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By T. Cronos. Sherman College of Straight Chiropractic.

Atrichia caused by mutations in the Vitamin D receptor gene is a phenocopy of generalized atrichia caused by mutations in the hairless gene generic 100mg viagra sublingual fast delivery. Hair cosmetics can be helpful in camouaging hair loss by optimizing the appearance of exist- ing hair; however purchase viagra sublingual 100mg otc, hair cosmetics may also be the cause of hair loss when improperly used or used to excess. The primary goal of this chapter is to help the reader understand how shampoos and conditioners can be incorporated into a treatment algorithm for patients undergoing hair disease treatment. The secondary goal of this chapter is to understand hair loss precipitated by hair coloring, permanent waving, and hair straightening. While these procedures can beautify the hair or appeal to fashion concerns, they can also permanently damage the hair protein and produce premature hair breakage and loss. Haircare is important because damage to the non- living ber is permanent until replaced by new growth, which is a time-consuming activity. Cleansing the hair is actually a complex task, since the average woman has 4 to 8 square meters of hair surface area to clean (2). Thus, the goal of a shampoo is to maintain scalp hygiene while beautify- ing the hair. A shampoo that has high detergent properties can remove the outer cuticle of the hair shaft rendering it frizzy and dull, while a well-designed conditioning shampoo can impart shine and improve manageability. Proper shampoo selection can be the difference between attractive and unattractive hair. Shampoo Formulation Shampoos cleanse by utilizing synthetic detergents, also known as surfactants, which are amphiphilic. The lipophilic site binds to sebum and oil-soluble dirt while the hydrophilic site binds to water allowing removal of the sebum with water rins- ing (4). There are four basic categories of shampoo detergents: anionics, cationics, amphoterics, and nonionics (5). Usually, a shampoo is a combination of two to four detergents with various abilities to remove sebum, produce foam, and condition the hair. Creating the perfect balance between hygiene and beautication is the goal of a successful shampoo. Anionic detergents are the most popular cleanser in general purpose shampoos and are named for their negatively charged hydrophilic polar group. Common anionic detergents include the lauryl sulfates, laureth sulfates, sarcosines, and sulfosuccinates. The second most popular detergents are the amphoter- ics, which contain both an anionic and a cationic group. This allows them to behave as cationic 60 Draelos detergents at low pH and as anionic detergents at high pH. Amphoteric detergents such as cocamidopropyl betaine and sodium lau- raminopropionate are found in baby shampoos. These detergents actually numb the tissues of the eyes, which accounts for the non-stinging characteristics of baby shampoo. Amphoteric detergents are also used in shampoos for ne and chemically treated hair because they foam moderately well while leaving the hair manageable. The main distinguishing characteristic between a bar cleanser and a shampoo is the addi- tion of a sequestering agent. Sequestering agents function to chelate magnesium and calcium ions thereby preventing the formation of insoluble soaps, known as scum. Without sequester- ing agents, shampoos would leave a lm on the hair, making it appear dull. Shampoo Diversity Even though all shampoos employ the same basic ingredients, the number of formulations on the market is diverse. This is because there are many different cleansing needs and hair types (Table 1). Shampoos designed for so-called normal hair thoroughly cleanse the scalp in persons with moderate sebum production and are best for chemically untreated hair. These shampoos are popular among men and use lauryl sulfate as the primary detergent, which provides good sebum removal and minimal conditioning. This is in contrast to dry-hair shampoos that provide mild cleansing and excellent conditioning. These products are excellent for mature hair, frequent use, and chemically treated hair since they reduce static electricity and increase manageability. A relatively new shampoo category is the conditioning shampoo, also known as the 2-in-1 shampoo, which cleans and conditions simultaneously (6,7). Detergents used in conditioning shampoos are generally amphoterics and anionics of the sulfosuccinate type, previously dis- cussed. These products are designed for patients with chemically damaged hair or those who prefer to shampoo frequently (8). Hydrolyzed animal protein is one of the ingredients added to conditioning shampoos, since it can minimally penetrate the hair shaft temporarily plugging surface defects, resulting in hair with a smoother feel and more shine. Dimethicone is the other common conditioning shampoo ingredient prized for its ability to create a thin lm over the hair shaft increasing shine and manageability. For persons with abundant sebum production, oily-hair shampoos are formulated with excellent cleansing and minimal conditioning properties.

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The area of spinal canal as a positive Babinski s reflex buy 100 mg viagra sublingual with amex, hyperreflexia generic 100 mg viagra sublingual with visa, loss of narrowing is demarcated by the arrowheads. Usually view: An anterior epidural abscess is seen in the spinal within 24 hours of the onset of paralysis, the spinal canal (arrowheads) compressing the spinal cord cord s vascular supply becomes irreversibly compro- (arrows) against the posterior wall of the canal. Ron Quisling, University of To prevent this devastating outcome, clinicians need to Florida College of Medicine. In the patient with back pain and fever, spinal epidural abscess must be strongly con- ferred test. In posterior epidural abscesses, severe The bacteriology of epidural abscess reects the pri- localized tenderness over the infected area is encoun- mary site of infection. Epidural abscess formation can be readily quent cause, followed by aerobic streptococci, S. Dexamethasone in adults with bacterial terior epidural space containing fat and small meningitis. The benecial effects of c) hematogenous spread from skin or urinary early dexamethasone administration in infants and children tract infection or intravenous drug abuse. The diagnostic c) signs of cord compression in later stages accuracy of Kernig s sign, Brudzinski s sign, and nuchal rigid- ity in adults with suspected meningitis. Practice guidelines for 24 hours of onset, irreversible paraplegia the management of bacterial meningitis. Treatment involves pesvirus 6 infection in 4 immunocompetent patients with a) emergency surgical drainage if physical encephalitis. Tuberculous Meningitis another important cause, most commonly associated with tuberculous infection of the thoracic vertebra. Dexamethasone for triaxone, and metronidazole are recommended as the treatment of tuberculous meningitis in adolescents and empiric therapy pending culture results. Subdural empyema: analysis of nition and evaluation of adjuncts to antifungal therapy. Cata- epidural abscess: the importance of early diagnosis and treat- strophic visual loss due to Cryptococcus neoformans meningitis. Efcacy and safety of cefotaxime in combination with metronidazole for empirical treatment of brain abscess in clinical practice: a retrospective study of 66 con- secutive cases. Cardiovascular Infections 7 Time Recommended to Complete: 1 day Frederick Southwick, M. Are bacteriostatic antibiotics effective in the treat- when should the antibiotic be given? When bacterial endocarditis is suspected, what are the skin lesions that should be searched for, 8. In recent series, more than half of the patients with endocarditis were over the age of 50 years. Subacute endocarditis expectancy increasing worldwide, the percentage of is an indolent disease that can continue for months. The incidence varies from series to series, being estimated to be as high as 11 per 1. A rare disease; a primary care physician is likely 100,000 population, and as low as 0. This sterile lesion serves as an ideal site to trap b) congenital heart disease (bicuspid valve, bacteria as they pass through the bloodstream. Disease of the mitral or aortic valve is most com- rheumatic heart disease, those with an audible murmur mon; disease of tricuspid valve is rarer (usually associated with mitral valve prolapse, and elderly patients seen in intravenous drug abusers). The higher the pressure gradient in aortic stenosis, the greater the risk of developing endocarditis. Intravenous drug abusers are at high risk of developing endocarditis as a 109 to 1011 bacteria per gram of tissue, and these bac- consequence of injecting bacterially contaminated solu- teria within vegetations periodically lapse into a meta- tions intravenously. Platelets and bacteria tend to accumulate in specic The frequency with which the four valves become areas of the heart based on the Venturi effect. The Venturi effect is most easily bacterial endocarditis involve the valves of the left side appreciated by examining a rapidly owing, rock-lled of the heart. When the ow of water is conned to a narrower to the highest pressures and are the most commonly channel by large rocks, the velocity of water flow infected. In aortic steno- Patients with prosthetic valves must be particularly sis, vegetations tend to form in the aortic coronary alert to the symptoms and signs of endocarditis, because cusps on the downstream side of the obstructing the articial material serves as an excellent site for bac- lesion. Patients who have recovered from an commonly seen in the atrium, the low-pressure side of episode of infective endocarditis are at increased risk of regurgitant ow. Phagocytes are incapable of The organisms responsible for infective endocarditis entering this site, eliminating an important host are sticky.

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Most common cause of syncope is neurocardiogenic cause; however the most malignant life threatening causes of syn- cope are of cardiac origin discount viagra sublingual 100 mg fast delivery. Patients are often times misdiagnosed with seizures as seen in our case 3 scenario generic viagra sublingual 100mg online. Effective treatment modalities are available and with prompt diagnosis appropriate treatment has proven to be life-saving. Case Scenarios Case 1 18-year-old female presents to the clinic with a 3-year history of recurrent syncopal and pre-syncopal episodes. Syncope in her is often times triggered by anxiety, long standing and is more frequent around the times of her menses. She often times gets nauseated, with profuse sweating, blurred vision and light headedness prior to fainting. Possibility of Orthostatic intolerance was also entertained based on blood pressure change with position at the time of her clinic visit Treatment: Adequate daily oral hydration was recommended. Awareness of her trig- gers and prodrome was lauded in this patient and it was recommended that should these symptoms recur; that she assumes the recumbent position as much as is possible. Physical examination: Heart rate was 92/min-irregular, Respiratory rate was 14/min. Treatment: He was subsequently evaluated by a pediatric electrophysiologist who has recommended genetic testing. Because he had remained asymptomatic no medication was started at the time of his last visit. Case 3 16-year-old male athlete presents with a history of recurrent fainting episodes for the past 4 years. He gives no history of nausea, or light headedness prior to fainting but does attest to scotomas just prior to the episodes. He says the episodes are of sudden onset and often times are triggered by playing basketball. He says he tries to abort the episodes of palpitations by holding his breath for a long time. He has been seen several times in the past and was diagnosed with pseudo-seizures. He was transferred to a tertiary center where he subsequently had an echocardiogram done which was within normal limits. Definition Chest pain is the second most frequent reason for referral of children and adolescents to a pediatric cardiologist despite the fact that chest pain is an unlikely manifesta- tion of heart diseases in children as the majority of cases are benign in nature. However, the association of chest pain with fatal heart disease in adults creates undue anxiety leading many pediatricians to refer children with heart diseases to I. Gonzalez (*) Department of Pediatric Cardiology, Rush University Medical Center, 1150 N. Pediatricians should become familiar with causes of chest pain in children and how to assess this complaint to be able to provide reassurance to patients and families in the majority of such cases. In addition, chest pain is the second most prevalent reason for referral to pediatric cardiologists. The male to female ratio appears to be equal and the average age of presentation is 13 years. Cardiac assess- ment is normal in the majority of patients and most cases are caused by noncardiac structures within the chest. Etiology The cause of chest pain in children and adolescence is noncardiac in most cases. The cause of chest pain in this age group is usually due to other structures within the thorax and respiratory system. However, psychological causes of pain should be made carefully and only after excluding other causes of chest pain. Organ systems responsible for causing chest pain in children include musculo- skeletal, pulmonary, psychiatric, gastrointestinal and cardiac. In most instances an etiology is difficult to identify, these are grouped as idiopathic and tend to be the most common category of chest pain. Musculoskeletal Conditions Costochondritis Definition: Costochondritis is an inflammatory process of the costochondral or cos- tosternal junction causing localized pain and tenderness. Costochondritis Is More Common in Females Presentation: Patients usually complain of insidious, sharp anterior chest pain, uni- lateral in the majority of cases. The pain is typically restricted to the affected costo- chondral junction (s), however, it may radiate to the back. The pain can be easily reproduced in the office by palpating the costochondral or costosternal junc- tions affected, although the majority of patients are typically not aware of the chest wall tenderness until physical examination.

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