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The literature that has examined the issue few days’ use cheap viagra sublingual 100mg overnight delivery erectile dysfunction johnson city tn, rebound insomnia (worsening of symptoms with of individual pharmacotherapy or cognitive behavioral treat- dose reduction purchase viagra sublingual with paypal erectile dysfunction age 30, typically lasting 1-3 days), potential physical as ment versus a combination of these approaches demonstrates well as psychological withdrawal effects, and recurrence of in- that short-term pharmacological treatments alone are effective somnia may all occur. Tapering the frequency of administration (such as improvements appear sustained at follow-up for up to two every other or every third night) has also been shown to minimize years. As noted elsewhere, tapering and discontinuation of demonstrate a clear advantage for combined treatment over hypnotic medication is facilitated by concurrent application of cognitive behavioral treatment alone. Buysse has consulted to and/or been on the advisory board of Actelion, The guidelines presented are generally appropriate for older Arena, Cephalon, Eli Lilly, GlaxoSmithKline, Merck, Neuro- adults as well as younger adults. However, lower doses of all crine, Neurogen, Pfzer, Respironics, Sanof-Aventis, Sepracor, agents (with the exception of ramelteon) may be required in Servier, Somnus Therapeutics, Stress Eraser, Takeda, and Tran- older adults, and the potential for side-effects and drug-drug scept Pharmaceuticals. The other authors have indicated no f- interactions should be carefully considered. International classifca- of insomnia comorbid with depression or anxiety disorders tion of sleep disorders, 2nd ed. Littner M, Hirshkowitz M, Kramer M; Standards of Practice at recommended doses, or an effcacious psychotherapy for the Committee of the American Academy of Sleep Medicine. Practice pa- rameters for clinical use of the multiple sleep latency test and the is used as monotherapy for a patient with comorbid depres- maintenance of wakefulness test. In many cases, this dose will be higher eters for the nonpharmacologic treatment of chronic insomnia. Standards of or olanzapine may be specifcally useful in individuals with bi- Practice Committee of the American Academy of Sleep Medi- polar disorder or severe anxiety disorders. In for the psychological and behavioral treatment of insomnia: an some cases, medications such as gabapentin or pregabalin may update. Practice parameters with a longer-acting analgesic medication near bedtime may for the use of actigraphy in the assessment of sleep and sleep also be useful, although narcotic analgesics may disrupt sleep disorders: an update for 2007. Rules of evidence and clinical recommendations for bid insomnia may beneft from behavioral and psychological the management of patients. The burden of chronic insomnia on society: awaken- Combined Therapy for Insomnia ing insomnia management. Characteristics of insomnia in the United Hypnotic medications are effcacious as short-term treatment States: results of the 1991 National Sleep Foundation Survey. Epidemiology of insomnia: what we know and what sleep in a model of transient insomnia related to a novel sleep we still need to learn. Beneft-risk assessment of zaleplon in the miology of insomnia: prevalence, self-help treatments, consul- treatment of insomnia. Philadelphia: Elsevier mary insomnia: results of a polysomnographic double-blind con- Saunders, 2005:714-25. A review of the evidence for the effcacy and safe- Psychophysiological insomnia: the behavioural model and a neu- ty of trazodone in insomnia. Quantitative criteria on sleep physiology measures with major depression and insom- for insomnia. Vale- diagnostic criteria for insomnia: Report of an American Academy rian-hops combination and diphenhydramine for treating in- of Sleep Medicine Work Group. National Institutes of Health State nightly use of zolpidem in chronic insomnia: results of a large- of the Science Conference statement on Manifestations and Man- scale, double-blind, randomized, outpatient study. Certifed behavioral sleep clone over 6 months of nightly treatment: results of a randomized, medicine specialists. Rebound insomnia: dura- zolpidem for chronic insomnia: A meta-analysis of treatment ef- tion of use and individual differences. Eszopiclone co-admin- mals and patients with insomnia after abrupt and tapered discon- istered with fuoxetine in patients with insomnia coexisitng with tinuation. Trazodone for antide- chological treatment for insomnia in the management of long- pressant-associated insomnia Am J Psychiatry 1994;151:1069-72. Am J Psychiatry pharmacological therapies for late-life insomnia: a randomized 2004;161:332-42. Sedative hypnotics in cotherapy combined with stimulus control treatment in chronic older people with insomnia: meta-analysis of risks and benefts. A methodological approach is used to obtain information from the patient, usually starting with determining the patient’s chief complaint, also known as the reason for the healthcare visit, and then 2 chapter 1 / the patient interview delving further into an exploration of the patient’s specific complaint and problem. A comprehensive patient interview includes inquiring about the patient’s medical, medication, social, personal, and family history, as well as a thorough review of systems and possibly a physical examination. The medication history is the part of the patient interview that provides the pharmacist the opportunity to utilize his or her expertise by precisely collecting each component of the medication history (however, a medication history may also be collected independent of a comprehensive patient interview). The questions that you ask the patient, as well as the technique used, will enable you to learn exactly how, when, and why a patient takes each medication, as well as about any adverse reactions, allergies, or issues with medication cost the patient may have experienced. The approach to the patient interview and medication history will change based on the setting in which you are practicing. For example, if the setting is a community pharmacy and you are responding to a problem that may allow for self-care, your questions will be directed at meticulously characterizing the patient’s complaint and obtaining specific information that will influence your assessment and plan for the patient. However, if you are in a hospital, the focus of the interview may need to be modified based on the patient’s condition and the particular unit or department in which he or she is being cared for so that the patient’s needs may be met. Regardless of the setting, your goal during the interview will be to provide patient-centered care; this can be accomplished by combining your pharmaco- therapeutic knowledge with a solid foundation of excellent communication and patient-interviewing skills. Excelling in these communication skills is a learned technique that takes time and practice to master. Once these skills are employed in practice, the relationship that is developed with the patient is often stronger, allowing for the patient to have increased confidence and trust in your role as a healthcare provider. The purpose of this chapter is to describe the various components of the compre- hensive health history and to provide an overview of the skills and techniques required when communicating with the patient. This chapter will focus on the best practices to follow when collecting information from the patient. Although communicating with a patient may seem like a simple task, it actually takes communication skills 3 practice and knowledge to communicate with the patient in a manner that encour- ages respect for the healthcare provider and that enables the pharmacist to obtain an accurate and complete history. Some practitioners are able to naturally commu- nicate with patients more effectively, whereas others have difficulty communicat- ing with patients due to a variety of reasons, including their personality, comfort level, and confidence. However, regardless of one’s natural abilities, communica- tion skills and questioning techniques, especially when it comes to communicating with patients, are learned and take time to develop. This chapter examines the most pertinent skills required to conduct a comprehensive medication history. These skills and questioning techniques include: • Active listening • Empathy • Building rapport • Open-ended questions • Closed-ended questions • Leading questions • Silence • “Why” questions • Nonverbal communication cues active Listening The first communication skill to be mastered is listening, specifically active listen- ing. Listening is defined as hearing what is being said, whereas active listening is a dynamic process that includes both hearing what is being said as well as processing and interpreting the words that are spoken (and/or unspoken) to understand the complete message that is being delivered. Whereas listening is a passive process, active listening requires the listener to consciously choose to give the patient atten- tion and concentration that is free of distractions and interruptions, both external and internal.

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It is characterized by the accumulation of mucinous ascites within the peritoneal cavity purchase viagra sublingual with visa erectile dysfunction weight loss. An epithelial neoplasm arises within the appendiceal lumen and consequently the lumen per se becomes occluded purchase viagra sublingual on line erectile dysfunction causes in early 20s. This occlusion finally causes a rupture in the wall of the appendix and therefore mucus containing epithelial cells is spilled within the abdominal cavity [12]. The natural progression of the disease is usually moderately slow, although rapid advancement is also seen on occasions. The typical course of disease comprises tumour spread on the peritoneal surfaces, but invasion of the organs is also seen, especially in cases with a high-grade histology. Nevertheless, those that can be seen are found in the livers or lungs of patients with high-grade histology. Eventually the progressive amount of mucus causes dyspnea, gastrointestinal obstruction, malnutrition, hydronephrosis, and other organ malfunctioning. Another Dutch study, in which data were retrieved from the Eindhoven Cancer Registry noted an increase in age-standardized incidence of appendiceal mucinous adenocarcinoma that varied between 0. The study period was 1980 to 2010 and the data cover a large part of the southern Netherlands, which comprises about 2. The following section will examine more closely the schemes considered to be the most relevant for the debate on classification. Cytological atypia and architectural complexity are sufficient to establish a diagnosis of mucinous carcinoma. Despite the peritoneal lesions, the primary lesion in the appendix lacks evidence of invasive features. Pai and Longacre proposed their differential diagnosis spectrum of appendiceal mucinous neoplasms in 2005 [16]. They considered mucinous adenoma lesions, which involve appendiceal mucosal surface and are composed of mucin-rich epithelium. There is no invasion by the epithelium into the muscular wall nor is there a presence of epithelium on the serosa. According to Pai and Longacre’s definition, mucinous adenoma is restricted to those cases without epithelium involvement in extra- appendiceal mucin. Consequently, if the appendix is surgically excised, no further treatment is required. Therefore, the 14 differential diagnostics between these two groups is challenging. It is impossible to definitely exclude the possibility of extra-appendiceal spread of epithelial cells, even if no macroscopic tumour can be seen on the peritoneal surfaces. They also restricted the use of this category to those cases with extremely well-differentiated mucinous neoplasms but which also had an uncertain stage of invasion. In contrast, mucinous carcinoma exhibits architectural complexity and high- grade cytological atypia with high mitotic activity. There is always uncertainty as to whether the epithelial cells have sprayed on peritoneal surfaces, thus the division of histological comparably homogeneous group of lesions by invasiveness might be somewhat irrelevant. On the other hand, a clear dividing line can be drawn between the mucinous carcinoma and the other groups. The lesion can be classified according to the definition as low-grade or high-grade pseudomyxoma. The alternative terms low-grade and high-grade mucinous adenocarcinoma can be used as well. There are histopathological, immunochemical, and molecular genetic studies that suggest the appendix as an origin in those cases with synchronous tumour of appendix and ovary [10, 22, 24]. Thus, the pattern of immunoreactivity was distinct from primary ovarian tumour and similar to appendiceal adenoma [22]. The classic sign is increased abdominal girdle, which is caused by the accumulation of gelatinous ascites. This is characteristic of the progressive state of disease in which the most of the abdomen is filled with ascites and tumour [23]. The chief complaint may be a newly-onset hernia as a consequence of increased intra-abdominal pressure. A typical finding is an ovarian mass found by transvaginal ultrasonography during routine gynaecological examination. During surgery, there might be unexpected deposits of mucus on the peritoneal surfaces. Gastric antrum, lesser omentum, left subphrenic region, spleen, rectum and sigma are entangled by the tumour mass in the terminal stage of the disease. What is emblematic for the terminal stage is the aforementioned scalloping of the hepatic margin, and a displacement or compression of the intestines by the abundant mucus [23]. Bowel loops are positioned centrally and posteriorly by the surrounding mass instead of floating freely. Some authors have noted ultrasonography to be more beneficial for guide paracentesis [30]. The needle biopsies commonly produce less information than expected when no mucus or no cells within the mucus are aspirated. The quantity of epithelial cells within the mucus may be low even in high- grade disease, thus the final evaluation about the grade should not be made from biopsy alone [23]. Tumours of the appendix are infrequently seen in colonoscopy and rarely yield a diagnostic biopsy [35]. Complete radicality is uncommon, however, and relapses will develop in most cases. The relapses lead to increasingly difficult subsequent operations, after adhesions, scarring, and distortion of the anatomy has developed and the disease has progressed. These resections are as follows: greater omentectomy-splenectomy, left upper quadrant peritonectomy, right upper quadrant peritonectomy, lesser omentectomy- cholecystectomy with stripping of the omental bursa, pelvic peritonectomy with sleeve resection of the sigmoid colon, and antrectomy. These procedures are used on every single patient to an extent that is sufficient for the removal of the tumour. During the operation, the extent of the disease and the radicality of the surgery is assessed and scored. Indeed, tumour burden locating in the hepatic hilum or in the lesser omentum can be surgically unresectable. The extensively disseminated disease in the abdominal cavity that especially affects the small intestine may prevent radical surgery. If the tumour is not completely resected from the abdominal cavity during the cytoreductive surgery, the chemotherapeutic agent will not eliminate the disease. The cytoreduction is considered complete when residual tumour nodules are sized under 0. The administration of a chemotherapeutic agent is timed after complete cytoreductive surgery is finished but before the construction of any anastomoses. Perfusion drains are placed through the abdominal wall at specific sites: the right subdiaphagmatic space, the left subdiaphagmatic space, and two in the pelvis (Figure 6). One additional spiral- ended (Tenckhoff) catheter is positioned within the abdomen.

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Paracetamol in tablet buy viagra sublingual with mastercard erectile dysfunction pills australia, syrup or suppository forms may be given every 4-6 hours until the temperature is normal discount 100mg viagra sublingual overnight delivery erectile dysfunction doctors in atlanta. For children above 14 years and for adults, Aspirin (acetyl salicylic acid) may be given instead of Paracetamol. Patients who have been diagnosed with malaria and treated may fail to improve for various reasons including: Ÿ The presenting symptoms, such as fever, were due to a cause other than malaria. Absence of other differential diagnosis of common febrile illness such as upper respiratory tract infections and urinary tract infection. Inadequate treatment can be defined as failure to complete the initial course of treatment for whatever reason (e. One or more of the following criteria listed below is an indication for referral of a malaria patient to a hospital: Ÿ Altered consciousness (confusion, change in behaviour, delirium, coma persisting for over 30 minutes after convulsion). If the patient is already being managed in a hospital, the presence or persistence of the above conditions may prompt referral to a higher level of care. If referral is not possible immediately, continue treatment until referral is possible. Have the patient lie down on his/her side during the journey to avoid aspiration in case of vomiting. Send a clear letter or referral form about the clinical picture, the type of treatment given, dosages, times and route of administration for any medications given. Due to the risk of adverse drug effects in the first trimester of pregnancy, it is especially preferable to confirm the presence of malaria parasites before treatment is initiated. However, unavailability of laboratory testing should not be a reason for withholding anti-malaria treatment in pregnant women. Other conditions including urinary tract infection; pneumonia; enteric fever; intra- uterine infections (chorioamnionitis) may present with fever during pregnancy. To rule out other non-malarious causes of fever, it is therefore essential to take a comprehensive history and conduct a thorough examination, followed by a request for other relevant laboratory investigations (such as urine analysis). Two options are available: Ÿ Oral Quinine at 10mg/kg body weight (max 600 mg) three times per day for seven days. However, their use shall not be withheld in cases where they are considered to be life saving, or where other anti-malarials are considered to be unsuitable, including the possibility of non-compliance with a 7 day treatment with quinine. The following should be established before a diagnosis of treatment failure is made: a. That she completed the full treatment course and did not vomit after taking medications. That the symptoms are not due to other common infections such as ear, nose, throat, urinary tract infection, chorioamnionitis, enteric fever (typhoid), etc. In the event of treatment failure, the alternative drug to be used depends on which medicine was given first. It mostly occurs in children under five (5) years of age, pregnant women and non- immune individuals. The most common complications of severe/complicated malaria responsible for most deaths particularly in children under 5 years of age are: Ÿ Cerebral malaria – Prolonged coma not attributed to any other cause in a patient with falciparum malaria. The patient is likely to have experienced some of the typical symptoms of malaria. These may have included: chills, rigors, headache, body aches, sweating, nausea/vomiting, loss of appetite, and/or abdominal pain. In all patients, clinical diagnosis of severe/complicated malaria should be made in a patient with: Ÿ fever (history of fever or axillary temperature³ 38. In young children, a clinical diagnosis of severe/complicated malaria can also be made if there is; Ÿ fever (history of fever or axillary temperature ³ 38. While laboratory tests should not delay the initiation of treatment, it is mandatory to test for Plasmodium falciparum. Note: High parasitaemia is not always present in severe disease, and the initial blood slide examination may be negative. Where there is high clinical suspicion of malaria, the test should be repeated at 6 hourly intervals. Laboratory Findings: Ÿ Severe normocytic anaemia (severe anaemia; haematocrit <15% or Hb <5g/dl). These are non-specific clinical findings that suggest the presence of serious underlying illness. A child with fever and any general danger sign should be diagnosed and treated for severe/complicated malaria. The goals of management of severe/complicated malaria are to provide: Ÿ Urgent treatment of life threatening problems. This section provides guidance on management of severe/complicated malaria in the outpatient setting, prior to referral. If referral is not feasible immediately, continue treatment until the referral becomes possible. It is especially appropriate for the home/community setting, where there are no trained health workers who can administer injections. In the event that an artesunate suppository is expelled from the rectum within 30 minutes of insertion, a second suppository should be used especially in young children. The buttocks should be held together for 10 min to ensure retention of the rectal dose of artesunate. Table 9: Rectal Artesunate (Pre-Referral Treatment in Children) Weight (kg) Age Artesunate Dose Regimen (mg) 5 – 8 0 – 12 months 50 One 50mg suppository 9 – 19 13 – 42 months 100 Two 50mg suppositories 20 – 29 43 – 60 months 200 One 200mg suppository 30 – 39 6 – 13 years 300 Two suppositories of the 50mg and one of the 200mg suppository >40 > 14 years 400 Two of the 200mg suppositories Table 10: Rectal Artesunate (Pre-Referral Treatment in Adults) Weight (kg) Artesunate Dose (mg) Regimen 40 – 50 400 Two of the 200mg suppositories 60 – 80 800 Four of the 200mg suppositories >80 1200 Six of the 200mg suppositories 4. In situations where the patient is still within the facility following referral, parenteral treatment should be continued while waiting until patient leaves. Shake for 2-3 minutes minutes to ensure minutes to ensure to ensure dissolution dissolution into a dissolution into into a clear solution. Step 4 Step 4 Step 4 4 Withdraw the 4 Withdraw the 4 Withdraw the required amount of required amount of required amount of solution and inject at solution and inject solution and inject the chosen site. To prepare this, draw 2mls of Quinine 600mg and add 4mls of sterile water or saline (not dextrose). Supportive Treatment for Severe/Complicated Malaria in the Outpatient Setting Use ofAntipyretics In young children, high temperatures are associated with vomiting, often regurgitating their medication, and seizures. Antipyretics should be used if axillary temperatures are ³ 38°C) and the patient can tolerate oral medication. Paracetamol (acetaminophen) 15 mg/kg every 4 hours is widely used; it is safe and well tolerated, given orally or as a suppository (Refer Tables 6 and 7 for dosing). In case of convulsions the following should be done: Ÿ Clear and maintain airway Ÿ Treat with diazepam: – A slow intravenous injection of diazepam [0. Nursing Care Ÿ Provide good nursing care: For example, keep an unconscious patient on his or her side and monitor vital signs. If Hb<5gm/dl and Hct<15 - 20%, do grouping and cross-matching for possible transfusion. Parenteral treatment provides adequate blood-serum concentrations as quickly as possible initially. Parenteral treatment should continue until patient is well enough to swallow, and for at least 24 hours even if the patient is well enough to swallow before 24hours. Reconstituting ParenteralArtesunate Artesunate is dispensed as a powder of artesunic acid in vials of 30mg, 60mg or 120mg and usually in packs containing sodium bicarbonate solution and normal saline.

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Long-term safety and efficacy of telbivudine in infants born to mothers treated during the second or third trimesters of pregnancy buy 100 mg viagra sublingual amex diabetes and erectile dysfunction relationship. The reproductive effects of beta interferon therapy in pregnancy: a longitudinal cohort purchase generic viagra sublingual from india erectile dysfunction ka desi ilaj. Fewer than 20% of patients with acute infection have characteristic symptoms, including low-grade fever, mild right- upper-quadrant pain, nausea, vomiting, anorexia, dark urine, and jaundice. Coinfected patients with cirrhosis are at risk of life-threatening complications and should be managed in consultation with a gastroenterologist or hepatologist. Because of its relatively poor specificity and sensitivity, alfa-fetoprotein should not be the sole screening method. The armamenarium of approved drugs is likely to expand considerably in the next few years. Defects noted in animals include limb abnormalities, craniofacial defects, exencephaly, and anophthalmia. Inadvertent pregnancy during paternal exposure was not associated with adverse events in two newborns. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Survival of hepatitis C virus in syringes: implication for transmission among injection drug users. Transmission of hepatitis C virus by blood transfusions and other medical procedures: a global review. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic--Nevada, 2007. Hepatitis C virus infection among sexually promiscuous groups and the heterosexual partners of hepatitis C virus infected index cases. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. Highly active antiretroviral therapy and sexual risk behavior: a meta-analytic review. Obstetric management of hepatitis C-positive mothers: analysis of vertical transmission in 559 mother-infant pairs. Peginterferon alfa-2b therapy in acute hepatitis C: impact of onset of therapy on sustained virologic response. Natural history of liver fibrosis progression in patients with chronic hepatitis C. Liver fibrosis progression in human immunodeficiency virus and hepatitis C virus coinfected patients. The influence of human immunodeficiency virus coinfection on chronic hepatitis C in injection drug users: a long-term retrospective cohort study. Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study. National Institutes of Health Consensus Development Conference Statement: Management of hepatitis C: 2002--June 10-12, 2002. Screening for hepatitis C virus in human immunodeficiency virus-infected individuals. Reduced risk of hepatitis B and hepatitis C among injection drug users in the Tacoma syringe exchange program. Reductions in high-risk drug use behaviors among participants in the Baltimore needle exchange program. Potential role for interleukin-28B genotype in treatment decision-making in recent hepatitis C virus infection. Impact of alcohol on the histological and clinical progression of hepatitis C infection. A significant sex--but not elective cesarean section--effect on mother-to-child transmission of hepatitis C virus infection. Rates of postoperative complications among human immunodeficiency virus- infected women who have undergone obstetric and gynecologic surgical procedures. Because the demyelinating lesions can involve different brain regions, specific deficits vary from patient to patient. The focal or multifocal nature of the pathology is responsible for the consistency of clinical presentations with distinct focal symptoms and signs, rather than as a more diffuse encephalopathy, or isolated dementia or behavioral syndrome, all of which are uncommon without concomitant focal findings. Headache and fever are not characteristic of the disease, and when present may indicate presence of another opportunistic infection. The lesions are hyperintense (white) on T2-weighted and fluid attenuated inversion recovery sequences and hypointense (dark) on T1- weighted sequences. Although contrast enhancement is present in 10% to 15% of cases, it is usually sparse with a thin or reticulated appearance adjacent to the edge of the lesions. Sensitive assays that detect as few as 50 copies/ml are now available, with some research labs exceeding this level of sensitivity. Neurological deficits often persist, but some patients experience clinical improvement. The trial was later halted by the sponsor, because demonstration of efficacy was futile (http://clinicaltrials. No clear guidelines exist for the timing of follow-up assessments, but it is reasonable to be guided by clinical progress. Histopathology typically demonstrates perivascular mononuclear inflammatory infiltration. In the absence of comparative data, adjuvant corticosteroid therapy should be tailored to individual patients. A taper may begin with a dose of 60 mg per day in a single dose, tapered over 1 to 6 weeks. If corticosteroid therapy is initiated during pregnancy, blood sugar monitoring should be included as insulin resistance is increased during pregnancy. Progressive multifocal leukoencephalopathy revisited: Has the disease outgrown its name? Natalizumab-associated progressive multifocal leukoencephalopathy in patients with multiple sclerosis: lessons from 28 cases. A case of progressive multifocal leukoencephalopathy in a patient treated with infliximab. Predictive factors for prolonged survival in acquired immunodeficiency syndrome- associated progressive multifocal leukoencephalopathy. Inflammatory reaction in progressive multifocal leukoencephalopathy: harmful or beneficial? Spinal cord lesions of progressive multifocal leukoencephalopathy in an acquired immunodeficiency syndrome patient. Hyperintense cortical signal on magnetic resonance imaging reflects focal leukocortical encephalitis and seizure risk in progressive multifocal leukoencephalopathy. Metabolite abnormalities in progressive multifocal leukoencephalopathy by proton magnetic resonance spectroscopy. Diagnosis of progressive multifocal leukoencephalopathy by stereotactic brain biopsy utilizing immunohistochemistry and the polymerase chain reaction. Progressive multifocal leukoencephalopathy: improved survival of human immunodeficiency virus-infected patients in the protease inhibitor era.

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