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How a given question was asked I: Insufcienor conficting evidence noallowing mighinfuence how a study was evaluad and a recommendation for or againsinrvention generic butenafine 15mg otc anti fungal oil for scalp. For example order generic butenafine online antifungal diet plan, a random- a standard language thaindicas the strength of ized control trial reviewed to evalua the diferenc- the recommendation buy generic butenafine 15mg on-line antifungal cleaner. Work group consensus staments clearly sta thaGuideline DevelopmenProcess �in the absence of reliable evidence, iis the work group�s opinion that� a sor inrvention may be? Trained guideline participants were asked to submia lisof clinical questions thathe guideline should levels of evidence and grades of recommenda- address. In evaluating studies as to levels of evidence for this guideline, the study design was inrpred as es-? As an Multidisciplinary ams were assigned to work example, a therapeutic study designed as a random- groups and assigned specifc clinical questions to ad- ized controlled trial would be considered a pon- dress. In the inadvernbiases in evaluating the lirature and example cid previously, reasons to downgrade the formulating recommendations is minimized. In keep- in the absence of subgroup analyses, a large number ing with the Lirature Search Protocol, work group of studies were excluded from consideration in ad- members have identifed appropria search rms dressing the questions and formulating recommen- and paramers to directhe lirature search. Specifc search stragies, including search rms, paramers and databases searched, are document-? Members have independently developed evidentia- ry tables summarizing study conclusions, identify-? Sp 4: Completion of the Lirature ing strengths and weaknesses and assigning levels Search of evidence. In order to sysmatically control for Once each work group identifed search rms/pa- pontial biases, aleastwo work group members ramers, the lirature search was implemend by have reviewed each article selecd and indepen- a medical/research librarian, consisnwith the dently assigned levels of evidence to the lirature Lirature Search Protocol. Identifcation of Lirature to Review Work group members reviewed all abstracts yielded? Sp 7: Formulation of Evidence-Based from the lirature search and identifed the lira- Recommendations and Incorporation of ture they will review in order to address the clini- ExperConsensus cal questions, in accordance with the Lirature Work groups held webcasts to discuss the evidence- Search Protocol. Members have identifed the besbased answers to the clinical questions, the grades of research evidence available to answer the targed recommendations and the incorporation of experclinical questions. Transparency in the incorporation of dence on the topic of cervical radiculopathy, and consensus is crucial, and all consensus-based rec- studies eligible for review were required to address Tis clinical guideline should nobe construed as including all proper methods of care or excluding other acceptable methods of care reasonably direcd to obtaining the same results. No revisions were made athis poinin the Consensus DevelopmenProcess process, bucomments have been and will be saved Voting on guideline recommendations was conduct- for the nexiration. When the mance Improvement) to identify those recommen- 80% threshold was noattained, up to three rounds dations rigorous enough for measure develop- of discussion and voting were held to resolve dis- ment. If disagreements were noresolved af- the guideline developmenand athe Consortium r these rounds, no recommendation was adopd. Revisions to recommendations were considered for Use of Acronyms incorporation only when substantiad by a prepon- roughouthe guideline, readers will see many ac- derance of appropria level evidence. Edits and revisions to recom- roughouthe guideline, readers will see thawhamendations and any other connwere considered has traditionally been referred to as �nonoperative,� for incorporation only when substantiad by a pre- �nonsurgical� or �conservative� care is now referred ponderance of appropria level evidence. Defnition and Natural History of Cervical Radiculopathy from Degenerative Disorders measures. Other commonly cid studies did noreporsubgroup analyses of patients with cervi- cal radiculopathy alone and thereby presend gen- eralized natural history data regarding a heroge- Cervical radiculopathy from degenerative neous cohorof patients with isolad neck pain, disorders can be defned as pain in a radicular cervical radiculopathy or cervical myelopathy. Frequenwork group was unable to defnitively answer the signs and symptoms include varying degrees question posed relad to the natural history of cer- of sensory, motor and refex changes as well vical radiculopathy from degenerative disorders. In as dysesthesias and paresthesias relad to lieu of an evidence-based answer, the work group nerve root(s) withouvidence of spinal cord did reach consensus on the following stamenad- dysfunction (myelopathy). Work Group Consensus StamenIis likely thafor mospatients with cervical radiculopathy from degenerative disorders Whais the natural history of cer- signs and symptoms will be self-limid and will resolve spontaneously over a variable length of vical radiculopathy from degener- time withouspecifc treatment. Work Group Consensus StamenTo address the natural history of cervical radicul- opathy from degenerative disorders, the work group Future Directions for Research performed a comprehensive lirature search and e work group identifed the following pontial analysis. However, all identifed studies failed to meethe guideline�s in- Recommendation #1: clusion criria because they did noade-qualy A prospective study of patients with cervical radicu- presendata abouthe natural history of cervical lopathy from degenerative disorders withoutreat- radiculopathy. Cervical spine degeneration Transforaminal sroid injections for the treatmenof cer- in fghr pilots and controls: a 5-yr follow-up study. Conservative treatmenof cervical radiculop- 20-60 years as measured by magnetic resonance imaging. Cervical spine degenerative changes (nar- myelopathy caused by disc herniation with developmen- rowed inrverbral disc spaces and osophys) in coal tal canal snosis. Recommendations for Diagnosis and Treatmenof Cervical Radiculopathy from Degenerative Disorders A. Residual sensory defciwas found diagnosis of cervical radiculopathy be considered in 20. In a in patients with arm pain, neck pain, scapular or large group of patients with cervical radiculopathy, periscapular pain, and paresthesias, numbness this study elucidas the common clinical fndings and sensory changes, weakness, or abnormal of pain, paresthesia, motor defciand decreased deep ndon refexes in the arm. Patients included in the study repord the raly predicd on the basis of clinical fndings. Eleven patients pre- porting the results of surgical inrvention in 11 cer- send with only lefchesand arm pain (�cervical vical radiculopathy patients with neck pain from C4 angina�). No pain or paresthesia was re- zial areas and upper extremities depending on the pord by 0. Excluding a single myelopathic patient, four felto be equally involved for the remaining 12. Patients underwenrelief and level of activity based on Odom�s criria, single level nerve roodecompression using a pos- good or excellenresults were obtained in 10 of the rior open foraminotomy. Neck or scapu- to surgical decompression unlike neck pain arising lar pain preceeded the arm/fnger symptoms in 35 from degenerative disc disease. When the pain was suprascapular, C5 or C6 radicu- In critique, no validad outcome measures were lopathy was frequent; when inrscapular, C7 or C8 used and the sample size was small. Arm and fnger symptoms improved ouupper extremity clinical fndings should prompsignifcantly in all groups afr decompression. Six- evaluation for a C4 radiculopathy and thathis eval- ty-one painful sis were nod before surgery: one uation should include C4 sensory sting. One month af- r surgery, 27 patients repord comple pain re- Posal38 repord a retrospective case series re- lief, 23 complained of pain in 24 subregions, seven viewing experience with the surgical managemenof which were the same as before surgery. All buone Symptoms included shoulder pain radiating into new si were nuchal and suprascapular. Aone year the laral aspecof the hand, hand weakness and follow-up, 45 patients repord no pain, fve patients weakness in fnger fexion, fnger exnsion and in- had pain in six sis, three of which were the same as trinsic hand muscles. Recovery of hand can orgina from a compressed cervical nerve roostrength was nod in each patient; however, recov- and is valuable for derming the nerve rooin- ery was incomple in two patients with symptoms volved. In critique, no validad outcome measures were used and the sample size is study provides Level I evidence thacervical ra- was small. Tanaka eal48 described a prospective observational Yoss eal55 conducd a retrospective observational study examining whether or nopain in the neck or study of 100 patients to correla clinical fndings scapular regions in 50 consecutive patients with cer- with surgical fndings when a single cervical nerve vical radiculopathy originad from a compressed roo(C5, C6, C7, C8) is compressed by a disc hernia- nerve root, and whether the si of pain is useful for tion. Symptoms included pain in the neck, shoulder, Tis clinical guideline should nobe construed as including all proper methods of care or excluding other acceptable methods of care reasonably direcd to obtaining the same results. Patients included in the study repord the presence of pain or paresthesia in the forearm following symptoms: arm pain (99. Eleven patients pre- sia corresponded to a single rooor one of two roots send with only lefchesand arm pain (�cervical in 70% and 27%, respectively.
Moreover buy cheap butenafine 15mg online antifungal essential oil blend, withholding medications greatly increases the risk of relapse to illicit opioid use and overdose death buy 15mg butenafine visa topical antifungal yeast infection. For individuals who are already on a stable low to moderate dose of buprenorphine discount 15 mg butenafine antifungal meaning, the implant delivers a constant low dose of buprenorphine for 6 months. Buprenorphine is associated with improved outcomes compared to placebo for individuals (including pregnant women and their infants) with opioid use disorders,140 and it is effective in reducing illegal opioid use. As a result, there is an upper limit to how much euphoria, pain relief, or respiratory depression buprenorphine can produce. However, if the combined medication is injected, the naloxone component can precipitate an opioid withdrawal syndrome, and in this way serves as a deterrent to misuse by injection. When they frst receive their waiver, physicians can provide buprenorphine treatment for only up to 30 individuals. Although approximately 435,000 primary care physicians practice medicine in the United States,148 only slightly more than 30,000 have a buprenorphine waiver,149 and only about half of those are actually treating opioid use disorders. Naltrexone is an opioid antagonist that binds to opioid receptors and blocks their activation; it produces no opioid-like effects and is not abusable. It prevents other opioids from binding to opioid receptors so that they have little to no effect. It also interrupts the effects of any opioids in a person’s system, precipitating an opioid withdrawal syndrome in opioid-dependent patients, so it can be administered only after a complete detoxifcation from opioids. Naltrexone may be appropriate for people who have been successfully treated with buprenorphine or methadone who wish to discontinue use but still be protected from relapse; people who prefer not to take an opioid agonist; people who have completed detoxifcations and/or rehabilitation or are being released from incarceration and expect to return to an environment where drugs may be used and wish to avoid relapse; and adolescents or young adults with opioid dependence. Oral naltrexone can be effective for those individuals who are highly motivated and/or supported with observed daily dosing. Extended-release injectable naltrexone, which is administered on a monthly basis, addresses the poor compliance associated with oral naltrexone since it provides extended protection from relapse and reduces cravings for 30 days. Prescribing health care professionals should be familiar with these side effects and take them into consideration before prescribing. Thus, once disulfram is taken by mouth, any alcohol consumed results in rapid buildup of acetaldehyde and a negative reaction or sickness results. The intensity of this reaction is dependent on the dose of disulfram and the amount of alcohol consumed. Disulfram is most effective when its use is supervised or observed, which has been found to increase compliance. Thus, an individual who wants to reduce, but not stop, drinking is not a candidate for disulfram. Because it blocks some opioid receptors, naltrexone counteracts some of the pleasurable aspects of drinking. Many studies have examined the effectiveness of naltrexone in treating alcohol use disorders. Adherence to taking the medication increases under conditions where it is administered and observed by a trusted family member or when the extended-release injectable, which requires only a single monthly injection, is used. These therapies also teach and motivate patients in how to change their behaviors as a way to control their substance use disorders. Despite this, many counselors and therapists working in substance use disorder treatment programs have not been trained to provide evidence-based behavioral therapies, and general group counseling remains the major form of behavioral intervention available in most treatment programs. These therapies have been studied extensively, have a well-supported evidence base indicating their effectiveness, and have been broadly applied across many types of substance use disorders and across ages, sexes, and racial and ethnic groups. Individual counseling is delivered in structured sessions to help patients reduce substance use and improve function by developing effective coping strategies and life skills. Most studies support the use of individual counseling as an effective intervention for individuals with substance use disorders. These sessions typically explore the positive and negative consequences of substance use, and they use self-monitoring as a mechanism to recognize cravings and other situations that may lead the individual to relapse. Contingency management, which involves giving tangible rewards to individuals to support positive behavior change,85 has been found to be effective in treating substance use disorders. A group providing generic group counseling, not only because it is an individual mutual support and fellowship for therapy, but also because it involves a systematic set of people recovering from addictive 85 behaviors. All three treatments reduced the quantity and frequency of alcohol use immediately after treatment. Studies of various family therapies have demonstrated positive fndings for both adults and adolescents. In a recent review of controlled studies with alcohol-dependent patients, marital and family therapy, and particularly behavioral couples therapy, was signifcantly more effective than individual treatments at inducing and sustaining abstinence; improving relationship functioning and reducing intimate partner violence; and reducing emotional problems of children. Research has shown that incorporating tobacco cessation programs into substance use disorder treatment does not jeopardize treatment outcomes212 and is associated with a 25 percent increase in the likelihood of maintaining long-term abstinence from alcohol and drug misuse. Specifc supports include help with navigating systems of care, removing barriers to recovery, staying engaged in the recovery process, and providing a social context for individuals to engage in community living without substance use. Further, active recovery and social supports, both during and following treatment, are important in maintaining recovery. Telemedicine refers specifcally The use of telehealth to deliver health care, provide health to remote clinical services, whereas information or education, and monitor the effects of care, has telehealth can include remote non- 217 clinical services such as provider training, also rapidly increased. Telehealth can be facilitated through administrative meetings, and continuing a variety of media, including smartphones, the Internet, medical education, and patient-focused videoconferencing, wireless communication, and streaming technologies, in addition to clinical services. It offers alternative, cost-effective care options for individuals living in rural or remote areas or when physically travelling to a health care facility poses signifcant challenges. They can increase access to care in underserved areas and settings; free up time so that service providers can care for more clients; provide alternative care options for individuals hesitant to seek in-person treatment; increase the chances that interventions will be delivered as they were designed and intended to be delivered; and decrease costs. Reduce Your Self-guided web- N = 225 individuals After 6 weeks, the intervention Rooke et al. Electronic Assessments and Early Intervention Several studies have been conducted on technology-assisted screening, assessment, and brief intervention for substance use disorders. Many of these studies focus on Internet-based assessments and brief interventions for at-risk, college-age populations. Early research suggests the value of applying Web-based treatment approaches for moderate levels of substance misuse and for individuals who may not otherwise seek face-to-face treatment. For example, one study explored the effect of adding daily self-monitoring calls to an interactive voice response technology system with personalized feedback and compared it to standard motivational enhancement practice. Study results showed that those who received the intervention reduced the number of drinks they had on the days they did drink. In general, Web- and telephone-based recovery support tools focus on providing remote support to individuals following substance use disorder treatment. However, disparities exist in the outcomes and effectiveness of substance use treatment for different populations. The study concluded that accounting for these factors when tailoring a substance use disorder intervention is critical to meeting the needs of the community it is aiming to serve. Many of the interventions developed for substance use disorder treatment services in general have been evaluated in populations that included Black or African American patients, and many of these interventions are as effective for Black or African American patients as they are for White patients. Multiple research studies have noted that mindfulness, an attentional exercise originally developed in Buddhist cultures, is potentially useful in helping people gain mastery over substance cravings.
Cardiogenic shock By decrease of cardiac output: – Direct injury to the myocardium: infarction order butenafine 15 mg amex anti fungal cream in japanese, contusion cheap butenafine 15mg with mastercard fungus virus, trauma best butenafine 15 mg fungus treatment for grass, poisoning. Clinical features Signs common to most forms of shock – Pallor, mottled skin, cold extremities, sweating and thirst. Cardiogenic shock – Respiratory signs of left ventricular failure (acute pulmonary oedema) are dominant: tachypnoea, crepitations on auscultation. The aetiological diagnosis is oriented by: – The context: trauma, insect bite, ongoing medical treatment, etc. Management according to the cause Haemorrhage – Control bleeding (compression, tourniquet, surgical haemostasis). Antibiotic therapy according to the origin of infection: Origin Antibiotic therapy Alternative Cutaneous staphylococci, streptococci cloxacillin + gentamicin Pulmonary pneumococci, Haemophilus ampicillin or ceftriaxone co-amoxiclav or ceftriaxone influenzae +/- gentamicin + ciprofloxacin Intestinal or biliary enterobacteria, anaerobic co-amoxiclav + gentamicin ceftriaxone + gentamicin bacteria, enterococci + metronidazole Gynaecological streptococci, gonococci, co-amoxiclav + gentamicin ceftriaxone + gentamicin anaerobic bacteria, E. Example: dopamine: 10 micrograms/kg/minute in a patient weighing 60 kg Hourly dose: 10 (micrograms) x 60 (kg) x 60 (min) = 36 000 micrograms/hour = 36 mg/hour In a 50 ml syringe, dilute one 200 mg-ampoule of dopamine with 0. If there is no electric syringe pump, dilution in an infusion bag may be considered. However, it is important to consider the risks related to this type of administration (accidental bolus or insufficient dose). The infusion must be constantly monitored to prevent any, even small, change from the prescribed rate of administration. Example for epinephrine: – In adults: Dilute 10 ampoules of 1 mg epinephrine (10 000 micrograms) in 1 litre of 5% glucose or 0. For administration, use a paediatric infusion set; knowing that 1 ml = 60 drops, in a child weighting 10 kg: • 0. In pregnant women, eclamptic seizures require specific medical and obstetrical care (see Special situation: seizures during pregnancy). Initial treatment During a seizure – Protect from trauma, maintain airway, place patient in ‘recovery position’, loosen clothing. If generalized seizure lasts more than 3 minutes, use diazepam to stop it: diazepam: Children: 0. The patient is no longer seizing – Look for the cause of the seizure and evaluate the risk of recurrence. Status epilepticus Several distinct seizures without complete restoration of consciousness in between or an uninterrupted seizure lasting more than 10 minutes. If necessary, a second dose of 10 mg/kg may be administered (as above) 15 to 30 minutes after the first dose. If necessary, a second dose of 5 to 10 mg/kg may be administered (as above) 15 to 30 minutes after the first dose. There is a high risk of respiratory depression and hypotension, especially in children and elderly patients. Iatrogenic causes – Withdrawal of antiepileptic therapy in a patient being treated for epilepsy should be managed over a period of 4-6 months with progressive reduction of the doses. Only patients with chronic repetitive seizures require further regular protective treatment with an antiepileptic drug, usually over several years. However, these risks must be balanced with the risks of aggravation of the epilepsy, ensuing seizure-induced cerebral damage and other injury if the patient is not treated. The effective dose must be reached progressively and symptoms and drug tolerance evaluated every 15 to 20 days. The rate of dose reduction varies according to the length of treatment; the longer the treatment period, the longer the reduction period (see Iatrogenic causes). In the same way, a change from one antiepileptic drug to another must be made progressively with an overlap period of a few weeks. Adults: initial dose of 600 mg/day in 2 divided doses; increase by 200 mg/day every 3 days until the optimal dose for the individual has been reached (usually 1 to 2 g/day in 2 divided doses). Adults: initial dose of 200 mg/day in 1 or 2 divided doses; increase by 200 mg every week until the optimal dose for the individual has been reached (usually 800 to 1200 mg/day in 2 to 4 divided doses). Then infuse 1 g/hour, continue magnesium sulfate for 24 hours following delivery or the last seizure. Before each injection, verify the concentration written on the ampoules: it comes in different concentrations. Always have calcium gluconate ready to reverse the effects of magnesium sulfate in the event of toxicity. Other causes During pregnancy, consider that seizures may also be caused by cerebral malaria or meningitis; the incidence of these diseases is increased in pregnant women. Blood glucose levels should be measured whenever possible in patients presenting symptoms of hypoglycaemia. If hypoglycaemia is suspected but blood glucose measurement is not available, glucose (or another available sugar) should be given empirically. Always consider hypoglycaemia in patients presenting impaired consciousness (lethargy, coma) or seizures. Clinical features Rapid onset of non-specific signs, mild to severe depending on the degree of the hypoglycaemia: sensation of hunger and fatigue, tremors, tachycardia, pallor, sweats, anxiety, blurred vision, difficulty speaking, confusion, convulsions, lethargy, coma. Diagnosis Capillary blood glucose concentration (reagent strip test): – Non-diabetic patients: • Hypoglycaemia: < 60 mg/dl (< 3. Symptomatic treatment – Conscious patients: Children: a teaspoon of powdered sugar in a few ml of water or 50 ml of fruit juice, maternal or therapeutic milk or 10 ml/kg of 10% glucose by oral route or nasogastric tube. Adults: 15 to 20 g of sugar (3 or 4 cubes) or sugar water, fruit juice, soda, etc. If there is no clinical improvement, differential diagnoses should be considered: e. If patient does not return to full alertness after an episode of severe hypoglycaemia, monitor blood glucose levels regularly. Treat the cause – Other than diabetes: • Treat severe malnutrition, neonatal sepsis, severe malaria, acute alcohol intoxication, etc. Record the temperature as measured and if taken using the rectal or axillary route. In a febrile patient, first look for signs of serious illness then, try to establish a diagnosis. There is an increased risk of severe bacterial infectiona if the rectal temperature is ≥ 38°C in children 0 to 2 months; ≥ 38. Signs of severity – Severe tachycardia, tachypnoea, respiratory distress, oxygen saturation ≤ 90%. Infectious causes of fever according to localizing symptoms Signs or symptoms Possible aetiology Meningeal signs, seizures Meningitis/meningoencephalitis/severe malaria Abdominal pain or peritoneal signs Appendicitis/peritonitis/typhoid fever Diarrhoea, vomiting Gastroenteritis/typhoid fever Jaundice, enlarged liver Viral hepatitis Cough Pneumonia/measles/tuberculosis if persistent Ear pain, red tympanic membrane Otitis media Sore throat, enlarged lymph nodes Streptococcal pharyngitis, diphtheria Dysuria, urinary frequency, back pain Urinary tract infection Red, warm, painful skin Erysipelas, cellulitis, abscess Limp, difficulty walking Osteomyelitis/septic arthritis Rash Measles/dengue/haemorrhagic fever/Chikungunya Bleeding (petechiae, epistaxis, etc. Do not wrap children in wet towels or cloths (not effective, increases discomfort, risk of hypothermia). It is expressed differently by each patient depending on cultural background, age, etc.
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Cluster outbreak of Pneumocystis pneumonia among kidney transplant patients within a single center generic butenafine 15 mg amex antifungal for nails. Molecular evidence of interhuman transmission in an outbreak of Pneumocystis jirovecii pneumonia among renal transplant recipients buy discount butenafine 15 mg online fungus gnats treatment. A cluster of Pneumocystis jirovecii infection among outpatients with rheumatoid arthritis order butenafine cheap online fungus in blood. Molecular evidence of nosocomial Pneumocystis jirovecii transmission among 16 patients after kidney transplantation. The risk of Pneumocystis carinii pneumonia among men infected with human immunodeficiency virus type 1. Risk factors for primary Pneumocystis carinii pneumonia in human immunodeficiency virus-infected adolescents and adults in the United States: reassessment of indications for chemoprophylaxis. Epidemiology of Pneumocystis carinii pneumonia in an era of effective prophylaxis: the relative contribution of non-adherence and drug failure. Pneumocystis carinii pneumonia: a comparison between patients with the acquired immunodeficiency syndrome and patients with other immunodeficiencies. Severe exercise hypoxaemia with normal or near normal X-rays: a feature of Pneumocystis carinii infection. Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host. Diagnosis of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected patients with polymerase chain reaction: a blinded comparison to standard methods. Diagnosis of pneumocystis pneumonia using serum (1-3)-beta-D-Glucan: a bivariate meta-analysis and systematic review. Quantification and spread of Pneumocystis jirovecii in the surrounding air of patients with Pneumocystis pneumonia. A Pneumocystis jirovecii pneumonia outbreak in a single kidney- transplant center: role of cytomegalovirus co-infection. A controlled trial of aerosolized pentamidine or trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus infection. Efficacy and toxicity of two doses of trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus. A randomized trial of daily and thrice-weekly trimethoprim- sulfamethoxazole for the prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected persons. Atovaquone suspension compared with aerosolized pentamidine for prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected subjects intolerant of trimethoprim or sulfonamides. Discontinuation of primary prophylaxis for Pneumocystis carinii pneumonia and toxoplasmic encephalitis in human immunodeficiency virus type I-infected patients: the changes in opportunistic prophylaxis study. A prospective multicentre study of discontinuing prophylaxis for opportunistic infections after effective antiretroviral therapy. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. Sulfa use, dihydropteroate synthase mutations, and Pneumocystis jiroveccii pneumonia. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. The National Institutes of Health-University of California Expert Panel for Corticosteroids as Adjunctive Therapy for Pneumocystis Pneumonia. Consensus statement on the use of corticosteroids as adjunctive therapy for pneumocystis pneumonia in the acquired immunodeficiency syndrome. The effect of adjunctive corticosteroids for the treatment of Pneumocystis carinii pneumonia on mortality and subsequent complications. Oral therapy for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. Trimethoprim-sulfamethoxazole or pentamidine for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. Clindamycin-primaquine versus pentamidine for the second-line treatment of pneumocystis pneumonia. Pentamidine aerosol versus trimethoprim-sulfamethoxazole for Pneumocystis carinii in acquired immune deficiency syndrome. Risk factor analyses for immune reconstitution inflammatory syndrome in a randomized study of early vs. Life-threatening immune reconstitution inflammatory syndrome after Pneumocystis pneumonia: a cautionary case series. Adverse reactions to trimethoprim-sulfamethoxazole in patients with the acquired immunodeficiency syndrome. Long-term safety of discontinuation of secondary prophylaxis against Pneumocystis pneumonia: prospective multicentre study. The teratogenic risk of trimethoprim-sulfonamides: a population based case-control study. Neural tube defects in relation to use of folic acid antagonistis during pregnancy. Is first trimester exposure to the combination of antiretoviral therapy and folate antagonists a risk factor for congenital abnormalities? Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. Failure of trimethoprim/sulfamethoxazole prophylaxis for Pneumocystis carinii pneumonia with concurrent leucovorin use. Respiratory failure in pregnancy due to Pneumocystis carinii: report a successful outcome. Pneumonia during pregnancy: has modern technology improved maternal and fetal outcome? Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies. Maternal drug use and infant cleft lip/palate with special reference to corticoids. Safety, efficacy and determinants of effectiveness of antimalarial drugs during pregnancy: implications for prevention programmes in Plasmodium falciparum-endemic sub-Saharan Africa. Embryofetal effects of pentamidine isethionate administered to pregnant Sprague-Dawley rats. Disease appears to occur almost exclusively because of reactivation of latent tissue cysts. Epidemiology Seroprevalence of anti-Toxoplasma antibody varies substantially among different geographic locales, with a prevalence of approximately 11% in the United States, versus 50% to 80% in certain European, Latin American, and African countries. If patients are truly seronegative, their toxoplasmosis presumably represents one of three possible scenarios: 1) Primary infection, 2) Re-activation of latent disease in individuals who cannot produce detectable antibodies, or 3) Testing with insensitive assays. In the United States, eating raw shellfish including oysters, clams, and mussels recently was identified as a novel risk factor for acute infection. Focal neurological abnormalities may be present on physical examination, and in the absence of treatment, disease progression results in seizures, stupor, coma, and death.