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Bowen s disease (intraepidermal squamous cell carcinoma) occurs either on sun-exposed or sun-protected skin The lesion is usually a small (1 3 cm), well-demarcated, slightly raised, pink to red, scaly plaque and may resemble psoriasis or a large actinic keratosis These lesions may progress to invasive squamous cell carcinoma Excision or other definitive treatment is indicated Extramammary Paget s disease, a manifestation of intraepidermal carcinoma or underlying genitourinary or gastrointestinal cancer, resembles chronic eczema and usually involves apocrine areas such as the genitalia Mammary Paget s disease of the nipple, a unilateral or rarely bilateral red scaling plaque that may ooze, is associated with an underlying intraductal mammary carcinoma

Akhdari N et al Bowen disease CMAJ 2006 Sep 26;175(7):739 [PMID: 17001052] Shepherd V et al Extramammary Paget s disease BJOG 2005 Mar;112(3):273 9 [PMID: 15713139]

The latter definition of the term became associated with the emerging concept of interactive computing. In fact, time-sharing can be viewed as an implementation of interactive computing (Lee 1992, 13 14). Conceptually, time-sharing occurs at many levels of the computing process. Traditionally, time-sharing is viewed as multiple users simultaneously accessing computing resources. The evolution of computing research that led to time-sharing constituted a paradigm shift from the computer being viewed as a discrete, self-contained calculating machine that (more or less) processed jobs sequentially, to the computer embodying interactive properties, capable of being simultaneously shared among

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Levothyroxine (thyroxine; T4) is the treatment of choice It is partially converted in the body to T3, the more active thyroid hormone Hypothyroid patients who are taking thyroxine replacement typically have serum T3 levels that are lower than normal, owing to their lack of thyroidal T3 secretion Oral administration of T3 causes abnormal peaks in serum T3 and the usefulness of T3 for hypothyroidism is controversial; a sustained-release T3 preparation is not commercially available In patients taking a certain daily dose of levothyroxine, significant increases in serum T4 levels are seen within 1 2 weeks, and near-peak levels are seen within 3 4 weeks It is best taken in the morning with water, avoiding concomitant intake of foods and drugs that may interfere with its absorption (see below) Brand preparations of levothyroxine in the United States appear to be bioequivalent to each other and certain generics Before therapy with thyroid hormone is commenced, the hypothyroid patient requires at least a clinical assessment for adrenal insufficiency, which would require concurrent treatment

(x >= !(x > !(x < ((x > ((x > y) y) y) y) y) && (y <= x) && (x > y) || !(x < y)) && (x > y) && ((y < x) || (x > y))) && (x == y)

Patients without coronary insufficiency who are under age 60 years may receive starting doses of oral levothyroxine of 50 100 mcg/daily up to a maximum of 16 mcg/kg body weight daily Women who are pregnant with significant hypothyroidism may begin therapy with levothyroxine at doses of 100 150 mcg orally daily Patients with coronary disease or those who are over age 60 years are treated with smaller initial doses of levothyroxine, 25 50 mcg daily; higher initial doses may be used if such patients are severely hypothyroid The dose can be increased by 25 mcg every 1 3 weeks until the patient is euthyroid Patients with hypothyroidism and ischemic heart disease may begin thyroxine therapy following coronary artery angioplasty or bypass Patients with severe hypothyroidism require larger initial doses of levothyroxine, particularly since myxedema itself can interfere with the intestinal absorption of T4 Myxedema coma is a medical emergency with a high mortality rate Levothyroxine sodium 400 mcg is given intravenously as a loading dose, followed by 100 mcg intravenously daily The hypothermic patient is warmed only with blankets, since faster warming can precipitate cardiovascular collapse Patients with hypercapnia require intubation and assisted mechanical ventilation Infections must be detected and treated aggressively Patients in whom concomitant adrenal insufficiency is suspected are treated with hydrocortisone, 100 mg intravenously, followed by 25 50 mg every 8 hours

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