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She states that she has been taking herbs and nonherbal supplements to help alleviate the symptoms of menopause buy chloramphenicol 500 mg free shipping antibiotics for cats, combat depression and anxiety buy discount chloramphenicol 500mg on-line antibiotic resistance genes in water environment, and improve her arthritis. Which of the following statements regarding CAM treatments is false? John’s wort (used to treat depression and anxiety) can decrease serum levels of digoxin ❏ B. Dong quai (used to treat the symptoms of menopause) can prolong the international normalized ratio (INR) in patients taking warfarin ❏ C. The cardioprotective effects of garlic are as yet unproven ❏ D. Kava kava (used to treat anxiety) may potentiate the effect of benzodi- azepines and other sedatives ❏ E. Glucosamine and chondroitin have been proven to be ineffective in treat- ing osteoarthritis Key Concept/Objective: To become aware of drug interactions of some very commonly used herbal and nonherbal supplements, as well as the effectiveness of these supplements Several drug interactions are associated with herbal and nonherbal supplements: St. John’s wort can decrease serum digoxin levels; dong quai can prolong INR; and kava kava is known to potentiate sedatives. The definitive beneficial effects of garlic in cardioprotec- tion are unproven. Glucosamine and chondroitin are some of the few supplements for which there are data showing efficacy. Current data suggest symptomatic improvement for osteoarthritis of the hips and knees. John’s wort in the treatment of mild to moderate depression. A patient with chronic back and neck pain reports that he has finally gotten some relief through a local chiropractor. He wants your opinion about the safety and efficacy of chiropractic therapy for such con- ditions. Which of the following statements is false regarding chiropractic therapy? Very little data support the use of chiropractic manipulation to treat hypertension, menstrual pain, or fibromyalgia ❏ B. Research may be insufficient to prove a benefit for patients with acute or chronic lower back pain ❏ C. Patients with coagulopathy should be advised against chiropractic therapy ❏ D. Patients who try chiropractic therapy become dissatisfied after the first several treatments ❏ E. Serious complications can occur with cervical manipulation Key Concept/Objective: To understand the efficacy and contraindications of chiropractic therapy Chiropractic manipulation has been touted as a treatment for a number of conditions, including hypertension, asthma, menstrual pain, and fibromyalgia. However, very little 22 BOARD REVIEW data support its use for these conditions. Much of the current use of chiropractic care stems from its utility in cases of low back pain. A number of controlled trials on chiropractic treatment for low back pain have been done, with conflicting results. A meta-analysis sug- gested that research was insufficient to prove a benefit for acute or chronic low back pain. In general, however, patient satisfaction is high with chiropractic therapy. Patients with coagulopathy, osteoporosis, rheumatoid arthritis, spinal neoplasms, or spinal infections should be advised against such treatments. Serious complications have been reported as a result of cervical manipulation, including brain stem or cerebellar infarction, vertebral fracture, tracheal rupture, internal carotid artery dissection, and diaphragmatic paralysis. It is therefore difficult to advocate routine use of cervical manipulation for treatment of head and neck disorders. One of your patients tells you that she attended a seminar on the use of mind-body interventions to treat various conditions. She has been using various methods to overcome problems with asthma, anxiety, and substance abuse. Which of the following statements is false regarding mind-body interventions?

Constipation should be avoided because it can cause the hyper- kalemia to worsen C order 500mg chloramphenicol mastercard antibiotics depression. The target hematocrit value for erythropoietin therapy is 30% D generic chloramphenicol 500 mg on line antibiotic for staph. Alkali should not be administered as sodium bicarbonate to patients receiving aluminum-containing phosphate binders E. Failure to respond to erythropoietin therapy is most commonly the result of underlying anemia of chronic renal disease Key Concept/Objective: To understand the principles of management of metabolic and hema- tologic abnormalities in chronic renal failure In chronic renal failure, hyperkalemia and acidosis are interrelated. Alkali therapy will certainly help to improve the acidosis and may improve the hyperkalemia through sev- eral mechanisms. First, alkalinization causes a shift of potassium into cells. Also, sodium bi- carbonate enhances distal sodium delivery and therefore augments potassium secretion from the distal tubule. One should not administer citrate-containing alkali to patients receiving aluminum-containing phosphate binders, because citrate is known to enhance the gastrointestinal absorption of aluminum. In this setting, sodium bicarbonate diminish- es the risk of aluminum toxicity. Constipation can cause hyperkalemia to worsen because potassium secretion by the colon is substantial in patients with advanced renal failure. Severe anemia contributes to the development of left ventricular hypertrophy, which in turn is an important predictor of subsequent cardiac morbidity and mortali- ty in patients receiving dialysis. Thus, early institution of erythropoietin therapy can improve dialysis outcomes. This is an important reason for timely referral of the patient with renal insufficiency to a nephrologist. A target hematocrit value of 30% in young patients who have no evidence of cardiovascular disease should provide relief of symp- toms attributable to anemia. By contrast, older patients with comorbidities may bene- fit by targeting the hematocrit value closer to normal. Failure to respond to erythro- 10 NEPHROLOGY 11 poietin therapy is most commonly the result of iron deficiency. A 34-year-old man with diabetes and hypertension comes for a check-up. Which of the following statements is true regarding the appropriate measures to slow progression of renal disease? Aggressive control of hyperglycemia may be more likely to slow pro- gression of renal disease in patients with type 1 diabetes mellitus than in patients with type 2 diabetes mellitus B. The targeted blood pressure should be below 140/90 mm Hg C. Because this patient has diabetes, microalbuminuria is predictive of progression of renal disease D. Smoking is a risk factor for microalbuminuria because of its associa- tion with hypertension E. Although not clearly of benefit, a low-protein diet can be prescribed with little concern about deleterious effects Key Concept/Objective: To understand the risk factors for renal disease progression Evidence clearly shows that aggressive control of hyperglycemia in patients with type 1 diabetes mellitus will reduce the occurrence of microalbuminuria and macroalbu- minuria and will slow the progression of nephropathy. Control of hyperglycemia in patients with type 2 diabetes mellitus is more controversial, as there are conflicting results of this approach in the literature. This may be related to the fact that renal lesions resulting from type 2 diabetes are more heterogeneous than the typical lesion from type 1 diabetes. Because uncontrolled hypertension can contribute to the pro- gression of renal disease, target blood pressure values have been established. These val- ues vary slightly, depending on the source of the recommendation, but in general, a blood pressure of 130/80 mm Hg or less should be sought. Microalbuminuria is a risk factor for progression to end-stage renal disease in diabetic and nondiabetic patients with renal disease.

Proteo- As regards cartilage lesions generic chloramphenicol 250 mg on-line treatment for folliculitis dogs, the patellotrochlear glycan monomers and aggregates consisting of a junction represents one of the main problematic central protein core and several bounded sul- areas of the knee joint order 500 mg chloramphenicol visa antimicrobial agents 1. This articulation serves fated glycoseaminoglycans are electronically often as a beginning point of further degenera- active chains. Mild or medium-grade damage of cations and water, and on the other hand the the patellar or trochlear chondral surfaces can be glycoseaminoglycan side chains repel each initiative factors in early osteoarthritis. This interactive feature keeps the mole- treatment of deep cartilage damage of this com- cules in a distended state. Proteoglycans tend to partment has an essential role in the prevention absorb a very high amount of water. In the nor- of a certain part of osteoarthritic problems. Consequent to this process, the car- ences have already made it clear that cartilage tilage will loose its elasticity and became damage of the patellofemoral articulation has softer. Presence of “compressive effect” on the partially hydrated these disadvantageous aspects of the patel- glycoseaminoglycan chains. The three-dimen- lotrochlear junction requires a sensitive diag- sional structure of collagen network in the hya- nostical approach, very well-planned treatment line cartilage consists of 90–95% type II strategy, and a demanding rehabilitation. Articular cartilage represents a well-organized This highly organized collagen network confers complex structure that provides an excellent high biomechanical value for the hyaline cartilage conduit for pain-free motion in the joint and tol- particularly during compressive and shear stress. Living cells of this tissue are stitial fluid can flow back to its original place. This the hyaline cartilage and therefore the solid phase complex arrangement contains mainly different – in case of “normal loading” – is protected from types of proteoglycans, collagens and other pro- permanent deformation. Not only does this teins in combination with water and elec- biphasic nature promote tolerance of intensive trolytes. This relatively high of the fluid for the nutrition of cartilage and amount of water contributes to nutrition of the metabolic activities of the chondrocytes. The dynamic alliance of cells, this highly organized tissue. They produce the Treatment of Symptomatic Deep Cartilage Defects of the Patella and Trochlea with and without Patellofemoral Malalignment 203 extracellular matrix and later maintain the home- eliminating the effect of such inhibitors demon- ostasis of the entire structure. Their synthetic strated a better repair capability of superficial function is altered by chemical and mechanical cartilage injuries. Prior to skeletal matura- In another regard, several authors have noted tion, chondrocytes show high activity – they pro- that partial-thickness injuries have poor healing liferate and actively synthesize extracellular capability. Upon completion of growth, cellular demonstrate only a very brief mitotic and matrix activity becomes lower and dividing ability and synthetic activity without effective repair ability. Columnar organization of this won- In spite of their poor healing activity, according derful structure can tolerate various types of to clinical experiences, these superficial injuries mechanical loading including shear forces. Cartilage flow observed in these trials present understanding the only reliable treat- can fill only very small defects. Lesions larger ment options are to imitate the structure or pro- than 2 to 3 mm in diameter will not heal in such duce the same tissue. These cells control the which penetrates through the subchondral plate components of the matrix and are responsible or – in degenerative cases – from small, superfi- for the homeostasis and turnover of the whole cial fissures of the same cortical layer. It is well known that in adults, chondro- bleeding results in clot formation from which cytes have a limited capacity to reproduce them- bioactive molecules (cytokines, chemotactic fac- selves and this feature seems to be essential in tors, etc. These cells have the capability to repro- tage in cartilage healing is the location of the duce themselves and can differentiate in various chondrocytes. Vascular granulating tissue of circulatory resources, multipotential cells, will develop from the former fibrinous network. These components dral bony plate, while superficial parts of the are necessary for an effective repair process. High oxy- Further disadvantages of cartilage’s response gen tension promotes bone formation while poor in healing are the matrix inhibitory factors. Experimental studies standing this replication, several features of the 204 Etiopathogenic Bases and Therapeutic Implications newly formed tissue are different from the to the nature of cartilage, coupled with clinical articular cartilage.

Which of the following therapies will best treat this patient’s muscle spasms? Tetanus toxoid Key Concept/Objective: To know the symptomatic management of patients who present with tetanospasm The use of muscle relaxants is essential to the control of muscle spasms and rigidity buy cheap chloramphenicol 500 mg line antibiotics to treat cellulitis, and diazepam is the drug of choice because it acts rapidly as a muscle relaxant and produces a sedative effect without inducing depression chloramphenicol 500 mg amex treatment for uti and yeast infection. The value of antimicrobial agents in the treatment of tetanus is doubtful; the only beneficial effects of antibiotics would be to eradicate from the wound vegetative cells of C. Tetanus antitoxin binds circulating toxin, but its administration does not alter those manifestations of tetanus already evident. Propranolol can be useful in treating sympathetic overactivity (hypertension, tachycardia, sweating) but not muscle spasm. Tetanus toxoid must be administered after an episode of tetanus because clinical 20 BOARD REVIEW tetanus does not establish natural immunity, but tetanus toxoid will not control tetanospasm once it is established. Metronidazole is effective as monotherapy for which of the following infections? Lung abscess caused by Actinomyces Key Concept/Objective: To know the antimicrobial activity of metronidazole Metronidazole is the drug of choice for B. Some Actinomyces, Propionibacterium acnes, and microaerophilic streptococci are resistant, however, as are facultative anaerobes. Thus, the addition of a second antimicrobial agent is indicated for mixed facultative-anaerobic infections, such as intra-abdominal or pulmonary infections. Metronidazole or penicillin very effectively treats Vincent angina or trench mouth, but the mainstay of therapy is sur- gery initially. A 52-year-old man with a history of alcoholism presents with a complaint of recurring fever, malaise, and cough with occasional hemoptysis. On physi- cal examination, the patient appears chronically ill, and he has a low-grade fever of 100. On the posterior chest wall there is a sinus tract draining fluid with a few sulfur granules. Chest x-ray shows a pleural-based cavitary lesion in the superior segment of the right lower lobe that appears to cor- respond with the fistulous tract. A smear of the fluid from the sinus tract shows slender, branching, gram-positive filamentous organisms. Resection of the cavitary lesion, followed by penicillin G, 10 to 20 million units/day I. Daily doses of 10 to 20 million units are usually administered intra- venously for a period of 2 to 4 weeks, followed by oral therapy for 3 to 6 months. These prolonged treatment schedules are designed to prevent recurrent infection. Resection does not play a role in the management of actinomycotic lung abscess. Tetracycline is the drug of choice for those patients allergic to penicillin; clindamycin, ceftriaxone, and ciprofloxacin have also been used with success. A 65-year-old man with poorly controlled diabetes underwent transurethral resection of the prostate 2 days ago. On physical examination, the patient is somnolent but arousable. His scrotum is markedly swollen, erythematous, and exquisitely tender. What is the best step to take next in the treatment of this patient? Immediate institution of broad-spectrum antibiotics 7 INFECTIOUS DISEASE 21 B. Immediate institution of broad-spectrum antibiotics and hyperbaric oxygen therapy C. Immediate surgical exploration and resection without regard to reconstruction D. Immediate surgical exploration and resection with caution with regard to future reconstruction Key Concept/Objective: To be able to recognize and treat Fournier gangrene Fournier gangrene is a form of necrotizing fasciitis occurring in the male genitals. It is a life-threatening infection with mortality ranging from 13% to 22%.