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By L. Kaffu. University of North Carolina at Greensboro. 2019.

Grades from one to three (least to most) be transmitted from any contact with a chancre buy meclizine 25 mg with mastercard. Likewise discount meclizine 25mg free shipping, if a chan- cre is in the mouth generic meclizine 25 mg on-line, merely kissing an infected cervical vertebrae The upper seven vertebrae in individual can spread syphilis. Charcot-Marie-Tooth disease A genetic dis- cervicitis Inflammation of the uterine cervix. The cervix The low, narrow part of the uterus, which foremost feature is marked wasting of the extremi- forms a canal that opens from the uterus into the ties, particularly in the calves, resulting in “stork vagina. The disease is opening of the cervix dilates during birth to permit one of the most common genetic diseases, and it is the newborn’s head to emerge. The disease can be inherited as an autoso- cervix, incompetent A cervix that has an abnor- mal dominant trait, an autosomal recessive trait, or mal tendency to dilate and so may not be able to an X-linked trait. There are also sporadic cases in keep a fetus from being spontaneously aborted which there is no family history due to a new domi- (miscarried). Also known as peroneal muscular atrophy and hereditary motor cesarean section See caesarean section. A Central and South America caused by the parasite charley horse can last anywhere from a few seconds Trypanosoma cruzi. It is not uncommon for through bites from bugs that carry it (known as one to recur before it finally resolves. Soon after chart, Snellen The familiar eye chart used to infection, there may be symptoms such as swelling measure how well a person sees at various dis- of the eye on one side of the face, usually at the bite tances. A Snellen chart is imprinted with block let- wound, but many people do not become ill until ters that decrease in size line by line, corresponding many years after being infected. Infants and persons to the distance at which that line of letters is nor- with immunodeficiency are at risk of severe infec- mally visible. Also known as American trypanosomi- chase the dragon A practice of heroin use that asis. Women’s menstrual periods may stop, cheek The side of the face, which forms the side and women may have hot flashes and vaginal dry- wall of the mouth. In some cases, poral bone of the skull, and it provides the promi- bone marrow transplantation and peripheral stem- nence of the cheek. The term cheek also refers to cell support are used to replace bone marrow tissue something that has the form of the human cheek, that has been destroyed by the effects of chemother- particularly with two laterally paired parts, such as apy. Cherubism is inherited as an auto- chemokine One of a large group of proteins that somal dominant condition. The chest contains the chemokine receptor A molecule that receives a lungs, the heart, and part of the aorta. The walls of chemokine and associated proteins (chemokine the chest are supported by the dorsal vertebrae, the docks). Chest pain is a warning to seek medical atten- injected into a vein, but some are given by mouth. Chemotherapy is gen- chest X-ray A type of X-ray commonly used to erally given in cycles: A treatment period is followed detect abnormalities in the lungs. A chest X-ray can by a recovery period, another treatment period, and also detect some abnormalities in the heart, aorta, so on. When white blood cells are affected by brain tissue protrudes into the spinal canal as a anticancer drugs, patients are more likely to result of a small or misshapen skull. When red blood cells are mation is usually present at birth (congenital), but affected, they may have decreased energy. Also known as line the digestive tract also divide rapidly, so Arnold Chiari malformation. Also known as vari- scribed to help with side effects, especially with nau- cella. Chickenpox has nothing to gradually go away during the recovery period or do with chicken; the name originated to distinguish after treatment stops. In some men and women, this mild pox from smallpox (chicken being used, chemotherapy drugs may result in temporary or as in chickenhearted, to mean weak or timid). Treatment, other than the use of calamine lotion or other topical solutions to diminish itching, is not child health The care and treatment of children. However, adults (and some- Child health is the purview of pediatrics, which times children) can have major problems from became a medical specialty in the mid-nineteenth chickenpox, including pneumonia and encephalitis century. Before that time the care and treatment of (inflammation of the brain) that can lead to diffi- childhood diseases were included within such areas culty with balance and coordination (cerebellar as general medicine, obstetrics, and midwifery. Other serious complications can include ear infections, damaged nerves (palsies), and childbed fever Fever due to an infection after Reye’s syndrome. In such cases, antiviral medica- childbirth, usually of the placental site within the tions may be tried. See also chickenpox developed world due to improved sanitary practices immunization; herpes zoster; neuralgia, posther- in midwifery and obstetrics. This can terized by apparently normal development for at worsen to an aching, prickly (“pins and needles”) least the first 2 years after birth, as manifested by the sensation, and then numbness. It can develop in only presence of age-appropriate verbal and nonverbal a few hours in skin exposed to extreme cold. The communication, social relationships, play, and treatment for chilblain is to stop exposure to cold, adaptive behavior. Children with this disorder dis- remove any wet or constrictive clothing, gently wash play significant loss of previously acquired skills and dry the injured area, elevate the injured area, (before age 10 years). This loss may affect expres- cover the injured area with layers of loose warm sive or receptive language, social skills or adaptive clothes, and allow the injured area to rewarm. Childhood disintegrative disorder also include child neglect and the physical, emotional, involves impairment in social interaction and com- and sexual abuse of children. Although most people munication, often with the development of repetitive think first of physical abuse when they hear the term stereotyped patterns of behavior, interests, and child abuse, physical abuse makes up only a small activities, including motor stereotypes and manner- percentage of reported cases. See also autism; develop- recognizes that in some cases the parent or care- mental disorder. Physical abuse includes punching, beating, kicking, biting, burn- children’s immunizations Vaccinations given ing, shaking, or otherwise physically harming a to children. Injuries that can be fatal include severe head that all children receive vaccination against the fol- trauma, shaken baby syndrome, trauma to the lowing unless the child has special circumstances, abdomen or chest, scalding, burns, drowning, suf- http://www. It is common for infected women to • Varicella zoster virus (chickenpox) have no symptoms. Also, an chimera 1 An imaginary monster made up of infant can acquire the disease during passage incongruous parts. Chlamydia is one of the reasons new- may be due to the fusion of two embryos at a very borns are routinely treated with antibiotic eyedrops. More commonly today, the Chlamydia can also cause inflammation of the ure- formation of a chimera is due to transplantation, thra, epididymis, and rectum in men. A chronic such as when bone marrow from one person is form of arthritis, called reactive arthritis, can used to reconstitute the bone marrow of an irradi- develop after chlamydia infection. Chloroform was once neering techniques are used to enclose therapeutic administered by inhalation to produce anesthesia, properties from one cell in another type of cell for given to relieve pain, and used as a remedy for delivery.

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These relationships generic meclizine 25mg otc, and also tissue distributions at target sites buy meclizine 25 mg with visa, affect dosing strategies order meclizine on line. Two important pharmacodynamic factors influencing antimicrobial efficacy include (i) the duration of time that target sites are exposed to the administered antimicrobial and (ii) the drug concentration achieved at these sites. On the basis of these factors, patterns of antimicrobial activity are defined as “time dependent” or “concentration dependent. In spite of tons of vancomycin being used in clinical settings, there are only seven reported cases of vancomycin-resistant S. However, over the last few years there have been accumulating data that the usefulness of this drug is steadily decreasing. In a recent practice statement in Clinical Infectious Diseases, the authors even go so far as to say that vancomycin is obsolete, although most clinicians feel this is a premature generalization (32). Overall incidence of nephrotoxicity from vancomycin alone remains low, and occurs in 1% to 5% of patients, but is clearly augmented by other concomitant nephrotoxic agents. Nausea, headache, and thrombocytopenia are the major side effects, the latter usually occurring about two weeks into therapy. There are increasing reports of linezolid resistance emerging during therapy in E. The dose should be administered every 48 hours if the creatinine clearance is <30 mL/min. Daptomycin’s adverse event profile involves an elevation in the serum creatine phosphokinase, and levels should be monitored weekly during therapy. The carbapenems are b-lactam agents with broad antimicrobial activity including Pseudomonas spp. Doripenem is a newer agent that apparently has better activity against Pseudomonas. However, there are important interclass differences including decreased activity of ciprofloxacin against S. In general, the fluoroquino- lones should not be used as monotherapy for serious staphylococcal infections. In addition, ceftobiprole demonstrates activity against vancomycin-intermediate and vancomycin-resistant S. Aminoglycosides like gentamicin and tobramycin are agents with gram-negative coverage and may be used as combination therapy for the “septic” patient until the susceptibility patterns are available for therapy de-escalation. The main side effect is nephrotoxicity, which can be diminished by extended-interval dosing as described above (except when used for synergistic dosing in enterococcal and staphylococcal infections, burns, pregnancy, or pediatric patients). Several studies conducted around the turn of the 21st century suggested great promise to this approach. In 2001, Raymond and colleagues reported that rotating empiric regimens even at one-year intervals might be beneficial (37). However, questions remained, and it was currently felt that the evidence is insufficient to recommend this practice as a routine measure (8,38). As we discussed in this chapter, prompt empirical therapy based on host factors and local epidemiological data reduces morbidity and mortality; however, clinicians must be mindful that their duty as stewards of our antimicrobial armamentarium does not end with the initial selection. Providers must reassess antibiotic regimens on a regular basis for early de-escalation to definitive therapy, dose optimization, compatibilities, untoward drug events, intravenous to oral conversions, and importantly, therapy duration. The role of the infectious diseases physician in setting guidelines for antimicrobial use. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients. Principles of antibiotic therapy in severe infections: optimizing the therapeutic approach by use of laboratory and clinical data. Prescription of antibiotic agents in Swedish intensive care units is empiric and precise. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial therapy for bacteremia. Pseudomonas aeruginosa ventilator-associated pneumonia: comparison of episodes due to piperacillin-resistant versus piperacillin-susceptible organisms. Antimicrobial resistance among gram-negative bacilli causing infections in intensive care unit patients in the United States between 1993 and 2004. Gram-negative rod bacteremia: microbiologic, immunologic, and therapeutic considerations. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit: a proposed solution for indiscriminate antibiotic prescription. Early transition to oral antibiotic therapy for community-acquired pneumonia: duration of therapy, clinical outcomes, and cost analysis. Effect of linezolid versus vancomycin on length of hospital stay in patients with complicated skin and soft tissue infections caused by known or suspected methicillin- resistant staphylococci: results from a randomized clinical trial. Antibiotic dosing in critically ill adult patients receiving continuous renal replacement therapy. Use of pharmacokinetic-pharmacodynamic target attainment analyses to support phase 2 and 3 dosing strategies for doripenem. Experience with a once-daily Aminoglycoside Program administered to 2,184 adult patients. Clinical failures of linezolid and implications for the clinical microbiology laboratory. Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylo- coccus aureus. Impact of a rotating empiric antibiotic schedule on infectious mortality in an intensive care unit. Rotating antibiotics in the intensive care unit: feasible, apparently beneficial, but questions` remain. Cunha Infectious Disease Division, Winthrop-University Hospital, Mineola, New York, and State University of New York School of Medicine, Stony Brook, New York, U. Group D streptococci may be further subdivided as enterococcal or non- enterococcal group D streptococci. The most important non-enterococcal group D streptococcus is Streptococcus gallolyticus (S. Group D enterococci, however, are the predominant streptococcal pathogens encountered in critical care. Because group D streptococci colonize the terminal colon, they are frequent colonizers of the urinary tract.

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During inspiration best purchase for meclizine, it is normal to hear the closing of the aortic valve (A2) before the closing of the pulmonic valve (P2) generic meclizine 25 mg online. A fixed split of the second heart sound occurs in the setting of an atrial septal defect order generic meclizine from india. With this congenital heart defect, the volume of blood that is shunted from the left atrium to the right atrium results in a stable right-ventricular stroke volume. Thus, there is no difference between inspiration and expiration, resulting in a fixed split of the second heart sound. Thickened myocardium increases back pressure in the coronary circulation thereby reducing coronary perfusion, leading to ischemia. In addition, diastolic pressures are lower when there is severe aortic regurgitation, which further decreases coronary perfu- sion. Myocardial oxygen consumption increases when there is ventricular hypertrophy as a result of increased mass and contractility. In chronic aortic regurgitation, the equilibration of end-diastolic left-ventricular and aortic pressures exacerbates left-ventricular remodeling and will cause premature closure of the mitral valve or functional mitral regurgitation. Diagnosing paroxys- mal atrial fibrillation with a 24-h monitor is an option if there is no evidence of pulmonary hypertension. There is no evidence that percutaneous or surgical repair of mitral stenosis is beneficial for slight or no functional impairment. Insulin resistance is thought to be a mediator of many of the other as- pects of the metabolic syndrome, including hypertension and hyperglycemia. Increases in visceral obesity are thought to be more harmful than subcutaneous stores because of the direct effect of free fatty acids on the liver from the visceral stores. The inflammatory milieu of the metabolic syndrome is enhanced by the overproduction of the proinflammatory cytokines by the expanded adi- pose tissue. Treating hypertension, hyperglycemia, dyslipidemia, and the oxidative stress of the proinflammatory state is important when treating metabolic syndrome. However, adi- pose tissue loss is the primary approach to treating the underlying cause of the disorder. Commonly used physiologic maneuvers include change with respiration, Valsalva maneuver, position, and exercise. In hypertrophic cardiomyopathy, there is asymmetric hypertrophy of the interventricular septum, which creates a dynamic outflow obstruction. Maneuvers that decrease left-ventricular filling will cause an in- crease in the intensity of the murmur, whereas those that increase left-ventricular filling will cause a decrease in the murmur. Of the interventions listed, both standing and a Val- salva maneuver will decrease venous return and subsequently decrease left ventricular filling, resulting in an increase in the loudness of the murmur of hypertrophic cardiomy- 224 V. Outflow obstruction is increased by decreasing preload, which occurs in standing, performing a Valsalva maneuver, or with the administration of vasodilators. Increasing preload by squatting or passive leg raise will lead to reduction of outflow tract obstruction and a di- minished murmur. The murmur of aortic stenosis is typically in the right second intercostal space and radiates to the carotids. The murmur of con- genital pulmonic stenosis is in the right second intercostal space. Mitral valve prolapse causes a late systolic murmur usually introduced by an ejection click. Chronic mitral re- gurgitation causes a holosystolic murmur that radiates to the apex. His hypertension, hypercholesterolemia, and diabetes mellitus, although significant, were not identified as independent risk factors. Atrial myxoma, which can cause syncope by obstructing blood flow with resultant decreased cardiac output, is not associated with ventricular tachycardia. The episodic symptoms and orthostasis despite marked hypertension are suggestive of pheochromocytoma. Thus, the most appropriate management of this patient should include an α-adrenergic receptor blocker. Phentolamine and nitroprusside are two agents that can be used intravenously in the setting of hypertensive crises. This patient should be managed as such as she has evidence of increased intracranial pressure on oph- thalmologic examination. The diagnosis of pheochromocytoma is best made by 24-h urine collection for metanephrines and vanillylmandelic acid. Plasma catecholamines are elevated in pa- tients with pheochromocytoma, but the routine measurement of these levels for diagnosis is confounded by the wide variation in levels associated with various stressors. If plasma catecholamines are to be used, the levels must be drawn with the patient at rest for at least 30 minutes and drawn through an indwelling intravenous catheter. Cardiovascular disease is more prevalent with age, affecting only 5% at age 20 with a rise to 75% at age >75 years. Al- though age-adjusted death rates for cardiovascular disease have declined by two-thirds since 1965, the actual number of hospitalizations for cardiovascular disease and congestive heart failure are increasing as more individuals are surviving an initial heart attack to live with chronic cardiovascular disease and heart failure. In 2002, it was estimated by the American Heart Association that 32 million women and 30 million men had cardiovascular disease. Heart disease is responsible for 43% of deaths in females and 37% of deaths in males. Cardiovascular disease in women is more likely to present atypically without chest pain and is also more likely to be due to dysfunc- tion of the microcirculation and thus less amenable to current interventional therapies. Most commonly, electrolyte disturbances such as hypokalemia and hypomagnesemia, phenothiazines, fluoroquinolones, antiarrhythmic drugs, tricyclic antidepressants, intracranial events, and bradyarrhythmias are associated with this malig- nant arrhythmia. Management, besides stabilization, which may require electrical cardiover- sion, consists of removing the offending agent. If an anticoagulant is added, enoxaparin has been shown to be superior to un- fractionated heparin in reducing recurrent cardiac events. Eptifibatide, tirofiban, and abciximab are beneficial for patients likely to receive percuta- neous intervention. Indications for intervention for descending dissections acutely include occlu- sion of a major aortic branch with symptoms. For example, paralysis may occur with oc- clusion of the spinal artery or worsening renal failure may occur in the case of dissection that involves the renal arteries. Once a descending dissection has been found, intensive medical management of blood pressure is imperative and should include agents that de- crease cardiac contractility and aortic shear force. Finally, patients with Marfan’s syndrome have increased complications with descending dissections and should be con- sidered for surgical repair, especially if there is concomitant disease in the ascending aorta as demonstrated by aortic root dilation to greater than 50 mm. Anemia, pain, and myocardial ischemia are also causes of tachycardia that should be considered when managing a new tachycardia. Patients with wide complex tachycardia suggestive of ventricu- lar tachycardia or known preexcitation syndrome should be treated with agents that de- crease automaticity, such as quinidine and procainamide. However, in patients with apparent ventricular tachycardia who have neither a history of ischemic heart disease nor preexcitation syndrome, adenosine may be a useful diagnostic agent to determine whether a patient has a reentrant tachycardia, in which case the drug may terminate it; an atrial tachycardia, in which case the atrial activity may be unmasked; or a true, preexcited tachy- cardia, in which case adenosine will have no effect.

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Some virulent Extremely noxious discount 25 mg meclizine with visa, damaging buy discount meclizine 25mg line, deleteri- vision therapists claim that eye exercises can help ous 25 mg meclizine amex, and disease causing (pathogenic); marked by people with neurological or learning disabilities. Vision therapy is not proven for the latter use, although some patients do report improvement. Viruses cause many common human infec- test may be done via a number of methods, includ- tions and are also responsible for a number of rare ing termed confrontation, tangent screen exam, and diseases. These tests are not painful or common cold, which can be caused by one of the uncomfortable. Vitamins of smaller virus families within these major classifi- play a part in dozens of crucial activities in the body: cations. Many viruses are host specific, capable of Some are antioxidants, preventing oxidation of cells infecting and causing disease in humans or specific and potentially preventing cancer; others permit or animals only. However, many peo- from an attenuated, less virulent strain of the virus: ple do not eat a diet that contains the minimum daily a virus that is capable of stimulating an immune requirements of certain vitamins. Nutritionists sug- response and creating immunity but not of causing gest that the best way to ensure appropriate doses of illness. These foods offer many benefits that visceral pericardium The inner layer of the vitamin supplements cannot, including fiber, and pericardium. Others are fat-soluble and may build up in voluntary Done in accordance with the con- the body, potentially reaching dangerous concentra- scious will of the individual. The terms voluntary and and over-the-counter drugs, making them more or involuntary apply to the human nervous system and less potent. The nervous system is consult a physician before adding vitamin supple- divided into two parts: somatic and autonomic. The auto- nomic (automatic, or visceral) nervous system vitamin P See bioflavinoid. For example, opening the mouth is voluntary, vitamin therapy The use of vitamins to prevent and blushing and the beating of the heart are invol- or cure disease, often as a complementary therapy untary. One variant on this theme, megavitamin therapy, is still volvulus Abnormal twisting of a portion of the rather controversial. It is important to consult a gastrointestinal tract, usually the intestine, which physician before adding vitamin supplements to a can impair blood flow. The stomach, small intestine, cecum, and sigmoid colon are all vitiligo A condition in which the skin turns white subject to volvulus. Malrotation of the bowel during due to the loss of pigment from the melanocytes, fetal development can predispose one to a volvulus, cells that produce the pigment melanin that gives which often has a sudden onset. In vitiligo, the melanocytes are signs of a volvulus may include abdominal pain, destroyed, leaving depigmented patches of skin. The treat- hair that grows in areas affected by vitiligo may also ment is surgery to free the obstruction and ensure turn white. Volvulus is a surgi- People with vitiligo must protect their skin from cal emergency. When vomit is vitreous humor A clear, jelly-like substance that reddish or coffee-ground colored, it indicates seri- fills the middle of the eye. When a per- vomiting in pregnancy, excess See hypereme- son breathes, the vocal cords relax, and air moves sis gravidarum. When a person talks or sings, the vocal vomiting of pregnancy, pernicious See hyper- cords tighten up and move closer together. The term void is also sometimes (renal cell carcinoma); pheochromocytomas used to indicate the elimination of solid waste (benign tumors of adrenal-like tissue); and (defecation). The hemangioblastomas in els of von Willebrand factor, which reduces the ten- the retina can cause vision loss and may be the ini- dency toward bleeding. Several types of von vulvodynia Chronic pain in the area of the Willebrand disease have been described. The main symptom is pain, usually a burning irritation or rawness of the genitals. Symptoms can pain may be constant or intermittent, localized or include easy bruising, nosebleeds, bleeding from diffuse. It can last for months or longer, and it can the gums after a dental procedure, heavy menstrual vanish as suddenly as it started. The cause of vulvo- bleeding in women, blood in the stool and urine, dynia is unknown. Many women with vulvodynia and excessive bleeding after a cut or other accident or after surgery. Von Willebrand disease is usually have a history of treatment for recurrent vaginal fun- mild and often does not require treatment. Treatments can include the use of Treatment may be needed only after surgery, a tooth drugs, use of nerve blocks to numb the vulvar nerves, and biofeedback therapy to relax pelvic extraction, or an accident. Plantar warts may attack blood vessels deep in the skin, and they can be quite painful. Waardenburg syndrome A genetic syndrome Avoidance and prompt treatment are essential. In that features varying degrees of hearing loss and some cases, allergy injection therapy is highly effec- pigmentation changes in the skin and hair. Some patients also take warfarin to reduce their risk of weaver’s bottom Inflammation of the bursa that clots, stroke, or heart attack. Warfarin works by separates the gluteus maximus muscle of the but- suppressing production of some clotting factors. Weaver’s bottom is a form of bursitis that is usually Warfarin taken by a woman during pregnancy can caused by prolonged sitting on hard surfaces that disturb the development of an embryo and a press against the bones of the bottom or midbut- fetus and lead to birth defects. Wegener granulomatosis See granulomatosis, wart A local growth on the outer layer of the skin Wegener. Papillomavirus is transmitted by contact, either with a wart on some- welt See hive. Warts that occur on the hands or feet are called Werner syndrome A premature aging disease common warts. A wart on the sole of the foot is a that begins in adolescence or early adulthood and plantar wart. Genital (venereal) warts are located results in apparent old age by 30–40 years of age. See also ture graying, early baldness, wizened face, beaked genital warts; human papillomavirus. Plantar warts are different from most other autosomal recessive manner and is due to mutation warts. It can affect any part of the body, leading to arthritis and then weight loss, Werner-His disease See trench fever. Whipple disease has mitted from birds to mosquitoes and then to people been discovered to be due to a type of bacteria by mosquito bites. Some patients relapse and virus occurs in parts of Africa and Asia and, infre- need long-term, even life-long, treatment. West Nile virus had never been seen in birds Whipple procedure A type of surgery that is or people in the Western Hemisphere prior to an used to treat pancreatic cancer and was devised by outbreak in summer 1999 in New York City. Most affected creas, the duodenum, a portion of the stomach, and people have no symptoms or minor symptoms, but other nearby tissues are removed.

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Multiple primary lesions buy cheap meclizine on-line, regional adenopathy cheap 25mg meclizine otc, and secondary bacterial infection are variably present purchase on line meclizine. Leishmania parasites are transmitted by the bite of the female phlebotomine sandfly. While probing for a blood meal, sandflies regurgitate the parasite’s flagellated promasti- gote stage into the host’s skin, which eventually get phagocytized by macrophages. The larvae of Trichinella spiralis are found in undercooked pork and game meat and cause the syndrome of trichonosis. Inhalation of the spores of Bacillus anthracis causes the pulmo- nary form of anthrax infection. The tsetse fly is the vector for the trypanosome parasite, which can cause sleeping sickness. Mosquito bites transmit a number of infections, most notably malaria and a variety of viral infections such as viral encephalitis. With terbinafine therapy, there is also a risk of drug-drug interaction with drugs that require the P450 enzyme for metabolism. Most treatment courses require se- rial monitoring of liver enzymes to avoid drug-induced hepatitis or liver failure. Lancet 360: ple index for prediction of cardiac risk of major noncar- 187–195, 2002 diac surgery. N Engl J Med 325:1621–1629, 1991 travenous unfractionated heparin in the initial treatment of Collaborative Group on Hormonal Factors in Breast Cancer: pulmonary embolism. Arch Intern stroke, and venous thrombosis in apparently healthy Med 166:391–397, 2006 men. Professor Department of Integrated Biology and Pharmacology and Graduate School of Biomedical Sciences Assistant Dean for Education Programs University of Texas Medical School at Houston Houston, Texas David S. Associate Professor Department of Integrated Biology and Pharmacology and Graduate School of Biomedical Sciences University of Texas Medical School at Houston Houston, Texas With special contributions by Medina Kushen, M. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner. The publisher is not responsible (as a matter of product liability, negligence or otherwise) for any injury resulting from any material contained herein. This publication contains information relating to general principles of medical care which should not be construed as specific instructions for individual patients. Manufacturers’ product information and package inserts should be reviewed for current information, including contraindications, dosages and precautions. Printed in the United States of America Library of Congress Cataloging-in-Publication Data Rosenfeld, Gary C. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. If you have comments or suggestions regarding this Lippincott Williams & Wilkins title, please contact us at the appropriate customer service number listed below, or send correspondence to book_comments@lww. If possible, please remember to include your mailing address, phone number, and a reference to the book title and author in your message. To purchase additional copies of this book call our customer service department at (800) 638-3030 or fax orders to (301) 824-7390. Preface to the Fifth Edition This concise review of medical pharmacology is designed for medical students, dental stu- dents, and others in the health care professions. This book presents condensed and succinct descriptions of relevant and current Board-driven information pertaining to phar- macology without the usual associated details. It is not meant to be a substitute for the comprehensive presentation of information and difficult concepts found in standard phar- macology texts. Other chapters discuss autocoids, ergots, anti-inflammatory and immunosuppressive agents, drugs used to treat anemias and disorders of hemostasis, infectious diseases, cancer, and toxicology. Each chapter includes a presentation of specific drugs with a discussion of their gen- eral properties, mechanism of action, pharmacologic effects, therapeutic uses, and adverse effects. A drug list, tables, and figures summarize essential drug information included in all chapters. This examination serves as a self-assessment tool to help students determine their fund of knowledge and diagnose any weaknesses in pharmacology. Nondiuretic Inhibitors of Tubular Transport 66 Review Test 68 vii viii Contents 4. Drug Poisoning 319 Review Test 321 Comprehensive Examination 324 Index 341 General Principles of chapter 1 Drug Action I. Drug effects are produced by altering the normal functions of cells and tissues in the body via one of four general mechanisms: 1. Interaction with receptors, naturally occurring target macromolecules that mediate the effects of endogenous physiologic substances such as neurotransmitters and hormones a. Figure 1-1 illustrates the four major classes of drug–receptor interactions, using specific examples of endogenous ligands. Figure 1-1A illustrates acetylcholine interacting with a nicotinic receptor that is a nonspecific Na+/K+ transmembrane ion channel. Interaction of a molecule of acetylcholine with each subunit of the channel produces a conforma- tional change that permits the passage of Na+ and K+. Other channels that are targets for various drugs include specific Ca2+ and K+ channels. The receptors all have seven transmembrane segments, three intracellular loops, and an intracellular carboxy-terminal tail. Figure 1-1B illustrates a b-adrenoceptor, which when acti- vated by ligand binding (e. Ligand binding causes conformational changes in the receptor; some receptor tyrosine kinases are monomers that dimerize upon ligand binding. The liganded receptors then autophosphorylate tyrosine residues, which recruits cytoplasmic proteins to the plasma membrane where they are also tyrosine phosphorylated and activated. Four major classes of drug–receptor interactions, with specific examples of endogenous ligands. Acetyl- choline interaction with a nicotinic receptor, a ligand-activated ion channel. Alteration of the activity of enzymes by activation or inhibition of the enzyme’s catalytic activity 3. Nonspecific chemical or physical interactions such as those caused by antacids, osmotic agents, and chelators B. The graded dose–response curve expresses an individual’s response to increasing doses of a given drug. The magnitude of a pharmacologic response is proportional to the number of receptors with which a drug effectively interacts (Fig. Magnitude of response is graded; that is, it continuously increases with the dose up to the max- imal capacity of the system, and it is often depicted as a function of the logarithm of the dose administered (to see the relationship over a wide range of doses). Antagonists bind to the receptor but do not initiate a response; that is, they block the action of an agonist or endogenous substance that works through the receptor. Because higher doses of agonist can overcome the inhibition, the maximal response can still be obtained.

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