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The increase in half-life permits administration as a bolus rather than by continuous infusion cheap 30caps himplasia amex herbs lower blood pressure. Streptokinase is a nonenzyme protein that is isolated from streptococci; it binds to plasmin- ogen to catalyze the conversion of plasminogen to active plasmin buy 30 caps himplasia amex krishna herbals. Many individu- als have antistreptococcal antibodies because of prior exposure to the bacteria; this can reduce effectiveness and complicate treatment 30 caps himplasia amex herbals in american diets. Although streptokinase is commonly used in Europe, it is no longer marketed in the United States. Urokinase is a protease originally isolated from urine; the drug is now prepared in recombi- nant form from cultured kidney cells. It is less antigenic than streptokinase and is indicated in patients sensitive to streptokinase. A patient is admitted to the hospital for gall- constant abdominal pain, nausea, and short- bladder surgery, and although the surgery is ness of breath. A young couple present to their primary (E) Folic acid care physician stating that they are trying to conceive. A man undergoing chemotherapy for lung future mom-to-be needs to be on any cancer complains of shortness of breath when supplements. Which of the following women develop iron deficiency anemia would be most appropriate for this patient? A 65-year-old diabetic man develops end- peripheral vision and dizziness that lasts for stage renal disease. A 53-year-old obese woman is brought into stored in the body the emergency room by her concerned husband (E) It participates in the mitochondrial reaction approximately 1 hour after complaining of that produces succinyl-CoA 186 Chapter 7 Drugs Used in Anemia and Disorders of Hemostasis 187 7. He states that since he does not have alcohol abuse presents to the urgent care medical insurance, he only comes to see a doc- clinic complaining of lightheadedness and tor when he experiences these ‘‘crises. His laboratory studies pain medication is the emergency physician indicate a low hemoglobin level. A 74-year-old woman who is undergoing (E) Folic acid chemotherapy for advanced lung cancer presents to the infusion center for her next 8. Before each treatment her white goes gastric bypass surgery to help her lose count, hemoglobin, and platelet counts are weight. Her surgeon reminds her that now she checked to make sure she is not experiencing will have to get a monthly injection of vitamin chemotherapy-related cytotoxicity. Her blood B12, since the part of her stomach responsible sample is run in the analyzer, and her platelet for production of intrinsic factor has been count is reported to be at a dangerously low removed. A 55-year-old woman undergoes an open (E) Neurologic deficits are not seen with this cholecystectomy. She is admitted for postopera- kind of anemia tive observation and started on subcutaneous heparin treatment to prevent formation of deep 9. A 31-year-old pregnant woman presents to venous thrombosis, a major risk factor for pul- her obstetrician for a routine visit. Which of the following is eral questions for her doctor, one of which has true regarding the mechanism of action of to do with the supplements that she was advised heparin? She stated she (A) Heparin increases activity of antithrombin leads a very busy lifestyle and sometimes forgets (B) Serine proteases of the clotting cascade are to take all the pills she is supposed to take. She deactivated wants to know the purpose of folic acid supple- (C) Heparin catalyzes clotting in vitro mentation in pregnancy. A 63-year-old man has a history of atrial fi- (C) It aids in bone growth of the maturing fetus brillation. To reduce his risk of a stroke, his phy- (D) It stimulates myelopoiesis of erythroid pro- sician had given him an anticoagulant genitor cells medication. This agent, while being of tremen- (E) It reduces blood viscosity during pregnancy dous benefit to this patient, comes with its asso- ciated risks, such as spontaneous hemorrhage. A 29-year-old African-American man To monitor the appropriateness of the current presents to the emergency department with a dosage of the medication, the patient comes in chief complaint of severe pain in his arms and frequently to have the laboratory check his pro- legs. Which medication must this knows that what he is experiencing is a sickle patient be taking? You are very excited, (D) Coumarin because you, in fact, had just reviewed your (E) Protamine pharmacology. A 75-year-old man is brought to the emer- (B) Coumarin gency department after being found on the floor (C) Clopidogrel of his room. His wife tells you that his medical (D) Alteplase history includes two prior strokes, for which he (E) Dextran is now taking a ‘‘small pill that works on plate- lets. After 6–7 days of parenteral feeding, vitamin K stores are depleted and clotting factor biosynthesis is impaired. Ticlopidine is an anticoagulant, and urokinase is a thrombolytic; both would be contraindicated in this circumstance. Digoxin is a cardiac glycoside that can improve contractility in impaired myocardium but would not be used in this circumstance. Prophylactic antiplatelet therapy should be instituted while the diagnosis is confirmed. While increased bleeding tendency, dietary deficiency, and malabsorption are all true causes of iron deficiency anemia, they are not the culprits during pregnancy. Iron storage is regulated at the level of absorption, and very little of it is lost from the body. Participation in the mitochondrial reaction that produces succinyl-CoA refers to the mechanism of action of one of the natural cobalamins, deoxyadenosylcobalamin. Sideroblastic anemia may develop in alcoholics and patients undergoing anti- tuberculin therapy. Vitamin B12 and folic acid are used for megaloblastic anemias caused by depletion of the vitamin. Loss of vitamin B12 is a very slow process, with hepatic stores being sufficient for up to 5 years. Folic acid supplementation has been shown to decrease the incidence of neu- ral tube defects. Increasing the oxygen-carrying capacity of the blood refers to a possible role of iron supplements. Stimulating myelopoiesis of ery- throid progenitor cells refers to the mechanism of action of erythropoietin. Finally, reduction of blood viscosity during pregnancy refers to pentoxifylline; however, this medication is not recom- mended during pregnancy. Hydroxyurea increases the production of fetal hemoglobin and has been shown to be effective in reducing painful episodes of sickle crisis. Acetaminophen is unlikely to be helpful in this patient’s situation, as this agent is useful for mild-to-moderate pain.

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The mechanism of the hypercalcemia of sarcoidosis is related to excess vitamin D generic 30 caps himplasia free shipping herbals teas for the lungs, therefore calcitriol would be contraindicated buy himplasia 30caps with amex xena herbals. Thiazide diuretics buy himplasia 30caps without a prescription equine herbals, calcium channel blockers, or centrally acting alphablockers are better choices for an antihypertensive agent in a pa- tient with bilateral renal artery stenosis. Factors such as infection, drugs, position, and exercise impact solute and water clearance. In the developed world, hemodialysis is often the preferred method for renal replacement for pa- tients. However, in poorer countries where access to hemodialysis centers is limited, peri- toneal dialysis is used more commonly. Residual renal function alters the dose of dialysis but does not impact the mode of dialysis. Moreover, patients with no residual renal func- tion who receive peritoneal dialysis are at higher risk of uremia than patients on hemodial- ysis. High-transporters through the peritoneum require more frequent doses of peritoneal dialysis, potentially negating the benefit of this modality. Patients with prior abdominal surgeries often have difficulty with peritoneal dialysis catheter placement and dialysate delivery. The calculated urine anion gap (Na + K – Cl ) is +3; thus, the acidosis is un- likely to be due to gastrointestinal bicarbonate loss. This condition may be associated with calcium phosphate stones and nephrocalcinosis. The history and labora- tory features are also consistent with this lesion: some associated hypertension, diminution in creatinine clearance, and a relatively inactive urine sediment. The “nephropathy of obesity” may be associated with this lesion secondary to hyperfiltration; this condition may be more likely to occur in obese patients with hypoxemia, obstructive sleep apnea, and right-sided heart failure. Hypertensive nephrosclerosis exhibits more prominent vascular changes and patchy, ischemic, totally sclerosed glomeruli. In addition, nephrosclerosis seldom is associated with nephrotic-range proteinuria. Minimal-change disease usually is associated with sympto- matic edema and normal-appearing glomeruli as demonstrated on light microscopy. This pa- tient’s presentation is consistent with that of membranous nephropathy, but the biopsy is not. With membranous glomerular nephritis all glomeruli are uniformly involved with subepithe- lial dense deposits. As a result of the effects of aldosterone and the avid sodium reabsorption, urine potassium will be higher than urine sodium. Sweat is hypotonic relative to serum, and so patients with excessive sweating are more likely to be hypernatremic than hyponatremic. Although primary polydipsia can present similarly with thirst and polyuria, it does not cause hypernatremia; instead, hyponatremia results from increased extracellular water. Often patients with diabetes insipidus are able to compensate as out- patients when they have ready access to free water, but once hospitalized and unable to receive water freely, they develop hypernatremia. The first step in the evaluation of diabe- tes insipidus is to determine if it is central or nephrogenic. In central diabetes inspidus it is low be- cause of a failure of secretion from the posterior pituitary gland, whereas it is elevated in nephrogenic disease, in which the kidneys are insensitive to vasopressin. After measure- ment of the vasopressin level, a trial of nasal arginine vasopressin may be attempted. Generally nephrogenic diabetes inspidus will not improve significantly with this drug. Free water restriction, which will help with primary polydipsia, will cause worsening hy- pernatremia in patients with diabetes insipidus. Serum osmolality and 24-h urinary so- dium excretion will not help in the diagnosis or management of this patient at this time. This patient has multiple warning signs for the use of agents to alter her weight, including her age, gender, and participation in competitive sports. Once diuretic use and vomiting are excluded, the dif- ferential diagnosis of hypokalemia and metabolic alkalosis includes magnesium deficiency, Liddle’s syndrome, Bartter’s syndrome, and Gittleman’s syndrome. Liddle’s syndrome is as- sociated with hypertension and undetectable aldosterone and renin levels. It may also include polyuria and nocturia because of hypokalemia-induced di- abetes insipidus. Gittleman’s syndrome can be distinguished from Bartter’s syndrome by hypomagnesemia and hypocalciuria. These are associated with a feeling of excess tory of peptic ulcer disease, for which he takes a proton- gas. On physical examination, she is writhing in dis- namically stable and his hematocrit has not changed in tress and slightly diaphoretic. Which of the rate 127 beats/min, blood pressure 92/50 mmHg, res- following findings at endoscopy is most reassuring that piratory rate 20 breaths/min, temperature 37. Which of the following statements about alcoholic greatest in the periumbilical and epigastric area with- liver disease is not true? There is no evidence of jaun- dice, and the liver span is about 10 cm to percussion. Serum aspartate aminotransferase levels are often phosphatase level 268 U/L, lactate dehydrogenase greater than 1000 U/L. After 3 L of normal sa- room with severe mid-abdominal pain radiating to line, her blood pressure comes up to 110/60 mmHg her back. She has had two episodes lowing statements best describes the pathophysiology of emesis of bilious material since the pain began, but of this disease? She currently rates the pain as a 10 out of 10 and feels the pain is worse in the A. For the past few months, she has had autodigestion and acinar cell injury intermittent episodes of right upper and mid-epigas- B. Chemoattraction of neutrophils with subsequent tric pain that occur after eating but subside over a few infiltration and inflammation 307 Copyright © 2008, 2005, 2001, 1998, 1994, 1991, 1987 by The McGraw-Hill Companies, Inc. All of the following necessitate sending bacterial 2 stool cultures in patients with diarrhea for 2 days severe A. The pain is mostly in the right flank cur- you see a 70-year-old male patient with multisystem or- rently but began in the periumbilical area. His preoperative laboratory results showed: sodium, She is tender in the right flank without costovertebral an- 133 meq/dL, potassium, 5. The genitourinary and pelvic examina- dL, bicarbonate, 14 meq/dL, blood urea nitrogen 85 tions are normal.

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Decision Independent- The distribution of Length of stay is Samples Reject the 1 the same across categories of Mann- generic 30caps himplasia with visa himalaya herbals products. Non-parametric tests By double clicking on the Hypothesis Test Summary table 30caps himplasia visa wise woman herbals 1, the Model Viewer screen will open generic 30 caps himplasia with mastercard herbals on demand down. The Model View has a two panel views, with the Hypothesis Test Summary table shown on the left hand side, referred to as the Main View. On the right side, the linked Auxiliary View is displayed which shows the following population pyramid chart and test table. The chart displays back-to-back histograms for each category of the group, that is, ‘No’ infection and ‘Yes’ infection. The number of cases in each group and the mean rank of each group are also reported. The mean ranks provide an indication of the direction of effect but because the data are ranked, the dimension is different from the original measurement and is therefore difficult to communicate. Independent-Samples Mann-Whitney U Test Infection No Yes 300 300 N = 80 N = 52 Mean Rank = 58. The asymptotic significance value is reported when the sample size is large, say more than 30 cases. The difference between the groups could be reported in a table as shown in Table 3. Another approach to non-normal data is to divide the outcome variable into cat- egorical centile groups as discussed in Chapter 8. Decision about whether to use non-parametric tests, to transform the variable or to categorize the values requires careful consideration. The decision should be based on the size of the sample, the effectiveness of the transformation in normalizing the data and the ways in which the relationship between the explanatory and outcome variables is best presented. Adventure education and outward bound: out-of-class experiences that make a lasting difference. This test is used when two continuous variables are related because they are collected from the same participant at different times, from different sites on the same person at the same time or from cases and their matched controls. When using a paired t-test, the variation between the pairs of measurements is the most important statistic and the variation between the participants, as when using a two-sample t-test, is of little interest. The null hypothesis for a paired t-test is that the mean of the differences between the two related measurements is equal to zero, that is, no difference. Thus, the number of rows in the data sheet is the same as the number of participants when the outcome variable is measured more than once for each participant or is the number of participant-pairs when cases and controls are matched. When each participant is measured on two or more occasions, the sample size is the number of participants. In a matched case–control study, the number of case–control pairs is the sample size and not the total number of participants. For this reason, withdrawals, loss of follow-up data and inability to recruit matched controls reduce both power and the generalizability of the paired t-test because participants with missing paired values or cases who are not matched with controls are excluded from the analyses. Treating paired or matched measurements as independent samples will artificially inflate the sample size and lead to inaccurate analyses. The decision of whether to use a one- or two-tailed test must be made when the study is designed. If a one-tailed t-test is used, the null hypothesis is more likely to be rejected than if a two-tailed test is used (Chapter 3). In general, two-tailed tests should always be used unless there is a good reason for not doing so and a one-tailed test should only be used when the direction of effect is specified in advance. Does the head circumference of babies increase significantly in a 2-month growth period? Variables: Outcome variables = weight, length and head circumference measured at 1 month of age and 3 months of age (continuous) 4. The distribution of these differences between the paired measurements can then be examined using the commands shown in Box 4. The histograms indicate that the difference variables for weight and length are fairly normally distributed. The distribution of scores for the difference variable for head cir- cumference is quite skewed. The checks of normality as discussed in Chapter 2 indicate that this variable is not normally distributed. Therefore, a non-parametric test is more appropriate to analyse this variable, which is discussed later in this chapter. By entering the data variables at 3 months before the data variables at 1 month, the direction of the summary statistics will be in the appropriate direction and have the correct signs. The Paired Samples Correlations table shows the correlations between each of the paired measurements. This table is not relevant because it does not make sense to test the hypothesis that two related measurements are associated with one another. The second column, which is labelled Mean, gives the main outcome measurement that is the mean within-pair difference. When conducting a paired t-test, the means of the differences between the pairs of measurements are computed as part of the test. These mean values provide an indication that babies increased in measurements over a 2-month period. However, they do not provide infor- mation as to whether this increase was statistically significant. The 95% confidence intervals of the differences are calculated as the mean paired dif- ferences ± (1. These are shown in the Paired Samples Test table and do not contain the value of zero for any variable, which also provides evidence that the difference in body size between 1 and 3 months is statistically signif- icant. The t value is calculated as the mean differences divided by their standard error. Because the standard error becomes smaller as the sample size becomes larger, the t value increases as the sample size increases for the same mean difference. Thus, in this example with a large sample size of 277 babies, relatively small mean differences are highly statistically significant. However, the alternative hypothesis for this study was one-tailed; therefore, the P val- ues have to be adjusted by halving them. The P values (one-tailed) from the paired t-tests for all three variables indicate that each null hypothesis should be rejected and that there is a significant increase in body measurements between the two time periods. As with any statistical test, it is important to decide whether the size of mean difference Paired and one-sample t-tests 97 Table 4. These effect sizes are very large but are expected in babies studied in a critical growth period.

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