睿学教育Wisdome Education

Adam Greenbaum, MD

• Associate Director, Cardiac
• Catheterization Laboratory
• Henry Ford Hospital
• Assistant Professor of Medicine
• Wayne State University
• Detroit, Michigan

Zebeta dosages: 10 mg, 5 mg
Zebeta packs: 60 pills, 90 pills, 120 pills, 180 pills, 270 pills, 360 pills

Generic 5 mg zebeta free shipping

Oculinum) injected intramuscularly produces func- tional denervation that lasts about 3 months blood pressure upon waking up buy zebeta 5 mg without a prescription. Adverse effects range Guanidine from diplopia and irritation with blepharospasm to Guanidine hydrochloride is the drug of choice in the muscle weakness with dystonias blood pressure top number high order zebeta line. One gram of crystalline toxin adequately dispersed can Its ability to enhance transmitter release may involve a kill a population of a million people high blood pressure medication z buy discount zebeta 5 mg on-line, so its use in bioter- block of K channels and prolongation of the nerve ac- rorism is a possibility. Agents that have a similar effect include local limited by the ability or inability to aerosolize the toxin anesthetics, barbiturates, and phencyclidine. Contaminating the water or duce the flow of ions and shorten the duration of time food supply is also a possibility, although the toxin is the channel is open. Although both are activated by risk, but prophylactic administration of trivalent equine nicotine, each is blocked by a different antagonist (e. It involves an antibody response against part of hyporeflexia, and autonomic dysfunction. How- and weakness due to diminished postjunctional re- ever, particles at the active zones of nerve terminals that sponse. Thymectomy is a good option for thesia, gastrointestinal distress, renal tubular necrosis, patients under 50 years of age. The most serious effect is bone agents, such as corticosteroids and possibly azathioprine marrow depression, which is dose-related and poten- or cyclosporine A, are also effective. Corticosteroids and plasmapheresis may also be of some benefit, whereas anticholinesterase agents are only marginally effective. The ically occlude the open channel, and cations are allowed complex is a cylindrical unit about 8 nm in diameter that to flow and depolarize the end plate. Neuromuscular block with succinylcholine occurs Histrionicotoxin, obtained from a Panamanian frog, by two sequential events. Apart from its rapid onset and brief action, succinyl- this is called phase I, or depolarization block. Succinylcholine also causes prolonged contraction of the diseased muscles of patients with myotonia or Absorption, Metabolism, and Excretion amyotrophic lateral sclerosis. Succinylcholine is given systemically because the mole- Succinylcholine-induced hyperkalemia may lead to cardiac arrhythmia and arrest when plasma K reaches cule is charged and does not easily cross membranes. It is rapidly hydrolyzed by plasma cholinesterase to succinyl- 7 and 10 mM, respectively. Be- tate a fulminant attack of malignant hyperthermia in cause plasma cholinesterase is synthesized in the liver, susceptible individuals (not to be confused with neu- neuromuscular block may be prolonged in patients with roleptic malignant hyperpyrexia, which involves do- liver disease. The response to succinylcholine of cooling the body and administering oxygen and may also be prolonged in individuals with a genetic defect dantrolene sodium (discussed later). In this case, the enzyme has Nondepolarizing Blockers: d-Tubocurarine, a decreased affinity for substrates such as succinylcholine Atracurium, Mivacurium, Pancuronium, that can be measured by the dibucaine test. Vecuronium, Rocuronium, and Rapacuronium Pharmacological Actions Mechanism of Action Succinylcholine acts primarily at the skeletal neuromus- With the exception of succinylcholine, all neuromuscular cular junction and has little effect at autonomic ganglia blocking agents are nondepolarizing. Succinylcholine has no the prototype for this group is d-tubocurarine, an alka- direct action on the uterus or other smooth muscle loid used as a South American arrow poison. It may, however, release histamine nary ammonium) separated by a “thick” organic moiety from mast cells. In hu- mans, d-tubocurarine has a moderate onset of action (3- Other Nondepolarizing Blockers 4 minutes) followed by progressive flaccid paralysis. The of Importance head and neck muscles are affected initially, then the limb muscles, and finally the muscles of respiration. Atracurium besylate (Tracrium) is a benzylisoquinolin- Recovery from paralysis is in the reverse order. Its actions are simi- lar to those of d-tubocurarine, but its duration of action Clinical Uses is shorter (45 minutes) because of spontaneous degra- dation of the molecule (Hofmann elimination). Because Nondepolarizing blockers are used to relax skeletal of this, atracurium is useful in patients with low or atyp- muscle for surgical procedures, to prevent dislocations ical plasma cholinesterase and in patients with renal or and fractures associated with electroconvulsive therapy, hepatic impairment. They do not Mivacurium chloride (Mivacron) is a newer agent produce anesthesia or analgesia. The primary the degree of blockade can be influenced by body mechanism of inactivation is hydrolysis by plasma pH and electrolyte balance.

Purchase 10 mg zebeta with amex

Doctors sometimes prescribe higher doses of birth control pills to use as a “morning after” pill to be taken up to 72 hours after unprotected intercourse to prevent fertilization and pregnancy hypertension from stress discount 5 mg zebeta otc. Side Efects: Nausea blood pressure rates chart buy 10 mg zebeta fast delivery, edema hypertension kidney damage generic 10 mg zebeta with mastercard, weight gain or loss, breakthrough bleeding, mood changes, libido changes, migraine headaches, severe depression, blurry vision, or loss of vision. Contraindications or Cautions: rombophlebitis or thromboembolic disorders, history of cerebrovascular accident, breast cancer or estrogen-dependent malignancy, pregnant and lactating women, liver disease, smoking, hypertension, diabetes, and gallbladder disease. Examples: Ovral, Ovcon, Norinyl, Loestrin, Ortho-Novum, Tri-Norinyl, Depo-Provera, Nortrel, and Paragard. Lupron and depot These are used as antineoplastic drugs to stop the growth of hormone-dependent tumors. Side Efects: Hot fashes, headaches, insomnia, mood swings, nasal congestion, or weight gain or loss. Fertility medication Fertility drugs remain the primary treatment for women with ovulation disorders and are used alone or in combination with assisted reproductive techniques such as in vitro fertilization. If Clomid on its own is unsuccessful, then injectable hormones to stimulate ovulation are sometimes recommended. Contraindications or Cautions: Ovarian cysts, endometrial cancer; liver, thyroid, adrenal disease. Example: Clomid, Serophene, Novarel, Follistim, Pergonal, Factrel, Lupron, Antagon. Often the physician orders a broad-spectrum antibiotic while waiting for the results of culture and sensitivity tests. This can sometimes cause additional problems if the organism is resistant to the antibiotic, or if it turns out that the pathogen is not bacterial but viral. Because antibiotics do not discriminate between good and bad bacteria, taking antibiotics when the infection is really viral can often compromise the immune system and inhibit the client’s ability to heal from the organism. In addition, certain bacteria that are immune to specifc antibiotics can pass that immunity to other types of bacteria. Overuse of antibiotics has led to resistant strains of bacteria that now pose a major health threat all over the world. As antibiotic resistance increases, these drugs are not as efective as they used to be and treating infections becomes more difcult. Relevance to the Massage Therapist Persons taking anti-infective agents have a compromised immune system. Care must be taken by the massage therapist when treating immunocompromised clients so that they are not exposed to any infections, colds, or drafts. Conversely, if the client is ill, it might be advisable to reschedule the appointment if the client is in the contagious stage of the disease, rather than expose the therapist and other clients to the pathogens, or the client or therapist can wear a mask. If there is inclement weather, the client should be instructed to reschedule rather than be exposed to conditions that can exacerbate the illness. Massage can be very helpful for treating constipation or diarrhea, nausea, and abdominal bloating, as well as calming the client. Of course, universal precautions should always be followed, especially when treating anyone sufering from pathogens. This infection happens when a person takes antibiotics that kill of the healthy fora of the colon. Many antibiotics that at one time were in the forefront of the treatment of bacterial infections are no longer efective against these pathogens. The development of resistant bacteria is why antibiotics should never be used to treat the common cold, which is generally caused by a virus, even though patients, in their ignorance, often demand antibiotics from their physician. Side Effects of antibiotics Although there are numerous antibiotics, the side efects are generally of three types: 1. Sometimes a severe reaction, such as anaphylaxis, can follow a mild reaction and can be life threatening. Anaphylaxis is an allergic hypersensitivity reaction of the body to a foreign protein or drug.

Diseases

• Hallucinogen persisting perception disorder
• Aseptic meningitis
• Mental retardation short stature scoliosis
• MODY syndrome
• Varadi Papp syndrome
• Nerve sheath neoplasm
• Waardenburg syndrome type 2B

Discount zebeta 5 mg otc

He had had an angioplasty to an isolated Digoxin has a steep dose–response curve and a narrow thera- atheromatous lesion in the left anterior descending coron- peutic range heart attack chords zebeta 5 mg buy with visa, and clinically important interactions are com- ary artery two years previously arrhythmia online cheap zebeta 10 mg free shipping, since when he had not had angina blood pressure chart by age canada zebeta 10 mg buy otc. Pharmacokinetic interactions droflumethiazide for his hypertension and takes meclofena- with digoxin include combined pharmacokinetic effects involv- mate regularly to prevent recurrences of his gout. He ing displacement from tissue-binding sites and reduced renal disregarded his cardiologist’s advice to take aspirin because elimination (e. On examination, he has a regular pulse of 88 beats/minute, blood pressure of 160/98 Pharmacodynamic interactions are also important. In mmHg, a 4–5cm raised jugular venous pressure, mild pretib- particular, drugs that cause hypokalaemia (e. Routine biochemistry tests are β-agonists, glucocorticoids) predispose to digoxin toxicity by unremarkable except for a serum urate level of 0. These (a) Digitalization increase cardiac output and may bring some symptomatic (b) Intravenous furosemide benefit, but they worsen survival. New England Journal of Medicine 1998; 339: (e) Hold the bendroflumethiazide temporarily and start 387–95. Managing hyperkalemia caused by inhibitors of the Comment renin–angiotensin–aldosterone system. New England Journal of the aetiology of the heart failure in this case is uncertain. New England Journal of Medicine corrected, this could improve the blood pressure, dyslipi- 1999; 341: 577–85. Mechanisms of disease – aldosterone in congestive heart done immediately this is likely to precipitate an acute failure. Treatment with a fibrate would be useful for this pattern of dyslipi- daemia, but only after establishing that it was not alcohol- induced. If patho- • Second degree: There are two types, namely Mobitz I, in logical, treatment is directed at the underlying cause. This is common in athletes, in young the importance of first- and second-degree block is that healthy individuals especially if they are physically fit, and either may presage complete (third-degree) heart block. Severe cerebral underperfusion with if it causes or threatens haemodynamic compromise. Ventricular filling is consequently inad- to failure of conduction in one or other bundle and ‘aberrant’ equate and cardiac output falls. The method of treating atrial conduction with broad complexes because of the rate-dependent fibrillation is either to convert it to sinus rhythm, or to slow bundle-branch block. In an acutely ill patient, consider the possible immediate cause of the rhythm disturbance. The cardiogram usually shows a example from a distended bladder in a stuporose patient). Multifocal ectopics does not necessarily improve the prognosis – (ectopic beats of varying morphology, arising from more anti-dysrhythmic drugs can themselves cause than one focus) are likely to be pathological. Always think carefully before dysrhythmic drug to use in a particular patient remains largely prescribing one. If the patient is acutely ill on account of a cardiac some of the most clinically effective drugs used to treat certain dysrhythmia, the most appropriate treatment is almost dysrhythmias, some of which are listed in Table 32. Remember that several anti-dysrhythmic drugs can the European Resuscitation Council provides guidelines for themselves cause dysrhythmias and shorten life. Largely Diltiazem voltage-dependent Ca2 conductance superseded by adenosine for treating acute attacks. Digoxin (rapid atrial fibrillation) Shout for help Atropine (symptomatic sinus bradycardia) Adenosine (supraventricular tachycardia) Open airway Adrenaline (cardiac arrest) Calcium chloride (ventricular tachycardia caused by Not breathing normally? When a person is found to have collapsed, make a quick check to ensure that no live power lines are in the immediate vicin- Precordial thump if ity. Otherwise roll them on their back (on a firm surface if possible) and loosen the clothing around the throat. Tilt the head and lift the chin, and sweep an index finger 2 breaths through the mouth to clear any obstruction (e. If the patient is not breathing spontaneously, start mouth- Continue until breathing and pulse restored of emergency services arrive to-mouth (or, if available, mouth-to-mask) ventilation. Hypovolaemia Cardiac tamponade (Redrawn with permission from the Hypo/hyperkalaemia/other metabolic disturbance Toxins European Resuscitation Council Hypothermia Thrombosis (coronary or pulmonary) Guidelines, 2005. Check for a pulse by feeling carefully for the carotid or femoral artery before diagnosing cardiac arrest.

Buy cheapest zebeta

A half-life value can be readily determined for most drugs by administering a dose of the drug to a subject heart attack quiz questions cheapest zebeta, taking blood samples at various time intervals and then assaying the samples pulse pressure 2013 zebeta 5 mg buy fast delivery. In most of the cases the rate of disappearance of a drug from the body is reflected in the rate of lowering of its plasma concentration following a single intravenous dose blood pressure chart jnc purchase zebeta 10 mg line, the plasma concentration of the drug is focused to fall exponentially. With drugs whose elimination is exponential, the biological half – life is independent of the dose, the route of administration and the plasma concentration. Order of kinetics Drugs are used for the treatment of diseases but the modes of administration of drugs are different. For example atenolol is administered once daily where as paracetamol needs 3-4 times administration daily. Morphine is more effective in intramuscular route, and insulin is in subcutaneous route. Drugs usually follow two processes for their phamacokinetic behaviour in the body. The rate at which absorption, distribution, metabolism and excretion occur are proportional to the concentration of drugs i. Zero order kinetic: It is independent of the amount of drug present at the particular sites of drug absorption or elimination. On repeated administration of drug after certain stage it goes on accumulating in the body and leads to toxic reactions. Steady state plasma concentration: When a drug dose is given repeatedly over a given period, a steady state is eventually reached, at which point the amount of drug absorbed is in equilibrium with that eliminated from the body. For example a drug with half life of 6 hours will be expected to be at steady state after more than 24 hours of administration. The pattern of drug accumulation during repeated administration of drug at intervals equal to its elimination half-life. For some drugs, the effects are difficult to measure, toxicity and lack of efficacy are both potential dangers, and/or the therapeutic window is narrow. In these circumstances doses must be adjusted carefully to a desired steady- state concentration by giving loading and maintenance doses. Loading dose: the loading dose is one or a series of doses that may be given at the onset of therapy with the aim of achieving the target concentration rapidly. Maintenance dose: To maintain the chosen steady-state or target concentration, the rate of drug administration is adjusted such that the rate of input equals to rate of loss. Factors modifying the dosage and action of drugs : Individuals differ both in the degree and the character of the response that a drug may elicit and therefore the optimum dose of a drug which produces the desired therapeutic effect varies from person to person. Drug intolerance: It is a quantitative deviation from the anticipated response to a given dose of a drug. Sex difference: Special care should be exercised when drugs are administrated during menstruation, pregnancy and lactation. Drugs which may stimulate the uterine smooth muscle, are contraindicated during pregnancy. Further, many drugs administered to mother are capable of crossing the placenta and affecting the foetus. Teratogenicity means congenital malformation i) Drugs known to produce teratogenicity. Therefore the drugs, which are excreted in the milk and harm the infant health should be, avoided by breast-feeding mothers. Body Weight: the average dose is mentioned either in terms of mg per kg body weight or as the total single dose for an adult weighing between 50-100kg. However, dose expressed in this fashion may not apply in cases of excessively obese individuals or those suffering from edema, or dehydration nutritional factors can sometimes alter drug metabolizing capacity and this should be kept in mind in malnourished patients. Thus gastric emptying is prolonged and the gastric pH fluctuates in neonates and infant, further the liver capacity to metabolize drugs is low, renal function is less developed and the proportion of body water is higher in the newborn and the neonates. With a few exceptions, drugs are more active and more toxic in the new born than the adults. Like children, old people also present problems in dosage adjustment and this may vary widely with different people. The metabolism of drugs may diminish in the elderly and the renal function declines with age. Elderly are sensitive to the drugs like hypnotics, tranquilizers, phenylbutazone, diazepam, pethidine, etc.

Zebeta 10 mg purchase without prescription

British of spore-specifc and vegetative-specifc murine monoclonal Veterinary Journal arteria magna order zebeta 5 mg with visa, 111:215–217 heart attack recovery diet purchase zebeta paypal. Inactivation of microorganisms in cine human reactogenicity and immunogenicity clinical trial arteria ethmoidalis anterior cheap zebeta 5 mg amex. War and Strategic Studies Seminar Series, university Logan nA, Berkeley rC (1981). London, study of one hundred consecutive cases; their clinical features Academic Press (105–140). Letters in Applied Microbiology, assessing the regional distribution of anthrax in india. Bacillus anthracis lethal toxin induces tnF-alpha-independent hypoxia-mediated tox- McKendrick dr (1980). Journal of Applied Microbiology, ity testing of Bacillus anthracis: comparison of results 87:256–260. Anthrax: transmission of infection by carbon dioxide in capsule formation by Bacillus anthracis. Bulletin of the Louisiana State University, Journal of General Microbiology, 34:153–164. Blood-sucking insects as transmit- and the manner of cell-wall formation in Bacillus anthra- ters of anthrax or charbon. Effects of the Bacillus anthracis staining reaction of anthrax blood with methylene blue. Molecular els in the Sudan with reference to the disease in the Microbiology, 42:1189–1198. Sporulation, germina- tective antigen antibody completely protects rabbits tion and outgrowth. Serologic testing for anthrax vidual toxin components to virulence of Bacillus anthra- antibodies in workers in a goat hair processing mill. Infection and Immunity, skin test with the russian allergen “Anthraxin” in a 47:306–310. Onderstepoort Journal of Veterinary Research, antibodies against spore antigens of Bacillus anthracis. Manual of diagnostic tests and vaccines for ter- wild animals and the control of anthrax epizootics restrial animals. Anthrax prophylaxis by antibiotic resistant Sti-Ar in combination with urgent antibiotic therapy. Beiträge zur Land- und Forstwirtschaft in den Tropen und Medical Services Journal, Canada, 20:531–540. Topley and Wilson’s microbiology and microbial infec- oral immunization of wildlife against anthrax. Emerging tative enzyme-linked immunosorbent assay for human Infectious Diseases, 10:1887–1888. Bacillus anthracis multiplica- anthracis Ames and comparison to closely related bacte- tion, persistence and genetic exchange in the rhizosphere of ria. Anthrax derived from donors vaccinated with anthrax vaccine post-vaccinal cell-mediated immunity in humans: adsorbed. A bacteriolytic ryngeal anthrax: an unusual manifestation of human agent that detects and kills Bacillus anthracis. Serological studies of esis protein 2 functions as an anthrax toxin recep- patients with cutaneous and oral-oropharyngeal tor. Proceedings of the National Academy of Sciences, 100: anthrax from northern thailand. Brucellosis, anthrax, pseudo- tuberculosis, tetanus, vibrio infection, avian vibrionic Sterne M (1966). Antimicrobial susceptibility minant protein and other proteins of the Bacillus anthra- of Bacillus anthracis against macrolides. Their dormancy chromosomally-encoded factors in virulence of Bacillus and germination. European Journal Onderstepoort Journal of Veterinary Science and Animal of Clinical Microbiology and Infectious Diseases, 21:697. Onderstepoort Journal of Veterinary Science peptide synthesis by Bacillus anthracis and Bacillus sub- and Animal Industry, 9:49–67.

Buy 10 mg zebeta mastercard

Beneath the synovium are sheets of histiocytes pulse pressure 71 5 mg zebeta order with amex, xanthoma cells blood pressure medication blue pill buy cheap zebeta 5 mg online, hemosiderin-laden macrophages heart attack demi lovato chords purchase zebeta australia, and multinucleated giant cells, all in variable proportions. The wrist is the most common location; other sites include the metatarsophalangeal joints and the ankle and knee joints. When the lesions are located in unusual sites, the diagnosis is often less obvious. It must be emphasized that all masses are not ganglia and should be critically evaluated. Excision is undertaken, and the correct diag- nosis is made only after extensive soft tissue contamination has occurred. These heterogeneous groups of tumors arise specifically from the support- ing extraskeletal mesenchymal tissues of the body, that is, muscle, fascia, connective tissues, fibrous tissues, and fat. The surgical grading system developed by the Musculoskeletal Tumor Society applies to both bone sarcomas and soft tissue sarcomas. Clinical Findings and Physical Examination Soft tissue sarcomas are a disease of adulthood, occurring in persons between 30 and 60 years of age. The anterior thigh (quadriceps) is the most common com- partment, followed by the adductors and hamstrings. Any adult pre- senting with an extremity mass must be presumed to have a sarcoma until proved otherwise and should be further evaluated. Unfortunately, a presumptive diagnosis of lipoma, ganglion, hematoma, or muscle tear is often made, thereby delaying definitive evaluation and treatment. Clinical photograph demonstrates a large soft tissue sarcoma of the posterior leg (soleus muscle). This patient underwent an open biopsy (not recommended) before referral for definitive diagnosis. Resection of this tumor will require complete excision of the biopsy tract and scar in addition to en bloc removal of the tumor. In half of all cases, wide local exci- sion is followed by local recurrence within 12 to 24 months, followed by pulmonary metastases resulting from hematogenous dissemination to the lungs. If distant metastases have not occurred, a 5-year salvage rate of 50% to 80% can be achieved. Decision-Making Process In order to accurately assess the diagnosis, stage, and grade of a suspected soft tissue tumor, rigid protocol should be followed to facilitate the deci- sion-making process as to what staging studies are required and when a biopsy should be performed. Figure 4-21 entitled Evaluation of Patient with a Soft-Tissue Mass succinctly describes the steps any clinician should follow for patients presenting with any type of soft tissue tumor. Individual grading is often difficult; in general, however, the extent of pleomorphism, atypia, mitosis, and necrosis correlates with the degree of malignancy. Notable exceptions are synovial sarcomas, which tend to behave like high-grade lesions even in the absence of these findings. The exact histogenesis of some soft tissue sarcomas often cannot be accurately defined, although grading can still be adequately performed. The surgical stage is determined by grade, location, and the presence or absence of pulmonary or lymphatic metastases, similar to other malignancies. Tumors of the Musculoskeletal System 157 Angiography Biplane angiography remains the standard technique for demonstrating the position of the major vessels. Bone Scans Bone scintigraphy is used to determine the relation of adjacent bony struc- tures to the tumor. Treatment of these patients requires a multimodal- ity approach, and successful management requires cooperation of the surgeon, chemotherapist, and radiation oncologist. The appropriate role of each modality is continuously changing but can be described in general as follows. This lesion has compressed the surrounding anatomical structures and has a heterogeneous appearance. Angiogram demonstrates an incredibly vascular soft tissue tumor arising in the thigh.

Eupatorium purpureum (Gravel Root). Zebeta.

• Are there safety concerns?
• How does Gravel Root work?
• What is Gravel Root?
• Urinary and kidney stones, arthritis-like pain, gout, malaria, and other conditions.
• Dosing considerations for Gravel Root.
• Are there any interactions with medications?

Source: http://www.rxlist.com/script/main/art.asp?articlekey=96662

Purchase zebeta in india

The amino- alarming increase in bacterial resistance to -lactam an- penicillins are effective against streptococci hypertension jnc 7 guidelines zebeta 10 mg order on-line, enterococci heart attack jack smack u blue buy zebeta american express, tibiotics heart attack nitroglycerin buy generic zebeta on-line. They can be subdivided and classified by their chemical structure and spectrum of activity. The struc- Natural Penicillins ture common to all penicillins is a -lactam ring fused with a thiazolidine nucleus (Fig. The antimicrobial Penicillin G (benzylpenicillin) is an acid-labile com- activity of penicillin resides in the -lactam ring. Consequently, penicillin G is most appropriate or -lactamases results in the formation of penicilloic for intramuscular or intravenous therapy. Addition of tributes to most tissues and serosa-lined cavities, al- various side chains (R) to the basic penicillin molecule though low concentrations appear in breast milk and 45 -Lactam Antibiotics 529 cerebrospinal fluid. When the meninges are inflamed, achievement of high antibiotic concentrations in the cerebrospinal fluid concentrations of penicillin G ap- cerebrospinal fluid. G is among the antibiotics of first choice for therapy of Penicillin G is excreted by the kidneys, with 90% of meningitis caused by susceptible S. In con- renal elimination occurring via tubular secretion and trast, a depot formulation of benzathine penicillin G 10% by glomerular filtration. Additional pharmacokinetic informa- spectrum of activity that is similar to that of penicillin tion can be found in Table 45. Penicillin V is used to treat streptococcal infections the clinical uses of penicillin G include endocarditis when oral therapy is appropriate and desirable. Depot intramuscular formulations of penicillin G, Nafcillin, oxacillin, cloxacillin, and dicloxacillin are more including procaine penicillin and benzathine penicillin, resistant to bacterial -lactamases than is penicillin G. Drug concentrations are detectable streptococci and most community-acquired penicilli- 24 hours after injection of procaine penicillin, and low nase-producing staphylococci. For historical reasons, staphylococci resistant mulations, practitioners must individualize treatment to to oxacillin or nafcillin are labeled methicillin resistant. These nosocomial pathogens are resistant in vitro to all For acute streptococcal meningitis, the goal is rapid -lactam antibiotics. Although both drugs undergo hepatic metabolism, gram-negative pathogens, including most anaerobes. Indications for nafcillin or oxacillin include used to treat pneumonias associated with cystic fibrosis severe staphylococcal infections like cellulitis, empyema, or mechanical ventilation. The drug For oral therapy, cloxacillin and dicloxacillin are achieves negligible carbenicillin concentrations in the comparable alternatives. Consequently, car- lism, and neither drug requires dose adjustment in pa- benicillin is not appropriate for patients with renal fail- tients with hepatic insufficiency. Indications for cloxacillin carbenicillin indanyl sodium is used to treat urinary or dicloxacillin include clinically mild staphylococcal in- tract infections caused by P. Aminopenicillins -Lactamase Inhibitor Combinations the pharmacokinetics of ampicillin and amoxicillin are Several formulations combine a -lactam antibiotic similar (Table 45. Both have good oral bioavailabil- with a -lactamase inhibitor (ampicillin-sulbactam ity; ampicillin is also bioavailable after intramuscular [Unasyn], ticarcillin-clavulanic acid [Timentin], piper- injection. Concomitant ingestion of food decreases acillin-tazobactam [Zosyn], and amoxicillin–clavulanic the bioavailability of ampicillin but not amoxicillin. All of the -lactamase inhibitor Consequently, oral doses of ampicillin should be given combinations except amoxicillin-clavulanic acid are on an empty stomach. Amoxicillin–clavulanic acid is concentrations in the cerebrospinal fluid only during in- the only combination drug with oral bioavailability. Therefore, ampicillin is effective treatment Elimination of the combination drugs occurs primarily for meningitis caused by Listeria monocytogenes. Therefore, all of the -lactamase in- Amoxicillin does not reach adequate concentrations in hibitor combinations require dose adjustments in pa- the central nervous system and is not appropriate for tients with renal insufficiency. Other indications for ampicillin in- lactamase inhibitor significantly broadens the spectrum clude serious infections like enterococcal endocarditis of antibacterial activity against -lactamase-producing and pneumonia caused by -lactamase-negative H. Amoxicillin oral therapy is appropriate for in treating infections with known or suspected mixed clinically acute nonserious bacterial infections like otitis bacterial flora, such as biliary infections, diabetic foot media and sinusitis. During their distribution phase, an- Obstetricians frequently prescribe ampicillin, penicillin tipseudomonal penicillins achieve only low concentra- G, and penicillin V because they are effective against tions in the cerebrospinal fluid.

Purchase 5 mg zebeta overnight delivery

Cinchonism A large single dose or higher Though effective in terminating an acute attack therapeutic doses taken for a few days produce of falciparum malaria atrial fibrillation treatment purchase cheap zebeta online, quinine may not prevent a syndrome called ‘cinchonism’ hypertension risk factors discount 5 mg zebeta mastercard. It consists of recrudescence—indicating incomplete clearance ringing in ears blood pressure higher in one arm zebeta 5 mg generic, nausea, vomiting (due to both of the parasites. The syndrome subsides base, and acts in an analogous manner to inhibit completely if the drug is stopped. Nocturnal muscle cramps: a single tablet of quinine (300 Few individuals are idiosyncratic/hypersensitive to mg) at bed time may benefit some, but not all cases, and quinine; cinchonism may appear after a single therapeutic risks may not justify use. During pregnancy it should be used only for life- Proguanil (Chloroguanide) threatening infection, with special care to prevent hypoglycaemia. Gametocytes exposed to proguanil are not killed Uses but may fail to develop properly in the mosquito. It acts more rapidly than It is partly metabolized and excreted in urine; t½ is 16–20 S/P alone. However, proguanil alone cannot be depended upon in nonimmune patients, (b) Complicated and severe malaria including particularly those with falciparum malaria, due to slow cerebral malaria: Quinine. Currently in India, proguanil has little role either in prophylaxis or in clinical cure drug of choice for cerebral malaria (falciparum of malaria. However, its combination with atovaquone (see malaria with impaired consciousness) and other p. However, recent countries as a fast-acting erythrocytic schizontocide for studies indicate that parenteral artemisinins are treatment of multidrug resistant falciparum malaria. Pyrimethamine Supportive treatment needed in cerebral It is a directly acting inhibitor of plasmoidal malaria is cooling for fever, i. Selective be employed as a clinical curative, particularly antimalarial action depends on high affinity for for P. In contrast to development of resistance to pyrimethamine is trimethoprim, it has very poor action on bacterial retarded. Pharmacokinetics Absorption of pyrimetha- Sulfadoxine and sulfamethopyrazine are ultra- mine from g. Certain organs long acting sulfonamides — attain low blood like liver, spleen, kidney and lungs concentrate concentrations, but are able to synergise with pyrimethamine. Prophylactic combination has the potential to cause serious concentrations remain in blood for 2 weeks. Adverse effects Pyrimethamine is relatively Therefore, use is restricted to single dose safe. Prophylactic use, needing blastic anaemia and granulocytopenia may occur multiple unsupervised doses is not approved. It with higher doses, especially in those with is contraindicated in infants and in individuals marginal folate stores. Compliance is good due to single Sulfonamides/dapsone are not particularly dose therapy and few acute side effects. In India, S/P sequential block (as in case of cotrimoxazole: resistance appears to be sporadic, except in the p. To contain further spread of S/P highly sensitive and haemolytic anaemia can resistance in India, the National drug policy on occur with 15–30 mg/day. Passage of dark Unlike other antimalarial drugs, primaquine is urine is an indication of haemolysis; primaquine a poor erythrocytic schizontocide: has weak should be promptly stopped if it occurs. It is highly active against Vivax malaria: the primary indication of gametocytes and hypnozoites. Relapse rate with 5 day primaquine treatment, Pharmacokinetics Primaquine is readily absorbed after oral ingestion. These can be minimized by taking the primaquine is given with the curative dose of drug with meals. Its metabolites is an alternative drug for Pneumocystis jiroveci pneumonia in are more potent in this regard. Clindamycin is a second choice drug to doxycycline of primaquine for effective relapse prevention is the biggest for adding to quinine or to artesunate for the treatment of hurdle in implementing antirelapse therapy. In contrast to doxycycline, it can be used in children Thus, it continues to act for weeks.

Generic zebeta 10 mg visa

With the exception of ni- Vascular Smooth Muscle Relaxation troglycerin prehypertension jnc 8 generic zebeta 5 mg visa, which is a liquid having a high vapor pres- sure blood pressure drop symptoms cheap zebeta 10 mg buy on-line, these compounds are solid at room temperature arrhythmia certification zebeta 10 mg purchase without prescription. Proposed mechanism by which nitroglycerin and the organic nitrates produce relaxation in vascular smooth muscle. Intact vascular endothelium is not necessary for result is vascular smooth muscle relaxation. Isosorbide dinitrate and pentaerythritol tetrani- to reduce myocardial ischemia is still controversial (Fig. Although nitroglycerin dilates both peripheral ca- these compounds have a slower onset and slightly pacitance and resistance vessels, the effect on the ve- longer duration of action than sublingually or buccally nous capacitance system predominates. This reduces ventricular diastolic vol- lized in the liver by the enzyme glutathione organic ume and pressure and shifts blood from the central to nitrate reductase. Although the metabolites of nitro- the peripheral compartments of the cardiovascular sys- glycerin are virtually inactive as vasodilators, two tem. These effects of nitroglycerin and other organic ni- metabolites of isosorbide dinitrate, isosorbide 2- trates are similar to those of mild phlebotomy, which mononitrate and isosorbide 5-mononitrate, do retain has been shown clinically to relieve acute anginal at- some vasodilator and antianginal activity. The latter esters and lar pressure and heart size results in a decrease in the their metabolites are water soluble and are readily ex- myocardial wall tension that is required to develop a creted by the kidney. Since blood flow to the subendo- cardium occurs primarily in diastole, the reduction in Pharmacological Actions left ventricular end diastolic pressure induced by nitro- There is little doubt concerning the effectiveness of ni- glycerin reduces extravascular compression around the troglycerin in the treatment of angina pectoris. This effect of nitro- pated physical or emotional stress, to prevent anginal glycerin on the distribution of coronary flow is impor- attacks. Sustained-release transdermal nitroglycerin has arteriolar smooth muscle, which leads to a decrease in been shown to deliver an antianginal effect for 2 to 4 both peripheral vascular resistance and aortic imped- hours following small doses and up to 24 hours after ance to left ventricular ejection (decreased afterload). The decreased resistance to ventricular ejection may Orally administered long-acting nitrates, including also reduce myocardial wall tension and oxygen re- nitroglycerin and various nitrate esters, nitroglycerin quirements. Considerable consequence of the reduction in cardiac preload and af- controversy surrounds the therapeutic use of the orally terload, and this results in a decrease in myocardial wall active agents because of their extensive first-pass me- tension. Oxygen supply to the subendocardium of isch- tabolism, and many clinicians consider them to be inef- emic areas is increased because extravascular compres- fective. More recently, however, numerous clinical in- sion around the subendocardial vessels is reduced. In vestigations have demonstrated the efficacy of addition, nitroglycerin may increase blood flow to isch- transdermal nitroglycerin, although tolerance can be a emic areas by its direct vasodilator effect on eccentric problem with prolonged transdermal exposure to nitro- epicardial coronary artery stenoses and collateral blood glycerin. The drugs and dosage forms of organic nitrates vessels and by its action to inhibit platelet aggregation. Nitrate-induced Late Preconditioning Tolerance and Dependence Recent findings suggest a potential new action of ni- Repeated and frequent exposure to organic nitrates is trates in the treatment of patients with ischemic heart accompanied by the development of tissue tolerance to disease. When nitroglycerin for- dermal nitroglycerin to conscious rabbits exerts a pro- mulations (e. The mechanism underlying the phe- persist in animals that displayed tolerance to the vascu- nomenon of nitrate tolerance is not as yet completely lar effects of nitroglycerin. Although this effect of nitro- understood but may be related to a nitrate-induced ox- glycerin has not been demonstrated unequivocally in idation of sulfhydryl groups via the formation of free patients receiving long-term nitrate therapy, these re- radicals, a decrease in the sensitivity of vascular smooth sults are provocative and may support new uses of ni- muscle soluble guanylate cyclase, or activation of the trates in patients or benefits that have until now re- renin–angiotensin system. To help avoid nitrate tolerance, clinicians should employ the smallest effective dose and administer the Clinical Uses compound infrequently. A daily nitrate-free period is Sublingual or buccal nitroglycerin is used either to ter- also recommended, particularly with use of the trans- minate an acute attack of angina or for short-term pre- dermal patches or ointment. Nitroglycerin is also the mainstay of the pharmacokinetic profile achieved with these sus- therapy for relieving acute coronary vasospasm because tained-release formulations should result in more effec- of its rapid onset of action. An ef- the antinitrate tolerance effect of this compound has fective dose of nitrate usually produces a fall in upright not been universally confirmed. Thus, further well- systolic blood pressure of 10 mm Hg and a reflex rise in controlled clinical studies are necessary to establish the heart rate of 10 beats per minute. Larger changes than effectiveness of sulfhydryl-containing compounds at these should be avoided, because a reduction in myo- preventing or reversing nitrate tolerance.

Generic zebeta 5 mg amex

For certain drugs hypertension 2 discount zebeta american express, studies in patients have provided infor- mation on the plasma concentration range that is safe and effective in treating specific diseases—the therapeu- tic range (Figure 1-7) blood pressure log chart pdf cheap zebeta amex. Below it blood pressure time of day order line zebeta, there is greater probability that the therapeutic benefits are not realized; above it, toxic effects may occur. No absolute boundaries divide subtherapeutic, thera- peutic, and toxic drug concentrations. A gray area usu- ally exists for most drugs in which these concentrations overlap due to variability in individual patient response. Numerous pharmacokinetic characteristics of a drug may result in variability in the plasma concentration achieved with a given dose when administered to vari- ous patients (Figure 1-8). The drug’s desired pharmacologic effects cannot be centration (x-axis, on a logarithmic scale) and its assessed readily by other simple means (e. This figure illustrates that as the concentration of theophylline increases, so does the intensity of the the value of therapeutic drug monitoring is limited response for some patients. There is no well-defined therapeutic plasma con- choose to follow in making drug dosing decisions by centration range. The formation of pharmacologically active metabo- the relationship of pharmacokinetic and pharmacody- lites of a drug complicates the application of plasma namic factors. Toxic effects may occur at unexpectedly low drug table, most drug concentrations are expressed as a unit concentrations as well as at high concentrations. This is important from a clinical amount of time that the drug is present at the site of action. The rate of bacterial killing by beta-lactams (the bac- terial cell would be considered the site of action) is usually determined by the length of time that the drug concentration remains above the minimal con- centration that inhibits bacterial growth. Copyright 1973, Massachusetts Medical Process for reaching dosage decisions with therapeutic drug Society. Relationship of pharmacokinetics and pharmacodynamics and factors that affect each. There are one-compartment, two-compart- the handling of a drug by the body can be very complex, ment, and multicompartment models. The compart- as several processes (such as absorption, distribution, ments do not represent a specific tissue or fluid but may metabolism, and elimination) work to alter drug concen- represent a group of similar tissues or fluids. Simplifications of body pro- models can be used to predict the time course of drug cesses are necessary to predict a drug’s behavior in the concentrations in the body (Figure 1-13). One way to make these simplifications is to apply Compartmental models are termed deterministic mathematical principles to the various processes. Com- evident when we examine one- and two-compartment partmental models are categorized by the number of models. Organs and tissues in which drug distribution is similar are grouped into one compartment. For example, Drug Range distribution into adipose tissue differs from distribution into renal tissue for most drugs. The compartment that includes blood (plasma), heart, lungs, liver, and kidneys is Phenobarbital 15–40 mg/L usually referred to as the central compartment or the Phenytoin 10–20 mg/L highly blood-perfused compartment (Figure 1-14). The arrow pointing into the box simply indicates that drug is put into that compartment. Another simplification of body processes concerns this model is the simplest because there is only one the expression of changes in the amount of drug in the compartment. The elimination rate describes the change in the that after a dose of drug is administered, it distributes amount of drug in the body due to drug elimination over instantaneously to all body areas. Some drugs do not distribute instantaneously to all the value of any model is determined by how well it parts of the body, however, even after intravenous predicts drug concentrations in fluids and tissues. Intravenous bolus dosing means ally, it is best to use the simplest model that accurately administering a dose of drug over a very short time predicts changes in drug concentrations over time. A common distribution pattern is for the drug one-compartment model is sufficient to predict plasma to distribute rapidly in the bloodstream and to the drug concentrations (and those concentrations are of most highly perfused organs, such as the liver and kidneys. This pattern of drug distribution may be els are often required to predict tissue drug concentrations. Drug moves back and forth between these compartments to main- tain equilibrium (Figure 1-16).

Zuben, 29 years: Even if the protective effect was three times higher in the high-risk group, there was no significant difference in the effect of raloxifene between those patients at low and those at high risk of breast cancer based on the Gail model (interaction p = 0. The adequacy of the clinical pharmacology program in the overall drug development plan of pembrolizumab is summarized in the table below. As a consequence, during the An additional mode of estrogen and progesterone luteal phase, estrogen production is reduced and andro- action is classified as nongenomic effects.

Will, 61 years: Unfortunately, given the difficulty of generalizing results from immortalized cell lines, the interpretation of these findings should await further experimentation. Although cattle and been attributed to the social cohort of dead animals sheep do exhibit different grazing behaviours, it is licking and sniffng around the carcass, and this was hard to defne the reason why one species is favoured the theory accepted in the large 1997 outbreak in over the other for infection in one area or property. Salicylic acid ointment is most frequently used either on its own or in com- bination with coal tar or dithranol.

Kalesch, 21 years: These factors are normally produced in the body also show promise as immunostimulators, principally as by monocytes, fibroblasts, and endothelial cells. Examples Patients with dyspnea or fatigue due to left ventricular systolic dysfunction; asymptomatic patients who are undergoing treatment for prior symptoms of heart failure. The Shoulder 343 A lag sign can be documented when the patient has a loss of active motion with preservation of passive motion.

Yespas, 55 years: The most relevant findings of phase 1 trials were the reduced body weight and total fat mass, the reduced fasting levels of insulin, leptin and T3 and the increased insulin sensitivity. This reduction of the enzyme sensitivity for calcium is probably due to an impairment of calmodulin-induced transition from a low to a high Ca2+ affinity form (Ca- roni and Carafoli 1981). The large posterior facet articulates with the corre- sponding articular facet on the inferior surface of the talus.

Lisk, 28 years: With the exception of the divisions, nerves originate from each level of the brachial plexus to innervate muscles of the shoulder girdle. Nasal administration of butorphanol decreases the Respiratory depression and increased heart rate, body onset of action to 15 minutes and decreases the first- temperature, and blood pressure accompany overdose. Human incidence • the age, sex and condition of animals may all naturally acquired human anthrax infection gener- infuence the incidence of the disease at any one ally results from contact with infected animals, or site.

Yorik, 62 years: Used as the initial induction regimen for serious fungal infections (immunosuppressed patients, severe fungal pneumonia, and cryptococcal meningitis with altered mental status). Ergot had been used by midwives to quicken Ketanserin is an effective antihypertensive, but α1 labour since the middle ages. The neurological manifestations can be either acute or subacute and usually develop within six weeks.

Irmak, 49 years: Although an initial debridement should aggressively remove necrotic or devitalized tissues, marginal tissue may be preserved to permit potential recovery. Alcohol • Chronic effects cirrhotic liver - fibrosis – Alcoholic hepatitis and of liver parenchyma cirrhosis and regenerative nodules of hepatocytes – Gastrointestinal bleeding due to portal hypertension, ulcers – Thiamine deficiency • Peripheral neuropathy • Wernicke-Korsakoff syndrome not uncommon – Encephalopathy – Cardiomyopathy – Pancreatitis – Cancer Alcohol no one knows what the threshold is • Effects in pregnancy – First trimester is particularly vulnerable period – Fetal alcohol syndrome: • Microcephaly • Growth retardation • Facial abnormalities • Mental deficiencies Outline • Pollution and poisons • Tobacco • Alcohol • Occupational exposures • Drugs – Therapeutic – Recreational • Physical agents Therapeutic drugs "I cannot stress to you how important this • Adverse drug reactions is to you" – Extremely common • Affect about 10% of patients admitted to the hospital • 1 in 10 of these is fatal – Most drugs have known side effects list of big ones - "if you feel like memorizing stuff. If one remembers that a move- ment is created by a force acting over a distance, it can be appreciated that altering either factor will cause a Trendelenburg limp: a.

Giacomo, 54 years: Buscopan produces typical anticholinergic side effects of blurred vision, dry mouth, tachycardia and urinary retention. Aluksi selvitettiin kahden McKenzien menetelmään koulutetun tutkijan välistä luotettavuutta luokiteltaessa alaselkäkipupotilaat mekaanisen terapian kannalta oleellisiin alaryhmiin ja oireyhtymiin. So, treatment that eliminates these species from the red blood cells four or more weeks after inoculation of the sporozoites will cure these infections.

Angar, 47 years: Pharmacokinetics the pharmacokinetic characteristics of acebutolol: Contraindications Propranolol is contraindicated for patients with de- Oral bioavailability 70% pressed myocardial function and may be contraindicated Onset of action 1–3 hours 16 Antiarrhythmic Drugs 185 Peak response 3–8 hours Clinical Uses Duration of action 12–24 hours Esmolol is used in the treatment of supraventricular Plasma half-life 3–4 hours tachyarrhythmias for rapid control of ventricular rate Primary route of Hepatic and reduction of myocardial oxygen consumption. The patella is normally resurfaced as well after resecting the articular surface parallel to the anterior surface. Less than which can destroy viruses in this situation remains a 1% of the parent drug is excreted in the urine.

Hengley, 60 years: Bipolar depression tends to run in families, so there may be a genetic element to its aetiology. Lithium is readily absorbed after oral administration and injectable preparations are not available. Treatment often involves excision of the deep constriction band and multiple Z-plasties for recon- struction.

Ketil, 24 years: Due to the paucity of literature addressing this question, the work group was unable to generate a recommendation. They degenerate in a retrograde manner—deafness is interfere with mobilization of centrally located synaptic vesicles permanent. It has been shown that this drug prevents bone mass loss and reduction of bone biomechanical properties in these rats, which may be indicative of its po- tential role in the treatment of male osteoporosis secondary to hypogonadism or simply associated with old age (Ke et al.

Gonzales, 59 years: As the tendon continues to deteriorate and becomes incompetent, a pro- gressive asymmetrical flatfoot deformity develops with lateral hindfoot impingement. This suggests the need to more critically evalu- Pharmacokinetics ate and use erythropoietic agents in such patients and in cancer Elimination occurs by catabolism in the erythroid cells in the patients generally, as many tumours express erythropoietin marrow following internalization, by hepatic metabolism and receptors. Fansidar should be used with caution in those with severe allergic disorders, and bronchial asthma.

Lares, 42 years: It also facilitates accurate serial comparisons over time and allows comparison of preoperative and postoperative spinal alignment. Considering that the liver and the small intestine have the highest activities of cytochrome 4. Biochemically, it is related to the proteins, and physiologically, to the kidneys.

Musan, 50 years: Maintained from original guideline with minor word modifcations Work Group Consensus Statement In patients with imaging evidence of degenerative lumbar spondylolisthesis, the following clinical characteristics have been reported: asymptomatic with only occasional back pain; chronic low back pain with or without radicular symptoms and with or without positional variance; radicular symptoms with or without neurologic defcit, with or without back pain; and intermittent neurogenic claudication. A ‘prototype’ approach has been followed by describing the representative drug of a class followed by features by which individual members differ from it. It is possible that there is loss of inhibitory control in the limbic system because of a disorder in the right frontal cerebral cortex.

Hector, 48 years: Ethosuximide has seizure incidence and contact you immediately if not, but there is little evidence that ethosuximide is the incidence appears to be increasing. Interestingly, this compound also lacked the ability 3 to stimulate the release of [H]serotonin from prelabeled rat brain synaptosomes (Nichols et al. A prospective The work group recommends the undertaking of cost-analysis randomized study of unilateral versus bilateral instrumented pos- terolateral lumbar fusion in degenerative spondylolisthesis.

Gelford, 64 years: In some cases, flexion may offer pain relief; in other cases, it may be limited by hamstring spasm. In some instances, if there are no objective findings, such a trigger-point injection can be considered as early as the third week after onset of symptoms. Contraindications or Cautions: Cardiovascular disease, elderly clients, and diabetes.

Redge, 30 years: The annual rate of all lumbar discectomies decreased by approximately 50% and elective first time discectomies by two thirds in the catchment area of the McKenzie clinics, while the surgery rates remained unchanged during the same period in the rest of Denmark. An extreme example is seen with organophos- and is the standard treatment for this reaction. Two distinct estrogen-regulated promoters generate transcripts encoding the two functionally different human progesterone receptor forms A and B.

Lars, 44 years: For this, a great understanding of purinergic metabolism is necessary in order to correctly and effectively approach this matter. Similarly, Ling and colleagues19 screened the posterior isthmus 268 cases of neurodegenerative disease and 5. The abundance 20 of the pGlu N-terminal forms suggests that these 0 Aβ variants can play important roles in the deposi- tion of amyloid in Alzheimer’s disease brains.

References

• Yeo W, Chan PK, Ho WM, et al. Lamivudine for the prevention of hepatitis B virus reactivation in hepatitis B s-antigen seropositive cancer patients undergoing cytotoxic chemotherapy. J Clin Oncol. 2004;22(5):927-934.
• Guys JM, Simeoni-Alias J, Fakhro A, et al: Use of polydimethylsiloxane for endoscopic treatment of neurogenic urinary incontinence in children, J Urol 162:2133n2135, 1999.
• Cheema GS, Quismorio FP Jr. Interstitial lung disease in systemic lupus erythematosus. Curr Opin Pulm Med 2000;6(5):424-9.
• Kelty CJ, Kennedy CW, Falk GL. Ratio of metastatic lymph nodes to total number of nodes resected is prognostic for survival in esophageal carcinoma. J Thorac Oncol 2010;5: 1467.
• Fujishima H, Misawa T, Chijiwa Y, et al. Scirrhous carcinoma of the stomach versus hypertrophic gastritis: findings at endoscopic US. Radiology. 1991;181:197-200.
• Shen MM. Chromoplexy: a new category of complex rearrangements in the cancer genome. Cancer Cell 2013;23(5):567-569.