Next to stimulants, antidepressants are the most commonly prescribed psychotropic medications for children and adolescents. In addition to depression, these medications are often prescribed for anxiety and related disorders Obsessive-Compulsive Disorder, Panic Disorder, Acute Stress Disorder, etc. ; . The most commonly prescribed antidepressants are selective serotonin reuptake inhibitors SSRIs ; fluoxetine, sertraline, paroxetine, fluvoxamin, citalopram. There appears to be a general consensus in the professional literature that the SSRIs are more effective and safe than other classes of antidepressants, such as TCAs, although what determines `efficacy' and `safety' is a matter of some dispute. Of the SSRIs, fluoxetine Prozac ; appears to have the best track record. One recent study confirmed a 61% response rate among adolescents to fluoxetine alone, compared to a 35% response rate to a placebo.50 The response rate goes up when fluoxetine is combined with cognitive behavior therapy CBT ; . A host of other studies have demonstrated the effectiveness of fluoxetine and other SSRIs such as sertraline Zoloft ; and paroxetine Paxil ; , but the issue is always "compared to what." The research shows a consistently high response rate to placebo among children and adolescents, leading some to assert that, while the controlled studies show the "statistical" superiority of the SSRIs, they may have less "clinical" superiority to, say, combining CBT with the "expectation effect" of a placebo. Ultimately, the cost-benefit of using SSRIs and all medications, for that matter ; must be established by weighing "the potential benefit of improved symptomatology, accompanied by adverse side effects, against the risk of leaving the disease untreated."51 With regard to the efficacy of antidepressants for children and adolescents, the following general points are noted.
The most serious drug interactions reported to date involve 3a4, and either initiation or discontinuation or sjw may result in adverse effects, because citalopram 40.
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Used, the long waiting period in obtaining results by these methods may delay the initiation of proper treatment, resulting in the patient transmitting drug-resistant infection in the community. In recent years, several new methods have been reported for reducing the time interval between the collection of the specimen and the receipt of results to three weeks or less. However, these methods require considerable technical expertise and financial inputs in a routine laboratory setup in disease endemic developing nations, for example, citalopram sexual.
The clinical effectiveness and tolerability of citalopram in the long-term treatment seem to be comparable with the observations of other ssris in childhood and adolescent ocd.
Depression often requires months or even years of continuous pharmacotherapy. Thus, it is quite likely that many patients will take at least 1 other drug--be it an over-the-counter cough syrup, a nasal decongestant, or an antibiotic--with their SSRI at some time during treatment. For some patients e.g., those with chronic medical conditions ; , polypharmacy is a daily necessity. SSRIs are relatively safe when administered alone, but the risk of combining them with other medications varies significantly from agent to agent. Underlying this variability is the cytochrome P450 CYP ; system, a group of enzymes that metabolizes most marketed drugs. All of the SSRIs are extensively biotransformed by the P450 system, but fluoxetine, fluvoxamine, and paroxetine also significantly inhibit 1 or more of the major P450 enzymes.2032 Therefore, these agents have the potential to impair the metabolism of a wide variety of medications Table 2 ; . In contrast, citalopram and sertraline do not substantially inhibit P450 enzymes.25, 26, 29, 30, When initiating therapy with an SSRI, the single most important means of avoiding adverse drug interactions is and chloromycetin.
Objective: This open label study was designed to determine whether citalopram has antiaggressive activity in subjects with comorbid cluster B personality disorders or intermittent explosive disorder. Methods: In this 8-week trial, subjects were initiated on 20 mg day of citalopram and titrated up to 60 mg by the fourth week, if tolerated. The Overt Aggression Scale-Modified OAS-M ; was used to quantify verbal and physical aggression, subjective irritability and overt irritability. Results: Eight subjects completed the study. The average daily dose was 55 mg day and citalopram was generally well tolerated. Statistically significant decreases were found in OAS-M aggression scores 25.25 16.85 to 3.62 3.81, p 0.01 ; , subjective irritability scores 3.50 .53 to 1.50 1.51, p 0.01 ; , and overt irritability scores 3.38 .744 to .88 1.13, p 0.01 ; . Conclusions: These results suggest that citalopram may be an effective treatment for reducing impulsive aggressive behavior.
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Mean SEM ; ovarian stromal time averaged maximum velocity TAMX ; was 10.55 0.91 ; and 10.89 1.80 ; cm s in groups 2 and 3 respectively, both significantly greater than mean ovarian stromal TAMX of group 1 P 0.001 ; . There was no significant difference in pulsatility index PI ; between the three groups. There thus appears to be significantly greater ovarian stromal blood flow velocity in women with PCO as detected by colour and pulsed Doppler ultrasound. However, to date, there has been no study of changes in velocity after laparoscopic ovarian treatment of PCO. Such a study would permit verification of our first hypothesis. B.Cohen 1989 ; postulated that drainage of androgens and inhibin from surface follicles could prevent the excessive collagenization of overlaying ovarian cortex and facilitate a softening of the ovaria tunica. Neighbouring follicles that are not undergoing atresia may then mature and gain access to the ovarian surface, facilitating normal ovulation. It remains a mystery as to how the use of laparoscopic techniques brings about the reversal of an endocrinological dysfunction. What is certain, however, is that laparoscopic techniques suppress ovarian tissue less than when wedge resection is used, but have a similar mode of action. Conclusions A considerable amount of data has allowed the assessment of the impact of the laparoscopic treatment of PCOS on the resumption of ovulation and the rate of pregnancy in infertile patients 50% ; . A significant difficulty encountered in the evaluation of these studies is their lack of uniformity. There was a great variation in the diagnosis criteria used to define PCOS and none of the studies included a treatmentindependent control group. Some of the patients became pregnant following medical treatment after laparoscopy the same treatment having been ineffective prior to surgery ; . Nevertheless, many of the reports of clinical experience have stressed the advantages of the laparoscopic surgical method, including elimination of the risk of ovarian hyperstimulation syndrome OHSS ; and multiple gestations, the achievement of multiple ovulatory cycles from a single treatment and a lower rate of spontaneous abortion, and elimination of the need for intensive monitoring and high-cost gonadotrophin therapy. Additionally, the laparoscopic techniques have the advantage over the surgical wedge resection of cost savings and a lower risk of postoperative adhesions. They have the advantage over gonadotrophin therapy of serial repetitive ovulatory events resulting from a single treatment, no increased risk of ovarian hyperstimulation or multiple pregnancies, and a lower incidence of spontaneous abortion.
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| Citalopram drugBecause their side effects are relatively mild, selective serotonin reuptake inhibitors ssris ; , such as celexa citalopram ; , prozac fluoxetine ; , paxil, paroxetine ; and zoloft sertraline ; , are the most commonly prescribed medications for patients with dysthymia and atacand.
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Overdoses with tricyclic antidepressants, such as amitriptyline and nortriptyline, have been linked to cardiac arrhythmias. Citalop4am is a serotonin reuptake inhibitor with low potential for toxicity, when taken alone. This presentation will discuss the combined effects of these antidepressant drugs in the presence of ethanol.
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STRM M, ERIKSSON A, THORSON J, SPIGSET O: Fatal overdose with citalopram. Lancet 348: 339-340, 1996. PACHER P, MAGYAR J, SZIGLIGETI P, BANYASZ T, PANKUCSI C, KOROM Z, UNGVARI Z, KECSKEMETI V, NANASI PP: Electrophysiological effects of fluoxetine in mammalian cardiac tissues. NaunynSchmiedebergs Arch Pharmacol 361: 67-73, 2000. PARK KS, KONG ID, PARK KC, LEE JW: Fluoxetine inhibits L-type Ca2 + and transient outward K + currents in rat ventricular myocytes. Yonsei Med J 40: 144-151, 1999. PUCELIK P: Membrane Electrophysiology of the Heart in Czech ; Avicenum, Prague, 1990. RAWLING D, FOZZARD H: Effects of imipramine on cellular electrophysiological properties of cardiac Purkinje fibers. J Pharmacol Exp Ther 209: 371-375, 1979. REUTER H: Ion channels in cardiac cell membranes. Annu Rev Physiol 46: 473-484, 1984. ROOSE SP, GLASSMAN AH, ATTIA E, WOODRING S, GIARDINA EG, BIGGER JT: Cardiovascular effects of fluoxetine in depressed patients with heart disease. J Psychiatry 155: 660-665, 1998. SHAPIRO PA, LESPERANCE F, FRASURE-SMITH N, O'CONNOR CM, BAKER B, JIANG JW, DORIAN P, HARRISON W, GLASSMAN AH: An open-label preliminary trial of sertraline for treatment of major depression after acute myocardial infarction. Heart J 137: 1100-1106, 1999. SLAVCEK J, PACLT I, HAMPLOV J, KITTNAR O, TREFN Z, HORCEK BM: Antidepressant drugs and heart electrical field. Physiol Res 47: 297-300, 1998. VAN DER BURGHT M: Citaloprqm Product Monography, H Lundbeck A S, Coppenhagen, Denmark, 1994. Reprint requests J. Hamplov, Psychiatric Clinic, The First Medical Faculty, Charles University, Ke Karlovu 11, CZ-128 00 Prague 2, Czech Republic.
A management plan should include global care of the patient with careful attention to psychosocial aspects category 3 recommendation ; Established post-herpetic neuralgia PHN ; can be treated first-line with the -2- ligands as they provide efficacy comparable with that of tricyclics, with a preferable side-effect profile compared with tricyclics. However, cost considerations may dictate the use of tricyclics as the beginning treatment category 1 recommendation ; Nortriptyline is the preferred tricyclic for first-line treatment of established PHN because of its more favourable side-effect profile category 1 recommendation ; If a first-line tricyclic antidepressant fails, any of the available non-tricyclics may be tried, especially duloxetine. Selective serotonin re-uptake inhibitors SSRIs ; , especially citalopram and paroxetine, may also be effective in some patients with PHN given that beneficial effects have been demonstrated in painful diabetic neuropathy category 3 recommendation ; Analgesia with weak opioids, such as tramadol, is effective and recommended for established pain, but there is no evidence to support the use of nonsteroidal anti-inflammatory drugs NSAIDs ; in the treatment of PHN category 1 recommendation ; Opioids, such as oxycodone, morphine and methadone, should typically be considered for second-line therapy but can also be used as first-line therapy for patients with severe pain or in whom prompt pain relief is necessary. Their use should comply with contemporary guidelines for use of this class of drugs in chronic benign pain, such as: britishpainsociety pds opioids doc 2004. pdf or ampainsoc advocacy opioids category 1 recommendation ; The 5% lidocaine patch should be considered firstline for PHN as it is approved for this indication by the FDA category 1 recommendation and desloratadine.
Welcome to the electronic CDR Weekly. You will find that its appearance reflects that of the old paper CDR, and will be following the same four-weekly cycle of subject matter. The first week of the month will present data on respiratory tract infections, animal associated infections and imported infections; the second gastrointestinal illnesses; the third bacteraemias and MRSA, and the fourth immunisable diseases and HIV. Data on sexually transmitted diseases will be published on the fifth week of five-week months. For the first month the presentation of data will follow that used previously, so as to complete the data tables for 2000. Pages for all sections are in place, but some will remain empty until we reach the appropriate week in the cycle. There is information at the top of each page showing when it was last updated, and when each update is due. In February we will begin revised presentations, with more focused information on different diseases and conditions. The reporting frequency for some conditions will also change to reflect their relative importance. Information on forthcoming meetings and workshops will appear in the diary section. Notifications of infectious diseases will no longer be published as part of CDR Weekly but will appear separately on the PHLS website. Click on the link at the foot of our home page to get to there. As with any new development there will be a steady stream of minor improvements over the coming weeks. We therefore particularly welcome any feedback on the presentation and content of CDR Weekly, which should be emailed to the deputy editor nhough phls.
NIDA, one of the National Institutes of Health, supports most of the world's research on the health aspects of drug abuse and addiction.and NIDA NOTES tells you all about it and serophene.
N any given one-year period, 30% approximately 18.8 million American adults suffer from a 25% depressive illness.l Depression is a disease of both the body and 20% mind with symptoms that include feelings of worthlessness; helpless15% ness; decreased energy; difficulty 10% concentrating, eating, and sleeping; and suicide attempts. It is a major 5% source of economic strain on the public health system in terms of lost 0% work days, worker productivity, and Venlafaxine Sertraline Paroxetine Citalipram Fluoxetine Fluvoxamine Escitalopram HCl HBr HCl oxalate * direct medical costs.2 In the last Figure 1 Percentage of depressed hospitalized patients taking SSRIs or SNRIs in calendar year, almost 900, 000 hospithe third quarters of 2001, 2002, and 2003. Asterisk Data shown only for 2003. tal inpatients had a diagnosis of depression, according to MediMedia's Hospital Diagnosis & Therapy Audit.3 The Average Cost per Patient symptoms can last from a few weeks to several $46.62 Fluvoxamine years, but appropriate treatment is readily available. $24.29 Atomoxetine Several classes of drugs are used to treat depres$23.41 Venlafaxine HCl sive disorders, ranging from the older tricyclic anti$17.82 depressants, such as amitriptyline HCl various manSertraline ufacturers ; , to the monoamine oxidase inhibitors $17.42 Fluoxetine HCl MAOIs ; , such as tranylcypromine sulfate Par$16.23 Clomipramine HCl nate, GlaxoSmithKline ; , to the newest class, the $15.58 Paroxetine selective serotonin reuptake inhibitors SSRIs ; and $14.31 Citalopam HBr the selective norepinephrine reuptake inhibitors $12.58 SNRIs ; , such as escitalopram oxalate LexaproTM, Escitalopram oxalate $8.85 Forest ; . Trimipramine maleate $7.65 In the SSRI SNRI class, inpatient treatment patAmoxapine $5.52 terns have been dominated for more than three years Protriptyline HCl $3.78 by sertraline Zoloft, Pfizer ; , which has retained the Nortriptyline HCl $1.58 largest consistent market share, followed by venImipramine HCl $1.56 lafaxine HCl Effexor, Wyeth ; . Citalopram hydrobromide CelexaTM, Forest ; , fluoxetine Prozac, Eli Doxepin HCl $0.76 Lilly ; , paroxetine Paxil GlaxoSmithKline ; , and fluAmitriptyline HCl $0.41 voxamine maleate Luvox, Solvay ; have all seen Figure 2 Costs of various antidepressants per hospital inpatient shifts in prescribing patterns toward escitalopram stay. oxalate in the past year Figure 1 ; . The newer medications that affect neurotransmitters such as dopamine or norepinephrine generally have information about joining PharmScope Insights, a division fewer side effects than the tricyclics but are more expensive. of MediMedia USA, Inc., please visit the Web site at Figure 2 illustrates the average cost per inpatient stay for mminfotech and click on Hospitals. both SSRIs and tricyclics. Although the direct costs of the prescriptions for the newer agents are obviously higher, REFERENCES the costs of hospitalizations and relapses attributable to non- 1. National Institutes of Health, National Institute of Mental Health. NIH Publication No. 02-3561. Bethesda, MD. Printed compliance in patients taking the less tolerable medications 2000, reprinted September 2002. Available at: nimh. must be factored into the equation. gov publicat depression . Accessed March 6, 2002. The data cited in this article are available free of charge 2. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression in 1990. J Clin Psychiatry 1993; to hospitals that participate in the PharmScope Insights pro54: 405418. gram. The program specializes in helping hospital pharma3. Hospital Diagnosis and Therapy Audit, 20002003. Yardley, cies target areas for performance improvement by providing PA: MediMedia USA. benchmarks from a panel of 80 hospitals nationwide. For.
If you are a retired public employee, you are eligible for PEIA health and life benefits, provided you meet the minimum eligibility requirements of the applicable State retirement system and if your last employer immediately prior to retirement is a participating employer under the State retirement system. Members of the Teacher's Defined Contribution Retirement plan must have 12 or more years of credited service or be age 60 with 5 years of service to qualify to continue PEIA insurance benefits upon retirement. Members who participate in a non-State retirement system must, in the case of education employees such as TIAA-CREF or similar plans ; , meet the minimum eligibility requirements of the State Teachers Retirement System, and in other cases, meet the minimum eligibility requirements of the Public Employees Retirement System. If you have questions about your retirement, contact the Consolidated Public Retirement Board CPRB ; toll-free at 1-800-654-4406. If you have PEIA coverage as an active employee, you may continue coverage into retirement without interruption. To do so, you must complete Retired Employee Enrollment Forms during the calendar month of retirement or the two following calendar months. Continuous coverage and employment are necessary if you wish to use your accrued sick and or annual leave for extended employer-paid PEIA coverage. You cannot defer your sick and or annual leave. If you were not covered under a PEIA Plan as an active employee or if you allow your coverage to lapse, you may choose to enroll for health coverage at the time of your retirement if your last employer immediately prior to retirement is a participating employer under the State retirement system and as long as you meet the minimum qualifications. Coverage will be effective on the first day of the month following enrollment. Please Note: If you retire, then return to active employment with a participating agency, you will lose your right to use your sick and or annual leave for extended employer-paid PEIA coverage. When you return to active employment and have PEIA benefits as an active employee, your new effective date of coverage in the PEIA plan will be after July 1, 2001, and therefore you will be ineligible for the sick annual leave benefit and clomiphene and citalopram, because citalopramm loss weight.
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6-3 THE EFFECT OF FRUIT AND VEGETABLE INTAKE ON RISK FOR CORONARY DISEASE The data support a protective effect of greater consumption of fruits and vegetables, particularly green leafy vegetables and vitamin C rich fruits and vegetables, against CHD. Practical point: Primary care clinicians should repeatedly advise patients about the benefits of a healthy diet and clozaril.
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Risk of suicide should be assessed for whole class of antidepressants Editor--Gunnell et al's report on suicide risk with selective serotonin reuptake inhibitors SSRIs ; raises several issues.1 Firstly, clinicians have observed that the first weeks of treatment of severe depression with an antidepressant are accompanied by a higher risk of suicide because of a drug induced motor disinhibition that is not yet accompanied by mood improvement.2 Secondly, the authors' finding of a trend towards a protective effect of SSRIs against suicidal thoughts odds ratio 0.77 ; compared with a trend towards an increased risk of self harm odds ratio 1.57 ; is paradoxical. More surprising is the heterogeneity of results among SSRIs. Why would sertraline show a protective effect for suicidal thoughts and simultaneously increase the risk of self harm? The risk difference between citalopram and its active S-enantiomere, escitalopram, is also strange. No strong biological rationale can explain such heterogeneity among drugs with the same mechanism of action. Thirdly, the authors mention that the Medicine and Healthcare products Regulatory Agency found little evidence for a risk difference between SSRIs and the other antidepressants. The two accompanying papers show that the suicidal risk seems similar for serotoninergic and tricyclic antidepressants.3 4 The risk of suicide must be assessed for the whole class of antidepressants. The next stage would be to measure the risk of suicide according to the time since starting an antidepressant. Initially, the risks are higher than the benefits. To confirm old clinical observations by evidence based methods would be interesting and useful.
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Target was raised. For an effective analgesic, this proportion fell slowly until high relief targets were reached. The difference remained largely unaltered over a wide range of targets, thus generating stable NNTs. An NNT of 1 describes an event which occurs in every patient given the treatment but in no patient in a comparator group. This could be described as the `perfect' result in, say, a therapeutic trial of an antibiotic compared with placebo. For therapeutic benefit, the NNT value should be as close as possible to 1; there are few circumstances in which a treatment is close to 100% effective and the control or placebo completely ineffective, so NNTs of 2 or often indicate an effective intervention. For unwanted effects, NNT becomes the NNH number-needed-to-harm ; , which should be as large as possible. It is important to remember that the NNT is always relative to the comparator and applies to a particular clinical outcome. The duration of treatment necessary to achieve the target should be specified. The NNT for cure of head-lice at 2 weeks with permethrin 1% compared with a control was 1.1 95% CI, 1.01.2 ; .2, 19.
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The data about other medicaments than citalopram taken by the mother Table 2 ; in cases 2, 6, are known only from mothers, not from any official documentation. Therefore it was not possible to estimate the dose really taken. Neverthless none of these drugs was detected in the urine of the babys`. Moreover, the case 6 was complicated by an infection that appeared within 4 days after birth and the urine sample delivered to the laboratory was taken on the 18th day. The data in the case 7 are known from medical documentation. Mother was taking escitalopram 20 mg day and quetiapine 200 mg day. Quetiapine was neither detected in meconium nor in urine. There are only a few studies about the influence of citalopram and some other SSRIs on the neonates, sometimes with contradictory conclusions. Neverthless, most of them state clearly that withdrawal symptoms occured within few days after birth and lasted up to one month at least at 30 % of neonates.
| Citalopram 20 mg side effectsA 76-yr-old, 70-kg woman, ASA physical status II, presented to the ambulatory surgery center for foot osteotomy. Her history was significant for anxiety and depression. Her oral medications included daily citalopram 20 mg, olanzapine 2.5 mg, and twice daily diazepam 5 mg. Physical examination and electrocardiogram ECG ; were unremarkable. Routine ASA monitors and supplemental oxygen were applied. Midazolam 3 mg and fentanyl 100 g IV were titrated for sedation. Using an insulated needle and a nerve stimulator Braun Medical, Bethlehem, PA ; , a femoral nerve block was performed using 20 mL of 1.5% mepivacaine with 1: 400, 000 epinephrine to provide anesthesia in the area of the tourniquet. The patient remained relaxed and conversant. Five minutes later, using the same technique, an anterior sciatic block was done with 0.5% ropivacaine with 1: 400, 000 epinephrine for prolonged analgesia. Plantar flexion of the toes was obtained at 0.4 mA ; and stopped after injecting 1 mL. The remainder of the solution was injected over 120 180 s. A negative aspiration occurred between each 3- to 5-mL dose. No changes in heart rate or blood pressure cycled every 3 min ; were noted. After injecting 32 mL 160 mg ; , the patient became less responsive. The injection was aborted and 510 s later twitching of the hand and face as well as tachycardia developed. Midazolam 2 mg IV was administered; however, the twitching rapidly progressed to a tonic-clonic seizure.
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Uous-positive-airway-pressure device was recommended, but Mr. A refused it because of financial concerns. He began treatment with topiramate, 25 mg day; the dose was progressively increased to 100 mg day. My sole recommendation was the use of this medication. A remarkable reduction in snoring was reported soon thereafter; there remained only slight dorsal-decubitus snoring. A follow-up polysomnography, allowed by Mr. A's health insurance, showed obstructive sleep apnea of degree I, moderate snoring, periodic-movement syndrome of the legs, and fragmented sleep. There was a drastic decrease approximately 70% ; in his episodes of apnea, falling from 20.0 hour to 6.6 hour. There were no changes in body weight. some residual depressive symptoms. She was followed up in the community between admissions. She was admitted again on two occasions after being seen for treatment of manic and hypomanic symptoms, respectively. She was then treated with haloperidol and hypnotic medications. After follow-up in the community, she was admitted again. She exhibited features of psychotic depression and was therefore administered lithium and imipramine. Since then, she had had minor relapses managed with adjustment of her dose of imipramine. When Ms. A was next admitted, she was profoundly depressed and mute, with akinesia associated with negativism and psychomotor retardation. Upon physical examination, she was found to have bilateral pitting edema. She had a history of chronic cardiac failure; otherwise, her past medical history was unremarkable. The results of an ECG and a chest X-ray were normal. There was no evidence of constipation or dehydration as indicated by her urea, creatinine, and packed cell volume values ; . Obesity was present. In view of Ms. A's age, lack of response, and potential physical complication, mainly related to side effects, imipramine was switched to citalopram, 20 mg day, and the citalopram dose was increased to 40 mg day after 4 weeks. When Ms. A started to improve to a degree that allowed her to walk around with a walker, shortness of breath upon minimal exertion was noted. A repeat physical examination and another ECG revealed no new features. Ms. A was referred to a medical unit, where she was admitted with a diagnosis of multiple pulmonary emboli, which was confirmed with a ventilation perfusion scan. She was prescribed an anticoagulant and eventually made a good physical and mental recovery.
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People with HIV take anti-HIV drugs to reduce the amount of HIV in their blood. The amount of HIV in the blood of someone who has HIV is called their "viral load." Your doctor will prescribe anti-HIV drugs to try to get your viral load as low as possible. In some cases, viral load can become so low that HIV may not be detected in the blood. Doctors call this "undetectable viral load." This doesn't mean you no longer have HIV. But it is still good because the less HIV in your blood, the less damage it can do to your body.2.
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