By C. Marius. Norwich University. 2018.

Convalescence has been slow cheap 50mg pletal mastercard spasms around heart, and I am still very feeble best 100mg pletal muscle relaxant non drowsy, but gaining ground every day. I have proven on my own person what I had long been convinced of, that the use of tonics and stimulants, in a majority of cases of continued fever, does not facilitate convalescence, but that in many cases their action is the reverse of that desired. Third day started to business, but felt so badly returned home by 10 o’clock, suffering from chills, and went to bed; fever came up in the afternoon, and he passed a restless night. Tongue moist, broad, thick, pallid, and covered with a white pasty coat; breath has a peculiar sweet, mawkish odor. The joke was, there was a Regular physician in the house - a relation, who claimed that there was no salvation for the patient except by the use of Calomel or Blue-pill; insisting that the peculiar appearance of the tongue was a strong indication for mercurials. Friends conclude to change treatment, and the attending physician is discharged, and I am called. Condition - Has been delirious for the past four days, and sleeps but very little. The skin is dry and harsh, the urine scanty, the bowels freely acted upon by physic, are now irritable, abdomen tender. The tongue is dark red, contracted, and covered with a brownish fur, sordes on the teeth. No change was made in the treatment, the patient improving steadily to convalescence on the twenty-third day from the commencement of disease. I report a typical case, in which nothing but an acid was used - it might be called a test case. Though the indications for acids are so pronounced that they form the basis of a good treatment, yet we employ various means in addition, as they may be indicated. It might be said that twenty-one days being the natural duration of such a fever, the acid was a mere placebo. The discharges are very peculiar, frothy, illy concocted, and have a very unpleasant cadaveric odor. The treatment served the purpose, the diarrhœa was checked, and by the third day the patient was taking his milk kindly, and convalesced the fourth week. Tongue, fauces and pharynx swollen, and of a deep purplish color, dark brown, nasty coat on tongue, bowels tympanitic, stools dark and excessively fetid, pulse 130, without strength, temperature 105½ evening. Prescribed - ℞ Baptisia Tinctoria in infusion, a teaspoonful every two hours, also wash the mouth with it. Use an acid bath (muriatic) with Quinine On the third day of this treatment there was decided improvement, the diarrhœa checked. Muriatic Acid internally, and continued to convalescence on the twenty-sixth day of the disease. The typhomania has been a marked feature, and is now sinking to a muttering delirium. Muscular feebleness has been especially marked, and now the patient lies on the back and slips toward the foot of the bed. On the morning of the thirteenth day found retention of urine, and difficulty in respiration. There has been seemingly an indication for an acid treatment in the deep-red of the tongue and mucous membranes. The feeble pulse and tendency to congestion seemed to call for Aconite and Belladonna. But the treatment thus far has been a failure, and unless something more is done the patient will die. Add Bicarbonate of Potash to water, so that it will be pleasant to take and use as a drink; a weak lye as a bath once daily. There was marked improvement within twenty-four hours, and the patient convalesced, without change of remedies. Here was one of those rare cases in which, though there was an alkaline condition, there was a want of Potash as shown by the extreme muscular feebleness, and the salt of Potash became a true restorative; whilst Strychnia increased innervation from the spinal cord and sympathetic, and was just what was needed to increase the strength of the circulation and respiratory movement.

Chronic glaucoma may produce result of genetic defects or maternal rubella during no symptoms except gradual loss of peripheral the first trimester of pregnancy purchase pletal 100mg overnight delivery spasms in colon. Headaches buy pletal 50mg fast delivery muscle relaxant general anesthesia, blurred cataract is treated in the same manner as age-related vision, and dull pain in the eye may also be pres- cataract. Cupping of the optic discs may be noted on ed lens by emulsifying it using ultrasound or a laser ophthalmoscopic examination. If particles that can be removed through the tiny inci- untreated, acute glaucoma causes complete and sion. The surgery ing test that measures intraocular pressure by is usually performed using a topical anesthetic, and determining the resistance of the eyeball to inden- the incision normally does not require stitches. Treatment for glaucoma all of them eventually lead to blindness unless the includes medications that cause the pupils to con- condition is detected and treated in its early strict (miotics), which permits aqueous humor to Artificial lens Lens capsule Cataract removal Artificial lens insertion Figure 15-5. Eye showing normal flow of aqueous humor (yellow arrows) and abnormal flow of aqueous humor (red arrow) causing destruction of optic nerve. The devi- Strabismus ation may be a constant condition or may arise Strabismus, also called heterotropia or tropia, is a intermittently with stress, exhaustion, or illness. Applanation tonometry using a slit lamp to measure intraoc- ular pressure (courtesy of Richard H. Blood and other fluids leak but not always, associated with “lazy-eye syn- from these vessels and destroy the visual cells, leading drome” (amblyopia). Vision is suppressed in the to severe loss of central vision and permanent visual “lazy” eye so that the child uses only the “good” eye impairment. The vision pathway fails to develop in gery can be employed to destroy the newly forming the “lazy” eye. There is a critical period during which ambly- It is successful in about one half of the patients with opia must be corrected, usually before age 6. However, the effects of the procedure detected and treated early in life, amblyopia can commonly do not last and new vessels begin to form. It commonly drusen develop on the macula and interfere with consists of covering the normal eye, forcing the central vision. However, the most common culprit is most commonly affected is the stapes, the bone Streptococcus pneumoniae. In the patient perceives a ringing sound (tinnitus) its most severe form, otitis media may lead to infec- within the ear, along with dizziness and a progres- tion of the mastoid process (mastoiditis) or inflam- sive loss of hearing, especially of low tones. De- mation of brain tissue near the middle ear (otoen- velopment of otosclerosis is typically closely tied cephalitis). Recurrent episodes of otitis media may to genetic factors; if one or both parents have the cause scarring of the tympanic membrane, leading disorder, the child is at high risk for developing to hearing loss. Surgical correction involves removing medications to relieve pain (analgesics), and part of the stapes (stapedectomy or, more com- antibiotics. Occasionally, an incision of the eardrum monly, stapedotomy) and implanting a prosthetic (myringotomy, tympanotomy) may be necessary device that allows sound waves to pass to the inner to relieve pressure and promote drainage. The procedure requires only a local anesthetic The usual treatment for children with recurrent and usually lasts only 45 minutes. Hearing is infection is the use of pressure-equalizing tubes immediately restored. Malignant tumors of the ear include basal cell retinoblastoma, found primarily in children, and carcinoma and squamous cell tumors. Most re- common ear malignancy is basal cell carcinoma, tinoblastomas tend to be familial. The cell involved which usually occurs on the top of the pinna as is the retinal neuron. It is found more com- about 30% of patients, the disease is found in both monly in elderly patients or those with fair eyes (bilateral). Small, craterlike ulcers form as the disease the bony cavity of the eyeball, the iris, or the ciliary progresses. Basal cell carcinoma does not readily body, but it arises most commonly in the pigment- metastasize; however, failure to treat it in a time- ed cells of the choroid. The disease is usually asymp- ly manner may result in the need for extensive tomatic until there is a hemorrhage into the anteri- surgery to remove the tumor. Any discrete, fleshy mass on the iris cinoma, on the other hand, is much more inva- should be examined by an ophthalmologist. Squamous cell carcinoma the removal of the affected eye(s) (enucleation), grows more slowly than basal cell carcinoma; followed by radiation.

And all experience shows discount pletal 100mg online spasms near belly button, that just in proportion as we get this normal performance purchase pletal 50mg on line muscle relaxant pediatrics, disease is arrested. From its inception Eclecticism has been, to a very considerable extent, Specific Medication. Hydrastis for enfeebled mucous membranes, Aralia and Apocynum for dropsy, Baptisia for putrid sore throat, and similar conditions of mucous membranes, Hamamelis for hemorrhoids, Macrotys for rheumatism, etc. In our Materia Medicas, remedies were classed as Emetics, Cathartics, Diaphoretics, Tonics, Alteratives, etc. In all acute, and most chronic diseases, our examination of the patient and our therapeutics will take this order: 1. With reference to the condition of the stomach and intestinal canal - bringing them to as nearly a normal condition as possible, that remedies may be kindly received and appropriated, and that sufficient food may be taken and digested. With reference to the presence of a zymotic poison, or other cause of disease - which may be neutralized, antagonized or removed. With reference to the processes of waste and excretion - that the worn out or enfeebled material may be broken down and speedily removed from the body. With reference to blood-making and repair - that proper material be furnished for the building of tissue, and that the processes of nutrition are normally conducted. We may illustrate this further by calling attention to the tongue as a means of diagnosing conditions of the stomach and intestinal canal, and of the blood. You will bear in mind that diagnosis - or determining the real condition of disease is the most important part of Specific Medication. And that it is not that rough diagnosis which will enable us to guess off a name for the associated symptoms, at which name we will fire our Materia Medica promiscuously. Hence, when we question the tongue, it is not with reference to a remittent or typhoid fever, an inflammation of lungs, or rheumatism, but it is - I want you to tell me the condition of the stomach and intestinal canal, and especially the condition of the blood. Now let us briefly see what it will tell us, with regard to the condition of the primœ viœ: If the tongue is heavily coated at its base with a yellowish-white fur, we know that there are morbid accumulations in the stomach; and we have to determine between the speedy removal by emesis, the slower removal by the Alkaline Sulphites, or the indirect removal by catharsis. If the tongue is uniformly coated from base to tip with a yellowish fur, rather full, moist, we have the history of atony of the small intestine, and we give Podophyllin, Leptandrin, and this class of remedies with considerable certainty. The therapeutics is plain: get rid of the irritation first, and be careful not to renew it by harsh medication. It is variously colored, but it looks as if a fly should light on it he would slip up and break his neck. It is the evidence of a want of functional power, not only in the stomach and bowels, but of all parts supplied by sympathetic nerves. We treat such a case very carefully, avoid all irritants, and use means to restore innervation through the vegetative system of nerves. The tongue tells us of acidity and alkalinity of the blood, and in language so plain that it can not be mistaken: The pallid tongue, with white fur, is the index of acidity, and we employ an alkali - usually a salt of soda, with a certainty that the patient will be benefited. Indeed one who has never had his attention directed in this way, would be surprised at the improvement, in grave forms of disease, from one day’s administration of simple Bicarbonate of Soda. The deep-red tongue indicates alkalinity, and we prescribe an acid with a positive assurance that it will prove beneficial. Grave cases of typhoid fever and other zymotic diseases, presenting this symptom, have been treated with Acids alone, and with a success not obtained by other means. But it makes no difference what the disease is, whether a recent diarrhœa, or a grave typhoid dysentery, if there is the deep-red tongue, we give Muriatic Acid with the same assurance of success. Impairment of the blood - sepsis - is indicated by dirty coating, and by dark-colored fur - brownish to black. When we have either the one or the other we employ those remedies which antagonize the septic process. The bitter tonics are indicated by fullness of tissue, with evident relaxation, impairment of circulation and muscular movement. We give Tincture of Chloride of Iron if the tongue is red, Iron by Hydrogen if the tongue is pale. The pale bluish tongue, expressionless, is the indication for the administration of Copper. You will notice that we have made this “unruly member” tell us a good deal, yet it might tell us more - it will tell us more when we thoroughly study it. My object is not to point out all that we might learn from it, but to show that it is possible to arrive at positive conclusions, from symptoms that are always definite in their meaning.

Currently purchase 100mg pletal muscle relaxant review, donation in this country is based solely on an altruistic basis discount pletal 100mg amex spasms pelvic floor, and paid donation is prohibited. Surgical Techniques The kidney transplant operation is well described in Chapter 65, “Kidney Transplantation and Dialysis Access,” in Surgery: Basic Science and Clinical Evidence, edited by J. An important point to note is the difference between placing a kidney obtained from a cadaver donor and placing a kidney obtained from a live donor. During the procurement of a kidney from a cadaveric donor, a cuff of vena cava and aorta can be left on the renal vein and artery, respec- tively. The renal vein anastomosis actually is sewn between the cuff of the vena cava and recipient’s external iliac vein in an end-to-side fashion. This anastomosis can be done without the worry of tearing the thin wall of the right renal vein. Large hemostatic bites of the vena cava may be taken without concern for narrowing the anastomosis. Having a cuff of aorta allows for a single anastomosis even in the presence of multiple renal arteries. Once again, with a large cuff, the surgeon need not be concerned with narrowing the renal artery anastomosis. In kidneys obtained from live donors, the renal artery may be sewn to the external iliac artery in an end-to-side fashion or to the internal iliac artery in an end-to-end fashion. The left kidney often is the preferred kidney, especially from a live donor, as the left renal vein is considerably longer and thicker-walled than the right renal vein. Occa- sionally, the recipient’s internal iliac vein is divided to enable the exter- nal iliac vein to be moved more anteriorly and out of the pelvis. If the kidney from a live donor has two arteries, they may both be sewn directly into the external iliac artery. The incidence of renal artery steno- sis may be reduced by the uses of an aortic punch biopsy. More com- monly, the smaller of the two arteries is sewn into the larger main renal artery in an end-to-side fashion under ice on the back table. The kidney is then placed within the recipient, and a single anastomosis between the main renal artery and the recipient iliac artery (external or internal) is performed. Vascular thrombosis of the artery and vein are rare events: arterial thrombosis occurs less than 1%, and venous thrombo- sis occurs less than 2%. Posttransplant Period The differential of an increasing serum creatinine is influenced sig- nificantly by the amount of time from the day of the transplant to the increase in serum creatinine (Fig. Three different time periods can be created based on the most likely cause for an increasing serum creatinine post–kidney transplant: the early period, the intermediate period, and the late period. Throughout the posttransplant period, a thorough history and a thorough physical exam help narrow the differential diagnosis of a rising serum creatinine. Duplex ultrasound identifies fluid col- lection around the kidney and reveals the status of blood flow through the artery and vein. A renal scan often is helpful in identifying changes in renal flow and urinary leaks, and a kidney biopsy is needed to make a definitive diagnosis of rejection. These tests are used routinely in sorting out the correct etiology for the recipient of a renal allograft who presents with a rising serum creatinine. The following sections describe the most likely causes of deteriora- tion in renal function, based on time from transplant to change in func- tion, and focus the history and physical exam on the most pertinent facts (Fig. The Early Period In the early postoperative period, day 0 to day 7, the differential diag- nosis can be broken down into immunologic causes, technical causes, 712 D. Immunologic Causes Hyperacute rejection has become a rare event, as the ability to detect preformed antibodies prior to the transplant has improved. Hyper- acute rejection derives from antibodies in the recipient’s serum directed against the donor’s antigens. These preformed antibodies bind to the donor tissues, activating the complement cascade, which leads to imme- diate graft thrombosis. The two methods for screening for donor-specific antibodies are lymphocytic crossmatch and flow cytometric studies. The level of preformed antibodies is too low to be detected by the current screening test, but it quickly rises with stimulation by exposure to the new donor antigen.

These can be used to nucleotides into the probe identify colonies with successful recombinants pletal 50 mg visa 303 muscle relaxant reviews. Splicing the gene for β-galactosidase into the also carry antibiotic resistance genes that allow the probe recombinants to be purified generic 100mg pletal with visa back spasms 26 weeks pregnant. Heat denaturation of the probe followed by acid recombinant bacteria results in large amounts of the treatment gene, which can be harvested using the restriction Molecular/Apply principles of special procedures/ enzyme, denatured, and labeled to make the probe. After washing to remove unbound streptavidin, a colorimetric, fluorescent, or chemiluminescent substrate is added. D Mosaicism occurs when cells within the same individual contain different numbers of chromosomes and results from nondisjunction during early embryonic development. Chimeras are molecules created when translocation occurs between genes (exons) on different chromosomes. A Each phosphoric acid subunit within a phosphodiester separated by agarose gel electrophoresis. Since the charge is distributed evenly, smaller fragments move more rapidly through the gel. If the distance traveled is plotted against the log of molecular weight, the plot will be a straight line with a negative slope because the larger the molecule, the more slowly it moves through the pores of the gel. It is frequently added to molten agarose or capillary electrophoresis buffer at a A. Ethidium bromide is the binding of the complementary base sequence Molecular/Apply principles of basic laboratory of the probe to the target sequence. Which of the following types of mutation causes Answers to Questions 9–11 the premature termination of protein synthesis? D The human genome contains approximately 3 billion base pairs and approximately 25,000 genes. They are subject to selection pressures that cause genes to drift in the population. Over 350,000 such differences are present in the human genome, but very few are associated with human disease. Which of the following is the most common type Answers to Questions 12–13 of polymorphism? The sequence can repeat 3 to Molecular/Apply principles of special procedures/ 14 times, resulting in 12 different alleles. Unlike conventional electrophoresis, a stationary support such as agarose is not used. Instead, a small-bore open tubular column is immersed in buffer solution at its ends and subjected to an electric field. The negative nature of the glass capillary attracts cations that are pulled to the cathode when the voltage is applied. An ultraviolet light detector or laser-induced fluorescence detector is located near the cathode and detects the molecules as they migrate. Such high resolution is possible because very high voltage can be used, since the heat produced is lost through the capillary wall. Annealing→Denaturation→Extension steps that are repeated to double the number of C. Denaturation→Extension→Annealing denaturation to separate the complementary strands. This can due to low stringency derive from other samples, positive controls, or B. Contamination of control sample with a trace common source of contamination is by amplicons. Use of aerosol barrier pipette tips when Mg+2, this will inhibit amplicon production. An transferring samples or reaction products internal control can identify this problem. A separate area for performing preamplification, control should always be amplified, but the product postamplification, and detection steps can be distinguished from the target amplicons. Pretreatment of samples with high-intensity Failure of a sample to demonstrate the internal ultraviolet light control product in an assay where positive and negative control reactions are valid indicates the Molecular/Apply knowledge to identify sources of presence of an inhibitor in the sample. In addition to standard precautions, cotton-plugged tips are used to prevent aerosol contamination of samples.

Indicates altered clotting gastrointestinal bleeding manifestations: ecchymosis discount pletal 100mg online spasms kidney area, mechanisms epistaxis pletal 50 mg fast delivery xanax muscle relaxer, petechiae, and Is free of ecchymotic areas bleeding gums. Record vital signs at frequent Exhibits normal vital signs hemorrhagic shock intervals, depending on patient acuity (every 1–4 h). Assist physician in passage blood transfusions and and combative patient for of tube for esophageal measures to treat bleeding immediate treatment of balloon tamponade, if its bleeding insertion is indicated. Observe during blood toothbrush, blows nose transfusion reactions (risk is transfusions. Measure and record nature, transfusions needed for active during defecation) time, and amount of vomitus. Assists in evaluating extent of bleeding and blood loss Takes all medications as 15. Reduces risk of aspiration of gastric contents and minimizes Identifies rationale for 16. Remain with patient during risk of further trauma to precautions with use of all episodes of bleeding. Provide soft bleeding by promoting toothbrush and avoid vasoconstriction of esophageal use of toothpicks. Permits detection of new bleeding sites and monitoring of previous sites of bleeding g. Provides information for Verbalizes concerns appearance and the meaning assessing impact of changes in related to changes in these changes have for appearance, sexual function, appearance, life, and patient and family. Assist and encourage patient Uses past effective coping coping strategies that are to maximize appearance and strategies to deal with familiar to patient and have explore alternatives to changes in appearance, been effective in the past previous sexual and role life, and lifestyle functions. Encourages patient to continue Maintains good grooming safe roles and functions while 5. Assist patient in identifying and hygiene encouraging exploration of short-term goals. Accomplishing these goals in decision making about them serves as positive reinforcement care. Assist patient in identifying resources and accepting Verbalizes that some of previous practices that may assistance from others when previous lifestyle practices have been harmful to self indicated have been harmful (alcohol and drug abuse). Recognition and Uses healthy expressions acknowledgment of the harmful of frustration, anger, effects of these practices are anxiety necessary for identifying a healthier lifestyle. Nursing Diagnosis: Chronic pain and discomfort related to enlarged tender liver and ascites Goal: Increased level of comfort Nursing Interventions Rationale Expected Outcomes 62 1. Reduces metabolic demands Reports pain and discomfort patient experiences and protects the liver if present abdominal discomfort. Administer antispasmodic gastrointestinal tract and decreases activity in and analgesic agents as decreases abdominal pain presence of pain prescribed. Provides baseline to detect analgesics as indicated and presence and character of further deterioration of status as prescribed pain and discomfort. Promotes excretion of fluid potassium, and protein through the kidneys and Takes diuretics, potassium, supplements as prescribed. Indicates effectiveness of response to interventions and treatment and adequacy of Exhibits increased urine on patient acuity. Monitors changes in ascites Exhibits decreasing abdominal girth and weight formation and fluid abdominal girth daily. Prepare patient and assist and cooperation with it sodium and fluid restriction with paracentesis. Paracentesis will temporarily Shows a decrease in ascites decrease amount of ascites with decreased weight present. Provides close monitoring of new symptoms and minimizes trauma to the confused patient 8. Prevents masking of symptoms of hepatic coma and prevents drug overdose secondary to reduced ability of the damaged liver to metabolize opioids and barbiturates 64 9. May occur with bacterial peritonitis Nursing Diagnosis: Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites, abdominal distention, and fluid in the thoracic cavity Goal: Improved respiratory status 1. Prevents inadvertent character of fluid Experiences absence of bladder injury aspirated. Indicates irritation of the pleural space and evidence of pneumothorax or hemothorax. Collaborative Problem: Gastrointestinal bleeding and hemorrhage Goal: Absence of episodes of gastrointestinal bleeding and hemorrhage 1.

Two patients experienced serious musculoskeletal events; one patient reported osteomyelitis cheap pletal 50mg spasmus nutans treatment, and one reported arthralgia 100 mg pletal with amex spasms post stroke. The five events, which all occurred in different patients were: vertigo, acute asthma (2 patients), peritonisllar abcess, and increasing pleural effusion (pt. The patients with asthma and the peritonsillar abcess received remedial drug therapy. There were 2 patients with pseudomembranous enterocolitis (270024 and 500011); one of these patients also had gastroenteritis (270024). Of these, 7/35 ciprofloxacin patients and none (0/9) of the comparator patients had an event(s) occurring by Day +42 as well as an event(s) occurring between Day +42 and one year. Corazon Oca; Irvine, California), the following was noted by the inspector on the form: Failure to report Adverse Events: Subject #33 developed right wrist pain three days after starting the study drug. The subject was seen for follow up on February 28, 2001, with this visit recorded as a Module 2 visit. The case report forms listed only right and left wrist pain and left lower back pain. The Division requested the applicant include a description of the patient with fibrocartilage tear in the Adverse Reactions section of the package insert. The following is a narrative of the patient cited on Form 483: Patient 250033 was a 13 year old female who was enrolled in the observational study on November 6, 2000 and prescribed ciprofloxacin for "sinus problems" (sinusitis and cervical adenitis). She was active in gymnastics in the summer of 2000, but quit because of the back pain. The patient reported mild right wrist pain on the third day of taking ciprofloxacin (November 9, 2000). Study drug was discontinued due to the adverse event on November 13, 2000, after 7 days of treatment. The patient was referred for physical therapy and prescribed anti-inflammatory medication (prescribed Relafen®, but subsequent note says that she only took acetaminophen) and braces (both wrists) by an orthopedic surgeon. She did not respond to two telephone messages asking her to come back for a follow-up visit. On February 28, 2001 the patient was seen by a rheumatologist and had complaints of pain in the left wrist and left lower back. The rheumatologist diagnosed the patient with "probable tenosynovitis versus overuse syndrome secondary to gymnastics" and "no evidence of inflammatory arthritis. The results for events, regardless of relationship to study drug that occurred in at least 2% of patients are shown in Table 14. The most common events (other than musculoskeletal events) were otitis media and pharyngitis (5% each [25/487] and [24/487], respectively). Through 42-day follow-up period, 26% (134/507) of control patients experienced at least one adverse event. Most of the events were in the Body as a Whole and Respiratory body systems (10% each [50/507] and [50/507], respectively). The incidence rate of any drug-related adverse event was 14% (70/487) in the ciprofloxacin group and 4% (20/507) in the control group. Specific drug-related adverse events (other than musculoskeletal events) with drug-related incidence rates of 1% or higher for ciprofloxacin were abdominal pain (2%; 8/487), diarrhea (2%; 9/487), and vomiting (2%; 9/487). All events (other than musculoskeletal events) with drug-related incidence rates were 1% or less in the control group. Specific adverse events reported through the 42-day follow-up period, other than those affecting the musculoskeletal and central nervous systems, are shown in Table 18, if incidence was at least 2% of patients in either group. The most common severe adverse events in the ciprofloxacin group were sepsis and fever (4 patients each). Three ciprofloxacin patients experienced severe musculoskeletal events; 2 had severe arthralgia, and 1 had severe osteomyelitis. The most common severe adverse event in the control group was asthma (2 patients). Two control patients experienced severe nervous system events (1 convulsion and 1 vertigo).