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Inhibitors can act competitively antiviral yiyecekler purchase 250mg famciclovir with visa, noncompetitively hiv infection rates uk buy famciclovir 250mg without prescription, or allosterically; noncompetitive inhibitors are usually allosteric hiv infection fever buy famciclovir 250mg lowest price. The most common method by which cells regulate the enzymes in metabolic pathways is through feedback inhibition quimioterapia antiviral buy famciclovir 250mg with visa. During feedback inhibition, the products of a metabolic pathway serve as inhibitors (usually allosteric) of one or more of the enzymes (usually the first committed enzyme of the pathway) involved in the pathway that produces them. In each case, does enthalpy increase or decrease, and does entropy increase or decrease Energy is stored long-term in the bonds of and used short-term to perform work from a(n) molecule. Which type(s) of energy is/are associated with the pendulum in the following instances: i. Which of the following comparisons or contrasts between endergonic and exergonic reactions is false Endergonic reactions have a positive G and exergonic reactions have a negative G b. Both endergonic and exergonic reactions require a small amount of energy to overcome an activation barrier d. Endergonic reactions take place slowly and exergonic reactions take place quickly 8. Which of the following is the best way to judge the relative activation energies between two given chemical reactions Binds to an enzyme away from the active site and changes the conformation of the active site, increasing its affinity for substrate binding b. Binds to an enzyme away from the active site and changes the conformation of the active site, decreasing its affinity for the substrate d. Which of the following analogies best describe the induced-fit model of enzyme-substrate binding Name two different cellular functions that require energy that parallel human energy-requiring functions. Explain in your own words the difference between a spontaneous reaction and one that occurs instantaneously, and what causes this difference. Describe the position of the transition state on a vertical energy scale, from low to high, relative to the position of the reactants and products, for both endergonic and exergonic reactions. Imagine an elaborate ant farm with tunnels and passageways through the sand where ants live in a large community. In which of these two scenarios, before or after the earthquake, was the ant farm system in a state of higher or lower entropy This type of generating plant starts with underground thermal energy (heat) and transforms it into electrical energy that will be transported to homes and factories. Like a generating plant, plants and animals also must take in energy from the environment and convert it into a form that their cells can use. In the process of photosynthesis, plants and other photosynthetic producers take in energy in the form of light (solar energy) and convert it into chemical energy, glucose, which stores this energy in its chemical bonds. Then, a series of metabolic pathways, collectively called cellular respiration, extracts the energy from the bonds in glucose and converts it into a form that all living things can use-both producers, such as plants, and consumers, such as animals. An oxidation reaction strips an electron from an atom in a compound, and the addition of this electron to another compound is a reduction reaction. Because oxidation and reduction usually occur together, these pairs of reactions are called oxidation reduction reactions, or redox reactions. Electrons and Energy the removal of an electron from a molecule, oxidizing it, results in a decrease in potential energy in the oxidized compound. The electron (sometimes as part of a hydrogen atom), does not remain unbonded, however, in the cytoplasm of a cell. Rather, the electron is shifted to a second compound, reducing the second compound. The shift of an electron from one compound to another removes some potential energy from the first compound (the oxidized compound) and increases the potential energy of the second compound (the reduced compound). The transfer of electrons between molecules is important because most of the energy stored in atoms and used to fuel cell functions is in the form of high-energy electrons. The transfer of energy in the form of electrons allows the cell to transfer and use energy in an incremental fashion-in small packages rather than in a single, destructive burst. This chapter focuses on the extraction of energy from food; you will see that as you track the path of the transfers, you are tracking the path of electrons moving through metabolic pathways. Electron Carriers In living systems, a small class of compounds functions as electron shuttles: They bind and carry high-energy electrons between compounds in pathways. The principal electron carriers we will consider are derived from the B vitamin group and are derivatives of nucleotides. These compounds can be easily reduced (that is, they accept electrons) or oxidized (they lose electrons). Excess free energy would result in an increase of heat in the cell, which would result in excessive thermal motion that could damage and then destroy the cell. Rather, a cell must be able to handle that energy in a way that enables the cell to store energy safely and release it for use only as needed. The energy is used to do work by the cell, usually by the released phosphate binding to another molecule, activating it. In this way, the cell performs work, pumping ions against their electrochemical gradients. The negative charges on the phosphate group naturally repel each other, requiring energy to bond them together and releasing energy when these bonds are broken. In nearly every living thing on earth, the energy comes from the metabolism of glucose. Phosphorylation Recall that, in some chemical reactions, enzymes may bind to several substrates that react with each other on the enzyme, forming an intermediate complex. This very direct method of phosphorylation is called substrate-level phosphorylation. Symptoms of mitochondrial diseases can include muscle weakness, lack of coordination, stroke-like episodes, and loss of vision and hearing. Most affected people are diagnosed in childhood, although there are some adult-onset diseases. The educational preparation for this profession requires a college education, followed by medical school with a specialization in medical genetics. Medical geneticists can be board certified by the American Board of Medical Genetics and go on to become associated with professional organizations devoted to the study of mitochondrial diseases, such as the Mitochondrial Medicine Society and the Society for Inherited Metabolic Disease. Glycolysis is the first step in the breakdown of glucose to extract energy for cellular metabolism. One method is through secondary active transport in which the transport takes place against the glucose concentration gradient. Glycolysis begins with the six carbon ring-shaped structure of a single glucose molecule and ends with two molecules of a three-carbon sugar called pyruvate. The first part of the glycolysis pathway traps the glucose molecule in the cell and uses energy to modify it so that the six-carbon sugar molecule can be split evenly into the two three-carbon molecules. In the second step of glycolysis, an isomerase converts glucose-6-phosphate into one of its isomers, fructose-6-phosphate. An isomerase is an enzyme that catalyzes the conversion of a molecule into one of its isomers. The third step is the phosphorylation of fructose-6-phosphate, catalyzed by the enzyme phosphofructokinase. The newly added high-energy phosphates further destabilize fructose-1,6-bisphosphate. The fourth step in glycolysis employs an enzyme, aldolase, to cleave 1,6-bisphosphate into two three-carbon isomers: dihydroxyacetone-phosphate and glyceraldehyde-3-phosphate. In the fifth step, an isomerase transforms the dihydroxyacetone-phosphate into its isomer, glyceraldehyde-3-phosphate. The sugar is then phosphorylated by the addition of a second phosphate group, producing 1,3-bisphosphoglycerate.
Pernicious anaemia is caused by a deficiency of intrinsic factor hiv infection greece discount 250mg famciclovir with mastercard, which is required for the absorption of vitamin B12 in the intestinal tract how long after hiv infection will symptoms appear generic famciclovir 250mg fast delivery. Water-soluble vitamins are absorbed by special transport proteins hiv infection rates scotland discount famciclovir 250 mg visa, some require active transport stages of hiv infection symptoms proven 250 mg famciclovir, others facilitated diffusion in order to cross the gastric lumen. Vitamin B12 cannot be absorbed by itself; it has to be bound to intrinsic factor which is secreted into the lumen of the stomach by the parietal cells. Intrinsic factor binds to vitamin B12 to form a complex that is subsequently absorbed in the ileum. Signs and symptoms are: I I numbness and tingling in her legs and consequent difficulty walking and glossitis. Dose: by intramuscular injection, pernicious anaemia and other macrocytic anaemias without neurological involvement, initially 1 mg three times a week for two weeks then 1 mg every three months. Pernicious anaemia and other macrocytic anaemias with neurological involvement, initially 1 mg on alternate days until no further improvement, then 1 mg every two months. It should be explained: I I I I that she has low levels of vitamin B12, that she is not absorbing it properly from her intestine which is why it has to be administered as an injection, that her levels are very low so she is receiving the injection every other day until her symptoms improve, and that after she goes home she will need to have the same injection every three months to keep her vitamin B12 levels up. The porphyrias are a heterogeneous group of inherited disorders of haem biosynthesis. Acute intermittent porphyria is a severe form of porphyria which is due to a deficiency of porphobilinogen deaminase (hydroxymethylbilanesynthase). The most common presenting symptoms are acute abdominal pain, tachycardia and dark urine. Muscular weakness including a proximal myopathy of the arms is also common and can progress to quadraparesis, respiratory paralysis and arrest. Acute attacks are often triggered by exposure to drugs as well as by fasting, stress or infection. During an acute attack, a fresh urine sample which has been protected from light should be sent to a specialist laboratory to be tested for aminolaevulinic acid and porphobilinogen concentrations. If urinalysis confirms raised urinary excretion of aminolaevulinic acid and porphobilinogen, an analysis of faecal porphyrins can be used to identify the specific porphyria. In acute intermittent porphyria, raised porphobilinogen is present and the pink precipitate formed is insoluble in chloroform. However, between attacks urinary levels of aminolaevulinic acid and porphobilinogen may be normal. Blocks at various parts of the pathway result in different porphyrias (numbers in parentheses show inheritance). Glucose 10% should be infused intravenously for mild attacks and pending the administration of haem arginate. The summary of product characteristics for Normosang gives the following advice: I I Human hemin should be administered once daily in a dose of 3 mg/kg (up to a maximum of 250 mg or one ampoule). The relevant dose should be drawn up and diluted immediately prior to administration in 100 mL of 0. Sickle cell anaemia is the result of the homozygotic inheritance of the gene for haemoglobin S. The sickle haemoglobin gene shows autosomal recessive inheritance, thus both parents must be carriers of the gene in order for it to be inherited. The red blood cells of individuals with sickle cell anaemia are capable of carrying oxygen. However when they give up oxygen to the tissues the haemoglobin S molecules can crystallise, causing the deformation or sickle shape. The cells regain their original shape when they are reoxygenated but as this process is repeated the cells become irreversibly sickled. It is these sickled cells which produce the symptoms and complications seen in the disease as they occlude the blood vessels. The frequency of sickle cell disease is: I I 1 in 4 in West Africans 1 in 10 in Afro-Caribbeans. Haemoglobin S is also common in Cyprus, Greece, Italy, the Middle East and in populations who originate from these areas. A crisis occurs when the sickled cells clog together and occlude the blood vessels causing tissue ischaemia, pain and eventually organ damage. This may be precipitated by: hypoxia, sudden changes in temperature, physical activity (causing tissue anoxia), extreme fatigue, acidosis, infection, stress and anxiety, pregnancy or physical trauma. The majority of patients admitted to hospital during a 236 P ha r ma c y Ca s e St ud ie s sickle cell crisis also require strong opioid analgesia for pain management. This is usually given in the form of intravenous morphine either as an infusion or a patient-controlled analgesia system. The low haemoglobin and haematocrit are due to the excessive destruction of red cells that occurs in this haemolytic form of anaemia and the raised bilirubin is due to the rapid breakdown of the cells. Raised reticulocytes are seen in sickle cell anaemia as the body compensates for the increased cell breakdown by increasing production of red cells. Target cells are blood cells which resemble a shooting target and are found in patients with sickle cell anaemia as well as in a number of other conditions. Broad-spectrum antibiotics may be required to treat infection, 24% oxygen should be given at 4 L/min. Sickle cell patients are hyposplenic and receive prophylactic phenoxymethylpenicillin to help prevent pneumococcal infection. Sickle cell patients should also be advised to: I I I I ensure sufficient fluid intake keep warm maintain a healthy diet rich in folates; regular supplements of folic acid should be taken, especially during pregnancy. All women with sickle cell disease should be advised to take 5 mg folic acid daily take enough rest Nut rit io n an d blo o d cas e s tudie s I I 237 obtain prompt treatment of any infection avoid vascular stasis (not to wear tight clothing). Patients travelling abroad should be advised to: I I I I I I I obtain medical insurance increase fluid intake abstain from alcohol move around during travel, including flights take appropriate antimalarial prophylaxis when travelling to malarious areas (unlike sickle cell trait, sickle cell anaemia offers no protection against malaria) ensure a bacteriologically clean drinking water supply increase oral fluid intake above the standard 3 L/day for adults when they are in hot climates to compensate for the increased insensible losses. What are the prognosis and long-term complications for patients with sickle cell anaemia Hydroxycarbamide has been shown to restimulate fetal haemoglobin production, reducing organ damage and maintaining splenic function. Starting doses of 15 mg/kg per day may be increased by 5 mg/kg per day until crises are controlled or the dose is not tolerated. The Summary of Product Characteristics for hydroxycarbamide states: the complete status of the blood, including bone marrow examination, if indicated, as well as kidney function and liver function should be determined prior to , and repeatedly during, treatment. The determination of haemoglobin level, total leukocyte counts, and platelet counts should be performed at least once a week throughout the course of hydroxycarbamide therapy. Counts should be rechecked after 3 days and treatment resumed when they rise significantly towards normal. As every pharmacist assumes a duty of care to a patient when supplying a medicine, this means that if an adverse reaction is suffered, the supplying pharmacist may assume some liability along with the doctor who prescribed it. As a pharmacist you are expected to take the steps that a reasonably competent pharmacist would take to ensure that a supply of medication is made in the best interests of the patient. This is also necessary because the patient information leaflet which you are supplying with the medication will not include anything to suggest that the product can be used in sickle cell anaemia. Malnutrition can lead to poor wound-healing, post-operative complications and sepsis. These include standard feeds, fibre-enriched, high-energy and disease-specific feeds. These feeds provide protein, fat, carbohydrate, vitamins, minerals, trace elements and water. For example, Nepro is a suitable feed for a patient with renal disease who are on haemodialysis or continuous ambulatory peritoneal dialysis because it contains lower nitrogen content than standard feed. Cortisol secretion can rise from 30 mg/day to 50 mg/day following minor surgery and 150 mg/day following major surgery. However, an abrupt withdrawal after a prolonged period may lead to acute adrenal insufficiency, hypotension or shock.
Additional signs and symptoms that may indicate septicaemia include: I I I I I I severe pains and aches in the limbs and joints very cold hands and feet shivering rapid breathing red or purple spots that do not fade under pressure (non-blanching) diarrhoea and stomach cramps antiviral fruit cheap famciclovir 250mg on-line. Patients who are in an immunocompromised state hiv infection rates by gender order 250 mg famciclovir free shipping, have new-onset seizures how the hiv infection cycle works generic 250 mg famciclovir overnight delivery, moderate-to-severe impairment of consciousness or signs that are suspicious of space-occupying lesions (e hiv infection gp120 purchase famciclovir 250mg free shipping. Lymphocytes predominate in tuberculous, viral and cryptococcal meningitis, as well as early or partially treated bacterial meningitis. Polymorphonuclear leucocytes (immature and mature neutrophils) usually predominate in bacterial meningitis. There are a number of serogroups of Neisseria meningitidis including A, B, C and the less common W135 and Y. In 1999 a vaccine against Neisseria meningitidis group C (MenC) was introduced into the routine immunisation schedule and has now been extended to include everyone under 25 years of age. There is currently no vaccine available for the B serogroup, which is accountable for almost 90% of meningococcal meningitis in England and Wales and is the likely pathogen in this case. Haemophilus influenzae type B, a Gram-negative cocco-bacillus, accounts for approximately 40 cases per year. The incidence of meningitis caused by Haemophilus influenzae type B has fallen considerably following introduction of the Hib vaccine in 1992. Benzylpenicillin remains an option, however, for treatment of confirmed meningococcal infection. The drug of choice in penicillin/cephalosporinallergic patients is chloramphenicol. Addition of ampicillin or amoxicillin is recommended in patients over 55 years of age to cover Listeria. Randomised clinical trials have demonstrated a significant beneficial effect of dexamethasone on mortality and morbidity in pneumococcal meningitis, although no benefit was seen for patients with meningococcal meningitis. Steroid treatment is now recommended routinely with or before the first dose of antibiotics, beyond which time dexamethasone begins to lose its effectiveness (van de Beek et al. However, in practice it may be difficult to persuade the clinician to discontinue the initial therapy if the patient shows signs of improving. Rifampicin (600 mg orally twice daily for 2 days) should be administered to patients with meningococcal or H. Alternatively ciprofloxacin (500 mg orally stat) has proven efficacy for elimination of nasal carriage of meningococcus only. The goals of therapy are to rapidly control the infection and stabilise the patient to minimise morbidity and mortality. Early recognition of septicaemia and shock is essential to permit timely intervention, including securing the airway, administering high-flow oxygen and providing volume resuscitation. Identification of the pathogen is valuable for diagnostic and treatment purposes but administration of antibiotics should not be delayed until lumbar puncture in an acutely ill patient. Patients require close observation and monitoring of vital signs during treatment to ensure response to therapy. Patients with meningococcal meningitis should be isolated until after at least 48 hours of antibiotic therapy to prevent infection spreading to other patients. Spread of meningococcus between family members and close contacts is well recognised and chemoprophylaxis is recommended for close contacts as soon as possible, preferably within 24 hours. Rifampicin 600 mg every 12 hours for 2 days is licensed for chemoprophylaxis but ciprofloxacin 500 mg orally as a single dose (unlicensed) is also effective and often recommended for convenience. Close contacts are considered to be individuals who have slept in the same house as the patient at any time in the 7 days before onset of symptoms, and boyfriends or girlfriends of the patient. Only healthcare workers who have administered mouth-to-mouth resuscitation or had prolonged face-to-face contact with the patient require prophylaxis and this should be initiated after consultation with the hospital infection control team. Prophylaxis for other contacts from closed communities such as nurseries, schools or universities should be considered where two or more linked cases have occurred and this should be initiated by a public health doctor. Smoking is a risk factor for carriage of the meningococcal bacteria and the patient should be referred to a stop smoking service. Neuropathy of the sensory, motor and autonomic nerves, along with microvascular and macrovascular disease and impaired neutrophil function all contribute to the development of foot ulcers in diabetic patients. Features associated with infection include cellulitis, lymphangitis, purulent drainage, sinus tract formation, osteomyelitis, septic arthritis, abscess 130 P ha r ma c y Ca s e St ud ie s formation and sometimes the development of gangrene. Systemic manifestations may include fever, tachycardia, confusion and hypotension. Neuropathy and ischaemia may obscure or mimic these cardinal signs of inflammation in patients with diabetes and experts have suggested that antibiotics are indicated in patients with evidence of cellulitis, fever, leucocytosis, foulsmelling wounds or deep tissue infection (Cavanagh et al. Diabetic foot ulcers are often colonised by multiple organisms that may or may not be pathogenic, therefore a swab of the ulcer surface is unreliable for identifying causative organisms in infection. The most reliable sample for culture is a specimen of deep tissue obtained by aspiration or biopsy without contact with the ulcer surface or draining lesions. Mild ulcers are frequently infected by Staphylococcus aureus and Streptococcus pyogenes (group A strep). Other pathogens include Gram-negative rods and anaerobic bacteria (although anaerobes are seldom successfully cultured). Gram-positive pathogens include Staphylococcus aureus, Staphylococcus epidermidis (coagulasenegative staphylococcus), streptococci, enterococci, corynebacteria (diphtheroids) and clostridia. Gram-negative pathogens include Enterobacteriaceae (coliforms) such as Escherichia coli, Klebsiella, Proteus and Pseudomonas species. The need to be right this is an important principle which governs selection of empirical therapy. If a patient has a severe or life-threatening infection or if they are vulnerable (for example due to immunocompromise), the empirical therapy regimen must be broad spectrum enough to encompass the majority of likely pathogens. Bearing in mind that broad-spectrum anti-infectives are not necessarily the most effective agents against specific pathogens, the regimen can later be streamlined to narrower spectrum agents once the pathogen(s) and anti-infective sensitivities are known. Previous microbiology results may influence the choice of empirical treatment providing they are within a reasonable timeframe and representative of infection rather than colonisation. I n f e ctio n s cas e s tudie s 131 the risk of resistant organisms Whether an infection is community-acquired or healthcare-acquired is of fundamental importance in choosing empirical therapy. Community-acquired infections tend to be caused by pathogens that are typically sensitive to a wide range of first-line anti-infectives. Healthcare-acquired infections in contrast are often caused by multi-resistant pathogens by virtue of the characteristics of the healthcare environment, including intensive anti-infective use and close cohorting of vulnerable patients. Patients who have failed an anti-infective regimen at adequate dosing are also more likely to have resistant organisms. Contraindications and cautions the major groups of patients to whom contraindications may apply are patients with a history of hypersensitivity, pregnant or breastfeeding women, patients with organ dysfunction and the very old and very young. The regimen should ideally cover the organisms identified from his previous microbiology specimens, although these may be unreliable if taken from the surface of the ulcer. Intravenous administration affords greater penetration of the anti-infective to areas of poor perfusion. The patient is on gabapentin but this is for neuropathic pain rather than epilepsy so fluoroquinolones may be used. Alternatives to piperacillin-tazobactam for a penicillin-allergic patient with infected diabetic foot ulcer include: I I Clindamycin (to cover staphylococci, streptococci and anaerobes) plus gentamicin, ciprofloxacin, ceftazidime or aztreonam (to cover Gram-negative organisms including Pseudomonas). Serum creatinine indicates mild renal impairment which may influence choice and monitoring of antibiotic therapy. Leucocytosis is an indication of infection but this may be absent in patients with diabetes.
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However hiv infection in infants discount famciclovir 250 mg without a prescription, it must be emphasised that clients will have to maintain a long-life condition of abstention from illicit drugs an antiviral agent quizlet buy generic famciclovir 250 mg on line. Recent reviews of approved pharmacotherapies for the treatment of addictions demonstrate both a striking paucity of novel treatment agents and the modest efficacy of traditionally prescribed medication (Ghodse et al hiv infection rate circumcision cheap 250mg famciclovir visa. Recent population surveys indicate a growing popularity of alternative medicines among drug addicts seeking help or undergoing treatment hiv infection rate tanzania buy 250mg famciclovir amex. A number of reports indicate the extensive use of such medications in Asia (China, Thailand, Burma, Laos), designed to treat opium/heroin addicts. Similar herbal preparations are marketed in various European countries for the symptomatic treatment of alcohol- and nicotine-addicted people. The know-how for such herbal remedies usually comes from local systems of traditional medicine. Published yet insufficient evidence suggests that some of these remedies may have potential value and deserve further investigation and possible development into marketed products (Ghodse et al. Scenario A mother and her 6-year-old son present a post-dated prescription for penicillin V syrup 250 mg q. The mother is anxious to start antibiotic treatment straight away so that her son can get back to school and she can get back to work, but the prescription is not valid for 3 more days. Questions 1 2a 2b What are the causes of sore throat and how are they differentiated What is the oral bioavailability of penicillin V and what is the impact of administration with food Little P, Watson L, Morgan S and Williamson I (2002) Antibiotic prescribing and admissions with major suppurative complications of respiratory tract infections: a data linkage study. Scenario A 27-year-old woman presents a prescription for nitrofurantoin tablets 50 mg q. A friend has recommended she also purchase cranberry extract tablets and the patient would like your advice. Richards D, Toop L, Chambers S and Fletcher L (2005) Response to antibiotics of women with symptoms of urinary tract infection but negative dipstick urine test results: double blind randomised controlled trial. Blenkinsopp A, Paxton P and Blenkinsopp J (2005) Symptoms in the Pharmacy, 5th edn. Gillespie S and Bamford K (2003) Medical Microbiology and Infection at a Glance, 2nd edn. A portable chest X-ray taken in A&E shows consolidation in the right lower lobe of her lungs and she is admitted to hospital. She had a myocardial infarction 3 years previously and underwent coronary artery bypass grafting. On examination, her vital signs are recorded as follows: I I I I I heart rate 110 bpm temperature 38. The patient is diagnosed with community-acquired pneumonia and the treatment plan is as follows: I I I I I I continue oxygen salbutamol nebulised 2. The patient is assessed on the post-take ward round at 8am the following morning and is noted to have improved slightly with saturations currently at 95% on 2 L/min of oxygen. Blood culture results have been phoned to the ward reporting Gram-positive cocci in one culture bottle; further identification and antibiotic sensitivity testing are pending. What are the important pathogens and appropriate treatment options for severe community-acquired pneumonia Outline a pharmaceutical care plan for this patient with severe communityacquired pneumonia, including advice to the clinician. What are the prognosis and potential complications of community-acquired pneumonia On examination, the patient has a fever and he is unable to touch his chin to his knees. He takes occasional caffeine tablets prior to examinations but otherwise takes no regular medication. On arrival at A&E, his vital signs are recorded as follows: I I I I I heart rate 124 bpm temperature 39. The patient is diagnosed with suspected meningitis and the treatment plan is as follows: I I I I I I cefotaxime i. Questions 1 What are the signs and symptoms of meningitis and meningococcal septicaemia (bloodstream infection) What are the important pathogens and appropriate treatment options for bacterial meningitis, including alternatives in penicillin allergy Which antibiotic regimens achieve therapeutic concentrations in the cerebrospinal fluid and which should be avoided Outline a pharmaceutical care plan for this patient with meningitis, including advice to the clinician. He also has a 5-year history of ischaemic heart disease and underwent coronary artery bypass grafting one year ago. Dorsalis pedis and posterior tibial pulses were palpable, suggesting adequate arterial supply I n f e ctio n s cas e s tudie s 113 to the foot. His vital signs are recorded as follows: I I I I I heart rate 117 bpm temperature 38. A urine dipstick indicates a urinary glucose of >25 mmol/L but is negative for nitrites and leucocyte esterase. Planned investigations include: I I I I I I I I I I blood cultures wound cultures blood glucose creatinine urea and electrolytes and full blood count C-reactive protein liver function tests arterial blood gases X-ray magnetic resonance imaging if X-ray inconclusive. Questions 1a 1b What are the signs and symptoms of foot infection in diabetic patients and when are antibiotics indicated Comment on the choice of anti-infective regimen in this case and discuss alternative regimens. Outline a pharmaceutical care plan for this patient with infected diabetic foot ulcer including advice to the clinician. What are the prognosis and potential long-term complications of diabetic foot ulcers What are the relevant social pharmacy issues in this case, including lifestyle issues Sore throat is most often caused by viral infection, often associated with cough and cold symptoms or flu-like illness. Although group A strep can be isolated from throat swabs of up to 30% of patients with a sore throat, asymptomatic carriage of the organism in the population is estimated at between 6% and 40%. Sore throat is a self-limiting condition and symptoms will resolve within 3 days in 40% of patients and within one week in 85% of patients, regardless of whether the infection is caused by Streptococcus. Patients with group A strep throat infection are at risk of complications (<5% of cases) including: otitis media, sinusitis, peritonsillar abscess (quinsy), cervical adenitis (lymph node inflammation), and scarlet fever. In developing countries, other complications of group A strep infection such as rheumatic fever and glomerulonephritis remain problematic (Clinical Knowledge Summaries, 2008). A systematic review found that antibiotics reduced the proportion of people with symptoms of sore throat at 3 days (47%) compared with placebo (66%) (Del Mar et al. This represents a shortening in duration of illness by an 116 P ha r ma c y Ca s e St ud ie s average of 1 day. Antibiotics were found to be more effective in patients with throat swabs positive for Streptococcus. Antibiotics also reduce the risk of developing complications but because the absolute risk of complications is low, a considerable number of patients need to be treated with antibiotics to prevent one complication (200 patients in the case of otitis media for example). A 10day treatment course is recommended for reliable eradication of group A strep (Joint Formulary Committee, 2008).