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There is no reported resistance to vancomycin for S zoloft 100 mg on line. The vir- ulence and clinical manifestations of MRSA are no different from those of methicillin- susceptible S discount zoloft 25 mg mastercard. With the increase in use of vancomycin quality 100mg zoloft, strains of S generic zoloft 50mg. Daptomycin and linezolid have excellent activity against van- comycin-intermediate and vancomycin-resistant Staphylococcus. A 34-year-old African-American woman presents to the emergency department complaining of fever, chills, pain in the right upper quadrant, and productive cough with blood-tinged sputum. She reports that she recently had a cold and that about 2 days ago she had a severe chill lasting about 20 minutes. Subsequently, she developed a temperature of 105° F (40. She reports that initially she was able to control the fever with antipyretics, but now the fever will not sub- side with medications. She reports that she has sickle cell anemia and that she smokes two packs of cig- arettes daily. On examination, she appears toxic; her temperature is 104. Chest x-ray shows a bronchopneumonic pat- tern in the right lower lung field. Sputum Gram stain reveals many polymorphonuclear leukocytes and abundant lancet-shaped gram-positive diplococci. For this patient, which of the following statements is false? The virulence of this infectious agent is related to surface protein A and penicillinase production B. The case-fatality rate for this infection is 5% to 12%; bacteremia is the most common extrathoracic complication, increasing the case-fatality rate to 20% D. This patient should be treated with ceftriaxone or cefotaxime until the results of susceptibility testing are available E. The capsule allows the bacteria to resist phagocytosis by leukocytes. Although the polysaccharide capsule is the critical factor in determining the virulence of the pneumococci, several proteins, including surface protein A, contribute to the pathogenesis of pneumococcal infections. Pneumococcal infections typically occur after a viral respiratory infection. Patients present with severe rigor or chill and pleurisy. Chest x-rays display findings of lobar consolidation or bronchopneumonic involvement. The key to diagnosis is Gram stain of a sputum smear, which typically reveals many polymorphonuclear leukocytes and abundant lancet-shaped gram-positive diplococci. Pneumococci display penicillin resistance, the mechanism of which is chromosomal mutation, not penicillinase pro- duction. Cigarette smoking is the strongest independent risk factor for invasive pneu- mococcal disease in immunocompetent adults who are not elderly. Other patients at increased risk are those with cirrhosis, sickle cell anemia, chronic lung disease, or can- cer. Pneumococci cause or contribute to 40,000 deaths annually; the overall case-fatali- ty rate of this pneumonia is 5% to 12%. Bacteremia is an adverse prognostic sign and increases the case-fatality rate to 20%: a rate that has not changed over the past 40 years.

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Most patients with peripheral vascular atherosclerosis also have coronary atheroscle- rosis discount 50mg zoloft with amex; mortality in patients with peripheral vascular disease is usually caused by myocar- dial infarction or stroke discount 25mg zoloft free shipping. This patient’s risk of myocardial infarction far outweighs her risk of developing limb ischemia or of requiring limb amputation 50mg zoloft mastercard. Although the risk of lung cancer is 10-fold higher in cigarette smokers than in nonsmokers order zoloft 100 mg fast delivery, this patient is less still likely to develop lung cancer than myocardial infarction: annual deaths from myocardial infarction attributable to smoking are estimated at 170,000, whereas deaths from lung can- cer that are attributable to smoking number 100,000. Moreover, this patient’s coronary risk factors would place her more at risk than would be indicated by these statistics. Because this patient does not use hypoglycemic agents, she is unlikely to experience hypoglycemia. Although 2% to 4% of patients with intermittent claudication develop critical limb ischemia annually, death and morbidity from myocardial infarction are much more like- ly. A 45-year-old woman is receiving enoxaparin and warfarin for deep vein thrombosis (DVT) of the right thigh, which developed after she underwent an abdominal hysterectomy 3 weeks ago. On day 5 of treat- ment, she reports abrupt onset of pain in her left leg. On examination, her blood pressure is 150/90 mm Hg; she has a regular heart rate of 95 beats/min without murmur; and she has lower extremity petechiae. Her left foot is pale, pulseless, and cold, and there is an absence of sensation. Results of laboratory testing are as follows: prothrombin time, 45; INR for prothrombin time, 2. Which of the following changes in this patient’s medication regimen should be made next? Discontinue warfarin therapy Key Concept/Objective: To be able to recognize heparin-induced thrombocytopenia and associat- ed acute arterial thrombosis and to understand that heparin must be discontinued immediately in patients with this condition This patient is experiencing an acute arterial occlusion. Given her heparin use and her low platelet count, heparin-induced thrombocytopenia is the likely diagnosis. Discontinuance of heparin therapy as soon as possible is key in reversing this antibody-mediated process. Increasing the heparin dose or even continued exposure to low doses of heparin (as through heparin I. Although therapy with catheter-directed tissue plasminogen activator (t-PA) is used for acute arterial occlusion in many cases, this patient’s recent abdominal surgery is an absolute contraindication to t-PA therapy. This patient’s low platelet count and her use of oral warfarin are relative contraindications to the use of thrombolytic ther- apy. She needs continued anticoagulation for her DVT and new arterial thrombus; there- fore, warfarin should be continued at its currently therapeutic dosage. A 44-year-old man presents to your office complaining of right leg pain and swelling of 3 days’ duration. The patient was well until he had a wreck while riding his dirt bike 1 week ago. The patient states that 46 BOARD REVIEW he injured his right leg in this accident. Initially, his leg was moderately sore on weight bearing, but swelling and persistent pain have now developed. On physical examination, you note an extensive bruise on the patient’s right calf and 2+ edema from the foot to the midthigh. You suspect trauma-asso- ciated deep vein thrombosis (DVT). Which of the following statements regarding DVT is true? Thrombi confined to the calf are large and typically result in pul- monary venous thromboembolism (VTE) ❏ B.

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Subsequent definitions always remarked Merlen’s observation that it involved ‘‘foot hypothermia with a significant difference in local temperature purchase zoloft 100mg visa. This pathology generic 50 mg zoloft mastercard, often cursorily defined as lymphedema buy 100 mg zoloft fast delivery, venous insufficiency buy discount zoloft 50 mg on-line, or cellulite, is widespread among 65% of women between 14 and 35 years of age, and the percentage increases among individuals over 40 years under the form of lipodystrophy and/or lipolymphedema. In this instance, venous insufficiency is absent or is present only as a secondary trait, but a positive correlation with the peripheral metabolism of fatty tissues may be observed. Although incomplete, the following physiopathological considerations derive in part from recent studies in microangiology, personal clinical observations, and response to a treat- ment protocol applied to over 500 patients between October 1, 1995, and December 30, 1999. This protocol foresees the combination of several traditional and natural methodol- ogies aimed not only at local therapy but also, and mainly, at cleansing and restoring general organic balance. Cellulite is widespread among 65% of women between 14 and 35 years of age, with this percentage increasing among individuals over 40. All these authors participated in the scientific works of the Phlebolymphology Center of the University of Siena where, under the direction of Prof. Sergio Mancini, many interesting studies about aesthetic pathologies of legs was organized. Our starting hypothesis was that the metabolism of the interstitial matrix and the adipocytic activity are fundamental in the manifestations of lipolymphedema and various forms of cellulite disease. We further noticed that there is a preferential adipocyte–lymph route, so that the hypothesized functional lymph–adipose system might provide local metabolic control and originate degenerative pathologies. These hypotheses have been confirmed by the recent studies on the function and role of the extracellular matrix in the economy of the metabolism of all the tissues today. LYMPH Lymph is a fluid generated in the argentophilic cells of every tissue. It is formed in the inter- stitial matrix and later flows through the lymph vessel system. Additionally, lymph compo- sition is different from the composition of the interstitial liquid. The interstitium contains many ‘‘sol’’ droplets that, under certain conditions, form a ‘‘gel’’ or coagulated mass of intertwining hyaluronic acid filaments into which protein molecules cannot penetrate. The enzymatic rupture of hyaluronic acid molecules entails an immediate increase in osmotic pressure due to incoming protein molecules. Besides, the interstitial fluid does not contain free water: water is bound to other components that flow along the fibroblast fibers and fibrils. According to Starling’s and Pappenheimer’s hypotheses, water and solutes are filtered away from arterial blood because capillary pressure is higher than oncotic pres- sure. In the venous system, however, pressure relationships are exactly the opposite, and thus water and solutes are reabsorbed. In normal conditions, blood contains approxi- mately 3 L of water, whereas interstitial tissue contains approximately 11 L. During the course of 24 hours, 18 to 22 L of water and solutes are filtered away. Approximately 16 to 17 L are reabsorbed by the venous system, and the remaining 2 to 5 L constitute lymph. Beside this filtering process, there is a diffusion process favoring the passage of solutes and water through the capillary membrane (27–33). The capillary membrane is absolutely permeable to water and solutes, but only partially permeable to proteins. Thus, lymph proteins (originated in blood plasma and fil- tered through the capillary wall) cannot reenter into the bloodstream and are forced into the lymphatic system. Therefore, the lymphatic system is an optional route for solutes and water from the interstitium and a compulsory route for protein transport. Hence, the primary function of the lymphatic system is to carry proteins into blood, but it also has a secondary homeostatic function in maintaining both transcapillary and oncotic pressure gradients. Moreover, lymph contains all clotting proteins and other thromboplastic substances needed to induce thrombin and fibrin formation. Even though no platelets are present, these substances have coagulating potential and increase ‘‘lymph density. Lipids in the intestinal interstitial cells are not free fatty acids (FFA): they are orga- nized in micelles (chylomicron) and huge lipoprotein compounds that can enter only into lymph vessels. Glycerol, steroids, and smaller fatty acids, instead circulate through blood vessels.

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Adult tetanus and diphtheroid toxoid (Td) given intramuscularly C order zoloft 50mg otc. Diphtheria and tetanus toxoid combined with pertussis vaccine (DTP) E buy zoloft 25mg with amex. Vigorous cleansing of the wound and oral administration of an antibiotic with activity against anaerobes (e buy zoloft 100mg without prescription. The organism exists throughout the world in soil and feces and produces a potent neurotoxin that induces intense muscle spasm discount 25mg zoloft fast delivery. Tetanus is rare in industrialized nations because of widespread active immunization with tetanus toxoid. Immunization is recommended for all infants (in the form of DTP or diphtheria- tetanus-acellular pertussis vaccine) at ages 2, 4, 6, and 18 months and again at 4 to 5 years of age. A booster dose of the Td vaccine is recommended at 16 years of age. Immunization with tetanus toxoid does not confer lifelong immunity, and booster doses are recommended every decade thereafter. There are well-established guidelines for the prevention of tetanus after wounds are sustained. Patients who have received more than three doses of tetanus toxoid previously, as this patient has, and who have a contaminated wound or a puncture wound will require Td if the last booster was given more than 5 years ago; patients who have received three doses of tetanus toxoid previously and who have a clean, minor wound will require Td if the last booster was given more than 10 years ago. Wound cleansing is an important com- ponent of management, but routine use of antibiotics has no role in tetanus prophy- laxis. An elderly man with complaints of weakness and shortness of breath is brought to the emergency department by his neighbor. He awoke that morning with nausea, vomiting, and abdominal cramping, and several hours later he began to experience blurred vision and weakness in his arms. The neighbor reports that the patient appeared well yesterday. The patient lives alone; he cooks and cleans for him- self. He is known to consume home-canned vegetables, which he grows in a garden during the spring months. Within 3 hours of arriving at the emergency department, he is intubated for respiratory failure. His neurologic symptoms are caused by irreversible binding of toxin to presynaptic nerve endings, which prevents the release of acetylcholine B. Diagnosis can be established by demonstration of toxin in serum or stool specimens C. Clinical disease is caused by ingestion of spores, which germinate and allow colonization of the intestinal tract with toxin-producing organisms D. Antitoxin is only effective in neutralizing toxin before it binds to cholinergic synapses and therefore must be administered promptly Key Concept/Objective: To understand the pathogenesis and management of food-borne botulism Botulism is caused by the spore-forming anaerobe C. Food-borne bot- 18 BOARD REVIEW ulism, which this patient has, is an intoxication (i. Spores of the organism may contaminate foods such as home-processed canned goods; these spores subsequently germinate into organisms that produce the neurotoxin. The toxin is heat labile, but if food is heated insufficiently, the intact toxin will be ingested and can be absorbed from the gastrointestinal tract. The toxin binds to peripheral choliner- gic synapses and induces weakness, which progresses to flaccid paralysis. Infant botu- lism is an infection caused by the ingestion of spores (typically in honey), which repli- cate in the GI tract and produce toxin. Wound botulism is caused by direct inoculation of a wound with the organisms or its spores; heroin use is an important predisposing factor. Proper recognition and diagnosis of this relatively rare illness can be difficult with- out a high index of suspicion: the presentation can resemble Guillain-Barré syndrome, myasthenia gravis, or stroke.

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