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Further tests etoricoxib 60mg on line, including the peripheral smear for malaria or babesiosis buy etoricoxib 120 mg amex, should be guided by the patient’s history buy discount etoricoxib 120 mg online. Furthermore, Howell–Jolly bodies or other evidence of hyposplenism should be sought, especially in an individual with a history of an illness predisposing to hyposplenism. However, the literature does support that an aggressive approach improves survival (48). Despite the absence of any controlled studies, self- administration of an antibiotic at first sign of suspicious illness in the asplenic or hyposplenic person is advised, this should be specially instituted if delivery of medical care is not immediately available. In an outpatient setting, a patient suspected to have postsplenectomy sepsis should receive an appropriate broad-spectrum antimicrobial such as ceftriaxone parenterally prior to hospital transfer, whether or not blood cultures are obtained. Local resistance patterns should be taken into account when selecting an initial presumptive regimen, with consideration of antibiotic, such as ceftriaxone and cefotaxime, which are active against penicillin-resistant pneumococci, as well as beta-lactamase producers such as H. Some penicillin-resistant pneumococcal isolates are also resistant or only intermediately susceptible to cephalosporins. If such resistance is suspected, the use of vancomycin combined with gram-negative antibiotic coverage for organisms such as meningococcus must be considered. High-level penicillin-resistant pneumococci will definitely require vancomycin with or without rifampin. Other choices include an anti-pneumococcal quinolone, such as levofloxacin, amoxicillin/clavulanic acid, trimethoprim/sulfamethoxazole, or a newer macrolide (clarithromycin, azithromycin). The decision to broaden the gram- negative coverage to other gram negatives including P. In patients with known or suspected central nervous system infections, vancomycin with or without rifampin plus a third-generation cephalosporin is the most optimal initial therapy. Intravenous immunoglobulin is another intervention that has been shown to decrease mortality in asplenic animals (49,50). Granulocyte-macrophage colony– stimulating factor has increased macrophage bactericidal activity in eusplenic and asplenic mice. Babesiosis in the asplenic host is best treated with a combination of clindamycin and quinine. Exchange transfusions to lower high levels of parasitemia also have been used (52,53). Other therapeutic modalities, such as vasopressors, may be warranted in selected cases. Prevention Preventive strategies fall into three major categories: education, immunoprophylaxis, and chemoprophylaxis (33,54). Most patients with asplenia (11% to 50%) remain unaware of their increased risk of serious infection or the appropriate health precautions that should be undertaken (55,56). Asplenic patients should be encouraged to wear a Medi-Alert bracelet or necklace and carry a wallet explaining their lack of spleen and other medical details (33). Patients should be explained regarding the potential seriousness of postsplenectomy sepsis and rapid time course of progression. Patients should be instructed to notify their physician in the event of any acute febrile illness and proceed to nearest emergency department. They should inform any new health care provider, including their dentist, of their asplenic or hyposplenic status. Patients should also be educated regarding travel-related infections such as malaria and babesiosis. Malaria chemoprophylaxis relevant to the local pattern of infestation should be prescribed and preventive measures implemented to reduce mosquito bites (33,54). They should also be educated regarding prompt treatment of even minor dog or other animal bites. Asplenia or hyposplenism itself is not a contradiction for routine immunization including live vaccines. Vaccination significantly reduces the risk of bacteremia of any cause beyond the postoperative period, and vaccinated patients carry a lower risk of infection than non-vaccinated ones (57). Pneumococcal Vaccine Efficacy of pneumococcal polysaccharide vaccine in preventing postsplenectomy infections has not been determined. Most virulent pneumococcal serotypes tend to be the least immunogenic, and the efficacy of vaccine is poorest in younger patients who would be at the highest risk (58,59). Studies indicate that 30% to 60% postsplenectomy patients never receive the pneumococcal vaccine (55,56). Pneumococcal vaccination should be performed at least two weeks before an elective splenectomy (60). If this could not be done then patients should be vaccinated as soon as possible after surgical recovery and before discharge from hospital. Unimmunized patients who are splenectomized should be immunized at the first opportunity. The immunogenicity of the vaccine is reduced if it is given after splenectomy or while the patient is receiving cancer therapy (58). For this reason the manufacturer recommends that the immunization be delayed for at least six months following immunosuppressive chemotherapy or radiotherapy. Revaccination is recommended for persons two years of age or older who are at highest risk for serious pneumococcal infections. Revaccination in three years may be Severe Infections in Asplenic Patients in Critical Care 355 considered in asplenic individuals two years or older. Pneumococcal conjugate vaccine is used for routine vaccination of children younger than 24 months and children 24 to 59 months with high-risk medical conditions including asplenia (61). In order to expand the spectrum of protection against pneumococcal disease, consideration should be given to use of both vaccines in all age groups. Haemophilus Influenzae type B Vaccine The Haemophilus vaccine has been shown to be immunogenic in patients with impaired splenic function associated with sickle cell anemia (62). The specific concentration of antibody required in patients lacking a spleen is not known. Previously non- vaccinated persons older than 59 months having high-risk condition like functional or anatomic asplenia should be given at least one pediatric dose of a HiB conjugate vaccine (63). Meningococcal Vaccine The quadrivalent, unconjugated capsular meningococcal vaccine (type A, C, Y, and W135) is immunogenic in the asplenic patient but less so in those patients who are also treated with chemotherapy and radiotherapy (64). Vaccine is recommended for persons with increased risk of meningococcal disease, including persons with functional or anatomical asplenia. The efficacy and importance of meningococcal vaccination in splenectomized individuals is unknown. The antibody levels rapidly decline in two to three years and postsplenectomy patients will always be at risk, revaccination may be considered five years after receipt of the first dose. The quadrivalent conjugated meningococcal vaccine is used for routine immuni- zation of adolescents and persons 2 to 55 years of age who are at increased risk of meningococcal disease, which includes asplenia (65). The exact duration of protection is unknown but is longer than polysaccharide vaccine. Influenza Vaccine Annual administration of influenza virus vaccine is recommended in asplenic or hyposplenic individuals to prevent the primary disease as well as complications of secondary bacterial infections (33). Chemoprophylaxis The first one to three years after splenectomy is the most important time for the risk of infection and mortality. Therefore, the institution of antibiotic prophylaxis in this period is likely to reduce morbidity and mortality. The risk of infection declines significantly beyond that time, and continuing antibiotic prophylaxis would provide lesser benefits. Since most patients are unwilling to take antibiotics lifelong, they should be persuaded to take antibiotics for at least three years, in addition to vaccines as described above. The likelihood of a second or third infection is high in the first six months after a first infection and antibiotic prophylaxis could offer the most benefit in this period for patients who have had a first severe infection (66). Some guidelines advocate continuing the antibiotic prophylaxis in children for five years or until the age of 21. Compliance is a problem in long-term prophylaxis in adults as is the inevitable selection for colonization with nonsusceptible pathogens. A single daily dose of penicillin or amoxicillin is the regimen of choice, but these antibiotics will not protect against organisms resistant to penicillin. Cefotaxime or ceftriaxone have been recommended as presumptive treatment for symptomatic patients who have been taking antibiotic prophylaxis or those with strains known to show intermediate resistance to penicillin (33,67).

Cytarabine is highly myelosuppressive and can produce severe leukopenia order 90mg etoricoxib visa, thrombocyto- penia buy etoricoxib 90 mg fast delivery, and anemia generic 60mg etoricoxib with visa. Fluorouracil is administered parenterally; it is also administered topically to treat skin cancers. Applied topically, fluorouracil is used to treat premalignant keratoses and superficial basal cell carcinomas. It is an oral agent used for metastatic breast cancer when patients are resistant to pacli- taxel/anthracycline therapy and for metastatic colorectal cancer. Hepatic enzymes should be monitored, as capecitabine may elevate bilirubin levels. This appears to be its major site of action, although the precise mechanism of cytotoxicity is unknown. Cladribine (Leustatin), a purine antagonist,isanadenosine analogue that is resistant to adeno- sine deaminase. They bind to b-tubulin heterodimers and block polymerization with a-tubulin into microtubules, thus disrupting microtubule assem- bly and the formation of the mitotic spindle. These agents are most active during mitosis at metaphase, blocking chromosomal migra- tion and cell division. Although a marker for its therapeutic effect, bone mar- row suppression with leukopenia is the dose-limiting toxicity; other adverse effects include neurologic toxicity, nausea and vomiting, alopecia, and ulceration from subcu- taneous extravasation. Paclitaxel stabilizes microtubule formation to disassembly with arrest in mitosis. Paclitaxel shows activity in ovarian cancer and in breast and non–small-cell lung cancer, and Kaposi sarcoma. Paclitaxel also causes hypersensitivity specific to the vehicle (50% polyethoxylated castor oil and 50% ethanol) used for its administration. Epipodophyllotoxins are bulky, semisynthetic, multiringed structures derived from the mayap- ple plant. They block cells at the boundary of the S phase and prevent entry into the G2 phase. Structure and mechanism of action (1) Dactinomycin is a chromophore containing peptides isolated from Streptomyces. Therapeutic uses (1) Dactinomycin is used to treat rhabdomyosarcoma and Wilms tumor in children. It is also used for gestational trophoblastic tumor, metastatic testicular carcinoma, and Ewing sarcoma. Chapter 12 Cancer Chemotherapy 297 (2) This agent has been used in combination with vincristine and cyclophosphamide for the treatment of solid tumors in children. Doxorubicin (Adriamycin, Doxil), daunorubicin (daunomycin, [Cerubidine]), idarubicin (Idamy- cin), and the analogs of doxorubicin, epirubicin (Ellence), valrubium (Valstar), and mitoxan- trone (Novantrone) a. Daunorubicin and idarubicin are used primarily in the treatment of acute lymphocytic and myelogenous leukemias, often in combination with cytarabine. Structure and mechanism of action (1) Bleomycin is a mixture of copper-chelating glycopeptides produced by Streptomyces verticillus. The most serious adverse effect is a cumulative dose-related pulmonary tox- icity that may be fatal. Acute reactions that can be fatal occur in 1% of patients with lymphoma; this reaction consists of the anaphylac- toid-like reactions of profound hyperthermia, hypotension, and cardiorespiratory collapse. Toxicity of this drug includes diarrhea, which can be severe, and myelosuppression. Cisplatin is a small platinum coordination complex that enters cells by diffusion and active transport. The dose-limiting toxicity of cisplatin is cumulative damage to the renal tubules that may be irreversible following high or repeated doses, but which is routinely prevented by hydration and diuresis of the patient. It is ototoxic, with tinnitus and hearing loss, and it also produces peripheral neuropathy. Procarbazine is a weak monoamine oxidase inhibitor that may cause hypertension, particu- larly in the presence of sympathomimetic agents and food with high tyramine content. Hydroxyurea is primarily used in the management of chronic granulocytic leukemia and other myeloproliferative disorders. L-asparaginase is an enzyme that reduces levels of L-asparaginase, an amino acid not synthe- sized by some tumors, to inhibit protein synthesis and cell division. This agent is synergistic with methotrexate when the folic acid analogue is administered prior to L-asparaginase. L-asparaginase is minimally marrow suppressive; it is toxic to the liver and pancreas. Bortezomib is approved for treatment of multiple myeloma in patients who have received at least two prior courses of therapy. Biologic response modifiers are compounds that influence how an individual responds to the presence of a neoplasm. Interferon alfa-2b (Intron-A) is approved for treatment of hairy cell leukemia, and Kaposi sarcoma. Interleukin-2 (aldesleukin) (Proleukin) is approved for metastatic kidney cancer and melanoma. Thalidomide (Thalomid) and lenalidomide (Revlimid) are tumor necrosis factor modifiers. These agents are used in treatment of brain tumors, Kaposi sarcoma, multiple myeloma, and many noncancerous conditions. Thalidomide’s most common adverse effects are sedation, constipation, and pe- ripheral neuropathy (30%). Lenalidomide is an ana- log of thalidomide with increased potency and an apparent decreased toxicity. Imatinib (Gleevec), Dasatinib (Sprycel) (1) Imatinib and dasatinib are tyrosine kinase inhibitors that are specific for Bcr-Abl onco- protein (dasatinib also inhibits several other kinases). Gefitinib (Iressa) (1) Gefitinib is an inhibitor of epidermal growth factor receptor tyrosine kinase that is over- expressed in many cancers. Erlotinib (Tarceva) (1) Erlotinib is another inhibitor of epidermal growth factor receptor tyrosine kinase. The net effect of this interaction is cell lysis, possibly secondary to antibody-dependent cy- totoxicity or complement cytotoxicity. Expression of this protein is associated with decreased survival due to more aggressive disease. The net effect is the arrest of the cell cycle via antibody-mediated cytotoxicity. Its mechanism of action differs from that of imatinib in that cetuximab actually blocks the receptor. The action of this drug results in inhibition of cancer cell growth and induction of apoptosis. Use of these agents in neoplasia is predicated on the presence of steroid hor- mone receptors in target cells and on the ability of the hormone to stimulate or inhibit cell growth. In the former case, hormonal antagonists are used; in the latter, hormonal agonists. Adrenocorticosteroids have significant systemic effects, and long-term use is not recommended. Mitotane is an oral agent specific for the treatment of inoperable adrenocortical carcinoma. Mitotane inhibits glucocorticoid biosynthesis and selectively causes atrophy of the tumors within zona reticularis and fasciulata by an unknown mechanism. Progestins are useful in the management of endometrial hyperplasia and carcinoma and as second-line therapy for metastatic hormone-dependent breast cancer. Estrogens inhibit the effects of endogenous androgens and androgen-dependent metastatic prostatic carcinoma. Cardiac and cerebrovascular complications and carcinoma of breast, endometrium, and ovary are potential adverse effects. Tamoxifen and toremifene are used in postmenopausal women with or recovering from meta- static breast cancer.

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Plaque growth can be prevented by twice-daily rinsing with chlorhexidine but because of the intra-oral side-effects of chlorhexidine (changed taste sensation safe 120mg etoricoxib, poor taste discount etoricoxib 60 mg on-line, and tooth staining) order etoricoxib 120 mg otc, it is usually recommended for short-term use only to aid periodontal care. However, the literature is controversial and there are many conflicting views and opinions regarding sugar consumption. This is probably irrelevant, as bacteria need a fermentable source of carbohydrate to produce acid. The review paper of Burt and Pai (2001) summarizes the conflict in opinions on sugar. However, we should concentrate on giving sensible practical everyday advice to our patients as shown in Table 6. Advising parents to completely stop their children from eating sugary foods is not achievable! Plaque pH responses of these drinks showed falls to below the critical pH of apatite (pH = 5. We should promote that for young children drinks are consumed from trainer cups, beakers, and to use straws. In addition to fruit and vegetables, crisps and peanuts have also been recommended as safer alternatives. However, citrus fruits have been implicated in the aetiology of dental erosion and peanuts are associated with inhalation risk in small children. At the end of the meal or snack the acid is buffered by saliva and the mineral loss stops and reverses under favourable conditions. Frequent snackers have predominantly mineral loss and little if any remineralization. When volunteers did not use a fluoride toothpaste mineral demineralization was observed with the frequency as low as three times per day. However, when fluoride toothpaste was used twice daily no significant mineral demineralization was observed up to a frequency of sugar consumption of seven times per day. Therefore, brushing twice per day with a fluoride toothpaste, subjects should safely be able to have five meal moments per day. Non-sugar sweeteners Those allowed for use in foods and drinks in the United Kingdom are given in Table248H 6. The intense sweeteners and xylitol are non-cariogenic while the other bulk sweeteners can be metabolized by plaque bacteria but the rate is so slow that these sweeteners can be considered safe for teeth. The use of non-sugar sweeteners is growing rapidly particularly in confectionery and soft drinks. Confectionery products which have passed a well-established acidogenicity test can be labelled with the Mr Happy-Tooth logo (Fig. Tooth-friendly sweets are available in about 26 countries; in Switzerland about 20 per cent of confectionery sold carries the Tooth-friendly (or Mr Happy-Tooth) logo. There is good evidence that sugarless chewing gums are not only non-cariogenic but also positively prevent dental caries, by stimulating salivary flow. As an example, they have accredited dentrifices which have proven effectiveness, for many years. More recently, foods and drinks have been accredited⎯for example, a fruit- flavoured drink which demonstrated to have negligible cariogenic and erosive potential. The bulk sweeteners can have a laxative effect and should not be given to children below 3 years of age. People vary in their sensitivity to these polyols as some adults in the Turku sugar studies were consuming up to 100 g of xylitol per day without effect. Dietary advice for the prevention of dental caries The basic advice is straightforward⎯reduce the frequency and amount of intake of fermentable carbohydrates. This especially applies to parents of young children who need to be given the correct advice at the appropriate age of the child. Dietary advice is often too negative; energy that has been provided by confectionery has to be replaced and it is very important to emphasize positive eating habits. The variety of foods available has increased enormously in most countries in recent years; we must use this increased choice to assist our patients to make better food choices. The second level of advice is a more thorough analysis of the diet of children with a caries problem. One practical drawback of this method is that it requires at least three visits⎯an introductory visit where the patient is motivated and informed about the procedure and the diet diary given out, the diary collection visit, and a separate visit for advice and to agree targets. At the first visit it is vital that the patient and parent appreciate that there is a dental problem and that you are offering your expert advice to help them overcome this problem. Any requests by parents for advice at the first visit should be parried and delayed until the third visit. At the third visit, advice must be personal, practical, and positive⎯all three of these are important (Table 6. Food preference of children, cooking skills, food availability, and financial considerations vary enormously⎯advice must be personally tailored and practical for that patient. Dietary changes are difficult, targets often have to be limited and constant reinforcement of advice and encouragement is essential. However, health gains can be considerable, to general as well as dental health and often to other members of the family, so that dietary advice is an essential part of care of children. This is the protected logo of the International Toothfriendly Association to be seen on products that have passed the internationally accepted toothfriendly test. Mode of action of fluoride and the caries process The mineral of tooth tissues exists as a carbonated apatite, which contains calcium, phosphate, and hydroxyl ions, making it a hydroxyapatite [Ca10. Carbonated portions weaken the structure and render the tissue susceptible to attack. Food remnants and debris mix with saliva and adhere to tooth surfaces as a slimy film known as dental plaque. Mutans streptococci and Lactobacilli species), metabolize dental plaque and produce acid which lowers the pH of the oral environment. If fluoride is present during remineralization, it is incorporated to form fluorapatite [Ca10. This is now widely believed to be the most important preventive action of fluoride, and a constant post-eruptive supply of ionic fluoride is thought to be most effective. A number of mechanisms have been proposed to explain the action of fluoride (Table254H 6. The first is that fluoride has an effect during tooth formation by substitution of hydroxyl ions for fluoride ions, thereby reducing the solubility of the tooth tissues. Third fluoride inhibits the demineralization of tooth mineral when present in solution at the tooth surface. Fourth, fluoride enhances remineralization by combining with calcium and phosphate to form fluorapatite. Fluoride enhances crystal growth, stabilizes and makes the tissue resistant to further acid attack. However, when fluorapatite is formed during remineralization, it is even more resistant to demineralization as the critical pH for fluorapatite is pH 3. Therefore, it is most important to have an intraoral source of fluoride when remineralization is taking place. Lastly, fluoride affects the morphology of the crown of the tooth, making the coronal pits and fissures shallower. Such shallower pits and fissures will be less likely to collect food debris, allow stagnation and become decayed. The most important of these mechanisms is that when fluoride is present in the oral environment at the time of the acid attack it inhibits demineralization and promotes remineralization. As early as 1890, Miller drew attention to the dissolutive process of dental caries and directed efforts to inhibit dissolution. The clinical findings of the anti-caries activity of drinking water with fluoride caused researchers to seek reasons for this. The finding that fluoride-treated enamel had a lower solubility led many to consider this as a cause and effect relationship. The anti-caries action of fluoride was thought to be one of preventing dissolution of enamel, and efforts were made to incorporate more and more amounts of fluoride into surface enamel.

In rare cases etoricoxib 90mg on line, as when a heterochromia iridis A difference in color patient’s immune system is severely compromised order etoricoxib 90mg without a prescription, between the iris of one eye and the iris of the other this virus can cause infection of the brain eye 60 mg etoricoxib with mastercard. A person with both brown and herpes simplex virus type 2 A herpes virus blue in the same eye has sectoral heterochromia that causes genital herpes, which is characterized by iridis. In rare cases, as when a patient’s immune formed by the experimental fusion of two genetically system is severely compromised, this virus can different cells. Treatment posed of nuclei from Hurler syndrome and Hunter involves use of topical or oral antiviral medication. This proves that the two syndromes affect different proteins and so can correct each herpes zoster The herpes virus that causes other in the heterokaryon. Herpes zoster and chicken- pox are usually contracted in childhood, at which heteromorphism Something that is different in time the virus infects nerves (namely, the dorsal form. See also human Abnormal numbers of chromosomes are associated herpesvirus 6; human herpesvirus 7; human her- with a number of disorders. Closure of the glottis then halts the heterozygous Possessing two different forms of incoming air. The column of air strikes the closed a particular gene, one inherited from each parent. Also hexadactyly The presence of an extra digit: a known as a singultus and hiccough. The sixth digit can be located in three hidradenitis suppurativa An illness character- different locations: on either side of the extremity or ized by multiple abscesses of the skin that form in somewhere in between. With the hand, for example, and around oil and sweat glands and hair follicles, the extra finger can be out beyond the little finger most commonly under the armpits and in the groin (ulnar hexadactyly), out beyond the thumb (radial area. Hydradenitis suppurativa is treated by antibi- hexadactyly), or between two of the normally otics and anti-inflammatory medications often along expected fingers (intercalary hexadactyly). Histiocytes usually stay in place, but when they are stimulated by infection or inflammation, they Hippocratic Oath An oath taken by new physi- become active, attacking bacteria and other foreign cians authored by Hippocrates. The result can be tissue damage, pain, the development of tumor-like lumps, fatigue, and other Hirschsprung’s disease An abnormal condition symptoms. If histiocytosis affects the pituitary gland, that is present at birth and is due to absence of the diabetes insipidus may also develop. Nerves includes radiation and chemotherapy, although for can be missing starting at the anus and extending up reasons unknown, some cases of histiocytosis go a variable distance of the bowel. Hirschsprung’s disease is the most common cause histiocytosis, lipid See Niemann-Pick disease. The symptoms are vomiting, constipation, distention of histiocytosis, sinus A type of histiocytosis in the abdomen, and intestinal obstruction. Hirsutism can be a side effect of certain med- of another organism without the immune system ications (such as prednisone) or reflect an underly- rejecting it. Also known as microscopic anatomy, Hirudin is the main chemical in the secretion of as opposed to gross anatomy. Histoplasma capsulatum A fungus that is found worldwide that is particularly common in the cen- His disease See trench fever. It is carried in bird histamine A substance that plays a major role in and bat droppings, and it is deposited in the soil. Most people with histo- to infection by human immunodeficiency virus plasmosis have no symptoms. Symptoms include seminated histoplasmosis, which affects a number fever, sore throat, headache, skin rash, and swollen of organs. This syndrome pre- sons—particularly those with chronic lung dis- cedes the development of detectable antibodies to ease—are at increased risk for severe disease. A hive can be rounded or flat when a child passed developmental milestones, topped but is always elevated above the surrounding such as walking and talking. It reflects circumscribed edema (local on social-emotional development may be included. Hives are usually well circum- A developmental history is used primarily in the scribed but may be coalescent, and they blanch with diagnosis of developmental disorders. Approximately 20–25 per- history, family An account of past and current cent of the population has experienced hives. A social cer that develops in the lymph system, part of the history may include aspects of the patient’s develop- body’s immune system. Because there is lymph tis- mental, family, and medical history, as well as rele- sue in many parts of the body, Hodgkin’s disease can vant information about life events, social class, race, start in almost any part of the body. It holandric inheritance Inheritance of genes on injures the cells that line arteries and stimulates the the Y chromosome. Homocysteine can have Y chromosomes, Y-linked genes can only be also disrupt normal blood clotting mechanisms. Elevated levels of homocysteine also appear to increase the risk of Alzheimer’s disease. A Holter monitor keeps a record of the heart rhythm, typi- homocystinuria A genetic disease that is due to cally over a 24-hour period, and the patient keeps a an enzyme deficiency that permits a buildup of the diary of activities and symptoms. Progressive mental retar- is then correlated with the person’s activities and dation is common, but does not always occur, in symptoms. This homologous chromosomes A pair of chromo- principle is similar to the concept behind exposure somes that contain the same gene sequences, each therapy for allergies, but the amounts of active med- derived from one parent. First signs are itching homocysteine, which can be measured in the blood, http://www. The infection can be fatal, partic- ularly for infants, pregnant women, and persons hormone therapy Treatment of disease or who are malnourished. The term is most commonly used to describe use of medications containing both estro- horizontal Parallel to the floor. A person lying on gen and progestogen to reduce or stop short-term a bed is considered to be in a horizontal position. In the See also Appendix B, “Anatomic Orientation more general sense, hormone therapy may be used Terms. It may also be used for thyroid disorders, and body that controls and regulates the activity of cer- illnesses associated with hormone production or tain cells or organs. Hormone therapy may include giving hor- special glands, such as thyroid hormone produced mones to the patient or using medications that by the thyroid gland. Many hormones, such as neuro- transmitters, are active in more than one physical Horner syndrome A condition resulting from process. Testosterone is an androgenic sweating (anhidosis) and flushing of the affected hormone. Also known as Horner-Bernard syn- drome, Bernard syndrome, Bernard-Horner syn- hormone, follicle-stimulating See follicle- drome, and Horner ptosis. For that regulates the balance of water and electrolytes those with severe reactions, injectable epinephrine (ions such as sodium and potassium) in the body. In selected cases, The mineralocorticoid hormones act specifically on allergy injection therapy is highly effective. The two most important thyroid cial care for people who are near the end of life and hormones are thyroxine (T4) and triiodothyronine for their families. Thyroid hormones are critical for regulation home, in a hospice or other freestanding facility, or of the body’s metabolism. Hospitalists assume the care of hospitalized patients hormone replacement therapy The use of in the place of patients’ primary care physicians. An usually acquired in childhood, and is associated immunization against commonly found types of with roseola. Its goals a cause of cancer of the cervix and other cancers of included the identification and sequencing (order- the ano-genital region. Humidified air makes it easier to breathe for disorder of the brain cells characterized by pro- persons with certain conditions, such as cystic gressive mental and physical deterioration that fibrosis, Sjogren’s syndrome, and others. Mood disturbance is normally present in the anterior chamber of the eye, usually the first symptom seen, with bipolar disor- between the cornea and the iris. Other symptoms include chorea duced by the ciliary body, that is normally present in (restless, wiggling, turning movements), muscle the anterior chamber of the eye, between the cornea stiffness and slowness of movement, and difficulties and the iris. The Hurler syndrome An inherited error of metabo- humors were phlegm (water), blood, gall (black lism characterized by deficiency of the enzyme bile, thought to be secreted by the kidneys and alpha-L-iduronidase, which normally breaks down spleen), and choler (yellow bile secreted by the molecules called mucopolysaccharides.

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