睿学教育Wisdome Education

Steven J. Kronowitz, MD, FACS

• Professor
• Department of Plastic Surgery
• University of Texas
• MD Anderson Cancer Center
• Houston, Texas

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The ability to directly address a persisting deviation symptoms bladder cancer cheap 3 ml bimatoprost with visa, elevating the mucosal flap directly over the offending deviation using endoscopic techni- ques symptoms pneumonia generic bimatoprost 3 ml with visa, greatly facilitates treatment medications rights buy cheap bimatoprost on line. For an isolated posterior deformity, the incision may be positioned in the immediate vicinity of the deformity. Three patients—all revision surgeries— mucoperiosteal flap elevation is facilitated by a suction elevator. One and the contralateral mucoperichondrial and mucoperiosteal patient required repair of choanal stenosis. If an iso- after a septoplasty, persisting nasal obstruction may require lated posterior deformity is addressed, the cartilage or bone is revision septoplasty. Because the mucosal flaps are often incised several millimeters posterior to the mucosal incision, densely adherent after a septoplasty, revision septoplasty and the contralateral mucosal flap is elevated. Deviated por- involving a traditional approach may present technical diffi- tions of septal cartilage and bone are corrected or removed. Straightened or morselized cartilage may be replaced, and the Endoscopic septoplasty is a relatively recent and important septal flaps may be closed with a quilting suture, although in technique that has direct application in this situation. Clear commu- these cases, typical surgical dissection planes are obliterated nication between surgeon and patient, and clear understanding and complete elevation of the mucoperichondrial or mucoper- of the patient’s surgical goals, are important ingredients for suc- iosteal flaps may be difficult. Though obviously not a surgical technique, computer deviation, elevating the mucosal flap directly over the offending imaging has been an indispensable communication tool in revi- deviation using endoscopic techniques, greatly facilitates treat- sion rhinoplasty and warrants highlighting here. Indeed, Becker and Kallman report that in a series of 90 author rarely performs cosmetic rhinoplasty when computer primary septorhinoplasties, one patient underwent endoscopic imaging has not been performed. In 23 revision functional septorhinoplasties, 4 The senior author’soffice computer network provides for patients benefited from endoscopic septoplasty approaches. However, The senior author explains to the patient that computer these advantages may not be as widely recognized in the rhino- imaging is just a “video game,” that it is a way to communicate plasty community. It is further explained that of course this techniques including endoscopic septoplasty, are important is not an “after” picture, that it is not a guarantee and should tools in the revision rhinoplasty surgeon’s armamentarium. If a small composite graft is needed, primary closure of the donor site may be achieved. If a large graft is required, a “revolving door” postauricular flap may facilitate closure. An incision several millimeters from the nostril rim is fol- lowed by careful dissection with freeing of adhesions, creating a Fig. Volume and sup- port must be restored to hold the nostril rim in position—this role is fulfilled by the composite graft. When more extensive light dressing intranasally to apply light pressure for 1 to 3 days revision rhinoplasty is being performed, with wider elevation. The office diagnosis of nasal and sinus disorders using rigid nasal ders; 1997 endoscopy. Endoscopic septoplasty: Oper Techn Otolaryngol Head Neck Surg 2000 indications, technique, and results. Aesthetic correction of alar-columellar dis- Head Neck Surg 1997; 116: 274–277 proportion. Laryngoscope 1994; 104: 1507–1509 438 The Decision Process in Choosing Costal Cartilage 56 The Decision Process in Choosing Costal Cartilage for Use in Revision Rhinoplasty Scott Chaiet, Robert J. However, their use has been ing or augmenting long-term tip projection, restoring rigid dor- limited because of significant complications, such as lack of sal stability, and restoring optimum respiratory function, the mobility, foreign body reaction, and higher rates of infection methods set forth to obtain these objectives are inherently dif- and extrusion. Irradiated costal cartilage6,7 and acellular dermis8 are homo- To achieve an esthetically pleasing result that is in harmony grafts that have been applied with variable success. Advantages with the rest of the face, septal and auricular cartilage grafts are of irradiated rib include its lack of donor-site morbidity, short- frequently used for columellar struts, tip grafts, and dorsal ened operating time due to elimination of graft harvest, resist- onlay grafts during a primary rhinoplasty. The theoretical arises during revision procedures is that these materials are in transmission of disease, material shortage within the tissue limited supply due to their depletion during the primary rhino- banks, and a variable or potentially increased rate of resorption plasty. In the case of congenital nasal deformities, the septum is and infection have limited the use of these materials in the set- normally underdeveloped and is frequently severely deviated. However, it should be noted that One of the main problems that arises with the use of auricular several authors use irradiated costal cartilage as their material cartilage grafts is that they frequently do not contain the struc- of choice without encountering these complications. It should be noted that saddle deformity, defects after neoplastic resection, congenital although this is the best option for the reconstruction in this nasal deformities, severe tip weakness or underprojection, rhi- setting, this option does not come without its downfalls. Most noplasty in the ethnic patient, and revision rhinoplasty, alterna- significantly, these include availability, varying degrees of tive options must be explored.

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Despite the imposing challenge of balancing risks versus benefits medicine zyrtec bimatoprost 3 ml purchase with visa, drug therapy during pregnancy cannot and should not be avoided symptoms pancreatic cancer generic 3 ml bimatoprost free shipping. Uncontrolled maternal asthma is far more dangerous to the fetus than the drugs used to treat it symptoms quitting smoking bimatoprost 3 ml with amex. The incidence of stillbirth is doubled among pregnant patients who do not take medications for asthma control. One of the greatest challenges in identifying drug effects on a developing fetus has been the lack of clinical trials, which, by their nature, would put the developing fetus at risk. Current research often focuses on comparing histories of women who have had children with and without birth defects. Additionally, there are a number of pregnancy registries in which a woman who needs to take a drug while pregnant can enroll. Physiologic Changes During Pregnancy and Their Effects on Drug Disposition and Dosing Pregnancy brings on physiologic changes that can alter drug disposition. By the third trimester, renal blood flow is doubled, causing a large increase in glomerular filtration rate. As a result, there is accelerated clearance of drugs that are eliminated by glomerular filtration. Three antiseizure drugs—phenytoin, carbamazepine, and valproic acid—provide examples. Tone and motility of the bowel decrease in pregnancy, causing intestinal transit time to increase. Similarly, there is more time for reabsorption of drugs that undergo enterohepatic recirculation, possibly resulting in a prolongation of drug effects. Placental Drug Transfer The factors that determine drug passage across the membranes of the placenta are the same factors that determine drug passage across all other membranes. Accordingly, drugs that are lipid soluble cross the placenta easily, whereas drugs that are ionized, highly polar, or protein bound cross with difficulty. Nonetheless, for practical purposes, the provider should assume that any drug taken during pregnancy will reach the fetus. Adverse Reactions During Pregnancy Not only are pregnant patients subject to the same adverse effects as nonpregnant patients, but they may also suffer effects unique to pregnancy. For example, when heparin (an anticoagulant) is taken by pregnant patients, it can cause osteoporosis, which in turn can cause compression fractures of the spine. Drugs taken during pregnancy can adversely affect the patient as well as the fetus. The neonate should be weaned from dependence by giving progressively smaller doses of the drug on which he or she is dependent. Additionally, certain pain relievers used during delivery can depress respiration in the neonate. Drug Therapy During Pregnancy: Teratogenesis The term teratogenesis is derived from teras, the Greek word for monster. Consistent with this derivation, we usually think of birth defects in terms of gross malformations, such as cleft palate, clubfoot, and hydrocephalus. Incidence and Causes of Congenital Anomalies The incidence of major structural abnormalities (e. The incidence of minor structural abnormalities is unknown, as is the incidence of functional abnormalities (e. Congenital anomalies have multiple causes, including genetic predisposition, environmental chemicals, and drugs. Teratogenesis and Stage of Development Fetal sensitivity to teratogens changes during development; thus the effect of a teratogen is highly dependent on when the drug is given. During the preimplantation/presomite period, teratogens act in an all-or-nothing fashion. This is the time when the basic shape of internal organs and other structures is being established. Because the fetus is especially vulnerable during the embryonic period, pregnant patients must take special care to avoid teratogen exposure during this time.

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Arch Otolaryngol Head Neck Surg 1990; 116: 671–675 530 Management of the Aging Nose 67 anagem ent of the Aging Nose Vito C medications harmful to kidneys buy 3 ml bimatoprost visa. Pearson Demographic changes in the United States over the next couple some degree of external valve improvement is typically accom- of decades will result in a rapidly expanding population of plished medicine joji buy cheap bimatoprost 3 ml. In that case treatment viral pneumonia best purchase bimatoprost, the plasty may be indicated for functional or cosmetic reasons or resiliency of the aging lateral crura may be compromised. The facial plastic surgeon will increasingly be charged Lateral crural strut grafting or alar batten grafting may be indi- with addressing the needs of this growing patient population. Some issues pertinent to the aging popu- Given the anatomic changes inherent to aging, certain techni- lation include psychological motivation, medical comorbidities, cal considerations should be heeded. First, nasal lengthening anatomic changes typical of the aging process, and technical may result in the development of an apparent dorsal hump. Any recent traumatic events, such as the death of a vexity and may be interpreted as a hump. Surgical planning should allow height may be well within normal limits once nasal projection for adequate time to elapse enabling the patient to adjust to and rotation are adjusted to the desired extent. The sur- attempts at lowering dorsal height, the nasal surgeon should geon should recognize that patients in this age group typically first visualize the ideal dorsal height by manually holding the have a well-formed self-identity and may not be seeking or pre- tip in a desirable location. Only then should dorsal height be pared for a dramatic change in nasal appearance. Using this method, excessive lowering of patients who have lived their entire adult lives with what they dorsal height may be avoided. Many authors advise against performing osteotomies be undertaken about the patient’s motivations and goals for in this age group for that reason unless absolutely necessary. When osteotomies are indicated, several authors recommend In terms of comorbidities, medical clearance should be using a transcutaneous external technique to minimize the sought from the patient’s primary doctor. Similarly, ossification of septal cartilage may preclude its use as Age-related anatomic changes are most dramatic in the lower a grafting material. The patient should be counseled about and nasal third, which becomes relatively elongated. Consistently the surgeon should be prepared for the possible harvest of observed changes include thinning of the nasal skin, weakening alternative sources of grafting material including auricular and of the nasal cartilages, and separation of the fibrous attach- costal cartilage. To address these changes, surgical techniques that increase pro- The nasal tip is a dynamic structure, hinged by the upper lateral jection and rotation are the focus of methods to surgically man- cartilages and by the recurvature of the lower lateral cartilages. Various proven methods to accomplish Major and minor tip support mechanisms play a central role in those goals are described in this chapter. In addition to aesthetic effects, the same age-related ana- The nasal tip is composed of the paired lower lateral carti- tomic changes may predispose to functional impairment. Some lages, or alar cartilages, each of which may be divided into three degree of nasal airway obstruction is often encountered in the crura: medial, middle, and lateral. The sites of obstruction may be at the internal nasal the border between the lateral and middle crura, and the valve or the external nasal valve. Using the methods region demonstrates characteristic changes during the aging described below to reposition a derotated and deprojected tip, process including gradual flattening of the cartilaginous 531 Age Considerations in Rhinoplasty Fig. The nasal tip is a dynamic structure, hinged by the upper lateral carti- lages and by the recurva- ture of the lower lateral cartilages. With Simons’s method, tip pro- Nasal tip projection is defined as the horizontal distance from jection should equal the height of the upper lip. Crumley and the alar crease of the facial plane to the nasal tip on lateral view, Lanser described a right triangle with dimensions correspond- or the posterior-to-anterior distance that the nasal tip extends ing with nasal proportions; ideally, projection:height:length in front of the facial plane as seen on basal view. Powell and Humphries defined the ideal 532 Management of the Aging Nose relationship between tip projection and nasal height as a 2. Likewise, lengthening the conjoined medial crura Nasal tip rotation is defined as movement of the nasal tip alone would increase both projection and rotation. Tip rotation is described with Projection and Rotation reference to the Frankfurt horizontal plane and the long axis of the nostril. Ideally, the long axis of the nostril is oriented paral- Alar cartilage—modifying techniques to address tip underrota- lel to the columella, but often discrepancy exists between the tion and underprojection in the aging nose include insertion two. When addressed surgically, the long axis of the nostril is of a columellar strut, tip grafting, lateral crural steal, lateral first rotated to an angle favorable to the Frankfort horizontal crural overlay, and the tongue-in-groove techniques.

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The infant was noted to have a good cry and pink color but was not moving its right arm medications 44 175 discount 3 ml bimatoprost with amex. There is shoulder dystocia (the infant’s shoul- ders are stuck after delivery of the head) medicine vial caps cheap bimatoprost on line. In this situation medications similar to abilify bimatoprost 3 ml with visa, the fetal head emerges, but the shoulders become wedged behind the maternal symphysis pubis. An obstetrician will use maneuvers such as flexion of the maternal hips against the maternal abdomen (McRobert maneuver) or fetal maneu- vers such as pushing the fetal shoulders into an oblique position. These actions are designed to allow delivery of the fetal shoulders without excessive traction on the fetal neck. Despite such carefully executed maneuvers, infants may be born with stretch injuries to the brachial plexus, resulting in nerve palsies. The most common of these is an upper brachial plexus stretch injury, in which nerve roots C5 and C6 are affected, resulting in weakness of the infant’s arm. Be able to describe the spinal cord segments, named terminal branches, and motor and sensory deficits of an upper brachial plexus injury 2. Be able to describe the mechanism, spinal cord segments, named terminal branches, and motor and sensory deficits of a lower brachial plexus injury 3. It is formed by the ventral primary rami of spinal nerves C5 through C8 and most of T1. The network of nerves that form the brachial plexus is divided anatomically from proximal (medial) to distal (lateral) into roots, trunks, divi- sions, cords, and terminal branches (mnemonic: “Randy Travis drinks cold Texas beer”). The roots of the plexus emerge from between the anterior and mid- dle scalene muscles together with the subclavian artery. Arising from the roots are branches to the longus colli and scalene muscles and the dorsal scapular and long thoracic nerves. The suprascapular nerve and the nerve to the subclavius muscle arise from the superior trunk. Each trunk is divided into anterior and posterior divisions, which will innervate musculature of the anterior and posterior compartments, respectively (Figure 1-1). The anterior divisions of the superior and middle trunks unite to form the lateral cord, which branches off to the lateral pectoral nerve. The anterior division of the inferior trunk continues distally as the medial cord, whose branches are the medial pectoral, medial brachial cutaneous, and medial antebrachial cutaneous nerves. The posterior divisions of all three trunks unite to form the posterior cord, and its branches are the upper and lower subscapular and thoracodorsal nerves. The three cords are named according to their relation to the axillary artery, which passes through the plexus at this level. The terminal branches of the brachial plexus are the axillary, musculocutaneous, median, ulnar, and radial nerves. The axillary nerve (C5 and C6) arises from the posterior cord and courses poste- riorly around the surgical neck of the humerus, where it is at risk for injury. The axillary nerve supplies the deltoid and teres minor muscles, is sensory to the skin over the lower portion of the deltoid, and is optimally tested on the “shoulder patch” portion of the upper arm. Axillary nerve injury, such as that due to fracture at the surgical neck of the humerus, results in an inability to abduct the arm at the shoulder to a horizontal position and in sensory loss in the shoulder patch area (Figure 1-2). Similar splitting is noted in the lumbar and sacral plexuses for the supply of muscles of the lower extremity. The lateral antebrachial cutaneous nerve to the skin of the lateral forearm represents the terminal continuation of this nerve. Damage to the musculocutaneous nerve causes weakness in supination and flex- ion of the shoulder and elbow. The upper portion of the brachial plexus arises from spinal cord segments C5 and C6; forms the superior trunk; and makes major contributions to the axillary, musculocutaneous, lateral pectoral, and suprascapular nerves and the nerve to the subclavius muscle. Injury to the upper plexus typically occurs with an increase in the angle between the shoulder and the neck. This can occur in a newborn during an obstetrical delivery or in adults as the result of a fall on the shoulder and side of the head and neck, which produces a widened angle. The resultant muscle paralysis due to such an injury may be understood more easily in an adult with such an injury. The upper extremity hangs limp by the side because the deltoid and supraspinatus (abductors of the arm) are paralyzed as a result of injury of the axillary and supra- scapular nerves, respectively. In addition, the anterior deltoid, biceps brachii, and coracobrachialis (flexors of the arm) are paralyzed due to injury of the axillary and musculocutaneous nerves.

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In severe exacerbations symptoms 6 dpo cheap bimatoprost 3 ml otc, gram-negative bac­ teria (Klebsiella medicine identifier bimatoprost 3 ml buy cheap, Pseudomonas) can also play a role symptoms 0f kidney stones 3 ml bimatoprost purchase mastercard, so antibiotic coverage needs to be broader. The number of annual exacerbations can be reduced by receiving appropriate vaccinations (influenza and pneumococcal), smoking cessa­ tion counseling, education about current medications and their proper use. Patients should be encouraged to discuss social concerns, psychiatric problems (such as anxi­ ety), and proper nutrition and exercise with their physician. She has never smoked cigarettes, has no known passive smoke expo­ sure, and does not have any occupational exosure to chemicals. Pulmonary fnction testing shows obstructive lung disease that does not respond to bron­ chodilators. In counseling him about the benefts of smoking cessation, which of the fllowing statements is most accurate? By quitting, his current pulmonary fnction will be unchanged, but the rate of pulmonary fnction decline will slow. By quitting, his current pulmonary fnction and the rate of decline are unchanged, but there are cardiovascular benefts. By quitting, his pulmonary fnction will approach that of a nonsmoker of the same age. The air­ way obstruction of asthma would be at least partially reversible on testing with a bronchodilator. Smoking cessation will not result in reversal of the lung damage that has already occurred, but can result in a slowing in the rate of decline of pulmonary fnction. In fct, smoking cessation can result in the rate of decline returning to that of a nonsmoker. He is best treated by a long-acting bronchodilator (eg, tiotropium) and an inhaled steroid (eg, fluticasone) used regularly, along with an inhaled, short-acting bronchodi­ lator on an as-needed basis. Right heart failure causes increased right atrial pressures and right ventricular end-diastolic pressures, which then lead to liver congestion, jugular venous distension, and lower extremity edema. He says that the pain started suddenly afer dinner and was severe within a span of 3 hours. On examination, his temperature is 98°F, his pulse is 90 beats/min, his respi­ rations are 22 breaths/min, and his blood pressure is 129/88 mm Hg. The patient is reluctant to flex the lef knee, wincing in pain at touch, and has passive range of motion. There is pain to movement and touch of the lef knee, with evident edema, erythema, and warmth of the joint. Have a diferential diagnosis fr nontraumatic joint pain, based on clinical presentation. Be fmiliar with the most common diagnostic tests fr the above conditions, and have a rationale when ordering these tests. Considerations This 45-year-old man presents with the sudden onset of monoarticular joint pain. A joint becomes septic by blood inoculation, by contiguous infction (such as fom bone or sof tissue), or fom direct inoculation fom trauma or surgery. Exclusion of an infc­ tious etiology is paramount as cartilage can be destroyed within the frst 24 hours of infction. There are several additional pieces of infrmation that guide the diagnosis in this case. Most gout attacks occur between the ages of 30 and 50 in men and in postmenopausal women (50-70 years of age). Premenopausal women are less likely to sufer fom gout due to the increased level of female sex hormones, which aid in the urinary excretion of uric acid. Other fctors that may also increase the risk of a gout attack include trauma, surgery, or a large meal (especially one high in purines such as red meat, liver, nuts, or seafod) that induces hyperuricemia. Other medications that increase the risk of a gout attack include loop diuretics and chemotherapeutic agents. The gross appearance of fluid is not very specifc, as both a septic aspirate and a heavily con­ densed crystal-induced arthritis may have a thick, yellowish/chalky appearance.

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It is particularly important to try to determine if the patient has made an advanced directive detailing their wishes regarding treatment osteoporosis treatment order 3 ml bimatoprost free shipping. Pathogenesis Despite the constant presence of microbes in the upper airways medicine 911 purchase bimatoprost 3 ml mastercard, the lungs usually remain sterile medications list form cheap 3 ml bimatoprost with mastercard. Pneumonia develops when the defense mechanisms that enable the lungs to remain sterile are overwhelmed. This can occur because of: • Reduced host defence • Particularly virulent pathogens • An overwhelming inoculum. It also affects bacterial adherence to epithelial cells, resulting in increased adherence of bacteria such as S. Patients with haematological disorders, and those receiving immunosuppressive drugs or chemotherapy, are at increased risk of developing pneumonia. Bacterial virulence factors Bacteria have developed techniques for overcoming host defenses. The presence of this factor is associated with the development of a severe pneumonia in young people that is often fatal. Pneumococci traverse eukaryotic cells within vacuoles without intracytoplasmic multiplication, partly via platelet-activating factor receptor-mediated endocytosis. Overwhelming inoculums The lungs’ defences, even if functioning appropriately, can be over- whelmed if they encounter very large numbers of bacteria. This most fre- quently occurs with aspiration of gastrointestinal contents, where large numbers of anaerobic and Gram-negative enteric bacteria of relatively low pathogenicity can cause pneumonia. It may also occur in near-drowning when infection with a range of pathogens may occur. The patho- gens vary according to whether it is salt- or freshwater near-drowning. In research studies an agent is identified in about 60% of cases but this can drop to as low as 20% in clinical practice. Aureus Aspiration Gram-negative enteric pathogens, oral anaerobes Intravenous drug S. The presence of an infiltrate on chest radiograph in conjunction with evidence of infection is central to the accurate diagnosis of pneumonia. History Pneumonia may be suggested by one or more of the following features in the history: • Cough • Fever • Pleuritic chest pain • Dyspnoea • Sputum production. Investigation Radiography Clinical signs and symptoms may not be typical and their sensitivity is limited when compared to the chest radiograph in predicting pneumonia. This may be because the radiograph was taken very early in the course of the disease or the patient may have been significantly volume depleted. In these circumstances it is reasonable to treat as pneumonia if there is high clinical suspicion and repeat the chest radiograph at 24–48h. Opacification in the right upper and mid zones is sharply demarcated inferiorly by the horizontal fissure, allowing confident localization to the right upper lobe (anterior segment). The right-sided opacity is sharply demarcated superiorly by the horizontal fissure and the adjacent right heart border is obscured, allowing confident localization to the right middle lobe. On the left the heart border is preserved, indicating that this is lower lobe consolidation. Routine testing has limita- tions, including: • Time delay in obtaining results • Relatively low yield of some tests • Little evidence that microbiological-guided treatment offers significant benefit over empirical treatment in terms of mortality • Previous antibiotic treatment for many patients presenting to hospital • The danger of contaminant results (up to 10% in some studies of blood cultures) adversely altering treatment regimes. Positive microbiological tests remain important as they may significantly alter the care of an individual patient. They also help to provide the epide- miological data that empirical treatment guidelines are based upon. The severity of pneumonia, healthcare setting, other co-morbidities, and previous antibiotic therapy should guide the use of additional tests. Specific microbiological tests • Blood cultures—have a relatively low yield, revealing a causative organism in 7–16% of hospitalized patients. There is a significant incidence of false positive blood cultures from contaminants, particularly S. The low sensitivity, (<20%) and specificity (<30% in some studies) have led to some authorities questioning their utility in routine practice. They continue to be recommended because in the sickest patients sensitivity may be increased, as bacteremia is more common, and the value of a positive result remains significant. As a result quoted sensitivity and specificity both vary from around 10% in some studies to over 90% in others.

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Potential fetal changes include vaginal malformation treatment trichomoniasis order bimatoprost 3 ml overnight delivery, clitoral enlargement medicine omeprazole 20mg bimatoprost 3 ml amex, and formation of a structure resembling the male scrotum medications contraindicated in pregnancy order bimatoprost discount. Women who become pregnant while using androgens should be informed about the possible effect on the fetus. Beers Criteria identify testosterone and methyltestosterone as potentially inappropriate for patients 65 years and older. Virilization in Women, Girls, and Boys Virilization is the most common complication of androgen therapy. When taken in high doses by women, androgens can cause acne, deepening of the voice, proliferation of facial and body hair, male-pattern baldness, increased libido, clitoral enlargement, and menstrual irregularities. Boys may experience growth of pubic hair, penile enlargement, increased frequency of erections, and even priapism (persistent erection). To prevent irreversible masculinization, androgens must be discontinued when virilizing effects first appear. Premature Epiphyseal Closure When given to children, androgens can accelerate epiphyseal closure, thereby decreasing adult height. To evaluate androgen effects on the epiphyses, radiographic examination of the hand and wrist should be performed every 6 months. Hepatotoxicity Androgens can cause cholestatic hepatitis and other disorders of the liver. Androgens may also be carcinogenic: hepatocellular carcinoma has developed in some patients after prolonged use of these drugs. It must be emphasized that not all androgens are hepatotoxic: liver damage is associated primarily with the 17-alpha-alkylated androgens. These androgens all share a structural feature in common: an alkyl group substituted on carbon 17 of the steroid nucleus. Because of their capacity to cause liver damage, the 17- alpha-alkylated compounds should not be used long term. In contrast to the 17- alpha-alkylated androgens, testosterone and the testosterone esters (testosterone cypionate, testosterone enanthate) are not associated with liver disease. These actions may increase the risk for atherosclerosis and related cardiovascular events. Prostate Cancer Androgens do not cause prostate cancer, but they can promote the growth of this cancer after it occurs. Accordingly, androgens are contraindicated for men with diagnosed prostate cancer. Men without diagnosed prostate cancer should be monitored for emergence of covert cancer. This complication is a concern for patients with heart failure and for those with a predisposition to developing edema from other causes. Treatment consists of discontinuing the androgen and giving a diuretic, if needed. Abuse Potential As discussed later, androgens are frequently misused (abused) to enhance athletic performance. Risk for Thromboembolic Events There have been post-marketing reports of thromboembolic events, including stroke, myocardial infarction, deep vein thrombosis, and pulmonary embolism. While long-term clinical trials are not available and randomized control trials have been inconclusive, the concern was sufficient to prompt the U. Today, we have six attractive alternatives: a nasal gel, transdermal patch, transdermal gel, topical solution, buccal tablet, and implantable subcutaneous pellets. Oral Androgens Only two androgens are approved for oral therapy of male hypogonadism. Both drugs—fluoxymesterone and methyltestosterone—are 17-alpha-alkylated androgens and therefore pose a risk for hepatotoxicity. Accordingly, they should not be used long term and hence are not first-line agents. Transdermal Testosterone Testosterone is available in three transdermal formulations: patch, gel, and liquid. With all three formulations, testosterone is absorbed through the skin and then slowly absorbed into the blood. Gels B l a c k B o x Wa r n i n g : The s t o s t e ro n e G e l a n d To p i c a l S o l u t i o n Secondary exposure to testosterone gel on uncovered skin and to testosterone gel on unwashed clothing has resulted in virilization in children.

Reto, 60 years: In cases of meningitis, the intrathecal the same as the International Nonproprietary Name and route is useful in administering antibiotics that do not cross the British Approved Name. Identifying Adverse Drug Reactions It can be very difficult to determine whether a specific drug is responsible for an observed adverse event because other factors—especially the underlying illness and other drugs being taken—could be the actual cause.

Sigmor, 39 years: With increased tightening of the knot, there is narrow- ing of the angle of domal divergence and the width of the nasal tip. The parenteral formulation is primarily Mixed Opioid Agonist-Antagonists used as a preanesthetic medication and as a supplement to and Partial Agonists surgical anesthesia.

Bengerd, 33 years: Sometimes in severe pain, local steroid injection (methylpred- nisolone or triamcinolone). Heparin and warfarin differ with respect to time course of action: effects of heparin begin and fade rapidly, whereas effects of warfarin begin slowly but persist several days.

Bozep, 64 years: A pur ified prot ein der ivat ive ( P P D ) placed on admission is posit ive, and bacterial cultures are negative at 48 hours. This led to and methods of the proposed clinical studies and the quali- the subsequent development of clonidine for treating fcations of the investigators.

Mannig, 30 years: Obesity is a risk fctor fr osteoarthritis, which is common in the knees and typically presents with a gradual onset and worsening of symptoms. In Another advantage of sail excision is that it can give a coun- noses of good ala-columellar relationship, the groove is noted to terrotation look of the tip because the rim is elevated, resulting be near the alar rim as seen commonly in Caucasian noses to a better columellar show.

Corwyn, 59 years: P h ysiologically, cou gh is a r eflexive d efen se mech an ism t o clear the upper airways. Important among these are inadequate prescriber training in pain management; unfounded fears of addiction (shared by prescribers, patients, and families); and a health care system that focuses more on treating disease than relieving suffering.

Ilja, 45 years: In one human study, resveratrol suppressed production of tumor necrosis factor and free radicals; both actions could reduce blood vessel inflammation and subsequent atherosclerosis. It will correct any buckling or asymmetries of the medial crura rotation is needed and/or the nasolabial angle is very acute, the and will help maintain or slightly improve projection and rota- graft can be carved longer in its inferior border, and this border tion, but is not a technique that will result in important changes sutured securely to the fibrous connections surrounding the in the nasal base.

Jerek, 26 years: A glycosylat ed h em oglobin level ( H bA ) < 7% correlates to neonatal morbidity and 1c mortality rates similar to the general population. Patients should also be asked about a family history of thyroid can cer, h yp er par at h yr oid ism, or ph eoch r omocyt oma.

Kor-Shach, 22 years: Aesthetic Plast Surg 1998; 22: internal nasal valve: modified splaygraft techniquewith endonasal approach. Usually for children under 16 years old, consent of a person with parental responsibility is required.

Malir, 36 years: It o ft e n h a s a p re cip it a t in g e ve n t, p ro d ro m a l sym p t o m s, and an excellent prognosis. Rotarix, but not RotaTeq, is contraindicated for infants with any uncorrected congenital malformation of the gastrointestinal tract that could predispose to intussusception.

Zuben, 57 years: Patient s wit h seminomatous cancers generally have normal or only slightly elevated tumor markers values. Adverse Effects Although ribavirin and interferon alfa are generally well tolerated, both drugs can cause significant adverse effects.

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