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Prominent discount 500mg erythromycin with amex virus 41 states, cephalically oriented without reconstitution or suture contouring of the lateral crura convex alae make the nose look wide and round and lacking in to achieve the desired form buy erythromycin 500 mg lowest price infection from antibiotics. A conservative cephalic trim should preserve at least risks external valve collapse purchase 500 mg erythromycin fast delivery antibiotic eye drops otc, buckling discount erythromycin 500mg online infection xrepresentx lyrics, bossa, and other deform- 8 to 10mm (laterally) and 5 to 7mm (medially) of alar carti- ities. Although weak, flimsy alae are not always iatrogenic, they lage) If the alae remain convex and difficult to contour, they are typically encountered in revision rhinoplasty. The auricular cymba concha is the pri- significantly more malleable, allowing easy repositioning. The natural curvature of important to preserve the cartilage-mucosal attachments later- the cymba closely resembles the three-dimensional contours of ally along to the pyriform aperture to increase stability. Typically, a single cymba concha can be used alae require excision and 180-degree rotation to turn the con- to reconstruct both alae. Alar replacement grafts Following, or in conjunction with a cephalic trim, the domal must be long enough to span the distance between the dome angle and tip-defining points are created. Grafts that are too short do not pro- defined as the angle between the long axis of the medial and vide the requisite support to the lateral limb of the tripod and intermediate crura and the long axis of the lateral crura. Costal cartilage can be dynamics of the nasal tip modifications can be conceptualized obtained to provide adequate grafting material when the ears with the tripod theory. External nasal Thus, tip position can be altered with combinations of length- valve collapse frequently results in complaints of nasal obstruc- ening or shortening tripod limbs. A strut graft can be harvested from the Domal incisions are designed to lower the cephalic septum or rib. Typically, a cephalically based triangle of the ala, and is placed between the vestibular mucosa and ven- cartilage is excised from the dome (▶ Fig. If the cephalic margin is placed higher than the caudal margin, the supratip break will be located Many surgeons rely on cephalic recontouring of the ala com- higher on the dorsum, creating the illusion of an elongated bined with interdomal suturing to refine the nasal tip. They can be used to camouflage subtle amoreacuteangleandasharpermarginthanasimple irregularities, asymmetries, and misshapen dome cartilages. If the mattress suture is overtightened, the tension The graft is harvested from the septum such that the leading can displace the ala medially. A simple suture is placed at edge of the tip graft is created from the septal cartilage that the cephalic margin to prevent pinching of the ala. A mattress suture placed at the caudal border (point A) narrows the dome angle marked in yellow. Plumping grafts augment a retracted columella, enhanc- external auditory meatus is the thickest portion of the concha ing the lobule-to-columella ratio. The skin is elevated from the perichondrium, enhancing tip definition in thick nasal skin. An skin is unlikely to accentuate the contours of refined dome car- intact perichondrium contributes to the cartilage’s strength. They con- grafts push into the thick soft tissue envelope and enhance defi- tribute to the structural integrity of the nasal tip but are not nition. Judicious resection of the soft tissue envelope will allow sufficient to prevent recidivistic ptosis in the absence of other the skin to conform to a contoured nasal skeleton. The leading edge of the graft scissors, the fibroadipose tissue can be excised, revealing the should project 1 to 2 mm above the nasal dome. Even with broad dissection, This establishes the tip-defining point and contributes to the external scarring, pincushioning, and other sequelae are rarely presence of a supratip break. Shield Extremely thin nasal skin is a more challenging variable in grafts projecting>3 mm above the dome should be supported rhinoplasty. Thin skin makes cartilage structure appear more by a vertically positioned buttress graft placed between the prominent, and subtle asymmetries are accentuated. Many sur- shield-medial crura complex to reinforce and prevent bending geons are reluctant to place tip grafts under thin nasal skin to back of the tip graft. The dimensions of the tip graft may vary avoid risking postoperative visualization of the graft. However, with individual patient needs; however, most grafts are approx- patients with thin nasal skin are still good candidates for tip imately 10 to 15mm×8 to 12 mm×1 to 3mm. External visualization and “gravestone” deformities can The medial crura can be prepared to augment or decrease tip be avoided with proper precautions. Conservative resection of the caudal margin at the In thin-skinned patients, grafts are initially made 15 to 20% base of the medial crura will decrease the amount of graft rota- larger than will ultimately be required. Any irregularities of the cartilage surface and lateral and Plumping grafts are small pieces of cartilage stacked into a superior borders should also be feathered and smoothed using pocket created at the base of the columella, above the nasal a 15-blade scalpel. The primary enhance definition, establish the tip-defining point and supra- choice is a cap graft created from the residual septal cartilage. Shield graft cam- A relatively small piece of cartilage (7×7mm) can be morsel- ouflaging techniques and bruised cartilage cap grafts can be ized to create a 15×15-mm piece of bruised cartilage to be used used in patients with thin skin to avoid external visualization of as a cap graft. A fascia graft requires a separate incision in the temporal scalp, but it is relatively easy to harvest a 3 ×4-cm piece of fas- References cia. Cap grafts are secured using several 2006; 8: 156–185 6–0 nylon sutures to prevent migration. Arch Facial Plast Surg 1999; 1: 246–256, dis- cussion 257–258 external visualization of the tip graft can be avoided in even the [3] Bernstein L. Refinements to the nasal tip should be created with 89: 216–224 sufficient integrity to resist postoperative forces. Arch Otolaryngol deformities, loss of projection, and recurrent ptosis can all be 1984; 110: 349–358 prevented by enhancing the cartilaginous framework. Facial Plast Surg base stabilization and structural grafting provide the requisite 2002; 18: 223–232 308 Versatile Grafting at the Nasal Tip 40 Versatile Grafting at the Nasal Tip Trimartani Koento This chapter describes the various types of nasal tip grafts used 40. The grafts at the nasal tip are used to improve tip projection, rotation, definition, and support. Beside various Appropriate Graft grafts, surgical approaches and the techniques used to modify Analyzing the tip is very important to decide the operative plan the tip will be discussed in this chapter too. The tip can Tip surgery can be a major determinant in the success of rhi- be assessed based on four criteria to define the tip form: tip def- noplasty. Clinicians should perform thorough examinations to inition, projection, rotation, and position. Skin thickness is a major factor in tip definition, which the optimal procedures can be decided upon. The thickness of the tip soft tissue and surgical procedures will be required regarding the anatomic the interdomal distance determine the width of the tip. Projec- variation of the soft tissue and the cartilaginous to the tip that tion represents the tip height, which is the distance from the will enhance the appearance. Tip rotation is defined as the tip angle, which is measured from the vertical plane of the 40. Rotation is a term used to describe whether the tip is raised (upward rotation) or droopy (down- The framework of the nasal tip formed by the lower lateral car- ward rotation). The shape and position of the tip After analyzing the tip, surgeons should consider whether depends on skin thickness, subcutaneous tissue strength, and the alar anatomy will tolerate the planned surgery, whether an curvature of the cartilage. The tip shape, position of the lower lateral cartilage, and thick- ness of the overlying skin determine the appearance of the tip. Other factors contributing to nose appearance include the fibrous attachments and abutments to the anatomic structures.

H owever cheap erythromycin 500 mg visa bacteria in urinalysis, the disease incidence is approximately 100 times greater in Crohn disease patients order erythromycin 500 mg line antibiotic prophylaxis for joint replacement. Surgical treatment options include intestinal resection 250 mg erythromycin sale antibiotic question bank, strictureplasty purchase 250 mg erythromycin with visa antibiotics for uti caused by e coli, and intesti- nal bypass. Endoscopic dilat ation of intestinal st rictures is a new technique that is being applied for some patients with Crohn disease related intestinal obst ructions. O n e of the p ot en - tial long-term complications associated with reoperative treatments for patients wit h Crohn disease is the loss of bowel lengt h to maint ain normal nut rit ional func- tions (short bowel syndrome); this complication is reported in less than 1% of patients with Crohn disease. Po st o p e ra t ive St ra t e g ie s The initiation of medical therapies early during the postoperative periods has been suggested to reduce disease recurrences. Because these medications can affect wound healing and increase surgical complicat ions, most pract it ioners rec- ommend a slight delay before initiation of pharmacologic treatments after a sur- gical op er at ion ( 10 days). T h e d ecision r egar d in g t im in g an d the t yp es of med ical treatments should be determined by a multidisciplinary team. For smokers, smoking ces- sat ion has been demonst rated to be associated wit h up to a 50% reduct ion in disease recurrences. Studies comparing the postoperative pharmacological treat- ment s suggest t hat t he ant i-T N F st rategy t o be most effect ive in reducing recur- rences aft er surgical t herapy. The disease manifestation is consistent in terms of being inflammatory, st rict uring, or penet rat ing B. T h e an at o m ic lo cat io n s r em ain fair ly st ab le over the co u r se of d isease progression in most individuals C. Medical refractory disease is the most common indication for surgical treatments D. Surgical treatments should be avoided at all costs in this patient popula- tion 26. A review of t he pat hology report from h is operat ion reveals involve- ment of the appendix base with transmural inflammation and granulomatous ch an ges. Which of the followin g is the most appr opr iat e t r eat m ent at this time? Exploratory laparotomy to identify and remove the segment of intestine involved in t he leakage of enteric cont ent s B. C T of the ab d o m en fo llowed b y in ject io n of t h r o m b o gen ic agen t t o p lu g the leakage C. Radionucleotide-tagged leukocyte imaging study to assess the location of disease D. Croh n disease an at omic locat ion s r emain fairly st able in most pat ient s over the pat ient’s lifetime. The disease characteristics can vary during the lifetime of the patient with Crohn disease, but the inflammatory pattern is the most com mon in it ial pr esent in g pat t er n. An or ect al pr esent at ion is the in it ial pr e- sent at ion in 10% of pat ient s. Ter min al ileum/ r igh t colon disease is seen in 35% t o 50% of pat ient s; ileal disease is seen in 30% to 35% of patients; colonic disease is seen in 25% to 35% of patients; stomach/ duodenal disease is seen in 0. M edical refract or y disease is the most common in dicat ion for sur ger y in Crohn disease patients. The role of surgery is to improve the patient’s quality of life, and surgery has no impact on the disease itself. Surgery is indicated when medical therapy is not working or if medical treatment side effects are compromising the patients’quality of life significantly. This pat ient ’s present at ion is compat ible wit h ent erocut an eous fist u la pre- sumably relat ed t o Croh n disease. Ent erocut aneous fist ula format ion in t he sett ing of Crohn disease does not always require surgical t reat ment, espe- cially wh en it is associat ed wit h min imal amount of syst emic syst ems. A t r ial of conservative treatment including infliximab may be helpful to promote spont aneous closure of t he fist ula. T h e rat e of ent eric fist ula closure using infliximab has been report ed t o range from 6% t o 70%. Medical t h er apy is the appropr iat e ch oice for this pat ient wit h un compli- cat ed an d n ewly diagn osed Cr oh n disease. M edical management may be effect ive for all of the fin dings/ complica- tions listed. Surgery is also indicated for these same complications if a patient does not respond to medical therapy, or if medical therapy compromises the patients’quality of life significantly. Smoking cessat ion amon g p ost op er at ive pat ient s is associat ed wit h 50% r edu ct ion in reoperation rates. Comparative efficacy of pharmacologic interventions in preventing relapse of Crohn’s disease after surgery: a syst emat ic review an d n et work met -an alysis. Hi s c u r r e n t medications consist o prednisone and mesalamine (a 5-aminosalicylate deriva- tive), and he recently completed a course o cyclosporine therapy 2 months ago or another bout o disease lare-up. Previous colonoscopy has shown that his disease extends rom the rectum to the cecum. Next step: The opt ion of surgical t herapy should be present ed t o t his pat ient. The discussion should explain the benefits, risks, and limitations of surgery ver su s t h o se of co n t in u ed m ed ical t h er ap y. Learn with the clinical presentation, natural history, medical management, and complicat ion s of U C. In this case, a 45-year-old man presents with a 15-year history of pancolitis that is producing disabling symptoms that appear to be refrac- tory to medical therapy. The discussion regarding treatment should include medical treatment options as well as surgical options. H owever, t he operat ion would result in permanent changes in bowel functions and body image. Toxic megacolon occurs when these clinical findings are associated with radiographic evidence of significant colonic distension (t ransverse colon > 8 cm diameter). Pat ient can becom e extrem ely ill with clinical signs of sepsis, and this condition is highly lethal if not promptly rec- ognized and treated. W hen identified with either condition, the patient requires prompt fluid resuscitation, broad-spectrum antibiotics administration, and maxi- mal supportive therapy. Skin-erythema nodosum and pyoderma gangrenosum are the two most common, and others include psoriasis stomatitis. Type 2 art hropat hy is chronic and typically involves more than six joints and can be migratory. Axial arthropathy manifestation includes ankolysing spondylitis and sacroiliitis, and these conditions can lead t o d ecr eased mobilit y an d ch r on ic disabilit y. The risk of cancer associated with dysplasia varies depending on the severity of the dysplastic changes. Roughly 40% of the patients with high-grade dysplasia harbor synchronous cancers, and 20% of patients with low-grade dysplasia harbor synchronous cancers. Patients with these fin d in gs sh ou ld be r ecom men d ed t o u n d er go pr oct ocolect omy. Patients with this disease pattern have a significantly greater risk of developing cancers in comparison to individuals with shorter segments of colon ic involvement.

Malignant transformation occurs in three major stages generic erythromycin 250 mg with amex bacteria reproduce by binary fission, called initiation generic erythromycin 500mg line antibiotic resistance conference, promotion order erythromycin 250 mg infection 3 weeks after surgery, and progression purchase 250mg erythromycin overnight delivery antibiotic heartburn. This accumulated genetic damage leads to dysregulation of cell division and protection against cell death. It is important to appreciate that the changes in cellular function caused by malignant transformation are primarily quantitative rather than qualitative. That is, malignant transformation simply results in the overexpression or underexpression of the same gene products made by normal cells. As a result, cancer cells employ the same metabolic machinery as normal cells, use the same signaling pathways as normal cells, and express the same surface antigens as normal cells. Nonetheless, even though these changes in cellular function are only quantitative, they are still sufficient to allow unrestrained growth and avoidance of cell death. Epidemiology The American Cancer Society estimated that 589,430 Americans died from cancer in the year 2015. Cancer is a leading cause of death among all age groups, including children aged 1 to 18 years, in whom it is the leading nonaccidental cause of death. Among men, the most common cancers are prostate, lung, and colorectal cancer (Table 82. Cancers with a high cure rate include Hodgkin disease, testicular cancer, and acute lymphocytic leukemia. For many patients whose cancer is not yet curable, chemotherapy can still be of value, offering realistic hopes of palliation and prolonged life. However, although progress in chemotherapy has been encouraging, the ability to cure most cancers with drugs alone remains elusive. Treatment of Cancer We have three major modalities for treating cancer: surgery, radiation therapy, and drug therapy. In contrast, drug therapy is the treatment of choice for disseminated cancers (leukemias, disseminated lymphomas, and metastases) along with several localized cancers (e. Drug therapy also plays an important role as an adjunct to surgery and irradiation: by suppressing or killing malignant cells that surgery and irradiation leave behind, adjuvant drug therapy can reduce recurrence and improve survival. You should note that the term cancer chemotherapy applies only to the cytotoxic drugs—it does not apply to the use of hormones, biologic response modifiers, or targeted drugs. Introduction to the Cytotoxic Anticancer Drugs The cytotoxic agents constitute the largest class of anticancer drugs. As their name implies, these agents act directly on cancer cells to cause their death. The cytotoxic drugs can be subdivided into eight major groups: (1) alkylating agents, (2) platinum compounds, (3) antimetabolites, (4) hypomethylating agents, (5) antitumor antibiotics, (6) mitotic inhibitors, (7) topoisomerase inhibitors, and (8) miscellaneous cytotoxic drugs. Note that, with the exception of asparaginase, all of the cytotoxic drugs disrupt processes carried out exclusively by cells that are undergoing replication. As a result, these drugs are most toxic to tissues that have a high growth fraction (i. Cell-Cycle Phase Specificity Some anticancer agents, known as cell-cycle phase–specific drugs, are effective only during a specific phase of the cell cycle. About half of the cytotoxic anticancer drugs are phase specific, and the other half are phase nonspecific. Consequently, before we discuss the anticancer drugs, we must first understand the growth fraction. The Cell Cycle The cell cycle is the sequence of events that a cell goes through from one mitotic division to the next. On completing mitosis, the resulting daughter cells have two options: they can enter G and repeat the cycle, or they can enter the phase1 known as G. Cells that enter G become mitotically dormant; they do not0 0 replicate and are not active participants in the cycle. Under appropriate conditions, resting cells may leave G and resume active participation in the cycle. A tissue with a large percentage of proliferating cells and few cells in G has a 0 high growth fraction. Impact of Tissue Growth Fraction on Responsiveness to Chemotherapy As a rule, chemotherapeutic drugs are much more toxic to tissues that have a high growth fraction than to tissues that have a low growth fraction. Because most cytotoxic agents are more active against proliferating cells than against cells in G. Unfortunately, toxicity of anticancer drugs is not restricted to cancers: These drugs are also toxic to normal tissues that have a high growth fraction (e. Having established the relationship between growth fraction and drug sensitivity, we can apply this knowledge to predict how specific cancers will respond to chemotherapy. As a rule, the most common cancers—solid tumors of the breast, lung, prostate, colon, and rectum—have a low growth fraction, so they respond poorly to cytotoxic drugs. In contrast, only some rarer cancers —such as acute lymphocytic leukemia, Hodgkin disease, and certain testicular cancers—have a high growth fraction, so they tend to respond well to cytotoxic drugs. Cell-Cycle Phase–Specific Drugs Phase-specific agents are toxic only to cells that are passing through a particular phase of the cell cycle (see Fig. Vincristine, for example, acts by causing mitotic arrest and hence is effective only during M phase. Because of their phase specificity, these drugs are toxic only to cells that are active participants in the cell cycle; cells that are “resting” in G will not be harmed. To accomplish this, phase-specific drugs are often administered by prolonged infusion. Alternatively, they can be given in multiple doses at short intervals over an extended time. Because the dosing schedule is so critical to therapeutic response, phase-specific drugs are also known as schedule-dependent drugs. Cell-Cycle Phase–Nonspecific Drugs The phase-nonspecific drugs can act during any phase of the cell cycle, including G. Among the phase-nonspecific drugs are the alkylating agents and0 most antitumor antibiotics. Because phase-nonspecific drugs can injure cells throughout the cell cycle, whereas phase-specific drugs cannot, phase- nonspecific drugs can increase cell kill when combined with phase-specific drugs. Although the phase-nonspecific drugs can cause biochemical lesions at any time during the cell cycle, as a rule these drugs are more toxic to proliferating cells than to cells in G. First, cells in G0 have time to repair drug-induced damage before it can result in significant harm. This is much like inflicting a flat tire on an automobile: the tire can be deflated at any time; however, loss of air is consequential only if the car is moving. Carrying the analogy further, if the flat occurs while the car is stopped, and is repaired before travel is attempted, the flat will have no functional effect at all. Specifically, cells that divide frequently are harmed more readily than cells that divide infrequently because the cytotoxic drugs have more opportunities to act. Toxicity to Normal Cells Toxicity to normal cells is a major barrier to successful chemotherapy. That is, dosage cannot exceed an amount that produces the maximally tolerated injury to normal cells.

Whilst you are revising cheap erythromycin 500 mg visa antibiotics for acne safe during pregnancy, don’t forget to eat discount erythromycin 250 mg free shipping infection years after hip replacement, sleep order erythromycin 500mg virus classification, and relax too – all these things will improve your performance! To pass the exam reading and revision is required cheap erythromycin 250mg visa virus xp, but understanding the style of questions and practising questions will improve your chance of success. Learning Outcomes This module covers history taking; clinical examination and investigation; note keeping; legal issues relating to medical certifcation; time management and decision making; communication; and ethics and legal issues. It is easy to set clinical questions on history, examination, or investigation, but quite a challenge to set written questions to test the other areas. We have also tried to look at attitudes and behaviour using written ques- tions concentrating on issues such as consent, domestic violence, and con- fdentiality. When tak- ing a history, which of the following symptoms suggests that the diagnosis might be endometriosis? There is a linear burn across the patient’s abdomen that occurred during ironing E. The woman seems unsure about her request for termination of unwanted pregnancy Answer [ ] 1. When they suffer an early pregnancy complication, which one of these non- sensitised, rhesus negative women does not need anti-D immunoglobulin? Miscarriage less than 12 weeks when the uterus is evacuated surgically or medically B. Every maternal death in the United Kingdom is scrutinised to look for substandard care B. Reducing the number of maternal deaths worldwide by the year 2050 is a ‘millennium development goal’ C. The maternal mortality rate is lower in the United States than in the United Kingdom D. The maternal mortality ratio is defned as the number of maternal deaths per hundred thousand pregnancies E. She is healthy with no other medical problems and is using the withdrawal method for contraception. Which of the following statements is correct regarding Ebola infection in pregnancy? The fetus is likely to survive if delivered now because she is in the third trimester D. Site an intravenous infusion for a severely dehydrated patient with hyperemesis B. Review a woman who has just miscarried an 18-week fetus but not deliv- ered the placenta E. Her booking blood pressure in the first trimester was 130/88 mmHg but it is now 160/95 mmHg, and the midwife has checked the blood pressure twice. On examination you find thickening of both labia minora with a couple of shal- low ulcers on both sides and a split area at the fourchette. On examination severe lower abdominal tenderness with gen- eralised guarding and rebound, also foetor oris. Pelvic examination reveals no tenderness but uterus is small for dates and the cervical os is closed. Transvaginal ultrasound scan shows an intrauterine sac with a fetal pole but no heart pulsation detected. Last menstrual period was 2 weeks ago and on examination has a tender abdomen with guarding. Her cycles are still regular with a cycle of 26 days but the bleeding is now very heavy with clots. The uterus is enlarged to the size of an orange, smooth, and very tender but mobile with no adnexal tenderness. She works long hours as a computer programmer and smokes fifteen ciga- rettes a day. Which of the following factors is the most likely cause of her recurrent miscarriages? The patient tells you that she has experienced severe dyspareunia since her marriage 2 years ago and discloses that she was sexually abused as a child. Abuse in childhood predisposes to depressive illness in later life that does not respond to treatment B. Women who have been abused as children rarely disclose such a history 11 03:11:16 04 12 E. Abuse in childhood is known to be associated with illicit drug use as an adult Answer [ ] 1. Which one of these statements about the quadrivalent vaccine (Gardasil®) is correct? The vaccine will reduce the chance of her developing genital warts as well as cervical intraepithelial neoplasia C. If she completes the course of vaccinations she will not need cervical smears in the future D. Over the last year her periods have become heavier and she is not currently sexually active. On examination she is pale with a tachycardia of 100 bpm but her blood pressure is normal. An urgent ultrasound scan shows an endometrial thickness of 12 mm but no gestation sac seen. She had an embryo transfer 5 days previously and now has shortness of breath, nausea, and abdominal pain. She only had one embryo replaced in the uterus because only one of the oocytes that were retrieved fertilised. She has a scan picture with her, showing an intrauterine pregnancy with a viable 6-week fetus. Pelvic examination reveals tenderness in the left adnexa, and she has cervical excitation. Answer [ ] 14 03:11:16 04 15 A Bacterial vaginosis B Beta-haemolytic streptococcus C Candida D Chlamydia E Gonorrhoea F Herpes genitalis G Primary syphilis H Streptococcus A (streptococcus pyogenes) I Trichomonas vaginalis These clinical scenarios relate to women presenting to a hospital clinic or gen- eral practice surgery. Select the most likely infecting organism given the clinical information for each woman. Her temperature is 38oC, pulse 110 bpm; her respiratory rate is raised; and her uterus is enlarged and tender. She has a sore throat with a red pharynx and white spots on her tonsils on examination. For each patient select the most appropriate investigation given the clinical information described in each case. Whilst taking the smear, a friable 3 mm diameter red lesion is noted on her cervix, which bleeds profusely. On examination her cervix looks normal but atrophic with radiotherapy changes and an ultrasound scan shows that the cavity of the uterus is distended with blood.