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O-negative mother; A-positive baby; second fetus pregnancy; no anti-D in mother D cheap generic levitra plus canada erectile dysfunction doctor dublin. Yes buy levitra plus 400mg line erectile dysfunction doctor miami, if the baby’s type is Rh negative anti-K order genuine levitra plus on-line erectile dysfunction with new partner, she will be monitored to determine if the C order levitra plus on line amex erectile dysfunction female doctor. Yes, if the baby’s type is Rh positive antibody level and signs of fetal distress necessitate D. C RhIg is immune anti-D and is given to Rh-negative Blood bank/Correlate clinical and laboratory data/ mothers who give birth to Rh-positive babies and Hemolytic disease of the newborn/RhIg/3 who do not have anti-D already formed from 8. Should an A-negative woman who has just had a previous pregnancies or transfusion. Yes, but only if she does not have evidence of the fetus is unknown, termination of a pregnancy active Anti-D from any cause presents a situation in which an B. Yes, but only a minidose regardless of trimester is used if the pregnancy is terminated in the first D. The on a woman who is 6 weeks pregnant with woman is weak D positive, and, therefore, is not a vaginal bleeding as O negative. Typically, a test for weak D is not tells the emergency department physician she is done as part of the obstetric workup. Is A-positive baby and has no anti-D formed from a this woman a candidate for RhIg? Yes, based upon the Provue results immunization typically has a titer >4, compared with passive administration of anti-D, which has a Blood bank/Correlate clinical and laboratory results/ titer <4. All of the following are routinely performed on a 40 fetal cells in 2,000 maternal red cells. Divide this number by 30 to arrive at the Blood bank/Apply knowledge of biological principles/ number of doses. When the number to the right of Hemolytic disease of the newborn/1 the decimal point is less than 5, round down and add one dose of RhIg. Anti-E is detected in the serum of a woman in the right of the decimal point is 5 or greater, round the first trimester of pregnancy. Perform plasmapheresis to remove anti-E from cross into the central nervous system, causing brain the mother damage to the infant. Perform an intrauterine transfusion using mother and provides a temporary solution to the E-negative cells problem until the fetus is mature enough to be Blood bank/Correlate clinical and laboratory data/ delivered. The procedure may need to be performed Hemolytic disease of the newborn/3 several times, depending upon how quickly and how 14. Administration of RhIg when the mother’s serum contains an would not contribute to solving this problem caused alloantibody? Crossmatch and antibody screen performed before week 20, and would be considered B. A crossmatch is necessary as long procedures/Hemolytic disease of the newborn/ as maternal antibody persists in the infant’s blood. O negative only Blood bank/Select course of action/Hemolytic disease of the newborn/Hemotherapy/2 4. Why do Rh-negative women tend to have a Answers to Questions 17–19 positive antibody screen compared to Rh-positive women of childbearing age? It is known as a single entity Blood bank/Apply knowledge of biological principles/ as opposed to separate antibodies. Anti-D would Hemolytic disease of the newborn/3 not be the cause because this is the first pregnancy. Anti-D from the mother coating the infant red physician can communicate with the pathologist cells once he or she receives this information from the B. Maternal anti-A, B coating the infant cells Blood bank/Correlate clinical and laboratory data/ Hemolytic disease of the newborn/3 19. Te nurse then requests to take 50 mcg from the 300 mcg syringe to satisfy the physician’s orders. Instruct the nurse that the blood bank does not stock minidoses of RhIg and manipulating the full dose will compromise the purity of the product D. Instruct the nurse that the blood bank does not stock minidoses of RhIg, and relay this information to the patient’s physician Blood bank/Select course of action/Hemolytic disease of the newborn/RhIg/3 4. Pools of up to 16 donors are tested; if pool is Blood bank/Apply knowledge of standard operating reactive, individual samples are screened procedures/Processing/1 D. All donors are screened individually; if samples are reactive, blood is discarded Answers to Questions 1–5 Blood bank/Standard operating procedures/Processing/3 1. Told to come back in 6 months Blood bank/Select best course of action/Processing/3 6. B The recipient’s physician should be notified by the positive, then the unit may be used medical director to ascertain the current health C. Cellular components may be prepared but must what treatment, if any, the recipient should receive. However, testing may be done on procedures/Processing/2 units intended for transfusion to low birth weight 8. Red blood cells made from the used for intrauterine transfusion; units intended whole blood were transfused to a recipient of a for immunocompromised patients who are community hospital in June with no apparent seronegative; prospective transplant recipients who complications. Te blood supplier notified the are seronegative; or transplant recipients who have medical director of the hospital that the donor received a seronegative organ. Repeat the reverse grouping using A1 cells that inconclusive are negative for M antigen D. Repeat the reverse grouping using A1 cells that nonsecretor are positive for M antigen Blood bank/Evaluate laboratory data to make D. A The blood typing result demonstrates A antigen on Mixed field 0 1+ 4+ the red cells and anti-B in the serum. Type patient cells with anti-A1 lectin and type agglutination when A1 cells were added. Retype patient cells; type with anti-H and H antigen; therefore, the H antigen in the saliva anti-A,B; use screen cells or A2 cells on patient would be bound by anti-H reagent. No agglutination serum; run patient autocontrol would occur when the O cells are added. A positive reaction with anti-A,B would help to differentiate an A subgroup from group O. If A2 cells are not agglutinated by patient serum, the result would indicate the presence of anti-A1. If the patient’s serum agglutinates A2 cells, then an alloantibody or autoantibody should be considered. B The scenario showed an antibody in the patient serum directed toward the M antigen, and the M antigen happened to be on the A1 cells in reverse grouping. An Rh phenotyping shows the following results: department of a community hospital complaining Anti-D Anti-C Anti-E Anti-c Anti-e of dizziness and fatigue. History included no 4+ 2+ 0 0 3+ transfusions and a positive rheumatoid factor 1 year ago. Fearing the sample would clog the ProVue, testing was performed Blood bank/Apply knowledge of fundamental using the tube method. An obstetric patient, 34 weeks pregnant, shows Anti-A Anti-B Anti-D Rh Control A1 cells B cells a positive antibody screen at the indirect 0 0 4+ 2+ 4+ 4+ antiglobulin phase of testing. She has with saline, and testing was repeated giving the no prior history of transfusion. What is the most following results: likely explanation for the positive antibody screen? She has developed an antibody to fetal red cells Anti-A Anti-B Anti-D Rh Control A1 cells B cells B. She received an antenatal dose of RhIg Crossmatch testing using two O-positive donor D. Run the crossmatch using the Gel system plasma proteins causing a positive result with the D. Perform a saline replacement technique Blood bank/Correlate clinical and laboratory data/Rh to rectify the incompatible crossmatches at discrepancy/3 immediate spin. Run a saline control in forward grouping pregnant, she probably has not formed any atypical D. Although technical error cannot be ruled out, it is far less likely than RhIg administration. What technique(s) may be helpful to anti-Jka (reaction enhanced) and anti-Fya (destroyed). Lowering the pH and increasing the incubation help to reveal an additional antibody or antibodies. Because the detection of Kidd more clinically significant antibodies may be antibodies is subject to dosage effect, selection of revealed? Adsorption with homozygous cells would also react more strongly in the presence of D. However, because this patient was recently anti-Jka, but the antibody identification panel does transfused, the variation in reaction strength may be not fit this pattern conclusively. Although following would not be effective in determining if autoadsorption would remove anti-I, this procedure the specificity is anti-Jka? Select panel of homozygous cells cells express primarily i antigen with very little I C. A cold-reacting antibody is found in the serum of a recently transfused patient and is suspected to be anti-I. Te antibody identification panel shows reactions with all cells at room temperature, including the autocontrol. What procedure would help to distinguish this antibody from other cold-reacting antibodies? An antibody identification panel reveals the Answers to Questions 12–15 presence of anti-Leb and a possible second specificity. C Lewis antibodies are usually not clinically significant neutralize the Leb antibody?

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There is a specific use for acids in the treatment of disease purchase levitra plus once a day erectile dysfunction treatment las vegas, which we wish to study carefully purchase levitra plus overnight delivery cialis causes erectile dysfunction. This may be the basis of diseased action purchase levitra plus overnight erectile dysfunction chicago, or but a complication rendering it more intense cheap 400 mg levitra plus otc erectile dysfunction pills made in china, but whether the one or the other, it needs to be recognized and have direct treatment. The indications of excessive alkalinity are very plain, and need not be mistaken by the youngest practitioner. The color of the mucous membranes is deep red, especially of mouth and tongue; the coating of tongue, sordes, or any exudative material, has a dark color, usually brownish. It makes no difference what the diseased action is, in its totality, or what it is called, the deep red, somewhat dusky color, always demands the administration of acids. There is but one exception to this, and that is a rare one, in which the excess is of soda, but with a defect of potash. In this case the administration of a salt of potash will answer a better purpose than the acid, or may be combined with it. Muriatic acid is preferable in most acute cases, and should be used so diluted, and in such quantity, as to be pleasant to the patient, and until the indication for its use is removed. Lactic acid is sometimes preferable with children, and in some cases of chronic disease, especially when associated with indigestion. The vegetable acids may be used in acute disease, but are not so good as those named. It should be prepared by percolation, the strength being ounce for ounce; though, if constantly made in the office, it will be easier to make it ℥viij, to the pint, the dose being proportionately increased. The medium dose one-third of a drop, and the form of administration: ℞ Tincture of Aconite root, gtt. Aconite is a stimulant to the sympathetic system of nerves, and increases the power of the heart to move the blood, at the same time that it places the blood-vessels in better condition for its passage. It will be recollected that the same system of nerves governs the movements of the heart and of the entire system of blood-vessels. But Aconite is said to be a sedative; and by a sedative we are to understand a remedy that diminishes the frequency of the pulse. There is no doubt but that Aconite is one of the most certain remedies we have to reduce the frequency of the pulse in certain conditions of disease. And the condition is that in which there is a want of power on the part of the heart, and a like want of innervation to the capillary system of blood-vessels. Aconite in small doses lessens the frequency of the pulse, because it removes obstruction to the flow of blood in the vessels, and gives greater cardiac power. We employ it in all forms of fever, to control the circulation, and diminish the temperature. Used in the doses named, it gives greater freedom to the circulation, at the same time that it diminishes the frequency of the pulse. It seems to remove obstruction to the free circulation of the blood, at the same time that it removes irritation of the cardiac nerves, and gives increased power to the heart. It directly antagonizes inflammatory action, and in the early stage will arrest it speedily - if this is the sedative indicated. There are some diseases of an inflammatory character to which Aconite is specific, that deserve mention. In some forms of mucous croup, with enfeebled circulation, in muco-enteritis, and in simple colitis or dysentery from cold, I never think of making any other prescription. As the notice of the action of Aconite in croup may not impress the reader sufficiently, I desire to say that I regard it as the most certain internal remedy in all forms of this disease, and if one cannot find a specific indication for another remedy, let him give this. To point out the special indications for the use of Aconite I can not do better than reproduce the editorial in September Journal of 1868 on the “Differential Therapeutics of Veratrum and Aconite:” To determine which of a class of remedies is applicable in a given case, is the most difficult task of the physician, and any information in this respect is of much value. I doubt whether any one using the two remedies named, would be willing to risk giving this estimate. Many may have an empirical intuition in regard to it, but most could venture nothing but a guess. It is also the remedy where there is an active capillary circulation, both in fever and inflammation. A full and bounding pulse, a full and hard pulse, and a corded or wiry pulse, if associated with inflammation of serous tissues, call for this remedy. Aconite is the remedy when there is difficulty in the capillary circulation, a dilatation and want of tonicity of these vessels, both in fever and inflammation. In general terms, Veratrum is the remedy in sthenia, Aconite in asthenia; but there are too many exceptions to this to make it a safe rule for our guidance. It is the sedative I associate with Belladonna in congestion, especially of the nerve centers, and to relieve coma. Whilst I would use Veratrum with Gelseminum in determination of blood to the brain, and in active delirium. Veratrum acts more efficiently upon the excretory organs; indeed I believe it to be one of the most certain remedies we have to increase excretion. Hence it is employed with great advantage for those purposes usually called alterative. Aconite controls excessive activity of the excretory organs, whether of the bowels, kidneys, or skin. Thus it is our most certain remedy in the summer complaint of children, associated with Belladonna in diabetes insipidus, with the bitter tonics and Strychnia in phosphuria and oxaluria, and with the mineral acids in night sweats. The white cohosh has had but a limited use in medicine, yet it possesses such properties that it will undoubtedly prove useful when studied. The direction of experiment will be to determine its influence on the functions of waste and nutrition, and its special action on the reproductive organs of the female. As you have reached it in your order, you can do as you wish in regard to inserting this. This power in controlling after-pains suggests that it will prove valuable in congestion and neuralgia of the womb. In large doses it is a violent purgative, and may produce inflammation of the bowels. It causes tormina and tenesmus, and seems to extend its influence to all the abdominal viscera, the urinary apparatus included. Its action is attended with unpleasant sensations in the head, and some times it produces severe headache. One ounce of the bark was boiled in a pint and a half of water to one pint, and the whole taken in the course of a day. A tincture may be prepared in the usual way from the bark, and used in doses of from one to thirty drops, as a sedative, diaphoretic and antiperiodic, in the treatment of malarial and other fevers. Take of the recent nuts, fully ripened, four ounces; bruise them thoroughly, and cover with alcohol 76 one pint; let it stand for two weeks; strain and filter. Of this tincture add from one to two drachms to four ounces of water - the dose being one teaspoonful. The buckeye has been used to but a limited extent in medicine, yet its activity is such (as a poison), that it will probably prove very valuable when thoroughly studied. In my boyhood, I well remember persons carrying “buckeyes” in their pockets as a sovereign cure for “piles,” and at a later period as a remedy for rheumatism. It has been used in the treatment of hemorrhoids with much success, and I am satisfied that in some forms of the disease it is the most certain remedy we possess. I have also given it in a few cases of diseased uterus with good results - cases in which the entire organ was enlarged, the cervix tumid, with to frequent recurrence of the menstrual flow. The marked influence of the Æsculus on the nervous system would suggest a line of experiment likely to lead to the development of valuable properties. It has already been employed as a stimulant to the nervous system in some cases of paralysis. We may reason in this way: a remedy that cures hemorrhoids must exert a powerful influence upon the circulation; whilst its poisonous action, often witnessed - vertigo, diminished sight, wry neck, fixed eyes, paralysis, convulsions, etc. The bark of this variety has been employed to a limited extent as a tonic, and possesses feeble antiperiodic powers. Quinine being employed to break the chill, this agent was sufficient to prevent its recurrence. The pulverized kernel has been used as a sternutatory for the relief of headache and facial neuralgia. The nuts were also thought to possess some special influence over hemorrhoids and rheumatism. This probably will be its best field of action, standing midway between Belladonna on the one hand and Nux Vomica on the other. It exerts the same influence upon the circulation as the Æsculus Glabra, and has been successfully employed in the treatment of hemorrhoids. It will doubtless be found to improve the circulation generally, and may be employed whenever there is want of power in the heart, capillary stasis, or tendency to congestion. It may be recommended in active delirium, when patients become excited from slight causes, and are liable to transports of rage. They absorb a great amount of oxygen with evolution of hydrogen and carbonic acid gas, and contain considerable proportions of nitrogen. Those species formerly included in Boletus, and whose hymenium is composed of pores, now form the genus Polyporus. The Polyporus Officinalis (Boletus Laricis), known by the name of White Agaric, Purging Agaric, etc. It is in masses, varying from the size of an ordinary apple to that of a large nutmeg-melon; its shape somewhat resembles a horse’s hoof; it is reddish gray or yellow externally, whitish internally, and of a spongy, friable consistence; hymenium concrete; substance of the pileus consisting of subrotund pores, with their simple dissepiments; pileus corky-fleshy, ungulate, zoned, smooth; pores yellowish; it has a feeble odor, and a bitter, acid, somewhat sweetish taste.

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James buy levitra plus 400mg with amex rogaine causes erectile dysfunction, “Infectious complications in patients with diabetes domonas aeruginosa cystic fbrosis strains: frst steps towards mellitus discount 400mg levitra plus with amex erectile dysfunction doctors buffalo ny,” International Diabetes Monitor discount levitra plus 400 mg with visa over the counter erectile dysfunction pills uk,vol order 400mg levitra plus otc erectile dysfunction urinary tract infection. Rossini, “Streptozotocin induced pancre- atic insulitis: new model of diabetes mellitus,” Science,vol. Chaudhry, “A clinico-microbiological study of diabetic foot ulcers in an Indian tertiary care hospital,” Diabetes Care, vol. Brussow,¨ “Human volunteers receiving Escherichia coli phage T4 orally: a safety test of phage therapy,” Antimicrobial Agents and Chemotherapy,vol. Soothill, “Treatment of experimental infections of mice with bacteriophages,” Journal of Medical Microbiology,vol. Wright, “Bacterial resistance to antibiotics: enzy- matic degradation and modifcation,” Advanced Drug Delivery Reviews,vol. Zuber, “T4 phages against Escherichia coli diarrhea: potential and problems,” Virology, vol. Ackermann, “Frequency of morphological phage de- scriptions in the year 2000,” Archives of Virology,vol. Loessner, “Application of bacteriophages for detection and control of foodborne pathogens,” Applied Microbiology and Biotechnology,vol. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. For general information on our other products and services or for technical support, please contact our Customer Care Department within the United States at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002. Antibiotics are unique among medicines in that they act selectively on bacteria, among them the pathogens, while leaving human cells and tissues unaffected. A description of how antibiotics work and of the mechanisms by which bacteria resist them often falls between the medical discipline of infectious diseases and the field of microbiology. It should serve as a brief handbook for physicians, veterinarians, and pharmacists and as a textbook for students in these areas of study. I also describe the rapid and very worrying development of antibiotic resistance among pathogenic bacteria, including the molecular mechanisms of this resistance and newly observed genetic principles for the spread of resistance among species. Our ubiquitous use of antibiotics for medical purposes and for growth promotion in farm animals has been a toxic shock to the microbial world, which has responded by developing resistance. It can be looked upon as a piece of Darwinian evolution taking place right in front of us. No microbiologist can escape being astonished and impressed by the ingenuity of evolution in finding and combining molecular mechanisms to protect the bacterial world from the dramatic environmental change that our use of antibiotics has effected. Finally, I describe the future possibilities that, under the threat of resistance evolution, can be envisioned to help maintain the health standard that antibiotics have helped us reach in controlling bacterial infections, which we have come to take for granted. This is a health standard that we have become accustomed to and have come to regard as self-evident. Today, it is impossible to imagine health care that is not able to cope efficiently with bacterial infections. Medical disciplines such as oncology and organ transplantation surgery would simply collapse without access to modern antibiotics. The tremendous success of antibiotics in the field of infectious diseases for seven decades or so has led to very wide distribu- tion and consumption of these agents. Besides their medical use for human beings and animals, antibiotics have been used in very large quantities as growth stimulants in husbandry and as prophylactic protection against plant pathogens. All this has led to the spread of millions of tons of antibiotics in the biosphere during the antibiotics epoch. This has induced a drastic envi- ronmental change, a toxic shock to the bacterial world. It has been said that ‘‘the world is immersed in a dilute solution of antibiotics. The bac- terial world, including human pathogens, has developed and mobilized molecular defense mechanisms for protection against the human-produced poisons that antibiotics are. This has led to increased antibiotics resistance among human pathogens, which are becoming more difficult to treat. This poses a serious threat to our health standard in that the ability of medicine to cope with bacterial infections has slowly been eroded. Medical journals and daily newspapers report on cases of infectious disease that were untreatable because of antibiotics resistance. One recent report described a young woman dying of tuberculosis despite intensive treatment. The tuberculosis bacteria causing the dis- ease were multiply resistant and thus resisted treatment with all available antituberculosis drugs. In the first case, our own cells lose their growth regulation by genetic changes, thereby causing cancer. In the second, foreign organisms infect and establish themselves in the tissues of the human body, inhibiting their functions and destroying them by the action of toxins. Bacteria form the dominant part of the latter group: tuberculosis, syphilis, cholera, typhus, typhoid fever, and bubonic plague, for example. The medical treatment of cancer and that of bacterial infections are related in that both include the use of cell growth–inhibiting or cell-killing agents. Cancer cells are treated with cytostatics, which are difficult to use and must be handled by oncology specialists. This is because cancer cells originate from normal cells and are metabolically very similar to normal cells, letting cytostatics also interfere with healthy cells, such as those of the bone marrow, where the continuous growth of cells is necessary for the support of life. They can be inhibited in growth and also killed by agents that do not interfere with our cells. That is, antibacterial agents, antibiotics, used for clinical purposes in medicine must act selectively on bacteria. Their handling can therefore be focused on the characteristics of the infecting bacterium. Penicillin and its many followers, all with a selectively inhibiting effect on bacteria, had a tremendous impact on the treatment of infectious diseases and on their panorama of occurrence in the first decades of their ubiquitous clinical use (1950–1980). The great clinical success of antibiotics changed the attitude of the medical profes- sion toward bacterial infections. Antibiotics are unique among pharmaceutical remedies in that they do not direct their action toward our own cells but selec- tively toward foreign cells, bacteria coming from the outside and infecting our tissues. Their selective action means that they must target physiological and biochemical differences between our cells and bacterial cells in order to effect bacteriostatic or bacteri- ocidal activity. It can be noted that in the search for new antibiotics in molds and other microorganisms, with Peni- cillium as an example, many selective and useful antibiotics were found (e. In many patients showing signs of infection they are given simply for safety, without a strict bacterial diagnosis. This has contributed heavily to the very large consumption of antibiotics that can be estimated from sales figures, which can be used as good proxies for actual consumption (Chapter 2). Resistance to antibiotics among pathogenic bacteria has developed within a short time and in many ways faster than could have been expected. This can be explained partially by the short generation time of bacteria, allowing them to undergo a Darwinian evolution in a much shorter time than has been possible for animals and other organisms. Furthermore, bacteria have the ability to manipulate their own genetic makeup, leading to a faster adaptation to the toxic effects of antibiotics: that is, the development of resistance. It can be looked upon as the natural genetic engineering of bacteria, including the uptake and incor- poration of resistance-mediating genes from related organisms by adaptation of evolutionary old genetic mechanisms to the new environmental situation of the large presence of antibiotics. No microbiologist can escape feeling surprise and wonder as these phenomena continuously unfold. The great asset that antibiotics represent is devalued by the evolution of resistance. Will we be able to maintain control of bacterial infections, or will our descendants look back nostalgically and talk about the time that we had both oil and antibiotics? Later, Robert Koch at the Imperial Health Office in Berlin provided proof, with Bacillus antracis as an example, that there is a definite causal relation of a particular microorganism to a particular disease. From these ideas Koch formulated his postulates for characterizing a pathogenic microbe: 1. Based on these basic ideas, Paul Ehrlich at the Royal Institute for Experimental Therapy in Frankfurt am Main advanced the idea of direct selective action of a drug on infecting microbes. Ehrlich further observed that dyes stained different cell components selectively and proposed the idea that organic stains taken up, particularly by living cells, could have a therapeutic effect by interfering with bacterial infections. In the 1930s, these ideas led Gerhard Domagk, who was working at the Institute of Experimental Pathology at the I. Farbenindustrie in Elberfeld, Germany, to the discovery of Pron- tosil rubrum (4-sulfonamide-2,4 -diaminoazobenzol, Domagk 1935) (Fig. Jaques and Therese Trefouel´ ¨ of the Pasteur Institute in France could show that patients treated with Prontosil excreted a simpler product, sulfanilamide, which was active in vivo as well as in vitro against the growth of bacte- ria. This was a dramatic development since it finally established Ehrlich’s principle of chemotherapeutic action. Sulfanilamide is a colorless substance and not a dye, partly contradicting the theory leading to its discovery. Sulfanilamide was set free from the dye by hydrolysis in vivo in animal experiments. He could show that mice infected experimentally with Streptococcus pyogenes by injection into the peritoneum were protected from peritonitis with this agent. The results were published in Deutsche medi- zinische Wochenschrift in 1935, and sulfonamides were soon used widely for the clinical treatment of infections with streptococci, staphylococci, meningococci, and other severely pathogenic bac- terial agents.

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