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A 64-year-old woman with systemic lupus erythematosus took chloroquine for 7 years (cumulative dose 1000 g) womens health and cancer rights act cheap sarafem 20mg with visa. She developed syncope women's health center of clarksville tn discount sarafem online master card, and the electrocardiogram showed complete heart block; a permanent pacemaker was inserted menstruation begins because best 10mg sarafem. The next year she presented with biventricular cardiac failure women's health clinic toronto bay and college generic 10 mg sarafem free shipping, skin hyperpigmentation, proximal muscle weakness, and chloroquine retinopathy. Chloroquine cardiomyopathy occurred during longterm (7 years) treatment for rheumatoid polyarthritis in a 42-year-old woman, who had an isolated acute severe conduction defect, confirmed by histological study with electron microscopy (6). A 50-year-old woman took chloroquine for 6 years for rheumatoid arthritis and developed a restrictive cardiomyopathy, which required heart transplantation (7). Regular cardiac evaluation should be considered for those who have taken a cumulative chloroquine dose of 1000 g, particularly elderly patients. Severe hypokalemia after a single large dose of chloroquine has been documented, and some studies show a correlation between plasma potassium concentrations and the severity of the cardiac effects (8). Light and electron microscopic abnormalities were found on endomyocardial biopsy in two patients with cardiac failure. Chronic use of hydroxychloroquine in rheumatic diseases should be weighed against the risk of potentially lethal cardiac dysrhythmias. Long-term chloroquine can caouse cardiac complications, such as conduction disorders and cardiomyopathy (restrictive or hypertrophic), by sturctural alteration of the interventricular septum (5). Thirteen cases of cardiactoxicity associated with long-term chloroquine and hydroxychloroquine have been reported in patients with Є 2010 Elsevier B. A 41-year-old man with chronic discoid lupus erythematosus was given chloroquine 150 mg bd for 10 days followed by 150 mg/day. He improved on withdrawal of chloroquine and treatment with cefpiramide and roxithromycin. Nervous system the incidence of serious nervous system events among patients taking chloroquine for less than a year has been estimated as one in 13 600. Both of these effects are associated with the administration of the drug over longer periods of time. Keratopathy Chloroquine-induced keratopathy is limited to the corneal epithelium, where high concentrations of the drug are readily demonstrable. Slit lamp examination shows a series of punctate opacities scattered diffusely over the cornea; these are sometimes seen as lines just below the center of the cornea, while thicker yellow lines may be seen in the stroma. The keratopathy is often asymptomatic, fewer than 50% of patients having complaints. Keratopathy can appear after 1­2 months of treatment, but dosages of under 250 mg/day usually do not cause it. The incidence of keratopathy is high, occurring in 30­70% of patients treated with higher dosages of chloroquine. Retinopathy the retinopathy encountered with the prolonged use of chloroquine or related drugs is a much more serious adverse effect and can lead to irreversible damage to the retina and loss of vision. However, it is not possible to predict in which patients and in what proportion of patients an early retinopathy will progress to blindness. At this stage the retinal vessels are contracted, there are changes in the peripheral retinal pigment epithelium, and the optic disk is atrophic. However, the picture is not always clear, and peripheral retinal changes may appear as the first sign. Retinopathy can occur after chloroquine antimalarial chemoprophylaxis for less than 10 years: the lowest reported total dose was 110 g (15). A case of hydroxychloroquine-induced retinopathy in a 45year-old woman with systemic lupus erythematosus has illustrated that maculopathy can be associated with other 4-aminoquinolines (16). The resulting functional defects are varied: difficulty in reading, scotomas, defective color vision, photophobia, light flashes, and a reduction in visual acuity. Symptoms Chloroquine, especially in higher doses, can cause a marked neuromyopathy, characterized by slowly progressive weakness of insidious onset. Reduction in nerve conduction time and electromyographic abnormalities typical of both neuropathic and myopathic changes can be found. Neuromyopathy is a rare adverse effect and is usually limited to patients taking 250­ 750 mg/day for prolonged periods. An 80-year-old woman developed symptoms after taking chloroquine 300 mg/day for 6 months (10), once more demonstrating that a standard dosage can be too much for elderly people.

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Inclusion criteria were: (a) prospective randomized design with initiation of dexamethasone therapy within the first 15 days of life; (b) report of the outcome of interest; and (c) less than 20% crossover between the treatment and control groups during the study period women's health university of iowa 20mg sarafem visa. The primary outcomes were mortality at hospital discharge and the development of chronic lung disease at 28 days of life and 36 weeks postconceptional age breast cancer nail decals buy 10mg sarafem mastercard. The secondary outcomes were the presence of a patent ductus arteriosus and treatment adverse effects pregnancy x ray lead apron sarafem 20mg without a prescription. These reductions were more significant when dexamethasone was started in the first 72 hours of life menstruation 19th century generic sarafem 20 mg visa. The 27% reduction in patent ductus arteriosus and the 11% increase in infections were not statistically significant, nor were any other changes. The conclusion from this meta-analysis was that systemic dexamethasone given to at-risk infants soon after birth may reduce the incidence of chronic lung disease. The potential benefits of early dexamethasone therapy in the regimen used in this trial need to be weighed against the risk of early intestinal perforation. Although dexamethasone is commonly associated with transient adverse effects, several randomized trials have shown that it rapidly reduces oxygen requirements and shortens the duration of ventilation. A randomized study was designed to evaluate the effects of two different dexamethasone courses on growth in preterm infants (11). The first phase included 30 preterm infants at high risk of chronic lung disease, of whom 15 (8 boys) were given dexamethasone for 14 days, from the tenth day of life; they received a total dose of 4. The second phase included 30 preterm infants at high risk of chronic lung disease, of whom 15 babies (7 boys) were treated with dexamethasone for 7 days, from the fourth day of life; they received a total dose of 2. Infants given dexamethasone had significantly less weight gain than controls, but they caught up soon after the end of treatment. At 30 days of life, the gains in weight and length in each group were similar to those in control infants, but those given dexamethasone had significantly less head growth. The longer-term impact of postnatal dexamethasone on mortality and morbidity is less clear. Better data, from larger clinical trials with longer follow-up, will determine whether this kind of treatment enhances lives, makes little difference, causes significant harm, or does several of these things (12). Systematic reviews A systematic review of glucocorticoid adjunctive therapy in adults with acute bacterial meningitis has been published (13). Five trials involving 623 patients were included (pneumococcal meningitis = 234, meningococcal meningitis = 232, others = 127, unknown = 30). The authors recommended the early use of glucocorticoid therapy in adults in whom acute community-acquired bacterial meningitis is suspected. A systematic review of randomized controlled trials has been performed to determine whether dexamethasone therapy in the first 15 days of life prevents chronic lung disease in premature infants (14). Studies were identified by a literature search using Medline (1970­97) Є 2010 Elsevier B. General adverse effects the incidence and severity of adverse reactions to glucocorticoids depend on the dose and duration of treatment. Even the very high single doses of glucocorticoids, such as methylprednisolone, which are sometimes used, do not cause serious adverse effects, whereas an equivalent dose given over a long period of time can cause many long-term effects. The two major risks of long-term glucocorticoid therapy are adrenal suppression and Cushingoid changes. During prolonged treatment with anti-inflammatory doses, glucose intolerance, osteoporosis, acne vulgaris, and a greater or lesser degree of mineralocorticoidinduced changes can occur. In children, growth can be retarded, and adults who take high doses can have mental changes. There may be a risk of gastroduodenal ulceration, although this is much less certain than was once thought. Some of these effects reflect the catabolic properties of the glucocorticoids, that is their ability to accelerate tissue breakdown and impair healing. Anyone who prescribes long-term glucocorticoids should have a checklist in mind of the undesired effects that they can exert, both during treatment and on withdrawal, so that any harm that occurs can be promptly detected and countered. The main groups of risks arising from long-term treatment with glucocorticoids are summarized in Table 2. The adverse reactions that were reported in a study of 213 children are listed in Table 3 (15). Drug interactions that affect the efficacy of glucocorticoids have been reviewed (16). Corticosteroids-glucocorticoids 461 Table 2 Risks of long-term glucocorticoid therapy 1.

Mladenovic V pregnancy kidney stones discount sarafem 10mg otc, Domljan Z women's health clinic elizabeth nj buy generic sarafem 10 mg on line, Rozman B women's health issues in the united states order sarafem 10mg with amex, Jajic I womens health and cancer rights act order sarafem overnight delivery, Mihajlovic D, Dordevic J, Popovic M, Dimitrijevic M, Zivkovic M, Campion G, et al. Safety and effectiveness of leflunomide in the treatment of patients with active rheumatoid arthritis. Strand V, Cohen S, Schiff M, Weaver A, Fleischmann R, Cannon G, Fox R, Moreland L, Olsen N, Furst D, Caldwell J, Kaine J, Sharp J, Hurley F, Loew-Friedrich I. Treatment of active rheumatoid arthritis with leflunomide compared with placebo and methotrexate. Efficacy and safety of leflunomide compared with placebo and sulphasalazine in active rheumatoid arthritis: a doubleblind, randomised, multicentre trial. A comparison of the efficacy and safety of leflunomide and methotrexate for the treatment of rheumatoid arthritis. Slowing of disease progression in rheumatoid arthritis patients during long-term treatment with leflunomide or sulfasalazine. Two-year, blinded, randomized, controlled trial of treatment of active rheumatoid arthritis with leflunomide compared with methotrexate. Utilization of Leflunomide in the Treatment of Rheumatoid Arthritis Trial Investigator Group. Treatment of active rheumatoid arthritis with leflunomide: two year follow up of a double blind, placebo controlled trial versus sulfasalazine. The efficacy and safety of leflunomide in patients with active rheumatoid arthritis: a five-year followup study. Infliximab and leflunomide combination therapy in rheumatoid arthritis: an open-label study. Concomitant leflunomide therapy in patients with active rheumatoid arthritis despite stable doses of methotrexate. Safety of leflunomide plus infliximab combination therapy in rheumatoid arthritis. Short-term efficacy and safety of leflunomide in the treatment of active rheumatoid arthritis in everyday clinical use. Efficacy and safety of leflunomide 10 mg versus 20 mg once daily in patients with active rheumatoid arthritis: multinational double-blind, randomized trial Rheumatology (Oxford) 2004;43(6):744­9. Leflunomide in active rheumatoid arthritis: a prospective study in daily practice. Efficacy and safety of leflunomide in the treatment of psoriatic arthritis and psoriasis: a multinational, double-blind, randomized, placebo-controlled clinical trial. Leflunomide and rheumatoid arthritis: a systematic review of effectiveness, safety and cost implications. Life-threatening hypertriglyceridemia during leflunomide therapy in a patient with rheumatoid arthritis. Leflunomide use during the first 33 months after food and drug administration approval: experience with a national cohort of 3,325 patients. Rozman B, Praprotnik S, Logar D, Tomsic M, Hojnik M, Kos-Golja M, Accetto R, Dolenc P. Pulmonary hypertension in a patient with rheumatoid arthritis treated with leflunomide. Kamata Y, Nara H, Kamimura T, Haneda K, Iwamoto M, Masuyama J, Okazaki H, Minota S. Rheumatoid arthritis complicated with acute interstitial pneumonia induced by leflunomide as an adverse reaction. Leflunomide-related acute interstitial pneumonia in two patients with rheumatoid arthritis: autopsy findings with a mosaic pattern of acute and organizing diffuse alveolar damage. Doubleblind, randomized, placebo-controlled pilot study of leflunomide in systemic lupus erythematosus. Leflunomide for the treatment of rheumatoid arthritis: a systematic review and metaanalysis. Maddison P, Kiely P, Kirkham B, Lawson T, Moots R, Proudfoot D, Reece R, Scott D, Sword R, Taggart A, Thwaites C, Williams E. Leflunomide in rheumatoid arthritis: recommendations through a process of consensus.

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Ternak rentan tidak perlu secara aktif berbuat sesuatu untuk menjadi kebal 5 menstrual cycles in 2 months discount sarafem on line, di dalam tubuh terna ktidak terjadi reaksi antara antigen dengan antibodi womens health 7 day cleanse generic 20mg sarafem free shipping. Resistensi yang dihasilkan hanya bersifat sementara women's health center west bloomfield effective 20mg sarafem, memberi perlindungan yang cepat namun cepat pula dikatabolisme women's health center udel order discount sarafem line, sehingga ternak resipien menjadi rentan kembali terhadap infeksi ulang. Pada ayam, imunitas pasif diturunkan dari induk kepada anak ayam melalui kuning telur. Contoh-contoh imunisasi pasif, antara lain adalah (1) antibodi dalam kolustrum yang diberikan oleh induk sapi kepada pedet yang baru lahir. Imunisasi Aktif Imunisasi aktif adalah suatu usaha untuk mendapatkan kekebalan tubuh pada ternak melalui pemberian antigen pada ternak sehingga ternak menanggapinya dengan meningkatkan tanggap kebal protektif berperantaraan sel atau antibodi atau keduaduanya. Pada imunisasi aktif, kekebalan tidak terbentuk secara cepat, namun sekali terbentuk akan bertahan lama dan terbentuk sel ingatan, sehingga memiliki kemampuan perangsangan ulang. Imunitas aktif bisa dirusak oleh sesuatu yang berdampak negatif terhadap sistim kebal humoral maupun seluler yang mengakibatkan hilangnya kemampuan tubuh ternak berespon terhadap antigen. Pengobatan hanya digunakan setelah usaha pencegahan dan pengendalian penyakit terlaksana dengan baik. Pertimbangan penting untuk membantu pengobatan ternak secara efektif yang dapat diikuti, antara lain adalah (1) diagnosis harus ditegakkan dengan isolasi dan identifikasi penyebab penyakit melalui pemeriksaan mikrobiologis (2) bibit penyakit harus peka terhadap obat terpilih (3) obat-obatan diberikan berdasarkan dosis dan waktu pemberian yang tepat yang sesuai dengan rekomendasi pabrik pembuat obat (4) harus dilakukan kontrol respon ternak terhadap obat yang telah diberikan (5) pengobatan hanya dilakukan apabila diproyeksikan masih menguntungkan (6) harus mengetahui dan mematuhi waktu henti obat (withdrawl time), untuk menghindari residu obat. Penggunaan antibiotik di bidang peternakan sudah sangat luas, baik sebagai imbuhan pakan maupun untuk tujuan pengobatan. Dampak yang ditimbulkan bisa menguntungkan atau merugikan tergantung dari berbagai faktor, termasuk dosis, route pemberian, dan sering tidaknya antibiotik jenis tertentu digunakan. Penggunaan Antibiotik dalam Bidang Peternakan Antibiotik merupakan senyawa kimia yang dihasilkan oleh berbagai jasad renik, seperti bakteri dan jamur yang memiliki fungsi menghentikan pertumbuhan atau membunuh jasad renik. Penicillin dihasilkan oleh Penicillium, Cephalosporin dihasilkan oleh Cephalosporium. Antibiotik yang diperoleh secara alami oleh mikroorganisme disebut antibiotik alami, antibiotik yang disintesis di laboratorium disebut antibiotik sintetis, seperti sulfa. Antibiotik yang dihasilkan oleh mikroorganisme dan dimodifikasi di laboratorium dengan menambahkan senyawa kimia disebut antibiotik semisintetis. Berdasarkan cara kerjanya, antibiotik dibedakan dalam 4 kelompok, yaitu (1) antibiotik penghambat sintesis dinding sel, misalnya Penicillin, Bacitrasin, Novobiosin, Sefalosporin dan Vancomisin (2) antibiotik perusak membrane sel, misalnya Polimixin, Colistin, Novobiosin, Gentamisin, Nistatin dan Amfoterisin B (3) antibiotik penghambat sintesis protein, misalnya Tetrasiklin, Khloramfenikol, Neomisin, Streptomisin, Kanamisin, eritromisin, Oleandomisin, Tilosin dan Linkomisin (4) antibiotik penghambat sintesis asam nukleat, misalnya Aktinomisin, Sulfonamida dan derivat kuinolon. Antibiotik dibedakan juga berdasarkan kemampuannya menekan pertumbuhan atau membunuh bakteri, yaitu antibiotik yang bersifat bakterisidal dan bakteriostatik. Antibiotik bakterisidal adalah antibiotik yang mampu membunuh sel bakteri, contohnya: Penicillin, Streptomisin, Bacitrasin, Neomisin, Polimiksin dan Nitrofurans. Antibiotik yang bersifat bakteriostatik yaitu antibiotik yang hanya mampu menekan pertumbuhan sel bakteri, contohnya: sediaan Sulfa, Tetrasiklin, Khloramfenikol, Eritromisin, Tilosin, Oleandomisin dan Nitrofuran. Secara umum antimikroba yang mempengaruhi pembentukan dinding sel atau permeabilitas membrane sel bekerja sebagai bakterisid, sedangkan yang mempengaruhi sintesis protein bekerja sebagai bakteriostatik. Bakterisid adalah zat yang dapat membunuh bakteri dan bakteriostatik adalah zat yang dapat mencegah pertumbuhan bakteri, sehingga populasi bakteri tetap. Beberapa senyawa kimia antimikroba, antara lain fenol, alkohol, halogen, logam berat, zat warna, deterjen, senyawa ammonium kuartener, asam dan basa. Berdasarkan atas sifat bakteri yang peka, antibiotik dibedakan dalam 3 kelompok, yaitu (1) antibiotik yang peka terhadap bakteri Gram-positif, misalnya Penicillin, Basitrasin, Novobiosin, Sefalosporin, Eritromisin, Tilosin dan Oleandomisin 2) antibiotik yang peka terhadap bakteri Gram-negatif, misalnya Streptomisin dan Dehidrostreptomisin, Neomisin, Polimiksin, Colistin, Kanamisin dan Gentamisin (3) antibiotik spektrum luas, seperti Ampisillin, Amoksisillin, Tetrasiklin, Khloramfenikol, sediaan Sulfa, Nitrofurans dan Sefalosporin. Dampak Negatif Penggunaan Antibiotik di Bidang Peternakan Residu Antibiotik Tiap senyawa anorganik atau organik, baik yang berupa obat-obatan, mineral atau hormon yang masuk atau dimasukkan ke dalam tubuh individu, akan mengalami berbagai proses yang terdiri dari: penyerapan (absorbsi), distribusi, metabolisme (biotransformasi) dan eliminasi. Kecepatan proses biologik tersebut di atas tergantung kepada jenis dan bentuk senyawa, cara masuknya dan kondisi jaringan yang memprosesnya. Apabila bahan tersebut dimasukkan melalui mulut, penyerapan terjadi di dalam saluran pencernaan yang sebagian besar dilakukan oleh usus. Setelah terjadi penyerapan, senyawa yang berbentuk asli maupun metabolitnya akan dibawa oleh darah dan akan didistribusikan ke seluruh bagian tubuh. Metabolisme akan terjadi di dalam alat-alat tubuh yang memang berfungsi untuk hal tersebut dan pada sel-sel serta jaringan yang mampu melakukannya.

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These theories revolve around the presence of proto-oncogenes that playa role in cell division menstrual cramps 8 weeks postpartum generic 20 mg sarafem amex. Viruses have been implicated as possible activators of oncogenes (acti vated proto-oncogenes) and as inhibitors of oncogene repressors womens health exercise equipment discount sarafem 20mg fast delivery. Culturing Viruses in Whole Organisms Most of our knowledge of viral replication has been derived from research on bac teriophages women's health clinic grenada ms purchase sarafem on line, which are relatively easy to culture because bacteria are easily grown and maintained pregnancy hotline generic sarafem 20 mg on-line. Phages can be grown in bacteria maintained in either liquid cul tures or on agar plates. Such plates enable the estimation of phage numbers via a technique called plaque assay. Maintaining laboratory animals can be difficult and expensive, and the prac tice raises ethical concerns for some. Therefore, scientists have developed alter native ways of culturing animal and human viruses using fertilized chicken eggs or cell cultures. Culturing Viruses in Cell (Tissue) Culture Viruses can also be grown in cell culture, which consists of cells isolated from an organism and grown on the surface of a medium or in broth. They are of two types: Diploid cell cultures are created from em bryonic animal, plant, or human cells that have been isolated and provided appropriate growth conditions. Continuous cell cultures are more long lasting because they are derived from tumor cells, which divide relentlessly. Characteristics of Prions Prions are infectious protein particles that lack nucleic acids and replicate by con verting similar normal proteins into new prions. Prions are not destroyed by normal cooking or sterilization, though they are destroyed by incineration. For some scientists, however, three observations indicate that viruses are the least complex living entities: First, viruses use sophisticated methods to invade cells. Third, they possess genomes con taining the instructions for their own replication. Thus, viruses teeter on the thresh old of life: Outside of cells, they do not appear to be alive, but within cells, they direct the synthesis and assembly required to make copies of themselves. Viruses, viroids, and prions by their very nature defy classification in the tradi tion sense of biology. Remember the following while studying this chapter: Chapter 13 Characterizing and Classifying Viruses, Viroids, and Prions 123 Viruses, viroids, and prions are acellular and do not form branches of the tree of life: It is doubtful if any of these microscopic entities are living, and any relationships they may have had with living cells is so remote as to be impos sible to uncover. When studying viruses, viroids, and prions, we are there fore studying microbes completely different from any of the other microbes we have come to know. Refer to the answers only after you have attempted to solve the ques tions on your own. Which step of the viral replication cycle of T4 phage is performed for the virus by E. Which event below generally occurs as a discrete step in the replication cycle of animal viruses but not in that of phages? By introducing an oncogene By stimulating oncogenes that are already present By interfering with tumor repression All of the above 10. When studying a human virus in the laboratory, the best way to culture the virus would be to use: a. Viroids differ from viruses in that viroids: Are larger than viruses Are always linear whereas viruses are not Lack a capsid whereas viruses always have a capsid Infect only animals whereas viruses can infect any cell type c. Which of the following mechanisms is not a method by which prions are transmi tted? Ingestion of infected tissue Transplantion of infected tissue Mucous membrane contact with infected tissue All of the above are methods of transmission Fill in the Blanks 1. The virion consists at a minimum of a protein - - - - - - - - - - - and a nucleic acid - - - - - - - - - - 2. This enzyme is also used during (name the stage of replication). Phages can undergo one of two types of replication inside a host cell, or 6. It carries the enzyme - - - - - - - - - - - so it can make a - - - - - - - intermediate from its genome. Enveloped viruses are released from a host cell by In this process, the host cell 10. Cells that divide uncontrollably are said to be mass of such cells forms a malignant, they spread in a process called cause and.

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