Douglass A. Morrison, MD
- Cardiology Department
- University of Arizona
- Tucson, Arizona
Baked goods: Hamburger buns infection x girl discount nitrofurantoin online visa, crackers antibiotic levofloxacin for sinus infection purchase nitrofurantoin 50mg on line, cookies antibiotic before surgery purchase nitrofurantoin australia, pizza dough antibiotic 54 312 discount 100 mg nitrofurantoin mastercard, cakes antimicrobial towels buy nitrofurantoin in india, pies and pastries best antibiotics for acne uk order 50 mg nitrofurantoin otc. Premixed ingredients: Pancake mix, hot chocolate, salad dressing, croutons and breadcrumbs. However, foods sold only to restaurants are not required to provide this information. Instead of stick margarine or butter, choose soft tub spreads with saturated and no trans fat. Ask your food suppliers for baked products, pre-fried and packaged foods that are made without partially hydrogenated vegetable oil. No food containing partially hydrogenated vegetable oils, shortenings, or margarines with 0. If any of these terms are listed, go to Step 2 to see if the product contains too much trans fat. If the ingredients list contains the words "partially hydrogenated," "shortening," or "margarine," the letter must also include information on the Also beginning July 1, 2008, when the regulation takes full effect, you will need to save the label for any food containing oils, shortenings, or margarines, regardless of how you use the product. For instance, if you are frying frozen French fries, you should save the label for both the frying oil and the French fries until both have been completely used. When buying containers of oil that are shipped in a box, the containers may not have labels but the box should. You will need to save the label for any oils, shortenings, or margarines used for frying, pan-frying (sautйing), or grilling, or as a spread, until the product is completely used. Step 1: Look at the package label or ingredients list to see if "partially hydrogenated," "shortening," or "margarine" are listed. This requirement does not apply to menu items that are listed on a menu or menu board for less than 30 days in a calendar year. Workers who use electrical machinery keep long hair tied back and remove loose jewelry and rings. Tamps, push sticks, or other tools are used to feed or remove food from grinders, slicers, and choppers. Burns Pot holders, mitts, and gloves are used to handle hot items Pot handles and cooking utensils are turned away from edges of counters or stove fronts. Health and safety hazards and risks for workers may be found throughout food establishments, especially in the the kitchen. Some of the most common injuries to restaurant workers are: Muscle strains, sprains and tears from slips, trips and falls; overexertion in lifting; repetitive motions; reaching and twisting. Cuts and lacerations from knives; food and beverage processing machinery such as slicers, grinders and mixers; and broken glass. Burns and scalds from hot liquids; hot oils and grease; heating and cooking equipment such as ovens and grills; hot pots and trays; and steam. Controlling Hazards that new hazardous conditions or other safety problems are reported and discussed. Written materials on safety rules and policies should be available in languages understood by your staff. The checklist below can be used to audit your workplace on a daily or weekly basis. Auditing your workplace helps to document corrective actions needed, identify responsible parties, and track expected remediation date and verification of action taken. Muscle strains and sprains · Workers use safe lifting techniques and get assistance for awkward or heavy items. Every new employee should receive an orientation and be trained in health and safety policies and procedures. Provide the proper knives for the specific task and train workers on having the right knife for the job. Inspect regularly to make sure safety devices, such as guards, are in working order Make sure food is dry when placed in hot oil. Cuts and Lacerations Burns and Scalds Workplace Violence Dealing with irate customers Robberies Domestic violence towards staff Violence between customers Motor vehicle injuries Car accidents; Runover Pesticides Cleaners Refrigerants Infectious materials (blood from cuts & needles, etc. Nearly all bicyclist fatalities occurred as a result of crashes with motor vehicles and most crashes occurred at or near intersections. The Law City laws require businesses to supply their bicycle delivery workers with helmets and other safety devices. The laws also require that commercial bike riders wear the helmets while cycling on the job. Avoid the most commonly cited violations and improve your chances to achieve an "A. Protect food from contamination during storage, preparation, transportation and display. Avoid cross-contamination by separating potentially hazardous foods (like raw poultry) from ready-to-eat items (like salad mix). Hot food item that has been cooked and refrigerated is being held for service without first being reheated to 165°F or above within 2 hours. Precooked potentially hazardous food from commercial food processing establishment that is supposed to be heated, but is not heated to 140°F within 2 hours. Whole frozen poultry or poultry breasts, other than a single portion, is being cooked frozen or partially thawed. Meat, fish or molluscan shellfish served raw or undercooked without prior notification to customer. Cold food item held above 41°F (smoked fish and reduced oxygen packaged foods above 38°F) except during necessary preparation. Food not cooled by an approved method whereby the internal product temperature is reduced from 140є F to 70є F or less within 2 hours, and from 70°F to 41°F or less within 4 additional hours. Food prepared from ingredients at ambient temperature not cooled to 41°F or below within 4 hours. Filth flies include house flies, little house flies, blow flies, bottle flies and flesh flies. Food/refuse/sewage-associated flies include fruit flies, drain flies and Phorid flies. Hot and 7 8 9 10 10 10 10 10 10 10 10 10 28 28 28 28 28 28 28 28 28 cold running water at adequate pressure to enable cleanliness of employees not provided at facility. Tobacco use, eating, or drinking from open container in food preparation, food storage or dishwashing area observed. Harborage or conditions conducive to attracting vermin to the premises and/or allowing vermin to exist. Garbage storage area not properly constructed or maintained; grinder or compactor dirty. Non-food 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 4 4 4 4 4 4 4 5 5 5 5 5 5 5 contact surface or equipment improperly maintained and/or not properly sealed, raised, spaced or movable to allow accessibility for cleaning on all sides, above and underneath the unit. Resuscitation equipment: exhaled air resuscitation masks (adult & pediatric), latex gloves, sign not posted. Deputy Commissioner Division of Environmental Health Robert Edman Assistant Commissioner Elliott S. The policy set forth below is effective March 30, 2003 for all [company name] locations. Smoking is not permitted anywhere in the workplace, including all indoor facilities and company vehicles with more than one person present. Smoking is not permitted in private enclosed offices, conference and meeting rooms, cafeterias, lunchrooms, or employee lounges. Compliance with the smoke-free workplace policy is mandatory for all employees and persons visiting the company, with no exceptions. Smoking Cessation Opportunities [Company name] encourages all smoking employees to quit smoking. Any questions regarding the smoke-free workplace policy should be directed to [company department and phone number handling inquiries]. List three defects which will cause canned foods to be rejected:,. All food items must be stored at least 6 inches 8 inches 12 inches off the floor the temperature danger zone for food is between °F and °F. In a refrigerator, raw food products should be stored above cooked foods below this is to prevent. Under favorable growth conditions, bacteria will double every to minutes. Home canned foods cannot be used in a food establishment because of the fear of 8 3. All food service establishments must have hand-wash sinks within each and each and they must be provided with and running water, soap, and individual disposable towels or a hot air dryer. Pork should therefore be cooked to a minimum temperaEmployees with an illness that can be transture of °F. Bacteria commonly found on the surface of raw chicken are called: Salmonella Staphylococcus B. Cereus When using raw shell eggs in a food that will not be cooked or will only be cooked lightly, we should use eggs instead. The proper safe holding temperature for potentially hazardous foods is at or below for cold foods and at or above for hot foods. It is good practice to make cold salads with ingredients that were previously chilled? When cooling hot foods in a refrigerator, they must be covered: after being cooled when first placed in the refrigerator 2 On a buffet table, maintaining proper food temperature is equally as important as having a proper sneeze guard. Refrigerated foods that will be served hot must be rapidly reheated to 165° F using: a hot holding unit a stove or an oven 3. An air break is necessary in the waste line of the potwash and handwash sinks potwash and culinary sinks. When bacteria from a raw food get into a cooked or ready-to-eat food, this is called. The correct cooking temperature for poultry, stuffed meat and stuffing is °F. When handling foods that have already been cooked and are ready to be eaten we must use, 11 Thick foods cool faster in: small amounts and small containers large amounts and large containers. It is acceptable to use pesticides in food establishments by food workers as long as label directions are followed. The three key strategies of integrated pest management are to starve them, build them out, and destroy them. Suitable work shoes are (check all that apply): slip resistant leather soled canvas sneakers flats List four foods that contain trans fats. Clean and sanitize the thermometer probe with a single-use alcohol wipe or other approved sanitizer. Insert the probe into the center, or thickest part of the food; between the folds of flexible packaged products, or between packages of food. Bi-metallic stem thermometer must be inserted in the food up to the dimple in the stem. Wait for the reading to register l 1520 seconds for bi-metallic stem thermometer and digital readout Few seconds for thermocouple l Step 4. All food areas must be constructed away from overhead waste or condensation lines. All food must be stored at least six inches above the floor, so that proper cleaning can take place. Foods must also be stored away from the walls and ceilings to allow for proper air circulation. Look out for signs of vermin activity, such as rat or mouse droppings, vermin eggs or odors. Store food in vermin-proof containers - metal or glass containers, with tightly fitted lids. Place a refrigeration thermometer in the warmest spot in the unit to measure ambient air temperature of the unit Check for condensation that may contaminate food. Keep equipment clean and perform regular checks to ensure satisfactory performance. Place the pan in the refrigerator uncovered (best place is where the cold air can blow across it). This is a term typically used for any situation where harmful microorganisms transfer from a raw or contaminated food to a cooked or ready-to-eat food. Use clean gloves when you resume food preparation, but remember to wash hands first. Manual dishwashing is allowed only in a three-compartment sink: Wash in the first; Rinse in the second; Sanitize in the third; then air dry. For heat sanitizing, water temperature in the third compartment must be at least 170° F or higher, and the dishes must be immersed for at least 30 seconds. For chemical sanitizing, the chlorine-based sanitizer in the third compartment must be at least 50 parts per million (ppm), and the dishes must be immersed in the sanitizing solution for at least 60 seconds. To make 50 ppm sanitizing solution, take Ѕ-ounce (or one tablespoon) of household bleach and mix it with one gallon of water. Final rinse temperature of mechanical high-temperature dishwasher must be at least 180° F or higher. Eliminate all holes, cracks, and crevices in food storage, preparation, and handling areas. Make all parts of food storage, preparation, and handling areas easily accessible for routine cleaning.
Gastroesophageal reflux involuntary movement of stomach contents into the esophagus; physiologic reflux is found in all newborns; pathologic reflux can result in failure to thrive antibiotic and yeast infection purchase nitrofurantoin 100 mg, recurrent respiratory problems/aspiration bacteria vs bacterium cheap 100 mg nitrofurantoin with mastercard, bronchospasm antibiotic therapy buy nitrofurantoin 100 mg on line, and apnea antibiotics for sinus ear infection buy nitrofurantoin 100mg online, irritability antibiotic pregnancy buy nitrofurantoin visa, esophagitis antibiotic ear drops purchase nitrofurantoin pills in toronto, ulceration and gastrointestinal bleeding. Jaundice hyperbilirubinemia from increased bilirubin load and poor hepatic conjugation/unconjugated, physiologic/ or abnormalities of bilirubin production, metabolism, or excretion/non-physiologic/. Hypoglycemia blood sugar less than 40 mg/100ml, characterized by lethargy, hypotonia, tremors, apnea, and seizures. Hypocalcemia total serum calcium concentration less than 7 mg/100ml or ionized calcium less than 3. Characterized by bradycardia, respiratory irregularity, apnea, seizures, and hypotonia. Premedication the primary goals of premedication in children are to facilitate a smooth separation from the parents and to ease the induction of anesthesia. Other effects that may be achieved by premedication include: Amnesia Anxiolysis Prevention of physiologic stress Reduction of total anesthetic requirements Decreased probability of aspiration Vagolysis Decreased salivation and secretions Antiemesis Analgesia Children greater than 10 months usually receive midazolam 0. The circuits used for pediatrics were traditionally designed specifically to decrease the resistance to breathing by eliminating valves; decrease the amount of dead space in the circuit; and in the case of the Bain circuit, decrease the amount of heat loss by having a coaxial circuit with warm exhaled gas surrounding and warming the fresh gas flow. It is less bulky, allowing laryngoscopy to be performed while cricoid pressure is applied with the fifth finger of the same hand. In general straight blades/Miller/ are used in infants to facilitate picking up the elongated epiglottis and exposing the vocal cords. The wider-phlanged WisHippel or Robert-Shaw blades are sometimes preferred for ease of exposure. The Bullard laryngoscope consists of a rigid blade with a fixed fiberoptic bundle. The Shikani optical stylet is a combination of a lightwand, stylet and fiberoptic scope. Endotracheal tubes: small-diameter endotracheal tubes increase airway resistance and work of breathing. The anesthesiologist should calculate ideal tube size and have available one size larger and one size smaller. Age/yr/+16/4 or wt/kg/+35/10 Cuffed tubes are generally not used for patients under age 8. Ultimately the proper tube size is confirmed by the ability to generate positive pressure greater than 30 cm H2O and by the presence of a leak at less than 20 cm H2O. Laryngospasm is defined as approximation of true vocal cords or both true and false cords. It is caused most often by inadequate depth of anesthesia with sensory stimulation /secretions, manipulation of airway, surgical stimulation/. Treatment includes removal of stimulus, 100% oxygen, continuous positive pressure by mask, and muscle relaxants. Usually laryngospasm will break under positive pressure but on the rare occasion that this fails, only a very small dose of succinylcholine is required for relaxation of the vocal cords, which are quite sensitive to muscle relaxation. While 1-2 mg/kg maybe required for complete relaxation, only one tenth of this will generally relax the vocal cords. Blood pressure monitoring: Cuff size can be determined using the following criteria: cuff bladder width should be approximately 40% of the arm circumference; bladder length should be 90 to 100% of the arm circumference. Invasive monitoring (intraarterial catheters); Smaller catheters provide greater accuracy in monitoring, but larger are more practical for blood sampling. The consequences of thermal stress include cerebral and cardiac depression, increased oxygen demand, acidosis, hypoxia, and intracardiac shunt reversal. Use of the oximeter is particularly important in pediatrics because of the greater tendency of the infant to develop rapid desaturation and hypoxemia. The goal of neonatal oxygen monitoring is to maintain saturation in the low 90s to minimize risks of oxygen toxicity. In infants, two probes/preductal (right ear or right arm) and postductal (left arm or either leg) will reflect the amount of right to left shunting occurring. Also, while a patient may become noticeably cyanotic when the sat drops below 90%, there is no level of hypercarbia that is reliably clinically evident. In the recovery area, hypercarbia itself acts as a sedative and will contribute to delayed emergence. Such factors include hypovolemia (decreasing arterial pressure) and increased mean airway pressure (increasing alveolar pressure). Infants will not display head lift or respond to commands, even with full return of neuromuscular function. Lifting both legs may indicate that the patient can generate adequate negative inspiratory force. Nerve stimulation is recommended at the superficial ulnar nerve and posterior tibial nerve. Also, direct muscle stimulation in this area may result in the administration of excessive amounts of relaxant. Small-gauge catheters are available for venous cannulation: 24G, 22G; a 25 or 27-gauge for very small premature infants. It will be much easier to administer medications and remove air from the intravenous system by using a separate stopcock and attaching it to a plain piece of extension tubing. In children who weigh less than 10kg a burette/150cc/ should be used for fluid administration. Extensions for intravenous systems are particularly advisable as intravenous access is sometimes obtained in lower extremities. Fluids, electrolytes and transfusion therapy Preterm and small infants have a relatively high percentage of total body water/85% in a preterm and 75% in a full-term infant/. The minimum amount of water required to meet ongoing insensible losses is 60 to 100 ml/kg/day. Dehydration is classified by its tonicity according to the concentration of serum sodium. Replacement of fluid deficits: "easy- to- use" formula 4-2-1; 4ml for first 10kg. Glycogen stores in the neonatal liver are limited and are rapidly depleted within the first few hours of life. Preterm infants may be hypoglycemic without demonstrable symptoms, necessitating close monitoring of blood glucose levels. Full-term neonates undergo a metabolic adjustment after birth with regard to glucose. Hypoglycemia is defined in full-term infants as a serum glucose concentration less than 30mg/100ml in the first day of life or less than 40 mg/100ml in the second day of life. The routine intravenous replacement solution for normal neonates contains 5- 10% dextrose. Transfusion of blood components is indicated to increase oxygen-carrying capacity or to improve coagulation. Fresh whole blood may also be chosen for trauma patients, transplant patient, or infants needing exchange transfusion or having open heart surgery. Transfusion reactions: Acute hemolytic reactions are usually the result of clinical errors. Febrile reactions occur when antibodies against leuckocytes or platelets are transfused. Anaphylaxis is seen in patients with IgA deficiency who have antiIgA antibodies as a result of previous transfusion. The most important aspect of awakening is the return of cardiorespiratory reflexes: the ability to gag and cough to protect the airway, the return of baroreceptor reflexes to support perfusion, and the return of chemoreceptor responses to hypercapnia and hypoxia. Oxygenation: Children recovering from general anesthesia are at greater risk for hypoxia; continuous administration of oxygen during monitoring of SpO2 has been advocated for children. Normothermia: Both hypothermia and hyperthermia are common intraoperative problems, particularly in infants. Brisk flexion of the hips and knees is an indication of return of adequate peripheral muscle strength in infants. Crying is not always an indicator of pain but may represent anxiety, hunger, thirst or nausea. Control of nausea and vomiting begins in the selection of agents/techniques used for anesthesia. The important time interval is the time between the last ingestion and the time the trauma occurred. On the other hand, if he had just eaten dinner at 6 pm- he will continue to have a full stomach for many hours (possibly even more than 24 hours). This latter child is one who might benefit from metoclopramide ("chemically emptying the stomach"). Amputation of the placenta results in an increase of systemic vascular resistance. The increase in pulmonary blood flow will result in increased blood volume in the left atrium and subsequent closure of the flap of the foramen ovale. The cardiac output of the neonate is dependent upon heart rate and left ventricular filling pressure. Infant ventricular myocytes can not increase contractility, so heart rate and volume status determine output. The neonate can achieve twice the cardiac output of the fetus with volume loading and heart rate increases. At birth, the lungs undergo the transition from a fluid-filled organ to an air-filled organ for gaseous exchange. In order to overcome surface active forces and fully expand the lungs, the neonate must generate negative intrathoracic pressures of up to 70 cm H2O. Because neonatal oxygen consumption is two to three times that of the adult, respiratory rate must be increased proportionally. In infants less than 3 weeks of age, hypoxia initially stimulates ventilation, followed by a decrease in ventilation. Large surface area, poor insulation, a small mass from which heat is generated, and inability to shiver place newborn at a disadvantage for maintaining temperature. Catecholamine-stimulated nonshivering thermogenesis (brown fat metabolism) may cause such complications as elevated pulmonary and systemic vascular resistance and higher O2 consumption with resultant stress on the newborn heart. Securing the airway may also involve a cooperative effort between the surgeon and the anesthesiologist. The anatomic location of the surgical procedure has direct anesthetic implications. Oropharyngeal lesions may increase the difficulties of intubation or maintaining mask ventilation. To avoid fires, delivered oxygen concentration should be kept as low as possible when electrocautery is being used. Procedures involving the larynx, trachea and bronchi necessitate the greatest anesthetic depth to prevent airway hyperreactivity. Inhalation inductions are commonly used in children undergoing otolaryngologic procedures. In children with airway edema or foreign body, inhalation agents may improve bronchodilation and decrease airway reactivity. In children with airway emergencies an inhalation induction allows for continuous maintenance of spontaneous ventilation and delivery of high concentration of oxygen. An intravenous induction is appropriate for removal of esophageal foreign body or airway lesions without airway compromise but with high risk of aspiration. Intravenous induction may also be used for upper airway obstruction when mask ventilation may be very difficult but uneventful intubation is anticipated. Intravenous agents such as propofol may also be beneficial adjuncts to primarily inhalational anesthetics. Commonly anticipated complications include airway edema or obstruction, bleeding, and nausea and vomiting. For direct laryngoscopy and rigid bronchoscopy a gentle inhalation induction may be preferred. Spontaneous ventilation is important if there is a suspicion of tracheomalacia or laryngomalacia. Otherwise, muscle relaxation during rigid bronchoscopy is an excellent method of preventing coughing or bucking on the bronchoscope which could cause the life-threatening complication 13 of bronchial rupture. Primary intubation can be performed before bronchoscopy when the airway must be rapidly secured. Intravenous atropine or glycopyrrolate/10 to 20 mcg/kg/ may be useful as an antisialogue. The anesthesia circuit can be connected to the rigid bronchoscope from a proximal side port. Use of 100% oxygen while the bronchoscope is in the trachea offers a margin of reserve against possible hypoxia. Hypercapnia frequently occurs because passive ventilation is difficult with the high airway resistance caused by the narrow bronchoscope. High flows may be necessary if there is much discrepancy between the size of the bronchoscope and the size of the trachea. On the other hand, if there is a tight fit, air trapping and "stacking" of ventilation (lungs unable to completely deflate prior to the next inflation) can lead to pneumothorax or impede venous return. For children spontaneous or assisted ventilation through a ventilating bronchoscope is preferred to jet ventilation because of the risk of barotraumas and air trapping. If jet ventilation is used, limit delivered pressure and place a hand on the chest to detect "stacking". At the end of procedure an anesthesia mask can be used for emergence but intubation is preferred in the presence of airway compromise, edema, blood or secretions.
Djupesland D virus scanner buy cheapest nitrofurantoin and nitrofurantoin, Lyberg T when do antibiotics kick in for sinus infection discount nitrofurantoin 50 mg without prescription, Krogstad O: Cephalometric analysis and surgical treatment of patients with obstructive sleep apnea syndrome how do antibiotics for acne work discount nitrofurantoin master card. Following rhinoplasty virus journal order nitrofurantoin in united states online, nasal obstruction is clinically suspected as being an important functional sequela in many patients undergoing this procedure antibiotics japan over counter 50mg nitrofurantoin otc. From personal experience bacteria list discount nitrofurantoin line, many surgeons would support the belief that little or no deterioration occurs in the nasal airflow in this group of patients. Before performing this cosmetic procedure, the surgeon must consider the ethical and legal implications, since it is important to realise the physiological effects following aesthetic rhinoplasty on a normal functioning nose. Nasal airflow has been studied extensively following cosmetic rhinoplasty, but there has been no evidence that this alters significantly after surgery. For aesthetic reasons, a low-approach lateral osteotomy is recommended by many authors,3,4 in order to avoid a step deformity. Since lateral osteotomy starts at the pyriform aperture, many authors were particularly interested to investigate the effects on the nasal airflow caused by surgery on this anatomical structure,5,6 which is, in fact, an integral part of the nasal valve system. An important prerequisite in the choice of the correct fracture line is that, along the nasal pyramid, sections can be performed that represent equilateral triangles descending from the base towards the root of the nose, and therefore, when performing lateral osteotomy, this architecture must be respected. Indeed, during a rhinoplasty procedure, careful preoperative evaluation and planning is indispensable to the surgeon, in order to maximize the best aesthetic result, while preserving nasal functionality. This study was designed to deal with the following questions: does rhinoplasty affect nasal airflow? Material and methods Fifty-six patients were selected for this study and were subdivided into two groups: the first group consisted of 50 primary rhinoplasty cases (17 males, 33 females, mean age 24 years), and the second group of six secondary cases (three males, four females, mean age 33 years). All participants were asked the following question: · Compared to your ability to breath through your nose before the operation, is your breathing now better, worse, or the same? The physical examination was particularly directed towards the nasal valve area, and a group of ten patients additionally underwent acoustic rhinometry. The following lesions were found in the group of secondary cases: step deformity, synechiae, pinched tip (from interruption of domes and/or suture of domes), upper lateral cartilage detachment, nasal valve collapse, septal deviation at the nasal valve area, vestibular scar tissue. If necessary, in secondary cases, the surgical technique should include outfracture of a narrow piriform aperture. Results With regard to the primary cases, the patients replied to the questionnaire as follows: 536 · · · G. On rhinoscopic examination, all patients were negative for nasal stenosis, although a scar could usually be seen at the level of the intercartilaginous incisions, apparently being displaced slightly toward the septum at the caudal border of the upper lateral cartilages. With regard to the secondary cases, six of the seven patients noted improvement in breathing, according to the questionnaire and the physical examination, and one case noted no change, due to vestibular scar tissue. Discussion Although surgeons generally strive to avoid reducing nasal airflow during aesthetic rhinoplasty, there is still no definitive means of follow-up and assessment, especially in the long-term following these procedures. Studies often have mixed results, based on functional and cosmetic cases, different methods of nasal flow evaluation, i. The correct approach to this problem must take into account the nasal valve, which is undoubtedly the most critical anatomical structure in the procedure. It has the smallest cross-sectional area of the entire respiratory tract and consequently produces the greatest resistance to airflow. The nasal valve consists of, and is essentially limited by, the caudal end of the upper lateral cartilages and the corresponding septum and nasal floor. This is why, during a lateral osteotomy, medial displacement of the nasal bones causes the inner tissue to approach the septum, thus reducing this critical area. Some authors stress the importance of a high lateral osteotomy,7,10,12-14 while others attach less importance to this approach, since they do not consider it to be critical. The three cases of referred nasal obstruction could have been due to pre-existing anatomical conditions or postoperative vasomotor reactions. As far as the secondary cases are concerned, nasal airflow improved in six of the seven patients, showing that, even after two rhinoplastic procedures, the simple re-establishment of the correct nasal anatomy leads to the recovery of normal breathing. The patient who reported no return of function confirms our opinion that vestibular scarring is one of the most difficult iatrogenic lesions to repair. The surgical technique described in this article would appear to be safe for the purpose it was used, but we must emphasize the importance of recognizing Nasal respiratory function after pyramid surgery 537 any pre-existing anatomical or pathological conditions well ahead of the procedure. We feel that the key to safe and intact nasal breathing in patients undergoing rhinoplastic procedure is the careful application of the correct surgical technique. Our technique primarily stems from two warnings: firstly, do not start lateral osteotomy too low;7 secondly, to avoid excessive medical displacement of the nasal bones, outfracture the nose after infracture. The present article would seem to confirm the importance of carrying out rhinoplasty correctly. Our current knowledge on rhinoplastic techniques is adequate for preventing the impairment of nasal function. These segments have been loosely categorized as retropalatal and retrolingual,1 although some authors have also begun to quantify the degree of lateral pharyngeal wall collapse (from lateral to medial). A new technique has recently been introduced that improves the nocturnal retrolingual airway without the morbidity of a midline glossectomy, nor the potential risks of a mandibular osteotomy with genioglossal advancement. All patients underwent a complete head and neck evaluation (including fiberoptic endoscopy and a Mьller maneuver6), and Address for correspondence: David J. Patients in whom evidence of both retropalatal and retrolingual obstruction was manifested, were offered multilevel pharyngeal surgery, consisting of a palatopharyngoplasty with either mandibular osteotomy with genioglossal advancement or tongue suspension (with the Repose device). Nineteen consecutive patients who underwent multilevel pharyngeal surgery with tongue suspension using the Repose device form the cohort evaluated in this study. Surgical techniques the palatopharyngoplasty procedure utilized has been described previously. The suture is passed submucosally around the posterior tongue, and tied at the front in the floor of the mouth. Anatomical and radiographic changes as a result of surgery are depicted in Figure 1. Complications Four patients suffered transient velopharyngeal insufficiency, and two patients complained of limited anterior excursion of the tongue. Comparison of preoperative and postoperative values for both anatomical and radiographic measures of the upper airway in patients who underwent multilevel pharyngeal surgery (palatopharyngoplasty and tongue suspension with the Repose device). Discussion Moderate to severe obstructive sleep apnea is usually associated with multilevel pharyngeal collapse. Therefore, multilevel surgery is required to overcome the collapse at these segments. Both soft tissue1 and skeletal framework2 approaches to multilevel surgery have been advocated,3,4 but each carries with it a significant degree of morbidity. Recently, DeRowe and coworkers5 introduced a novel technique of tongue suspension, designed to improve the retrolingual airway. We have achieved a moderate degree of success by combining the tongue suspension procedure with palatopharyngoplasty in a small number of patients. The anatomical improvement (as determined by the Mьller maneuver) is similar to that obtained after mandibular osteotomy with tongue advancement. The radiographic improvement in the posterior airspace is modest, as might be predicted, since the goal is to stabilize and support the posterior tongue, rather than to advance it. The encouraging polysomnographic results seen so far in this small group of non-randomized patients will need to be confirmed in a larger cohort, and long-term durability of the anatomical improvement will need to be demonstrated. However, this would appear to be a promising new technique for the surgical management of obstructive sleep apnea. Kunda the tongue suspension procedure represents a minimally invasive technique for improving the nocturnal retrolingual airway in patients with obstructive sleep apnea. It is easily performed by the average otolaryngologist, thereby distinguishing it from other techniques designed to address tongue-base obstruction. Fujita S: Midline laser glossectomy with linguoplasty: a treatment of sleep apnea syndrome. DeRowe A, Gunther E, Fibbi A, Lehtimaki K, Vahatalo K, Maurer J, Ophir D: Tonguebase suspension with a soft tissue-to-bone anchor for obstructive sleep apnea: preliminary clinical results of a new minimally invasive technique. Surgical management of snoring is aimed at reducing the soft palate by removing redundant tissue when the problem lies at the soft palate level. Different techniques have been described to create stiffening of the palate to reduce snoring, but long-term outcome and morbidity due to pain in the immediate postoperative period remain a major concern. Method: the authors propose a new technique with the aim of improving the outcome of surgery and reducing postoperative pain. A retrospective survey was carried out via a questionnaire which was filled in by patients who had undergone surgery in the previous six months. Results: Thirty patients filled in the questionnaire: in 28 of whom (93%), snoring had disappeared completely or was reduced to such a level that it did not disturb either them or their partners. Three patients (10%) noted an alteration in speech in the immediate postoperative period, but this was of short duration. Fifteen patients had been sleeping in a separate room from their partners before the operation, which number dropped to just four (13. Twenty-one (70%) patients responded positively regarding recommending this operation to friends or family members, five (16. Conclusions: the six-month postoperative results show that this new technique is successful in reducing snoring, and that it is also less painful. A fairly new series of low-frequency, bipolar radiowave instruments (Coblation), which combines effective low pain volumetric tissue reduction and excision possibilities, has recently been introduced. These include palatal incision and upward channelling, as well as partial uvulectomy and channelling. All the patients were controlled after six and 12 months, with an average number of treatments of approximately 1. The one-year follow-up results showed the classification and treatment to be extremely satisfactory, with proper results for more than 90 of 100 patients. As seen on long-term follow-up, this is a complete and logical method for the step-by-step treatment of snoring and mild obstructive sleep apnea. The authors present the results of 39 patients (34 male and five female), as measured by polysomnography, for a mean follow-up of 8. The majority of the patients underwent other procedures in addition to the tongue stabilization. Two patients required further surgical intervention, such as maxillomandibular or genioglossal advancement. Two patients could use their positive airway pressure devices successfully, thanks to the procedures. Although tongue stabilization was performed as part of a multistage procedure in most patients, the results appeared better than expected with only one level of treatment. Method: A study was undertaken using a simple anonymous questionnaire sent to all patients who had undergone palatal surgery by the senior author. All patients within the study were chronic habitual snorers who had initially been referred for snoring problems. All patients had undergone preoperative polysomnography, to exclude sleep apnea and sleep naso-endoscopy, in order to rule out tongue-base collapse as a cause for their snoring. Results: Fifty-nine questionnaires were sent to patients, 36 of which (61%) were returned. This reduction included all patients in the study even if there had been no improvement in the snoring. Twenty-one patients (61%) reported an improvement in their snoring, and just eight (22%) reported a > 50% reduction. This figure is generally quoted in studies as a level at which the operation can be regarded as being successful. Conclusions: Short-term results of palatal somnoplasty have suggested a high (83%) success rate in treating snoring within six weeks of surgery. However, our longer-term results suggest that the percentage of patients with a successful result over a longer term reduces to approximately 22%. However, despite these low figures, 50% of the patients in our study remarked that they would undergo further palatal somnoplasty, and only 22% would not have further surgery. Palatal somnoplasty is a procedure with a low morbidity, is less disfiguring than other forms of snoring surgery, and can be repeated. Among the different mechanisms involved, a decline in pharyngeal (genioglossus) muscle activity has been implicated. This system consists of an implantable pulse generator, a respiratory pressure sensor, a half-cuff stimulation lead, and a programming system. Stimulation occurs early during inspiration and is triggered by intrathoracic pressure changes during the respiratory cycle. A patient-programmer allows fine tuning of stimulation parameters by the physician during postoperative polysomnographies. The system is well tolerated by the patients and the reported use of the stimulator is good. Moreover, apnea and hypopnea could be prevented without patients being aroused from sleep. The data demonstrate that the improvement in obstructive apnea during hypoglossal stimulation can be attributed to recruitment of the genioglossus muscle and the concomitant reduction in upper airway collapsibility, and not to arousal from sleep. One parameter for defining upper airway collapsibility is the critical closing pressure (Pcrit). The patients implanted at our center were selected on the basis of having predominantly tongue base obstruction (documented by intraluminal pressure measurements during sleep). Yet, although the patients implanted at other participating centers were not included on the basis of the Functional electrical stimulation of the nervus hypoglossus 551 site of upper airway obstruction, a similar improvement in obstructive apnea was found. Another feature likely to affect treatment efficacy is the presence of concomitant central sleep apnea. Since stimulation is triggered by respiration, as detected by the transsternal pressure sensor, it can be anticipated that the system will fail to do so in the absence of respiratory movement (central apnea). Although upper airway occlusion has been demonstrated during central apneas, alterations in ventilatory drive are the primary mechanism in this disorder. Optimization of the stimulation parameters requires fine tuning, and regular visits are necessary to achieve these goals. Therefore, good cooperation by the patients, and their understanding of the treatment, are prerequisites for therapeutic success. Further studies are necessary to define patient selection criteria, based on baseline measurements of upper airway collapsibility and site of upper airway obstruction.
This PreTest reviews all of the anatomical disciplines encompassing early embryology antibiotic resistance wildlife buy nitrofurantoin in india, cell biology antibiotics for sinus infection during first trimester 50mg nitrofurantoin sale, histology of the tissues and organs antibiotics for mrsa cheap nitrofurantoin 50mg mastercard, as well as regional human anatomy of the head and neck antibiotic resistance vs tolerance purchase 100 mg nitrofurantoin with visa, thorax bacteria worksheet middle school order nitrofurantoin online, abdomen antibiotic kinds discount 100 mg nitrofurantoin overnight delivery, pelvis, extremities, and spine. This edition represents a comprehensive effort to integrate the anatomical disciplines with clinical scenarios and cases. The sections on cell biology and microscopic anatomy have been updated to include important new knowledge in Cell and Tissue Biology. There is also a greater focus on clinically-related questions, problems, and scenarios. It is imperative that students be able to recognize structures and relationships as part of their radiological anatomy knowledge base. An updated High-Yield facts section is provided to facilitate rapid review of specific areas of Anatomy that are critical to mastering the difficult concepts of each subdiscipline: embryology, cell biology, histology of tissues and organs, regional human (gross) anatomy, pathology, and a brief review of neuroanatomical tracts. This page intentionally left blank Introduction Each PreTest Self-Assessment and Review allows medical students to comprehensively and conveniently assess and review their knowledge of a particular medical school discipline, in this instance anatomy and cell biology. Although the main emphasis of this PreTest is preparation for Step 1, the book will be very beneficial for medical students during their preclinical courses whether they are enrolled in a medical school with a problem-based, traditional, or hybrid curriculum. This book is a comprehensive review of early embryology, cell biology, histology (tissue and organ biology), and human (gross) anatomy with some neuroanatomical topics covered through cases that integrate neuroanatomical tract information with regional anatomy of the head and neck. In keeping with the latest curricular changes in medical schools, as much as possible, questions integrate macroscopic and microscopic anatomy with cell biology, embryology, and neuroscience as well as physiology, biochemistry, and pathology. This PreTest begins with early embryology, including gametogenesis, fertilization, implantation, the formation of the bilaminar and trilaminar embryo, and overviews of the embryonic and fetal periods. This first section is followed by a review of basic cell biology, with separate chapters on membranes, cytoplasm, intracellular trafficking, and the nucleus. There are questions included to review the basics of mitosis and meiosis as well as regulation of cell cycle events. Tissue biology is the third section of the book, and it encompasses the tissues of the body: epithelium, connective tissue, specialized connective tissues (cartilage and bone), muscle, and nerve. Organ biology includes separate chapters on respiratory, integumentary (skin), digestive (tract and associated glands), endocrine, urinary, and male and female reproductive systems, as well as the eye and the ear. The topics in tissue and organ histology and cell biology include light and electron microscopic micrographs of appropriate structures that xv Copyright © 2007 by the McGraw-Hill Companies, Inc. The last section of the book contains questions reviewing the basic concepts of regional anatomy of the head and neck, thorax, abdomen, pelvis, and extremities. Where possible, information is integrated with development and histology of the organ system. Each multiple-choice question in this book contains four or more possible answer options. Each question is accompanied by an answer, a detailed explanation, and a specific page reference to an appropriate textbook. A bibliography listing sources can be found following the last chapter of this PreTest. Acknowledgments the authors express their gratitude to their colleagues who have greatly assisted them by providing light and electron micrographs as well as constructive criticism of the text, line drawings, and micrographs. They also acknowledge Eileen Roach for her painstaking care in the preparation of photomicrographs. Erlandsen, WenFang Wang, Wolfram Sterry, and Xiaoming Zhang for their contribution of micrographs and ideas for question development. Also, thanks to the Jeffrey Modell Foundation and the Primary Immunodeficiency Resource Center for use of the Martin Causubon case. The authors remain indebted to their students and colleagues at the University of Kansas Medical Center, past and present, who have challenged them to continuously improve their skills as educators. This page intentionally left blank High-Yield Facts Embryology Embryological development is divided into three periods: the Prenatal Period consists of gamete formation and maturation, ending in fertilization. The Embryonic Period begins with fertilization and extends through the first 8 weeks of development. Errors can result in duplication or deletion of all or part of a specific chromosome. Spermatogenesis the process of spermatogenesis is continuous after puberty and each cycle lasts about 2 months. Spermatogonia in the walls of the seminiferous tubules of the testes undergo mitotic divisions to replenish their population and form a group of spermatogonia that will differentiate to form spermatocytes. Spermiogenesis During this phase, spermatids mature into sperm by losing extraneous cytoplasm and developing a head region consisting of an acrosome (specialized secretory granule) surrounding the nuclear material and grow a tail. Maturational events include retention of protein synthetic machinery in the surviving oocyte, formation of cortical granules that participate in events at fertilization, and development of a protective glycoprotein coat, the zona pellucida. Following coitus, exposure of sperm to the environment of the female reproductive tract causes capacitation, removal of surface glycoproteins and cholesterol from the sperm membrane, enabling fertilization to occur. Release of cortical granules from the acrosome causes biochemical changes in the zona pellucida and oocyte membrane that prevent polyspermy. During the second week, the blastocyst differentiates into two germ layers, the epiblast and the hypoblast. During the third week, the process of gastrulation occurs by which epiblast cells migrate toward the primitive streak and ingress to form the endoderm and mesoderm germ layers below the remaining epiblast cells (ectoderm). Lateral body folding at the end of the third week causes the germ layers to form three concentric tubes with the innermost layer being the endoderm, the mesoderm in the middle, and the ectoderm on the surface. High-Yield Facts 3 Axial mesoderm is located in the midline and forms the notochord. Somites are divided into sclerotomes (bone formation), myotomes (muscle precursors), and dermatomes (precursor of dermis). Lateral plate mesoderm forms bones and connective tissue of the limbs and limb girdles (somatic layer, also known as somatopleure) and the smooth muscle lining viscera and the serosae of body cavities (splanchnic layer, also known as splanchnopleure). Intermediate mesoderm is not found in the head region, and the lateral plate mesoderm is not divided into layers there. The neural plate ectoderm (neuroectoderm) forms two lateral folds that meet and fuse in the midline to form the neural tube (neurulation). Cells from the tips of the folds (neural crest) migrate throughout the body to form many derivatives including the peripheral nervous system. The bony skeleton of the head is comprised of the viscerocranium and the neurocranium. The neurocranium (cranial vault) is composed of a base formed by endochondral ossification (chondrocranium) and sides and roof bones formed by intramembranous ossification. The chondrocranium is derived from both somitic mesoderm (occipital) and neural crest. The viscerocranium (face) is derived from the first two pharyngeal (branchial) arches (neural crest in origin). Somatic lateral plate mesoderm (somatopleure) forms the bony and connective tissue elements of the limbs and limb girdles while skeletal muscle of the appendages is derived from somites. Homeobox genes encode trancription factors that regulate processes such as segmentation and axis formation. Rotation of the limb buds establishes the position of the joints, the location of muscle groups, and the pattern of sensory innervation (dermatome map). Overexposure of the cranial region to retinoic acid can result in "caudalization," i. During development, the spinal cord and presumptive brainstem develop three layers: (1) a germinal layer or ventricular zone, (2) an intermediate layer containing neuroblasts and comprising gray matter, and (3) a marginal zone containing myelinated fibers (white matter). Other layers are added in the cerebrum and cerebellum by cell migration along glial scaffolds. The notochord induces the establishment of dorsal-ventral polarity in the neural tube. Ventral portions of the tube will become the basal plate and give rise to motor neurons, whereas the dorsal portions become the alar plates, derivatives of which subserve sensory functions. Meninges are formed by mesoderm surrounding the neural tube with contributions to the arachnoid and pia from neural crest. Folic acid, also known as folate, is a B-vitamin that can be found in some enriched foods and vitamin supplements. Public Health Service recommends that all women who could possibly become pregnant get 400 µg (or 0. Folic acid is found in some foods, such as enriched breads, pastas, rice, and cereals (some with 100% of the daily requirement). Damage is dependent on gestational age, alcohol dosage, and pattern of maternal alochol abuse. Focal deficiencies in neural crest cell migration may result in lack of innervation to specific organs or parts of organs. In Hirschsprung disease (aganglionic megacolon), failure of neural crest cells to migrate to a portion of the colon results in a localized deficiency in parasympathetic intramural ganglia that may cause a loss of peristalsis and bowel obstruction. Each arch receives its blood supply from a specific aortic arch and its innervation from a specific cranial nerve (special or branchial visceral efferent fibers). The third aortic arch provides most of the adult blood supply to the head and neck. The skeletal muscles of the head and neck primarily arise from the pharyngeal arches and have a unique innervation (special visceral efferent). The face develops from a midline frontonasal prominence and bilateral maxillary and mandibular prominences. Teeth originate from both ectodermal (enamel) and neurectodermal (neural crest: dentin, pulp, cementum, and periodontal ligament) derivatives. Eye the eye is derived from three different germ layers: Neuroectoderm: Vesicular outgrowths of the forebrain differentiate into retina and optic nerve. Surface ectoderm: Contributes to the lens, cornea, and epithelial coverings of the lacrimal glands, eyelids, and conjunctiva. Structures of the outer and middle ear are derived from the first and second pharyngeal arches and the first pharyngeal cleft. Structures of the inner ear are derived from the ectodermal otic placode, not neuroectoderm. Maternal rubella can cause defects in both eye (fourth to sixth weeks of gestation) and ear (seventh to eight weeks). The heart tubes forming on either side of the endodermal tube are brought together by lateral body folding. Looping of the heart tube occurs while the tube is being divided into left and right portions by the interatrial and interventricular septa. In the interatrial septum, the septum primum and septum secundum do not close off the foramen ovale until birth. Failure of the atrioventricular endocardial cushions to fuse can result in septal and valve defects. Neural crest cells contribute to septation of the truncus arteriosus and the formation of the aortic and pulmonary outflows, as well as the aortic arches. Vasculature Vasculogenesis versus Angiogenesis the endothelial lining of most blood vessels forms by coalescence of vascular endothelial progenitors (angioblasts) of mesodermal origin. The endothelial cells proliferate, migrate, differentiate, and organize into tubular structures with subsequent vacuolization to form a lumen. Subsequently, periendothelial cells form from local mesoderm and differentiate into muscle and connective tissue elements. That process is known as vasculogenesis and occurs in both embryonic and adult tissues. Vasculogenesis is the de novo formation of blood vessels and differs from angiogenesis, initiated in a pre-existing vessel. Angiogenesis also is a prominent characteristic of inflammation, pathology such as diabetic retinopathy, wound repair, placental development during embryogenesis, and tumor formation. Molecular triggers for angiogenesis include the cytokines, small, extracellular signal proteins or peptides that function as local mediators in cell-cell communication. Pharmaceutical agents modeled after these anti-angiogenic peptides are being developed to inhibit tumor growth. Development of the Vasculature the paired doral aortae and the five aortic arches form an early symmetric arterial system. Regression of portions of these vessels later results in the asymmetrical adult arterial system. High-Yield Facts 9 the vitelline arteries connect the yolk sac to the abdominal dorsal aorta. Blood islands are the first sites of hematopoiesis and seed other hematopoietic tissues. The paired umbilical arteries develop from the caudal end of the dorsal aorta and invade the mesoderm of the placenta. The caval venous system is derived mostly from the right anterior and posterior cardinal veins. The vitelline veins form the veins of the digestive system, including the portal vein, and the terminal part of the inferior vena cava. No components of the umbilical veins remain patent after closure of the ductus venosus. These are, in succession, the liver (week 5), spleen (week 5), and bone marrow (month 6). All components of hematopoietic organs are derived from mesoderm except for the epithelium of the thymus, which is derived from endoderm of the third pharyngeal pouch. The midgut endoderm is the last to fold into a tube and remains connected to the yolk sac via the yolk stalk. Formation of the mesodermal urorectal septum divides the cloaca into the urogenital sinus and primitive rectum. Failure to recanalize can result in stenosis, preventing the passage of amniotic fluid swallowed by the fetus causing polyhydramnios. Failure of neural crest cell migration to the distal hindgut results in aganglionic megacolon (Hirschsprung disease), which may cause fatal intestinal obstruction. Failure of the midgut loop to return to the abdominal cavity may result in an omphalocele or umbilical hernia.
Mucous membrane hypertrophy is often selectively localized at the base of the inferior turbinates antibiotic 1st generation cheap 50 mg nitrofurantoin with mastercard, whose hypertrophy may in part obstruct the choana antibiotic resistance video youtube discount 100mg nitrofurantoin fast delivery. From a histological point of view bacteria h pylori buy nitrofurantoin 50mg amex, hypertrophy appears to be considerable in many cases with especially high levels of serum mucous glandular structures bacteria zapper for face purchase online nitrofurantoin, in other cases due to hyperplastic vascular structures antibiotic 500 mg nitrofurantoin 50 mg amex, and in yet others due to the chronic bruised condition of the mucous chorion; because of the frequent overlapping of vasomotor phenomena killer virus purchase nitrofurantoin 100mg otc, the obstruction may increase alternatively in the nasal cavities. This causes contraction of the subepithelial precapillary sphincters, arteriolar vessels, and venous sinusoids. This initial vasoconstriction is followed by a secondary vasodilatation caused by the constricting mechanisms and hypoxia. An increase in the secretions from the muciparous glands and of the nasal obstruction, and a reduction of mucous clearance, will be seen. We have previously observed how nasal obstructions increase nasal resistance and lead to sleep with respiratory problems, including apnea, ipopnea, and snoring. It must be mentioned that, even relief from nasal obstruction, allows the patient to sleep more comfortably, alleviating the inconvenience of fragmented sleep. Hill W: On some causes of backwardness and stupidity in children and the relief of these symptoms in some instances by nasopharyngeal scanfications. Kurtz D, Meunier-Carus J, Bapst-Reiter J et al: Nosologic problems raised by certain forms of hypersomnia. De Weese D, Saunders W, Schuller D, Schleuning A: In: Saunders W (ed) Otolaryngology Head and Neck Surgery, pp 223-229. Young T, Finn L, Kim H: Nasal obstruction as a risk factor for sleep disordered breathing. Series F, St Pierre S, Carrier G: Effects of surgical correction of nasal obstruction in the treatment of obstructive sleep apnea. Weight-loss management strategies can be classified into three broad categories: basic treatment, pharmacotherapy, and surgical treatment. Basic treatment All obese patients, whether or not they are candidates for pharmacotherapy or surgical treatment, should undergo basic treatment. This basic treatment should include counselling, caloric restriction, behavior therapy, and physical activity. Many placebo-controlled studies have shown that such basic treatment can successfully yield a weight loss of approximately one pound per week in some patients, without the aid of pharmacotherapy or surgical treatment. Therefore, a structured weight-maintenance program with indefinite, continual contact is also needed to help the patient sustain weight loss. Fabiani © 2003 Kugler Publications, the Hague, the Netherlands 88 Essential modes of therapy D. This approach enables patients to accept the concept of a healthy lifestyle, while de-emphasizing weight loss as the primary goal. The physician should also explain the importance and benefits of realistic weight loss, as well as emphasize the importance of good, basic nutritional principles. For instance, an obese woman with an energy expenditure of 1500 kcal/day would lose one pound a week on a 1000 kcal/day diet, whereas an obese woman with a daily energy expenditure of 2500 kcal/day would lose approximately three pounds a week on the same diet. For patients with renal disease, diabetes, or other metabolic disorders, the physician should determine protein requirements. Energy restriction and weight loss may also necessitate changes in scheduling or dosage of medications such as orally administered glucose-lowering agents or insulin. Food logs or record books should be completed by the patient and, if necessary, adjusted to ensure that the rate of average weight loss does not exceed, or fall short of, the weekly goal. Potential complications include the following:4 ketosis (if the diet contains < 100 g of carbohydrates daily), excessive loss of lean body mass, arrhythmias, dehydration, and a tendency for recidivism. Usually, however, they are only associated with minor complications when administered to carefully selected patients by experienced physicians. Serious complications can include excessive loss of lean body mass and sudden death in medically vulnerable persons who have comorbidities, especially if their daily caloric intake is < 600 kcal. At each visit, the patients should undergo a basic serum chemistry evaluation, including electrolytes and liver function tests. This enables patients to evaluate and modify eating practices, physical activity habits, and emotional responses to weight. Physical activity Although regular, moderate physical activity alone results in a limited weight loss of four to seven pounds in the long term,4 it is an essential and highpriority element of any weight-management program. Regular physical activity is the most important predictor of long-term weight maintenance. The goal of any weight-management program should be at least 30 minutes of moderate-intensity physical activity five to seven times per week. When needed to reduce a health risk, used in the context of long-term disease management, and prescribed and supervised by an experienced physician such as an endocrinologist, internist, or family practitioner, pharmacotherapy may increase the effectiveness of a basic weight-management program, and should be used only in conjunction with such a program. Although anti-obesity agents can improve weight loss, they may also be associated with adverse effects, even including the possibility of a fatal outcome. The physician should be aware of the recommended treatment duration, although long-term use of an appropriate anti-obesity agent may be necessary for successful, long-term maintenance of weight loss. Weight loss Patients who take active drugs are more likely than those who do not to achieve a clinically significant weight loss of 10% of initial body weight. Maintenance of weight loss Although their utility for weight loss has long been recognized, anti-obesity 92 D. Pharmacotherapy is contraindicated in pregnant or lactating women, patients with unstable cardiac conditions, those with uncontrolled hypertension, serious medical conditions, or psychiatric disorders, and patients taking other incompatible drugs. Anti-obesity agents approved for use for up to one year Sibutramine A centrally acting anti-obesity agent, sibutramine blocks the re-uptake of norepinephrine, serotonin, and dopamine in nerve terminals in order to produce substantial weight loss and maintenance of loss of weight. It does not stimulate serotonin, norepinephrine, or dopamine release,22 nor does it have an affinity for these receptors. The clinical efficacy of sibutramine has been evaluated in approximately 4600 patients worldwide. When administered in conjunction with a reducedcalorie diet, it is effective for weight loss and maintenance of weight loss for up to one year. Most adverse events, including dry mouth, anorexia, and constipation, were transient and mild to moderate in severity. Sibutramine should not be used in patients with uncontrolled or poorly controlled hypertension. It increases sympathetic nervous system activity through its norepinephrine re-uptake inhibition. In placebo-control trials of obese patients, sibutramine (5-20 mg daily) was associated with mean increases in systolic and diastolic blood pressure of from 1-3 mmHg relative to placebo, and increases in pulse rate of 4-5 beats/min relative to placebo. Larger increases were seen in some patients, particularly when sibutramine treatment was initiated at higher doses. Sustained, potentially clinically significant increases in blood pressure are usually detectable within the first month of treatment. Sibutramine should not be used in patients with a history of narrow-angle glaucoma or seizures. Additionally, patients with poorly controlled or uncontrolled hypertension, severe renal impairment, severe hepatic dysfunction, congestive heart failure, coronary artery disease, arrhythmia, or stroke, should not be treated with sibutramine, nor should it be given to patients who are being treated with medications that regulate the brain neurotransmitter, serotonin (such as fluoxetine, sertraline, venlafaxine, fluvoxamine, and paroxetine). Anti-obesity agents approved for short-term use Diethylpropion An anorexiant agent considered one of the safest for patients with mild to moderate hypertension, diethylpropion is effective in producing weight loss and is indicated for use for up to a few weeks. Side-effects of the drug include mild restlessness, dryness of the mouth, and constipation. Cases of psychological dependence have reportedly occurred with use of diethylpropion. Adverse reactions include stimulant effects similar to amphetamines; however, mazindol does not seem to cause euphoria, and the abuse potential is low. A small increase in heart rate (ten beats/min) is noted with orthostatic position change. No case reports have been published of heart valve abnormalities with use of phentermine alone. This agent acts on the 1-receptor and is classified as a direct -adrenergic agonist with indirect catecholaminereleasing effects. Probably related to reduced lipid solubility, compared to amphetamines, it has little central nervous system stimulant effects, and its use has not been shown to result in the development of dependence. In a comprehensive obesity-management program, phenylpropanolamine increased weight loss by 0. Currently, its labelling warns that its use in patients with hypertension, depression, heart disease, diabetes, or thyroid disease should be under the supervision of a physician. They produce a transient sense of fullness and can temporarily lessen the desire to eat (for about 30 minutes). These products are not absorbed into the system, but require large quantities of water and can increase peristalsis. Accumulation of mucilaginous bulk laxatives may also result in esophageal, gastric, small intestinal, or rectal obstruction, and they are not indicated in persons with pre-existing intestinal problems, those with difficulty swallowing, or patients on a carbohydrate-restricted diet. Ephedrine is a sympathomimetic agent that, in short-term studies of small numbers of patients, has been shown to increase thermogenesis and promote weight loss, especially when combined with caffeine. Finally, after they were linked to more than 1500 cases of eosinophilia-myalgia syndrome, these drugs were abandoned. Clinical trials of efficacy demonstrated clinically significant weight loss (5% more than with placebo) in slightly more than half the patients who received orlistat for up to one year. Olestra A product of sucrose esterification with certain fatty acids, scheduled to be marketed during 1998, olestra is a non-digestible fat substitute that reduces 96 D. Surgical treatment of obesity Two proven surgical options are available for the treatment of morbid obesity: (1) restrictive operations such as vertical banded gastroplasty (gastric stapling) or laparoscopic gastric banding; and (2) gastric bypass operations such as Rouxen-Y gastric bypass or extensive gastric bypass (biliopancreatic diversion). The weight loss associated with vertical banded gastroplasty can also considerably reduce the comorbid conditions, including diabetes mellitus type 2, hypertension, respiratory distress, hyperlipidemia, and disability. This procedure is a more complicated gastric bypass which successfully promotes weight loss, but is associated with a risk of nutritional deficiency. It requires a lifelong commitment to a change in lifestyle, behavioral responses, and dietary practices. A patient who experiences a reduction in comorbidities and an improved sense of well-being is more likely to be motivated to maintain weight loss. In addition, psychological therapy should be encouraged for patients experiencing negative life events or family dysfunction, both of which are negative predictors of the maintenance of weight loss. National Task Force on the Prevention and Treatment of Obesity, National Institute of Health: Very low-calorie diets. Life Sciences Research Office: Management of Obesity by Severe Caloric Restriction. Institute of Medicine, Food and Nutrition: Board Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity. National TaskForce on the Prevention and Treatment of Obesity: Long-term pharmacotherapy in the management of obesity. Guy-Grand B, Apfelbaum M, Crepaldi G, Gries A, Lefebvre P, Turner P: International trial of long-term dexfenfluramine in obesity. Proceedings of the 64th Meeting of the United States Food and Drug Administration Endocrinologic and Metabolic Drugs Advisory Committee. Lane R, Baldwin D: Selective serotonin reuptake inhibitor-induced serotonin syndrome: review. Enzi G, Baritussio A, Marchiori E, Crepaldi G: Short-term and long-term clinical evaluation of a non-amphetamine anorexiant (mazindol) in the treatment of obesity. Inoue S, Egawa M, Satoh S et al: Clinical and basic aspects of an anorexiant, mazindol, as an antiobesity agent in Japan. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Friedman D, Bachi V: Partial and total biliopancreatic bypass in surgical treatment of obesity. National Institutes of Health Consensus Development Conference Statement: Gastrointestinal surgery for severe obesity. Weight excess and reduced respiratory compliance account for only 60-70% of variance. For these reasons, the degree of weight loss able to induce a clinical improvement of the respiratory function is highly variable. Measurement of waist circumference (at the midpoint between the lower border of the rib cage and the iliac crest) is correlated with visceral fat mass, while hip circumference (the largest in the gluteal region) is correlated with subcutaneous fat mass. With the knowledge that 1 kg of adipose tissue corresponds to about 7200 kcal, a monthly weight loss of about 3-5 kg is the optimal rate. Caloric intake must be supplied by a balance of energetic nutrients: carbohydrates and proteins (4 kcal/g) and fats (9 kcal/g). Protein calories must be distinguished from carbohydrate and lipid calories, because they are chiefly utilized not for energy purposes but for maintenance (turnover) and growth of lean mass. Carbohydrates are subdivided in complex carbohydrates (80%) and simple sugars (20%), i. When prescribing a hypocaloric diet, it is also necessary to evaluate the absolute amount of carbohydrates since, in a healthy adult, under physiological conditions 140 g of glucose is consumed daily by the brain and 40 g by the erythrocytes. They should be given in a total amount of at least 100 g/day for their protein-sparing effect. From a practical point of view, it is usually sufficient to recommend splitting fat intake into 50% animal and 50% vegetable origin, in order to follow the proportions mentioned above, since animal fat is about two-thirds saturated and one-third mono-unsaturated, while vegetable fat is one-third saturated and two-thirds mono- and poly-unsaturated. Anorectic drugs are not recommended due to their possible effects on the cardiovascular system, while inhibitors of fat absorption, such as orlistat ((N-formil-L-leucine(s)-1-(((2S,3S)-3-esil-4-ossi-2ossietanil) metil)dodecil ester), could be added to the regimen. World Health Organization: Diet, nutrition, and the prevention of chronic disease. Lojander J, Mustajoki P, Ronka S, Mecklin P, Maasilta P: A nurse-managed weight reduction programme for obstructive sleep apnea syndrome. National Institutes of Health: Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults: the evidence report, pp 137-138. Fidanza F: Alimentazione e Nutrizione Umana: Sezione Quarta: Calutazione dello Stato di Nutrizione e Rilevamento dei Consumi Alimentari. Stenlof K, Grunstein R, Hedner J, Sjostrom L: Energy expenditure in obstructive sleep apnea: effects of treatment with continuous positive airway pressure.
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