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By K. Uruk. Brandeis University.

A patient in your clinic states that her entire family is using acupuncture for everything that ails them purchase stromectol 3 mg with amex. Which of the following statements regarding the practice of acupuncture is true? Clear evidence supports the use of acupuncture for chemotherapy- induced vomiting ❏ B 3 mg stromectol with mastercard. There are essentially no adverse events associated with acupuncture ❏ C discount 3mg stromectol with mastercard. Acupuncture was proven ineffective for postoperative vomiting ❏ D order stromectol 3 mg line. Acupuncture likely has a role in smoking cessation ❏ E. Acupuncture works by stimulating nerves at the needle site Key Concept/Objective: To understand basic concepts of acupuncture and in which settings it has been proven to be useful To date, no clear mechanism of action has emerged to explain the potential therapeutic response to acupuncture. In 1997, the National Institutes of Health held a Consensus CLINICAL ESSENTIALS 21 Development Conference on Acupuncture, which concluded that there is clear evidence to support the use of acupuncture for postoperative, chemotherapy-induced, and probably pregnancy-associated nausea and vomiting. Rare case reports of seri- ous adverse events, including skin infections, hepatitis, pneumothorax, and cardiac tam- ponade, seem to stem from inadequate sterilization of needles and practitioner negligence. A 65-year-old woman with a medical history of paroxysmal atrial fibrillation with episodes of rapid response, congestive heart failure, and osteoarthritis comes to your office for a routine follow-up visit. She states that she has been taking herbs and nonherbal supplements to help alleviate the symptoms of menopause, combat depression and anxiety, and improve her arthritis. Which of the following statements regarding CAM treatments is false? John’s wort (used to treat depression and anxiety) can decrease serum levels of digoxin ❏ B. Dong quai (used to treat the symptoms of menopause) can prolong the international normalized ratio (INR) in patients taking warfarin ❏ C. The cardioprotective effects of garlic are as yet unproven ❏ D. Kava kava (used to treat anxiety) may potentiate the effect of benzodi- azepines and other sedatives ❏ E. Glucosamine and chondroitin have been proven to be ineffective in treat- ing osteoarthritis Key Concept/Objective: To become aware of drug interactions of some very commonly used herbal and nonherbal supplements, as well as the effectiveness of these supplements Several drug interactions are associated with herbal and nonherbal supplements: St. John’s wort can decrease serum digoxin levels; dong quai can prolong INR; and kava kava is known to potentiate sedatives. The definitive beneficial effects of garlic in cardioprotec- tion are unproven. Glucosamine and chondroitin are some of the few supplements for which there are data showing efficacy. Current data suggest symptomatic improvement for osteoarthritis of the hips and knees. John’s wort in the treatment of mild to moderate depression. A patient with chronic back and neck pain reports that he has finally gotten some relief through a local chiropractor. He wants your opinion about the safety and efficacy of chiropractic therapy for such con- ditions. Which of the following statements is false regarding chiropractic therapy? Very little data support the use of chiropractic manipulation to treat hypertension, menstrual pain, or fibromyalgia ❏ B. Research may be insufficient to prove a benefit for patients with acute or chronic lower back pain ❏ C. Patients with coagulopathy should be advised against chiropractic therapy ❏ D. Patients who try chiropractic therapy become dissatisfied after the first several treatments ❏ E. Serious complications can occur with cervical manipulation Key Concept/Objective: To understand the efficacy and contraindications of chiropractic therapy Chiropractic manipulation has been touted as a treatment for a number of conditions, including hypertension, asthma, menstrual pain, and fibromyalgia. However, very little 22 BOARD REVIEW data support its use for these conditions.

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Conclusions These results have shown that heparin can be immobilized using photochemical coupling tech- niques such that it (1) covers substrate surfaces completely and uniformly stromectol 3mg visa; (2) inhibits thrombin in a buffer solution buy 3mg stromectol visa; (3) retards the generation of fibrin in plasma in vitro stromectol 3 mg with visa; (4) withstands washing Figure 13 Comparison of the average platelet attachment rates and thrombus weights on photoheparin- treated and untreated PU 3 mg stromectol mastercard. Samples were implanted for 1 h and the attachment of radiolabeled platelets was monitored quantitatively in real time using gamma camera imaging. The heparin-based coatings significantly decreased platelet attachment and thrombus formation. Photoimmobilized Non-Heparin-Based Surface Modifications As shown in the previous discussion, heparin-based coatings provide excellent antithrombogenic performance for medical device materials. There are, however, several potential regulatory hur- dles associated with heparin-based coatings, especially in the European Union where heparin is considered a biological and medicinal product and a heparin coating may thereby change a device’s classification and regulatory pathways. Therefore, there is a growing interest in non- heparin-based, nonbiological hemocompatible coatings. After careful examination of the complex mechanism and pathways of blood clotting and the relevant scientific literature, novel photoimmobilized alternatives to heparin have been developed for preventing surface-induced thrombus formation. In these approaches, synthetic, nonbiological molecules are photoderivatized and immobilized onto a surface to create surfaces with improved blood compatibility. One approach employs the strategy of passivation with hydrophilic molecules to mask the underlying thrombogenic surface from the blood. The passiv- ated surface reduces or prevents the adhesion of thrombogenic cells and proteins onto the underly- ing substrate or material, thereby preventing surface-induced blood clotting. Another approach involves coatings that actively recruit and bind native albumin from the patient’s own blood onto the device surface. This albumin-binding coating acquires a thin, self-regenerating absorbed albumin layer on the surface. In turn, the albumin-covered surface minimizes and prevents the adhesion of unwanted thrombogenic cells and proteins. To assess the performance of these non-heparin-based coatings, we have carried out a variety of in vitro and in vivo experiments, in some cases comparing directly with heparin- based coatings. In Vitro Performance Figure 10c shows the results of in vitro platelet adhesion experiments, analogous to those de- scribed above for heparin coatings. The hydrophilic, passivating coating showed results similar to those of heparin coatings in this experiment, providing substantially reduced platelet binding. Figure 14 shows the results of another in vitro test of blood compatibility. Hydrophilic passivating coatings, with and without heparin, were exposed to flowing blood in a recirculating loop model of the circulatory system. In this experiment, the amount of platelet adhesion was quantified by using radiolabeled platelets. Both of these coatings showed greatly reduced platelet adhesion compared to uncoated surfaces. The albumin-binding coatings have also been assessed using in vitro and in vivo test systems. Figure 15 shows the results of an experiment in which surfaces were exposed to human plasma, and the amount of albumin bound to the surface was determined using antibody binding techniques. As can be seen in this figure, the albumin-binding coating was capable of increasing the affinity of the surface to albumin four-fold compared to the uncoated surface. This result demonstrates the affinity that these coatings have to bind albumin. In Vivo Performance The photographs of explanted coated and uncoated polymer heart valves in Fig. In this experiment, polymer heart valves were implanted in the mitral position in sheep for 5 months to compare an uncoated valve with a valve coated with an albumin-binding agent. The albumin-binding Surface Modification of Biomaterials 113 Figure 14 Platelet adhesion under flow condition in an in vitro circulating blood loop model. Uncoated PE and SurModics synthetic passivating coating, with and without heparin, were tested in the blood loop model for1hwithanaverage flow velocity of 15 cm/s.

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Although the color varies stromectol 3mg otc, the most common coloring is that of coffee cheap 3mg stromectol free shipping. Physical findings include signs of accompanying conditions buy generic stromectol 3mg on-line. GIANT HAIRY PIGMENTED NEVUS These are congenital lesions buy stromectol 3 mg visa. The ones classified as “giant” are over 20 cm in diameter in adults and adolescents. In infants and children, giant lesions cover at least 5% of the body surface area. The lesions have a high likelihood of becoming malignant. They are typically round or oval in shape and have an irregular surface, with coarse hairs in approximately 50% of cases. They are usual single lesions and the color ranges from light to dark brown. Inflammatory or Red Lesions CHERRY HEMANGIOMAS Cherry hemangiomas, or angiomas, arise from dilated venules. The cause is unknown, and they are not inflammatory lesions. The patient may describe onset after age 30, with number and size increasing over time. The color is typically bright red, though they may be darker, including purple to black in coloring. PYOGENIC GRANULOMAS (PLATE 23) Pyogenic granulomas are benign lesions that stem from vascular proliferation. These hemangiomas often occur after a minor skin injury, but also occur spontaneously. While the cause is not known, they are not caused by infection, as the name would imply. The 1–10-mm lesion initially appears as a bright-red papule, which consists of capillar- ies and collagen, and quickly evolves over a period of a few weeks to become a more dull shade of red with a roughened and friable surface. While the lesion may become a pale, flesh-colored chronic lesion, they rarely resolve spon- taneously. It is important to diagnose these early so that they can be treated at a more man- ageable stage. Biopsy will reveal specific histopathologic findings, if performed. FURUNCLES (PLATE 14) Furuncles are also commonly called “boils. Multiple or clustered furuncles are called carbuncles. Patients complain of pain, redness, and swelling at the affected site. The temperature may be elevated and there is often lymphadenopathy. CELLULITIS Cellulitis is an infection of the skin and subcutaneous tissue. The causative organism varies, although staphylococcal and streptococcal infections are common. Superficial cel- lulitis, erysipelas, is associated with streptococcal infections. The patient often describes a skin injury preceding the onset of redness, swelling, and pain at the site. The affected area is tender, swollen, reddened, and warm. When streptococcal infection is involved, bullae may form on the sur- face. Typically none are indicated unless the condition is severe; if so, CBC and cultures may be warranted. HIDRADENITIS SUPPURATIVA (PLATE 16) Hidradenitis suppurativa involves occlusions of hair follicles.

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MRI: intramedullary signal changes purchase stromectol 3 mg with visa, as a sign of myelopathy buy stromectol 3 mg lowest price. Trauma: Fractures and dislocations with associated spinal cord damage stromectol 3 mg with amex. Root avulsions are usually associated with plexus trauma and myelopathy purchase stromectol 3mg. Neoplastic: Most commonly tumors affecting the cervical vertebral column are breast, prostate and lung cancer. Cervical vertebrae are less involved compared with thoracic or lumbovertebral column metastasis. Additionally, the spinal cord may be compressed, by either local extension of tumor, or through nerve root foramina paraspinal malignant deposits (see Figs. Nerve root and spinal nerve tumors: Schwannomas, or neurofibromas, in combination with NF1. Neuroimaging: Diagnosis CT, MRI CSF in inflammatory disease EMG: The EMG sensitivity depends on the motor involvement. Most commonly, C6 and C7 roots are affected, followed by C5 and C8. The sensory NCV can be expected to be normal as are the SNAPs of the median nerve (C6), third digit (C7), ulnar nerve/5th digit (C8) and the medial antebra- chial cutaneous nerve (T1). NCV motor: Injury to motor fibers distal to the cell body results in CMAP amplitude reduction. Differential diagnosis Acute cervical radiculopathies: Neuralgic amyotrophy Acute traumatic brachial plexopathy (with or without avulsions) Limitation of shoulder movement can have several causes and may be accom- panied by non-radicular pain (bursitis, capsulitis, tendinitis, impingement), muscle trauma from exercise, and frozen shoulder. Other conditions producing pain in the neck: myocardial infarction, shoul- der disease, bursitis, and arthritis. Brachial plexus lesions: Upper trunk plexus vs C 5/6 Lower trunk vs C8/T1 Middle trunk vs C7 Other considerations: Herpes infection Mononeuropathies MS (radiculopathies due to spinal cord involvement) Osteomyelitis, discitis Pancoast tumor “Pseudoradicular” symptoms Referred pain: Cardiac ischemia Spinal cord lesions Syrinx Thalamic ischemia Thoracic outlet syndrome Chronic cervical radiculopathies: ALS Multifocal motor neuropathy Mononeuropathies (e. In a study comparing conservative treatment vs surgery, the results after 12 months were equal. Neck manipulation and chiropractic maneuvers are controversial. Surgical: Used in cases of suspected myelopathy, progressive sensorimotor deficit, or failure of conservative measures. Complications: operative risks of root or cord injury, hoarseness from recurrent laryngeal nerve injury, esophageal perforation or vertebral artery injury, graft displacement. Extensive lami- nectomies carry the risk of reverse lordosis, or “swan neck deformity”. Hanley References & Belfus, Philadelphia, pp 523–584 Levin KH (2002) Cervical radiculopathies. In: Katirji B, Kaminski HJ, Preston DC, Ruff RL, Shapiro B (eds) Neuromuscular disorders in clinical practice. Butterworth Heinemann, Boston Oxford, pp 838–858 Matthews WB (1968) The neurological complications of ankylosing spondylitis. J Neurol Sci 6: 561–573 Mumenthaler M, Schliack H, Stöhr M (1998) Klinik der Läsionen der Spinalnervenwurzeln. In: Mumenthaler M, Schliack H, Stöhr M (eds) Läsionen peripherer Nerven und radikuläre Syndrome. Thieme, Stuttgart, pp 141–202 Radhakrishnan K, Litchy WJ, P‚Fallon WM, et al (1994) Epidemiology of cervical radicul- opathy. A population based study of Rochester, Minnesota, 1976 through 1990. Brain 117: 325–335 126 Thoracic radiculopathy Genetic testing NCV/EMG Laboratory Imaging Biopsy + + +++ Fig.

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