By V. Ernesto. Eastern Mennonite University.

He has had asthma since childhood buy 100 mg dipyridamole mastercard blood pressure chart org, and he has been experiencing occasional wheezing discount dipyridamole 100 mg visa arteria temporal, shortness of breath, and cough productive of yellow sputum. He cannot identify specific irritants that trigger his asthma. He lives with his wife and their two children in an apartment building and works in an auto-body shop. He has no nasal polyps, and his physical examination is unremarkable. Because he has no specific allergic precipitants (i. His occasional cough associated with yellow sputum is likely to be infectious in origin 4 BOARD REVIEW C. The fact that his physical examination is normal should raise suspi- cion that his symptoms are caused by something other than asthma alone D. You should caution him against starting a regular exercise program, because this may worsen his asthma symptoms Key Concept/Objective: To understand that occupational asthma is common and that patients with long-standing asthma may not be aware that an occupational irritant is contributing to their asthma Occupational exposure plays a role in 10% of patients with asthma. Patients with asth- ma often experience delayed hypersensitivity reactions more than 12 hours after expo- sure; because of this, a patient who had asthma before starting a job may not be aware of a noxious irritant in the workplace. Workers in auto-body shops are at risk for occu- pational asthma caused by paint spray. The distinction between intrinsic and extrinsic asthma has no bearing on asthma management. Eosinophils and their debris often cause yellow discoloration of sputum even in the absence of infection. Patients often have a normal physical examination between exacerbations. Although exercise can trigger asthma, with appropriate therapy almost all patients with asthma can perform regular exercise without difficulty. At your urging, the patient in Question 5 attempts to start exercising, but he finds that he develops short- ness of breath soon after he finishes jogging. Which of the following statements about this patient is most correct? His shortness of breath may very well result from being out of shape B. He would benefit from use of ipratropium bromide before exercise C. He would benefit from use of a beta agonist before exercise D. He would benefit from use of theophylline before exercise E. He would benefit from use of an inhaled steroid before exercise Key Concept/Objective: To understand the appropriate therapy for exercise-induced asthma The most effective therapy for exercise-induced asthma is an inhaled beta agonist. Cromolyn is also effective, and newer leukotriene modifiers may also have a role. Theophylline, corticosteroids, and anticholinergics have no role in the treatment of exercise-induced asthma. The patient in Question 5 returns to clinic for follow-up 12 weeks later. He mentions that 7 days ago he had a headache, for which he took two aspirin. Later, as the headache began to subside, he also devel- oped itchy eyes and an itchy throat. Which of the following statements about this patient is most correct? Because he does not have nasal polyps, it is unlikely that he has aspirin hypersensitivity B. He is likely to have similar reactions to all NSAIDs C. This reaction was the result of salicylate sensitivity, so ibuprofen should be safe for him to use D. This reaction suggests that he would not benefit from a leukotriene modifier E. A COX-2 inhibitor, such as celecoxib, is likely to be safe for him to use 14 RESPIRATORY MEDICINE 5 Key Concept/Objective: To understand the relationship between asthma and aspirin hypersensitivity Aspirin hypersensitivity can initially present with bronchoconstriction or other allergic symptoms.

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The use of sand bags is recommended buy 25 mg dipyridamole free shipping yaz arrhythmia; they should weigh approximately 5 kg effective 25 mg dipyridamole arrhythmia or anxiety, be made from a washable mate- rial, and be wrapped in sterile fabric (3). Such bags produce a more uniform and efficacious compression than that achieved manually. Dressings: The treated areas are covered with sterile adhesive bandages and given addi- tional compression with dressings and compressive clothing (elastic pants or shorts) that should be worn for 30 days. The patient receives the following postoperative instructions: & Use analgesics for the first 48 hours; this period can be extended if pain persists. Acetaminophen at a dose of 750 mg every six hours is recommended. SUBCISIONâ & 257 Figure 7 A gentle pinch test is performed to find residual septa pulling the skin surface. Hematomas and hemosiderosis are expected in all patients during this period. The hematomas should follow a normal evolu- tion of spontaneous reabsorption over a period varying from 10 to 20 days. Hemosiderosis may persist for several months and is directly proportional to the absorption of iron present in the extravasated red blood cells. Other complications may arise as a result of this procedure and they are listed below. Infection 258 & HEXSEL AND MAZZUCO Figure 8 Hematomas in the third postoperative day in well-compressed areas. Alterations to the consistency of the treated area 5. Alterations to the color of the skin in the treated area 6. Keloid scars 1 In fact, complications arising from the use of Subcision (5) for the treatment of cellulite are rare, owing to the safety of the method and the fact that regions of the anat- omy commonly treated are free of vital structures and large blood vessels. Hemosiderosis: This occurs due to the extravasation of the red blood cells and the deposit of hemosiderin, a pigment that contains iron, and the resulting degradation of the hemo- globin, (12) giving the skin a chestnut pigmentation (Fig. It occurs in all treated patients to varying degrees and resolution occurs spontaneously within 2 to 12 months. Organized hematomas: This may occur in some treated areas, but usually clear up spon- taneously in a period from one to three months, although they can be treated with intralesional corticosteroids. False excess response: This is characterized by a raised area of skin at the treated area, appearing as a herniation of the skin and fat (Fig. This does not respond well to 1 corticoid injections and may be due to bad technique (e. Favorable results can be obtained with the use of liposuction in the affected area. SUBCISIONâ & 259 Figure 9 Hemosiderosis one month after Subcision1. Figure 12 1 Same patient as in Figure 11, after two Subcision treatments. SUBCISIONâ & 261 It is a precise surgical procedure, in which the septa that retain the skin are cut, and the resulting traction and tension forces are redistributed among the fat lobules in the treated area, giving an immediate improvement to the skin surface. The production of new connective tissue from the hemotomas occurs in two to five weeks and normally persists for a considerable time in the correction of the treated defect. The results are technique dependent and are usually long lasting (3). Subcutaneous incisionless (Subcision) surgery for the correction of depressed scars and wrinkles. Subcision: Uma alternativa cirurgica para a lipodistrofia ginoide (‘‘celulite’’) e outras alteracoes do relevo corporal. Simple technique provides option for treat- ing scars and other skin depressions. In: Robinson JK, Ardnt KA, LeBoit PE, Wintroub BU, eds. Catecholamines, sympathomimetic drugs and adrenergic receptor antagonists. Goodman & Gilman’s Pharmacological Basis of Therapeutics. Antisepsis, anesthesia, hemostasis, and suture placement.

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After the planktonic organisms were washed away purchase dipyridamole 100 mg with amex arteria records, inoculated pins were inserted into the medular cavity of a rabbit leg through a hole drilled into the proximal tibia buy dipyridamole 100mg mastercard hypertension during pregnancy. The explanted pins were sonicated to remove bacteria, which were enumerated by plate counting. In addition, the bone adjacent to each pin was collected and homogenized and the bacteria enumerated. Coated pins containing antiseptic reduced the number of bacteria by approximately 3 logs (Fig. Therefore, the photoimmobilized hy- drogel coating containing chlorhexidine was shown to be efficacious in preventing osteomyelitis caused by S. Immobilization of Antimicrobials Another coating strategy is to immobilize antimicrobials directly to the medical device surface using a ‘‘linker’’ molecule. Immobilized antimicrobials on medical devices must have at least three characteristics: (1) a surface-active mode of action; (2) activity against a broad spectrum of pathogenic microorganisms; and (3) a chemical structure which allows linkage to the device surface while retaining its antimicrobial activity. There are some advantages and disadvantages associated with immobilizing antimicrobials directly to the device surface versus antimicrobials that are eluted from a coating matrix. A potential benefit of immobilization is longer lasting activity. A few drawbacks include (1) the microorganisms must intimately contact the immobi- lized antimicrobial for the surface-active agent to exert its effect; (2) if the device surface is fouled, biologically or otherwise, contact between the microbe and the immobilized antimicrobial may be masked; and (3) there may be a limited selection of surface-active antimicrobials which meet the criteria above. However, a group of novel cationic antimicrobial peptides fulfill these requirements. These peptides have been isolated from a variety of sources and include peptide derivatives of human Figure 20 Efficacy of surface-modified pins in a rabbit tibial intramedullary model. Figure 21 Osteomyelitis associated with surface-modified pins in a rabbit intramedullary model. These peptides, which kill a broad spectrum of bacteria, possess an amphiphilic -helical structure and form holes in artificial membrane systems. Hence, the mechanism of bactericidal activity of these peptides is probably by insertion of the helix into the bacterial membrane, causing osmotic lysis. Finally, these peptides (1) are surface-active [41–45]; (2) are microbicidal to variety of pathogens including Staphylococcus epidermidis, Escherichia coli, Pseudomoas aeruginosa, and Pseudomonas mirabilis [42,46,47], all of which play a role in device-centered infections [32,40,48,49]; (3) contain functional groups available for covalent coupling to support materials; and (4) are available as synthetic peptide products with high specific activities [42,46,50]. Darveau (Bristol- Myers Squibb Pharmaceutical Research Institute, Seattle, WA) kindly provided a synthetic pep- tide analog of the bactericidally active 13-residue carboxy-terminal portion of human platelet factor IV (377VV). The 377VV peptide was photoderivatized, HPLC purified, and evaluated by microdilution assay to determine the minimal inhibitory concentration (MIC) against a variety of microorganisms. The results shown in Table 2 indicate that a photoreactive derivative of 377VV could be synthesized with little or no loss in microbicidal activity against a variety of gram-negative and gram-positive bacteria. Table 2 Minimal Inhibitory Concentration of Peptides on Various Organisms Microorganism 377VV ( g/mL) Photo-377VV ( g/mL) E. Briefly, the SR disks were placed individually in the wells of a microtiter plate. Bacteria-coated disks were incubated overnight at 37 C on tryptic soy agar, and the number of colonies growing on the surface of each disk was enumerated. Conclusions Device-related infections are a significant problem in the health care industry. Controlling the sterility of an implant area and device is extremely difficult to maintain before and after implanta- tion. Proper insertion site preparation, maintaining a strict sterile field, appropriate hygiene of HCW, and postwound site cleanliness are crucial elements in this continuous battle against a vast variety of pathogens. Systemic antibiotic dosing has many disadvantages associated with it, including but not limited to the buildup of resistant organisms. Coating medical devices with antiadherent and/or antimicrobial agents offers a value-added benefit to medical devices serving as perhaps the last line of defense in minimizing the risk of nosocomial infections. The photoacti- vatable processes described in this chapter offer an environmentally friendly, flexible, and eco- nomical means to coat many medical devices on the market. COATINGS FOR LOCAL DRUG DELIVERY Most medical devices have limitations in terms of their efficacy or longevity because of the inherent response of the body or pathogens to the implant. For example, tissue ingrowth, infec- Figure 22 Antimicrobial activity of an immobilized peptide against S. Bacterial growth was evaluated on SR disks that were untreated; coated with underivatized peptide and illuminated with UV light; coated with photoderivatized peptide, but not illuminated; or coated with photoderivatized peptide and illuminated with UV light. In many situations, pharmaceuticals or antimicrobial agents are given to a patient systemically to improve or enable the performance of the implanted medical device.

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