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The drug can kill tubercle bacilli at concentrations 10 purchase propecia with visa,000 times lower than those needed to affect gram- positive and gram-negative bacteria cheap 1mg propecia. Isoniazid is bactericidal to mycobacteria that are actively dividing but is only bacteriostatic to “resting” organisms purchase 5mg propecia with amex. Although the mechanism by which isoniazid acts is not known with certainty, available data suggest the drug suppresses bacterial growth by inhibiting synthesis of mycolic acid, a component of the mycobacterial cell wall. Because mycolic acid is not produced by other bacteria or by cells of the host, this mechanism would explain why isoniazid is so selective for tubercle bacilli. The ability to acetylate isoniazid is genetically determined: about 50% of people in the United States are rapid acetylators, and the other 50% are slow acetylators. It is important to note that differences in rates of acetylation generally have little effect on the efficacy of isoniazid, provided patients are taking the drug daily. However, nonhepatic toxicities may be more likely in slow acetylators because drug accumulation is greater in these patients. In patients who are slow acetylators and who also have renal insufficiency, the drug may accumulate to toxic levels. For patient convenience, isoniazid is available in two fixed-dose combinations: (1) capsules, sold as Rifamate, containing 150 mg of isoniazid and 300 mg of rifampin; and (2) tablets, sold as Rifater, containing 50 mg of isoniazid, 120 mg of rifampin, and 300 mg of pyrazinamide. Liver injury is thought to result from production of a toxic isoniazid metabolite. The greatest risk factor for liver damage is advancing age: the incidence is extremely low in patients younger than 20 years, 1. Patients should be informed about signs and symptoms of hepatitis and instructed to notify the provider immediately if these develop. Caution should be exercised when giving isoniazid to alcoholics and individuals with preexisting disorders of the liver. B l a c k B o x Wa r n i n g : I s o n i a z i d [ G e n e r i c ] Isoniazid therapy may cause severe hepatitis. Principal symptoms are symmetric paresthesias (tingling, numbness, burning, pain) of the hands and feet. Peripheral neuropathy results from isoniazid-induced deficiency in pyridoxine (vitamin B ). Prophylactic use of pyridoxine at 25-50 mg/day can decrease the6 risk of acquiring peripheral neuropathy. Preventive supplementation is especially important for at-risk people with diabetes or with high alcohol intake. If peripheral neuropathy develops, it can be reversed by administering pyridoxine, however, higher doses are required (typically 100 mg daily). By inhibiting these isoenzymes, isoniazid can raise levels of drugs that are metabolized by these isoenzymes, including phenytoin, carbamazepine, diazepam, and triazolam. Plasma levels of phenytoin should be monitored, and phenytoin dosage should be reduced as appropriate. Daily ingestion of alcohol or concurrent therapy with rifampin, rifapentine, rifabutin, or pyrazinamide increases the risk for hepatotoxicity. The drug is active against most gram- positive bacteria as well as many gram-negative bacteria. Other bacteria that are highly sensitive include Neisseria meningitidis, Haemophilus influenzae, Staphylococcus aureus, and Legionella species. However, if dosing is done with or shortly after a meal, both the rate and extent of absorption can be significantly lowered. Rifampin induces hepatic drug-metabolizing enzymes, including those responsible for its own inactivation. As a result, the rate at which rifampin is metabolized increases over the first weeks of therapy, causing the half-life of the drug to decrease—from an initial value of about 4 hours down to 2 hours at the end of 2 weeks. This agent is bactericidal to tubercle bacilli at extracellular and intracellular sites. Despite the capacity of rifampin to produce a variety of adverse effects, toxicity rarely requires discontinuing treatment. Because resistant organisms emerge rapidly, rifampin should not be used against active meningococcal disease. When employed at recommended dosages, the drug rarely causes significant toxicity. Asymptomatic elevation of liver enzymes occurs in about 14% of patients; however, the incidence of overt hepatitis is less than 1%. Hepatotoxicity is most likely in people who abuse alcohol and patients with preexisting liver disease. Tests of liver function (serum aminotransferase levels) should be made before treatment and every 2 to 4 weeks thereafter. Patients should be informed about signs of hepatitis (jaundice, anorexia, malaise, fatigue, nausea) and instructed to notify the prescriber if they develop. Rifampin frequently imparts a red-orange color to urine, sweat, saliva, and tears. Permanent staining of soft contact lenses has occurred on occasion, and hence the patient should consult an ophthalmologist regarding contact lens use. Gastrointestinal disturbances (anorexia, nausea, abdominal discomfort) and cutaneous reactions (flushing, itching, rash) occur occasionally. Rarely, intermittent high-dose therapy has produced a flu-like syndrome, characterized by fever, chills, muscle aches, headache, and dizziness. In some patients, high-dose therapy has been associated with shortness of breath, hemolytic anemia, shock, and acute renal failure. Women taking oral contraceptives should consider a nonhormonal form of birth control. Hence, when these drugs are used in combination, as they often are, the risk for liver injury is greater than when they are used alone. Both drugs have the same mechanism of action, adverse effects, and drug interactions. In the liver, rifapentine undergoes conversion to 25-desacetyl rifapentine, an active metabolite. Like rifampin, the drug imparts a red-orange color to urine, sweat, saliva, and tears. Because of the risk for hepatotoxicity, liver function tests (bilirubin, serum transaminases) should be performed at baseline and monthly thereafter. Patients should be informed about signs of hepatitis (jaundice, anorexia, malaise, fatigue, nausea) and instructed to notify the prescriber if these develop. Drug Interactions Like rifampin, rifapentine is a powerful inducer of cytochrome P450 drug- metabolizing enzymes. Rifabutin Actions and Uses Rifabutin [Mycobutin] is a close chemical relative of rifampin. Like rifampin, rifabutin can impart a harmless red-orange color to urine, sweat, saliva, and tears; soft contact lenses may be permanently stained. Rifabutin poses a risk for uveitis and hence should be discontinued if ocular pain or blurred vision develops.

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Ultrasound confrmed intrauterine fetal death and a day afer the induction of labour she delivered a macerated fetus purchase genuine propecia. On review by the community midwife 3 days later order genuine propecia on-line, she was pyrexial with a temperature 37 buy propecia 5mg otc. Fracture humerus Instructions For each of the scenarios below, choose the single most appropriate diagnosis from the above list of options. Labour was augmented with syntocinon and she had a forceps delivery for a prolonged second stage, followed by shoulder dystocia. The baby was admitted to the neonatal unit afer initial resuscitation and being ventilated. A 30-year-old para 1 woman was admitted in spontaneous labour at term and had an emergency caesarean section for failed instrumental delivery. A 30-year-old para 1 woman with previous normal delivery went into spontaneous labour at term and was fully dilated for 3 hours. Afer pushing for 90 minutes, ventouse delivery was performed for maternal exhaustion and the baby was born in good condition. The parents were extremely anxious afer looking at the large sof tissue swelling of the fetal scalp at the ventouse cup application area. Open airway and give 3 infation breaths Instructions For each of the scenarios below, choose the single most immediate plan of action from the above list of options. A 30-year-old nulliparous woman with no known medical problems had an uncomplicated low-risk pregnancy and went in to spontaneous labour at 39 weeks’ gestation. She had good progress in labour and has just delivered a male neonate, who cried at birth, pink, breathing and has good tone. A 33-year-old para 2 woman just delivered a male infant who is blue, foppy at birth with poor respiratory efort and a slow heart rate. The umbilical cord is clamped and cut immediately and placed on the warm resuscitaire afer drying and wrapping with warm towels. A 33-year-old para 2 woman just delivered a male infant who is blue, foppy at birth with poor respiratory efort and a slow heart rate. The umbilical cord is clamped and cut immediately and placed on the warm resuscitaire afer drying and wrapping with warm towels. Antibiotics to the newborn Instructions Each clinical scenario described below tests knowledge about management of a woman in labour and/or postnatally. For each case, choose the single most appropriate course of action from the above list. A 36-year-old woman in her second pregnancy is admitted in early labour with ruptured membranes. A 34-year-old woman is seen in the antenatal clinic with a history of lower abdominal pain for the past 4 days. Gram-negative bacteria Instructions Each clinical scenario described below tests knowledge about the most probable cause of sepsis in a woman postnatally. A 36-year-old woman who had an emergency caesarean section 5 days ago has presented feeling unwell with lower abdominal pain. She is seen by the community midwife, who notices that she looks unwell and checks her temperature, which records 39. The woman is sufering from abdominal pain and loin pain, and was treated for urinary tract infection while pregnant. A 38-year-old woman is brought by ambulance in a state of shock, with sudden-onset lower abdominal pain. She had a baby a week ago and sufered from a recent sore throat, for which she has been taking paracetamol. Breastfeeding is contraindicated if the woman has inverted nipples during the puerperium. Late onset afer one week with signs of bleeding from unusual sites, possibly due to organic pathology 6. Most deaths due to obstetric haemorrhage in the report were due to substandard care. More than 90% of the neonates born vaginally are colonized with chlamydia in the presence of maternal infection. Only half of the exposed neonates will develop conjunctivitis in the frst 1–2 weeks afer birth, in the presence of maternal infection. Anti-D administration is not necessary following a miscarriage afer 20 weeks’ gestation. Partial breast and bottle feeding can be used as lactation amenorrhoea method of contraception E. Ergometrine should be avoided if possible in women with pre-eclampsia as it can cause sudden increase in blood pressure E. About 30% of the blood loss causes mild shock with vasoconstriction in the skin and muscles. Blood loss of 40% or more of blood volume is associated with severe shock afecting heart and brain. The use of postoperative laxatives is recommended to reduce the incidence of postoperative wound dehiscence. Rectovaginal and anovaginal fstulas are common complications of third- and fourth-degree perineal tears. Hence prophylactic oxytocics should be ofered to all women routinely in the third stage of labour. Answer 2: B Neonatal complications of diabetic pregnancy include hypoglycaemia, hypocalcaemia, hypomagnesaemia, hypothermia, respiratory distress syndrome, jaundice, polycythaemia, cardiomegaly and birth trauma including shoulder dystocia leading to Erb’s palsy, fractures and birth asphyxia. Answer 3: C The umbilical cord contains two umbilical arteries and one umbilical vein embedded into the Wharton’s jelly. The arteries carry deoxygenated blood from the fetus to the placenta and the umbilical vein carries oxygenated blood to the fetus from the placenta. Answer 4: B Puerperal pyrexia is defned as a maternal temperature of ≥38°C maintained over 24 hours or recurring in the frst 10 days afer childbirth or abortion. Prolonged labour, prolonged rupture of membranes, intrapartum pyrexia, operative delivery, multiple pelvic examinations, episiotomy, vaginal tears, vulvovaginal hematomas and anaemia are predisposing factors. Answer 5: E Puerperal psychosis is a psychiatric emergency, occurring in about 1 in 500 pregnancies and associated with a suicide rate of 5% and an infanticide rate of up to 4%. It usually presents within 2 weeks of delivery and symptoms include delusions, hallucinations, irritable behaviour and suicidal thoughts or thoughts of harming the baby. Active surveillance by the British Paediatric Surveillance Unit reported an incidence of 1:60,000 live births annually. Disseminated infection with multiple organ involvement Infant mortality is <2% with treatment in localized skin, eye and mouth infection. In disseminated herpes in the newborn mortality is around 30% if treated with antiviral treatment. Answer 8: C If maternal infection occurs at term, there is a signifcant risk of varicella of the newborn.

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Oropharyngeal mucosal changes including pharyngeal erythema order cheap propecia, red cracked lips discount propecia 1mg on line, and strawberry tongue 3 5 mg propecia for sale. Polymorphous generalized erythematous rash (usually most pronounced in the perineum where there may also be desquamation) 4. Edema of the hands or feet and erythema of the palms and soles in the acute phase; periun- gual desquamation in the subacute phase 5. Acute nonsuppurative cervical lymphadenopathy (usually unilateral and measures ≥1. Thus, incomplete disease should be considered when fever is for five or more days and two clinical features along with supportive laboratory data are found. Cerebrospinal fluid pleocytosis and mildly elevated hepatic transaminase levels are the other most commonly seen laboratory abnormalities. Associated symptoms include painful and frequent urination, meningismus, vomit- ing, or right upper quadrant pain. Echocardiogram should be obtained at time of diagnosis, as well as at 2 weeks and at 6 to 8 weeks. W ithout treatment, up to 25% of children may have coronary artery aneurysms and fever lasting 2 weeks. Even with treatment, approximately 2% to 4% of children develop coronary artery abnormalities. Aneurysms can develop at other sites, such as the brachial, axillary, femoral, mesenteric, and renal arteries. Aneurysm risk fac- tors include male gender, fever more than 10 days, age younger than 12 months or older than 8 years, higher baseline neutrophil (>30,000cells/mm2) and band counts, lower hemoglobin level (<10gm/dL), and platelet count less than 350,000/ mm3. Children with mild coronary artery dilation usually return to their normal state of health within 2 months. Death is rare and is caused by myocardial infarc- tion or, less commonly, aneurysm rupture. Which of the following examination findings would prompt you to order an echocardiogram? The rash is maculopapular, blanching, with a sandpaper-like texture and located on the cheeks, axillae, and trunk, with streaks of linear confluent petechiae on the axillae and in the antecubital fossa. Tonsillar ery- thema and exudates are noted along with an erythematous oropharynx and strawberry tongue. Urinalysis is normal, but the cerebrospinal fluid shows pleocytosis with a negative Gram stain and negative culture. After 48 hours of ceftriaxone, he continues to have high fever and has developed foot edema. Although he has only had 4 days of fever, the erythema of the lips and erythema of the palms and soles are two findings that are not commonly seen in other illnesses. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. He denies having a sore throat, upper respiratory infection symptoms, gastrointestinal distress, change in appetite, or fever. His immuniza- tions are current, he has no significant past medical history, and he has been developing normally per his mother. His weight, however, has fallen from the 25th percentile to the 5th percentile, and he has been hospitalized on three occasions in the last year with pneumonia or dehydration. The patient is afebrile today, but his examination is notable for severe gingivitis, bilateral cervical and axillary lymphadenopathy, exudates on his buccal mucosa, and hepatomegaly. Considerations Recurring infections in this patient presenting with oral lesions, weight loss, and lymphadenopathy are concerning for immune system dysfunction. Additional patient and family histories and selected initial laboratory tests will aid in diagnosis and help guide management. Clinicians should inquire about perina- tal history, growth and development, and past illnesses. Family history includes parental health concerns (unexplained weight loss, growth failure, or develop- mental delay in siblings) and recurring or atypical infection in immediate family members. A focused physical examination should then be performed to identify signs consistent with immunosuppression (wasting, generalized lymphadenopa- thy, and organomegaly). Primary (syndromic) immunodeficiency is due to a genetic defect, either inherited or related to de novo gene mutation. Most are humoral in origin or characterized by both humoral and cellular dysfunction (severe combined immu- nodeficiency). Some arise due to congenital malformations that affect proper development of the immune system (thymic dysgenesis in DiGeorge syndrome). Other primary immunodeficiencies include phagocytic cell deficiency (chronic granulomatous disease due to impaired respiratory burst), complement deficiency (autoimmune disease or serious bacterial infection due to C2 deficiency), and neu- trophil dysfunction (autosomal-recessive leukocyte adhesion deficiency). Approximately 75% of pediatric cases diagnosed prior to age 13 involve intrapartum transfer. Sexual contact was the primary means of transmission in this group, espe- cially among homosexual teens. A comprehensive social history, including sexual orientation and activity, should be obtained at all routine adolescent visits, and counseling regarding safer sex practices should always be provided. The remainder of patients progress rapidly during the first several months of life. The three major classes of antiretrovirals are nucleoside reverse transcriptase inhibitors (didanosine, stavudine, zidovudine), nonnucleoside reverse transcriptase inhibitors (efavirenz, nevirapine), and protease inhibitors (indinavir, nelfinavir). Possible other abnor- malities include anemia, neutropenia, elevated transaminases, hyperglycemia, and hyperlipidemia. An existing treatment regimen is altered when toxicity becomes an issue or disease progression occurs. The child with sickle cell disease (Case 13) has an acquired immune defi- ciency due to splenic auto-infarction and a higher incidence of infection due to encapsulated (pneumococcus) organisms. Patients with frequent pneumo- nia (Case 14) or as a result to unusual organism and patients who have fre- quent or unusually severe otitis media (Case 16) may have a primary immune deficiency. The patient with cystic fibrosis (Case 18) has a variety of medi- cal issues such as malnutrition, vitamin deficiency, and frequent pneumonia characteristic of a patient with secondary immune deficiency. Leukemia (Case 19) and neuroblastoma (Case 33) represent secondary immune deficiencies. He admits to being sexually active, including oral sex, with a male partner over the past month. On physical examination, he is afebrile, with cer- vical and inguinal lymphadenopathy and a nonexudative pharyngitis. His examination is notable for a cord without evidence of separation and a shallow, 0. The mother declares that the “sore,” caused by a scalp probe, has been slowly healing since birth and was deemed unremarkable at his 2-week checkup.

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Philadelphia: Lippincott Williams & airflow propecia 1mg overnight delivery, especially when combined with the previously Wilkins; 2001:261–271 described procedures cheap 1mg propecia free shipping. Arch Otolaryngol Head Neck Surg dle turbinate order cheap propecia on-line, will result in a smaller cross-sectional area and 1996; 122: 41–45 can contribute to nasal obstruction. Nasal obstruction after rhinoplasty: etiology, and techniques for turbinoplasty has shown superior short-term results when correction. An alar base flap to correct nostril and vestibular stenosis Reconstr Surg 1983; 72: 9–21 and alar base malposition in rhinoplasty. Reduction rhinoplastyand nasal patency: change in the cross-sec- 1666–1674 tional area of the nose evaluated byacoustic rhinometry. Operative Tech in Oto- lar surgery in correcting airway obstruction in primary and secondary rhino- layngology–Head and Neck Surg 1999; 6: 228–239 plasty. Plast Reconstr Surg 1996; 98: 38–54, discussion 55–58 [21] Keck T, Lindemann J, Kühnemann S, Sigg O. Long-term patient satisfaction after revision taneous auricular grafts covered by skin flaps in nasal reconstructive surgery. Use of alar batten grafts for Facial Plast Surg Clin North Am 2004; 12: 451–458, vi–vii correction of nasal valve collapse. Spreader graft: a method of reconstructing the roof of the middle 123: 802–808 nasal vault following rhinoplasty. Surgical treatment of the inferior turbinate: new techni- Laryngoscope 2002; 112: 1917–1925 ques. Facial Plast Surg Clin North Am 1995; 3: 421–448 turbinate hypertrophy: a randomized clinical trial. Plast Reconstr Surg 1998; 2003; 112: 683–688 102: 856–860, discussion 861–863 [27] Doğru H, Tüz M, Uygur K, Cetin M. The role of outfracture in correcting post-rhino- management of concha bullosa: our short-term outcomes. Ear Nose Throat J 1998; 77: 106–108, 111–112 2001; 111: 172–174 409 Revision Rhinoplasty 53 Revision Rhinoplasty: An Overview of Deform ities and Techniques Santdeep H. Nolst Trenité Revision corrective procedures remain one of the most chal- evaluation to identify the presence of residual septal deviations, lenging aspects of modern rhinoplasty surgery. The rary techniques evolve, the rhinoplasty surgeon is ever seeking presence of remaining septal cartilage may be assessed endo- an ultimate postoperative result that will please the discrimina- scopically by transillumination or palpation and should be tive patient and surgeon alike. New computer-aided preopera- documented as it may be required as grafting material. The informed patient is likely to be more critical Accurate documentation is made of the findings following a of postoperative results. The need for revision rhinoplasty may arise from either inad- equate or overzealous primary surgery, most often the result of poor judgment by an inexperienced surgeon. This time metic result after rhinoplasty into a suboptimal result with allows maturing of scar tissue, diminishing the risk of further time. In both cases, the resultant localized loss of contour or deformity due to poor tissue healing after subsequent surgery. The revision rhinoplasty patient of minor, diagnosed deformities such as an inadequate osteot- may further present with psychological issues relating to the omy may allay patient anxieties without compromising overall original surgery, and these must be both recognized and results. Other deformities that may be similarly rectified at an addressed during any preliminary consultation. The majority case, it is particularly important not to convey false expecta- of revisions, however, are best deferred, and a clear explanation tions regarding a revision procedure to the expectant patient. Doctor-patient rapport and trust must be built, laying the foun- The advantage of soft mature scar tissue during the revision dations for extended counseling to convey a realistic outcome operation facilitates easier dissection. Overall, it is Although accurate noting of the offending deformities together vital to ensure that the patient’s concerns and expectations are with intended corrective procedures should be performed on elucidated early in the consultation. Dissatisfaction expressed all rhinoplasty patients, it is specifically important in revision by the patient should be specific rather than general and should cases where the deformities, particularly if not related to the be perceived as realistic and true by the evaluating specialist. When in doubt, sensitive counseling of the patient and referral for psychiatric review is always prudent, and surgery is deferred pending this. As a rule, it is best to try to limit surgical tissue dissection to a Specifically, the nose can conveniently be divided into thirds6 minimum to reduce the risk of vascular compromise of the skin for analysis and deformities evaluated in each area separately. In this way, additional scarring is pre- Within these areas, a further subdivision of underlying skeletal vented, and healing is more predictable. Limited dissection also support, soft tissue thickness and scarring, and overlying skin makes it easier to judge the position of a placed underlying texture will help elucidate anatomic and structural deformities. Augmentation of specific areas is best performed in pre- Intranasal examination may be complemented with endoscopic cise pockets, minimizing disruption of the blood supply. An 410 Revision Rhinoplasty: An Overview of Deformities and Techniques endonasal approach with minimal soft tissue dissection is thus 53. The external approach Corrective Procedures requires more soft tissue dissection but affords an unparalleled view of the nasal structural components, facilitating accurate We describe common deformities encountered in revision rhi- diaposis and correction by bimanual tissue handling. The list this method for most reconstructive revisions and particularly is by no means exhaustive, and as corrective techniques often where the nasal tip needs addressing. Dissection of the soft tis- do not differ markedly from standard techniques, the principles sue envelope in the right surgical plane is desirable to ensure outlined can be applied to both. Problems with soft tissue minimal bleeding and to minimize the risk of future unpredict- deformities are discussed separately from structural deform- able scarring. For the latter, we divide the nose into its anatomic thirds valve area is preserved. Revision septal surgery may prove difficult if large areas of cartilage were excised in the original surgery, and the risk of 53. It is our own policy to crush and replace any unused cartilage after harvesting during primary surgery. This Preoperative skin and soft tissue evaluation is important, as prevents scarring after apposition of the mucoperichondrial deformities are not always correctable. Accurate documentation flaps, thus facilitating easier revision surgery and harvesting if of specific areas is critical because perioperative injection of required. The risk of a septal perforation is reduced, and in any local anesthesia may mask such deformities. Dissection in cor- case it may provide additional support to the cartilaginous skel- rect surgical planes, both during primary and revision rhino- eton. Judicious resection of such irregu- revision rhinoplasty surgery is the unpredictability of the find- larities during revision rhinoplasty may be required, but cau- ings during surgery. Soft tissue contractures and scarring may tion is advised as skin and soft-tissue envelope changes are mimic underlying structural deformity, and even with meticu- largely permanent and correction can prove troublesome. Of lous planning, the surgeon must remain able to adapt or even particular concern are the erythematous changes over the dor- change the planned techniques to suit the discovered anomaly. Patients with rosacea are particularly prone to such be considered as being required to help correct such unforeseen changes. Correction may require treatment with a laser or deformities when formulating the preoperative plan. The use of postoperative steroid (triamci- ence in a variety of techniques is naturally a prerequisite to nolone) injections to reduce the risk of soft tissue pollybeak for- undertaking this sort of procedure due to the very nature of mation is discussed later.

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