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By: X. Achmed, M.B. B.A.O., M.B.B.Ch., Ph.D.

Assistant Professor, University of Illinois at Urbana-Champaign Carle Illinois College of Medicine

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The main reason for giving levodopa, the precursor of dopamine, instead of dopamine is: a) Dopamine does not cross the blood-brain barrier b) Dopamine may induce acute psychotic reactions c) Dopamine is intensively metabolized in humans d) All of the above 011. Indicate a peripheral dopa decarboxylase inhibitor: a) Tolcapone b) Clozapine c) Carbidopa d) Selegiline 012. Carbidopa is unable to penetrate the blood-brain barrier, it acts to reduce the peripheral conversion of levodopa to dopamine. When carbidopa and levodopa are given concomitantly: a) Levodopa blood levels are increased, and drug half-life is lengthened b) the dose of levodopa can be significantly reduced (by 75%), also reducing toxic side effects c) A shorter latency period precedes the occurrence of beneficial effects d) All of the above 015. Which of the following preparations combines carbidopa and levodopa in a fixed proportionfi Gastrointestinal irritation, cardiovascular effects, including tachycardia, arrhythmias, and orthostatic hypotension, mental disturbances, and withdrawal are possible adverse effects of: a) Amantadine b) Benztropine c) Levodopa d) Selegiline 018. Which of the following agents is the most helpful in counteracting the behavioral complications of levodopafi Which of the following vitamins reduces the beneficial effects of levodopa by enhancing its extracerebral metabolismfi Which of the following drugs antagonizes the effects of levodopa because it leads to a junctional blockade of dopamine actionfi Levodopa should not be given to patients taking: a) Bromocriptine b) Monoamine oxydase A inhibitors c) Carbidopa d) Nonselective beta-adrenergic antagonists 022. Indicate D2 receptor agonist with antiparkinsonian activity: a) Sinemet b) Levodopa c) Bromocriptine d) Selegiline 023. Which of the following antiparkinsonian drugs has also been used to treat hyperprolactinemiafi Indicate a selective inhibitor of monoamine oxidase B: a) Levodopa b) Amantadine c) Tolcapone d) Selegiline 025. Indicate selective catechol-O-methyltransferase inhibitor, which prolongs the action of levodopa by diminishing its peripheral metabolism: a) Carbidopa b) Clozapine c) Tolcapone d) Rasagiline 029. Which of the following antiparkinsonian drugs is an antiviral agent used in the prophylaxis of influenza A2fi The mechanism of amantadine action is: a) Stimulating the glutamatergic neurotransmission b) Blocking the excitatory cholinergic system 44 c) Inhibition of dopa decarboxilase d) Selective inhibition of catechol-O-methyltransferase 031. Cycloplegia, tachycardia, urinary retention, and constipation) are possible adverse effects of: a) Sinemet b) Benztropine c) Tolkapone d) Bromocriptine 033. Alcohol: a) Increases body temperature b) Decreases body heat loss c) Increases body heat loss d) Does not affect body temperature 003. It is undesirable to take alcohol before going outdoors when it extremely cold, but it may be harmless to take some after coming into a warm place from the cold. The most common medical complication of alcohol abuse is: a) Liver failure including liver cirrhosis b) Tolerance and physical dependence c) Generalized symmetric peripheral nerve injury, ataxia and dementia d) All of the above 005. Effect of moderate consumption of alcohol on plasma lipoproteins is: a) Raising serum levels of high-density lipoproteins b) Increasing serum concentration of low-density lipoproteins c) Decreasing the concentration of high-density lipoproteins d) Raising serum levels of very low-density lipoproteins 006. Which of the following metabolic alterations may be associated with chronic alcohol abusefi Which of the following drugs is most commonly used for causing a noxious reaction to alcohol by blocking its metabolismfi Indicate the drug, which alters brain responses to alcohol: a) Naltrexone b) Disulfiram c) Amphetamine d) Chlorpromazine 011. Alcohol causes an acute increase in the local concentrations of: a) Dopamine b) Opioid c) Serotonine d) All of the above 013. Management of alcohol withdrawal syndrome contains: a) Restoration of potassium, magnesium and phosphate balance b) Thiamine therapy c) Substituting a long-acting sedative-hypnotic drug for alcohol d) All of the above 014. The symptoms resulting from the combination of disulfiram and alcohol are: a) Hypertensive crisis leading to cerebral ischemia and edema b) Nausea, vomiting c) Respiratory depression and seizures d) Acute psychotic reactions 016. The combination of disulfiram and ethanol leads to accumulation of: a) Formaldehyde b) Acetate c) Formic acid d) Acetaldehyde 017. The combination of naltrexone and disulfiram should be avoided since both drugs are potential hepatotoxins.

Syndromes

  • Certain chemicals (for example, benzene)
  • Levodopa (Sinemet)
  • Malaise
  • Sodium sulfacetamide with sulfur
  • You lose weight without trying
  • Chronic infection
  • Side effects from treatment

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Hungary, Poland and Switzerland appear to require submission of local pre-marketing cases of serious adverse events, not just reactions. There is commonality across most countries for requirements covering expedited reports of suspected serious unexpected adverse reactions, whether they be of local or foreign origin. Therefore, multinational companies should be able to prepare centrally a standard report for such 190 cases; the submission of such reports will still depend on local requirements based on the local data sheet. It is obvious that in spite of attempts to standardize safety reporting criteria and procedures over the past decade, there remains considerable divergence for which there does not appear to be a scientific or public health rationale. Furthermore, for those companies operating centrally, the same automation can be used to prepare and deliver to their subsidiaries case reports that will satisfy the various regulatory requirements. It is believed that some commercial vendors of clinical safety data management software systems have designed such tools. However, given the current differences as shown in the Appendix tables and the complexity involved, as well as the seemingly frequent changes to such regulations, any algorithm would have to be updated and validated carefully on an ongoing basis to ensure its utility and accuracy. From a system-wide perspective, there are some practical steps that regulators can take to help rationalize a more consistent, internationallybased approach to safety reporting requirements, based on good science and public health needs. Although it may be necessary or advantageous to have some regionalor country-specific safety reporting requirements, there are compelling arguments for achieving consistency on the nature, amount and timing of clinical safety report information (individual case or aggregate data) received by different regulators around the world. In the interest of public health and efficiency, the ideal situation would be to enter a case only once into a single database with worldwide access, something already feasible with distributed-database technology. Those local company offices may then have to submit the same case to their local regulators. Monitoring drug safety is a shared responsibility and the focus must always be on the collection, reporting, interpretation and any necessary action on important safety information on behalf of patients and the healthcare professionals that serve them. Spontaneous reports are always considered to have an implied causal relationship to the subject drug(s). Remember that reasons which might prompt a patient to contact a company include reimbursement, legal concerns and requests for information. Medical confirmation means that the patient exists, that the event occurred and is considered to be drug related by a healthcare professional. If the report is received from a third party, that party should be asked to encourage the consumer to report the information to their physician or to authorize the sponsor/authority to contact the doctor directly. It is possible that regulators may be in a better position to obtain confirmatory data from healthcare professionals and can be asked to do so when companies are unsuccessful. If the event is not considered to be drug-related, the case should be retained in the database but not reported. Also monitor special publications relevant to the drug or its current circumstances. Broadcast and lay media should not ordinarily be monitored; however, if important information from these sources is specifically made available to a company, attempts should be made to ascertain whether there is a valid case. All staff in all countries have a responsibility to be aware of publications in their local journals and bring them to the attention of the safety department as appropriate. The most aggressive follow-up efforts should be directed at valid reports of serious, unexpected adverse drug reactions that lack details for case assessment. If the product source or brand is not specified, until clarified a company should assume that it was their product although reports should indicate that the specific brand was not identified. It is recommended that English be the accepted standard language for literature report translations. It is important to distinguish between the dissemination of drug safety information over the Internet by companies and regulators, and the collection (receipt) of safety information from healthcare professionals or consumers. The need for personal data protection is particularly important with a medium such as the Internet.

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Make films 3-5cm in length, of the marrow fragments and the remaining blood using a smooth-edged glass spreader of not more than 2cm in width. The marrow fragments are dragged behind the spreader and leave a trail of cells behind them. It is in these cellular trails that the differential counts be made commencing from the marrow fragments and working back towards the head of the film; in this way, smaller numbers of cells from the peripheral blood become incorporated in the differential count. The preparation can be considered satisfactory only when marrow particles as well as free marrow cells can be seen in stained films. Fix the films of bone marrow and stain them with Romanowsky dyes as for peripheral films. However, a longer fixation time (at least 20 minutes in methanol) is essential for high quality staining. While the technique gives preparations of authentic marrow cells, squashing and smearing out the particles causes disruption and distortion of cells and the resultant thick preparations are difficult to stain well. Examination and Assessment of Stained Bone marrow Preparations the first thing to do is to look with the naked eye at a selection of slides and to choose from them the best spread films containing easily visible marrow particles. The particles should then be examined with a low power objective with particular reference to their cellularity and an estimate of whether the marrow is hypoplastic, normoplastic or hyperplastic. Cellularity of Marrow the marrow cellularity is expressed as the ratio of the volume of hematopoietic cells to the total volume of the marrow space (cells plus fat and other stromal 213 Hematology elements). It is judged by comparing the areas occupied by fat spaces and by nucleated cells in the particles. For example, at age 50 years, the average cellularity in the vertebrae is 75%; sternum, 60%; iliac crest, 50%; and rib, 30%. If the percentage is increased for the age of the patient, the marrow is said to be hypercellular or hyperplastic. If the percentage is decreased for the age of the patient, the marrow is said to be hypocellular or hypoplastic. Myeloid to Erythroid Ratio (M:E Ratio) the myeloid/erythyroid (M/E) ration is the ratio of total granulocytes to total normoblasts. This is used as an expression of the myeloid and erythroid compartments relative to each other and is calculated after classifying at least 200 cells (leucocytes of all types and stages of maturation are counted together). In normal adult bone marrow, the myeloid cells always outnumber the 214 Hematology erythroid cells with a mean value of 4:1. An increased M:E ratio shows an increase in the number of leucocytes and depression of the erythroid series while a decrease in the ratio shows the presence of erythroid hyperplasia and suppression of granulocytes. Differential Count on Aspirated Bone marrow: the Myelogram Expression of the incidence of the various cell types as percentages is not a mandatory part of bone marrow examination because of the relatively long time required to perform the count and the little clinical usefulness of such an effort. The count is also unreliable due to irregular distribution of the marrow cells and inclusion of cells from the peripheral blood for which there is no compensation. Because of the naturally variegated pattern of the bone marrow and the regular distribution of the marrow cells, differential counts on marrow from normal subjects vary so widely that minor degrees of deviation from the normal occurring in disease are difficult to establish. Indicate the sites of bone marrow aspiration in: adults, children under 12 years of age and children less than 2 years of age. What elements of the stained bone marrow architecture are mainly assessed in bone marrow examinationfi Systemic lupus erythematosus involves chronic inflammation that can affect many parts of the body, including: Heart, lungs, skin, joints, blood-forming organs, kidneys, nervous system. It is a connective tissue disease that affects most commonly women of child bearing age and is characterized by skin rash, arthralgia, fever, renal, cardiac and vascular lesions, anemia, leucopenia and often thrombocytopenia. The bulk of the cell is occupied by a spherical, homogeneous mass that stains purplish brown. Occasionally, a group of polymorphs will collect around an altered nuclear material and will form a "rosette". New cases of lupus are more common in families where one member already has the disease. A good method of achieving the necessary degree of trauma is to rotate the whole blood sample to which glass beads have been before concentrating the leucocytes by centrifugation. Four glass beads are added and the tube is sealed with a tightly fitting rubber bung.

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Development of an congenital in cattle and an experimental inoculation of indirect immunofluorescence technique for the diagnosis of gestating cows with oocysts. Toxoplasmosis and other Chaigneau F Infection with Toxoplasma gondii in a red intestinal coccidial infections in cats and dogs. Vet Clin North kangaroo (Macropus rufus) and a Patagonian mara (Dolichotis Am Small Anim Pract. Available at: and survival of Toxoplasma gondii in milk and cheese from. Isolation and genetic Toxoplasma gondii exposure in Arctic foxes (Vulpes lagopus) characterization of Toxoplasma gondii from alpaca (Vicugna while navigating the imperfect world of wildlife serology. Toxoplasma gondii in small ruminants in Al Wabra Wildlife Preservation, the State of Qatar. Toxoplasmosis in a red-bellied Jokelainen P, Deksne G, Holmala K, Nareaho A, Laakkonen J, woodpecker (Melanerpes carolinus). Feline toxoplasmosis in Finland: cross-sectional bovine neosporosis in Switzerland. Waterborne toxoplasmosis-recent Hartmann K, Addie D, Belak S, Boucraut-Baralon C, Egberink H, developments. Publishing and Multimedia Service, Information Toxoplasma gondii in Jeju Island, Korea. Molecular Rigoulet J, Hennache A, Lagourette P, George C, Longeart L, Le detection of Toxoplasma gondii in snakes. Toxoplasmosis in a bar-shouldered dove (Geopelia humeralis) from the Zoo of Cleres, France. Vertical transmission of Toxoplasma gondii in two major Brazilian clonal lineages of Toxoplasma gondii. Toxoplasma toxoplasmosis amongst squirrel monkeys in an Israeli monkey gondii infection in Bactrian camel (Camelus bactrianus) in colony. Diagnosis of gastrointestinal parasitism in caninum and Toxoplasma gondii in zoo animals. Sos E, Szigeti A, Fok E, Molnar V, Erdelyi K, Perge E, Biksi I, * Link defunct Gal J. Writing this instructional book posed challenges, and we were fortunate in having help with the task from many individuals. From the beginning of the development in mid-2000 through production stages in 2004, Susan M. We also wish to thank the outside reviewers who unselfishly gave their time and expertise to review and comment on a draft document. In addition, we are indebted to the practitioners who participated in focus groups that helped define the scope and form of this guidance. With the assistance of the University of Connecticut School of Medicine Student Continuity Practice and the Massachusetts Medical Society, focus group discussions provided information and feedback that informed the authors on specific areas of most concern in clinical settings. We are most grateful to our patients at the University of Connecticut Health Center Occupational and Environmental Medicine Clinic. Our special thanks go to those who graciously allowed us to profile their cases and who serve as important instructional examples for this book. Karen Daigle, for consulting with us on environmental considerations and for providing us the informative case description of the infant with recurring respiratory illness. We are indebted to Kathleen McDermott and Cheryl Steciak at the University of Connecticut Health Center for editing assistance and administrative support, and to the Cadmus Group, Inc. All of the individuals noted here contributed to the final quality of the document; however the authors are solely responsible for the content of this guidance. B-12 Appendix C: Evaluating Patients For the Presence of Specific Antibodies to Molds. D-3 Table C: Environmental Questionnaire (For Patients with Sentinel Conditions, Symptoms that Vary by Environment, or a History of Recurrent Moisture Incursion). D-4 Table D: Current Symptoms History and Relationship to Home, Work, or School (For Patients in Which a Potential Exposure to Mold Exists). D-6 Table E: Environment Intervention Guidance (Selected World Wide Web Resources).

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