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However seroquel 100 mg visa medicine 8 iron stylings, unusual extrapul- monary manifestations and late relapses can occur in those infected with HIV generic seroquel 200 mg symptoms diabetes type 2. A 68-year-old man is evaluated for symptoms of fever, weight loss, and dyspnea on exertion. Physical examination reveals a new diastolic murmur and stigmata of peripheral emboli. He is admitted to the 8 BOARD REVIEW hospital for further evaluation and management of endocarditis. A cardiac echocardiogram shows a 1 cm aortic valve vegetation, and two of two blood cultures subsequently grow Streptococcus bovis that is susceptible to penicillin. No specific further evaluation is warranted Key Concept/Objective: To understand the association between Streptococcus bovis and colon carcinoma The patient in this case has Streptococcus bovis bacteremia with endocarditis. Which of the following statements about pneumococcal resistance to penicillin is true? Penicillin resistance is usually mediated by a plasmid-encoded β-lactamase B. The frequency of penicillin resistance is significantly higher among HIV-infected patients than among others C. Penicillin resistance is usually mediated by a chromosomally mediated β-lactamase D. Most penicillin-resistant pneumococci are also vancomycin-resistant E. Penicillin resistance is mediated by altered penicillin-binding proteins Key Concept/Objective: To understand the mechanism of penicillin resistance in Streptococcus pneumoniae Penicillin resistance among pneumococci is becoming increasingly common. The usual mechanism of resistance is alteration of penicillin-binding proteins, not production of either plasmid or chromosomal β-lactamase. Penicillin resistance is commonly associ- ated with resistance to other classes of antibiotics, further complicating treatment of such infections. The prevalence of penicillin-resistant pneumococci appears to be high- er in patients taking antibiotics, children younger than 6 years, and adults older than 65 years. A young woman presents to your office and states that her roommate has just been diagnosed with active tuberculosis. She recently had a fever, a nonproductive cough, and pleuritic chest pain. A chest x-ray shows no infiltrate, but there is a moderate-sized left pleu- ral effusion. Which of the following statements is true regarding this patient? If this patient has become infected, the most likely initial site of infec- tion is the lung apices 7 INFECTIOUS DISEASE 9 B. A test with purified protein derivative (PPD) should have 10 mm of induration to be considered positive D. If this patient does have tuberculous pleuritis, the diagnosis can be reli- ably made on the basis of an acid-fast smear of pleural fluid E. Tuberculosis is transmitted by inhalation of a tubercle bacillus into the pulmonary alveoli. Initial infection usually occurs in the lower lung fields, not the apices, because of gravity and the greater venti- lation of the lung bases. Reactivation (in an immunocompetent host) tends to occur in the apices because the bacillus has a propensity to disseminate to areas of higher Po2. About 90% of patients with primary tuberculosis infection are asymptomatic. Thus, pleuritis is fairly uncommon, as are the three other potential manifestations of symp- tomatic primary infection (atypical pneumonia, extrapulmonary tuberculosis, and direct progression to upper lobe disease). Patients who are HIV positive, who are immunologically suppressed, or who are in some way debilitated are at increased risk for symptomatic primary infection.

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A positive result on PSA or DRE will suggest that he should undergo invasive testing purchase 200 mg seroquel with amex medicine just for cough, such as transrectal ultrasound and prostate biopsy D buy seroquel 200 mg otc treatment narcolepsy. Should he be found to have prostate cancer, he will want to consider aggressive therapy, and there is a small but finite risk of early death and a significant risk of chronic illness, particularly with regard to sex- ual and urinary function E. All of the above Key Concept/Objective: To understand the uncertainty surrounding screening for prostate cancer, and be able to communicate that uncertainty intelligibly to patients There is disagreement as to whether men should be screened for prostate cancer. It is important to understand that it is not yet known whether screening for prostate cancer will help men live longer and that significant morbidity and mortality have been associ- ated with the diagnostic and therapeutic procedures involved in screening. These facts should be conveyed to the patient to help him make an informed decision. A 65-year-old man who is otherwise in excellent health comes to you for a second opinion regarding therapy for his recently diagnosed prostate cancer. His records show that his cancer was diagnosed on the basis of a screening PSA level of 5. Transrectal ultrasound revealed no apparent tumor, but four of six random biopsy specimens tested positive for cancer. Low, because his clinical tumor stage is T1c and his PSA level is less than 10 C. Intermediate, because his clinical tumor stage is T2b D. High, because a Gleason score of 7 indicates a high-grade tumor Key Concept/Objective: To understand the clinical staging of prostate cancer Clinical staging is based on the means of diagnosis and the size and location of the tumor. This case highlights the point that the tumors of 12 ONCOLOGY 25 patients whose Gleason scores are greater than 6 should be considered high grade. From your assessment of risk for the patient in Question 41, what is the best advice that you can give him about treatment? It is highly likely that his tumor is confined to the prostate, so radical prostatectomy, external-beam radiation, brachytherapy, and watchful waiting are all reasonable options B. There is about a 50% chance of recurrence in 5 years, so radical prosta- tectomy is of no benefit C. There is about a 50% chance of recurrence in 5 years, and radical prostatectomy is curative in 50% of patients with his profile D. There is conclusive evidence that external-beam radiation is superior to radical prostatectomy in patients with his profile E. Although this means that 50% of men with cancer of this stage will have clinically silent metastases, rad- ical prostatectomy is curative in 50% of men in this risk group who undergo that proce- dure. There are as yet no data to suggest that prostatectomy or radiation therapy is of ben- efit with regard to mortality, and patients should be educated about the risks and benefits of both. The patient in Question 41 elects to undergo external-beam radiation. For 3 years, his PSA result is neg- ative, then it rises to 2. Which of the following treatment regimens has the best data to support it? Salvage radical prostatectomy and either surgical castration or chemi- cal castration with LHRH agonists C. Repeated external-beam radiation and either surgical castration or chemical castration with LHRH agonists D. Antiandrogens, such as flutamide, bicalutamide, and nilutamide, and either surgical castration or chemical castration with LHRH agonists E. Neither would further radiation treatment be of benefit. From the available data, the best therapy would be to combine lowering of testos- terone levels (which can be effected either surgically or through hormonal manipulation wih LHRH analogues) and treatment with antiandrogens, such as flutamide, bicalutamide, or nilutamide. A 67-year-old nulliparous white woman presents to the clinic for evaluation of increasing abdominal girth and bloating; these symptoms have been occurring for several months and are associated with some abdominal discomfort. She previously underwent upper GI evaluation, the results of which were negative. She has not had a gynecologic examination for several years, but she denies having any vagi- nal bleeding or discharge. She also denies having any other relevant medical history, but her sister and her mother have breast cancer.

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Overflow incontinence generic seroquel 50 mg otc treatment 4 pimples; discontinue the diuretic and teach the patient intermittent self-catheterization C order seroquel 100mg without prescription medicine 8 capital rocka. Urge incontinence; recommend behavioral therapies, including scheduled voiding and bladder retraining D. Functional incontinence; reassure the patient that the changes are age-related, and recommend diapers during excursions out of the house E. Detrusor hyperactivity secondary to chronic urinary tract infection; check urine culture and prescribe appropriate antibiotics Key Concept/Objective: To recognize and treat urinary incontinence in the elderly Urinary incontinence is an important condition in elderly patients; it is not a normal consequence of aging and is often curable. This patient describes symptoms of urge incontinence caused by involuntary detrusor muscle contractions at relatively low bladder volumes. Urge incontinence can be improved with bladder retraining and scheduled voiding. Additionally, bladder relaxant medications such as oxybutinin or tolterodine are frequently helpful. Functional incontinence describes an inability or refusal to toilet, usually as a result of cognitive impairment or physical limitations. There is no 8 INTERDISCIPLINARY MEDICINE 23 evidence on urinalysis that this patient has a urinary tract infection, and culture in this setting would not be helpful. An 86-year-old resident of a long-term care facility who has suffered multiple strokes in the past is noted to have an ulcer measuring 2 × 2 cm over the sacrum. On examination, the wound appears to extend partially through the dermis but not to the fascial plane (i. There is minimal surrounding erythema and no apparent eschar formation or undermining. Which of the following interventions is most likely to prevent progression and promote healing of the ulcer? Daily topical antibiotic therapy with silver sulfadiazene B. Dressings with povidone-iodine–soaked gauze applied daily C. Sharp debridement followed by wet-to-dry dressings D. Frequent turning and use of a low-air-loss mattress to reduce pres- sure under bony prominences E. Initiation of tube feeding to improve nutrition Key Concept/Objective: To understand the treatment of pressure ulcers in the elderly Pressure is the most important factor in the development and progression of pressure ulcers. Other etiologic factors include shearing forces, moisture, and injury from fric- tion. The first step in managing ulcers of all stages is pressure reduction. This patient does not have evidence of full-thickness ulcer or eschar that would require surgical debridement. Topical antibiotics are appropriate for use in clean ulcers that are not healing with pressure relief and dressings, but their use alone is unlikely to result in healing. It is also important to optimize nutrition to promote wound healing, but it would be inappropriate to initiate tube feeding without first attempting local measures, such as pressure relief and use of wet-to-dry dressings with saline-soaked gauze. Povidone-iodine should not be applied to open wounds because of its toxic cellular effects. A 78-year-old man is brought to clinic from a nursing home for evaluation after a fall. He has a history of hypertension, benign prostatic hypertrophy, and Parkinson disease, which was diagnosed 5 years ago. The fall was unwitnessed and occurred shortly after the patient had breakfast. He was awake and ori- ented to person and place after the fall. His medications include terazosin, hydrochlorothiazide, aspirin, carbidopa-levodopa, and temazepam. On physical examination, the patient appears frail; he has an unsteady, shuffling gait, and he uses a cane for support.

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This is disadvantageous for two main reasons: (1) the process of degradation reduces the structural integrity and (2) degradation products may react unfavorably with the host purchase 100mg seroquel otc medicine over the counter. Metallic implant degradation results from both electrochemical dissolution and wear purchase seroquel 200 mg without prescription medicine zantac, but most frequently occurs through a synergistic combina- tion of the two [1,2]. Electrochemical corrosion processes include both generalized dissolution uniformly affecting an entire surface and localized areas of a component. Locally these areas tend to be at both identifiable areas relatively shielded from the environment (e. In the past, these electro- chemical and other mechanical processes have interacted to cause premature structural failure and accelerated metal release (e. Current clinical questions persist regarding the degree to which elevated local and systemic metal concentrations and particulate corrosion products persist in peri-implant tissues. This chapter will overview implant corrosion basic science, in vitro corrosion testing techniques, corrosion properties of orthopedic alloys, and biocompatibility issues such as metal release, local tissue response to implant corrosion products, and implications for potential sys- temic effects. GENERAL CORROSION CONCEPTS Metal implant corrosion is controlled by (1) the extent of the thermodynamic driving forces which cause corrosion (oxidation/reduction reactions) and (2) physical barriers which limit the kinetics of corrosion. In practice these two parameters that mediate the corrosion of orthopedic biomaterials can be broken down into a number of variables: geometric variables (e. Thermodynamic Considerations: How and Why Metals Corrode The basic reaction that occurs during corrosion is the increase of the valence state (i. These ‘‘end’’ products may also be soluble in solution or may precipitate to form solid phases. Solid oxidation products may be subdivided into those that form adherent compact oxide films, or those that form nonadherent oxide (or other) particles that can migrate away from the metal surface. For corrosion to occur at all there must be a thermodynamic driving force for the oxidation of metal atoms. This driving force can be quantified thermodynamically using the Gibbs function, or free energy equation (the Gibbs function incorporates both the entropy and enthalpy changes of the above chemical reaction, or the total work to reach equilibrium). This assumption is only really true in infinitely dilute solutions where released ions do not interact and molality equals activity, but it remains a good approximation for dilute solutions as well. By convention, if G 0, then the process requires energy; or if G 0, then the oxidation process releases energy and will spontaneously occur. There are two interrelated sources of energy to be considered in corrosion processes: chemical and electrical (charge separation). The chemical driving force ( G) determines whether or not corrosion will take place under the conditions of interest. When the free energy for oxidation is less than zero, oxidation is energetically favorable and will take place spontaneously. The second energy force relates to how the positive and negative charges (metal ions and electrons, respectively) are separated from one another during corrosion. This charge separation contributes to what is known as the electrical double layer and creates an electrical potential across the metal–solution interface (similar to that of a capacitor), which can be quantified by the expression: ∆ = −z (3) where G is the free energy change z is the valence of the ion F is known as the Faraday constant (i. Corrosion and Biocompatibility of Implants 65 This potential is also a measure of the reactivity of the metals, or the driving force for metal oxidation. It shows that the more negative the potential of a metal in solution, the more reactive it will tend to be (i. At equilibrium, the chemical energy balances with the electrical energy, which can be quantified using the Nernst equation, which defines the electrical potential across an idealized metal–solution interface when in a solution. From this equation, a theoretical scale of metal reactivity can be established, known as the electrochemical series, which is a ranking of the equilibrium potential from most positive (i. Be aware that this ranking is based only on thermodynamic equilibrium. That is, it is only true if we assume that there are no barriers (i. Table 1 shows some selected idealized reactions and their electrochemical potential (using a standard hydrogen electrode). Certain metals owe their corrosion resistance to the fact that their equilibrium potentials are very positive. Gold and platinum are examples of metals that have little or no driving force for oxidation in aqueous solutions, and thus they tend to corrode very little in the human body. However, most orthopedic metals have very negative potentials, indicating that from a chemical driving force perspective they are much more likely to corrode.

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