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Excess bile salts are excreted and deposited in the skin resulting in jaundice and generalized itching discount 500 mg keftab with visa antibiotics for acne clindamycin. Possible interventions • Administer antipruritics as prescribed (often not very effective) discount keftab 125 mg on-line antimicrobial home depot. Possible complications due to cirrhosis Ascities Damage to liver cells can cause disturbance in the bodies excretory system discount keftab 500mg line bacteria lab report, causing fluid to accumulate in the abdominal cavity. Possible interventions • Observe all patients with hepatitis B for possible accumulation of fluid in the abdomen. This may progress in terminal illness to incontinence of urine and faeces and coma. Possible Interventions • Observe the patient for early signs of altered mental functioning and report any changes promptly. Risk of haemorrhage The liver may be unable to metabolise Vitamin K, in order to produce prothrombin (clotting factor), therefore the patient is potentially at risk of haemorrhage. Aims of care: to minimize risk of hæmorrhage Possible interventions • Observe for symptoms of anxiety, epigastric fullness, restlessness and weakness, which may indicate bleeding. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals Updated December 2017 I. Roles and Responsibilities of Authors, Contributors, ical Journal Reviewers, Editors, Publishers, and Owners 1. Publishing and Editorial Issues Related to Publication porting of research and other material published in medical in Medical Journals journals, and to help authors, editors, and others involved A. Corrections, Retractions, Republications, and Ver- in peer review and biomedical publishing create and dis- sion Control tribute accurate, clear, reproducible, unbiased medical journal B. The recommendations may also provide useful in- and Retraction sights into the medical editing and publishing process for the C. Duplicate and Prior Publication These recommendations are intended primarily for use 3. Acceptable Secondary Publication by authors who might submit their work for publication to 4. Supplements, Theme Issues, and Special Series no authority to monitor or enforce it. Sponsorship of Partnerships should use these recommendations along with individual I. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals Journals that follow these recommendations are en- that qualify an individual for authorship. Substantial contributions to the conception or de- request removal from this list. In addition, authors should have confidence of standardizing manuscript format and preparation across in the integrity of the contributions of their co-authors. Over the years, issues in publishing that went well All those designated as authors should meet all four beyond manuscript preparation arose, resulting in the de- criteria for authorship, and all who meet the four criteria velopment of separate statements, up-dates to the docu- should be identified as authors. These authorship criteria are intended to reserve the Work in Medical Journals” to reflect its broader scope. Defining the Role of Authors and Contributors The individuals who conduct the work are responsible 1. Why Authorship Matters for identifying who meets these criteria and ideally should Authorship confers credit and has important aca- do so when planning the work, making modifications as demic, social, and financial implications. It is the collective re- implies responsibility and accountability for published sponsibility of the authors, not the journal to which the work. The following recommendations are intended to work is submitted, to determine that all people named as ensure that contributors who have made substantive intel- authors meet all four criteria; it is not the role of journal lectual contributions to a paper are given credit as authors, editors to determine who qualifies or does not qualify for but also that contributors credited as authors understand authorship or to arbitrate authorship conflicts. If agree- their role in taking responsibility and being accountable for ment cannot be reached about who qualifies for author- what is published. If au- tributions qualified an individual to be an author, some thors request removal or addition of an author after man- journals now request and publish information about the uscript submission or publication, journal editors should contributions of each person named as having participated seek an explanation and signed statement of agreement for in a submitted study, at least for original research. Editors the requested change from all listed authors and from the are strongly encouraged to develop and implement a con- author to be removed or added. Such policies remove much of the am- The corresponding author is the one individual who biguity surrounding contributions, but leave unresolved takes primary responsibility for communication with the the question of the quantity and quality of contribution journal during the manuscript submission, peer review, 2 www. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals and publication process, and typically ensures that all the tific advisors,” “critically reviewed the study proposal,” “col- journal’s administrative requirements, such as providing lected data,” “provided and cared for study patients”, “partic- details of authorship, ethics committee approval, clinical ipated in writing or technical editing of the manuscript”). The corresponding author should be available author obtain written permission to be acknowledged from throughout the submission and peer-review process to re- all acknowledged individuals. Author Responsibilities—Conflicts of Interest work and cooperate with any requests from the journal for Public trust in the scientific process and the credibility data or additional information should questions about the of published articles depend in part on how transparently paper arise after publication. A conflict of interest exists when professional judg- When a large multi-author group has conducted the ment concerning a primary interest (such as patients’ wel- work, the group ideally should decide who will be an au- fare or the validity of research) may be influenced by a thor before the work is started and confirm who is an secondary interest (such as financial gain). They will also be expected as individuals to com- credibility of the journal, the authors, and science itself. However, conflicts can occur for other reasons, such as Some large multi-author groups designate authorship personal relationships or rivalries, academic competition, by a group name, with or without the names of individu- and intellectual beliefs. When submitting a manuscript authored by a group, agreements with study sponsors, both for-profit and non- the corresponding author should specify the group name if profit, that interfere with authors’ access to all of the one exists, and clearly identify the group members who can study’s data or that interfere with their ability to analyze take credit and responsibility for the work as authors. The and interpret the data and to prepare and publish manu- byline of the article identifies who is directly responsible scripts independently when and where they choose.

Coenzyme Q10 is a vital cell membrane antioxidant and facilitates cellular respiration purchase keftab 375 mg with mastercard antibiotics on factory farms. Coenzyme Q10 is often included in anti-aging potions in view of its role in energy generation and the finding that cellular levels decrease with age order 500mg keftab amex antibiotic resistance related to natural selection. As an electron and proton carrier buy generic keftab 750mg on line virus download, it is essential for production of adenosine triphosphate in the electron transport chain. In addition to its role in energy production, coenzyme Q10 is thought to have membrane-stabilizing proper- ties. Rich dietary sources are fatty fish such as sardines and beans, nuts, whole grains, and meat. Some patients do lose their appetite and have skin eruptions during supplementation with coenzyme Q10. A synthetic analogue of coenzyme Q10, idebenone [2,3-dimethoxy- 5-methyl-6-(10-hydroxydecyl)-1,4-benzoquinone], is available. It may improve immune function, preventing metastasis and enhancing remission in certain cancers; reduce the risk of obesity; enhance myocardial contractility; reduce male infertility; protect gastric mucosa as a result of its antioxidant effects; and improve blood sugar control in patients with diabetes. However, clinical trials in which coen- zyme Q10 (100-200 mg daily) was used for the management of congestive heart failure have had conflicting results. Coenzyme Q10 is also of interest with respect to energy production in patients with chronic fatigue syndrome. Patients with chronic fatigue syn- drome are often deficient in coenzyme Q10, and in one study, supplementa- tion with 100 mg daily over 3 months improved exercise tolerance and reduced clinical symptoms. Two potential dietary means of delaying the effects of free radicals on cellular aging are enrichment of mitochondrial membranes with monounsaturated fatty acids and supplementation with antioxidants. A preliminary study of elderly male rats suggests that dietary supplementation with coenzyme Q10 and enrichment of cell membranes with monounsaturated fatty acids protect mitochondrial membranes from free radical insult. Antihypertensive agents—such as the β-blockers propranolol and metoprolol, pheno- Chapter 59 / Coenzyme Q10 (ubiquinone) 495 thiazines, and tricyclic antidepressants—inhibit coenzyme Q10–dependent enzymes. Overvad K, Diamant B, Holm L, et al: Coenzyme Q10 in health and disease, Eur J Clin Nutr 53:764-70, 1999. Congestive heart failure and hypercholesterolemia, Am Fam Physician 62:1325-30, 2000. Morisco C, Trimarco B, Condorelli M: Effect of coenzyme Q10 therapy in patients with congestive heart failure: a long-term multicenter randomized study, Clin Investig 71(suppl 8):S134-S136, 1993. Willis R, Anthony M, Sun L, et al: Clinical implications of the correlation between coenzyme Q10 and vitamin B6 status, Biofactors 9:359-63, 1999. The total body content of copper is pri- marily regulated by means of excretion rather than absorption. Copper is excreted attached to taurochenodeoxycholic acid, a sulfur-containing bile acid that is stored in the liver. When mobi- lized, copper is found in the plasma firmly attached to protein as cerulo- plasmin. Copper (Cu) plays a role in hemoglobin synthesis, neural function, glu- cose utilization, and skeletal and cardiovascular health. Copper salicylate is known to have analgesic and anti-inflamma- tory effects, and the efficacy of various copper-based anti-inflammatory drugs is under investigation. Its effi- cacy is often mediated by oxidation-reduction reactions in which Cu+ is con- verted to Cu2+. Copper is an essential component of superoxide dismutase, an enzyme that protects cell membranes by contributing to the breakdown of toxic free radicals, and cytochrome C oxidase, an enzyme of the electron transport chain involved in oxidative energy pro- duction ● Iron metabolism. Copper plays an important role in the oxidation-reduc- tion, mobilization, and transport of iron (Fe), which is stored as Fe3+, mobi- lized as Fe2+, and deoxidized as Fe3+ for transport as transferrin. Lysyl oxi- dase, a copper requiring enzyme, cross-links lysine in collagen and elastin. Additional copper can be obtained by drinking water that flows through copper pipes, by using copper cookware, and by eating farm products sprayed with cop- per-containing chemicals. The copper content of acidic foods decreases when they are stored in tin cans for long periods. The absorption of copper is reg- ulated by the thioneines, sulfur-rich binding proteins found in the intestinal lining and other body cells. The thioneines are responsible for binding cop- per, zinc, and various other divalent metals. The efficiency of copper absorp- tion is reduced by sulfides, ascorbic acid, zinc, and molybdenum. Both men and women fed diets close to 1 mg of copper per day experienced reversible, potentially harmful changes in blood pressure control, in cardiac electrical conduction as shown on electrocardiograms, cholesterol levels, and glucose metabolism. Animal studies also suggest that copper deficiency below a thresh- old level can induce atherosclerotic lesions. A longitudinal study of young men demonstrated that although most indices of copper status were unchanged, biomarkers of bone resorption were significantly increased on switching from medium (1. Nausea, abdominal and muscle pain, irritability, and depression may indicate copper toxicosis. Daily zinc supplementation of 150 mg over 2 years will precipitate copper deficiency. Similarly, simulta- neous use of oral zinc supplements with copper supplements may decrease copper absorption. Copper and zinc supplements should be taken at least 2 hours apart to obtain the maximum benefit from each.

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The following week cheap keftab 125 mg virus war, Zack and his therapist had scheduled a two-hour exposure session discount keftab 750 mg overnight delivery antibiotic resistance markers in plasmids. Because Zack was willing to start with some of the more difficult items on his hierarchy discount 250mg keftab amex antibiotic with sulfur, they skipped some of the easier practices. The session began with Zack watching as his therapist used a finger prick blood test kit (the type that someone with diabetes might use to check blood sugar) to draw blood from her own finger. Initially, Zack was able to use the applied tension exercises to control his feelings of faintness. Although Zack was unwilling to practice any exposure homework over the next week, he agreed to continue practicing the tension exercises. Hewasdiscouragedaboutwhathadhappenedat the last session and was thinking about discontinuing his treatment. His therapist encouraged Zack to keep his appointment, offering reassurance that Zack would not be forced to do anything before he was ready. At the next session, his therapist suggested that they begin with some easier items from Zack’s hierarchy. He was then ready to once again watch his therapist prick her finger while he used the tension exercises. His therapist then pricked several more fingertips and encouraged Zack to watch the blood on her fingers. Although his anxiety level was quite high, he was suc- cessfully able to prevent himself from fainting. In the remaining hour of the session, Zack practiced pricking his own finger and then practiced let- ting his therapist prick his finger. At one point he felt as though he might faint, but the feeling passed after he lay down for a few minutes. Once the faintness passed, he resumed the exposure exercises until his anxiety decreased. For homework over the coming week, Zack practiced the finger prick tests daily with the help of his parents and his girlfriend. The following week, Zack and his therapist prac- ticed watching several surgery videos, at first using the applied tension exercises, and later watching them with- out tensing. At the end of the two hours, Zack was able to watch videos depicting cardiac surgery, removal of a facial mole, and a patient receiving stitches, all with only minimal anxiety. In the end, Zack was quite happy with his progress, and he was glad he had stuck with the treatment. Although he was still nervous about watching live 92 overcoming medical phobias surgery, he decided to work on that fear on his own, after starting medical school. Jacob—dentists Jacob had been fearful of the dentist for as long as he could remember. As soon as he became an adult, he stopped going on a regular basis and only saw a dentist if he had a problem that was causing him pain (which happened about every five years). When he did see the dentist, he insisted on being knocked out with a general anesthetic. His main concern was that the experi- ence would be painful; he remembered having a number of uncomfortable visits to the dentist as a child. By the time Jacob decided to seek treatment at age forty, he had several cavities that needed to be filled and his teeth hadn’t been cleaned for years. His children were aware of his fear, and he worried that some of his fear might rub off on them. When he made the appointment, he had a choice of several hygienists, so he requested to see the one with the reputation for being the most gentle. He had several teeth to fill and one that was likely to require a root canal and crown. When he made his first appointment, Jacob asked whether the dentist and hygienist could begin with less frightening procedures, such as examining his teeth and taking X-rays, and save more difficult procedures such as cleanings, injections, and fillings for subsequent appoint- ments. In fact, the dentist offered to spend an entire appointment just helping Jacob get used to the feeling of having various dental instruments (mirror, probe, scaler, suction tube, and so forth) in his mouth. First, he decided to focus just on the procedures he would have done at each appointment, rather than thinking about all the dental work he needed to have done. He also thought about how his wife, coworkers, and friends often told him that the discomfort they experience at the dentist is always manageable, and how the procedures used during dental treatment have changed since he was younger. Finally, he asked the dentist and hygienist to describe to him what procedures would be done, what they were likely to feel like, and how long they would take. Although the first visit was frighten- ing, he was reassured because he knew he wouldn’t have any dental work done that day. After having his teeth cleaned and his cav- ities filled, he decided to get his root canal and crown done. Although terrified of the procedure, he was 94 overcoming medical phobias reassured when his dentist said that the discomfort would be no worse than that he experienced during the other procedures. In the end, he felt almost no pain despite the reputation root canals have for being painful. Ella—doctors and hospitals Ella had been afraid of visiting doctors and hospitals since she was a teenager, though she was unsure what ini- tially triggered the fear. She was uncomfortable being examined and undergoing tests and, to some extent, was afraid she might find out she had a problem that she didn’t know she had. She wasn’t sure why she didn’t like hospitals, but she avoided them at all costs, even if it meant not visiting friends and relatives in the hospital. Now, at age fifty-five, Ella had become increasingly con- cerned about her phobia.

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The patient may have complaints of fatigue 500mg keftab mastercard bacteria at 8 degrees, loss of appetite order keftab 750 mg on-line antibiotics have no effect on quizlet, sleeplessness buy cheap keftab 125mg on-line antibiotics for uti e coli, and a sore throat. After two to three days, swollen lymph glands may appear on the sides and back of the neck, in the armpits, and the groin. A mild reddish skin rash like that of Rubella (German Measles) may occur in about 10% of the cases, but particularly those treated with a penicillin-related drug. Enlargement of the spleen is noted in 50% of young adults, and jaundice (yellow color) of the skin and eyes in about 4%. The diagnosis is aided by finding lymphocytosis of greater than 50% with 10% or more atypical lymphocytes on a peripheral blood smear. There is no specific treatment for infectious mononucleosis except bed rest during the acute phase. Bed rest should be extended in cases with prolonged fever and those that resemble hepatitis. Robust exercise should be avoided by any cases with abdominal pain or tenderness, which may be associated with enlargement of the spleen, to reduce the possibilities of rupture. The disease may run its course in a week, in a few weeks, or more rarely, in months. Mumps is an acute, contagious, viral disease identified by tenderness and swelling of one or more of the salivary glands. The virus may be spread by direct or indirect contact with nose and throat discharges from an infected person. The disease begins with malaise, headache, a slight rise in temperature, and o o possibly nausea. In severe cases the temperature may reach 104 F (40 C) and last as long as a week. On the second day the swelling usually begins on one side of the jaw or cheek and increases greatly. In a couple of days, there is considerable enlargement at the side of the neck, posterior part of the cheek, and underneath the side of the jawbone. The opposite side of the face usually becomes affected in a few days, though infection may occur unilaterally. In the average case in childhood, the patient has little trouble beyond stiffness of the jaw, discomfort from swelling, and pain on opening the mouth. However, in young adult males, the infection may spread to one or both testicles to produce a painful inflammation and swelling called orchitis. Treatment The patient should have bed rest with strict isolation nursing technique. There is no specific medicine for the cure of mumps and symptoms should be treated as they arise. Analgesics-antipyretics such as acetaminophen relieve pain caused by salivary gland inflammation and reduce fever. If the testicles become involved, bedrest, narcotic analgesics, support of the inflamed testes, and ice packs may relieve discomfort. Plague is an acute, sometimes fulminating disease caused by the Gram-negative bacillus, Yersinia pestis. Plague is primarily a disease of rodents and is most often transmitted to humans by the bite of infective rodent fleas. Plague in the past has been a maritime disease because of rat infestation of ships. Federal regulations require that vessels be maintained free of rodent infestation through the use of traps, poisons, and other accepted methods of rodent control. Plague remains endemic in limited areas in Asia, Africa, and the Americas and occasionally results in outbreaks of disease. Outbreaks of human plague are usually associated with outbreaks (epizootics) of the disease in rats or other rodents. Three principal clinical forms of human plague occur: the bubonic type that affects the lymph glands, the pneumonic type that affects the lungs, and the septicemic type that occurs when Y. All three forms are usually characterized by rapid onset of severe illness with high fever, chills, and prostration. Signs of general toxicity may be accompanied by neurologic signs such as incoherent speech, clouding of consciousness, and incoordination. Transmission occurs when the plague bacillus is regurgitated by the flea into the bite wound at the time of taking a blood meal. The disease may also be transmitted by direct contact with tissues or body fluids of an infected animal. Persons with cuts or abrasions on their hands are especially at risk of infection when handling infected animals. Once introduced through the skin, the bacteria lodge and multiply within the lymph nodes draining the site of introduction. The onset of illness is usually heralded by fever, intense headache, fatigue, and o o profound weakness. The pulse is rapid, sweating and chills may occur, and the patient may experience extreme thirst. The patient often becomes anxious or agitated, and delirium and convulsions may develop. The characteristic buboes (swollen, extremely tender lymph nodes) usually develop on the second or third day of illness, most often in the inguinal (groin) area. Buboes may also form in the axillary (armpit) area and in the cervical (neck) region. The affected glands often swell to a size of 2 or more inches (5 cm) in diameter and are surrounded by edema of the soft tissues.

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