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N indicates the presence and extent of regional lymph node spread and is classified from 0 to 3, with 0 indicating no regional lymph node involvement and 3 indicating extensive involvement. M indicates the presence of distant metastases and is classified as 0 (for absence) or 1 (for presence of distant metastases). For example, T2N1M0 indicates a moderate-size tumor with limited nodal disease and no distant metastases. A high number indicates larger tumors with extensive nodal involvement and/or metastasis. Survival depends on the tumor type, the extent of disease, and the therapy received. Although some patients are free of all detectable disease, not all patients are cured. The terms complete response and remission are used to indicate that the patient has no evidence of disease after treatment. This is not a synonym for cure, as several patients who have achieved complete remission may relapse. Knowledge of the cell life cycle and cell cycle kinetics is essential to the understanding of the activity of chemotherapy agents in the treatment of cancer (Figure 50-1). M phase, or mitosis, is the phase in which the cell divides into two daughter cells. G0 phase, or resting phase, is the phase in which the cell is not committed to division. In a process called recruitment, some chemotherapy regimens are designed to enhance this reentry by killing a large number of actively dividing cells. Cell growth fraction is the proportion of cells in the tumor dividing or preparing to divide. As the tumor enlarges, the cell growth fraction decreases because a larger proportion of cells may not be able to obtain adequate nutrients and blood supply for replication. Cell cycle time is the average time for a cell that has just completed mitosis to grow and again divide and again pass through mitosis. As the tumor gets larger, its doubling time gets longer because it contains a smaller proportion of actively dividing cells owing to restrictions of space, nutrient availability, and blood supply. The gompertzian growth curve illustrates these cell growth concepts (Figure 50-2). Because a large number of cells is required to produce symptoms and be clinically detectable (approximately 109 cells), the tumor may be in the plateau phase of the growth curve by the time it is discovered. The cell kill hypothesis states that a certain percentage of tumor cells will be killed with each course of cancer chemotherapy. As tumor cells are killed, cells in G0 may be recruited into G1, resulting in tumor regrowth. Thus, repeated cycles of chemotherapy are required to achieve a complete response or remission (Figure 50-3). In theory, the tumor burden would never reach absolute zero because only a percentage of cells are killed with each cycle. The cell growth cycle, emphasizing the relationship between proliferating cell populations. By the time a tumor becomes large enough to cause symptoms and be clinically detectable, the majority of its growth has already occurred and is no longer exponential. Chemotherapeutic agents may be classified according to their reliance on cell cycle kinetics for their cytotoxic effect. Combinations of chemotherapy agents that are active in different phases of the cell cycle may result in a greater cell kill. Phase-specific agents are most active against cells that are in a specific phase of the cell cycle. Theoretically, administering these agents as continuous intravenous infusions or by multiple repeated doses may increase the likelihood of hitting the majority of cells in the specific phase at any one time. G2 phase: bleomycin, etoposide 1012 1011 1010 109 108 Cell number 107 106 105 104 103 102 101 100 1 2 3 4 5 Cycles of chemotherapy Time Tumor regrowth following premature cessation of therapy 3 log cell kill 1 log cell regrowth Clinically overt disease Disease in clinical remission Figure 50-3. The exponential relationship between chemotherapy drug dose and tumor cell survival dictates that a constant proportion, not number, of tumor cells is killed with each cycle of treatment.

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A randomized comparison of manual, mechanical and high-impulse chest compression in a porcine model of prolonged ventricular fibrillation. The relationship between rate of chest compression and compression:relaxation ratio. Determinants of blood flow to vital organs during cardiopulmonary resuscitation in dogs. Cardiac output during cardiopulmonary resuscitation at various compression rates and durations. Efficacy of audio-prompted rate guidance in improving resuscitator performance of cardiopulmonary resuscitation on children. The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest. Better adherence to the guidelines during cardiopulmonary resuscitation through the provision of audio-prompts. A study of chest compression rates during cardiopulmonary resuscitation in humans: the importance of rate-directed chest compressions. Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: a prospective interventional study. Chest compression quality management and return of spontaneous circulation: a matched-pair registry study. Real-time audiovisual feedback system in a physician-staffed helicopter emergency medical service in Finland: the quality results and barriers to implementation. Debriefing to improve outcomes from critical illness: a systematic review and meta-analysis. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Effects of half the tidal volume during cardiopulmonary resuscitation on acid-base balance and haemodynamics in pigs. Smaller tidal volume is safe and effective for bagvalve-ventilation, but not for mouth-to-mouth ventilation: an animal model for basic life support. Influence of tidal volume on the distribution of gas between the lungs and stomach in the nonintubated patient receiving positive-pressure ventilation. Effects of decreasing peak flow rate on stomach inflation during bag-valve-mask ventilation. Survival and neurologic outcome after cardiopulmonary resuscitation with four different chest compression-ventilation ratios. Effect of implementation of new resuscitation guidelines on quality of cardiopulmonary resuscitation and survival. Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation. Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies. Association between survival and early versus later rhythm analysis in out-of-hospital cardiac arrest: do agency-level factors influence outcomes? A study comparing the usability of fully automatic versus semi-automatic defibrillation by untrained nursing students. Safety of fully automatic external defibrillation by untrained lay rescuers in the presence of a bystander. Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest. Identifying locations for public access defibrillators using mathematical optimization. Differences between out-of-hospital cardiac arrest in residential and public locations and implications for publicaccess defibrillation. Health system costs of out-of-hospital cardiac arrest in relation to time to shock. Survival and health care costs until hospital discharge of patients treated with onsite, dispatched or without automated external defibrillator.


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Eliminates radiation by employing electromagnetic wave technology to determine the relative depth and direction of a reflective device placed percutaneously in the vicinity of a breast lesion under radiographic and/or ultrasonic guidance during a prior procedure 3. Advantage: bypass nuclear regulation associated with the radioactive seed program D. Pathology diagnosed by ductography is seen as intraductal filling defects and include both benign and malignant etiologies. The diagnostic quality of a ductogram is largely dependant on the experience and technique of the imager, which will be reviewed here. To present various commonly encountered axillary lesions in challanging quiz format. To discuss the salient features and enhance general understanding of these axillary processes to help radiologists to develop reasonable differential diagnosis and guide clinical management. Salient features, differential diagnosis and management will be discussed at the end of each case. Review the pathophysiology, epidemiology, clinical presentation, natural course and management considerations of granulomatous mastitis2. To present a case based approach towards making the diagnosis utilizing clinical presentation and characteristic imaging findings3. The purpose of this exhibit is to: 1) provide examples of clustered ring enhancement with radiology and pathology correlation and 2) review benign and malignant causes of this pattern to help improve recognition and specificity. Describe the proposed pathophysiology of clustered ring enhancement using radiology-pathology correlation. Provide case examples of malignant (invasive ductal carcinoma, ductal carcinoma in situ) and benign causes (sclerosing adenosis, benign breast tissue) of clustered ring enhancement with pathologic correlation. Tomosynthesis-guided biopsy is often successful at accessing far posterior lesions and in patients who cannot tolerate prone biopsy. How we perform tomosynthesis-guided biopsy, including a step-by-step example with equipment and procedural review, with an emphasis on differences between tomosynthesis and prone stereotactic biopsies. Review of the literature: Compared to prone stereotactic core biopsy, tomosynthesis-guided biopsy is faster, requires less attempts at patient positioning, and less exposures for lesion localization, without an increase in complication rate. Appropriate knowledge of these diagnoses is imperative in appropriate determination of radiologic-pathologic concordance. Review of the pathologic diagnoses (with images) on the core biopsy reports and detailed review of why the pathology is concordant or discordant will be highlighted after each case. We will also review the appropriate imaging management of breast symptoms in the lactating woman. We will provide pictorial examples and definitions of commonly encountered benign breast pathology in this population, including fibroadenoma, lactating adenoma, galactocele, mastitis and abscess. The imaging manifestations of breast carcinomas and special considerations when performing biopsy of the lactating breast will also be reviewed. Discuss the available treatment options for this malignancy during pregnancy and during lactation. Challenges associated with the diagnosis of malignancy during pregnancy and lactation. Review the imaging approach for the evaluation of symptomatic patients after mastectomy3. Case examples illustrating spectrum of imaging findings-Benign causes -Malignant causesV. Mammographic and sonographic location, size, shape, and margins should be concordant and carefully correlated to avoid errors. This exhibit reviews radioactive seed placement in clipped metastatic axillary lymph nodes and discusses common pitfalls, including failure to localize the appropriate lymph node and failure to surgically excise the appropriate lymph node. Rationale for radioactive seed localized excision of clipped metastatic axillary lymph nodes. Specimen radiography following radioactive seed localized excision of clipped metastatic axillary lymph nodes. To review breast cancer screening guidelines for average risk women from various organizations. To examine the potential impact these guidelines may have on patients and practices. Understanding the spectrum of negative, benign, and malignant findings on both images is important for image interpretation, reporting, and management. New surgical protocol derived from American College of Surgeons Oncology Group Z0011 trial c.

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For instance, portal venous pressure refers to the amount of pressure found in the portal vein, while jugular venous pressure is an indirect measure of venous pressure as seen in the neck over the internal jugular vein. Measurement of the central venous pressure is important to understand the amount of pressure in the blood that enters the heart from circulation, because it impacts how well the heart is able to pump the blood back into circulation after the blood has been oxygenated. In comparison to arteries, veins bring blood back to the heart in a process known as venous return. This process is often facilitated through outside mechanical forces, such as with the movement of skeletal muscles or with breathing. Because of this, veins have less of an ability to contract and to minimize their diameter as compared to arteries; however, they do have the capacity to stretch and can extend their size to accommodate more blood when needed. Unfortunately, this stretching can also contribute to low blood pressure levels when blood pools in the veins and is not returned to the heart at an adequate rate. An increase in venous pressure can also occur when there is an increase in blood volume within the veins. Depending on how compliant the veins are, such as through their ability to stretch and dilate, an increase in venous volume also increases venous blood pressure. A change in the sympathetic nervous system can increase or decrease the tone of the vessel wall and can lead to vasodilation or vasoconstriction of the venous system. Drugs that are designed to lower venous blood pressure are those that relax the venous blood vessels, improve their capacitance, and ultimately lower venous blood pressure levels as well as central venous pressure. Venous dilators are typically administered for the management of conditions such as angina or heart failure. Drugs that are venous dilators often have combination mechanisms of arterial and venous dilation, although there are some whose actions are more focused primarily on venous dilation only. By decreasing venous blood pressure, venous dilator drugs reduce preload, which decreases demands on the heart. Some patients with angina benefit from decreased preload because it reduces oxygen demands of the myocardial tissue and decreased stress on the ventricles. The decrease in preload reduces the stroke volume and cardiac output, which then also decreases afterload on the left ventricle. These drugs are therefore administered for management of heart failure not only to control blood pressure levels, but also to prevent excess fluid buildup in the peripheral tissues. A decrease in cardiac output due to heart failure causes the heart rate to slow and blood is more likely to back up into venous circulation. Venous constriction may also develop from the administration of certain drugs that cause the blood vessels to constrict as part of treatment for other conditions, such as with administration of epinephrine or dopamine. Venous constriction in these situations can also lead to an increase in venous circulation when the diameter of the venous lumen is smaller. Nitroglycerin is an example of a drug that has been used for decades in the treatment of angina because it is a potent vasodilator. Other examples of drugs that act specifically as venodilators include sodium nitroprusside (Nitropress) and isosorbide mononitrate (Imdur). Sodium nitroprusside is a vasodilator drug that works to relax the walls of the veins, which decreases venous blood pressure, reduces preload, and decreases afterload. It is used in cases of hypertensive crisis as well as in the management of complications associated with heart failure. Because it is sometimes given during periods of hypertensive crises, it may be administered emergently. Isosorbide mononitrate is another type of nitrodilator that is also used for the treatment of angina. It causes a decrease in preload and afterload, as well as a decrease in left ventricular end-diastolic pressure and systemic vascular resistance. By decreasing venous blood pressure, isosorbide mononitrate can improve blood flow and can resolve symptoms of angina. It may be given as an oral preparation, to be taken daily among patients who suffer from stable angina. Upon standing, the brain does not initially receive as much blood because the blood has collected in other areas within the venous system. The affected person may then experience dizziness or syncope with position changes unless blood flow is allowed to catch up. As with administration of other types of drugs used to manage blood flow through the cardiovascular system, patients who take venous dilators should be closely monitored for ill effects associated with hypotension. Summary With increasing rates of cardiovascular disease, the types and mechanisms of cardiac drugs continue to expand to meet the needs of those who suffer nursece4less.

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Spironolactone (Aldactone) is particularly useful in patients with hyperaldosteronism, as it has direct antagonistic effects on aldosterone (aldosterone-receptor blocker). Eplerenone (Inspra), is another aldosterone-receptor blocker recently approved by the U. Potassium-sparing diuretics achieve their diuretic effects differently and less potently than the thiazides and loop diuretics. A growing number of products are available as combination products and can be found within Table 33-5. Proposed mechanisms of action include the following: (a) Stimulation of renin secretion is blocked. Young (45 years) whites with high cardiac output, high heart rate, and normal vascular resistance respond best to -blocker therapy. B (d) Abrupt stoppage of a -blocker in cardiac patients puts the patient at risk for a withdrawal syndrome that may produce (i) exacerbated anginal attacks, (ii) myocardial infarction, and (iii) a life-threatening rebound of blood pressure to levels exceeding pretreatment readings. Vasoconstriction can occur and, in predisposed patients, might result in a clinically significant problem. Relative to propranolol (Inderal), -blockers have a greater tendency to occupy the 1-receptor in the heart, rather than the 2-receptors in the lungs. These agents have the ability to release catecholamines and to maintain a satisfactory heart rate. Intrinsic sympathomimetic activity may also prevent bronchoconstriction and other direct -blocking actions. This agent is not used routinely in treating hypertension owing to its duration of action and the need for intravenous administration. B been used for hypertension and or tachycardia during and after surgical procedures. Initial reports also suggest that nebivolol has vasodilatory properties through its release of nitric oxide. Nebivolol is administered in a single daily dose of 5 mg with dose titration required based on therapeutic response. Peripheral 1-adrenergic blockers-for example, prazosin (Minipress), terazosin (Hytrin), and doxazosin (Cardura) (1) Indications. This group of drugs is available for hypertensive patients who have not responded to initial antihypertensive therapy. The 1-blockers (indirect vasodilators) block the peripheral postsynaptic 1adrenergic receptor, causing vasodilation of both arteries and veins. Also, the incidence of reflex tachycardia is lower with these agents than with the vasodilator hydralazine (Various). These hemodynamic changes reverse the abnormalities in hypertension and preserve organ perfusion. Recent studies have also shown that these agents have no adverse effect on serum lipids and other cardiac risk factors. A syncopal episode may occur within 30 to 90 mins of the first dose; similarly associated are postural hypotension, nausea, dizziness, headache, palpitations, and sweating. To minimize these effects, the first dose should be limited to a small dose (1 mg) and administered just before bedtime. Centrally active -agonists have been used in the past as alternatives to initial antihypertensives, but their use in mild-to-moderate hypertension has been reduced primarily owing to other available agents. Methyldopa decreases total peripheral resistance through the aforementioned mechanism while having little effect on cardiac output or heart rate (except in older patients). Hypertension 627 (b) Precautions and monitoring effects (i) Common untoward effects include orthostatic hypotension, fluid accumulation (in the absence of a diuretic), and rebound hypertension on abrupt withdrawal. Sedation is a common finding upon initiating therapy and when increasing doses; however, the sedative effect usually decreases with continued therapy. Clonidine is effective in patients with renal impairment, although they may require a reduced dose or a longer dosing interval. Clonidine stimulates 2-receptors centrally, decreasing vasomotor tone and heart rate. These agents are recommended as adjunctive therapy with other antihypertensives for additive effects when initial therapy has failed.


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B (3) the time required for a drug to degrade to 90% of its original concentration (t90%) is also important. This time represents a reasonable limit of degradation for the active ingredients. Thus, for tЅ, it takes the same amount of time to reduce the concentration of the drug from 100 to 50 mM as it does from 50 to 25 mM. Factors other than concentration can affect the reaction rate and stability of a drug. These factors include temperature, the presence of a solvent, pH, and the presence of additives. An increase in temperature causes an increase in reaction rate, as expressed in the equation first suggested by Arrhenius: k or log k log A Ea ( 2. The constants A and Ea are obtained by determining k at several temperatures and then plotting log k against 1/T. The activation energy (Ea) is the amount of energy required to put the molecules in an activated state. As temperature increases, more molecules are activated, and the reaction rate increases. A change in the solvent system alters the transition state and the activity coefficients of the reactant molecules. It can also cause simultaneous changes in physicochemical parameters, such as pKa, surface tension, and viscosity. For example, with an increasing concentration of ethanol in an aqueous solution, aspirin degrades by an extra route and forms the ethyl ester of acetylsalicylic acid. Rate constants in the intermediate pH range are typically less than those at higher or lower pH. To determine the effect of pH on degradation kinetics, decomposition is measured at several H concentrations. The pH of optimum stability can be determined by plotting the logarithm of the rate constant (k) as a function of pH (Figure 2-8). Buffer salts must be added to many drug solutions to maintain the formulation at optimum pH. These salts can affect the rate of degradation, primarily as a result of salt increasing the ionic strength. This increased stability appears to result from the formation of a less reactive complex between the aromatic ester and the caffeine. The decomposition of active ingredients in a dosage form occurs through several pathways. Hydrolysis is the most common type of degradation because many medicinal compounds are esters, amides, or lactams. Because esters are rapidly degraded in aqueous solution, formulators are reluctant to incorporate drugs that have ester functional groups into liquid dosage forms. Oxidation is usually mediated through reaction with atmospheric oxygen under ambient conditions (auto-oxidation). Medicinal compounds that undergo auto-oxidation at room temperature are affected by oxygen dissolved in the solvent and in the head space of their packages. Molecules may absorb the proper wavelength of light and acquire sufficient energy to undergo reaction. Usually, photolytic degradation occurs on exposure to light of wavelengths 400 nm. An amber glass bottle or an opaque container acts as a barrier to this light, thereby preventing or retarding photolysis. For example, sodium nitroprusside in aqueous solution has a shelf life of only 4 hrs if exposed to normal room light. The shelf life of a drug preparation is the amount of time that the product can be stored before it becomes unfit for use, through either chemical decomposition or physical deterioration. It is generally understood to be ambient temperature unless special storage conditions are specified.

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Dark chocolate consumption appears to affect the facial skin of young men by enhancing corneocyte desquamation and promoting bacterial colonization of the residual skin surface components [117]. Four ounces of shrimp provides about 325 -375 milligrams of omega-3 fatty acids [118]. After 10 weeks of omega-3 fatty acid supplementation, inflammatory and noninflammatory acne lesions decreased significantly [105]. Low glycemic loads, with or without metformin, has been associated with greater reduction in acne lesion counts compared with high loads [53]. Isotretinoin, Retinol (Vitamin A), carotenoids (provitamin A) and retinoids (Vitamin A metabolites) are absorbed better with parallel intake of vegetable oils [11]. Weight loss and the use of metformin are both associated with lower plasma insulin levels and decreased androgen levels and therefore for acne patients, a weight loss diet may be indicated [119,120]. Masturbation results in general debility, unnatural pale eyes and forehead acne [122]. Sitting in the Sun to Clear Pimples Despite popular myth, diet, lack of exercise, lack of hygiene, greasy hair hanging over the face, and masturbation do not have any effect [123]. After adjustment for sex and age, the presence of acne remained highly associated with less sexual activity [124]. The dark color of blackheads has nothing to do with dirt: They look dark because this kind of blackhead is "open" and the skin pigment melanin reacts with oxygen in the air [83]. Although squeezing pimples may make skin look better in the short term, it might force the pus even deeper into skin, which can make it become even more inflamed and the chance that the area will become dark as it tries to heal [83]. Other factors involved in this process are corticotropin-releasing hormone, -melanocyte-stimulating hormone and substance P [63]. During puberty, alteration of the sebaceous lipid profile, called dysmenorrhea, stress, irritation, cosmetics and potential dietary factors lead to inflammation and formation of different types of acne lesions [64,65]. However, clinicians should not be didactic in their recommendations regarding diet, hygiene and face-washing, and sunlight to patients with acne. This leads to epidermal hyperplasia, which may also contribute to follicular hyperkeratosis in acne [66]. Foam cells are lipid-loaded macrophages and neutrophils that are generated from a massive uptake of oxidized lipid. Foam cells are a pathological hallmark of atherosclerosis, and have also been found in acne lesions [67]. They are among the most important epidermal sphingolipids and compose about 50 % of intercellular stratum corneum lipids by mass and are involved in the prevention of transepidermal water loss [70]. Increased sebum production and follicular hyperkeratosis result in the development of microcomedones, and changes in follicular milieu in intensive growth of P. The most common drug class utilized was topical antibiotics, accounting for 63% of all prescriptions [77]. Acne affects a large proportion of the Canadian population and has psychosocial and financial consequences. A 2016 study shows Oral isotretinoin 3-month costs ranged from $400to $500 (approx. Many methods have been performed to achieve a satisfying outcome in acne scars but some of them were high cost and also were associated with low results and some complications [80]. This disorder is generally considered mild but represents a high economical and psychological burden for the society. Approximately 50 million individuals within the United States are affected by acne, making it one of the most common dermatological complaints in patients presenting to a general dermatology office [85]. Patients experience high levels of anxiety, depression, and low self-esteem which leads to impaired quality of life. Therefore, treatment should focus on early intervention to decrease the physical and esthetic burden of the disease, and improvement of quality of life [81]. The common differential diagnosis of acne includes folliculitis, keratosis pilaris, perioral dermatitis, seborrheic dermatitis and rosacea. History and physical examination can help determine if there is an underlying cause of the acne, such as an exacerbating medication or endocrinologic abnormality causing hyperandrogenism. Other dermatologic manifestations of androgen excess include seborrhea, hirsutism and androgenetic alopecia. Endocrinologic testing is not ordered routinely for women with regular menstrual cycles. Older women, especially those with new-onset acne and other signs of androgen excess.

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Still, the lack of evidence for product safety and efficacy raises concerns for health care providers who attempt to make appropriate recommendations to patients seeking nonprescription weight loss products. The most commonly seen ingredients in weight loss products currently marketed, organized by purported mechanisms of action, include the following: a. Products formulated with ephedrine alkaloids (ephedra, ma huang, sida cordifolia, Pinellia) were removed immediately, although, unlike other dietary supplements currently available, ephedra-containing supplements did have convincing evidence for short-term weight loss. If combined with other stimulants such as caffeine, bitter orange may be cardiotoxic. Modulate carbohydrate metabolism (1) Chromium, an essential mineral, increases insulin sensitivity, lean body mass, and basal metabolic rate and decreases insulin blood levels and body fat. Chromium is used in weight loss products in the form of chromium picolinate, 200 to 400 mcg/day, with no reported significant adverse effects. Rhabdomyolysis and renal failure have been reported with the use of chromium picolinate in doses exceeding 1000 mcg/day. Although widely marketed, there have been no large, well-designed studies for the use of chromium in weight loss. Although its efficacy for weight loss remains uncertain, over 100 products marketed for weight loss contain chromium. Although ginseng is found in at least 20 commercially available weight loss products, it has no demonstrated efficacy for weight loss in humans. Enhance satiety (1) Guar gum, a fiber derived from the Indian cluster bean, has been deemed relatively safe in doses of 7. Preliminary evidence has demonstrated that glucomannan (3 to 4 g/day) may be well tolerated and efficacious for weight loss. Potential adverse effects are significant, including esophageal obstruction and nephrotoxicity (if seeds are crushed, chewed, or ground, a pigment may be deposited in the renal tubules). If used, patients should be instructed to not crush, chew, or grind the seeds, and adequate fluids must be consumed. Increase fat oxidation or reduce fat synthesis (1) l-Carnitine is synthesized in the liver, kidney, and brain. It is purported to inhibit mitochondrial citrate lyase, thereby suppressing acetyl coenzyme A and fatty acid synthesis. Green tea has demonstrated increased fat oxidation and thermogenesis but lacks data regarding efficacy in weight loss. Reported adverse effects of licorice include pseudoaldosteronism, hypertension, and hyperkalemia. Although some studies have linked calcium intake to weight loss, clinical trials have failed to demonstrate statistically significant results. Chitosan, a common ingredient in "fat-trapper" supplements, is derived from the exoskeleton of shellfish. Furthermore, it is questionable if chitosan is safe in individuals with shellfish allergies. Dandelion (Taraxacum officinale) seems to have a diuretic effect but has not been studied for weight loss in humans. Spirulina (blue-green algae) contains phenylalanine, an agent theorized to inhibit appetite. Sleep requirements vary widely among individuals and change throughout the life cycle. The usual range of sleep time per night is 5 to 10 hrs, with an average of about 7. Adolescents typically do not become sleepy until after midnight and awaken very late in the morning (if allowed), but require a total of 9. The typical adult requires 7 to 8 hrs of sleep to feel adequately restored, but this time may diminish with aging. Polysomnography is the predominant tool for characterizing sleep physiology, although guidelines from the American Sleep Disorders Association do not indicate it as useful in the diagnosis and management of patients with insomnia. Each stage is a progression into a deeper sleep; and stages 3 and 4 are considered deep, restorative sleep. If time spent in stages 3 and 4 of sleep is diminished (as seen with aging), then sleep quality is compromised.

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For most available intravaginal products, application time should be recommended as bedtime to increase vaginal mucosa contact time. Available products include Monistat (miconazole 1-, 3-, and 7-day), Vagistat (tioconazole 1-day; miconazole 3-day), and GyneLotrimin (clotrimazole 3- and 7-day). Thus when 1- and 3-day products are purchased, the woman should be aware that she may still experience symptoms after she has completed the treatment but should resolve within several days. If symptoms are still present after 7 days, a medical provider should be consulted. Symptom improvement typically will not be seen for 5 to 7 days after initiation of treatment. There are a variety of feminine hygiene products available for cleansing and controlling odor associated with normal vaginal discharge and products available for vaginal dryness. Vaginal lubricants are used for immediate relief of vaginal dryness, which can cause pain during intercourse. Oil-based lubricants typically contain baby oil or petroleum jelly and should not be recommended for use with latex condoms because they can deteriorate the latex. Additionally, oilbased lubricants can harbor bacteria in the vagina and lead to infections. Thus if used for intercourse, vaginal moisturizers need to be applied 2 hrs prior to allow for adequate lubrication. The efficacy and pregnancy rates for various means of contraception depend greatly on the degree of compliance. Table 24-1 lists ranges of pregnancy rates reported for a variety of contraceptives. Methods of contraception that may make use of nonprescription products or devices include the following: 1. Fertility awareness methods make use of information concerning the menstrual cycle to determine the days when intercourse is most likely to result in a pregnancy. A typical couple who initiated a method that either was not always used correctly or was not used with every act of sexual intercourse, and who experienced an accidental pregnancy. B estimated to average 2 to 3 days (up to 5 days), and the fertile period of the ovum, which is estimated to be 24 hr. Recent studies indicate that conception is most likely to occur when couples have intercourse during a 6-day period ending on the day of ovulation. Conception is highly unlikely if sexual intercourse occurs 6 or more days before ovulation or the day after ovulation. These methods are based on reproductive anatomy and physiology and are applied according to the signs and symptoms naturally occurring in the menstrual cycle. This method estimates the possible day of ovulation, based on documentation of prior menstrual cycle events. Abstinence should be practiced during the period around ovulation when there may be a fertilizable egg present. The calendar method is not as well-used as it once was and is not accurate for women with irregular cycles, women who are breastfeeding, or women with postponed ovulation. The rise in temperature is thought to be the result of progesterone release, which indicates the occurrence of ovulation. Spermicidal agents are composed of an active spermicidal chemical, which immobilizes or kills sperm, and an inert base. However, although it is spermicidal, it is not a microbicide and therefore cannot be used alone for protection against sexually transmitted infections. Contraceptive spermicides, which are available in several forms, offer the greatest variety within one specific method of contraception (Table 24-2). The concentration of spermicide is less than the necessary 8% to be employed as a single contraceptive method. Over-the-Counter Menstrual, Vaginal, and Contraceptive Agents 475 (2) Foams disperse better into the vagina and over the cervical opening but provide less lubrication than creams, jellies, and gels. Although solid at room temperature, suppositories melt at body temperature, whereas foaming tablets effervesce. Each repeated act of intercourse requires insertion of another tablet/suppository.

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Screening of asymptomatic individuals is controversial, and recommendations from major medical groups have been conflicting. Women older than 60 years and others at high risk for thyroid dysfunction (history of autoimmune disease or type 1 diabetes) b. There are varying degrees of hypothyroidism from mild, clinically insignificant forms to the lifethreatening extreme, myxedema coma. However, pregnant women with subclinical hypothyroidism may benefit from T4 replacement. A Clinical or subclinical detected hypothyroidism; subclinical hyperthyroidism infrequently Hypothyroidism is usually during the first 3 months after starting therapy; continue to detect patients at 6 months. Regions where patients have adequate intake of iodine in their diet have been associated with higher rates of hypothyroidism. Hyperthyroidism Treatment High Normal Subclinical hyperthyroidism Close follow-up Figure 47-4. Hashimoto thyroiditis, a chronic lymphocytic thyroiditis that is considered to be an autoimmune disorder 2. Treatment of hyperthyroidism, such as radioactive iodine therapy, subtotal thyroidectomy, or administration of antithyroid agents 3. This is common in regions with iodine-depleted soil and in areas of endemic malnutrition. Sporadic goiter can follow ingestion of certain drugs or foods containing progoitrin (L-5-vinyl-2-thiooxazolidone), which is inactive and converted by hydrolysis to goitrin. Less common causes include acute (usually traumatic) and subacute thyroiditis, nodules, nodular goiter, and thyroid cancer. It causes decreased T3 production, T3 receptor binding, and direct toxic effect on thyroid follicular cells. Early clinical features tend to be somewhat vague: lethargy, fatigue, depression, forgetfulness, sensitivity to cold, unexplained weight gain, and constipation. Progressively, the characteristic features of myxedema emerge: dry, flaky, inelastic skin; coarse hair; slowed speech and thought; hoarseness; puffy face, hands, and feet; eyelid droop; hearing loss; menorrhagia; decreased libido; and slow return of deep tendon reflexes (especially in the Achilles tendon). Laboratory findings (Table 47-1) Treatment goal is replacement therapy to mimic normal, physiologic levels and alleviate signs, symptoms, and biochemical abnormalities (Table 47-5). At one time the agent of choice, desiccated thyroid (Armour Thyroid, Westhroid) has fallen out of favor since standardized synthetic levothyroxine preparations have become available. Desiccated thyroid preparations are not considered bioequivalent; they have evidenced varying amounts of active substances. The content assay, while specific for iodine, was unable to specify the ratio of T3 to T4, and this ratio varies with the animal source. Porcine gland preparations are most commonly used, and have a higher T3 to T4 ratio than those from ovine and bovine sources. In an effort to standardize the T3 to T4 ratio, substances that mimic glandular content were developed. However, the T3 component proved unnecessary (because T4 is metabolized to T3) and even disadvantageous because of T3-induced adverse effects. Generic formulations manufactured by Pharmaceuticals Basics for Geneva Generics and Rugby have been shown to be bioequivalent to Synthroid and Levoxyl. Bioequivalence of generic and brand-name levothyroxine products in the treatment of hypothyroidism. Predictable results of the synthetic T4 preparation and lack of T3-induced side effects have made levothyroxine (Levothroid, Synthroid, and Levoxyl) the agent of choice. Levothyroxine preparations are generally considered bioequivalent despite significant controversy. However, when switching formulations, it is recommended to monitor the patient closely because there may be some individual patient variability among formulations (Figure 47-6). Levothyroxine should be administered preferably on an empty stomach in the morning, before breakfast. Clinical improvement begins in 2 weeks with full resolution of signs and symptoms of hypothyroidism by 3 to 6 months of therapy. However, it may be useful treating patients with persistent clinical symptoms on levothyroxine. Adult patients with a history of cardiac disease and elderly patients should begin therapy with lower doses. Patients should be observed on initiation of therapy for possible cardiac complications, such as angina, palpitations, or arrhythmias.


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