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It is apparently widespread in cies of vitamin B12 and fat-soluble vitamins may occur purchase 2 mg ginette-35 mastercard menstrual cramps but no period. Adults the environment ginette-35 2 mg fast delivery breast cancer 86 year old woman, and most people are exposed at an early and children older than 8 years with symptomatic giardiasis age. Infections are mild or asymptomatic in immunocom- should be treated with oral metronidazole. However, the organism can form cysts in the lungs, persist for long periods, and become activated in im- munocompromised hosts. Groups at risk include parts of the world, especially in tropical regions. In the United human immunodeficiency syndrome (HIV) seropositive States, malaria is rare and affects travelers or immigrants from persons; those receiving corticosteroids or antineoplastics malarious areas. Plasmodium vivax, Plasmodium malariae, and Plasmodium ovale cause recurrent malaria by Toxoplasmosis forming reservoirs in the human host. In these types of malaria, signs and symptoms may occur months or years after Toxoplasmosis is caused by Toxoplasma gondii, a parasite the initial attack. Plasmodium falciparum causes the most life- spread by ingesting undercooked meat or other food contain- threatening type of malaria but does not form a reservoir. This ing encysted forms of the organism, by contact with feces from type of malaria may be cured and prevented from recurring. Once infected, the organism may persist in tis- opment occurs within the human body. However, symptoms rarely bites a person with malaria, it ingests blood that contains ga- occur unless the immune system is impaired or becomes im- metocytes (male and female forms of the protozoan parasite). When the mosquito bites cancer or organ transplantation), it is especially common and 616 SECTION 6 DRUGS USED TO TREAT INFECTIONS serious in people with AIDS, in whom it often causes en- SCABIES AND PEDICULOSIS cephalitis and death. Scabies is caused by the itch mite (Sarcoptes scabiei), which Trichomoniasis burrows into the skin and lays eggs that hatch in 4 to 8 days. The burrows may produce visible skin lesions, most often be- The most common form of trichomoniasis is a vaginal in- tween the fingers and on the wrists. Antitrichomonal drugs Pediculosis capitis (head lice) is the most common type of may be administered systemically (ie, metronidazole) or ap- pediculosis in the United States. It is diagnosed by finding plied locally as douche solutions or vaginal creams. Pediculosis corporis (body lice) is diagnosed by finding lice HELMINTHIASIS in clothing, especially in seams. Pediculosis pubis (pubic or crab lice) Helminthiasis, or infestation with parasitic worms, is a com- is diagnosed by the presence of nits in the pubic and genital mon finding in many parts of the world. Occasionally, pubic lice may infest the axillae, mustache, often found in the gastrointestinal (GI) tract. Pediculosis may infect persons of any socio- eral types of parasitic worms penetrate body tissues or pro- economic status. Although scabies and pediculosis are caused duce larvae that migrate to the blood, lymph channels, lungs, by different parasites, the conditions have several common liver, and other body tissues. Most anthelmintics act locally to kill or cause occur in any geographic area and socioeconomic group. The goal of anthelmintic therapy effects (eg, clothing, combs and hairbrushes, bed linens). In BOX 41–1 HELMINTHIC INFECTIONS Hookworm infections are caused by Necator americanus, a Tapeworms attach themselves to the intestinal wall and may species found in the United States, and Ancylostoma duodenale, grow as long as several yards. Segments called proglottids, which a species found in Europe, the Middle East, and North Africa. Tapeworms are Hookworm is spread by ova-containing feces from infected peo- transmitted by ingestion of contaminated, raw, or improperly ple. Beef and fish tapeworm infections are burrow through the skin (eg, if the person walks on the soil with not usually considered serious illnesses. Pork tapeworm, which is bare feet), enter blood vessels, and migrate through the lungs to uncommon in the United States, is more serious because it pro- the pharynx, where they are swallowed. Larvae develop into adult duces larvae that enter the bloodstream and migrate to other body hookworms in the small intestine and attach themselves to the tissues (ie, muscles, liver, lungs, and brain). Threadworm infections (strongyloidiasis), caused by Strongy- Pinworm infections (enterobiasis), caused by Enterobius ver- loides stercoralis, are potentially serious infections.

Keep the interviewee on track discount ginette-35 2 mg with amex menopause vitamins, 65 THE A–Z OF MEDICAL WRITING though sometimes desperate measures may be needed buy ginette-35 2 mg free shipping menstrual vomiting remedy, such as knocking over a glass of water. Using a tape recorder will free you to concentrate on the business in hand – though keep some written notes as well, just in case there is a systems failure. Interviewees will often ask to see a copy of what you have written before it is published. The danger with this is that they will try to get rid of their bright, clear quotes and try to put back their posh overcoat (see putting on the posh overcoat). On the other hand, passing your copy to them will probably pick up one or two errors of fact. Use your discretion: a sensible compromise is to read what you have written over the phone. In that way they can pick up errors but will have no time to fiddle with the style. Wherever possible go through the information as soon as the interview is over. When you come to write, you should be in a position to take out of it, from memory, what you need. Avoid where possible writing up transcripts: this takes up huge amounts of time. The test of a good interviewer is not what the interviewee thinks, but the quality of the information elicited, or the liveliness of the quotes. Introductions Many people believe that the role of the first part of a piece of writing is to introduce the reader to what you are going to say so that the reader can decide whether or not to become involved. This probably stems from school essays and has a slightly old-fashioned feel to it. Intro This is the term used by journalists to describe the first sentence of a news story. It is based on the assumption that your best chance of being read is to put your finest information into the first sentence. Once you have done that, you can put in all the qualifying information, in order of importance. The occasional (or perhaps more than occasional, depending on the papers you buy) lapses into extremity should not distract from the fact that this is a sensible approach, and we should adopt it for many types of writing up to about 400 words – particularly letters, e- mails and executive summaries (see marketing). Much of what we call jargon today is actually a technical language that has a precise meaning for fellow professionals, but is mean- ingless to outsiders. All have meanings within their group and are useful because they can describe complex notions and ideas in a simple way. The difficulty comes when these terms are used inappropriately to the wrong audiences. Jargon (as opposed to gobbledegook) has proliferated because of the increasing tendency to write one document for a number of different audiences (see effective writing), or even for the wrong audience (see false feedback loop). The answer is not to get rid of all 67 THE A–Z OF MEDICAL WRITING these uncommon words completely, but to make sure that we use the right language for our audience. Jokes It is difficult to make these work in the unforgiving black and white of the printed word. Journalese Doctors often use this word as a general term of abuse for vulgar and sensational writing. Journalism At its worst the hounder of innocent princesses and enemy of sensible government. At its best the exposer of unprin- cipled villains and deposers of evil regimes. Whether you love it or loathe it, the practice of journalism provides some useful lessons for those wishing to learn how to communicate effectively (see tabloids). It also provides major opportunities for putting out important public health messages (see press releases).

Te effect of the female hormone is inhibited buy 2 mg ginette-35 overnight delivery women's health issues video, and the breast enlargement is suppressed generic ginette-35 2mg amex pregnancy induced hypertension. If enough female hormone is present, breast enlargement will occur in a male of any age. In the adult male, there are only two endogenous sources of female hormones—the testicles and the adrenal glands. Both, however, can develop tumors that are capable of secreting large amounts of estrogens. Tat was my first concern, because these tumors are highly malignant, that is, they grow and spread rapidly. Tere is a very narrow window of time when surgical removal is still curative. Lung cancer, for instance, can produce this bizarre biochemical aberration. Jim, with these ominous and very serious possibilities of cancers in mind, I ordered all the tests that would identify the presence of estrogens or the hormones that can stimulate estrogen production. All the tests showed the very low and normal levels of estrogens typical for a man his age. I repeated the physical examination, this time giving extra time and attention to palpating Dr. I rea- soned that there are numerous compounds that can have an es- trogen effect. Jim could be secreting a hybrid estrogen, if you will, and thus appear to have normal levels because the tests I ordered were not seeing the novel hormone. It was a bit of fancy thinking, but I did not want to miss a malignancy that might still be surgically removable. He had no new thoughts but suggested repeating the tests once more, which we did—only to find the same normal results. He was a young boy about six years old who had developed gynecomastia at age five. After an exhaustive but negative search for tumors in the boy, I began to look around for other causes. I had his mother bring in all the medicines in the house, thinking that the boy might be getting into her birth-control pills or some estrogen-type compound. A few months later, there was a report in a medical journal that a certain brand of vitamins had been contaminated with estrogens. Enough es- trogen was carried over on the press to contaminate the vitamins. I immediately thought of the little boy who had me so puzzled, and I called his mother. I was amazed at how such a minute dose of estrogen could produce such a profound physical effect. I had taken a careful drug history when I first saw him and got no clue that he was taking anything that might have estrogen in it. I had even got- ten the nerve to ask him if he smoked marijuana, a frequent cause of gynecomastia in the drug subculture. After he laughed at my question, he asked me if I thought he was one of those long-haired dope fiends. I asked him to see if he could come up with anything he was doing or taking that could stimulate the breasts to enlarge. I was not at all satisfied with failing to make a diagnosis for such an obvious and ominous abnormality. He was grinning and blurted out, Tis was just too good to tell you over the phone. For years, she had used a vaginal cream for an atrophic vaginitis (a condition 112 Symptoms of Unknown Origin in older women due to the absence of estrogen) and as a lubricant. Not knowing what was in the cream, she began to check around after I asked Dr. Sure enough, this cream com- monly prescribed to postmenopausal women for atrophic vagini- tis contained estrogen. Jim must have absorbed enough estrogen through the skin to produce breast enlargement but not enough to measure in the tests. Te couple stopped using the estrogen cream as a lubricant, and within a few months the remaining breast returned to normal.

During this phase discount ginette-35 2 mg fast delivery pregnancy early signs and symptoms, I want you to care- fully monitor your weight purchase 2 mg ginette-35 breast cancer lymph nodes, measurements, and clothing size and fit. Also, if you are extremely carb sensitive, adding certain carbs back in may set off a binge. As you add foods back in, start with the healthiest carbs first, the ones that are least likely to spike your blood sugar and send you on a binge. I recommend you eat your chosen carb later rather than earlier in the day, but not past 3 P. Having fruit for breakfast, for example, will start your insulin levels off on the wrong foot and lead to cravings later on. This will help keep your motivation strong for the rest of the week, reduce cravings, and prevent bingeing. If you find yourself craving a particularly naughty food, reserve it for your cheat meal. Mindless eating—the demon that will definitely take you off track and undermine your hard work—is waiting for you at every turn. Research shows that the body will turn up the metabo- lism and burn off excess calories during occasional indulgences. So you can safely cheat once a week without seeing ill effects on your waistline. That said, cheating any more than one meal a week could have disastrous consequences. ULTIMATE BODY MAINTENANCE 239 TLFeBOOK SOUND BITES The more your food resembles something that grows in nature, the better. Raw foods are better than cooked because your body must work harder to break them down. Stick to the following Sound Bites when adding the A, B, C, D, E, and F foods back into your diet. ALCOHOL Alcohol is one of the trickiest foods to reintroduce to your diet. After the two- week Ultimate New York Body Plan, your body is like a clean, dry sponge. Finally, it contains far fewer calories and carbs than other types of alcohol. Reserve bread for your cheat meal, and even then, minimize it as much as possible. When having a sandwich, order it open-faced with just one slice of bread. When eating out, choose just one piece of bread from the basket and then send the basket away. Sourdough bread and whole grain bread will break down somewhat more slowly than other varieties, making them slight- ly better choices. STARCHY CARBS Stick to whole grain varieties such as quinoa, lentils, beans, brown rice, and slow-cooking oatmeal. Quinoa in particular is a wonder grain that contains a high amount of protein. Stay away from cups of flavored yogurt, which are two banned foods in one because they contain so much sugar. Although chocolate milk is a big no-no, there are certain brands of cocoa mix that are unsweetened and taste rather delicious. FRUIT AND FAT Choose the lower carb and calorie varieties such as blueberries, strawber- ries, cantaloupe, kiwi, apples, and pears. Stay away from sweet tropical fruits such as papaya, mango, and pineapple. You may also have controlled servings of nuts— about 7 to 10 as a snack. You followed the workout program closely and adhered to the nutrition guidelines, and you are feeling pretty proud of yourself and your accomplishments. The things most difficult to achieve are often the most rewarding to savor.