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The most common underlying dis- eases are autoimmune diseases discount rumalaya liniment 60 ml without prescription, malignancies (lymphoma 60 ml rumalaya liniment for sale, prostate cancer) generic rumalaya liniment 60 ml visa, and derma- tologic diseases. Developing the coagulation disorder later in life is more suggestive of an acquired inhibitor if there is no antecedent history of coagulopa- thy. A tobacco history and laboratory evidence of chronic illness (anemia, hypoalbuminemia) in this scenario raise the suspicion of an underlying malignancy. It has a prevalence in the general population of 1:5000 in contrast to Hemophilia B that has a prevalence of 1:30,000. The disease phe- notype correlates with the amount of residual Factor activity and can be classified as se- vere (<1% activity), moderate (1–5% activity) or mild (6–30% activity). Hemophiliacs have a normal bleeding time, platelet count, thrombin time and prothrombin time. This and the presence of ascites raise the possibility of liver disease and cirrhosis. It is estimated in 2006 that >80% of hemophilia patients >20 years old are infected with hepatitis C virus. Hepatitis C is the major cause of morbidity and the second leading cause of death in patients exposed to older factor concentrates. Patients develop cirrhosis and the complications including as- cites and variceal bleeding. Hepatitis B was not transmitted in significant numbers to patients with hemophilia. Diverticular dis- ease or peptic ulcer disease would not explain the prolonged prothrombin time. In contrast, these tests should not fluctuate as much in patients with severe liver disease. This step may be not necessary however in those individ- uals with hemoglobin greater than 20 g/dL. Once absolute erythrocytosis has been deter- mined by measurement of red cell mass and plasma volume, the cause of erythrocytosis must be determined. If there is not an obvious cause of the erythrocytosis, an erythropoi- etin level should be checked. An elevated erythropoietin level suggests hypoxia or auton- omous production of erythropoietin as the cause of erythrocytosis. When symptoms are present, the most common complaints are related to hyperviscosity of the blood and include vertigo, headache, tinnitus, and transient ischemic attacks. Molluscum contagiosum gency room with a transient ischemic attack characterized B. She calls your office 2 weeks later slightly distressed man with disheveled appearance. Cardiac examination reveals an early diastolic murmur over the left 3d intercostal space. Write her a prescription for oseltamivir and call her right hand and on the fourth finger of his left hand that are in 24 h to ensure improvement. A 56-year-old man with a history of hypertension cells coated with coccobacillary organisms. Which of the and cigarette smoking is admitted to the intensive care following therapies is indicated? Minority women aged 13–19 from the southeastern mens is recommended as first-line treatment for her United States account for a growing proportion of malarial infection? Which of the following is true years ago and is maintained on prednisone, 5 mg, and cy- regarding enteroviruses as a cause of aseptic meningitis? A 38-year-old female pigeon keeper who has no sig- trichomonal parasites are identified. Which of the follow- nificant past medical history, is taking no medications, has ing statements regarding trichomoniasis is true? When given as a first-line agent for invasive As- her shoulder presents with fever and severe low back pain. Bilirubin, lactose dehydrogenase, as well as gram-negative coverage and haptoglobin are all within normal limits. White blood cell count is 4300, with an of friends go on a 5-day canoeing and camping trip in ru- absolute neutrophil count of 2500. Which of the following tests is most likely to ers develops a serpiginous, raised, pruritic, erythematous produce a diagnosis? Treatment only for symptomatic illness ioides infection in an immunocompetent host? Asymptomatic seroconversion not been compliant with his physician’s request to off- C. A metal probe is used to probe the wound and it detects bone as well as a 3-cm deep cavity. You are a physician working on a cruise ship travel- Gram stain of the pus shows gram-positive cocci in ing from Miami to the Yucatán Peninsula. In the course of chains, gram-positive rods, gram-negative diplococci, 24 h, 32 people are seen with acute gastrointestinal illness enteric-appearing gram-negative rods, tiny pleomor- that is marked by vomiting and watery diarrhea. The phic gram-negative rods, and a predominance of neu- most likely causative agent of the illness is trophils. Isolation in cell culture health care provider after an accidental needle stick from E. The patient whose blood is on the contaminated therapeutic regimen for mono-infection with hepatitis B? Adequate therapy that allows for eradication of in- with severe dyspnea, confusion, productive cough, and fe- fection in index cases before person-to-person vers. She had been ill 1 week prior with a flulike illness spread can occur characterized by fever, myalgias, headache, and malaise. Earlier diagnosis due to a new culture assay Her illness almost entirely improved without medical in- C. Federal laws limiting the import of foreign cattle tervention until 36 h ago, when she developed new rigors D. Laws prohibiting the feeding of uncooked garbage followed by progression of the respiratory symptoms. On examination she is clammy, confused, and very cells, moderate gram-positive cocci in chains, and yeast dyspneic.

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Mitotane inhibits glucocorticoid biosynthesis and selectively causes atrophy of the tumors within zona reticularis and fasciulata by an unknown mechanism buy rumalaya liniment 60 ml cheap. Progestins are useful in the management of endometrial hyperplasia and carcinoma and as second-line therapy for metastatic hormone-dependent breast cancer buy rumalaya liniment 60 ml without a prescription. Estrogens inhibit the effects of endogenous androgens and androgen-dependent metastatic prostatic carcinoma purchase rumalaya liniment 60 ml with visa. Cardiac and cerebrovascular complications and carcinoma of breast, endometrium, and ovary are potential adverse effects. Tamoxifen and toremifene are used in postmenopausal women with or recovering from meta- static breast cancer. Tamoxifen is also used as adjunctive therapy to oophorectomy and to leuprolide or goserelin (see below) in premenopausal women with estrogen receptor-positive tumors. Tamoxifen and raloxifen are used as prophylactic agents in women at high risk for breast cancer. Moderate nausea, vomiting, and hot flashes are the major adverse effects of tamoxifen; endo- metrial cancer and thrombosis are potential adverse effects of long-term therapy. Pure antiestrogens, Fulvestrant (Faslodex) Fulvestrant is a pure anti-estrogen; it has no agonist activity in any tissue. It is approved for use in hormone receptor positive metastatic breast cancer in postmenopausal women with disease pro- gression following antiestrogen therapy H. Gonadotropin-releasing hormone analogues: leuprolide (Lupron), triptorelin (Trelstar), and goser- elin (Zoladex) 1. Use of these agents results in castration levels of testosterone in men and postmenopausal levels of estrogen in women. These agents are effective in prostatic carcinoma and in estrogen-positive breast cancer. Leuprolide and goserelin are often administered with antiandrogen fluta- mide (Eulexin) or bicalutamide (Casodex), which block the translocation of androgen receptors to the nucleus and thereby prevent testosterone action. Aromatase inhibitors: Anastrozole (Arimidex), Letrozole (Femara), Exemestane (Aromasin), Amino- glutethimide (Cytadren) 1. Anastrozole and letrozole are reversible aromatase inhibitors that have no effect on synthesis of steroids other than estrogens. Anas- tozole is approved for use in women who have received 2–3 years of tamoxifen and are switch- ing to anastrazole for a total of 5 years of adjunct therapy. Recent studies have shown that anastrozole offers advantage over tamoxifen in these circumstances. This agent is used for postmenopausal women with breast cancer who have progressed on tamoxifen. Aminoglutethimide inhibits corticosteroid synthesis as well as the enzyme aromatase, which aids in conversion of androstenedione to estrone. This agent is used in treatment of metastatic receptor-positive breast cancer (both estrogen and progestin receptors); it has also been used in prostate cancer. Hydrocortisone has to be administered at the same time to prevent adrenal insufficiency. All of the above agents are thrombolemic but with a reduced incidence compared to tamoxifen. Androgen antagonists: flutamide (Eulexin), bicalutamide (Casodex), nilutamide (Nilandron) 1. Flutamide and bicalutamide are competitive antagonists of the androgen receptor; nilutamide is an irreversible inhibitor of the androgen receptor. These agents are used in combination with either chemical or surgical castration for the treat- ment of prostate cancer. Adverse effects are due to decreased androgen activity and include fatigue, loss of libido, and impotence. Leucovorin (folinic acid, [Fusilev]) is a form of folate that is used to ‘‘rescue’’ patients from methotrexate toxicity (Fig. Epoetin alfa (Epogen) and darbepoetin alfa (Aranesp) are used in anemia caused by chemother- apy or renal failure. It inhibits xanthine oxidase and is frequently used during chemotherapy to prevent acute tumor cell lysis that results in severe hyperurice- mia and nephrotoxicity. Oprelvekin (Neumega) is a recombinant interleukin that is indicated for chemotherapy- induced thrombocytopenia as well as for prophylaxis of this potentially dangerous complication. Amifostine (Ethyol) is a cytoprotective agent that is dephosphorylated to active free thiol, which then acts as a scavenger of free radicals. It is also used to reduce xerostoma in patients undergoing irradiation of head and neck regions. A second-year medical student finds a few occasional bright red blood in the stool. A fur- hours a week to work in a cancer research labo- ther work-up, including computed tomography ratory. She performs which of the following chemotherapeutic Northern blot analysis on multiply resistant cell agents? A 53-year-old woman with breast cancer undergoes a breast-conserving lumpectomy 2. The pathology report bouts of hypoglycemia with mental status returns with mention of cancer cells in two of changes that are rapidly reversed by eating. Following radia- is not diabetic, and his serum levels of insulin tion therapy, chemotherapy is started that are markedly elevated. A 74-year-old man with a 100-pack/year his- tory of smoking is evaluated for hemoptysis. The bi- agent’s activity is related to its ability to do opsy report is small-cell carcinoma of the lung, what? A 53-year-old man presents with changes in fragmentation bowel frequency and pencil-thin stools with 304 Chapter 12 Cancer Chemotherapy 305 7. Her initial diagnosed with early stage breast cancer, which treatment will include both cyclophosphamide is initially managed by partial mastectomy and and doxorubicin.

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Delirium is asso- ciated with a substantial mortality with in-hospital mortality estimates ranging from 25– 33%. Overall estimates of delirium in hospitalized patients range from 15–55% with higher rates in the elderly. Postoperative patients, especially status post hip surgery, have an incidence of delirium that is some- what higher than patients admitted to the medical wards. Because of these associated symptoms, pa- tients may be misdiagnosed as having sinus headache due to allergic rhinitis and treated inappropriately with antihistamine and nasal steroids. A typical presentation of cluster headaches is one of episodic severe headaches that occur at least once daily at about the same time for a period of 8–10 weeks. An attack usually lasts from 15–180 minutes, and 50% of headaches will have nocturnal onset. Men are af- fected three times more commonly with cluster headaches than women, and alcohol in- gestion may trigger cluster headaches. 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.