Colin M. Bucks, MD

• Department of Emergency Medicine
• Albert Einstein Medical Center
• Philadelphia, Pennsylvania

Thiscanresultindiseasesof imprinting menopause doctors order female viagra 50mg free shipping, since only one parent contributes to the epigenetic pattern menstruation at 9 discount 50 mg female viagra otc. Diagnostic approaches to pediatric cardiomyopathy of metabolic genetic etiologies and their relation to therapy women's health big book of 15 minute exercises order 100 mg female viagra free shipping. Inverylong-chainfattyaciddisorders womens health questions answers generic female viagra 100mg with amex,limitintaketolow-fatfoods and supplement with medium-chain triglyceride oil. Olderinfant/child:globaldevelopmentaldelays,choreoathetoidor dystonic movements secondary to metabolic stroke in the basal ganglia, bone marrow suppression, frequent infections, pancreatitis, cardiomyopathy c. Presentation:Episodesofacutedecompensationcharacterizedby headache, vomiting, lethargy, and altered mental status due to hyperammonemiathatcausesrespiratoryalkalosis. Failure to thrive and poor appetite are chronic symptoms in undiagnosed patients with mild urea cycle defects. Musclebiopsy is no longer indicated except in the case of severe myopathy, as diagnosis can be made by molecular testing of blood. Other presenting symptoms include failure to thrive, lethargy, hemolytic anemia, hyperbilirubinemia, cataracts, hepatic dysfunction, and renal dysfunction. Otherfeaturesinclude doll-like facies, xanthomas, hepatic adenomas, polycystic ovaries,andpancreatitis. Afterage18months, considercornstarchornewlyavailableGlycosade(modified slow release starch) after consulting a geneticist. Clinical features therefore include progressive psychomotor retardation and neurologic problems, such as epilepsy, ataxia, and spasticity. Theclinicalspectrumiswideandrangesfrom intrauterine demise to mild malformations and normal lifespan. History Pastmedicalhistoryincludingpregnancyhistory,prenataldrug/other exposures,typeofconception(naturalorassisted),perinatalhistory, developmental milestones, three-generation pedigree. Examples include structural brain abnormalities, growth <3%,cleftlipand/orpalate, congenital heart defects, or skeletal dysplasia. Minor anomalies: Structural anomalies that are found in <5%ofthe population with little or no cosmetic or functional significance to the patient. Examplesinclude atypically shaped ears or eyes, inverted nipples, birthmarks, atypical skinfoldsorcreases. Genetic skeletal survey for patients with apparent short bones, short stature,visibleexternalanomalies. Therefore,theriskincreaseswith 13 Chapter 13 Genetics: Metabolism and Dysmorphology 347. Presentation:Disorderofcoppermetabolismthatpresentswith hepatic, neurologic, renal and psychiatric complications including chronicliverdisease,jaundice,cirrhosis,dysarthria,poor coordination, depression and occasionally intellectual deterioration. Features:Defectsofforebraindevelopment(holoprosencephaly), severe developmental disability, low-set malformed ears, cleft lip and palate, microphthalmia, aplasia cutis congenita, polydactyly (mostfrequentlyofthepostaxialtype),narrowhyperconvexnails, apneic spells, cryptorchidism, congenital heart defects. Thediagnosisshouldbeconsideredinafemale fetus with hydrops, increased nuchal translucency, cystic hygroma, orlymphedema. Intelligenceisusuallynormal,but patients are at risk for cognitive, behavioral, and social disabilities. Adolescentandadultmalesmay present with infertility and hypoandrogenism with eunuchoid body habitus,gynecomastiaandsmalltestes. Connective tissue diseases27,37,38 ExamplesincludeMarfansyndrome,Loeys-Dietzsyndrome,familial thoracic aortic aneurysm disease, bicuspid aortic valve and aneurysm syndromes,Ehlers-Danlossyndrome,Shprintzen-Goldbergsyndrome, cutis laxa syndromes, arterial tortuosity syndrome, Stickler syndrome (descriptionofalloftheseisbeyondthescopeofthischapter). Presentation:Myopia,ectopialentis(60%),dilatationoftheaorta atlevelofsinusesofValsalva,predispositiontoaortictearand rupture, mitral valve prolapse, enlargement of proximal pulmonary artery,pneumothorax,boneovergrowthandjointlaxity,extremities disproportionatelylongforsizeoftrunk,pectuscarinatumor excavatum, scoliosis, pes planus. Healthsupervision:Annualophthalmologicexamination;annual echocardiography unless aortic root diameter exceeds 4. Epidemiology:Autosomaldominantcondition;1/2cases spontaneous or de novo genetic mutations. Scaphocephaly occurs from premature closer of the sagittal suture and is the most common form of craniosynostosis. Frontal plagiocephaly is the next most common form and results from premature fusion of a coronal and sphenofrontal suture. Earlytreatmentandmanagement may decrease the risk of associated complications such as hydrocephalus and cognitive impairment. Features:Characterizedbyseverehypotoniaandfeeding difficulties in infancy, followed by an insatiable appetite in later 13 Chapter 13 Genetics: Metabolism and Dysmorphology A. Shortstatureiscommon; males and females have hypogonadism, and in most, infertility. Thepatienthasabnormalpaternal-specificimprinting,a paternal deletion, or maternal uniparental disomy within the Prader-Willi/Angelmancriticalregionof15q. Replacesex hormones in puberty for secondary sexual characteristics and bone health. Features:ClassicRettsyndromeisaneurodevelopmental syndrome that presents after 6-18 months of typical development with acquired microcephaly, then developmental stagnation, Chapter 13 Genetics: Metabolism and Dysmorphology 355 6. Repetitive, sterotypical hand-wringing, fits of screaming or inconsolable crying, autisticfeatures,episodicbreathingabnormalities(sighing,apnea orhyperpnea),gaitataxia,tremors,andgeneralizedtonic-clonic seizuresareobserved. Multiplegenesarebeingdiscovered,which may be causative in syndromic forms of cleft lip and palate, and may alsoplayaroleinnonsyndromicforms. Maternalsmoking,heavyalcohol use(morethanfivedrinksperoccasion),systemiccorticosteroiduse, folic acid and cobalamin deficiency increase the risk of cleft palate. Central:Depressedlevelofconsciousness,predominantlyaxial weakness, normal strength with hypotonia, abnormalities of brain function, dysmorphic features, and other congenital malformations. Infantswithpulmonicstenosisandsmallsizemayhave another rasopathy with a more severe prognosis than Noonan syndrome. Assessmentsshouldincludeserumcalcium, absolutelymphocytecount,B-andT-cellsubsets,renal ultrasound, chest x-ray, cardiac examination, and echocardiogram. Ethics of Genetic Testing in Pediatrics59 Genetic testing in pediatric patients poses unique challenges given that childrenrequireproxies(mostoftenparents)togiveconsentfortesting. Please see Expert Consult for important considerations and information on informed consent. Pretest counseling should include the discussion of this possibility, but what happens when a patient or family member chooses not to disclose the results of genetic testing with other at-risk family members TheAmericanSocietyofHumanGeneticsreleasedastatementon professional disclosure of familial genetic information which outlines "exceptionalcircumstances,"whichifall are present, disclosure may be permissible:(1)attemptstoencouragedisclosurebythepatienthave failed,(2)harmis"highlylikely"tooccur,(3)theharmis"seriousand foreseeable,"(4)eitherthediseaseispreventable/treatable,orearly monitoringwillreducethegeneticrisk,(5)theat-riskrelative(s)are identifiable,and(6)theharmoffailuretodiscloseoutweighstheharm thatmayresultfromdisclosure. Legalframeworksrangefromprotecting absolutepatientconfidentialitytorecognizingthatlimiteddisclosureof genetic test results to at-risk family members may be an ethical obligation. First-line cytogenetic test for all patients with unexplained global developmental delay, intellectual disability, autism, and/or at least 1 major + 2 minor congenital anomalies. Informed Consent60 Asgenetictestinghasbecomemoreavailable,patientsmayhavegenetic testing sent without direct consultation of a geneticist or genetics counselor. With this in mind, it is recommended that pretest counseling be provided including the following possibilities: 1. Negative-eithernocausative/relatedvariantispresent,or the available technology or scope of the test methodology was unable to detectthecausative/relatedvariant. Ingeneral,itis recommended that incidental findings should be reported when there is strong evidence of benefit to the patient and the finding was in constitutional(nottumor)tissue. Genetic evaluation of the pediatric patient with hypotonia: perspective from a hypotonia specialty clinic and review of the literature. The American Society of Human Genetics Social Issues Subcommittee on Familial Disclosure. Consistent with clinically significant homozygous sickle Hb genotype (S/S) or sickle -thalassemia, with manifestations of sickle cell anemia during childhood. This heterozygous condition could lead to manifestations of sickle cell disease during childhood. Submit another filter paper blood specimen when infant is 4 mo of age, at which time the transfused blood cells should have been cleared.

Environmental release record: the need to control releasesfrom specific areasdemonstratingprevious problems menstrual 10 days discount female viagra 50 mg line. The plan should be initiated with clear support and input from facility management employees womens health resource center female viagra 100 mg with visa. The committee functions to conduct activities and shoulder the responsibilities of all elementsdiscussedin Exhibit 2-3 best women's health tips cheap female viagra 50mg without a prescription. Good housekeeping Preventivemaintenance Inspections Security Employee training Recordkeepingand reporting Reevaluation Phase Evaluation and Considerations 10 menstrual vs pregnancy symptoms cheap 50mg female viagra otc. Periodically or as needed,repeat stepsl-9 To be most effective, the committee must perform tasks efficiently and smoothly. Some of the considerationsfor personnelselection include the following: l A lead committee member must be determined Committee members must include persons knowledgeableof the plant areas involved. With this in mind, the selection of the committee memberscan be limited to a select set of individuals, while the resourcesof interestedand knowledgeableemployeescan still be utilized. In order to ensurea properly run organization, one person should be designatedas the lead committee member. The determination of a single leader will assistin the smooth conduct of meetings and the designation of tasks, and will aid in the decision-making process. As part of the 3P program, 3M has created a 3P Coordinating Committee which includes employee representatives from the engineering manufacturing, laboratory, and corporateenvironmental sectors. The 3P Coordinating Committee provides support and coordination for nationwide teams establishing 3P programs. These 3P Teams are organized by employeesthat have identified pollution problems and recognizepotential solutions. The 3P Coordinating Committee and the 3P Teams have been instrumental in sourcereduction of hydrocarbons,odor, water, dissolvedsolids, sulfur, zinc, alcohol, and incinerated scrap. In the first year of the 3P programs, air pollutants have been reducedby 123,000tons, water pollutants by 16,400tons, wastewaterby 1,600 million gallons, and solid wastes pollutants by 409,000 tons. Zeal, "Case Study: How 3M Makes Pollution Prevention Pay Big Dividends," Pollution Prevention Review, Winter 1990-91. Potential candidatesfor this role are plant managers, environmental coordinators, or other distinctly knowledgeabletechnical and managementpersonnel. Personnel might be selected who have a full understandingof the manufactureprocesses from raw materials to final products, as well as of the recycling, treatment, and disposalof wastes. Possiblecandidatesinclude foremen in manufacturing, production, or waste treatment and disposal; maintenanceengineers; environmental and safety coordinators; and materials storage and transfer managers. Somecommitteemembersmust representcompanymanagement havethe authority to implement and measuresadoptedby the committee. Forming a committee comprised solely of upper level managementand administrative personnel would exclude general personnel whose input is critical for the developmentand implementationof the plan. Selecting employeechosenrepresentatives,such as union stewards, may be an appropriate meansto ensureemployee involvement. The committee must be small enoughto communicate in a open and interactive manner, yet large enough to allow for input from all necessaryparties. Where needed, committee members should call upon the expertise of others through the establishmentof project-specific task forces. This methodof calling upon specialists, when the needarises, should allow the committeeto remain a manageable size. Generally, the size selection processoutlined below presentsa good rule of thumb: l For `small facilities, a single committee member is acceptableas long as that personhas the requisite expertiseand authority For larger facilities, selection of six to eight people as permanent members of the committee should be ideal. This is of particular importancewhere a technical specialistor manager simply would not have the time to contribute on a regular basis. As part of their "Environmental Policy and Guidelines," Dow has set forth a hierarchy similar to that developedas part of the Pollution Prevention Act of 1990. Where disposal is necessary,Dow has specifiedthat incineration be consideredfirst, followed by land disposal on Dow-owned property, and finally land disposal on property not owned by Dow. Dow reasoned incineration was the most appropriatedisposal that method since it resulted in the pollutants in the ash materials being in elemental form. In many cases,the companyhas identified opportunities for recycle of materials found in the incinerator ash. Dow also imposed a $215 per drum surchargefor hazardous wastes going to a landfill to provide incentives for finding alternativesto landfilling. Dow also believes that they can better exercise control of onsite disposal, thus influencing the preferencesfor onsite rather than offsite disposal. For example, at the Dow Pit&burg, California facility, wastewater dischargeshave been reduced by 95 percent over the past 10 years. A responsible corporate officer can be the president, vice president, or the principal managerof manufacturing,production, or operations. Generally, the policy statementauthor should be a person who performs policy- or decision-makingfunctions for the corporation/facility. If specific goals are outlined, the level of information and the expectationspresentedshould be reasonable,to avoid overwhelming the reader. Complete distribution can be best ensured if the statementis both delivered to each employee and posted in common areas. What Is Release Identification Releaseidentification is the systematic cataloging of areas at a facility with ongoing or is potential releasesto the environment. A releaseassessment used to determine the impacts on humanhealth and the environmentof any on-going or potential releases identified. The identification and assessment processinvolves the evaluationof both current dischargesand potential discharges. In somecases,the assessment be performed basedon experienceand knowledge of the substances circumstancesinvolved. In other cases, and more detailed analysesmay be necessary provide the correct focus, and releaseassessments to may then rely on some of the techniquesof risk assessment. However, in in some instancesprioritizing potential hazardsis the most sensibleand cost effective approach. Among other things, this facility containsa large stockpile of building sandusedto prepare concrete,a vehicle maintenanceareawhere oil is drained from companyvehicles, and a shedwhere drums of solventsusedin cleaning operationsare stored. Although each of the three materials mentionedat the site (sand, used oil, and solvents)can cause environmental or health damageunless they are controlled, it would not be feasible or reasonable to control lossesof small amountsof clean building sandwith the samecareful attention given to the releaseof toxic solvents. An example of the effectivenessof this type of assessment provided in Exhibit 2-6. A completed version is also provided to demonstratehow this worksheet can assistfacilities in data compilation. Initially, Borden conductedextensivemonitoring to determine the sourcesof organic loadings. Then, knowledgeableplant personnelconducteda plant inspectionto identify and assesssources of organic loadings. The comprehensiveinspection involved the evaluation of the entire site from initial materials arrival, through production, to final product shipment. Basedon the information from the monitoring program and the inspection, the plant managementprioritized three areas in which modifications were needed: filter rinse operations, reactor vesselrinses, and employeepractices. Basedon this assessment, Borden implementeda systemwhich involves process changes, employee training, and a continuing monitoring program. The first step in the conduct of a releaseidentification and assessment involves the review of existing materials and plans to gather neededinformation. Many industrial facilities are already subject to regulatory requirements to collect and provide information that may be useful in the identification and assessment releases. In some cases,these plans may have been developedby of personsin plant safety or processengineeringwho do not normally considerthemselvespart of the environmental staff. The second step of conducting a release identification and assessment to characterize is current and potential pollutant sources. This stepmay be conductedthrough assemblinga description of facility operationsand chemical usageand then verifying information through inspections. This processallows facility personnelto confirm the accuracyof information on hand. Generally, the preparation of a site map or maps covering the entire facility is very useful in this evaluation. Maps should cover the entire property and illustrate plant features including material storage areasfor raw materials, by-products, and products; loading and unloading areas; manufacturing areas; and waste/wastewater managementareas.

Pharmacotherapy (see inside front cover and consider stress-dose corticosteroids and/or antibiotics if applicable menopause hot flashes relief buy 50mg female viagra free shipping. Assess airway patency; think about obstruction: Head tilt/chin lift (or jaw thrust if injury suspected) to open airway women's health center at presbyterian dallas buy generic female viagra 100 mg on line. Recognize signs of distress (grunting women's health issues in third world countries buy 50 mg female viagra mastercard, stridor women's health clinic jefferson city mo buy 100 mg female viagra with mastercard, tachypnea, flaring, retractions, accessory muscle use, wheezes). Use oral or nasopharyngeal airway in patients with obstruction: (1) Oral: Unconscious patients-measure from corner of mouth to mandibular angle. Intubation: Indicated for (impending) respiratory failure, obstruction, airway protection, pharmacotherapy, or need for likely prolonged support a. Mouth-to-mouth or mouth-to-nose breathing: provide two slow breaths (1 sec/breath) initially. Bag-mask ventilation is used at a rate of 20 breaths/min (30 breaths/ min in infants) using the E-C technique: a. Patients should therefore be observed for a minimum of 6 to 24 hours for late-phase symptoms. Asthma22-25 Lower airway obstruction resulting from triad of inflammation, bronchospasm, and increased secretions: 1. Administer inhaled -agonists: metered-dose inhaler or nebulized albuterol as often as needed. Infusion should be started with lowest possible dose; doses as high as 10 mcg/kg/min have been used. Intubation of those with acute asthma is potentially dangerous, and should be reserved for impending respiratory arrest. Hypotension: Result of air trapping, hyperinflation, and therefore decreased pulmonary venous return. Upper Airway Obstruction26-29 Upper airway obstruction is most commonly caused by foreign body aspiration or infection. Epiglottitis: Most often affects children between 2 and 7 years, but may occur at any age. Summon epiglottitis team (most senior pediatrician, anesthesiologist, intensive care physician, and otolaryngologist in hospital). Epiglottitis may also be caused by thermal injury, caustic ingestion, or foreign body. Croup is a common syndrome involving inflammation of the subglottic area; presents with fever, barking cough, and stridor. Mild (no stridor at rest): Treat with minimal disturbance, cool mist, hydration, antipyretics, and consider steroids. After administering, observe for a minimum of 2 to 4 hours, owing to potential for rebound obstruction. Alternatively, nebulized budesonide may be used, although little data exist to support its use, and some studies find it inferior to dexamethasone. Most events are unwitnessed, so suspect this in children with sudden-onset choking, stridor, or wheezing. Assessment: Range of mental status includes alert, confused, disoriented, delirious, lethargic, stuporous, and comatose. Obtain history of trauma, ingestion, infection, fasting, drug use, diabetes, seizure, or other neurologic disorder. Phenytoin may be contraindicated for seizures secondary to alcohol withdrawal or most ingestions (see Chapter 2). The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Part 13: Pediatric basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 11: Pediatric basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Part 12: Pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Dallas: American Heart Association, Subcommittee on Pediatric Resuscitation; 2006:228. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Second symposium on the definition and management of anaphylaxis: summary report-Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Intravenous aminophylline for acute severe asthma in children over two years receiving inhaled bronchodilators. Treatment of refractory status epilepticus: literature review and a proposed protocol. Phase 2 (24 to 72 hr):abovesymptomsresolve,rightupperquadrant painandhepatomegalydevelop. Phase 3 (72 to 96 hr):returnofnonspecificsymptomsaswellas evidenceofliverfailure. Acetaminophen plasma concentration 2 le ib ss he pa tic to ty ci xi 26 Part I Pediatric Acute Care 3. Poisoning mortality in United States: comparison of national mortality statistics and poison control center reports. Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention. Consent Before performing any procedure, it is crucial to obtain informed consent from the parent or guardian by explaining the procedure, the indications, any risks involved, and any alternatives. All invasive procedures involve pain, risk for infection and bleeding, and injury to neighboring structures. Sedation and analgesia should be planned in advance, and the risks of such explained to the parent and/or patient as appropriate. Introduction to Ultrasound Ultrasound has become an increasingly important bedside diagnostic and procedural aid. Ultrasound can improve visualization of subcutaneous structures noninvasively during procedures and improve precision. Ultrasound caveats important for certain procedures are noted below, where applicable. Linear transducers use high frequencies to produce high resolution images and are primarily used for procedures in pediatrics. A wide area of contact at the skin surface facilitates needle placement in procedures. Curvilinear transducers use low to midrange frequencies and permit deep structure visualization. Depth: Adjust to visualize structure of interest and at least a centimeter of tissue below that structure. Indications: Blood sampling in infants for laboratory studies less affected by hemolysis. Puncture heel using a lancet on the lateral part of the heel, avoiding the posterior area. Wipe away the first drop of blood, and then collect the sample using a capillary tube or container. Alternate between squeezing blood from the leg toward the heel (or from the hand toward the finger) and then releasing the pressure for several seconds. Indications: Blood sampling and access to peripheral venous circulation to deliver fluid, medications, or blood products. After removing tourniquet, attach a syringe and apply gentle negative pressure to withdraw blood for serum sampling. Perform this by sliding the probe along the course of the vessel and identifying its direction and branching. Restrain patient securely and place with head turned away from side of cannulation. The vein runs from the angle of the mandible to the posterior border of the lower third of the sternocleidomastoid muscle. With continuous negative suction on the syringe, insert the needle at about a 30-degree angle to the skin.

Diluted concentrations of 1 U/mL or 10 U/mL may be necessary for smaller doses in neonates and infants ectopic pregnancy buy 100mg female viagra overnight delivery. Use with caution in dehydration menstruation euphemisms purchase 100mg female viagra with amex, previous allergic reaction to a contrast medium menstruation 60 year old buy female viagra 100 mg on line, iodine sensitivity women's health center abington buy female viagra 50mg with mastercard, asthma, hay fever, food allergy, congestive heart failure, severe liver or renal impairment, diabetic nephropathy, multiple myeloma, pheochromocytoma, hyperthyroidism, and sickle cell disease. Allergic reactions, arrhythmias, hypothyroidism, transient thyroid suppression, and nephrotoxicity have been rarely reported. Use with caution in narrow-angle glaucoma or bladder neck obstruction, although ipratropium has fewer anticholinergic systemic effects than atropine. Reversible anisocoria may occur with unintentional aerosolization of drug to the eyes, particularly with mask nebulizers. Combination ipratopium and albuterol products are currently approved for use only in adults and have not been officially studied in children. Doses were administered during the last hr of each dialysis and are recommended at a frequency of 3 times a week. May continue to administer at lowest dose to maintain target Hb, Hct, and iron levels. Nonhemodialysis dependent: 200 mg elemental Fe on 5 different days over a 2-wk period (total cumulative dose: 1000 mg). Hypersensitivity reactions have been reported for iron dextran and sucrose products; use of test dose prior to first therapeutic dose is recommended. Common side effects include headache, respiratory tract viral infection, peritonitis, vomiting, pyrexia, dizziness, and cough. Contraindicated in acute liver disease and previous isoniazid-associated hepatitis. Peripheral neuropathy, optic neuritis, seizures, encephalopathy, psychosis, and hepatic side effects may occur with higher doses, especially in combination with rifampin. May cause flushing, ventricular arrhythmias, profound hypotension, anxiety, and myocardial ischemia. Clinical deterioration, myocardial necrosis, congestive heart failure, and death have been reported with continuous infusion use in refractory asthmatic children. Elevation of liver enzymes may occur during treatment; a dosage reduction or continued treatment may result in normalization. Hormonal birth control (oral, injectable, and implantable) failures have been reported with concurrent use. Only the oral solution has been demonstrated as effective for oral and/or esophageal candidiasis. Use with caution in hepatic and/or renal impairment, cardiac dysrhythmias, and azole hypersensitivity. Recommended serum sampling time at steady state: any time after 2 wk of continuous dosing. Benzodiazepine may be used in the presence of a ketamine-associated recovery reaction (prophylaxis use in adults may be beneficial). Consider potential drug interactions with respective enzyme inhibitors and inducers, especially with prolonged use. Hypersensitivity reactions (including anaphylaxis) have been reported with all dosage forms. Safety and efficacy with topical use in seborrheic dermatitis for patients aged >12 yr has been established. Excessive sedation and prolonged hypnotic effects with triazolam use (also contraindicated). May increase levels/effects of phenytoin, digoxin, cyclosporine, corticosteroids, nevirapine, protease inhibitors, and warfarin. Achlorhydria, phenobarbital, rifampin, isoniazid, H2 blockers, antacids, and omeprazole can decrease levels of oral ketoconazole. To use shampoo, wet hair and scalp with water; apply sufficient amount to the scalp and gently massage for about 1 min. Also indicated for ocular itching associated with seasonal allergic conjunctivitis. Bronchospasm or asthma exacerbations, corneal erosion/perforation/thinning/melt, and epithelial breakdown have been reported with ophthalmic use. Use with caution in hepatic disease (dose reduction may be necessary), diabetes, liver function test elevation, hepatic necrosis, and hepatitis. Patients should be informed about potential dizziness, ataxia, and syncope with use. Multiorgan hypersensitivity reactions (affecting the skin, kidney, and liver), agranulocytosis, and euphoria (high doses) have been reported. If valproic acid is discontinued, increase by 50 mg weekly intervals up to 200 mg/24 hr. Reported rates for adults treated for bipolar/mood disorders as monotherapy and adjunctive therapy are 0. Diplopia, nystagmus, aseptic meningitis, aggression, and alopecia have also been reported. Use during the first 3 mo of pregnancy may result in a higher chance for cleft lip or cleft palate in the newborn. Reduce all doses (initial, escalation, and maintenance) in liver dysfunction defined by the Child-Pugh grading system as follows: Grade B: moderate dysfunction, decrease dose by ~50% Grade C: severe dysfunction, decrease dose by ~75% Withdrawal symptoms may occur if discontinued suddenly. A stepwise dose reduction over 2 wk (~50% per week) is recommended unless safety concerns require a more rapid withdrawal. Hypersensitivity reactions may result in anaphylaxis, angioedema, bronchospasm, interstitial nephritis, and urticaria. Microscopic colitis resulting in watery diarrhea has been reported, and switching to an alternative proton-pump inhibitor may be beneficial in resolving diarrhea. May be used in combination with clarithromycin and amoxicillin for Helicobacter pylori infections. Use of oral disintegrating tablets dissolved in water has been reported to clog and block oral syringes and feeding tubes (gastric and jejunostomy). Nonpsychotic behavioral symptoms reported in children are approximately 3 times higher than in adults (37. Disintegrating tabs (Spritam) may be administered by allowing the tablet to disintegrate in the mouth when taken with a sip of liquid or made into a suspension (see package insert); do not swallow this dosage form whole. Like other quinolones, tendon rupture can occur during or after therapy (risk increases with concurrent corticosteroids). Do not administer antacids or other divalent salts with or within 2 hr of oral levofloxacin dose; otherwise may be administered with or without food. May cause hyperthyroidism, rash, growth disturbances, hypertension, arrhythmias, diarrhea, and weight loss. Total replacement dose may be used in children unless there is evidence of cardiac disease; in that case, begin with one-fourth of maintenance dose and increase weekly. Phenytoin, rifampin, carbamazepine, iron and calcium supplements, antacids, and orlistat may decrease levothyroxine levels. Iron and calcium supplements and antacids may decrease absorption; do not administer within 4 hr of these agents. Excreted in low levels in breast milk; preponderance of evidence suggests no clinically significant effect in infants. Administer a 1 mg/kg bolus when infusion is initiated if bolus has not been given within previous 15 min. Apply topically to intact skin and cover with occlusive dressing; avoid mucous membranes or the eyes.

The counselor will work with the student to request the time off from the Clerkship/ Elective Director if the request is found to be appropriate menopause insomnia buy 100 mg female viagra with mastercard. The counselor and student will also determine if the student should offer to make up time in the clerkship/elective; however pregnancy 5 weeks 3 days buy 100mg female viagra fast delivery, the requirement for the time to be made up is at the discretion of the Clerkship/Elective Director women's health clinic lincoln ne discount female viagra 50mg mastercard. The Clerkship/Elective Director may not grant absences if this policy is not followed menstrual jelly like blood cheap female viagra 50mg amex. Your attendance is expected and required at all other times by the faculty and the Clerkship/Elective Director for satisfactory completion of each clinical clerkship or elective. Indeed, unexcused absences could severely affect your grade; as detailed elsewhere in the policies and procedures for each clerkship, a clerkship or elective may fail you if you do not show up for an assigned activity, miss call, etc. When you return even from an excused absence the student will discuss making up the missed clinical time with the Clerkship. Acknowledgments this teaching packet is a project of the National Gallery of Art, department of education publications. Writers Carla Brenner, Jennifer Riddell, and Barbara Moore extend sincere thanks to colleagues at the Gallery: curator of northern baroque paintings Arthur Wheelock, exhibition research assistants Jephta Dullaart and Ginny Treanor, and curatorial assistant Molli Kuenstner, who generously shared books and expertise; head of the education division Lynn Pearson Russell; editor Ulrike Mills and designer Chris Vogel; and fellow staff members Ira Bartfield, Barbara Bernard, Ricardo Blanc, Bob Grove, Peter Huestis, Greg Jecmen, Leo Kasun, Yuri Long, Donna Mann, Marjorie McMahon, Rachel Richards, Carrie Scharf, Neal Turtell, and Barbara Woods. We also thank our colleague Anna Tummers, lecturer in art history, University of Amsterdam, for her original manuscript, sustained collaboration, and precise editorial comments, which have nurtured this book to its final form. Patrons and artists discussed the fine points of composition, technique, and ways in which art engaged the attentions of the viewer. This connoisseurship (addressed in the section "Talking about Pictures") spurred the founding of specialized art academies and a new "business" of art. We hope you find this packet a useful resource for engaging students on such subjects as world history, the founding of the United States, visual and cultural analysis, geography, world religion, and social studies. This book introduces teachers of middle school students and up to seventeenth-century Dutch culture and its early influence in North America. Three introductory chapters, "Profile of the Dutch Republic," "A Golden Age for the Arts," and "Life in the City and Countryside," provide an overview. Next are five sections on the types of painting strongly associated with Dutch art of the Golden Age: "Landscape Painting," "Genre Painting," "Still-Life Painting," "Portraiture," and "History Painting. The result was a vast body of work enormously original in approach and varied in subject matter. The country is located on the North Sea, and large areas lie below sea level; its lowest point is more than 22 feet below sea level and its highest only about 1,050 feet above. Through the centuries, the Dutch have prevailed against the sea by hard work and constant vigilance, yet water and ocean winds have also been a boon, resources that played a key part in the success of the Netherlands in the seventeenth century. Shallow seas were drained to reclaim land, creating new arable areas called polders, a process begun in the 1200s to accommodate a growing population. Between 1590 and 1650, the area of northern Holland increased by one-third, and land reclamation projects continued through the seventeenth century. Today just under a thousand survive; at one time there were probably some nine thousand. In the seventeenth century they powered a range of activities, from grinding grain and mustard to sawing timber and processing paint. The mill in the etching seen here is a smock mill (named because it was thought to resemble a smock). This one is a top-wheeler: to angle the sails so they could capture the wind, the miller only had to rotate the cap where the sails are attached. The sails are supported on a boxlike wooden structure that rests on a strong vertical post. Carefully balanced on a revolving platform, the entire upper structure is turned so that the sails can catch the wind. A miller could communicate various messages by setting the idle sails of a mill in different positions. Russell Allen 10 Working Lightning made it inadvisable to leave a sail in the full vertical position for long periods. If a potential customer found an idle sail upright, he could assume that the miller would likely soon return. The descending sail arm (in the Netherlands all mills move counterclockwise) is stopped short of its lowest point, before the mill door, meaning good tidings are on the way. Mourning the departing sail, by contrast, stopped just after passing the lowest point, communicated sadness. The mill itself stands like a sentry on its bulwark, watching steadfast over small, reassuring motions of daily life: a woman and child are walking down to the river, where another woman kneels to wash clothes, her action sending ripples over the smooth water; an oarsman takes his boat to the opposite shore; in the distance, cows and sheep graze peacefully. Changes he made to the scene-painting and then removing a bridge, for example-indicate, however, that this is probably not any specific mill. Windmills, which kept the soggy earth dry, were also viewed as guardians of the land and its people. Although it is not clear whether Rembrandt intended his Mill to be an overt political statement, it is an image of strength and calm in the breaking light after a storm. It can easily be read as a celebration of peace and hope for prosperity in a new republic where people, like those Rembrandt painted here, can live their lives without fear or war. This print comes from an emblem book, a compendium of moralizing advice and commentary paired with illustrations that was a popular form of literature in the seventeenth-century Netherlands. A mill, pumping water from the soil, appears below the Latin legend Ut emergant (That they may rise up). Accompanying text (not illustrated) goes on to compare the windmill to a good prince who works selflessly for his people. The seventeen provinces of the Low Lands were administered by Spanish governors in Brussels. In 1579 the seven northern provinces-Holland, Zeeland, Utrecht, Overijssel, Gelderland, Friesland, and Groningen-formed a loose federation (the Union of Utrecht) and declared their independence. The struggle, however, had begun years earlier, in 1568, with a revolt led by the Dutch nobleman William of Orange. As defenders of the Catholic faith, Philip and his governors were in deepening religious conflict with the northern provinces, where Calvinism had become firmly rooted. The violent suppression of Protestants was a major reason for Dutch dissatisfaction with their Spanish overlords and sparked the rebellion. Other antagonisms grew out of fundamental differences in economies and styles of governance, as well as increasing competition for trade. Power in Spain resided with the aristocracy, but in the Dutch cities, it was an urban, upper middle class of wealthy merchants, bankers, and traders that held sway. Independent-minded citizens in the traditionally autonomous Dutch provinces balked at attempts to centralize control at the court in Madrid. Produced during the Twelve-Year Truce, this map marks the separation between the seven northern provinces that would become the Dutch Republic and those in the south that would remain the Hapsburg Netherlands. Major cities of the north are profiled in vignettes to the left and those of the south to the right. The lion - Leo Belgicus - was a traditional heraldic device that would come to represent the Dutch Republic and the province of Holland. The government that resulted was largely decentralized and local, with the greatest power residing in the richest cities, particularly Amsterdam. The office was reserved for princes of the House of Orange, whose family had long held hereditary title to the territory. He depicted each of the more than seventy diplomats and witnesses, including himself looking out from the far left. Ter Borch was careful to detail the hall, its furnishings, and the different gestures of the ratifiers - the Dutch with two fingers raised, and the Spanish motioning to a Gospel book and cross.

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