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Patients should be advised to make a record of each dose purchase 250 mg biaxin with amex gastritis que es bueno, rather than relying on memory generic biaxin 500 mg line chronic gastritis shortness of breath. Patients anticipating elective procedures should discontinue warfarin several days before the appointment order biaxin gastritis flare up. If an emergency procedure must be performed generic biaxin 250mg online gastritis diet 13, injection of vitamin K can help suppress bleeding. Fetal Hemorrhage and Teratogenesis From Use During Pregnancy Warfarin can cross the placenta and affect the developing fetus. In addition, warfarin can cause gross malformations, central nervous system defects, and optic atrophy. Women of childbearing age should be informed about the potential for teratogenesis and advised to postpone pregnancy. Long-term warfarin use (more than 12 months) may weaken bones and thereby increase the risk for fractures. Drug Interactions General Considerations Warfarin is subject to a large number of clinically significant adverse interactions—perhaps more than any other drug. As a result of interactions, anticoagulant effects may be reduced to the point of permitting thrombosis, or they may be increased to the point of causing hemorrhage. Patients must be informed about the potential for hazardous interactions and instructed to avoid all drugs not specifically approved by the prescriber. As indicated, the interactants fall into three major categories: (1) drugs that increase anticoagulant effects, (2) drugs that promote bleeding, and (3) drugs that decrease anticoagulant effects. The major mechanisms by which anticoagulant effects can be increased are (1) displacement of warfarin from plasma albumin, (2) inhibition of the hepatic enzymes that degrade warfarin, and (3) decreased synthesis of clotting factors. The major mechanisms for decreasing anticoagulant effects are (1) acceleration of warfarin degradation through induction of hepatic drug-metabolizing enzymes, (2) increased synthesis of clotting factors, and (3) inhibition of warfarin absorption. The interaction does mean, however, that the combination must be used with due caution. The potential for harm is greatest when an interacting drug is being added to or withdrawn from the regimen. The interaction of heparin with warfarin is obvious: being an anticoagulant itself, heparin directly increases the bleeding tendencies brought on by warfarin. By blocking aggregation, aspirin can suppress formation of the platelet plug that initiates hemostasis. Therefore, when the antifibrin effects of warfarin are coupled with the antiplatelet and ulcerogenic effects of aspirin, the potential for hemorrhage is significant. Accordingly, patients should be warned specifically against using any product that contains aspirin, unless the provider has prescribed aspirin therapy. Like aspirin, other antiplatelet drugs can increase the risk for bleeding with warfarin. In fact, acetaminophen was routinely recommended as an aspirin substitute for patients who needed a mild analgesic. Unlike aspirin, which promotes bleeding by inhibiting platelet aggregation, acetaminophen is believed to inhibit warfarin degradation, thereby raising warfarin levels. At this time, the interaction between acetaminophen and warfarin has not been proved. Warnings and Contraindications Like heparin, warfarin is contraindicated for patients with severe thrombocytopenia or uncontrollable bleeding and for patients undergoing lumbar puncture, regional anesthesia, or surgery of the eye, brain, or spinal cord. In addition, warfarin is contraindicated in the presence of vitamin K deficiency, liver disease, and alcoholism—conditions that can disrupt hepatic synthesis of clotting factors. Vitamin K for Warfarin Overdose1 The effects of warfarin overdose can be overcome with vitamin K1 (phytonadione). If vitamin K fails to control bleeding, levels of clotting factors can be raised quickly by infusing fresh whole blood, fresh-frozen plasma, or plasma concentrates of vitamin K–dependent clotting factors. Like medicinal vitamin K, dietary vitamin K can reduce the anticoagulant effects of warfarin. Dietary sources include mayonnaise, canola oil, soybean oil, and green leafy vegetables. Patients do not need to avoid these foods but instead should keep intake of vitamin K constant. If vitamin K intake does increase, then warfarin dosage should be increased as well. Conversely, if vitamin K intake decreases, the warfarin dosage should decrease too. Contrasts Between Warfarin and Heparin Although heparin and warfarin are both anticoagulants, they differ in important ways (Table 44. Although both drugs decrease fibrin formation, they do so by different mechanisms: heparin inactivates thrombin and factor Xa, whereas warfarin inhibits synthesis of clotting factors. 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. Finally, these drugs differ with respect to management of overdose: protamine is given to counteract heparin; vitamin K is given to counteract warfarin. Dosage Basic Considerations Dosage requirements for warfarin vary widely among individuals, and hence dosage must be tailored to each patient. Dosage reductions based on this information can be determined using the calculator at www. Preparations Warfarin sodium [Coumadin, Jantoven] is available in tablets (1, 2, 2. In addition, warfarin is available in a formulation for parenteral dosing, which is not commonly done. Direct Thrombin Inhibitors The anticoagulants discussed in this section work by direct inhibition of thrombin. Hence they differ from the heparin-like anticoagulants, which inhibit thrombin indirectly (by enhancing the activity of antithrombin). Dabigatran Etexilate Dabigatran etexilate [Pradaxa, Pradax ] is an oral prodrug that undergoes rapid conversion to dabigatran, a reversible, direct thrombin inhibitor. Compared with warfarin—our oldest oral anticoagulant—dabigatran has five major advantages: rapid onset; no need to monitor anticoagulation; few drug-food interactions; lower risk for major bleeding; and, because responses are predictable, the same dose can be used for all patients, regardless of age or weight. The drug binds with and inhibits thrombin that is free in the blood as well as thrombin that is bound to clots. In the United States dabigatran was first approved for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. At the lower dabigatran dose (110 mg twice daily), the incidence of bleeding with dabigatran was less than with warfarin, but protection against stroke was less, too. By contrast, at the higher dose (150 mg twice daily), the incidence of bleeding with dabigatran equaled that with warfarin, but the incidence of stroke or embolism was significantly lower. The half-life is 13 hours in patients with normal renal function (CrCl 50 mL/min or higher) and increases to 18 hours in patients with moderate renal impairment (CrCl 30–50 mL/min). Compared with warfarin, dabigatran is safer, posing a much lower risk for hemorrhagic stroke and other major bleeds. Because dabigatran is not highly protein bound, dialysis can remove much of the drug (about 60% over 2–3 hours). Because dabigatran is eliminated primarily in the urine, maintaining adequate diuresis is important.

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This type is associated with partial lipodystrophy (loss of subcutaneous fat on face and upper trunk) biaxin 250 mg online gastritis diet . Type 3: in which neither immunoglobulins nor complement are deposited in the glomeruli buy biaxin 250 mg low cost gastritis surgery. It is of 4 types: • Stress incontinence: Loss of urine with activity such as coughing purchase 250 mg biaxin with amex gastritis yahoo answers, sneezing cheap 250mg biaxin with mastercard gastritis pernicious anemia, lifting any object, exercise etc. A: As follows: • Initial haematuria: Presence of blood at the beginning of micturition, usually due to penile urethral cause. It occurs due to intravas- cular haemolysis due to any cause (such as falciparum malaria, cold agglutinin disease, paroxysmal noc- turnal haemoglobinuria, microangiopathic haemolytic anaemia etc. A:Passage of myoglobin in urine due to rhabdomyolysis or muscle destruction is called myoglo- binuria. A: As follows:(urine shows pus cells but is negative on culture): • Renal tuberculosis. It should be differentiated from frequency, which means frequent passage of small amount of urine. Physiological: Stress, fever, exercise, high protein intake, exposure to cold, orthostatic proteinuria. Pathological: • Renal: any primary renal disease (nephrotic syndrome, acute glomerulonephritis, chronic Glomerulonephritis, IgA nephropathy, pyelonephritis, renal tubular acidosis, tubulo- interstitial nephropathy, renal tumour). A: When proteinuria occurs during prolonged standing but not on recumbent position. A: As follows: • Selective proteinuria: infltration of low molecular weight protein like albumin through the glomerular membrane. However, these cases are probably the most straightforward in terms of diagnosis and defning the site of lesion. To attain effciency and skill, a good deal of practice is required that will suffce to score highly. The signs need to be elicited carefully for exact anatomical localization of any lesion. Occasionally, examiner may ask, ‘Examine the legs or lower limbs’ (In such case, examine the legs thoroughly, also perform neurological examination). Hence, never forget the non-neurological cases and examine prop- erly, keeping these in mind. Even if asked to perform neurological examination, quickly look carefully to exclude the above diseases. After good visual survey, if nothing is obvious, proceed for the neurological examination. Proceed as follows: Introduce yourself, ensure that lower limbs are well exposed (with permission), patient lying in supine position. Inspection: • Wasting (mention whether of right, left or both, involving thigh or leg). Bulk of the muscles (measure with tape from a particular point): • Unilateral wasting (in old poliomyelitis). To test, ask the patient to follow your instructions as follows: • Hip fexion: ‘Raise your leg straight, do not let me push it down’. Mention your fnding, ‘Plantar is extensor or fexor or equivocal or cannot be elicited’. Ask the patient to pull his or her clasped hands outwards (Jendrassik’s manoeuvre), or clench the teeth and then see the refex again. There will be extensor plantar response, if the signs are positive (indicates extensive pyramidal lesion). Superfcial refexes: • Abdominal refex (T6 to T11): Elicited by lightly stroking the abdominal wall diagonally towards umbilicus in each of the four quadrants of abdomen. It is absent in upper motor neuron lesion (early loss is found in multiple sclerosis). Normally, contraction of cremasteric muscles pulls up the scrotum and testis on the side stroked. Sensory test: Explain to the patient with light touch by cotton-wool in normal area such as forehead. If no, continue to touch above, until the patient can feel to fnd out the level of sensory loss. Perform the test according to the nerve distribution: • Outer thigh L2 (upper thigh). Now, test is done placing the vibrating fork on bony prominence such as side of great toe, medial malleolus. Test for proximal myopathy: ask the patient to stand up from sitting without support. Test for Rombergism: Ask the patient to stand with feet together and close the eyes. Gait: • Ask the patient to walk, look any abnormality such as hemiplegic gait, foot drop, scissor gait. Finally, look at the spine to see any deformity, scar, gibbus and local tenderness. A: In the motor pathway from anterior horn cells (or cranial nerve nucleus) via peripheral nerve to motor end plate. A: Normally, outstretched hands in front are held symmetrically even when the eyes are closed. A: Reinforcement acts by increasing the excitability of anterior horn cells and by increasing the sensi- tivity of muscle spindle primary sensory endings to stretch by increased gamma fusimotor drive. Isolated loss of jerk indicates radiculopathy of the affected segment (such as disc prolapse): • Loss of biceps (C5,6 lesion). A: As follows: • First year of life (due to lack of myelination of pyramidal tract. C2 C2 C3 C3 C4 C4 C5 T3 T4 C5 T5 T6 T1 T7 C6 T8 T9 C6 L1 T 1 L3 L2 C7 C8 S2 C8 L3 S2 C7 L4 L4 L5 S1 L5 S1 S1 L4 L5 L5 Dermatomes of human body (anterior and posterior) mebooksfree. Always look at the back to fnd any scar, bony deformity and gibbus or local tenderness in spine. Presentation of a Case: • There is some wasting of right or left, or both thigh or leg (mention, if any). If wasting is present in spastic paraplegia, it is more likely due to disuse or prolonged immobilization. A: As follows (remember the age and also sensory loss): • Spinal cord compression due to any cause (see below). A: As follows: • Sphincter disturbance: Common (urinary retention and loss of bladder control). Gibbus in tuberculous spondylitis Cerebral palsy—spastic diplegia Q:What is mass refex? A: After stimulation of skin of lower limbs or lower abdominal wall, there is refex fexion of lower trunk muscles and lower limbs, evacuation of bladder, bowel and semen with sweating, called mass refex. Intradural (extramedullary and intramedullary): a) Extramedullary causes (within dura): • Meningioma.

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Concavities and depressions which compose the bony vault purchase cheap biaxin online gastritis diet options, may be deviated due to a devi- may manifest as nasal obstruction purchase biaxin cheap online gastritis symptoms headache. If a patient is reveal humps or depressions buy biaxin 250mg on-line chronic gastritis operation, and the high dorsal view often struck from one side order biaxin once a day gastritis symptoms night sweats, oftentimes the nasal bone will be emphasizes dorsal irregularities that may contribute to the per- depressed on the side of the insult and may be deviated later- ception of a crooked nose. If the cartilaginous dorsal septum is mine how each bone’s position should be changed to achieve a 145 Management of the Dorsum Fig. Moreover, deviation of the bony vault can affect the crookedness of the nose in the middle vault and tip by transmitting a twisted, deviated bony septum via fibrous attachments to the middle vault and, subsequently, to the nasal Fig. In addition, when considering bony vault position, eyebrow and glabellar position must be noted. The mid- should be sutured to the periosteum of the anterior nasal spine line of the face, therefore, is relative to the point it is based on. These spreader grafts may have a Straightening the lower vault involves several techniques, each length of up to 2cm and stretch from the bony vault to extend of which is designed to address a specific aspect causing devia- past the anterior septal angle. First, addressing a caudal septal deviation is a complex the added benefit of straightening the dorsal septum after the task. If the deviation is near the posterior nasal spine, the fibrous attachments have been taken down. The septum can then the anterior and posterior septal angle, and the caudal septal be sutured to the periosteum along the anterior nasal spine or margin, then an extracorporeal septoplasty can be performed. If asymmetries exist, the septum can be trimmed or asymmetric spreader grafts. A partial resection of tion, asymmetric tension can be placed on the horizontal mat- the septum with replacement is technically easier. These techniques include lateral spreader grafts (4mm) are typically placed on the concave side crural turnover flaps that rotate the cephalic portion of the lat- of the curvature. In addition, curved spreader grafts can be used eral crura on itself to create a more rigid construct. Bony tion of lateral crural strut grafts, alar batten grafts, and alar rim spreader grafts constructed from ethmoid bone or a resected grafts can also aid in creating symmetry of the nasal tip and 9 dorsal bony hump may also be used in particularly challenging eliminating the perception of a twisted or crooked tip. The simplest technique that will be effective is always the pro- Sometimes the middle vault is straight but still appears cedure of choice. It is best to suture these contour grafts in place eral osteotomies whereas medial osteotomies start in the mid- to prevent migration during the healing phase. It is not uncommon for facial injuries to cause one side of the bony vault to have a concave, depressed deformity while the other has an outwardly displaced deformity. To address the bony vault, familiarity with medial, intermediate, and lateral osteotomies is essential. Another alternative is to start on the convex side and move to the concave side in a step-by-step fashion, like moving the pages of a book. The medial oblique technique is used for the first two indications, whereas the medial vertical technique is preferred for the third indication. Lateral osteotomy indications include closing an open roof deformity, straightening a deviated nasal Fig. As a general rule, if significant tip work is necessary or a severe caudal septal deflection exists, then an external approach is warranted. Crookedness attributed to the middle and bony vault, without tip modifications, may warrant an endonasal approach. Endonasal approaches can always be converted to open approaches if deemed necessary Fig. Common grafting materials used during any rhinoplasty pro- cedure include septal, conchal, and/or rib cartilage. Bone grafts from the perpendicular plate of the ethmoid or split cal- varial bone grafts are also options for grafting material. Irradiated rib grafts are also an option as the quantity and quality of the cartilage may exceed that of autologous rib, especially in older patients where the rib may be calcified. This means establishing a rigid structure with a midline septum, from which all other structures can be based. Repairing the individual components from the base up (inferior to superior) then becomes a logical and stepwise procedure around a stable reference point. Osteotomy or rasping techniques can a stable midline caudal septum helps bring the tip structures then be selected as required. Whether electing to suture the septum to the grafts are often convenient for depressions of the bone nasal spine or translocating it over the spine, midline stability (▶ Fig. The medial crura may be stabilized with to make sure all components are aligned as desired. When suture fixation to the septum if desired (tongue-in-groove techni- viewing the nose from the surgeon’s perspective only, it is easy que). The domes are then approximated for symmetry with suture to miss significant deviations. Once all components are con- techniques or asymmetric trimming of the cephalic edges. It is essen- The middle vault is then repaired as necessary with spreader/ tial that the surgeon not depend on the dressing to obtain cor- onlay grafts or suture techniques. Management of posttraumatic nasal deformities: the Aesthetic reconstruction of a crooked nose via extracorporeal septoplasty. Treatment by separation cussion 607–608 of its components and internal cartilage splinting. Arch Facial Plast Surg 111: 2449–2457, discussion 2458–2459 2009; 11: 378–394 151 Management of the Dorsum 19 The Current Trend in Augm entation Rhinoplasty Jeffrey M. The typical Asian nose is char- cone implants are more likely to become distorted from calcifi- acterized by a broad low dorsum, decreased tip projection, cation. The sur- These characteristics often create the desire for alteration; most geon may use Gore-Tex sheets or carve the preformed implant Asian patients presenting for aesthetic rhinoplasty require aug- from a Gore-Tex block. However, it cosmetic surgery often demand higher nasal dorsum, a more is more expensive and harder to carve intra-operatively than projected and better-defined tip, and narrower alar bases. In a case series of 309 primary or revision rhinoplasty achieve higher dorsum and tip projection, various alloplastic operations, only 3. Of umella, where the greatest amount of pressure is exerted by the these, silicone implants and Gore-Tex are at present the most implant. Silicone implants can be largely divided varial bone grafts and costal cartilage grafts can provide an into two groups: (1) L-shaped ones that augment both the nasal ample supply of autogenous material for dorsal augmentation; tip and the dorsum and (2) straight ones for dorsal augmenta- nevertheless, many patients often shy away from these options tion only. Silicone implants are inexpensive, easy to carve, and implants for the nasal dorsum and autogenous grafts at the easily removed during revision surgeries. They are also well tol- nasal tip, where thinning of the skin and extrusion most often erated by most Asian patients with typically thicker subcutane- occur. In one surgeon’s 10-year experience,9 with monly employed for dorsal augmentation, and either septal car- 98% of the study population being Southeast Asian, only 0. On the other hand, not all Asian patients have thick skin and weak cartilaginous support. Therefore, it is important for the surgeon to carefully examine the patient and determine the cat- egory the patient belongs in: (1) thin skin+strong cartilage, (2) thick skin+strong cartilage, or (3) thick skin+weak cartilage.

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