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Which of the following statements regarding allergy practice complaining of chronic cough the pharmacokinetics of theophylline is correct? The condition (A) It is primarily metabolized by the kidney occurs about twice a week and is beginning to (B) Its metabolism depends on age interfere with his studies order acivir pills 200 mg otc hiv infection flu symptoms. Which of the follow- (C) It is poorly absorbed after oral ing would be most appropriate treatment for administration this patient? Which of the following statements correctly (C) Diphenhydramine describes the action of theophylline? Which of the following is most likely re- (B) It can cause diarrhea sponsible for the increase in liver enzymes? Which of the following statements about the mechanism of action of ipratropium is correct? In the last (C) It decreases mast cell release of histamine month discount acivir pills 200mg overnight delivery antiviral lubricant, he has used his albuterol inhaler at least (D) It blocks the action of histamine at H1 20 times following baseball practice, but he has receptors not been waking much at night. Zileuton is useful in the treatment of asthma lowing would be the best change in treatment because it for this patient? This is a fairly classical presentation of asthma, which should be confirmed with further pulmonary testing. Mild persistent asthma can be treated several ways (Table 9-1), but inhaled glucocorticoids are very effective. Omalizumab is for patients who are refractory to other treatments and those with allergies. Antihistamines such as diphenhydramine are poorly effective in asthma, and theophyl- line is only moderately effective. Zileuton is a leukotriene synthesis inhibitor that can cause increases in hepatic enzymes and altered liver function. It decreases the rate of heparin metabolism, leaving patients prone to easy bruising. Zafirlukast and albuterol are antiasthmatic agents but do not alter liver enzymes. Aspirin might cause bleeding disorders, but the low dose this patient is taking is unlikely to be responsible for the liver enzyme abnormalities. The patient’s asthma is worsening, especially in response to exercise or increased allergen exposure, and the excessive of short-acting b2-agonists requires a change in medication. Oral glucocorti- coids have many adverse effects, and zileuton and nedocromil are unlikely to be sufficiently effi- cacious in the worsening asthma. The metabolism of theophylline depends on age; the half-life of the drug in chil- dren is much shorter than in adults. Theophylline may have several mechanisms of action, but its adenosine-recep- tor antagonist activity and the inhibition of phosphodiesterase are the best understood. Opioids act centrally to decrease the sensitivity of the cough center; they also decrease propulsion in the bowel. It does not cross the blood–brain barrier and does not block mediator release or H1-receptors. By inhibiting 5-lipoxygenase, zileuton reduces leukotriene biosynthesis; it does not inhibit (and in fact it might increase) prostaglandin synthesis. Membrane-associated receptors transmit signals into the cell by a variety of ‘‘second messen- ger’’ mechanisms, including the following: a. Increased phosphoinositide turnover via increased phosphoinositide kinase activity 2+ 2+ c. Increased tyrosine phosphorylation on specific proteins by the action of tyrosine kinases B. Intracellular receptors bind hydrophobic hormones (which penetrate the plasma membrane easily) such as cortisol, retinol, and estrogen inside the cell—either in the cytoplasm or the nucleus. Intracellular receptors modulate the transcription rate of specific target genes to change the levels of cellular proteins. The endogenous ligand for this receptor is ghrelin, a peptide secreted by the stomach in response to fasting. Somatotropin release-inhibiting hormone has two forms, a 14-amino acid peptide and a 28- amino acid peptide that are produced by differential proteolysis from the same precursor. It also inhibits the secretion of vasodilator hormones, especially within the gut.
Currently purchase 200mg acivir pills amex graphs on hiv infection rates, these materials are used pri- wavelengths are currently in development that will be marily in developing countries where electricity and even more efficient and effective at removing caries discount 200mg acivir pills with amex anti viral hpv. These lasers can be selective in carious tissue removal, leaving the surrounding tissue intact and much stronger x Remain durable and flexible and become an inte- than is the case for a conventional amalgam preparation. Flowable composites can be used to fill these cavity preparations, and better materials will become available x Stimulate growth of new or reparative dentin. There exists and use of magnification during endodontic therapy some controversy regarding the extent to which dem- will improve the effectiveness of treatment. The use of ineralized tissues can be remineralized and the means lasers in endodontic therapy, including indirect and by which demineralization should be diagnosed in the direct pulp capping, vital pulp amputation and prepa- clinic (Thylstrup and Fejerskov, 1994). The future will polishing of the partially dissolved external surface also see new emphasis on treatment of disease process- of an active lesion. However, several studies have es that affect the periradicular tissues, including persist- demonstrated an increase in hardness and mineral ent apical disease, tooth perforations and fractures, and content and reduced subsequent demineralization at internal and external resorption. Definition of the the surface of tooth tissues that were remineralized importance of growth factors in pulpal repair will like- (Shannon and Edmonds, 1978; Retief et al, 1983; ly be an important area of future research, with a focus Vissink et al, 1985; Larsen and Fejerskov, 1987; on clinical application (Roberts-Clark and Smith, White, 1988; and Linton, 1996). Concern has been raised, however, about deliv- Restorative materials are continually being im- ery of these agents to injured pulp tissue (Tziafas et al, proved. The potential impact of untreated endodontic disease as a risk factor to certain systemic diseases needs x Release antibacterial agents or fluoride on de- to be explored (Grau et al, 1997). Improved understanding of wound healing associated with implant placement, with x Be readily placed in very small conservative cav-ity a particular emphasis on the implant-bone interface, preparations. Relying on both met- individuals at a high risk of caries, "actively smart mate- allurgical and biological science, these studies will lead rials" similar to glass ionomer, but with greater fracture to improved implant surface coatings. The challenge for the technology also provides a route to structures made future is to reduce the cost of this treatment so more of gradient materials, i. In underway, targeting decreased polymerization addition, it is likely that algorithms will be devel- shrinkage. Decreased polymerization shrinkage is oped to identify patients at risk for implant failure. Ring-opening monomers and certain epoxy systems that can Research of importance to the practicing dentist expand during polymerization are being developed necessarily includes topics associated with dental or investigated for dental use (Guggenberger et al, biomaterials. Improved filler forming methods have already been introduced into phases, bonding agents and toughened polymer both clinical and dental laboratory settings. It is matrixes are being investigated to improve wear and anticipated that advanced process development will structural behavior and add remineralizing capabil- continue. Much focus will remain on the optimiza- ity (Antonucci et al, 1991; Stansbury and Anto- tion of current materials, minimizing contraindica- nucci, 1992; Skrtic et al, 1996; Schumacher et al, tions and broadening use of esthetic materials for 1997; Stansbury and Antonucci, 1999; and Xu et al, posterior restorations. Novel posterior restorative materials are are under development that combines diagnostic, being developed, including mercury-free, condensa- restorative and therapeutic (controlled release) ble silver fillings and esthetic interpenetrating-phase capability. Work continues on improving adhesive composites (non-shrinking), based on the resin infil- chemistries and on mercury-free restorative materi- tration of porous, three-dimensional ceramic skele- als. Increased focus is being given to the develop- tons (Dariel et al, 1995; Eichmiller et al, 1996; ment of laboratory tests that validly reproduce clin- Giordano et al, 1997; Kelly and Antonucci, 1997; ical behavior. Biomimetic approaches are becomes available regarding intraoral damage mech- being investigated, as are tissue engineering con- anisms and microstructure-property relationships. Surface chemistries ening the use of titanium in fixed prosthodontics, par- and topologies of implantable materials are being ticularly with respect to improving the interface with studied to enhance cellular interactions. Advanced forming systems, almost all involving Many academicians recognize the need for a more some computer control, will (1) broaden the range robust evidence base to guide clinical decisions of currently available materials that can be used in involving comparisons among materials and the dental practice, (2) improve the precision and auto- rational development of clinical indications for new mate dental laboratory fabrication, (3) foster devel- materials (Laskin, 2000). Investigations are being opment of novel prostheses and craniofacial called for to identify the relative technique sensitivi- implants, and (4) provide routes to novel materials. Research is anticipated in the development involves three-dimensional printing of powder/ of in vitro test methodologies predictive of clinical binder combinations followed by sintering to form behavior to evaluate dental biomaterials and assist solid objects from ceramics or alloys (Cima, 1996). Future analysis) of too large a percentage of published den- research will form an improved definition of genet- tal clinical trials (Kelly, 1999; and Palmer and Sendi, ic, environmental, and microbial risk factors for 1999). Rather than focusing on component materi- periodontitis that will lead to development of a pro- al properties, dental prostheses are being evaluated file for patients at risk for advanced disease. It can be antici- and cellular processes with implanted materials pated that subtraction radiography will be intro- remains a research focus to both enhance the clini- duced as part of patient management, but may be cal application of titanium dental implants and to limited to specialized treatment centers. The development possible that this area of investigation will see and microstructure of tissues continues to be studied renewed interest because of the growing body of evi- with the hope that biological processes can be mim- dence linking periodontal diseases and various sys- icked in the fabrication of biomimetic prosthetic temic diseases.
Tambunan1 1 634 Faculty of Medicine generic acivir pills 200 mg without prescription hiv infection urethra, Physical Medicine and Rehabilitation De- partment of Dr cheap 200mg acivir pills free shipping typical timeline hiv infection. Results: A to- mum expiratory and inspiratory pressure, mobility of the diaphragm tal of 12 patients, mean age of 53 years with a female predomi- and diaphragmatic thickness were evaluated by ultrasound. Urodynamic studies have revealed abnormalities in 8 tory pressure, diaphragm thickness rate, and mobility increased by patients. Inappropriate used of antibiotic in the treatment admitted to our clinic complaining of drop foot for two weeks. Also, he complaint This study was to determine the common pathogen associated with the nausea and vomiting in this time. Material and Methods: This retrospective the sprain of him right foot two weeks ago. After this injury, he observational study was conducted from Sep 2012 to Sep 2014. How- cal examination, they were determined that minimal steppage gait, ever patient with other concurrent infection has been excluded. The weakness of the right foot and toe dorsifexors, and paresthesia of target sample size calculated using was 63 subjects. The fnal sample size was 22 in the tibialis anterior and extensor digitorum brevis and gastrocne- patients. The high- and electroneuromyographic fndings were consistent with a right est isolated bacteria in these patient were E. Gynecology Department and pelvic foor muscle exercise training This study showed our practice in antibiotic usage concordance to at the Rehabilitation Medicine outpatient clinic in the frst visit. The pelvic foor muscle endurance after 6 weeks biofeedback method of pelvic foor muscle exercise between Network, Rehabilitation Medicine, Liverpool, United Kingdom groups were the same and not signifcantly different (10 second, Introduction/Background: Urinary tract infections are a common p=0. Conclusion: Biofeedback method of pelvic foor muscle problem in rehabilitation units as many patients have impaired exercise for 6 weeks can improve pelvic foor muscle endurance in mobility, neurologically conditions, catheterised and constipated. Circumferential measurements were performed 639 from specifc anatomic landmarks before and after the treatment (wrist, mid forearm, elbow, mid upper arm, axilla). Each participant underwent physi- life by reducing pain and sensation of heaviness. J Rehabil Med Suppl 55 Poster Abstracts 187 641 quent metastatic sites include the pleura, brain, and skin. The aim of this study was to evaluate the these impairments and their effect on the life quality. Material and Meth- 1Baskent University, Physical Medicine and Rehabilitation, Adana, ods: The study included 100 patients (age:55±10. Patients were screened and examined for the presence of upper extremity Introduction/Background: In this study, it was aimed to determine impairments such as motion restrictions, lymphedema, pain, numb- whether there is a correlation between the serum level of vitamin D ness and loss of strength. Lymphedema was noted as in three stages and lymphedema in patients with malignancy. Fifty-fve patients had moder- affected and unaffected extremities, the volumetric differences be- ate to severe upper extremity lymphedema. Weight gain after the tween affected and unaffected extremities, range of motion and mo- disease was common and forty-six patients were obese. It was evaluated the correlations patients reported moderate-severe deconditioning. Beck Depression Scale scores showed that 59 one patient had endometrial carcinoma. Only, seven patients tients had stage 1 lymphedema while fve patients had stage 2, the did not report fatigue. There was low statistically in patients with moderate to severe fatigue or lymphedema. Also, low level of this vitamin can be precipitate the pain and decreased of the quality of life. Doruk Analan1 Introduction/Background: Etiologies of traumatic, compressive, 1Baskent University, Physical Medicine and Rehabilitation, Adana, ischemic, neoplastic, or idiopathic etiologies may cause sciatica.
Gene signature in melanoma associated with clinical activ- ity: a potential clue to unlock cancer immunotherapy 200mg acivir pills antiviral imdb. A genomic approach to colon cancer risk stratification yields biologic insights into therapeutic opportunities order acivir pills 200 mg visa hiv infection treatment guidelines. Intratumor heterogeneity and branched evolution revealed by multiregion sequencing. The late radiotherapy normal tissue injury phe- notypes of telangiectasia, fibrosis and atrophy in breast cancer patients have distinct genotype- dependent causes. Pharmacogenetics of tamoxifen biotransformation is associ- ated with clinical outcomes of efficacy and hot flashes. From targeted therapy in ovarian can- cer to personalizing therapy for ovarian cancer. NanoFlares for the detection, isolation, and culture of live tumor cells from human blood. A novel alternative approach for prediction of radiation response of squamous cell carcinoma of head and neck. A genomic predictor of response and survival following taxane-anthracycline chemotherapy for invasive breast cancer. Prognostic and predictive biomarkers in adult and pediatric gliomas: toward personalized treatment. Integrated data from 2 randomized, double-blind, placebo-controlled, phase 3 trials of active cellular immunotherapy with sipuleucel-T in advanced prostate cancer. X-ray enabled detection and eradication of circulating tumor cells with nanoparticles. A genome-wide approach to identify genetic variants that contribute to etoposide-induced cytotoxicity. Clinical benefit associated with idiotypic vac- cination in patients with follicular lymphoma. Human 3D vascularized organotypic microfluidic assays to study breast cancer cell extravasation. Targeted next-generation sequencing at copy-number break- points for personalized analysis of rearranged ends in solid tumors. Genomic predictors for recurrence patterns of hepatocellular carcinoma: model derivation and validation. Detection of epidermal growth factor receptor muta- tions in serum as a predictor of the response to gefitinib in patients with non-small-cell lung cancer. Universal Free E-Book Store 376 10 Personalized Therapy of Cancer Kishiki T, Ohnishi H, Masaki T, et al. Advances in personalized targeted treatment of meta- static melanoma and non-invasive tumor monitoring. Transport properties of pancreatic cancer describe gem- citabine delivery and response. Monitoring response to anticancer therapy by target- ing microbubbles to tumor vasculature. Systems biology of cancer: a challenging expedition for clinical and quantitative biologists. Lentiviral vector-mediated autonomous differentiation of mouse bone marrow cells into immunologically potent dendritic cell vaccines. A practical molecular assay to predict survival in resected non-squamous, non-small-cell lung cancer: development and international validation studies. Pre-radiation chemotherapy with response-based radiation therapy in children with central nervous system germ cell tumors: a report from the Children’s Oncology Group. Noninvasive prediction of tumor responses to gem- citabine using positron emission tomography. Integrated analysis of homozygous deletions, focal amplifica- tions, and sequence alterations in breast and colorectal cancers.
The following pedigree is an example of what pat- ilar to this one with fever of unknown origin proven 200mg acivir pills antiviral face masks, which of the tern of inheritance? Chronic hypoxia causes biochemical changes whereby oxygen delivery to tissues is not impaired buy acivir pills 200 mg visa antiviral vaccines ppt. In comparison to someone living at sea level, which of the following changes would be expected in a healthy person acclimated Solid figure Affected individual to living at high altitude? Independent of insurance status, income, age, and comorbid conditions, African-American patients are less I-106. Diseases that are inherited in a multifactorial genetic likely to receive equivalent levels of care when compared fashion (i. Prescription of analgesic for pain control bearing certain histocompatibility antigens include B. A 32-year-old man seeks evaluation for ongoing fevers vidual who has lost nondeclarative memory? Inability to recall a spouse’s birthday 3 months ago, and for the past 6 weeks, he has been experi- B. Inability to recognize a photo that was taken at one’s ens with night sweats once weekly and has lost 4. Inability to recognize a watch as an instrument for no rashes and reports no ill contacts. He has seen his pri- keeping time mary care physician on three separate occasions during E. Inability to remember the events of one’s high this time and has had documented temperatures of 38. A complete blood count showed a white and complains only of small masses in her groin. She states blood cell count of 15,700/µL with 80% polymorphonu- that they have been present for at least 3 years. His past medical history is significant for coronary guinal lymph nodes that are mobile, nontender, and dis- artery bypass grafting many years ago, status post-carotid crete. His medications include aspirin, carvedilol, simvastatin, lisinopril and furosemide. Fine-needle aspiration for culture and cytopathology most likely cause of this patient’s erectile dysfunction? All of the following diseases are associated with mas- sive splenomegaly (spleen extends 8 cm below the costal I-118. The wife of the patient in the preceding scenario also margin or weighs >1000 g) except reports to you that she has experienced a low sexual de- A. Her medications include an aspirin, meto- prolol, simvastatin, verapamil, and a multivitamin. The presence of Howell-Jolly bodies, Heinz bodies, asks whether an oral agent will assist with her sexual de- basophilic stippling, and nucleated red blood cells in a sire. Which of the following is true regarding infection sexual arousal disorder risk after elective splenectomy? Splenectomy patients over the age of 50 are at great- body weight in the past year. Staphylococcus aureus is the most commonly impli- recently being widowed, he has no pertinent social his- cated organism in postsplenectomy sepsis. He is not able to generate an erec- complete blood count; electrolytes, renal function, liver 16 I. Maculopapular rash that begins on the face and trunk chest x-ray, which are unrevealing. He is up to date on his and spreads to the extremities (centrifugal spread) routine cancer screening. Upper endoscopy cisella tularensis is cultured from both patients’ sputum samples. You are conducting research on a novel nonsteroidal mesticated animals in the past 2 weeks. To ascertain the safety the following except profile of the drug you recruit 100 volunteers who lack the ability to produce IgE. The IgE receptor in the patients with anaphylaxis is fects of smoking marijuana except constitutively activated.
If the result of a negative troponin T test taken 12 hours or m ore after the onset of chest pain is taken in conjunction w ith a pre-discharge exercise test buy acivir pills 200 mg amex hiv infection cd4, this further reduces the chance of an inappropriate discharge buy acivir pills 200mg low cost antivirus wiki. A positive test identifies high-risk individuals w ho m ay benefit from aggressive anti-platelet therapy or early intervention, w hilst negative troponin T tests 12 or m ore hours after the onset of sym ptom s identify those at low risk w ho can be considered for early hospital discharge. Em ergency room triage of patients w ith acute chest pain by m eans of rapid testing for cardiac troponin T or troponin I. Relation betw een troponin T and the risk of subsequent cardiac events in unstable coronary artery disease. Braunw ald’s classification categorises patients according to the severity of the pain (new onset/accelerated and pain at rest, either w ithin the last 48 hours or >48 hours) and to the clinical circum stances (prim ary, secondary (e. The event rate is highest at and shortly follow ing presentation, falling off rapidly in the first few m onths to a level sim ilar to stable angina patients after one year. Patients w ith new onset angina have a better prognosis than those w ith acceleration of previously stable angina or patients w ith rest pain. Patients w ith accelerated or crescendo angina have an in-hospital m ortality of 2-8% and a 1 year survival of 90%. Infarct extension in-hospital is associated w ith a far w orse prognosis in non-Q w ave M I (43% m ortality, vs 15% in Q w ave M I). O utcom es in patients w ith acute non-Q -w ave m yocardial infarction random ly assigned to an invasive as com pared w ith a conservative m anagem ent strategy. Diana Holdright The treatm ent of unstable angina is dictated by the underlying pathophysiology, nam ely, rupturing of an atherom atous plaque and secondary platelet aggregation, vasoconstriction and throm bus form ation. Anti-ischaemic therapy Nitrates relieve ischaem ic pain but there is no evidence of prognostic benefit from their use. How ever, in the absence of beta blockade, nifedipine should be avoided due to reflex tachycardia. Verapam il and diltiazem have useful rate-low ering properties, but should be used cautiously in patients w ith ventricular dysfunction and patients already taking beta blockers. Beta-adrenoceptor blockers are an im portant treatm ent in unstable angina, not only relieving sym ptom s but also reducing the likelihood of progression to infarction and cardiac death. Antithrombotic therapy Aspirin has an im portant and undisputed role in the treatm ent of unstable angina, reducing the risk of fatal/non-fatal M I by 70% acutely, by 60% at 3 m onths and by 52% at 2 years. M ore recent data support a w ider role for their use in the m edical m anagem ent of high-risk patients w ith unstable angina i. Adding heparin to aspirin reduces the incidence of m yocardial infarction and death in patients w ith unstable angina. Indeed, there w as the im pression that patients fared better w ith an initial conservative approach. How ever, 64% of patients crossed over to the invasive strategy because of recurrent angina or an abnorm al treadm ill test, raising doubts about the clinical application of the trial results. How ever, w ith longer follow up (23 m onths) the m ortality difference w as lost. O f note, 9% of eligible patients w ere excluded due to very high-risk ischaem ic com plications. How ever, M I and death rates w ere sim ilar for all 46 100 Questions in Cardiology countries during a 6 m onth follow up. Countries w ith high intervention rates had higher stroke rates but low er rates of recurrent angina and readm ission for unstable angina. The greatest benefit w as seen in high risk patients, in w hom potentially beneficial treatm ents are often denied in routine clinical practice. By 6 m onths, 37% of the non-invasive group had crossed over to the invasive strategy. Although there w as a higher event rate initially in the invasive group, associated w ith revascularisation, the event rate subsequently fell and the hazard curves crossed after 4 w eeks. Patients in the invasive arm w ere initially stabilised m edically, w ith the aim to perform all invasive procedures w ithin seven days.
Initially buy acivir pills 200 mg fast delivery hiv infection canada statistics, cases associated with menstruation accounted for as many as 91% of the total cases (95) acivir pills 200mg amex anti viral hand sanitizer. Patients may also present with headache, vomiting, diarrhea, myalgias, pharyngitis, conjunc- tivitis, vaginitis, arthralgias, abdominal pain, or encephalopathy (102–105). Nonmenstrual cases are caused by abscesses, cellulitis, bursitis, postpartum infections, vaginal infections, sinusitis, burn wounds, insect bites, and surgical procedures (104,109). Other laboratory abnormalities may include hypocalcemia, elevated liver enzymes, elevated creatinine, thrombocytopenia, pyuria, and proteinuria (106). Skin and soft-tissue infections are often the source of invasive group A and B streptococci (92,94). Minor trauma, injuries resulting in hematoma or bruising, surgery, viral infections, and use of nonsteroidal anti-inflammatory drugs are associated with the development of severe streptococcal infections (94). The exfoliative toxins are also known as epidermolytic toxins, epidermolysins, and exfoliatins. Bullous impetigo (also known as bullous varicella or measles pemphigoid) presents with a few localized, fragile, superficial blisters that are filled with colorless, purulent fluid (118). The lesions are located in the area of the umbilicus and perineum in infants and over the extremities in older children (119). Risk factors for development in adults include renal dysfunction, lymphoma, and immunosup- pression (112,119,120). Patients with pemphigus neonatorum present with fever, erythema, malaise, and irritability. They then develop large superficial blisters that rupture easily because of friction (112). A positive Nikolsky sign refers to dislodgement of the superficial epidermis when gently rubbing the skin (121). If untreated, the epidermis will slough off leaving extensive areas of denuded skin that are painful and susceptible to infection. Potentially fatal complications in infants and young children occur because of the loss of protective epidermis. A thorough exam looking for foci of infection (pneumonia, abscess, arthritis, endocarditis, sinusitis, etc. Blood cultures are usually negative because toxins are produced at a distant site (119,124). The biopsy typically reveals mid-epidermal splitting at the level of the zona granulosa without cytolysis, necrosis, or inflammation (126). Staphylococci may be seen in bullous lesions of localized disease, but are rarely seen in the bullous lesions of generalized disease (120). Scarlet Fever Scarlet fever is the result of infection with a Streptococcus pyogenes strain (i. There are three different toxins, types A, B, and C, which are produced by 90% of these strains. The rash of scarlet fever starts on the head and neck, followed by progression to the trunk and then extremities (8,127). There are numerous papular areas in the rash that produce a sandpaper-type quality. On the antecubital fossa and axillary folds, the rash has a linear petechial character referred to as Pastia’s lines (127). Confirmation of the diagnosis is supported by isolation of group A streptococci from the pharynx and serologies (111). The signs and symptoms evolve over the first 10 days of illness and then gradually resolve spontaneously in most children. Fever for five days or more that does not remit with antibiotics and is often resistant to antipyretics. Changes in the lips and mouth: reddened, dry, or cracked lips; strawberry tongue; diffuse erythema of oral or pharyngeal mucosa 36 Engel et al.
