Cardizem

Pedro R.Moreno, MD

• Director, Interventional Cardiology Research
• Mount Sinai Hospital
• Associate Professor
• Department of Medicine
• Mount Sinai School of Medicine
• New York, New York

Patients should be advised on the importance of adhering to their prescribed regimen for the full duration of the course to ensure the most effective treatment blood pressure medication used for opiate withdrawal cheap 180 mg cardizem free shipping. Treatment failure more than 14 days after completion or commencement of initial treatment can be retreated with the same artemisinin-based combination (if mefloquine was included in the initial treatment blood pressure danger zone chart buy cardizem 180mg cheap, treat as a failure within 14 days arrhythmia reference guide buy cardizem 180mg lowest price, as below) blood pressure medication that does not cause joint pain trusted 120 mg cardizem. If treatment failure occurs within 14 days of initial treatment blood pressure medication effect on heart rate order discount cardizem online, one of the following regimens may be suitable: a different artemisinin-based combination known to be effective in the region; artesunate (2 mg/kg once daily) in combination with either doxycycline (3 pulse pressure 80 order genuine cardizem line. For travellers returning to non-endemic countries, one of the following regimens may be suitable (note that if malaria chemoprophylaxis was taken, a different drug should be used for treatment): artemether + lumefantrine (see under Artemether + lumefantrine for dose); quinine (10 mg/kg every 8 hours) in combination with either doxycycline (3. Pregnancy and breastfeeding In the first trimester of pregnancy, quinine in combination with clindamycin for 7 days is the treatment of choice; this combination can be used throughout pregnancy. In the second and third trimesters, an artemisinin-based combination therapy or artesunate and clindamycin can be given for 7 days. Breastfeeding women should receive standard antimalarial treatment (including artemisinin-based combination therapy), but not regimens that include tetracyclines or dapsone. Anti-infective medicines Treatment of severe cases Treatment of severe falciparum malaria requires either parenteral artemether or artesunate, or parenteral quinine. Intravenous artesunate is the drug of choice in low to moderate transmission areas, or outside malaria endemic areas. Parenteral antimalarials are also used to initiate treatment in patients unable to take oral treatment. The risk of death in severe malaria is greatest in the first 24 hours; it is therefore recommended that the first dose of parenteral treatment be given before referral to a health facility. Combination antimalarial treatment should start as soon as patients are able to take oral medication. Fever and vomiting associated with acute malaria should be treated with an antipyretic (for example, paracetamol, section 2. Alternatives in chloroquine-resistant areas include amodiaquine or an artemisinin derivative or mefloquine, in all cases followed by primaquine for radical cure. Anti-infective medicines Malaria epidemics In malaria epidemics, artemisinin-based combinations are the recommended treatment (except in countries in Central America and in the Island form of Hispaniola, where chloroquine and sulfadoxine + pyrimethamine still have high efficacy against P. When artemisinin-based combinations are not available during epidemics, the most effective alternative should be used until they become available. Pregnancy For severe malaria in pregnancy during an epidemic, intravenous artesunate is the treatment of choice; the preferred alternative is intramuscular artemether. Chloroquine, a rapidly-acting schizontocide, is well tolerated, safe, and inexpensive. However, widespread resistance has limited its value in the treatment of falciparum malaria. Amodiaquine is used in combination with other antimalarials for the treatment of uncomplicated P. Hepatitis and blood disorders were reported when amodiaquine was used for prophylaxis of malaria; patients should be told how to recognize the symptoms of these conditions and advised to seek medical help if they occur. The combination of sulfadoxine + pyrimethamine is also used in combination with other antimalarials for the treatment of uncomplicated P. Resistance to sulfadoxine + pyrimethamine is now widespread, particularly in south-east Asia and South America, to a lesser extent, in east and central Africa. Because sulfonamides are associated with haemolysis and methaemoglobinaemia in neonates, quinine is preferred for chloroquine-resistant malaria during pregnancy (see below). Mefloquine resistance is common in Cambodia, Myanmar, and Thailand, and has occurred in the Amazon region of South America and occasionally in Africa. A parenteral preparation is not available and thus it is suitable only for patients who can take drugs by mouth. It is generally well tolerated but some adverse effects have been reported (see Mefloquine below). Quinine, given orally, is used in combination with clindamycin or doxycycline to treat relapses of P. Anti-infective medicines quinine was, until recently, rare, but the prevalence of resistant strains is now increasing in parts of south-east Asia and South America. Doxycycline, which is an effective oral blood schizontocide, is given with quinine except in pregnant women and children under 8 years. Preparations of artemisinin or its derivatives (artemether or artesunate) are used in combination with other antimalarial drugs for the treatment of falciparum malaria. When given alone or in combination with other rapidly eliminated antimalarials a 7-day course is required, but when given in combination with slowly eliminated antimalarials, a 3-day course is effective. They should not be used in the first trimester of pregnancy, except where no other effective antimalarial medicine is available. Parenteral artemether or artesunate are effective alternatives to quinine for the treatment of severe falciparum malaria and are preferred in areas with decreased efficacy of quinine. A fixed-dose oral formulation of artemether + lumefantrine is available for the treatment of uncomplicated falciparum malaria; the combination is not for use in the first trimester of pregnancy. Oral multidrug therapy in blister packs is available for artesunate and amodiaquine, artesunate and mefloquine, and artesunate and sulfadoxine + pyrimethamine. Patients and their carers should be told how to recognize the signs of blood disorders and advised to seek medical attention as soon as possible if symptoms such as fever, sore throat, rash, mouth ulcers, purpura, bruising, or bleeding develop. They should also be told how to recognize signs of hepatitis and advised to seek medical attention if symptoms such as anorexia, abnormal weight loss, asthenia, abdominal pains, fever, nausea, or vomiting develop. Anti-infective medicines Adverse effects: blood disorders including leukopenia and agranulocytosis; hepatitis; gastrointestinal disturbances, visual disturbances (retinopathy associated with long-term, high-dose therapy); rarely rash, pruritus, skin pigmentation, and neuromyopathy. Since small volumes are required for children, a 1-ml syringe should be used to ensure correct dosage. Adverse effects: headache, nausea, vomiting, abdominal pain, diarrhoea; dizziness, tinnitus, neutropenia, elevated liver enzyme values; cardiotoxicity (after high doses); neurotoxicity (in animal studies). Anti-infective medicines impairment (Appendix 4); hepatic impairment (Appendix 5); interactions: Appendix 1. Take tablets with food; repeat dose if vomiting occurs within 1 hour of administration. Adverse effects: abdominal pain, anorexia, diarrhoea, nausea and vomiting; headache, dizziness, sleep disorders; palpitation; arthralgia, myalgia; cough; asthenia, fatigue; pruritus, rash. Artesunate Injection: ampoules, containing 60 mg anhydrous artesunic acid with a separate ampoule of 5% sodium bicarbonate solution. Dizziness may impair ability to perform skilled tasks, for example, operating machinery or driving. Artesunic acid should be dissolved in sodium bicarbonate 5% solution for injection (to form sodium artesunate), and then further diluted in 5 ml of glucose 5% solution for injection before administration; solutions should be freshly prepared prior to administration. Oral chloroquine should be taken after meals to minimize nausea and vomiting; if part or all a dose is vomited, the same amount must be readministered immediately. Anti-infective medicines Adverse effects: headache, gastrointestinal disturbances; also convulsions; visual disturbances (retinopathy associated with long-term, high-dose therapy or inappropriate self-medication); depigmentation or loss of hair; rash; pruritus (may become intolerable); bone marrow suppression; hypersensitivity reactions including urticaria and angioedema; atrioventricular block (may be result of inappropriate self-medication); porphyria and psoriasis in susceptible individuals. Precautions: avoid exposure to sunlight or sunlamps (risk of photosensitivity reactions, see Adverse effects); renal impairment (Appendix 4); hepatic impairment (Appendix 5); breastfeeding (Appendix 3); interactions: Appendix 1. Adverse effects: gastrointestinal disturbances; anorexia; flushing, tinnitus; photosensitivity reactions; hypersensitivity reactions; headache and visual disturbances; hepatotoxicity, blood disorders, pancreatitis and antibiotic associated colitis reported; staining of growing teeth and occasional dental hypoplasia. Precautions: pregnancy (use only if other antimalarials are inappropriate; Appendix 2); avoid pregnancy during, and for 3 months after, use; cardiac conduction disorders; breastfeeding (Appendix 3); not recommended for infants under 3 months (5 kg); interactions: Appendix 1. Adverse effects: nausea, vomiting, diarrhoea, abdominal pain, anorexia, headache, dizziness (can be severe), loss of balance, somnolence, insomnia and abnormal dreams; neurological and psychiatric disturbances including sensory and motor neuropathies, tremor, ataxia, visual disturbances, tinnitus, and vestibular disorders; convulsions, anxiety, depression, suicidal ideation, confusion, hallucinations, panic attacks, emotional instability, aggression, agitation and psychoses; circulatory disorders, tachycardia, bradycardia, cardiac conduction disorders; muscle weakness, myalgia, arthralgia; rash, urticaria, pruritus, alopecia; disturbances in liver function tests, leukopenia, leucocytosis, thrombocytopenia; rarely Stevens-Johnson syndrome, atrioventricular block, and encephalopathy. Anti-infective medicines Contraindications: pregnancy (treatment with primaquine should be delayed until after delivery; Appendix 2) and breastfeeding (Appendix 3); conditions that predispose to granulocytopenia (including active rheumatoid arthritis and lupus erythematosus). Anti-infective medicines the 300 mg quinine bisulfate tablets provide less quinine than the 300 mg quinine sulfate or dihydrochloride tablets. If all or part of a dose is vomited within one hour of administration, the same amount must be readministered immediately. Adverse effects: cinchonism (tinnitus, headache, blurred vision, temporary blindness, altered auditory acuity, nausea, diarrhoea, hot and flushed skin, rash, and confusion); hypersensitivity reactions including angioedema; rarely haemorrhage and asthma; hypoglycaemia (especially after parenteral administration); renal damage (culminating in acute renal failure and anuria); blood disorders; cardiovascular, gastrointestinal, and central nervous system effects; very toxic in overdosage (immediate medical attention required). Uses: treatment of falciparum malaria in combination with other antimalarials (see also introductory note above). Contraindications: hypersensitivity to sulfonamides or pyrimethamine; severe hepatic or renal impairment (except where no alternative treatments available). Adverse effects: rash, pruritus, slight hair loss; rarely erythema multiforme (Stevens-Johnson syndrome) and toxic epidermal necrolysis; gastrointestinal disturbances including nausea, vomiting, and stomatitis; rarely hepatitis, leukopenia, thrombocytopenia, megaloblastic anaemia, and purpura (withdraw treatment); fatigue, headache, fever, and polyneuritis also reported; pulmonary infiltrates such as eosinophilic or allergic alveolitis resulting in cough or shortness of breath (withdraw treatment). Avoidance of mosquito bites using insect repellents, mosquito nets (preferably impregnated with an insecticide), and door and window screens is an important preventative strategy. When possible, pregnant women should avoid travel to malarious areas; when travel is unavoidable effective prophylaxis is essential. Chloroquine, which is usually well-tolerated at the required dosage for prophylaxis, is preferred where P. The combination of proguanil with chloroquine may overcome mild chloroquine resistance (see below). Chloroquine is best started 1 week before exposure, and continued for at least 4 weeks after the last exposure in non-immune individuals. Mefloquine may be used for prophylaxis in areas of high risk or where multidrug resistance has been reported. Mefloquine can be used for prophylaxis during the second and third trimesters; it should be used in early pregnancy only if alternative drugs are either not available or unlikely to be effective and when it is impracticable for the woman to leave the endemic area. Anti-infective medicines Doxycycline is an alternative to mefloquine in areas of high risk or where multidrug resistance has been reported; it should not be given during pregnancy. Proguanil, a predominantly tissue schizontocide with little blood schizontocidal activity, is active against the pre-erythrocytic intrahepatic forms of the malaria-causing parasites, particularly P. Proguanil is used for prophylaxis with chloroquine in areas where there is resistance to chloroquine but a low risk of infection because it may give some protection against P. Proguanil and chloroquine can also be used prophylactically in areas of high risk or multi-drug resistance as a third choice where mefloquine or doxycycline are not appropriate. There is no evidence that proguanil is harmful in prophylactic doses during pregnancy. Because of the vulnerability of pregnant women to falciparum malaria, it should be used at full prophylactic dosage wherever the disease is prevalent and likely to be responsive to proguanil, if chloroquine is not available. Proguanil can be given with chloroquine if chloroquine alone is unlikely to be effective. Oral chloroquine should be taken after meals to minimize nausea and vomiting; if part or all of a dose is vomited, the same amount must be readministered immediately. Inform travellers about the importance of taking measures to avoid mosquito bites, of taking prophylaxis regularly, and of the need to visit a doctor immediately if they fall ill within 1 year, and especially within 3 months, of their return from a malaria-endemic area. Avoid rapid parenteral administration (risk of toxic plasma concentrations and fatal cardiovascular collapse). Adverse effects: headache, gastrointestinal disturbances; also convulsions; visual disturbances (retinopathy associated with long-term, high-dose therapy or inappropriate self-medication); depigmentation or loss of hair; rash; pruritus (may become intolerable); bone marrow suppression; hypersensitivity reactions including urticaria and angioedema; atrioventricular block (may be result of inappropriate self-medication); porphyria and psoriasis in susceptible individuals. Contraindications: pregnancy (Appendix 2); children under 8 years; porphyria; systemic lupus erythematosus. Precautions: avoid exposure to sunlight or sunlamps (risk of photosensitivity reactions; see Adverse effects); renal impairment (Appendix 4); hepatic impairment (Appendix 5); breastfeeding (Appendix 3); interactions: Appendix 1. Adverse effects: gastrointestinal disturbances; anorexia; flushing, tinnitus; photosensitivity reactions; hypersensitivity reactions; headache and visual disturbances; hepatotoxicity, blood disorders, pancreatitis, and antibiotic associated colitis reported; staining of growing teeth and occasional dental hypoplasia. Contraindications: history of neuropsychiatric disorders including depression or convulsions; hypersensitivity to quinine. Precautions: early pregnancy (use only if other antimalarials are inappropriate; Appendix 2), avoid pregnancy during and for 3 months after use; cardiac conduction disorders; avoid for prophylaxis in severe hepatic impairment (Appendix 5) and in epilepsy; breastfeeding (Appendix 3); not recommended for infants under 3 months (5 kg); interactions: Appendix 1. Patients should be informed about the adverse effects associated with mefloquine and, if they occur, advised to seek medical advice on alternative antimalarials. Dizziness may impair ability to perform skilled tasks, for example, operating machinery or driving; effects may persist for up to 3 weeks. Adverse effects: nausea, vomiting, diarrhoea, abdominal pain, anorexia, headache, dizziness (can be severe), loss of balance, somnolence, insomnia and abnormal dreams; neurological and psychiatric disturbances including sensory and motor neuropathies, tremor, ataxia, visual disturbances, tinnitus, and vestibular disorders; convulsions, anxiety, depression, suicidal ideation, confusion, hallucinations, panic attacks, emotional instability, aggression, agitation and psychoses; circulatory disorders, tachycardia, bradycardia, cardiac conduction disorders; muscle weakness, myalgia, arthralgia; rash, urticaria, pruritus, alopecia; disturbances in liver function tests, leukopenia, leucocytosis, thrombocytopenia; rarely, Stevens-Johnson syndrome, atrioventricular block, and encephalopathy. Contraindications: use in areas of known resistance to either proguanil or pyrimethamine. Precautions: renal impairment (Appendix 4); pregnancy (folate supplements required, Appendix 2) and breastfeeding (Appendix 3); interactions: Appendix 1. Inform travellers about the importance of taking measures to avoid mosquito bites, of taking prophylaxis regularly, and of the need to visit a doctor immediately if they fall ill within 1 year, and especially within 3 months, of their return from a malaria area. Adverse effects: mild gastric intolerance, diarrhoea, constipation; occasional mouth ulcers and stomatitis; rarely skin reactions and hair loss, cholestasis, vasculitis, and hypersensitivity reactions such as urticaria and angioedema. Pentamidine is used in patients unresponsive to , or intolerant of, sulfamethoxazole + trimethoprim. Toxoplasmosis Toxoplasmosis is caused by infection with the protozoan parasite, Toxoplasma gondii. Congenital transmission may occur if there is a primary infection in early pregnancy or if the mother is immunodeficient. Such cases often result in spontaneous abortion, fetal death, or severe congenital disease. Ocular toxoplasmosis causes chorioretinitis and is often the result of a childhood infection that only becomes apparent in adulthood. Anti-infective medicines the treatment of choice for toxoplasmosis is a combination of pyrimethamine and sulfadiazine; a folate supplement is also given to counteract the megaloblastic anaemia associated with these drugs (see section 10. Uses: Pneumocystis carinii (Pneumocystis jiroveci) pneumonia unresponsive to sulfamethoxazole + trimethoprim; leishmaniasis (section 6. Contraindications: severe renal impairment Precautions: risk of severe hypotension following administration (establish baseline blood pressure and administer with patient lying down); monitor blood pressure during administration and treatment period; hypotension or hypertension; hypoglycaemia or hyperglycaemia; hepatic impairment (Appendix 5); renal impairment (Appendix 4); leukopenia, thrombocytopenia, anaemia; immunodeficiency (interrupt or discontinue if acute deterioration in bone marrow, renal, or pancreatic function); in potentially fatal P.

Diseases

• Mastroiacovo De Rosa Satta syndrome
• Neuroectodermal tumors primitive
• Carnosinase deficiency
• Hydantoin antenatal infection
• Necrotizing fasciitis
• Impossible syndrome
• Mucolipidosis type 4
• Hypodontia of incisors and premolars
• Chromosome 1, monosomy 1q4

Access to medical care is During early to mid puberty this junction slowly invaginates critical to this objective heart attack i was made for loving you best buy cardizem. Teenagers should Primary prevention focuses largely on education and risk be asked open-ended questions about their sexual experi reduction techniques arteria3d unity generic cardizem 60 mg with visa. If the adolescent has ever ence of hepatitis B surface antigen indicates either the carrier engaged in sexual activity blood pressure quizzes order cardizem in united states online, the provider needs to determine state or active infection prehypertension pdf discount 60 mg cardizem with amex. Presence of only hepatitis B surface what kind of sexual activity (mutual masturbation or oral prehypertension exercise generic 180mg cardizem with visa, antibody identifies vaccinated individuals blood pressure medication common cardizem 60mg fast delivery, whereas presence of anal, or vaginal sex); whether it has been heterosexual, hepatitis B core antibody and hepatitis B surface antibody homosexual, or both; whether birth control and condoms identifies individuals with past infection (see Chapter 21). Screening and A routine laboratory screening process is warranted if the diagnosis guidelines for primary care pediatricians. Routine chlamyd For males, the most common symptoms are dysuria and ial testing should be considered for all adolescent males and, penile discharge resulting from urethral inflammation. Less in particular, males who have sex with men, have new or common symptoms are scrotal pain, hematuria, proctitis, and multiple sex partners, or are in correctional facilities. Signs include epididymitis, orchi Initial screening for urethritis in males begins with a tis, and urethral discharge. Vaginal itching and irregular hours) should be sent for Chlamydia and N gonorrhoeae menses or spotting are also common. With signs or symptoms, a urethral swab should the genital region and dyspareunia may be present. Screening asymptomatic females has become more com plicated because a variety of approaches are available. C trachomatis is an For both sexes if high-risk behavior is present (three or obligate intracellular bacterium that replicates within the more partners in the last 6 months or more than two partners cytoplasm of host cells. Destruction of Chlamydia-infected per year for several years), then screening for hepatitis B cells is mediated by host immune responses. Proctitis or proctocolitis from Chlamydia may occur in for the 2006 Centers for Disease Control and Prevention sexu adolescents practicing receptive anal intercourse. Among females in 2005, 15 ously used for screening asymptomatic, sexually active to 19-year-olds and 20 to 24-year-olds had the highest rates males. Urethritis and pyuria may also be as schools and correctional facilities, or among the military present. Approximately 15% of females with endocervi Epididymitis is a complication in males. Reiter syndrome cal gonorrhea have signs of involvement of the upper genital occurs in association with chlamydial urethritis. Compared with Chlamydia infection, pelvic inflamma be suspected in male patients who are sexually active and tion with gonorrhea often has a shorter duration, but an present with low back pain (sacroiliitis), arthritis (polyartic increased intensity of symptoms, and is more often associ ular), characteristic mucocutaneous lesions, and conjunc ated with fever. Adequate, well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester of pregnancy. Adequate, well-controlled studies in pregnant women have not shown increased risk of fetal abnormalities despite adverse findings in animals, in the absence of adequate human studies, animal studies show no fetal risk. Adequate, well-controlled human studies are lacking, and animal studies have shown a risk to the fetus or are lacking as well. There is a chance of fetal harm if the drug is administered during pregnancy; but the potential benefits outweigh the potential risk. Studies in humans, or investigational or postmarketing data, have demonstrated fetal risk. Nevertheless, potential benefits from the use of the drug may outweigh the potential risk. For example, the drug may be acceptable if needed in a life threatening situation or serious disease for which safer drugs cannot be used or are ineffective. Studies in animals or humans, or despite adverse findings in animals, or investigational or postmarketing reports have demonstrated positive evidence of fetal abnormalities or risk that clearly outweighs any possible benefit to the patient. Alternative therapies during pregnancy which include erythromycin, azithromycin, and amoxicillin are not as effective, but are clinically useful if the recommended regimens cannot be used due to allergy or pregnancy. Some evidence indicates that cefpodoxime (400 mg) and cefuroxime axetil (1 g) might be oral alternatives. If culture for gonorrhea is positive, treatment should be based on results of antimicrobial susceptibility. If males and females can develop gonococcal proctitis and retesting is indicated it should be delayed for 1 month after pharyngitis after appropriate exposure. Pharyngeal infection requires gonorrhea due to high levels of quinolone resistance in all more intensive therapy. Failure of initial treatment reside in the vagina, thereby negating the value of the Gram should prompt reevaluation of the patient and consideration stain in a female. If proctitis is present, appropriate cultures should be obtained and treatment for both gonorrhea and Chlamydia infection given. Hematoge Cervicitis is caused by C trachomatis or N gonorrhoeae nous spread most commonly causes arthritis and dermatitis. Skin lesions are typi vaginosis has emerged as a new condition associated with cally tender, with hemorrhagic or necrotic pustules or bullae cervicitis. Disseminated disease occurs more frequently in females than Clinical Findings in males. Gonorrhea is complicated occasionally by peri hepatitis and very rarely by endocarditis or meningitis. Cervicitis is often asymptomatic, but many females have an abnormal vaginal discharge or postcoital bleeding. Purulent Treatment or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen is Historically, patients diagnosed with gonorrhea were treated characteristic of cervicitis. Symptoms and Signs trachomatis, N gonorrhoeae, and trichomoniasis by using the most sensitive and specific tests available at the site. No single historical, clinical, or Complications laboratory finding has both high sensitivity and specificity for the diagnosis. Typical patients have lower abdominal pain, nausea, sessment of the initial diagnosis. Cervical motion tenderness, uter ectropion can contribute to persistent cervicitis. Treatment Tubo-ovarian abscesses can often be detected by careful physi Empiric treatment for both gonorrhea and chlamydial infec cal examination (feeling a mass or fullness in the adnexa). Laboratory Findings questionable or the patient is part of a high-risk population. Patients should be instructed to abstain from sexual rhoeae or C trachomatis is supportive, although 25% of the intercourse until they and their sex partners are cured and time neither of these bacteria is detected. It is the most common gynecologic disorder necessitating hospitalization for female patients of repro Minimum criteria ductive age in the United States. The women and others at risk for sexually transmitted infections if incidence is highest in the teen population. Many adolescents with subacute or asympto secretions matic disease are never identified. Causative agents or Chlamydia trachomatis include N gonorrhoeae, Chlamydia, anaerobic bacteria that Definitive criteria (selected cases) reside in the vagina, and genital mycoplasmas. Recent menses and bacterial vaginosis have Sexually transmitted diseases treatment guidelines 2006. Transvaginal ultrasound is more sensitive therapy to ensure the resolution of symptoms. Duration of symptoms appears to be the the most common bacterial causes of urethritis in males are largest determinant of infertility. This results in right upper quadrant dial urethritis can be attributed both to M genitalium and U pain and elevation of liver function tests. Mechanical manipulation or Treatment contact with irritants can also cause transient urethritis. It is important to recognize that urethritis in both males and the objective of treatment is both to achieve a clinical cure females is frequently asymptomatic. Recent data have demon Females often present with symptoms of a urinary tract strated no differences in short-term and long-term clinical infection from which no enteric bacterial pathogens are and microbiologic response rates between parenteral and isolated, and often have urethritis caused by the organisms oral therapy. Severe systemic symptoms and toxicity, signs of peri tonitis, inability to take fluids, pregnancy, nonresponse or A. Symptoms and Signs intolerance of oral antimicrobial therapy, and tubo-ovarian If symptomatic, males present most commonly with a clear abscess support hospitalization. In addition, if the health or purulent discharge from the urethra, dysuria, or urethral care provider believes that the patient will not adhere to pruritus. Surgical drainage Most infections caused by C trachomatis and T vaginalis are may be required to ensure adequate treatment of tubo asymptomatic, while 70% of males with M genitalium and ovarian abscesses. All treatment regimens should be effective against N gonorrhoeae and C trachomatis because negative endocervi In a symptomatic male a positive leukocyte esterase test on cal screening tests do not rule out upper reproductive tract first-void urine, or microscopic examination of first-void infection with these organisms. Laboratory evaluation is iden vaginalis by a wet preparation of either urethral discharge or tical to evaluation for suspected urethritis. Complications Complications Complications include recurrent or persistent urethritis, epididymitis, prostatitis, or Reiter syndrome. As an adjunct to therapy, bed rest, scrotal elevation, and with objective evidence of urethritis should receive empiric analgesics are recommended until fever and local inflamma treatment for gonorrhea and Chlamydia infection, ideally tion subside. Sex partners should be evaluated trichomoniasis should be ruled out, and nongonococcal, and treated as well for gonorrhea and Chlamydia infections. Proctitis occurs predominantly among persons who partici Sexual partners should either be evaluated or treated as well pate in anal intercourse. Common sexually transmitted pathogens causing proctitis Falk L et al: Symptomatic urethritis is more prevalent in men infected with Mycoplasma genitalium than with Chlamydia tracho or proctocolitis include C trachomatis (including lym matis. Acute proctitis among persons who have among males who are the insertive partners during anal inter recently practiced receptive anal intercourse is most often course and in males who have urinary tract abnormalities. The symptoms of proctocolitis combine those of proctitis, plus diarrhea or abdominal cramps (or both), because of inflamed colonic mucosa more than 12 cm Clinical Findings from the anus. The spermatic cord may also be tender and Evaluation may include anoscopy or sigmoidoscopy, stool swollen. Often these symptoms are accompanied by asymp examination, culture for appropriate organisms, and serology tomatic urethritis. Reinfection may be difficult to adverse outcomes such as premature labor, preterm delivery, distinguish from treatment failure. Pregnant patients should receive causes of discharge include T vaginalis, C trachomatis, N treatment to prevent adverse outcomes of pregnancy. Candidiasis ment for patients who do not complain of vaginal discharge is a yeast infection that produces vaginal discharge, but is not or itching, but who demonstrate bacterial vaginosis on usually sexually transmitted. Discharge may be white, gray, or to have a low threshold for treating asymptomatic bacterial yellow. Follow-up visits are unnecessary if symptoms neous, and not associated with itching, irritation, or foul resolve. Mechanical, chemical, allergic, or other noninfectious Follow-up examination 1 month after treatment for high irritants of the vagina may cause vaginal discharge. Trichomoniasis the most common symptom is a heavy, malodorous, homo General Considerations geneous gray-white vaginal discharge. Laboratory Findings Clinical Findings Bacterial vaginosis is most often diagnosed by the use of A. Diagnosis requires three out of four criteria, although many female patients who fulfill these Mixing the discharge with normal saline facilitates detection criteria have no discharge or other symptoms. The infection may be detected by the Complications pathologist when reviewing the Pap smear. Half of males with fluconazole as a one-time dose is an effective oral medication. Trichomonas infection in Patients should be instructed to return for follow-up visits females has been associated with adverse pregnancy outcomes.

Avail able in packages that contain 1- blood pressure machine cheap cardizem line, 2- hypertension leads to buy cheap cardizem 120 mg on line, or 5-mg vials with a specifed volume of histidine diluent arteria pancreatica magna buy cardizem line. Reconstitute powder with provided diluent arrhythmia electrolyte imbalance generic 60mg cardizem fast delivery, aiming the needle (20 to 26-gauge needle recommended) and the stream of diluent against the side of the vial blood pressure 220 generic cardizem 60mg with mastercard. Promotes hemostasis by activating the extrinsic pathway of the coagulation cascade blood pressure 60 0 generic cardizem 120 mg on line. This leads to the formation of a hemostatic plug by converting fbrinogen to fbrin. Arterial and venous thrombotic and thromboembolic events have been reported during post-marketing surveillance. Studies have shown an increased risk of arterial thrombo embolic adverse events. Monitor: Evaluation of hemostasis should be used to determine the effectiveness of ther apy and to provide a basis for modifcation of the treatment schedule; coagulation param eters do not necessarily correlate with or predict the effectiveness of therapy. Patient Education: Discuss benefts versus risk of therapy and signs of hypersensitivity reactions including hives, urticaria, chest tightness, wheezing, hypotension, and anaphy laxis. Elderly: Numbers in clinical studies insuffcient to determine if the elderly respond differ ently than younger subjects. The most common side effects are arthralgia, edema, fever, headache, hemorrhage, hypertension, hypotension, injection site reaction, nausea, pain, rash, and vomiting. Most serious adverse reactions are thrombotic events; however, the risk in patients with hemophilia and inhibitors is considered to be low. Fatal and non-fatal thrombotic events have been reported when used for both labeled and off-label indications. Post-Marketing: High d-dimer levels and consumptive coagulopathy, thromboembolic events including myocardial ischemia and/or infarction, cerebral ischemia and/or infarc tion, thrombophlebitis, arterial thrombosis, deep vein thrombosis and related pulmonary embolism, and isolated cases of hypersensitivity reactions including anaphylaxis have occurred following use in both labeled and unlabeled indications. Follow with 20 mg administered as a continuous infusion evenly distributed over 24 hours. May be administered for an additional 1 to 3 days as a continuous infusion of 20 mg/day. The total duration of infu sion (after the loading dose) should not exceed 4 days. Follow with a continuous infusion of 10 mg over 24 hours for 2 days to a maximum of 4 days. If sodium is not rising at the desired rate, the conivaptan dose may be titrated up to 20 mg/day. Should not be combined with any other product in the same intrave nous line or bag. Conivaptan blocks V2 receptors in the renal collecting ducts, resulting in aquaresis (excretion of free water). This is generally accompanied by increased net fuid loss, increased urine output, and decreased urine osmolality. Raising serum sodium with conivaptan has not been shown to provide a symptomatic beneft. Should be used to raise sodium in these patients only after other treatment options have been considered. Although not observed in clinical trials, osmotic demyelination syndrome (brain cell dehydration) has been reported following rapid correction of low serum sodium concen tration. Osmotic demyelination results in dysarthria, lethargy, affective changes, spastic quadriparesis, seizures, coma, or death. Patients with severe malnutrition, alcoholism, or advanced liver disease may be at increased risk; use slower rates of correction; see Monitor. If an overly rapid increase in serum sodium concentration occurs (greater than 12 mEq/L/24 hr), administration should be discontinued. If hyponatremia persists or recurs (after initial interruption of therapy) and the patient has no evidence of neurologic sequelae, conivap tan may be resumed at a reduced dose. Once the patient is again euvolemic and is no longer hypotensive, therapy may be resumed at a reduced dose; see Dose Adjustments. Patient Education: Promptly report any burning at the infusion site or other side ef fects. Maternal/Child: Category C: use during pregnancy only if benefts justify risk to the fetus. Coadministration with inhibitors of this enzyme could lead to an increase in conivaptan concentrations, the effect of which is unknown. Coadministration with amlodipine (Norvasc), midazolam (Versed), and simvastatin (Zocor) resulted in increased concentrations of each of the drugs. Discontinue therapy if there is an overly rapid increase in serum sodium concentration or if the patient experiences hypotension or hypovolemia. Discontinue therapy permanently if neurologic sequelae are present; see Precautions, Monitor, and Dose Adjustments. Manufacturer lists as incompatible with ascorbic acid, protein hydrolysate, or any solution with an acid pH. According to the manufacturer, infusion with other agents is not generally recom mended. Acts at several points on the clotting cascade, enhancing coagulability of the blood, especially in the capillary beds. Indicated for short-term use only to provide a rapid and temporary increase in estrogen levels. However, warnings and precautions associated with oral therapy should be considered. Patient Education: Review health history and disease states with physician before begin ning treatment with conjugated estrogens. De tectable amounts have been found in breast milk and may decrease quantity and quality of milk. Extended use may acceler ate epiphyseal closure, which could result in short adult stature. However, the numerous adverse reactions associ ated with oral therapy should be considered. Post-Marketing: Anaphylaxis within minutes to hours of infusion, angioedema involving the face, tongue, larynx, hands, and feet. Does not increase cortisol secretion in patients with primary adrenocortical insuffciency. Administer in a facility equipped to monitor the patient and respond to any medical emergency. Patients receiving cortisone, hydrocortisone, or spironolactone should omit their pre-test doses on the day of testing. Malignant diseases (adult and pediatric patients): As a single agent: the initial dose may be 40 to 50 mg/kg of body weight, usually given in divided doses over 2 to 5 days. Alternate dosing schedules are 3 to 5 mg/kg twice weekly or 10 to 15 mg/kg every 7 to 10 days. Higher doses have been used with some protocols based on the condition being treated. Adequate hydration is indicated, and the use of mesna can be considered to attenuate or reduce the incidence of hemorrhagic cystitis. Has been used with bleomycin, bortezomib, carboplatin, cispla tin, cytarabine, dacarbazine, dactinomycin, dexamethasone, doxorubicin, epirubicin, eto poside, fudarabine, fuorouracil, ifosfamide, methotrexate, prednisone, procarbazine, rituximab, and vincristine. Adjuvant treatment of operable node-positive breast cancer: Treatment protocol includes cyclophosphamide, doxorubicin, and docetaxel. Filters: May be fltered through available micron sizes of cellulose ester membrane flters. Do not use cyclophosphamide vials if there are signs of melting (clear or yellowish viscous liquid or droplets). Infusion: Doses greater than 500 mg to approximately 2 Gm may be given over 20 to 30 minutes, or a single dose may be administered over 1 to 24 hours. Cyclophos phamide has been used in the treatment of the following malignancies: malignant lym phomas. Fibrosis of the urinary bladder, with or without cystitis, has also been reported. Usually seen when cyclophosphamide is used as a com ponent of an intensive antineoplastic multidrug regimen or in conjunction with transplan tation procedures. These effects are dose dependent and may occur up to several days after cyclo phosphamide is discontinued. Post-Marketing: Asthenia, interstitial pneumonitis, malaise and, rarely, Stevens-Johnson syndrome and toxic epidermal necrolysis. Interrupt therapy, reduce dose, or discontinue in patients who have or who develop potentially serious infections. Administered at 1/ 3 of the oral dose in patients temporarily unable to take oral cyclosporine. Administered in conjunction with adrenal corticosteroids; different regimens used; see prescribing information. Conversion from Neoral dosing to Sand immune may result in lower cyclosporine blood concentrations. May leach phthalate from polyvinylchloride containers; use diluents in glass infusion bottles. A large-bore needle flter may be used when withdrawing cyclosporine from an ampule. Adsorption should be negligi ble, but if there is concern, draw diluent through the same flter. Manufacturer indicates that cyclosporine molecules are small enough to pass through an in-line flter as small as 0. Prolongs survival of kidney, liver, and heart allogeneic transplants in the human. Do not administer cyclosporine with any other immunosuppressive agent except adrenocortical steroids. In impaired renal function, if rejection is severe, try other immunosuppressive therapy or allow rejection and removal of the kidney rather than increase dose of cyclosporine. Increased risk of develop ing a malignancy appears to be related to the intensity and duration of immunosuppres sion. May be manifest as impaired consciousness, convul sions, visual disturbances (including blindness), loss of motor function, movement dis orders, and psychiatric disturbances. Predisposing factors may include hypertension, hypomagnesemia, hypocholesterolemia, high-dose corticosteroids, high cyclosporine blood levels, and graft-versus-host disease. Patients receiving liver transplants may be more susceptible to encephalopathy than patients receiving kidney transplants. Reversal of encephalopathy has occurred after discontinuation or dose reduction of cyclospo rine. Monitor continuously for the frst 30 minutes of the infusion and frequently there after. Initiation or modifcation of antihypertensive therapy may be indicated; do not use potassium-sparing diuretics. Should not be used unless beneft to the mother justifes potential risk to the fetus. Reported outcomes of pregnancies in women who received cyclosporine are diffcult to evaluate. It is not possible to separate the effects of cyclosporine from the effects of other medications, underlying maternal disorders, or other aspects of the transplantation process. Negative outcomes included prematurity, low birth weight, fetal loss, and various malformations. Accidental parenteral overdose in premature neonates has caused serious symptoms of intoxication. If impairment of renal function is signifcant, either reduce the dose of cyclosporine and/or the coadministered drug, or consider an alternative treatment. Other sources list acyclovir (Zovirax), foscarnet (Foscavir), selected quinolones. Cyclosporine may decrease the clearance and in crease the toxic effects of colchicine. Other sources list sulfamethoxazole/trimethoprim; monitor levels and adjust cyclosporine dose as indicated to avoid transplant rejection. Cyclosporine reduces clearance and may increase blood levels of ambrisentan (Letairis), bosentan (Tra cleer), colchicine, digoxin, etoposide, methotrexate, and prednisolone; in addition, it may decrease the volume distribution of digoxin and cause toxicity rather quickly. With con current use, monitor digoxin levels, reduce digoxin dose, or discontinue as indicated. Cases of myotoxicity (including muscle pain and weakness, myositis, and rhabdomyolysis) have been reported with concomitant use. Statins may be temporarily withheld or discontin ued in patients with S/S of myopathy or potential for renal injury, including renal failure, secondary to rhabdomyolysis. Monitor levels closely when cyclosporine is added or removed from a drug regimen containing mycopheno late. To minimize the effect on blood levels, administer sirolimus 4 hours after cyclosporine dose.

Prerenal or postrenal factors should be excluded children is compromised renal perfusion heart attack xi purchase generic cardizem pills. Strict measurement of input and output leakage and respiratory compromise from intra-abdominal must be maintained arteria thoracica interna safe 120 mg cardizem, and input adjusted as reduction in dialysate fluid hypertension kidney group 08755 cardizem 120 mg overnight delivery. Peritoneal fluid cultures are obtained as clinically examination and urinary output blood pressure medication and zoloft purchase cheap cardizem. The Potassium (absent from standard dialysate solutions) can be effective dose will depend on the amount of functional com added to the dialysate as required blood pressure medication dosage too high buy cardizem 60 mg low cost. Phosphate is also absent promise (if < 50% function heart attack 30 year old woman buy generic cardizem 120 mg on-line, initiate attempt at diuresis with because hyperphosphatemia is an expected problem in renal maximum dose). Nonetheless, if phosphate intake is inadequate, hypo and the urine output remains low (< 0. Correction of fluid over furosemide dose, if not already maximized, should be load is accomplished by using high osmolar dialysis fluids. Fluid removal may also be increased with more fre administration of diuretics should cease. Fluid major metabolic and electrolyte disturbances, as well as overload and dialysis may be averted. The process is highly efficient, but the tions and nutrients required exceed the urinary output, dialysis speed of the changes can cause problems such as hemody is indicated. Care tions of acute renal failure develop is likely to improve clinical ful monitoring of the appropriate biochemical parameters is management and outcome. Note that during or immediately following the tion dosage according to the degree of renal function. Immediate indications for dialysis are (1) severe hyperkale mia; (2) unrelenting metabolic acidosis (usually in a situa tion where fluid overload prevents sodium bicarbonate Course & Prognosis administration); (3) fluid overload with or without severe If severe oliguria occurs, it usually lasts about 10 days. The diuretic phase begins with an increase in urinary output to large volumes of isosthenuric B. During the recovery phase, signs and symptoms subside rapidly, although Peritoneal dialysis is generally preferred in children because of polyuria may persist for several days or weeks. If peritoneal dialysis is technically less efficient than hemodialy renal recovery does not ensue, arrangements are made for sis, hemodynamic stability and metabolic control can be better chronic dialysis and eventual renal transplantation. Chronic renal failure in children most commonly results from developmental abnormalities of the kidneys or urinary C. Uremic peri or severe vesicoureteral reflux nephropathy, without (or carditis, congestive heart failure, pulmonary edema, and despite) surgical intervention, continues to cause a signifi hypertension may occur. In older children, the chronic glomerulonephritides and ne Treatment phropathies, irreversible nephrotoxic injury, or hemolytic A. When chronic renal failure is congenital, the inability to Treatment of chronic renal failure is primarily aimed at concentrate urine results in polyuria. Without medical care, children with long hyperkalemia, hyperphosphatemia, acidosis, and anemia are standing chronic renal failure may present with complica among the early problems. Hyperphosphatemia is con Growth failure depends on age at presentation and the trolled by dietary restriction and dietary phosphate binders rapidity of functional decline. Any child with a history of chronic or anorexic, dietary protein should be restricted. Output may be monitoring to minimize symptoms while the need for expected to gradually diminish as renal failure progresses to chronic dialysis and transplantation continues to be assessed. In contrast, children who develop chronic renal fail ful management relies greatly on education of the patient ure due to glomerular disease or renal injury will character and family. Attention must also be directed toward the psychoso Metabolic acidosis and growth retardation occur early in cial needs of the patient and family as they adjust to chronic renal failure. Disturbances in calcium, phosphorus, chronic illness and the eventual need for dialysis and and vitamin D metabolism leading to renal osteodystrophy kidney transplantation. Although renal compensation and increased parathyroid hormone can maintain a normal B. Dialysis and Transplantation serum phosphate level early in the course, this pathophysio logic response to hyperphosphatemia will be reflected by an At present the graft survival rate for living-related kidney increase in parathyroid hormone and alkaline phosphatase. With cadaveric transplantation, graft survivals are include anorexia, nausea, and malaise. Overall, the mortality rate from confusion, apathy, and lethargy to stupor and coma. More commonly, seizures are a result of untreated by the increased mortality, reported to be as high as 75% in hypertension or hypocalcemia (especially with rapid correc infants younger than age 1 year, primarily due to technical tion of acidosis). Anemia (normochromic and normocytic issues and complications of immunosuppression. Careful measurement of blood pressure Chronic peritoneal dialysis (home-based) and hemodial requires correct cuff size and reliable equipment. The cuff ysis provide life-saving treatment for children awaiting renal should be wide enough to cover two thirds of the upper arm transplantation. The best measure of the success of chronic and should encircle the arm completely without an overlap dialysis in children is the level of physical and psychosocial in the inflatable bladder. Although an anxious child may rehabilitation achieved, such as continued participation in have an elevation in blood pressure, abnormal readings must day-to-day activities and school attendance. Repeat measure catch-up growth rarely occurs, patients can grow at an ment is helpful, especially after the child has been consoled. Use of epoetin alfa, growth hormone, and better count, urinalysis, and urine culture. Radiography and ultra control of renal osteodystrophy contribute to improved sonography are used to study the anatomy of the urinary outcome. Gonzales Celedon C et al: Progression of chronic renal failure in children with dysplastic kidneys. In children, end-organ abnormalities sec Hypertension in children is commonly of renal origin. Treatment anticipated as a complication of known renal parenchymal varies with the clinical presentation. The primary classes of disease, but it may be found on routine physical examination useful antihypertensive drugs are (1) diuretics, (2) and in an otherwise normal child. Increased understanding of the adrenergic blockers, (3) angiotensin-converting enzyme roles of water and salt retention and overactivity of the inhibitors, (4) calcium channel blockers, and (5) vasodilators. Acute include (1) congenital anomalies of the kidneys or renal elevations of blood pressure not exceeding the 95th percentile vasculature, (2) obstruction of the urinary tract, (3) throm for age may be treated with oral antihypertensives, aiming for bosis of renal vasculature or kidneys, and (4) volume over progressive improvement and control within 48 hours. Some instances of apparent paradoxic elevations of blood pressure have been reported in clinical situations in 1. The liquid from a 10-mg ined for renal, vascular, or aortic abnormalities (eg, thrombo capsule can be drawn into a syringe and the dosage approxi sis, neurofibromatosis, coarctation) as well as some endocrine mated. Because the treatment is given for rising blood pressure, it is unlikely that the effects will be greater Clinical Findings than desired. Incremental increases with growth occur, gradually hypertension and should begin at about 0. Intravenous administra a blocker (unless contraindicated, eg, in reactive airway tion of 0. Metabolism are useful to treat renal insufficiency, but the disadvantages of of the drug results in thiocyanate; thus, with prolonged possible electrolyte imbalance must be considered. Single-drug usage, levels of thiocyanate must be monitored, especially therapy with an angiotensin-converting enzyme inhibitor is in renal insufficiency. Calcium channel blockers are increasingly this diuretic reduces blood volume and enhances the effec useful, and appear well tolerated in children. Drug Oral Dose Major Side Effectsa Drug Oral Dose Major Side Effectsa Nifedipine 0. The clinical presentation is one of failure to of the kidneys and collecting system. Hyperchlor include metabolic abnormalities, failure to thrive, nephrolithia emic metabolic acidosis, hypokalemia, and a urinary pH sis, renal glomerular or tubular dysfunction, and chronic renal exceeding 6. The test is cumbersome and can produce severe hood, is characterized by an alkaline urine pH, loss of acidosis. Secondary forms result from reflux or obstructive urop and dehydration with hypercalciuria and early-onset nephro athy or occur in association with other tubular disorders (see calcinosis. Bicitra con Treatment with prostaglandin inhibitors and potassium tains 1 mEq/mL of Na+ and citrate. Polycitra contains 2 conserving diuretics (eg, amiloride combined with magnesium mEq/mL of citrate and 1 mEq each of Na+ and K+. Potassium prognosis is guarded, a few patients seem to have less severe supplementation may be required, because the added forms of the disease that are compatible with long survival times. There are three types of cystinosis: adult, adolescent, and Alkali therapy can usually be discontinued after several infantile. Growth should be normal, and the deposition, which if not treated with phosphocysteamine gradual increase in the serum bicarbonate level to greater (Cystagon), is accompanied by the development of the renal than 22 mEq/L heralds the presence of a raised bicarbonate Fanconi syndrome and varying degrees of renal failure. The infantile type is the most complex tubular abnormality (Fanconi syndrome with common and the most severe. Characteristically, children attendant phosphaturia, glycosuria, and amino aciduria), the present in the first or second year of life with Fanconi prognosis depends on the underlying disorder or syndrome. Cystine is stored in cellular lysosomes in virtually all gene, which codes for a Golgi apparatus phosphatase. Eventually, cystine accumulation results in cell dam males have anomalies involving the eyes, brain, and kidneys. Renal the physical stigmata and degree of mental retardation vary failure between ages 6 and 12 years is common. In addition to congenital Whenever the diagnosis of cystinosis is suspected, slit cataracts and buphthalmos, the typical facies includes promi lamp examination of the corneas should be performed. Increased white cell cys renal abnormalities are of tubule function and include hypo tine levels are diagnostic. Treatment includes management is directed toward all side effects of renal alkali therapy, phosphate replacement, and vitamin D. Ante failure, with particular attention paid to the control of renal natal diagnosis is possible. These children are particularly susceptible to manifestations are related to stone formation: ureteral colic, episodes of dehydration, fever, vomiting, and convulsions. Urinary excretion of cystine, lysine, arginine, of polydipsia and polyuria insensitive to the administration and ornithine is increased. The diag the most reliable way to prevent stone formation is to nosis is confirmed by performing a vasopressin test. This involves fully monitored water restriction does not increase the tubu generous fluid intake. Primary Hyperoxaluria osmolality exceeds 320 mOsm/kg, vasopressin should be Oxalate in humans is derived from the oxidative deamina administered. At least two enzymatic blocks potassium depletion, hypercalcemia, cystinosis and other have been described. Serum sodium levels should be evaluated the main effect is on the kidneys, where progressive oxalate at intervals to avoid hyperosmolality from inadvertent water deposition leads to fibrosis and eventual renal failure. In later childhood, sodium intake should con Pyridoxine supplementation and a low-oxalate diet have tinue to be restricted to 2. Renal patients show improvement with administration of prosta transplantation is not very successful because of destruction glandin inhibitors such as indomethacin or tolmetin. Renal calculi in children may result from inborn errors of Hyperoxaluria may also be a consequence of severe ileal metabolism, such as cystine in cystinosis, glycine in hyper disease or ileal resection. Treatment is limited to that of the primary condi It is estimated that 8% of girls and 2% of boys will acquire tion, if possible. Specific adhe primarily an abnormality of amino acid transport across both sins present on the fimbria of uropathogenic bacteria allow the enteric and proximal renal tubular epithelium. There are colonization of the uroepithelium in the urethra and bladder at least three biochemical types. In the renal tubule, basic amino acids are again rejected by the tubule, but cystine Pathogenesis absorption appears to be normal. The reason for cystinuria Dysfunctional voiding, which is uncoordinated relaxation of remains obscure. Heterozygous individuals have no aminoac the urethral sphincter during voiding, leads to incomplete iduria. The second type is similar to the first except that emptying of the bladder, increasing the risk of bacterial heterozygous individuals excrete excess cystine and lysine in colonization.

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