A 41-year-old female presents to your clinic with 3 she intermittently developed painful mouth ulcerations that weeks of weakness purchase 20 mg prilosec, lethargy purchase prilosec with american express. She also reports a severe “sun- notes increasing difﬁculty with climbing steps buy prilosec 40 mg online, rising from burn” on her face 10mg prilosec overnight delivery, upper neck, and back that occurred after a chair, and combing her hair. The patient also notes some past medical history is positive for two spontaneous vaginal dyspnea on exertion and orthopnea. She is taking oral contraceptive pills and has no tions, and the past medical history is otherwise uninfor- allergies. The physical examination is notable for an beats/min, respiratory rate 12 breaths/min, SaO2 98% on elevated jugular venous pressure, an S , and some bibasilar room air. This area has an atrophic center proximal muscle weakness in the deltoids and biceps and with hair loss and is erythematous with a hyperpigmented the hip ﬂexors. Her conjunctiva are pink and no scleral icterus is examination and reﬂexes are normal. The oropharynx shows a single 2-mm aphthous ul- remarkable except for a negative antinuclear antibody ceration on the buccal mucosa. All the following clinical condi- The patient is incapable of closing her hands tightly. In addi- tions may occur in polymyositis except tion, there is warmth and a possible effusion in the right knee and tenderness with range of motion in the left knee. A 64-year-old man with congestive heart failure pre- Mean corpuscular hemoglobin count 32 g/dL sents to the emergency room complaining of acute onset of Platelet 98,000/mL severe pain in his right foot. The pain began during the night The differential is 80% polymorphonuclear cells, 12% lym- and awoke him from a deep sleep. He reports the pain to be phocytes, 7% monocytes, 1% eosinophils, and 1% basophils. She carial lesions, which occasionally leave a residual discol- denies any prior similar episodes. The sedimentation ually active and estimates her last sexual activity to be 8 rate now is 85 mm/h. She has a history of seasonal the correct diagnosis in this case would be rhinitis, but is taking no medications currently. Arthrocentesis is The pain is worse in the morning and when the patient is performed and is consistent with inﬂammatory arthritis barefoot. On examination, pain can be elicited with pal- without crystals or organisms seen on Gram stain. Which of the fol- cal probes for Neisseria gonorrhoeae and Chlamydia lowing is required to make a deﬁnitive diagnosis of trachomatis are negative. Chronic joint symptoms affect 15% of individuals, cine bone scan and recurrences of the acute syndrome may occur. Reactive arthritis is self-limited and should be ex- demonstrating heel spur pected to resolve spontaneously over the next 2 weeks. Which of the following ﬁndings on joint aspiration comes following an initial episode of reactive arthritis. A 54-year-old female with rheumatoid arthritis is treated with inﬂiximab for refractory disease. Fluid, clear and viscous; white blood cell count, 400/ lowing are potential side effects of this treatment except µL; crystals, rhomboidal and weakly positively bire- fringent A. A 26-year-old man presents with severe bilateral 12,000/µL; crystals, needle-like and strongly nega- pain in his hands, ankles, knees, and elbows. He is recov- tively birefringent ering from a sore throat and has had recent fevers to E. Social history is notable for recent unprotected 4800/µL; crystals, rhomboidal and weakly positively receptive oral intercourse with a man ~1 week ago. Physi- birefringent cal examination reveals a well-developed man in moderate discomfort. A 45-year-old woman presents to the emergency with pustular exudates on his tonsils. He has tender ante- room for evaluation of fatigue, fever, and acute onset of rior cervical lymphadenopathy. His cardiac examination joint pain and swelling of the right knee, left ankle, and is notable for a normal S1 and S2 and a soft ejection mur- right second toe. He has no rash, and genital examination is tion as the symptoms resolved spontaneously over 48 h. Three days ago, she developed a feeling of malaise sophalangeal joints are red, warm, and boggy with ten- with fevers and pain in her right second toe. His erythrocyte sedimentation recently noticed stiffness and pain in her hips, making it rate is 85 mm/h and C-reactive protein is 11 mg/dL. Acute rheumatic fever carotid bruits present, but palpation of the temporal ar- C. Which rent treatment consists of azathioprine 75 mg/d and of the following is the next most important step in the prednisone 5 mg/d. Warn her that exacerbations can occur in the ﬁrst time to obtain full anticoagulation. A patient presents with 3 weeks of pain in the lower lipin antibodies are detected in her serum. Stop the prednisone just before she attempts to be- of spine pathology except come pregnant. A 64-year-old man with coronary artery disease and following treatments has been shown to improve symp- atrial ﬁbrillation is referred for evaluation of fevers, ar- toms the best at this stage of the illness? Antibodies directed against which of room for an episode of vision loss in her right eye. A 28-year-old woman seeks evaluation from her pri- nary artery disease, undergoing angioplasty and stenting mary care doctor for recurrent episodes of hives and of the right coronary artery 8 years previously. An 18-year-old man is admitted to the hospital with hives has become more frequent. Other than cold expo- acute onset of crushing substernal chest pain that began sure, she can identify no other triggers for development abruptly 30 min ago. He currently plays trumpet in his high school tive pills, which she has taken for 5 years. She lives in a marching band but does not participate regularly in aero- single-family home that was built 2 years ago. On physical examination, he is diaphoretic nation, she develops a linear wheal after being stroked and tachypneic. His cardiovascular examina- her hand in cold water, her hand becomes red and swol- tion has a regular rhythm but is tachycardic. In addition, there are several areas with a wheal and systolic murmur is heard best at the apex and radiates to ﬂare reaction on the arm above the area of cold exposure. Assess for the presence of antithyroglobulin and an- past medical history, he recalls having been told that he timicrosomal antibodies. A 34-year-old man is admitted to the hospital for eval- cause of this patient’s acute coronary syndrome? Presence of a myocardial bridge overlying the left aise, and intermittent fevers to as high as 38. About 3 anterior descending artery weeks ago, he sought treatment from his primary provider C. Stenosis of a coronary artery aneurysm for sinus pain and congestion with a purulent and bloody D. Vasculitis involving the left anterior descending artery sulbactam, but his symptoms have only minimally im- proved. A 29-year-old male with episodic abdominal pain bolic panel was performed which showed a creatinine of 2. A urinalysis showed 1+ protein with 25 red blood casionally the larynx is likely to have low functional or cells per high-power ﬁeld. Antiglomerular basement membrane antibodies and symptoms of carpal tunnel syndrome.
An attack usually lasts from 15–180 minutes buy prilosec visa, and 50% of headaches will have nocturnal onset buy 10 mg prilosec with mastercard. Men are af- fected three times more commonly with cluster headaches than women purchase prilosec 20 mg with amex, and alcohol in- gestion may trigger cluster headaches generic prilosec 20 mg line. A distinguishing feature between cluster headaches and migraine headaches is that individuals with cluster headaches tend to move about during attacks and frequently rub their head for relief, whereas those with migraines tend to remain motionless during attacks. Interestingly, unilateral phonophobia and photo- phobia can occur with cluster headaches but do not with migraines. Treatment of acute at- tacks of cluster headaches requires a treatment with a fast onset as the headaches reach peak intensity very quickly but are of relatively short duration. High-ﬂow oxygen (10–12 L/min for 15–20 min) has been very effective in relieving the headaches. Alternatively, sub- cutaneous or intranasal delivery of sumatriptan will also halt an attack. The oral-route triptan medications are less effective because of the time to onset of effect is too great. Pre- ventive treatment may be considered in individuals with prolonged bouts of cluster head- aches or chronic cluster headaches that occur without a pain-free interval. Paroxysmal hemicrania is characterized by unilateral severe head- aches lasting only 2–45 min but occurring up to ﬁve times daily. In this case, the plan to switch to long-term maintenance with steroid-sparing immunosuppressants should still be pur- sued. There have been no controlled studies comparing mycophenolate to methotrexate for the long-term use in polymyositis, and in the absence of an adverse reaction to myco- phenolate, therapy should not be changed. Dermatomes above and below the level of the destruction are usually spared, cre- ating a “suspended sensory level” on physical examination. As the lesion grows, corticospinal tract or anterior horn involvement can produce weakness in the affected myotome. Common causes include syringomyelia, intramedullary tumor, and hyperex- tension in a patient with cervical spondylosis. A lateral hemisection syndrome (the Brown-Séquard syndrome) is classically due to penetrating trauma from a knife or bullet injury and produces ipsilat- eral weakness and contralateral loss of pain and temperature sensation. Amyotrophic lat- eral sclerosis presents with combined upper and lower motor neuron ﬁndings; sensory deﬁcits are uncommon. Hyperventilation causes vasoconstriction, reducing cerebral blood vol- ume and decreasing intracranial pressure. However, this can be used only for a short pe- riod as the decrease in cerebral blood ﬂow is of limited duration. Mannitol, an osmotic diuretic, is recommended in cases of increased intracranial pressure resulting from cyto- toxic edema. Instead, hypertonic saline is given to elevate sodium levels and prevent worsening of edema. Further decreases in mean arterial pressure may worsen the patient’s clinical status. The patient already has had more than a 20% reduction in mean arterial pressure, which is the recommended reduc- tion in cases of hypertensive emergency. Finally, in cases of increased intracranial pressure, nitroprusside is not a recom- mended intravenous antihypertensive agent because it causes arterial vasodilation and may decrease cerebral perfusion pressure and worsen neurologic function. It is also associated with increased complications during pregnancy (premature rupture of membranes, placenta previa, abruption placenta), delay in healing of peptic ulcers, osteoporosis, cataracts, macular degeneration, cholecystis in women, and impo- tence in men. Children born to smoking mothers are more likely to have preterm deliv- ery, higher perinatal mortality, higher rates of infant respiratory distress, and higher rates of sudden infant death. In this disorder paroxysmal vertigo resulting from labyrinthine lesions is associated with nausea, vomiting, rotary nystagmus, tinnitus, high-tone hearing loss with recruitment, and, most characteristically, fullness in the ear. Vertebral-basilar insufﬁciency and multiple sclerosis typically are asso- ciated with brainstem signs. Acoustic neuroma only rarely causes vertigo as the initial symptom, and the vertigo it does cause is mild and intermittent. A positive sign occurs when the patient has head/neck pain when pas- sively straightening the knee. The sensitivity and speciﬁcity of this sign (also Brudzinski’s) for bacterial meningitis are unknown, but they imply meningeal irritation, not an intracra- nial lesion or elevated intracranial pressure. While cerebrospinal ﬂuid cultures may be im- pacted by administration of antibiotics prior to lumbar puncture, stains, antigen tests, and polymerase chain reaction tests will not be affected. The normal respiratory response to decreased atmospheric oxygen tension is to increase the respiratory rate. This hyperventilation causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias. Acetazolamide is often given to patients who have a past history of altitude sickness manifested as headache, nausea with vomiting, and in severe cases pulmonary edema. This patient is experiencing none of those symptoms, and in fact, dysesthesias are a common side effect related to treatment with acetazolamide. No further blood testing is necessary as the symptoms are not asso- ciated with any neurologic abnormalities. Diabetes mellitus, vitamin B12 deﬁciency, and tertiary syphilis are all associated with a sensory neuropathy, which this patient does not demonstrate. The course can ﬂuctuate over the course of a day, which may explain why his symptoms appear worse at the end of the day. The absence of any sensory deﬁcit is also characteristic of a neuromuscular junction disorder. Diseases of the muscle usually do not exhibit such a marked difference on the examination over the course of hours. Spinal root disorders are symptomatic in a nerve root distribution, and limb pain is usu- ally a prominent component. Clues to a brainstem disease are isolated cranial nerve pal- sies and “crossed” weakness and sensory abnormalities of the head and limbs. Because the clinical scenario is consistent with a myelopathy, an electromyogram is not indicated. Migraine headache, limb weakness, and breathing difﬁculties are non- speciﬁc but may be seen in serotonin syndrome or alcohol withdrawal. Hypertension, tachycardia, and diaphoresis may be seen in a patient with an Arnold-Chiari malformation. Postconcus- sive syndrome is a constellation of symptoms including fatigue, headache, dizziness, and difﬁculty concentrating that follows a concussion. The patient described above ﬁts this di- agnosis; strict diagnostic criteria do not exist. Patients who were energetic and highly functioning prior to their trauma have an excellent prognosis. The human prion diseases described to date include Creutzfeldt- Jacob disease, kuru, Gerstmann-Straüssler-Scheinker disease, and fatal insomnia. Symptoms are often not present, and severe ﬁndings such as paralysis and urinary incontinence are rare. Acquired factors that contribute to spinal stenosis include trauma, osteoporosis, hypo- parathyroidism, renal osteodystrophy, and Paget’s disease. Tethered cord syndrome usu- ally presents as a cauda equina disorder (urinary incontinence, perineal anesthesia) in a young adult. Pain associated with disk herniation is differentiated from spinal stenosis when the pain is made worse with sitting. Vertebral metastases are a common cause of back pain in patients at risk of common malignancies. Mesial temporal lobe epilepsy is the most common syndrome associated with complex partial seizures. Patients are unable to respond to verbal or visual commands during the seizure and they often manifest complex automatisms or complex posturing. Patients often have a history of febrile seizures or a family history of seizures.
At the end of the season cheap prilosec 40 mg overnight delivery, in- experiences of offce visits in clinics and treatment failures discount 40mg prilosec mastercard. Shoul- dependent variables were selected and analysed using Cox propor- der pain and elbow pain were top two complaints order prilosec cheap online. Results: complaints were hand numbness order 40 mg prilosec fast delivery, hip pain, upper back pain and low The injury incidence was 47. A majority of injuries (70%) occurred in the frst visiting the sport clinic for disabled athletes will help further im- 35 hours of exposure. The aim of this trail is sys- history and female players are at a greater risk for rugby-related tematically evaluate the protective effects of Baduanjin exercise injuries in university players. The transition from off-season train- on ischemic stroke risk in the community elder population with ing to increase in training volume may need careful consideration high risk factors. Acknowledgments: The authors thank the Hong participants were randomly allocated into the Baduanjin exercise Kong Rugby Football Union and players from the 3 university and control group (usual physical activity group) in a 1:1 ratio. Participants in the Baduanjin group accepted a 12-week Badu- anjin exercise training with a frequency of 5 days per week and 60 minutes one day, while those in the control group maintained 807 their original physical activity. It affects the sport clusion: Regular Baduanjin exercise may be beneft to improv- performance, absence from training sesions or games and reduce ing cerebral hemodynamic parameters, blood pressure, sleep and quality of life. Risk factor of sport injury of lower extremity can mood in community elder adults with risk factors of ischemic be classifed as intrinsic risk, exposure to extrinsic risk and inciting stroke. Acknowledgements: This study is supported lete, exposure to extrinsic risk factors make the susceptible athlete by the Program for Fujian Provincial Health and Family Planning and inciting event factors will trigger injured athlete. At very early phase, the identifcation of intrinsic risk factors is very important. Type of sport were classifed from most high contact/impact to less high contact/impact. Landing task 2 2 2 2 was correlated positively to non weight bearing quadriceps angle Ogurkowski , I. Introduction/Background: Raising a child with a disability re- duces fulfllment parents, which contributes to a reduction in the quality of life of caregivers. Results: The studies that women Rehabilitation Medicine, Fuzhou, China, 2Fujian University of are weaker than men emotionally. The results showed that among Traditional Chinese Medicine, Department of Physical Education, the families surveyed more frequent in girls with disabilities. Frequently deterioration in the relationship between parents dete- 811 riorating since the emergence of a disabled child. Community-based programs can be an appropri- ate approach to address developmental needs of youth refugees. Participants engaged in ten one-hour group training, incorporating Bandura’s Self-Effcacy theory and the logic model rology- Department of Education and Research, Taipei, Taiwan, 2 process. The Program included fve modules: attitude, responsibil- National Taipei University of Nursing and Health, Department of 3 ity, communication, problem solving and college or job prepara- Health Care Management, Taipei, Taiwan, National Yang-Ming tions. Results: Descriptive and inferential statistics were conducted University, Institute of Health and Welfare, Taipei, Taiwan, 4Wan on the six assessment tools completed prior to and following each Fang Hospital - Taipei Medical University, Department of Neuro- of the appropriate training modules. Scoring improved for all meas- surgery- Department of Physical Medicine and Rehabilitation, Tai- ures. The Program Feedback Form indicated the life skills train- pei, Taiwan, 5Wan Fang Hospital - Taipei Medical University, De- ing has a signifcant effect on student’s English skills (t=7. Introduction/Background: Issues related to aging is a great con- The life skills training demonstrated potential for improving the cern in Taiwan. Aging population comprised 12% of the popula- skills development of self-effcacy and college preparation for par- tion in 2014, will hit 14% in 2018 and 20% in 2025, making Tai- ticipants. The government is making efforts to in education, religious activities, relationships, future aspirations, provide the elderly with adequate provisions, reduce the burden on helping others, and volunteerism within a variety of contexts. Con- caretakers and spur development of sectors catering to the specifc clusion: Adolescent refugees often face with obstacles and new needs of this population group. Due to cultural differences, nity hospital, our day care center is the frst institution providing these opportunities may be perceived as a struggle. Ma- suggest the importance of skills training for adolescent refugees by terial and Methods: In the day care center of Yangming Branch, building their capacities. Taipei City Hospital, Taiwan, we arrange recreational therapy programs to stimulate cognitive functions, gross and fne motor function, and equilibrium. Conclusion: Day care center of Yangming Branch, Taipei City Hospital, Taiwan, a N. According to our experiences, recreational therapy can help icine, Kuala Lumpur, Malaysia, 3University Malaya, Rehabilitation disabled dementia patients improve or maintain their functional Medicine Department, Kuala Lumpur, Malaysia and psychological status. The authors believe that the programs can apply not Introduction/Background: Diabetic Charcot foot can cause gross only to hospital-based day care center, but also in non-hospital- structural deformities of the foot and ankle, and subsequent skin based day care centers. Chung have equal study is to explore complications of diabetic charcot foot in particu- contribution to this poster. Moridnia 1Shahid Beheshti University of Medical Sciences, Clinical Re- mortality rate during the follow-up period was 15. The mean survival time based on Kaplan- Maier Survival Analysis search Development Center of Shahid Modarres Hospital and is 44. The remaining 83 alive sample population Physical Medicine and Rehabilitation Research Center, Tehran, (84. Conclusion: Recurrent new philosophy which tries to lead clinical services to effective and ulcer in Charcot foot patients has high predilection towards limb advantageous ways with the least side effects and errors. Members of faculty, participants who referrals from all states in Malaysia for intensive spinal rehabilita- had attended workshops and physicians who spent more time on tion program or other specialised rehabilitation programs that are research and article review had more knowledge (p=0. Hence, epidemiology data on spinal cord 3 most common sources used for research were PubMed, Google injured patients that was analysed in this study should represent scholar and Cochrane, respectively. Material and Methods: cal practice, the most common source used was reference books Data on all new patients admitted to Spinal Rehabilitation Ward in (86. Analysis was done on the incidence, with getting access to associated databases and lack of suffcient age, gender and level of injury. Results: From Aug 2014 until Nov activity in judging and analyzing related articles. Age group of the studied population are as shown in with its concepts and applications. It may also of benefts for effcient resource allocation for the rehabilitation management of spinal cord injured 1Thomas Jefferson University, Rehabilitation Medicine, Philadel- patients in Malaysia. Material and Methods: The authors reviewed a sample of 220 discharges from J Rehabil Med Suppl 55 Poster Abstracts 237 Thomas Jefferson University Hospital rehabilitation unit readmit- to prevent absenteeism due to sickness. Readmissions were categorized as: (1) from the reha- questionnaire focusing on the organizational setting and its impact bilitation hospital to the acute hospital or (2) from the community on employee wellbeing – reported as mental energy, work-related to the acute care hospital. The questionnaire measures good into categories to provide meaningful information to implement and poor work environment factors to help managers improve or- policies to minimize readmissions. The questionnaire was validated qualitatively plete management, (2) recurrences, and (3) development of new and quantitatively. Cases with new conditions: thors followed a company undergoing organizational change and 36 (73%. Cases with ers uncertain about employee mental status can measure employee new conditions: (54%). Cases with incomplete care or recurrences: wellbeing easily and cost effectively to prevent illness. Conclusion: (1) Most of the cases were readmitted to created a method, statistically evaluated, to proactively identify acute hospitals before completion of their rehabilitation hospital good and poor work Environments to promote healthy co-workers. Japan, 2Fujita Health University, School of Medicine, Toyoake, Hashemi2 Japan, 3Fujita Health University Hospital, Department of Reha- 1 bilitation, Toyoake, Japan, 4Fujita Health University Banbuntane Physical Medicine and Rehabilitation Research Center of Shahid Beheshti University of Medical Sciences and Clinical Research De- Hotokukai Hospital, Department of Rehabilitation, Nagoya, Japan velopment Center of Shahid Modarres Hospital, Physical Medicine 2 Introduction/Background: Previous studies have shown that toe and Rehabilitation, Tehran, Iran, Physical Medicine and Reha- clearance during the swing phase affects the risk of tripping; this bilitation Research Center of Shahid Beheshti University of Medi- is considered a predominant cause of falls. In healthy subjects, toe cal Sciences, Physical Medicine and Rehabilitation, Tehran, Iran, clearance is obtained mainly by lower limb movements. However, 3Arak University of Medical Sciences-Vali-Asr Hospital, Physical in stroke patients, the compensatory movements are more important Medicine and Rehabilitation, Tehran, Iran in obtaining toe clearance. The purpose of this preliminary study is to clarify the system of obtaining toe clearance in stroke patients in Introduction/Background: Trend to non surgical treatments in mus- comparison to healthy subjects.
Lupus and sarcoid can both present with facial rashes; however prilosec 10 mg fast delivery, the periorbital involvement seen here is more associated with dermatomyositis 40mg prilosec amex. Rheumatoid arthritis and scleroderma are not distinctly associated with facial rashes prilosec 40 mg overnight delivery. It is characterized by erythematous proven 20mg prilosec, sharply demarcated papules and rounded plaques covered by a silvery scale. Fingernail lesions such as pitting, onycholysis, or nail thickening or subungual hy- perkeratosis are present in 50% of patients. Topical treatment options for psoriasis include mid-potency glucocorticoids, vitamin D analogues, retinoids, and ultraviolet light. Oral glucocorticoids should not be used for the treatment of psoriasis due to the life-threatening risk of devel- oping pustular psoriasis when therapy is discontinued. They typically begin on the trunk and consist of symmetric macules and pap- ules that may become conﬂuent. In contrast to Stevens-Johnson syndrome and toxic shock syndrome, involvement of the mucus mem- branes is uncommon. The rash usually develops within 1 week of initiation of therapy and resolves with discontinuation. The most common drugs that cause morbilliform eruptions in- clude penicillin derivatives, allopurinol, sulfonamides, and nonsteroidal anti-inﬂamma- tories. Pemphigus is an autoimmune bullous disease of the skin and mucus membranes that is rarely associated with drugs such as penicillin. Biopsy of this lesion would show neutrophil-rich inﬁl- trates in the dermal papillae. There is no associ- ation with carpal tunnel syndrome or type 1 diabetes mellitus. Tinea pedis is commonly associated with tinea manuum, unguium, or cruris (dermato- phytosis of the hands, nails, or groin, respectively). Candidal onychomy- cosis usually occurs only in the immunocompromised host or with chronic mucocutane- ous candidiasis. The lesions are usually erythematous papules or plaques with a thick scale that occludes hair follicles. If that is ineffective, systemic therapy with an aminoquinoline antimalarial may be indicated. Systemic glucocorticoids or immunosuppressives are not indicated for local- ized disease. Although malignant melanoma may take on myriad appearances, the loca- tion, progress, and description of this lesion is more suggestive of discoid lupus, therefore, surgical excision and lymph node dissection are not indicated at this time. Multiple primary lesions, regional adenopathy, and secondary bacterial infection are variably present. 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.