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By: Bertram G. Katzung MD, PhD
- Professor Emeritus, Department of Cellular & Molecular Pharmacology, University of California, San Francisco
The drug is a purine analog that causes continue for up to cheap 500 mg valparin overnight delivery medicine abbreviations 10 days after the last dose valparin 750mg sale treatment quadriceps strain. There is also been demonstrated in very small case series order valparin 250mg amex symptoms 3 days after embryo transfer, both alone a risk of pancreatitis and hepatotoxicity discount 750 mg valparin free shipping treatment water on the knee, which may be and in combination with rituximab [55, 56]. A gastrointestinal hypersensitivity reaction abine can cause severe bone marrow suppression. Life characterized by severe nausea and vomiting has also threatening and sometimes fatal autoimmune hemolytic been reported and may occur in the first few weeks of anemia and immune thrombocytopenic purpura have treatment. Hepatic or renal impairment may require a been reported following one or more cycles of fludarabine dose reduction. However, with six Symptomatic treatment strategy patients in the rituximab group dropping out of the Symptomatic treatment of the neuropathy itself usually in study, the per protocol analysis showed significant im volves membrane stabilizers, tricyclic anti-depressants, and/ provement in the rituximab group for secondary end or serotonin-norepinephrine reuptake inhibitors. Both trials evidence-based information on pharmacologic and non indicate statistically significant improvement in clinical pharmacologic treatments for painful neuropathy . It exerts its anti levels are very high, similarly as with Waldenstrom’s nociceptive effect by binding the alpha-2 delta calcium macroglobulinemia [52–54]. It should be used with caution in renal insufficiency; of age) with major depressive disorder and other psychi the dose must be adjusted. In Valproate patients with mild to moderate hepatic impairment, reduce total daily dose by 50 %. Valproate agent should be used with caution in hepatic impairment; dose reduction is required. In rare instances anaphylactic reactions have sary to monitor for complications and recurrence. Testing should include 50 % of patients treated with radiation show improvement a general and detailed neurological exam to characterize of the neuropathy, but improvement in some patients may phenotype, and may include various diagnostic tests de be delayed, occurring after six months or longer . For these to accommodate for limbs with a loss of sensation and individuals and their families, psychological support is weakness is often done by patients with peripheral neu often needed. Treatments may incorporate arts and and edited the manuscript with additional citations. Patients responsible for the intellectual content of the paper along with critical appraisals, and revisions. Both authors participated in and provided with chronic disease, especially the elderly, who are iso significant contributions in writing the manuscript. Both authors read and lated and at risk for depression, may benefit from these approved the final manuscript. Acupuncture has produced improvement of Medicine-Los Angeles County Medical Center, and is a Fellow of the in both subjective symptoms and objective nerve conduc American Association of Neuromuscular and Electrodiagnostic Medicine. Neurology and Vascular Neurology, and Neurocritical care and Neuroimaging by the United Council of Neurologic Subspecialties. We also gratefully acknowledge and are very appreciative of the reviewers whose detailed pulse widths. Patients may experience skin irritation due comments and thoughtful suggestions helped us to significantly improve to drying out of the electrode gel. The clinical and laboratory features of chronic sensory ataxic neuropathy References with anti-disialosyl IgM antibodies. Papilloedema and hypertrichosis: the varied and harried manifestations (Paris, France: 1983). Neuropathy in lymphoma: a relationship between the pattern of neuropathy, type of lymphoma and prognosis J Neurol Neurosurg Prevalence of monoclonal gammopathy of undetermined significance. Neuropathy associated with the monoclonal clinical spectrum of peripheral neuropathies associated with benign gammopathies. Peripheral neuropathy in monoclonal gammopathy of undetermined the utility of plasma vascular endothelial growth factor levels in the significance: prevalence and immunopathogenetic studies. European Federation of glycoprotein paraprotein-associated peripheral neuropathies. Cochrane Neurological Societies/Peripheral Nerve Society Guideline on Management Database Syst Rev. Ferri C, La Civita L, Cirafisi C, Siciliano G, Longombardo G, Bombardieri S, doi:10. Placebo-controlled trial of rituximab in IgM anti-myelin associated glycoprotein antibody demyelinating neuropathy. Placebo-controlled trial of rituximab in IgM anti-myelin-associated glycoprotein neuropathy. Paradoxical increases in serum IgM and viscosity levels following rituximab in Waldenstrom’s macroglobulinemia. Practical considerations on the use of rituximab in autoimmune neurological disorders. Flare in neuropathy following rituximab therapy for Waldenstrom’s macroglobulinemia. Long-term response to rituximab and fludarabine combination in IgM anti-myelin associated glycoprotein neuropathy. High-dose therapy and autologous hematopoietic stem cell transplantation for patients with primary systemic amyloidosis: a Center for International Blood and Marrow Transplant Research Study. Successful Submit your next manuscript to BioMed Central treatment with pneumatic bag dilatation. Pseudoachalasia and • We accept pre-submission inquiries secondary amyloidosis in a patient with rheumatoid arthritis.
Technical notes While reported methods vary discount 750 mg valparin overnight delivery symptoms thyroid, the Dutch trial employs a schedule of erythrocytapheresis of 300-800 ml of erythrocytes every 2-3 weeks order valparin 750mg online symptoms quivering lips. Duration and discontinuation/number of procedures: Erythrocytapheresis every 2-3 weeks cheap valparin 250mg overnight delivery medicine kit, or as tolerated order 750mg valparin free shipping 10 medications doctors wont take, until serum ferritin <50 ng/mL. Maintenance treatment can follow with infrequent therapeu tic phlebotomy or erythrocytapheresis. Infection, pregnancy or drugs may trigger clinical disease in the presence of these mutations. All candidates for renal transplan tation must have genetic testing, as transplantation outcome may be related to mutation type. However, 30-100% of transplant patients, depending on the type of muta tion, have recurrence in the graft, causing graft failure. The alternative therapies may include use of purified complement factors or comple ment inhibitors, i. These guidelines address neither continued treatment after initial therapy failure nor ongoing prophylactic treatment for patients with remission. Myeloid blasts are larger and more rigid than lymphoid blasts, and their cytokine products may upregulate endothelial cell adhesion molecule expression and activate inflammation. These processes can lead to microvascular leukoag gregates, hyperviscosity, tissue ischemia, infarction and hemorrhage. Clinical manifestations are not reliably predicted by the degree of hyperleukocytosis alone. The frequency and severity of leukostasis complications, particularly pulmonary, are greater with the monoblastic/monocytic subtypes. Pulmonary complications include dyspnea, hypoxemia, diffuse alveolar hemorrhage, respiratory failure and radiographic findings of interstitial and/or alveolar infiltrates. Plasma, cryoprecipitate and/or platelets are given, as indicated, for bleeding or coagulopathy. Red cell transfusions should be avoided in patients with symptomatic leukostasis prior to cytoreduction because of the risk of augmenting hyperviscosity. Adjunctive radiation therapy may be considered in cases with parenchymal brain lesions; prophylactic cranial irradiation is not indicated. A second cohort study found no decrease in early mortality and raised concerns that leukocytapheresis may delay the start of chemotherapy. Prophylactic leukocytapheresis should, therefore, be consid ered in those patients. Severe end-organ injury or hemorrhage may not improve, however, particularly if extensive pre-existing tissue damage exists. Leukocytapheresis should be repeated in persistently symptomatic patients until clinical manifestations resolve or a maximum benefit is achieved. Chemotherapy should not be postponed and is required to prevent rapid reaccumulation of circulating blasts. Red cell priming may be employed for selected adults with severe anemia; however, undiluted packed red blood cells should be avoided in small children with hyperviscosity. These include acute pancreatitis, chronic abdominal pain, hepatosplenomegaly, eruptive xantho mas, lipemia retinalis, peripheral neuropathy, memory loss/dementia, and dyspnea. Endothelial damage due to chemical irritation by fatty acids and lysolecithin is felt to cause pancreatitis while hyperviscosity and tissue deposition produce the other complications. Current management/treatment Treatment includes dietary restriction and lipid lowering agent administration. Heparin may exacerbate hem orrhage into the pancreatic bed in the setting of pancreatitis and, therefore, its use is controversial. The number of treatments ranged from 1 to 10 (median 2) with Cesarean section due to fetal distress and delivery of a preterm infant occurring in 5 of 6 cases. In two additional cases, patients were treated prophylactically because of a history of pancreatitis. In the larger of the series (6 patients), the frequency of pancreatitis was reduced by 67%. For patients treated prophylactically, chronic therapy for years has been reported. As blood viscosity rises, a nonlinear increase in shear stress in small blood vessels, particularly at low initial shear rates, produces damage to fragile venular endothelium of the eye and other mucosal surfaces. The term ‘‘hyperviscosity syndrome’’ refers to the clinical sequelae of mucous membrane bleeding, retinopathy, and neurological impairment. Specific signs and symptoms include headache, dizziness, vertigo, nystagmus, hearing loss, visual impairment, somnolence, coma, and seizures. Other mani festations include congestive heart failure (related to plasma volume overexpansion), respiratory compromise, coagulation abnormalities, anemia, fatigue (perhaps related to anemia), peripheral polyneuropathy (depending on specific properties of the immunoglobulin), and anorexia. This syndrome occurs most typically in Waldenstrom’s macroglobulinemia, a lymphoplasmacytic lymphoma associated with the elaboration of! In vivo whole blood viscosity is not necessarily identical to in vitro serum viscosity (relative to water: normal range being 1. Therefore, serum viscosity measurement does not consistently correlate with clinical symptoms among individual patients. Almost all patients will be symptomatic when their serum viscosity rises to between 6 and 7 cp. Some may be symptomatic at a viscosity as low as 3–4 cp, others not until their viscosity reaches 8–10 cp. Recent data indicate that early manifestations of hyperviscosity-related retinopathy in Waldenstrom’s macroglobulinemia can be detected in the peripheral retina at a serum viscosity as low as 2.
It can also be helpful to buy 750mg valparin treatment of schizophrenia those in allied specialties such as rheumatology cheap valparin 500 mg on-line symptoms wisdom teeth, gastroenterology best valparin 250mg medications adhd, and ophthalmology generic 500 mg valparin inoar hair treatment. While all rea sonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual edi tors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical sci ence, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright hold ers if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or here after invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. We have not attempted to appraise critically the evidence of effectiveness for different drugs in diseases in order to keep a concise and easy-to-read format Prescribers are advised to check doses in up-to-date formularies and to consult manufacturers for full product information and details of excipients, for use in rare metabolic diseases such as porphyria and Lapp lactose galactose defciency this edition attempts to generalize across countries However, each country may have special aspects of prescribing that should be considered Sarah H. Further research led to development of the second generation of retinoids, the monoaromatic retinoids, etretinate and its metabolite, acitretin. Etretinate (which is no longer available) and acitretin are effective treatments for psoriasis and severe congenital disorders of keratinization. A major problem with systemic retinoids is their teratogenicity, and separation of this from their therapeutic effects has never been achieved. Acitretin has a much shorter half-life than etretinate, but a long duration of pregnancy avoidance post-treatment is still advised, as it transpires that acitretin can be converted to etretinate in the presence of alcohol, and the latter is stored in fat with a half-life of 120 days. Acitretin is an established treatment for psoriasis and, despite development of biological agents (the biologics), it remains an important therapy due to its unique mode of action. Subsequently, the ligand/receptor complex binds to specifc gene regulatory regions to modulate gene expression. In the epidermis, acitretin reduces keratinocyte proliferation and normalizes differentiation and cornifcation. It also inhibits production of vascular endothelial growth factor and inhibits intraepidermal neutrophil migration. In addition, there is emerging evidence that acitretin may be successfully combined with biologics. Monotherapy is indicated for erythrodermic or pustular psoriasis while combination therapy (with phototherapy) is often used for chronic plaque psoriasis. The effcacy of acitretin monotherapy in chronic plaque psoriasis is limited and dose dependent, with approximately 70% of patients achieving a moderate or greater response. Various studies have reported partial clearance rates of 25–75% with daily doses of 30–40 mg. Complete clearance is rare and adherence at high dosage is often limited by side-effects. The comparative effcacy of acitretin monotherapy in chronic plaque psoriasis is less than methotrexate and ciclosporin (cyclosporine). Topical therapy such as calcipotriol should be continued with acitretin as it may enable increased effcacy at lower dosage. There is preliminary evidence for improved effcacy in combination therapy with the antidiabetic drug pioglitazone, although further studies are needed. There is also limited evidence for the effective combination of acitretin with etanercept and with hydroxycarbamide (hydroxyurea). As monotherapy, acitretin is highly effective in erythrodermic and pustular psoriasis. Another potential therapeutic use of acitretin is the prophylaxis of non melanoma skin cancer in organ transplant recipients. Acitretin may be considered a frst-line systemic therapy for pityriasis rubra pilaris and lichen planus (especially the hyperkeratotic and erosive variants). Acitretin has similar effcacy to antimalarials in the treatment of cutaneous lupus erythematosus. For pustular psoriasis, the dose should be escalated up to the maximum maintenance dose of 75 mg or 1 mg/kg daily. An initial fare of plaque psoriasis may occur, but improvement is usually evident by 4 weeks. Lower starting doses of 10 mg daily are indicated for Darier’s disease, with maintenance doses of 10–25 mg daily.
This small but pivotal study (based on 2 cases) wielded huge influence in this area of research 750mg valparin fast delivery symptoms exhaustion. Early nodal changes in the acute motor axonal neuropathy pattern of the Guillain-Barre syndrome buy valparin 250mg cheap symptoms mercury poisoning. The study focused on identifying early changes and establishing the sequence of those changes purchase valparin 250mg online symptoms 3 days before period. By electron microscopy the earliest and mildest changes consisted of lengthening of the node of Ranvier with distortion of the paranodal myelin valparin 500mg online medicine 2410, and in some instances breakdown of the outermost myelin terminal loops. At this stage many nodes had overlying macrophages which extended their processes through the Schwann cell basal lamina covering the node and apposed the axolemma. At later time points macrophage processes extended beneath the myelin terminal loops and the whole macrophage entered the periaxonal space at the paranode. Macrophage processes dissected the axon from the adaxonal Schwann cell plasmalemma and the macrophages advanced into the internodal periaxonal space, where they typically surrounded a condensed-appearing axon. This association of macrophage and axons appeared to be stable for some time, and the axons subsequently underwent Wallerian-like degeneration. The internodal myelin sheath and the abaxonal Schwann cell cytoplasm remained normal. The pathologic sequence emerging from these studies is that early in the course there are only mild changes at the nodes of Ranvier, sufficient to induce paralysis; it is only later that the axons degenerate. This study suggests that macrophages are critical to the pathogenesis and injury and dysfunction of the nodal axolemma initially and of the internodal motor axons subsequently. Moreover, the nodal and axonal injury likely depends upon macrophage contact with the axons/axolemma (contact-dependent). In separate studies, the same group has demonstrated the deposition of IgG and C3d (membrane bound cleaved product of C3) at the nodes of Ranvier initially and at paranodal and internodal axolemma at later time points after the onset of the disease . Whether early complement component(s) deposits at structural specializations along myelinated axons originate from circulation or adjacent microglial/macrophage cells in the endoneurium and/or perinodal and periaxonal spaces is not established. It has been shown previously that macrophage populations can synthesize and secrete various complement components. It is believed that complement activation products may provide chemotactic cues for macrophage recruitment at the nodes and periaxonal location. Proceedings of the National Academy of Sciences, 2004 In this study Yuki and colleagues report an animal model of post-infectious autoimmune neuropathy induced by immunization of rabbits with C. Whether autoantibodies against gangliosides are by themselves sufficient to induce nerve damage or require other effectors of the innate immune system was not established in this study. The presence of periaxonal macrophages in this experimental model again emphasized that axonal injury may depend on contact between axons and macrophages. A fundamental principle learned from this series of nerve crush studies was that inflammatory milieu, primarily consisting of activated FcR bearing macrophage/microglia, are critical mediators of Ab-mediated nerve injury. Anti-ganglioside antibodies induce nodal and axonal injury via fcgamma receptor mediated inflammation. Notably, macrophages were seen adjacent to widened nodes of Ranvier at early time points. In sum, inflammatory cells in the endoneurium, particularly macrophage recruitment, is associated with early injury to the nodes of Ranvier in both demyelinating and axonal variants of the disease. Could endoneurial glia (including microglia) be activated by soluble signals diffusing from systemic immune compartment and subsequently set up endoneurial inflammation including macrophage recruitment in these situations Moreover, our experimental studies in the context of anti-ganglioside antibodies and axonal injury indicate that activating FcRs on macrophage populations are key molecular effectors mediating nerve injury. Whether the macrophage and activating FcRs interactions with immune complexes formed on nerve fibres are random or other molecular signals abet in this process (such as complement activation products) acting as chemoattractants for directing the macrophages within endoneurium to specific sites along the nerve fibres remains to be established. Moreover, the kinetics and evolving phenotype(s) (pro-inflammatory, anti-inflammatory or in between these polarized states) of macrophage/microglial cells in the endoneurial compartment of intact and injured/diseased nerves are not well defined. The molecular effectors of nerve fibre injury downstream of macrophage-immune complex interactions are also not elucidated. Indeed novel strategies to deliver such therapies selectively to endoneurial compartment would be a requisite and a challenge. Serial clinical, electrophysiological, biochemical, and morphological observations. Introduction Everything we think about is predicated on the discoveries of those who thought long before us. We gathered techniques and reagents that had been previously developed and used to study neuromuscular synaptic function in experimental mouse preparations, and applied them to investigate our hypotheses. In doing so we quickly realised that pretty much everything we thought about had already been thought about by someone before us, and we were simply inching an old idea forward or nudging it sideways towards our application. When Jaap starting quoting that we should not aim to drag “oude koeien uit de sloot” (old cows out of the ditch) we both knew that truly new knowledge was a rare beast, mostly well beyond our grasp. The purpose of this memoir is to highlight some of the pre-existing ideas, reagents and methods described within our ‘Top 10’ papers that helped us to investigate this problem, rather than describe the findings and conclusions that we reached; these can be accessed in great detail elsewhere [1,2]. Working one’s way through ganglioside nomenclature and committing the structures to memory in a clinically meaningful way is greatly aided by the logical layout of the members of the complex and large ganglioside family described by Lars Svennerholm, one of the founding fathers of ganglioside biochemistry . His classification, based on the migration pattern seen on thin layer chromatography, is still widely used today, and the underlying synthesizing enzymatic pathways leading to this neuronal ‘sialome’ are now well-known. An analysis of the end-plate potential recorded with an intracellular electrode, the Journal of Physiology, 1951 the ability to record and analyse the synaptic signals, i. The neuromuscular junction offers a perfect ex vivo system, and Bernard Katz used this system to work out key aspects of the quantal theory of neurotransmission  for which he was awarded the Nobel Prize for Physiology or Medicine in 1970 (jointly with Ulf von Euler and Julius Axelrod). Our studies on the electrophysiological effects of anti-ganglioside antibodies at neuromuscular junctions, first performed with the Miller Fisher syndrome sera in Oxford, and subsequently in Leiden, relied heavily on the classical technical and theoretical knowledge of this process provided by Katz.
Any alteration of normal intact skin such as a wound order valparin 500mg without a prescription symptoms of hiv, ulcer purchase valparin 250 mg otc medications quit smoking, or dermatologic condition B buy cheap valparin 750mg on-line symptoms bowel obstruction. However discount 250 mg valparin with visa symptoms 2 year molars, certain conditions or exposure may provide acquisition of other specic pathogens: A. Vibrio vulnicus (usually presents as sepsis and associated with salt water exposure). Tinea Infections are most commonly caused by three genera of fungi, also known as dermatophytes: Trichophyton (most common), Microsporum, and Epidermophyton. Candidiasis (most commonly Candida albicans) often is represented as an intense erythema (beefy red) with pustules. Malassezia furfur Causes a Supercial Fungal Infection (Known as Tinea Versicolor) That Results in Alteration of Pigmentation. The clinical manifestations of skin and soft-tissue infections are variable and depend on the anatomical site, host comorbid illnesses, immune response, and pathogen. Usually include signs of inammation: redness (rubor; due to increased blood ow to the affected area), warmth (calor; due to increased blood ow to the affected area), swelling (tumor; due to exudation of uid), and tenderness or pain (dolor; due to mechanical and/or chemical mediators of inammation). Often not all of the cardinal ndings are found because of early treatment or the comorbid status of the host. Usually occurs with skin and soft-tissue infections but may be absent owing to early treatment or immunodeciency. Fatigue, malaise, arthralgias, and myalgias (typically in association with Lyme disease) may be present. Mild tenderness and pain are part of the classic ndings, but signicant pain may indicate a necrotizing skin infection. Isolation of group A Streptococcus by culture (from a sterile or nonsterile site) B. Hypotension (systolic blood pressure less than 90 mmHg) and two or more of the following: 1. Generalized erythematous macular rash with a tendency to desquamate and/or involve soft-tissue necrosis Denite case is dened as isolation of group A Streptococcus from a sterile site, hypotension, and two or more of the clinical and laboratory abnormalities. Probable case is dened as isolation of group A Streptococcus from a nonsterile site, hypotension, and two or more of the clinical and laboratory abnormalities. While foul-odor drainage may indicate anaerobic infection, a sweet (or fruity) odor may indicate a Pseudomonas infection. A complete and careful history is important in determining the poten tial exposure and cause of the infection. A complete physical examination should be performed, as it is important to differentiate skin and soft-tissue infection from other condi tions such as the following: 1. Carcinoma erysipeloides (most often associated with breast cancer with lym phatic involvement). These studies are important for identication of the patho gen and severity of illness. Anemia and intravascular hemolysis may also suggest an infection due to Clostridium perfringens. Serum chemistries may identify comorbid diseases such as diabetes or renal failure. Are rarely helpful in uncomplicated skin and soft-tissue infections (less than 5%). Supercial swab cultures from nonpurulent infections are not recommended; however, Gram stain and culture of the pus or exudates in association with purulent infections are recommended. Cultures of skin needle aspirates or punch biopsies from nonpurulent infections are helpful in about 50% of cases involving S. Needle-aspirated contents from intact bullae or vesicles may also yield positive cultures. Finally, deep cultures from abscesses or sur gically obtained sources are most helpful to identify a causative pathogen. Plain lms may be useful in identifying gas in tissues from an anaerobic infection such as from Clostridium spp. Most cases of infections are mild to moderate in severity with a fairly normal host and due most commonly to beta-hemolytic streptococci or S. Oral therapy can be effectively provided in most cases, and recommended agents are: a. Clindamycin 300 mg three times daily may be an alternative (depending on antibiotic susceptibilities) for peni cillin-allergic patients. Penicillin V 250 mg three times daily, amoxicillin 250 to 500 mg three times daily, or clindamycin 300 mg three times daily. Patients can usually be changed to oral therapy (see the preceding) when the vital signs and laboratory values are improving (or normalized) and skin ndings are improving. Penicillin G 2 million units q4–6, cefazolin 2 g q8, or clindamycin 600 mg q8 or ceftriaxone 2 g daily. A treatment of 21 to 28 days or longer may be needed for certain multidrug-resistant pathogens and/or complex infections (see the following). Recommended Adjunct Anti-Inammatory Agents Used for Skin and Soft Tissue Infections. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus.
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