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By O. Sobota. University of New England. 2019.

Although these effects may protect some individuals of East Asian descent from alcohol use disorder quality clomid 25 mg, those who drink despite the effects are at increased risk for esophageal76 and head and neck cancers order clomid 100mg otc. Another study found that even low levels of alcohol consumption by Japanese77 Americans may result in adverse effects on the brain buy genuine clomid on-line, a fnding that may be related to the differences in alcohol metabolism described above order clomid online. Additional research will help to clarify the interactions between race,78 ethnicity, and the neuroadaptations that underlie substance misuse and addiction. This work may inform the development of more precise preventive and treatment interventions. Recommendations for Research Decades of research demonstrate that chronic substance misuse leads to profound disruptions of brain circuits involved in the experience of pleasure or reward, habit formation, stress, and decision-making. This work has paved the way for the development of a variety of therapies that effectively help people reduce or abstain from alcohol and drug misuse and regain control over their lives. In spite of this progress, our understanding of how substance use affects the brain and behavior is far from complete. Effects of Substance Use on Brain Circuits and Functions Continued research is necessary to more thoroughly explain how substance use affects the brain at the molecular, cellular, and circuit levels. Such research has the potential to identify common neurobiological mechanisms underlying substance use disorders, as well as other related mental disorders. This research is expected to reveal new neurobiological targets, leading to new medications and non-pharmacological treatments—such as transcranial magnetic stimulation or vaccines—for the treatment of substance use disorders. A better understanding of the neurobiological mechanisms underlying substance use disorders could also help to inform behavioral interventions. As with other diseases, individuals vary in the development and progression of substance use disorders. Not only are some people more likely to use and misuse substances than are others and to progress from initial use to addiction differently, individuals also differ in their vulnerability to relapse and in how they respond to treatments. For example, some people with substance use disorders are particularly vulnerable to stress-induced relapse, but others may be more likely to resume substance use after being exposed to drug-related cues. Developing a thorough understanding of how neurobiological differences account for variation among individuals and groups will guide the development of more effective, personalized prevention and treatment interventions. Additionally, determining how neurobiological factors contribute to differences in substance misuse and addiction between women and men and among racial and ethnic groups is critical. Continued advances in neuroscience research will further enhance our understanding of substance use disorders and accelerate the development of new interventions. Data gathered through the National Institutes of Health’s Adolescent Brain Cognitive Development study, the largest long-term study of cognitive and brain development in children across the United States, is expected to yield unprecedented information about how substance use affects adolescent brain development. Technologies that can alter the activity of dysfunctional circuits are being explored as possible treatments. Moreover, continued advances in genomics, along with President Obama’s Precision Medicine Initiative, a national effort to better understand how individual variability in genes, environment, and lifestyle contribute to disease, are expected to bring us closer to developing individually-tailored preventive and treatment interventions for substance-related conditions. Neurobiological Effects of Recovery Little is known about the factors that facilitate or inhibit long-term recovery from substance use disorders or how the brain changes over the course of recovery. Developing a better understanding of the recovery process, and the neurobiological mechanisms that enable people to maintain changes in their substance use behavior and promote resilience to relapse, will inform the development of additional effective treatment and recovery support interventions. Therefore, an investigation of the neurobiological processes that underlie recovery and contribute to improvements in social, educational, and professional functioning is necessary. Prospective, longitudinal studies are in which data on a particular group of people are gathered repeatedly over a needed to investigate whether pre-existing neurobiological period of years or even decades. Studies that follow groups of adolescents over time to learn about the developing human brain should be conducted. These studies should investigate how pre-existing neurobiological factors contribute to substance use, misuse, and addiction, and how adolescent substance use affects brain function and behavior. Neurobiological Effects of Polysubstance Use and Emerging Drug Products Patterns of alcohol and drug use change over time. New drugs or drug combinations, delivery systems, and routes of administration emerge, and with them new questions for public health. Concerns also are emerging about how new products about which little is known, such as synthetic cannabinoids and synthetic cathinones, affect the brain. Additional research is needed to better understand how such products - as well as emerging addictive substances - affect brain function and behavior, and contribute to addiction. Review of risk and protective factors of substance use and problem use in emerging adulthood. Phasic vs sustained fear in rats and humans: Role of the extended amygdala in fear vs anxiety. How adaptation of the brain to alcohol leads to dependence: A pharmacological perspective. The attribution of incentive salience to a stimulus that signals an intravenous injection of cocaine. Cocaine cues and dopamine in dorsal striatum: Mechanism of craving in cocaine addiction. Increased occupancy of dopamine receptors in human striatum during cue-elicited cocaine craving. Stimulant-induced dopamine increases are markedly blunted in active cocaine abusers. Parallel and interactive learning processes within the basal ganglia: Relevance for the understanding of addiction. Decreased striatal dopaminergic responsiveness in detoxifed cocaine-dependent subjects. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Glucocorticoid receptor antagonism decreases alcohol seeking in alcohol- dependent individuals. Dysfunction of the prefrontal cortex in addiction: Neuroimaging fndings and clinical implications. Dysfunctional amygdala activation and connectivity with the prefrontal cortex in current cocaine users. Drug addiction and its underlying neurobiological basis: Neuroimaging evidence for the involvement of the frontal cortex. Profound decreases in dopamine release in striatum in detoxifed alcoholics: Possible orbitofrontal involvement. Association of frontal and posterior cortical gray matter volume with time to alcohol relapse: A prospective study. Fear conditioning, synaptic plasticity and the amygdala: Implications for posttraumatic stress disorder. Marijuana craving questionnaire: Development and initial validation of a self-report instrument. Cannabis craving in response to laboratory-induced social stress among racially diverse cannabis users: The impact of social anxiety disorder. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Childhood maltreatment and psychopathology: A case for ecophenotypic variants as clinically and neurobiologically distinct subtypes. Substance Abuse and Mental Health Services Administration, & Center for Behavioral Health Statistics and Quality. Genetic and environmental contributions to alcohol abuse and dependence in a population-based sample of male twins. Human cell adhesion molecules: Annotated functional subtypes and overrepresentation of addiction‐associated genes. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Co- occurrence of 12-month alcohol and drug use disorders and personality disorders in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Epidemiological investigations: Comorbidity of posttraumatic stress disorder and substance use disorder. Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. The use of alcohol and drugs to self‐ medicate symptoms of posttraumatic stress disorder.

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Show your doctor or pharmacist how you use your inhalers You are being exposed to a trigger purchase clomid without a prescription. Read the Asthma Basics Booklet called Triggers for information about things that can make your asthma worse trusted 100mg clomid. Talk to your doctor about allergy tests You are not using your controller medication regularly order cheapest clomid. Use your controller medication every day You may have something other than asthma purchase clomid cheap online, such as an infection, and you may need another different medication, in addition to your asthma medication One indicator of poor asthma control = needing your reliever inhaler 4 or more times a week because of breathing problems 5 Medications: Asthma Basics Booklet Controller medications Having asthma means having long-term inflammation in your airways. Avoiding your asthma triggers by modifying your environment is the best way to help reduce this swelling (see the Asthma Basics Booklet called Triggers), but it is often not enough to achieve and maintain good asthma control. Regular use of a controller medication, will treat the persistent inflammation of the airways. Inflamed airway and mucus Regular use of controller medicine Normal airway = normal function 6 © Asthma Society of Canada Controllers: Inhaled Corticosteroids Inhaled corticosteroids have an anti-inflammatory effect on the airways. When used regularly, inhaled corticosteroids reduce inflammation and mucus in the airways, making the lungs less sensitive to triggers. Everyone with asthma, including mild asthma, benefits from regular use of inhaled corticosteroids. When your asthma is poorly controlled, your doctor may prescribe an inhaled corticosteroid. It can take days or weeks for the inhaled corticosteroid to reduce the inflammation in your airways, so be patient. The longer you are using it, the less you will need to use your reliever medication. The common side effects of inhaled corticosteroids are hoarse voice, sore throat and mild throat infection called thrush (yeast infection). Rinsing out your mouth with water after every dose of inhaled corticosteroids will also help reduce these side effects. If your asthma is not well controlled with one controller medication, another may be added to your current treatment. Continue taking your inhaled corticosteroid while taking the “add on” medications; the medications are meant to work together. Some of the side effects of Combination Medications include hoarseness, throat irritation, and rapid heart beat. Combination medication First choice Add-on Combination therapy therapy therapy Long-acting Corticosteroid bronchodilater Two medications (reduces (relieves airway in one device inflammation) constriction) 9 Medications: Asthma Basics Booklet Reliever Medication Short-acting bronchodilators are called "relievers" or "rescue medications". They provide temporary relief of bronchospasm by relaxing the muscles that have tightened around the bronchiole tubes. Most bronchodilators open the airway and help restore normal breathing within 10 to 15 minutes. If you need it 4 or more times a week for relief your asthma is not well controlled. Your doctor may prescribe one or more controller medications or may change the dose or type of controller that you are currently using to get the asthma under control. Tell your doctor if you need your reliever 4 or more times per week 10 © Asthma Society of Canada Relievers can be used for short-term prevention of exercise-induced asthma. Some of the side-effects of short-acting bronchodilators are headache, shaky hands (tremor), nervousness and fast heartbeat. Muscles around airway tighten Reliever Muscles relaxed 11 Medications: Asthma Basics Booklet Medication: Questions & answers What is the difference between corticosteroids and anabolic steroids? When your doctor prescribes an inhaled corticosteroid, he is giving a very small amount of this same hormone, to reduce the amount of inflammation in the airways. Some people worry that the more asthma medication they take or the longer they take it, the more they will need it. Many people do not take their medications because they think they can tolerate their asthma symptoms. Their poorly controlled asthma may lead to: Decreased quality of life (exercise, sleep) Higher risk of severe, life-threatening asthma attacks Permanent damage to the lungs My doctor wants me to use a corticosteroid inhaler. The dose of the corticosteroid inhaler is in micrograms, which is one millionth of a gram. Corticosteroids in a tablet form are in grams, a much higher dose than in the inhaler. Corticosteroid tablets are used when a larger dose is needed to get the asthma under control. Mild asthma may still cause regular symptoms, limit your quality of life and cause long-term inflammation in your airways that may lead to permanent damage of your lungs. So, people with "mild, persistent" asthma will most likely be treated with a low dose of daily controller medication. Six out of ten people with asthma have poor asthma control and do not take their symptoms seriously. If you are having regular asthma symptoms, then your asthma is not well controlled, and you are at risk of having a severe asthma attack. It is very important for your baby’s health to maintain excellent asthma control throughout the pregnancy. Asthma medications are well tolerated in pregnancy but it is a good idea to discuss all your medications with your doctor. When your asthma is under control talk to your doctor about adjusting the dose of your medications. There is no evidence of any benefit from the unconventional therapies for asthma, such as acupuncture, chiropractic, homeopathy, naturopathy, osteopathy and herbal remedies. If you decide to use unconventional therapies, tell your doctor and keep taking your asthma medications. Before starting a new medication, always ask if it is okay for people with asthma to use. Inhaled corticosteroids are the most effective prescribed medication for most patients with asthma. Inhaled corticosteroids at the doses they are currently recommending for asthma have not been shown to cause weak bones, growth suppression, weight gain and cataracts. Inhaled corticosteroids are much less likely to cause these side effects, but they can cause throat irritation and hoarseness. When corticosteroids are taken in higher doses, such as in a tablet form, for long periods of time, they can cause weak bones and growth suppression. When you decide to take any medication, you must weigh the possible risks of taking medication against the benefits. Low amounts of inhaled corticosteroids are generally considered to be the best option and are used by many people for asthma control. Inhaled asthma medications go directly to the site of inflammation and constriction in the airways instead of travelling through the bloodstream to get there. Inhaled medications only work if they get to the airways, so learn how to use your inhaler properly (see pages 18 to 21). Many people do not use their inhalers properly, so the medication does not reach their airways. It is very important that you show your doctor, pharmacist or asthma educator how you use your inhaler to make sure the medication is getting to your lungs, where it’s needed. When the canister is pushed down, a measured dose of the medication is pushed out as you breathe it in. Dry powder inhalers contain a dry powder medication that is drawn out of the device and into your lungs when Dry powder inhalers you breathe in (pgs 20 & 21). The spacer helps you to have a better delivery of the medication into your airways. Spacer and pressurized metered dose inhaler Poor inhaler technique leads to poor drug delivery into the lungs. Hold the inhaler upright 2 Twist the coloured grip of your Turbuhaler® as far as it will go, then twist it all the way back. Breathe in forcefully and deeply through your mouth 5 Remove the Turbuhaler® from your mouth before breathing out 6 Always check the number in the dose counter window under the mouthpiece to see how many doses are left. For the Turbuhalers® that do not have a dose counter window, check the window for a red mark, which means your medication is running out. When finished, replace the cap *Symbicort®: For first time use, hold the inhaler upright, turn the grip as far as it will go in one direction and then turn it back again as far as it will go in the opposite direction. This means that there is swelling and mucus inside the breathing tubes in your lungs.

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A well chosen drug treatment consists of as few drugs as possible (preferably only one) buy cheap clomid 50 mg on line, with rapid action buy clomid american express, with as few side effects as possible purchase clomid 25mg otc, in an appropriate dosage form discount clomid 25mg fast delivery, with a simple dosage schedule (one or two times daily), and for the shortest possible duration. Patients need information, instructions and warnings to provide them with the knowledge to accept and follow the treatment and to acquire the necessary skills to take the drugs appropriately. In some studies less than 60% of patients had understood how to take the drugs they had received. Information should be given in clear, common language and it is helpful to ask patients to repeat in their own words some of the core information, to be sure that it has been understood. A functional name, such as a ‘heart pill’ is often easier to remember and clearer in terms of indication. Box 9: Aids to improving patient adherence to treatment Patient leaflets Patient leaflets reinforce the information given by the prescriber and pharmacist. If they are not available, make pictorials or short descriptions for your own P-drugs, and photocopy them. Day calendar A day calendar indicates which drug should be taken at different times of the day. It can use words or pictorials: a low sun on the left for morning, a high sun for midday, a sinking sun for the end of the day and a moon for the night. Drug passport A small book or leaflet with an overview of the different drugs that the patient is using, including recommended dosages. Dosage box 73 Guide to Good Prescribing The dosage box is becoming popular in industrialized countries. It is especially helpful when many different drugs are used at different times during the day. The box has compartments for the different times per day (usually four), spread over seven days. The important thing is to give your patients the information and tools they need to use drugs appropriately. The six points listed below summarize the minimum information that should be given to the patient. Effects of the drug Why the drug is needed Which symptoms will disappear, and which will not When the effect is expected to start What will happen if the drug is taken incorrectly or not at all 2. Side effects Which side effects may occur How to recognize them How long they will continue How serious they are What action to take 3. Instructions How the drug should be taken When it should be taken How long the treatment should continue How the drug should be stored What to do with left-over drugs 4. Warnings When the drug should not be taken What is the maximum dose Why the full treatment course should be taken 5. Future consultations When to come back (or not) In what circumstances to come earlier What information the doctor will need at the next appointment 6. Ask the patient whether everything is understood Ask the patient to repeat the most important information Ask whether the patient has any more questions 74 Chapter 10 Step 5: Give information, instructions and warnings This may seem a long list to go through with each patient. You may think that there is not enough time; that the patient can read the package insert with the medicine; that the pharmacist or dispenser should give this information; or that too much information on side effects could even decrease adherence to treatment. Yet it is the prime responsibility of the doctor to ensure that the treatment is understood by the patient, and this responsibility cannot be shifted to the pharmacist or a package insert. Maybe not all side effects have to be mentioned, but you should at least warn your patients of the most dangerous or inconvenient side effects. Having too many patients is never accepted by a court of law as a valid excuse for not informing and instructing a patient correctly. Exercise: Patients 34-38 Review the following prescriptions and list the most important instructions and warnings that should be given to the patient. Patient 34 (depression) It will take approximately two to three weeks before the patient starts to feel better, but side effects, such as dry mouth, blurred vision, difficulty in urinating and sedation, may occur quickly. Because of this many patients think that the treatment is worse than the disease and stop taking the drug. If they are not told that this may happen and that these effects disappear after some time, adherence to treatment will be poor. For this reason a slowly rising dosage schedule is usually chosen, with the tablets taken before bedtime. You can also ask 75 Guide to Good Prescribing the pharmacist to explain it again (write this on the prescription). Instructions are to follow the dosage schedule, to take the drug at bedtime and not to stop the treatment. Warnings are that the drug may slow reactions, especially in combination with alcohol. Patient 35 (vaginal trichomonas) As in any infection the patient should be told why the course has to be finished completely, even when the symptoms disappear after two days. The patient should also be informed that treatment is useless if the partner is not treated as well. If possible, pictures or leaflets should be used to show the procedure (see Annex 3). Side effects of metronidazole are a metal taste, diarrhoea or vomiting, especially with alcohol, and dark urine. Patient 36 (essential hypertension) The problem with the treatment of hypertension is that patients rarely experience any positive effect of the drugs, yet they have to take them for a long time. Adherence to treatment may be very poor if they are not told why they should take the drug, and if treatment is not monitored regularly. The patient should be told that the drug prevents complications of high blood pressure (angina, heart attack, cerebral problems). You can also say that you will try to decrease the dosage after three months, or even stop the drug entirely. Patient 37 (boy with pneumonia) The patient’s mother should be told that the penicillin will need some time to kill the bacteria. If the course of treatment is stopped too soon, the stronger ones will survive, and cause a second, possibly more serious infection. Knowing that any side effects will disappear soon will increase the likelihood of adherence to treatment. She should also be told to contact you immediately if a rash, itching or rising fever occur. Patient 38 (migraine) In addition to other information the important instruction here is that the drug (preferably a suppository) should be taken 20 minutes before the analgesic, to prevent vomiting. Because of possible sedation and loss of coordination she should be warned not to drive a car or handle dangerous machinery. Drug will prevent complications of high blood pressure (angina, heart attack, cerebrovascular accident). Angina pectoris: decreases blood pressure, prevents the heart from working too hard, preventing chest pain. Angina pectoris: within one month, earlier if attacks occur more frequently, or become more severe. Angina pectoris: in case frequency or severity of the attacks increase, more diagnostic tests or other treatment are needed. Your personal formulary During your medical studies you should continue to expand your list of common complaints and diseases, with your P-drugs and P-treatments. However, very soon you will notice that many drugs are used for more than one indication. Examples are analgesics, certain antibiotics, and even more specific drugs like beta-blockers (used for hypertension and angina pectoris). You can, of course, repeat the necessary drug information with each disease or complaint, but it may be easier to make a separate section in your personal formulary where you collect the necessary information for each of your P-drugs. It is good advice to note the essential instructions and warnings with each P- drug in your personal formulary. If you do this for every new drug you learn to use, the formulary will be reasonably complete and ready for use by the time you finish your medical studies. An example of the contents of such a personal formulary is given on the previous page. Please note that this is not a published text, but should be your personal (handwritten? Effects of the drug Which symptoms will disappear; and when; how important is it to take the drug; what happens if it is not taken; 2.

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Multidrug-resistant tuberculosis in pregnancy: case report and review of the literature 25mg clomid with visa. Treatment of multidrug-resistant tuberculosis during pregnancy: long-term follow-up of 6 children with intrauterine exposure to second-line agents order clomid once a day. Drug-resistant tuberculosis and pregnancy: treatment outcomes of 38 cases in Lima discount 100 mg clomid visa, Peru cheap clomid 50mg without a prescription. Pregnancy outcome following gestational exposure to fluoroquinolones: a multicenter prospective controlled study. Effects of hydroxymethylpyrimidine on isoniazid- and ethionamide-induced teratosis. Study of teratogenic activity of trifluoperazine, amitriptyline, ethionamide and thalidomide in pregnant rabbits and mice. The mode of transmission is thought to be through inhalation, ingestion, or inoculation via the respiratory or gastrointestinal tract. Symptoms include fever, night sweats, weight loss, fatigue, diarrhea, and abdominal pain. Other focal physical findings or laboratory abnormalities may occur with localized disease. Localized syndromes include cervical or mesenteric lymphadenitis, pneumonitis, pericarditis, osteomyelitis, skin or soft-tissue abscesses, genital ulcers, or central nervous system infection. Other ancillary studies provide supportive diagnostic information, including acid-fast bacilli smear and culture of stool or tissue biopsy material, radiographic imaging, or other studies aimed at isolating organisms from focal infection sites. Available information does not support specific recommendations regarding avoidance of exposure. Azithromycin and clarithromycin also each confer protection against respiratory bacterial infections. Patients will need continuous antimycobacterial treatment unless they achieve immune reconstitution via antiretroviral drugs. Improvement in fever and a decline in quantity of mycobacteria in blood or tissue can be expected within 2 to 4 weeks after initiation of appropriate therapy; clinical response may be delayed, however, in those with more extensive disease or advanced immunosuppression. Adverse effects with clarithromycin and azithromycin include nausea, vomiting, abdominal pain, abnormal taste, and elevations in liver transaminase levels or hypersensitivity reactions. Managing Treatment Failure Treatment failure is defined by the absence of a clinical response and the persistence of mycobacteremia after 4 to 8 weeks of treatment. The regimen should consist of at least two new drugs not used previously, to which the isolate is susceptible. Two studies, each with slightly more than 100 women with first-trimester exposure to clarithromycin, did not demonstrate an increase in or specific pattern of defects, although an increased risk of spontaneous abortion was noted in one study. Diagnostic considerations and indications for treatment of pregnant women are the same as for women who are not pregnant. Pregnant women whose disease fails to respond to a primary regimen should be managed in consultation with infectious disease and obstetrical specialists. Microbiology and Minimum Inhibitory Concentration Testing for Mycobacterium avium Complex Prophylaxis. A prospective, randomized trial examining the efficacy and safety of clarithromycin in combination with ethambutol, rifabutin, or both for the treatment of disseminated Mycobacterium avium complex disease in persons with acquired immunodeficiency syndrome. Early manifestations of disseminated Mycobacterium avium complex disease: a prospective evaluation. Incidence of Mycobacterium avium-intracellulare complex bacteremia in human immunodeficiency virus-positive patients. Incidence and natural history of Mycobacterium avium- complex infections in patients with advanced human immunodeficiency virus disease treated with zidovudine. Disseminated Mycobacterium avium-intracellulare infection in acquired immunodeficiency syndrome mimicking Whipple’s disease. Mycobacterium avium complex infection presenting as endobronchial lesions in immunosuppressed patients. Mycobacterial lymphadenitis associated with the initiation of combination antiretroviral therapy. Mycobacterial lymphadenitis after initiation of highly active antiretroviral therapy. Prophylaxis against disseminated Mycobacterium avium complex with weekly azithromycin, daily rifabutin, or both. A randomized trial of clarithromycin as prophylaxis against disseminated Mycobacterium avium complex infection in patients with advanced acquired immunodeficiency syndrome. Discontinuing or withholding primary prophylaxis against Mycobacterium avium in patients on successful antiretroviral combination therapy. Comparison of combination therapy regimens for treatment of human immunodeficiency virus-infected patients with disseminated bacteremia due to Mycobacterium avium. A randomized, placebo-controlled study of rifabutin added to a regimen of clarithromycin and ethambutol for treatment of disseminated infection with Mycobacterium avium complex. A randomized evaluation of ethambutol for prevention of relapse and drug resistance during treatment of Mycobacterium avium complex bacteremia with clarithromycin-based combination therapy. A randomized, double-blind trial comparing azithromycin and clarithromycin in the treatment of disseminated Mycobacterium avium infection in patients with human immunodeficiency virus. Uveitis and pseudojaundice during a regimen of clarithromycin, rifabutin, and ethambutol. Tolerance and pharmacokinetic interactions of rifabutin and clarithromycin in human immunodeficiency virus-infected volunteers. Paper presented at: national Jewish Center for Immunology and Respiratory Medicine. Recommendations on prophylaxis and therapy for disseminated Mycobacterium avium complex disease in patients infected with the human immunodeficiency virus. In vitro activity of new fluoroquinolones and linezolid against non- tuberculous mycobacteria. Postmarketing surveillance of medications and pregnancy outcomes: clarithromycin and birth malformations. Tachypnea and decreased arterial oxygen saturation indicate moderate-to-severe pneumonia and clinicians should strongly consider hospitalizing such patients. Patients with bacterial pneumonia typically have signs of focal consolidation, such as egophony, and/ or pleural effusion on lung examination. Individuals with bacterial pneumonia characteristically exhibit unilateral, focal, segmental, or lobar consolidation on chest radiograph. The frequency of these typical radiographic findings, however, may depend on the underlying bacterial pathogen. Disease severity and arterial oxygenation should be assessed in all patients with pneumonia. Noninvasive measurement of arterial oxygen saturation via pulse oximetry is an appropriate screening test. Arterial blood gas analysis is indicated for those with evidence of hypoxemia suggested by noninvasive assessment and for patients who have tachypnea and/or respiratory distress. If previous radiographs are available, they should be reviewed to assess for presence of new findings. Gram stain and culture of expectorated sputum should be performed only if a good-quality specimen can be obtained and quality performance measures can be met for collection, transport, and processing of samples. Correlation of sputum culture with Gram stain can help in interpretation of sputum culture data. Bronchoscopy with bronchoalveolar lavage should be considered, especially if the differential diagnosis is broad and includes pathogens such as Pneumocystis jirovecii. Diagnostic thoracentesis should be considered in all patients with pleural effusion, especially if concern exists for accompanying empyema, and therapeutic thoracentesis should be performed to relieve respiratory distress secondary to a moderate-to-large-sized pleural effusion. Modifiable factors associated with an increased risk of bacterial pneumonia include smoking cigarettes and using injection drugs and alcohol. Antibiotic therapy should be administered promptly, however, without waiting for the results of diagnostic testing. Preferred beta-lactams are high-dose amoxicillin or amoxicillin-clavulanate; alternatives are cefpodoxime or cefuroxime.

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