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By M. Chenor. Albion College. 2019.

Treatment of the underlying malignancy may resolve the oral and skin lesions in the malignant form of the disease discount maxalt 10 mg amex. Usage subject to terms and conditions of license 218 Papillary Lesions Familial Acanthosis Nigricans Definition buy 10mg maxalt otc. Familial or genetic acanthosis nigricans is a rare benign mucocutaneous disorder cheap maxalt online visa, characterized by papillary lesions and skin discoloration. The cutaneous lesions appear as multiple, painless small papillary growths (skin tags) and dark discoloration (Fig. The axillae, groin, neck, umbilicus, genitalia, and perianal area are more frequently affected. Oral lesions occur in 10–25% of the cases and present as multiple, small, painless, papillomatous growths with normal color (Fig. Hypertrophy and elongation of the filiformpapillae result in a shaggy appearance of the tongue. Endocrine-related acanthosis nigricans, malig- nant acanthosis nigricans, Darier disease, Cowden disease. Usage subject to terms and conditions of license 220 Papillary Lesions Darier Disease Definition. Darier disease, or dyskeratosis follicularis, is a relatively rare mucocutaneous disease. The disease affects mainly the skin and nails, but the mucosae may also be involved (oral mucosa, pharynx, genitalia, rectum). The skin lesions appear as multiple, painless, brownish-red papules that usually coalesce into plaques (Fig. Oral lesions occur in 20–40% of cases and appear as small multiple whitish confluent papules, which may become hypertrophic, assuming a cobblestone or papillary pattern (Fig. The clinical diagnosis should be confirmed by a biopsy and histo- pathological examination. Familial acanthosis nigricans, familial benign pemphigus, papillary hyperplasia of the palate, Cowden disease. Usage subject to terms and conditions of license Laskaris, Pocket Atlas of Oral Diseases © 2006 Thieme All rights reserved. Usage subject to terms and conditions of license 223 7 Gingival Enlargem ent A common characteristic of this group of lesions is that they are located on the gingiva and present as a submucosal enlargement covered by normal epithelium. Local diseases, drug-induced lesions, systemic diseases, and tumors are included in this particular group of disorders. Usage subject to terms and conditions of license 224 Gingival Enlargement Generalized Hyperplastic Gingivitis Definition Hyperplastic gingivitis is a chronic inflammatory process that produces gingival enlargement. Local and systemic factors may involve sus- ceptibility to the oral microbial flora, and the host response. Clinical features Clinically, the interdental papillae and marginal gin- giva appear diffuse, red, and swollen, and significantly increased in size due to connective-tissue fibromatosis and edema (Figs. Loss of normal stippling, gingival bleeding even after mild local stim- ulation, and formation of pseudopockets are common findings. Differential diagnosis Gingivitis of pregnancy, drug-induced gingival overgrowth, mouth-breathing gingivitis, leukemias. Treatment Oral hygiene improvement, elimination of causative fac- tors, and, in severe hyperplasia, surgical reconstruction. Usage subject to terms and conditions of license 226 Gingival Enlargement Mouth-Breathing Gingivitis Definition Mouth-breathing gingivitis is a unique formof hyperplastic gingivitis. Clinical features This formof gingivitis affects the anterior facial gin- giva in young persons. Clinically, the gingiva appear swollen, red, dry, and shiny, covering part of the crown of the teeth (Fig. Differential diagnosis Drug-induced gingival overgrowth, hyperplas- tic gingivitis. Usage subject to terms and conditions of license 228 Gingival Enlargement Drug-Induced Gingival Overgrowth Definition Drug-induced gingival overgrowth is a relatively common disorder of the gingiva due to several drugs. Etiology The most common drugs associated with the condition are phenytoin, ciclosporin, and calciumchannel blockers. Clinical features The gingival overgrowth is usually related to the dose of the drug, the duration of therapy, the serumconcentration, and the presence of dental plaque. Clinically, both marginal gingiva and inter- dental papillae appear enlarged and firm, with a surface that may be smooth, stippled, or lobulated, with little or no inflammation (Figs. The gingival overgrowth may be localized or gener- alized, and can partially or entirely cover the crown of the teeth. The diagnosis is made on the basis of the medical history and the clinical features. Usage subject to terms and conditions of license 230 Gingival Enlargement Differential diagnosis Hereditary gingival fibromatosis, mouth- breathing gingivitis, leukemia, Crohn disease, amyloidosis. Treatment Improvement of oral hygiene, gingivectomy, discontinua- tion of the offending drug. Usage subject to terms and conditions of license 232 Gingival Enlargement Gingival Overgrowth in Pregnancy Definition Gingival overgrowth in pregnancy, or pregnancy gingivitis, is a relatively rare formof gingival hyperplasia that occurs exclusively during pregnancy. Clinical features The condition presents as significant gingival en- largement, generalized or localized in one or more quadrants. The gin- giva is soft, edematous, bright red, with dense inflammation, and is hyperplastic and bleeds easily (Fig. Usage subject to terms and conditions of license 234 Gingival Enlargement Gingival Overgrowth due to Leukemia Gingival overgrowth is a common and early finding in leukemia (see also p. Gingival swelling occurs most frequently in patients with mye- lomonocytic and myelocytic leukemia. Gingival infiltration by leukemic cells causes diffuse enlargement of the gingiva, which becomes edema- tous, red, and inflamed, and bleeds spontaneously (Figs. Differential diagnosis Scurvy, agranulocytosis, drug-related gingival overgrowth, hereditary gingival fibromatosis. Usage subject to terms and conditions of license 236 Gingival Enlargement Hereditary Gingival Fibromatosis Definition Hereditary gingival fibromatosis is a unique gingival en- largement caused by collagenous proliferation of the fibrous connective tissue of the gingivae.

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Some patients suffering from chronic pain may not experience any relief or experience only partial relief by using analgesics buy cheap maxalt line, anesthetics generic maxalt 10 mg without a prescription, steroids buy discount maxalt, and even surgical therapies, which sometimes produce serious side effects or drug addiction. In the earlier trials, promising results have emerged, for example, demonstrating the efficacy of acupuncture in the postoperative dental pain. Note that acupuncture analgesia is used in most of the major countries and regions all over the world. The Chinese Medical Theory considers that pain is the result of imbalance of Yin and Yang, stasis or blockade of meridian Qi flow, and the 163 Acupuncture Therapy of Neurological Diseases: A Neurobiological View subsequent blood stagnation. Based on this concept, acupuncture is applied to the acupoints (located in parts of the meridian network) and Ashi points (which are also highly important in the treatment of headache) to treat diseases, aiming to restore the balance of Yin and Yang, the normal flow of Qi flow, and blood circulation (Zhao et al. The acupoints are selected based on a traditional Chinese syndrome diagnosis, the acupuncturists’ personal experience, localization of pain, or other symptoms. Neurobiological researches have supported the hypothesis proposed by the famous Chinese neurophysiologist, Zhang, in the 1970s, who stated that acupuncture analgesia is an integrative effect of the two different signals from acupuncture and pain at different levels in the central nerve system, including the spinal cord, brainstem, and thalamencephalon. During acupuncture analgesia, the specific sites related to pain modulation in the central nervous system were observed to be activated, with the release of various endogenous bioactive substances in the nervous system. These substances that are involved in pain relief include opioids, classical neurotransmitters (such as 5-hydroxytryptamine, acetylcholine), neuropeptides, etc. The separation of the specific effects of acupuncture from its non-specific effects is extremely difficult, because acupuncture is a physical, invasive, and manual procedure involving considerable time of the practitioner as well as some rituals. However, it is important to quantify the relative effects of these two factors (Hammerschlag 1998). Furthermore, other possible confounding factors might be linked to a patient’s preconceived ideas of the efficacy of a particular treatment regime, and this too must be assessed as a part of the non-specific effect (White et al. To provide an effective and credible placebo (defined as a physiologically inert procedure), the control must be convincing and should mimic, in all respects, apart from the physiological effect, the real active treatment (Ernst and White 1997; Peck and Coleman 1991). However, till date, none have simultaneously fulfilled all the criteria of being truly inert, easily usable, and effective in mimicking the real pragmatic acupuncture, as shown in Table 7. Therefore, in the clinical practice, appropriate control groups should be selected to demonstrate the results of acupuncture. It was first recorded in The Yellow Emperor’s Classic of Internal Medicine (Veith 2002). In the past thousands of years, various acupuncture approaches have been developed during clinical practice. Sometimes, two approaches could be useful, while for some instances, one approach may be better than the other. Manual application is very important for the acupuncture therapy, and certain acupuncture manipulation, such as rotating the needle, is observed to be necessary to increase the acupuncture therapeutic effect. Often no feeling might be experienced, until the needle reaches the layer where the needle sensation is felt. This sensation might be soreness, numbness, distension, or heaviness, which is called the acupuncture feeling or “De-Qi”. This is carried out to promote inter-meridian com- munication, and is observed to increase the therapeutic effect. Twisting causes the acupuncture points to be additionally stimulated, thus, eliminating obstructions in the flow of the Qi (He and Qu 1994). The clinical practice has demonstrated that the therapeutic effects of acupuncture are closely related to achieving the acupuncture feeling or “De-Qi” as well as the intensity of the acupuncture feeling, except the acupoints. The other important factor that influences the therapeutic effects is the acupuncture manipulation. There are many different types of acupuncture manipulation used in clinic, such as the method of reinforcement and reduction, twisting and twirling, lifting and thrusting, etc. Through manipulation, the location, intensity, and quantity of stimulation of the acupuncture could be adjusted during acupuncture therapy (He and Qu 1994). Han et al (1991) observed that low-frequency stimulation releases enkephalin, while high-frequency stimulation releases dynorphin. In addition, the therapeutic effect of different frequencies is often observed to be different. Wave forms Previously, there were three wave forms commonly used in clinical practice: sharp wave, square wave, and sinusoidal wave (Fig. Sharp wave was observed to easily transverse the skin and reach the deep tissues, and assist in exciting the nerves and muscles. It was found to accelerate the nerve-tissue regeneration by improving circulation, accelerating the metabolism, and improving the local tissue nourishment Hence, it was usually used to treat peripheral nerve injury, facial paralysis, post- polio syndrome, muscular atrophy, etc. On the other hand, square wave was observed to produce effects of pain relief, sedation, and hypnosis (He and Qu 1994). Hence, it was widely used to treat acute soft-tissue injury, headache, insomnia, stroke sequel, arthritis, stomach convulsion, terminal neuritis, etc. For example, the positive square wave and negative sparse wave were combined together, and the resulting new wave form was widely used for relieving pain. The combination of different frequencies produced dense-disperse wave, continuous wave, and chopping wave (Fig. The dense wave demonstrated high frequency, often in the order of 50 100 Hz, while the disperse wave was found to have a low frequency of 2 10 Hz. Intensity The high-intensity stimulation may produce severe pain, and may not be tolerated by the patient. Duration of stimulation After the insertion of needles, it usually takes 20 40 min to reach the highest pain- threshold level in the human body, and the electrical stimulation has been observed 168 7 Acupuncture Analgesia in Clinical Practice Table 7. Although acupuncture has been widely used to treat a variety of pain conditions, there is still limited convincing scientific evidence demonstrating its efficacy. In the following sections, acupuncture analgesia in clinical practice is demonstrated with respect to different kinds of pains. Migraine and tension-type headaches are the common headache disorders in clinic and 169 Acupuncture Therapy of Neurological Diseases: A Neurobiological View result in significant reduction in social activities and work capacity of the suffers (Woolhouse 2005). Medications commonly used to treat headache, such as acetaminophen, aspirin, non-steroidal anti-inflammatory drugs, triptans, narcotics, or barbiturates, can have problematic side effects and paradoxically contribute to the transformation of episodic headaches to chronic daily headache (Coeytaux et al. Given the limitations of medical therapy, acupuncture as an important promising nonpharmacological treatment for headaches has demonstrated its advantages and has been widely used for the treatment of different types of headache disorders (Table 7. No significant differences were observed between the acupuncture and metoprolol (a frequently used first-line drug in migraine prophylaxis) groups. Furthermore, the results of the acupuncture group were slightly better than those of the metoprolol group, with respect to migraine attacks and several parameters mentioned in the pain questionnaire (Streng et al. However, it should be noted that several trials have suggested that acupuncture was not more effective than sham acupuncture in reducing headaches, although both the interventions were more effective than a waiting list control (Table 7.

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Causes large bullae containing pus and clear serum maxalt 10 mg, which rupture easily leaving raw−areas cheap maxalt 10 mg otc. Admit If • Patient is toxic with suspected of septicaemia Patient Education • Spreads easily in schools • Isolate and treat infected individuals • Separate towels and bath facilities order maxalt pills in toronto. Severity varies from localised form (bullous impetigo) to generalised form of epidermolysis. Clinical Features • Vesicles which are flaccid, gentle lateral pressure causes shearing off leaving raw areas • Focus of infection may be found in the nose, umbilical stump, purulent conjunctivitis, otitis media, nasopharyngeal infection Investigations • Pus swab for C&S is essential. Change antibiotics according to culture and sensitivity results • Skin care: 290 − topical care baths with normal saline − if widespread and weeping lesions are present treat like burns [see 1. Sources of infection include other persons, animals such as puppies or kittens and more rarely the soil. Tinea pedis (athletes foot) Scaling or maceration between toes particularly the fourth interspace. Tinea cruris An erythematous and scaly rash with distinct margin extending from groin to upper thighs or scrotum. Tinea corporis (body ringworm) Characteristically annular plaque with raised edge and central clearing scaling and itching variable. Tinea capitis (scalp ringworm) Mainly disease of children and spontaneous recovery at puberty normal. Tinea anguum Involves the nails and presents with nail discolouration and subungual hyperkeratosis (friable debris) Investigations • Direct microscopy of skin scale in 20% potassium hydroxide mounted on a slide to demonstrate hyphae. Transmission via beddings or clothing is infrequent (the mites do not survive for a day without host contact) Clinical Features • Intense itching worse at night or after hot shower • Burrows occur predominantly on the finger webs, the wrists flexor surfaces, elbow an axillary folds, and around the areolar of the breasts in females, the genitals especially male, along the belt line and buttocks. Day three bathe and apply • Other drugs: 5−10% sulfur ointment • Nonspecific: − personal hygiene − antihistamines for pruritus − treat the whole family and personal contacts • Treat secondary bacterial infection − cloxacillin in severe cases. Clinical Features Presents with characteristic dermatitis, diarrhoea, dementia and death if not treated. Weight loss, anorexia, fatigue, malaise, pruritus burning, dysphagia, nausea diarrhoea vomiting, impaired memory, confusion and paranoid psychosis. Clinical Features Symptoms develop gradually as: • Dry or greasy diffuse scaling of scalp (dandruff) with pruritus • Yellow− red scaling papules in severe cases found along the hairline, external auditory canal, the eye brows, conjunctivitis and in naso−labial folds. Management • Control scaling by 2% salicylic acid in olive oil • Shampoos containing selenium sulfide, sulfur and salicylic acid, or tar shampoos daily till dandruff is controlled (more recently ketaconazole shampoo is excellent) • Topical steroids − use mild lotion (e. It is an infiltration into the dermo−epidemial junction by mono−nuclear cells leading to vesicle, generally found in the extremities, palms and soles in the mild form of disease. Refer to ophthalmologist • Mouth care − antiseptic wash • Keep patient warm • Cradle nursing. Serious, life threatening reaction pattern of the skin characterised by generalised and confluent redness with scaling associated systemic toxicity, generalised lymphadenopathy and fever. Constitutional symptoms − fatigue, weakness, anorexia, weight loss, malaise, feeling cold (shivering) clinically skin is red, thickened and scaly, commonly without any recognizable borders. Prognosis: Guarded and therefore a medical problem that should be dealt with using modern inpatient dermatology facility and personnel. Management Bath soaking • Bland emollients: Liquid paraffin, Emulsifying ointment • Nursing care − single room, keep warm etc. History i) A thorough history must be taken (this should include a history of chronic illnesses, a drug history and history of previous surgical encounters). Examination i) A thorough physical examination and in particular check for: − anaemia 295 − jaundice − level of hydration − fever − lymph node enlargement. For any major operation a check chart need be kept for at least 24 hours before surgery. Management − Supportive before surgery Correction of conditions that are identified in the evaluation is necessary and critical: • Correction of volume and electrolyte imbalance • Control of blood pressure • Control of thyrotoxicosis • Control of diabetes mellitus (and any other metabolic disease) • Correction of anaemia and malnutrition • Prophylactic antibiotics where indicated [see appropriate section for details]. A pint of blood is removed every 7 days prior to surgery and is re−transfused at the time of surgery. It is important to liaise with the blood donor bank to ensure that the patient gets his own blood • Do not correct post−operative anaemia with transfusion if there is no active bleeding or shock. The administration of antibiotic agents to prevent infection cannot be substituted for either sound surgical judgement or strict aseptic technique. Other highly contaminated wounds involve operations on the large intestines and severe burns. Other high risk factors include: • Development of infection because of malnutrition, impoverished blood supply, obesity, old age and immunodeficiency states • Treatment− specific factors such as use of steroids, anticancer agents and radiotherapy • Operative procedures of long duration such as cardiac and vascular procedures, orthopaedic and in neurosurgery • Insertion of a prosthesis or graft. Management • Prophylactic use of antibiotics should be distinguished in dosage and duration from their therapeutic use. To achieve the above, the surgeon must give legible, concise and clear post−operative instructions. Transit from theatre to ward • Keep airway clear to avoid upper airway obstruction and aspiration pneumonitis. Titrate against state of hydration • Watch for airway obstruction, reactionary bleeding, etc. Post−operative period 72 hrs−7 days • Mobilise out of bed about 18−72 hrs to avoid static pneumonia and deep vein thrombosis • Encourage independence e. It is critical in these patients that a variety of diagnosis be suspected and diagnosed or clearly excluded before definitive management. Clinical Features Meticulous history and physical examination is very important in establishing diagnosis. Abdominal pain, distension, guarding, rigidity, altered bowel sounds, alteration of bowel habits. In adults suspect bowel obstruction if, there is constipation, abdominal distension, fever (if advanced obstruction is present), features of dehydration exist, altered bowel sounds, abdominal pain, vomiting. Management • Correct fluid and electrolyte imbalance • Group and cross match blood • Deflate the distended stomach with nasogastric suction. This is more effective for small bowel than in large bowel obstruction • High enema may be effective for faecal impaction only • Remove the cause of the obstruction usually by surgery. The aseptic type is usually due to chemical irritants like bile, gastric juices, etc. Peritonitis usually ends up producing adhesions that may cause future bowel obstructions of varying degrees. Clinical Features Presentation is with an acute tender abdomen, abdominal distension, altered bowel sounds, guarding, rigidity, rebound tenderness and fever.

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Reduction in the incidence of type 2 diabetes with lifestyle intervention of metformin buy genuine maxalt on line. The association of physical activity with obesity buy maxalt toronto, fat distribution and glucose intolerance in Pima Indians discount 10mg maxalt fast delivery. Physical activity and reduced occurrence of non-insulin- dependent diabetes mellitus. Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships. A 20-year follow-up of the Finnish and Dutch cohorts of the Seven Countries Study. Habitual dietary intake and glucose tolerance in euglycaemic men: the Zutphen Study. Relationship of dietary saturated fatty acids and body habitus to serum insulin concentrations: the Normative Aging Study. Insulin sensitivity is related to the fatty acid composition of serum lipids and skeletal muscle phospholipids in 70-year-old men. Prevalence and determinants of glucose intolerance in a Dutch Caucasian population. Skeletal muscle membrane lipid composition is related to adiposity and insulin action. Effects of two high-fat diets with different fatty acid compositions on glucose and lipid metabolism in healthy young women. Substituting polyunsaturated for saturated fat as a single change in a Swedish diet: effects on serum lipoprotein metabolism and glucose tolerance in patients with hyperlipoproteinaemia. Dietary fiber, glycemic load, and risk of non-insulin-dependent diabetes mellitus in women. A high carbohydrate leguminous fibre diet improves all aspects of diabetic control. Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus. Dietary advice based on the glycaemic index improves dietary profile and metabolic control in type 2 diabetic patients. The use of low glycaemic index foods improves metabolic control of diabetic patients over five weeks. This epidemic is now emerging, and even accelerating, in most developing countries, while infections and nutritional deficiencies are receding as leading contributors to death and disability (1). In developing countries, the effect of the nutrition transition and the concomitant rise in the prevalence of cardiovascular diseases will be to widen the mismatch between health care needs and resources, and already scarce resources will be stretched ever more thinly. Because unbalanced diets, obesity and physical inactivity all contribute to heart disease, addressing these, along with tobacco use, can help to stem the epidemic. A large measure of success in this area has already been demonstrated in many industrialized countries. Overweight, central obesity, high blood pressure, dyslipidaemia, diabetes and low cardio-respiratory fitness are among the biological factors contributing principally to increased risk. Unhealthy dietary practices include the high consump- tion of saturated fats, salt and refined carbohydrates, as well as low consumption of fruits and vegetables, and these tend to cluster together. There is a probable increase in risk from dietary cholesterol and unfiltered boiled coffee. Possible associations for reduced risk include intake of flavonoids and consumption of soy products, while possible associations for increased risk include fats rich in lauric acid, b-carotene supplements and impaired fetal nutrition. Myristic and palmitic acids have the greatest effect and are abundant in diets rich in dairy products and meat. Stearic acid has not been shown to elevate blood cholesterol and is rapidly converted to oleic acid in vivo. The most effective replacement for saturated fatty acids in terms of coronary heart disease outcome are polyunsaturated fatty acids, especially linoleic acid. This finding is supported by the results of several large randomized clinical trials, in which replacement of saturated and trans fatty acids by polyunsaturated vegetable oils lowered coronary heart disease risk (6). Trans fatty acids are geometrical isomers of cis-unsaturated fatty acids that adapt a saturated fatty acid-like configuration. Several large cohort studies have found that intake of trans fatty acids increases the risk of coronary heart disease (8, 9). Even though trans fatty acids have been reduced or eliminated from retail fats and spreads in many parts of the 82 world, deep-fried fast foods and baked goods are a major and increasing source (7). The only nutritionally important monounsaturated fatty acids is oleic acid, which is abundant in olive and canola oils and also in nuts. The most important polyunsaturated fatty acid is linoleic acid, which is abundant especially in soybean and sunflower oils. Therefore, their effect on coronary heart disease is probably mediated through pathways other than serum cholesterol. Several prospective studies have found an inverse association between the intake of a-linolenic acid, (high in flaxseed, canola and soybean oils), and risk of fatal coronary heart disease (13, 14). Cholesterol in the blood and tissues is derived from two sources: diet and endogenous synthesis. Egg yolk is particularly rich in cholesterol but unlike dairy products and meat does not provide saturated fatty acids. There is no requirement for dietary cholesterol and it is advisable to keep the intake as low as possible (2). If intake of dairy fat and meat are controlled, there is no need to severely restrict egg yolk intake, although some limitation remains prudent. The cholesterol-lowering effects of plant sterols has also been well documented (18) and commercial products made of these compounds are widely available, but their long- term effects remain to be seen. Several large cohort studies carried out in different countries have reported that a high fibre diet as well as a diet high in wholegrain cereals lowers the risk of coronary heart disease (20--23). Also, the results of the Heart Protection Study indicated that no significant benefits of daily supplementation of vitamin E, vitamin C and b-carotene were observed among the high-risk individuals that were the subject of the study (25). In several studies where dietary vitamin C reduced the risk of coronary heart disease, supplemental vitamin C had little effect. Observational cohort studies have suggested a protective role for carotenoids but a meta-analysis of four randomized trials, in contrast, reported an increased risk of cardiovascular death (26). Reduced plasma folate has been strongly associated with elevated plasma homocysteine levels and folate supplementation has been demonstrated to decrease those levels (27).

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