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8. Centers for disease control and prevention. A comprehensive immunization strategy to eliminate transmission of hepatitis b virus infection in the united states. Recommendations of the advisory committee on immunization practices (acip). Part 2. Immunization of adults. Mmwr. 2006;55(no. Rr-16):1–33. 9. Brotherton jml. Human papillomavirus vaccination. Where are we now?. J paediatr child health. 50(12):959–965. 2014;10. 1111/ jpc.

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Hydroxychloroquine/chloroquine. T ese medications are used to treat systemic lupus erythematosus (sle) and other autoimmune diseases, and act by inhibiting intracellular toll-like receptors. T ey cause myopathy by disrupting muscle membranes. Clinically the patient presents with painless progressive proximal weakness and elevation o ck level. Emg typically shows a myopathy with f brillation potentials. Abnormalities o sensory and motor nerve conduction studies may also be seen. Muscle biopsy may show a vacuolar myopathy due to lipid deposition. With electron microscopy, myeloid bodies and curvilinear bodies are seen. Improvement occurs with cessation o the drug. 3. Amiodarone.

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Frova [package insert]. Malern, pa. Endo pharmaceuticals. 2013. 34. Amerge [package insert].

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A urinalysis is attained in patients with an unknown history of renal disease to rule out nephrotic syndrome. Lastly, a toxicology screen is obtained in patients in whom the use of illicit drugs is suspected. Assays measuring bnp and its degradation product n-terminal probnp (nt-probnp) are being used with greater frequency in clinical practice. Bnp is synthesized, stored, and released from the ventricles in response to increased ventricular filling pressures. Hence plasma levels of bnp can be used as a marker for volume overload. The most widely accepted indication for bnp 82  section 1  |  cardiovascular disorders clinical presentation of acute heart failure subset i (warm and dry) •• ci greater than 2. 2 l/min/m2, pcwp less than 18 mm hg (2. 4 kpa) •• patients considered well compensated and perfused, without evidence of congestion •• no immediate interventions necessary except optimizing oral medications and monitoring subset ii (warm and wet) •• ci greater than 2. 2 l/min/m2, pcwp greater than or equal to 18 mm hg (2. 4 kpa) •• patients adequately perfused and display signs and symptoms of congestion •• main goal is to reduce preload (pcwp) carefully with loop diuretics and vasodilators subset iii (cool and dry) •• ci less than 2. 2 l/min/m2, pcwp less than 18 mm hg (2. 4 kpa) •• patients are inadequately perfused and not congested •• hypoperfusion leads to increased mortality, elevating death rates fourfold compared with those who are adequately perfused •• treatment focuses on increasing co with positive inotropic agents and/or replacing intravascular fluids •• fluid replacement must be performed cautiously because patients can rapidly become congested subset iv (cool and wet) •• ci less than 2. 2 l/min/m2, pcwp greater than 18 mm hg (2. 4 kpa) •• patients are inadequately perfused and congested •• classified as the most complicated clinical presentation of ahf with the worst prognosis •• most challenging to treat. Therapy targets alleviating signs and symptoms of congestion by increasing ci as well as reducing pcwp while maintaining adequate mean arterial pressure •• treatment involves a delicate balance between diuretics, vasodilators, and inotropic agents •• use of vasopressors is sometimes necessary to maintain bp should be obtained 2 hours after the end of a nesiritide infusion, or alternatively the nt-probnp assay should be utilized. Other diagnostic tests should also be obtained to rule out precipitating factors (chest radiograph) and to evaluate cardiac function (ecg). Invasive hemodynamic monitoring in patients with hf entails placement of a right heart or pulmonary artery catheter (pac). The catheter is inserted percutaneously through a central vein and advanced through the right side of the heart to the pulmonary artery. Inflation of a balloon proximal to the end port allows the catheter to “wedge,” yielding the pcwp, which estimates pressures in the left ventricle during diastole. Additionally, co can be estimated and svr calculated (table 6–8). There are no universally accepted guidelines dictating when invasive monitoring in hf is required, and invasive monitoring has not been shown to improve mortality or reduce hospitalizations in high-risk patients. Nonetheless, the use of a pac remains an essential component of management and monitoring of patients in cardiogenic shock. However, use of inotropic agents does not mandate invasive monitoring. Invasive hemodynamic monitoring is most commonly used to aid in assessment of hemodynamics when there is disagreement between signs and symptoms and clinical response. In addition, invasive monitoring is helpful in guiding ongoing therapy for ahf and offers the advantage of immediate hemodynamic assessment of an intervention, allowing for prompt adjustments. Risks with pacs include infection, bleeding, thrombosis, catheter malfunction, and ventricular ectopy. Table 6–8  hemodynamic monitoring. Normal values hemodynamic variable normal value central venous (right atrial) pressure, mean right ventricular pressure pulmonary artery pressure pulmonary artery pressure, mean pulmonary artery occlusion pressure, mean systemic arterial pressure mean arterial pressure < 5 mm hga (0. 67 kpa) cardiac index stroke volume index systemic vascular resistance pulmonary vascular resistance measurement is as an adjunctive aid for diagnosing a cardiac etiology for dyspnea. 10 the current values for ruling out a cardiac etiology for dyspnea are a bnp less than 100 pg/ml (100 ng/l or 28. 9 pmol/l) or an nt-probnp less than 300 pg/ml (300 ng/l or 35. 4 pmol/l). Bnp measurements require cautious interpretation because numerous conditions can also elevate bnp concentrations. These include older age, renal dysfunction, pulmonary embolism, and chronic pulmonary disease.

Nesiritide, a recombinant bnp drug, has an identical structure to native bnp and will interfere with the commercial bnp assay, resulting in a falsely elevated level.