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Associate Professor, Meharry Medical College School of Medicine
Continuous research and development in the field of biomaterials has led to the introduction of reliable bioabsorbable internal fixation devices medicine 503 order prothiaden 75mg visa. At the advancing front of successful implants are the new self-rein- forced (SR) devices symptoms nicotine withdrawal order prothiaden 75mg online, which will replace metallic devices medications in canada purchase 75mg prothiaden with amex, at least in certain osteofixation indica- tions. We review here the developments that have led to the current state-of-the-art use of bioabsorbable devices in bone surgery. Pseudomigration Pseudo-migration of metals [4–10] can be a problem, especially in the growing skulls of children, because cranial growth takes place by the laying of new bone on the outer surface and resorption of old bone on the inner side of the skull. Consequently, metals that are applied on the outer surface of the skull can occasionally sink into the bone, be found on the inner side of the skull, or even against the dura. Although no neurological complications have been reported yet (follow-up of 2–6 years), there is a potential risk of damage to the brain should implant dislodgement occur in conditions such as trauma. In minipigs, total invagination of titanium plates with initial intracranial translocation occurs after 12 to 16 weeks postimplantation. Hence, it is recommended that all metals used in infant crania should be removed as early as possible (within 3 months). Currently, such devices are not removed unless they give rise to problems. Pseudomigration more often complicates the use of longer plates and application in the temporal region. Growth Disturbance In pediatric CMF surgery, metals may lead to growth disturbance of the skull bones. This can occur with the placement of rigid plates, especially across sutures (in rabbits) [11–14], but it may also occur even when sutures are not crossed (in monkeys). The more complex the fixation, the greater the magnitude of growth changes seen, and hence it is advised that the least amount of fixation needed to provide three-dimensional stability should be used. Stress Protection Because of the rigidity of metals (E 100–200 GPa), which is higher than that of bone itself (e. Bone mineral density was found to be lower when metallic screws were used to fix distal femoral osteotomies in rabbits, compared with bioabsorb- able screws. In experimental studies, stress shielding has been shown to occur in grafted mandibular bone [25,26], and bone resorption has been reported clinically in association with the use of rigid plate fixation. However, the clinical significance of this problem remains unclear. Radio-opacity The radio-opacity of metals can lead to obliteration of the view of tissues lying behind them, interfering with adequate radiological evaluation [27–31] such as CT scanning [32,33] and MRI. This is a disadvantage in the field of CMF surgery, where neuroimaging is needed, e. In addition, radio-opacity of metals may interfere with radiotherapy used in the treatment of cancer patients. Infection Implants may be colonized by bacteria that can form a biofilm, as may occur with Staphylococcus epidermidis. A biofilm is known to interfere with the reach of antibodies and phagocytes to the residing bacteria, and with antibiotic sensitivity [37–39,42], leading to a status of persistent Bioabsorbable Devices in CMF Surgery 171 infection. Various solutions are being explored to enhance the resistance of biomaterials to bacterial adhesion. Corrosion Stainless steel may suffer from corrosion in body fluids. With titanium, corrosion is limited by the formation of an oxide film, but titanium particles have been reported to be found at distant locations. Corrosion products can accumulate in tissues encapsulating the implant [3,43] or in the draining lymph nodes. The effect of metal ions on osteoblasts has been investigated and it was found that they may alter osteoblast behavior even at subtoxic concentrations. These effects may not be very apparent clinically, but it is a matter of concern and there is a need to develop better and ‘‘smarter’’ materials. Costs As mentioned earlier, in pediatric CMF surgery, the problems of implant pseudomigration and interference with growth of the skull warrant the removal of metal implants.
Consider stopping measures after 10 min if resuscitation has been unsuccessful and the patient remains in asystole C medicine klimt safe 75 mg prothiaden. Treat the hypothermia aggressively medicine quotes buy cheapest prothiaden; continue with resuscitation and asystole protocol D symptoms you have diabetes order discount prothiaden online. Attach a monitor; confirm asystole; administer 40 mg of vasopressin I. The sequence of resuscitation steps in the management of asystole is as follows: activation of EMS; CPR, rhythm evaluation, and asystole confirmation; intubation; I. If asystole persists for more than 10 min despite optimal CPR, oxygenation, ven- tilation, and epinephrine or atropine administration, efforts should stop unless there is hypothermia or drug overdose. A 66-year-old female patient is admitted to the orthopedic surgery service with a left hip fracture. She has a history of hypertension and osteoporosis but is otherwise in good health. She has no history of chest pain, but she says she gets short of breath when she walks about a half mile. She smoked one pack of cigarettes a day for 30 years, but she quit 5 years ago. She is taking an ACE inhibitor for her hyper- tension. Which of the following statements regarding preoperative cardiovascular risk assessment is true? The most important risk factor for cardiac death or complication perioperatively is a recent myocardial infarction B. The most important preoperative use of echocardiography is to assess the degree of systolic dysfunction 10 BOARD REVIEW C. Most patients who do not have an independent clinical need for coronary revascularization can proceed to surgery without further cardiac investigation D. There is good evidence that diastolic dysfunction increases perioper- ative risk significantly Key Concept/Objective: To understand the basic principles of preoperative cardiovascular risk assessment Uncontrolled heart failure is the most important risk factor for cardiac death or com- plications. A history of functional limitation appears to be the most helpful of all the historical points in this assessment. Patients who can perform activities that require four metabolic equivalents have a good chance of survival for most surgical procedures; such patients require no further testing. The use of echocardiography as a predictive tool is controversial. Although many experts advocate echocardiography as a good tool for assessing heart failure control, the procedure may provide little prognostic infor- mation beyond that available from a careful history and physical examination. The most important preoperative use of echocardiography is in the differentiation of sys- tolic dysfunction from diastolic dysfunction in patients with new-onset heart failure. The distinction is important, because data clearly show that systolic dysfunction, in a patient with substantial clinical manifestations (i. On the other hand, there are no data showing that echocardiographic evidence of systolic dysfunction in a patient without symptoms or signs of heart failure has any prognostic implications. There are also no good data indi- cating that diastolic dysfunction increases risk significantly. The preoperative evalua- tion of the patient with established or probable coronary artery disease (CAD) is of great importance. Recent myocardial infarction is second only to decompensated heart fail- ure as a risk factor for perioperative complications. Decisions regarding the evaluation of chest pain in patients without a history of CAD can be difficult under any circum- stance. The American College of Physicians clinical guidelines on the perioperative assessment and management of risk from CAD state that most patients who do not have an independent clinical need for coronary revascularization can proceed to sur- gery without further cardiac investigation. In other words, if there is no prior reason to perform coronary artery bypass surgery, further cardiac investigation usually does not need to be carried out for the anticipated surgery, unless there is some other overriding consideration. A 63-year-old white man has severe osteoarthritis and wants to have knee replacement surgery. His orthopedic surgeon has referred him to you for preoperative evaluation. The patient uses an albuterol and ipratropium bromide combination inhaler. Which of the following statements regarding assessment of preoperative pulmonary risk is false?
His medical history is remarkable for type 2 (non–insulin-dependent) diabetes mellitus symptoms 9 dpo purchase cheapest prothiaden, presumed cytogenic cirrhosis medicine park ok purchase 75mg prothiaden otc, and “arthritis” in his hands symptoms schizophrenia generic prothiaden 75 mg without prescription. An echocardiogram reveals normal ejection fraction and normal valvular function. You order lab work that includes iron studies and make the diagnosis of hemochromatosis. What is the pathogenesis of heart failure in this patient? Idiopathic cardiomyopathy Key Concept/Objective: To recognize infiltrative cardiomyopathy as a cause of dyspnea in a patient with normal ejection fraction but symptoms of both left- and right-side heart failure Infiltrative causes of ventricular dysfunction, which are usually associated with restrictive cardiomyopathy, include amyloidosis, hemochromatosis, and sarcoidosis. It should be noted that patients with hemochromatosis may develop dilated cardiomyopathy. The normal ECG and the absence of wall motion abnormalities on the echocardiogram make ischemic car- diomyopathy an unlikely diagnosis. The normal ejection fraction and normal size of the ventricles exclude the diagnosis of idiopathic cardiomyopathy. Finally, there is no echocar- diographic evidence of valvular heart disease. A 56-year-old patient with stage D ischemic cardiomyopathy comes to you for a second opinion. He is already receiving furosemide, an angiotensin-converting enzyme (ACE) inhibitor, a beta blocker, and spironolactone. He has been told by a specialist that he needs a device to avoid dying from an irregular heart rhythm. What nonpharmacologic treatments are available for the prevention of sudden cardiac death in patients with ischemic cardiomyopathy? Intra-aortic balloon pump (IABP) Key Concept/Objective: To understand that sudden cardiac death contributes significantly to the mortality of patients with heart failure The management of heart failure has evolved from primarily noninvasive medical thera- pies to include invasive medical devices. In addition to contributing to worsening heart failure, ventricular arrhythmias are a likely direct cause of death in many of these patients; the rate of sudden cardiac death in persons with heart failure is six to nine times that seen in the general population. The use of ICDs for the primary prevention of sudden death in patients with left ventricular dysfunction has grown enormously in recent years. There is increasing evidence that ICD placement reduces mortality in patients with ischemic car- diomyopathy, regardless of whether they have nonsustained ventricular arrhythmias. The role of these devices in patients with heart failure of a nonischemic cause has yet to be elu- cidated and is the subject of several ongoing trials. Biventricular pacing improves progno- sis in patients with severe CHF but has no role in the management of lethal arrhythmias. Both IABP and VAD are mechanical devices utilized as a bridge to cardiac transplantation for patients with very severe CHF. A 38-year-old man with stage C CHF remains symptomatic in spite of diuretic therapy. You are consid- ering adding a second and perhaps even a third agent to his regimen. Which of the following pharmacologic agents used in the management of heart failure lacks trial data indicating a mortality benefit and does not prevent maladaptive ventricular remodeling? ACE inhibitors or angiotensin receptor blockers (ARBs) ❏ B. Digoxin 1 CARDIOVASCULAR MEDICINE 3 Key Concept/Objective: To be aware of proven pharmacologic therapy aimed at counterbalancing the activation of the renin-angiotensin and sympathetic systems Left ventricular dysfunction begins with an injury to the myocardium. The unanswered question is why ventricular systolic dysfunction continues to worsen in the absence of recurrent insults. This pathologic process, which has been termed remodeling, is the struc- tural response to the initial injury. Mechanical, neurohormonal, and possibly genetic fac- tors alter ventricular size, shape, and function to decrease wall stress and compensate for the initial injury.
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Finally medications derived from plants buy discount prothiaden 75mg on line, we report on the presumably comedolytic properties treatment hepatitis b buy prothiaden 75 mg mastercard, it has now come into results obtained from the combined use of isotretinoin disuse treatment 2 generic prothiaden 75 mg amex, particularly because of its odor. Sulfur-containing and methylprednisone in severe inflammatory acne, to formulations have been reported to be comedogenic in the prevent a possible triggering of the ‘pseudo’ acne fulmi- rabbit ear model and also in humans, when applied under nans. Karger AG, Basel failed to reproduce this experience on the potential come- dogenicity of sulfur-containing preparations. Although its use has been discontinued, it may eventually be found Recent advances in the etiology and pathogenesis of in some preparations in combination with benzoyl perox- acne have led to the development of new treatment ide, resorcinol and other compounds. Recommended modalities which have significantly expanded the spec- concentrations are 1–5%. Both still have tions of 15–35%, complementary to the treatment of non- their advocates. Vleminckx’s solution: Sublimed sulfur 250 g ·-Hydroxy Acids Calcium oxide 165 g The ·-hydroxy acid family is made up of different Water to 1,000 ml compounds with application for the treatment of several dermatoses. They are weak organic acids and, structur- A spoonful of this solution is dissolved in 250 ml of hot ally, all of them have one hydroxyl group attached to the water and stupes impregnated with it are applied for alpha position of the acid. The mechanism particularly its unpleasant odor put it at a disadvantage in of action is unknown. However, it has been shown that, at comparison with other treatments. This solution has been low concentrations, ·-hydroxy acids decrease corneocyte shown to be highly effective in the treatment of moderate cohesion at the lower levels of the stratum corneum and it and severe inflammatory acne. Essentially, by dissolving Precipitated sulfur/zinc sulfate (equal parts) 3. In lower concentra- It is applied locally on inflammatory lesions. In higher concentrations they cause unroofing Lately, hydrogen peroxide cream was compared with of pustules and loosening of the corneocytes that line the fusidic acid in the treatment of impetigo. It is used for brief exposures, in con- and prolonged antimicrobial effect. The formulation is centrations of 30, 50 and 70% but it is considered a com- based on crystalline lipids and it is effective against gram- plement rather than a first-line treatment. It may there- fore be an additional topical treatment for patients with Corticosteroids gram-negative folliculitis in particular. A few topical preparations contain weak corticoste- roids, but proof of their efficacy is lacking. Clobetasol pro- Hydroxy Acids pionate is a potent corticosteroid that may help to reduce ß-Hydroxy Acid inflammation in nodular acne when applied twice a day Salicylic acid: This is the best known of the keratolytic for 5 days. This desquamative agent acts on the stratum corneum producing a dissolution of Dapsone the intercellular cement and, sometimes, a moderate peel- Dapsone in a gel formulation, at concentrations of 3 ing. It acts on the interfollicular epidermis and on the and 5% has been experimentally used for the last 3 years. In acne, it is the active ingredient in a It appears to be a new and promising therapeutic modali- variety of cleansers and astringent lotions and has a mild ty for moderate to moderately severe acne. It has not been comedolytic and anti-inflammatory effect. It is used in available in the past as it is highly insoluble in the aqueous concentrations of 1–3%. As well, 5% salicylic acid in pro- solvents traditionally used in dermatological prepara- pylene glycol may be useful. New technologies provide a formulation based on In comparison with tretinoin and isotretinoin, it is a the solvent ethoxydiglycol, which will eventually solve the mild comedolytic agent. The delivery is through the skin in two stages; tolerated probably due to its anti-inflammatory effects with preferential uptake of the drug immediately in the. As this was observed in our department in 18 of 590 patients between 1983 and 1990, we decided to use isotretinoin and corticosteroids simul- taneously and from the beginning in the very inflammato- ry and severe acne. We preferred methylprednisone at a starting dose of 40 mg every other day for 6 weeks and progressively decreased the dose until total withdrawal of the corticoste- roid in the 10th week, leaving isotretinoin as sole course of therapy (fig. Simultaneous utilization of isotretinoin and methylpredni- sone in very severe inflammatory acne. There is altered immunological reaction to Propioni- surrounding region (Dr.
Normal depth and length of the trochlea and height of the condyles (a) medications with dextromethorphan cheap prothiaden amex. Too short trochlea with normal height and depth (c) treatment molluscum contagiosum purchase prothiaden 75 mg fast delivery. Incomplete osteotomy of the lateral condyle (dotted line) about 5–7 mm from the cartilage down to the sulcus terminalis (d) treatment 30th october best purchase for prothiaden. The lateral condyle (osteochondral flap) is raised with a chisel (carefully! Dotted line showing the lateral incomplete osteotomy in a too short trochlea (f). Situation after length- ening of a too short trochlea: Lengthening includes 10–15 mm of the lateral femoral shaft (g). Axial CT-scans in extension 6 years postoperative with the reconstructed trochlear groove and the well-centered patella on the left side. Summary first 30° of knee flexion gives the most impor- tant diagnostic information about the This case outlines unsuccessful treatment per- patellofemoral congruence. This agrees with forming medialization of the tibial tuberosity in Goodfellow’s biomechanical studies demon- recurrent patellar dislocation in patients with strating that the most susceptible position for dysplastic trochlea. A distal correction is not suf- patella dysfunction is at the beginning of knee ficient and adequate to treat a proximal patho- flexion. In contrast, it can starts to center itself in the femoral trochlea. The patella lies in extension more lateral and The goal of the surgical reconstruction must be proximal in the femoral groove and the lateral the elimination of the real pathology. The pathol- condyle gives less osseous support to the ogy in recurrent patellar dislocations is in most patella. At this position, the patella must be cases a dysplastic trochlea and only a few dislo- cations are really traumatic. This maneuver is missing in a short knee flexion with and without quadriceps muscle trochlea or a patella alta. Different treatment is necessary in young patients with open epiphyseal carti- 1. The bone graft wedge in the treatment of habitual dislocation of the patella. Die Trochleaplastik bei Trochleadysplasie medialis obliquus muscle or shortening/tighten- zur Therapie der rezidivierenden Patellaluxation. In ing of the medial patellofemoral ligament, Wirth, CJ, and M Rudert, eds. Darmstadt: Steinkopff Verlag, 2000, lengthening of the lateral retinaculum) can be pp. One hundred twenty-four operations to physeal fusion. Patellofemoral Patellofemoral Study Group, Garmisch-Partenkirchen, malalignment in adolescents: Computerized tomo- Germany, 2000. Patellaposition: Eine klinische und computertomo- 18. In Wirth, CJ, and M Rudert, tact-surface measurements within the femoropatellar eds. Darmstadt: joint and their variations following lateral release. Medial subluxation of the lar release: Clinical outcome. J Sports Traumatol Rel Res patella as a complication of lateral release. Patellar sub- of the patellofemoral joint with and without quadriceps luxation and dislocation. Proceedings International Patellofemoral release of the patella: Indications and contraindica- Study Group, Lyon, France, 1998. Quantitative gait analysis in patients with medial patel- 9.