemiology is now well understood, e. Some of these outbreaks are a result of spillover of infection from livestock epidemics especially where there is a breakdown in livestock vaccination.

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