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W. Lukar, M.A., Ph.D.

Professor, University of Nevada, Reno School of Medicine

Tooth brushing, flossing, and preventive dental visits by Detroit-area residents in relation to demographic and socioeconomic factors. Renal tubular maximum for magnesium in normal, hyperparathyroid and hypoparathyroid man. High dietary calcium level decreases colonic phytate degradation in pigs fed a rapeseed diet. Vitamin D toxicity complicating the treatment of senile, postmenopausal, and glucocorticoid-induced osteoporosis: Four case reports and a critical commentary on the use of vitamin D in these disorders. Interrelationship of magnesium and estrogen in cardiovascular and bone disorders, eclampsia, migraine and premenstrual syndrome. Influences on skeletal mineralization in children and adolescents: Evidence for varying effects of sexual maturation and physical activity. Effect of dietary calcium and phosphorus levels on the utilization of iron, copper, and zinc by adult males. Effects of vitamin D and calcium on markers of bone metabolism in geriatric patients with low serum 25-hydroxyvitamin D levels. Biochemical markers of bone turnover in lactating and nonlactating postpartum women. Evidence for an interaction between calcium intake and physical activity on changes in bone mineral density. Cyclical serum 25-hydroxyvitamin D concentrations paralleling sunshine exposure in exclusively breast-fed infants. Sunshine exposure and serum 25-hydroxyvitamin D concentrations in exclusively breast-fed infants. Effects of sex, race, age, season, and diet on serum minerals, parathyroid hormone, and calcitonin. Changes in calcium homeostasis over the first year postpartum: Effect of lactation and weaning. Effect of phosphorus on the absorption of calcium and on the calcium balance in man. The reduction of growth-promoting and calcifying properties in a ration by exposure to ultraviolet light. Bone mineralization and growth in term infants fed soy-based or cow milk-based formula. Trabecular bone density in a two year controlled trial of peroral magnesium in osteoporosis. Risk factors in the pathogenesis of arteriosclerotic heart disease and generalized atherosclerosis. Calcium supplementation during pregnancy may reduce preterm delivery in high-risk populations. Subclinical vitamin D deficiency in postmenopausal women with low vertebral bone mass. The influence of numerous pregnancies and lactations on bone dimensions in South African Bantu and Caucasian mothers. An evaluation of the relative contributions of exposure to sunlight and of diet to the circulating concentrations of 25-hydroxyvitamin D in an elderly nursing home population in Boston. Serum free 1,25-dihydroxyvitamin D and the free 1,25-dihydroxyvitamin D index during a longitudinal study of human pregnancy and lactation. Reduction of blood pressure with oral magnesium supplementation in women with mild to moderate hypertension. Subclinical vitamin D deficiency in neonates: Definition and response to vitamin D supplements. Randomized doubleblind study of potassium citrate in idiopathic hypocitraturic calcium nephrolithiasis. The skeleton as an ion exchange system: Implications for the role of acid-base imbalance in the genesis of osteoporosis. The effects of chronic acid and alkali administration on bone turnover in adult rats. Creatinine clearance, electrolytes, and plasma renin activity related to the blood pressure of white and black children-The Bogalusa Heart Study.

The 24-h whole body leucine and urea kinetics at normal and high protein intakes with exercise in healthy adults. Resting metabolic rate and body composition of healthy Swedish women during pregnancy. Effect of chronic dietary treatment with L-tryptophan on spontaneous salt appetite of rats. Role of insulin and branched-chain amino acids in regulating protein metabolism during fasting. Impact of supplemental lysine or tryptophan on pregnancy course and outcome in rats. Adaptation of protein metabolism in relation to limits to high dietary protein intake. Human protein requirements: the effect of variations in energy intake within the maintenance range. Mutagenic activity of glycine upon nitrosation in the presence of chloride and human gastric juice: A possible role in gastric carcinogenesis. Protein-energy requirements of prepubertal school-age boys determined by using the nitrogen-balance response to a mixed-protein diet. Protein-energy requirements of boys 12-14 y old determined by using the nitrogen-balance response to a mixed-protein diet. Gaudichon C, Mahe S, Benamouzig R, Luengo C, Fouillet H, Dare S, Van Oycke M, Ferriere F, Rautureau J, Tome D. Net postprandial utilization of [15N]-labeled milk protein nitrogen is influenced by diet composition in humans. Multicenter, double blind, placebo-controlled, multiple-challenge evaluation of reported reactions to monosodium glutamate. Oral L-histidine fails to reduce taste and smell acuity but induces anorexia and urinary zinc excretion. Effect of oral alanine on blood beta-hydroxybutyrate and plasma glucose, insulin, free fatty acids, and growth hormone in normal and diabetic subjects. Human protein requirements: Assessment of the adequacy of the current Recommended Dietary Allowance for dietary protein in elderly men and women. Mutagenicity spectra in Salmonella typhimurium strains of glutathione, L-cysteine and active oxygen species. Effects of central administration of alanine on body temperature of the rabbit: Comparisons with the effects of serine, glycine and taurine. Substituting ornithine for arginine in total parenteral nutrition eliminates enhanced tumor growth. Influence of leucine on arterial concentrations and regional exchange of amino acids in healthy subjects. Serum amino acid patterns and toxicity symptoms following the absorption of irrigant containing glycine in transurethral prostatic surgery. Hara S, Shibuya T, Nakakawaji K, Kyu M, Nakamura Y, Hoshikawa H, Takeuchi T, Iwao T, Ino H. Observations of pharmacological actions and toxicity of sodium glutamate, with comparisons between natural and synthetic products. Clinical trials of vitamin B6 and proline supplementation for gyrate atrophy of the choroid and retina. Rate and amount of weight gain during adolescent pregnancy: Associations with maternal weight-for-height and birth weight. Cerebellar dysfunction, mental changes, anorexia, and taste and smell dysfunction. L-Tryptophan-associated eosinophilic fasciitis prior to the 1989 eosinophilia-myalgia syndrome outbreak. The effect of a histidineexcess diet on cholesterol synthesis and degradation in rats. Dimethylglycine and chemically related amines tested for mutagenicity under potential nitrosation conditions. L-Glutamine supplementation in home total parenteral nutrition patients: Stability, safety, and effects on intestinal absorption. Sweat losses by and nitrogen balance of preadolescent girls consuming three levels of dietary protein. Protein requirements of normal infants at the age of 1 year: Maintenance nitrogen requirement and obligatory nitrogen losses.

Periodic alternating eye movements have been reported in patients with a variety of structural injuries to the brainstem or even bilateral cerebral infarcts that leave the oculomotor system largely intact, but are most common during metabolic encephalopathies. Spontaneous nystagmus is uncommon in coma because the quick, saccadic phase is generally a corrective movement generated by the voluntary saccade system when the visual image drifts from the point of intended fixation. However, continuous seizure activity with versive eye movements may give the appearance of nystagmus. In addition, several unusual forms of nystagmoid eye movement do occur in comatose patients. Retractory nystagmus consists of irregular jerks of both globes back into the orbit, sometimes occurring spontaneously but other times on attempted upgaze. Electromyography during retractory nystagmus shows that the retractions consist of simultaneous contractions of all six extraocular muscles. Convergence nystagmus often accompanies retractory nystagmus and also is typically seen in patients with dorsal midbrain lesions. The patients were comatose and the movements were not affected by caloric vestibular stimulation. The initially described patients had caudal pontine injuries or compression, although later reports described similar eye movements in patients with obstructive hydrocephalus, uncal herniation, or even metabolic encephalopathy. A variety of related eye movements have been described including inverse bobbing (rapid elevation of the eyes, with bobbing downward back to primary position) and both dipping (downward slow movements with rapid and smooth return to primary position) and inverse dipping (slow upward movements with rapid return to primary position). Seesaw nystagmus describes a rapid, pendular, disjunctive movement of the eyes in which one eye rises and intorts while the other descends and extorts. It is most commonly seen during visual fixation in an awake patient who has severe visual field defects or impairment of visual acuity, and hence is not in a coma. Seesaw nystagmus appears to be due in most cases to lesions near the rostral end of the periaqueductal gray matter, perhaps involving the rostral interstitial nucleus of Cajal. Rather than testing power in specific muscles, it is focused on assessing the overall responsiveness of the patient (as measured by motor response), the motor tone, and reflexes, and identifying abnormal motor patterns, such as hemiplegia or abnormal posturing. Paratonia is often seen in patients with dementia and is normally found in infants between the second and eighth weeks of life, suggesting that it represents a state of disinhibition of forebrain control as the level of consciousness becomes depressed. As patients become more deeply stuporous, muscle tone tends to decrease and these pathologic forms of rigidity are less apparent. Motor Reflexes Muscle stretch reflexes (sometimes erroneously referred to as ``deep tendon reflexes') may be brisk or hyperactive in patients who are drowsy or confused and have increased motor tone. As the level of consciousness becomes further depressed, however, the muscle stretch reflexes tend to diminish in activity, until in patients who are deeply comatose they may be unobtainable. Cutaneous reflexes such as the abdominal or cremasteric reflex typically become depressed as the level of consciousness wanes. On the other hand, in patients who are drowsy or confused, some abnormal cutaneous reflexes may be released. If the extensor plantar response is bilateral, this may signify nothing more than a depressed level of consciousness, but if it is asymmetric or unilateral, this implies injury to the descending corticospinal tract. Prefrontal cutaneous reflexes, sometimes called ``frontal release reflexes' or primitive reflexes,135 may also emerge in drowsy patients with diffuse forebrain impairment. Rooting, glabellar, snout, palmomental, and other reflexes are often seen in such patients. However, these responses become increasingly common with advancing age in patients without cognitive impairment, so they are of limited value in elderly individuals. The grasp is often so strong that it is possible to pull the patient from the bed. Many elderly Motor Tone Assessment of motor tone is of greatest value in patients who are drowsy but responsive to voice. Tone can also be assessed in the neck by gently grasping the head with two hands and moving it back and forth or up and down, and in the lower extremities by grasping each leg at the knee and gently lifting it from the bed or shaking it from side to side. Normal muscle tone provides mild resistance that is constant or nearly so throughout the movement arc and of similar intensity regardless of the initial position of the body part. Spastic rigidity, on the other hand, increases with more rapid movements and generally has a clasp-knife quality or a spastic catch, so that the movement is slowed to a near stop by the resistance, at which point the resistance collapses and the movement proceeds again.

Performance standards for antimicrobial susceptibility testing: twentieth informational supplement. Two cases of multidrugresistant Neisseria gonorrhoeae related to travel in south-eastern Asia, France, June 2019. First cases of Neisseria gonorrhoeae resistant to ceftriaxone in Catalonia, Spain, May 2011. Molecular characterization of two high-level ceftriaxone-resistant Neisseria gonorrhoeae isolates detected in Catalonia, Spain. Gonorrhoea treatment failure caused by a Neisseria gonorrhoeae strain with combined ceftriaxone and high-level azithromycin resistance, England, February 2018. Pharmacokinetic data are predictive of in vivo efficacy for cefixime and ceftriaxone against susceptible and resistant Neisseria gonorrhoeae strains in the gonorrhea mouse model. The efficacy and safety of gentamicin plus azithromycin and gemifloxacin plus azithromycin as treatment of uncomplicated gonorrhea. Gentamicin compared with ceftriaxone for the treatment of gonorrhoea (G-ToG): a randomised non-inferiority trial. In vitro efficacy of 21 dual antimicrobial combinations comprising novel and currently recommended combinations for treatment of drug resistant gonorrhoea in future era. Intersecting epidemics and educable moments: sexually transmitted disease risk assessment and screening in men who have sex with men. Sexually transmitted infections among brothel-based sex workers in Tel-Aviv area, Israel: high prevalence of pharyngeal gonorrhoea. Extragenital chlamydia and gonorrhea among community venueattending men who have sex with men-five cities, United States, 2017. Evidence for a new paradigm of gonorrhoea transmission: cross-sectional analysis of Neisseria gonorrhoeae infections by anatomical site in both partners in 60 male couples. Early repeat Chlamydia trachomatis and Neisseria gonorrhoeae infections among heterosexual men. Genetic characterization and enhanced surveillance of ceftriaxone-resistant Neisseria gonorrhoeae strain, Alberta, Canada, 2018. IgE-mediated hypersensitivity to cephalosporins: cross-reactivity and tolerability of penicillins, monobactams, and carbapenems. Tr e am e no f g o n o c o c c a l conjunctivitis with single-dose intramuscular ceftriaxone. Characteristics and impact of disseminated gonococcal infection in the "Top End" of Australia. Disseminated gonococcal infections in patients receiving eculizumab: a case series. Periocular ulcerative dermatitis associated with gentamicin ointment prophylaxis in newborns. Severe ocular reactions after neonatal ocular prophylaxis with gentamicin ophthalmic ointment. Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections in men with nongonococcal urethritis: predictors and persistence after therapy. Mycoplasma genitalium detected by transcription-mediated amplification is associated with Chlamydia trachomatis in adolescent women. Mycoplasma genitalium infections in asymptomatic men and men with urethritis attending a sexually transmitted diseases clinic in New Orleans. The overall agreement of proposed definitions of mucopurulent cervicitis in women at high risk of Chlamydia infection. The immunopathogenesis of Mycoplasma genitalium infections in women: a narrative review. The association between Mycoplasma genitalium and pelvic inflammatory disease after termination of pregnancy. Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service.

Tx: plasma exchange, no plts unless bleeding; role of steroids & rituximab still debated. If only urticarial sx treat symptomatically, resume transfusion once Sx resolve 3. Sx: cardiomyopathy, purpura, nephrotic syndrome, peripheral neuropathy, orthostasis, hepatomegaly, macroglossia. Use clinical judgement based on acuity of illness prior to engaging in conversation; may be preferable to discuss w/ outpatient providers first Reference guide above for opening conversation (Introduce and Assess understanding steps) Suggested Prompts See table on above for suggested prompts "Unfortunately, we are in a different place now. Ask family if they would like to see a Chaplain or Social Worker or have last rites. Choose the smallest syringe that will hold the dose (smaller barrel clearer scale markings). Insulin Secretagogues: stimulate release of insulin from pancreatic beta cells, thus only effective in pts who still have beta cell function Sulfonylureas: - Severe renal or hepatic - Affordable second oral - Weight gain $5 Glipizide 2. Continue home insulin regimen with dose reduction (~25-50% reduction) given expected change in diet while hospitalized. Hypoglycemia is associated with increased mortality in elderly, so reasonable to be cautious. Allow patient to drink to thirst and if unable to drink, oral or nasogastric water is preferred to avoid rapid changes in serum sodium. Iodine (100-250mg Q6-Q8H) must be given at least critically ill (T4 conversion to T3 takes several days), give only 1hr after thionamide; can cause Jod-Basedow in toxic adenoma with endo guidance, can cause rebound hypermetabolism and Wolff-Chaikoff in Graves. Consider preventive tx perimenstrually w/ slow Nasal: Sumatriptan 5-20mg q2hrs (max 40mg/day), triptan (frovatriptan) 2. In acute setting it may be helpful to educate patients about functional neurologic symptoms. Typically involves ocular (ptosis, diplopia), bulbar, respiratory, neck and proximal>distal limb muscles. Studies of neurological prognostication are hampered by heterogenous patient populations and variable definitions of "coma". Poor prognosis: Bilateral absence of N20, which reflects the integrity of thalamocortical projections. If patient on clozapine, consult psychiatry early to continue medication in house. Relevant Clinical Information: At minimum: diagnosis, proposed intervention, its purpose, its risks/benefits, alternatives, and risks/benefits of alternatives (including no intervention) 2. Voluntary Decision: the decision must be voluntary and without coercion from hospital staff or family/friends 3. Documenting Capacity Assessment: "Based upon my evaluation of the pt, he/she does/does not express a consistent preference regarding the proposed treatment, does/does not have a factual understanding of the current situation as evidenced by [example], does/does not appreciate the risks and benefits of treatment and non-treatment, and is able/unable to rationally manipulate information to make a decision as evidenced by [example]. Therefore, in my opinion, this pt has/lacks capacity to make this medical decision. Normal pupils do not exclude opioid toxicity co-ingestions may be sympathomimetic/anticholinergic. Can give additional 4mg/1mg for withdrawal symptoms, but max dose for Day #2 is 16mg suboxone. Commonly used benzos Comparative dosages (approx) Half-life (hours) (approx) alprazolam (Xanax)* 0. If tibia feels unrestrained, positive test Posterior drawer Pt supine with knee flexed, can stabilize foot by sitting on it. Glenohumeral Arthritis/ Aching, stiff; chronic loss of active and passive motion in all planes.