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His vital signs include the following: afebrile erectile dysfunction mental order generic extra super cialis on-line, blood pressure 172/94 mm Hg circumcision causes erectile dysfunction cheap extra super cialis master card, pulse 84 bpm impotence by age purchase line extra super cialis, respiratory rate 16/min erectile dysfunction treatment in singapore extra super cialis 100 mg line. On physical examination an S3 gallop is heard; 3+ pitting edema is noted in his lower extremities, and a chest examination reveals inspiratory rales bilaterally. In the USA, drugs are divided by law into two classes: those restricted to sale by prescription only and those for which directions for safe use by the public can be written. The latter category constitutes the nonprescription or over-the-counter (OTC) drugs. In 2010, the American public spent approximately $17 billion on over 100,000 OTC products to medicate themselves for ailments ranging from acne to warts. These products contain approximately 1000 active ingredients in various forms and combinations. It is apparent that many OTC drugs are no more than "me too" products advertised to the public in ways that suggest significant differences between them. There is a price attached to all of these features, and in most cases a less expensive generic product can be equally effective. It is probably safe to assume that the public is generally overwhelmed and confused by the wide array of products presented and will probably use those that are most heavily advertised. Over the past four decades the Food and Drug Administration (FDA) has been engaged in a methodical review of OTC ingredients for both safety and efficacy. Indeed, more than 700 OTC products contain ingredients and dosages that were available only by prescription less than 30 years ago. Some agents such as docosanol and the nicotine polacrilex lozenge have bypassed the prescription route altogether and have been released directly to the OTC market. Other OTC ingredients previously available in low doses only are now available in higher-strength or original prescription strength formulations. Examples of other prescription drugs with the potential for future OTC reclassification include nicotine replacement therapy (oral inhaler, nasal spray) for smoking cessation, proton-pump inhibitors (pantoprazole) for heartburn, and second-generation nonsedating antihistamines (desloratadine, fexofenadine, levocetirizine) for relief of allergy and cold symptoms. The frequency of prescription-to-OTC switches, while commonplace in the mid-1990s, has largely declined over the past decade. The prescription-to-OTC reclassification process is both costly and rigorous and fewer prescription medications are appropriate candidates for a switch (eg, a consumer can self-diagnose and safely treat the condition). For example, the cholesterol-lowering agents cholestyramine, lovastatin, and pravastatin were denied OTC status on the basis that these agents could not be used safely and effectively in an OTC setting. In a similar recommendation, oral acyclovir for OTC use in the treatment of recurrent genital herpes was not approved because of concerns about misdiagnosis and inappropriate use leading to increased viral resistance. There are three reasons why it is essential for clinicians to be familiar with the OTC class of products. First, many OTC medications are effective in treating common ailments, and it is important to be able to help the patient select a safe, effective product. Second, many of the active ingredients contained in OTC drugs may worsen existing medical conditions or interact with prescription medications. Phenylpropanolamine, for example, a sympathomimetic previously found in many cold, allergy, and weight control products, was withdrawn from the United States market by the FDA based on reports that the drug increased the risk of hemorrhagic stroke. Although severe complications associated with dextromethorphan as a single agent in overdose are uncommon, many dextromethorphan-containing products are formulated with other ingredients (acetaminophen, antihistamines, and sympathomimetics) that can be fatal in overdose. Additionally, pseudoephedrine, a decongestant contained in numerous OTC cold preparations, has been used in the illicit manufacture of methamphetamine. A general awareness of these products and their formulations will enable clinicians to more fully appreciate the potential for OTC drug-related problems in their patients. The selection of one ingredient over another may be important in patients with certain medical conditions or in patients taking other medications. Select the product that is simplest in formulation with regard to ingredients and dosage form. Although some combination products contain effective doses of all ingredients, others contain therapeutic doses of some ingredients and subtherapeutic doses of others. Furthermore, there may be differing durations of action among the ingredients, and there is always a possibility that the clinician or patient is unaware of the presence of certain active ingredients in the product. Acetaminophen, for example, is in many cough and cold preparations; a patient unaware of this may take separate doses of analgesic in addition to that contained in the cold preparation, potentially leading to hepatotoxicity. This is critical because many products with the same brand name contain different ingredients that are labeled for different uses. For example, multiple laxative products (with different active ingredients) carry the Dulcolax name including Dulcolax Balance (polyethylene glycol), Dulcolax Laxative (bisacodyl), and Dulcolax Stool Softener (docusate sodium). This marketing practice of "extending a brand name" across product lines, while legal, is confusing and can lead to medication errors. Be wary of "gimmicks" or advertising claims of specific superiority over similar products.

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Presentation Pancytopenia (pallor erectile dysfunction how common order 100 mg extra super cialis amex, infection impotence over 60 order cheap extra super cialis, bleeding) erectile dysfunction under 30 generic extra super cialis 100 mg otc, fatigue erectile dysfunction treatment delhi order extra super cialis with mastercard, anorexia, fever, bone pain. Prognosis depends on clinical signs, biologic features of lymphoblasts and response to induction chemotherapy. Low risk: these patients meet the standard risk criteria and have favourable genetics, such as trisomy 4, 10 or 17. High risk: Patients do not meet standard criteria or have extra-medullary involvement (eg brain/testis). Very high risk: Have unfavourable genetics, such as the Philedelphia chromosome, hypodiploidy-or poor response to initial chemotherapy. Event-free survival at 5yr is 95% in the low risk group; 30% in the very high risk. Revaccinate (1 dose of each type, p151) 6 months after chemotherapy (as vaccine-specific antibody). Relapses: Consider FLAG,38 clofarabine, 437 or marrow transplant; consider if risk, eg WCC >200109/L, MLL gene rearrangement, B-cell ALL with t(8;14). ALL Paediatrics Pitfalls Ignoring quality of life; eg most cytotoxics may be given at home. Grampositive organisms predominated (80%) and most were coagulase-negative staphs. If blood culture does prove +ve, either change imipenem after microbiological advice, or continue it for 5 days, if he has been afebrile for >24h. There are few clinically important drug interactions, eg seizures if co-therapy with ganciclovir. Dose: 10mg/kg/12h IV for 3 doses, max 400mg, then 6mg/kg/24h (max 400mg); neonates: 16mg/kg on day 1, then 8mg/kg/day). Paediatrics 196 Anaemia the clinical problem You have the results of a full blood count, showing anaemia (Hb <110g/L, p220, the WHO criterion). IDA/iron deficiency anaemia (poor diet, poverty, bleeding, stomatitis, koilonychia) or thalassaemia (Mediterranean/SE Asia areas, short stature, muddy complexion, icteric sclerae, distended abdomen hepatosplenomegaly, bossed skull, prominent maxillae, from marrow hyperplasia). Signs of B12: poor feeding, late milestones; odd movements; microcephaly, failure to thrive. Hypochromic microcytic RBCs IDA; target cells liver disease or thalassaemia; ferritin for IDA; sickling tests + Hb electrophoresis for thalassaemia & sickle-cell anaemia; B12; red cell folate. Iron deficiency anaemia (~26% of infants, worldwide; 454 peak age ~18 months) this is despite fortification of, formula, breakfast cereals and noodles etc. If poor compliance, try Iron Spangles which can be poured into yoghurt or ice cream. Get help, and try to provide the expert with sufficient information to answer these 4 questions: 1 Any evidence of RBC production Hereditary spherocytosis is the main cause of haemolysis in north European children (mainly autosomal dominant; spontaneous mutations in 25%). Flow cytometric analysis of eosin-5-maleimide (EMA) binding to red cells, and cryohaemolysis test have replaced osmotic fragility tests. Treating low ferritins may improve: Memory Lassitude Developmental delay Sleep Mood Cognition-in toddlers and adolescent girls, facing demands of puberty and menstruation. Purpura (purple spots/nodules not disappearing on palpation), arthritis/arthralgias (74%)-often knees/ankles-and abdominal pain (51%) are the classic triad. Steroids may help resolve abdo pain, 465 but role in prevention of chronic kidney disease is less clear. Complications (worse in adults): massive GI bleeds, ileus, haemoptysis (rare), and acute renal failure (rare). One option in HSP nephritis (not usually needed) is high-dose steroids + cyclophosphamide; this decreases proteinuria (a risk factor for renal insufficiency in HSP). Idiopathic (immune) thrombocytopenic purpura (ITP) is most common acquired bleeding disorder in childhood. May follow CMV, EBV, parvovirus, varicella zoster, or live virus vaccine (eg MMR/rubella). If there is significant mucosal bleeding, or lymphadenopathy, hepatosplenomegaly, or pancytopenia, another diagnosis is likely. Tests: Isolated thrombocytopenia (<20109 in 80%); do a film to ensure no other abnormalities. Marrow is unnecessary, unless: 468 Unusual signs are present, eg abnormal cells on a film, lymphadenopathy. Intracranial haemorrhage occurs in <1% (mortality is 50%) 469-do CT if there is headache or CNS signs. Disorders of B cells increase Arthropathy susceptibility to infections by encapsulated bac- Lymphopenia teria, but not (usually) viral or fungal infections. Primary immunodeficiency is more likely if there is a positive family history/parental consanguinity.

Engagement the level of the head is assessed in 2 ways: engagement erectile dysfunction caused by radiation therapy buy generic extra super cialis on line, or fifths palpable abdominally impotence testicular cancer order extra super cialis once a day. Engagement entails passage of the biggest diameter of the presenting part through the pelvic inlet erectile dysfunction treatment in thailand purchase extra super cialis 100 mg with mastercard. Fifths palpable abdominally states what you can feel erectile dysfunction and diabetic neuropathy buy extra super cialis on line, and makes no degree of judgement on degree of engagement of the head. In primigravida, the head usually enters the pelvis by 37 weeks, otherwise causes must be excluded (eg placenta praevia or fetal abnormality). Anatomia uteri humani gravidi tabulis illustrata (The anatomy of the human gravid uterus exhibited in figures). Obstetrics 6 Physiological changes in pregnancy Hormonal changes Progesterone, synthesized by the corpus luteum until 35 post-conception days and by the placenta mainly thereafter, decreases smooth muscle excitability (uterus, gut, ureters) and raises body temperature. Oestrogens (90% oestriol) increase breast and nipple growth, water retention, and protein synthesis. Vaginal discharge increases due to cervical ectopy, cell desquamation, and mucus production from a vasocongested vagina. Haemodynamic changes Blood: From 10 weeks the plasma volume rises until 32 weeks when it is 3. With increased venous dispensability, and raised venous pressure (as occurs with any pelvic mass), varicose veins may form. Vasodilatation and hypotension stimulate renin and angiotensin release-an important feature of BP regulation in pregnancy. Aorto-caval compression From 20 weeks the gravid uterus compresses the inferior vena cava (and to a lesser extent the aorta) in supine women, reducing venous return. Other changes Ventilation increases 40% (tidal volume rises from 500 to 700mL), the increased depth of breath being a progesterone effect. Breathlessness is common as maternal PaCO2 is set lower to allow the fetus to off-load CO2. Gut motility is reduced, resulting in constipation, delayed gastric emptying, and, with a lax lower oesophageal sphincter, heartburn. Frequency of micturition emerges early (glomerular filtration rate by 60%), later from bladder pressure by the fetal head. The bladder muscle is lax but residual urine after micturition is not normally present. Skin pigmentation (eg in linea nigra, nipples, or as chloasma-brown patches of pigmentation seen especially on the face), palmar erythema, spider naevi, and striae are common. Hair shedding from the head is reduced in pregnancy but the extra hairs are shed in the puerperium. Pregnancy tests Increasingly sensitive and may be positive from 9 days post-conception (or from day 23 of a 28-day cycle). They detect the -subunit of human chorionic gonadotrophin in early morning urine, so are positive in trophoblastic disease (p264). Obstetrics Pre-pregnancy counselling the aim is to minimize the risks to the mother, neonate, or fetus by modifying pre-pregnancy conditions and risk factors. This may involve advising against pregnancy or delaying conception until a safer time. Stop smoking Smoking reduces ovulation and Fallopian tube function, causes abnormal sperm production (less penetrating capacity), rates of miscarriage (2), and is associated with preterm labour and fetal growth restriction, placenta praevia, and abruption. Women should be encouraged and supported to stop smoking, and if this is not possible, to reduce the amount they smoke. Folic acid supplementation To prevent neural tube defects (NTDS) and cleft lip, all should have folate-rich foods + folic acid 0. Vitamin D supplementation in at-risk ethnic groups, the obese, and those with chronic medical disease and reduced mobility. Alcohol High levels of consumption are known to cause fetal alcohol syndrome (p138). Recreational drug use is associated with miscarriage, preterm birth, poor fetal development, and intrauterine death; refer the woman for help early. Pre-existing medical disorders may worsen during pregnancy, or be worsened by pregnancy. As a general rule, poorly controlled disease will remain the same or worsen with poorer outcomes, and well controlled disease remains the same or improves, with a better outcome. Refer for specialist help early: this enables optimal control of the disease and reduces risk (eg fetal malformation in diabetes mellitus, or deterioration with SLE).

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Like crude marijuana erectile dysfunction from stress purchase extra super cialis 100 mg mastercard, dronabinol is a psychoactive agent that is used medically as an appetite stimulant and as an antiemetic erectile dysfunction due to old age purchase 100mg extra super cialis free shipping, but the mechanisms for these effects are not understood erectile dysfunction remedy purchase cheap extra super cialis on-line. Because of the availability of more effective agents weak erectile dysfunction treatment cheap extra super cialis 100 mg amex, dronabinol now is uncommonly used for the prevention of chemotherapy-induced nausea and vomiting. Combination therapy with phenothiazines provides synergistic antiemetic action and appears to attenuate the adverse effects of both agents. Adverse effects include euphoria, dysphoria, sedation, hallucinations, dry mouth, and increased appetite. It has some autonomic effects that may result in tachycardia, conjunctival injection, and orthostatic hypotension. Dronabinol has no significant drug-drug interactions but may potentiate the clinical effects of other psychoactive agents. Nabilone is a closely related THC analog that has been available in other countries and is now approved for use in the USA. Their primary mechanism of antiemetic action is believed to be dopamine-receptor blockade. The usual dose of trimethobenzamide is 300 mg orally, or 200 mg by intramuscular injection. The principal adverse effects of these central dopamine antagonists are extrapyramidal: restlessness, dystonias, and parkinsonian symptoms. As single agents, these drugs have weak antiemetic activity, although they are particularly useful for the prevention or treatment of motion sickness. Their use may be limited by dizziness, sedation, confusion, dry mouth, cycloplegia, and urinary retention. Aminosalicylates are believed to work topically (not systemically) in areas of diseased gastrointestinal mucosa. Up to 80% of unformulated, aqueous 5-ASA is absorbed from the small intestine and does not reach the distal small bowel or colon in appreciable quantities. To overcome the rapid absorption of 5-ASA from the proximal small intestine, a number of formulations have been designed to deliver 5-ASA to various distal segments of the small bowel or the colon. These include sulfasalazine, olsalazine, balsalazide, and various forms of mesalamine. In sulfasalazine, 5-ASA is bound to sulfapyridine; in balsalazide, 5-ASA is bound to 4-aminobenzoyl-alanine; and in olsalazine, two 5-ASA molecules are bound together. The azo structure markedly reduces absorption of the parent drug from the small intestine. In the terminal ileum and colon, resident bacteria cleave the azo bond by means of an azoreductase enzyme, releasing the active 5-ASA. Treatment choice is predicated on both the severity of the illness and the responsiveness to therapy. Agents at the bottom of the pyramid are less efficacious but carry a lower risk of serious adverse effects. Patients with moderate disease or patients who fail initial therapy for mild disease may be treated with oral corticosteroids to promote disease remission; immunomodulators (azathioprine, mercaptopurine, methotrexate) to promote or maintain disease remission; or anti-TNF antibodies. Patients with moderate disease who fail other therapies or patients with severe disease may require intravenous corticosteroids, anti-TNF antibodies, or surgery. Cyclosporine is used primarily for patients with severe ulcerative colitis who have failed a course of intravenous corticosteroids. Azo compounds (balsalazide, olsalazine, sulfasalazine) are converted by bacterial azoreductase to 5-aminosalicylic acid (mesalamine), the active therapeutic moiety. Mesalamine Compounds Other proprietary formulations have been designed that package 5-ASA itself in various ways to deliver it to different segments of the small or large bowel. Asacol and Apriso have 5-ASA coated in a pH-sensitive resin that dissolves at pH 6-7 (the pH of the distal ileum and proximal colon). On dissolution of the pH-sensitive resin in the colon, water slowly penetrates its hydrophilic and lipophilic core, leading to slow release of mesalamine throughout the colon. It is thought that 5-ASA modulates inflammatory mediators derived from both the cyclooxygenase and lipoxygenase pathways. Other potential mechanisms of action of the 5-ASA drugs relate to their ability to interfere with the production of inflammatory cytokines. Clinical Uses 5-ASA drugs induce and maintain remission in ulcerative colitis and are considered to be the first-line agents for treatment of mild to moderate active ulcerative colitis. The effectiveness of 5-ASA therapy depends in part on achieving high drug concentration at the site of active disease. Pharmacokinetics & Pharmacodynamics Although unformulated 5-ASA is readily absorbed from the small intestine, absorption of 5-ASA from the colon is extremely low. Absorbed 5-ASA undergoes N-acetylation in the gut epithelium and liver to a metabolite that does not possess significant anti-inflammatory activity.