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A tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) is approved for use in persons 11 64 years of age All should receive a primary series of immunizations against tetanus, diphtheria, and pertussis (Table 30 12) Adults who have not previously been immunized should receive a dose of Tdap followed by a dose Td 4 weeks later and a booster with Td 6 12 months after the second dose The Advisory Committee on Immunization Practices (ACIP) recommends that adults aged 19 64 years should receive a single dose of Tdap to replace tetanus and diphtheria toxoids vaccine (Td) for booster immunization if they received their last dose of Td 10 years earlier and they have not previously received Tdap To prevent pertussis among infants less than 12 months of age, a single dose of Tdap is recommended for those adults anticipating close contact with these infants (eg, parents, grandparents aged < 65 years, childcare providers) When possible, women should receive Tdap before becoming pregnant Women who have not previously received Tdap should receive a dose of Tdap in the immediate postpartum period Health-care personnel who work in hospitals or ambulatory care settings and have direct patient contact should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap For wound management, adults between the ages of 19 and 64 should receive Tdap instead of Td if they have not previously received Tdap Tdap is contraindicated if there is a history of anaphylaxis to vaccine components or if there is a history of unexplained encephalitis within 7 days of administration of a pertussiscontaining vaccine

namespace Example_5_6_ _ _ _Nested_if_Statements { class Program { static void Main( )

Patients with mild asymptomatic hyperparathyroidism may not need therapy However, they should be monitored closely for the development of symptoms of hypercalcemia and worsening hypercalcemia Patients should be evaluated every 6 months with determination of blood pressure and serum calcium Rising serum calcium should prompt further evaluation and determination of PTH levels Serum creatinine should be measured yearly A bone density should ideally be determined every 1 to 2 years at 3 points: wrist, hip, and vertebrae

Completely asymptomatic patients with mild hypercalcemia may be observed and treated medically without compromising survival There can be unexplained exacerbations and partial remissions Surgical removal of sporadic parathyroid adenomas generally results in a permanent cure Patients with MEN 1 undergoing subtotal parathyroidectomy may experi-

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Serum 25-hydroxyvitamin D levels often low as a comorbid condition Demineralization, especially of spine, hip, pelvis, and wrist

{ int temp = 32; if (temp <= 32) { Console.WriteLine("Warning! Ice on road!"); if (temp == 32) { Console.WriteLine("Temp exactly freezing, beware of water."); } else { Console.WriteLine("Watch for black ice! Temp: {0}", temp); } } else { Console.WriteLine("No ice; drive with confidence."); } } } }

ence long remissions, but hyperparathyroidism usually recurs Spontaneous cure due to necrosis of the tumor has been reported but is exceedingly rare The bones, in spite of severe cyst formation, deformity, and fracture, will heal if a parathyroid tumor is successfully removed The presence of pancreatitis increases the mortality rate Acute pancreatitis usually resolves with correction of hypercalcemia, whereas subacute or chronic pancreatitis tends to persist Significant renal damage may progress even after removal of an adenoma Parathyroid carcinoma tends to invade local structures and may sometimes metastasize; repeat surgical resections and radiation therapy can prolong life Aggressive surgical and medical management of parathyroid carcinoma can result in an 85% 5-year survival rate and a 57% 10-year survival rate

Block GA et al Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis N Engl J Med 2004 Apr 8;350 (15):1516 25 [PMID: 15071126] Coburn JW et al Doxercalciferol safely suppresses PTH levels in patients with secondary hyperparathyroidism associated with chronic kidney disease stages 3 and 4 Am J Kidney Dis 2004 May;43(5):877 90 [PMID: 15112179] Grey A et al Vitamin D repletion in patients with primary hyperparathyroidism and coexistent vitamin D insufficiency J Clin Endocrinol Metab 2005 Apr;90(4):2122 6 [PMID: 15644400] Lambert LA et al Surgical treatment of hyperparathyroidism in patients with multiple endocrine neoplasia type 1 Arch Surg 2005 Apr;140(4):374 82 [PMID: 15841561] Peacock M et al Cinacalcet hydrochloride maintains long-term normocalcemia in patients with primary hyperparathyroidism J Clin Endocrinol Metab 2005 Jan;90(1):135 41 [PMID: 15522938] Rao DS et al Randomized controlled clinical trial of surgery versus no surgery in patients with mild asymptomatic primary hyperparathyroidism J Clin Endocrinol Metab 2004 Nov;89(11):5415 22 [PMID: 15531491]

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