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Go to a bookshop or use the Internet to browse cheap furosemide 40mg line arrhythmia foods to eat, then construct a proposal generic furosemide 100 mg with visa hypertension 4010, and send it in. Publishers are interested in good ideas, and want evidence that you are likely to do it well. Start with a brief description (200 words or so) of what you intend to do and who will buy the book. Include a list of chapter headings (for non-fiction) or a sample chapter (if fiction). You will also need a covering letter, giving perhaps one or two reasons why you think you should be trusted (author of 17 other books, professor of book writing, UN expert on pagination, etc). Finally, add supporting information, such as articles you may have written, or a CV. Now try to obliterate any trace of it from your memory until you receive the reply. Your contract will almost certainly offer substantially less than you think you are worth. You may wish to consult a lawyer or the Society of Authors; alter- natively you may wish to take the view that publishers are doing this all the time, and as a newcomer and first-time author it will be unwise to rock the boat. Work out when you have to submit the manu- script and put the key dates in your diary. Also allow time for other people to look at the manuscript, and for doing the tricky administrative things like seeking copyright. Then put down some deadlines for the actual writing: how many of your 50 000 words do you intend to write a month? How will you find time – do you plan to give up your evenings at the gym, or your mornings in bed, or your weekends in the garden? It helps if your editor still has positive feelings towards you when you send in your manuscript. If, like me, you are one of those people who need to fiddle with the way your writing actually looks (see layout), feel free to do so. Your publisher will have been involved in many more books than you have and will be better attuned to the target audience. If you think every proposed change is an insult to your great talent, you are either being unrealistic or are with the wrong publisher. You then have a simple decision to take: do you negotiate, or do you end the relationship and try to find another publisher? After about six months the book will be published – and there will probably be an anticlimax. Your friends will say (to your face) that the book is wonderful (and then drop hints about a free signed copy); letters of 13 THE A–Z OF MEDICAL WRITING praise from unknown admirers are less likely. The real point about writing books is that, like mountains, they are there. Books, writing of chapters in One of the great advan- tages of multi-authored books is that they meet the huge demand for authorship. Be flattered by the invitation to contribute, and then consider whether you really want (or need) to invest the time. Saying no at this stage will be appre- ciated: publishers say that their biggest problem in multi-authored books is dealing with the delays caused by those who keep insisting that they want to contribute, but never get around to doing so. Approach the project as you would any other writing task (see process of writing). Divide the chapter into manageable chunks of 1000 words or so, and use the structure of a feature article for each section. You are unlikely to get paid, and if so it will rarely be above £200 a chapter. You should be offered a free copy of the book; make sure you display it prominently.

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OVERVIEW used for many years contained live virus and caused viral shedding and a few cases of polio cheap furosemide 40 mg arteria gastroepiploica. The main dis- Immune responses and types of immunity are described in advantages of IPV are that it must be injected and it is Chapter 42 buy furosemide 40mg with visa blood pressure cuff size. Early sci- • Hepatitis B virus (HBV) infection can cause serious entists observed that people who contracted certain diseases liver diseases such as acute and chronic hepatitis, cir- were thereafter protected despite repeated exposure to the rhosis, and hepatocellular carcinoma. As knowledge evolved, it was discovered that pro- of HBV may be asymptomatic reservoirs for viral trans- tection stemmed from body substances called antibodies, and mission. Children who become infected are at high risk that antibodies could also be induced by deliberate, controlled of becoming chronically infected. Subsequently, immunization tech- cumstances, hepatitis B vaccine is now recommended niques were developed. Overall, been used, the development of immunizing agents and rec- the goal is to achieve universal immunization, decrease ommendations for their use continue. The oral vaccine One strategy is to combine vaccines so that only one in- 640 CHAPTER 43 IMMUNIZING AGENTS 641 jection is required when the need and time for multiple For maximum effectiveness, vaccines and toxoids must be vaccines coincide. In addition to the long-used, measles- given before exposure to the pathogenic microorganism. They mumps-rubella (MMR) and diphtheria-tetanus-pertussis should also be given by the recommended route to ensure the (DTaP) combinations, available combinations include desired immunologic response. Haemophilus b (Hib) with hepatitis B (Comvax), DTaP with Haemophilus b (DTaP-HIB; TriHIBit), and he- patitis A and hepatitis B (Twinrix). Another strategy is Indications for Use to give multiple vaccines (in separate syringes, at differ- ent sites) at one visit to a health care provider when fea- Clinical indications for use of vaccines and toxoids include sible. For example, several vaccines are recommended the following: to be given at the same time for routine immunization of 1. Routine immunization of all children against diphthe- infants and young children. In addition, influenza and ria, Haemophilus b infection, hepatitis B, mumps, per- pneumococcal vaccines can be administered concur- tussis, pneumococcal infection, poliomyelitis, rubella rently, and at least one study indicates that varicella and (German measles), rubeola (red measles), tetanus, and MMR can be given at the same office visit. Immunization of prepubertal girls or women of apparently withdrawn because of infrequent use. Rubella during the first trimester of pregnancy is associated with a high incidence of birth defects in the newborn. Immunization of people at high risk of serious morbid- ity or mortality from a particular disease. For example, Immunization or vaccination involves administration of an hepatitis B, influenza, and pneumococcal vaccines are antigen to induce antibody formation (for active immunity) recommended for selected groups of people. Immunization of adults and children at high risk of ex- rations used for immunization are biologic products prepared posure to a particular disease. For example, some dis- by pharmaceutical companies and regulated by the Food and eases (eg, yellow fever) rarely occur in most parts of Drug Administration (FDA). Thus, immunization is recommended only for people who live in or travel to geographic areas where the disease can be contracted. AGENTS FOR ACTIVE IMMUNITY The biologic products used for active immunity are vaccines Contraindications to Use and toxoids. Vaccines are suspensions of microorganisms or their antigenic products that have been killed or attenuated Vaccines and toxoids are usually contraindicated during febrile (weakened or reduced in virulence) so that they can induce illnesses; immunosuppressive drug therapy (see Chap. Attenuated live vaccines produce immunity, usually lifelong, that is similar to that produced by natural infection. However, there is a small risk of producing disease with live AGENTS FOR PASSIVE IMMUNITY vaccines, especially in people with impaired immune function. Vaccines developed with recombinant deoxyribonucleic acid Immune serums are the biologic products used for passive im- (DNA) technology have a low risk for causing active disease. They are used to provide temporary immunity in peo- Toxoids are bacterial toxins or products that have been ple exposed to or experiencing a particular disease. The goal of modified to destroy toxicity while retaining antigenic prop- therapy is to prevent or modify the disease process (ie, decrease erties (ie, ability to induce antibody formation). They may consist of whole clude aluminum phosphate, aluminum hydroxide, or calcium serum or the immunoglobulin portion of serum in which the phosphate.

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Physiatrists evolved from the need for so that patients can obtain equipment generic furosemide 40 mg with visa arrhythmia natural cure, services discount furosemide 100mg amex mrf-008 hypertension, a rehabilitation discipline after World War II and pertinent disability reports. Thus, cilitators of the team, especially on an inpatient from their roots in syphilis, polio, and war- service. Here, the physician leads a weekly related trauma, neurologists and physiatrists are team conference that reviews the progress of most likely to participate with an inpatient team. The conference allows the team Physicians are especially responsible for antic- to share notes and thoughts about each patient ipating and managing the medical complica- and to solve lingering problems. A physician tions and rehabilitation needs of their patients leader articulates, mobilizes, and persuades the (see Chapter 8). In addition, physicians who patient, family, and team of therapists toward specialize in neurologic rehabilitation educate goals that they come to share. Team meetings and journal clubs with pain and disability and the present degree may be used to discuss new and relevant re- of disability. These issues include interference impairments will affect rehabilitation potential. Is in- functional activities, physical fitness, mood, somnia associated with anxiety or depression, and lifestyle. These elements will impact reha- a noisy roommate, and pain at rest or with cer- bilitation care and goal-setting. Although neuroimaging point to a urinary tract infection, phlebitis or studies cannot themselves predict impairments aspiration, as well as caloric and fluid intake, and prognosis, tests such as computerized to- short-term therapy goals, how the patient and mography (CT) and magnetic resonance imag- family are coping with unexpected burdens, ing (MRI) offer useful insights. During daily rounds, the physician that reveals an old, silent lacuna in the right encourages patients to spend more time out of basis pontis, however, offers insight into the bed, reiterates specific exercises for improving cause of a pseudobulbar palsy and alters the endurance, motor control, and skills that can prognosis. Families and people with neurologic dis- pably tender musculoligamentous tissue cause eases are quick to check for experimental and pain or limit movement? Does a medication or alternative treatments on the Internet and in episodic orthostatic hypotension lessen atten- articles. The physician needs to put animal re- tion span and endurance for exercise? Is hy- search results, ongoing clinical trials, uncon- ponatremia or anemia having negative clinical trolled use of substances that include much consequences? Does a muscle group show in- hype by the seller, and alternative medicine ap- creased paresis with a few repetitive contrac- proaches into perspective. Nor does the com- problems related only to the cerebral injury, or pulsive clinician ever disregard the insights of does a metabolic abnormality, a medication or, the rest of the team. A modest decline in at- in an older person, an underlying dementia tention span or exercise tolerance noted by the 218 Common Practices Across Disorders speech therapist or occupational therapist may should insist on definable interventions. If one mean, for example, incipient sepsis, a new approach is not working, a different approach metabolic complication, or side effects of a can then be defined and tested. A few minutes of assessment and measures of success, such as changes in the explanation prevents lost opportunities to un- time needed to eat a meal or walk 50 feet, help cover unrecognized problems and misunder- label success beyond nonparametirc tools that standings. Vigilance is necessary in regard to are used to define levels of independence (see identifying inpatient and outpatient medical Chapter 7). System For Medical Rehabilitation14 helps put During outpatient care, physicians must de- features of the recovery of impairments and dis- velop their skills at counseling about matters abilities into perspective. This information such as exercise13 and specific directions about stimulates collective deliberations that may build home practice paradigms for motor and cogni- a consensus toward alternative solutions and the tive retraining. I make it a point to review the design of a single-case study or larger clinical details of how the patient is practicing to im- trial. Newly shared knowledge gives the team a prove the functional use of an affected upper greater sense of competence and gets all re- extremity, language and memory skills, and so- thinking what they do. For pa- Responsibilities tients with chronic diseases that progress, prac- tice is perhaps even more important, since it Inpatient rehabilitation nurses monitor the may spur gradual neural reorganization to vexing medical complications that accompany maintain function (see Chapter 3). A follow-up by 1 month after inpatient patient every 2 hours, along with other meas- discharge and at 3 and 6 months for disabled ures to prevent pressure ulcers over bony patients will allow adjustments in the formal prominences. They protect patients from be- and informal rehabilitation program, changes in ing pulled across the bed, which can shear the assistive devices and braces, and ascertainment skin, and work out ways to prevent inconti- of community resources over the time that most nence so that moisture does not macerate the patients make their fastest improvements.

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When • 4 oz of fruit juice discount furosemide 40 mg without prescription hypertension 2008, such as orange cheap furosemide 40 mg line prehypertension meaning in urdu, apple, or grape hypoglycemia is suspected, the blood glucose level should be mea- • 4 oz of ginger ale sured if possible, although signs and symptoms and the plasma glu- • Coffee or tea with 2 teaspoons of sugar added cose level at which they occur vary from person to person. Hypoglycemia is a blood glucose below 60 to 70 mg/dL and is es- These products must be swallowed to be effective. If they do nervous system effects may lead to accidental injury or permanent not subside, the client should take another 10 to 15 g of oral car- brain damage; cardiovascular effects may lead to cardiac dysrhyth- bohydrate. If acarbose or miglitol has been taken with insulin or mias or myocardial infarction. Causes of hypoglycemia include: a sulfonylurea and a hypoglycemic reaction occurs, glucose (oral • Intensive insulin therapy (ie, continuous subcutaneous [SC] or intravenous [IV]) or glucagon must be given for treatment. Sucrose (table sugar) and other oral carbohydrates do not relieve • Omitting or delaying meals hypoglycemia because the presence of acarbose or miglitol pre- • An excessive or incorrect dose of insulin or an oral agent that vents their digestion and absorption from the gastrointestinal tract. Therefore, the treatment choices renal insufficiency) are parenteral glucose or glucagon. It acts rapidly to raise blood glucose levels and arouse the than SC client. If the client is at home or elsewhere, glucagon may be given • Drug interactions that decrease blood glucose levels if available and there is someone to inject it. A family member or • Increased physical exertion roommate may be taught to give glucagon SC or IM. Glucagon is a pan- Hormones That Raise Blood Sugar creatic hormone that increases blood sugar by converting liver Normally, when hypoglycemia occurs, several hormones (glucagon, glycogen to glucose. It is effective only when liver glycogen is pres- epinephrine, growth hormone, and cortisol) work to restore and ent. Some clients cannot respond to glucagon because glycogen maintain blood glucose levels. Glucagon and epinephrine, the stores are depleted by such conditions as starvation, adrenal insuffi- dominant counter-regulatory hormones, act rapidly because they ciency, or chronic hypoglycemia. The hyperglycemic effect of are activated as soon as blood glucose levels start declining. People with diabetes who develop hypoglycemia may have Caution is needed in the treatment of hypoglycemia. Although impaired secretion of these hormones, especially those with type the main goal of treatment is to relieve hypoglycemia and restore the 1 diabetes. The client having a hypoglycemic re- cretion of epinephrine also occurs in people who have been action should not use it as an excuse to eat high-caloric foods or treated with insulin for several years. Health care personnel caring for the client creases tachycardia, a common sign of hypoglycemia, and may should avoid giving excessive amounts of glucose. Posthypoglycemia Care The Conscious Client Once hypoglycemia is relieved, the person should have a snack or Treatment of hypoglycemic reactions consists of immediate ad- a meal. Slowly absorbed carbohydrate and protein foods, such as ministration of a rapidly absorbed carbohydrate. For the conscious milk, cheese, and bread, are needed to replace glycogen stores in client who is able to swallow, the carbohydrate is given orally. In addition, the episode needs to include: be evaluated for precipitating factors so that these can be mini- • Two sugar cubes or 1 to 2 teaspoons of sugar, syrup, honey, mized to prevent future episodes. Repeated episodes mean that the or jelly therapeutic regimen and client compliance must be re-evaluated • Two or three small pieces of candy or eight Lifesaver candies and adjusted if indicated. Glitazones tion increases or restores the effectiveness of circulating insulin and results in increased uptake of glucose by pe- • These drugs, pioglitazone and rosiglitazone, are also ripheral tissues and decreased production of glucose by called thiazolidinediones or TZDs and insulin sensitizers. The drugs stimulate exercise or in combination with insulin, metformin, or receptors on muscle, fat, and liver cells. The drugs lower blood sugar by decreasing absorption or production of glucose, by increasing secretion of insulin, or by increasing the effectiveness of available insulin (decreasing insulin resistance). They are also con- should be skipped; if a meal is added, a drug dose traindicated in clients who are hypersensitive to them. Glitazones increase plasma volume and may cause HERBAL AND DIETARY fluid retention and heart failure. In people who did not With most herbs and dietary supplements, even the commonly take a glitazone, 2. Thus, anyone with diabetes who Meglitinides wishes to take an herbal or dietary supplement should consult • Nateglinide and repaglinide are nonsulfonylureas that a health care provider, read product labels carefully, seek the lower blood sugar by stimulating pancreatic secretion of most authoritative information available, and monitor blood insulin.

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