When mixed with alcohol buy super avana 160mg with mastercard impotence stress, cocaine is metabolized by the liver to produce cocaethylene buy generic super avana on-line erectile dysfunction hypnosis, a substance that is significantly more cardio- and hepatotoxic than alcohol or cocaine alone. These medications have become a significant drug of abuse among children and adolescents. Illicit metham- phetamine is produced in illegal laboratories and is popular among adolescents and young adults because of its potency and ease of absorption. Amphetamines and cocaine are associated with increased physical activity, rapid and/or irregular heart rate, increased blood pressure, and decreased appetite. Binge effects result in the development of psychotic ideation with the potential for sudden violence. Acute agitation and delusional behaviors can be treated with haloperidol and may be diminished by administering a sedating dose of lorazepam or diaz- epam. Marked reactive hypertension or dysrhythmia may need treatment with a cardiovascular agent (β-blocker) until the intoxication resolves. As in teens with other drug use, com- prehensive cognitive-behavioral interventions have been shown to be an effective treatment modality. Sympatho- mimetic effects include mydriasis, tachycardia, hypertension, and hyperreflexia. Overdoses have been associated with respiratory arrest, severe hyperthermia, and coagulopathy. Somatic symptoms of ingestion include nausea, jaw clenching, teeth grinding (bruxism), and blurred vision. Reported impairments include memory loss, diminished learning ability, sleep disturbances, and depression. Common products include volatile solvents (paint thinners, glue), aerosols (spray paint, hair spray), and gases (propane tanks, lighter fluid). Paint “huffers” often present with residual perioral or fingertip paint from inhalation. Because of the increased solvent content in metallic-colored paints, gold and silver spray paints are particularly popular. Initial stages of acute inhalant use are characterized by eupho- ria, excitation, exhilaration, dizziness, hallucinations, excess salivation, sneezing, flushed skin, and bizarre behavior. More concerning signs of inhalant intoxication are disorientation, double vision, nystagmus, bizarre dreams, epileptiform activity, arrhythmias, and unconsciousness. Chronic use causes difficulty coordinating movement, gait disorders, muscle tremors, and spasticity due to neurotoxic effects of inhalants, hypoxia, or both. Other toxicity includes pulmonary hypertension, restrictive lung defects or reduced diffusion capacity, hematuria, tubular acidosis, and possibly cerebral and cerebellar atrophy. Treatment is supportive and directed toward control of dysrhythmias and stabi- lization of respirations and circulation. Bath Salts “Bath salts” are newly popular drugs that act as a central nervous system stimulant by inhibiting norepinephrine-dopaminergic reuptake. Legal until early 2012, “bath salts” con- sumption and distribution was widespread and difficult to follow. Common symp- toms include euphoria, dilated pupils, loss of inhibition, involuntary muscle move- ment, tachycardia, and hypertension. Thus, early diagnosis and intervention at routine health screenings is an important component of the well-child examination. In addition, a family history of drug addiction or abuse should raise the level of concern about potential drug abuse. A significant change in school performance or other daily behaviors is noted, and frequent or serious accidents occur (atypical motor vehicular accidents). Screening and diagnostic testing in an older, competent adolescent may be carried out, with few exceptions, only with the patient’s consent. Parental permission is not sufficient for involuntary screening in these patients. Consent may be waived when the patient’s competency is questionable or when findings from the interview and physical examination strongly suggest the patient is at high risk for serious harm from substance use. Staging substance abuse provides the clinician with a means of monitoring progress and providing an objective means of conveying treatment goals (Table 49–2). Group counseling, individualized counseling, and multifamily educational intervention have been found to be effective interventions for teens with substance use disorders. Outpatient management is often the first line of treatment for teens identified as meeting Stage 4 or Stage 5 criteria. Candidates for inpatient treatment have significant comorbid psychiatric illness; are experiencing withdrawal; have sui- cidal ideation, runaway behavior, behavior that threatens the lives of their family and/or friends; or have not responded to intensive outpatient treatment. Certain substances are commonly associated with specific comorbid psychiatric diagnoses: amphetamines with eating disorders; cocaine with depression; marijuana with amotivational syndrome; and alcohol use with affective disorder, anxiety disorder, and mania. Asthma (Case 20) can be triggered by any pulmonary irritant, tobacco being one of the most common. The younger child who is exposed to exogenous testosterone, such as accidental exposure to parental testosterone replacement, may have precocious puberty (Case 45) as a finding. Young infants who are born to or in homes with substance abus- ing caretakers are at higher risk of sudden infant death syndrome (Case 21) and child abuse (Case 38). Stage 2 Experimentation • May try various drugs, typically out of curiosity or to “fit in with friends. Drug Seeking • Multiple consequences and risk taking in order to obtain Preoccupation drugs or hide drug use. He is brought to the local emergency depart- ment, where he appears euphoric, emotionally labile, and a bit disoriented. On examination he is a healthy, athletic-appearing 17 year old with decreased extraocular range of motion and left eye visual acuity. Parents are unaware of drug use, but did note he has been acting “dazed and confused” at times, and that his hygiene has worsened over the past few months. Despite previous drug experimentation, his current neurologic symptoms and physical findings make drug use a less likely etiology. Previous criteria were combined for abuse and dependence, with the exception of “drug craving,” a new addition, and “problems with law enforcement,” eliminated due to cultural considerations. Management of the adolescent with substance use disorders and comorbid psychopathology. Committee on Substance Abuse, American Academy of Pediatrics; Council on School Health, American Academy of Pediatrics. Testing for drugs of abuse in children and adoles- cents: addendum—testing in schools and at home. The mother reports that because of lack of insurance she has not had a regular pediatrician for her children for the previous 8 years. She reports the girl to be in generally good health other than recurrent bouts of otitis media.
Septal extension grafts: a method 2007; 15: 293–307 generic super avana 160 mg free shipping erectile dysfunction due to diabetic neuropathy, v ofcontrolling tip projection shape cheap super avana 160 mg mastercard erectile dysfunction 43. J Laryngol Otol 2000; 114: 514–518 2000; 44: 173–180 563 Ethnic Rhinoplasty 71 Nuances w ith the Asian Tip Tae-Bin Won and Hong Ryul Jin Although no formal census has been conducted, it seems that Although alar flare is not frequent in northeast Asians, includ- more Asians seek rhinoplasty than before, and the perceived ing Koreans and Japanese, Southeast Asians tend to have both number is increasing. More important, there has been a gradual change in the way that the Asian community regards cosmetic 71. Globalization, Westernization, and frequent appear- Asian Tip-Plasty ance of celebrities with altered looks have altogether played a positive role in increasing acceptance to facial plastic proce- The general goal of Asian tip-plasty is to create a natural-look- dures. Whatever the reason, personal or sociological, contem- ing nasal tip that is in harmony with the nasal dorsum and porary Asian society is in general more comfortable with facial overall facial features. Specific ways Rhinoplasty is one of the most common facial plastic surgery to achieve this harmony can only be substantiated with suffi- performed in Asia. Although the principles and goals may be cient understanding of the cultural environment and continu- similar, the actual execution is quite diﬀerent from the Western ous exposure and dedication to the Asian patient. Anatomic characteristics of the Asian nasal tip each operation must be highly individualized. A harmo- been published highlighting these diﬀerent approaches and niously matched projection of the nasal tip according to the techniques. In this chapter, characteristics of the Asian tip will be projection and definition, with aesthetically pleasing width and addressed with emphasis on anatomy and specific surgical flare at the nostrils while maintaining symmetry. One impor- techniques that the authors have used to obtain reliable and tant point that should be kept in mind is that many Asian consistent results. The amount of projection and rotation diﬀer according to personal preference, age, sex, occu- 71. In general, because the dor- sum of Asians is relatively low, most undergo augmentation, Asian Nasal Tip and the amount of tip projection should be balanced accord- Geographically, Asia is the world’s largest and most populous ingly or more frequently the other way around. Nasal tip width continent, with ~4 billion people, hosting 60% of the world’scur- should always be evaluated in the context of other facial anat- rent human population. The term Asian people is a demonym based a narrow tip can appear conspicuous and operated. Although variation exists, most commonly it refers to people with ancestry coming from a partic- 71. Therefore, designating the collective Anatomically, the Asian tip is characterized by thick skin with term of Asian rhinoplasty to this group of patients is of minimal abundant subcutaneous fibrofatty tissue, weak cartilaginous value as the needs in each individual are complex and diverse. Gener- collectively contribute to poor tip support, resulting in lack of ally, the typical Asian tip appears wider and less projected, and projection and definition. Managing and reshaping a tip with as a consequence, the Asian nose appears more triangular when these characteristics can be more challenging because the fragile viewed from the front. Alar columellar disproportions, espe- cartilage-reshaping sutures or cephalic resection will often yield cially a retracted columella with acute nasolabial angle, are also inconsistent and incomplete results in the Asian tip, and this has quite common, requiring fundamental changes in the nasal tip. Weak cartilaginous structures and deficient caudal septum collectively contribute to poor tip support, resulting in lack of projection and definition. However, long-term complications with implant extrusion, skin break- down, and infection. Complexity of the deformity, choice of procedure, and surgeon’s preference will collectively dictate the approach. The drawback of the open approach, which is a noticeable columel- lar scar, can be a rare source of complaint considering the Fig. However, we think that it can be decreased support and minimal increase in tip projection. In the authors’ experience, problems associated with tip support and/or need substantial increase in tip projection. The the endonasal approach to patients whose tip support is second step is fine sculpturing of the nasal tip. This is done by sufficient and only requires a minor to moderate degree of combining sutures and a variety of grafts to obtain the desired manipulation. However, septal cartilage in Asians is thin, and the Projection and Rotation) portion of the graft higher than the dome may bend or rotate cephalically, making the nose look short and overrotated. This Because many Asians have weak tip support, tip projection and can be prevented by a buttress graft behind the shield graft or rotation are more eﬀectively modified using structural grafts. The choice of is that tip grafts usually augment only the infratip lobule seg- maneuvers to augment the nasal tip depends on two factors: ment of the tip and can result in an unnatural-looking tip if too the degree of tip support and the amount of projection needed 4 much grafting is placed. Tip support can be estimated by careful preoperative palpa- tion with emphasis on tip recoil, skin thickness, integrity of the 71. Not only does it provide a the patient’s wishes, anatomic characteristics, and overall aes- firm foundation upon which the lower lateral cartilages can be thetics of the nose and the face. Therefore, by varying its shape and loca- projection, onlay grafts alone or in combination with suture tion, it can be efficiently used to augment, rotate or derotate, modifications can be performed. The choice depends on the underlying deformity, desired outcome, sculpted graft can be sutured, inserted in a symmetric pocket, surgeon’s preference, strength of the cartilage, integrity of the or fixed externally using a tagging suture tapped to the skin caudal septum, and amount of available grafting material. It can be performed unilaterally or bilaterally, overlapping the For the typical Asian patient with weak tip support, augmen- caudal septum or in an end-to-end fashion, secured only to the tation is usually accomplished in two steps. The first step is sta- caudal septum, based on the anterior nasal spine, or integrated bilization of the nasal tip. The objective is to establish a firm ent shapes and sizes, depending on the desired changes of the foundation on which further grafting can be added on. Tip support is restored by applying a septal extension graft followed by fine sculptur- ing with additional onlay tip grafts. Care is taken to bevel or ponent, which can cause an unnatural appearance on the basal thin this portion of the graft overlapping the septal cartilage and lateral view. Another preventive measure in addition to fixation of the caudal septum to the anterior nasal spine is adding strength to the caudal septum with batten grafts or extended spreader grafts in case the caudal septum is weak. This is achieved by thorough dissection of the lower lateral cartilages laterally to the pyriform aperture and cephalically releasing the scroll area between the upper lateral cartilages. Increasing Definition) Because of this diversity, there have been limited attempts to try to classify the bulbous nose. The common features of a bulbous of the Asian nasal tip render it to be more round and perhaps tip include rounded shape, broad or absent tip-defining point, more bulbous to start with. The basal view looks more natural because the columellar and infratip components have been augmented simultane- ously. This shows that vari- One additional issue to consider in managing a bulbous nose ety exists among the same ethnic group, and the assumption is that most Asian noses need dorsal and tip augmentation. A of characteristics according to ethnic backgrounds can be tip may appear less bulbous and more balanced without any misleading. Procedures to aug- Techniques to manage a bulbous nose are targeted to correc- ment the tip can also reduce tip bulbosity. An algorithm for the manage- the alar cartilages and procedures that reduce volume of the ment of the bulbous nose in Asians should include all these alar cartilages. Diverse suture techniques and/or grafts are considerations and the strategy need to be personalized employed for the former, and excision techniques are employed. Managing the thick skin is the most challenging aspect of managing a bulbous nose.
A: As follows: • Bony swelling or enlargement in other parts of the body—Leg (bowing of tibia) generic super avana 160 mg on-line erectile dysfunction treatment in thailand, spine (kypho- sis) best purchase super avana erectile dysfunction doctors in cleveland, other bony enlargement. A: Paget’s disease is characterized by excessive and disorganized resorption and formation of bone, resulting in deformity and fracture. In Paget’s disease, there is increase in both osteoclastic bone resorption and osteoblastic activity. The disease may involve one bone (monostotic, 10 to 15%) or many bones (polyostotic). A: As follows: • Many cases are asymptomatic (60 to 80%), detected incidentally during X-ray. Appearance of night pain probably indicates development of osteosarcoma in Paget’s disease. A: As follows: • X-ray—Shows enlargement of bone with typical lytic and sclerotic lesion. X-ray skull shows lytic lesion, osteoporosis circumscripta, enlargement and sclerosis, thickening of trabeculae. To prevent further bone break down— • Bisphosphonates—Pamidronate, zoledronate, risedronate are more effective. Presentation of a Case: • There is bluish (or violaceous) discoloration at the tip and ala of the nose. A: It is a multisystem granulomatous disease of unknown aetiology, characterized by non-caseating granuloma in different organs. There is an imbalance between subset of T lymphocyte and disturbance of cell mediated immunity. A: As follows: • Skin lesions—erythema nodosum, plaque, maculopapular rash, hyper or hypopigmentation, subcutaneous nodule. Asymptomatic (incidental fndings are—bilateral hilar lymphadenopathy in X-ray chest or abnormal liver function test). Symptomatic— • Fever, polyarthritis or arthralgia, erythema nodosum, other skin lesions such as lupus pernio, plaque, skin rash. There may be cranial nerve palsy, meningism, seizure, psychosis, diabetes insipidus). Q: What is Heerfordt syndrome (uveoparotid fever or Heerfordt–Waldenström syndrome)? A: In sarcoidosis, presence of fever, bilateral parotid enlargement, anterior uveitis and lower motor neuron facial palsy is called Heerfordt syndrome. May be lung infltrate, pulmonary fbrosis, honeycomb shadow, miliary mottling, eggshell calcifcation). Lung function tests (shows restrictive lung disease, also reduction of gas transfer). Transbronchial or percutaneous (pneumothorax may develop), open biopsy may be required (by thoracotomy). Biopsy is done from the nodule, which shows typical sarcoid lesion (this test is not done now a days). A: Noncaseating granuloma (shows epithelioid cells, macrophages, lymphocytes and multinucleated giant cells). There is progressive ventilatory failure, pulmonary hypertension and cor pulmonale. If the disease is not improved 6 months after the diagnosis—prednisolone should be given, 30 mg for 6 weeks, reduced to alternate day treatment with 15 mg for 6 to 12 months. Other treatment: • Avoid strong sunlight (may precipitate hypercalcaemia and renal impairment). A: As follows: • Severe symptoms such as persistent erythema nodosum, fever, arthritis or arthralgia. Death is due to cardiac involvement, pulmonary fbrosis and cor-pulmonale or renal damage. Look at the patient carefully: • Dyspnoeic or orthopnoeic (may be found in left ventricular failure), cachexia (in severe heart failure). Compare other pulses simultaneously (carotid pulse should not be seen at the same time, may cause syncope due to cerebral ischaemia). Next, measure the height from sternal angle (It indicates mean right atrial pressure. If pulse is absent in one arm or there is radio-radial or radio-femoral delay, then see B. If the thrill coincides with carotid pulse, it is systolic and if it does not coincide (comes after or before), it is diastolic. Apical thrill is best seen by turning the patient to left lateral position with breath hold after expiration. Basal thrill is best seen by palm, the patient sitting and bending forward, breath hold after expiration. Left parasternal heave or lift: Place the fat of right palm in left parasternal area and feel by giving gentle sustained pressure. First heart sound coincides with carotid pulse, second sound does not (comes after). Pathological: • Hyperdynamic circulation (due to fever, anaemia, thyrotoxicosis, arteriovenous fstula, beriberi). It is found in: • Sinus arrhythmia (pulse increases on each inspiration, decreases on each expiration), abolished by exercise. Character of Pulse: • Anacrotic pulse—slow rising, small volume pulse (notch on upstroke). Mechanism of pulsus paradoxus: During inspiration, intrathoracic pressure falls, blood pools in pulmonary vessels and hence left heart flling is reduced with reduction of cardiac output. Causes of pulsus paradoxus: • Pericardial effusion (especially, cardiac tamponade). A:Collapsing pulse is always a high volume pulse, but all the high volume pulses are not collapsing. External jugular vein is not examined as it is tortuous and subject to compression). A: As follows: Venous Arterial 1 It is wavy (two peaks with cardiac cycle) 1 Not wavy 2 It has an upper limit 2 No defnite upper limit 3 Upper limit falls with inspiration 3 Not so 4 Varies with posture 4 Independent of posture 5 It is better seen than palpation 5 It is better felt than seen 6 Upper limit is increased by pressing the abdomen 6 Not so (hepatojugular refux) 7 Just felt or lightly felt 7 Thrusting 8 Obliterated by light pressure at the root of the neck 8 Cannot be obliterated Causes of cannon wave (giant ‘a’ wave): Occurs when atria contracts against closed tricuspid valve. Precordium: Deformity of chest (kyphosis, scoliosis, pectus excavatum and pectus carinatum) may be associated with Marfan’s syndrome, also may cause cor pulmonale. Kyphosis Scoliosis Pectus excavatum Pectus carinatum Apex Beat: It is the lowermost and outermost, defnitely palpable cardiac impulse. Normally, it is 9 cm from midline or 1 cm internal to the mid-clavicular line in left ffth intercostal space. Suprasternal pulse: Usually arterial (due to aneurysm of aorta and atherosclerosis).
Although vitamin D2 and calcium formulations receiving an assigned Pregnancy Risk Category were given a C classification order genuine super avana line erectile dysfunction treatment yoga, this is generally considered to be a concern only if the intake exceeds recommendations generic super avana 160 mg online top 10 causes erectile dysfunction. For the remaining drugs, with the exception of calcium and vitamin D, breastfeeding is not recommended because of inadequate studies. Older adults Estrogen meets Beers Criteria (strength of recommendation: strong) for potentially inappropriate use in older patients. Because frail older adults commonly have difficulty swallowing, those who take bisphosphonates may be at an increased risk for esophagitis. Owing to occurrences of low-impact atypical femur fractures in older women who have had long-term bisphosphonate therapy, some orthopedists recommend against continuing bisphosphonate therapy beyond 5 years. Primary Prevention: Calcium, Vitamin D, and Lifestyle The risk for osteoporosis can be reduced by lifelong implementation of measures that can help maximize bone strength. Specifically, we need to ensure sufficient intake of calcium and vitamin D, and we need to adopt a lifestyle that promotes bone health. Calcium is needed to maximize bone growth early in life and to maintain bone integrity later in life. Note that calcium requirements are greatest for adolescents and teens (1300 mg/day), then drop for younger adults (1000 mg/day), and then rise for older adults (1200 mg/day). Other important predictors include a family history of hip fractures, a personal history of fractures, low body mass index, and use of oral glucocorticoids. Individual risk is calculated after entering the following data: • Age • Gender • Weight • Height • Previous fracture • Hip fracture in a parent • Secondary osteoporosis (i. In 2016, The American Association of Clinical Endocrinologists and the American College of Endocrinology released joint clinical practice guidelines for diagnosis and treatment of postmenopausal osteoporosis. Treating Osteoporosis in Women The objective of osteoporosis treatment is to reduce the occurrence of fractures by maintaining or increasing bone strength. American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2016. Antiresorptive drugs—estrogen, raloxifene, bisphosphonates, calcitonin, and denosumab—are used most often. These agents do a good job of preventing bone loss by reducing osteoclast activity, but are largely unable to reverse bone mass that has already occurred. Accordingly, antiresorptive drugs are most beneficial when used early—before substantial loss has occurred. With all antiresorptive drugs, success requires a sufficiency of calcium and vitamin D. At this time, teriparatide [Forteo] is the only drug that effectively promotes bone formation. Of the drugs employed for osteoporosis, three agents—teriparatide, denosumab, and zoledronate (a bisphosphonate)—are most likely to reduce fractures. Treating Osteoporosis in Men In the United States about 2 million men have aging-related osteoporosis, and another 3 million are at risk. Hip fractures occur in 80,000 American men annually, compared with 269,000 American women. Although rates of osteoporosis and fractures in men are significant, they are still much lower than in women. As discussed, bone mass in men peaks in the third decade and begins progressive decline at about age 50 years. The rate of decline in men is about equal to that in women—except that in men, there is no counterpart to the accelerated phase of bone loss that occurs after menopause. If men and women lose bone mass at similar rates, why do men experience less osteoporosis? The main reason is that bones in men, at their peak, are larger and stronger than bones in women. Hence, after decline begins, male bones can tolerate more loss before fractures are likely. Factors that contribute to the risk for osteoporosis in men include low testosterone, prolonged use of glucocorticoids, white race, calcium deficiency, vitamin D deficiency, smoking, excessive alcohol consumption, and insufficient exercise. For alendronate, zoledronate, and teriparatide, dosages are the same as those used in women. If testosterone deficiency underlies osteoporosis, testosterone replacement therapy is indicated, unless the patient has testicular cancer or some other disorder that contraindicates testosterone use. Prescribing and Monitoring Considerations Vitamin D Assessment Therapeutic Goals Goals include treatment of rickets, osteomalacia, and hypoparathyroidism, and prevention of vitamin D deficiency. Baseline Data The prescriber may order serum levels of vitamin D, calcium, phosphorus, and alkaline phosphatase as well as a 24-hour urinary calcium determination. Ongoing Monitoring and Interventions Monitoring Summary Monitor serum calcium, serum phosphorus, and urinary calcium. Vitamin D–induced hypercalcemia can cause dysrhythmias in patients taking digoxin. Large therapeutic doses may cause hypervitaminosis D, a syndrome characterized by hypercalcemia, hypercalciuria, decalcification of bone, and deposition of calcium in soft tissues. If vitamin D toxicity develops, instruct the patient to discontinue vitamin D immediately, increase fluid intake, and institute a low-calcium diet. Oral Calcium Salts Assessment Therapeutic Goals Goals include treatment of mild hypocalcemia and supplementation of dietary calcium. Identifying High-Risk Patients Calcium salts are contraindicated for patients with hypercalcemia, renal calculi, and hypophosphatemia. Administration Considerations Individual calcium salts differ with respect to percentage of elemental calcium. As a result, the dose required to provide a specific amount of calcium differs among the salts. Ongoing Monitoring and Interventions Minimizing Adverse Effects Prolonged therapy can cause hypercalcemia. Calcitonin-Salmon Assessment Therapeutic Goals Goals include treatment of postmenopausal osteoporosis, Paget disease of bone, and hypercalcemia. Baseline Data The prescriber may order measurements of serum alkaline phosphatase, calcium, and phosphorus, as well as a 24-hour urinary hydroxyproline. Identifying High-Risk Patients Salmon calcitonin is contraindicated for patients allergic to this preparation. Ongoing Monitoring and Interventions Evaluating Therapeutic Effects Postmenopausal Osteoporosis. Monitor for reductions in bone pain, serum alkaline phosphatase levels, and 24- hour urinary hydroxyproline value. Bisphosphonates Used for Osteoporosis Assessment Therapeutic Goals Goals include prevention and treatment of osteoporosis. For patients receiving zoledronate, obtain a baseline value for creatinine clearance and assess for adequate hydration. Identifying High-Risk Patients Oral bisphosphonates are contraindicated for patients with esophageal disorders that can impede swallowing and for patients who cannot sit or stand for at least 30 minutes (60 minutes with ibandronate). Administration Considerations Proper administration is needed to maximize absorption and minimize the risk for esophagitis.
Augustana College, Sioux Falls South Dakota. 2019.