By: Christopher Whaley PhD
Furthermore hair loss cure 9090 0.5mg dutas mastercard, we aim to recognize words from continuous speech hair loss cure kurosawa order dutas 0.5 mg without prescription, where words are not segmented hair loss cure 2015 cheap dutas 0.5 mg otc, and there may be co-articulation of the lips from preceding and subsequent words hair loss 5 months after baby buy 0.5mg dutas otc. In lip-reading there is a fundamental limitation on performance due to ho- mophemes hair loss cure prediction dutas 0.5 mg discount. These are sets of words that sound dierent, but involve identical movements of the speakers lips. For example, in English the phonemes p b and m are visu- ally identical, and consequently the words mark, park and bark, are homophemes (as are pat, bat and mat) and so cannot be distinguished by lip-reading. This problem has been well studied and there are lists of ambiguous phonemes and 2 J. It is worth noting that the converse problem also applies: for example m and n are easily confused as audio, but are visually distinct. We take account of such homopheme ambiguity in assessing the performance of our methods. Apart from this limitation, lip-reading is a challenging problem in any case due to intra-class variations (such as accents, speed of speaking, mumbling), and adversarial imaging conditions (such as poor lighting, strong shadows, motion, resolution, foreshortening, etc. The usual approach to inference for temporal sequences is to employ se- quence models such as Hidden Markov Models or Recurrent Neural Networks (e. For lip-reading such models can be employed for predicting indi- vidual characters or phonemes. Clearly, visual registration is an important element to consider in the design of the networks. Typically, the imaged head will move in the video, either due to actual movement of the head or due to camera motion. One approach would be to tightly register the mouth region (including lips, teeth and tongue, that all contribute to word recognition), but another is to develop networks that are tolerant to some degree of motion jitter. We make contributions in two areas: rst, we develop a pipeline for automated large scale data collection, including visual and temporal alignment. In particular we propose and compare dierent input and temporal fusion architec- tures, and discuss their pros and cons (Section 3). We analyse the performance and ambiguity of the resulting classications in Section 4. As discussed in the related work below, in these three aspects: speaker in- dependence, learning from continuous speech, and lexicon (vocabulary) size, we go far beyond the current state of the art. Many of the existing works in this eld have followed similar pipelines which rst extract spatio- temporal features around the lips (either motion-based, geometric-feature based or both), and then align these features with respect to a canonical template. Lip Reading in the Wild 3 A number of recent papers have used deep learning methods to tackle prob- lems related to lip reading. One of the major obstacle to progress in this eld has been the lack of suitable datasets . The amount of available data is far from sucient to train scalable and representative models that will be able to generalise beyond the controlled environments and the very limited domains (e. I for Isolated (one word, letter or digit per recording); C for Continuous recording. Their work shows that it is feasible to train a general and scalable word recognition model for a large pre-dened dictionary, as a multi-class classication problem. Of relevance to the architectures and methods developed in this paper are ConvNets for action recognition that learn from multiple-frame image sequences such as [12, 13, 35], particularly the ways in which they capture spatio-temporal information in the image sequence using temporal pooling layers and 3D convo- lutional lters. Zisserman 1000s of hours of spoken text covering an extensive vocabulary of 1000s of dif- ferent words, with over 1M word instances, and over 1000 dierent speakers. The key ideas are to: (i) obtain a temporal alignment of the spoken audio with a text transcription (broadcast as subtitles with the program). This in turn provides the time alignment between the visual face sequence and the words spoken; (ii) obtain a spatio-temporal alignment of the lower face for the frames corresponding to the word sequence; and, (iii) determine that the face is speaking the words. The pipeline is summarised in Figure 2 and the individual stages are discussed in detail in the following paragraphs. We require programs that have a chang- ing set of talking heads, so choose news and current aairs, rather than dramas with a xed cast. There is a signicant variation of format across the programs – from the regular news where a single speaker is talking directly at the camera, to panel debate where the speakers look at each other and often shifts their attention. The yield is the proportion of useful face appearance relative to the total length of video. A useful face appearance is one that appears continuously for at least 5 seconds, with the face being that of the speaker. We require the alignment between the audio and the subtitle in order to get a timestamp for every word that is being spoken in the videos. The subtitles are not time-aligned, and also not verbatim as they are generated live. This method of obtaining the alignment has signicant performance benets over regular speech recognition methods that do not use prior knowledge of what is being said. The alignment result, however, is not perfect due to: (1) the method often misses words that are spoken too quickly; (2) the subtitles are not verbatim; (3) the acoustic model is only trained to recognise American English. In this case, the only remaining label noise is where an interview is dubbed in the news, which is rare. The shot boundaries are determined to nd the within-shot frames for which face tracking is to be run. If the track overlaps with face detections on the majority of frames, it is assumed to be correctly tracking the face. Facial landmarks are needed to (1) determine the mouth position for cropping; and (2) for speaker/ non-speaker classication. Facial landmarks are determined in every frame of the face track using the method of  (Figure 4 right). To identify who is speaking, we assume that a person speaking will have lip movements that fall within a particular frequency range that is dierent to that arising from tracking noise. The openness of the mouth is measured on every frame using the distance between the top and the bottom lip, normalised with respect to the size of the face in the video. For a speaking face, the openness signal contains the actual lip motion as well as the tracking noise, whereas for a non-speaking face (e. A simple method of taking the Fourier transform of the mouth openness temporal signal is performed to separate the lip movements that fall into dierent frequencies bins. Note that we leave a weeks gap between the test set and the rest in case any news footage is repeated. The lexicon is obtained by selecting the 500 most frequently occurring words between 5 and 10 characters in length (Figure 6 gives the word duration statistics). This word length is chosen such that the speech duration does not exceed the xed one-second bracket that is used in the recognition architecture, whilst shorter words are not included because there are too many ambiguities due to homophemes (e. Regardless of the actual duration of the word, we take a 1- second clip for training and test. These 500 words occur at least 800 times in the training set, and at least 40 times in each of the validation and test sets. For each of the occurrences, the one-second clip is taken, and the face is cropped with the mouth centered using the registration found in Stage 4. The words are not isolated, as is the case in other lip-reading datasets; as a result, there may be co-articulation of the lips from preceding and subsequent words. Set Dates # class #/class Train 01/01/2010 - 28/02/2015 500 800+ Val 01/03/2015 - 25/07/2015 500 50 Test 01/08/2015 - 31/03/2016 500 50 Table 3. The input format to the network is a sequence of mouth regions, as shown in Figure 5. Previous attempts at visual speech recognition have relied on very precise localisation of the facial landmarks (the mouth in 8 J. Zisserman particular); our aim is learn from from more noisy data, and tolerate some lo- calisation irregularities both in position and in time. We develop and compare four models that dier principally in how they ingest the T input frames (where here T= 25 for a 1 second interval). These variations take inspiration from previous work on human action classi- cation [12, 13, 35, 42]. We next describe the four architectures, summarized in Figure 7, followed by a discussion of their dierences. This architecture is inspired by the work of  on human action recognition using 3D ConvNets. The network ingests a T-channel image, where each of the channels encode an individual frame in greyscale. This method is related to the Early Fusion model in , which takes colour images and uses a T3-channel convolutional lter at conv1. We did experiment with 253-channel colour input, but found that the increased number of parame- ters at conv1 made training dicult due to overtting (resulting in validation performance that is around 5% weaker; not quoted in Section 4). There are T= 25 towers with common conv1 layers (with shared weights), each of which takes an input frame. The activations from the towers are concatenated channel-wise after pool1, producing an output ac- tivation with 1200 channels. The subsequent 11 convolution is performed to reduce this dimension, to keep the number of parameters at conv2 at a man- agable level. There are two basic divisions of the architectures: between early fusion and multiple towers, and between 2D and 3D convolutions. The models perform time- domain operations beginning from the rst layer to precisely capture local motion direction and speed . For these methods to capture useful information, good registration of details between frames is critical. However, we are not imposing strict registration, and in any case it goes slightly against the signal (lip motion and mouth region deformation) that we are trying to capture. This gives tolerance against minor registration errors (the receptive eld size at conv2 is 11 pixels). The experimental results show that these registration- tolerant models gives a modest improvement over their counterparts, and the 10 J. Zisserman performance improvement is likely to be more signicant where the tracking quality is less ideal. In contrast the 2D convo- lutions extend over the entire temporal range, and thus might be thought to waste parameters or require redundancy when trying to respond to such spatio- temporal features. Despite this intuition, the experimental results show that the 2D convolutions are superior to their 3D counterparts. This was chosen as 112112 pixels, which is smaller than that typically used in image classication networks. Data augmentation often helps to improve validation performance by reducing overtting in ConvNet image classication tasks . We apply the augmentation techniques used on the ImageNet classication task by [18, 32] (e. It was not feasible to scale in the time-domain as this results in artifacts being shown due to the relatively low video refresh rate of 25fps. The training was stopped after 20 epochs, or when the validation error did not improve for 3 epochs, whichever is sooner.
Wyllies Treatment of Epilepsy hair loss cure yale cheap dutas 0.5mg line, Principles and Practice hair loss in men grooming proven 0.5 mg dutas, 5th drug with a generic prescription hair loss cure 300 order dutas pills in toronto. Wyllies Treatment of Epilepsy hair loss 7 year cycle buy generic dutas 0.5 mg line, Principles and treating epilepsy patients must discuss the possibility of Practice hair loss in men whom men buy cheap dutas 0.5mg, 5th edn, Lippincot Williams and Wilkins: Philadelphia, Pa, 2011:614-621. Wyllies Treatment of Epilepsy, Principles and Practice, 5th edn, generics may be undesirable. Wyllies Treatment of Epilepsy, Principles and New aEds have expanded our therapeutic options for Practice, 5th edn, Lippincot Williams and Wilkins: Philadelphia, treating difcult to treat epilepsies. Seizures exacerbated by antiepileptic drugs in patient giving serious thought about risk beneft ratio. Psychology, pharmacotherapy and new new aEds as these may unfold with wider use, as happened diagnostic approaches. Benzodiazepines in the treatment of epilepsy: randomized controlled trial to assess acceptability of Phenobarbital a review. Epilepsia controlled, crossover study of lamotrigine in treatment-resistant 1997;38:1261-1264. Lamotrigine versus valproic acid as frst line monotherapy in newly diagnosed atypical 35. Tiagabine therapy for crossover add-on trial of lamotrigine in patients with treatment- complex partial seizures: a dose frequency study. Tiagabine for complex efcacy and safety of lamotrigine in patients with partial seizures. The synaptic vescicle controlled, dose-ranging trial in refractory partial epilepsy. Multicenter double-blind, adjunctive therapy in infants and young children with partial randomized, placebo controlled trial of levetiracetam as add-on seizures. A multicentre, double-blind, oxcarbazepine and carbamazepine in patients with newly randomized, parallel group study to evaluate the tolerability and diagnosed, previously untreated epilepsy. Once daily extended release levitiracetam as adjunctive treatment of partial onset seizures 108. Epilepsy Res 1994;19:79- profle of levetiracetam in rodent models of seizures and epilepsy. Pregabalin add-on for drug demonstrate dose-dependent visual loss from vigabatrin therapy. Prevalence of visual feld loss following exposure to vigabatrin Epilepsia 2004;45Suppl6:19–27. Baltimore, add-on therapy with pregabalin in patients with refractory partial Md: Eisai inc; 2011. Rufnamide for generalized seizures associated with Lennox- with pregabalin for partial seizures with or without generalisation: gastaut syndrome. Pregabalin efficacy and tolerability in patients with intractable partial seizures. Ben-Menachem E, Biton V, Jatuzis d, abou-Khalil B, doty P, rudd clobazam in Lennox-gastaut syndrome. Adjunctive lacosamide for partial-onset seizures: efcacy and safety results from a randomized controlled trial. Deerfeld, Efcacy and safety of adjunctive ezogabine (retigabine) in refractory iL: Lundbeck; 2009. Metabolism of two new controlled study of vigabatrin as frst line treatment of infantile antiepileptic drugs and their principal metabolites S(+)- and r(-)-10, spasms. Eslicarbazepine acetate: a treatment for infantile spasms: a randomized prospective study. Placebo-corrected efcacy of infantile Spasm study comparing vigabatrin with prednisolone modern antiepileptic drugs for refractory epilepsy: Systematic or tetracosactide at 14 days: a multicentre randomized controlled review and meta-analysis. Med Princ and efectiveness as initial monotherapy for epileptic seizures and Pract 2005;14: 31-34. The Treatment of Epilepsy, 3rd edition: (Special indian of efcacy and side efects using odds ratios. Use of anti-epileptic drugs in a tertiary care hospital of Eastern carbamazepine-induced hypersensitivity reactions in Europeans. Lancet Neurol prescription utilization behaviour and direct cost of treatment in a 2007;6:693-698. Healthcare professionals are asked to report + Aztreonam :Risk of seizures due to a decrease in valproic acid plasma concentra- any suspected adverse reactions. In addition, reduced valproic acid plasma tablet. Therapeutic indications dose adjustment during treatment with felbamate and after its discontinuation. When coadministered with antiepileptic treatment: valproate, a reduction in propofol dose should be considered. Posology and method of administration In children weighing less than 30 kg: the total dose of 600 mg/day after dose titration • Female children, female adolescents, women of childbearing potential and pregnant should not be exceeded. A blood count •• regular treatment reviews. Preferably Depakine should be prescribed as monotherapy should be performed to test for anemia during the rst two months of the combination. This dosage form is not appropriate for children under the age of 6 (risk of choking). Combinations to be taken into account • Of the oral pharmaceutical forms, the syrup, oral solution and prolonged-release + Nimodipine (oral route and, by extrapolation, by injection) •• granules are particularly suitable for administration in children under 11 years of age. Risk of enhanced hypotensive e ect of nimodipine due to an increase in its plasma • Dosage:Mean daily dose:• Infants and children: 30 mg/kg (the syrup, oral solution or concentrations (decrease in its metabolism by valproic acid). Other forms of interaction • • Adolescents and adults: 20 to 30 mg/kg (the tablets, prolonged-release tablets or + Oral contraceptives :As valproate has no enzyme-inducing activity, it does not • • prolonged-release granules should preferably be used). Fertility, pregnancy and lactation • • during meals. Pregnancy :Depakine should not be used in female children, in female adolescents, in Initiation of treatment:• If the patient is already being treated and is taking other women of childbearing potential and in pregnant women unless other treatments are • antiepileptics, treatment with sodium valproate should be initiated gradually, to reach ineective or not tolerated. Women of childbearing potential have to use eective • the optimal dose in approximately two weeks, then the concomitant treatments contraception during treatment. In women planning to become pregnant all eorts should be made to switch to • If the patient is not taking any other antiepileptics, the dose should preferably be appropriate alternative treatment prior to conception, if possible. Both valproate monotherapy and multiple agent therapy including valproate are •• • If necessary, combination treatment with other antiepileptics should be instituted associated with abnormal pregnancy outcomes. Available data suggest that antiepileptic "• gradually (see section 4. Contraindications :• History of hypersensitivity to valproate, valproate malformations than valproate monotherapy. Congenital malformations :Data derived from a meta-analysis (including registries and • Acute hepatitis. This is a greater risk of major malformations than for the general •• • Hepatic porphyria. The risk is dose dependent but a threshold • • Patients with known urea cycle disorders (see section 4. Special warnings and precautions for use Neuro-developmental disorders :Studies have shown that exposure to valproate in •• • Special warnings utero increases the risk of neuro-developmental disorders in exposed children. The risk • Female Children/Female adolescents/Women of childbearing potential/Pregnancy seems to be dose-dependent but a threshold dose below which no risk exists, cannot be Depakine should not be used in female children, in female adolescents, in women of established based on available data. The period of risk could involve the entire childbearing potential and pregnant women unless alternative treatments are pregnancy. Although the role of confounding factors cannot be pregnancy (see section 4. He or she must also ensure that the Available data show that children exposed to valproate in utero are at increased risk of • patient has duly lled in and signed the treatment agreement form. Limited data to date suggest that children exposed to valproate in utero may be more • the need to use eective contraception. Female children, female adolescents and women of childbearing potential (see above • the need to rapidly consult her physician if she is thinking of becoming pregnant or and section 4. Depakine should not be used in female children, in female adolescents, in women of In women planning to become pregnant all eorts should be made to switch to childbearing potential and pregnant women unless alternative treatments are appropriate alternative treatment prior to conception, if possible (see section 4. Women of childbearing potential must use eective Valproate therapy should only be continued after a reassessment of the bene ts and contraception during treatment. These seizures should be dierentiated from those that may and risks of the treatment with valproate for the patient by a physician experienced in occur due to a pharmacokinetic interaction (see section 4. During pregnancy, maternal tonic-clonic seizures and encephalopathy - see sections 4. The use of a prolonged-release formulation may Infants and young children under the age of 3 with severe epilepsy and, in particular, be preferable to other treatment formulations in order to avoid high peak plasma epilepsy associated with brain damage, mental retardation and/or a genetic metabolic concentrations. Over the age of 3, the incidence of onset is • provide folate supplementation before the pregnancy, which may decrease the risk of •• signi cantly reduced and gradually decreases with age. However the available evidence • In the great majority of cases, such liver damage has been observed within the rst 6 does not suggest it prevents the malformations due to valproate exposure. However, cases of hyperammoneamia with neurological symptoms (which Patients, or their families if the patient is a child, should be advised to consult their to thrombocytopenia, hypobrinogenemia and/or to a decrease in other coagulation may progress to coma) have also been reported, and require additional tests (see section 4. Therefore, General disorders and administration site conditions • the most pertinent of the conventional tests are those re ecting protein synthesis and, platelet count, brinogen plasma level, coagulation tests and coagulation factors should • Uncommon: hypothermia, non-severe peripheral edema. Musculoskeletal and connective tissue disorders use the same metabolic pathway). The mechanism of action of • appearing to be particularly at risk. Psychiatric disorders :• Common: confused state, hallucinations, aggression*, agitation*, patients with severe epilepsy, brain damage or those taking multiple-agent antiepileptic Valproate is excreted in human milk with a concentration ranging from 1% to 10% of attention decit disorders*. Hematological disorders have been observed in breast-fed If pancreatitis occurs along with liver failure, the risk of fatal outcome is increased. It allows continued monitoring of the • alternative therapeutic measures implemented. Healthcare professionals are asked to report any suspected adverse reactions via Email: pharmacovigilence. Valproate administration may also impair placebo-controlled trials of antiepileptic drugs has also shown a slight increase in risk of fertility in men (in particular, decreased sperm motility) (see section 4. Case reports which may be more or less deep, with muscle hypotonia, hypore exia, miosis, reduced suicidal ideation and behavior. The causes of this risk are unknown and the available indicate that fertility dysfunctions are reversible after treatment discontinuation. Patients (and their care to the risk of drowsiness, especially in patients receiving multiple-agent anticonvulsant Patient management in a hospital setting includes: gastric lavage if indicated, maintenance of providers) should be advised to seek medical advice if there are signs of suicidal therapy or concomitant administration with other medicinal products that may increase eective diuresis, cardiorespiratory monitoring. However, a few deaths have been clinical signs of underlying mitochondrial diseases caused by mutations of Classication of expected incidence rates: reported.
Effect of the addition of vasopressin or vasopressin plus nitroglycerin to epinephrine on arterial blood pres- sure during cardiopulmonary resuscitation in humans hair loss under arms order dutas overnight. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation hair loss cure yet discount dutas amex. Usefulness of vasopressin administered with epinephrine during out-of-hospital cardiac arrest hair loss in men 90s buy line dutas. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shock- able rhythms: retrospective analysis of large in-hospital data registry hair loss 1 year old order 0.5mg dutas fast delivery. Effects of prehospital epinephrine during out- of-hospital cardiac arrest with initial non-shockable rhythm: an observa- tional cohort study hair loss lexapro generic dutas 0.5mg. Association between timing of epinephrine administration and intact neurologic survival following out-of-hospital cardiac arrest in Japan: a population-based prospective observational study. Rapid epineph- rine administration improves early outcomes in out-of-hospital cardiac arrest. Hayashi Y, Iwami T, Kitamura T, Nishiuchi T, Kajino K, Sakai T, Nishiyama C, Nitta M, Hiraide A, Kai T. Impact of early intravenous epinephrine administration on outcomes following out-of-hospital cardiac arrest. Impact of delayed and infrequent administration of vasopressors on return of spontaneous circulation during out-of-hospital cardiac arrest. Vasopressin, steroids, and epinephrine and neurologically favor- able survival after in-hospital cardiac arrest: a randomized clinical trial. The effect of hydrocortisone on the outcome of out-of-hospital cardiac arrest patients: a pilot study. Repeated administration of vasopressin but not epinephrine maintains coronary perfusion pressure after early and late administration during prolonged cardiopulmonary resuscitation in pigs. Association of delay to first intervention with return of spontaneous circulation in a swine model of cardiac arrest. The intraosseous route is a suitable alternative to intravenous route for fluid resuscitation in severely dehydrated children. Tibial length following intraosseous infusion: a prospective, radiographic analysis. Are laboratory values in bone marrow aspirate predictable for venous blood in paediatric patients Five-year experience in prehospital intraosseous infusions in children and adults. Macnab A, Christenson J, Findlay J, Horwood B, Johnson D, Jones L, Phillips K, Pollack C Jr. A randomized comparison of cardiocerebral and cardiopulmonary resuscitation using a swine model of prolonged ventricular fibrillation. Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation. Endotracheal and endobronchial lidocaine administration: effects on plasma lidocaine concentration and blood gases. Endobronchial application of high dose epinephrine in out of hospital cardiopulmonary resuscitation. Raymondos K, Panning B, Leuwer M, Brechelt G, Korte T, Niehaus M, Tebbenjohanns J, Piepenbrock S. Absorption and hemodynamic effects of airway administration of adrenaline in patients with severe cardiac disease. Plasma lidocaine levels and PaO2 with endobronchial administration: dilution with normal saline or distilled water The efficacy of lidocaine in ventricular fibrillation due to coronary artery ligation: endotracheal vs intravenous use. Endobronchial vasopressin improves survival during cardiopulmonary resuscitation in pigs. A comparison of the endotracheal tube and the laryngeal mask airway as a route for endobronchial lidocaine administration. Effects of different techniques of endotracheal epinephrine administration in pediatric porcine hypoxic-hypercarbic cardiopulmonary arrest. Efrati O, Ben-Abraham R, Barak A, Modan-Moses D, Augarten A, Manisterski Y, Barzilay Z, Paret G. Elizur A, Ben-Abraham R, Manisterski Y, Barak A, Efrati O, Lotan D, Barzilay Z, Paret G. Endotracheal drug administration during out-of-hospital resuscitation: where are the survivors A comparison of distilled water and normal saline as diluents for endobronchial administration of epinephrine in the dog. Ahrens T, Schallom L, Bettorf K, Ellner S, Hurt G, OMara V, Ludwig J, George W, Marino T, Shannon W. End-tidal carbon dioxide measure- ments as a prognostic indicator of outcome in cardiac arrest. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in- hospital cardiac arrest: an observational study and propensity analysis. 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Effects of atropine in patients with bradyarrhythmia complicating myocardial infarction: usefulness of an optimum dose for overdrive. Atropine often results in complete atrioventricular block or sinus arrest after cardiac transplantation: an unpredictable and dose-independent phenomenon. Transthoracic cardioversion of atrial fibrillation: comparison of rectilinear biphasic versus damped sine wave monophasic shocks.
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Progesterone: Maintain support hair loss forum 0.5mg dutas amex, used for luteal phase support hair loss hypothyroidism purchase discount dutas line, or for patient with frequent miscarriages a hair loss treatment product purchase 0.5 mg dutas amex. Bromocriptine: Decreases prolactin levels; prolactin lowers progesterone levels hair loss nutritional deficiency buy dutas overnight, may prevent ovulation 3 hair loss in men 4x100 dutas 0.5mg line. Guaifenesin: May help thin the cervical mucus to aid in conception (off-label use) 5. Aspirin: Used before fertility procedures for uterine blood fow and decreased risk of ovarian hyper- stimulation syndrome Patient Case 8. Patient may start to feel bloated; shortness of breath may occur; lethargy, nausea, vomiting, and diarrhea 3. A reported 69% of women and 21% of men at a fertility clinic had a psychiatric disorder, possibly because of fertility issues but unknown exact reason 2. Treatment can partly control symptoms but does not affect the risk, frequency, or severity of recur- rences after it is discontinued. Symptoms include itching, genital burning, vesicle formation, and ulcer formation. After the primary infection, the virus is latent in the sacral dorsal root ganglia. From 50% to 80% of patients have recurrent infections (generally less severe and of shorter duration). If treatment is initiated within 1 day of lesion onset, patients with recurrent infections may beneft. Signs and symptoms (nonspecifc) (a) Headache (b) Fever (c) Speech disorders and behavioral changes (d)Focalseizures ii. Cerebrospinal fuid analysis (a) Moderate pleocytosis (generally lymphocytosis) (b) Normal glucose and moderately elevated protein iii. Therapy: Acyclovir intravenously 5–10 mg/kg every 8 hours for 2–7 days, followed by oral antiviral therapy for at least 10 days of total therapy Patient Cases 9. Treatment of the initial infection will decrease the risk of recurrent herpes infections. Treatment will shorten the duration of symptoms and infectivity of the initial infection. Treatment of the initial infection will decrease the severity of recurrent herpes infections. Treatment of the initial infection will prevent the virus from remaining latent in the dorsal root ganglia. Valacyclovir 500 mg orally twice daily to be used for 5 days whenever she notices a recurrence beginning. Acyclovir 400 mg orally three times daily to be used for 10 days whenever she notices a recurrence beginning. Dark-feld examination and direct fuorescent antibody stains of exudate for spirochetes b. Nontreponemal (Venereal Disease Research Laboratory and rapid plasma reagin); detect serum concentrations of antibody to cardiolipin c. In general, perform a nontreponemal test for screening purposes and confrm with a treponemal test. If penicillin allergy: Doxycycline 100 mg orally twice daily or tetracycline 500 mg four times daily for 2 weeks 3. If penicillin allergy: Doxycycline 100 mg orally twice daily or tetracycline 500 mg four times daily for 2 weeks 4. If penicillin allergy: Doxycycline 100 mg twice daily or tetracycline 500 mg four times daily for 4 weeks 5. Infectious granulomas and cardiovascular effects: Aortic insuffciency and aortitis b. If penicillin allergy: Doxycycline 100 mg twice daily or tetracycline 500 mg four times daily for 4 weeks 6. Recommended treatment: Aqueous crystalline penicillin G 3–4 million units intravenously every 4 hours or continuous infusion for 10–14 days b. Sexual partners should be presumptively treated if exposed within 90 days preceding the diagnosis in their partner. If exposure occurred more than 90 days prior, sexual partners should be tested and monitored closely or treated presumptively if serologic test results are not available immediately. Alternatives: Erythromycin base 500 mg orally four times daily for 7 days, ofoxacin 300 mg orally twice daily for 7 days, levofoxacin 500 mg/day orally for 7 days, or erythromycin ethylsuccinate 800 mg orally four times daily for 7 days c. Abstain from sexual intercourse for at least 7 days and until sexual partners are adequately treated. New in 2012: Alternative if ceftriaxone not an option, cefxime 400 mg orally as single-dose plus azithromycin 1 g in a single dose or doxycycline 100 mg twice daily for 7 days and test for cure in 1 week b. Gonococcal infection of the pharynx: Ceftriaxone plus treatment of chlamydia (azithromycin 1 g in a single dose or doxycycline 100 mg twice daily for 7 days) c. Recurrent or persistent: Ensure adherence and no reinfection from infected partner; if these are ensured, treat with metronidazole or tinidazole for Trichomonas vaginalis and azithromycin. Ascending infection of the female genital tract involving primarily the fallopian tubes 2. In general, sexually transmitted and caused by Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci 5. Regimen A: Cefotetan 2 g intravenously every 12 hours or cefoxitin 2 g intravenously every 6 hours plus doxycycline 100 mg intravenously or orally every 12 hours. Regimen B: Clindamycin 900 mg intravenously every 8 hours plus gentamicin intravenously or intramuscularly 2-mg/kg loading dose, then 1. Parenteral therapy can be discontinued 24 hours after clinical improvement and changed to oral therapy for 14 days. Alternative regimens: Ampicillin/sulbactam 3 g intravenously every 6 hours plus doxycycline 100 mg intravenously or orally every 12 hours b. Oral treatment: Ceftriaxone 250 mg intramuscularly once or cefoxitin 2 g intramuscularly plus probenecid 1 g orally once plus doxycycline 100 mg twice daily for 14 days with or without metronidazole 500 mg orally twice daily for 14 days c. Malodorous vaginal discharge caused by an overgrowth of anaerobic bacteria (circumventing the normal fora of Lactobacillus); more than 50% with bacterial vaginosis asymptomatic 2. Infection risk is increased in relation to sexual activity, but it is unknown whether acquired through sexual partner. Diagnosis is based on a malodorous vaginal discharge that is high in pH, contains clue cells, and is whiff test positive (fshy odor after potassium hydroxide 10% added to sample). Nonpregnant women: Metronidazole 500 mg orally twice daily for 7 days or clindamycin 2% cream, 1 full applicator intravaginally at bedtime for 7 days, or metronidazole 0. Alternatives: Clindamycin ovules 100 mg intravaginally at bedtime for 3 days, clindamycin 300 mg orally twice daily for 7 days, tinidazole 2 g orally once daily for 2 days, or tinidazole 1 g orally once daily for 5 days c. Pregnant women: Metronidazole 500 mg orally twice daily for 7 days, metronidazole 250 mg orally three times daily for 7 days, or clindamycin 300 mg orally twice daily for 7 days d. Do not use clindamycin cream during pregnancy because of the increased risk of preterm deliveries. Her medical history is unremarkable except for recurrent genital herpes (one or two episodes a year). Her medications on admission include birth control pills (ethinyl estradiol 30 mcg/desogestrel 0. Cefotetan 2 g intravenously every 12 hours with doxycycline 100 mg orally every 12 hours for 14 days. Ceftriaxone 125 mg intramuscularly 1 with doxycycline 100 mg intravenously twice daily for 7 days. There is no need for concern because this condition is not transmittable to or acquired from a sexual partner. Men often have no symptoms, but women generally have a malodorous, yellow-green vaginal discharge and vaginal irritation. Metronidazole 2 g orally in a single dose or tinidazole 2 g orally in a single dose b. Seventy-fve percent of women have at least one episode (40%–45% will have many episodes). Therapeutic regimens: 1- and 3-day regimens may take up to 7 days for full effect. Initial treatment for 7–14 days or fuconazole 100-, 150-, or 200-mg dose every third day for three doses b. Fluoroquinolones: Ciprofoxacin 500 mg twice daily, levofoxacin 500–750 mg once daily, ofoxacin 400 mg twice daily iii. Chronic bacterial prostatitis (symptoms should have been present for at least 6 months) a. Fluoroquinolones: Ciprofoxacin 500 mg twice daily, levofoxacin 500–750 mg daily, ofoxacin 200 mg twice daily, norfoxacin 400 mg twice daily (not for gonorrhea) ii. Ceftriaxone 250 mg intramuscularly once plus doxycycline 100 mg twice daily for 10 days 2. Persistent (at least 6 months) inability to achieve or maintain an erection of suffcient duration and frmness to complete satisfactory intercourse through vaginal penetration b. Hormonal abnormalities because of excess prolactin (hyperprolactinemia) or decreased testosterone concentrations (hypogonadism) iv. Medical conditions such as angina, shortness of breath because of asthma or chronic obstructive pulmonary disease v. Drugs such as antihypertensives, psychiatric medications (antidepressants and antipsychotics) B. Cardiovascular disease must be stabilized and assessed before treatment; must assess whether sexual activity in stable relationship does not increase risk of cardiovascular events or put undue stress on heart. Venous constriction rings (may cause adverse effects such as pain and bruising) c. Depot intramuscular injection of testosterone enanthate 200 mg or cypionate 300 mg every 2–3 weeks c. Transdermal patches placed daily: Androderm 2–6 mg at bedtime on back, abdomen, or arms; rotate sites; available in 2 mg/day and 4 mg/day transdermal systems. Testim has 50 mg of testosterone per tube, apply to shoulders, upper arms only ii. Fortesta gel may have between 10 and 70 mg applied; 1 pump = 10 mg; apply to thighs; avoid genitals. Vogelxo 50 mg/one tube or packet and Vogelxo Pump (4 actuations, 1 actuation = 12. Axiron topical solution: Apply 60 mg (1 actuation = 30 mg) to underarms once daily. Striant 30-mg buccal system; placed on gum tissue above incisors with fat section facing cheek; used twice daily h. Sildenafl (Viagra), tadalafl (Cialis), vardenafl (Levitra/Staxyn), avanafl (Stendra) b. Sildenafl 50 mg orally 1; maximal dose 100 mg/day, usually take tablet 1 hour before intercourse ii. Tadalafl 10 mg orally 1; maximal dose 20 mg/day; effects may last up to 36 hours; may also use as daily dose without respect to timing of intercourse, tadalafl 2.