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By: J. Eduardo Calonje, MD, DipRCPath

bulletDirector of Diagnostic Dermatopathology, Department of Dermato-Histopathology, St John's Institute of Dermatology, St Thomas' Hospital, London, UK

In the preantibiotic era medications 563 generic cytoxan 50mg on-line, about 10% of recovered patients had relapses medicine 54 092 generic 50mg cytoxan with visa, and chloramphenicol treatment has not reduced this rate medications for schizophrenia generic cytoxan 50mg without prescription. Intestinal bleeding or perforation occurs in about 5% of patients and may not be prevented by antibiotic treatment medicine 44 159 order cytoxan 50 mg otc. Thus, bleeding or perforation is occasionally detected after patients have defervesced during treatment. Travelers to developing countries should avoid consuming untreated water, drinks served with ice, peeled fruits, and other food that is not served hot. American international travelers face an overall risk of developing typhoid fever of fewer than 1 case in 10,000 trips, but travelers to high-risk countries like India 1683 and Pakistan have a probability of about 4 in 10,000 trips of getting typhoid fever. Travelers wishing immune protection should receive either typhoid vaccine live oral Ty21a given as one capsule every other day for a total of four capsules or typhoid Vi polysaccharide vaccine given as a single intramuscular injection, with booster doses given every 2 years if needed. These vaccines give only partial protection, and thus vaccinated persons should still exercise dietary precautions. The traditional method of controlling typhoid is to follow stool cultures of convalescent cases and report positive cultures to the health department. The health department investigates non-imported typhoid cases to identify possible food sources or contact with a chronic carrier. Review of field trials of three different vaccines concluded that whole cell vaccines were most effective but the live oral Ty21a and Vi polysaccharide vaccines were less toxic. In Indonesian patients, tumor necrosis factor and interleukins 6 and 8 were modestly elevated, but anti-inflammatory molecules, including receptors for tumor necrosis factor and interleukin-1 receptor antagonist, were more prominent. In China, India, and Pakistan, large numbers of cases of infection caused by Salmonella typhi resistant to ampicillin, chloramphenicol, and trimethoprim/sulfamethoxazole have emerged. In Vietnam, a short course of ofloxacin for 5 days was more effective than a 3-day course of ceftriaxone. A case report of an unimmunized pregnant patient who recently returned from India is presented. Prevention of infection by the live oral Ty21a vaccine or the Vi polysaccharide vaccine for travelers is advised. Salmonella, a genus of the family Enterobacteriaceae, can cause an asymptomatic intestinal carrier state or clinical disease in both humans and animals. In humans, the most common clinical manifestation is enterocolitis, with diarrhea as the major symptom. Localization from bacteremia may result in osteomyelitis, a mycotic aneurysm, or other localized infection. An asymptomatic intestinal carrier state of variable duration may follow inapparent or symptomatic infection. A chronic carrier state, defined as lasting more than 1 year, is usually permanent and is most often related to persistent infection in the gallbladder. As another confounding exception, lactose-fermenting strains of salmonellae have been isolated. Salmonellae can be differentiated into over 2000 serotypes (serovars) by their somatic (O) antigens, which are composed of lipopolysaccharides and are part of the cell wall, and their flagellar (H) antigens. Each serovar is commonly referred to as a separate species and is so indicated in this chapter. The remaining serovars of salmonellae are widely spread in the animal kingdom, and salmonellae have been isolated from virtually all species, including birds, poultry, mammals, reptiles, amphibians, and insects. Salmonella infection in humans usually occurs from ingesting contaminated animal food products, most often eggs, poultry, and meat. Eggs usually become contaminated from feces on the surface of the egg, with small cracks allowing entry into the egg. However, infection of the ovary allows primary incorporation of salmonellae into the egg. Meat and poultry become widely contaminated at the slaughterhouse with salmonellae spread from carcass to carcass, usually on the surface. Salmonellae may survive cooking at relatively low temperatures in the center of eggs or turkeys, or food may be contaminated after cooking from kitchen utensils or from the hands of food preparers who handle raw food. This was related to transport of pasteurized ice cream base in containers previously used for transport of non-pasteurized liquid eggs. Salmonella infections have been acquired after contamination of food or water with feces of pet turtles, chicks, ducks, birds, dogs, cats, and many other species.

Urban yellow fever was a major killer until the early 1900s medicine in french safe cytoxan 50 mg, when mosquito control in Havana symptoms cervical cancer purchase 50 mg cytoxan otc, Rio de Janeiro symptoms 28 weeks pregnant discount cytoxan 50 mg with mastercard, Guayaquil medications elavil side effects order 50 mg cytoxan, and other large urban centers eliminated the disease. Major epidemics were recorded in Ethiopia, 1960-1962; Nigeria, 1969; Senegal, 1965 and 1979; Gambia, 1978; Ghana and Burkina Faso, 1983; and Kenya, 1993. In 1986, an epidemic involving at least 3000 persons occurred in Nigeria, in Benue and Cross River States, and it extended into Oyo and Niger States in 1987. In addition, some African epidemics are maintained by other Aedes species, such as A. After urban yellow fever had been controlled in the Americas, sporadic cases continued to occur in persons exposed to mosquitoes in the jungles of South America and Africa. This sylvan form is maintained in tropical America by Haemagogus mosquitoes and forest primates, and sometimes by other sylvan animals. Evidence favors the hypothesis that the virus moves through the forest, cycling in one place until the monkeys are immune, then dying out and moving to areas where susceptible monkeys live. Sylvan yellow fever extends periodically outside the enzootic zone into forests such as those in Panama and Central America. The virus can be maintained over dry periods by transovarial transmission in mosquitoes, although it remains to be shown whether maintenance in mosquito eggs is more than a temporary mechanism. The sylvan cycle in Africa is more complicated than in the Americas; in tropical Africa, the virus cycles between A. Modern oceangoing ships no longer harbor mosquito-breeding sites, but the mosquito continues to travel by small boats, airplanes, and cars, and especially in the form of dried eggs transported by used tires. Cities such as Rio de Janeiro, which were once freed of the mosquito, are now reinfested, as are most tropical Latin American cities. To control the mosquito again in the Americas will be difficult because of insecticide resistance, population growth, and the high price of labor and materials. Jungle yellow fever continues to cycle, reappearing in the same locale every 5 to 40 years. The scene is thus set again for emergence of the virus from the jungle to reinitiate the urban cycle in the Americas. It has white thoracic scales in the shape of a lyre and black legs with white bands. Mosquitoes that have fed on a viremic vertebrate become infective after an extrinsic incubation period of 9 to 30 days, the shorter periods correlating with higher ambient temperatures. This extrinsic incubation period in the mosquito accounts for the delay from the first human infection in an urban outbreak to subsequent clusters of infection. India and other Asian nations require vaccination of travelers from yellow fever-endemic regions. However, sylvan yellow fever is found almost always in young males because they are the individuals who venture into the forest. During an epidemic, the population at risk may therefore be limited to age groups not covered by prior immunization or those born since a prior outbreak. There is also some evidence that persons may be protected by antibody to heterologous flaviviruses. During the 24-year period from 1965 to 1988, 3324 cases of yellow fever were reported in the Americas and 7701 in Africa. The lesions of yellow fever involve primarily the liver, heart, kidneys, and lymphoid tissues. Grossly, the skin is icteric, and there may be multiple hemorrhages or petechiae of the skin, mucous membranes, and multiple organs. Histologic findings are often characteristic in patients who die before the ninth day of illness, but the lesions are not always pathognomonic. Hepatocyte destruction is most marked in the midzone of the lobule, with relative sparing of the central vein and portal areas. Intranuclear eosinophilic granular inclusions or enlarged nucleoli (Torres bodies) are also described.

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Other contributors medications 563 discount cytoxan 50 mg amex, including immune system dysfunction treatment yeast infection nipples breastfeeding purchase 50mg cytoxan visa, orthostatic hypotension medications j-tube buy 50mg cytoxan visa, and endocrinologic systems symptoms chlamydia cheap 50 mg cytoxan with amex, are under investigation. There are as yet no credible neurobiologic explanations for the somatoform disorders. They must be understood as psychological phenomena, with variable levels of self-awareness in each individual as to the factitious nature of the disorder. Freud and his colleagues believed that symptoms could be produced by a process of dissociation-the expulsion from consciousness of a painful memory or feeling and its replacement by a physical symptom. Onset is usually early in life, and psychosocial and vocational achievements are limited. Conversion disorder Pain disorder Hypochondriasis Body dysmorphic disorder Factitious disorder Malingering Syndrome of symptoms or deficits mimicking neurologic or medical illness in which psychological factors are judged to be of etiologic importance. Clinical syndrome characterized predominantly by pain in which psychological factors are judged to be of etiologic importance. Preoccupation with an imagined or exaggerated defect in physical appearance Other Somatoform-Like Disorders Intentional production or feigning of physical or psychological signs when external reinforcers. Intentional production or feigning of physical or psychological signs when external reinforcers. Dissociative disorders Disruptions of consciousness, memory, identity, or perception judged to be due to psychological factors. This protection afforded from the psychological pain and stress is referred to as the primary gain of the somatoform illness. The primary gain is usually not readily discernible, since the patient is almost always unaware of it. The secondary gain associated with a conversion illness refers to the clearly visible financial gain or relief from responsibility conferred by the sick role. Such gains may be seen in many guises, such as disability pensions, relief from work, enhanced attention from family and physicians, and litigation payouts. Cross-sectional studies of patients attending general neurologic clinics indicate high prevalence rates of 15 to 20% in these populations. Disorder-specific and population-based studies are not available for these disorders. The long-term goal of treatment for the somatoform disorders is to enable the patient to convert from a medical into a psychiatric patient. General medical interventions may be invoked initially, including biologic tests, medical rehabilitation, and pharmacotherapy. These interventions may make sense if an underlying medical disease is present or if the patient adamantly views the illness as a physical one. The danger of biologic interventions is that they may strengthen the conviction on the part of the patient that the illness is physical. If a pharmacologically accessible symptom complex, such as anxiety or depression, accompanies the conversion phenomena, it may be helpful to initiate psychopharmacologic treatment. It is unclear how often the treatment of associated emotional symptoms results in improvement of conversion symptoms, but this approach is clearly effective on occasion. Action and style are additional dimensions of behavior that are essential to success and satisfaction in life. Sustained dysfunctional patterns of coping with the world are called character disorders. An individual is typically unaware of these style qualities since they are formed in childhood as enduring aspects of the personality. Some individuals demonstrate clusters of maladaptive traits that cause recurrent psychosocial difficulties. These clusters of maladaptive traits are called character disorders or personality disorders. We have many names for such character qualities, including honesty, timeliness, reliability, aggressiveness, and submissiveness. The clinical descriptive research that underlies and validates these disorders as distinct clinical entities is more limited than it is for the Axis I disorders. The personality disorders have a spectrum of severity, with poorly specified boundaries and thresholds.

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