Ideally best order cialis professional what age can erectile dysfunction occur, plans for the fair and just rationing of critical care resources during periods of overwhelming demand should be developed prior to the disaster buy discount cialis professional 20mg online impotence under 40. Importantly, in order to implement such processes, providers must feel secure in their legal protection. Hence, providers should be legally protected from local and state law if there is a need to deviate from the usual standards of care during periods of scarce resources. The need for such legal protection was poignantly highlighted in New Orleans during the Hurricane Katrina disaster, as palliative care was provided to some patients as evacuation attempts were repeatedly delayed and hospital capabilities were overwhelmed [44]. In response to these events, New York State has developed ventilator allocation guidelines for pandemics and other mass-casualty events, with other states now following its lead [45]. Critical Care Triage There remains debate about the preferred method of triage during a major disaster where patient needs have exceeded critical care resources. Although each of these concepts has its merits; none have been prospectively evaluated in a disaster setting. Such triggers would include a lack of critical equipment or medical supplies, inadequate critical care spaces, inadequate staff, and inadequate capability to transfer noncritically ill patients to other facilities. Once the requirement to triage care has been directed, critical care providers must determine which patients should receive critical care and which patients should not. This process needs to be carefully planned and evaluated with community involvement prior to a catastrophic event. If, for example, a health care system or region proposes to exclude critical care to the very elderly during a major disaster, then community representatives from the elderly population would need to be included in such decisions. That is, the elderly would participate in advance planning with providers on how to triage the elderly during future mass-casualty emergencies. However, all have similar limitations in that they have not been rigorously evaluated in emergency mass critical care scenarios. A triage team, consisting of an experienced intensivist and another acute care physician, may be preferable to a single triage officer, given the emotional burden and the utility of a second “set of eyes” during a crisis. This group, operating independently from the bedside clinicians, would gather periodic patient data to determine the severity of illness and document improvement, stability, or deterioration of critically ill patients over time. The patients who deteriorate or fail to improve over time would have their critical care resources reallocated to other patients. The availability of an experienced critical care triage team has the advantage of removing the burden of triage decisions from busy clinicians who are providing critical care at the bedside. This team also removes some of the inherent bias that providers may have when making decisions for patients personally known to them. This committee, distinct from the triage team, would: Work with regional planners and maintain situational awareness of the community and state, regarding the ongoing use and need of triage protocols. Review the implementation of the local triage protocol, to ensure compliance and integrity of triage operations. Serve as a forum for appeals by patients, families, and staff regarding the accurate and ethical implementation of the triage tool. Ideally, hospitals are the optimal setting to provide critical care for severely ill and injured patients. During major disasters, hospitals should coordinate with community medical response systems to offload patients with minor injuries or illnesses so that hospital resources can be focused on the care of critically ill patients. Predisaster planning and training are essential for mitigating the adverse effects of an overwhelming disaster on hospitals and their communities. Carefully developed plans for surging critical care resources will facilitate continuation of usual hospital processes for the largest number of the patients. However, when surge procedures fail to meet the critical care demands of an overwhelming patient influx, processes to triage and alter the usual standards of critical care must be implemented. These planning concepts and guidelines can help guide critical care practitioners to care for their patients under the challenging conditions of a catastrophic disaster. The opinions and assertions contained herein are those of the authors and do not necessarily reflect the views or position of the Department of the Navy, Department of Defense, Department of Veterans Affairs, the United States Government, nor of the academic institutions with which the authors are affiliated. Medicare and Medicaid Programs: Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Fiscal Year 2016 Public Health and Social Services Emergency Fund—Justification of Estimates for Appropriations Committees. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care. Kudo D, Furukawa H, Nakagawa A, et al: Resources for business continuity in disaster-based hospitals in the great East Japan earthquake: survey of Miyagi Prefecture disaster base hospitals and the prefectural disaster medicine headquarters. Morton B, Tang L, Gale R, et al: Performance of influenza-specific triage tools in an H1N1-positive cohort: P/F ratio better predicts the need for mechanical ventilation and critical care admission. In these days of total warfare, the civilians, including women and children, are subject to attack at all times [1,2]. Critical care physicians must be familiar with these agents, their impact on patients, and the potential dangers these compounds can cause to health care workers. Although terrorists have traditionally focused their efforts on the use of conventional explosives, chemical agents have emerged as attractive weapons of terrorism for a variety of reasons: Raw materials for their production are readily available throughout the world. This chapter focuses on the recognition and management of patients exposed to common chemical agents of mass destruction. However, those that have been successfully weaponized are characterized by ease of production, ease of handling during weapon assembly, dispersion properties, and ability to cause injury and death at relatively low concentrations [4]. The next major use of chemical weapons took place more than 2 years later, on July 12, 1917, again near Ypres, when German forces attacked Allied troops with artillery shells containing sulfur mustard. Although many of the 20,000 casualties had debilitating injuries, less than 5% of the troops died as a result of the chemical attack. Persistent and nonvolatile, sulfur mustard caused a host of new problems for Allied forces, including a latency period before the effects appeared and the need for men, and their horses, to wear protective overgarments [5]. The Geneva Convention of 1925 banned the use of chemical warfare agents because of the physical and psychologic trauma they imposed on their victims. Gerhard Schrader, began research into the development of stronger insecticides, the first two of which were tabun and sarin. Later in the 1980s, reports implicated Iraq in the use of cyanide against the Kurdish population of northern Iraq [6]. The first took place on June 27, 1994, in Matsumoto and resulted in 600 persons exposed, 58 admitted to the hospital, and seven deaths [7]. The more famous and larger event took place the following year, on March 20, 1995, when they released sarin gas in the Tokyo subway system during rush hour. The subway system attack resulted in the deaths of 11 commuters and the medical evaluation of approximately 5,000 individuals [8]. Four days later Russian Special Forces fumigated the building with a derivative of the narcotic fentanyl. Although this method broke the siege, all but two of the 41 terrorists and 129 hostages died from opiate toxicity [9]. The most recent use of chemical weapons occurred in the early morning hours of August 21, 2013 in the Ein Tarma and Zamalka suburbs of Damascus, Syria. Social media reports and videos as well as satellite imagery demonstrated large numbers of sick adults and children with no visible trauma; medical personnel described the symptoms as most consistent with exposure to a nerve agent [10]. Three Damascus hospitals received over 3,000 casualties where the principle antidote atropine was in short supply and exposure to contaminated patients at one hospital resulted in 41 staff members, including 10 doctors, becoming contaminated [11].

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Ampicillin (with or without the addition of gentamicin) is the drug of choice for the gram-positive bacillus Listeria monocytogenes and susceptible enterococcal species cheap cialis professional line impotence under 40. These extended-spectrum agents are also widely used in the treatment of respiratory infections purchase cheap cialis professional line erectile dysfunction pills in south africa, and amoxicillin is employed prophylactically by dentists in high-risk patients for the prevention of bacterial endocarditis. These drugs are coformulated with β-lactamase inhibitors, such as clavulanic acid or sulbactam, to combat infections caused by β-lactamase–producing organisms. Resistance in the form of plasmid-mediated penicillinases is a major clinical problem, which limits use of aminopenicillins with some gram- negative organisms. Formulation of piperacillin with tazobactam extends the antimicrobial spectrum to include penicillinase-producing organisms (for example, most Enterobacteriaceae and Bacteroides species). Resistance Survival of bacteria in the presence of β-lactam antibiotics occurs due to the following: 1. They are the major cause of resistance to the penicillins and are an increasing problem. Some of the β-lactam antibiotics are poor substrates for β-lactamases and resist hydrolysis, thus retaining their activity against β-lactamase–producing organisms. In gram-positive bacteria, the peptidoglycan layer is near the surface of the bacteria and there are few barriers for the drug to reach its target. Reduced penetration of drug into the cell is a greater concern in gram-negative organisms, which have a complex cell wall that includes aqueous channels called porins. An excellent example of a pathogen lacking high permeability porins is Pseudomonas aeruginosa. The presence of an efflux pump, which actively removes antibiotics from the site of action, can also reduce the amount of intracellular drug (for example, Klebsiella pneumoniae). Antibiotic exposure can prevent cell wall synthesis and can lead to morphologic changes or lysis of susceptible bacteria. Administration the route of administration of a β-lactam antibiotic is determined by the stability of the drug to gastric acid and by the severity of the infection. Penicillin V, amoxicillin, and dicloxacillin are available only as oral preparations. They are slowly absorbed into the circulation and persist at low levels over a long time period. Absorption the acidic environment within the intestinal tract is unfavorable for the absorption of penicillins. In the case of penicillin V, only one-third of an oral dose is absorbed under the best of conditions. Food decreases the absorption of the penicillinase-resistant penicillin dicloxacillin because as gastric emptying time increases, the drug is destroyed by stomach acid. All the penicillins cross the placental barrier, but none have been shown to have teratogenic effects. Metabolism Host metabolism of the β-lactam antibiotics is usually insignificant, but some metabolism of penicillin G may occur in patients with impaired renal function. Nafcillin and oxacillin are exceptions to the rule and are primarily metabolized in the liver. Excretion the primary route of excretion is through the organic acid (tubular) secretory system of the kidney as well as by glomerular filtration. Because nafcillin and oxacillin are primarily metabolized in the liver, they do not require dose adjustment for renal insufficiency. Probenecid inhibits the secretion of penicillins by competing for active tubular secretion via the organic acid transporter and, thus, can increase blood levels. Reactions range from rashes to angioedema (marked swelling of the lips, tongue, and periorbital area) and anaphylaxis. To determine whether treatment with a β-lactam is safe when an allergy is noted, patient history regarding severity of previous reaction is essential. Diarrhea Diarrhea is a common problem that is caused by a disruption of the normal balance of intestinal microorganisms. It occurs to a greater extent with those agents that are incompletely absorbed and have an extended antibacterial spectrum. Pseudomembranous colitis from Clostridium difficile and other organisms may occur with penicillin use. Nephritis Penicillins, particularly methicillin, have the potential to cause acute interstitial nephritis. Neurotoxicity the penicillins are irritating to neuronal tissue, and they can provoke seizures if injected intrathecally or if very high blood levels are reached. Hematologic toxicities Decreased coagulation may be observed with high doses of piperacillin and nafcillin (and, to some extent, with penicillin G). Cytopenias have been associated with therapy of greater than 2 weeks, and therefore, blood counts should be monitored weekly for such patients. Cephalosporins the cephalosporins are β-lactam antibiotics closely related both structurally and functionally to penicillins. Most cephalosporins are produced semisynthetically by the chemical attachment of side chains to 7-aminocephalosporanic acid. Structural changes on the acyl side chain at the 7-position alter antibacterial activity and variations at the 3- position modify the pharmacokinetic profile (ure 29. Cephalosporins have the same mode of action as penicillins, and they are affected by the same resistance mechanisms. However, they tend to be more resistant than the penicillins to certain β-lactamases. Antibacterial spectrum Cephalosporins have been classified as first, second, third, fourth, and advanced generation, based largely on their bacterial susceptibility patterns and resistance to β-lactamases (ure 29. First generation the first-generation cephalosporins act as penicillin G substitutes. Most oral cavity anaerobes like Peptostreptococcus are sensitive, but the Bacteroides fragilis group is resistant. Second generation the second-generation cephalosporins display greater activity against gram-negative organisms, such as H. They are the only cephalosporins commercially available with appreciable activity against gram-negative anaerobic bacteria. However, neither drug is first line because of the increasing prevalence of resistance among B. Third generation These cephalosporins have assumed an important role in the treatment of infectious diseases. The spectrum of activity of this class includes enteric organisms, such as Serratia marcescens and Providencia species. Third-generation cephalosporins must be used with caution, as they are associated with significant “collateral damage,” including the induction of antimicrobial resistance and development of Clostridium difficile infection. Cefepime has a wide antibacterial spectrum, with activity against streptococci and staphylococci (but only those that are methicillin susceptible).

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Disorders of Impulse Generation Sinus Arrhythmia Sinus arrhythmia is the change in beat-to-beat P-P interval with unchanged morphology of the P waves (sinus rhythm) 40mg cialis professional amex erectile dysfunction doctor orlando. It is usually a normal physiologic response to alteration of vagal tone during respiration or external irritation buy cialis professional 20mg without a prescription erectile dysfunction bph. Certain pathology such as digitalis toxicity, ischemic heart disease, or intracranial hemorrhage can mimic the benign form of this sinus arrhythmia [83]. However, sinus arrhythmia usually does not cause hemodynamic instability, and treatment is not required. This happens as a result of alteration of vagal tone or pharmacologic agents such as parasympathomimetics, β-Blockers, calcium antagonists, and digitalis. Sinus node dysfunction can manifest as a combination of bradycardia and atrial tachycardia, known as “tachy- brady syndrome,” which occurs in approximately half of the patients with sinus node dysfunction [84]. Sinus node dysfunction is commonly related to age and can occur as a result of hypothyroidism, infiltrative disease, collagen vascular disease, trauma, ischemia, infection, or ion channel dysfunction [4]. Patients can develop sinus arrest especially immediately after sudden termination of a tachyarrhythmia which may require immediate intervention. In this setting, latent pacemaker foci below the level of conduction may assume control of the ventricular rhythm such as junctional or ventricular escape rhythm. Hence, it is often unstable and requires temporary or permanent pacemaker depending on their reversibility [87]. Treatment Providers need to evaluate hemodynamic stability of the patients and distinguish reversible causes from permanent etiologies. In addition, isoproterenol infusion may be used to stimulate heart rate via the β-1 agonist (Table 189. One should be careful when using chronotropic infusions because they can exacerbate ischemia in the setting of cardiogenic shock by reducing coronary perfusion. For instance, glucagon can be used in the setting of β- blocker overdose; sodium bicarbonate and hemodialysis can be used for acidosis; calcium, insulin, and hemodialysis can be used in the setting of hyperkalemia (Table 189. Pacemaker Therapy Pacemakers are used to improve circulatory hemodynamics by improving cardiac output by controlling the heart rate and/or rhythm. Transcutaneous cardiac pacing is usually used in an emergent setting for patients not responsive to intravenous medications. However, owing to its instability and painful pacing, this modality should only be used as a temporizing measure for a short period of time. The pacing system is consisted of a pulse generator attached to high- impedance external patch electrode pads that are applied to the anteroposterior or anterolateral positions of the patient’s bare chest. The need for continued pacing can be evaluated by gradually decreasing pacing output, resulting in returning of stable rhythm. Transvenous endocardial pacing is predominantly used for patients with unstable bradyarrhythmias that will last for a period of time while waiting for permanent pacemaker implantation or resolving of underlying etiology. In transvenous pacing, the heart is directly paced using catheters placed in the apex of the right ventricle. Central venous access is achieved using an introducer sheath through the jugular, subclavian, femoral, or brachial veins [89]. A chest X-ray is then used to confirm placement of the catheter, and the pacing and sensing thresholds are tested. Yoshida T, Fujii T, Uchino S, et al: Epidemiology, prevention, and treatment of new-onset atrial fibrillation in critically ill: a systematic review. Tchou P, Young P, Mahmud R, et al: Useful clinical criteria for the diagnosis of ventricular tachycardia. Bou-Abboud E, Nattel S: Relative role of alkalosis and sodium ions in reversal of class I antiarrhythmic drug-induced sodium channel blockade by sodium bicarbonate. Eidher U, Freihoff F, Kaltenbrunner W, et al: Efficacy and safety of ibutilide for the conversion of monomorphic atrial tachycardia. Gonzalez-Torrecilla E, Almendral J, Arenal A, et al: Combined evaluation of bedside clinical variables and the electrocardiogram for the differential diagnosis of paroxysmal atrioventricular reciprocating tachycardias in patients without pre-excitation. Gupta A, Naik A, Vora A, et al: Comparison of efficacy of intravenous diltiazem and esmolol in terminating supraventricular tachycardia. D’Este D, Zoppo F, Bertaglia E, et al: Long-term outcome of patients with atrioventricular node reentrant tachycardia. Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Kodama S, Saito K, Tanaka S, et al: Alcohol consumption and risk of atrial fibrillation: a meta-analysis. Koniari I, Apostolakis E, Rogkakou C, et al: Pharmacologic prophylaxis for atrial fibrillation following cardiac surgery: a systematic review. Nattel S, Burstein B, Dobrev D: Atrial remodeling and atrial fibrillation: mechanisms and implications. Delle Karth G, Geppert A, Neunteufl T, et al: Amiodarone versus diltiazem for rate control in critically ill patients with atrial tachyarrhythmias. Kiss O, Sydo N, Vargha P, et al: Prevalence of physiological and pathological electrocardiographic findings in Hungarian athletes. Stockburger M, Trautmann F, Nitardy A, et al: Pacemaker-based analysis of atrioventricular conduction and atrial tachyarrhythmias in patients with primary sinus node dysfunction. Kornberger A, Schmid E, Kalender G, et al: Bridge to recovery or permanent system implantation: an eight-year single-center experience in transvenous semipermanent pacing. When the mean arterial blood pressure falls below approximately 60 mmHg, end-organ perfusion becomes compromised and is manifested clinically as cool skin, decreased urine output, and altered mental status. Cornerstones of management include volume resuscitation and therapy directed toward the underlying cause of hypotension (e. When these measures fail to restore blood pressure and vital organ perfusion or while awaiting their availability, administration of intravenous vasoactive agents may be necessary. This chapter reviews the general management of the hypotensive patient with an emphasis on coronary care and the pharmacologic properties of commonly used vasopressor and positive inotropic agents. An overview of shock (see Chapter 37); volume resuscitation (see Chapter 37); sepsis (see Chapter 39); and the use of intra-aortic balloon counterpulsation and mechanical circulatory support devices (see Chapter 196) is given elsewhere. This practice is especially important when automated devices are used to make these measurements in the setting of tachyarrhythmias or respiratory distress. For patients with peripheral arterial disease, upper extremity blood pressure should also be compared to measurements in the legs in the supine position. In rare circumstances, true central aortic pressure may differ significantly from peripherally obtained blood pressures and can only be confirmed by invasive measurement during diagnostic catheterization. This situation should be suspected when clinical features of hypoperfusion do not accompany low blood pressure. Hypotension is generally defined as a mean arterial pressure of less than 60 mmHg and/or a systolic blood pressure less than 100 mmHg. However, higher values may be consistent with clinically relevant hypotension if there are concomitant clinical signs of hypoperfusion such as mental status changes, oliguria, pallor, and cool extremities.

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Activation of vitamin D requires 25-hydroxylation in the liver and 1- hydroxylation in the kidney to form the active hormone 1 20 mg cialis professional with amex smoking erectile dysfunction statistics,25 D purchase cialis professional with mastercard erectile dysfunction doctors in south africa. The effects of 1,25 D are exerted through interactions with nuclear receptors located in a variety of cells, including enterocytes, parathyroid chief cells, osteoblasts, and renal tubular cells. Medullary carcinoma of the thyroid is a malignant neoplasm of the C-cells and is characterized by elevated calcitonin levels. Also, patients can have undetectable levels of calcitonin after a thyroidectomy with no clear detrimental systemic effects. Despite the lack of clinical consequences from endogenous calcitonin excess or deficiency, exogenous calcitonin is a potent inhibitor of bone resorption. This phenomenon, possibly due to downregulation of calcitonin receptors, is of clinical importance when treating patients with hypercalcemia. The excellent short-term effects of calcitonin to lower serum calcium (within 12 to 48 hours) allows the institution of therapies that require several days to attain maximal effectiveness (e. The administration of a salmon calcitonin nasal spray has been shown to decrease markers of bone turnover, increase bone mineral density at the spine, and decrease the risk of vertebral fractures in postmenopausal women with osteoporosis [13]. The mental manifestations of hypercalcemia include stupor, obtundation, apathy, lethargy, confusion, disorientation, and coma. In general, for a given level of hypercalcemia, older patients exhibit more of the mental signs than younger patients. The neurologic and musculoskeletal effects of hypercalcemia are reduced muscle tone and strength, myalgias, and decreased deep tendon reflexes. Differential Diagnosis Elevated serum calcium measurements have been reported in approximately 1% of the general population [14]. The causes of hypercalcemia can be differentiated into two broad groups defined by whether or not the process is driven by abnormal parathyroid tissue. The malignancies most often associated with hypercalcemia include lung (35%), breast (25%), hematologic (myeloma and lymphoma [14%]), head and neck (6%), and renal (3%) [15]. Hypercalcemia occurs in 10% of patients, though hypercalciuria has been documented in as many as 20% [17]. Immobilization causes hypercalcemia as a result of decreased bone formation and persistent bone resorption. Hypercalcemia in the immobilized individual occurs most commonly among patients with high bone turnover (e. The routine measurement of serum calcium has altered the clinical presentation of hyperparathyroidism with most patients presenting with asymptomatic hypercalcemia. The latter occurs typically after chronic secondary hyperparathyroidism in the setting of end-stage renal failure. Hypercalcemia develops due to increased bone resorption, increased intestinal calcium absorption from stimulation of 1,25 D production, and increased renal tubular calcium reabsorption. In primary hyperparathyroidism, a single adenoma is present in 80% to 85% of cases, whereas four-gland hyperplasia occurs in 10% to 15% of cases [18]. Parathyroid cancer is present among less than 1% of these patients and typically presents with much higher serum calcium levels [19]. Hypercalcemia associated with the use of thiazide diuretics is often an indicator of underlying primary hyperparathyroidism. However, altered binding of calcium to proteins, as can occur with hypoalbuminemia or with abnormal proteins (e. Because of the interrelationships of calcium, magnesium, and phosphorus, the latter two minerals should be measured in all cases involving altered calcium metabolism. Because myeloma is characterized by bone resorption with little bone formation, the bone scan is usually negative, but a skeletal survey may find lytic lesions. The diagnosis would then be confirmed by urine immunoelectrophoresis, serum protein electrophoresis, and bone marrow examination. The diagnosis of milk-alkali syndrome is made by the patient’s history, often revealing large quantities of calcium carbonate ingestion. Thyrotoxicosis and Addison’s disease can be ruled out with thyroid function tests and a cosyntropin stimulation test, respectively (see Chapter 139 for a discussion about evaluating adrenal function in the critically ill). Vitamin D intoxication is quite rare, but the possibility can be eliminated by measuring 25-hydroxyvitamin D levels. General concepts in the management involve attempts to (a) increase renal calcium clearance, (b) decrease bone resorption, and (c) decrease intestinal calcium absorption. If, for example, the hypercalcemia in a patient with myeloma is due to a combination of increased bone resorption plus decreased renal calcium clearance, successful management of the hypercalcemia requires that both processes be treated. Saline hydration creates a diuresis that increases renal calcium excretion by decreasing calcium reabsorption in the proximal tubule. Hydration plays a critical role in the initial management of hypercalcemia because the onset of the therapeutic response is rapid. Because a potential complication of administration of this amount of saline is congestive heart failure, extreme care must be taken in treating the patient with underlying cardiac disease or renal insufficiency. The concomitant administration of a loop diuretic helps prevent volume overload and further increases renal calcium excretion by inhibiting distal tubular calcium reabsorption. Measurement of serum electrolytes, phosphorus, and magnesium is mandatory during saline hydration to replace adequately the quantities lost in the urine. If renal or cardiac failure precludes the use of saline hydration, dialysis with a calcium-free dialysate is an effective alternative. It also exerts transient effects to increase the renal excretion of calcium, along with sodium, potassium, magnesium, and phosphate. The benefits of calcitonin for the treatment of hypercalcemia include (a) rapid onset within 2 hours, (b) maximal effect within 24 to 48 hours, and (c) low toxicity [12]. It can be used safely in patients with renal failure, and its side effects are limited to transient nausea, facial flushing, and occasional hypersensitivity at the injection site. Usually calcitonin is effective for only 4 to 7 days [12], but it is still used for the rapid response, as bisphosphonates often require several days to attain maximal effectiveness. Bisphosphonates are synthetic analogues of pyrophosphate that are potent inhibitors of bone resorption through inhibition of osteoclastic activity and survival [16]. Because of the delay of reduction in serum calcium with bisphosphonates, these agents are often used in conjunction with other therapies. Zoledronic acid at a dose of 4 mg intravenously over not less than 15 minutes has been shown to be more effective at normalizing serum calcium in patients with hypercalcemia of malignancy [26]. Renal function must be monitored, and the doses of either medication may be repeated after a minimum of 7 days to allow a full response to the initial dose [16]. This agent is approved for the treatment of postmenopausal women with osteoporosis and has been shown to reduce the incidence of vertebral, non-vertebral, and hip fractures [28]. It has also been approved for the prevention of skeletal-related events in patients with bone metastases from solid tumors [29]. Recently, a single-arm study of 33 patients with hypercalcemia of malignancy refractory to bisphosphonates showed that 64% of subjects had a complete response to a dose of 120 mg subcutaneously on days 1, 8, 15, 29, and every 4 weeks for a median of 8 weeks [30].