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By J. Grompel. Averett College.

Some months later floxin 200 mg without prescription, Bryant contacted her to ask if she would evaluate a number of papers on germanium floxin 400mg sale, a mineral which Monica Bryant was considering marketing in Britain. Goodman accepted the job and within a short time was engrossed in a mountain of material about germanium. From the beginning, it was the immunological information that Goodman found fascinating. She read about how germanium modulated the immune system and how it had been used to fight cancer. Papers published in Japan showed precisely the effect which the mineral had upon the immune system. Although she had begun her work with a degree of cynicism, Goodman found that the results in many of the vast number of papers she reviewed were impressive and recorded by reputable scientists. Coming to the end of her work for Monica Bryant, she decided that even if she could not find funding for such work the information should be published. When she had finished her review, assessing the claims made for germanium, she began a search for someone who might help her publish a book. Monica Bryant Monica Bryant has committed most of her life to the field of human nutrition and health. With others, she has brought to British nutrition the experience and the learning of the American field leaders, and an experience of Scandinavian and German approaches to biological medicine. On her own initiative, she was involved in work to improve prison nutrition and attended the first meeting at the House of Lords on this issue. In the mid-eighties she lectured in nutrition at the University of Sussex for four years. In 1984, on a visit to Denmark, she learnt about probiotics, the use of beneficial lactic acid producing bacteria to maintain health. In February 1986 she published one of the first British articles on the use of probiotics for human 64 health. Monica Bryant felt proud of the fact that she was a pioneer in bringing probiotics to Britain. This approach to health seemed timely when doctors were getting disillusioned with the adverse effects and over-use of antibiotics. Probiotics were a natural way to redress the imbalances created in the intestinal flora through the use of drugs and stressful lifestyle habits. In Europe, lacto-fermented foods are commonly used for their health-giving qualities. In 1986, with her business just keeping afloat, Bryant was offered the agency, in Britain, for germanium. Germanium had not previously been marketed in Britain as it had in other European countries. Being a responsible person, Bryant felt the need to obtain a review by a scientist of all the information currently available about germanium. Monica Bryant could see that germanium had a wide range of established uses: it had an oxygen-enhancing effect, and helped interferon production, as well as modulating the immune system in other ways. In 1986, she set up an agency called Symbiogenesis; a number of major companies acted as distributors for her. No claims were made for germanium and the information on the packets was kept to a few lines which Bryant had cleared with the Products Advertising Authority. Then Monica Bryant developed her own probiotic product, giving it the trade name Symbion. The supplier for the particular bacterial strain which Monica Bryant used in Symbion was a man called Yves Delatte. Delatte delivered the bacteria directly from the University of Dundee, where it had been made up. Yves Delatte Yves Delatte is a European, a man who has spent much of his life shuttling between France, Holland, Finland and Britain. In 1979, Delatte was working with a French company, developing probiotics for use in animal welfare. He was working principally with mink which, because of constant inbreeding in captivity, have a weak immune system. In 1986, Delatte and his work were taken up by a Swedish company, Kemi Interessen, part of the Kema Nobel group. The company wanted to develop his ideas and work on probiotics, for use in animal welfare, again with mink. His work with Kemi Interessen took Delatte to mink farms in Ireland and Scotland, and during this time he settled in England. He worked for only a year with Kemi Interessen, and left following disagreements about the direction which his research should take.

The labo- ratory calls that night and informs you that the patient’s sodium level is 126 mEq/L generic 400 mg floxin amex, potassium level is 6 cheap floxin 400mg with mastercard. Which of the following is the likely cause of his hyponatremia given his presentation? Her medical history is remarkable only for hypertension, which is well controlled with hydrochlorothiazide. Her examination and laboratory tests show no signs of infection, but her serum sodium level is 119 mEq/L, and plasma osmolarity is 245 mOsm/kg. On the first postoperative day, he is noted to have significant hypona- tremia with a sodium level of 128 mEq/L. You suspect that the hypona- tremia is due to the intravenous infusion of hypotonic solution. In the postoperative state or in situations where the patient is in pain, the serum vasopressin level may rise, leading to inappropriate retention of free water, which leads to dilution of the serum. Hyponatremia in the setting of hyperkalemia and acidosis is sus- picious for adrenal insufficiency. This patient’s examination is also suggestive of the diagnosis, given his complaints of fatigue, weight loss, low blood pressure, and hyperpigmentation. The underlying cause of the adrenal gland destruction in this patient probably is either tuberculosis or malignancy. Because the patient is hypovolemic, probably as a result of the use of diuretics, volume replacement with isotonic saline is the best ini- tial therapy. Hyponatremia caused by thiazide diuretics can occur by several mechanisms, including volume depletion. In a patient with hyponatremia due to the infusion of excessive hypotonic solution, the serum osmolality should be low. The kidneys in responding normally should attempt to retain sodium and excrete water; hence, the urine sodium concentration should be low, and the urine osmolality should be low. When the infusion of hypotonic solution is used, the serum potassium level will also be low. This is in contrast to a situation of mineralocorticoid deficiency in which the sodium level will be decreased and potassium level may be elevated. Similarly, hyperaldosteronism can lead to hypertension and hypokalemia (Conn syndrome). Clinical Pearls ➤ Hyponatremia almost always occurs by impairment of free water excretion. Criteria include euvolemic patient, serum hypoosmolarity, urine that is not maximally dilute (osmolality >150-200 mmol/L), urine sodium more than 20 mmol/L, and normal adrenal and thyroid function. Patients with severe symptoms, such as coma or seizures, should be treated with hypertonic (3%) saline. This page intentionally left blank Case 6 A 42-year-old man is brought to the emergency room by ambulance after a sudden onset of severe retrosternal chest pain that began an hour ago while he was at home mowing the lawn. It was not relieved by three doses of sublingual nitroglycerin administered by the paramedics while en route to the hospital. He is a basketball coach at a local high school, and is usually physically very active. On physical examination, he is a tall man with long arms and legs who appears uncomfortable and diaphoretic; he is lying on the stretcher with his eyes closed. He is afebrile, with a heart rate of 118 bpm, and blood pressure of 156/100 mm Hg in the right arm and 188/94 mm Hg in the left arm. His chest is clear to auscultation bilaterally, and incidental note is made of pectus excavatum. His heart rate is tachycardic and regular, with a soft, early diastolic murmur at the right sternal border. His blood pressure is elevated but asymmetric in his arms, and he has a new murmur of aortic insufficiency. All of these fea- tures strongly suggest aortic dissection as the cause of his pain. He is tall with pectus excavatum and other features of Marfan syndrome, which may be the underlying cause of his dissection. Learn the clinical and radiographic features of aortic dissection as well as complications of dissection. Understand the management of dissection and the indications for surgical versus medical treatment. In hypertensive patients with dissection, urgent blood pressure lowering is indicated to limit propaga- tion of the dissection. Aneurysms can occur anywhere in the thoracic or abdominal aorta, but the large majority occur in the abdomen, below the renal arteries.

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Alfred Blalock Scholarship Fund This endowed scholarship was established in scholarship generic floxin 200 mg, established by Dr cheap 400mg floxin otc. Carver for students in Thomas Harrold, commemorates the great the School of Medicine. Chinese students service to human kind and the many contri- are to have preference insofar as there may butions of one of Johns Hopkins’ most distin- be qualifed applicants; second preference is guished surgeons, Alfred Blalock, who devel- for students of other Asian nationalities; third oped the blue baby operation designed to preference is for American students. The fund is to be used to aid deserv- Bongiovanni was a member of the faculty in ing students in the School of Medicine. The income from the fund is to provide This fund was established in 2003 by Helena fnancial aid to needy students in the School Chang Chui, M. The fund was established by given to students that are pursuing an Mas- his estate in 1998. Turner Scholarship Fund Established by cal students pursuing a degree in one of the friends and admirers of Dr. Scholarship Fund Established in 1999 by Class of 1915 Memorial Fund A fund estab- Dr. Brookhouser to provide scholar- lished through gifts and bequests from and ships to needy medical students. Grafton ing student or students at the Johns Hopkins Brown died in 1973, leaving a Trust to provide University School of Medicine. D’Agostino, Class of 1978, to honor his in 1950 by members of the School of Medi- devotion to medicine and his lifetime affli- cine Class of 1926 to provide income for a ation with the School of Medicine. Wells Davies Fund was established by Vir- Class of 1937 Philip Bard Scholarship ginia Wells Davies in November of 1981. Its Established as an endowed fund by the purpose is to provide scholarship assistance Class of 1937 in 1987 in honor of their 50th to fnancially needy students pursuing the Reunion. Doane established an Class of 1956 Memorial Fund Endowed in endowment fund in 1952 to provide tuition aid 1971 by members of the Class of 1956, the to certain students with fnancial need. Income from the by the members of the Class of 1965 in honor principal will be used to provide fnancial sup- of their 25th Reunion, the income to provide port for medical students in the School of scholarships to needy medical students. The fund is a tribute to in honor of their 25th Reunion, the income his wife, Victoria. Memorial Fund Estab- lished in 1990 by the family, friends, and col- Class of 1976 Scholarship Fund Endowed leagues of Dr. Marcia Thomas Duncan Memorial Schol- arship This scholarship, established in 1980 Class of 1978 Scholarship Fund Endowed in memory of Marcia Thomas Duncan, is by the Class of 1978 to commemorate their awarded annually to a frst year medical stu- 25th Reunion; the income will provide schol- dent. In addition to a four-year scholarship arships to needy medical students in the covering tuition and fees, the Duncan Scholar School of Medicine. Eggleston Memorial Fund An of Medicine alumni established the Class of endowed fund established in 1989 by family, 1980 Scholarship Fund in 1995 to provide friends and colleagues of Dr. The income is to provide scholarship was created by members of the Class of 1983 assistance to needy medical students in the upon their 15th Reunion to provide assis- School of Medicine. Robert Biggs Ehrman Scholarship Fund Class of 1986 Scholarship Fund Endowed Established in 1970 at the death of Mr. Engle Endowed Scholarship Fund Established previously served as his class representative. Sharon Fox Scholarship Fund in Memory Jean Epstein Memorial Fund This endow- of Henrietta B. The income from this income from which is to be used for student fund provides a scholarship to deserving aid in the School of Medicine. Ettinger Scholarship Fund lished as a bequest from the estate of Sallye Established by Mrs. Ettinger to provide schol- Lipscomb French as a memorial to her hus- arship assistance for students in the School band, Bernard S. Scholarship ship Fund This fund is in memory of Larry Established in 2000 by a gift from Dr. Scholar- arship Fund This fund was established in ship Fund This fund was established in 1999 1998 by Stuart L. Finesilver Memorial Schol- arship Fund This fund was established in arship Fund This fund was established in 1996 by Dr. Frances Blumenthal in memory vide scholarship support to students in the of her father, an alumnus of the Class of 1924. Firor Fund An endowed schol- able candidate applying for admission to the arship established in 1989 by the estate of Johns Hopkins University School of Medi- Mrs. Abraham Genecin Memorial Fischer Family Scholarship for Medical Fund This fund was established in 1999 by Education This scholarship fund recognizes Mrs. Rita Genecin and other donors to pro- the Hopkins family legacy of Janet Fischer, vide assistance to needy medical students. Givens to provide Fonkalsrud Endowed Scholarship Fund scholarships for students in the School of This fund was established in 2002 by Eric W. The couple has a life-long Emil Goetsch Fund for Medical Students affliation with the Johns Hopkins School of The income from this endowment, estab- Medicine. Fonkalsrud served on the fac- lished in 1963, is used for scholarships for ulty in the School of Medicine’s Department medical students.

It often reflects relationship problems discount floxin 200mg with visa, daily hassles cheap 400mg floxin with mastercard, and high stress 2065 Modified from Ritvo ea (2008, pp. Occasionally there is a specific sexual problem due to longterm sexual inhibition or an intractable biologically based low sex drive. It may be secondary to 2069 depression, but it doesn’t always clear up when the depression is treated. Tibolone (Livial) may enhance sexual function in post-menopausal women,(King, 2008, p. Flibanserin, originally developed as an antidepressant, is 2072 undergoing trials with some promise of success. In ‘sexual aversion disorder’ the person hates genital contact; it is severe and persistent; and the causes may be the same or similar to hypoactive desire disorder. There is avoidance of sexual experience because of a specific anxiety that is seen as excessive by the patient. The anxiety may be confined to an aspect of sexual activity (kissing, smells, nudity, etc) or it may be generalised. One partner constantly seeks sexual activity and becomes distressed if such desires are not fulfilled. An older definition was that on at least 50% of occasions the male is unable to delay orgasm long enough to satisfy the female. It is often learned from earlier experiences but organic causes include testosterone deficiency, prostatitis, and multiple sclerosis. Treatments include the squeeze technique, withdrawal of stimulation just before the build up to orgasm 2073 (stop-go technique ), and the application of a local anaesthetic ointment to the coronal ridge and frenulum to reduce stimulation. In the squeeze method the woman grips the corona glandis for a few seconds between her thumb and forefinger and then releases it suddenly. This technique may lead to loss of erection or even of ejaculation when employed too close to the point of ejaculatory inevitability. A topical lidocaine-prilocaine solution helps some sufferers as long as anaesthesia is not extreme and there is no allergic skin reaction. Delayed ejaculation (ejaculatory incompetence or retarded ejaculation) refers to a long delay in, or inability, to ejaculate. This is usually psychogenic if the patient is able to ejaculate outside the vagina. It may be due to fear of creating a pregnancy, negative feelings for the partner, religious taboo, etc. Physical 2069 Also, increased sexual interest is reported by a minority of people with depressive or anxiety states and many individuals with these disorders find no change in their interest in sex. Sex may act as a transient anxiolytic or as a source of comforting closeness for some people. It blocks production of thromboxane A2 and thereby inhibits aggregation of platelets (which can be problematic in people on warfarin). Other adverse effects include headache, anxiety, poor concentration, raised blood pressure, palpitations, and diarrhoea. It has a number of adverse effects including thrombophlebitis, hypertension, and vaginal bleeding. It should be noted that normal aged males often produce an ejaculate only every second or third time. In diabetics, neuropathic involvement of the bladder neck may lead to retrograde ejaculation (cloudy urine). Ephedrine taken prior to sexual intercourse has been recommended but this can be dangerous, especially if combined with caffeine. Diagnosis is based on a thorough history, including collateral information as necessary, and examination, supplemented by whatever investigations seem indicated and sensible. The International Index of Erectile Function, a validated questionnaire, has 5 domains: erectile function, orgasmic function, sexual desire, satisfaction with sexual intercourse, and overall sexual satisfaction. A cross-section of the erect penile shaft, 2079 2080 relative to the flaccid penis, reveals engorged veins, narrowed cavernous and Helicine arteries, and bloated sinusoidal spaces. The chronic alcoholic with hepatic dysfunction may have hypogonadism, feminisation, and peripheral neuropathy. Antihypertensives, by lowering systemic blood pressure, can reduce maximal penile filling capacity. Erythropoietin may improve sexual function, probably by reversing some of these hormonal changes. Diabetic women may have decreased sexual arousal, poor vaginal lubrication, reduced orgasmic capacity, or depression. Cultural mores must be respected, and a chaperone has become essential in the current litigious climate. Physical investigation of the aetiology of erectile dysfunction has become less imperative with the introductive of effective oral treatments. Measurement of penile arterial blood pressure involves a Doppler probe, a digital blood pressure cuff, and a 2099 sphygmomanometer.

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